- 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.
Segue to Successful Disease Management with Health IT
A 2005 Ambulatory Care Davies Award of Excellence recipient, the Southeast Texas Medical Associates, LLP (SETMA) has focused on disease management during the implementation of the EMR. James L. Holly, M.D. and Mark A. Wilson, M.D founded this group practice in 1995 with the goal of designing a healthcare delivery system that would integrate all of the various components of a family's health needs in a multi-specialty setting. The practice has grown to become a multi-specialty clinic with four clinical locations and a secure electronic medical record system for all patients. Clinical support services include a clinical laboratory, mobile x-ray services, and physical therapy department, as well as a number of Special Clinics.
Now SETMA is part of an American Medical Association (AMA) Foundation CARDIO-HIT study. Of the six practices participating in CARDIO-HIT, which range from academic, university-based programs to large specialty-based practices, the AMA staff said that SETMA “has the most expansive and impressive tools for fulfilling the goals of the study.” They added, “We have never seen anything like this anywhere.” (editorial note – SETMA did not continue in this study due to other commitments)
Links to more information from SETMA:
More Than A Transcription Service: The paper, written in 1999, looks at SETMA’s philosophy of “electronic patient management.”
The Less Initiative at SETMA: Read more about the practice’s approach to disease management: Lose Weight – Exercise – Stop – Smoking.
Electronic Patient Management:Read Dr. Holly’s presentation – Spanning the Specialties — at HIMSS2006 to learn about the design of an EMR from the perspective of “electronic patient management” and Dr. Peter Senge’s systems thinking concepts from The Fifth Discipline.