Changing Behavior for Better Healthcare

March 7, 2013
The concept of behavioral change is one that James L. "Larry" Holly, M.D., feels is necessary for any healthcare system to succeed. On March 5th at HIMSS13 in New Orleans, HCI Assistant Editor Rajiv Leventhal caught up with Holly to discuss effective strategies for moving forward in the new healthcare.

A little more than four years ago, James L. “Larry” Holly, M.D., co-founder of Southeast Texas Medical Associates (SETMA), in Beaumont, Texas, embarked on a journey to recognize his organization as a patient-centered medical home (PCMH), a concept that is becoming more mainstream in healthcare.

Around that time, Holly attended a lecture introducing the concept of the medical home. He left the meeting unclear about what being a medical home meant, but was determined to learn. Over the next 16 weeks, Holly expanded his knowledge base and wrote weekly articles on what he was learning about becoming a PCMH.

James L. "Larry" Holly, M.D.

STEMA would then perform a comprehensive analysis of its operations in an attempt to figure out what needed to change. Holly recognized that any new approach would require scrutiny of patient-care data in order to change provider and patient behavior.

“I realized we had to change everything we were doing. Typically, a plan of care for a physician was to tell the patient to take two pills and call back in a week if [he or she] was not better,” said Holly. “In this complex world, we need to get patients to partner with us. We want to be their collaborators, colleagues, and consultants. It’s one of the most principal concepts for the PCMH.”

The concept of behavioral change is one that Holly feels is necessary for any healthcare system to succeed. On March 5th at HIMSS13 in New Orleans, HCI Assistant Editor Rajiv Leventhal caught up with Holly to discuss effective strategies for moving forward in the new healthcare.

Where did this notion of behavioral change originate?

In 1996, I read “The Fifth Discipline” by Peter Senge. The book is about business but its concepts can all apply to healthcare. Senge said we have more information than anyone can learn, which is true in healthcare, more so than any other industry. He said information is changing more rapidly than anyone can keep up with, which is also true in healthcare. What we need is a change in mind, we need to re-think that learning is not so much taking in information, but instead changing our approach in how we do things. He really is the one that let us to radically change healthcare and build an EMR based on systems thinking.

Can you talk about effective strategies SETMA is currently deploying to improve healthcare?

The first thing we do at SETMA is track more than 300 quality metrics on every patient we see every time we see them. Quality metrics are like a medical GPS in that they tell you where you want to go. The problem is that people in healthcare don’t know where they are, so they don’t know how to get anywhere. People are afraid to look at where they are because they’re afraid they’re not doing well. In healthcare, we’re lacking that piece of knowing where we are. I’ve never been ashamed of not doing as well as I should be; I’d only be ashamed if when it’s pointed out to me, I’m not willing to change.

We then track the patients and audit them by population so we can do analytics on them. The analytics tell us where we need to improve and also tell us leverage points. We looked at how many medicines patients were on, how often they were seen, their ethnicity, their age, even their insurance. And with that, we discovered HMO patients had better care than those on the Medicare fee-for-service plan. We assumed—and have since proved—that was due to HMO patients having zero copay. There is no barrier that prevents us from seeing them as often as we want and vice versa. It costs them nothing. We also began to report publically by provider name on those quality metrics. That transparency has changed things—since nobody wants to be embarrassed or humiliated, [physicians] began to improve.

For us to know where we are and how we’re doing is imperative. Today, it takes us 26 seconds to produce a report of physician performance, something that used to take a month. We close our clinic a half a day each month and all of our providers come join a discussion on how to get better. Each day my staff gets a report that tells them how they did the day before. So real-time analytics become very important. If you tell someone his or her performance from one year ago, it will have zero impact. Right now, on the other hand, matters. Information and facts become operational and actionable when they are transformed into knowledge through analytics. It can’t be driven from the outside, through regulation. Transformation needs to come internally.

What advice would you give other practices looking to become a PCMH?

Look into your own organization for the creativity and energy to change, but also use others who have been successful examples as counsel. Don’t feel like you can’t catch up, because it’s very possible to do these things. I want SETMA to be seen as an example, not as something that scares people. Attitude is crucial, and that is what really needs to change. That drive that gets people up early in the morning and makes them exhausted when they go to bed will change healthcare. People who say they are perfect don’t impress me. I’m impressed by the person who says, “I want to be perfect,” and then moves in the right direction. 

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