JamesLHollyMD.com

	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
EPM Tools Association of Medication and Diagnosis Automated Team Function Behavioral Health Adult Weight Management Tutorial Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care Depression Tutorial Fall Risk Tutorial Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive LESS Initiative Tutorial Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Pain Management Tutorial Reduction of Antipsychotic Medications Toolkit Smoking Cessation Tutorial Stratifying End-of-Life Risk for Hospice Services Tutorial Chronic Conditions Tutorial Chronic Renal Disease Management Tool Tutorial Calculating the Stages of Renal Disease Proteinuria Disease Management Tools Acute Coronary Syndrome Tutorial Adult Weight Management Tutorial Angina Tutorial Cardiometabolic Risk Syndrome Tutorial Chronic Renal Disease Tutorial Congestive Heart Failure Tutorial Diabetes Tutorial Hypertension Tutorial Lipids Tutorial Lipid Quality Audit Tutorial Primary Pulmonary Hypertension Tutorial Framingham Cardiovascular Risk Cardiometabolic Risk Assessment Framingham Heart Study Risk Calculators Tutorial Frederickson Classification of Dyslipidemia LDL Level Lipid Disease Management Risk Assessment General principles about ICD-9 Codes and HCC/RxHCC Codes Charge Posting Tutorial Coding to Ensure Accurate Health Risk Scoring E & M Codes Tutorial HCC & RxHCC Risk HCC/RxHCC Risk Tutorial ICD-9 Code Training Manual Hepatitis Screening Hospital Based Tools Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial Admission Orders Tutorial Daily Progress Notes Tutorial Care Transition Data Set from PCPI Tutorial Using The Clinic and Hospital Follow-up Call Templates Respiratory Failure Tutorial Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA's Internal HCAHPS Survey Master GP Suite of Templates Master GP Suite of Templates Tutorial Medical Home Support Materials Department of Care Coordination, Director of Care Coordination and Care Coordination Referral Template Electronic Tickler File Electronic Tickler File Tutorial Follow-up Calls Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Services Medical Home Coordination Review Tutorial Medical Home Plan of Care and Treatment Plan Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Patient-Centered Medical Home Annual Questionnaires Patient-Centered Medical Home: SETMA's Medical Home Coordination Review (MHCR) Tutorial Patient Document for Coordination of Care Transitions of Care Management Coding (TCM Code) Tutorial Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial Nursing Home Depression Tutorial Fall Risk Tutorial Hydration Assessment Tutorial Nursing Home Guidelines for Care Tutorial Nursing Home Principal Suite of Templates Nutrition Assessment Tutorial Reduction of Antipsychotic Medications Toolkit Skin Care Tutorial Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds Preventive Health Tools Adult Weight Management Tutorial CHF Exercise Tutorial Diabetic Exercise Tutorial Diabetes Prevention Tutorial Exercise Prescription Tutorial Hypertension Prevention Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Initial Preventive Physical Exam & Annual Wellness Visit Tutorial LESS Initiative Tutorial Progression to Type 2 Diabetes Smoking Cessation Tutorial Progression to Type 2 Diabetes Quality Metrics ACO and Medicare Advantage Stars HEDIS: NCQA, History, Quality, Safety, STARS, ACO ACO Quality Measures Performance Tool ACO Quality Measures Performance Tool Tutorial STARs - A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Your Life Your Health - The Remarkable Commonalities Between Healthcare Providers in China and the USA

James L. Holly,M.D.

August 04, 2016

Your Life Your Health - The Examiner

Last week’s Your Life Your Health offered a preliminary report written before the beginning of the two-day meeting with SETMA and the following representatives from Primary Care in China.

Dr. Gu Yuan, The founder of China Family Physicians
Dr. William Li Yongwei, Internal Medicine, Dr Gu Yuan’s Assistant
Huang Yanli, Wuhou Healthcare Bureau, Director, Innovation Center
Dr. Luo Xiaolu, Wuhou Healthcare Bureau, Director, Tiaoshanta Community Healthcare Center
Dr. Ma Xidan, Wuhou Healthcare Bureau, Director, Jitou Community Healthcare Center
Huang Lei, Wuhou, Director, Healthcare Bureau, CDC
Liu Jingwei, CETC-SS, Director, Healthcare Transformation innovation Center
Hao Jiaping, CETC-SS , Healthcare Business Analyst
Chen Zhao Yang, CETC-SS, Diabetes Doctor
Dr. Li De Fu
Wei Zhang, PhD, Professor, University of Massachusetts

Dr. Gu (standing behind my left shoulder) is the leader of Primary Care transformation in China.

Our first contact with the Chinese representatives was June, 2014 visit, with a second meeting in November, 2015. In that time, this group has begun the creation of an electronic medical record and has built data analytics functions with excellent reports on the patients in the system. The system is not integrated as of yet. The large hospitals have an electronic record, public health has an electronic record and a few community centers do. None of these communicate with one another.

I am very impressed with the progress they have made, although we all know that this is only a beginning; it is a beginning. As we discussed, I am fond of saying that I have started many things which I have never finished, but I have NEVER finished anything I did not start. There is no doubt that they will succeed. Liu Jingwei is the leader of the group and by everyone’s agreement he is a driving force who is relentless. That is what this task will take.

During the two-day conference, we discussed SETMA’s healthcare transformation which led us from adopting electronic medical records to morphing to electronic patient management to the deployment of patient-centered medical home as our model of care. This led us to an extensive discussion of the tension between technology and humanity. They were as sensitive as we are to the potential for technology to supplant the concern for the human. We spent an extensive time discussing how electronic medical records - high tech - should not over shadow the concern for the individual as a real person - high touch.

In our quest for excellence, we must not be seduced by technology with its numbers and tables. This is particularly the case in healthcare. In the future of medicine, the tension - not a conflict but a dynamic balance - must be properly maintained between humanity and technology. Technology can contribute to the solving of many of our disease problems but ultimately cannot solve the "health problems" we face. It is my judgment that the major issue facing healthcare delivery today is that men and women, boys and girls have replaced the trust they once had in their physician with a trust in technology. It is as if the "front porches" of healthcare have disappeared and the air-conditioning has forced us inside the building so that we can't say "howdy" to one another any longer.

The entire focus and energy of "health home" is to rediscover that trusting bond between patient and provider. In the "health home," technology becomes a tool to be used and not an end to be pursued. The outcomes of pure technology alone are not as satisfying as those where trust and technology are properly balanced in healthcare delivery.

The challenge for our new generation of healthcare providers and for those of us who are finishing our careers is that we must be technologically competent while at the same time being personally compassionate and engaged with our patients. This is not easy because of the efficiency (excellence x time) of applied technology. A referral or a procedure is often faster and more quantifiable than is a conversation or counseling.

The enthusiastic embracing by our visitors of the primacy of each patient was refreshing. Moving from a paternalistic medical system where the doctor is “in charge” and the patient is essentially passive to a collaborative relationship where the doctor and patient form a team with other healthcare providers is a new concept in China as it was in the USA. Our visitors have embraced that change and are working toward incorporating it into the entire healthcare system in China.

We discussed one example of care in China where a particular hospital sees 18,000 ambulatory patients a day. When I asked how many physicians would see these patients, it was determined that doctors had three minutes with each patient. There was no need to judge that there was no way to do effective medicine in that time frame; they already knew it and want to change it. We did discuss how electronics can increase efficiency and quality with a growing database which is available at every point-of-care.

In that context, we discussed how healthcare providers can instill in each patient a sense of personal worth. It is out of the sense of “personal value” that patients are able to make changes in their lives which will make a difference in their health. We discussed how patients who have a sense of personal value can develop “virtue” which empowers patients to believe and to know that they are able not only to make changes but to sustain those changes until a difference has been made.

Further demonstrating the similarities in our countries, our friends from China commented that often patients do not trust the healthcare provider and that they respond angrily when things don’t go well. That is no different than in the USA, where patients will sue any doctor who does not meet their expectations or if the do make a mistake. We added to the concepts of “value” and “virtue” with the concept that from this foundation will come an extending of “trust” to the provider by the patient. Expecting patients to trust you when they have no sense of “value” or “virtue” is hopeless, but out of them “trust” will inevitably come. People who have a sense of personal, intrinsic value can develop the sense of ability to make changes from which will come trust in others. Perhaps surprisingly, but certainly delightfully, these concepts resonated with Chinese and America alike.

Once a patient is able to trust others, he/she will begin to see the value of collaboration and out of that “team spirit” a new found sense of hope will come. Hope is the expectation of good things happening and it produces the resiliency needed to maintain the team even when things do not turn out the way we wanted.

There will be more to report in coming columns. At the end of the conference each person was able to give their summary of the value of the conference and to ask questions. We taped that almost three-hour session and will share it when it is transcribed.

The delegation from China is on the way to Boston. I have given our Chinese friends a brief introduction to the Institute of Healthcare Improvement (IHI) and to their work in China. We have particularly discussed The Triple Aim with which they were already familiar.

I am very impressed with how far Jingwei Liu and his team have come. They are well on their way to deploying an EMR, analytics and continuity of care documents in a demonstration project. The magnitude of their challenge is great but I believe they have the vision and passion for success. They have also greatly benefited from the work of Dr. Richard Jackson, formerly of Joslin and an expert in diabetes management. They will be meeting with him in Boston as well. They have taken signed copies of SETMA’s TCPI Library for their use in China. We were going to ship them the 9-volume Library but they wouldn’t leave without a set in hand.

I have at last committed to visiting China this fall. I personally feel a kindred spirit with our Chinese friends and am confident that they will stay the course to success.

The following link is to a presentation on the Importance of Data Analytics in Primary Care Practice which I delivered in 2012 to the Massachusetts Medical Society and which I promised to send to our friends from China: Presentations - The Importance of Data Analytics in Physician Practice

The following are links to four documents with connections to others of SETMA’s interaction with the Chinese Delegation in three visits (July, 2014; November, 2015; July, 2016). The titles are self explanatory, I think. The links at the bottom of some of the references are related to our discussions with China.

Summary of November, 2015 visit from Chinese delegation with links to multiple posts.

November 11, 2015 Follow-up to Second Chinese Delegation to SETMA and Future Plans

Introduction to Story of July, 2016 visit and context of visit

Introduction to the story of the visit, Chinese delegation, July 26-27, 2016

Story of the July 26-27, 2016 Visit From China

Delegation of Healthcare Executives from China: Third Visit and the Transforming Clinical Practice Initiative Library

The following link gives the content of the syllabus prepared for the November, 2015 Visit by Chinese Delegation

November 11, 2015 Follow-up to Second Chinese Delegation to SETMA and Future Plans

About SETMA	In The News	Syllabus PC-MH Externship	Patient Information	Presentations
Governance Board	Your Life Your Health	Public Reporting	Accreditations/Awards	Diabetes Center of Excellence
EPM Tools	Transforming Your Practice Library	Medical Home	I-CARE Initiative	NextMD