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Hilo Medical Center – Health Information Exchange (HIE) Menu Case Study
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Hilo Medical Center
1190 Waianuenue Avenue, Hilo, HI 96720
Money Atwal
CIO & CFO
[email protected]
Health Information Exchange (HIE)
Executive Summary
Hilo Medical Center (HMC) is a leading participant and driver in the development and use of the
Hawai’i Health Information Exchange (HHIE). The need to establish connectivity to other state
health care resources to manage the patient population and improve upon patient care across the
isolated islands of Hawai’i was a challenge addressed when establishing the requirements for and
selecting HMC’s EHR vendor in 2009. HMC implemented the EHR in May 2010, which opened
the door for taking numerous additional steps, such as, now utilizing the Hawai’i HIE and Health
eNet encrypted electronic system to provide a platform for health information sharing between
hospitals and providers throughout the state – physician orders, referrals, medication allergies,
medication lists, transcription reports, laboratory and pathology reports, imaging reports and
more are all now available to increase the effectiveness of communication and coordinate care of
patients regardless of geographical location. HMC was awarded HIMSS Analytics Stage 7 in
November 2013 acknowledging the tremendous work accomplished in information sharing
among its numerous other advancements.
1. Background Knowledge
The East Hawai’i Region of the Hawai’i Health Systems Corporation (HHSC), of which 276-bed
Hilo Medical Center (HMC) is the largest facility, shares a single mission: “Improving our
community’s health through exceptional and compassionate care”. The East Hawai’i Region is
supported by a Regional Board of Directors with the HMC CEO participating as an active
member. HMC’s Senior Leadership Team is comprised of the CEO, a Regional CFO/CIO,
Assistant Hospital Administrator/Long Term Care and Rehabilitation Director, CMO, Corporate
Compliance Officer and Regional Human Resources Director. HMC currently employs over
1000 employees and 250 physicians, representing 33 specialties. The Level III Trauma Center is
the second busiest Emergency Department in the state.
The regional and local responsibilities of the HMC leadership team lend themselves to
progressive thinking regarding interoperability of communications and networking across the
state of Hawai’i, and naturally led to participation in development of the Hawai’i HIE. Its
CFO & CIO sits on the Hawai’i HIE Board of Directors and is chairman of the Finance/Audit
Committee. The Hawai’i HIE is a 501 (c) (3) non-profit organization established in 2006 to
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enhance care coordination, to improve the health outcomes of Hawai’i patients and reduce the
cost of care for both patients and healthcare providers.
To support these goals, in September 2009, Hawai’i HIE was directed by the state to develop a
seamless, effective, and secure statewide health information exchange that ultimately links to the
nationwide health information network.i Currently, Hilo Medical Center, Queens Medical
Center, Hawai’i Pacific Health, Castle Medical Center and 458 providers are exchanging
information via the HHIE.
Health eNet is electronic system implemented to accomplish the exchange and access of clinical
information. The Hawai’i Pacific Regional Extension Center (HPREC) is also under the
umbrella of the HIE to assist providers in making the EHR implementation and upgrades easier
for meeting Meaningful Use.
2. Local Problem Addressed and Intended Improvement
Chronic disease management of Diabetes and Coronary Heart Disease are at the top of HMC
patient population concerns. Diabetes rates for HMC patients have increased from 5.4% in 2002
to 9.2% in 2010 while Coronary Heart Disease death rates for the Big Island are nearly 20%
higher than the rest of the state.ii As seen in the State of Figure 1: Comparison of Native Hawai’ian
Hawai’i Healthcare Innovation Plan, the unique Native
and Pacific Islander Health Rates to Other
Hawai’ian and Pacific Islander populations experience
Races
significant health disparities as compared to other races,
e.g., breast cancer rates are 5 times higher and colon
cancer, stroke and suicide death rates are all 3 times
higher; see Figure 1.iii
Implementing an EHR in 2010, and integrating secure
messaging technology with the Hawai’i HIE in 2014,
allows the advanced sharing of data by providers
required to continue to strive for additional improved
population health for these and other diseases. Taking a
proactive approach to monitoring and addressing local
chronic disease processes, like diabetes, can help improve the overall health of the local
population while decreasing the healthcare expenses these patients are likely to incur over time.
Theses additional heath care resources are necessary in a region where nearly 1 in 5 residents has
an income at or below the Federal Poverty Level.iv Through the use of the Hawai'i HIE,
improved tracking and patient management for chronic illnesses can be achieved by reviewing a
comprehensive patient record.
The Hawai’i Journal of Medicine & Public Health’s (2012) Transforming and Improving Health
Care through Meaningful Use of Health Information Technology discusses the mission of the
HHIE, logistics of becoming a meaningful user and provides an overview of the HPREC.
Further, the article concludes the benefits for Hawaii providers to include accurate and complete
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information needed to diagnose,
provide treatment, and safer care
effectively and efficiently.v HMC’s
vision along with the East Hawai’i
Region is to align the enterprisewide EHR and its providers with
HHIE and Health eNet to
accomplish information exchange;
see Figure 2.
Figure 2: East Hawai'i Region Strategic Vision
3. Design and
Implementation
Architectural Design
An understanding of the strategic
vision led to the ability to plan the design of the architectural structure between the enterprise
EHR and the HHIE. Architectural diagrams such as, Figure 3, are extremely helpful in
communicating the flow of data to the HIE side-by-side with other directional data flows. HMC
utilized its EHR technical, interface, and application team resources along with discussions with
HHIE and Medicity ProAccess (provides the HHIE system infrastructure) resources to
accomplish exchange connectivity.
Figure 3: East Hawai'i Region Interfaces to External Entities.
Hawai'i HIE Relationship Represented with Yellow Highlighted Text.
The process began in March 2012 when initial contact was made with HHIE thru the Beacon
Community Program. The Beacon Community Program is a federally funded project to increase
the quality, efficiency and sustainability of health care through health information technology
(health IT). Its work is a significant part of a larger effort to modernize the nation’s health care
delivery system. A Medicity ProAccess demonstration occurred, an initial scope was established
in August 2012 to send ADT data and reports to HHIE as the host for community resources
through ProAccess. Scope was expanded in March 2013 to fulfill Meaningful Use Stage 2
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(MU2) requirements, beginning with MU2 immunizations in April 2013. In June 2013,
successful interface connectivity with Medicity ProAccess was accomplished. HHIE suggested
electronic Lab reporting via the reference lab provider, Clinical Labs with development
underway by August 2013. HHIE and DOH established Syndromic Surveillance delivery in
September 2013 with a successful transmission to Medicity in the same month. The Domain
name for direct secure messaging was established in November of 2013 and successful test
messages were sent and received from HMC’s EHR to Queens Medical Center through the
Medicity platform in December 2013. Live direct messaging continued in December 2013, with
a HMC pilot in January 2014. Syndromic Surveillance and Immunizations also went live in
February 2014.
Financial Sustainability
The HHIE initial funding model was heavily dependent on the Federal HIE Grant, State of
Hawai’i Department of Health and private funding from the Health Systems and Insurance
Payors in Hawai’i. The HHIE organization was designated by the State of Hawai’i as the sole
provider for information exchange, the designation allowed the HHIE to become the Regional
Extension Center. HHIE was awarded approximately $4.8M in federal grants. Further, HHIE
secured funding from prominent stakeholders in the private sector contributing an additional
$461K.
As indicated in Figure 4 below, the on-going funding forecasted for 2014-2015 is less dependent
on federal grant funding while increasing financial sustainability through State and private
funding. Notably, 2014 & 2015 funding has increased the number of stakeholders from the
insurance sector, with an overall contribution at approximately $629K.
Figure 4: HHIE Sustainability and Funding
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4. How Health IT Was Utilized
HMC conducted its EHR system selection process in 2009. Having chosen MEDITECH as the
vendor, the implementation of all core applications was completed on version 6.0 in May 2010.
This was followed in 2011 by accomplishment of a Computerized Provider Order Entry (CPOE)
initiative utilizing Zynx Health evidence-based Order Sets, and, also, included a drive toward
Physician Documentation in August 2013. The data repository, Medisolv, was integrated with
the EHR in 2011 leading to the ability to view and begin trending data at a high level or review
detailed drill down patient level information. Additionally, a RIS/PACS system (2009)
implementation was followed by PowerScribe 360 (2013) to further accomplish integration.
Two critical access hospitals were added to the HMC’s EHR – Ka’u Hospital in May 2011 and
Hale Ho’ola Hamakua in July 2012. On the ambulatory front, 10 clinics were added over 16
months from December 2011 through January 2013. Every methodical implementation whether
an individual EHR application or upgrades, hospital or clinic add-ons to the EHR, or another
system implementation brought the East Hawai’i Region one step closer to sharing all pieces of
essential clinical patient data utilizing the HHIE.
Utilizing queries constructed within the HMC EHR, the identification of at risk patients and
improved patient tracking for chronic disease conditions was obtained. In the case of Diabetes,
some of the specific data points include: type of Diabetes, BMI, Blood Pressure, HbA1c levels,
and Patient Education; see Figure 3 Diabetic Management Data. In conjunction with an
enhanced level of patient tracking, this data allows care providers to develop trend data to
determine if their treatments are being followed as well as the impacts they are having. As seen
in Figure 4 below, trend data shows a marked increase in self-management support being
provided to Diabetic patients. This indicates staff is better able to both identify and track
patients with this chronic condition. Trend data also indicates patients are following the care
plans and utilizing the self-management education being offered as overall improvements in both
Diabetic patient Blood Pressure measurements and BMI are observed.
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Figure 5: Diabetic Management Data
5. Value Derived/Outcomes
Through the integration with the HHIE, HMC is generating valuable outcomes, which also
encourages additional physician participation. HMC successfully piloted direct secure
messaging in January / February 2014. Direct secure messaging by December 2014 rose to
nearly 5,000 transmissions via the HHIE; see Figure 5.
Figure 6: Progression of Direct Secure
Messaging via the HHIE
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Transitions of Care Messaging for HMC alone have been tracking between 12 – 18% of all
facilities in the last 6 months of 2014; see Figure 6.
HMC interfaces (ADT, RAD,
TRANS) contributed 1,196,330 of
8,076,807 messages to the HHIE in
2014, i.e., 15% of the total messages
transmitted. HIE medication
reconciliation queries continue to
thrive, as well, with over 600 made in
December 2014; see Figure 7.vi
Figure 7: HHIE Medication History Utilization
A pharmacy-to-pharmacy messaging
program called Pharm2Pharm was
also initiated. The Pharm2Pharm
model transitioned patients qualifying
under specific criteria to include age,
present co-morbidities, medication types, or the number of concurrent prescriptions. Qualifying
Pharm2Pharm patients are paired with a hospital pharmacist and a community pharmacist to
assist in the transition from the hospital to home. The goal of the program is to reduce
readmissions from medication discrepancies and inadequate instructions on how to take
medications. The hand-off from hospital pharmacist to community pharmacist allowed patients
to be tracked and monitored by the community pharmacist for up to a year. The community
pharmacist would provide counseling and ensure prescriptions were filled timely. Verifying
medication history using the HHIE proved advantageous to the program as prescription fill
history from a number of sources are collected by HHIE and the patient can be easily tracked in
one system. From October through December 2014, secure Pharm2Pharm messaging
transmitted an average of 1,010 messages per month. The HIE direct secure messaging
utilization is also used by the Department of Health (DoH).
Figure 8: HPREC PCPs Progress toward EHR implementation
and Meaningful Use Achievement
The associated HPREC Program has led to
an ever increasing number of providers
achieving EHR and Meaningful Use goals.
Over 525 primary care providers (PCPs) are
enrolled in the program with essentially the
same number having implemented an EHR
meeting HHIE targets. These same
providers still have work to do to achieve
Meaningful Use; however, approximately
300 are demonstrating Meaningful Use as of
April 2014; see Figure 8.
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6. Lessons Learned
Challenges were encountered along the way of establishing connectivity to the HHIE, but none
that could not be overcome. HMC found itself in a position of learning the Medicity system
alongside HHIE rather than HHIE having the Medicity knowledge at the onset. This created a
steeper learning curve than anticipated. Challenges were also encountered in filing EHR data to
HIE and Medicity, which led to numerous interface mapping issues and the need for an extended
period of testing.
Resourceful staff and great communication between HHIE, Medicity and HMC assisted in
moving the project along. Through the process, the ability to transfer images through BEAM, a
radiology point-to-point image exchange product, was implemented. BEAM opened another
successful avenue of transferring data. The overall lesson learned is to adjust and adapt to
ongoing challenges and obstacles encountered during implementing new technology and
processes.
7. Financial Considerations
HMC did not use external funding for the EHR project. In fact, all funding was from internal
operational sources, including hardware, software, consultant implementation resources, and
labor costs. The low cost of ownership for a MEDITECH EHR system was a key in eliminating
the need for external funding of approximately $8M.
A number of programs and initiatives are supported by HHIE – ONC State HIE Cooperative
Agreement, ONC Regional Extension Center Cooperative Agreement, and CMMI University of
Hawai’i College of Pharmacy – Pharm2Pharm Services vendor. HHIE, also, provides the
infrastructure for the State of Hawai’i Healthcare Innovation Plan. The HHIE and Hawai’i
Pacific REC have been funded by federal and state grants along with the private sector. Federal
grant funding was provided by ONC HIE, ONC REC and Pharm2Pharm, whereas; state funding
was provided through the State Department of Health and State Department of Human Services.
Initial private sector funding was provided by four of the hospitals associated with the initiative,
including HMC, and two Hawai’i laboratory services. The list of private sector participants has
grown to also include ambulatory providers and payors among others. As an example, HPREC
was awarded a federal grant for $6.5M to assist with funding program development. The state
matching grant funds equaled an additional $7.3M. Grant total of federal and state matching
funds for the REC program was $13.8M. Looking at FY2015, the HHIE forecasted funding is
$4.6M.
The dollars invested in the HHIE have established a program of lasting value for the Hawai’i
patient population and the providers who care for them. The quality of information being shared
across this diverse island geography is positively impacting the outcomes of patient care today.
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i
From the Hawai’i Health Information Exchange website, www.Hawai’ihie.org
Hawai’i Island Beacon Community, Metrics and Projections (2013). Retrieved from
http://www.hibeacon.org/index.php/annual_report/About_Hawai’i_Island
iii
The Hawai’i Healthcare Project, State of Hawai’i Healthcare Innovation Plan, February (2014)
iv
Same as (ii) above.
v
Hawai’i Journal of Medicine & Public Health, April (2012), Vol 71, No 4, Supplement 1, Transforming and
Improving Health Care through Meaningful Use, Beverly J. Chin, MBA, MPH, and Mai’I Sakuda, MBA
vi
Presentation from the HHIE Board of Directors Meeting, Executive Director Update, January (2015). Pertains to
Figures 5, 6 and 7.
ii
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