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