1. Hawai‘i Island Beacon Community
East Hawai`i IPA Symposium
August 19, 2012
Hawai‘i Island Beacon Community

2. Components of HITECH Act
BEACON
Taken from: Blumenthal, D. “Launching HITECH,” posted by the NEJM on

3. Beacon Community National Program Aims
17 grantees each funded ~$12-16M
April 2010 – March 2013:
Build and strengthen health IT infrastructure and exchange capabilities - positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.
Improve cost, quality, and population health - translating investments in health IT into measureable improvements.
Test innovative approaches to performance measurement, technology integration, and care delivery - accelerating evidence generation for new approaches.

4. 17 Beacon Communities
Bangor Beacon Community Brewer, ME
Western New York Beacon Community
Buffalo, NY
Beacon Community of Inland Northwest Spokane, WA
Southeastern Minnesota Beacon Community
Rochester, MN
Rhode Island Beacon Community
Providence, RI
Southeast Michigan Beacon Community
Detroit, MI
Central Indiana Beacon Community
Indianapolis, IN
Keystone Beacon Community
Danville, PA
Utah Beacon Community
Salt Lake City, UT
Colorado Beacon Community
Grand Junction, CO
Greater Cincinnati Beacon Community
Cincinnati, OH
Represent communities from Hawaii to Maine, with more advanced E.H.R adoption and HIT infrastructure investments.
Diverse communities with very different starting points (very sophisticated delivery systems e.g., Geisinger, Intermountain Mayo, and HIEs e.g., HealthBridge, IHIE, to rural communities in the Mississippi Delta and other very competitive provider markets like San Diego and New Orleans). Award was given to a lead organization (listed here), but was very much awarded to all the other partners (payers, providers, employers, public health departments etc).
Southern Piedmont Beacon Community
Concord, NC
Great Tulsa Health Access Network Beacon Community
Tulsa, OK
San Diego Beacon Community
San Diego, CA
Delta BLUES Beacon Community
Stoneville, MS
Hawaii Island Beacon Community
Hilo, HI
Crescent City Beacon Community
New Orleans, LA

5. Trajectory to Value Based Purchasing
HIT Infrastructure:
EHRs and Connectivity
Primary Care Capacity:
PCMH
Care Coordination and Transitions:
FQHC/Hospital/Private Sector Model
Value/Outcome Measurement:
Reporting of Quality, Utilization and Patient Satisfaction Measures
Value Based Purchasing:
Reimbursement tied to Performance on Value (shared savings)
It is a Journey – not a fixed model of care
Supports base for ACOs, PCMH Networks and Bundled Payments

6. Health Information Technology and Meaningful Use
HIT and MU Are the Foundation for Obtaining
Measurable Results
Improving patients’ access to and experience of care within the Institute of Medicine’s 6 domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity.
Better care
Screening
HgA1c control
BP control
Lipid control
Increasing the overall health of populations: address behavioral risk factors; focus on preventive care.
Better health
Health Eating
Active Living
No Smoking
Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries.
Lower costs $
Potentially Avoidable re-admissions and ER visits by condition
Health Information Technology and Meaningful Use

7. Hawaii Island Beacon Community Transformation Strategy
VISION:
Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.
OBJECTIVES:
Improve access to primary care, specialty care & behavioral health care
Avert the onset and advancement of diabetes, hypertension
and hyperlipidemia
Reduce health disparities for Native Hawaiians and
other populations at risk
Achieve EHR adoption and meaningful use
>60% of primary care providers
Primary Drivers:
Secondary Drivers:
Interventions
Leadership
Reliable Processes
Provide care in appropriate setting
Delivery System Design
Community, Patient and
Family Voice
Communication
Decision Support
Clinical Transformation
Patient, Provider and Community Engagement
Health Information Exchange
Practice Redesign
- PCMH Coaching
- EMR/MU Stage I
- Care Coordination
Care Transitions
- Hospital Discharge
Enabling Services
Healthy Lifestyles
HEAL Projects
Alere/Wellogic
- Clinical Decision Support
Caradigm/Amalga
- Population Health
Monitoring

8. Hawaii Island Beacon Community Transformation Strategy
VISION:
Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.
OBJECTIVES:
Improve access to primary care, specialty care & behavioral health care
Avert the onset and advancement of diabetes, hypertension
and hyperlipidemia
Reduce health disparities for Native Hawaiians and
other populations at risk
Achieve EHR adoption and meaningful use
>60% of primary care providers
Primary Drivers:
Secondary Drivers:
Interventions
Leadership
Reliable Processes
Provide care in appropriate setting
Delivery System Design
Community, Patient and
Family Voice
Communication
Decision Support
Clinical Transformation
Patient, Provider and Community Engagement
Health Information Exchange
Practice Redesign
- PCMH Coaching
- EMR/MU Stage I
- Care Coordination

9. PCMH Coaching Partners: Beacon Leadership: Activities:
Melinda Nugent, MS, Clinical Program Manager
Kahealani Wakinekona, Practice Coach
Activities:
Support to Practices/Practice Coaches – National Kidney Foundation
Outcome Data Reporting – HMSA
Practice Assessments - TransforMED
Learning Collaborative/Interactive Instruction – TransforMED
Delta Exchange On-line Information Sharing - TransforMED

10. PCMH Coaching Participating Providers: West Hawai‘i North Hawai‘i
NEXT LEARNING COLLABORATIVE:
SEPTEMBER 15 AND 16, 2012
West Hawai‘i
Minolu Cheng MD
Dominador Genio MD
David Arthurs DO
Elizabeth Catanzaro MD
Lambert Lee Loy MD
Sukchai Satta MD
Robert Laird MD
North Hawai‘i
John Dawson MD
Maria Perlas MD
William Lawrence MD
Malcolm MacDonald MD
Michele Shimizu MD
East Hawai‘i
Doug Olsen MD
Kara Okahara MD
David Jung MD
Joseph D’Angelo MD
Roy Koga MD
Julie Chee MD
Kristine McCoy MD

11. PCMH Reporting Requirements
HMSA PCMH Pay for Quality Measures
Data Not Yet Available for the second PCMH cohort.

12. Primary Care Access Measure
Source of ER data: Hawaii Health Information Corporation Emergency Department Database.
Sources: Denominator(Population) U.S. Census, 2009 Intercensal Estimates of the Resident Population for Counties of Hawaii (CO-EST00INT-01-15), 2010 to 2011 Estimates of the Resident Population for Counties of Hawaii (CO-EST )
Notes: Census population is annualized over 4 quarters. Where population estimates have not been updated, the most current previous year estimate is used. The National Uniform Billing Committee (NUBC) dropped ""Admitted via ER"" as a valid code for ""Admission Source"" effective July 1, 2010 to better capture patient origin prior to presenting to the ER. HHIC has updated data through December 31, 2010 to account for admissions via ER. To allow continued tracking of patients admitted via ER, HHIC will capture data from revenue codes submitted by the hospitals.

13. Primary Care Access Measure
UTI, Headache, Sore Throat and Lower Back Pain
The percent of potentially avoidable ER visits has trended upward over the eight quarters. After an initial decrease from 10.4% avoidable visits in Q to 8.4% avoidable visits in Q3 2010, the rate has increased to 11.6% in Q4 2011, a 38% increase of avoidable ER visits over the five quarter period. Annualizing the data shows an increase in Avoidable ER visits from 9.4% in 2010 to 11% in 2011.
Source of ER data: Hawaii Health Information Corporation Emergency Department Database Numerator = total number of avoidable ER visits. Denominator = total number of ER visits Source of Avoidable ER Visit definitions: 2008 Statewide Collaborative QIP, Reducing Avoidable Emergency Room Visits, Re-Measurement Report. California Department of Health Care Services Health Services Advisory Group, Inc. November (Appendix A). = total number of ER visits

14. Meaningful Use Stage 1 Partners: Beacon Leadership: Activities:
Melinda Nugent, MS, Clinical Program Manager
Technical Support: Saturnino Doctor, Kevin Ikeda, Linda Ranney
Activities:
Network, Hardware and Connectivity Support
Monitoring of Progress Toward Stage 1 MU
Basic MU Technical Preparation for Handoff to REC

15. Meaningful Use Stage 1 Progress: June 2012

16. Care Coordination Partners: Beacon Leadership: Activities:
Della Lin, M.D., Performance Improvement Consultant
Cynthia Ross, MPA, Clinical Program Coordinator
Activities:
Public/Private Partnership in Care Coordination Infrastructure Development
Clinical Transformation/Process Change
Target Population of Focus
Process/Outcome Measurement

17. Hawai‘i Island Beacon Community Clinical Transformation: Target Population of Focus: Patient Enrollment
Selection Criteria: Diagnosis, Co-morbidities, Age, Utilization

18. Blood Pressure Screening Performed June 2012 = 94%
Clinical Transformation Population of Focus diabetic patients who had an HbA1c screen in the last 12 months.

19. BP < 140/90 June 2012 = 69%
Diabetic patients whose most recent BP was less than 140/90 in the last 12 months. The patient is counted if the most recent BP for the last 12 months is less than 140/90. The patient is not counted if the result for the most recent BP test during the measurement period is ≥ 140/90, or is missing, or if an HbA1c test was not performed.
The goal is for 70% of diabetic patients to achieve HbA1c<9.0%.

20. HbA1c Screening Performed June = 73%
Clinical Transformation Population of Focus diabetic patients who had an HbA1c screen in the last 12 months.

21. HbA1c < 9.0
June 2012 = 55%
Diabetic patients whose most recent HbA1c was less than 9.0% in the last 12 months. The patient is counted if the most recent HbA1c for the last 12 months is less than 9.0%. The patient is not counted if the result for the most recent HbA1c test during the measurement period is ≥ 9.0%, or is missing, or if an HbA1c test was not performed.
The goal is for 70% of diabetic patients to achieve HbA1c<9.0%.

22. LDL-C Screening Performed June 2012 = 63%
Clinical Transformation panel patients who had a LDL-C screen performed in the last 12 months.

23. LDL-C < 100 mg/dL June = 33%
Patients whose most recent LDL-C was less than 100 mg/dl in the last 12 months. The patient is counted if the most recent LDL-C for the last 12 months is less than 100 mg/dl. The patient is not counted if the result for the most recent LDL-C test during the measurement period is ≥ 100 mg/dl, or is missing, of if an LDL-C test was not performed.
The goal is for 70% of patients to achieve LDL-C<100 mg/dl.

24. Summary Measure Percentage Screened Percentage Controlled
Blood Pressure control < 140/90
94%
69%
HbA1C control < 9.0
73%
55%
LDL-C control < 100 mg/dL
63%
33%

25. Hawaii Island Beacon Community Transformation Strategy
VISION:
Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.
OBJECTIVES:
Improve access to primary care, specialty care & behavioral health care
Avert the onset and advancement of diabetes, hypertension
and hyperlipidemia
Reduce health disparities for Native Hawaiians and
other populations at risk
Achieve EHR adoption and meaningful use
>60% of primary care providers
Primary Drivers:
Secondary Drivers:
Interventions
Leadership
Reliable Processes
Provide care in appropriate setting
Delivery System Design
Community, Patient and
Family Voice
Communication
Decision Support
Clinical Transformation
Patient, Provider and Community Engagement
Health Information Exchange
Practice Redesign
- PCMH Coaching
- EMR/MU Stage I
- Care Coordination
Care Transitions
- Hospital Discharge

26. Care Transitions Partners: Beacon Leadership: Activities:
Alistair Bairos, M.D., Care Transitions Re-Design Manager
Activities:
Discharge Planning Process Improvements
Readmit Risk Factor Screen
Medication Reconciliation
Patient and Caregiver Education and Teachback
Post-Discharge Instructions and Handoffs
Alignment with Community Based Care Coordinators
Alignment with
PREMIER QUEST PATIENT SAFETY AND QUALITY IMPROVEMENT

27. Utilization Measure: Chronic Condition Composite PQI for Q1 2009 through Q1 2012
The Potentially Avoidable Hospitalization measure is one of several measures used to assess the HIBC program’s impact on averting disease onset and advancement. A chronic disease composite and risk-adjusted rate is calculated by an HIBC data contractor; the rate involves conditions for which effective outpatient care or early intervention potentially prevents the need for hospitalization. By definition, chronic diseases entail conditions such as short- and long-term and uncontrolled diabetes, lower extremity amputation among diabetics, CHF, angina, hypertension, COPD, and asthma.
Numerator - Hospital inpatient data) Hawaii Health Information Corporation, Inpatient Database [for more information, go to
Denominator – Population data) U.S. Census Bureau, Population Division, Inter-censal Estimates of the Resident Population for Counties of Hawaii: April 1, 2000 to July 1, 2010 (CO-EST00INT-01-15) and Annual Estimates of the Resident Population for Counties of Hawaii: April 1, 2010 to July 1, 2011 (CO-EST ). Notes: Census population is annualized over four quarters. Where population estimates have not been updated, the most current previous year estimate is used.
Risk-adjusted rate = (observed rate/expected rate)*reference population rate.
Chronic conditions include: short- and long-term and uncontrolled diabetes, lower extremity amputation among diabetics, COPD or asthma in older adults, hypertension, CHF, angina and asthma in younger adults.
Source of Potentially Avoidable Hospitalizations definition: The Prevention Quality Indicators (PQIs) were developed by the Agency for Healthcare Research and Quality (AHRQ) and can be used with hospital inpatient data to measure quality of care for conditions sensitive to ambulatory care.

28. Utilization Measure: 30-Day Potentially Preventable Hospital Readmissions All Causes Q through Q4 2011
Source: Hawaii Health Information Corporation
Potentially Preventable Readmission: A Potentially Preventable Readmission is a readmission (return hospitalization within the specified readmission time interval) that is clinically-related to the initial hospital admission.
Readmission: Readmission is a return hospitalization to an acute care hospital that follows a prior admission from an acute care hospital. Intervening admissions to non acute care facilities (e.g., a skilled nursing facility) are not considered readmissions and do not impact the designation of an admission as a readmission.
Source: 3M™ Health Information Systems: Potentially Preventable Readmissions Classification System

29. Premier QUEST Readmission Findings July 1, 2010 – June 30, 2011
Hilo Medical Center:
Top 3 MS-DRGs opportunities psychosis, heart failure, cellulitis
Principle diagnosis heart failure, chronic bronchitis, diabetes
53% of admissions within 30 days occur by day 10
Readmission rate is 8.1%
Kona Community Hospital:
Top 3 MS-DRG opportunities normal newborn, pneumonia and heart failure
Principle diagnosis perinatal jaundice, pneumonia and heart failure
63% of admissions within 30 days occur by day 10
Readmission rate is 4.9%

30. Utilization Measure: 30-Day Potentially Preventable Hospital Readmissions: Cardiovascular Conditions Q through Q4 2011
Potentially Preventable Readmission: A Potentially Preventable Readmission is a readmission (return hospitalization within the specified readmission time interval) that is clinically-related to the initial hospital admission.
Readmission: Readmission is a return hospitalization to an acute care hospital that follows a prior admission from an acute care hospital. Intervening admissions to non acute care facilities (e.g., a skilled nursing facility) are not considered readmissions and do not impact the designation of an admission as a readmission.
Source: 3M™ Health Information Systems: Potentially Preventable Readmissions Classification System

31. Hawaii Island Beacon Community Transformation Strategy
VISION:
Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.
OBJECTIVES:
Improve access to primary care, specialty care & behavioral health care
Avert the onset and advancement of diabetes, hypertension
and hyperlipidemia
Reduce health disparities for Native Hawaiians and
other populations at risk
Achieve EHR adoption and meaningful use
>60% of primary care providers
Primary Drivers:
Secondary Drivers:
Interventions
Leadership
Reliable Processes
Provide care in appropriate setting
Delivery System Design
Community, Patient and
Family Voice
Communication
Decision Support
Clinical Transformation
Patient, Provider and Community Engagement
Health Information Exchange
Practice Redesign
- PCMH Coaching
- EMR/MU Stage I
- Care Coordination
Care Transitions
- Hospital Discharge
Enabling Services
Healthy Lifestyles
HEAL Projects

32. Community Engagement Activities: Partners: Beacon Leadership:
HEAL – Jessica Yamamoto, MBA, Community Engagement and Communications Manager
HEAL – Mari Horike, Community Outreach Facilitator
Della Lin, M.D., Performance Improvement Consultant
Cynthia Ross, MPA, Clinical Program Coordinator
Activities:
Enabling Services
Healthy Eating and Active Living – Community Based Programs
Health Education
Outreach
Transportation
Social Services

33. H.E.A.L. PROJECTS

34. Hawaii Island Beacon Community Transformation Strategy
VISION:
Transforming health and health care delivery through collaboration, technology and community engagement resulting in better care, better health and lower cost.
OBJECTIVES:
Improve access to primary care, specialty care & behavioral health care
Avert the onset and advancement of diabetes, hypertension
and hyperlipidemia
Reduce health disparities for Native Hawaiians and
other populations at risk
Achieve EHR adoption and meaningful use
>60% of primary care providers
Primary Drivers:
Secondary Drivers:
Interventions
Leadership
Reliable Processes
Provide care in appropriate setting
Delivery System Design
Community, Patient and
Family Voice
Communication
Decision Support
Clinical Transformation
Patient, Provider and Community Engagement
Health Information Exchange
Practice Redesign
- PCMH Coaching
- EMR/MU Stage I
- Care Coordination
Care Transitions
- Hospital Discharge
Enabling Services
Healthy Lifestyles
HEAL Projects
Alere/Wellogic
- Clinical Decision Support
Caradigm/Amalga
- Population Health
Monitoring

35. Health Information Exchange
Partners:
Beacon Leadership:
Jeff Jendrysik, Senior Project Manager
Laurie Bass, HIT Manager
Andy Levin, Patient Ombudsman
Brad Peska, Strategic Technology & Innovation Consultant
Activities:
Governance
Contracting
Data Security/HIPAA Compliance
Project Implementation Management Oversight

36. Alere-Wellogic Implementation

37. Caradigm/Amalga Implementation
Project has been re-scoped
Final deliverable – successful data input
Caradigm currrently evaluating data feeds from Hilo Medical Center
ADT
Medications
Discharge Summaries

38. A Familiar Patient Story
Kimo is a 280 pound, 44 year old male with a BMI of 46 suffering from coronary artery disease (triple bypass), diabetes and renal insufficiency. His sibling is a diabetic amputee. Kimo is a Native Hawaiian QUEST patient. He farms livestock and lives off the grid in a remote rural location in North Hawaii. He was identified for the BEACON Care Coordination program at Hamakua Health Center is now with a Private Practice. He was recently admitted to NHCH through the Emergency Department with a diagnosis of cellulitis and an infected abscess. His hospital length of stay was 10 days.

39. Improvement Cycle: PDSA
1. Discharge Note/Med List (NHCH)
2. Patient Contact List (NHCH & Hamakua)
3. Informed of Discharge (Hui Malama)

40. Testing in Progess… Ownership through small tests

41. Reflections “This puts everything together so it makes sense!”
“The fact that we could come together is the most rewarding thing that I have done!”
“We understand better now why we do things.. the little every day tasks… we know the impact of those little everyday tasks that we do.. there is a feedback loop”
“No task is too great if we do it together!!”

42. Next Steps First steps in transforming care Next steps Relationships
Communication channels
Trust
Follow-through
Problem solving strategy
Next steps
Health Information Exchange to streamline communication channels and facilitate problem solving strategies
Measure effectiveness of interventions
Process
Outcome
Cost

43. Future Direction
HIE and Clinical efforts implemented in North Hawaii to spread island wide
Sustainability business model for 501c3 Service Lines include support for physician practices:
HIT Network and Connectivity
Performance Improvement/Care Redesign
Management/Leadership
Administrative Functions
Data Analysis for Performance Incentives
Central Authority for Health Information Exchange on Hawaii Island
Current and future activities lay foundation for Accountable Care
Value Proposition with an Affordable Price
Alignment with State Transformation Vision
Actively pursuing program investment funding for continued transformative change

44. Commitment to a Hawaii Island Shared Vision
Transforming Health and
Health Care Delivery through
Collaboration, Technology
and Community Engagement