A year into its large-scale EHR implementation, the newly formed Hawaii Pacific Health system was experiencing some serious growing pains. In fact, it appeared that CIO Steve Robertson had an Epic failure on his hands. But instead of killing the project, he and his team reevaluated the situation and decided to focus on driving out waste. As a result, the organization got back on track. In this interview, Robertson talks about the organization’s seven-year Epic journey, their innovative ACO work, how he is leveraging in-house talent to optimize systems, and the core values that guide him. He also discusses micromanaging, what it’s really like to work in Hawaii, and the best advice he ever received.
Chapter 2
- Partnering with BCBS — “We made an offer they couldn’t refuse.”
- Building a successful patient portal
- MU Stage 2 — “It will be much, much harder.”
- Stimulus dollars are “like pennies from heaven.”
- Hawaii’s HIE success
- Exchanging lab results through clinical messaging system
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We’re operating in the top 10 percentile in most of these metrics. That success positioned us perfectly to do the same sort of thing on the inpatient side and to begin to really focus on our accountable care strategy.
When we looked at the ROI from a Medicare point of view, it just wasn’t there. So we felt that our unique partnership with the BCBS player here was a much bigger, broader opportunity for us.
It’s that 5 percent requirement for patients sending secure messages to their docs and electronically transmitting summary of care documents for more than 10 percent of transitions. If you’re leading the pack and you’ve got no one to send these things to, it’s going to be hard to hit your 10 percent.
It’s just good karma. If you’re doing the right thing and if you’ve got the resources and the mindset to do it, you’ll be fine. You’ll do great. Not only will you improve quality and reduce cost, but you’ll increase market share at the same time.
There was actually a point two years before ARRA where we were sitting in the board room and challenging whether we should even exist at all. I made the comment, ‘I get the impression we’re all just attending this meeting to ensure that nothing bad happens.’
Gamble: Let’s talk a little bit about the clinical aspects of it.
Robertson: When we began to finish up our CPOE efforts, which was more than three years ago at this point, we approached our Blue Cross/Blue Shield payer and made an offer they couldn’t refuse. What we said was, we want to sit down with you, and we want you to invest in us and our capabilities, because we know we are in a position where we can work in collaboration with our physicians to really improve care. And we’ll measure our performance. What we’d like to do with you is to agree to a set of mutually beneficial metrics. We’ll hold ourselves accountable, but your investment in us will allow us to build out our disease registries and be able to support outreach staff to do true population health for our chronic disease patients. Our focus ended up being diabetes management, hypertension, cancer screening — HEDIS measures that they were interested in but we offered to look at ways to reduce cost as well and improve efficiency.
All of this work was done before the HITECH Act and all the hoopla around ACOs, and that program was incredibly successful. So we staffed up and we got the investment dollars and PMPM to sustain it, and within the first six months, we began to move by quartiles in these measures. Today, we’re actually operating in the top 10 percentile in most of these metrics — cancer screening, diabetes management, and hypertension. That success positioned us perfectly to do the same sort of thing on the inpatient side and to begin to really focus on our accountable care strategy. So deploying that success and offering those benefits to our community physicians is part of a PHO, which will be a separate legal entity for us, but will be in place within the next two months. And I didn’t mention this, but we do provide a physician subsidy for our EHR. There are roughly 128 providers running their practice off our EMR on the same clinical record.
Gamble: Okay. And that’s something that was put into place a while ago just to get that going? With 128 practices, I’m sure that that takes a lot of work.
Robertson: That’s right. That was roughly three years ago as well.
Gamble: Were there challenges in getting them all to use the same system?
Robertson: Yes, there were. We had a couple attempts at this. We didn’t really start seeing adoption until the Stark exemption went into place where the subsidy could occur. But when we first looked at this probably five or six years ago, there was a real concern about sharing clinical information. There are probably three top issues that prevented us from moving forward. Those barriers began to break down when the stimulus money became available for Meaningful Use. And it’s the same story — we were successful with a couple of our implementations, and then word of mouth really began to mushroom.
Gamble: That’s interesting that you had kind of a pre-ACO set up with Blue Cross. I’m sure that that’s something other organizations probably would want more information on — just being able to set up something like that.
Robertson: Actually, one of our case studies touches on this. There are five case studies. It’s either the one on patient engagement or the patient-centered medical home. There’s some overlap with those two.
Gamble: Right.
Robertson: Hawaii is kind of unique in that we have either the lowest or the second lowest cost per Medicare beneficiary, which is an interesting situation, because when you look at the Medicare programs like MSSP, there’s great benefit in being able to reduce the medical cost trend. But Hawaii has already bent that curve, so we don’t have as much opportunity. When we looked at the ROI from a Medicare program point of view, it just wasn’t there. So we felt that our unique partnership with the Blue Cross/Blue Shield player here — which has about 78 percent of the commercial insurance market — was a much bigger, broader opportunity for us. So we’ve taken our early successes and have done much more with that, and have included not just the ambulatory side, but also our hospitals. We’ve agreed to terms on what that means, but we’re still working on signing the contract. It will go into effect on January 2014.
Gamble: So some of the Medicare patients there are just healthier.
Robertson: I think there are a lot of different reasons for it. Maybe we’re healthier; maybe there are other things associated with politics or being able to get the influence you need to get those types of rates at the national level.
Gamble: True. Yeah, it can get a little cloudy there. But I’m envisioning a warmer climate where maybe people are more active, but who knows. It’s really tough to measure those kinds of things.
Robertson: I think we were declared the second healthiest place on the planet or the country not that long ago.
Gamble: That’s a good thing. Now in terms of patient engagement, do you have a portal set up?
Robertson: Yes, we do. Today we have about 35,000 patients who actively use it. We have 800 logins a day, so it’s a very, very useful tool. I think it’s also been a key factor in our ability to improve outcomes, because we do engage our patients in their health. For example, if you’re a diabetic patient, the portal is specifically set up so that you get focused attention. If you need a diabetic foot exam or eye exam or whatever it might be, you’ll get those reminders in the portal. And of course, you can go online and schedule your appointment.
Another huge benefit is that our patients can get their lab results within 24 hours without having to call the clinic. The lab results — except for the sensitive tests — are automatically released within 24 hours. So if you’re really concerned about your cholesterol, it’s nice being able to log on and see those kinds of results. You just feel a lot more empowered by it. It can do trending — all the things that a data wonk would be interested in.
Gamble: Now as far as having that kind of engagement, is this something where maybe it started out with a smaller group and spread through word of mouth?
Robertson: Yes. It started out kind of meager. Part of the issue we had was our physicians were really concerned about the added workload that this would create; that patients being able to email them could create a lot of extra work. And of course there’s no reimbursement for that activity. What we did eventually was change our physician compensation model to account for the quality outcome measurements we were using to drive these improvements on the primary care side. Then we began to market aspects of it as well with brochures and incentivizing clinics to sign up patients.
And we saw an interesting thing; while the email traffic did increase, it also reduced a lot of phone calls to the clinics, because patients could do more self-service types of things. So we increased the workload a little bit, but being able to have physician assistants or the extenders in the clinics to help address the questions was a big help in reducing some of that workload.
Gamble: I’m thinking that when you did make changes to the reimbursement model, that was a huge part of it.
Robertson: Yes.
Gamble: Okay. Now when we talk about Meaningful Use, I imagine it’s kind of like what you said with the ACOs — that this was something you were already on track for.
Robertson: That’s certainly true for Stage 1. There was a lot of effort that we had to put in place for the reporting part of it. It was a challenge, but we got through it. By far, I believe stage 2 will be much, much harder.
Gamble: With CHIME recommending the delay, that’s something where I’m sure a lot of people will breathe a sigh of relief if that happens.
Robertson: Yes, because I think as it stands right now, very few will actually be able to qualify for Stage 2.
Gamble: It’s a tight timeline.
Robertson: Yes, and it’s that 5 percent requirement for patients sending secure messages to their docs and electronically transmitting summary of care documents for more than 10 percent of transitions of care. If you’re leading the pack and you’ve got no one to send these things to, it’s going to be hard to hit your 10 percent.
Gamble: I think that that’s a sticking point for a lot of organizations. In terms of your organization’s strategy, it just seems like if you take away the administrative work, that Meaningful Use is something you were already on pace to do. Is that just kind of the organization’s strategy?
Robertson: Yes, I always say it’s just good karma. If you’re doing the right thing — focusing on the correct direction that we all know we need to do, and if you’ve got the resources and the mindset to do it, you’ll be fine. You’ll do great. Not only will you improve quality and reduce cost, but you’ll increase market share at the same time. Getting the stimulus money is like pennies from heaven. That was just an added bonus for us. But it has allowed us to reinvest, again, in our internal capabilities for driving accountable care.
Gamble: Another component of Meaningful Use is data exchange. Tell me about the exchange that you guys are doing. I know you said you are the largest private health system in the state but what type of work are you doing with other organizations in the state?
Robertson: We are active members with the Hawaii Health Information Exchange (HHIE), and that is a state designated entity. I’m a past president and also a founding member. This HIE was originally founded, once again, before anything like ARRA came about. There was actually a point two years before ARRA where we were sitting in the board room and challenging whether we should even exist at all. I made the comment, ‘I get the impression we’re all just attending this meeting to ensure that nothing bad happens, or that we just stay abreast of who is doing what, but we’re really not achieving a damn thing.’ So we took a vote of confidence and we agreed to recommit ourselves. We started work and then HITECH came about, and it was like all these HIEs began popping up out of the blue.
We were successful, I think, probably because of our history and credibility. Today, we’re connected. The population of Hawaii is only about 1.5 million; in total, there are only about a thousand or so priority primary care providers. We’re probably similar to New Hampshire. We’ve got roughly 400 or 500 physicians using the HHIE clinical messaging system. The idea is that lab results will begin getting exchanged as well before the end of the year, along with some basic direct functionality with a couple of the hospitals. So we’re not moving along as fast as we’d like, but like anything, it’s all about data sharing agreements, HIPAA privacy, and agreements on how the data will be used and when it will be used.
Gamble: And you have the foundation in place, so that’s a big part of it.
Robertson: Yes.
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