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Some of the lessons SETMA learned derived from seminal moments that forever changed how we approach patient care and the use of an EHR in that care. Our first such moment was the realization of the inadequacy of our vision.

In March 1999, we realized that if all we gained from implementing an EHR was an electronic means of documenting a patient encounter, it was not worth the time, energy, effort and cost. If we did not gain the ability to do electronic patient management, then we had made a mistake in undertaking this task. It was then that we realized the power of the tool we had.

We began developing disease management tools and functionalities, which leveraged the capabilities of electronic speed and data analysis. Suddenly, a whole new world opened to us. We examined the problems that were unique to various populations within our practice. One large group of patients commonly experiences five problems: nutrition, hydration, fall risk, skin care and depression. Because simply documenting patient visits in an EHR was an inadequate use of electronic capabilities in the nursing home, SETMA designed tools for evaluating, monitoring and treating these five problem areas and others.

Standardization of quality of care was achieved with guidelines. Analysis of data was achieved electronically to assess the state of hydration, nutrition, the risk for falls, whether skin lesions were preventable or not, and depression. Now we continue to develop new tools for improving data documentation, data analysis and outcomes measurements, achieving in the process the promise of electronic patient management of which we only dreamed in 1999.

In May 1999, we experienced another seminal moment. It taught us to have a celebratory spirit about the development, progress and improvement in our electronic patient management. In that month, my co-founding partner lamented our state of use of the EHR when he said, "We aren't even crawling yet." We started using the EHR Jan. 26, 1999. On the 29th, we used the EHR for every patient, and we have done so since. Yet, even with that success, it did seem that we were not moving very fast.

As I listened to my friend and partner, I said, "When your son turned over in bed for the first time, did you call for your wife and say, 'this dimwitted kid can't even walk, all he can do is turn over in bed?'" He smiled and I continued, "You celebrated his achievement. If a year later, all he was doing was turning over in bed, you would have reason to lament, but for the moment enjoy the progress." I concluded, "If in a year, we are doing no more than we are now, I will join you in your lamentation. But for now, I am going to celebrate what we have achieved."

Through the years, our vision has grown as to what electronic patient management is, and we have celebrated our advances from having the lab interface up and running, to using the EHR in the hospital for history and physical examinations, to creating discharge summaries in the EHR, and now to using the EHR for daily progress notes. We have celebrated the automation of formulas for the calculating the stage of renal disease, Framingham Risk Factors, Cardiometabolic Risk Factors, stages of hypertension, Fredrickson's Classifications of Dyslipidemia, Homeostasis Model Assessment (HOMA) of Insulin Resistance and the list goes on and on and on.

We continue to dream-and some would say hallucinate-and we continue to celebrate. As the old adage says, "We ain't what we was and we ain't what we gonna be, but we're moving forward."