Formed August 1, 1995, Southeast Texas Medical Associates, LLP (SETMA, LLP) recognized that excellence in 21st-Century healthcare was not possible with 19th-Century medical-record methods, i.e., pencil and paper, or with 20th-Century methods, i.e., dictation and transcription. Therefore, in 1997, SETMA began the process of adopting an electronic medical record (EMR).
Prior to the EMR, early In 1995, SETMA believed that 21st Century healthcare was going to be driven by quality performance. SETMA rejected the old model of care where the healthcare provider was the constable imposing health upon a passive recipient, the patient. Therefore, SETMA developed a model of care where the patient is an active member of his/her healthcare team and where the healthcare provider is like a consultant, a colleague, a collaborator to facilitate healthy living, with safe, individualized and personalized care for each patient. SETMA’s model is driven by the fact that we serve a population which had received disjointed, unorganized, episodic care, focused upon things done to or for patients who have limited resources with which to support their health care goals.
The first step in 1995 in the forming of what is now SETMA was the adoption of a team approach to patient care. (see The SETMA Team and The SETMA Culture) That team focus will be the central part of the story when the history of SETMA is written. The second critical decision was the EMR. But, in SETMA’s history, May, 1999 will always be central. In the first week of May, 1999, only 100 days after SETMA deployed the EMR, four seminal events took place which defined and guided SETMA’s future.
The first event took place the first week of May, 1999, when SETMA’s CEO announced that the EHR was too hard and too expensive if all we gained was the ability to document a patient encounter electronically. When we began, it took a provider five minutes to create a chart note. Our CEO concluded EHR was only “worth it,” if we leveraged electronics to improve care for each patient; to eliminate errors which were dangerous to the health of our patients; and, if we could develop electronic functionalities for improving the health and the care of our patients and of population groups. This was our transition from EMR to “electronic patient management” (EPM).
We also recognized that healthcare costs were out of control and that EPM could help decrease that cost while improving care. Therefore, we began designing disease-management and population-health tools, which included “follow-up documents,” allowing SETMA providers to summarize patients’ healthcare goals with personalized steps of action through which to meet those goals. We transformed our vision from how many x-rays and lab tests were done and how many patients were seen, to measurable standards of excellence of care and to actions for the reducing of the cost of care. We learned that excellence and expensive are not synonyms. In ten years, these steps would lead us to begin public reporting by provider name on over three hundred quality metrics (Public Reporting - Reporting by Type).
The second event was drawn from Peter Senge’s The Fifth Discipline, from which we defined the principles which guided our development of EMR and which defined the steps of SETMA’s transformation from an EMR to EPM (Designing an EMR on the Basis of Peter Senge's The Fifth Disciple). These principles would also be the foundation of SETMA’s ultimately morphing into a patient-centered medical home (PC-MH). The principles were to:
- Pursue Electronic Patient Management rather than Electronic Patient Records
- Bring to every patient encounter what is known, not what a particular provider knows
- Make it easier to do “it” right than not to do it at all
- Continually challenge providers to improve their performance
- Infuse new knowledge and decision-making tools throughout an organization instantly
- Promote continuity of care with patient education, information and plans of care
- Enlist patients as partners and collaborators in their own health improvement
- Evaluate the care of patients and populations of patients longitudinally
- Audit provider performance based on endorsed quality measurement sets
- Integrate electronic tools in an intuitive fashion giving patients the benefit of expert knowledge about specific conditions
In 2009, we would discover that these principles are essentially the principles of PC-MH and that the ten years from 1999 to 2009 had prepared SETMA to formally become a PC-MH. Between 2009 and 2014, SETMA became accredited as a medical home by the National Committee for Quality Assurance (NCQA, 2010-2019), the Accreditation Association for Ambulatory Health Care (AAAHC, 2010-2017), URAC (2014-2017) and the Joint Commission (2014-2019) and in doing this, SETMA became the only practice in America to be accredited by all four organizations.
Cortez - Fahrenheit 451 - Maginot Line
The third seminal event was the preparation of a philosophical base for our future; written in May, 1999 and published in booklet form in October, 1999, this blueprint was entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine With Electronic Health Records which Evolves into Electronic Patient Management. The content of that booklet can be read at: More Than a Transcription Service: Revolutionizing the Practice of Medicine And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management.
This booklet was distributed to our practice and our community. It became our declaration that we were going to succeed at this process at any cost and at any effort. Like Cortez, who scuttled his ships on his expedition to Mexico so that there was no turning back, this booklet was SETMA’s public declaration that there was no going back. We were going to succeed. Our charge to ourselves was and our counsel to others is, “Don't give up!”
Yet, the key to success is the willingness to fail successfully. Every story of success is filled with times of failure, but every story is also characterized by the relentlessness of starting over again and again and again until the task is master. When we started our IT project, we told people about what we were doing. We called that our "Cortez Project."
There were other “named” initiatives in SETMA’s history in addition to the Cortez declaration each of which defined an element of the dynamic of SEMTA’s development. There was the Fahrenheit 451 Initiative (the kindling point of paper) where we recognized and declared that paper was too expensive and too inefficient for record keeping and for transformation of healthcare. While we did not burn books, we set our sights on getting rid of paper in our practice.
There was also the Maginot Line Initiative. Like the fixed fortifications built by the French after World War I as an obstacle to invasion by Germany and which fortifications were defeated by the ability of mechanized war-machines to “go around the line,” when confronted by a seemingly insurmountable obstacle to our successful transformation, SETMA went around the obstacles.
As we began defining and developing critical supports required for success in Performance Improvement, we found them to be an active department of care coordination, a hospital-care support team which is in the hospital twenty-four hours a day, seven days a week, aggressive end-of-life counseling with all patients over fifty, and active employment of hospice in the care of patients when appropriate among others.
The fourth seminal event was that we determined to adopt a celebratory attitude toward our progress. In May, 1999, my cofounding partner was lamenting that we were not crawling yet with our use of the EMR. I agreed and asked him, “When your son first turned over in bed, did you lament that he could not walk, or did you celebrate this first milestone of muscular coordination of turning over in bed?”
He smiled and I said, “We may not be crawling yet, but we have begun. If in a year, we are doing only what we are currently doing, I will join your lamentation, but today I am celebrating that we have begun.” SETMA’s celebratory spirit has allowed us to focus on the future through many lamentable circumstances and has allowed us to press forward through many disappointments. Focusing on our successes kept us moving forward and the cumulative effect was always success.
Without these conceptual and philosophical principles as a foundation, the adoption of the “tools of SETMA” will not necessarily result in the same success as we have experienced.
Between 1995 and 2017, SETMA developed extensive Clinical Decision Support and Disease Management Tools. Almost all of these are display at www.setma.com under EPM Tools - Electronic Patient Management Tools. All of these tools are available for use by anyone at no cost.
One evaluation of SETMA’s website was made by a healthcare executive, who said:
“Thanks for the opportunity to review the Automated Team Tutorial Workbook. I found the information very informative. I believe your organization is well ahead of the curve in balancing the needs of the patient and the medical staff. I took the opportunity to review both the documents you provided to me and the website information. The information was informative and well organized.
“...you have the most informative web site I have ever utilized. Bravo, for sharing valuable information with the entire medical community.”
In 2009, SETMA adapted the IBM Business Intelligence software package, COGNOS, to healthcare management. At the root of this project was Abraham Lincoln’s 1858 statement, “If we can first know where we are, and whither we are tending; we can better judge what to do and how to do it.” Even if healthcare providers know where they want to be or where they want to go, if they do not know where they are in that progress or pilgrimage, they cannot successfully design a way to get there. A detailed explanation of SETMA’s use of business intelligence and data analytics can be reviewed at: The Importance of Data Analytics in Physician Practice. Later, SETMA worked with IBM to help develop the concept of Analytics Quotient. (see: Business Analytics and Your AQ)
The power of SETMA’s us of analytics was seen in our eliminating of ethnic disparities of care in diabetes and hypertension (see: EHR, Business Intelligence and Ethnic Disparaties of Care) Key to analytics is “process analysis.” SETMA’s use of this capability Is explained in the following study: Process Analysis and How Many Tasks Can You Get A Provider to Perform at Each Encounter?.
SETMA’s Model of Care was initially enunciated in 1999 but it has evolved and expanded. For a complete explanation of this Model see: SETMA’s Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change.
MIPS and MACRA
This foundation has prepared SETMA successfully to function in the new “performance based payment model,” in “shared risk” relationships with insurance companies and with CMS. It has allowed SETMA to prepare for the Merit-Based Incentive Payment System (MIPS) and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
In fact, an analysis of SETMA’s strategies for transforming healthcare reveals that what SETMA developed between 1999-2004 perfectly correlates with the MIPS Categories of Scoring System:
- The methodology of healthcare must be electronic patient management:
- The content and standards of healthcare delivery must be evidenced-based medicine:
MIPS Quality (This is the extension of PQRI which in 2011 became PQRS and which in 2019 will become MIPS -- evidence-based medicine has the best potential for legitimately effect cost savings in healthcare while maintaining quality of care)
- The structure and organization of healthcare delivery must be patient-centered medical home:
MIPS Clinical Practice Improvement activities (This MIPS category is met fully by Level 3 NCQA PC-MH Recognition).
- The payment methodology of healthcare delivery must be that of capitation with additional reimbursement for proved quality performance and cost savings:
MIPS Cost (measured by risk adjusted expectations of cost of care and the actual cost of care per fee-for-service Medicare and Medicaid beneficiary)
This concept and SETMA’s preparation for MIPS and MACRA are summarized in the following documents:
Taken in the context of SETMA’s Awards and Accreditation, this brief description of our achievements and advancements helps anyone understand “from whence we have come, and wither we are going.”