JamesLHollyMD.com

	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
EPM Tools Association of Medication and Diagnosis Automated Team Function Behavioral Health Adult Weight Management Tutorial Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care Depression Tutorial Fall Risk Tutorial Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive LESS Initiative Tutorial Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Pain Management Tutorial Reduction of Antipsychotic Medications Toolkit Smoking Cessation Tutorial Stratifying End-of-Life Risk for Hospice Services Tutorial Chronic Conditions Tutorial Chronic Renal Disease Management Tool Tutorial Calculating the Stages of Renal Disease Proteinuria Disease Management Tools Acute Coronary Syndrome Tutorial Adult Weight Management Tutorial Angina Tutorial Cardiometabolic Risk Syndrome Tutorial Chronic Renal Disease Tutorial Congestive Heart Failure Tutorial Diabetes Tutorial Hypertension Tutorial Lipids Tutorial Lipid Quality Audit Tutorial Primary Pulmonary Hypertension Tutorial Framingham Cardiovascular Risk Cardiometabolic Risk Assessment Framingham Heart Study Risk Calculators Tutorial Frederickson Classification of Dyslipidemia LDL Level Lipid Disease Management Risk Assessment General principles about ICD-9 Codes and HCC/RxHCC Codes Charge Posting Tutorial Coding to Ensure Accurate Health Risk Scoring E & M Codes Tutorial HCC & RxHCC Risk HCC/RxHCC Risk Tutorial ICD-9 Code Training Manual Hepatitis Screening Hospital Based Tools Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial Admission Orders Tutorial Daily Progress Notes Tutorial Care Transition Data Set from PCPI Tutorial Using The Clinic and Hospital Follow-up Call Templates Respiratory Failure Tutorial Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA's Internal HCAHPS Survey Master GP Suite of Templates Master GP Suite of Templates Tutorial Medical Home Support Materials Department of Care Coordination, Director of Care Coordination and Care Coordination Referral Template Electronic Tickler File Electronic Tickler File Tutorial Follow-up Calls Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Services Medical Home Coordination Review Tutorial Medical Home Plan of Care and Treatment Plan Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Patient-Centered Medical Home Annual Questionnaires Patient-Centered Medical Home: SETMA's Medical Home Coordination Review (MHCR) Tutorial Patient Document for Coordination of Care Transitions of Care Management Coding (TCM Code) Tutorial Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial Nursing Home Depression Tutorial Fall Risk Tutorial Hydration Assessment Tutorial Nursing Home Guidelines for Care Tutorial Nursing Home Principal Suite of Templates Nutrition Assessment Tutorial Reduction of Antipsychotic Medications Toolkit Skin Care Tutorial Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds Preventive Health Tools Adult Weight Management Tutorial CHF Exercise Tutorial Diabetic Exercise Tutorial Diabetes Prevention Tutorial Exercise Prescription Tutorial Hypertension Prevention Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Initial Preventive Physical Exam & Annual Wellness Visit Tutorial LESS Initiative Tutorial Progression to Type 2 Diabetes Smoking Cessation Tutorial Progression to Type 2 Diabetes Quality Metrics ACO and Medicare Advantage Stars HEDIS: NCQA, History, Quality, Safety, STARS, ACO ACO Quality Measures Performance Tool ACO Quality Measures Performance Tool Tutorial STARs - A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Your Life Your Health - Health Illiteracy: Not Knowing What Your Doctor Said

James L. Holly,M.D.

November 18, 2004

Your Life Your Health - The Examiner

Health literacy -- the ability to understand and act on health information -- is essential for high-quality healthcare. Many people, especially the elderly, who bear the greatest burden of disease, have inadequate health literacy. This adversely affects their quality of care. Learning to recognize when a patient may have low literacy skills and understanding the common ways in which these people misinterpret medical information can help physicians develop strategies to improve patients' health literacy.

In order to identify patient's at risk of not getting the maximum benefit from their health care, Southeast Texas Medical Associates is adopting the Test of Functional Health Literacy in Adults (TOFHLA) to help patients know if they understand what their healthcare provider tells them. Patients who score lower than 60 points on the TOFHLA are considered to have inadequate health literacy, and often misread dosing instructions and appointment slips. If a patient's TOFHLA is low, special attention can be given to helping all patients understand their role in their own health.

A 2002 study reported in the Journal of the American Medical Association, stated "for each 1 point decrease in the Test of Functional Health Literacy in Adults (TOFHLA), the glycosylated hemoglobin (HbA1c, a measure of blood glucose levels over time) increased by 0.02. Patients with inadequate health literacy were less likely than patients with adequate health literacy to achieve tight glycemic control and were more likely to have poor glycemic control and to report having retinopathy (eye disease)." The study concluded, "After adjusting for other socioeconomic and clinical factors affecting glycemic control, patients with inadequate health literacy had nearly one-half the odds of patients with adequate health literacy of achieving tight glycemic control (hemoglobin HbA1c of 7.2 percent or less) and a two-fold greater odds of having poor glycemic control (HbA1c of 9.5 percent or more) and to report having retinopathy."

The more a patient knows about his/her illness, the better healthcare outcome the patiet will have with chronic diseases such as diabetes, congestive heart failure, asthma, headaches, high blood pressure, metabolic syndrome and others.

Language Illiteracy Promotes Health Illiteracy

A shocking number of patients cannot participate effectively in their own care for the simple reason that they cannot read adequately. Compounding the problem, physicians speak a specialized language ('medicalese') that is often unintelligible to outsiders. Moreover, many patients are expert at concealing their poor literacy skills. Inadequate health literacy has measurable ill effects on health. Given the increasing complexity of health care, which requires increased involvement of patients, we need to address this common but underappreciated problem and find ways to communicate with patients more effectively.

Good communication between physician and patient is a cornerstone of good health care.

Yet, many patients have difficulty understanding their doctors' instructions. Even immediately after leaving the physician's office or the hospital, patients may recall no more than 50% of the important information just given to them.

Furthermore, communication between physician and patient is becoming more difficult as health care becomes more complex. For example:

30 years ago there were only about 650 prescription drugs, and
the average hospital stay for acute myocardial infarction was 4 to 6 weeks;
today there more than 10,000 prescription drugs, and
a hospital stay for acute myocardial infarction is typically 2 to 4 days.

In addition, with the increasing prevalence of chronic conditions such as diabetes, high blood pressure, and congestive heart failure, patients are required to know how to manage their own health care outside the clinic and hospital.

Health Literacy

The sentiment that "what I don't know can't hurt me" was clearly never true in the area of health, and the increasing complexity of medicine has made what the patient doesn't know ever more dangerous. Health care providers are often unaware of the shocking ineffectiveness of our communication of basic information to patients about their diseases and treatments. Patients often walk out of a medical office newly burdened with diagnoses they don't understand, armed with powerful and dangerous drugs and with precious little to help them in case something goes wrong.

An individual's health literacy - "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" -- may be significantly worse than his or her general literacy, because functional literacy is context-specific.

Teaching Methods Obsolete

At least in the case of chronic diseases, it may be time to recognize that the traditional one-on-one method by which a physician teaches a patient about the disease has become obsolete. While face-to-face time with the physician is certainly necessary, it may be beneficial to supplement this with more formal classroom teaching by professional educators as part of a team approach to patient care. Patient education has become a discipline in itself, with its own scientific basis, and physicians need to take better advantage of it.

SETMA recognizes these problems and addresses them

At the very least, patients should be given written information about self-management of their illness at each visit. In subsequent visits, the patient's understanding of that material should be tested. That is why at SETMA, we not only have developed an education department for diabetes, metabolic syndrome, hypertension, congestive heart failure and weight management, but we also have the capacity to give every patient precise and useful educational information on their illness each time they attend clinic.

How Can Healthcare Providers Help?

Do not assume that the patient understands what they are being told. The language of medicine is highly technical, and outsiders may not understand it. Studies have reported a large variation among patients in their ability to comprehend commonly used medical terms:

only 13% of the 125 participating patients understood the meaning of "terminal,"
35% understood "orally," and
18% understood "malignant."

Other studies reported low comprehension in other critical areas of good health care, such as understanding written directions for taking medications, understanding clinical appointment slips, and informed consent forms. A study of Medicare patients found that:

48% did not understand the written instructions "take medicine every 6 hours"
68% could not interpret a blood sugar value
27% could not identify their next appointment
27% did not understand "take medicine on an empty stomach" (instructions written at 4th grade level)
100% could not understand a statement of Medicaid rights (written at a 10th grade level).

More than 2,500 patients tested at two public hospitals and found that 35% of English-speaking patients and 62% of Spanish-speaking patients had inadequate or marginal health literacy. Patients over 60 years old have a particularly high prevalence of inadequate health literacy: more than 80% at one of the public hospitals.

Physicians are often unaware that patients do not understand them. Patients, on their part, often feel shame over their lack of literacy skills and most often will not acknowledge this deficiency despite its interference with their care.

Recognizing inadequate health literacy

A healthcare provider may not know that his/her patient has inadequate or marginal health literacy. The patient's level of education does not guarantee that he or she can read. A study in five family practice clinics found that over 60% of patients tested had a reading skill that was at least three levels below the school grade they completed. In the large Medicare survey previously described, 27% of the patients who had a high school diploma and 17% of those who had some college education had inadequate or marginal health literacy.

H LITERACY WILLIAMS

Toward Better Communication

Physicians can improve their communication with patients with low literacy skills by learning to recognize the particular ways in which these patients deal with communication. Patients with low literacy skills tend to:

interpret words literally (e.g., thinking hypertension means "being hyper") and
often have difficulty identifying key concepts (or prioritizing or distinguishing them from minor details).

This difficulty with language is the most frequent area of miscommunication between physician and patient. Several types of words that physicians commonly use are difficult for these patients to comprehend, such as:

words denoting concepts (e.g., normal range),
categories (e.g., ACE inhibitors), or
value (e.g., excessive bleeding).

Another area of miscommunication is related to the lack of training in science and medicine in most patients, which can lead to logic problems. For example, it may seem logical to patients to stop a 10-day course of antibiotics once they feel better, even though they've been instructed to take the full course. Physicians understand the science and medical implications of stopping antibiotics mid-course, but this is not clear to many patients (even those with higher levels of literacy).

Ways to improve health literacy include:

simplifying or clarifying patient education materials,
with particular focus on the use of visual aids such as videos, pictographs, and cartoons.
Studies show that visual aids improve comprehension, compliance, and retention.

Physician involvement in delivering these materials and educating the patient are critical for enhancing health literacy. Including family and friends in helping deliver health information is also important, as patients with inadequate health literacy often go first to people they know for explanation.

Patients May Misunderstand Many Medical Terms

The following are ways to improve understanding in patients with low health literacy

Slow down -- Take time to assess patients' health literacy skills
Use "living room" language instead of medical terminology -- Use language that patients can understand
Show or draw pictures -- Visual aids enhance understanding and subsequent recall
Limit information given at each interaction and repeat instructions
Use a "teach back" or "show me" approach to confirm understanding -- Ask patients to demonstrate their instructions to ensure that instruction has been adequate. Never ask "do you understand?" Typically, patients will say yes even if they don't understand
Be respectful, caring, and sensitive -- This attitude reassures patients and helps them to improve participation in their own health care

And, for the patient, the charge is always to ask and keep asking until you are clear and sure you understand. Remember, it is your life and it is your health.

About SETMA	In The News	Syllabus PC-MH Externship	Patient Information	Presentations
Governance Board	Your Life Your Health	Public Reporting	Accreditations/Awards	Diabetes Center of Excellence
EPM Tools	Transforming Your Practice Library	Medical Home	I-CARE Initiative	NextMD