The National Committee for Quality Assurance (NCQA) recently sent SETMA a series of questions in preparation for publishing an article on SETMA.  The first question was, “SETMA has been involved in patient-centered care since before NCQA’s launched its program in 2008. What was delivering primary care like back then and how has becoming recognized changed the way you deliver care?  The answer follows.

When I started practicing medicine in 1975, and when SETMA was formed in 1995, primary care was high volume - which referred more to the number of patients seen, than to the number of tests and procedures ordered. At that time healthcare was paternalistic. Under the old model of care patients were very often told what to do and it was expected that they would follow the healthcare providers’ instructions without modification. The definition of “paternalism” helps understand the old model; it is: “A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities.”

Medical home redefines the dynamic of the relationship between healthcare provider and patient!  Rather than the patient encounter being didactic (to lecture or teach, as one with knowledge instructions or informs those who do not) - where the healthcare provider tells the patient what to do, how to do it and when to do it €“ in medical home the patient/provider encounter becomes a dialogue (an exchange of ideas or opinions) - where the healthcare provider and the patient discuss a mutual concern and then together come to a mutual conclusion with a mutually agreed upon plan. This new relationship is somewhat like a partnership. (see more at Paternalism or Partnership: The Dynamic of the Patient-Centered Transformation)

In the mid-80s, laws changed so that primary care physicians could only charge for laboratory work which they actually performed in their offices. The sequence in which the changes were made, i.e., in July, 1984 or 85, physician fees were frozen and in August the laboratory regulations changed. For those who had not raised their fees in years and who did not over-utilize laboratory, this put tremendous financial pressure on primary care practices.

In the 1990s, managed care came to Southeast Texas and it challenged some of the fundamental assumptions we had made.  Formed in 1995, in 1996, SETMA began talking about electronic medical records, having no idea what we were talking about. In October, 1997, SETMA’s partners attended the MGMA meeting in Washington, D.C. and examined dozens of EHRs. March 30, 1998, SETMA bought the EHR which we are still using.

I wrote a paper May 1, 1999, in part it stated:

“Doctors need to learn new technological ways of organizing and conducting the business of medicine. They need to allow the power of information systems to change the way they approach healthcare. They need to maintain personal contact; patients are people first and last, but doctors need to see CPR as a powerful tool and not simply as a new and expensive toy. If they do, they will begin the 21st Century with an ability to impact the delivery of healthcare in America.

“Healthcare providers must never lose sight of the fact that they are providing care for people, who are unique individuals. These individuals deserve our respect and our best. Healthcare providers must also know that the model of healthcare delivery, where the provider was the constable attempting to impose health upon an unwilling subject, has changed. Healthcare providers progressively are becoming counselors to their patients, empowering the patient to achieve the health the patient has determined to have. This is the healthcare model for the 21st Century and the computerized patient record is the tool, which makes that model possible.” (see the full text at More Than a Transcription Service: Revolutionizing the Practice of Medicine: And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management)

SETMA’s evolution to a new model of care had already started in 1999. In the paper referenced above on “paternalism,” the following was included from a paper written in 1999. In speaking of transformation of our practice, we said:

“There are two aspects of this transformation. The first is structural; the second is dynamic. The structural change, being based on electronic patient records and electronic patient management of patients, is essential and in some ways it is easier than the required dynamic change. In 1999, ten years before we knew about medical home, SETMA defined both the structure and the dynamic of patient-centered medical home. We just did not know it.

“In May, 1999, SETMA defined the principles which would guide the structural changes Index four which would prepare us to become a medical home, at a time when we did not know the name or the concept. Those principles were:

1. Pursue Electronic Patient Management rather than Electronic Patient Records
2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows.
3. Make it easier to do it right than not to do it at all.
4. Continually challenge providers to improve their performance.
5. Infuse new knowledge and decision-making tools throughout an organization instantly.
6. Establish and promote continuity of care with patient education, information and plans of care.
7. Enlist patients as partners and collaborators in their own health improvement.
8. Evaluate the care of patients and populations of patients longitudinally.
9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets.
10. Create multiple disease-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health.

Remember, these principles were defined fifteen years ago. If reiterated today, they would be slightly changed but for our purposes, it is useful to see them as they were stated early in our development.”

February 16, 2009, five SETMA leaders attended our first lecture on PC-MH. It was not very helpful and did not answer our questions. The next day, I began reading and writing about medical home. Over the next sixteen weeks, I wrote an article a week about medical home. The following link is to SETMA’s website where those articles can be read (Your Life Your Health - Medical-Home) In September, 2009, four SETMA leaders attended the NCQA PC-MH Conference in Washington where we continued to study and learn about Medical Home. Gradually, our vision and understanding of PC-MH (a registered trademark of NCQA) deepened as we studied NCQA’s 2009 version of PC-MH standards and measures. In June of 2013, we would complete NCQA medical home recognition under the 2011 standards and received once again the Tier III Recognition.

While our use of EHR and the transformation which had already taken place in our practice enabled us to achieve NCQA recognition, we were fully aware that we had not yet arrived. We still had a lot to learn and a lot to do. We had adopted the structure of medical home but we were only beginning to learn and practice the dynamic. Our relationship with NCQA would continue to challenge us to learn and to change so that by the time we renewed our recognition we were much more confident of our medical home. We expect that same process to continue as NCQA grows and changes, so we do. We are anticipating that by the time we renew our Recognition in 2016 and in 2019, we will be amazed at the changes and differences we will see from 2010 when we were first recognized.

As we continue to learn about patient activation, engagement and about shared decision, we experience the power of the medical home model of care.  As we expand and improve our dialogue and our patient-centered conversation with patients, we see the value of medical home to provider and patient.  That is the major difference between practice style before medical home and practice method after medical home.