Eighteen years ago, three months after beginning the use of electronic medical records (EMR) and fifteen months after beginning the development of the EMR, SETMA determined that electronic record was an inadequate goal for the energy and cost required.  Therefore, in May, 1999, SETMA began developing disease management tools and clinical decision making tools in order to harvest the potential of the EMR.  After two years of that development, SETMA realized that there were three foundations to all of these tools.  From this came “The Less Initiative.”

SETMA's LESS Initiative was undertaken to globally improve the health of those who receive their care at our clinics.  “LESS” stands for:

L -- Lose weight
E -- Exercise
S -- Stop
S -- Smoking

While no one would argue that each of these is not valuable in the life or health of anyone, to our knowledge, there has never been a concentrated effort to confront an entire patient group with all three elements consistently every time they seek healthcare.

Here is how the Initiative has worked for eighteen years. Every time a patient is seen in the clinic, no matter what the occasion for the visit is, they will be alerted to the health risk of:

• Their current weight, as measured by their body mass index (BMI) and their body fat content (%). They will be given a Weight Management Assessment which tells them their disease risk associated with their current BMI and waist measurement, their percent body fat and an explanation as to how a 5% change in their weight will impact their health and future.

• The benefit which their heart and lungs are receiving from their current participation in exercise as indicated by the "aerobic points" which that exercise achieves for them and a recommend minimum exercise level which they need in order to achieve a "good" aerobic status for their age and sex. This exercise prescription will include information on how to increase the number of steps they take each day in order to have an "active" lifestyle which is defined by taking 10,000 or more steps a day. The average America takes fewer than 6,000.

• The imperative for stopping smoking. Even the tobacco companies' websites now state, "The only way to avoid the health hazards of tobacco smoke is to stop smoking completely." This is clever because with this warning, the tobacco companies which continue to encourage tobacco smoking have immunized themselves from future litigation because they have warned you that their product is harmful. Now, legally, the only one to blame for the harmful effects of smoking is the smoker. Also, the initiative includes the questioning of patients about exposure to "environmental tobacco smoke" either at home or at work. This is the tobacco smoke in the air due to others smoking. 

Since the LESS Initiative was stared, it has been discovered that there is a third way in which tobacco smoke harms your health.  That is, if you smell tobacco on someone’s self or clothing, you are inhaling particles of tobacco which contribute to poor health. 

With the LESS, the following personalized documents are given to each patient:

• Weight Management Assessment - one page
• Exercise Prescription - 7 pages
• Smoking Cessation - 7 pages

Smokers will be given the full smoking cessation document.  Non-smokers who are at work or at home with a smoker will be given a document on the hazards of what has been variously called "environmental", "second-hand" or "passive" tobacco smoke.

While this initiative may seem simple, it is a rather complex undertaking. To do this occasionally is simple, but consistently to do it, every time a patient, is seen is not.

Shared Responsibilities

The LESS Initiative is dependent upon the sharing of responsibility by the various members of SETMA's healthcare team:

• The IT team (Information technology) has to make it possible to easily produce the documents and to audit that performance.
• The nursing and support staff have to collect the data - weight, height, waist size, abdominal girth, hip measurements, neck size, chest size, body fat, etc. - which allows the computation of the information used in determining the patient's health risk.
• The nursing staff have to create, print and distribute the documents, as well as initiate the discussion with the patient of the information in each.
• The Healthcare providers - physicians and nurse practitioners - have to interact with the patient about the imperatives for change which are indicated by the information in the document, discussing with the health risks of doing nothing and the health benefits of changing the lifestyles...

In addition:

• Patients who decide to change their health and their future will be referred to SETMA's Education Department for dietary education weight management, diabetes, cholesterol, hypertension, or the metabolic syndrome and other conditions where improvement is dependent upon patient dietary adherence.
• Patients who are serious will be referred to SETMA's weight management clinic which has a proved record in helping patients. Utilizing SETMA’s Adult Weight Management program published which was developed by the American Medical Association and developed into  SETMA's electronic version of this excellent tool is used to assist patient's in achieve their weight reduction goals.
• Patients who are serious about cardiac and pulmonary conditioning can be referred to SETMA's cardiopulmonary rehabilitation program for assistance and guidance in that process.

Rationale for LESS Initiative

The first element of LESS is "lose weight."  There is no doubt that losing weight benefits your health, but, the reality is that you do not have to achieve your ideal body weight in order to make a difference in your health. A 5 to 10% decrease in body weight will begin to improve your health, no matter how overweight or obese you are. 

The second element of LESS is exercise. Commonly, we associate this with going to the gym, or structured, formal working out. Actually, it is much more than that. Exercise which benefits your health is not necessarily participation in competitive sports or a work-out regimen. It does mean that you are active. For those whose job has them moving all day, they may get in 10,000 steps a day and find it unnecessary to add additional exercise to achieve good health. For those whose job has them sitting at a desk all day, they will have to walk, jog, cycle, swim or in some other way get their exercise to stay fit.

In past issues of Your Life Your Health, we have discussed the health risks of "not smoking but inhaling." A puff of smoke has several billion free radicals - destructive, highly active particles which damage your body and health. Whether you inhale while smoking, or being around someone who does, it damages your health.

The good news is that it is never too late to stop. Even those with emphysema and shortness of breath will benefit from stopping smoking. And, after a person develops lung cancer, their medications work effectively if they quit smoking.  As part of SETMA's LESS Initiative, in addition to confronting smokers with the need to stop, and giving them information and/or medication to help with the process, SETMA providers will create an electronic tickler file in order to remind themselves to call the patient in one month to see if they have successfully stopped.

SETMA's goal is to have a smoke-free practice. While we may never totally achieve that, it will be our goal nonetheless. As for smokers who are irritated with this focus, we encourage them to realize that our confronting of them is out of caring. We are no longer going to passively conspire with a self-destructive habit; we are going to actively help all of our patients get healthy and stay that way.