HIMSS Davies Enterprise Application Submission Form
Hilo Medical Center – Leadership and Governance Menu Case Study
--- Cover Page --Name of Applicant Organization:
Organization’s Address:
Submitter’s Name:
Submitter’s Title:
Submitter’s E-mail:
Menu Item:
Hilo Medical Center
1190 Waianuenue Avenue, Hilo, HI 96720
Money Atwal
CIO & CFO
matwal@hhsc.org
Leadership and Governance
Executive Summary
In 2009, Hilo Medical Center made a critical decision between applying for Medicare incentive
funds or to prepare for Medicare reimbursement reductions. Strategically, the East Hawai’i
Regional Board voted to implement an Electronic Health Record (EHR) and improve its
Information Technology infrastructure to apply for Meaningful Use (MU) incentive funds. The
decision was a pivotal moment in history for the East Hawai’i Region as they accepted the
challenge of the 2009 American Recovery and Reinvestment Act and undertook substantial
organizational change to enact MU Stage 1 and MU Stage 2 measures. Over the course of six
years, Hilo Medical Center's leadership and governance has evolved to ensure the facilitation of
progressive changes in an organized manner with proven success. Creating groups to allow for
direct and open discussion between stakeholders and establishing channels for decisions to be
presented, deliberated, and voted upon has improved Hilo Medical Center's ability to effectively
communicate EHR and IT changes.
Background Knowledge
Hilo Medical Center (HMC) is a part of the East Hawai’i Region of the Hawai’i Health Systems
Corporation (HHSC) serving as a safety-net hospital for two critical access hospitals, Hale
Ho’ola Hamakua and Ka’u Hospital. The East Hawai’i Region also includes nine outpatient
clinics with specialties. HMC is a 276-bed facility comprised of 137 acute beds, 20 bed
behavioral health facility, and 119 bed long-term care facility. Overall, 72% of HMC's patients
have Medicare or Medicaid insurance.
Hilo Medical Center’s Emergency Department is an established Level III Trauma Center
providing 24 hour care for the community. The Emergency Department visits total
approximately 45,000 patients annually making it the second busiest in the State of Hawai’i.
Emergency Department visits range in caring for critically ill or critically injured to low acuity
patients not able to obtain primary care services.
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The island of Hawai’i, also referred to as Hawai’i County can be compared in size to the land
area of Connecticut, Hawai’i Island is home to approximately 194,000 residentsi. The county
has three major hospitals and four critical access hospitals covering a land mass of 4,028 square
miles. Geographically, the three main hospitals are separated by at least 50 miles in distance and
an idyllic scenario for development of a robust EHR system
The population by county shows Hawai’i County appropriating 15% of adults who are uninsured
in comparison to the City and County of Honolulu at 9.2%, Hawai’i County includes a higher
number of uninsured seniors than any other countyii. Death rates for cardiovascular disease,
smoking, and diabetes are also highest in the state compared to other countiesiii. As a whole,
Hawai’i County is designated as a Medically Underserved Area (MUA), 18.3% of the population
is living below the poverty level and 16% of patients stating they do not have a usual source of
health careiv. Physician shortages are estimated at 36% indicating an 18% higher rate than the
City and County of Oahuv.
Health care on Hawai’i Island is a collaboration of safety net services with limited access,
funding, and capacity when compared to the island of Oahu or large medical centers. Hilo
Medical Center is also the sole provider of emergency and acute care for the East Hawai’i region
and for the majority of Hawai’i County. Without the services provided by HMC health care in
the East Hawai’i community would be drastically affected.
1. Local Problem Addressed and Intended Improvement
The American Recovery and Reinvestment Act (ARRA) and HITECH Act provision of 2009
included an initial $19.2 billion dollars for health information technology grounded in the belief
that technology would lead to significant improvements in the quality of care and eventual
savings on health care costs.vi Majority of the HITECH funding would be used to reward
hospitals for meeting “Meaningful Use” measures of implementing a certified EHR system. The
program sought to begin in 2011 with Stage 1 measures defined by the Centers of Medicare and
Medicaid Services (CMS).vii
Hilo Medical Center realized the severity of their healthcare environment and knew that
implementing policy changes called for in ARRA would affect the operations of the sole source
of emergency and acute services for the East Hawai’i region. Knowing the potential onset of
negative effects, the organization ultimately believed in the long term organizational
sustainability an EHR would provide as the benefits from potential incentive payments would
outweigh the risks of remaining on paper, loss of interoperability, and decreased reimbursement
rates.
The challenge was to transform the organization from paper to electronic processes while
maintaining engagement with the hospital workforce and local physicians. Hilo Medical Center
established a governance plan. Governance was designed to assist HMC in laying out the EHR
implementation strategy and provided an arrangement for assessing physician workflows,
defining the implementation process and structure, addressing regulatory compliance, outlining
the tools, and keeping patient safety and other desired high priority goals at the forefront.
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2. Design and Implementation
Initial Challenges
A small working team of physicians, executive leaders, and nursing champions were assembled;
their first task was to find a system requiring minimal resources and capital investment amid
decreased reimbursement rates and dependency on state appropriation. The East Hawai’i Region
sought an all-inclusive solution built with the infrastructure to weather numerous federal
mandates, incorporate other vendor systems, and integrate with legacy systems. The
organization further searched for a partner with strong industry prominence, not just a software
vendor. It was essential the system was user friendly, provide quality analytics, increase
productivity, and deliver safer patient care. If the system selected did not prove its value or
removed providers from direct patient care, overall adoption would be at risk.
Critical success factors for EHR implementation and MU achievement were identified in the
governance of the project to include HMC administrative and physician leadership “buy-in” with
a committed desire to move the organization forward with the EHR implementation. Physician
collaboration and involvement, identifying Physician Champions, and creating a Physician
Advisory Group were important in early governance establishment. Other factors such as
designing a well-planned change management process and setting realistic expectations
regarding physician usage, timelines, and system functionality were also significant.
Additionally, to determine the scope of the EHR implementation initiative, it was important to
understand and document the drivers compelling the organization to move forward with a
governance structure. The many areas were identified including improving patient safety by
implementing drug-drug and allergy checking, reduction of illegible written orders,
interoperability via the Health Information Exchange (HIE) with other hospitals and remote
access to the EHR providing real time patient information.
Hilo Medical Center then determined the scope of the initial project to meet MU stage one
measures, these included:
 Computerized Provider Order Entry (CPOE), Physician Documentation, and eSignature
 Development of CPOE and Zynx Health evidence-based Orders Sets to facilitate best
practice order entry process
 Medication Reconciliation
 On-line Physician Documentation of daily Physician Progress Notes
 Patient Problem Lists
 eSignature to expedite signing of transcribed reports, such as, H&Ps, Operative Reports
 Prescription management
 Clinical Decision Support (CDS) with carefully considered medication alert generation
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The implementation was scheduled for May 1, 2010 with ongoing phases to compliment the
initial “go-live” over subsequent months to reach the 2011 fall MU Stage 1 attestation goal.
Figure 1: HMC Implementation Timeline
Creating a Lasting Leadership & Governance
The project phases were undertaken along with identification of EHR organization stakeholders
followed by establishment of team roles and responsibilities. To provide Information
Technology governance, the Medical Informatics Subcommittee (MIS) was created and is
accompanied by Medical Executive Committee (MEC) for advisement on all physician IT
matters. The result was the construction of an EHR Project Governance Hierarchy to include all
key organization diversities. At the top of the governance is the MEC and MIS, below are
committees and departments directly impacted by ongoing organizational change. MIS and
MEC are ultimately supported by the Executive Management Team (EMT), below EMT are the
application specific user committees; See Figure 2.
Figure 2: HMC Governance
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Creating Specific Integrated Forums
Integrated Operational Review Forum (iORF)
A working group of steering committee members called the Integrated Operational Review
Forum or iORF was created to discuss ongoing implementation issues, advise on progressive
changes, and host integrated decisions among organizational department heads. iORF also
allowed for formal change control tracked by the organizations internal ticket system. All crossdepartmental matters are brought to iORF for formal discussion. Department heads are expected
to contribute to the ongoing conversation as to how changes directly affect specific areas.
Change control is either approved, denied, or tabled by committee members. Members include
but are not limited to finance, medical records, nursing, information technology, admitting,
ancillary services, pharmacy, and quality. Issues raised in iORF affecting physicians are also
brought to PiORF for discussion.
Physician Integrated Operational Review Forum (PiORF)
The next governance structure Hilo Medical Center created is a Physician Integrated Operational
Review Forum or PiORF. PiORF is chaired by a physician champion and is a forum for
physicians to discuss and deliberate on progressive changes like physician documentation, new
order sets, or physician workflows. It also allows for integrated discussion and collegial debate
on issues or suggestions for the EHR or other integrated Information Technology initiatives.
Medical Informatics Subcommittee (MIS)
Sitting above PiORF is the Medical Informatics Subcommittee, the committee is composed of a
cross sectional group of physicians and chaired by the Information Technology (IT) physician
champion and Chief Information Officer. Issues brought to MIS have been discussed at iORF,
PiORF, and require approval for majority vote to pass into implementation. Policy changes
proposed and passed in PiORF are voted upon by specified voting members. Using majority
vote ensures over half the committee agrees on a change to be implemented or further voted
upon at the MEC level.
Medical Executive Committee
The MEC is the primary governing body for the independent medical staff. For Hilo Medical
Center the MEC also includes a number of employed physicians. MEC is primarily responsible
for key leadership decisions related to policies, procedures, and rules as well as implementing
rules surrounding physician matters. All matters voted upon at MEC also follow a majority rule
whereas the majority of the voting members must agree in order for proposed change to pass on
to implementation.
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Figure 3: HMC Committees
3. How Health IT Was Utilized
Using the governance system, HMC has been able to implement progressive changes and further
refine internal policies and procedures directly affecting physicians. In 2013 Hilo Medical
Center’s physician report deficiency rate was at 84%. Without final reports and signatures,
charts could not be closed and accounts could not be billed, increasing Hilo Medical Center’s
accounts receivable (AR) days. Using the governance structure now in place a suggestion from
the Director of Heath Information Management (HIM) department was brought to iORF for
discussion. The suggestion was to create a policy in which physicians are suspended after 24
days of unsigned deficiencies. iORF ensured the physicians had all the tools possible to sign
reports timely then passed the policy to PiORF for discussion. PiORF agreed to the new policy
and passed it to the MIS for vote, MIS voted with majority rule, where it was also voted and
ultimately passed at MEC.
The policy was the first ever to be passed through each committee, and one of the strongest
policies on unsigned reports. By implementing EHR technology physicians were able to sign
charts electronically on and off campus and eliminated the reliance upon paper. Moreover, using
IT systems like physician portals and reports from the EHR data repository, physicians are also
able to create deficiency reports listing the outstanding charts and a total number of outstanding
records. These reports are also viewed and monitored by a number of committees including the
MEC. The result of the policy and organizational efforts resulted in a drop in deficiencies to a
current 1%.
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Figure 5: HMC HIM Process
Other initiatives part of the initial scope for the EHR implementation such as CPOE provides a
standardized tool to incorporate best practices. Prior to the EHR, orders were left to physician
memory and individual ordering practices. CPOE allows for the creation of electronic orders sets
to guide physician ordering. Alerts and warnings were also built into the system to assist in the
ordering process and compliance with best practice. See CPOE Physician Workflow and an
Order Set example in Figure 5.
Pneumonia and sepsis order sets were also developed using the same governance structure. The
process started with a multidisciplinary team of physicians, nurses, pharmacists, and experts
from the Quality and Infection Control Committee. The group came together for collaboration
and discovery, ideas drawn by the subcommittee were presented to iORF for evaluation. The
build for the new order sets were completed by members of iORF, accepted for change control,
and presented to PiORF. Approved changes were presented to MIS who voted the order sets into
the EHR production environment.
Figure 6: CPOE Physician Workflow and Order Set
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Physician documentation or PDOC followed similar practices. PDOC was a method of
standardizing physician documentation and decreasing the reliance on transcription services but
HMC was cautious on creating a high volume of templates. To effectively manage the
implementation and system changes, HMC knew that they would not be able to support creating
a PDOC for individual preferences. The organization urged each specialty to create one History
and Physical, Progress Note, and Discharge Summary. Using the same democratic principles,
specialties named a physician champion able to solicit feedback from department constituents.
The EHR Clinical Analysts built PDOC's to the specifications provided by the physician
champion and changes were then presented at iORF for discussion and education, then presented
at PiORF to ensure appropriateness and that required elements were included. All PDOC's were
presented at MIS prior to building the electronic documentation in the EHR production
environment.
4. Value Derived/Outcomes
Upon the implementation of PDOC, dramatic improvements were seen in electronically signed
documentation by physicians, rising from 1,690 documents in August 2013 to 11,994 documents
in the October – December period of 2014; see Figure 7. HMC has over 120 document
templates built for all 3 facilities.
By implementing PDOC, HMC was able to
reduce the number of Transcriptionists from 6
to 2 over a 1-year period. The Transcriptionists
were introduced to Coder roles at the end of
2014.
Figure 7: Post Implementation Improvement of Electronically Signed
Physician Documentation
Delinquency rates monitored by Health
Information Management (HIM) also
experienced an immediate reduction to rates
that are consistently < 5% due to use of EHR
notifications; see Figure 8.
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Figure 1: Pre and Post Physician Documentation Chart Delinquency Rates
The manual process of analyzing physician documentation for required elements became
increasingly efficient and streamlined with the implementation of PDOC in August 2013. As a
result, there was a remarkable increase in physician compliance from 8% in 2011 to a
phenomenal 94% compliance rate in January 2014. An analysis of Discharge Summaries for
required elements also saw an increase from 21% in 2011 to 99% in 2014.
Additional gains with physician documentation improvements showed a downward trend in the
hospital’s Procedure Complication Ratio Report of observed vs. expected rates for surgery and
medical procedures, as shown in
Figure 2: Procedure Complications Report Observed vs. Expected Ratio
Figure 9. As compliance with
physician documentation
increased, the hospital was able to
capture data that more accurately
reflected the decreasing
complications rate. The report is
monitored by HMSA’s (Hawai’i
Medical Services Association), an
independent Licensee of the Blue
Cross and Blue Shield Association
Advanced Care Program, which
supports the delivery of quality
care and efficient management.
With the adoption of CPOE and standardized Order Sets, a reduction in medication errors
occurred falling from a 16.8 error rate per 10,000 doses to a 2.6 error rate per 10,000 doses.
From 2009 to November 2012, the Department of Health and Human Services (HHS) made
incentive payments of over $9 billion to American hospitals and eligible providers authorized
under HITECHviii. By 2012 year end, 38% of eligible hospitals had achieved stage one MU.ix
Incentive programs under Medicare commenced in 2014 and penalties increase from 1% in 2015
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to 5% in 2019.x To avoid penalties, the last day to have begun attestation for incentive payments
was October 1, 2014. The East Hawai’i Region is proud to say it met this challenge.
On May 1, 2010 HMC’s MEDITECH EHR system was activated as scheduled. The strategic
‘big-bang’ went ‘live’ with clinical documentation, orders, pharmacy, imaging, electronic
medication reconciliation, emergency department, laboratory, health information management,
along with the admissions and registration. A few months later additional physician tools were
implemented such as physician order entry and physician documentation. The organization
continued to push forward with community wide scheduling, bedside medication verification,
and the operating room module.
Research currently shows that over 73% of EHR implementations are considered failures
because end-users are not using the system a year later as originally planned.xi The East Hawai’i
region did not succumb to this statistic. Through the diligent efforts and governance structure put
into place, end user adoption was high and physicians were provided a forum to offer feedback
and input.
Through hard work, perseverance and governance, the East Hawai’i Region has been awarded
$4.8M in incentive funds. In 2011 the region achieved MU stage one totaling $2.6M in
Medicare incentive payments. In 2014 the region received $1.5M in Medicaid funding, and
further received $1.8M in incentive payments for the achievement of MU stage two. Had Hilo
Medical Center and the East Hawai’i Region chosen not to implement an EHR and attest for
Meaningful Use incentive funds under the American Recovery and Reinvestment Act, the
region’s estimated annual reduction in Medicare reimbursement would equal $320K for fiscal
year (FY) 2016 to FY 2018, and $1.6M in FY 2019. The sum of reductions from FY 2016 to FY
2019 are calculated to equal $2.56M.
5. Lessons Learned
Identifying key stakeholders early in the process helped to facilitate those reluctant to change and
mitigates the possibility from derailing a project. For HMC, the team identified early those
potentially opposed to change and included those stakeholders in initial conversations.
Leadership from members of the Executive Management Team with the support of the Regional
Board was essential to implementing mass change across health care disciplines.
Ongoing progressive changes takes time and permanence. HMC's governance structure was not
created overnight, it was shaped overtime and has been adapted to the needs of the organization
and the culture maintained herein. Most of the employees at HMC belong to a union with
multiple collective bargaining agreements. Engaging the union early on in the process was
effective in communicating the changes facing the membership and the challenges they may
encounter moving forward. Providing employees with a systematic approach to addressing
issues through the governance structure and documented change control also mitigated the
reoccurrence of issues previously resolved in the build or workflow.
In a hospital environment the relationships among physicians, clinical end-users, non-clinical
end-users, information technology, and executive management is a refined balance of
coordination. Relationships between stakeholders were built and developed to gain a better
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understanding of the tasks ahead. Many on the implementation team never worked with an EHR
and some physicians were reluctant to use a computer. Through the use of governance structures
and forums Hilo Medical center was able to create a non-partisan effort between work teams.
Converting a hospital from a paper to an electronic record and revolutionizing every process in
which physician's document, order, dispense medication, and communicate for the past 20 years
requires strong leadership and governance structure. Healthcare that was once controlled from
the paper chart on the unit of the hospital is now controlled by servers in the basement. The
paradigm shift from paper documentation to documenting in an EHR may be the new normal,
but changing the processes in an underserved rural population and the only safety net hospital
available to the region is an edge-of-your-seat experience. Planning, contingency planning, and
risk mitigation was built into every step and every process to ensure success. For Hilo Medical
Center the implementation of an EHR and IT functionality changed the way providers practiced
medicine, patients received information, and ultimately improved the safety and care that HMC
offers.
6. Financial Considerations
HMC did not use external funding for the EHR project, all funding was from internal operational
sources to include the purchase of hardware, software, consultant implementation resources, and
labor costs. The purchase of Zynx Health Order Sets was also funded from operations. The
low cost of ownership for the selected EHR system was a key in eliminating the need for
external funding of approximately $8M.
Throughout the implementation initiative, HMC invested $31.01M in total costs with a resultant
net benefit value of $4M over the period. The actual-to-date cost breakdown is divided into the
following categories: a) operational costs: $19,379,517; b) vendor costs: $12,199,986; and, c)
on-going annual maintenance costs: $2,311,266. The financial value of a successful CPOE and
PDOC initiative is also seen by HMC accomplishing ARRA Meaningful Use Stage 1 (2011) and
Stage 2 (2014), with receipt of $4.8MM in incentives.
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i
Hawaii Island Beacon Community. (2013). Final Report. Retrieved from:
http://hibeacon.org/images/uploads/HIBC_FINAL_REPORT_12-27-2013.pdf
ii
University of Hawai’i System Report. (2015). Hawaii Physician Workforce Assessment Project. Retrieved from:
http://www.hawaii.edu/offices/eaur/govrel/reports/2015/act18-sslh2009_2015_physician-workforce_report.pdf
iii
Hawaii Island Beacon Community. (2013). Final Report. Retrieved from:
http://hibeacon.org/images/uploads/HIBC_FINAL_REPORT_12-27-2013.pdf
iv
Hawaii Health Matters. (2015). Disparities Dashboard, indicators for county: Hawaii. Retrieved from:
http://www.hawaiihealthmatters.org/modules.php?op=modload&name=NSIndicator&file=index&topic=0&topic1=County&topic2=Hawaii&breakout=all&regname=Hawaii
v
University of Hawai’i System Report. (2015). Hawaii Physician Workforce Assessment Project. Retrieved from:
http://www.hawaii.edu/offices/eaur/govrel/reports/2015/act18-sslh2009_2015_physician-workforce_report.pdf
vi
Steinbrook, R., M.D. (2009). Health care and the american recovery and reinvestment act. The New England
Journal of Medicine, 360(11), 1057-60.
vii
Murphy, J. (2010). Nursing Informatics. The Journey to Meaningful Use of Electronic Health Records. Nursing
Economics, 28(4), 283-286.
viii
2013 Annual report of the U.S. hospital IT market. (2013). Chicago, IL: Healthcare Information and Management
Systems Society. Retrieved from http://apps.himss.org/foundation/docs/2013HIMSSAnnualReportDorenfest.pdf
ix
Diana, M.L., Harle, C.A., Huerta, T.R., Ford, E.W. & Menachemi. N. (2014). Hospitals Characteristics Associated
with Achievement of Meaningful Use. Journal of Healthcare Management, 59(4), 272-284. Randall, D. (2014).
Policy Challenges of Electronic Health.
x
Vila, P., & Pfeffer, M. A. (2014). Finding Meaning in the Electronic Health Records (EHR) Meaningful Use Incentive
Program. Proceedings of UCLA Healthcare, Volume 18.
xi
2013 Annual report of the U.S. hospital IT market. (2013). Chicago, IL: Healthcare Information and Management
Systems Society. Retrieved from http://apps.himss.org/foundation/docs/2013HIMSSAnnualReportDorenfest.pdf
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