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RHIOs Struggle to Find a map to Success
Health Data Management Magazine, February 1, 2008
About four years ago, health care leaders in eastern Tennessee and southwestern Virginia wanted to create a patient data exchange across their region. So they sought advice from several more established regional health information organizations.
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“From day one, we knew we’d have to design our network looking at other RHIOs and deciding whether we wanted to be the same or different,” Jenkins says. “We also found things we wanted to do that no one else was doing. I don’t have faith for initiatives that say there’s only one way to do this.”
Lack Of Traction
While CareSpark expected its health data exchange to go live January 31, many other RHIOs — or HIEs — are having difficulty getting off the ground. A few already have called it quits.
A Harvard University survey published late last year found that 54% of RHIOs in existence in July 2006 were still in the planning stages as of early 2007. An additional 26% could be classified as defunct, according the survey. Among those is the Santa Barbara County Care Data Exchange, one of the organizations that CareSpark looked to for guidance.
Meanwhile, a November 2007 report from the Information Technology & Innovation Foundation, a Washington-based technology think tank, contended that most RHIOs are financially unsustainable.
“The strategy of building a National Health Information Network from the bottom up by establishing many regional health information organizations throughout the country is not working,” the report states. “More than 100 RHIOs have been established across the country, but in the absence of clear national standards for sharing medical data, achieving system interoperability for RHIOs has been difficult.”
A few I.T. vendors have echoed the reports’ findings, complaining that connecting members of RHIOs has been difficult to achieve without clear national standards and more electronic health records adoption.
Further, some hospitals have discovered they don’t need to be part of a RHIO to exchange patient data with area physicians, (see sidebar, page 62.)
In an effort to help emerging RHIOs that are struggling to get started, some industry analysts have recommended best practices for achieving a successful, viable data exchange.
For example, the advisory board of the Center for Community Health Leadership released a white paper last October titled “The Best Practices for Community Health Information Exchange.” The center’s advisory board, created by Misys Healthcare Systems, a Raleigh, N.C.-based physician software vendor, includes physicians and consultants. The best practices are based on discussions center leaders have had with executives at several RHIOs over the past few years, says Michael Fleming, M.D., a center board member.
“We’ve pointed out some of the challenges we’ve seen and given ideas about how organizations can meet them,” he says. “Each RHIO’s structure will be unique to its community. But to succeed, they need these pieces.”
For example, the center’s white paper explains how RHIOs should create value propositions for each stakeholder group. It also outlines how RHIOs should build roadmaps and facilitate an ongoing discourse among stakeholders during the planning process.
Skeptics, however, still question whether RHIOs will prove viable given their spotty performance so far, which, in many ways, parallels the failure of Community Health Information Networks in the mid-1990s.
“I don’t have a high level of confidence in RHIOs or HIEs,” says Jeffrey Bauer, a Chicago-based partner in the futures practice of ACS Healthcare Solutions, a Dearborn, Mich.-based consulting firm.
Bauer says RHIOs will never be able to provide access to all of a patient’s relevant medical information. Instead, he advocates creation of a personal health record stored on a patient’s secure Web site. Another alternative, he says, would be for patients to wear a small data storage device containing their complete records.
“We’ve got to build the information exchange around the patient, not around the providers,” he says.
Learning The Ropes
Nevertheless, some RHIO organizers hope to capitalize on the emerging recommendations for best practices. Further, many now understand they must be able to deliver measurable value to their constituents to achieve success and viability, says Lorraine Fernandes, vice president at Initiate Systems Inc., a Chicago-based vendor of identity and data management software. And participants in different RHIOs may have widely varying definitions for value, she adds.
For example, CareSpark organizers decided that decision support would be valuable to its participants, although they were unaware of another health data exchange that planned to offer it, says Jenkins, the executive director. So in addition to working with various vendors to integrate its participating providers’ EHRs and build a master patient index and Web portal, CareSpark is using technology from New York-based ActiveHealth Management to offer physicians decision support when they access patient data.
The vendor’s software offers alerts for physicians based on analysis of a patient’s claims and clinical data. Clinicians use CareSpark’s portal to locate a patient in its MPI and receive their clinical data and the decision support alerts. Some of the RHIO’s payer stakeholders integrated their members’ claims data into the software so the alerts could be functional at go live.
While decision support can offer numerous care benefits, CareSpark also plans to turn it into a revenue generator.
The RHIO’s leaders believe the alerts can offer information that will help reduce duplicate tests and medical errors, which ultimately will reduce care costs. So they plan to charge a per-member, per-month fee to employers and payers who enroll their employees or members in the decision support service. The decision support system also offers population analysis tools, which CareSpark will use to help ensure financiers understand how it’s saving money and improving care.
The expected revenue from the decision support service is likely to subsidize infrastructure support costs for the RHIO, Jenkins says.
“You get a real value when you have decision support across the exchange,” Jenkins says. “That’s a convincing ROI for this.”
CareSpark also plans to collect revenue from donations, transaction fees for large data file exchange and contracts for related projects, such as the NHIN.
Finding Funding
Developing and maintaining funding sources can be one of the biggest challenges RHIOs and HIEs face. It wasn’t much of an issue, however, for the Western North Carolina Health Network.
The Asheville-based organization was formed in 1995 to support various health care initiatives. In 2003, when its 16 original hospital participants decided to develop an HIE, they decided to use the same funding structure they had for previous projects. Hospitals pay from $17,000 to $100,000 per year for the services of the HIE, based on their size, providing a total of $500,000 per year, says Gary Bowers, executive director. The exchange also received $3.5 million in start-up grants.
“We already had governance established through our existing network,” he says. “With that comes a lot of trust and relationships that have been established already. It’s not like this was a new group comin together.”
By 2005, the network had a business plan to develop a federated data exchange. It hired Birmingham, Ala.-based MedSeek to develop a Web portal that integrated with participating hospitals’ clinical information systems. It hired IBM Corp., Armonk, N.Y., to host it and offer project management. WNC Data Link began rollout in April 2006, and the final hospital was expected to go live in January. Not all hospitals, however, have implemented Web portal access enterprisewide.
Clinicians use the Web portal to connect to an admissions database that includes the names, addresses and insurance information for patients from each hospital’s HIS.
The system uses proprietary algorithms to match patients in the database with the information the physician enters. Once a match is made, the system pulls the information from the HIS and displays it via the portal. Physicians can access lab data, radiology reports, microbiology results, patient allergies, medications and transcribed reports via the exchange.
Although its participating hospitals already had an established relationship, the biggest challenge for the new RHIO was to form a consensus on policies and procedures for a data exchange because there weren’t many RHIOs in existence at the time, he adds.
“This was a new area,” he says. “We looked at a handful of organizations. But what works in one community might not work for another.”
Trends Arise
While RHIOs’ business plans vary, certain newer organizations have some strategies in common. For example, some have adopted a centralized approach to data sharing, in which information from various facilities is integrated into a database, says Lynne A. Dunbrack, program director at Health Industry Insights, a Framingham, Mass.-based health care I.T. research and consulting firm.
“A lot of the approach depends on the technical sophistication of the organization,” she says. “But if data is contributed, it’s easier to analyze. It’s also easier to segregate information in a centralized model if a hospital no longer wants to participate.”
Centralized databases can be supported by a RHIO member, a third party or independent health record trust organization.
“Centralized RHIOs can help small facilities participate even if they don’t have a lot of automation,” Dunbrack says. “In a federated model, if a practice turns off their systems at night, other organizations can’t access the data.”
In November 2006, the Louisiana Rural Hospital Coalition Inc. decided to develop a somewhat centralized health data exchange to help its small hospital members treat more patients locally. But the Baton Rouge-based advocacy group had to help some of them get automated before they could participate, says Jamie Welch, CIO.
After receiving $13 million from the state legislature for the project early last year, Welch began evaluating hospital information systems to purchase for seven coalition members. She found three systems that would be functional and cost-effective for the data exchange, but hospitals weren’t limited to using those applications.
“The goal wasn’t to take the whole hospital wireless,” Welch says. “But it was the push they needed to start doing things electronically.”
Additionally, the coalition hired four vendors—Carefx Corp., CA, IBM Corp. and Initiate Systems—to develop an MPI and a Web portal physicians can use to access it.
But the HIE has a narrow focus. It will only be used during scheduled telemedicine consultations between The Louisiana State University Health Sciences Center, a Shreveport-based referring hospital, and coalition members. Participating hospitals will receive telemedicine technology, including a high-definition monitor, digital stethoscope, video cameras and other equipment to facilitate the consultations.
The MPI will receive select information during a consultation, such as labs, discharge summaries, medications and allergy information, from each hospital’s HIS. LS U, a referring hospital to coalition members, will serve as the third-party host for the MPI.
The Louisiana Rural Health Information Exchange expects to go live in three hospitals March 17. Four others are expected to follow within eight weeks.
“LSU runs at 100% capacity, so the goal was to help rural clinicians see if they have to send their patients there or if they can monitor them remotely,” she says. “The biggest advantage we have over other RHIOs is that we were able to skip the data ownership issue because our members aren’t competitors.”
Coalition executives plan to lobby the legislature for additional funding for the HIE, but they also have other revenue strategies in the works. For example, they eventually will charge hospital participants a subscription fee, Welch says. Further, the coalition might enable other referring hospitals to subscribe to the service and access patient data to relieve LSU of some of its patient load, she adds.
Show Value First
Other HIEs, however, believe they should prove their worth before discussing revenue strategies. The Mid South E-health Alliance, for one, has been live since 2005 but has yet to ask stakeholders for money.
Development of the Memphis, Tenn.-based HIE began in 2004 with a $5 million grant from the Agency for Healthcare Research and Quality and a $7 million grant from the state legislature.
The state grant required the group to begin exchanging data within a year, so executives quickly forged ahead with their plans. Because so few HIEs existed at the time, the Mid South E-health Alliance decided to develop its own technology to facilitate data exchange, says Mark Frisse, director of regional informatics at the Nashville, Tenn.-based Vanderbilt Center for Better Health, which operates the HIE. But the decision also was financially motivated, he adds.
“How can you pick a vendor when you don’t know what your value will be?” he says. “We decided the best way to get a return on investment would be to keep our costs as low as possible.”
The Vanderbilt Center, affiliated with Vanderbilt University Medical Center, was established in 2002 to promote the use of I.T. in health care. To develop an HIE for the Memphis area, it copied the hospital’s infrastructure to enable myriad clinical systems to send information to a single database. It also built a Web browser to enable clinicians to access the information. The center maps information in the database so participating hospitals aren’t burdened with ensuring their data is compatible with other participants’ data.
Clinicians use a password and personal identification number to log into the portal. Then they are prompted to enter information about their patient to help a record locator application match it to a patient in the database. Once a match is made, a clinician can see a variety of data for the patient, including labs, radiology reports and medications and allergy lists.
The center has been funding the nearly $2.5 million annual operating costs for the Mid South E-health Alliance via the initial grant money. But it’s researching the value the HIE has brought so far so it can attract other funding sources, Frisse says.
While the HIE plans to work with public health entities, managed care organizations and individuals for future funding, it wants to demonstrate actual benefits to these stakeholders before asking them for money, he adds.
“You can’t define who pays what until you understand what the benefits are,” Frisse says. “If we can show that we have saved an organization x amount of dollars, we will make efforts to share in these savings.”
But the most fundamental test for the success of the Mid South E-health Alliance is whether clinicians find it usable, Frisse contends. “We have instances of clinicians using the HIE to find that they don’t have to repeat a test on a patient,” he says. “And we have comment cards from physicians expressing their satisfaction.”
Visit healthdatamanagement.com for more information on RHIOs and HIEs: * Survey: HIE Initiatives Advancing: (Search for HIE) * Study: Quarter of RHIOs are Defunct (search information exchange portal) * Report: RHIOs Don’t Work (search for RHIOs) (c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.cardforum.com http://www.sourcemedia.com/
SIDEBAR
Initiatives exchange data without RHIOs
Saint Luke’s Health System is participating in the planning of two regional health information organizations across the Kansas City, Mo. area. But rather than wait for those projects to get off the ground, the 11-hospital delivery system also has developed its own initiative to exchange health data with area physicians.
In 2006, Saint Luke’s implemented technology from RelayHealth, a subsidary of McKesson Corp., that distributes patient test results from its various clinical information systems to their physician’s electronic health records system. The system also enables physicians to populate the results into a personal health record for their patients that other physicians then can access via a secure Web portal.
The data sharing initiative came out of requests from group practices that wanted to receive patient data via computers rather than by fax, says Deborah Gash, vice president and CIO.
“We didn’t have the resources to do so many point-to-point interfaces,” she says. “Now we have just one integration with the vendor, and they are the integrator for all the other systems.”
Saint Luke’s shares the cost of the service with the 124 physicians enrolled in it. The physicians pay for integrating their EHRs with RelayHealth plus a subscription fee, Gash says.
Since rolling out the service in December 2006, more than 2,462 PHRs have been created for patients and physicians to share, while the area RHIOs still have yet to get off the ground.
We don’t want to exclude ourselves from something that happens in our community,” Gash says. “But it’s hard to get everyone together to participate and decide who will pay for the costs involved in developing a RHIO. Our initiative isn’t just a PHR, but a way for physicians to share data.”
Payer Activity
Some payer organizations also are helping physicians share data without the massive systems integration and governance creation that RHIOs usually require.
For example, Wayne, Pa.-based MEDecision Inc. has 13 managed care organizations offering its Patient Clinical Summary payer-based electronic health records service to their members.
Each patient clinical summary includes information, such as patient medications and problem lists, derived from claims data generated by the payer. Clinicians can access the summaries via a secure Web portal. And because managed care organizations pay for each clinical summary transaction, hospitals just need an Internet connection to access the data, says David St. Clair, MEDecision founder and CEO.
“Our view is to improve the quality of care by focusing less on the short-term use of I.T. at the point of care and more on the use of information at the point of care,” St. Clair says. “We’re trying to get payers to share what information they have about their members with providers because it can produce real value.” (c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.cardforum.com http://www.sourcemedia.com/
SIDEBAR
NHIN not dependent on RHIOs
Though the National Health Information Network initiative has focused on exchanging data among RHIOs or HIEs, federal officials say the national network’s success isn’t contingent upon these regional networks.
As the result of a presidential executive order, the Department of Health and Human Services has been spearheading the development of a NHIN infrastructure, which would enable secure clinical data exchange across provider organizations nationwide.
The first phase of the project, which was completed last year, required four prime contractors to work with various HIEs to develop prototype architectures for a NHIN. The second phase, which began late last year, will require nine HIEs to begin exchanging data by September. Some federal agencies, as well as pharmacies and labs, also will participate in the exchange, says Robert Kolodner, M.D., national coordinator for health information technology in the Department of Health and Human Services.
Including a variety of organizations is essential because not every locality, region or state will have a RHIO or HIE, he says.
Further, the NHIN won’t be a central entity or router that organizations connect to, so data exchange can happen in other ways, such as via a health records bank, Kolodner adds.
Health records banks, which can be operated by local entities or trusts, serve as a central repository for medical records information, paid for and controlled by patients. Health records banks charge account fees to individuals to collect their medical records from physicians, hospitals, pharmacies, insurers, labs and other sources and then maintain the records. They enable patients to determine who accesses it.
“Some local organizations have the capabilities to make information flow, so they won’t need to be part of a RHIO to take part in the NHIN,” he says. “All entities must use national standards to connect, but the NHIN isn’t dependent on the viability and survivability of HIEs.”
To ensure the NHIN is prepared to facilitate data exchange among a variety of organizations, the four prime contractors in the first phase worked with several different RHIOs. For example, Northrop Grumman, Los Angeles, developed a core set of data exchange services for RHIOs in California, Colorado and Ohio, says Robert “Rim” Cothren, chief scientist. And each had different architectures, technologies, approaches and governance structures, he adds.
“Each RHIO is different because the environment in every community isn’t the same,” Cothren says. “So the NHIN needs to be flexible to adapt to those differences. It also has to be flexible enough to connect any type of organization together, whether via EHRs, PHRs, labs or RHIOs.” (c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.cardforum.com http://www.sourcemedia.com
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