Hawai i Island Beacon Community

Transcription

1 Final Report September 2013 Overview The Hawai i Island Beacon Community (HIBC) was established to address the objectives and requirements of the Beacon Community Cooperative Agreement Program between the U.S. Department of Health & Human Services, Office of the National Coordinator for Health Information Technology (ONC) and the University of Hawai i at Hilo (UHH). The Research Corporation of the University of Hawai i (RCUH) acted as the fiscal, contracting and staffing agent for the HIBC project. The Hawai i Beacon Community Cooperative Agreement was under the direction of Principal Investigator, Daniel E. Brown, Ph.D. The Hawai i Island Health Information Exchange (HIHIE) 501(c)(3) non-profit corporation was formed to engage Hawai i Island stakeholders in the governance and operations of collaborative clinical transformation and health information exchange. An agreement with UHH designated the HIHIE Board of Directors as an advisory body to the University guiding the execution of HIBC project activities. Susan B. Hunt, MHA served as the HIBC Project Director and continues to serve as CEO for the HIHIE non-profit corporation. Hawai i Island, also referred to as Hawai i County, is similar in size to the State of Connecticut and is home to approximately 189,000 residents. The HIBC project faced several unique challenges, the primary being geographic isolation as an island community. Access to healthcare services is limited by geography, lack of comprehensive public transportation and critical health professional shortages. Hawai i Island has substantial health and economic disparities. Death rates for cardiovascular disease for are the highest in the State. Obesity and smoking rates are higher than the rest of the State and more adults suffer from diabetic complications. 1 Populations at higher risk for disease and adverse health outcomes include Native Hawaiians, other Pacific Islanders, the under and uninsured and the elderly. Hawai i Island, in comparison to the rest of the State, has the highest percentage of individuals living below 100 percent of the federal poverty level. 2 Ethnic and cultural diversity also create special challenges to effectively engaging patients in their care. The majority of providers are solo practitioners employing only one or two office staff. Others work in one to three person groups. Most lack resources to implement and maintain health information technology. Internet connectivity in several remote areas on Hawai i Island lack bandwidth to connect to a cloud based electronic health record system requiring installation of an on-site network server and/or working with telecommunications companies to increase bandwidth. In response to these unique challenges and through efforts to improve health and health care on Hawai i Island, the following project aims were addressed: 1. Improve access to primary, specialty and behavioral health care. 2. Avert the onset and advancement of diabetes, hypertension and hyperlipidemia. 3. Reduce health disparities for Native Hawaiians and other at-risk populations. 4. Achieve electronic health record (EHR) adoption and meaningful use. 1 Hawai i State Department of Health Diabetes Report State of Hawai i Primary Care Needs Assessment Databook 2012 Hawai i Island Beacon Community 1

2 Quantitative Information The Hawai i Island Beacon Community (HIBC) was awarded $16,091,390 on May 4, The project awarded one sub-recipient, North Hawai i Community Hospital, $680,000 for the implementation of Alere Accountable Care Solutions (Wellogic) Regional Health Information Exchange (HIE) software. Final Financial Summary Exhibit 1: Spend Down by Budget Category 3 rd Quarter 2010 to 4 th Quarter 2014 Exhibit 2: Expenditures by Quarter All major service contracts were executed and underway by the 4 th Quarter 2011 with peak activity occurring throughout calendar year 2012 and into the 1 st Quarter Hawai i Island Beacon Community 2

3 YEAR 1 August 2010 March % of Total Expenditures: $435, The primary activities within the first year of the cooperative agreement included planning, policy and governance infrastructure development to support health information exchange, and recruitment of five core staff. A Master Plan and Budget was created to guide project management, contracting and additional staffing. Supply costs for office operations included laptop computers. Professional service contracts were executed for legal, technical, and clinical transformation planning. Travel expenditures included education, training and site visits for new staff. Exhibit 3: Year 1 Expenditures Budget Categories Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 TOTAL Personnel $20,181 $45,921 $48,367 $48,367 $49,585 $51,047 $263,468 Fringe Benefits $1,893 $5,264 $5,498 $4,717 $6,877 $6,252 $30,500 Travel $316 $375 $1,373 $12,432 $3,106 $6,362 $7,518 $5,216 $36,698 Equipment $0 Supplies $15,789 $58 $15,847 Contractual $1,329 $1,329 $938 $2,471 $2,495 $8,561 Other $2,960 $1,108 $2,268 $6,335 Total Direct Costs $1,645 $1,704 $23,447 $63,617 $57,908 $80,666 $67,640 $64,782 $361,409 Indirect Costs $339 $351 $4,830 $13,105 $11,929 $16,617 $13,934 $13,345 $74,450 TOTAL $1,984 $2,055 $28,277 $76,722 $69,837 $97,283 $81,574 $78,127 $435,860 YEAR 2 April 2011 March % of Total Expenditures: $3,452, Implementation of the Master Plan began with the hiring of health IT technicians, the Project Director and additional staff experts in the areas of financial management, measurement and evaluation, and clinical practice redesign. An official office location was opened at 1437 Kilauea Avenue in Hilo, Hawai i. Travel expenses increased due to the distances traveled island-wide by health IT staff to provide EHR implementation support to the private practices. Major contracts were signed with: 1) Booz Allen Hamilton for assistance with health information exchange (HIE) business modeling, program management, and measurement and evaluation consultation; 2) DataHouse, a Honolulu based firm, to host and provide software support for Microsoft s Amalga Unified Intelligence System(UIS); and 3) North Hawai i Community Hospital (NHCH) which received a sub-recipient award for implementation of the Alere Accountable Care Solutions (Wellogic) software for regional information exchange and clinical decision support. Clinical Transformation requests for proposals were issued for care coordination, care transitions and patient engagement. Contracts were executed with hospitals, federally qualified health centers and the Native Hawaiian Health Care System. Community wellness service contracts were awarded to 19 local organizations island wide to engage their communities in lifestyle changes involving healthy eating and active living (HEAL). Exhibit 4: Year 2 Expenditures Budget Categories Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 TOTAL Personnel $51,047 $51,047 $63,902 $78,939 $86,333 $89,386 $91,297 $94,265 $97,765 $104,850 $112,369 $136,605 $1,057,805 Fringe Benefits $6,251 $6,256 $8,187 $10,884 $11,723 $12,329 $13,550 $18,025 $16,842 $20,905 $21,932 $28,598 $175,481 Travel $1,785 $906 $9,156 $4,925 $5,636 $6,307 $6,073 $10,060 $11,268 $4,698 $10,476 $12,673 $83,962 Equipment $0 Supplies $7,789 $2,400 $269 $2,723 $616 $600 $2,219 $301 $14,789 $435 $701 $32,842 Contractual $2,495 $9,000 $24,463 $28,000 $124,071 $93,734 $687,472 $139,001 $37,134 $374,566 $1,519,936 Other $344 $718 $2,440 $1,713 $8,205 $1,861 $9,169 $4,278 $2,416 $3,172 $8,041 $5,495 $47,852 Total Direct Costs $59,426 $69,211 $95,084 $96,730 $139,082 $138,499 $244,759 $222,581 $816,064 $287,415 $190,387 $558,638 $2,917,878 Indirect Costs $12,242 $14,257 $19,587 $19,926 $28,651 $28,531 $50,420 $45,852 $101,159 $59,207 $39,220 $115,079 $534,133 TOTAL $71,668 $83,468 $114,671 $116,657 $167,733 $167,029 $295,180 $268,433 $917,224 $346,623 $229,607 $673,718 $3,452,011 Hawai i Island Beacon Community 3

4 YEAR 3 April 2012 March % of Total Expenditures: $8,228, The project was in full production during year three. A complete staff was in place supporting HIBC initiatives. All clinical transformation activities were underway. Private practice care coordination services were launched. TransforMED was engaged to facilitate physician practice redesign focused on achieving PCMH status and meaningful use. Community based learning collaboratives were being held for both clinical transformation and practice redesign. Alere Wellogic was fully implemented as a Regional HIE at NHCH and received the first data feeds from community based private practice EHRs primary care and specialty care. A HISP to HISP connection was successfully tested between NHCH and the State HIE. Private practice physicians received technical support for EHR implementation and meeting meaningful use requirements in conjunction with the Hawai i Pacific Regional Extension Center. Amalga UIS privacy and security policies and protocols were completed and data feeds were under development. Exhibit 5: Year 3 Expenditures Budget Categories Apr-12 Apr-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 TOTAL Personnel $130,167 $131,559 $120,409 $128,649 $124,429 $132,073 $137,729 $143,742 $120,555 $125,744 $103,032 $55,464 $1,453,551 Fringe Benefits $23,480 $23,666 $22,982 $26,061 $26,738 $28,305 $28,126 $27,631 $23,394 $25,547 $22,036 $11,311 $289,277 Travel $5,718 $16,257 $13,228 $12,135 $7,157 $6,731 $4,148 $16,490 $10,131 $4,892 $7,267 $6,278 $110,431 Equipment $0 Supplies $266 $4,143 $6,430 $3,498 $467 $202 $800 $1,700 $1,609 $744 $289 $222 $20,371 Contractual $369,714 $811,643 $281,694 $615,555 $213,952 $417,834 $241,043 $471,320 $233,919 $492,725 $600,127 $201,314 $4,950,840 Other $9,366 $5,726 $3,082 $2,013 $4,540 $3,471 $4,537 $4,597 $2,978 $6,442 $6,449 $1,661 $54,862 Total Direct Costs $538,710 $992,994 $447,825 $787,911 $377,282 $588,615 $416,384 $665,480 $392,587 $656,093 $739,200 $276,250 $6,879,332 Indirect Costs $110,974 $204,557 $92,281 $35,476 $33,646 $94,475 $85,775 $307,968 $80,873 $93,955 $152,275 $56,907 $1,349,161 TOTAL $649,684 $1,197,551 $540,106 $823,387 $410,928 $683,090 $502,158 $973,448 $473,459 $750,048 $891,475 $333,157 $8,228,493 Exhibit 6: Sub-recipient - NHCH Deliverable Schedule and Payments Sub-recipient Award: $680,000 North Hawai i Community Hospital was awarded a subrecipient agreement for $680, to install Alere Wellogic. Four major deliverables were achieved over the course of the project and paid upon successful completion. D1: Project management plan D2: Go live implementation D3: Hospital based data feeds D4: Community-based physician EHR data feeds NCE PERIOD April 2013 September % of Total Expenditures: $3,974, The Beacon Nation Information Dissemination project under contract with Booz Allen Hamilton was completed during the no cost extension period resulting in six learning guides, webinars, workshops and shared learning (site) visits with innovation partners thus laying the foundation for continued ONC national transformation work. Alere Wellogic, working with the Alliance of Chicago and GE Centricity, Hawai i Island Beacon Community 4

5 established an active data feed from Hamakua Health Center/FQHC to NHCH. Clinical transformation and health IT contracts were completed with work accomplished under the HIBC project either absorbed into the daily operations of local partner organizations or transitioned to new entities for further development and implementation. Exhibit 7: No Cost Extension Period Expenditures Budget Categories Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 TOTAL Personnel $84,713 $83,713 $64,228 $47,788 $45,346 $34,877 $24,358 $30,711 $415,733 Fringe Benefits $16,248 $15,947 $13,802 $10,078 $9,011 $7,374 $5,170 $8,275 $85,903 Travel $2,897 $8,774 $8,245 $1,114 $197 $3,686 $389 $25,302 Equipment $0 Supplies $436 $571 $92 $38 $1,137 Contractual $490,457 $429,720 $389,388 $419,326 $5,396 $521,063 $165,227 $338,890 $2,759,467 Other $5,047 $3,372 $1,860 $1,397 $1,208 $1,178 $922 $148 $15,131 Total Direct Costs $599,797 $542,097 $477,523 $479,795 $61,157 $568,178 $196,103 $378,024 $3,302,674 Indirect Costs $123,558 $111,672 $98,370 $98,838 $12,598 $117,044 $40,397 $69,842 $672,319 TOTAL $723,355 $653,768 $575,893 $578,632 $73,755 $685,222 $236,501 $447,866 $3,974,992 Exhibit 8: Spending by Project/Category for 36 Month Project Period The HIBC project funds were allocated as indicated above. Beacon Operations expenses were comprised of salary and fringe benefits, office location and office infrastructure. Subject matter experts were contracted to provide programmatic support for information exchange governance, policy development and technical program management, as well as, guidance with measurement and evaluation. Clinical Transformation and Practice Redesign and Community Wellness allocations consisted of vendor service contracts with community based organizations involved in front line service delivery. Health Information Exchange allocations funded work with software development, hosting, implementation and interfacing agreements for both Amalga UIS clinical/claims data repository and Alere Wellogic Regional HIE. The National Information Dissemination project funds were allocated to ensure that best practices and lessons learned from all 17 Beacon Communities were shared nationwide. HIBC contracted with Booz Allen Hamilton in collaboration with all Beacon Communities and the ONC to produce an overall strategy for disseminating information which included web based resources and working with allied organizations and innovation partners that participated in shared learning visits, webinars and workshops. Hawai i Island Beacon Community 5

6 Major Milestones Achieved Over Life of the Program 2010 Hawai i Beacon awarded 5/4/10. Microsoft Amalga predetermined to be the HIE platform by Hawai i Medical Service Association (HMSA) Privacy Policy, Participant Agreement Adopted, Steering Committee Formed Core staff hired via RCUH Alere/Wellogic recommended for Regional HIE option at North Hawai i Community Hospital May June July Aug Sept Oct Nov Dec Hawai i Island Health Information Exchange Incorporated 6/22/10 Data use issues resolved HMSA decided to retain Amalga UIS license with Microsoft 2011 \ Clinical transformation acknowledged as a necessary component of Beacon Project Master Plan for clinical transformation approved. Project Director with Clinical Transformation experience hired Clinical Transformation plan launched Hawai i Beacon Website Launched RFPs Issued Practice Redesign, Care Coordination, Care Transitions Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Proceed with Alere-Wellogic Regional HIE HIT/Technical staff hired Project management and technical assistance from BAH initiated. NHCH Sub-recipient Application to expand Alere-Wellogic as regional HIE approved DataHouse contracted as Amalga UIS host GO LIVE Alere/Wellogic Deliverables 1 & 2 completed 2012 Clinical Transformation Steering Committee launch Hospital based Project BOOST Kick-off event Community Wellness HEAL Project Kick-off TransforMED Practice Redesign launch Private Practice Care Coordination launch TransforMED Learning Collab #1 Clinical Transformation Learning Collab #1 TransforMED Learning Collab #2 Clinical Transformation Learning Collab #2 Alere/Wellogic test HISP connection with State HIE Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Alere/Wellogic/NCHC internal primary interfaces complete Amalga UIS Phase II data feed development begins HIHIE 501(c)(3) Determination 4/19/12 First secure connection established to Amalga Issues with Amalga UIS software result in reduced scope of work Alere/Wellogic Phase II interfaces complete Lab, Pharm Alere/Wellogic Deliverable 3 Complete - Progress Notes 60% of MediCARE providers achieve MU Stage 1 Hawai i Island Beacon Community 6

7 2013 TransforMED Learning Collab #3 Beacon Nation Project launch with BAH Wellogic User Group Meeting TransforMED Learning Collab #4 Clinical Transformation Project Wrap up. First grant for HIHIE 501(c)(3) received from County of Hawaii Beacon Nation Info Dissemination 6 Learning Guides Published; Site Visits, Webinars and Workshops conducted Jan Feb Mar Apr May Jun Jul Aug Sep [No Cost Extention period Apr Sep] Alere/Wellogic Deliverable 4 Private Practice data feeds Caradigm completes repairs to Amalga UIS software. Alere/Wellogic provides 1 year free license to NHCH. Amalga UIS hosting and software development acquired by IDEAS Dataworks. Hamakua Health Center data feed to Alere/Wellogic Designates start of fiscal year - April 1. Final Results for Beacon Measures Focus Measures Clinical Measures: 1. Diabetes Care - HbA1c Control (<9.0): Increase the number/percentage of diabetic patients with HbA1c < 9.0 over the course of the intervention. 2. LDL-C Control (<100 mg/dl): Increase the number/percentage of patients with LDL-C < 100 mg/dl over the course of the intervention. 3. Blood Pressure < 140/90 mm/hg: Increase the number/percentage of patients with BP < 140/90 mm/hg over the course of the intervention. Utilization Measures: 4. Potentially Avoidable Emergency Department (ED) Visits: Reduce potentially avoidable ED visits: measurement is a percentage of total ED visits that involved care or treatment for ambulatory-sensitive conditions or Primary Care Physician (PCP)-treatable conditions. 5. Potentially Avoidable Hospital Admissions: Reduce potentially avoidable hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs): measurement is chronic condition composite PQI 3 per 100,000 (risk adjusted). 6. Potentially Preventable Hospital 30 Day Readmissions: Reduce potentially preventable hospital readmissions: measurement is a percentage of return hospitalizations for any condition within 30 days that is clinically related to the initial hospital admission, or one that may have resulted from the process of care and treatment during the prior admission. 3 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. ( Hawai i Island Beacon Community 7

8 CARE COORDINATION INTERVENTIONS: CLINICAL MEASURES Exhibit 9: Federally Qualified Health Center Care Coordination Clinical Outcome Measures Three FQHCs in HIBC s Care Coordination initiative Bay Clinic, Hamakua Health Center and West Hawai i Community Health Center reached a collective peak enrollment of 457 patients island-wide in December of the enrolled were diabetics. The health centers utilized embedded care coordinators and patient navigators working collaboratively within a regional community care network to address care coordination needs for complex, adult patients between the ages of 18 and 74 years, with frequent hospitalizations and/or ED visits and one or more of the following chronic illnesses diabetes and cardiovascular disease. FQHC service contracts began in January 2012 and ended in December 2012 with continuous enrollment throughout the contract service period. Interventions were administered and improvements recognized over a nine month period from April to December The Hawai i Island FQHCs each have different EHRs Intergy, NextGen and GE Centricity. They are currently not connected via health information exchange nor are data shared between health centers. Data was collected for the project from EHR registries and submitted via Excel spreadsheets to HIBC for aggregation. Results 9 months April December 2012: HBA1c < 9.0 improved by 37% BP < 140/90 mm/hg improved by 32% LDL-C < 110 mg/dl improved by 21% Hawai i Island Beacon Community 8

9 Exhibit 10: Patient Engagement and Support Services/Self-Management Clinical Outcome Measures Hui Malama Ola Na Oiwi (HMON O) was an integral part of the HIBC regional community care network working closely with the hospitals, FQHCs, private practice care coordinators and social service agencies. HMON O provided a series of chronic disease self-management education programs and transportation services to and from remote locations for hard to reach diabetics and cardiovascular patients many of whom were referred by the hospitals and FQHCs. HMON O s service contract with HIBC began in January 2012 and ended in December They continued to collect and submit data for their target population through the end of June HMON O enrolled a total of 180 participants in education programs in the West and North regions of Hawai i Island. Seventy-eight (78) of the participants were diabetic and highly engaged. HbA1c levels <9.0 were consistently maintained well above the targeted 70% for this group throughout the project period. This selfmotivation carried over to improvements in blood pressure and LDL-C levels. Interventions included education about the disease, risk factors, self-management, nutrition and physical activity. The project did not utilize health IT to engage patients as many of the participants did not own computers and/or lived in remote areas without internet connectivity. Peer support and culturally sensitive innovations tied to Hawaiian values, such as connection to the land through planting a garden and curriculum presented in the local style were crucial to engaging patients. Results 12 months July 2012 to June 2013: HgA1c < 9.0 average of 90% maintained BP < 140/90 mm/hg improved by 22% LDL-C < 110 mg/dl improved by 32% Hawai i Island Beacon Community 9

10 Exhibit 11: Private Practice Care Coordination Clinical Outcome Measures Hawai i Island Care Coordination Services (HICCS), a joint venture between West Hawai i Home Health Services and Ho okele Health Innovations, facilitated the integration of complex care coordination services in partnership with primary care practices which were part of the HIBC practice redesign initiative. Through placement of innovative in-home selfmonitoring technology, HICCS empowered patients to self-manage their chronic conditions and helped providers monitor patient self-care remotely. HICCS service contract with HIBC began in May 2012 and was extended to June There were 72 patients enrolled by participating PCPs from May to October patients received in-home monitoring technology and were monitored over the eight month intervention period. The first care coordination clinical outcome data was submitted in November The most significant improvement was seen in the percentage of patients with HbA1c levels <9.0 in months six through eight of the intervention. Although not portrayed graphically, HICCS reported that as a group HbA1c levels improved from a mean of 8.0 to a sustained 5.0. Results 8 months November 2012 to June 2013: HBA1c < 9.0 improved by 46% BP < 140/90 mm/hg improved by 6% LDL-C < 110 mg/dl improved by 15% Overall mean values for the group improved in the following areas: Weight improved from 190 to 174 lbs. BP improved from 137/81 to 122/70 Total cholesterol improved from 162 to 131 Hawai i Island Beacon Community 10

11 CARE COORDINATION INTERVENTIONS: UTILIZATION MEASURES Hospitalizations and ED utilization for diabetes and cardiovascular conditions were self-reported by the participants for each intervention group. The percentage of patients admitted and/or utilizing the emergency department remained consistent throughout the intervention period for FQHC patients averaging two percent per month for hospital admissions and 4 percent per month for ED utilization. Those patients engaged in the HMONO chronic disease self-management education programs demonstrated the best results with no admissions or ED utilization reported December 2012 to June After six months of intervention activity HICCS reported zero admissions and no visits to the emergency department in the final two months of the intervention period. Overall HICCS reported a 29 percent reduction in hospitalizations and a 25 percent reduction in ED visits between November 2012 and June Exhibit 12: Hospital Admissions and ED Visits for All Intervention Groups FQHC FQHC HMON O HMON O HICCS HICCS Hawai i Island Beacon Community 11

12 CARE COORDINATION INTERVENTIONS: CLAIMS DATA USING AMALGA UIS Throughout the HIBC project, the Amalga UIS contained member claims data for all Hawai i Medical Service Association (HMSA) insurance products. HMSA is a Blue Cross/Blue Shield health plan and Hawai i s largest health insurance company. The Amalga UIS was used to track paid claims for the participants in the FQHC and Private Practice care coordination intervention groups with HMSA PPO, HMO, Medicare Part D and QUEST (Medicaid managed care) insurance coverage for calendar year 2011, the year prior to intervention, and calendar year 2012, the year during intervention. Exhibit 13 shows that for both 2011 and 2012 combined, nine (9) percent of the patients meeting demographic and clinical inclusion criteria 4 and receiving care coordination services with HMSA coverage, comprised 50 percent of the total dollars paid. This is consistent with the significant amount of literature confirming that a high percentage of health care expenditures are associated with a small proportion of the population those people with complex health care needs. Exhibit 13: Total Dollars Paid for HMSA Members Receiving Care Coordination Interventions 2011 and 2012 Combined The analysis of claims data was also intended to identify whether or not care coordination interventions impacted how patients were accessing services and if changes in access had an impact on overall cost. Use of the Amalga UIS to analyze claims data for selected HMSA members receiving care coordination interventions was helpful in identifying patient utilization frequency by service type. Exhibit 14 provides information on total dollars paid for HMSA members by service type, comparing 2011 to During the intervention year 2012, there was an increase of $86,720 in total dollars paid, with a 28 percent increase in emergency department payments, an increase of 8 percent in inpatient payments and a 12 percent decrease in outpatient payments. Medication payments remained consistent as a percentage of total payments. Costs were not decreased from 2011 to 2012 however utilization of services did appear to change. Further analysis is necessary to determine whether or not the increase in emergency department 4 Patients selected were 75 years, receiving care coordination services for one or more chronic conditions - diabetes, cardiovascular disease, mental health, with three or more claims filed in both 2011 and One outlier, patient with liver transplant, was removed from study population. Hawai i Island Beacon Community 12

13 payments was due to severe illness in a small number of patients, decreased availability of primary care providers or some other reason. Exhibit 14: Total Dollars Paid for HMSA Members Receiving Care Coordination Interventions by Service Type Comparing 2011 Baseline with 2012 Total Dollars Paid for HMSA Members by Service Type 2011 and 2012 Comparison Further analysis of the number of claims paid by service type provided a better understanding of the variability in PCP practice patterns. Exhibit 15 shows a significant increase in the number of claims filed for office visits by Bay Clinic and West Hawai i CHC for the target population from 2011 to Hamakua Health Center and the private practice PCPs had higher percentages of claims filed for prescription medications. When comparing the percent of claims filed by service type (Exhibit 15) with the total dollars paid by service type in Exhibit 16 a greater understanding of utilization and distribution of dollars is obtained. For example: In 2011 at Hamakua Health Center, 2% of the claims filed for inpatient services resulted in 43% of the total dollars paid indicating a costly hospitalization for a small number of patients. There was also a small increase in the number of emergency department claims filed by Hamakua Health Center between 2011 and 2012 but a significant increase in the total dollars paid for emergency services. Additional questions arise regarding private practice outpatient visits. For HICCS East the number of outpatient visit claims remained constant from 2011 to 2012 but the total outpatient dollars paid dropped by 25 percent. For HICCS West the number of outpatient visit claims increased by 22 percent but the total outpatient dollars paid dropped by 47 percent. Although the Amalga UIS capability for combining clinical and claims data for analytic purposes was still quite immature during the HIBC project period, the claims data provides an opportunity to further explore billing practices, business strategy and variations in methods of managing patients with chronic illness. The data also warrants further study involving application of evidence based clinical practice guidelines and the effectiveness of data in driving standardization across the practice community in an effort to improve population health. What was gleaned from the claims data, even at a very basic level, draws attention to a variety of opportunities to better understand practice and utilization variation in an effort to improve quality and lower costs. Hawai i Island Beacon Community 13

14 Exhibit 15: Percentage of Total Number of Claims Filed for HMSA Members Receiving Care Coordination Interventions by Service Type Percentage of Claims Filed for HMSA Members by Service Type and Participating Organization Comparing 2011 and 2012 Exhibit 16: Percentage of Total Dollars Paid for HMSA Members Receiving Care Coordination Interventions by Service Type Percentage of Total Dollars Paid for HMSA Members by Service Type and Participating Organization Comparing 2011 and 2012 Percent of Total Dollars Paid Hawai i Island Beacon Community 14

15 HAWAI I COUNTY CLINICAL AND UTILIZATION MEASURES BENCHMARK DATA Exhibit 17: Annual Aggregated Health Plan Benchmark Data from HMSA and AlohaCare Annually reported clinical measure benchmark data from the health plans was provided for comparing outcomes for the participants in the care coordination intervention groups to Hawai i County population data. Diabetes Care Comparison 12/2012 FQHC HMONO HICCS Benchmark 40% >9.0 A1c 9% >9.0 A1c 18% >9.0 A1c 38%>9.0 A1c 29% <100 LDL 60% <100 LDL 47%<100 LDL 46%<100 LDL The Hawai i Health Information Corporation provided hospital utilization data from the first quarter of 2010 to the fourth quarter Reports for this benchmark data had, prior to Beacon, not been developed. The lag time for the data prevented any direct comparison to HIBC interventions and the intervention period for HIBC was not long enough, nor was the number of participants large enough to demonstrate any measureable improvement in population health. However, Hawai i County now has a baseline for future comparison. Exhibit 18: Hawai i Health Information Corporation Benchmark Data: Utilization Measures Sources: (Numerator - Hospital inpatient data) Hawaii Health Information Corporation, Inpatient Database [for more information, go to (Denominator Population data) U.S. Census Bureau, Population Division, Intercensal 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. Hawai i Island Beacon Community 15

16 Where population estimates have not been updated, the most current previous year estimate is used. 30-day readmission rates are based on 3M's Potentially Preventable Readmissions. The software is licensed from 3M. Data reflects two quarter delay in reporting. Hawaii County Population-CY Notes: 30-day readmission rates are based on 3M's Potentially Preventable Readmissions. The software is licensed from 3M. Data reflects a two quarter delay in reporting. Hawaii County Population data - CY Oct Used primary and secondary admission dx of Diabetes to increase sample size. Source: Hawaii Health Information Corporation Emergency Department Database Notes: Q ED data incomplete. Two island hospitals implemented new EHRs during February 2013 preventing the transmission of ER data to HHIC. Source: Hawaii Health Information Corporation Emergency Department Database Hawai i Island Beacon Community 16

17 PATIENT CENTERED MEDICAL HOME/PRIVATE PRACTICE REDESIGN Utilizing a four-pronged approach involving curriculum based learning collaboratives, practice coaches, health IT technical support and payment reform, 16 PCPs participating in the HIBC PCMH/practice redesign initiative achieved improvements in 14 HEDIS clinical process measures over nine months. Exhibit 19: Private Practice Redesign Clinical Process Measures The 16 PCPs involved in the practice redesign initiative demonstrated an 11.5% overall improvement for diabetic screening measures in nine months. The most significant improvement was achieved for diabetic retinal examinations a direct result of placement of portable retinal screening cameras in seven of the participating practices. Hawai i Island Beacon Community 17

18 Scope of Impact: Interventions, Infrastructure and Innovative Projects Pillar 1: Build and Strengthen Approach: HIBC developed an introductory foundation for information exchange on Hawai i Island which enables communication across the health care system and provides tools and data to aid clinical decisions, facilitate chronic illness management, support care coordination and improve efficiency. Health Information Technology (Health IT): HIBC supported primary care providers with selection and implementation of electronic health records. In partnership with the Hawai i Pacific Regional Extension Center (REC) HIBC also assisted eligible primary care providers with achieving Stage 1 Meaningful Use. Health Information Exchange (HIE): HIBC led the first regional HIE pilot in the State with North Hawai i Community Hospital and Alere Accountable Care Solutions Wellogic software as a service model connecting lab, pharmacy, radiology, hospital inpatient and outpatient EHR clinical data. The second pilot involved the use of Amalga UIS as a clinical and claims advanced data analytics repository combining insurance claim data, hospital admission, discharge and transfer data, and clinical data from FQHC and private practice EHRs. Impact: 122 (83%) of Hawai i Island s 147 primary care providers implemented certified electronic health records. 52 (35%) of eligible PCPs achieved Stage 1 Meaningful Use (HIBC data) 17 hospital and community based providers connected to the Regional HIE 30 unique and consistent users of the Regional HIE accessing over 20,000 page views for an average of 200 patients per month HISP to HISP connection established between the Regional HIE and the State of Hawai i HIE 7,500 Hilo Medical Center hospital admissions and 38,000 emergency department visits feeding annually to the data analytics repository 6 years of historical HMSA claims data available for analysis within the data analytics repository Pillar 2: Improve Approach: HIBC utilized an integrated, island-wide systems approach to improve quality that involved three rural acute care hospitals, three FQHCs and sixteen private practices. Emphasis on care transitions, care coordination, patient engagement and patient centered medical home practice redesign included meaningful use of patient registries involving both EHR and claims data. Care Transitions: Three Hawai i Island acute care hospitals - Hilo Medical Center, Kona Community Hospital and North Hawai i Community Hospital, focused on standardizing patient discharge protocols and tools and improving the handoff between discharge planners and practice based care coordinators. Each hospital followed Project BOOST methodology and participated in the national Premier Quest Quality and Patient Safety initiative data analysis to identify the target population in each facility. Hawai i Island Beacon Community 18

19 Care Coordination: Three Federally Qualified Health Centers Bay Clinic, Hamakua Health Center and West Hawai i Community Health Center, and Hawai i Island Care Coordination Services serving private practice physicians participated in a 12 month pilot project designed to improve care coordination in the practice setting for complex, chronically ill patients with diabetes and cardiovascular disease. Each utilized RN Care Coordinators and either patient navigators or health coaches as an important component of the PCMH care team. Patient Engagement: Value added, culturally based enabling services (e.g., selfmanagement education, transportation, financial assistance and translation) were provided to the hospital discharge planners and care coordinators for patients with diabetes and cardiovascular disease through the Native Hawaiian Health Care System Hui Malama Ola Na Oiwi. PCMH/Practice Redesign: HIBC partnered with TransforMED to bring a structured approach to achieving PCMH status and meaningful use of practice EHRs for private practice PCPs. Impact: 60+ clinicians island wide participated in clinical improvement interventions including hospitalists, private practice specialists and PCPs, FQHCs and clinics. 550 patients received care coordination and care transition services as participants in the HIBC pilot program. 16 primary care, private practice physicians participated in the PCHM/Practice Redesign initiative with HIBC 32,000 patients were impacted by changes in clinical practice Pillar 3: Innovate Approach: HIBC facilitated an ongoing partnership between the Retina Institute of Hawai i and private practice physicians participating in the PCMH/Practice Redesign initiative to bring portable digital retina imaging to the PCP office in an effort to increase the number of diabetic patients who receive retinal screenings. HIBC in partnership with Hawai i Island Care Coordination Services (HICCS) tested ihealthhome a remote in-home monitoring system that enables remote in-home telehealth and activity monitoring by care coordinators developed by Ho okele Health Innovations, LLC Impact: 15 private practices tested 7 retinal cameras placed island wide resulting in an 18 percentage point or 32% improvement in the HEDIS Diabetes eye exam rate for the participating practices. 42 (58%) of 72 patients participating island wide in the private practice care coordination pilot received ihealthhome systems. Meaningful Use Achievement HIBC s aim was to achieve Stage 1 Meaningful Use (MU) for 60 percent or more of Hawai i Island s eligible providers by December 31, According to ONC data through December 17, 2013, 32 percent of the eligible providers had achieved Stage 1 per CMS payment data as of 9/30/2013 and Hawai i Island Beacon Community 19

20 Hawai i Pacific Regional Extension Center (REC) data as of 10/19/2013. HIBC reviewed the SK&A listing and identified 147 of the 164 PCPs who fit the eligible provider definition and were open for business caring for patients on June 30, Fifty-two of the 147, or 35 percent, had achieved Stage 1 MU according to HIBC and REC records. All of the eligible providers who achieved Stage 1 MU were participating in the Medicare incentive program. Sixty-two percent (62%) of the 84 total eligible Medicare providers achieved Stage 1 MU. All of the 16 providers participating in the HIBC PCMH/Practice Redesign initiative achieved Stage 1 MU. The remaining providers eligible for the Medicaid MU incentive included pediatricians, family physicians and obstetricians both in private practice, employed by the FQHCs or Kaiser. The State of Hawai i became the 50 th (last) State in the nation to launch the Medicaid incentive program on September 3, As a result, none of the Medicaid eligible providers were attested before the end of the HIBC project period. HIBC did not achieve its target of > 60% of eligible providers reaching MU Stage 1. Exhibit 20: Meaningful Use Stage 1 Attestation Measure SK&A (4/30/13) HIBC (6/30/13) Total # Primary Care Providers in Beacon Catchment (PCPs) Total # of Medicare Providers from SK&A April listing who meet EP definition and are actively practicing as PCPs 84 (57% of total eligible PCPs) Total # of Medicaid Providers Total # of PCPs Beacon Targeted to Achieving MU (60% of total PCPs) Total # of PCPs Achieved MU in Beacon Catchment % MU Achievement in Catchment (of total # PCPs) (43% of total eligible PCPs) (all Medicare PCPs; includes 16 providers who participated in the PCMH/Practice Redesign initiative) 32% 35% Dissemination Impact HIBC worked with Olomana Loomis ISC on a local level to disseminate information about HIBC activities and Beacon efforts nationally. Please refer to Appendices A and B for a detailed listing of activities and dissemination impact. LOCAL DISSEMINATION Written Materials and Resources: HIBC published two annual reports in 2011 and Numerous brochures and instructional pieces were produced, most notable including the HIE Toolkit for providers and a patient oriented brochure titled The Future of Health Care and You: How is Health Information Technology Improving My Care? Both resources are available at One article resulting from a series of focus groups conducted to gain feedback on the concept of the Patient Centered Medical Home for patients at a rural FQHC providing care coordination services for the HIBC project was published in the Hawai i Journal of Medicine & Public Health by the HIBC Project Hawai i Island Beacon Community 20

21 Director and MPH student Alain Takane. 5 A second collaborative article is under development with Academy Health and the Hawai i Island, Southeast Michigan and Delta BLUES Beacon Communities. The article titled Community-Based Diabetes Interventions for the Underserved: Lessons and Promising Practices from Three Beacon Communities is targeted for publication in early 2014 in the Journal of Healthcare for the Poor and Underserved. Electronic and In-Person Stakeholder Outreach: Thirteen enewsletters were published April 2012 September 2013 and distributed to approximately 1,100 local and national recipients. The HIBC Project Director presented at two national meetings and to numerous local trade organizations and public officials. Two videos were produced, one announcing the Alere Wellogic implementation at North Hawai i Community Hospital, the second showcasing the care collaboration work conducted at West Hawai i Community Health Center. A monthly speakers bureau on a variety of clinical transformation topics for the public was held January through June 2013 in Kamuela, a North Hawai i Island community. Media and Social Media A 3-part series on health care transformation on Hawai i Island written by Andy Levin, HIBC Patient Ombudsman, was published October December 2012 in the Hawai i Tribune Herald, a local Hilo newspaper with island wide circulation. Eleven press releases resulted in over 50 on-line postings by a variety of media outlets. Collaborative public relations work with Alere Accountable Care Solutions also introduced HIBC to an international audience. Advertisements in the local newspapers and their on-line versions, local organization and individual blog sites, as well as, organization newsletters, e.g., Society for Hospital Medicine, University of Hawai i and TransforMED showcased activities conducted in partnership with HIBC. Radio interviews and announcements were also part of the dissemination strategy. NATIONAL DISSEMINATION The Beacon Nation Information Dissemination project, was funded and overseen by the Hawai i Island Beacon Community during the last six months of the HIBC project period in partnership with the ONC and the 16 other Beacon communities nationwide. Beacon Nation promoted innovation in health IT by gathering and disseminating information about successful health IT implementation strategies from the Beacon Communities. Different approaches, resources and interactions resulted in a variety of lessons learned about adopting technology-enabled solutions designed to improve population health, improve the quality of care and reduce cost. These lessons learned were compiled into six Learning Guides which are a set of documents describing promising IT-enabled interventions that can be deployed in a community to accelerate health care transformation. In addition to the Learning Guides, a variety of materials were developed and activities conducted to support the use of the Learning Guides. Exhibit 21: Beacon Nation Project Outcomes 6 5 Takane A, Hunt SB, Transforming Primary Care Practices in a Hawai i Island Clinic: Obtaining Patient Perceptions on Patient Centered Medical Home. Hawai i Journal of Medicine & Public Health September; 71(9): Credit is given to the Beacon Nation team at Booz Allen Hamilton and HIBC, and the staff at the Office of the National Coordinator for their invaluable contributions to the HIBC national information dissemination effort. Hawai i Island Beacon Community 21

22 Exhibit 22: Beacon Nation Dissemination Model Beacon Nation Website: The Beacon Nation webpages were added to the HIBC website. A description of the Beacon Nation project and supporting materials, as well as a complete overview of the HIBC project initiative, enewsletters, provider toolkits and annual reports can be accessed at or Beacon Nation Advisory Committee: The Beacon Nation Advisory Committee (BNAC) consisted of thirteen nationally recognized leaders representing a broad range of technical expertise and viewpoints related to the Beacon Community program, health IT, and quality improvement. The group provided advocacy, influence and guidance to the project to ensure that content and dissemination work was aligned with the national healthcare landscape. Members of the BNAC Anne Marie Audet, MD, Commonwealth Fund Amy Berman, John A. Hartford Foundation Lisa Bielamowicz, MD, The Advisory Board Company Asaf Bitton, MD, MPH, Comprehensive Primary Care Initiative Susan Dentzer, Robert Wood Johnson Foundation Willa Fields, RN, DNSc, San Diego State University and HIMSS Sachin Jain, MD, Journal of Delivery Science and Innovation Hawai i Island Beacon Community 22

23 Harold Miller, MS, Network for Regional Healthcare Improvement Elizabeth Mitchell, Network for Regional Healthcare Improvement Michael Painter, MD, Robert Wood Johnson Foundation Julie Schilz, BSN, MBA, WellPoint Marybeth Sharpe, Gordon and Betty Moore Foundation Will Shrank, MD, Centers for Medicare and Medicaid Innovation Indu Subaiya, MD, MBA, Health 2.0 Six Learning Guides: A series of six Learning Guides were developed between February 2013 and September 2013 during the HIBC project s no cost extension period. They are the highlight of the Beacon Nation project filled with actionable information and strategies that can be adapted by hospitals, health systems, individual practices, clinics and community organizations to assist with advancing community-level health care transformation using health IT. Learning Guides review the challenges and benefits of health IT and essential elements needed for success in multiple markets. Content includes: key foundational elements to support successful planning and implementation, experiences and lessons learned from the federally-funded Beacon Communities which are presented though strategic and implementation objectives, case studies, process maps and sample documents; summary of future opportunities and directions. Learning Guide Overviews LG #1: Improve Hospital Transitions and Care Management Using Automated Admission, Discharge and TransferAlerts The vision of a more coordinated, patient-centered health care delivery system will be driven forward by a more timely exchange of patient information during encounters with the health care system. With an eye toward reducing avoidable hospital readmissions and emergency department (ED) visits and improving care transitions and coordination, several Beacon Communities developed automated alerting programs based on hospital-generated admission, discharge, and transfer (ADT) feeds. This Learning Guide distills the experiences and lessons learned from Beacon Communities as they set goals, planned for implementation, constructed a technical approach, and coached practices on effective workflow redesign to accommodate and use the new alerts to improve patient care. This Learning Guide is designed for communities that have a goal to reduce avoidable ED visits, avoidable hospitalizations, and preventable readmissions and have identified the implementation of ADT-based alerts as a potential strategy to achieve their goals. It is also a useful tool for learning collaborative organizers. LG#2: Strengthening Care Management with Health Information Technology By bringing together patient health information from disparate sources coupled with measurement algorithms and other decision support tools, health IT can play a central role in supporting communities efforts to improve the health of patients through care management. With a focus on improving care for patients with chronic disease, several Beacon Communities invested in new health IT to support care management services across the community. This Learning Guide distills the experiences and lessons learned from Beacon Communities as they set goals, selected appropriate tools, identified the necessary data elements, supported practices Hawai i Island Beacon Community 23

24 through implementation, and engaged patients in their health. This Learning Guide is designed for communities and learning collaborative organizers that are interested in using health IT to support the integrated and comprehensive delivery of care management services to patients with chronic illness. LG#3: Capturing High Quality Electronic Health Records Data to Support Performance Improvement As the industry moves toward value-based reimbursement reimbursement based on quality and cost measures improving the quality of the data used for measurement is imperative. With a focus on supporting their performance improvement activities, several Beacon Communities invested in assessing and addressing the quality of data within their EHR systems. This Learning Guide distills the experiences and lessons learned from Beacon Communities as they engaged provider and physician champions, conducted data mapping for selected measures, assessed and improved the quality of data in their EHRs, and established ongoing processes to monitor and address ongoing data quality issues. This Learning Guide is designed for health care providers and learning collaborative organizers that will rely upon EHR data to support performance improvement and new payment models. LG#4: Enabling Health Information Exchange to Support Community Goals Electronic health information exchange (HIE) is an important component in improving the quality of care delivered to patients across the country. With the goal of connecting disparate sites and systems to allow information to follow patients, all Beacon Communities strengthened existing or, if required, implemented new technical infrastructure to share health data in pursuit of more coordinated, patient-centered care. This Learning Guide distills the experiences and lessons learned from Beacon Communities as they convened stakeholders, assessed the landscape, created a legal framework for information sharing, developed a technical path forward, and agreed upon metrics to track usage and impact. This Learning Guide is designed for communities and learning collaborative organizers that are interested in using data exchange capabilities to support important goals such as care coordination, care management, quality improvement and aligning payment incentives with value of health care services. LG#5: Health Information Technology Capabilities to Support Clinical Transformation in a Practice Setting The increase in health IT adoption brings with it opportunities and challenges to transforming primary care delivery. With new access to information about care that occurs beyond their clinic walls, providers are adapting their practice workflows in order to better care for their patients. Clinical transformation and performance improvement as supported and driven by health IT are key areas of focus for several Beacon Communities. This Learning Guide distills the experiences and lessons learned from Beacon Communities as they engaged practices, assessed readiness, considered practice transformation models, and collaborated on the effective deployment and use of health IT in their communities. The Learning Guide is designed for individual practices, communities, and learning collaborative organizers that are interested in using transformation models and health IT to improve practice performance and care management. LG#6: Building Technology Capabilities for Population Health Measurement at the Community Level The Affordable Care Act and other health reform activities are advancing the health care system toward a greater focus on provider accountability for a population of patients. With the goal of developing a more complete view of patient health and care, several Beacon Communities Hawai i Island Beacon Community 24