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The federal government has pushed hard for the development of regional health information organizations. But the mission of RHIOs will change dramatically within two or three years as the government's effort to build a national network gains momentum, predicts David Brailer, M.D., the federal government's national coordinator for health information technology.

That doesn't mean RHIOs should change course now, he adds, as their work is important toward getting widespread adoption of interoperable electronic medical records. "Being a RHIO is a journey," Brailer explains. "We know it has a beginning and a middle, but we don't know what the end looks like." The February cover story of Health Data Management will provide an in-depth look at the issues and challenges that face RHIOs.

The very fact that communities and regions across the nation are working on RHIOs is testament to the determination of the health care industry to reinvent itself, Brailer believes. "No one has told these communities that they have to go out and build RHIOs. There is no upfront financing incentive to do it. But folks are going out, collaborating and doing it anyway."

But health care networking technology now being developed under federal contracts could change the core functions of RHIOs.

The Department of Health and Human Services recently awarded four contracts for development of prototype national health information networks. The department expects the prototypes to be delivered this fall, then scaled up in 2007.

This means the tools to create a national network within the existing Internet infrastructure and tools to connect to the network could be available by the end of 2007.

And that means it will be tough for RHIOs to justify why they are developing regional or statewide networks that share data locally and link to the national network, Brailer says.

Consequently, he sees RHIOs evolving into governing or advisory bodies to decide how to share data across regional or state boundaries. "In two years, most RHIOs won't have reached a critical mass stage of acceptance and will have the option of changing their strategy."

Eventually, physicians and hospitals will buy electronic medical records software with the network connectivity tools embedded, Brailer predicts. Initially, opportunities will exist for vendors--and some RHIOs--to sell the tool kits.

"But RHIOs in the end won't be the purveyors of technology for doctors and hospitals," he adds. "RHIOs are here to stay. Some will handle the technological end but most won't have the scale to make it affordable."

For these reasons, RHIOs don't have to tackle what many have identified as their biggest challenges--developing a business model and sustainable sources of funding, Brailer says.

Most RHIOs are not-for-profit and being built for the common good; Brailer even doubts for-profit RHIOs ever would make money. "Charging transaction fees is an exceedingly M.B.A. way of thinking," says the former health I.T. entrepreneur.

Rather than a business model and sustainable funding, the critical test for RHIOs will be a governance model that brings in all stakeholders and has procedures to resolve conflict.

"Most RHIOs will want to make local decisions on how data will be shared," Brailer explains. "In the end, the technology doesn't matter; it's who controls the data. The less centralization there is, the more value people will see because they will have more decision making ability."

The national health information network won't be physically different from the existing Internet, he envisions. But parts of the health network will be sequestered from the rest of the Internet. This means sequestered data will move on the same physical wires as other data on the Internet, but its nodes and related storage and transfer equipment will be different.

For instance, much of the nation's air traffic control system runs on the "normal" Internet, Brailer explains. But landing controls--deemed as mission-critical data--are sequestered.

Consequently, the health care industry and policymakers will have to decide what health data is mission-critical.

"Is it data monitoring devices in the body, or data to support real-time care, or data collection for research?" Brailer asks. "Some data uses will be declared critical and others will not."