In preparation to write an article about SETMA, MGMA asked a series of questions.  SETMA’s answers to some of them are as below.

Why Does it Make Sense to become a Patient-Centered Medical Home (PC-MH)?

For SETMA, becoming a PC-MH was an imperative of our principles and development.  A brief history explains this statement.   In October, 1997, three founding partners of SETMA attended the annual MGMA meeting in Washington, D.C.  Having formed in August, 1995, we realized that the demands of 21st Century medicine required a different method of documenting patient encounters than the 19th Century method of pencil and paper, or the 20th Century method of dictation and transcription.  At that meeting, SETMA looked at over 50 electronic health record systems (EHR).  By the time we chose our current EHR and had signed our first $650,000 check on March 30, 1998, half of those fifty EHR vendors were out of business.

Over the next 14 months, we implemented the EHR.  We saw our first patients with the EHR on January 26, 1999.  By May, 1999, we realized that EHR was not an appropriate goal and it was not our goal. The ability to document a patient encounter electronically was inadequate for the cost and effort of implementing an EHR.  In order to achieve the promise of EHR, we needed to leverage the power of electronics to improve the care our patients.   Immediately, we change our goal from EHR to electronic patient management (EPM).   We immediately began building disease management tools, clinical decision support tools and creating the ability to make the healthcare process easier.

Principles of EHR and Practice Design

Incorporating many ideas and ideals from Peter Senge’s The Fifth Discipline which defined a “systems approach” to business, in that month, SETMA defined and published the following principles of EHR and practice design:

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.

After the 2005 meeting of the Healthcare Information and Management Systems Society (HIMSS), HIMSS published a statement about SETMA on their website under the title, "The SETMA Approach to patient care.”  That statement was a recital of the above ten principles.
When  SETMA first heard of the PC-MH in a lecture on February 16, 2009, we realized that many of the principles of PC-MH were identical to the above ten principles, which we had defined ten years earlier.  While many of the newest concepts of PC-MH were not part of our experience, the overall concept seemed to be a natural extension of SETMA’s growth and development.

Not having learned much in that lecture, beginning the following day, February 17, 2009, I began writing an article each week on Medical Home for sixteen weeks.  Over the next five years, SETMA  published over 100 articles about Medical Home. All of those articles can be found at  http://jameslhollymd.com/your-life-your-health/medical-home.

Four Strategies for transformation effort

During this five-year transformation effort, SETMA defined what we believe to be the key to the future of healthcare, which  is an internalized ideal and a personal passion for excellence rather than reform which comes from external pressure. Transformation is self-sustaining, generative and creative. In this context, SETMA believes that efforts to transform healthcare may fail unless four strategies are employed, upon which SETMA depends in its transformative efforts:

1. The methodology of healthcare must be electronic patient management.
2. The content and standards of healthcare delivery must be evidenced-based medicine.
3. The structure and organization of healthcare delivery must be the patient-centered medical home.
4. The payment methodology of healthcare delivery must be that of capitation with additional reimbursement for proved quality performance and cost savings.

All of these efforts gradually developed into SETMA’s Model of Care which is described in detail at:  http://jameslhollymd.com/The-SETMA-Way/pdfs/setma-model-of-care-pc-mh-healthcare-innovation-the-future-of-healthcare.pdf.

PC-MH was not so much a choice for SETMA as it has been a logical imperative of our growth and development.  SETMA was moving toward PC-MH before we ever heard the term and before we understood the concept.

Why did your group decide to do this at this time?

SETMA did not so much “decide” to become a PC-MH as we arrived at a point in our development where it was the only logical next step for us.  As EHR had transformed our approach to healthcare and to patient encounters, PC-MH provided a method for achieving the results we wanted.   On August 24, 2000, I made a presentation to the Beaumont, Texas Chamber of Commerce on how to solve the healthcare challenges of the 21st Century and particularly how to solved the challenges of excellent healthcare for the indigent and uninsured.  In part I said:

“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.”

After starting the process of PC-MH transformation in February, 2009, on April 14, 2009, I summarized some of our progress with the following note:

"Yesterday, I asked my assistant to tally the number of pages of materials which we have possessed in our Medical Home pilgrimage. I was amazed to learn that it is 2,280 pages, contained in 9 notebooks with material from NCQA, CMS, NQF, and PQRI, along with over 600 pages of materials which have been produced and written by SETMA staff. This has been a prodigious effort and a Herculean project. We are virtually at the end of the beginning.

"...by the end of this year, at the very latest, we expect to have incorporated into our EMR and into our work flow evidence-based standards and structure of healthcare , with the capacity for each provider to daily evaluate their own performance at the point-of-care, from multiple organizations including: Healthcare Effectiveness Data and Information Set (HEDIS), National Committee on Quality Assurance (NCQA), National Quality Forum (NQF) , etc.  As this is written, June 2, 2009, all of the above is complete.”