 Welcome. This is Craig Thomas, your host on Much More on Medicine, part of Think Tech Hawaii's live stream series and assisted as always by our engineers Rich and Ray. With me this morning is Dr. Linda Rosen. She's the CEO of the Hawaii Health Systems Corporation, which I've heard described as the largest sort of state-run care delivery system in the nation. There are many different definitions of large and I suspect in terms of volume of patients treated or a small state that may not be true, but in terms of variety, distribution of and distance between facilities, it might well be true. And I'm delighted to have you here. I work at a number of facilities. I work also across the state in some similar although not part of the state system facilities and I've come to appreciate them. The task of providing health services to people far removed from the larger privately owned or at least maybe public, but non-state-affiliated facilities is a real challenge and thanks for taking it on. Thank you Craig. I'm glad to be here. Great to have you. Would you mind describing to me and to our audience of course sort of the mission and scope of what's happening? I don't think most people know. Well you know I think to start with we can talk about what is a public hospital system or state hospitals and as you mentioned we are one of the larger systems depending on how you describe it, but certainly when you look at the proportion of the state's residents and communities that we are the primary hospital provider for, it's a quite large part of the state and we are predominantly on the neighbor islands, although we do have two long-term care facilities here on Oahu. So I think that for folks perhaps it might be interesting to sort of think about why is government you know a state agency providing health care. That's not usually what you find and that's why we are one of the biggest because in most states it's quite unusual to have government operated facilities, but in Hawaii I think it's it's important to kind of go back to the history of the islands and the neighbor islands particularly with the plantations that they provided health care and they were predominant providers of health care you know back in the day in many of these rural communities and then you know when the plantations and sugar industry dwindled the county started to try to step in and try to provide that health care but with great difficulty and eventually the state became the provider. The Department of Health incorporated these facilities, spenceries, some of them were into a state hospital system which existed within the Department of Health until the 90s when it was then separated as a different agency the Hawaii Health Systems Corporation. We're still a state agency but we're not an executive department of the state so we are a little bit still a state agency a little separate maybe a little bit like the University of Hawaii in that regard. And it sort of fits in with the focus on health that Hawaii's demonstrated ever since the 70s with its sort of insurance safety net the affordable care well I'm saying the photo carac is interestingly rather similar more recent national thing honestly it's it's got many similarities with Hawaii and achieves more or less the same percentage of coverage. Or tries to. Or tries to. We have a very high percentage of insured population thanks to that the law Hawaii law which of course came way before the Affordable Care Act but I think that law and also the support for my hospitals is something I'm very proud of as a state we take care of folks in our state and we think health care is important and for everyone and all communities and part of what I appreciate about my current position is to try to if you will kind of even out the health care delivery system to improve care on the neighbor islands and to not necessarily be so a Wahoo centric because our neighbor island communities are growing and as an Wahoo resident I do hope that's where the most of the growth will be in the future but from an economic perspective adequate health care is very important to growth of those communities and so I think we have a role in improving the health care not that it's not good now but provide more services in these communities than we have in the past and we're doing that bit by bit and we'll talk about some of those services in a minute I just like to say based on my personal experience that distances are large populations are often scattered in small especially on some of the well especially on the big island I would say but definitely true on some of the other ones also and I've come to appreciate that the best care is obviously the right care you have to be able to provide the right care or know when to send that person on or get a resource from outside your facility that you may need that happen but that kind of care that happens closest to home people do better close to home the other thing I was we both seen a lot of change when I started a Hilo you could drive from Hilo to Honoka and see sugar the whole way and when I started at Wahiwa there was a Wahoo sugar Wailua sugar and two pineapple plantations and there used to be a health clinic for Wahoo sugar down in central Wahoo and Wailua hospital which closed before my time but not much so yes it's and Molkai was of course mostly pineapple so it's been a huge change and these people need a resource and thankfully the stages providing it and it's a pleasure to work at these places you can sit down with people I had the privilege of visiting with a family and seeing the medical record the birth record from the 1950s in a small it was in Huala Hula Hospital I didn't know there was such a thing and those records still exist they were in the Molokai Hospital not a state facility but as another small facility medical record you could look back 60 years of medical records and trace a life it was wonderful and I could visit with the person I had a great time yeah some of our facilities have you know been around more than a hundred years Huala Hospital, Samahalona on Kauai I met probably leaving out one or two but yes they've been serving the community for a very long time and I think that I'm getting back to your the discussion of the services on the neighbor islands we are challenged because the distances are great as you say and the populations are relatively small so you know in the economics of health care as you know very well if you need some population to spread out the cost of expensive services or you have to subsidize those services and to some degree this is kind of where we're at but the you know sort of evolution of our services is I think commensurate with the increase in population on the neighbor islands and you know the relative influx if you will of different professionals and some of it is the part-time residents but there's definitely increasing demand to have services close to home and as you said the outcomes are definitely better and so we really need to look for ways to bridge those two worlds yes there's a lot of sophisticated specialists with a lot of knowledge on Oahu but sending patients from the neighbor islands to Oahu hospitals is not always the best thing so if we can bridge that by bringing some of that expertise to our rural hospitals then we may have the best of both worlds I agree and the one of the challenges is clearly economic and part cost is part of quality so that's not an easy problem to solve but another is if you don't have enough people even if you were subsidizing let's say a specialty services service if it's not used very much it's hard to maintain the quality of that service if we we're good at what we do a lot of and so we need to look at more creative ways of sharing expertise and bringing help to people in isolated areas or when appropriate facilitating them going somewhere to somewhere larger possibly across the water and then back again because you not only have to go do whatever it is you did but you have to get them back with support for whatever was done and of course the post-acute care is another big challenge yes we do provide long-term care in many of our facilities and in many of our facilities we are the only providers of specialty long-term care so for instance you know as at Hilo Medical Center they have some patients that are there long-term and who are on ventilators there is no provider in the community that would take those patients so they they have to be kept at Hilo and we're glad to provide the service but that's just an example of where we really have to sort of step in and fill different kinds of gaps in the services that are available and our communities but I think that one of the things that we like said we can work on more is to really narrow the the types of patients that will that go to Oahu certainly there are still those who go to Oahu who could have been cared for at one of our facilities and I I'm proud to say that several of our facilities have gotten very very good marks recently in quality measures you may know that our Kauai Hospital KVMH is a premier award winner with national competition and I think Hilo is a four-star hospital so really they're hitting the quality measures and I think that the communities are seeing that the quality of care provided by our facilities is good and maybe in some cases better because of some of the things we talked about staying in your own community and so I think little by little that has improved the base you know that we have to work with but certainly you're correct I mean there are certain things that you wouldn't want to have a neurosurgeon that only did three cases a year even if you had all the money in the world to bring them to your community and and you know practice matters volume matters but the literature shows that that's only one factor and the other factor is having the time the time to get the story straight the time to talk to patients the time that and that's really what does contribute to the good outcome one of the factors that contributes to good outcomes in our smaller rural hospitals people have the time they can be more personal and it doesn't just feel good it results in better care as you know so I'm glad you mentioned that because so we staff a bunch of different apartments all different sizes and honestly there's real time pressure at the bigger ones because time is also part of quality but the ideal is actually being able to spend enough time that you can have high quality service and the really interesting thing is you have another advantage you didn't touch on yes you have more time to connect with the patient admire their birth certificate from 1957 and ho and talk with them but guess what a staff all know them to and they chip in they're like uncle remember or it's it's awesome and so yes I think we get better histories I think we are much more likely to give appropriately personalized care and together can make a plan because they're always trade-offs it might be that a procedure available say only on a wahoo might provide some benefit it also of course all interventions have potential for harm as well as being displaced from your community and so sometimes we reach different answers than we might in a more urban setting yes and I think that one other factor is that it's not always available to just be sent to a wahoo and the economic challenges and even if you know you have health insurance it would pay for it all that ancillary costs that are associated with leaving the island the family maybe have coming over to support and all of these kinds of things are sometimes such an economic barrier that people who could use specialty care and whose physicians let's say you know on the big island recommend that they see someone on a wahoo or they refuse because they really just can't afford it yes and whether it's the money which is very real or the other pain with transfer which is very real or it's a capacity at the tertiary center that is devoted to patients that maybe could have been kept locally all those things matter and after the break we'll talk about some of the options we have to get specialty services in the remote corners of the state be great excellent again this is much more medicine and we'll resume with dr. Linda Rosen after our break this is think tech Hawaii raising public awareness you can be the greatest you can be the best you can be the king come pay and now your chest you can be the world you can be the war you could talk to bad dog banging on his door cyber underground every Friday here at 1 p.m. on think tech Hawaii calm and then every episode is uploaded to the cyber underground that library of shows that you can see of mine on YouTube calm and I hope you'll join us here every Friday we have some topical discussions about why security matters and what could scare the absolute bejesus out of you if you just try to watch my show all the way through hope to see you next time on cyber underground stay safe welcome back this is your host Craig Thomas I'm much more on medicine assisted as always by rich and Ray and I'm with dr. Linda Rosen the CEO of the Hawaii Health Systems Corporation and before the break we were talking about how I think it's partly the culture of the state taking care of people with difficulty access to services and particularly health services in this case but also the challenges the fact that some of the places that are in the state health care systems are oh an hour and a half from Hilo Medical Center oh by the way there's an active volcano in between the facility in Kahoo and Hilo Hospital and you can see vivid fountaining from Hilo Hospital and drive by it on your way to and from Kahoo so clearly that kind of thing demonstrates the importance of having services available distributed through the rather vast areas of some of our other islands and now we're going to talk about some tools and opportunities to provide services possibly a more specialized nature far from Oahu yes Craig I think it's worth mentioning that technology may be something that will help us with this sort of dilemma that we have of scattered population in need of specialized services and one of those tools is people called telehealth which is of course basically sort of virtual visits where one the health care providers not physically in the same location and we have examples of that going on today although it's sort of the initial steps not not widespread but I do think that this is going to be one of the key solutions and strategies that we will employ in the future to provide more specialized care in our more rural communities so we have a few examples of that and you know for the listeners often the physician provider will be not even in the state of Hawaii and that has caused people some concern when some of these projects were initiated in terms of you know what people call cultural competency but it isn't something that you that is you know overwhelming it can certainly be be dealt with on the other hand my hope is that more physicians here in Hawaii will become interested in being a telehealth provider we have you know these other physicians because they are working for you know companies that provide this service and we really weren't didn't have something equivalent here in Hawaii that would sort of step up and say we want to be the telehealth provider now that we are deploying these telehealth services and several of our facilities very hopeful that it that people it's going to catch on and spread and that when others see what can be accomplished and the advantages that physicians would have if you think about it if you're an Oahu specialist especially if you're maybe one of the newer ones trying to build your practice you can suddenly have a whole lot of referrals because you're able to provide through telehealth care to patients that you wouldn't otherwise see and we're also very fortunate another way our state is very progressive and that we've had laws that they have a law that telehealth services have to be reimbursed by insurers at the same rate as face to face services and this is very unusual when you speak with the telehealth providers who you know are responding to our RFP to provide services and you ask them about their billing experience of course it's extremely poor they kind of laugh because so few payers would pay telehealth in the past but this is changing even Medicare so Medicare paid for some telehealth services in some areas like hella dermatology in Alaska as an extreme example but the there's a lot of progress being made and there's been recent announcements that this is probably going to open up for Medicare in terms of paying for a larger variety of telehealth services and that will be important for us so for me telehealth has been a little bit like speech recognition I've been hearing about it for oh 25 years and the comment always was on five years this can be everywhere and then in five years like it's in five years this can be everywhere however I think you're right I think that there's a convergence here the technology used to be honestly not very good quite expensive and cumbersome to deploy we had these big carts you had to connect with like over the web to a cart somewhere else and then people had to walk to that's all over we've got the cart in our pocket now it's our phones and there are secure ways of using them and especially for visually important specialties dermatology being the perfect one I can try to describe a rash or I can send an image which do think works better but also others there are a sort of talk heavy specialties I'm taking care of psychiatry but obviously history matters in almost every medical condition and so dermatology is clearly something we'd love to move into because aren't many dermatologists and they're mostly on a walkthrough psychiatry is a challenge due to distribution of psychiatrists and congratulations on Hilo's recent launch of telepsychiatry is it's been a huge boon for the emergency department figures out who should stay and they can stay at Hilo or who should go sometimes they have to come to Wahoo or who should go home which is a huge item the other program and I know you have been involved with this from the beginning although it's not a state project the telestroke thing has been really good it's not only sort of pioneered and evolved the equipment but it's gotten people engaged in pulling in a key specialist early both to help with the decision and on-site treatment but also determine who might go for tertiary procedures because of course not you're not doing procedures over telehealth not yet anyway well that may be coming with robotics in the near future but that's not really something we're looking at now it's more the knowledge piece of it rather than you know the if you will mechanical piece of it but I think that will eventually come in the sense that you can have a surgeon in a community guided by a surgeon in another community and have a sort of a combination but you know going back to what would you say telestroke for those who may not know what the reason the telestroke was I think so instrumental is that when a person is experiencing a stroke they have a window of time to receive treatment not all are appropriate for treatment for those who are candidates for treatment if they're not treated early it's it's not going to be good so right which is the treatment is more efficacious delivered the sooner the better and so it's less dangerous both more effective and and less bad outcomes exactly and so dr. Matt Koenig who is a neurologist intensive care neurologist was really instrumental in starting this with a grant and as he said the equipment you know it's kind of beginning type equipment but the other factor besides the camera which enabled the neurologist to if you will beam into the emergency department at Hilo and evaluate the patient and they can evaluate they can say lift your arms smile you know do the kind of things that they do in person the other big enabling factor which we accomplished about maybe about eight seven years ago was the introduction of the ability to transfer images between facilities and meaning if I did a CAT scan on you in Hilo I can send it to Queens in anticipation of your transfer there before that people would repeat studies and of course in stroke the neurologist needs to see the head CT in order to be able to you know make a recommendation so the combination of the camera if you will and the image transfer that what enabled this and now we have the ability to give that kind of advanced treatment pretty much all over the state very rapid and the numbers the data really show a difference many patients before this effort just basically didn't get you know the care that they could have gotten and the because there's a data collection times are tracked and because of this effort all facilities have improved and the difference between the facilities that could do it and the ones that couldn't is now pretty much I agree and that actually is so just a way in that we're going to wrap up in a minute but you don't want me describing to the specialist your CAT scan you want the specialist to see it and related to that there are some efforts to facilitate sharing of data between different health systems usually within health systems it works but not always and outside of health systems it's like a moat and we're pushing for all the emergency partners in the state to be collected in something called EDI so I'll know what happened yesterday at a different facility and they'll know what I did tomorrow at a different one yet and I'm excited about that you know thank you for spearheading these changes this I'm excited about it there are many other things we could talk about using paramedics in rural communities particularly to provide care at home or in other settings it'll have to wait till next time so there's always a lot to talk about with you Craig it's true thank you my friend thank you and thanks for watching thank you everyone for joining us this is much more in medicine with Dr. Linda Rosen thank you