PPC1 - Access and Communication

Element  A
·  Evaluation: SETMA is located in a predominantly English speaking area. Fewer than 1% of our patients have a language preference other than English; those are:

• Spanish -- we have Spanish speaking employees
• Pakistani -- we have Urdu speaking providers
• French -- We have French speaking employees
• German -- We have German speaking employees
• Vietnamese -- we have Vietnamese speaking help available.

SETMA's website (www.setma.com) displays all of our electronic patient management tools, our Public Reporting of SETMA's providers' performance on the following quality measures: HEDIS, NQF (multiple comprehensive measure sets, as well as individual measures) AQA, PCPI (hypertension, diabetes, care transition, CHF, chronic stable angina and others) and several quality measure sets developed by SETMA in the absence of endorsement by national agencies, i.e., comprehensive lipids, Chronic Renal Disease Stage I-III).

We routinely have patient see multiple providers in the same day and/or schedule multiple procedures on the same days as a visit. With our multi-specialty capacity (endocrinology, cardiology, infectious disease, ophthalmology, neurology, Diabetes Center of Excellence and ADA DSME program, in house reference laboratory, physical therapy, pulmonary function laboratory, bone, density, ultrasonography, echocardiography and stress echo capacity, allergy clinic, along with specialty clinics in dyslipidemia and hypertension), this is ideal for our total care of our patients.

As is explained elsewhere, in addition to helping our patients obtain resources for needed care, through The SETMA Foundation, SETMA helps make funds available for the care of our patients when no other funding source can be found.

·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

PPC2 - Patient Tracking and Registry Functions

Element  A
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: Our EMR has a function for scanned documents which is where reports of procedures and tests which are done outside of our system are collected. When they are placed there a link is placed the provider's workflow where the document is able to be reviewed and where the provider can sign that it has been reviewed and any necessary action has been taken. The same is the case for pathology reports, mammograms, etc. In-house reports on echocardiograms, ultrasound, bone density, pulmonary function tests, etc are also placed into the providers' work flow for review.

Our Medical Coordination Review template has a place for documentation that code status issues, advanced directives, etc., have been discussed with the patient and family and that the document has been scanned into our system when it is made available. At every visit, a sample advanced directive is given to the appropriate patients with instructions on how to complete it.

·  Recommendation: None
·  Private Note: None

Element  C
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  D
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  E
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  F
·  Evaluation: In regard to PPC-2 Element F Data Point 7:

SETMA has relationships for certain of our high risk patients with case management nurses from our IPA, our home health and several of our insurance carriers. We do not claim credit for this because at present, we do not have a systematic means of applying these benefits to all of our patient population. Throughout this survey tool, we have decline to take credit for this. In the future, we plan to have this systematized and in structured fields so that we can track this data and thus claim credit.

·  Recommendation: None
·  Private Note: None

PPC3 - Care Management

Element  A
·  Evaluation: SETMA incorporates national standards of care both as to process and outcomes into disease management tools for diabetes, hypertension and dyslipidemia. SETMA has adopted the standards of NQF, PCPI, HEDIS and AQA for the establishment of quality metrics. SETMA reports on provider performance on these measures and that performance is reporting on our website at www.setma.com under “Public Reporting.”

Annually, SETMA reviews the ADA's Diabetes Treatment Update (a 100-page documented published in the winter of each year) and updates any changes into our Diabetes Treatment Plan. SETMA regularly monitors the American Heart Association and the American Cardiology Association's updates on the treatment of hypertension and update our disease management tools accordingly. The same process with ATP-III and the AHA is done with lipids.

The files attached to our document list are the disease management tools which we use daily for these diseases. While they are extensive and thorough, they are efficiently used as we train our providers and nurses in their use. We have three-hour monthly training sessions for all of our healthcare providers in the use of all PCMH and disease manage functions of our EMR.

In addition, we audit our providers use of these tools, as will be seen later.


·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: Thje material in this note is also linked as a document so that the data is structured correctly:

In 1999, as SETMA moved from the pursuit of electronic medical records to the pursuit of electronic patient records (for more on this see Your Life Your Health at www.setma.com the section on "Medical Records"), we began leveraging the power of electronics to improve pateint care. Over a ten-year period, we saw our performance on diabetes care improve every year.

As SETMA has analyzed our treatment of patients with diabetes, we have generated the following data from our electronic medical record. This data represents treatment of diabetes over a period of eight years and shows a consistent improvement in the treatment of diabetes.

From 2000 to 2008 our average Hgb AIC values have dropped from 7.778% to 6.5378% which is a collective drop of 1.240%. As you look at this data, it becomes clear that:

Between 2000 and 2001, there was a significant improvement in the Hgb A1Cs.

Another improvement is seen between 2004 and 2005.

And, another improvement is seen between 2006 and 2007.

As we examined these results, we realized that in 2000, we developed our disease management tool. In 2003-2004, we introduced our ADA approved DSME program and in 2006, we were successful in recruiting an endocrinologist.

Going forward, our strategy is to increase the use of the disease management took, increase the use of diabetes education and to increase the use of endocrinology for difficult and recalcitrant disease.

As we developed more disease management tools, we realized that there were three life-style changes we wanted everyone of our patients to practice. We wanted them to lose weight, exercise and stop smoking, so we developed the LESS Initiative. In this program (for more see Your Life Your Health on our website), for eight years, we have assessed every patients’ weight with a BMI, BMR, body fat and an explanation of who much weight they need to lose in order too improve their health. We give every patient a written personalized exercise program and we address active smoking, secondary smoking and now tertiary smoking with every patient we see.

These and other screening and prevention programs for diabetes and hypertension, enable us to provide primary and secondary disease prevention for our patients.

The following is a further example of our analysis of our diabetes treatment plan:

Mean, Standard Deviation, Median, Mode

As we looked at the data and tried to draw conclusions about it, we realized that we needed more statistical analysis than just the average (the mean). We need to know the median, the mode and the standard deviation and we needed to know them by provider.

• For a data set, such as the HgbA1C values, the mean (average) is the sum of the observations divided by the number of observations. The mean is often quoted along with the standard deviation. In that case, the mean describes the central location of the data (often called the average) and the standard deviation describes the spread. The mean may be 6.5% in the case of Hgb A1C which is excellent, but if the standard deviation is 1.6, the range would be from 4.0 to 8.1. The 8.1% is not good.
• A median is described as the number separating the higher half of a sample from the lower half. At most half the population has values less than the median and at most half have values greater than the median.
• The mode is the value that occurs the most frequently in a data set.
The analysis by provider in SETMA's treatment of diabetes showed the following. (The provider names have been removed.) As is often the case the worst numbers were found in the case of the best physicians because they see the sickest patients. As you analyze data, you begin to be able to devise a plan for future efforts at improvement of care.

In addition to excellence of care, there are also many population factors, not under the provider's control, which affect the results of HgbA1Cs:

• The age of the patients - younger patients tend to have better control
• The activity of the patients - older patients tend to be more sedentary
• The nutrition of the patients - nursing home patients and elderly often are under-nourished and will thusly skew the HgbA1Cs downward.
• Socio-economic status - patients with lower incomes have more difficulty eating right.
• Educational status of patients - often people with higher education are more motivated and better able to understand the complexities of DSME.
• How long the patient has been a diabetic can influence the HgbA1C.
• How long the patient has been cared for by our clinic. It would appear - and we shall examine this - that the longer a patient sees us, the better their HgbA1Cs will be.
• There are other factors in the care of a patient with diabetes which have equal and possibly superior important to the HgbA1C, i.e, blood pressure, etc. We will be looking at those factors.

Analysis and the future - plans for a 2008 breakpoint

As you analyze the data above, remember that the higher the median (the higher the value which represents the midpoint of your data set, i.e., 50% of our values are above the median and 50% are below), the higher your mean (average) will be and in general the higher your standard deviation will be.

For analysis purposes remember that if your standard deviation is ZERO, the mean (average), the median and the mode will be the same. The problem with the mean (average) as a standard of excellence is that many patients will still be experiencing end-organ damage, even though your mean (average) may be below the ADA target of 7.0. The goal is to lower the standard deviation, the mode and the median which will be reflected in an improved mean (average).

With the treatment of diabetes, as with any other biological-system-based data-set, it will be impossible to have a zero standard deviation but the result of improving the care for each individual will be the decreasing and improvement of your standard deviation.

In planning for the creation of a new breakpoint in 2009, we believe that our improvement in the care of diabetes will come as:

• Our nurses initiate the utilization of the Diabetes Disease Management Tool - remember the first break point in the improvement of diabetes care in SETMA was the development and use of the disease management tool in NextGen. Our next breakpoint will be a combination of things including the revitalization of our use of the disease management tool for diabetes.
• Our healthcare providers use the disease management tool and measure their performance with the Consortium for Physician Performance Improvement data set which is built into our diabetes disease management tool.
• Also, the first thing every provider should review for ANY patient with diabetes is the date and value of their last HgbA1C. That is easily done as both of these data points are displayed on the front page of the Diabetes Disease Management tool along with all other critical indicators for quality improvement in the care of diabetes.
• We continue auditing the above again and publishing that data to all providers so that everyone can compare their performance with their colleagues.
• We query our system and involved all patient not to goal in diabetes education (Diabetes Self Management Education) and in specialty care.
SETMA's goal for 2009 is going to be for all providers to improve their median HgbA1Cs by .30 at a minimum. This new breakpoint will result from the understanding that we have gained from our data analysis. The first three breakpoints happened almost by accident but they will each be a significant part of our next breakpoint.

Remember, the better your data, the better your planning can be and the better your results can be. In 2010, we will report how we did in 2009.

·  Recommendation: None
·  Private Note: None

Element  C
·  Evaluation: SETMA providers function as a true team. Care is coordinated between each member of the team. Our staff satisfaction, which is routinely examined in dialogue feed-back sessions with senior staff, reveals that while our staff is busy with every high expectations, they enjoy their work. We have over 60% five-year tenure with our staff which is unusual for a medical practice. We expect that to grow.

Our nurses function within their licenses and under direction of the physicians but they have independent functions as described in this section.

·  Recommendation: None
·  Private Note: None

Element  D
·  Evaluation: The PPC-3 Element D General Document link to our application is a tutorial for Coordination of Care Review tool. It is present for context and scale. It is the backbone of the documentation of our coordination of care. The following documents are also linked to these measures: A sample copy of the document generated by this function is given in the linked documents entitled PPC-3 Element D Coordination of Care Review Document.

A sample of the plan of care and treatment plan for diabetes, hypertension and dyslipidia of a real patient (with the name removed). These documents give an idea of the extent of information we give to patients. SETMA has placed a printer in every examination room in order to facilitate the patient receiving education material, the LESS Initiative, medication lists, treatment plans, plans of care, disease management tools, coordination of care review and other documents essential to their care.

The Concept of the Baton

Athletic metaphors are commonly used in analyzing life situations. Often they are overstated and/or overused but there is one place where an athletic metaphor is apt in defining a critical point in healthcare: that is in the transitions of care from one venue of care to another. The metaphor is found in track and field relay races.

No matter how talented the members of a relay team are, the most critical point of their collective performance is in the transition from one runner to another. At this point, one runner, moving as fast as he/she can, must hand the baton to another runner, who has started running as fast as he/she can, before the first runner has even arrived in the "transfer zone." As if this were not complex enough, the rules of the race require that the transfer of the baton must take place within a certain zone.

If the baton is dropped or if the transfer is not made in the prescribed time, the team, no matter how gifted will be disqualified and will lose the race. As with life and with healthcare, it is not always the brightest, fastest, best person who wins. It is the person, in this case, the team, which not only performs well in their individual area of responsibility but who also performs well in transferring the results of his/her performance to the next participant and who does so within the constraints of the rules. Often, it is forgotten that the member of the healthcare delivery team who carries the "baton" for the majority of the time is the patient and/or the family member who is the principal caregiver. If the "baton" is not effectively transferred to the patient or caregiver, then the patient's care will suffer.
In healthcare there are transition points-of-care, where the "baton", which now represents the transfer-of-care responsibility from one person to another, must be smoothly, efficiently and timely accomplished, or the value of the care provided by each care giver will be diminished to the point that the overall quality of care may be less than the sum of the contributions of each care giver. This diminishing of the value of care occurs when only a small part of the value of each participant's contribution is successfully transferred to the next point-of-care. This occurs when the "baton" is dropped.

These transfer points or interfaces of care are:

1. From the healthcare provider to the patient in the clinic setting.
2. From the emergency department to the inpatient setting.
3. From the inpatient setting to the patient or family at home.
4. From the inpatient setting to the rehabilitation unit or the nursing home.
5. From one provider to another provider.

Integrated - Coordinated - Continuous

It may be that within each patient encounter, the level of care is "fairly good." When a patient is seen by a family physician, internist, or nurse practitioner, the quality of the visit as measured by the content is good. The same is the case with procedures, labs, specialty referrals, and other points of care. The deficiencies seem to come at the transition points, or at the interface of care, i.e., when the patient is leaving the clinic, emergency department, inpatient hospital, or other point of care and moving into another sphere of care.

The most common transition of care for a patient is the moving into the sphere of personal care, family care, home care or however you wish to define, describe or denote that the patient is "going home." Often instructions, training or understanding is inadequate or absent in these transitions. Whether the interface is between the inpatient/home, clinic/home, laboratory/home, procedure/home, specialist/home or a number of others, the patient's vulnerability and the decreasing of the quality of their care most often happens at these points.

Southeast Texas Medical Associates (SETMA) has attempted to create methods for improving these transitions (interfaces) with the following tools. Each tool can be seen as a "baton" which must be successfully grasped by one provider and passed on to another in order for the content and value of one provider's work to be available to another. Remember, in the list of the providers of healthcare, the one who spends more time giving healthcare to a particular patient is the patient himself or herself. The "batons" or the "transition tools" designed and employed by SETMA and the transition points are:

The rest of this discussion can be found on our website at www.setma.com under Your Life Your Health, Medical Home.

·  Recommendation: None
·  Private Note: None

Element  E
·  Evaluation: As previously noted, created is not claimed for disease management as SETMA does not have a global disease management capacity for all of our patients but only for specifically identified groups. We hope to expand that until it is global, but at present it only applies to our HMO patients and our Medicare patients.
·  Recommendation: None
·  Private Note: None

PPC4 - Patient Self-Management Support

Element  A
·  Evaluation: The data presented shows a very low score for the barriers of hearing and vision being assessed. The reason for this is that we discovered that we do not have a field to document that we have assessed these barriers and found none. We are adding that function and in the future, this data will be dramatically improved. At present the low numbers only identifies the percentages of our patients with hearing and vision barriers to care.
·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

PPC5 - Electronic Prescribing

Element  A
·  Evaluation: SETMA uses e-prescribing for all patients except:

1. Controlled substances which require a special prescription
2. Patients using mail order prescriptions (we hope to remedy this soon)
3. Pharmacies who do not accept electronic prescriptions

All prescriptions at SETMA are generated using an electronic prescription writer.

·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  C
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

PPC6 - Test Tracking

Element  A
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

PPC7 - Referral Tracking

Element  A
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

PPC8 - Performance Reporting and Improvement

Element  A
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: SETMA collects patient satisfaction data and reports that data to providers and on our website to the public quarterly. The report presented here is for the entire year of 2009.
·  Recommendation: None
·  Private Note: None

Element  C
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  D
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  E
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  F
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

PPC9 - Advanced Electronic Communication

Element  A
·  Evaluation: SETMA has chosen not to submit materials on this measure as our satisfaction of all of the elements of PPC-9 are in their infancy. We have an interactive website www.setma.com. We have a web portal www.NextGen.com both of which satisfy many of the elements of this Standard. We also are in the midst of launching NextGen’s Community Health Services which will enable us to communicate seamlessly with other organizations delivery and receiving electronic patient data in a secure, HIPPS compliant environment.

Rather than await all of this being in place, we chose to make our application now and to continue with our launching of these new and exciting functions and capacities.

PPC 9: Advanced Electronic Communications

The practice maximizes use of electronic communication to improve timeliness, effectiveness, efficiency and coordination of care.

Element A: Availability of interactive web site

The practice provides patients/families with access to an interactive web site that allows them to:

1. Request appointments by reviewing clinicians schedules
2. Request referrals
3. Request test results
4. Request Prescription refills
5. See elements of their medical records
6. Import elements of their medical record into a personal health record


Element B: Electronic patient Identification

The practice combines use of electronic information and clinical decision-support to contact the following types of patients, once identified by e-mail

1. Patients needing clinical review or action
2. Patients on a particular medication
3. Patients needing preventive care
4. Patients needing specific tests
5. Patients needing follow-up visits
6. Patients who might benefit from disease or case management support.

Element C: Electronic Care Management Support

For patients with the three clinically important conditions the practice care management team sues electronic communication for the following:

1. To communicate with disease or case managers about patient needs
2. Web-based education modules for patient self management.

·  Recommendation: None
·  Private Note: None

Element  B
·  Evaluation: None
·  Recommendation: None
·  Private Note: None

Element  C
·  Evaluation: None
·  Recommendation: None
·  Private Note: None