Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Your Life Your Health - PC-MH: SETMA’s First Nine Years - Continuity, Creativity, Consistency
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James L. Holly,M.D.
February 24, 2017
Your Life Your Health - The Examiner

PC-MH:  SETMA’s First Nine Years - Continuity, Creativity, Consistency



  1. The Less Initiative

    The beginning combining the power of electronics, clinic decision support and practice transformation

  1. PC-MH

    Understanding the goal through the PC-MH Poster Child

  1. Auditing for Quality and Safety

    The real beginning of SETMA’s PC-MH journey which began in May, 1999 with the definition of ten principles of practice and EMR development with transformation as the goal, and with the realization that auditing of provider performance was key to this process. 

  1. Team Work:  The Key to Excellence in Healthcare

    The difference between a “collaboration-ist” and a “collateral-ist” and why the only foundation to PC-MH is team work.

  1. Organizational Philosophical Foundation

    “Look at this; everything they do is founded upon a philosophical foundation.  They know ‘what they are doing,’ but more importantly, they know why they are doing it.’” 

  1. Producing a Sustainable Health Quality Model of Care

    The goal of this series is to review the core values and functions which have enabled SETMA:

    • to connect the past with the present and to prepare for the future (Continuity);
    • to illustrate the ingenuity and healthcare transformation which have been central to SETMA’s progress (Creativity), and to allow SETMA
    • To sustain the progress of the past, tying it to the needs of the future, enabling SETMA to relentless pursue excellence in patient care quality and safety (Consistency).
  1. The Patient-Centered Conversation

    How do you modify, change, or transform the patient encounter into a patient-centric conversation, which encounter has always been provider-centric, or health-science centric?

  1. The Power of Story Tell

    In ancient times, the power of storytelling was well known.  History was communicated by storytelling.  Values and beliefs were transmitted from generation to generation by storytelling.  Families sat around fires and tables and told stories.  Young people sat at the feet of old people and listened to stories which helped them understand who they were and what was required of them.  Sacred texts began as stories told for generations, and they were told precisely and accurately.

  1. Care Coordination and Convenience

    The central role of care coordination in PC-MH and “the new word for quality is convenience.”

  1. Place & Spirit of Accreditation Activities for Improving Healthcare

    Why is the accreditation process critical to PC-MH transformation?


    March 2, 2017 Learning from Patients:  Diabetes or Not, by James L. Holly, MD and Jaweed Akhter, MD


This ten-part series is the fourth in SETMA’s PC-MH pilgrimage. The first was written in 2009, the second in 2010 and the third in 2011.  Each have chronicled SETMA’s expanding understanding and implementation of the medical home model of care.  However, the real beginning of this journey was in May, 1999.  The four seminal events which SETMA experienced in that month are described at the following link:  May, 1999 -- Four Seminal Events in SETMA’s History.  The formalization of our PC-MH began ten years later in February, 2009 (see Medical Home Part I: Is it the future of healthcare?). 

In February, 2009, I wrote, “Recently, I saw the last few minutes of Goodbye Mr. Chips, based on a novel by James Hilton; originally published in 1934, Hilton was also the author of Lost Horizon which was about the mythical Shangri-La (the movie was released in 1939).  Another movie version of Goodbye Mr. Chips was released in 1969 starring Peter O'Toole. The novel, Goodbye Mr. Chips, is very similar to my favorite British novel entitled, To Serve Them All of My Days, by R. F. Delderfield, published in 1972.

“I never see this movie without being deeply moved by the value of a life given to the service of others. The story is about Mr. Charles Chipping played by Robert Donat. Chipping comes to be called ‘Chips’ by the boys in the boarding school where he teaches and where, during WWI, he becomes the headmaster. As he dies, Mr. Chips is dreaming of all his past students. He over hears two colleagues lament that he is dying alone and that he lived a lonely life without his own children. He awakens and says that he has not lived alone. He has had thousands of children, ‘All boys, he declares.’ In the last scene, young Peter Colley III, the youngest of a family of boys whom Chips had taught through the years, waves to him and says ‘Goodbye, Mr. Chips, goodbye.’”

PC-MH is like a life lived in service to others. The principles and tools of PC-MH can be described in detail.  Many of the details are technological and many have an electronic foundation, but it must never be forgotten that ultimately PC-MH is about persons, individuals.  This is why “stories” end up being the most critical aspect of medical home, personal, individual, unique stories.

Our goal in this most recent series on PC-MH is to review the core values and functions which have enabled SETMA to:

  • connect the past with the present and to prepare for the future (Continuity);
  • illustrate the ingenuity and healthcare transformation which have been central to SETMA’s progress (Creativity),
  • allow SETMA to sustain the progress of the past, tying it to the needs of the future, enabling SETMA to relentlessly pursue excellence in patient care quality and safety (Consistency). 

As the 44th year of my medical career draws to a close, I must be coming to the end of a wonderful career; yet, I think and hope there will be future series of articles until finally there is a valedictory capstone to this magnificent opportunity to have lived the life of a physician and to have participated in an organization like Southeast Texas Medical Associates, LLP.

It can certainly be said that this ten-part summary of our journey is incomplete and the reality is that it always will be because just as we think we have learned something, just as we think we are closer to the end, our horizon expands and our vision enlarges and we see with delight and excitement that there is more to do, more to learn and we step off into the uncertainty and wonderment of the future. 

In February, 2009, I was asked by a healthcare executive, if medical home were just a passing fad or were we really serious about it?  I think now the answer is obvious, as it had already become obvious when the last installment of the first series of articles about medical home was published in June 2009 (see: Medical Home Part X: A Summation of the Beginning of a Journey). 

The journey continues. This series is only the latest installment.

Other Articles in the Continuity, Creativity, Consistency Series

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