HIMSS Davies Enterprise Application Submission Form
Hilo Medical Center – Clinical Value Core Case Study
--- Cover Page --Name of Applicant Organization:
Organization’s Address:
Submitter’s Name:
Submitter’s Title:
Submitter’s E-mail:
Core Item:
Hilo Medical Center
1190 Waianuenue Avenue, Hilo, HI 96720
Money Atwal
CIO & CFO
matwal@hhsc.org
Clinical Value
Executive Summary
Hilo Medical Center (HMC) accomplished an electronic health record (EHR) implementation in
May 2010 with well-defined goals of improving clinical outcomes, patient safety, and financial
performance. Lack of an integrated medical record prior to EHR implementation placed patients
at clinical risk, especially, when medication administration processes were encountered.
Medication ordering, verification, dispensing and administration processes all warranted careful
review and planned improvement to accomplish the transition from a disparate paper system to a
closed loop electronic platform. Addressing continuity of care was of paramount importance as
the capabilities of the EHR were evaluated for the provision of Computerized Provider Order
Entry (CPOE), Clinical Decision Support (CDS), improved medication processing, and Barcode
Medication Verification (BMV). The results demonstrated in this Case Study represent a
remarkable reduction in Adverse Drug Events (ADEs) along with associated cost savings to the
organization.
The overall impact of the EHR on clinical value is illustrated by the improvements in the
medication administration process, appropriate antibiotic usage, and the CMS core measure
addressing pneumonia.
1. 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.
The island of Hawai’i, also referred to as Hawai’i County can be compared in size to the land
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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.
2. Local Problem Addressed and Intended Improvement
The 2014 National Action Plan for Adverse Drug Event (ADE) Prevention indicates ADEs are
among the largest contributors to hospital-related complications.vi The Institute for Safe
Medication Practices (ISMP) relays that it is not possible to establish a national medication error
rate or set a benchmark for medication error rates. Each hospital or organization is different.vii
HMC determined baselines and organization tracking of errors could be monitored and trends
captured and acted upon. In May 2008, HMC’s all-encompassing medication error rate reached
a high of 23 medication errors for every 10,000 administered doses; see Figure 1.
Figure 1: Pre and Post EHR Medication Error Rates per 10,000 Administered Doses.
EHR Implemented May 2010. Closed Loop Medication Administration Initiated February 2011.
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In the 1997 study, “The Costs of Adverse Drug Events in Hospitalized Patients”, each avoidable
ADE was found to cost $4,685. When adjusted for health care inflation, the cost rises to $8,048
per preventable ADE.viii
The HMC pre-EHR medication process was as follows:
Doctor provides
written order
If STAT, order is faxed
to pharmacy & written
order is placed in
pharmacy bin to be
picked up when
rounding
Pharmacy receives
order & requests paper
labs from Clinical
Laboratory
Pharmacy fills order
and sends medication
to the floor
Nurse administers
medications
The medication process was vulnerable to errors and lacked efficiency every step of the way
with time to administration delays exceeding desired standards.
HMC approached the problem by implementing an integrated EHR targeting the following areas
related to medication ordering, verification, dispensing, and administration:
Closed Loop Medication Administration
Clinical Decision Support
Computerized Provider Order Entry
Smart Data
Bedside Medication Verification
In an effort to address the national problem of increased and inappropriate antibiotic usage, the
Pharmacy and Therapeutics Committee (P&T) developed an Antibiotic Stewardship Program
comprised of nursing, infection control, physician champions, pharmacist, administration, and
medical staff leadership. The overall goal of the program was to improve the appropriateness of
antibiotic ordering throughout the organization, prevent drug resistance organism, as well as a
business case to decrease the use of antibiotics and costs. Initiating an Antibiotic Stewardship
Program did not require additional staff or resources associated with starting a program. The
P&T Committee was essentially the Antibiotic Stewardship Committee with the addition of the
Lab and Infection Control Director and Pathologist. The Physicians on the committee are
volunteers. Staff members involved incorporated Antibiotic Stewardship duties in their normal
workday. Antibiotic use was monitored using Days of Therapy per 1000 patient days
(DOT/1000 patient days). Fifteen antibiotics were targeted for monitoring. The goal was to
reduce the DOT/1000 patient days by 5% for the fifteen-targeted antibiotics. Pre-Antibiotic
Stewardship Program DOT/1000 patients days was $129/admission (FY13).
The successful outcomes of this program were further supported by additional optimizations
created within the EHR. Together, the program and EHR processes, aimed to decrease hospital
acquired disease processes, like C. difficile impacted by inappropriate antibiotic treatments. “C.
difficile infections can be prevented by using infection control recommendations and more
careful antibiotic use.”ix The C. difficile rate prior to implementing the Antibiotic Stewardship
Program was four patients in 2012, which then climbed to nine patients in 2013. HMC also
looked to meet CMS core measures regarding pneumonia, through the utilization of the EHR.
3. Design and Implementation
The design of the Antibiotic Stewardship Program was well thought out by the P&T Committee
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who establishes and maintains a formulary of medications as well as functions related to the use
of medications in HMC. Antibiotic Stewardship is an essential function of the committee by
which they perform a consulting and decision-making role for the hospital. Utilizing the EHR to
track and monitor performance in the use and ordering of antibiotics provides the committee
valuable information to reach the goals of the Antibiotic Stewardship Program, which is to
decrease antibiotic use by 5% for the selected antibiotics. The design and build of the EHR
included reports, which the P&T/Antibiotic Stewardship Program monitors. In addition to the
monthly reports, Pharmacy generates automated and on demand daily reports to track appropriate
antibiotic ordering.
The core EHR modules implemented in May 2010 were designed to integrate all facets of the
inpatient medication process. In February 2011, the Closed Loop Medication Administration
process became an additional requirement for all acute medication administrations. The
combination of both implementations contributed in medication error rates dropping from 23 to
consistently 5 or fewer errors (only 1 error in March 2014) per 10,000 administered doses; see
Figure 1.
Current Closed Loop Medication Administration process – post-EHR implementation:
Doctor enters order in EHR
Pharmacy verifies order.
Lab results automated
and available
Nurse dispenses from
Pyxis & Documents on
the MAR
The HMC CPOE initiative began in May 2011with the involvement of over 125 of its 250
physicians. Hospitalists place over 70% of HMC’s inpatient orders, of these 54% are medication
orders. Protocol orders are primarily used in the Emergency and Obstetrics departments. The
system was designed to support CPOE and CDS with the implementation of rapid resulting of
laboratory orders to identify and document the critical values necessary for safe and effective
medication management. In addition to rapid results reporting, the EHR was developed to
collect Smart Data. Smart Data drives decision support, improved care, and better outcomes.
CPOE was instrumental in the ordering of antibiotics and
monitoring of antibiotic usage. The Antibiotic Stewardship
Committee was tasked to create an Order Set to assist
physicians in selecting the appropriate antibiotics for
specific conditions; see Figure 2.
Figure 2: Alternative Antibiotic Orders
The Order Set contained suggested orders and listed the
daily drug cost for more cost efficient alternatives; see
Figures 3 and 4.
Figure 3: Alert for Alternative Antibiotics
Figure 4: Antibiotic Order Set
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If the physician attempted to order an antibiotic outside of the Order Set, supplementary
questions were embedded in the order to guide further decision-making; see Figure 5.
Figure 5: Reserved Antibiotic Questions
Figure 6: Antibiotics Usage Report for Pharmacy
The Pharmacy generates a daily
report in the EHR to monitor the
Antibiotics Stewardship
Program. The report reflects
antibiotics usage for the clinical
pharmacist to evaluate the
appropriateness of therapy. See
Antibiotics Usage Report for
Pharmacy in Figure 6.
If the antibiotics are
inappropriate for the specific
clinical problem, it will prompt a
direct discussion with the
pharmacist and physician(s).
The Nursing Process design for Pneumococcal vaccinations contained built in rules with
required questions based on patient age and previous vaccination history. Once patient specific
criteria was met, a vaccination order was required.
Figure 7: Percentage of Patients Scanned
Patient wristbands were updated with 2D barcodes in
2013 and an improved scanning approach utilizing
wireless devices that increased the scanning rate by
40%. The percentage of patients scanned for the
period August – October 2013 recorded on or above
98%; see Figure 7. BMV scan rates continue to range
from
90 – 93%.
4. How Health IT Was Utilized
HMC chose MEDITECH as its EHR vendor. Additional applications were implemented in
short order to fully accomplish integration. Optimization of the system’s functionality to create
Smart Data to drive decision support has proven quite beneficial.
Prior to the implementation of the EHR, the workflow for medication ordering was on paper and
did not allow for real time conflict and interaction checking by a pharmacist prior to
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administration. Once the order was written in the paper chart by the physician, there were
numerous delays in providing a copy of the paper order to the pharmacist. A typical time frame
for a clerk or nurse to review orders could take 30 minutes to an hour. Following this process,
the paper order would sit in an outbox waiting to be delivered to Pharmacy. This amounted to a
total time span from written order to pharmacist review averaging 2-4 hours for non-STAT
orders.
The Pharmacy Department was also not available 24/7, further causing medication review delays.
Orders written late in the evening or during nightshift hours could experience a delayed review
time of up to 8 hours. With the EHR and now operating a 24/7 Pharmacy, notifications are
provided to the Pharmacy immediately upon a physician saving the entered order within the
system. System generated alerts and notifications are displayed, and the physician is prompted to
review at the time of ordering. Additional alerts, conflicts, and/or reactions are analyzed by the
pharmacist before the nurse is able to acknowledge, scan, or administer the medication. The EHR
allowed for adherence to medication administration best practices and improved overall patient
care by increasing patient safety levels.
To further supplement the reduction in ADE's, order logic was built into the EHR. Suggested
orders were added to the CDS functionality for medication interaction checking and the
configuration of proactive alerts. Figure 8 demonstrates the pre and post Order Entry workflow
comparisons.
Figure 8: Pre and Post EHR Physician Order Entry Workflow
Pre and Post EHR Physician Order Entry Workflow
Pre-EHR Physician Order Entry Workflow
Handwritten
orders placed for
medications,
labs, etc.
Physician
selects Patient
to place orders
Clerk or RN
transcribes
orders from
chart to needed
requisitions
Paper order
placed in outbox
for Pharmacy
pick-up
Phone call to
Pharmacy
required for
STAT
medications
RN administers
medication to
patient
No conflict or interaction
checking or reminders for
required related orders
for this process
Paper orders
sent to
Pharmacy 1-4
hours following
initial physician
order
Pharmacy
reviewed orders
for conflicts or
interactions
No conflict or interaction
checking by Pharmacy
prior to administration
Post-EHR Physician Order Entry Workflow
Navigates to
Orders Panel
Selects Medical
Admission Order
Set
Use of an Order Set
provides consistency in
ordering process
Selects ALL
needed orders
(i.e. ABG, EKG,
Aspirin,
Warfarin, etc.)
Best practice solutions
embedded within system
Physician
addresses any
conflicts in
selected and
suggested
orders
Order
electronically
transmitted to
Pharmacy.
System generates
alert prior to
verifying
medication
Orders display
on nursing
worklist or as
link on status
board
Increases Patient
Safety by enforcing
review for conflict or
interaction prior to
order placement
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Medication warnings, such as, those in Figure 9, were developed and are considered a cornerstone
of the medication ordering process.
Figure 9: Medication Warnings
A Medication Monitoring Report created from the EHR’s real-time data gathers patient specific
information monthly to track reasons why medications were stopped due to allergies, an adverse
reaction or drug intolerance; see Figure 10.
Figure 10: Medication Monitoring and Reporting
In January 2013, HMC implemented
Nova, Telcor’s mobile technology, which
integrates directly with the EHR’s on-line
electronic medication administration
record (eMAR). Introducing the mobile
scanning devices improved the scanning
rate by 40%, as noted in the previous
section.
The Antibiotic Stewardship Program
tracks and monitors antibiotic use by utilizing the EHR to provide real time reports to the
Pharmacy department. Use of the antibiotics Order Set was encouraged as it contained
associated lab results, recommended antibiotics, and information on cost, The additional
information supports clinical decision-making, although deviating from the order could not be
restricted and ordering outside of the Order Set was inevitable; see Figure 11.
Figure 11: Antibiotic Order Set
To monitor antibiotic ordering outside of the set, a
notification to pharmacy was triggered when antibiotics
were ordered from a reserved list. The reserved list is
broad-spectrum antibiotics that should be saved for more
resistant gram-negative organisms and/or for more
specific organism such as MRSA. Custom defined
questions were built into the order to assist the physician
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in justifying an antibiotic order and to consider
alternatives prior to saving; see Figure 12. An order
from the reserved list would appear on a compiled
patient report in the EHR that was reviewed daily by
Pharmacy to evaluate the appropriateness of antibiotics
for patients. Once Pharmacy completes their evaluation
of the patient, a recommendation is entered on the
patient’s record in a form of a Pharmacy note for nonemergent recommendations. If immediate action is
required the provider was contacted immediately by
phone or through face-to-face communication.
Figure 12: Custom Defined Questions When
Ordering Outside of the Antibiotic Order Set
Pharmacy also documents the outcome of recommendations in the EHR, which is reviewed
monthly by the Antibiotic Stewardship Committee. The reports from the meetings of the
Antibiotic Stewardship Committee are discussed in general medical staff meetings and
published on the hospital intranet, particularly the antibiogram that physicians use in
selecting antibiotics. The reports are also used for program efficacy and overall program
improvement. The reports are not currently used for any disciplinary action.
Optimizing the capture of outpatient Intravenous (IV) start and stop times was easily resolved
by building required fields into the Emergency Department Nursing Disposition Worksheet, a
form required for closing a chart. Documenting start and stop on the IV flowsheet; see Figure
13, automatically transfers the information to the Disposition Worksheet. If start and stop were
not documented in the IV flowsheet, it would trigger required fields in the Disposition
Worksheet creating “hard stop”; see Figure 14. The “hard stop” prevents the user from
completing the chart.
Figure 13: ED IV Flowsheet
Figure 14: ED Nursing Disposition Worksheet
Containing “Hard Stops”
Through the use of health technology improvements in the Imaging Department, the
volume of radiological studies increased from 50,000 studies/year to 59,000 studies/year;
however ratios of studies to patients remained the same. The graph in Figure 15, displays
the ratio of exam to patients for each modality from 2010 to 2015, which demonstrates a
consistent ratio trend from year to year. That trend clearly illustrates the increase in
volume was not associated to unnecessary radiological testing ordered per patient
.
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Figure 15: Ratio of Exams to Patients
In addition, through information collated within the EHR, imaging technologists are able to
question the appropriateness of ordered exams in an effort to limit duplicate or redundant
procedures from being performed. The patient's prior exam history is provided on every
requisition and immediately available electronically via the EHR; see Figure 16. Along with the
order history, a 'Diagnosis/Signs & Symptoms' field is required on every imaging order; see
Figure 17. By reviewing the patient's exam history along with this required field, the
technologist has the information to determine the suitability of the ordered exam. If the prior
exam history displays the same test or the indicated diagnosis or signs and symptoms are not an
indication for the exam, the technologist raises their concerns to the ordering physician.
Figure 16: Imaging Prior Exam History
Figure 17: Diagnosis/Signs & Symptoms Displayed on the
Technologist Desktop
This process, facilitated through the EHR and the use of tools within it, prevents duplicate or
superfluous procedures from being performed. Eliminating redundant or unnecessary exams
improves overall patient care by limiting their amount of exposure to ionizing radiation. In
addition, it allows technologists to more effectively utilize their time, performing only those
exams that are deemed medically necessary, all of which contribute to an increase in safe
imaging studies.
5. Value Derived/Outcomes
HMC’s implementation of the EHR changed the entire medication ordering and administration
process and produced real savings for the hospital and its patients. A fully integrated clinical
record for both inpatient and outpatient care is now in place and accessible anytime from any
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location. Clinicians can view real-time patient data for visits conducted anywhere in the
continuum of care. The ability to enter orders, including medication orders using CPOE,
improves patient safety by organizing meaningful data into Order Sets with timely clinical alerts
and results.
Prior to the EHR implementation, HMC’s monthly medication error rate averaged 16.8 errors per
10,000 doses administered per month for 27 months (January 2008 – March 2010). Using the
health care inflation adjusted cost per ADE of $8,048; these errors resulted in an ADE cost of
$3.7M per 10,000 doses administered over the period. After EHR implementation, the average
medication error rate fell to 2.6 errors per 10,000 doses administered over the next 27 months
(April 2010 – June 2012). Continuing to assume a single ADE costs $8,048, the total cost over the
same period was $564,970; avoided ADE costs equaled $3.0M. Over the subsequent months, the
average monthly medication error rate has remained at steady 2.7 errors per 10,000 doses
administered; please refer back to Figure 1.
Prior to the EHR implementation, HMC’s ADE costs were approximately $135,206 per month
per 10,000 doses administered. Those costs using the above assumptions have dropped to
$20,925 per month per 10,000 doses administered avoiding preventable ADE costs to the
organization and unnecessary complications for our patients. The achieved total cost savings
to the organization is $114,281 monthly or $1.4M annually.
HMC’s Antibiotic Stewardship Program uses the EHR to collect data and generate reports to
optimize antibiotic therapy for patients while also meeting fiduciary responsibilities. The
antibiotic medication tracking initiative reports monthly antibiotic expenditures per acute
admission. The tracking report alerts Pharmacy to changes in costs needing action. Real-time
and monthly clinical data allows clinicians to provide the best antibiotic therapy, avoiding costly
suboptimal therapies for patients.
The Antibiotic Stewardship Program set a goal of reducing antibiotic use when antibiotics were
not necessary and/or ordering antibiotics that
Figure 18: January 2015 Improvement in Antibiotic
were less costly but just as effective. HMC still
Usage and Ordering
has work to do in this arena, but the
improvements are noteworthy as seen in
Figure 18. For example, Caspofungin
experienced an ordering drop of 63.6% and
Tigecycline 80.4%. The results were
accomplished by implementing required
questions as well as antibiotic alternatives during
the medication ordering process. The goal of
reducing DOT/1000 patient days by 5% were
achieved in ten of the fifteen-targeted
antibiotics. Antibiotics costs were reduced from
$129/admission (FY13) to $120/admission
(FY14) or a 7% decrease.
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Exposure to antibiotics is the main risk factor associated with hospital acquired C. difficile
infections. While antibiotics are a necessary part of medical treatment, they need to be used
appropriately to ensure realization of the biggest benefit with a limited amount of risk. The
clinical benefits of having an Antibiotic Stewardship Program and an antibiotic Order Set that is
monitored daily by the pharmacist, coupled with questions built into the EHR, has led to a
decrease in the facility’s hospital acquired C. difficile rate. The decrease was significant enough
f o r the State Department of Health, which monitors the submitted data, to question the data
and completed an audit validating the numbers were correct.
Through the implementation of the Antibiotic
Stewardship Program and associated EHR processes,
a 66% decrease in the hospital acquired C. difficile
rate was recognized from a high of nine patients in
2013 to zero patients for the current two quarters of
2015; see Figure 19. If it were not for the one patient
in December of 2014, the C.diff rate would have been
zero for 15 months.
Figure 19: Hospital Acquired C. diff Rate per 1000 Pt. Days
In conjunction with the medication ordering and
appropriate usage of antibiotic enhancements created
through use of the EHR, the initiation of processes to
meet CMS core measures for Pneumococcal
Immunizations were also made. An overall
improvement for this core measure was identified
and could be correlated through a decrease in
Pneumonia mortality rates; see Figure 20.
Figure 20: Pneumonia Vaccination and Mortality Rate
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6. Lessons Learned
HMC’s goal was to create a system that increased the efficiency of clinical workflows. It was
imperative to involve all stakeholders in this broad organizational change effort, even though
some users were highly resistant to change. In order to complete the project with organizational
input, HMC integrated a formal change control process alongside the implementation. The
culture of the organization evolved with the unified efforts of engaging IT, clinical analysts, and
department leadership in the governance, as well as, change control processes.
A key means to accomplishing rapid
Figure 21: CPOE Adoption
deployment of CPOE required early
involvement with the hospitalists and
physician champions, along with
establishment of a CPOE Governance
Plan to guide the effort. Placing
decisions in the hands of those entering
the majority of the inpatient orders
promoted acceptance and follow
through when the tough conversations
surrounding topics such as ADEs needed to occur. HMC is now a leader in CPOE adoption with
percentages consistently above 90%; see Figure 21.
Although the Antibiotic Order Set was implemented in September of 2012 and the Antibiotic
Stewardship Program officially kicked off in January 2013, the adoption of utilizing the
recommended Antibiotic Order Set did not yield positive results until 2014 and 2015.
The C.diff rates in Figure 19 demonstrate the challenges of persuading physicians to adopt
recommendations from the Antibiotic Stewardship Committee. It took patience, tracking,
monitoring, and one-to-one physician discussions with peers and pharmacy to alter ordering
behavior. The hospital learned applying punitive damages was not necessary.
The spike of nine patients with hospital acquired C.diff in 2013 was analyzed by the Infection
Control Director who could not find a pattern to account for the increase. The increase was not
concentrated to one nursing unit or associated to a single physician, staff, or one antibiotic. The
increase highlighted the vigilance of preventing C.diff in the hospital. Over time, the C.diff rates
decreased due to the increase use of the Order Sets, direct discussions between physicians and
pharmacy, and peer-to-peer physician communication/education. At the same time, Infection
Control measures of hand washing and the use of personal protective equipment of staff and
housekeeping contributed to the decrease of C.diff patients.
7. Financial Considerations
HMC did not use external funding for the EHR project. All funding was from internal
operational sources, including hardware, software, consultant implementation resources, and
labor costs. East Hawai’i Region’s low cost of ownership for an EHR system was instrumental
in eliminating the need for external funding of approximately $8M.
Throughout the implementation initiative, HMC invested $31.0M in total costs resultant net
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benefit value of $4M over the period. For example, a reduction in transcription services has
yielded $2.2M, and a reduction of paper chart and paper communication has resulted in a net
savings of $2.6M. The benefits also include staff reductions in HIM and the clinics of
approximately $5.5M. The actual-to-date cost breakdown is divided into the following
categories: a) operational costs: $19,379,517 b) vendor costs: $12,199,986 c) on-going annual
maintenance costs: $2,311,266.
The savings HMC is now seeing in the ADE arena alone have made the investment more than
worthwhile. Improving the safety of using medications has progressed by leaps and bounds for
our patients – not only in measurable dollars but most importantly in the health and well-being of
our patient population.
i
Hawaii Island Beacon Community. (2013). Final Report. Retrieved from:
http://hibeacon.org/images/uploads/HIBC_FINAL_REPORT_12-27-2013.pdf
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
ii
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
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
v
vi
vii
U.S Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2014)
ISMP, (2014), http://www.ismp.org/faq.asp#Question_2
viii
Bates, David W. MD, et al., The Costs of Adverse Drug Event in Hospitalized Patients, 1997
ix
Centers for Disease Control and Prevention (2015), Healthcare-associated Infections (HAIs),
http://www.cdc.gov/hai/organisms/cdiff/Cdiff_clinicians.html
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