For those wondering if they can bridge the long distances of a health network and the longtime distancing of independents turned partners, consider one Army hospital in the mid-Pacific.
Tripler Army Medical Center has forged a network connecting its Honolulu location to virtually every healthcare outpost on the Hawaiian Islands. It's consulting electronically on cases in remote Pacific islands, dealing daily with military hospitals throughout the Pacific and preparing to expand its reach to ships at sea.
In the process, the 420-bed tertiary hub of military care has consolidated its communications across once-uncoordinated operations of the Army, Navy, Air Force, Marines, Coast Guard and Veterans Administration, covering nine time zones and 8,000 miles.
By any measure today, it's a community health information network taken to the extreme.
"There are very few good stories of working CHINs," said Samuel Schultz, one of the judges of the Crystal Award for Excellence in Healthcare Information Technology, which went this year to Tripler. The hospital's effort is "a striking example we could all listen to and benefit from," said Mr. Schultz, vice president of information services at University Hospital Consortium.
Unusual challenges.The impetus for the information network was a set of circumstances common to all would-be integrated systems but made more extreme by military healthcare's dual challenges of mobility and isolation.
Tripler is the key tertiary provider for all eligible military beneficiaries and their dependents in the Pacific region, said Richard I. Skinner, Tripler's chief information officer during the transition to computerization.
Yet it had trouble coordinating information even on Oahu because of reliance on paper records and phone conversations, combined with differing systems of the various military branches and dependence on patients to transport information and records.
To keep track of patients once they left the island, or to consult on remote cases that required Tripler's expertise, records were shipped back and forth by regular mail. For more pressing cases, a couple of airplanes continually shipped physicians out to bases or patients in to Tripler, Mr. Skinner said.
Integration initiatives.Five years ago, Tripler defined three major initiatives to integrate the Pacific healthcare system using information technology.
The first initiative was to standardize information systems across organizations as well as settings of care.
That set up the second initiative, establishing at least a rudimentary electronic medical record to make most, if not all, text-based clinical information available to every provider anyplace, anytime.
The third was to overcome the time and distance barriers to efficient care in the region and bring Tripler's expertise where needed in an economical way.
Ironically, the unusual barriers imposed by the military system also spawned unusual opportunities.
The integration effort had a captive audience and a guarantee of some cooperation, enforced or otherwise. That enabled it to dispense with the usual wrangling of deciding on a system and getting agreement from the intended participants, Mr. Skinner said.
There also was a 15-year effort under way to computerize clinical information through the Department of Defense's proprietary Composite Health Care System, which Tripler volunteered to test and expand. And there was ready access to a military communications network, part of the worldwide Internet, to transfer data to remote bases at virtually no cost.
Instructive effort.Those factors might make the example seem inapplicable to the private network-building efforts looking for successful precedents. But Mr. Schultz said the Tripler effort is instructive just because it doesn't have the usual "contaminants" to color an experiment testing whether an information network can work-no billing or financial considerations, gaps in participation or transmission barriers.
The military also knew the ropes of continuum of care before it became a reform term, Mr. Skinner said. Its traditional emphasis on outpatient care and passing patients around a widespread network gave it a head start on organizing around integration.
Today, the military information system handles virtually all clinical transactions in the Hawaiian Islands and many remotely in other Pacific areas, Mr. Skinner said. Almost every aspect of healthcare has been recorded on the system for the past four years, and physicians have been doing the ordering and entering, he added.
The system also has conquered distance problems by allowing text-based consultations by electronic mail instead of phone and airplane. Each practitioner linked to the system knows what's been done for a patient by every other practitioner, he said.
An in-house video-teleconference facility is now being used biweekly to bring physicians and patients together between Tripler and the Pacific Missile Test Range on Kwajalein Island in the West Pacific. In the first six months of operation, more than $80,000 in air evacuation costs alone was saved.
Mr. Skinner retired from the Army in February and moved to the private sector. At the time, the components were in place to connect the system to ships at sea, but the effort hadn't been tested.
Mr. Skinner said his experience will help him with information networking efforts at Sisters of Providence Health System in Portland, Ore., where he now is chief information officer.