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Your Life Your Health - Paternalism or Partnership: The Dynamic of the Patient-Centered Transformation
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James L. Holly,M.D.
September 19, 2013
Your Life Your Health - The Examiner

When you learn something new, and particularly when a light comes on and you “really” begin to understand that new idea, it is not uncommon for you to begin to see that the “new thing” has been all around you but you just did not recognize it.  And, so it is with patient-centric healthcare. 

SETMA began studying Patient-Centered Medical Home February 16, 2009.   At first the idea seem alien and in some ways even odd.  Over the next several years, SETMA began to transform our delivery of healthcare into a model which matched many of the elements of medical home.  We did that so well that we earned recognition by the National Committee for Quality Assurance (NCQA) as a Tier III PC-MH, the highest level of recognition offered by NCQA and we earned accreditation by the Accreditation Association for Ambulatory Healthcare (AAACH) for both Ambulatory Care and for Medical Home. 

Our commitment to this “new model” of healthcare grew until we determined to pursue accreditation by all four organizations offering medical home endorsement.  As a result, SETMA will submit an application to URAC within the month and in the first quarter of 2014 will submit application for medical home accreditation to The Joint Commission.   Once this process is complete, to our knowledge, we will be the only practice in the United States to have earned all four recognitions and/or accreditation.

The reason for going beyond one accreditation, which is typical, is that SETMA wants to learn as much as we can about medical home.   It will not be necessary for future generations of medical practices to be transformed into patient-centered medical homes, as they will be formed as what we wish to become.  SETMA was formed on an older model of care and because that older model is often contradictory to the medical home model, this transformative process is not easy and it does not happen quickly.

There are two aspects of this transformation. The first is structural; the second is dynamic.  The structural change, being based on electronic patient records and electronic patient management of patients, is essential and in some ways it is easier than the required dynamic change.   In 1999, ten years before we knew about medical home, SETMA defined both the structure and the dynamic of patient-centered medical home.  We just did not know it. 

In May, 1999, SETMA defined the principles which would guide the structural changes which would prepare us to become a medical home, at a time when we did not know the name or the concept.   Those principles were:

  1. Pursue Electronic Patient Management rather than Electronic Patient Records
  2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows.
  3. Make it easier to do it right than not to do it at all.
  4. Continually challenge providers to improve their performance.
  5. Infuse new knowledge and decision-making tools throughout an organization instantly.
  6. Establish and promote continuity of care with patient education, information and plans of care.
  7. Enlist patients as partners and collaborators in their own health improvement.
  8. Evaluate the care of patients and populations of patients longitudinally.
  9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets.
  10. 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.

Remember, these principles were defined over thirteen years ago.  If reiterated today, they would be slightly changed but for our purposes, it is useful to see them as they were stated early in our development.

Healthcare and Paternalism

These structural principles will only take SETMA so far in becoming a true medical home.  The next step is a radical change in the dynamic of care, a dynamic which will address how medical colleagues related to one another and how they relate to those they serve.  As will be seen below, five months after SETMA defined the structural changes needed for being a medical home, on October 1, 1999, we defined the new dynamic.  Under the old model of care, which we might refer to as a paternalistic healthcare system, patients were very often told what to do and it was expected that they would follow the healthcare providers’ instructions without modification.  The definition of “paternalism” helps understand the old model of care; it is:  “A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities.”

The dynamic of the medical home redefines the relationship of healthcare provider and patient, and changes how they relate!  Rather than the patient encounter being didactic (to lecture or teach, as one with knowledge instructions or informs those who do not) - where the healthcare provider tells the patient what to do, how to do it and when to do it - the patient/provider encounter becomes a dialogue (An exchange of ideas or opinions) - where the healthcare provider and the patient discuss a mutual concern and then together come to a mutual conclusion with a mutually agreed upon plan.  This new relationship is somewhat like a partnership.

Healthcare Providers No Longer Constables

The concept of a patient encounter being a dialogue where the interests and desires of both parties are respected and engaged is alien to the old paternalistic model of care.  The only way in which the patient-centric conversation in a healthcare encounter can be a dialogue is where patient and provider become collegial and where they entered into a collaborative relationship. 

On October 1, 1999, five months after SETMA had defined the structure of the medical home, SETMA published a booklet about EMR entitled, More Than a Transcription Service: Revolutionizing the Practice of Medicine And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management  (the booklet can be read at  In that booklet, SETMA said:

“Doctors need to learn new technological ways of organizing and conducting the business of medicine. They need to allow the power of information systems to change the way they approach healthcare. They need to maintain personal contact; patients are people first and last, but doctors need to see EMR as a powerful tool and not simply as a new and expensive toy. If they do, they will begin the 21st Century with an ability to impact the delivery of healthcare in America.

“Healthcare providers must never lose sight of the fact that they are providing care for people who are unique individuals. These individuals deserve our respect and our best. Healthcare providers must also know that the model of healthcare delivery, where the provider was the constable attempting to impose health upon an unwilling subject, has changed. Healthcare providers progressively are becoming counselors to their patients, empowering the patient to achieve the health the patient has determined to have. This is the healthcare model for the 21st Century and the computerized patient record is the tool, which makes that model possible.”

In 1999, we did not know that we were defining the most critical half of patient-centered medical home, i.e., patient-provider collaboration.  It would take thirteen more years before terms like “shared decision making,” “activated patients,” “patient engagement,” “patient-centered conversations,” and programs like “ConversationReady” would guide us to the fulfillment of the vision of patient-centered medical home.  In coming weeks, we will look at illustrations of the fulfillment of the dynamic of patient-centered care and at illustrates of how we failed to practice that dynamic.

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