As a geographically isolated region that is underserved by healthcare professionals, and with a high percentage of its population at risk for chronic diseases, Hawaii County has long-standing and serious challenges to efficient healthcare delivery. These barriers also made the region an ideal candidate for a Beacon Community grant, which would also serve as a challenging proving ground for the health information exchange (HIE) concept, and how well health information technology could bridge gaps in care.
In May 2010 the Office of the National Coordinator for Health IT provided 36-month grant through the College of Pharmacy of the University of Hawaii at Hilo, which would result in the Hawaii Island Beacon Community (HIBC). The project’s funding period ended on March 31, 2013.
Susan B. Hunt, M.H.A., Beacon Project Director and CEO of the Hawaii Island Beacon Community (HIBC), describes Hawaii County, also known as the “Big Island,” as a place of rugged beauty beset by daunting healthcare challenges. The Big Island is the largest and youngest island in the Hawaiian archipelago, with 4,000 square miles of land, two active volcanoes and three other dormant volcanoes. Most of the residents live around the perimeter of the island, and traveling between communities is difficult.
Hunt divides the healthcare communities on Big Island into three major areas: north, east and west. In an interview, she spoke of her experiences with the development of the Hawaii Island Beacon Community, as well as the specifics of setting up an HIE, known as the North Hawai’i HIE, on the northern section of the island. Regarding the latter, she notes that when the Beacon grant was written, the concept of setting up a small, regional HIE was built into the planning process. “We felt it was a great idea as far as how a small, regional approach might tie into a larger statewide approach,” she says.
Overall, the Big Island presents a host of challenges to efficient healthcare. One is geographic isolation: as an island community, most high-level tertiary care is accessed by plane; very ill patients are flown to Honolulu on the island of Oahu. The area lacks a good public transportation network, which makes it difficult for people to reach a doctor, and there is a severe shortage of healthcare professionals. The patient population consists of large sub-populations at risk of chronic diseases. “We have the largest percentage of chronic illnesses, such as cardiovascular disease and diabetes, in the state, Hunt says. The area also has the lowest per capita income, the highest poverty level, and the highest levels of unemployed and uninsured persons in the state.
A VISIONARY CALL TO ACTION
Hunt credits Harry Kim, who at the time was mayor of Hawaii County, for giving the initial impetus for the formation of the HIBC. In 2008 he called on all healthcare leaders on the island, including hospitals, federally qualified health facilities, physicians, business leaders and health plans, to develop a coordinated vision for healthcare. Hunt says that request stemmed from financial difficulties being experienced by the area’s safety net hospitals but was also in response to anticipated healthcare reform legislation.
Hunt notes that the Beacon Communities nationwide encompass a variety of healthcare models in various stages of development. The Hawaii Island Beacon Community started from scratch. “It was taking a rural community of independently practicing physicians and hospitals and bringing them together, under health information technology through electronic medical record, and taking those EMRs [electronic medical records] and connecting them to an exchange,” she says.
The first step in creating the North Hawai’i HIE was to make sure its physicians had a functioning EMR. Once that was established, the group laid the groundwork for sharing the information electronically. Some of the physicians on the Big Island lacked Internet access or up-to-date computers, she says. The North Hawaii community was a little further along with electronic medical record implementation than other areas of the island, and served as the site for the local HIE initiative. Funded by a $680,000 grant by HIBC to the North Hawaii Community Hospital, in Kamuela, the North Hawai’i HIE went live in December 2011. It became operational in March 2012.
North Hawaii Community Hospital, the center of the HIE, is a 33-bed facility with an ER, serving a population of about 35,000 people. “It’s a primary-care focused environment,” Hunt says. Prior to the Beacon Community initiative, its physicians as a group selected a single EMR (supplied by Westborough, Mass.-based eClinicalWorks). Because the solution was not cloud-based at the time, it was installed on the physicians’ individual servers. To enable sharing of share the information, the group selecting a cloud-based solution supplied by Wellogic (now Alere Accountable Care Solutions, Waltham, Mass.).
Hunt says the EMR selection was championed by William Park, M.D., a surgeon at the hospital. “He led the vision for making the selection of a single EMR for the community of physicians, and understanding what it would take to bring the physicians together in a single exchange,” she says.
One of the initial goals of the Hawaii Island Beacon Community was to have 60 percent of its physicians on the island achieving Stage 1 meaningful use with an EMR. Hunt says that threshold was reached among the 138 primary care physicians who accept Medicare, but not among physicians serving the Medicaid population, because Hawaii has yet implemented a Medicaid meaningful use incentive program. (As of last December 2012, about two-thirds of primary care physicians accepting both Medicare and Medicaid have attested, she says.)
IMPLEMENTATION AS A LEARNING EXPERIENCE
Hunt credits the support of what was then Alere Wellogic for being engaged and supportive during the implementation meetings. It also received some guidance from other Beacon Communities regardng governance issues, pricing structures, policies and procedures.
In terms of developing relationships with local physicians and hospitals, there was no playbook, she says. Hunt says the majority of North Hawaii primary care physicians were on board with the HIE, which made going forward easier, since North Hawaii Community Hospital employs a physician group of specialists and primary care physicians. “They were engaged by virtue of the fact they were employees of the hospital,” she says. In addition, she says independent practices in north Hawaii were also on board, and had been part of the EMR select ion process early on. She says the HIBC engaged independent physicians by offering them IT support, which helped to facilitate their connection to the HIE. Other stakeholders in the HIE includes the Hawaii Medical Service Association, a Blue Cross Blue Shield health plan, Hunt says.
Hunt says that the first 14 months of the HIBC project were focused on developing the governance infrastructure, honing its business objectives, and establishing the groundwork for procurement, which has to align with the state’s procurement process guidelines. Once those were established, it began to start with the project management process, which included IT implementation, parsing of data and building interfaces with the hospital EMR and physician EMRs, as well as links to laboratories for radiology information, discharge summaries and secure messaging.
One of the biggest challenges from a technology standpoint was the process of user acceptance testing, “and by the time you issued a production order, there are no bugs in the system whatsoever. We have tested and retested and it’s reliable and consistent on a daily basis,” she says.
Separate to the Beacon Project HIBC, Hawaii is in the process of building a statewide HIE. The Hawai’I Health Information Exchange, which received funding from the ONC, will be a collaborative partner with HIBC, says Hunt, noting that its regional extension center (REC), “will be absolutely essential to helping to get physicians to Stage 1 meaningful use.”
She adds that the North Hawai’i HIE, working with Alere, has implemented direct messaging with the statewide HIE. One of the challenges of the HIBC is that at least 20 percent of the patients who are hospitalized for any reason are hospitalized on the island of Oahu. “We have to have that connection, eventually, with other hospitals in the state,” she says. She foresees a federated model, in which the North Hawai’I HIE, and probably another regional HIE in the East Hawaii region, feed into the larger statewide HIE.
DEMONSTRATING VALUE IS THE NEXT STEP
The HIE is up and running now, and people are using it, Hunt says. The next task is to demonstrate its value, by beginning to identify gaps in care, doing population health management, operating registries and data analytics.
Hunt says that the challenge now is to convince other facilities and health plans to invest in the HIE. She notes that the North Hawai’I HIE is small, so it is difficult to charge physicians a fee that would help sustain the infrastructure. “We just have enough of them to make it sustainably viable,” she says. She also notes that the statewide Hawai’i Health Information Exchange is working on its own sustainability plan, adding that the state population is only 1.2 million. She points out that having more than one HIE, unless it’s supported by a hospital integrated health system or through a state subsidy, will compete with each other for dollars to stay alive.
The other piece to the sustainability picture is reduced costs. Hunt says North Hawai’i HIE has applied anecdotal information about streamlining its operation for better productivity. It still needs to demonstrate that its interventions, using HIE as a tool, has resulted in cost reductions through population health and the accountable care model.
If those interventions can indeed result in savings, then the next question is whether those savings can be re-invested in the community to support the HIE structure. “We have a ways to go in demonstrating that value,” she says. She says that will be the focus over the next year, and that the HIE is working closely with Alere to analyze the data and share it with area physicians and other healthcare leaders. “We are committed to continuing this effort even beyond Beacon,” she adds.
Another focus of the HIBC is clinical transformation, including practice redesign, and helping physician practices achieve patient-centered medical home status. “We have an interesting public-private partnership going on around care coordination in our community,” she says. It encompasses healthcare networks within each region where the hospital, care coordination services, and federally qualified clinics are connected with the native healthcare system. “They are working together to communicate and ensure that patients in the community have access to services, even though we have an incredible shortage of primary care physicians,” she says. In addition, HIBC is using registries to identify at-risk populations of, for example, diabetics, to check for screening and those patients who need to get their condition under control.
Hunt observes that HIBC has made strides in realizing the goals of the federal Beacon Project, namely, to strengthen the IT infrastructure and information exchange capability, and then to demonstrate reduction in cost. That’s a lot to accomplish in a relatively short period of time, but it appears to be off to a good start.