Just back from a hiking trip in Scotland and England, Virginia Pressler is continuing on that exercise track.

The mother of two grown children, she enjoys early-morning walks with her husband and keeps a fitness ball under her desk. In short, she is the picture of health.

Pressler grew up on Maui and actually started her working life in the banking industry. She felt unfulfilled until her brother-in-law, then in medical school, observed that she’d be a good doctor.

As a physician and now director of the state Department of Health, Pressler, 66, started with the finely detailed work of a general surgeon and now contends with the large, systemic challenges of health care.

She worked at DOH previously as head of the Health Resources Administration, and still embraces preventative health as key to improving wellness.

But while specializing in breast cancer surgery, she recognized that care is fragmented, with patients often left adrift in an uncoordinated system.

Changing that reality — what’s called “health transformation” these days — was her job as executive vice president and chief strategic officer at Hawaii Pacific Health, just before she was named DOH chief by Gov. David Ige.

Systemic problems are at the center of the financial woes of the state’s public hospitals, and Pressler rejoiced at the recent enactment of House Bill 1075, the privatization bill.

Bolstering the state’s services in behavioral health has seized the top spot on her job list now. Lapses in coordinating mental-health services as part of primary care, she said, is directly linked to many problems now, including homelessness.

Pressler also wants the department to give the social components of health their due.

Hawaii has a relatively healthy population, she said, but the disparities between the poorer groups and the richer ones is large. No resting on laurels for a while.

“We have some of the best health statistics in the country, so it’s easy for people to say, ‘Well, what’s the problem?’

“But even though we have such great health outcomes relative to other states, we still had a doubling in the rate of obesity in the last 10 years,” she added, “so we’re the best of the worst.”

QUESTION: What’s the next fire you have to put out?

ANSWER: Not so many fires as following up on things. A lot was done this (legislative) session. And in this administration, I’m very excited to say, we were chosen for our own personalities to be collaborative and breaking down silos and working across departments and agencies. So there’s an awful lot of work now that needs to be done to address those interdepartmental and interagency issues.

Because most of the problems that we see in the media on a regular basis, the ones that keep coming back, you know, those are system issues. It’s not that somebody messed up; it’s not usually an individual’s fault. …

We have an administration now, and a carefully selected Cabinet, that has the attitude toward collaborating to fix system issues. So I’m very excited about that, but that takes time.

Q: By system issues, do you mean IT (information technology)? Or not so much that?

A: I’m talking about issues that cross over departments. The homeless issue is a good example. It’s state, it’s city and county, it’s the other counties on the neighbor islands. It’s Department of Human Services, it’s Public Safety, it’s Department of Health.

And our piece of it is really the uninsured behavioral health piece, where we provide intervention. And in order to be effective at that, we support the Housing First initiative. If someone doesn’t have a roof over their head, it’s very difficult to get services to them.

The issues at Kakaako, a large number of them are the COFA (Compact of Free Association) individuals — so those are Department of Interior and state issues. These are complex problems, which is why they don’t get fixed overnight.

We are busy working on these things, trying to address them, and it takes time. And managing the public perception that we are not just sitting on our hands, we are actively working on these issues. …

Q: Can you bring me up to date on the hospital privatization bill?

Q: That’s huge. Because what we’ve been doing doesn’t work. We’ve had a real problem with deficits with the Hawaii Health Systems Corp. statewide hospital system. And having the ability to look at private partnerships as part of the solution is huge, because it allows us to look at totally different approaches to the problem.

Starting with Maui, regardless of who the partner ends up being, if that is successful, then hopefully in the next year or two the Lege (Legislature) will then allow the other Islands to do public-private partnerships as well. So we can learn from what happens on Maui. …

Q: Is this what we’re seeing at public hospitals on other islands, starting to fracture?

Q: Yes. Access to care is already an issue on the neighbor islands, both hospital as well as physician access. It becomes a downward spiral as you start closing programs and you lose physicians, and then you have no one to admit to the hospitals. And then you have a smaller patient base, and it becomes more expensive to operate for fewer people, at some point.

Right now I think quality and safety are pretty good; they do a remarkable job given the limited resources. But at some point they become compromised, as you have inadequate resources to really take care of a limited patient base. 

You need to have full services on the neighbor islands; you can’t ship everybody to Honolulu, nor should you. I mean, that’s not good care.

Q: Is Maui a test case, or do you feel this can be a template for the other Islands?

A: I think each of the islands is different, so I don’t know that it will be a template. But there will be a lot to learn from that partnership, in what’s working and what isn’t working as it gets launched. It does allow a new look at the problem. …

Q: Is anything about the problem unique to Hawaii? Many states have rural areas that are remote.

Q: Across the country, small rural hospitals that are not able to sustain themselves become part of a larger system. It’s been happening all across the country. You’re seeing more and more consolidations, partnering … It’s not unique at all, it’s a national trend.

Because of all the regulatory requirements — you mentioned IT, the information technology requirements — all of the expensive pieces and administrative rules and regulations, it’s not financially feasible for a small hospital to stand alone. …

Individual physicians are facing the same issues. It’s going to be harder and harder for them to survive, sole practitioners or groups of two or three. It’s just too much expense; infrastructure is part of practicing medicine today.

Q: This is an evolutionary stage, right? Things will get better?

Q: Yeah. And as the right systems are brought together, and the focus is on patients and quality, it will come out as better care. That’s pretty much what’s happening in the private sector in this state, at least that’s the progress that’s being made.

Q: What projects would you like to advance?

Q:  One of the major priorities that I have is the State Hospital in Kaneohe, the mental hospital; we have a master plan, and we need to build a new state-of-the-art facility. …

Just this year we will be demolishing an old building called the Goddard Building that hasn’t been used for years and is falling apart. … We have some preliminary plans that need to go to the Lege for CIP money so we can build a new 150-bed hospital.

Not only do we need it for capacity reasons — the utilization is way over its original licensed beds — but also the new hospital will be built state of the art, for forensic psychiatry.

So we can provide appropriate secure yards for exercise, and secure rehab and gym and line of sight for the nurses’ stations to rooms, appropriate security, those kinds of things.

Q: So these would be court referrals?

Q: For all intents and purposes, the patients that are at the Hawaii State Hospital in Kaneohe are almost entirely forensic, or court-referred patients. …

The Behavioral Health Division covers not just the inpatient State Hospital. Behavioral health includes adult mental health, alcohol and drug abuse, child and adolescent mental health …

My focus this year is to really put some attention into the whole Behavioral Health Division, because it’s an area that’s been neglected for many years. And I think with all the budget cuts a number of years ago, cutting community-based programs and things like that, we’re paying the price big-time now. Because that’s part of the homeless problem.

We’ve had increased ER admissions for behavioral health issues, because we don’t have those community-based services. I’m intent on trying to rebuild community-based, outpatient, preventative, trying to get behavioral health integrated into primary care, so there’s screening for depression and substance abuse, and those kinds of things. Because there are effective treatments now.

And because we haven’t been addressing those issues, these become the “frequent flyers” in emergency rooms. So until we deal with the root problems, we’re going to continue to battle with homelessness and high emergency room use and ambulance use that may not be necessary.

Q: I’m interested in public health topics, such as e-cigs. Do you think smoking is really kicking up here?

Q: What’s happening is we’re seeing less smoking and more use of e-cigs … a huge increase, 55 percent increase, is the high school kids using e-cigs.

And unfortunately, it’s being marketed as safer than cigarettes. … What’s happening is these kids are starting e-cigs, and they get hooked to the nicotine. And then they’re both using e-cigs and they’re smoking.

Nobody knows the safety of vapor you’re inhaling, the metals that might be in the devices. There’s no quality control.

You’re inhaling fragrances that aren’t meant to go into the lungs.

We don’t know what the impact of that is. It’s rather concerning.