1. Nancy Vorhees Inland Northwest Health Services
Using Shared Services and Integrated Information Systems To Improve the Delivery of Health Care
Nancy Vorhees
Inland Northwest Health Services
This presentations will highlight a unique organization that has successfully established a business model using shared services and integrated information systems to improve the delivery of health care across a large geographic region – eastern Washington, northern Idaho, northeastern Oregon and western Montana.
For those who don’t know this region, let me describe it in a little more detail. Spokane, Washington sits on the eastern border of Washington state. The surrounding region is largely high desert, rolling hills, and moderate sized mountains on the northern edge of the Rockies. The region is largely rural, with some areas having such a low population density as to be classified frontier.
Spokane is the largest population center in the region, with about 200,000 people in the city limits and another 200,000 in the surrounding county. Immediately east of Spokane is Couer d’Alene, Idaho, with a population of about 100,000. All of the other communities in the region are quite small, ranging in size from a few hundred to around 30,000.
Spokane has an extensive, complex health care system. It’s the greatest concentration of health care services in the northern tier states, east of Seattle and west of Minneapolis. Health care in the surrounding communities consists of primary care providers and small to mid-sized rural community hospitals, most of which are federally qualified Critical Access Hospitals. Spokane serves as the referral center for the region.

2. Presentation Overview
History of INHS
Organization and Oversight
Current Scope
Program Highlights
Lessons Learned
With that geography lesson out of the way, let me review my presentation. I’m going to give you a brief history of Inland Northwest Health Services, touching on the organization and oversight structure. I’ll also review our company’s current scope and the highlights of some of our programs. Finally, I’ll review some of the lessons we have learned over the years.

3. In the Beginning
Providence Services of Eastern Washington and Empire Health Services were fierce competitors, running competing hospitals, air ambulance services and rehabilitation programs.
Both were loosing money, and both recognized that the region’s customers were not being well served.
I described Spokane’s role as a referral center for the region. I did not mention that there are four hospitals in the county, two of which are run by one health system and two of which are run be another. These systems, Providence and Empire, have historically been, and still are, fierce competitors.
More than ten years ago, Providence and Empire competed at every opportunity, including running separate hospitals, air ambulance services and rehabilitation programs.
Both knew that they were loosing money on these programs, and both knew that this was not the best way to deliver health care to the region.

4. 1994
The two competitors began looking at opportunities for collaboration.
“It showed a lot of foresight and the realization that things could be better and less costly. There was a willingness of everyone involved to look for the common good.”
Joe Legel, retired executive vice president
Sacred Heart Medical Center
So, in 1994 they took the unprecedented step of looking at how they could collaborate in certain program areas, while remaining competitive in all others.
The participants in that process still look back in amazement at the willingness of the key players to talk to each other. But even with their strong competitive history, they recognized that everyone at the table was driven by a desire to improve health care.

5. Northwest MedStar
The competitors came together and formed Northwest MedStar, a single air ambulance program that is now financially stable and serves eastern Washington, northern Idaho, north-eastern Oregon, and western Montana.
The first collaborative program formed was a combined regional air ambulance service, Northwest MedStar. In ten years, that program has gone from loosing millions of dollars to being financially stable and serving a larger region that the original two programs combined.

6. St. Luke’s Rehabilitation Inst.
The competitors also formed St. Luke’s, a stand-alone medical rehabilitation hospital that each year treats about 1,500 patients with conditions related to brain or spinal cord injuries, neuromuscular disorders, stroke, and trauma.
Shortly after initiating that shared program, Providence and Empire looked at rehabilitation services, Together they created St. Luke’s Rehabilitation Institute, now Washington state’s largest stand-alone rehabilitation hospital.

7. Information Resource Management
After the first two programs, the competitors recognized the value of collaborating on information systems, and merged their networks to form Information Resource Management.
The formation of the first two shared service programs was a fairly logical approach to the problems the two health systems had experienced. Next, in 1997, came a quantum leap forward in the collaboration process. Empire Health Systems was planning to implement a new hospital information system in its two facilities. Providence recognized that if their hospitals used the same systems, there would be unprecedented opportunities for sharing and management of patient information, as well as significant cost savings. The two agreed to install the same system, and merged their networks to form Information Resource Management.

8. Along the way, Providence and Empire formed Inland Northwest Health Services (INHS) to operate the new shared programs.
In succeeding years, INHS has grown to provide services for hospitals and physicians across the region.
Providence and Empire recognized that a separate, neutral entity would be needed to operate these shared programs, and formed INHS.
Since it’s inception, INHS has grown to provide services beyond those needed by the sponsoring health systems, and facilitates health care across the region.

9. Inland Northwest Health Services
INHS is a not-for-profit 501(c)3 corporation, owned by the hospitals in Spokane and serving residents of WA, ID, MT, OR and Canada. We facilitate clinical care by:
Improving clinical outcomes through information access and integrated clinical systems for physicians, hospitals, clinics and other health providers
Acting as the “trusted party” and secure custodian for the regional clinical data repository and a community-wide electronic medical record
Maintaining strict data structures and standardization to insure ability to share and compare data
Leveraging collaborative assets to control costs and provide high levels of expertise using shared resources
Utilizing advanced systems to increase patient safety
We are a not-for-profit, that facilitates clinical care by providing improved information access for all components of the health care system.
We are the region’s trusted party, serving as the stewards and custodians of a clinical data repository, which is taking on the role of a community-wide electronic medical record.
As part of that regional stewardship role, we enforce data structures and data standards, which insures the ability to share and compare data.
The community and regional approach to sharing resources allows us to leverage assets and helps control health care costs.
Finally, the advanced systems we are putting in place help to increase patient safety.

10. INHS Programs Northwest MedStar St. Luke’s Rehabilitation Institute
Information Resource Management
Northwest TeleHealth
Community Health Education and Resources
Children’s Miracle Network
Northwest Med Direct
Northwest Med Van
Regional Outreach
The regional collaboration extends beyond the three programs I’ve already mentioned. We also operate Northwest TeleHealth, one of the largest telemedicine networks in the country. Another program is Community Health Education and Resources, which provides health education and promotion programs on behalf of the hospitals to community-residents.as well as continuing education programs for health professionals.
Northwest MedDirect serves to connect rural health care providers and patients with specialty services in Spokane, and Northwest MedVan helps patients reach medical appointments. Finally, our Regional Outreach program provides consultative services to rural hospitals, including hospital administration and management.

11. Scope of System
32 primarily independent hospitals, with over 2500 beds, participating in the integrated information system
More than 20 clinics receiving hospital, laboratory and imaging data via standard electronic messages
More than 200 offices able to view hospital, laboratory and imaging data via a virtual private network.
More than 500 physicians accessing patient records wirelessly in hospitals via personal digital assistants
55 hospitals, clinics and public health agencies connected to the region’s telemedicine network
To give you a sense of our size – we currently have 32 hospitals, most of which are independent, small rural facilities, connected to our integrated information system. This represents more than 2500 beds.
More than 20 clinics, not associated in anyway with our company or the hospital systems, are receiving data from this integrated information system,via standardized electronic messages.
For those physicians and clinics that are not ready to receive electronic messages, all data in our integrated system can be viewed remotely via a virtual private network.
We also receive data into our system from a large regional reference laboratory and imaging center. This information is available electronically to providers around the region.
We also have a program that lets physicians use PDAs to download and review patient data while they are conducting their rounds in the hospitals.
And, as I mentioned, our telemedicine network is one of the largest in the country, connecting 55 hospitals, clinics and public health agencies.

12. INHS Regional Healthcare Network INHS Regional Healthcare Network
Here’s a quick look to give you a sense of the geographic range in our network.
INHS Regional Healthcare Network
Legend
INHS Hospitals
Telehealth Sites
Helicopter Base
Affiliated Hospitals

13. Organization and Oversight
Executive Director
Eight-Member Board of Directors
Representatives from the boards of the sponsoring hospitals
Medical professionals
Community members
INHS is headed by a Chief Executive Officer, who leads a five member executive management team.
We are overseen by an eight member board of directors, consisting of representatives from the sponsoring hospitals, medical professionals, and community members.
We have 850 employees.

14. Funding Reimbursement for healthcare services
Fees paid by participating facilities
Support from the sponsoring hospital systems
The company’s programs are funded through three different mechanisms –
Reimbursement for health care services (primarily the rehabilitation hospital and the air ambulance service)
Fees paid by participating facilities (primarily information resource management)
And support from the sponsoring hospitals.

15. INHS Accomplishments
We established standard data sets, allowing comparison of clinical data and enhancing the longitudinal patient record
We established a regional Master Patient Index standard that has allowed us to gather and distribute patient data to the caregivers in our region
We created a regional integrated information system that connects hospitals and clinics, providing a community Electronic Medical Record
We connected Physicians throughout the region, directly in their offices and wirelessly within our hospitals, providing relevant clinical data when and where they need it
We enhanced care in rural areas by connecting residents and clinicians to specialists through an extensive regional telemedicine network
We have achieved a number of significant accomplishments over the years.
Establishing standard data sets was largely forced through use of a common system. There are many advantages to a single system, but this is understandably not a solution for all communities. However, standardization of data sets can be achieved even without using a common system, but it takes more effort and planning.
We have also established a regional Master Patient Index. This has been facilitated by a common system but the common system isn’t a requirement. The reference lab I menitoned is not on our system, but is collaborating with us to implement a common MPI, so that patients can be identified in both systems. Similarly INHS is working with the county health department to match and assign a standard MPI to their patients, even though they are not on our system.
The net effect of the regional integrated system has been the creation of a community Electronic Medical Record, available as needed to all health care providers. This integrated information system has formed a strong foundation that has allowed some incredibly creative and progressive projects, including projects that leverage both the telemedicine and information systems.

16. Electronic Medical Record
A common Electronic Medical Record system operates in all participating hospitals and clinics, providing one standardized clinical data structure and presentation
Visit Histories
Cumulative Laboratory results
Radiology exam profile/reports
Transcription reports including e-Sign
Patient Demographics
Computerized Physician Order Entry
Each patient has a unique Master Patient Index (MPI) – one number, one regional record – currently 2, 601, 900 records in the system
Let’s look in a little more detail at the electronic medical record, as it provides the basis for many of the projects that we are implementing. There are many advantages to having a common system across multiple facilities. In one standardized record we capture all hospital data associated with each visit. Because there is a unique master patient index, we have the ability to look across visits, resulting in a longitudinal, regional record for each patient. There are currently more than 2.6 million unique records in the system.

17. Physician EMR Views per Month
Office Staff = 36,000
Physicians = 49,000
These electronic records provide a wealth of information for physicians, as they are starting to recognize. This graph shows the increase in physician views of our integrated hospital information over the last five years.

18. Clinical System Usage and Strategy
Clinical Docu-mentation
EMR Usage
Mobile Chart
CPOE Readiness
Telehealth Rural
Access
ED/ Medication History
Imaging Systems – Rad, Card, Path/Other
INHS/IRM Community Foundation Meditech HIS System
Text & Speech Systems
Physicians Mercury MD “Mobile” PCI
Expert Systems CPOE – Rules and Alerts
Regional Telehealth Network
Physician Office Systems – Billing and EMR
The integrated information system and common MPI gives the region a foundation for innovative tools, including:
Computerized Physician Order Entry (CPOE)
Clinical Documentation Systems for Nursing Notes
Decision-Support Tools
Anywhere, Anytime Physician Access to Images
Remote Consultations and Support for Rural Residents
The integrated system creates tremendous opportunities for implementing additional technology to improve health care, including :
PHYSICIAN CONNECTIVITY for PCI Usage
PHYSICIAN CONNECTIVITY – WIRED or WIRELSS for MERCURYMD Usage
PROVIDENCE HEALTHCARE – READINESS for CPOE (Computerized Physician Order Entry) in conjunction with KNOWLEDGE BASE SYSTEMS (KBS)
Telehealth based systems providing remote consultations and support

19. Source: INHS/IRM – Server Farm, Spokane Datacenter
Physician EMR Server Farm
Collaborative server farm with 280 physician EMR systems managed by INHS:
Support 3 EMR systems
GE Logician
NextGen
LSS
Lower cost to physicians
Professional IT staff for implementation and local support
24 x 7 helpdesk
Interfaced with hospital HIS, PACS, Reference Lab
Momentum and community support
While our original focus was hospital information systems, we are also now supporting three different electronic medical systems for physician offices. By providing this service, physicians are able to implement EMRs more quickly and cheaply than they could if acting on their own. This server farm is also creating an outpatient, clinic-based integrated information system that, when combined with the hospital information system, opens the door for a complete, comprehensive inpatient and outpatient electronic medical record.
Source: INHS/IRM – Server Farm, Spokane Datacenter

20. INHS Telemedicine System
Nursing courses and education with universities and community colleges addressing Nursing Shortages
Rural hospital TelePharmacy program providing remote Pharmacist services
TeleER program assisting rural trauma doctors with ER cases remotely
Physicians provide remote Clinical Consults in Neurology, Pathology, Psychiatric services, and many other areas
Prison Based Health Services receive specialist care
Statewide Diabetes Education Program Including Native American Tribes
Now I’m going to spend a little time on our telemedicine system, as it also demonstrates the momentum created by collaboration and integration.
Our telemedicine system, Northwest Telehealth, is used for professional education, for health promotion, and also for the delivery of clinical services including individual patient consults and facility-to-facility services that allow the sharing of costs and expertise.

21. Telepharmacy
Currently four rural hospitals are receiving pharmacy services from Sacred Heart in Spokane. Four more are being added this year.
An example of the latter use is our TelePharmacy program, which allows one of our large urban hospitals to oversee pharmacy services in four rural hospitals. This program combines videoconferencing capabilities, the electronic medical record system, and automated dispensing devices to improve patient safety and decrease medical errors for the rural hospitals.

22. TeleER
TeleER links the Deaconess Emergency Room in Spokane with two rural hospitals. INHS has just received appropriations funding to expand the system to additional rural sites.
Another program that takes advantage of both telemedicine and electronic medical record capabilities is TeleER. This program allows providers in rural emergency rooms, who are often mid-level providers, to consult with experts in emergency care in one of Spokane’s trauma centers.

23. Collaborative Momentum
Common mission of lowering regional healthcare costs
Clinical data “shared”, not used as a competitive tool
Technical standardization saving millions
Developed a hot bed of healthcare technical expertise
Hospitals are beginning to see themselves as missing out if they do not participate
Over the years these different efforts have resulted in strong collaborative momentum. Participants have developed a common mission of lowering health care costs, for health care organizations and for patients. As part of this mission, participants have recognized the importance of sharing clinical data. The majority of our network members are competitors at one level or another. However, they’ve agreed that in the area of health information they will not compete. This is important for both the patients and the practitioners.
We recognize many communities will not be willing or able to use the approach of a common, integrated information system. But it is important to recognize that standardizing technology has saved the individual facilities and the region millions of dollars. The advantages are huge, and extend well beyond the ease with which health information can be exchanged. Hospitals and physician offices have been able to implement integrated information systems much quicker and at lower cost than they would on their own.
One side benefit has been the development of a hot-bed of technical expertise in healthcare information technology. This concentration of expertise speeds up the implementation of new projects and technologies. Another result of the collaborative momentum we have built is that hospitals are beginning to see themselves as left out if they do not participate. The message here is don’t worry if you don’t have participation from every provider and facility when you get started. If you are successful, show value, and build momentum, they will eventually join your efforts.

24. Obstacles and Challenges
Current funding model relies in part on INHS sponsors
Limited funds from rural hospitals slows their adoption of key clinical systems
Minimal physician office automation has slowed the longitudinal electronic medical record
Lack of healthcare industry data standards for data clinical exchange
Certainly there have been obstacles and challenges along the way. The current model still relies in part on funding from the original INHS sponsors. We are working hard to become financially independent, but it’s important to recognize that some up front investment is needed to initiate and maintain these kinds of organizations until they are self-sustaining.
We have also faced delays in implementation cause by funding issues in rural hospitals. They are not able to adopt new clinical systems as quickly as they would like.
Similarly, the overall implementation of a regional health information system has been delayed by slow implementation of electronic medical record systems in physician offices. There won’t be a free flow of information until the majority of physician offices are able to receive and utilize that information electronically.
Finally, standards for clinical data exchange have been slow to emerge and be widely accepted. This has delayed widespread deployment of some new technologies.

25. Obstacles and Challenges
Privacy and appropriate use of health information
All participants in network agree to protect the health information contained in the system.
HIPAA has added additional layers of complexity
Each facility as well as INHS has a HIPAA compliance officer
Data exchange for clinical care is handled under the standard network membership agreement
Data release for other purposes (I.e. research, health assessment) must be authorized through data sharing agreements
Privacy and security of health information has been a primary goal for INHS and participating health care facilities from the beginning. As the system grows and more hospitals are added, privacy and security issues become even more critical.
Each facility that joins the integrated information system agrees to protect all the health information contained in that system. Access is limited to individuals who have a specific rights based on their roles (provider, referral, billing, etc).
The integrated information system pre-dated HIPAA, which has added additional layers of complexity. The primary difference is the designation of HIPAA compliance officers at each participating facility as well as at INHS. These individuals are responsible for establishing each facilities policies and procedures for handling protected health information. Data exchange that is from facility to facility, or between providers, for the purpose of delivering care is covered under policies outlined in the standard INHS membership agreement. Larger data releases, where data is collected from multiple facilities, such as for research or population health assessment, must be authorized through data sharing agreements.
The hospitals maintain the primary responsibility for protecting the health information of their patients. INHS serves as a data steward and facilitates security and access.

26. Lessons Learned
Someone has to get the collaboration started, including seed money.
Collaborations must be based on real business needs of all participants.
EMRs must meet business needs as well as patient care needs.
Focus on developing a critical mass of EMR users in a community.
If you build it, they will come.
In closing, I’d like to highlight some of the key lessons that we’ve learned in the last ten years. Most importantly, someone has to get collaborations started, including being willing to invest some seed money. If no one is willing to put up seed money, then no one is convinced that the endeavor is worthwhile.
Collaborations must be based on real business needs, and all participants must believe that the collaboration will help them meet their business needs. Each of our shared service programs was initiated because several health care organizations had identified a particular business problem that they felt collaboration could address.
Electronic medical records will not be implemented in hospitals or physician offices unless they meet a business need. Everyone in the health system wants to improve patient care, but realistically improvement in patient care alone is not enough to encourage most businesses to make significant investments in technology.
As I mentioned earlier in this talk, you don’t need to have every health care provider and organization in the community committed to collaboration in order to get started. Focus on the ones who really want to move forward, and work to develop a critical mass. Once you have that critical mass, the others will see more advantage to joining the effort.
In other words, if you build it, they will come.

27. Thank You Nancy Vorhees vorheen@inhs.org (509)232-8104
Thank you very much for your time and interest. I’d be happy to entertain any questions.