Improving Transitional Care between Hawai`i’s Community Health Centers and Hospitals through a Health Information Exchange
Team Members: Christine Mai`i Sakuda, Beverly Chin, Orin Sherman, Alan Yamashiro
Background: Increasingly, healthcare is becoming a shared, community-based responsibility involving diverse care providers, providing services to a common population of patients. This is particularly true of primary care, safety-net and tertiary care providers who serve ethnic minority, indigenous, immigrant or otherwise vulnerable populations. Vulnerable populations experience two barriers to healthcare: 1) inaccessibility of care and fragmentation of care; and 2) ethnic minorities face the additional burden of barriers related to language and culture Not surprisingly, a growing body of research suggests that as a result of these barriers, vulnerable populations (when they do access services) often receive sub-optimal care and have poor outcomes.
Project Goal: The Holomua Project brings together the Hawai`i Primary Care Association, Kalihi-P?lama Health Center, K?kua Kalihi Valley Comprehensive Family Services, and the two largest hospitals in the state of Hawai`i, Hawai`i Pacific Health System and the Queen’s Medical Center, in an effort to improve coordination of care that patients receive when transitioning between community health centers and tertiary care facilities through health information technology. To achieve this goal, the Holomua Project was awarded a three year $3 million Health Information Technology Grant from the Agency for Health Care Research & Quality in 2005 to develop a Master Visit Registry.
Patient Population: The patients served by this project are those shared patients by the Community Health Center (CHC) Partners and the tertiary Partners who have either planned or unplanned visits to the emergency room (ER) services and/or inpatient services.
Technical Intervention: Holomua Master Visit Registry (HMVR) is a record locater service that relies on a Master Patient Index to identify the right patient across multiple health care institutions. HMVR serves as a connection broker between institutions that identify the type of service and who provided that service within the health system for a particular patient. The raw patient data remains at the host institution and once learning where the patient data is, the inquiring physician could then contact the host institution for their patient's data. The HMVR provides the following:
1. A compiled list of a patient’s medical visits across multiple institutions
2. Facility and physician contact information for each visit.
3. Patients’ demographic and contact information.
4. The primary and secondary diagnosis codes for each visit.
Non-Technical Intervention: The project also recognizes that technology is only a tool, and therefore relies also on non-technological solutions to advance improvements in transitional care. The non-technological solutions involve identifying the challenges in the transitional care process, improving work flow policies and procedures relative to transitional care, and using dialogue and communication to facilitate transitional care.
Findings & Results:
1. A live health information exchange as of March 2009
2. Roughly 150 clinician users, 250,000 patients, & 500,000 visits.
3. HMVR was of greater use to clinicians responsible for coordinating care rather than physicians due to the lack of clinical information contained.
4. Partners’ increased awareness of managing patients visiting multiple facilities.
5. A stronger relationship between participating CHCs and the tertiary care facilities
6. Convergence on the need for data standardization.
7. Common transitional care policies & procedures for transitioning patients.
8. Valued input from the project’s multi-ethnic patient, provider and community member focus groups.
Challenges:
1. Assumptions exist that healthcare facilities are no longer responsible for a patient’s care upon discharge.
2. Concept of transitional care is unfamiliar to most providers.
3. Tertiary care providers are unaware of services provided at CHCs.
4. CHC providers are unaware that ER physicians are open to direct provider-to-provider telephone contact.
5. Most healthcare providers are unaware of the independent transitional care processes adapted by their colleague institutions.
6. Basic streamlined transitional care processes need to be identified and developed.
Conclusions and Implications:
1. Strong partnerships, open communication and enabling tools can be built among committed healthcare providers to overcome existing challenges and to improve transitional care processes for shared patients.
2. Develop basic transitional care guidelines to improve continuity-of-care, that include encouraging direct provider-to-provider contact and suggesting that healthcare facilities routinely fax discharge summaries (current processes range from using postal mail to faxing only upon request).
3. Our next phase will expand the HMVR to include laboratory encounter information and medication list in order to be more useful to providers.
The word “Holomua” The name Holomua was taken from a Hawaiian proverb which states “Pupukahi i Holomua”- United in Order to Progress” . It was chosen to represent the unified partnership and spirit of collective effort across disciplines and organizations this program forged among community, primary and tertiary care.
Recognition:
1. Journal of Health Information Management 2009 Publication – Improving Transitional Care in Hawai`i
2. Agency for Healthcare Research & Quality – Improving Transitional Care in Hawai`i – Community-based Participatory Research
3. For more information contact Christine Maii Sakuda at cmaii@hawaiipca.net.