Some patients on the island of Hawaii live in communities far apart from each other and from physicians and hospitals, with few methods of transportation except the family vehicle.

The Hawaii Island Beacon Community is focused on improving care for individuals with complex chronic conditions to avoid hospital readmissions and engage these patients to better understand and get involved in their care.

[See also: Hawaii practices retool for patient-centered model]

[Podcast: Site Visit: Hawaii's Beacon Community]

Physicians, community clinics and hospitals embracing electronic health records and health information exchange are critical to making that happen, according to beacon staff members. The group has also engaged physicians to transform their practices to be more patient-centered.

“The real need is for helping patients avert disaster” among those with advanced stages of diabetes and other chronic conditions and the populations behind them that indicate a similar path, said D. Michiko Fried, a nurse and managed care coordinator for Bay Clinic family health centers on the east side of the island.

The Hawaii beacon, which received a $16 million three-year grant, is one of 17 model communities around the nation using health IT to improve individual patient outcomes and population health and in the process lower costs. It partners with 15 hospitals, physician practices, community clinics, including one that focuses on Native Hawaiian healthcare, and payers on the island of Hawaii, known as the Big Island.

[See also: North Hawaii at work on HIE]

While the mention of Hawaii typically conjures up scenes of big-city Honolulu and well-known crowded beach resorts, the rugged Big Island offers a different kind of paradise. Eco-adventures thrive thanks to access to continuous lava flows from Kilauea, the home of Pele, the goddess of fire in Hawaiian mythology, and two large dormant volcanos running down the middle of the island. 

One of those volcanos, the 14,000-foot Mauna Kea, hosts the world’s largest astronomical observatory and telescopes operated by astronomers from 11 countries to research the heavens.

Down below, Hawaii beacon is working to exchange data with geographically spread out clinics and hospitals within the Big Island to coordinate care so patients can avoid the onset and advancement of diabetes and related conditions.

Prevention is especially critical for the Big Island. Hawaii works on a hub system in which critical care patients are flown from neighbor islands to Honolulu for more advanced treatment, with air transport increasing costs further.

Two sides of the bridge together
Health IT infrastructure is the bridge for clinical intervention and coordination, said Jeff Jendrysik, beacon project manager. Beacon participants use Wellogic’s electronic health record and health information exchange tools, and eventually analytics about clinical outcomes.

For example, the North Hawaii health information exchange, in testing since December and the first HIE in the state, goes live officially in September with North Hawaii Community Hospital, Hamakua Health Center, which is the nearby safety net provider, as well as labs and other physicians’ groups.

The beacon’s objective is to get 60 percent of Big Island primary care providers and nurse practitioners to adopt and use EHRs in a meaningful fashion.

“If you get that base working, you’ve got folks starting to feed data and keying it into their system correctly, we can exchange data,” Jendrysik said.

North Hawaii Community Hospital has put in place hospital discharge planning, for instance, to get patients connected with care coordinators in Hamakua when they leave the hospital. Both providers will share the same technology platform.

“So we can take clinical interventions and start overlaying them on top of the technology we’re building. Hospital and care coordinators on the same platform sharing the same data across their EHRs with all that data connected,” Jendrysik said. “It’s the two sides of the bridge coming together at one point.”

Technology is a significant piece of how the Hawaii beacon is driving care coordination to reduce the fragmentation in the current healthcare system and build capacity in the care community, said Cynthia Ross, beacon clinical program facilitator.

“We’re streamlining the process so that instead of the patient going through the system like a bumper car, they’re going through smoothly and receiving the help and services that they require,” Ross said.

Nealry 500 patients sign up for coordinators, next page.