Center for Medicare and Medicaid Services’ (CMS) Twenty-eight Requirements for Medical Home Certification Documentation of Southeast Texas Medical Associates, LLP (SETMA) Fulfillment of all 28

(Editor’s note:  This is the work of Southeast Texas Medical Associates’ (SETMA’s, www.setma.com) team of providers and colleagues.  In itself that is appropriate as the dynamic of Medical Home is “team.”  Because each of the Center for Medicare and Medicaid Services (CMS) requirements stands alone as a measure to be met, there is of necessity some redundancy between some responses.)

Introduction – Intentional and Incidental

The most innovative aspect of Medical Home and the thing which perhaps distinguishes it from any other well-organized and highly-functioning medical organization is the concept of Coordination of Care.  This is the intentional structuring, reviewing, facilitating and practicing of a standard of care which meets all current National Committee for Quality Assurance (NCQA), CMS, national standards and Healthcare Effectiveness Data and Information Set (HEDIS) requirements for demonstration of excellence in the providing of care.

The concept of “intentionality” is critical in this process. This is contrasted with “incidental.”  In health care, most HEDIS compliance and coordination of care are done incidentally to a patient encounter as opposed to the having of  a purposeful, provable and persistent fulfillment of national standards of care.  Rather than hoping the result is good, Coordination of Care plans and reviews care to make certain that it meets the highest standards.  The Medical Home intentionally fulfills the highest and best healthcare needs of all patients.  In addition, the patient is involved in this coordination by making them aware of the standards and giving them a periodic review, in writing, of how their care is or is not meeting those standards.  Patients are encouraged to know and to initiate the obtaining of preventive care on their own.  Perhaps the ultimate judge of the success of Medical Home is when healthcare providers hear the following from their patients, “I am here today for preventive healthcare.”  Today, almost all healthcare providers would tell you that they have never had a patient present with that “chief complaint,” or reason for scheduling an appointment.

To qualify as a CMS Tier II Medical Home, a medical practice must meet 22 of 28 requirements.  The following is the documentation of SETMA’s fulfillment of all 28.

While Medical Home will ultimately qualify a practice for increased reimbursement from CMS and other healthcare payers, SETMA believes that this method of healthcare delivery is sufficiently promising to develop it with or without change in reimbursement and not only to apply it to Medicare, Medicaid or Medicare Advantage patients, but to all of SETMA’s patients. 

It is obvious to us that SETMA’s Medical Home will evolve over time.  While we will be guided by CMS and NCQA requirements and by the experience of others, it is our expectation that ultimately, we will innovate, experiment and create a unique expression of Medical Home which will fulfill all of the requirements imposed by these agencies but which will also go beyond that as our vision, understanding and experiences increase.

Medical Home Example

As SETMA began to think about Medical Home, we had the following example set before us on February 18, 2009.  In a memo to the SETMA staff, SETMA’s CEO said:.

“My business philosophy is, ‘I want it done right and I want it done right now!’  Thus, if we are going to do Medical Home, I want it to be done right.  As I have thought more about this project, it occurs to me that the dynamic and the potential of Medical Home is found in its name.  A ‘home’ is: 

• A place where you need fear no harm from those who are in the home with you. 
• A place where your needs are met.
• A place you can go when you don’t know what else to do. 
• A place where you can be yourself and you can tell others how you really feel without fear of rejection, judgment, or embarrassment.
• A place where others really want to see you succeed.
• A place where if you are away too long, someone is calling to find out if you are OK.
• A place where you are treating like family.
• A place where the safety of one in a crisis or danger is not satisfied until all are safe and secure.

“Coupled with excellence of care, Medical Home has the potential for leveraging great benefit for patients and providers from the healthcare delivery equation.  Seeing the Medical Home as a reflection of the value and attitudes of “a home,” make me think again that what I said this morning is right.  I repeat it:

“In 2008, the partners of SETMA finalized a 501-C3 not-for-profit foundation – The SETMA Foundation – which has as its purpose medical education and underwriting the care for our patients who cannot afford it.  In February, 2009, I saw a patient who has a very complex and fascinating healthcare situation.  I saw him during his hospitalization and then for the first time in my office.  What I discovered was that he is only taking four of his nine medications because he cannot afford them.  I believe in this case, SETMA practiced Medical Home as he left this encounter with:

1. Appointments to SETMA’s American Diabetes Association (ADA) approved diabetes self-management education (DSME) program.  The fees for the education have been waived.  However, while talking to the patient and his wife, I discovered that he could not afford the gas to come to the meetings.  He also left with a gas card with which to pay for the fuel to get the education which is critical to his care.
2. My staff negotiated a reduced cost for his medications with his pharmacy and made it possible for the pharmacy to bill The SETMA Foundation.
3. Because at 60 years-of-age and with his problems he cannot work at his job as a long-distance truck driver, his care also involved counseling him that even in the face of all of the abuse of the disability provision of Social Security, he can no longer work and I will coordinate his application for disability.

“Gas cards, disability, paying for medications – a part of a physician’s responsibilities?  Absolutely not!  Gas cards, disability, paying for medications,  part of Medical Home?  Absolutely! 

“This patient, who was depressed and glum in the hospital such that no one wanted to go into his room, left the office with a smile and feeling that there is hope.  He left as if he had just had a visit to home.  It may be that the biggest result of Medical Home is hope.  This IS Medical Home!!”

Seeing the Patient as a Whole

Because, we view the patient as a whole, both our practice of electronic patient management and our design of our EMR have revolved around the concept of the “whole person.”  Later in this discussion,  (Requirement Number 11, pp. 44ff), we will demonstrate that our concept of patient care and particularly electronic patient care, can be depicted by the following figure:

Core Value and Core Dynamic – Assessing the Patient’s Readiness to Change

The core value in Medical Home is health and/or optimal control of chronic illnesses, and appropriate and timely response to acute illness.  But, it is not possible to look at one aspect of a patient’s condition as each of his/her conditions are influenced by the one upon which our attention is focused.  With the proper design and use, electronic patient management can make it possible to “see” the patient as a whole.

The core dynamic of Medical Home is the patient being actively involved in his/her care, both at the decision and at the execution level.   In an ideal world, that would be accomplished with knowledge and information but human beings are much more complex than that.  As a result, SETMA’s Medical Home will continually be developing and refining tools with which to both assess the patient’s readiness to change, their ability to change, and the presence of the resources to sustain that change.

One of the tools which we will use is the standard Transtheoretical Stages of Change Model assessment for preparation to change.  The following is the adaptation of that model to the chronic problem of obesity.

SETMA has created an electronic version of this tool.  As applied to weight reduction the following is a picture of the template.  The facility with which the electronic display allows the patients current “will to change,” can be measured and contrasted with their prior responses.  This model can be adapted for all of the significant conditions which will be measures for SETMA’s Medical Home, which are:  Diabetes, Hypertension, Lipids and Congestive Heart Failure.

As we examine each of the twenty-eight CMS requirements for qualification of Medical Home, these ideas will be integrated and repeated.

James L. Holly, MD,
CEO, SETMA, LLP

Bryan Sims, CFNP
Candidate for Doctor of Nurse Practitioner
Chief Medical Officer, SETMA, LLP
Evidence-Based Medicine Officer, SETMA

Requirement Number 1.      The practice discusses with patients and presents written information of the role of the medical home that addresses up to 8 areas

The following is the introduction to Medical Home which will be distributed to all patients.  In addition, each will be given a document which summarizes their Medical Home Coordination of Care Review (see the explanation of this document below).  This review will be given to the patient at each visit and at least two times a year.

Welcome to Southeast Texas Medical Associates (SETMA), LLP’s Medical Home
By James L. Holly, MD

“What did you welcome me to? “ A Medical Home!  This is not a new idea. The American Academy of Pediatrics (AAP) introduced the concept over thirty years ago, but in the past five years, the American Academy of Family Practice and the American College of Physicians (internal medicine) have joined the AAP in promoting the concept.  The Centers for Medicare and Medicaid services (CMS) and the National Committee for Quality Improvement (NCQA) have also joined forces to promote Medical Home.

The goal is to bring you better medical care.  A Medical Home is not unlike your family home. It is a place where people care about you personally and where you can trust that your interests come first.  It is a place you can go when you have a need.  Like your home, a Medical Home is made up of a team, each member of which has a special role, but where no one person is more important than another. It is a place where the team makes certain that all of your needs are met.

In many ways, Medical Home is like the care you have been receiving from SEMTA for years.  With the use of electronics, SETMA has been able to develop systems which protect you from medical errors and which can insure that you are receiving the care you need and deserve.  Now a new dimension has been added which is the Care Coordination Team (CCT). This is a team of people who focus on your needs, whether they are ordinary, like every one else’s, or whether they are special needs which are unique to you.  The Care Coordination Team will make certain that you get the care you need as they assess any barriers which prevent you from obtaining that care, whether it is financial, access, understanding, transportation or other. 

The Care Coordination Team will also develop a plan to make sure that your needs are cared for in an emergency such as when an evacuation is ordered.  Medical Home is directed toward making certain that as we increase the “high tech” aspects of your quality care, we do not lose that “high touch” care we all experienced fifty or seventy-five years ago.

The CCT led by your personal physician will make certain that your care meets national standards and will share the elements of that standard with you so that you can be confident of the quality of care you are receiving..  Measured by HEDIS and the Consortium for Physician Performance Improvement standards, your care will be evaluated each time you come to the clinic and often at times when you don’t come to the clinic. When you have complex problems, the team will meet to discuss how to make sure that your care is optimal. Before you come for an appointment the team will review the state of your care to make certain that it meets the highest standards.
HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.  Altogether, HEDIS consists of 71 measures across 8 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.
HEDIS measures address a broad range of important health issues. Among them are:           

• Asthma Medication Use
• Persistence of Beta-Blocker Treatment after a Heart Attack
• Controlling High Blood Pressure
• Comprehensive Diabetes Care
• Breast Cancer Screening
• Antidepressant Medication Management
• Fall Risk Assessment in the elderly
• Advising Smokers to Quit
• Many other measures of care

SETMA has incorporated HEDIS standards into our Medical Home Care Coordination Review (MHCCR).  In addition to the LESS Initiative (Lose Weight Exercise Stop Smoking), to which you have become accustomed, and other educational materials on your medical conditions, you will receive a Medical Home Care Coordination Review (MHCCR) each time you come to the clinic.  The MHCCR will include:

• The names and contact information for your Care Coordination Team members.
• The status of your HEDIS compliance and the status of your preventive care needs.
• A list of your current medications with descriptions of your directions in plain English
• The names and numbers of emergency contacts and your medical power of attorney
• The name and number of your pharmacy as everyone who provides you care are a part of your healthcare team.
• A list of the conditions for which you are being treated.
• Information about who we are to contact in case of a mandatory evacuation so that your Medical Home can be aware if you need help in being safe.
• An assessment of any barriers to care which you have, whether they are social, financial or other.
• Any special needs they have including mobility and safety.

The MHCCR will help you take charge of your own care and for you to initiate the obtaining of the care which you need but have not received. It will allow you to judge whether you are receiving excellent care.  Of course you will continue to receive the encouragement to stay active, stay healthy, eat right, lose weight and avoid tobacco.

Medical Home will enable you to continue to receive:

• Same day appointments for urgent problems.
• Immediate attention in the ER for emergency conditions
• Response by telephone or e-mail to your questions or concerns.
• Follow-up by telephone for your results of testing when appropriate.
• And, all the other contact you have received in the past.
• 24 hour a days, seven day a week access to a SETMA provider for your healthcare needs.

In addition to this, you will receive calls and correspondence from the practice about issues of general medical interest and/or things related to your personal health concerns. We believe that Medical Home is going to make you feel “right at home” with your health care: safe, confident, secure and at ease. 

Welcome to SETMA’s Medical Home – welcome to YOUR Medical Home. Together, we will make your healthcare experience pleasant, satisfying, excellent and successful.  Welcome to your healthcare team, of which you are not only the main focus, but now you are a dynamic and critical part.

Just as the term “Medical Home” is new to healthcare provides, concept will be new to patients and other participants.  Therefore, other written materials will be prepared which will allow patients to know what they can and should expect from Medical Home.  Some of those materials can be found below in Appendix B.

Soon, all stakeholders in SETMA’s Medical home will realize that this is the fulfillment of SETMA’s oft repeated statement:  “We will no longer be a constable attempting to impose healthcare upon you; we will be your colleague and your counselor empowering you to obtain the degree and level of health which you desire and which is possible at our current state of knowledge.”  Through SETMA’s office of Evidence-Based Medicine led by SETMA’s Chief Medical Officer, Major Bryan Sims, SETMA will work to insure that the best science and the best medicine are used to achieve that health.

Patient active participation in this process will be imperative as only a patient can sustain the habits and treatments required for preventive health and for regaining or sustaining health.  For Medical Home to achieve its great promise patient engagement and active participation is imperative. 

To that end, education and information will be constantly provided to patient-participants in Medical Home.

Requirement Number 2:  The practice establishes written standards on scheduling each patient with a personal clinician for continuity of care and the practice collects data to show that it meets its standards on continuity.

The practice establishes written standards on scheduling each patient with their personal physician for continuity of care and the practice collects data to show that it meets its standards on this quality measure.

At every fourth visit, or every six months, which ever is the shortest time frame, the patient will be seen by the Primary Care Physician who is the leader of the Medical Home Coordination Team. Also the Primary-Care Physician will see the patient for any new major problem. Other care can be given by the Certified Family Nurse Practitioner (CFNP) team member in collaboration with the physician.  Typically, all members of the Care Coordination team will be in the same facility.

All appointment access including front desk, unit clerks, nurses, website, and appointments by telephone will review the patient-visit history prior to finalizing a new appointment; for efficiency this is done electronically. As a result, the staff can easily determine if the patient needs to have the next appointment scheduled with their Primary-Care Physician, or if another member of the Medical Home team can assist and see the patient.

When it is necessary for the Primary-Care Physician to see the patient, every attempt will be made to schedule with the leader of the team; however, if this delays the appointment process, another Primary-Care Physician within SETMA will be utilized. This is easily accomplished due to the electronic medical record, allowing every provider access to patient data, thus leading to timely appointments and continuity of care.

Patient records will be audited to verify compliance ensuring patients, at the determined set intervals, are seen by their Primary-Care Physician.

Clinical Information Systems

Requirement Number 3.      The practice uses an electronic data system that includes searchable data such as patient demographics, visit dates and diagnoses (up to 12 specific factors), and the practice uses an electronic or paper-based system to identify clinically important conditions or risk factors among its patient population, and the practice has an electronic health record, certified by the Certification Commission on Health Information Technology (C-CHIT), that captures searchable data on clinical information such as blood pressure, lab results or status of preventive services (up to 9 specific areas).

SETMA’s electronic data system is a software product purchased from NextGen.  While SETMA has extensively customized this system with disease-management tools, preventive-care initiatives and evidence-based reminders, NextGen is a robust C-CHIT certified electronic medical record that allows us to capture, store and search our patient population based on thousands of data points including the following ones. 

All of these data points are simultaneously shared throughout the data base, including:

• patient demographics
• visit dates,
• chief complaints
• History of present illness
• Extensive and in-depth review of systems, which on all disease management tools are modified electronically to focus on the review of systems relevant to that chronic condition
• chronic conditions
• Acute assessment diagnoses
• current medications
• laboratory results
• medical histories
• family histories
• surgical histories
• preventive health maintenance issues
• nutrition
• exercise
• fall risk assessment
• hydration assessment
• skin care assessment including algorithms for evaluating clinically unpreventable skin lesions
• smoking cessation
• weight management assessment
• specialty correspondence
• procedures
• vital signs

The vital signs include, for EVERY patient:

• BMI
• BMR
• protein requirement
• body fat percentage
• waist, neck, chest, and abdominal girth measurements, and when appropriate
• pulse oximetry,
• spirometry, and
• blood glucose. 

Details of Vital Signs and Methods

The waist/hip ratio, which can represent a cardiovascular risk, is automatically calculated and displayed on the vital signs.  There is a guideline displayed which indicates the proper way to measure the waist correctly.

Blood pressures are done with the appropriate size cuff, as established by arm circumference measures on all patients, which then automatically denotes what size cuff is required for proper blood pressure and the nurse is required to then note what size cuff was used.  Also, in the presence of hypertension, when the initial reading is elevated, it is require that a ten-minute interval take place where the patient is sitting quietly and then the pressure is repeated and recorded.  Also the pressure is taken with the patient sitting in a chair and NOT on the examining table.

This information is stored in a relational database allowing SETMA to mine information on our patient population based on virtually any criteria our providers determine, in order to:

• Evaluate provider performance
• Measure patient/provider HEDIS compliance needs
• Evaluate provider compliance with national standards of care
• Evaluate patient safety measures and needs
• Evaluate compliance with CMS standards and with Consortium for Physician Performance Improvement data sets..

In the event of a drug recall, SETMA has queried our system and sent a personalized letter to all patients affected by the recall within two hours of receiving notification of the recall.  We then have followed up on those patients who are still on the drug two weeks later.

HEDIS Measures Imbedded in EMR (see also Requirement Number 5, pp. 24ff)

NextGen’s platform has allowed SETMA to build HEDIS compliance protocols and Physician Consortium for Physician Performance Improvement data sets into the EMR to remind providers to complete preventive and standard of care requirements.  The ability to display labs and vital signs over time allows seasonal patterns of behavior to be discovered, allowing focused interventions which deal with social or environmental rather than medical issues.

SETMA has automated numerous risk calculations which are done automatically.  Where required for risk assessment, laboratory values are drawn into the equation on a template, along with vital signs and other historical information required by the formula.  The following are some examples of these calculations:

• Framingham Cardiovascular Risk
• Framingham Cerebrovascular Risk
• Global Cardiovascular Risk which is built upon Framingham with the elimination of gender and age.
• Diabetes Risk Assessment
• Cardiometabolic Risk
• Insulin Resistance Assessment
• Hydration Risk Assessment
• Nutritional Risk Assessment
• Fall Risk Assessment
• Skin Lesion Risk Assessment

All of these functions allow SETMA to fulfill this CMS requirement of Medical Home. 

Delivery System Redesign

Requirement Number 4.      The practice establishes written standards to support patient access, including policies for scheduling visits and responding to telephone calls and electronic communication (up to 9 specific factors)

SETMA has dedicated a separate department (Appointments) to ensure that all patients have access to care in a timely manner. Each patient can access this department by calling one number. The next available operator will answer the call, with calls being rotated among all operators. To ensure a timely response the department is staffed with six employees that perform this function during daily business hours. In addition, SETMA’s website (www.SETMA.com) allows access by all current and new patients to request a non-emergent appointment, communicate with their provider or pay a bill. The Appointment staff is responsible for monitoring this function and returning a phone call the next day with an appointment.

All patients needing urgent or immediate care are given an appointment the same day. In addition all of SETMA’s locations accept “walk-in” visits. To ensure that the information requested from the patient is standardized; a policy for this department was written and is used to train each of the operators. The policy is as follows:

POLICY: To ensure patients phone calls are accepted in a timely manner, transferred to the correct location, and all appointments scheduled correctly.

PROCEDURE:

I.          Phone Calls

a.         All calls are received at the main number 833-9797 and are answered by the appointments staff.
b.         The greeting to be used is:

1. “Thank you for calling SETMA. This is ______, how may I direct your call?”
2. “Is this for an appointment, or a medical question?”
3. If it is for an appointment, then follow these steps.

1.         “Who is your primary care physician?”
2.         “For what symptoms or medical condition do you want to see a physician?
3.         Always ask the patient’s date of birth and correct name to ensure the appointment is being made for the correct patient.
4.         Find out if there is a preference as to when and what time they are seen.
5.         Check for any future appointment already made.
6.         Try to accommodate their specific requests for date & time.
7.         If their provider is not available, offer another provider or a nurse     practitioner.
8.         If the patient has not seen a physician within the past 6 months or last 4 visits (whichever comes first), then make an appointment for them to see their PCP.

4. Always inform the patient of the actual date and time of their appointment.
5. Appointments are entered into NextGen EPM.
6. Make sure they have no further needs or any medical questions that need to be addressed at this time.
7. Always end the conversation with “Thank you for calling SETMA.”

c.         If the call is for a medical question ask “Who is your primary care physician?”
d.         Inform the patient you will be transferring their call. Use the following script, “I will be transferring your call, please hold.”
e.         Inform the patient they may get voice mail. Use the following script, “You may get the voice mail. If you do please leave a message and the staff will return your call within 2 hours.”

II.        New Patients

a.         Always find out what insurance the patient has before making the appointment.
b.         Follow that by finding out if the patient needs to come today or can the visit be scheduled for later.
c.         Enter the correct demographic information into the system.
d.         Make the appointment.

III.       Rescheduling Appointments

a.         If an appointment has to be rescheduled, always document the date and put your initials.
b.         Note how the call ended, either confirmed, left message, or no answer.

All phone calls that require input from a provider or nurse will be forwarded to the appropriate person. The staff associated with each of the providers will make sure all phone calls are answered in a timely manner either in person or by return call after a voice mail is left. To ensure consistency within the organization a standardized process is followed and is used to train all new employees. A policy for responding to phone calls and electronic communication is as follows:

POLICY: To ensure timely communication and follow up with SETMA patients

PROCEDURE:

1. Any communications that need to occur between SETMA employees and patients are to be given top priority.
2. No patient should be placed on hold to answer another line, unless it is the emergency line that is ringing.
3. Any message left on voice mail by patients must be returned within two hours.
4. It is acceptable to inform patients that the physician has not provided the answer but we will call them back as soon as we receive the information.
5. After documenting the call, forward to the providers work flow for their answers.
6. Return responses via work flow from the provider will be called to patients as soon as they are received. If the provider has not responded back within 24 hours the unit clerk or nurse will personally speak with the provider to ensure the patient gets a timely response to their question.
7. The oldest phone messages should be addressed first as those patients have waited the longest length of time for a response. The only exception would be a message that is urgent and needs prompt attention.
8. When at all possible, it is recommended to send the patient an information card in the mail. When taped, the card is appropriate to send via mail and meets HIPAA regulations.
9. Once completed, delete the call from the workflow.
10. In order to decrease the number of calls received to each work station, be proactive in returning calls to patients before they have to call us seeking test or lab results.
11. Work flow will be routinely monitored by management staff. Employees who are not consistently keeping their workflow updated will be counseled as necessary to improve performance

Requirement Number 5.      The practice collects data to demonstrate that it meets standards related to appointment scheduling and response times for telephone and electronic communication (up to 5 specific factors)

Southeast Texas Medical Associates (SETMA) is committed to giving our patients a same day appointment when requested. Each provider’s schedule has the capability of adding double books and even on the busiest of days there is always excess capacity in case an additional appointment needs to be added.

On a weekly basis a series of reports are generated and sent to the supervisor of Appointments and Scheduling for review. These reports consist of the following:

• Total Staff Time (Amount of time logged onto phone system)
• Total Ready Time (Amount of time waiting for a call to come in)
• Total Ring Time (Amount of time the phone rings before answered)
• Total Talk Time (Amount of time spent talking on the phone)
• Average Talk Time (Average amount of time spent on phone per call)
• Total Hold Time (Amount of time the phone is put on hold)
• Total Work Time (Not used)
• Total Break Time (Amount of time the phone is put on break)
• Total Calls Answered (Number of calls answered)
• Total Calls Transferred (Number of calls that are transferred)

The following is a sample of the detail we track:

The data is then used to determine if each of our patients received a timely response, if there is a need for additional staff, or if there are any operational issues that would impact the ability for us to expedite the scheduling process.

In addition, we ask patients on our quarterly Patient Satisfaction reports how effectively we have met their scheduling needs as well as their level of satisfaction for any returned calls in which the immediate needs could not be met.  These reports are then forwarded to the COO and other key management staff to review and make recommendations.

The following is a sample report of a summary of our patient satisfaction survey.

Requirement Number 6:  The practice defines roles for physician and non-physician staff and trains staff, with non-physician staff, involved in reminding patients of appointments, executing standing orders and educating patients/families.

Currently SETMA utilizes both staff members and an automated system for calling and reminding patients of upcoming appointments. Patients scheduled to see a specialist are called by staff to remind them of the date/time for their appointment. Those patients scheduled to see internal medicine, family practice, pediatrics, or a nurse practitioner receive an automated reminder call.  The difference in the methods for contacting primary care and specialty care patients has to do more with volumes than with type of patients.

The automated system is reviewed daily in late afternoon to identify any patients whose names are not recognized by the system. A staff member works with the HouseCall system by speaking the name of the unrecognized patients. Once this is done, the system is ready for making the automated calls. Calls from this system are done 48 hours in advance of an appointment which gives patients time to reschedule if necessary. The automated system is set to begin these calls after 5:30 pm. These calls also include the name of the patient, date/time of the appointment, as well as the provider they are scheduled to see.

Standing Orders

SETMA staff participates in training sessions designed to review documentation and requirements in association with standing orders. Many standing orders are built into the EMR such as the Consortium for Physician Performance Data Set for patients with diabetes and other chronic conditions. When completing the diabetes disease management templates, by choosing the Consortium Data Set, non-physician staff can see where patients are out of compliance with the standing orders based on the Consortium Data Set. At the time of review, non-physician staff have been trained to order lab, place referrals, administer flu vaccine, or complete a foot exam for any patient who is out of compliance with the set standards. Physicians review the data to verify accuracy.

HEDIS measures are used and reviewed/updated annually in order to maintain the highest level of care for patients. Monthly audits are performed by IT to determine utilization of these measures.

Tutorials for all functions of SETMA’s customized version of NextGen have been developed for both physician and non-physician staff to ensure compliance. As new functions are added, new tutorials area built.  These tutorials are accessible from:

• The Electronic Medical Record (EMR)
• SETMA’s Intranet
• Printed versions of the Manuals, with color versions of the tutorials

Non-physician staff, utilize standing orders for processing prescription refill authorizations via e-prescribing, or by calling the prescription refill authorization to pharmacies who are not yet quipped to receive e-prescriptions.  SETMA works with all pharmacies who are not yet so equipped to help them develop the capability to receive e-prescriptions.  Any medication refill falling outside of SETMA’s standing orders requires physician/NP approval. 

Educating Patient and Families

SETMA EMR also facilitates ease of patient education. Patients received follow up documents which are built into the Disease-Management Tools (for examples of these templates see Appendix A). These documents are personalized for each patient.  In addition to their own personal compliance and laboratory results, these follow-up notes list changes to plan of care, when the patient is to be seen and other special information related to a specific disease process. For example, the diabetes follow up note also informs the patient of the status of their compliance with the standards of care from the Consortium for Physician Performance Data Set as well as current vital signs, BMI, latest lab results, instructions about diabetic foot care and a current medication list.   An extensive educational piece on Hgb A1 C and its significance is included.

The weight-management follow-up document acts as a form of encouragement for patients making progress with their weight loss. This document provides patients with their starting weight, weight lost to date and their weight goal. It also lets the patient know that reaching their idea body weight is NOT necessary in order to gain health benefits from weight reduction.  The note lets them know that a 10-20 pound weight loss and particularly a 10-20% weight loss can have profound health benefits for ANY and ALL chronic conditions.

In addition, patients are given SETMA’s LESS Initiative’s (Lose Weight, Exercise, Stop Smoking) educational document. The LESS Initiative is done with every visit or at set intervals.  It is done at each visit, which is separated by at least two months. In other words, if a patient comes in after two weeks, the LESS Initiative is not given to a patient again until two months after his/her last receiving it has elapsed.  Compliance with the LESS Initiative by providers is audited.  After the data has been captured – it takes about 30 seconds for this to happen electronically --  the LESS document will be printed and given to patients. The document which includes a weight management assessment, a personalized exercise prescription and information on stopping smoking and nicotine addiction (if they smoke) is about 17-pages long.  An explanation is given to the patient by nursing staff on the LESS Imitative and the physician or NP reinforces the elements of the LESS.  Other educational material will automatically print to designated printers facilitating patient education.

Patients will also receive a document summarizing the status of their Medical Home Coordination Review. This document includes pharmacy-preference information for e-prescribing, emergency contact information for patients, any ancillary services the patient is receiving (Hospice, Home Health, Physical Therapy, Nursing Home) and the current status of their care’s compliance with HEDIS and Preventative Care Requirements. The document will inform patients who the members of their Care Coordination team are and how to contact each one.  Each patient has a team made up of physician, nurse practitioner, care coordinator, nurse and unit clerk. 

Also, in keeping with the emerging concept of a Medical Neighborhood, the document contains the name of all other physicians who regularly participate in their care.  The document will also indicate compliance with the Medical Home’s patient communication plan through clinic visits, home visits, correspondence and phone calls.

The Care Coordination Review will also detail the patient’s barriers to care whether they are social, financial, or the necessary use of assistive devices.  Staff will also note which patients may need assistance during evacuation periods for our area.  Medical Power of Attorney and Living Wills and Code Status will be denoted on this document as well.
 
The Care Coordination Review collects, and displays all preventative health care measures which will allow at a glance, a review of items a patient may be lacking and allow for ease of maintaining/reviewing/updating these measures. HEDIS measures will also be utilized as an educational tool both for staff and patients to note areas in need of additional services or information.

As part of the development of Medical Home in SETMA, we have designed a Medical Home Coordination Review.  It is composed of a main template as seen here and two “pop-ups” which are launched from the middle of the second column. See below for the screen shots and explanation of these two pop-ups.  As part of the empowerment of the family and the patient in Medical Home, they will receive a document which is automatically built from these screens.  With this document, they can know:

1.         What they can expect in the way of preventive and integrative care.
2.         Where they are in fulfillment of Preventive Care and HEDIS requirements.  We will also be building a quality standard based of Lean Six Sigma standards.
3.         What tools are being used in the management of their chronic conditions and particularly those which are the key ones selected by SETMA to measure, i.e., Diabetes, Hypertension, Lipids, CHF.

The following are screen shots of the Coordination of Care templates along with pop-ups for preventive health care and HEDIS review.

 
Below is a thumbnail sketch of Preventive health Care – this is gender specific and will look different for male and female.  As we review this other issues will be added.  For instance, the Tetanus may be changed to Tdap.

Below is the HEDIS template.  Contemporaneous with a patient encounter and care, automatically, in the back ground, data will be collected on HEDIS measures.  Some measures require brief input by the physician, for instance when a patient is treated for Acute Bronchitis, the provider will simply click on the HEDIS button and note that antibiotics were or were not used.  When the patient is treated initially for back pain, the provider will note on the HEDIS template that this encounter involved new-onset back pain and that imagining studies were or were not ordered.

The buttons at the top of the HEDIS template (see below) are blue in the EMR; they are navigational buttons which will automatically take a provider to that part of the HEDIS.  If this patient were a female, there would be a blue button entitled Gender Specific Female which would take you to the section for Mammogram, Pap, Pelvic and Bone Density.  At the end of the year, aggregation of the HEDIS measures on the physician’s part be just a matter of aggregating structured data which will take a few minutes.

The below is one template but is too long for a single screen shot therefore it appears on pages 24-27.

While this may seem daunting, it is being used successfully in the normal workflow of our practice.  The workflow issues have been worked out, particularly in that almost all of the data is automatically collected incident to patient care.  We expect SETMA’s HEDIS scores for 2009 to be outstanding.

SETMA believes that this innovation will provide an excellent foundation fo :

• Fulfilling standards of care in patient care
• Employing evidenced-based medicine in that care
• Engaging patient sin taking responsibility for their own care.
  

Requirement Number 7.      The practice uses electronic or paper-based tools including medication lists and other tools such as problem lists, or structured templates for notes or preventive services to organize and document clinical information in the medical record

SETMA patient encounters, including outpatient clinic encounters, hospital admission history and physical examinations, emergency-room evaluations, hospital discharge summaries, nursing home encounters, physical therapy, and all telephone calls and messages are captured using the Electronic Medical Record (EMR).  By the use of a common database in all of these locations, SETMA is able to maintain:

• Current and complete chronic conditions or problem lists
• Medication lists
• Laboratory result and aggregation of those results for comparison over time
• Patient evaluations and acute assessments
• Preventive health care and HEDIS data captured from all patient contacts.

This system is a state-of-the-art system encompassing a host of tools available to the user at every point of the patient encounter.  The EMR is divided into:

• user templates including special templates for:

• physical therapy
• nursing home
• rheumatology
• neurology
• podiatry
• ophthalmology
• pediatrics
• diabetes education
• surgical and special procedures
• etc

• references
• guidelines
• patient education material
• patient demographic
• laboratory
• medication
• allergies
• documents and notes for all patient contacts whether in person or by telephone or e-mail

The guidelines and references reflect the most currently available evidence-based information.  In addition, SETMA has employed an expert in evidenced-based medicine whose responsibility it will be to make certain that all decision tools used by SETMA meet national standards of care and to update SETMA’s data base to reflect advances in standards of care or the results of new random-controlled studies.

The EMR interface also offers the user disease- management tools that appear in template form to document ongoing care for a variety of diseases.  Among the many tools available are the:

• LESS initiative (Lose Weight, Exercise, Stop Smoking) which includes , a weight management assessment, a personalized exercise prescription and evaluation use of tobacco or exposure to environmental smoke. 
• Treatment guidelines for 26 common conditions are provided for geriatric patients including:

• nutrition,
• fall risk,
• depression,
• skin care,
• hydration,
• and others. . 

Patient-education materials from data generated during an encounter may be printed and given to the patient at the conclusion of the visit.  This information contains recommendations for improved health and planning for future visits.  These materials encourage the patient to become informed about, to become involved in and to become in charge of their own healthcare.

The medication record within the EMR is a comprehensive platform for medication management.  The record contains all currently active and previous medications prescribed.  The medication record automatically scans for drug interactions, allergies or alerts for each medication as it is prescribed.  Completed prescriptions may be printed and given to the patient, or electronically sent to participating e-script pharmacies. In addition, a historical record of all previously prescribed medications is maintained in the system also which shows date of prescription and the date it was discontinued. 

A 1000-page set of tutorials covering all aspects of the EMR and disease management  is available for review for each portion of this extensive integrated system upon request.  Examples of these tutorials for diabetes, hypertension, lipids and CHF are shown below. 

A brief synopsis of the available tools from the main template menu is given here in the master template.  The master template is the primary user interface and is divided into three tiers.  The first tier this interface encompasses:

• SETMA’s LESS Initiative and tutorial
• Preventing Diabetes and tutorial
• Preventing Hypertension and tutorial
• Charge Posting Tutorial
• ICD-9 Tutorial,E&M Coding Recommendations
• Medical Home Coordination

The second tier of the master template includes:

• Master GP Template and tutorial
• Nursing Home and tutorial
• Ophthalmology
• Pediatrics
• Physical Therapy
• Podiatry
• Rheumatology
• Daily Progress notes in the hospital
• Admission Orders and tutorial
• Discharge and tutorial
• Insulin Infusion
• Colorectal Surgery
• Pain Management and tutorial

The third tier of the master template includes:

• Exercise Prescription and tutorial
• Congestive Heart Failure (CHF) Exercise Prescription  and tutorial
• Diabetic Exercise Prescription and tutorial
• Drug Interactions and tutorial including an extensive presentation on the P450 system with an interactive list of inhibitors and inducers for hundreds of medications.
• Smoking Cessation and tutorial
• Hydration and tutorial
• Nutrition and tutorial
• Guidelines for the treatment of 26 common conditions in the geriatric population and tutorial
• Lab Future and tutorial
• Lab Results and tutorial

The Disease Management tier of the master template includes:

• Acute Coronary Syndrome and tutorial
• Angina and tutorial
• Asthma
• Diabetes and tutorial
• Headaches
• Hypertension and tutorial
• Lipids and tutorial
• Cardiometabolic Risk Syndrome and tutorial
• Weight Management and tutorial
• Renal Failure
• Diabetes Education

These tools provide a robust method for documenting patient care and a method for encouraging patients to be involved in and in charge of their own care, more than fulfilling this element of CMS’s requirement..

Requirement Number 8.  The practice conducts a comprehensive health assessment for all new patients to understand their risks and needs including past medical history, risk factors and preferences for advance care planning (up to 5 specific factors).

A comprehensive list of chronic conditions is established initially, which becomes a working tool for follow-up of the patient. Additional diagnoses are added as they are discovered.  The status of chronic conditions are also noted with multiple options being available, including: stable, controlled, worse, terminal, resolved, etc.  The assessment includes:

• Allergies to medications, environmental exposures and interactions with medications/medication
• Medications
• Family history
• Medical and surgical history
• Social History
• Habits including alcohol, tobacco
• Employment
• Family circumstances
• Health Maintenance and preventive health standards

An extensive review of systems and a thorough physical examination are completed on every new patient which becomes the foundation of uncovering undiagnosed conditions.  At the time of this complete assessment, referrals are made for updated deficiencies in preventive health – mammograms, bone densities, laboratory, imaging, colonoscopies, echocardiography, immunizations, etc.

The patient’s risk assessment is evaluated by:

• Framingham Cardiovascular and cerebrovascular risk assessments
• Global Cario Risk which is the Framingham data placed into a equation which eliminates age and gender
• Cardiometabiolic Risk Syndrome assessment
• CHF Mortality Risk.
• Insulin Resistance Risk
• Diabetes Risk and Prevention
• Hypertension prevention
• Insulin Resistance Risk

In addition, when clinically appropriate, the risk of the following conditions are evaluated and documented on each patient:

• Hydration
• Depression
• Fall Risk
• Nutrition
• Skin Care

Every patient is also given a Weight-Management Assessment which categorizes the health risk of their current BMI. In addition material is given on how to change their BMR in order to facilitate weight reduction.  Included with the Weight management assessment are a personalized exercise program and an assessment of the patients’ use of or exposure to tobacco. 

Each patient is questioned about living will and their desires for intubation or other interventions in the event of a catastrophic event.  The patient is provided with a living will document, if they wish to complete one which meets all of the state requirements.  They are told how to keep this in view so that EMS can be guided by it.  

Finally, disease management tools are used to evaluate the quality of care the patient has been receiving in:

• CHF
• Diabetes
• Hypertension
• Lipids
• Asthma
• Weight management
• Cardiometabolic Risk Syndrome
• Angina, Chronic Stable
• ACS
• Headaches
• Chronic Renal Disease

The patient is then provided with a Medical-Home-Care-Coordination -Review document which addresses:

• The names and contact information for your Care Coordination Team members.
• The status of your HEDIS compliance and the status of your preventive care needs.
• A list of your current medications with descriptions of your directions in plain English
• The names and numbers of emergency contacts and your medical power of attorney
• The name and number of your pharmacy as everyone who provides you care are a part of your healthcare team.
• A list of the conditions for which you are being treated.
• Information about who we are to contact in case of a mandatory evacuation so that your Medical Home can be aware if you need help in being safe.
• An assessment of any barriers to car which you have, whether they are social, financial or other.
• Any special needs they have including mobility and safety.

Because of the EMR, even in an acute visit many of these tools can be and are used.

Requirement Number 9:  For three clinically important conditions, the physician and non-physician staff conduct care management using an integrated care plan to set goals, assess progress and address barriers (5 specific factors)

SETMA has set goals for each of the following four clinically important conditions selected for our Medical Home:  Diabetes, Hypertension, Lipids, CHF.   The care-management team meets for training, education and collaboration on the meeting of these goals.  Those goals are:

Diabetes

Compliance with standards of care are measured at each encounter and are given to the patient with the date of their last evaluation. Those elements of compliance are:

Last Flu Shot                                   10/17/2008
Last Foot Exam                               02/25/2009
Last HgbA1C                                  10/31/2008
Last Pneumovax                              05/17/2007
Patient complaint with medications?  Yes
Patient compliant with follow-up?     Yes
Patient compliant with diet?              Yes
Patient compliant with education?     Yes
Patient compliant with exercise?       Yes

While many elements of the treatment of diabetes are measured, including blood pressure, lipid control, weight management, exercise and tobacco cessation, the focus on mean plasma glucose is at the forefront of our goal setting.  The following material on Hemoglobin A1C is given to and discussed with the patient at the time of the encounter:

Most recent value - 10.2%, drawn on 10/31/2008

• Check HgbA1C every 3 to 4 months.  Increase frequency when therapy has changed and/or when glycemic goals are not met.
• HgbA1C target should be individualized for each patient, aiming to achieve the lowest possible without increasing the risk of hypoglycemia.

If HgbA1C is >6.0% and <8.0% the standards are:

• Review and clarify the management plan with the patient with attention to:


• Meal plan
• Activity program
• Medication schedule and technique
• Self-monitoring of blood glucose (SMBG)
• Treatment for hyperglycemia and hypoglycemia
• Sick day management practices


• Re-assess goals and adjust medications as needed
• Communicate individualized glycemic goals to patient
• Consider referral to a diabetes educator for evaluation
• Schedule follow-up appointment with 3 months or more frequently as situation dictates

If HgbA1C is >8%, the standards are:

• Review and clarify the plan of care
• Assess for psychosocial stress
• Refer to a diabetes educator for evaluation/education
• Communicate individualized glycemic goals to patient
• Intensify therapy

Hypertension

The following guidelines are discussed with the patient in order to establish a goal. Those guidelines are:

• In persons older than 50, systolic blood pressure (BP) of more than 140 mm Hg is a much more important cardiovascular disease (CVD) risk factor than diastolic BP.
• The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg.
• Individuals with a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg should be considered as pre-hypertensive and encouraged to adopt health-promoting lifestyle modifications such as weight reduction, dietary sodium reduction, and regular physical activity.
• Thiazide type diuretics should be prescribed for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes.
• Most patients with hypertension require 2 or more antihypertensive medications to achieve BP 140/90 mm Hg, or < 130/80 mm Hg for patients with diabetes or chronic kidney disease.
• If BP is more than 20/10 mm Hg above goal BP, consideration should be given to initiating therapy with 2 agents, 1 of which usually should be thiazide-type diuretic.

With these principles our goal is to control the blood pressure of all patients, particularly with those who have diabetes or CHF.

Congestive Heart Failure

The goals of therapy in patients with congestive heart failure are:

• Improve Symptoms
• Improve Functional Capacity
• Improve Quality of Life
• Slow or Decrease Progression
• Decrease Need for Hospitalization
• Prolong Survival

In addition, our goals are to control:

•  BP <120 (Systolic)
• Heart Rate
• Weight
• Fluid Volume

SETMA’s treatment of CHF also recognizes inactivity as a, if not the, risk factor for the development of CHF.  As a result we have a CHF Exercise Prescription which begins the patient at 2-minute exercise periods and works them up to thirty minutes.  Even patients with Class 4 CHF are encouraged to exercise within their capacity.

The following is a sample exercise prescription which is given to the patient with CHF:

CHF Exercise Prescription for __________

Date - 03/05/2009 1:08 PM

Congestive heart failure (CHF) has been steadily increasing over the past 10 years.  Lack of physical activity is considered an independent risk factor for the development of CHF. In addition, other primary risk factors include: obesity, hypertension, and diabetes.

Causes of CHF

• Physical inactivity           9.2% of all cases of CHF,
• Hypertension                 10.2%,
• Diabetes                         3.2%,
• Obesity                          8.0%.

Patients diagnosed with CHF benefit greatly from participating in exercise-training programs. For example, exercise training of patients with moderate to severe CHF:

• lowered all-cause mortality by 63% and
• reduced hospital readmission for heart failure by 71%.

The Agency for Health Care Policy and Research Guidelines on Cardiac Rehabilitation recommended exercise training for patients with chronic stable HF.

First Steps

The first step is often interval training, in which you exercise for a few minutes and then rest. This alternating pattern gives you the benefits of exercise without undue strain. Gradually you can increase the time and pace as you grow stronger. Ideally, you will eventually exercise for 30 to 40 minutes three to five times a week.

Cautions

While exercising, if you develop:

• chest pain,
• extreme shortness of breath,
• dizziness, or
• swelling of the extremities,

you should stop exercising and contact your healthcare provider immediately.

Monitoring Exercise by Heart Rate

For improvement in your congestive heart failure, you should exercise between 50-80% of your maximum heart rate.  However, if you are taking mediations which prevent your heart rate from increasing significantly, you can use Borg’s Scale of Perceived Exertion for measuring your response to exercise.

Your Personal Data

Your resting heart rate is 91.00 beats per minute and your maximum heart rate is 133 beats per minute.   Therefore, your optimal exercise heart rate is between 79 and 106 beats per minute.

Borg's Ratings of Perceived Exertion (RPE) 

     6                 No exertion at all
     7-8              Extremely light (very, very light)
     9-10            Very light  (warm-up/recovery)
     11               Light
     12-13          Moderate
     14-15          Hard (400 m swimming pace)
     16-17          Very hard (200 m swimming pace]
     18-19          Extremely hard (very, very hard, 25-50 m pace)
     20               Maximum all-out effort with absolutely nothing being held in reserve

The American Heart Association Committee on Exercise, Rehabilitation, and Prevention states that exercising at a Borg Scale of Perceive Exertion of 12 to 13 is usually well tolerated by the stable patient.  The Borg Scale is particular useful in patients who are taking Beta Blockers which will prevent them from measuring the intensity of exercise by the increase in heart rate..

Duration of The Exercise

Warm-up

Before exerting yourself, spend 10 minutes in slow, easy activity -- walking slowly and stretching -- to increase blood flow to your muscles. The warm-up period may need to be longer in the most debilitated patients. Usually, a period of 10 to 15 minutes is recommended.  The warm up is where you very gradually increase your heart rate by stretching and walking.  If you don’t warm up, the risk of injury or adverse affect of exercise is increased.

Exercise

• Start with walking or stationary biking for 2 minutes at a comfortable pace. Rest or 1 minute. Repeat this five times, until you have exercised for a total of 10 minutes.
• Over 2 weeks, gradually increase the exercise period to about 4 minutes and the rest period to 2 minutes, until your total exercise time is about 20 minutes per session.
• As you become stronger, increase the exercise intervals to 5 minutes and keep the rest intervals at 2 minutes, until your total exercise time is 30 minutes per session. You can also step up your pace.
• Gradually increase the sessions to 40 minutes. You may keep or eliminate the rest stops.
• Vary your program. If you walk for exercise 1 month, for example, try a stationary bike the next. This makes workouts more interesting.
• When your healthcare provider agrees you can extend your exercise period and increase the intensity.  At this point always    remember the cautions mentioned above.  If any of those symptoms arise, stop exercising and call your healthcare provider immediately.

Cool Down Period

A cool-down period is also advised.  This is the reverse of the warm-up period.  You gradually slow down and extend your work out until your breathing and heart rate slow down.

How Often Should I Exercise?

Most studies have used 3 to 5 times per week as the optimal training frequency. Patients who develop exhaustion after training may need a day of rest between sessions. Supplemental walking should be encouraged on the non-training days.  With your healthcare providers agreement you can exercise 5-6 days a week, if you are not experiencing increasing fatigue..  

Resistance (Weight) Training

Fatigue comes from the muscles inability to continue work.  Fatigue can be helped by strengthening your muscles and increasing their ability to use oxygen.

• Respiratory muscle exercises to build up your chest, diaphragm, and abdominal muscles to help you breathe better.
• * Resistance training that uses light weights to strengthen muscle groups in your arms, torso, and legs. Stronger muscles will reduce fatigue.

Small free weights (1, 2, or 5 lb), elastic bands, or repetitive isolated muscle training can be used. In addition, the upper body should not be ignored because many activities of daily living require arm work. These muscle groups are often neglected in exercise training.  Working out with a personal trainer or getting instruction from our Physical Therapy department can help you improve your health without hurting yourself.

Resistance training using dumbbells and ankle weights or strength training machines can be added to address the muscle fatigue that often limits activity in CHF.

• Using low weight and high repetitions prevents straining and breath holding, which place greater demands on the heart.
• The focus should be on the major muscles of the upper and lower body and torso.
• One to two sets with 12 to 15 repetitions per set provides an adequate training stimulus.

Important Tips

• Be alert for symptoms like

• chest pain,
• increasing shortness of breath,
• weight gain,
• ankle swelling,
• abdominal bloating, or
• rapid pulse at rest.

• Call your doctor, and stop exercising until the symptoms are controlled.
• Exercise and medication usually work well together. However, if you work out shortly after taking your medication, you may become dizzy or faint. A change in timing of exercise will often relieve the problem. Also, avoid exercise right after meals.
• Warm up. Before exerting yourself, spend 10 minutes in slow, easy activity--walking slowly and stretching--to increase blood flow to your muscles.

Lipids

SETMA’s lipid philosophy establishes our goal; that philosophy is shared with our patients in a follow-up document and states:

The treatment of lipids has become more complex in that half of all patients who have heart attacks have "normal" cholesterol and only 25% of patients with premature coronary artery disease have abnormal LDL levels.  Premature CAD is not rare, in fact  25% of acute myocardial infarctions in community hospitals occurs in men under 55 and women under 65.  In fact, 58% of these patients had LDL cholesterol <130.  Also, 80% of patients who had an event in the Framingham study had ordinary lipids identical to the population that was event free.

This is why SETMA's lipid clinic will evaluate patients for other lipid particles including:

• Lp(a) which is ten times more atherogenic than R-LDL (Real LDL).   Lp(a) is unresponsive to statins but responses well to niacin, fenofibrate or estrogen/raloxifene.
• IDL (Intermediate Density Lipoproteins) is also more atherogenic than R-LDL  and is "statin-resistant," often requiring statin plus niacin for treatment.
• The density (size) of the LDL particles is also very important in treatment.  Small, dense LDL particles are much more    atherogenic because they slip through the coronary endothelial wall more easily and deposit their cholesterol burden, and are more easily oxidized.  Small, dense LDL occurs in 40-50% of patients with CAD.  Dense LDL (Pattern B) is associated with a 4 fold increased risk for CAD and a 6.9 fold risk for myocardial infarction.  By contrast, even very high total cholesterol and total LDL are associated with only a 2 fold increase in risk for CAD.
• Conversion from dense LDL (Pattern B) to buoyant LDL (Pattern A), with large particles) accounts for up to 50% of the regression of atherosclerosis in many studies.
• Dense LDL is amenable to treatment with niacin, fenofibrate, the insulin receptor sensitizing glitazones and omega-3 fatty acids/fish oils.
• The use of fish oils reduces risk of cardiac death and nonfatal MI in both high risk and low risk men and women and this may be due to the ability of omega-3 fatty acids to shift LDL particles from dense to buoyant forms.

Method

In the pursuit of these goals in these four areas, SETMA utilizes a health care team of:

• nurses,
• dietician,
• diabetic educator,
• physical therapists, and
• specialists

for care management with an integrated health plan to set goals, assess progress and address barriers to health care.  SETMA’s Metabolic Task Force monitors progress.  We have EMR chronic disease management software that specifically addresses Diabetes, Hypertension, CHF, and Lipids.

In addition, having established a Diabetes Treatment Center of Excellence, SETMA is finalizing an affiliate agreement with Joslin Diabetes Center at Harvard. SETMA’s Diabetes Center of Excellence will then be known as Joslin Diabetes Center at Southeast Texas Medical Associates. 

We monitor a host of data including Hgb A1c, lipids, blood pressure, weight, exercise, diet, vital signs, compliance etc.  Nursing staff systematically monitors for 10 gm monofilament neurological and complete foot exams, vaccines, double checks to see that lab is done routinely.  Diets are readily available to print specifically for hypertension and diabetes including DASH, Low Cholesterol, Low Triglycerides, etc..  SETMA’s nutrition education is available for consultation on all of these diets.  Progress is assessed at each visit by both MD/Provider and nurse.  Barriers to compliance are screened by nursing staff and then addressed by providers.  A nonprofit organization is now set up called the SETMA Foundation to meet needs not covered by insurers.  Home health providers are utilized also for the homebound.

Requirement Number 10:  For three clinically important conditions, the physician and non-physician staff conduct care management planning ahead of the visit to make sure that information is available and the staff is prepared as well as following up after the visit to make sure that the treatment plan (including medications, tests, referrals)is implemented

Before clinic each day, a computer query is sent to the Medical Home Coordinator for review.  Each patient who is identified as having one of SETMA’s Medical Home measures, i.e., diabetes, hypertension, dyslipidemia, CHF, is reviewed for laboratory needs, referral needs or medication issues.  In addition, any deficiency is HEDIS compliance or Consortium data sets is communicated to the team leader and nurse.

When the team leader has determined that all pre-encounter planning is complete, the item is checked off in the workflow module of the EMR.  The routine laboratory or
procedure results review and notification of the patient is followed. 
 
The standards of review are found in other places in this document and particularly in the disease-management tutorials for:

• Diabetes pages 96ff

• Hypertension pages 166ff

• Lipids pages 262ff

• CHF pages 334ff

Requirement Number 11.  The practice identifies appropriate evidence-based guidelines that are used as the basis of care for clinically important conditions.

SETMA has built disease-management tools based on the best data available.  For instance, annually, one of SETMA’s leaders reads the 100-page American Diabetes Associations standard of care in diabetes and measures SETMA’s Diabetes Disease Management tool by it.  In addition, SETMA has employed a Chief Medical Officer who is an evidence-based-medicine expert, whose responsibility it is to review SETMA’s standards of care and to update algorithms, guidelines, templates and treatment patterns based on the most recent random-controlled studies and the evidenced-based medicine which has resulted. In addition, this Chief Medical Officer, makes certain that our treatment is based on the best evidence.  Currently reference databases include:

• Cochrane Reviews
• UpToDate
• ACP’s PIER
• CINAHL
• SCOPUS
• PSYCHINFO
• PubMed (Medline)
• Health & Psychosocial Instruments (HAPI)
• PAIS (Public Affairs Information Service)
• DynaMed
• STAT!Ref

Disease Management Tools

The following disease management tools are employed in SETMA’s Medical Home to make certain that all care is excellent care.  The philosophy behind the development of SETMA’s disease management tools is detailed in the following presentation entitled, Building an EMR based on Peter Senge’s The Fifth Discipline.

Abstract:       

It is possible for healthcare providers to be overwhelmed by the volume of valuable information available for medical decision making.   The organization and storage of that information is particularly ill suited for easy access and application in clinical settings.  Electronic patient records has the potential for making current and future information available for use in improving the quality of treatment out comings. 

Success in applying medical science and random-controlled-trials date to healthcare will be dictated by the design of EMR products and particularly by the display of data and treatment decision-making tools.  In his book, The Fifth Discipline, Dr. Peter Senge identifies “systems thinking” as the solution to the management of complex data issues in business.  These principles are equally applicable in medicine and particularly in the design of EMR tools for the support of healthcare decision making.

Utilizing Senge’s concepts of metanoia and circular causality, this paper examines the implications of systems thinking for the design of EMRs and for the display of data.  In addition, the issues of data sharing between specialties, disciplines and disease management is addressed.                      
                       
Introduction

The complexity of medical knowledge is created both by its volume and by the manner in which that information is packaged.  Applying that complex knowledge base effectively will require a fundamental shift in physician approach to information.  Electronic medical records (EMR) provides the means for that shift but does not dictate that such a shift will take place.  Often EMR is only used as a glorified transcription tool whereby a patient encounter is documented electronically without providing significant advantages in processing of information and without the patient profiting from sound science.

Systems Thinking and Healthcare

In his seminal work, The Fifth Discipline, Dr. Peter Senge addresses “systems thinking.”  While the term does not refer to computer systems, the principles apply to health care delivery via an electronic format as legitimately as to other business enterprises. 

Senge states, “Learning has come to be synonymous with ‘taking in information.’…Yet, taking in information is only distantly related to real learning.”   Classically, healthcare has focused upon “taking in information” in the form of facts.  The hurdle required to enter medicine as a physician is the proven ability to absorb and retain tens of thousands of isolated pieces of information and then to be able to repeat that information in a test format.  Clinical training attempts to take the static database created by these facts and transform it into a dynamic tool which can provide answers to complex disease-process questions.  This is where the complexity comes into healthcare:  how do you take a linear database and transform it into a circular, global, decision-making tool?

Senge also identified the problem with which healthcare is faced today.  He stated:  “System thinking is needed more than ever because for the first time in history, humankind has the capacity:

• To create far more information than anyone can absorb,
• To foster far greater interdependency than anyone can manage
• To accelerate change far faster than anyone’s ability to keep pace.”

Undermining Confidence

Senge concludes, “Complexity can easily undermine confidence and responsibility.”  Confidence is undermined when the vastness of available, valuable and applicable information is such that it appears futile to the individual to try and “keep up.”  In healthcare, once confidence is undermined, responsibility is surrendered as providers tacitly ignore best practices, substituting experience as a decision-making guide. While experience is not without merit in medical decision making, it is not the best guide.

Any sense of healthcare provider helplessness has a solution, but it is not based on attempting to take in more and more information. Senge states, “Systems thinking is the antidote to this sense of helplessness that many feel as we enter the ‘age of interdependence.’”  The solution is not only to “see” the interrelatedness of disease-processes, one disease aggravating or precipitating another, but also to see the dynamic interaction between the treatments of two or more simultaneously occurring pathological processes.  The solution also allows the healthcare provider to “see” how the treatment of one disease processes is required in order to augment and/or to facilitate the treatment of another.

Medical Knowledge Overload

No intellectual discipline is more illustrative of Senge’s principle of undermining confidence/responsibility than is the knowledge base required to perform excellently in the delivery of healthcare.  Depending upon how you count, there are between 4,000 and 7,000 medically-related journals presently being published.  There are over 1,000 medically-related journal articles published each day. 

In 2004, the Journal of the Medical Library Association published an article entitled,  “How Much Effort is needed to keep up with the literature relevant to primary care?”  Here are the authors’ conclusions:

• There are 341 currently active journals which are relevant to primary care.
• These journals publish approximately 7,287 articles monthly.
• It would take physicians trained in epidemiology an estimated 627.5 hours per month to read and evaluate these articles.  That translates into 21 hours a day, seven days a week, every month.

In 1997, The British Medical Journal stated that there are over 10,000,000 medically-related articles on library shelves of which about 1/3rd are indexed in the Medline database compiled by the National Library of Medicine.  If a healthcare provider receives only an average of 8 journals, including those which are free, it can be seen how overwhelming the problem of information is. 

This is the level of the problem for individual physicians, but what about collaborative efforts to organize medical data?  The Cochrane Collaboration was started in 1992 following Dr. Archie Cochrane’s 1979 statement in which he opined “It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials.”

There are now fifteen Cochrane Centers around the world with 1,098 complete reviews and 866 protocols (reviews in progress).  It is estimated that it will take 30 years to complete reviews on random-controlled studies (RCTs) in all fields of medicine which presently exist.  At the end of those 30 years, nothing would have been done on the RCTs which will have been completed in the intervening 30 years.

Without medical knowledge, quality-of-care initiatives will falter, but the volume of medical knowledge is so vast that it can overwhelm healthcare providers.  Stated a different way, the good news about healthcare today is the state of our current knowledge; it is excellent.  The bad news is the form in which that knowledge is stored and/or accessed.   The solution is “a shift of mind.”

METANOIA – A Shift of Mind

In The Fifth Discipline, Senge comments about the Greek term Metanoia:

“The most accurate word in Western culture to describe what happens in a learning organization is one that hasn’t had much currency for the past several hundred years…The word is ‘metanoia’ and it means s shift of mind…For the Greeks, it meant a fundamental shift or change…

“To grasp the meaning of ‘metanoia’ is to grasp the deeper meaning of ‘learning,’ for learning also involves a fundamental shift or movement of mind.  Learning has come to be synonymous with ‘taking in information.’…Yet, taking in information is only distantly related to real learning.”

Change is not easy.  It often creates anxiety and insecurity, even and maybe especially among healthcare providers.   However, to create excellence in healthcare, which is more of a process than it is a characteristic of a product, providers must continually be “learning.,” which will require a change in the understanding of the nature of learning and will also require the elimination of barriers to learning.   To sustain the learning process created by this “shift of mind” healthcare providers need tools which facilitate change rather than processes which support the status quo.

Learning Disabilities

There are a number of “learning disabilities,” which afflict organizations which attempt to make this shift.  As an organization attempts to learn from experience and attempts to analyze that experience, these disabilities prevent an organization or an individual from making the changes which would make a difference in outcomes and in effectiveness.

Fixation on Events

 “Fixation of events” is a learning disability which results because we become mesmerized with things which occur rather than looking at their cause.  Events occur suddenly and demand our attention, while the processes which provide the leverage for effecting change are subtle and occur slowly over time.  In a biological system, such as the human body, this is also true.  The primary threat is not the heart attack but the weight gain, the inactivity, the cigarette smoking, and the cholesterol, all of which produce the heart attack.  Linear thinking focuses on the event and not the long-standing problems which resulted in the event. 

A patient has a heart attack.  Linear thinking results in the placing of a stent and the treatment of irregular heart beats.  Circular thinking and what we shall examine later – complex circularity – addresses the blood sugar, the weight, the tobacco, the waist size, the cholesterol, the stress, the inactivity, etc.  Linear thinking is valuable but it must be followed up by the global evaluation of the patient.  Because the slow processes do not demand our attention, it is easy to neglect them unless something requires us to focus upon them. 

In effecting a change in thinking in healthcare delivery, EMR allows the:

• Capturing and processing of data focusing on the slow processes,
• Auditing of efforts to change those slow processes and
• Measuring of the effectiveness of those efforts over time.
• Evaluation of the quality of his/her care by the provider at the point and time of care.

However, unless that display of data is integrated across an entire biological entity, the change itself will be imprisoned by a linearity of thinking which obscures the dynamic interaction of all systems of the biological entity.

The Parable of the Boiled Frog

A corollary to this mental barrier to learning is “The Parable of the Boiled Frog.”  “Learning to see slow, gradual processes requires slowing down our frenetic pace and paying attention to the subtle as well as the dramatic.” The slowly boiled frog does not react to the slowing heating water because the frog does not become uncomfortable until the damage has already been done. 

The slow “boiling” which comes from the deterioration of health requires a new methodology for effecting change in patient and provider behavior.  Part of that will be achieved by enhancing the capability of a healthcare provider to create discomfort in the patient in order to effect change which will benefit the patient in the long run.  Part of that will be achieved by the creation of discomfort in the provider via self-auditing at the point of care which allows the provider to measure his/her performance against an accepted standard. 

Because the processes which ultimately destroy health are mostly painless and are invisible, effective intervention requires making the effect of those those processes apparent.  Data display, which is longitudinal and comparative, can create discomfort in the patient and provider, which discomfort can contribute to change.

The Delusion of Learning from Experience

This disability also results from the slow change in systems, particularly biological systems, which make it impossible to associate personal experience with effective treatment. Healthcare strategies based on personal observation will by their nature be inadequate as the consequences are seen long after the intervention.  One of the problems with learning from experience is that it results not only in very slow change in patients but it also results in reluctance or neglect by providers to make changes which will benefit patients.

“Treatment inertia” is defined as “lack of treatment intensification in a patient not at evidence-based goals for care.” (Advances in Patient Safety, Vol 2, Patrick J O’Connor)   The causes of treatment inertia are these “learning disabilities” which prevent a healthcare organization from adopting a learning culture.  The shift of mind which is fundamental to learning – more even than memorizing new information – requires focusing upon the slow processes which cause deterioration in biological systems and it also requires the willingness to subject personal experience to the critique of evidenced-based care.  This shift of mind is at the core of systems thinking.

Patterns of Change Rather than Static Snapshots

In summarizing systems thinking, Senge almost seems to have healthcare in mind.  He describes systems thinking as, “A discipline of seeing wholes…a framework for seeing interrelationships rather than things and patterns of change rather than static ‘snapshots.’” Historically, medical records have been snapshots of a patient’s condition without any connection between the past and the future. EMR has changed that, or at least EMR has the potential of making that changing.  With the cumulative data capacity of EMR, which provides a longitudinal portrait of the patient, patterns of change can be viewed seasonally and progressively.

The application of these concepts to medicine provides an elegant framework with which to study the design of the tools used to effect change in behavior of patients and physicians, and to shift the focus from information and experience to evidenced-based outcomes and data analysis over time.  The shift of mind requires that the patient be seen as a whole. 

If the patient’s surgery is a success, it makes no difference if the patient dies; it makes no difference if the patient’s kidneys are in great condition but the patient dies of a heart attack.  Health initiatives must be global for the preservation of the life and well-being of the person.  The “interrelations” of disease processes and disease causation and the patterns of change required to regain or retain health are pivotal concepts in healthcare. 

Designing the Tools Needed When the Shift Takes Place

The final systems-thinking concept which will help design an EMR which will facilitate active learning, avoid learning disabilities and result in dynamic data management and which will change physician and patient behavior is the concept of “complexity.”.

Remember, The Fifth Discipline was written to effect change in corporations and business, but the principles apply eloquently to healthcare delivery and even to the behavior of biological systems.  Systems thinking requires the analysis of complex problems.  Most analysis focuses upon multiple variables and a plethora of data.  This is “detail complexity.”  However, the greatest opportunity for effecting change in an organization or an organism is in what Senge calls “dynamic complexity.”

“Dynamic Complexity” occurs when “cause and effect are subtle, and where the effects over time of interventions are not obvious.”  The applications to medical research design are intriguing but beyond this discussion, but whether in corporations or medicine, “the real leverage in most management situations lies in understanding dynamic complexity.”

To design a healthcare delivery tool which facilitates excellence will require a system which approaches healthcare from this vantage point.  Display of data can obscure effective management if all it does is present more detail while ignoring, or further obscuring, the dynamic interaction of one part of a biological system with another.  The circle describes a biological system much more effectively than a straight line.  Yet, most medical data is displayed in a linear fashion.  The difference is critical.

Seeing Circles of Causality

“Reality is made up of circles, but we see straight lines…Western languages…are biased toward a linear view.  If we want to see system-wide interrelationships, we need a language of interrelationships, a language of circles.” (The Fifth Disciple)

It is here that we see the application of The Fifth Discipline to medical information technology most clearly.  The following concepts derive from Senge’s systems principles:

1. Healthcare delivery is not improved simply by the providing of more information to the healthcare provider at the point of care. 
2. Healthcare delivery is improved when the organization of that information is such that there is a dynamic interaction between the provider, the patient, the consultant and all other members of the healthcare equation, as well as the simultaneous integration of that data across disease processes and across provider perspectives, i.e., specialties. 
3. Healthcare delivery is not necessarily improved when an algorithm for every disease process is produced and made available on a handheld, pocket-computer device but it is improved when the data and decision-making tools are structured and displayed in a fashion which dynamically change as the patient’s situation and need change. 
4. Healthcare delivery also improves when data and information processed in one clinical setting is simultaneously available in all settings.  This improvement does not only result from efficiency but from the impact the elements contained in that data set exert upon multiple aspects of a patient’s health.  In this way, the data reflects the dynamic within the system under analysis, which in the case of healthcare is a living organism which is constantly changing.
5. Healthcare is improved when there is simultaneous evaluation of the quality of care as measured by evidenced based criteria is automatically determined at the point of and at the time of care.  Healthcare is improved when the data display makes it simple for the provider to comply with the standards of care, if the evaluation demonstrates a failure to do so.
6. Healthcare is also improved when data can be displayed longitudinally, demonstrating to the patient over time how their efforts have affected their global well-being.  This is circular rather than linear thinking.  A person begins at health.  Aging and habits result in the relative lack of health.  Preventive care and positive steps preserve, or restore health. 
7. Healthcare improvement via systems will require dynamic auditing tools which give the provider and the patient immediate feedback on the effectiveness of the care being provided and received.

If then, excellent healthcare requires healthcare organizations:

1. to be “learning organizations”
2. to avoid “learning disabilities”
3. to think in a circular rather than a linear fashion
4. to look at dynamic complexity rather than detail complexity

how would data need to be displayed to support these functions? 

If health science has the capacity:

• To create far more information than anyone can absorb,
• To foster far greater interdependency than anyone can manage
• To accelerate change far faster than anyone’s ability to keep pace.

how can electronic patient records and/or electronic patient management help solve these problems and make it possible for healthcare providers to remain current and fulfill their responsibility of caring for patients with the best treatments available?

First, the data organization must see the patient:

• As a whole rather than as a summary of many different parts; this requires a circular perspective of a patient’s life.  
• As a living organism rather than as a disease process; this requires a circular perspective of a patient’s life.

Second, the data organization and management must:

• Encourage and provoke change in patient behavior.
• Encourage and provoke change in provider behavior.
• Provide feedback to the provider at the point and time of service whereby the excellence of care can be measured.

Third, the data manipulation must have:

• Multiple points of entry 
• Easy and dynamic interaction between the various elements of the database
• Automatic summarizing of the patient’s care as measured against evidenced-based criteria

The principles which have guided Southeast Texas Medical Associates’ development of a data base which supports these requirements are:

• Pursue Electronic Patient Management rather than Electronic Patient Records
• Bring to bear upon every patient encounter what is known rather than 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.
• Establish and 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 the Consortium for Physician Performance Improvement Data Sets.
• 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.

For more information on SETMA’s approach to IT and Disease Management see additional information at www.setma.com.   Particularly of interest may be Special Services which describes our specialty clinics and a series of articles on Medical Records under the section entitled, Your Life Your Health.

Linear and Circular Causality Thinking

Schematically, this data organization can be contrasted with linear thinking.  Thinking linearly, a healthcare provider would begin with a disease or problem and focus exclusively on that problem until it was resolved and then go to another problem.  Each problem would be dealt with in isolation and without interaction between the two.  In biological systems, as in business, nothing occurs in isolation.  The following is a simply representation of linear thinking in medicine.

 On the other hand, reality in a biological system can only be effectively approached from a circular- causality platform which is designed to encourage and facilitate the dealing with complex, interrelated problem solving for maximal effectiveness.  Schematically, this would be represented as follows.

Can this be done?  What would it look like?  While Southeast Texas Medical Associates’ EMR Data Base, which is built on NextGen’s platform, is not perfect, it is a significant step forward in addressing healthcare delivery utilizing Senge’s Fifth Discipline principles. 

The following disease management tools will illustrate these design issues which allow integration not only across disease management boundaries but also across specialties.

SETMA’s standards, evidence-based medicine, reminders and alerts are found throughout our EMR but particularly in our disease management tools.  The four areas we have chosen to focus on for our Medical Home are:  Diabetes, Hypertension, Lipids and CHF.  The following tutorials on each of these functions give insight into our workflow, commitment to excellence and use of technology to innovate solutions to complex healthcare-delivery problems.  These tutorials are not just “how to” in using SETMA’s EMR, but they are disease-management-education tools which teach evidenced-based medicine at the same time a provider learns how to use our EMR.

For the tutorials see Appendix A, beginning on page 98. Patient/Family Engagement

Requirement Number 12: The practice supports patient/family self-management through activities such as systematically assessing patient/family-specific communication barriers and preference, providing self-monitoring tools or personal health record, and providing a written care plan.

Each chronic disease template in SETMA’s EMR provides a section for engaging the patient and family in discussions related to the patient’s responsibilities in managing their disease through pro-active measures such as becoming educated about the disease process, making lifestyle changes in diet, exercise, smoking cessation, alcohol consumption, coping with stress, and becoming a partner with his/her physician to maintain and/or improve his/her health.  In addition, each patient is routinely assessed using the LESS (Lose weight, Exercise, Stop Smoking) initiative.  Patients and family are then provided with a document of their assessment including weight, body fat percentage, waist and hip measurement.  Based on the assessment, the patient is provided a documented plan to lose weight, an exercise prescription, and/or a smoking cessation contract. .  A referral can be made to the Registered Dietitian (R.D.) for a more detailed explanation of the patient’s diet through 24-hour recall and eating patterns, further emphasis on lifestyle changes and assistance in working the plan into the patient’s and family’s individual lifestyle   Each visit with the R.D. includes patient-chosen goals that are documented in the follow-up note for the applicable chronic condition.  These behavior-change goals may be followed by the referring provider or subsequent visits with the RD.

The CHF Treatment Plan template has several areas that assess the patient’s lifestyle and changes that need to occur to manage CHF effectively.  The general measures template allows the provider to collect in one place the patient’s:

• blood pressure
• lipids
• smoking habits
• alcohol consumption
• illicit drug use
• diabetes control
• thyroid levels

Any of these concerns about the care of a patient with CHR which are not at goal, appear in red and therapeutic recommendations appear.  The fluid management template allows the provider to document necessary fluid and sodium restriction and encourage daily weight measurements of the patient with the patient and family.  The provider is also able to give the patient education materials which allow the patient to take charge of their own care.

Weight loss, physical activity, and smoking cessation templates are also tied in to the CHF Treatment Plan template.  Once the provider assesses and documents needed directives for the patient, the CHF treatment plan and follow-up document can be printed and provided to the patient and family. 

The Hypertension Management suite in the EMR includes lifestyle changes, where the provider can document discussions about the expected reductions of systolic blood pressure with the following changes:

• Eliminate or reduce alcohol consumption to one drink per day.  A reduction in alcohol intake may reduce your systolic blood pressure 2-4 mmHg.
• Eliminate or reduce caffeine intake.
• Take measures to reduce and control stress.
• Weight Loss -- Each 20 pounds of body weight lost equates to a lowering  of systolic blood pressure by as much as 5-20 mmHg.  Providing the patient with their current body mass index (BMI) and letting them know that a BMI of 25 or less is desirable.
• Increase potassium intake.
• Increase calcium intake.
• Maintain adequate magnesium intake.
• Increase fish oil intake.
• Reduce sodium intake to no more than 2.4 grams per day.
• Following a low sodium diet may reduce your systolic blood pressure 2-8 mm Hg.
• Adhere to the principles of a DASH diet.  following the DASH diet may reduce your systolic blood pressure 8-14 mmHg.
• Increase potassium intake.  With a document entitled, “The following are good sources of potassium” 

The patient is given instructions on “Reasons To Call Your Doctor,” in which they are told, “If you have any of the following symptoms between appointments, you should call your doctor immediately.”

• Severe headache
• Excessive tiredness
• Confusion
• Visual changes
• Nausea or vomiting
• Chest pain
• Shortness of breath
• Significant sweating

And they are given the following information about “Take Care of Yourself”

• Take medications as prescribed.
• Don't abruptly stop or decrease your medications without asking your doctor.
• It is dangerous to stop taking certain blood pressure medications suddenly.
• Monitor your blood pressure regularly.
• You can do it yourself or have your doctor or other health care professional do it.  Keep a chart of the readings.
• If you smoke, quit.
• Reduce salt intake according to your doctor's prescription.
• Start exercising regularly, with your doctor's approval.
• If you are overweight, lose weight.
• Limit the amount of alcohol you drink.
• Reduce stress or learn stress management techniques.
• See your doctor or healthcare professional as often as he or she recommends.

The plan also includes areas to document instructing the patient and family on self-monitoring of blood pressure and maintaining a blood pressure log, keeping physician appointments, and consistently taking medications as indicated.  Documentation of the plan can then be printed and provided to the patient.  .

The lifestyle section of the lipids suite enables the provider to document the recommended actions of the patient and family regarding the need to change the diet to any of the following that apply:  low carbohydrate, high fiber, low fat, low cholesterol, low trans- fat, no sugar, and/or weight loss.  The links to smoking cessation contract, exercise prescription are also available.  Patient literature may be printed from the same template on the Step I and Step II diets, relationship between a inactivity and dyslipidemia.  Upon completion, the Lipids Management Plan Follow-up document can be printed for the patient and family.

SETMA’s Weight Management initial assessment engages the patient and family in determining goals for weight loss, willingness to make lifestyle changes, triggers to food intake in the absence of hunger, previous attempts at weight loss, what has worked, and what impedes success.  The patient and/or family are given instruction for a weight loss plan and individual behavior change goals are set.  A follow-up document with instructions and goals can then be printed for the patient and family to bring home.

SETMA’s Diabetes Self-Management Education (DSME) program meets all of the requirements of the American Diabetes Association and has been certified by the ADA for the past five years.  One such requirement is the initial assessment with the patient, which usually lasts about one hour, prior to the patient attending education.  Family members are welcome and encouraged to attend this and all visits.  The goal of the initial assessment is for the educators to have a clear idea of the patient’s/family’s understanding of diabetes, their current self-management skills and learning needs, the patient’s/family’s ability and motivation to learn, both cognitively and socially, barriers to learning and making lifestyle changes, and the patient’s/family’s personal goals for improvement.  All of this information is documented in the electronic medical record templates as it is collected.  A pre-program knowledge level is recorded for each of the content areas and an educational plan is then documented in the educational record. 

Requirement Number 13:   The practice supports patient/family self-management through providing educational resources, and providing/connecting families to self-management resources

Each chronic disease template in SETMA’s EMR enables the provider to print out educational literature related to the patient’s and family’s responsibilities in managing their disease through pro-active measures such as becoming educated about the disease process, making lifestyle changes in diet, exercise, smoking cessation, alcohol consumption, coping with stress, and becoming a partner with his/her physician to maintain and/or improve his/her health.  In addition, there is educational literature directed to the family of the patient to enhance understanding of the family’s role in managing the patient’ illness and encourage support.  A referral can be made to the Registered Dietitian (RD) for improved understanding of meal planning and assistance in working the plan into the patient’s and family’s individual lifestyle   The family is welcome and encouraged to attend each visit with the R.D., as often times dietary changes pose challenges for the entire household.  Recommendations may be made to Nutrition and Services for Seniors, Food Bank or County Agencies that may be able to assist in meeting the patient’s needs.

The CHF Management template has a patient information section that enables the provider to print out a self-management book for the patient and family that includes:

• Welcome letter
• Glossary
• What is CHF?
• Treatment
• Treatment options
• Recovery prospects
• Low sodium
• Potassium in foods
• What is an echocardiogram?
• When to call your doctor
• Questions for your doctor
• CPET
• Fluid Restriction
• Hyponatremia
• CHF and inactivity 

The Hypertension Management suite in the EMR includes lifestyle changes, where the provider can print out educational literature for the patient and family including low sodium diet, effects of excess alcohol consumption, smoking, and caffeine on blood pressure, losing weight, and the DASH diet.  Included in this section are links to exercise, where a specific exercise prescription can be created and printed, and smoking cessation, where a contract between the provider and the patient can be devised, printed, and a tickler file set up so that the provider can call the patient to ensure that progress toward cessation is being made.  A referral may be placed to the RD for the CardioMetablolic class where details of the DASH eating style and lifestyle changes that may decrease the risk of cardiovascular events are discussed with patients and families.  Presentation includes power point, additional handouts, and worksheets for patients/families to improve their understanding of presented information.

The lifestyle section of the lipids suite enables the provider to print out educational literature for the patient and family including:  low carbohydrate, high fiber, low fat, low cholesterol, low trans- fat, no sugar, and/or weight loss.  The links to smoking cessation contract, exercise prescription are also available.  Additional patient and family literature includes:

• Step I and Step II diets, description
• Step I, II diets and Fiber
• Alcohol and Lipids
• BMR --- Changing It
• Dining Out
• Dislipidemia and Inactivity
• Cholesterol and Weight Loss
• Foods to Eat, Avoid
• Inactivity and Cholesterol
• Training Intensity and Lipids
• Trans- fats and LDL

 
A referral may be placed to the RD for the Cardiobetabolic-Syndrome class where details of the heart healthy eating and lifestyle changes that may decrease cholesterol and the risk of cardiovascular events are discussed with patients and families.  Presentation includes power point, additional handouts, and worksheets for patients/families to improve their understanding of presented information.

SETMA’s Weight Management template enables the provider to print out the educational materials covering topics such as:

• Nutrition Basics
• Approach to Calorie Reduction
• Food Weight Loss Tips
• Serving Sizes
• Meal Replacements
• Food to Remove
• Importance of Glycemic Index
• Applying Glycemic Index
• Glycemic Load
• Diet Recommendations

Patient may then be referred to the RD, where patient will receive an individual meal plan and weight loss plan based on his/her initial assessment.  The provider may also print out an individualized exercise prescription.

SETMA’s Diabetes Self-Management Education (DSME) program meets all of the requirements of the American Diabetes Association.  Patients/families may be instructed individually or in a group setting based on needs/abilities assessed.  Modes of learning include lecture, PowerPoint presentation, video, in-class participation and worksheets, and demonstration.  Instruction is determined by the diabetes educator, patient, and family. 

The content areas of DSME include:

• Pathophysiology of diabetes
• Coping
• Monitoring- blood glucose monitor and prescription for testing supplies provided as needed
• Pattern Management
• Medications
• Prevention, Detection, and Treatment of Acute and Chronic Complications- referrals for diabetes shoes, and specialty departments provided as needed
• Sick Day Management
• Medical Nutrition Therapy
• Exercise
• Behavior Change Modifications/Goal Setting

Each education visit is documented in the EMR including the date and teacher’s initials.  A post-program level of understanding is also documented on the Educational Record in the EMR.  Patients are provided educational literature, videos, and log books to compliment their educational visits. Upon conclusion of planned educational visits, follow-up is based on post-level of understanding and goal setting.  Each patient is encouraged to attend the Diabetes Support Group, which meets monthly, at no charge.

Patients are provided educational literature, videos, and log books to compliment their educational visits.  Modes of instruction include individual/group discussion, lecture, PowerPoint presentation, in-class participation and worksheets.  Upon completion of any of these classes, documentation is made in the note that the patient attended and instruction content in the EMR.  Family/social support and patient goals are also documented, if applicable.

Requirement number 14:  The practice encourages family involvement in all aspects of patient self-management.

Family members are welcomed and encouraged to attend Diabetes Self-Management Education and all Medical Nutrition Therapy (MNT) visits whether held in a group class or individual setting.  Emphasis is placed on family support for MNT as changes for the patient often affect the entire household.  Our Registered Dietitians help patients and families understand how to make modifications to family meals in order to meet the patient’s nutritional needs while alleviating some of the burden of meal preparation for the family unit. 

By making certain that the patient designates appropriate family members on their HIPPA form, SETMA is able to communicate with family members about the self-care of the patient and to recommend strategies for the patient taking care of self.

Family attendance is highly encouraged, if not mandatory, for sick day management of diabetes and prevention, detection, and treatment of acute complications of diabetes.  An explanation that these are times when the patient may be unable to care for him/herself often gains attendance by family members.  If family cannot attend visits with the diabetes educator, patient is encouraged to share the information from the visit with his/her family and to have family members call the educator with any questions.  Patients are provided the diabetes educators’ phone numbers and direct extensions.

Family is a significant part of the health care team.  We need to help them understand the importance of the role they play in the total care of a patient.  They are the window into the world of the patient that we can not observe in the healthcare setting.  Family input will allow us to treat the whole patient. 

1. The family can alert us to subtle changes in the patient that can not be observed on a routine office visit.  Knowing theses changes could lead to better preventive care and earlier detection of major problems.
2. Make sure that all medications are purchased and taken as directed by the healthcare team.  Alert us to barriers that prevent the patient from purchasing medications or supplies needed for compliance. 
3. Keeping the Healthcare team informed of any care received outside of SETMA. (VA, ER, MHMR Specialty MDs etc.) Including all medications, prescription and over the counter.  As well as all alternative treatments.
4. Help the patient keep all follow up appointments.  Make sure that the patient and family understand the importance of follow up appointments.
5. Inform the health care team of educational barriers that will prevent patient from understanding their role in their own health care.

How do we communicate with the family?

1. By phone.  Calls to be taken by our staff with interest.  All concerns to be addressed in a timely manner. *
2. By email.  Once a system has been established, we will educate the patient and family on how to use this system.  Emails will be addressed to the Primary Care Physician or Care coordinator.  *
3. By letter. Addressed to the Primary Care Physician or Care coordinator.  *
4. In person.  This can happen one of two ways.

• Family to accompany patient to the visit.
• Appointment can be made with the Primary Care Physician or a member of the health care team to discuss concerns and issues. *

*We need to make sure that the family and the patient understands the HIPPA laws.  We can take information from any concerned caregiver but we can only give information to the person or persons listed on the HIPPA form filled out by the patient.  This form can only be changed by the patient or the persons who has a legal power of attorney on file.

How do we educate the patient and families?

• Utilize the educational materials, disease specific, already present in the EMR.  Not only give a handout, discuss its contents.  The menu below is a great source of information as well as the material found in the disease management templates.
• Educate the family and patient on programs and services provided within SETMA.
• Provide the family with resources available in the community.  Such as adult day care, support groups, APS/CPS, financial assistance programs and respite care.  As well as other services available such as home health care and hospice.

Requirement Number 15.  The practice systematically tracks test and follows up using steps such as making sure that results are available to the clinician, flagging abnormal test results, and following up with patients/families on all test results (up to 4 specific factors).

SETMA providers create laboratory orders at the time of a patient encounter.  There are two ways to do this: 

• First, laboratory tests  which are to be done at the time of service 
• Second, laboratory tests which are to be done at a later date. 

SETMA calls the latter “Future Labs.”  When a lab request is sent from the examination room to the laboratory, the provider associates the requested test (CPT Code)  with the diagnosis  (ICD-9).  The request is also associated with the provider’s name.  The test request also designates whether the patient is fasting or not.

The test request goes to the laboratory. When the patient arrives in the draw station, the phlebotomist opens the patient’s record and bar codes are automatically created which identify the blood sample, the test requested and the provider who ordered the test.  The sample is couriered to the laboratory when it is off site and the sample is processed.

When completed and verified by the laboratory personnel, the results are immediately sent back to the provider’s “work flow, ” which is a part of SETMA’s EMR.  It displays lab test results, telephone messages and procedures and correspondence which have been scanned into the system.  The provider checks his/her “workflow” multiple times a day, reviewing test results as soon as they are available.  After reviewing the test results the provider does the following:

1.         Signs off on the lab verifying that he/she has reviewed the tests.  The computer time and date stamps the signing off on lab.
2.         With the click of a button, the provider adds the lab results to the patient encounter record which resulted in the test request.
3.         The provider either contacts the patient personally or refers the results to a member of the Care Coordination team who speaks to the patient or family about the results, giving them follow-up instructions.
4.         This communication is documented in the patient’s record.
5.         If referrals, further tests, follow-up visits or follow-up tests are required as a result of the review, they are initiated electronically at this time.

SETMA audits provider workflow to make certain that all results and communications are handled in a timely manner.  While the standard we pursue is that lab work is reviewed within a few hours of being reported, the audit standard is that non critical results are reviewed within 72 hours of the results being reported to the provider.  Critical results are called by the laboratory to the provider and an e-mail correspondence is placed in their work flow indicating that a flagged, critical result is present.  Non critical results are displayed in the laboratory results module with color coding to alert the provider to abnormal but non-critical results. 

• High values are displayed in red
• Normal values are displayed in black
• Low values are displayed in blue.   

The display also provides normal ranges and where the test was performed.

When a “future lab” request is initiated, i.e., a test on a day other than the day of the encounter, the provider completes a Future Lab template which is sent to the laboratory with a designation of the ordering provider and the date on which the tests are to be performed.  An electronic tickler file is automatically created in the laboratory which can be searched by date of service or by patient name.

The patient is given instructions to fast and to appear on a specified date for the indicated tests.  The patient reports to the front desk of the clinic, indicates that they are there for lab work and are directed to the lab.  The laboratory personnel then opens the file which is in their work flow and go through the same process as they do for labs done on the day of an encounter.  If a patient does not return for their Future Lab tests for ten-days after the designated time, the provider is notified that the patient did not return so that a follow-up can be done.

The “data loop” is completed, all of which is documented in the EMR:

1.         Patient history, physical and evaluation is done.
2.         Testing is ordered.
3.         Blood or other body fluid specimens are obtained and processed.
4.         Results are reported to the provider
5.         Provider reviews the results and signs off on them.
6.         Results are added to the encounter at which the test results were requested.
7.         The provider or a member of the Care Coordination team contacts the patient with results and follow-up instructions.
  

Requirement Number 16.  The practice coordinates referrals designated as critical through steps such as providing the patient and referring physician with the reason for the consultation and pertinent clinical findings, tracking the status of the referral, obtaining a report back from the practitioner, and asking patients about self-referrals and obtaining reports from the practitioner(s).

Southeast Texas Medical Associates (SETMA) has developed a Template that providers use to initiate a referral to another provider, for a test or a procedure to be performed within, or outside SETMA.  The provider designates on the template:

• To whom the patient is being referred by name and specialty
• The reason for the referral
• The nature of the referral:  state, intermediate, regular

A separate department has been established to coordinate each of these referrals. Due to our use of electronic records that department is not connected to the provider areas allowing for focused attention to the details of proper referral processes.  Specific time frames can be requested by the provider ordering the referral:

• Stat, which will be set up the same day, or the next day depending on the time of day it was received -- this would be appropriate for a patient with an acute problem but which does not require hospitalization.
• Intermediate, which will be set up within 3 days – this would be appropriate for the scheduling of a stress test which is not consider urgent or emergent
• Regular, which will be set up within 5 days from the time it was ordered -- – this would be appropriate for an annual mammogram.

The department is staffed with 5 full-time coordinators to make sure all referrals are completed in a timely manner. The C  OO monitors the referral department to make sure that these targets are being met.

To monitor the process, a query is performed each night to determine if any referrals have gone unattended. The supervisor of the Referrals Department along with the Director of the Central Billing Office and the COO receive the report each day. If the number of referrals increases to a point where additional personnel are needed, several staff members within the CBO have been cross-trained to assist in the process.

After retrieving all information and after conferring with all necessary disciplines, the Referrals Department calls patients to inform them of their referral and to determine if there are any additional questions which need to be answer.  If a question cannot be answered the appropriate provider or nurse/unit clerk is contacted to provide the answer. After the referral is completed it is documented within the EMR. This documentation is reviewed when the nightly query is completed as described above.

If the lab tests or procedures are performed within the SETMA, the provider receives the information directly from the appropriate department in his/her workflow in the EMR. When the information is received from outside of SETMA, the Medical Records Tech scans the information into the system and sends the information to the appropriate provider via workflow. The provider “signs-off “in workflow indicating that they have received the information.  There are two nurses who also review all incoming specialty correspondence to make certain that diagnoses, medications, treatment  and other testing recommendations are captured in our EMR.

Any workflow items that are not “signed-off” will be highlighted in the workflow of the person that sent it. This is monitored daily and if the provider has not “signed-off on the information an email is sent to the provider informing them of the matter. If the information is still not “signed-off” a call is made to either the COO or CEO indicating a problem exists.

When the Medical Records Tech scans the information into the system, they document it in the EMR. Each week the Medical Records Supervisor performs a query to make sure that all referrals that have been ordered are completed. Any patient that misses an appointment to a referring provider, or does not have the test/procedure performed will continue to show up on the query report. After an appropriate period of time elapses the supervisor will contact the appropriate provider to inform them that the patient has not completed the necessary referral/test/procedure. The provider or designee will then contact the patient to discuss why this has occurred and will take appropriate action and document the response.

Requirement Number 17.  The practice reviews all medications a patient is taking including prescriptions, over the counter medications and herbal therapies/supplements.

SETMA’s EMR has a medication module which allows for the accurate listing of all prescribed, over the counter and herbal medications which a patient is taking.  The following is an actual patient’s medication list which presently exists in SETMA’s patient data base:

Each time the patient is seen, the mediation lists are checked by the nurse and then again by the physician. The patient is given a copy of their current, active medications which is reviewed with them to make certain that their medications are correct.

When a patient is discharged from the hospital, because the same data base is used in the hospital, nursing home and clinic, medication reconciliations are easy and done multiple times during the care.  There is no place where medication reconciliation is more difficult than in the nursing home where most orders are given by telephone.  As a result, SETMA has devised a notation on the Nursing Home suite of templates where the healthcare provider is able to denote when the medication lists was last updated.

When a nursing home patient goes to the hospital, SETMA has an accurate, up-to-date and complete list of medications. When the patient is sent back to the nursing home from the hospital, they are sent with a discharge summary which has an accurate, up-to-date and complete list of mediations. The same is true of patients seen in the clinic. And, because the same EMR data base is used in all three places the safety, continuity and accuracy of medications are excellent and constant.

 Following are the steps we use.

1. On every visit all medications are reviewed by the nurse first.
2. Medication list is updated for pt.
3. On the plan template, an easy to read medication list is generated and given to the patient.
4. Physician revisits the list of medication and makes changes as desired.
5. For ten years, SETMA has been printing electronically generated prescriptions to minimize the errors of writing.
6. Every time a prescription is printed or medications are added the computer generate a list of possible interactions with other medications the patient is taking. We can not print or add medication without acknowledging the interactions.
7. SETMA’s EMR also allows us to list the patient’s unique medication allergies and these are checked automatically by the computer at every visit..
8. Now that SETMA is using e-prescribing, we can e-mail prescriptions through the computer to the pharmacy.
9. State and Federal requirements make it necessary for us to continue to print electronically generated prescriptions for controlled substances.
10. SETMA has also created a pain management template which allows us to establish a plan of care for the use of chronic pain medications which places us in compliance with Texas State Medical Board requirements.  The pain management template also lists the board regulation governing pain medications for the education of our providers.
11. All dangerous abbreviations are deleted from the system to avoid mishap and to comply with new federal imitative for the elimination of Latin sig codes.
12. We can track by click of a button, how long and how much of any medication pt is taking.

In order to comply with the requirements of the Texas Medical Board regarding the use of scheduled chronic pain medication, SETMA has designed a pain management tool.  The following is part of the document on pain management which is given to the patient.

“Today's Prescriptions

“Today, you have been given the following prescriptions for drugs with the potential of habituation...

• This is how long your medication should last at the maximum allowable dosage.  However, pain medication and potentially habituating medications should not routinely be taken at the maximum prescribed dosage.  They should be taken only when needed.  Do not anticipate potential pain and take pain medication because of anxiety or fear of possible pain.  Take pain medication only when you are in pain. 

      
“Remember, the designation of how long your medication should last is calculated at the maximum prescribed dosage.  This does not mean that your medication will automatically be renewed at the time; it does mean that under no circumstance will  your medication be renewed before that time. 
 
“Our goal is to help you live well.  We will use medications appropriately for your benefit but you must monitor and regulate your own use of the important but potentially harmful medications.  We will help you by not making excessive medications available to you.

          “Refills                                              

“I have explained to ________ that these medications have a significant potential for habituation but are useful when used only as prescribed.

          “Under no circumstances will the medication be refilled:

• Prior to the renewal date at the prescribed dosage and frequency of use.
• Without the patient being seen in the office
• Without evidence of continuing need for medication
• On the weekend, evenings after hours, holidays or other times when your regular doctor is not available.

“The following reasons will not be accepted by any SETMA provider for an early refill of pain medication and/or medication with a significant potential for habituation:

• My medications were stolen.
• I only got half of the prescription filled.
• I dropped my medications into the sink, the sewer, the swimming pool or other watery body.
• I left my medication in my hotel on my trip.
• I missed my appointment.
• The neurosurgeon and/or the surgeon cancelled my appointment.”

Requirement Number 18.  The practice on its own or in conjunction with an external organization has a systematic approach for identifying and coordination care for patients who receive care in inpatient or outpatient facilities or patients who are transitioning to other care (up to 6 specific factors).

SETMA has a healthcare team organized for seamless transition of care from hospital, to nursing home, to clinic, to physical therapy, to ER, to hospice, to home health, or to the patient’s home.   The same data base is used in all of these settings, which makes it possible to share information from care center to care center.  The interval between a patient being seen in the clinic and in the ER is irrelevant as records are immediately available in all places protected by appropriate 128 bit and password security.  Even if the patient is in the ER minutes after being in the clinic, the record is there.  And, if the patient is in the ER several hours after the clinic visit, even the laboratory results will be present.

SETMA has a healthcare team which is available 24-hours-a-day, seven-day-a-week with a provider in the hospital and by telephone, e-mail, or fax 24-hours-a-day in all other places.  SETMA’s team includes NPs who exclusively focus on our nursing home patients supporting by visits from physicians.  In that the nursing home records are completed in the same data base as the clinic visits, telephone contacts, ER visits, hospital care and home care, there is an absolute continuity of care.

SETMA maintains an IMRC (Inpatient Medical Records Census) which is an electronic tracking of every patient who goes into any hospital.  The date and time of the completion of the history and physical examination and the discharge summary is documented in the IMRC. When the central billing office has a question about a hospitalized patient or a patient record, they simply post a question to the IMRC and it is researched and answered by the Hospital Medical Records team.  When the patient returns to the clinic from a hospital stay, or ER visit, the record of that care is in the EMR.

When care is provided by a specialist, who is not a part of SETMA, reports, procedures and recommendations are scanned into SETMA’s EMR on a daily basis and a work-flow alert is sent to the provider so that the care can be reviewed.  SETMA also has two nurses assigned responsibility to review those records before they are scanned in order to update our records with:

• new or modified diagnoses
• procedure results
• medications changes
• need for addition studies or care.

 NextGen has a new function which we are planning to launch which will allow consultants who are not using EMR to send notes and communications through secure means about SETMA patients whom they are treating.  This will be  step forward in producing a Medical Nationhood out of our Medical home.

The discharge summary is the most important document in the patient’s care as far as continuity is concerned.  When SETMA creates a discharge summary, a post-hospital instruction document is also created for the family and when the patient is returning to a nursing home a post-hospital following instruction sheet is created for the nursing home staff.

The following is a de-identified discharge summary of a real patient. It is followed by the post-hospital instruction sheet to the family and one for the nursing home.

The following are the post-hospital follow-up instructions for the patient and family.

The following is the post hospital follow-up instructions which have been sent to the nursing home.

Communication Among the Hospital Care team

Each morning after rounds, a detailed electronic message is sent to the Medical Records team who document the physicians care in the discharge summary and places it on the hospital chart.  The morning report also includes information on care needed for patients in the hospital and those issues are addressed throughout the day by the hospital team who remain in the hospital from 7:00 AM to 5:30 PM. Between 5:00 PM and 800 PM an NP is on call and goes to the hospital to take care of any problems which arise or to admit any patients.  A physician is available and goes to the hospital also when needed.  From 8:00 PM to 7:00 AM a SETMA team member is physically in the hospital supported by a physician who is on call and available in a matter of minutes when needed.
 
Because all care is documented in a common data base, care is consistent and without interruption.  Tests results, diagnoses, medications, allergies and all of the other details of a patient’s care and/or condition are available to ALL caregivers ALL of the time.

Requirement Number 19.  The practice reviews post-hospitalization medication lists and reconciles with other medications

SETMA does post-hospitalization medication reviews in order to reconcile pre-admission medications, hospital medications and post-hospital discharge medications. This review begins at admission when a current list of home medication is obtained from the EMR.  The medications listed in the EMR, whether the patient came from home, the clinic, or the nursing home should be correct, but further effort is made to insure accuracy by verifying the current medications with the patient and with family.

Care is taken to identify the correct doses and the frequencies of medications to insure that the directions have not changed since the patient was last seen by a SETMA provider. Every effort is made to have the patient, or family bring all medications from home. . Patients and families are reminded about medications they may keep in the refrigerator, medications they may only take “as needed,” and medications prescribed by any provider outside of SETMA.  This added layer of review insures accuracy and avoids errors.

All hospitals keep a medication reconciliation form that records orders to continue or discontinue each home medication at the time of admission and at the time of transfer form one unit to another. On this same document, there is a designated area to be filled out by the discharging physician in conjunction with consults on the case as to what medications should be continued, discontinued, or re-started at home after discharge. When a medication dose is changed, the old entry is discontinued and the medication, with the new frequency or dose, is added. By taking advantage of the medication reconciliation form, SETMA is able to quickly assess medications and track any changes in the hospital.      

At discharge, a SETMA nurse reviews each discharge as they are notified to complete an accurate summary that records several aspects of the hospital stay, based on the physician’s documentation. This document will then be available via the EMR to any provider at follow up, at a home-health visit, at a nursing-home visit, for phone calls prior to being seen for follow up, and in the case of an emergency and the patient comes to the emergency room. Portions of the discharge summary are as listed:

1. Admitting Diagnosis
2. Discharge diagnosis
3. Review and update chronic illness list with any newly identified chronic condition or any condition not listed
4. Procedures with brief summaries ( CT Scans, Ultrasound test, Endoscopies, surgeries, angiograms, heart catheterizations, etc. )
5. List of surgical procedures with dates
6. Radiology reports
7. Summary of admit lab data along side the discharge lab data
8. Update and review of PMH and PSH
9. Review of systems
10. Physical Exam with current vital signs
11. Hospital course that includes dates of stay, sum of IV fluids given, IV medications given, ABX given, complications, interventions, and consults made with dates
12. Follow up instructions
13. Updated list of discharge medications

The discharge-medication review shows all medications as intended to be taken at home with dose and frequencies.  If there are any new medication given, a script will either be given to the patient or family, or sent directly to the pharmacy by e-prescribing.. Any medication that the patient needs refilled at that time will be given as well with no refills to ensure pt follows up as directed.  The computer-generated, printed, post-hospital, patient-instruction sheet lists all medications and their dosing instructions.

Every effort is given to monitor for any change that may be made by consults at the time of discharge in the event they see the patient after the SETMA provider. Because of the possibility of medications being changed by non-SETMA providers, every patient is instructed and encouraged to bring ALL medications to EVERY visit. This ensures a constant ongoing monitoring of a patient’s medication profile.  This is stressed to patients as a safety measure, and as a way for them to participate and be an ACTIVE part of their healing and ongoing care.

As part of the discharge summary a patient-summary sheet (see pages 80ff above) with follow-up instructions is printed out to be given directly to the patient or family. This instruction sheet will also have a current list of the discharge medications with doses, frequencies, and any special instructions. This printed list can be carried for times of emergencies when the medications are not available to be reviewed directly.

The resulting document created at the time of discharge will now be available for review at any time. This will give any service provider an accurate summary of hospital events, medications, diagnostic data, and medications. This is useful in situations when the patient or family may call prior to the follow up appointment, or in situations when an emergency may arise and the patient comes to the emergency room.

This data also has the capability to be viewed over a secure connection via any internet connection. It allows unsurpassed access to critical patient information in a multitude of settings: nursing homes, home health, therapy departments, diagnostic departments, not only during office hours, but also during times the office may be closed..

The information is literally just a password away.

AND 3 of the 9 Additional Requirements
Continuity
(None)
Clinical Information Systems

Requirement Number 20.  The practice uses an electronic system to write prescriptions which can print or send prescriptions electronically, clinicians in the practice write prescriptions using electronic prescription reference information at the point of care, which includes safety alerts that may be generic or specific to the patient (up to 8 specific factors), and clinicians engage in cost-efficient prescribing by using a prescription writer that has general automatic alerts for generic or is connected to a payer-specific formulary

We use a prescription utility provided by our EMR vendor, NextGen.  NextGen maintains and regularly updates our medication database with every current FDA approved medication and with all published interactions.

Prescriptions are written in the patient’s electronic medical record so they are attached to the patient data.  When a provider selects a medication to add it is automatically compared against a robust database of medication interactions, as well as allergy interactions specific to the patient.  If there are any known interactions with the new medication and a medication the patient is already on, or with an allergy the patient has, the provider is alerted and has to acknowledge that they are aware of the interactions and indicate whether they wish to continue or not.  The provider can then print, fax or e-prescribe the medication to participating pharmacies.

Thus interactions and/or allergies are addressed on the level of:

• Drug to drug
• Patient allergy to drug
• Patient condition to drug 

If ERx is used the medication request is transmitted to SureScripts and they in turn transmit it to the pharmacy.  This whole transaction happens within seconds.  Pharmacies can also send electronic refill requests straight to the provider.  The provider approves or denies these refill requests from their EMR workflow.

NextGen’s medication module displays generic and brand names of drugs and providers are able to authorize generics preferentially for all patients.  It is also possible to search the medication data-base based on a particular health plan’s, or a particular medical condition’s formulary.

Requirement Number 21.  The practice provides patients/families with access to an interactive Web site that allows electronic communication.

SETMA’s website (www.setma.com) has been a work in progress for the last 15 years.  It began as just a static method of disseminating information about our providers and practice.  It has since become much more.  It is still primarily a source of information for our patients but it has expanded to include hundreds of articles written by our providers on disease management, weight loss, men’s health, women’s health, child safety and many other topics under the section entitled Your Life Your Health.  These articles are principally those published in SETMA’s weekly health column in a local newspaper, which has been running for over 10 years weekly.

It has become interactive as well.  Patients are able to access online patient services on our website.  They are able to log on to a secure section of our website that is secured with a 128 bit encryption certificate.  After logging in they are able to fill out and submit forms to:

1. request an appointment,
2. request a referral,
3. request a prescription refill request and
4. inquire about billing issues

Once these forms are filled out SETMA staff are notified that a new request has been submitted.  They then logon to the same secure site to get the details of the request and pass those details  along to the appropriate department via secure email.  The request is then deleted to prevent patient information from being stored on our web server for longer than is necessary.

SETMA’s patients also have access to their providers through NextGen’s NextMD portal.  NextMD allows for secure communications between patients and providers. It’s integrated with NextGen so communications can selectively and easily be made part of the permanent record. It also features the ability for patients to complete forms “pushed” from the practice.  Forms like histories, satisfaction surveys or any other information we want to gather from the patient.  This information can them be imported into our EMR templates and permanently stored in our patient database.

Requirement Number 22:  The practice provides for patient access to personal health information such as test results or prescription refills or to see elements of their medical record and import elements of their medical record into a personal health record.

At SETMA, patients are routinely provided access to their healthcare records.  An electronically generated document of each patient encounter is available to the patient upon the completion of each visit.  This document summarizes the entire encounter including a list of any chronic conditions, active medications, details of the physical examination and even the patient’s most recent lab results, etc. 

Additionally, each of SETMA’s disease management tools creates a patient follow-up document that is given to each patient.  These follow-up documents contain information that is specific to the patient’s problems such as diabetes, lipids, and hypertension.  The follow-up document lists the patient’s as well as the physician’s compliance with published standards of care and treatment which allows the patient to evaluate not only their own progress but the performance of the physician as well.  These follow-up documents also discuss helpful lifestyle changes relevant to the patient’s disease.

Patients have access to parts of their record through our NextGen NextMD portal.  NextMD allows for secure communications between patients and providers. It’s integrated with NextGen so communications can selectively and easily be made part of the permanent record. It also features the ability for patients to complete forms “pushed” from the practice.  Forms like histories, satisfaction surveys or any other information we want to gather from the patient.  This information can them be imported into our EMR templates and permanently stored in our patient database.

Delivery System Redesign

Requirement Number 23:  The practice measure or receives data on performance such as clinical process, clinical outcomes, service data or patient safety issues, and the practice collects data on patient experience with care, addressing up to 3 areas

SEMTA monitors the performance of its physicians, staff and patients in numerous ways.  Clinical outcomes are routinely monitored through the use of disease management templates.  The hypertension suite of disease management templates provide specific treatment recommendations based on an initial assessment of the patient’s blood pressure and risk factors.  Throughout the course of therapy each patient’s blood pressure is tracked over time.  Physicians can use this historical data to monitor each patient’s progress and adjust therapies if the recommended treatment recommendations have not been met.

Both patient and physician compliance are monitored through SETMA’s diabetes suite of disease management templates.  Physicians are measured against published national standards or care for diabetics for the following measures: HgbA1c, lipids, eye examinations, flu shots, urinalysis, routine foot examination, blood pressure monitoring, aspirin use and regular office visits.  Patients are also held accountable for their compliance in taking an active role in their care.  Each patient’s responses are documented electronically for their compliance in the following areas: medications, follow-up, proper diet, diabetic education attendance, and regular exercise.

Data is collected on patient experiences with care throughout our electronic database.  Specifically, in our Diabetes Education suite of templates, patients are polled upon completion of the course and asked to give their feedback on the relevance, level and quality of the care that they received.  More importantly, patients are asked to comment on how their behaviors have changed as a result of attending and completing the Diabetes Education course.  These responses are documented electronically in the patients chart.  These responses can then be used to gather aggregate data for all patients and help tailor new, more effective ways of evoking patient responses to care.

Requirement Number 24.  The practice reports performance data to physicians.

SETMA monitors physician performance electronically in numerous ways.  One example is quarterly reporting of average HgbA1c by provider for diabetic patients.  In these reports each provider is given the mean, median, mode and standard deviation of the HgbA1c tests that they have ordered within the last quarter.  Physicians can use this data to monitor their own performance as well as compare their progress to physician peers.  Additionally, daily audits are performed to evaluate compliance with SETMA’s LESS (Lose Weight, Exercise, Stop Smoking).  This report is broken down by provider to show their compliance in providing each and every patient with information about making or continuing healthy lifestyle changes.  These are just two notable ways that SETMA can report performance data to its providers.

The use of disease management data is also monitored and when a condition has a critical data point, such as hemoglobin A1C with diabetes, that data point is audited and the results shared with providers.

Requirement Number 25:  The practice uses performance data to set goals and take action where identified to improve performance.

SETMA audits performance in diabetes, hypertension, lipids and CHF.  Based on the Consortium for Performance Improvement data sets, SETMA reviews provider performance as individuals and as part of a team. The following is a recent review on nine years of diabetes management which illustrates our compliance with requirement number 25.

“Average Hgb A1Cs over our entire population of 7,863 patients with diabetes mellitus (Obviously we have not had over 7,000 patients for nine years thus the reason for fewer test in the early years; ths data was report in August of 2008)

“The history of SETMA’s diabetes treatment is marked by three “breakpoints” – points at which there was significant improvement in the treatment outcomes for the population of patients we treat with Diabetes.  Historically, these were:

1. The designing and initiation of use of disease management tools for diabetes
2. The inauguration of an ADA approved Diabetes Self Management Education (DSME) program in SETMA
3. An endocrinologist joining SETMA.

“As we move toward improving out mean and standard deviation of treatment of diabetes, we are looking for a new breakpoint for 2009.  this breakpoint will be found by a combination of the first three, i.e.:

1. A renewal of use by nurses and providers of the diabetes disease management tools which provide both guidelines for excellence and self evaluation tools for providers built upon the Consortium for Physician Performance Improvement data sets.
2. An increase of utilization of our education department for ALL patients with diabetes treated by SETMA.
3. An increased referral of not-at-target patients to Dr. Ahmed for specialty care.

“If our providers start utilizing the Diabetes Disease management program every time a patient with diabetes is seen, even if they are being seen for some other purpose, we will see our mean and standard deviations as an organization and/or as an individual provider decrease significantly over the next year.  To that end, we are scheduling training sessions for all of SETMA’s nursing staff to refresh our nurses knowledge of and utilization of the diabetes disease management tool.  We will be auditing our nurses utilization of the LESS Initiate with all patients with diabetes, as well as their completion of the 10gm monofilament foot examination and the nursing portion of the Disease management tool.

“We will be empowering our nurses to initiate quality measures for patients with diabetes including:

1. Referring patients to DSME if the patient has not had education in the past two years.
2. Referring patients to endocrinology if their Hgb A1C is, one, above 8 or two has not been improving over the past 12 months
3. Referring patients to ophthalmology if they have not had a dilated eye exam in the past 12 months
4. Ordering labs:

1)       HgbA1C if it has not been done in the past three months
2)       Lipids if they have not been done in the past twelve months
3)       UA if it has not been done in the past twelve months
4)       Thyroid profile if it has not been done in the past 24 months
5)       Microalbumin if it has not been done in the past 12 months

5. Complete the immunization with flu and pneumonia vaccine of our patients with diabetes.
6. Encouraging our patients with diabetes to have a dental examination each year and referring them to a dentist if they do not have one.
7. Recommending a baby aspiring a day
8. Initiating the Lipid Disease management tool if they are not to goal with cholesterol
9. Initiating the hypertension management tool if the patient is not to goal with blood pressure.

“We will also be establishing a monetary reward system for our nursing staff who achieves certain quality standards in these measures.

“To create this breakpoint prospectively rather than retrospectively seeing it through our data, we will be auditing our providers daily – and publishing those audit – as to the consortiums standards of excellence of Diabetes management.  We will have training sessions with our providers to make certain that everyone knows how to use the disease management tools for diabetes, lipids, hypertension, cardiometabolic risk syndrome and the LESS Initiative (Lose Weight, Exercise, Stop Smoking).

“I expect that in 2010, we will look back to a very successful 2009 in the treatment of diabetes and will see a fourth breakpoint in our data.

The following is a report of hgb A1C by provider.  We regularly measure, report and analyze this kind of data for the practice and by provider.

SETMA has established a goal for 2009 of each provider decreasing their standard deviation, thus improving the results of SETMA’s diabetes care. As part of this process, SETMA is entering into an affiliate agreement with Joslin Diabetes Center at Harvard University. 

Requirement Number 26:  The practice uses electronic information to generate list to patients and take action to remind patients or clinicians proactively of services needed, such as patients needing clinician review or action or reminders for preventive care, specific tests or follow-up visits (up to 5 specific factors).

SETMA has generated numerous lists using the data gathered through its EMR to generate medication recall lists, call lists for follow-up on patients that need PSAs, mammograms, diabetes management, etc.  We also generate lists from our EMR daily to do appointment reminders for patients.

We will expand this initiative as we embark on our Medical Home to continue to help us manage our patient populations and improve the medical care we deliver.

SETMA has be ability to search our database on:

• Age
• Gender
• Chronic Condition
• Medication
• Outcomes
• Preventive Care initiatives
• HEDIS Compliance
• Provider Performance, as measured by any standard we choose
• Etc..

Requirement Number 27.  The practice uses a paper-based or electronic system for reminders at the point of card based on guidelines for preventive services such as screening test, immunizations, risk assessments and counseling.

In the EMR, SETMA has designed a health-maintenance template that is checked each and every patient visit.  It shows providers the last time a patient has had things like flu shots, PSA screenings, pap smears, CBCs, diabetic foot exams, eye exams, etc.  Any issue that is important to a patient’s long-term health.  Items that are passed due are presented in bold red to make sure the clinical staff takes note of the issue. 

We also have numerous pop-ups that appear based on data that is entered by the provider.  If the provider indicates in the medical record that the patient smokes, an alert will popup and remind the provider to discuss smoking cessation with the patient and their need for an annual chest x-ray.  When this is done, it automatically populates the HEDIS measures with the fact.

Another example is the patient’s body mass index.  When the clinical staff input a patient’s height and weight the patient’s BMI is automatically calculated and a pop-up indicates if their BMI shows they are at risk.  The provider will then use our weight loss templates to design a diet and exercise regimen for the patient.

As discussed and explained under Requirement 6 above (see above), SETMA has HEDIS measures built in to our Medical Home Coordination of Care Review template. This allows the system to collect HEDIS standards incidental to a patient’s care and it allows providers to intentionally review HEDIS requirements to make sure that their care is up to standards.  Also, this allows SETMA to audit provider performance and to report that performance to all providers. 

Requirement Number 28.  The practice uses a paper-based or electronic system for reminders at the point of care based on guidelines for chronic care needs.

SETMA's disease management tools for chronic care are designed using published standards of care such as the Consortium for Physician Performance and Improvement Dataset.

These standards of care measures are evaluated on the plan templates of each disease management tool.  If any of the key elements have not been addressed or are not within the accepted ranges, the template will alert the provider to address the outstanding issues.

For example, if a diabetic patient has not had a dilated eye exam performed within the last year, the provider will be prompted to create a referral for the patient to have a dilated eye exam.

Also, in the case of CHF patients, providers can follow a CHF treatment flow sheet which provides treatment recommendations relative to ACE, Atrial Fibrillation, Beta Blocker therapy, etc..

This is illustrated in SETMA’s care of diabetes, hypertension, lipids, and CHF in the tutorials which follow in Appendix A. (see below).  

Appendix A

These are the disease management tutorials for Diabetes, Hypertension, Lipids and Congestive Heart Failure which are reference in the section on CMS Requirement 11 which begins on page 40.

Each of the disease management tools reflect the “circular” causality concept of Senge’s work.  And, the disease of the templates allows seamless interaction between diabetes and its various complications and complicating factor.