 Dr. James Holly is a distinguished alum of our medical school. He has been extraordinarily supportive of our school and its development and has been exceedingly generous over the years and is deeply involved in his own community and remains involved with us here in San Antonio. He is an adjunct professor of family and community medicine and he's the founder and CEO of Southeast Texas Medical Associates or CETMA. He has led his organization to adopt electronic medical records very early in the ballgame and his organization continues to be recognized for leadership and innovation in the area of health information technology. He writes and lectures extensively on health policy informatics and health care transformation. I can comment that last year our students got very active in a movement to promote primary care and Dr. Holly was present and providing leadership for that effort that our students initiated as well. And in 2012 last year he did receive the distinguished alumni award from from our university. So without further delay let me invite Dr. Holly to take the microphone. We've had one example of a walker and talker so thank you very much. I'm gonna let you keep this and so I walk for a really good reason and that is it's harder to hit me if you're gonna shoot me and I'm not paranoid just because you think people are after you doesn't mean you're paranoid. One of the things I have a habit of doing is answering a question that's been asked previously before I begin my talk and I want to address this issue about how do we deal with people who already have an infectious disease such as HIV and who then participate in high risk behaviors and develop syphilis or something else. One of the huge problems we have in in health care today is that if you're going to ask somebody to make a change in their life that will result in an improvement in their life that's going to change something that beneficial for them. It really is founded on the principle of hope. Progress is a relatively modern concept really it comes from about the 18th century where people really thought things could get better prior to that apocalyptic attitude was held by most the things we're gonna ultimately blow up and get worse and worse and worse and of course we went to a lot of that in the Cold War in the 60s and early 50s about nuclear holocaust but what we find in our our practice in dealing with people is that when we want them to make a change in their behavior for diabetes or for congestive heart failure or for sexual behavior that results in HIV or some other infectious disease oftentimes were unsuccessful not because they don't have enough knowledge but they don't have a fundamental concept that if they do make that change it will make a difference they really don't have hope and one of the things we deal with and struggle with every day is how do we invest a person with hope I want to give you two illustrations very quickly and not take too much of my time to talk about a subject today about four and a half years ago I went into a patient's room on Saturday morning I was on call and making rounds for my partner and there was a new patient there that had been our patient for about a month he had had diabetes for 10 years had never been treated to a goal he was losing his eyesight he was totally incapacitated had peripheral vascular disease and multiple other problems but what he really had was lack of hope he was angry hostile bitter and mean the nurses said you don't want to go see this patient I said I love people like that and so I went in the room and I did every song and dance I told him every story I did everything I could to try to to bridge the gap between his negative attitude about life and my perhaps exuberant positive one he wasn't buying any of it the next day I discharged him and I said I want to see you in my office personally and I did seem he was still bitter mean hateful angry but I discovered some things about him I didn't know in the hospital he was disabled he had no money he couldn't afford gas to come to the doctor or go to diabetes education he could only afford four of his nine medications he could not afford diabetes education the fees for that he was going blind but he couldn't afford to see an eye doctor he had no insurance no resources and no hope after making certain that his care was optimal I then went into because we're a patient center medical home both by N. C. Q. A. and by triple A. C. and we're in the process of applying for your act because we're going to get all four designations so then I can write critiques with authority about all four and hopefully move this whole process of patient cinematic home to where it ought to be and now we he left there that day with our foundation every year our partners give a half million dollars to our foundation from which we pay for the health care of our patients they can't afford it none of that money can come to us but it goes to others who won't see our patients if they can't be seen if they can't afford their care we paid for his medications we gave him a gas card so he could come to the doctor we waved the fees for the DSME diabetes self-management education program this ADA approved that we maintain we got him an appointment in Houston and an experimental program for eye preservation our care coordination department began working with him they helped him apply for disability and it seems like there are a couple other things that we did he came back six weeks later and for the first time in ten years his diabetes was treated to gold but more than that more importantly I had something I can't prescribe he had hope he had joy he was happy he was positive he was making changes in his life for the first time because he really believed there was life after diabetes he has been my dear friend since that four and a half years ago and I would love to a lot more stories about him because he is that he's our patient centered medical home poster child just a great story but medicine didn't change his life knowledge didn't change his life what changes life was hope that he thought there was really a life after diabetes and if we're going to change people's lives who are HIV positive or who are participating behaviors whether to get other infectious diseases that we all know will destroy their lives somehow we're gonna have to invest hope in them another story very quickly not too long after that I went to the hospital early as is my habit and I was going to see a patient that I'd not known but was on the HMO that I'm the hospitalist for and the nurse said you can't go in that room I said why so well he said he's gonna kill the next doctor the walks in the room well that was a novel concept to me I've known doctors I might wish to do that too but I wasn't one of them and I said does he have a gun and they said we don't think so I said good let's go see well they got two burly guys by the time I walked down the hall and these two huge guy I don't know what they did in the hospital but they were they were bruises and they walked in behind me and here lays in bed a little mousy guy I mean you know milk toast Marvin if you will and and I looked at him I thought this guy is gonna threaten to kill somebody you know there's two option you can have you can go in and try to help him or you could call the cops and put him in jail because what he committed was a crime and I looked at him I said may I listen to your lungs and he looked at me like what I said may I listen to your lungs and he said yes you know what had never happened in this man's life he had no personal autonomy had no money no friends no family no job no future he had no hope and the one thing he had power over was his body and an attempt to establish power autonomy personal dignity he had said you're not gonna touch me without my permission but he had never verbalized that he just did in hostility and for the first time somebody said to him may I touch you if I did to you what we physicians commonly do to patients I'd be arrested because I would be assaulting you I'd be in your personal space I get closer and closer and before long you'd slap me and say move away boy and we do that routinely and we commonly don't exercise the question but patients give their permission but in this case he wanted to give permission for specifically I listened to his lungs and I did something I don't do very well I listened to him for as long as he wanted to talk now you do have to understand I don't have ADD but I have a short attention span and I've been married 48 years so the same lady and I haven't listened to her for 30 minutes in 48 years probably collectively and I stood there and listen to that man for 30 minutes and I just was I wasn't gritting my teeth physically and I was gonna listen to him as long as he wanted to talk and when he finished I'd been thinking about one thing how can I empower him how can I give him a sense of personal dignity a sense of personal work worth autonomy in his life and I knew I needed to give him power over something the only thing I had the ability and the power to give him was power over me so I gave you my cell phone number I said call me anytime you have a problem about anything well be careful what you say because you may have to prove it for the last four years our foundation has paid his parole fee or the probation fees which we think is a part of patient center medical home well he has never abused the privileged economy but his his self-esteem and his self-worth went up a skyrocket he had my personal he had personal he told his acquaintances his neighbors I've got dr. Holly's cell phone number I can call him anytime and he does but he never has abused it it's never been an intrusive but his life has changed dramatically not because of medical knowledge not because of his information and knowledge not because we pay for his medication and all the other things he needs but because he has a sense of personal worth and he has hope I don't know how to do it for everybody but I know if we're gonna change people's lives somehow we've got to give them hope that there's life after illness there's life part of it is how we address them you know we don't have we don't treat any diabetics in our practice we're a Jocelyn diabetes affiliate Jocelyn's at in Boston at Harvard and we're the only multi-special group that's a formal affiliate of of Jocelyn we don't have a single diabetic in that in that practice although we have 8,752 people who have diabetes but none of them are diabetics they're not defined by their illness people who have HIV aren't HIV positive they're human beings who happen to have an infectious disease well that's not my subject today but it's so important that we refocus our attention on what makes people tick and what makes them tick is personal seeing self-esteem personal value a sense of personal worth and if we can't give them that in some way and I've written some articles on that because I think about it a lot about how can I can help someone have a sense of personal worth and you all deal with that every day but we need to think about it and we really need to teach one another how to do that and then go out and do it well let me get to our subject and that is the ethics of infectious disease and our our screening of HIV in our practice my grandchildren come to our practice and they're screened my wife comes our practice I'll show you a video a little bit later if we have time of I had my HIV test drone on public television live TV just so that people know that even physicians need to be participate in public health initiatives because if we have public health initiatives unless everybody participates we've diminished the value geometrically by every person who refuses to participate the the first thing I want to comment about is that ethics and economics are a major issue in fact as this states the World Health Organization talks about this so 1090 divide where 10% of medical research is devoted to diseases that affect 90% of people and that really is the case we we have done we have done more research on how to perform plastic surgery to augment or D augment or re-augment of various anatomical features on people's bodies than we have on many other things that affect tens of millions of people the next the infectious diseases have affected people the black death killed one third of the European population in the 14th century and eight nine 1989 well they get to close to home the flu killed between 20 and 100 million people nobody knows how many smallpox killed more three times more people than that developed that that had we killed in wars in the 20th century AIDS multi-drug resistant tuberculosis and things such as SARS and the new SARS that's coming out right now continue to have dramatic consequences and yet we don't really have a clear ethical principle about where we allocate resources for what's really affecting people you know we there's a new phenomena in the world that I am a very public opponent of is concierge medicine my dearest friend as I grew up call me one day and he said Larry he lives in Colorado my wife's doctors is going to become a concierge doctor and he said if she'll give him a $1,500 he'll give him give her his cell phone number I said 409-504-4517 he said what's that I said I just gave you my cell phone number send me $1,500 you know the how do you take 80 to 90% of your practice say I still have Easter baby and he got no more time for you I've got people that can pay me real cash up front and I'm gonna triple quadruple my my income and I'm gonna cut my work in half I'm gonna cut it down by 90 or 95% they the whole idea we're trying to do is increase access to care I believe that health care is a human right Don Burwick taught me that I used to say that that health care was a right of citizenship and that was a good idea but it left out a lot of people and I began to realize and I said well it's a health care ought to be a right of residency in this country there's a debate going on right now and a big feud about whether illegal immigrants ought to have access to our health care I don't care what your principle is but mine is this I don't know a child who I would deny care to and until I meet that child I can't limit access to care by anyone but Don Burwick was speaking one day and I heard him and I he said health care ought to be a human right and I suddenly realized that really includes a lot more people than residents or non-residents includes everyone and I believe that now as a social liberal and a fiscal conservative I get in lots of trouble I think we got to figure out a way to pay for it and I'm happy to help discuss ways to pay for it because I think there are ways to pay for it effectively but we start with the principle that everybody ought to have health care here public safety security and liberty a second reason why the topic of infectious disease deserves further attention it raises difficult ethical questions of its own in fact infected individuals can threaten the health of other individuals now change the the slide this is the dissident difference between a utilitarian and a libertarian utilitarians want to figure out how to promote public health and they really don't care about how they do it if they need to lock you up some of you are old enough as I am to remember when people had to be they would somebody would go to court and lock you up for a year and and you had no choice in the matter now you say well that that advanced public health but it didn't do much for human rights did it and then of course libertarians say nobody should ever inferior anybody else's life well I'm not advocating that I'm just saying here's the delicate balance in the whole issue of ethics next the burden of infectious disease is most heavily shouldered by the poor always every disease but particularly infectious disease living circumstances resources information knowledge the hopelessness why should I make a difference me ask you something which one of you would control your cholesterol control your blood pressure if your greatest hope is that you not be killed in a drive by shooting that day and that that is your only hope that you've got that you don't get shot that day well that's we have a lot of people living in that kind of environment maybe not a majority of people or even a large minority but we have to deal with people who have that sense of hopelessness and if we're going to ever change and the poor often have that sense of hopelessness next we've got to realize that people who have infectious disease are both victim and vector they they have the disease but they also have the capacity to pass the disease we're going to comment in a moment and you all know this it's been said today 72% of people that pass on AIDS don't know they've got it to begin with or 72% of new cases are caused by people don't know their HIV positive well that's the whole idea the bioethics has failed to see that the patient is both that victim and that vector great paper that's referenced for you there since the late 80s when HIV really became a real issue we've really wanted to help control it by identifying people who have HIV so they can be aware we had a notable case in our community of a physician who had family and declared himself an alternate lifestyle and and changed his lifestyle he was accused of a crime he was my friend so I called him one night when I found out about it I said I want to help you if I can I don't agree with your what you did but I'm not gonna abandon you he said this he said Larry I knew if you abandoned me I had no hope it was shortly after he was convicted and was awaiting sentencing discovered he was HIV positive and everybody ran from him I would have lunch with him and befriend him and the rumors around town were were were amazing look at him he is he is keeping company with that criminal that child molester I wasn't keeping company with a criminal or a child molester he was my friend he was a human being he deserved the care and affection that we could appropriately give him we're not embracing what he did he had rapid onset of not just HIV but of AIDS related disease unless then a year later my wife stood at his bedside holding his left hand and I stood by holding his right hand as he breathed his last abandoned by everybody but he did not die alone and he did not die without hope though he did die and as I as he breathed his last I looked down and his fingernail was bleeding and his blood was dropping on my hand my wife kind of was startling I said don't worry I went in cleaned it up watched it carefully I'm not going to be passive about that but I said Carolyn here's the deal I think the probability of me developing AIDS from HIV positive from this is so remote is not worth discussing but if I did would you change what we've done and caring for this man and loving for him giving him hope in the midst of hopelessness and he said she said no and I said neither would I but we want to know who has HIV next prevention is the best you know the best way to treat diabetes I can give it to you in a very short summary don't get it and there are some types of diabetes that you have the choice John has a great story about that but I can't tell it to it's not vulgar but I just can't tell it mixed company misunderstood but they about the the behavior patterns that develop people help people develop diabetes but just don't get it and the best way to treat HIV is what don't get it and and there are effective ways of working getting it and the ethics of infectious disease is that we've got to we've got to take responsibility for ourselves and we get others take responsibility for themselves and there is in Chicago and the Museum of Natural History there's a checkerboard and it has a kernel of corn on one square and the question is asked at the bottom if you and this making a lot of noise I know if you double the corn on each succeeding square how much corn will you have on the 64th square they might know you would have enough corn to cover the subcontinent of India eight feet deep that's the geometric progression principle so if you influence one person and I influence one person that's two and then four and eight and sixteen and sixty four and if we don't influence somebody every six months in seven years we reach the entire world I'm gonna stop this okay do you have the microphone that's just irritating me and I know it's irritating okay all right here we go and so if we each carry the message of learning do argue HIV positive then others will learn and if we each are tested let me ask you a question I asked in Austin at a recent meeting how many of you been tested for HIV raise your hand okay that's good but if you haven't been then you need to be not because you think you have HIV but because you're going to only be able to encourage others do what you've already done yourself and when I tell people I had my grandchildren tested whom I have eight did I mention them I'll resist that my time's gonna be over next John the next slide here's why people don't get tested and the one I want to focus on is the second one the doctor never recommended it it's amazing the influence that we have in health care people will do what their doctor tells them to do even if it doesn't make sense and that's why we have so much power when we have to guard it how we use it so carefully my mother is always adored doctors and thought they were wonderful and I graduated from medical school and she had to reconsider they but she still thinks doctors pretty special next the ethics of HIV screening public health and issues will not succeed without participation participation of all members of the public ethics involves making right and wrong moral choices in particular in regard HIV testing ethics dictates that everyone should be screened in regard HIV screening the moral behavior is to be tested and it is an ethical issue it is a moral issue it's the same as you won't go up and strike someone you'll respect their person you need to respect their person might be in tested and then you can encourage them to be tested I well I was doing my pre-med work in Waco I saw life insurance it's the only thing I've ever been good at that I was ashamed of and I that's a bit of a joke but I was really good at it and when I finished medical school and I was working in Clifton Texas one night a lady came in delivered a child the child was in extreme extremists took care of the child and then fortunately the child passed away I'm sitting with the family and I said you know I hate to say this and this crisis but I'm I know you they said yes six years ago you show sold as a life insurance policy that will help bury our child that's a remarkable coincidence but but even I was I was really good at selling life insurance but the while I was in for the life of me I just forgot why I'm telling you that story good I'll think over a minute what what oh thank you exactly right if I didn't have a life insurance policy on myself if I didn't believe it enough to take life insurance protect my family I couldn't sell it somebody else so if you won't have your your you if you won't be tested you won't have your family tested you won't have your friends tested then you can't get anybody else to be tested but if you would be tested then then you can get others to it go ahead the next next side ethics is the rule of conduct recognized by society morals is your personal conduct and your ethics are dictated by your morals and we could talk about this all day long I did an undergraduate degree in history and philosophy and masters in history and so philosophy is very important I I don't do things I don't understand the reason for them and philosophy tells me a lot of reasons why I should do things now go ahead next regardless your age you should be screened and after age 13 your children should be screened and going down the CDC you all know the recommendations I won't read those go ahead again the routine testing benefits everyone and no one has the right to act unethically and everyone is obligated to conduct their health in a way that contributes to the good of the community by being tested by allowing your children to be tested you advance the good of all even when you are negative for HIV your participation screening adds to the public health and we got to understand that sometimes people say well we've tested a hundred people and all of them are negative should we stop testing no because you can't extrapolate from a small sample to a large population next they the majority of HIV is transmitted from people are aware of their HIV status and this slide tells you that next they are an evolving approach to HIV screening it's over the past five to seven years emergency departments have been really good at increasing HIV testing as I talked to doctors around the country when I travel and speak I started asking them do you do HIV screening I'm really pleased to tell you that a lot of them do regularly and routinely but barriers still exist at patient provider and systems level next the patient perspective they'll most of them will accept HIV screening if we recommended it but some many of them are say they don't need HIV testing because they they don't believe that they have been exposed or they're afraid that they have been exposed and they don't want to know the only thing can hurt you and life is what you don't know the only people that today that will die suddenly from HIV are the people that don't know they've got it you know you can live a pretty normal life with HIV if you know it and so the ethics as you get next from a provider perspective concerns about lack of time to offer the test concerns about ability to facilitate linkage to care there's no good reason for providers not to know even if you fail in the next two steps you still want to know next the barriers HIV system barriers their lack of champion somebody will take responsibility to say this is good that we need to do it provider administrator education understand importance and value of HIV screening I was in Boston last year at the message medical society and the first speaker asked how many tasks can you get a doctor to do it each visit and the there was a big discussion I was a third speaker and I was gonna have an hour to speak and so I just kept quiet because I would answer the question the whole group when I got up to answer I said let me answer your question for you you ask and he said one thing I said you have to answer three other questions for you can answer that one question you have to ask how important is what you're asking them to do and how much time does it take how much energy does it take if it's very important and if it's not it doesn't take much time and it doesn't take much energy and time and energy are different measures then you can get them do a lot of things we ask our providers to do about 40 things at every visit but they take one second or less or sometimes they take no time at all and I'm gonna show you in a moment in reporting infectious disease to the state I was doing a CME class at Texas Ending University School of Medicine and I wanted to go home because I'd been in Austin speaking and speaking there I wanted to but it was a small meeting and Dr. Sherwood who is infectious disease professor there and you probably are familiar with Dr. Sherwood he was speaking on the ethics of infectious disease this none of this is his material I I did read his material but none of it really was relevant for what I wanted to say but I didn't want to walk out because I thought it'd be embarrassing so I sat down and listened best CME class I've ever heard in my life and he passed out a sheet of paper they had the 78 infectious diseases that physicians are are accountable for reporting to the state in Texas I've asked every doctor I've met send it can you name those well they can get about eight and they start wearing out I can't name them either I called John it was a Saturday I said Monday I want these in the EMR I want to template with all these on them and I want the following things to happen when the diagnosis is made I wanted to automatically populate that template automatically send a message to our care coordination department automatically have them report to the state and then report back to the doctor who's been reported you know what the doctor had to do make a diagnosis nothing else it took no time no energy and it was very important and guess how much frequency with which we report those 78 conditions a day 100% of the time provable because we system and ties an issue that was very complex and so if it doesn't take much time and it doesn't take much energy and it's very important you get them do a lot of things HIV testing is like that is it important absolutely can we systematize it so that it doesn't take much time yes I believe we can and where it doesn't take much energy and consequently I'll show you our performance in a bit they we're about to even take it further I was reading recently about some of the work at IBM in 1993 when they were in real trouble as a company they're hired a new CEO and they hired some people they called change agents and they made some radical changes that radically changed IBM put them on a course to renew their their companies vigor and I began to wonder how can we make such radical changes in health care and I thought you know there may be a way we can do it and we might be able to do it right here in Texas and that is to look at every process everything we do as primary care positions and see how many of those things require physician or human attention and how many of those things that don't and can we systematize can we automate all those things that do not require human attention we close our practice for a half a day every month and and for four hours these guys sit there and ladies to sit there and listen to me talk I like to talk and they they have to listen they and I asked him I said which one of you would be insulted if your patient has diabetes and needed an exam if we ordered that exam before you saw them who would be offended whose professional integrity would be compromised nobody raised their hand I said would that be okay with you said yeah so John and I for the four and a half hours this morning from 3 a.m. until we got here at 7 30 we talked about and we designed that program and we think I thought is going to take two years we think we can do it in about four months when a patient makes an appointment the computers are going to go out and look at that patient's whole chart and if they have diabetes and they haven't had their hemoglobin C in the last 90 days it's going to order one if they have diabetes and they haven't had not have not had a 10 middle 10 gram monofilament foot exam it's going to order one if they haven't had their dilated I exam it's going to order that and so if they have CHF they've had not had a echocortogram in two years it's going to order that so when the patient comes in they're going to be handed a sheet of paper to say the following things have been ordered for you and this is why it's going to be written in plain English or Spanish if they speak Spanish and it may be three pages long but you know what happens when you give a patient something that has their name on it and their data and their health care plan they read it you tear something off piece of paper they'll throw it away just a tear sheet and so I think we can take about about 35% of the time physicians have to spend and health care providers have to spend in taking care of the routine ordinary mundane things that are evidence-based medicine driven but don't have to be done by a person and we can expand the time the doctor can spend with the patient and yet we can improve the quality of care it's going to be exciting and I'll be glad to send you a note to tell you if we really succeed but I think we're gonna be able to do it the and HIV testing is going to be part of that and we'll give them the opt-out option and that'll probably be the first thing because that's going to be one of the few opt-out things the rest of them they they're gonna do it or else they the okay let's go to the next this slide all right here we are with at our HIV program and I've got a few minutes to go through this to go to the next what we did is we have a pre-visit preventing screening this is where you start around and surrounded in yellow we start every visit there now go to click the next when the button outline well it serves to let yellow here but it's really green is it deployed it launches set must pre-visit screening any I go to the next any item in red and these colors don't show true here but if it's in red it applies the patient needs be done if it's in gray it doesn't apply to the patient if it's in black it applies the patient and has been done but here's what we added when we started our HMI screening program we just added has the patient been screened at least for once for HIV ages 13 to 64 and a testing not required patient refused testing tested elsewhere if diagnosis confirmed and it if they haven't been screened and they are eligible you click this button order HIV screening three things happen it sends it to the lab to order the test it sends it to the chart and it sends it to charge posting a single click and a complex task has been reduced to a single I mean how long is that millisecond so we've taken a complex issue we made it easier to do it right than not do it at all the and next and then go to the next then we found it a few of our more ingenious staff was just rather than going through the process just checking if the patient refused and we we started that out by calling a bunch of patients and they said nobody asked me and so we then invited them go ahead next to come in and know and have them be tested because we've used the same EMR in the hospital as we do in the clinic when the hospital in Beaumont you saw the Beaumont numbers up there that's our hospital Baptist Hospital and when they do an HIV test we don't want to repeat it so we just put it in our EMR and document whether it's positive or negative and so that the collaboration between the hospital and the clinic and so when we send a patient the hospital it documents that they had been HIV tested and they so the hospital doesn't have to do it and we have a lot increasing population density of our our program go ahead next go ahead next the in this it just says that the same time we developed the HIV clinical decision support to which will we develop the the compliance of the Texas state reportable conditions go to next and now next I've already told you that story next alright here's what happens this is why we report things to the Texas state I'll just illustrate it for you we have the the diagnosis made measles without complications on the assessment next go ahead next it automatically this is the deployment of 78 conditions it automatically puts it there the providers done nothing the providers gone doing something else and the next and the next next and this is just where the reportable conditions if you want to look at it is on our in our EMR next and then you can click to download the form next this is the next this is the form that we can the goes to the care coordination they then do their thing and then report it to the state next and and it deploys a printable version of the initial provider disease reporting form next which is clicked up there I this that slide was out of order here's the report it can be fax emailed or called next next now let me tell you about our program and how we've tried to promote it I write a health column every week and have done so for 14 years and two of the columns were on our testing program and that's where they are May 26 in June the 2nd 2011 next they our public policy journal journey the progress is slower than I thought it would be I thought we could do it really fast and be right up to snuff next they the deployment events the one provider said I found every patient of a group age group I mean able to be tested another one said that the patients were resisting because of having paid for it I said in the mail email August 10th may appeal to you to initiate the HIV testing I didn't copy the second sentence was your firstborn child will be in jeopardy if you don't I have found that oftentimes threats and abuse will do my good that with doctors now nurse practitioners are much easier to get to do things next one of the questions the patients are asking is who's going to pay for it we told them if you don't if your insurance doesn't pay for it we'll pay for it's not gonna cost you anything we started to participate in the CDC program but it was too complicated so we set aside $60,000 that we were willing to invest in this program ourselves at the end of the first from 2 July 2011 to January of 2013 we had spent 59,000 in change on testing we'd collected $57,000 in change from insurance companies so we were down about 2000 we expected to spend 60,000 it cost us to so we were way ahead of the game next and these are the insurance companies we found that would pay for it next the next these are the results for 2011 2012 and for January through April 2013 and we report by provider name on our website we reported over 300 quality metrics by provider name for 2009 10 11 12 and the first quarter of 13 at the end of June will put up the first half but you can just go here and see how did how did this character do Holly well he's still 12.5% down but it's getting better this is how many what percent of time I did HIV testing on patients that were eligible for testing 87.4 we have one of our nurse practitioners 93.4 but some of our doctors were not these are new doctors by the way I'm sorry that that and you can see in our total clinic was 66.2% we'd like to see that over 85% and we think by the end of our third year which will be July of 2014 that we'll be there having 85% next we followed up on those who refused testing we wrote them a letter and it was amazing the results that letter because many of them called and said no one asked me and they came in and were tested so we've had multiple ways that we've tried to get this move forward next John we made public appeals in October of 2011 hide my blood drawn and John is the next one the yeah we're gonna show you a 60-second or about a 60-second this is okay this is there drawing my blood on TV this is live television if you're not getting audio after and war and how important it is and I wanted people to see that doctors practice what they preach and what's happening right now is Courtney trailer one of the 18 phlebotomists that sent my is drawing my blood and that they're gonna run a HIV test on me and next week we'll report the results so this is actually what you do right now for HIV test absolutely what's happening if everyone in Beaumont were tested we would expect to find 40 or 45 people who have our HIV positive that don't know their HIV positive many of them would not have high-risk behaviors and would not expect to have HIV positive the reality is that you can live with HIV you can live successfully you can live a normal life there was a time when you might not want to know because it would come a death sentence you know 30 years ago but that's not true anymore and so you really want to know my grandchildren come to my clinic they get tested everyone gets tested the only way public health initiatives are beneficial is if everyone participates and next week I'm going to volunteer for all the people of Fox 4 to be tested now there's results we kept confidential but everyone should be tested you know what you don't know as you talked about last week is the only thing that can help it can hurt you if you don't know that you have high blood pressure if you don't know you have dyslipidemia if you don't know that you have diabetes and there are millions of people have diabetes don't know it if you don't know that you're HIV positive we have the benefit and the blessing in this community that we're very concerned about screening and preventing health care of preventing health care and that's where the difference can be made if you have it you need to know it and do something about it because like you said you can live you know the medicine and so many things has come so far I mean we're seeing right here what you know this is actually out of one of the set my offices so tell us about you know how how advanced all this stuff is and it's about saving lives would you go ahead and do the test which I mean would you draw my blood oh you've already done it I didn't even realize it I didn't feel a thing Courtney's trailer is our friend here and she'd love to draw your blood going she's from friends of mine we're gonna cut that one off and go to the next week this is the follow-up the next week I told him I was gonna tell him my results but listen and joining us now is Dr. Anwar of Southeast Texas thank you for joining us today it's a pleasure well and last week Dr. Holly kind of freaked me out a little bit because I am who's the other side of blood but it was for a good cause of course I he did get an HIV test so do you have his results actually I do but much more importantly I think the philosophy is important part what Dr. Holly showed last week was that is important checked for HIV in the olden days people thought HIV is like a death sentence but not anymore you can have a normal life I was supposed to announce his results but Dr. Holly sent me a letter to tell the folks why he's not giving results okay and let me read if I may okay today it is possible to live successfully with HIV prevention is still a goal you need to know it if you have never been screened go to a health department department your personal health care provider or to SETMA it is a thing to do for yourself and for your community after having my HIV test drawn on live television on October 26 2011 I announced that next week the result will be revealed on television but it occurs to me that if I announce my result and if it is negative then others will be forced to reveal their test results in what would which is actually a very personal issue which I totally agree if everyone that has a negative result reveals that then those who don't will involuntarily have their results be considered as positive or people consider that as positive and that obviously will have an impact on men who desperately need to be screened as another barrier to the participant in the screening consequently I'm not going to announce my test result and I will encourage other people to probably announce do not do to publicly announce their outcomes whether positive or negative we are all in the public health together whatever the state of our health we need to know that I that they need to know that I choose to join the overwhelming majority of those with whose HIV status is known to the health care provider and their loved ones together we can continue to push back the fear and the self-imposed ignorance knowing that that is what that is what you do not know cannot hurt you as opposed to what the only thing that can hurt you is the thing that you do not know I would encourage all health care providers public officials educators ministers everyone to be tested announced to everyone that you've been tested results will remain confidential encourage all those who lives have their influence like me for example I totally agree with that I think showing up it was a remarkable realization for me that to report my test results which I won't tell you whether it's positive or negative I shouldn't do that because it would be a barrier to those who really need to be tested that perhaps they wouldn't and so it's confidential it was a it was I was glad I said that because they gave me opportunity to contrast it I'm sorry Dr. Anwar didn't read that quite so eloquently but it's the whole principle is that part of our public policy is we want to to show that we're going to be tested but we're not telling anybody what the results was what's the next slide various a patient participation go ahead we've already gone over that go go past that the cost we've spent okay here's the number actual numbers we've spent 50 we've been reimbursed $54,102 we've spent $58,591 we spent $224 a month that's not reimbursed which is such an inconsequential amount of money for for organizations as large as ours next they the future and it's important HIV testing is now part of SEPMA's healthcare DNA we'll continue this program until we can report that 100% of those who look to SEPMA for healthcare have been screened by our own example my grandchildren were tested when they were visiting SEPMA and by evidence-based medicine we'll continue this program nothing speaks more to our commitment than the statement even if you don't want to pay our can't we want you to be tested such that SEPMA will pay the cost we continue that commitment and I think that may be the last slide that that's the last slide follows as we're going so quickly but I wanted to get through as much as I can and I'd be glad to answer any questions about the ethics I think it's clear the only ethical position is be tested and to keep that test results to yourself they as far as our plan we we have a systemic solution to a complex problem we made it easier to do it right than not do it at all we we follow up and we audit to make sure that not only that we know who is doing the testing and who isn't but also those who aren't are they not doing it for the right reasons and we follow up with the patients who have refused so that we can make sure that they have a legitimate opportunity to be tested and we will continue this process it'll just be part of our no matter what the Texas state does and whether these wonderful ladies we enjoyed a relationship with continue to do it we will continue to do it can I answer any questions or do you have some comments or observations that you would like to add to this discussion we have a few minutes left yes ma'am we will pay for it in our situation I think in in most emergency departments that are doing this they will absorb that cost it's not a consequential cost per patient and the and of course the CDC and their contract they have means for paying for an agent patients who are uninsured people that don't have access to the money but that should never be a barrier you know it it would it does grieve me when I hear of somebody that can't get care because of money to me that's a failure of our system and our society we must get past that yes ma'am it varies depending on which machine which reagents you did it goes from I think the cheapest maybe four or five dollars to twelve or thirteen dollars depending on the machine I just saw that the report about the Cobus Integra by the way our practice had the first Cobus Integra in America it was developed in Switzerland in 1995 it was deployed in this country there was not one bought we we had a presentation and machine cost $250,000 we were a new young small practice but we knew that we needed quality material and so we negotiated and negotiated and negotiated and negotiated and and finally the guy said I said if you will do what you said you will sell us this machine for six for $60,000 you will pay for the two machines that we currently have that we owe money on and you'll pay those off and you'll let us keep them you won't charge us a anyway I went on and the and he finally said yes we'll do all of that about three weeks later a knock on my door and guys took his hand and said are you Dr. Holly I said yes sir he said I'm so-and-so and I'm the national vice president for sales for Roche Integra and I just want to come down and look a person in the face that did to us what you did and shake your hand let you know it will never happen again and my partners who had said well why don't you ask for more I said you got to know when it's a win-win when they need a stellar place to show off the product and so this guy was there and I said I want you to tell my partners what would you've done if we'd ask for one more thing he said I told my salesman already if they asked for one more thing walk away we won't sell it to them at any price and so it was a great relationship but we have a strong history with Roche Integra but thank you for listening to my story yes ma'am yes sir no doubt you know the most innovative thing has happened in asthma treatment for children and adults was health plans buying a HEPA vacuum cleaner for the home and they start getting the dander and all the other things out of the home and they cut down to ER visits by 90% and missions by 80% it's phenomenal just such something like that we've got to stop thinking about medicine and procedures and things we do to patients and cooperate with them and help them improve their their environment where they live and if it means that we're gonna pay for a hundred dollars for a vacuum cleaner as opposed to a $10,000 for admission in the hospital just from an economic standpoint that really makes sense for want of you know the the man that we paid for his health care for two for four years we paid twenty two hundred dollars a quarter if he had not had health care I had that during that period of time he had been blind dead but when he went on disability it was two years before his Medicare kicked in he couldn't wait two years you know we're if we as a national policy paid for all diabetes medications for every patient diabetes you know what we would do with dialysis with blindness with limb loss of limb it would go to the bottom but we can't get past that initial cost you know what if we are successful in doing what I think we do about automating and systematizing these it's going to initially raise the cost of care the first year we got really serious about doing immunizations we spent one million dollars a fact one million dollars just buying the vaccines now that was a herculean cost for us much of that was not reimbursed but the next year it was very low but initially a preventive care is going to be increased the cost we talked about but eventually and it may be five or ten years it will begin to decrease that cost we began reaping the benefits but exactly and I'll give you my card if you want to it's a let's see it's 282 miles from here you can do it in four and a half hours you come visit will buy you a meal and I'll show you the EMR it is it is phenomenal the things that we're able to framing him anybody know what framing him is it's a town in but in Massachusetts but it's the longest longitudinal study that's ever been done 1949 to present multiple generations of providers and multiple generations of patients 12 framing him risk scores have been published the American Academy of Family Practice and in August 2010 opined that every family physician should calculate one risk calculator for their patients every five years we have done multiple ones every time we see the patient we deployed all 12 of them and we added five what if scenarios because see we want our patients to know if they make a change it will make a difference but how do you do that well framing him though it's it's a little bit not precise but it's pretty good framing him gives us a chance to say here's your risk here's your age and here's your card in a risk if you change these things it will reduce that risk of this we can quantify if you make a change it will make a difference and we can calculate those 72 scores in our EMR in less than one second deploy them so we can show them to the patient and on their on their plan of care and treatment plan they get at the end of the visit it tells gives them all that information and explains it to them in precise detail and it is changing people's behavior because we finally can say if you make a change it will make a difference but I'll show you all that and then just tons of other things oh you don't have shut up no doubt there is some research suggesting that the what the mother does and with the baby in utero even if she has type 1 diabetes we can decrease the innocence of communicating that type 1 diabetic genetic link they're remarkable and by what we do then now I do tell you that when I have a patient that's 88 and her first comment when I was four so but you're absolutely right that's that's really important and you know the great thing about EMR that's that's built right you can document that and bring it forward and review it every time you see that patient so it can impact that information you can bring to bear not what I know of what you know but what is known we can update to current literature every year the American Diabetes Association publishes a 100 page update on the state of art of treating diabetes you know many providers in our practice that we can get to read that one me and I can update our disease management tool and it's as if they read it they're using it it's remarkable stuff but anybody else on our time is up but I really appreciate you're letting me come and enjoyed visiting with you and I love coming to San Antonio my heart is here my school is here and it's you're very blessed to have that school here it was not always the case that this community loved that school but I know that you do now and and well you should anything else thank you very much