Art Ushijima never could have envisioned 21st-century medicine when he first started in health care administration. That year was 1973, and the current chief executive officer of The Queen’s Health Systems was fulfilling his ROTC duty, starting seven years in the Air Force Medical Service Corps, administering military clinics and hospitals. Even in civilian hospitals of the time, the intensive-care unit was a fairly new innovation and countless other technological advances hadn’t even been contemplated.

Now Ushijima, 64, is dealing with all the industry changes, good and bad, that confront people in his profession nationwide — many of them efforts to manage the skyrocketing costs of health care. In particular, Queen’s has found 2012 to be a landmark year. Primary among the challenges that still lie ahead: finalizing the acquisition of the former Hawaii Medical Center-West, shuttered since January, a deal Ushijima expects to be inked in a few weeks.

And there are other headlines that become par for the course for the state’s largest hospital. The court drama over an elderly patient and the enforcement of her advanced health care directive is one. And the ongoing efforts to grapple with Honolulu’s homelessness problem often involves Queen’s, in whose emergency room indigent patients often end up.

Ushijima has watched Queen’s develop since he arrived as the hospital’s chief operating officer in 1989, after a civilian career in hospital administration across the Midwest. It was a homecoming for the Maui native, who has never quite returned to the tranquil neighbor-island lifestyle. Work is a six-day commitment, and the seventh, a somewhat more relaxed day with his wife, still involves chores. That’s time for the quintessential "honey do" list, he said.

What may have been the most stressful period of the year — ramping up to restart the organ transplant program — is largely behind him now, which he sees as a major source of satisfaction. Queen’s began its federally approved program only 90 days after application.

"Administratively, it was … do you see my hairline?" he asked with a laugh.

Then, more seriously: "Our people moved mountains to make this happen. And it did happen."

QUESTION: Do you hear concerns that Queen’s is taking on a lot?

ANSWER: Well, I think for any organization of our size, taking on these various initiatives, such as the West Oahu initiative, these represent growth. And with growth that means you’re stretching yourself and the organization.

So, does it mean we’re taking a big bite? Yes. Does it mean, do we have the capacity, and the individual employee and physician and management capacity to do this? I feel we do, otherwise we wouldn’t be pursuing it.

Q: Are there recruitment programs going on now?

A: We’ve been going through due diligence, as you know. We’re going through a period of time where we’ve been working through all the issues that go along with due diligence. And we’re still under a confidentiality agreement, so there’s a limited amount of what we can say about our findings. Nevertheless, I can say we’re very close to concluding this, very optimistic that we will have closure, we’ll get to closing. …

We’re going through that and, I’ll tell you, it’s a great learning experience for everybody; it’s certainly taken a lot of effort on everybody’s part who’s involved in this. But we’re going forward with this as a way to grow Queen’s. It gives us the opportunity to be in a geographic area where we’ve not had any significant presence. …

In the meantime we have put in place a team that represents different components, such as business development, physician development, operations, infrastructure. So there is a range of areas that we preparing ourselves to manage. … So it is a challenge.

Q: What happens after the deal finally closes? Will there be a lot of renovation work?

A: The facilities represent one significant piece of this undertaking. … For example, the emergency room is undersized for the population growth in that area. It is just not adequate to what we think will be the current and future demand. So that’s where we’re spending a lot of time on the facilities, looking at the space needs and the service needs: the emergency room, the imaging services, the operating rooms, all the major areas of the hospital.

Q: Do you have land to expand? How big is the site?

A: It’s a little under 20 acres. To give you some perspective, the Queen’s Medical Center is 171⁄2 … we’re close in size. So we’re looking at potential growth.

When we undertook this, we did look at the growth of the population.

We also looked at the west coast of Oahu which has the largest concentration of Native Hawaiians. So we felt it’s part of our mission. …

Our plan is really to create an extension of The Queen’s Medical Center, the services that will serve the population at the level of care that’s needed in that area.

Q: Is it going to be called The Queen’s Medical Center West?

A: Good question. We should do a contest: For an iPad, give us a name. (Laughs.) We’re actually going to go through a process to determine what would be the best name. But what I’m hearing is Queen’s West.

Q: How is Queen’s adapting to health care reform?

A: That movement was taking place for a long time, out of necessity because of costs and other pressures. …

Accessibility, patient safety, quality of care, all those issues are part of the health care reform movement that actually preceded the enactment of the Affordable Care Act. So with or without the Affordable Care Act, there would have been continued movements to reform health care.

What the law has done is to really provide the prescriptive changes that the law has enacted that will include a series of things in terms of payment reform, such as the value-based purchasing program, bundled payments. There are going to be insurance exchanges; there’s a whole gamut of things that the law is prescribing that the industry is going to have to deal with and implement.

We are preparing ourselves at Queen’s. We have undertaken initiatives, from investments in IT to new programs for patient safety, working with physicians in terms of models of practice that we going to have to implement. So there’s a range of activities that we are working on.

Are we working fast enough? I think we are saying that we’re working as fast as we can. We are trying to anticipate all the things we will need to put in place, put them in place as quickly as we can but do them as well as possible.

The biggest concern in health care reform is, will patient care suffer? Will patients get the care that they need when they need it? And will they have the quality of care and the level of service that they have come to expect out of the health care system? And will we be able to preserve the good parts of the health care system? So that’s what we’re trying to do.

Q: What do you see as driving costs up?

A: Medical technology has advanced far beyond what it was when I started as a health care administrator, and it’s advanced far beyond what most people expected. But along with that you also have other needs at the primary-care level that are still not being met.

So at one level, the front end still needs to get served better. The back end, with investments in technology, will continue to advance. Now, one of the things that isn’t always appreciated is, if you live in a remote area of this country, your access to the most sophisticated services are limited. We see it even in our own state. If you live in a remote area of the neighbor islands, you’re not going to have the same level of care as if you were living right on Oahu. So there are those issues of disparities in delivery and access that still need to be met.

So your basic question, what’s driving costs: There’s the back-end costs which we deal with all the time at the high end of sophisticated care, but there are also needs at the front end, the primary level of care that needs to be delivered more effectively and efficiently.

Q: Is the main issue a shortage of primary-care physicians?

A: The problem is if you just focus on medical schools, there aren’t enough physicians being graduated to meet the projected demand, in almost all specialties. … So I think we’re going to have to look at different types of delivery, or individuals to supplement and complement physicians at the primary-care level. We’re seeing more need for nurse practitioners, as an example, although there is a nursing shortage, too.

What we have is a health care conundrum where we don’t really have an ideal solution in place because the problems are so huge, and there is such huge demand.

Q: You mention nurse practitioners. Do you think there is a broader acceptance of a range of health care providers than there used to be?

A: Under the proper setting and circumstance, where you have the appropriate level of supervision for non-M.D. services, it works perfectly well. … There are certainly complementary services that other professionals can provide, and we’re seeing increasing acceptance.…

I think we’re going to be much more creative; we’re going to have to be. We’re going to have to look at different ways of providing care. We’re going to have to look at physician extenders as one; technology, telemedicine. Telemedicine is already being used in areas like imaging, radiology; we can transmit images. …

We’re going to be looking at telepresence: you’d have virtual consultations remotely. You can have, say, the world’s expert in dermatology in New York City do a consultation here, on a virtual basis. So I think we’re going to see that.

I think that, rather than saying health care is going to be overwhelmed — yes, on one level, it is — but the other side is I think we’re going to have so many opportunities to do things better. It’s going to be challenging, it’s going to be difficult, but I think the opportunity to make things better, out of necessity, I think this is where the environment is going to try to drive the change.