During the week of March 28th to April 1, 2011, Dr. Holly was in Washington, D.C. speaking at the Stakeholder's Workshop of the Patient-Centered Primary Care Collaborative PC-PCC) and also the Office of National Coordinator of Health Information Technology (ONC), a section of the Department of Health and Human Services. In a new publication entitled Practices in the Spotlight: The Medical Home and Diabetes Care, PC-PCC published a case study on ten practices selected for "the spotlight." SETMA was one of these.

The report was developed by Health2Resources on behalf of PC-PCC. Outside of key PC-PCC staff, two diabetes expert panelists served in this development Richard Jackson, MD, Director of Medical Affairs, Healthcare Services Strategic Initiatives at the Joslin Diabetes Center and Donna Tomky, MSN, RN, C-ANP, CDE, F.A.A.D.E, President, American Association of Diabetes Educators.

The report states:

"Recognition/Programs:

• "Diabetes Center of Excellence Affiliate
• "NCQA Diabetes Recognition Program
• "NCQA-recognized Level 3 Medical Home
• "Accreditation Association for Ambulatory Health Care Medical Home Accreditation

"Southeast Texas Medical Associates (SETMA) is a multi-specialty medical practice with four clinical locations in Southeast Texas. Its diabetes management program, in place since 2000, serves 7,232 patients. It is directed by 24 physicians and 14 nurse practitioners, and supported by 13 RNs, 26 LPNs, seven medical assistants, a certified diabetes educator, two nutritionists and two physical therapists.

"The progress towards excellence in diabetes care began with the development of a custom diabetes disease management tool in 2000. In 2004, the practice received recognition by the American Diabetes Association of its diabetes self-management education program. SETMA extended its diabetes expertise with the addition of an endocrinologist in 2006. In 2009, the adoption of COGNOS Business Intelligence data mining software allowed SETMA to audit populations of patients, and to understand and compare the processes and outcomes of care delivered to all of its patients, tracking data by ethnicity, gender, socioeconomic standing and other categories. This dedication to quality measurement and improvement earned SETMA an affiliation with the Diabetes Center of Excellence, the renowned research and clinical care organization affiliated with Harvard Medical School, in 2010.

"Anticipating the complexity of 21st century health care, SETMA adopted a system-wide health information technology system in 1998 with an eye toward supporting quality improvement efforts in a cost-effective manner. When asked to identify his practice's top success elements, SETMA CEO, James L. Holly, MD, referenced the value of the customized disease management tool and electronic medical record that actively support SETMA's quality improvement program.

"After three months of using the EMR, we realized that it is too expensive and too hard to use, if all we get from it is the ability to document a patient encounter," Holly said. "We wanted to bring to bear upon every patient evaluation what is known about a condition in order to improve quality outcomes." By building customized disease management tools that tap into clinical data, SETMA improved patient HbA1c results. Improvement for HbA1cs across the practice was .36 percent in the first year, and SETMA has seen consistent improvement year over year for more than a decade. From 2000 to 2010, the mean HbA1c was reduced from 7.8 percent to 6.54 percent. The standard deviation for all patients with HbA1c went from 1.98 to 1.2. SETMA's goal is a standard deviation of 0.8.

"SETMA's Model of Care begins with tracking of provider performance in real time on more than 200 quality metrics on every patient seen every day. Then SETMA audits each provider's performance on all patients seen each day. Third, SETMA analyzes the audit data through COGNOS BI tools to look for leverage points to improve population care. The fourth step is the public reporting of provider performance by provider name. From these four steps, SETMA designs quality improvement initiatives.

"Perhaps the most unique aspect of SETMA's Model of Care is its transparency. SETMA gives all patients the results of their quality-metric audit at the end of each visit. In January 2010, SETMA began publicly reporting more than 200 quality metrics (including those related to diabetes care) by individual provider name. The numbers are updated on the SETMA website on a quarterly basis, but providers can see their individual data every day in the COGNOS system and compare it to their colleagues. 'Every doctor in America believes they are doing a good job, but typically the data is not as good as they think,'

"Holly said. 'It's amazing how clinical inertia in SETMA has changed because of public accountability. We believe that the piece missing in quality metrics analysis is public reporting. Across the country, there are eight different diabetes quality metric sets, and we track all of them because they are all different. There is not a bad element in any of them, but we are encouraging that the different organizations harmonize their metrics with the metrics of others. Until you are tracking performance at the point of care, and until you give providers the ability to see how they perform, and until you publicly report that performance, it's not enough.'

"The quality tracking, auditing, analysis and reporting are ultimately aimed at improvement in care. SETMA's current goal is to successfully treat all patients with diabetes to goal and to sustain its having achieved the elimination of ethnic disparities in diabetes care. This year SETMA has an aggressive plan for intervening in the care of Caucasians and African-Americans in the practice, who are not controlled.

"Because diabetes education is a crucial element to better health, SETMA equips patients with tools for successful self-management. SETMA's 'Seven Stations for Success' is a formalization of the idea that a patient is 'in charge of his or her own health care 8,760 hours a year,' Holly said. The stations emphasize the medical-home principles of partnering in care and in comprehensive and coordinated care.

"The Seven Stations are posted in the hallway of SETMA's diabetes clinic. Then each station is posted in numerical order corresponding to how a patient typically moves through a routine diabetes visit. The first station addresses self-monitoring of blood glucose where the patient downloads their glucose monitor log. This station prompts patients to ask the diabetes educator to help create a plan for finding patterns in blood glucose readings. The second station is where the patient's point-of-service HbA1c is measured and the patient is reminded of the benefits of keeping the HbA1c reading below 7%.

"Station three reminds the patient of his or her responsibility to lose weight, exercise and stop smoking. SETMA provides a calculation of the patient's basal metabolism rate, body mass index and disease risk of their current weight at each appointment. A personalized exercise program is presented, along with an assessment of their use of or exposure to tobacco smoke. Station four points the patient to medical nutrition therapy and diabetes self-management education. Station five reminds patients that they work in partnership with their physician to set goals, determine risks for complications and plan for preventing complications.

"Station six focuses on coordinating referrals for other elements of diabetes care-from scheduling visits for diabetes education, dilated eye exams, nephrology care and physical therapy to coordinating needed resources. A practice director of care coordination and nurse care coordinators are tasked solely with keeping in touch with patients to ensure all care needs are met. 'If they find patients who can't afford medications, then we pay for it,' Holly said. The SETMA Foundation, formed in 2007, is a separate non-profit organization, partially funded by the practice partners but also accepting contributions from outside entities, that pays for unmet patient needs. 'We are seeing transformative change with that,' Holly said. In 2009 and 2010, the partners gave a total of $1,000,000 to the Foundation.

"Station seven's message is posted to the back of the exit door, and is the final visual reminder for patients leaving the practice. It is entitled, 'You are Home: SETMA is YOUR Medical Home,' and advises patients that they can communicate with their primary care provider during a visit, with a phone call, by email or letter. It also reminds the patient not to leave the clinic until they are confident that they are prepared to manage their care until their next visit or contact with their health care team.

"'That's part of passing the baton to the patient,' Holly said, referring to another visual he uses with patients, the hand-to-hand passing of a runner's relay baton. The baton represents the patient's plan of care and the treatment plan, or the instrument through which responsibility for care is transferred to the patient.

"The Seven Stations for Success draw heavily from the learning SETMA has taken from its Diabetes Center of Excellence affiliation. The idea for patient education going forward is to change patient behavior by demonstrating clearly that a small change on the patient's part can make a big difference in his or her health. 'We know what our patients' risks are, and so if we change the elements of those risk calculations, how will that change their result? We are now able to tell patients what their current status is, and can show them how to improve their health by changing each of the elements of the risk score. It will show the percentage of risk change if they just stop smoking, or just improve blood pressure. Then we put it into the treatment plan,' he said. 'The treatment plan is the 'baton' we use for passing healthcare responsibility back to the patient. If we're not engaging, empowering, enabling them to care for themselves with that knowledge- that baton-then they're going to lose the race.'"