Planning for the advent of community health information networks is like planning for retirement. Sure, it's something you should be doing, but there are all those other concerns that take precedence.
For healthcare organizations, just the task of computerizing and integrating departments within a building may be a tall order at this stage of the information-transfer game.
After that, the next level of work includes linking institutions, linking physicians to those institutions and ultimately establishing a routing network and data base.
A community health information network, or CHIN, forms the third level of electronic organization: a regional ring to carry clinical, financial and insurance data not only among providers but also insurers, business coalitions and other healthcare interests in the area.
Although some regions are forging ahead at this communitywide level, including the Chicago area (See story, p. 56), consultants indicate that most of their assignments involve putting institutional houses in order. But like retirement planning, failure to plan for the next phase of life could leave healthcare organizations unprepared for strategic imperatives that take time to hatch and collect interest.
Solving the technological aspect of CHIN development is only one piece of the problem, according to some consultants who are wrestling with start-up issues. "It's more political problems than anything else," said Robert Drewniak, who specializes in CHINs for Andersen Consulting's Boston office.
The larger picture includes reconciling competitive and cooperative urges among providers, defining needs of both the providers and the overall community, and cultivating consensus on the priorities of such a network. In some cases, just understanding differences of opinion at the start could help move the process along, Mr. Drewniak said.
Ironing out those political problems takes time, he said. In addition, trading sensitive information poses big legal headaches over security, ownership and scope of sharing, all of which will be time-consuming to broach and solve.
Information sharing is a strategic and competitive issue as well, requiring decisions on what clinical and business data to forward to the CHIN and what to keep guarded within a healthcare corporation, said Ralph Wakerly, national practice director for CHINs with First Consulting Group in Chicago.
No time like now.Administrators and board members may yearn to put off such thorny matters, but federal reform proposals virtually assume that healthcare will be able to quickly mobilize an information-transfer network on a national scale once a bill becomes law. CHINs are envisioned as the most efficient building blocks of such a network-much like banking's automatic teller system, which first organized regionally and then connected regions.
Even if government doesn't trigger a demand for CHINs, a competitor or local coalition may take the lead. Healthcare organizations that haven't hashed out a preliminary strategy or consensus may have key decisions made for them instead of by them.
Just getting agreement from the range of factions in a healthcare community can be a big hurdle, said Mr. Drewniak. Hospitals are head-to-head competitors. Physicians have their own hopes and fears concerning computerization. Pharmacies and public-health agencies need to be considered.
There's also an insurance eligibility and processing component, and with it concerns among patient advocates that insurers and employers will be linked too directly to data bases of sensitive patient information.
One thing hospital managers can do is act as agents of development and bring together prospective participants in a CHIN, Mr. Drewniak said. "Be a consultant to them," he said: Fill in the background on how a CHIN is supposed to work and what types of information it can carry, and get some agreement on the scope of its operation. "You want a homogeneous environment sooner or later," he said. That's the stage of planning under way in the Chicago effort, coordinated by the Metropolitan Chicago Healthcare Council.
Such basic agreement is necessary before any effort can get to the design stage, consultants said. To reach the point of specific requests for proposals, regional efforts first will need to define what information will be shared by all and where the information will be stored.
These definitions will go a long way toward answering questions about confidentiality, access to data and competitive concerns of health networks jockeying for market position.
Storage sites. One question to be addressed is whether all clinical and demographic information should be kept in a common repository. Early in the talking stages of CHIN theory, a central repository was proffered as a key component. But Mr. Wakerly said it may not be necessary or even wise to have a centralized data base for some kinds of information.
The organization of healthcare into accountable health plans means that most patients will get most of their care within the realm of the plan to which they belong. The network for that plan must be set up efficiently to transfer and store patient data.
Mr. Wakerly said it makes sense for each network to establish its own data repository as the engine that drives its efforts to deliver care cost-effectively, making maximum use of computerized patient records.
But as a regional network develops to tie together the competing plans, it can be configured to tap into individual data bases under certain instances pre-established by the CHIN's decisionmakers, he said. Using a directory of patient identification numbers installed as part of the CHIN's software, clinical and administrative data can be requested and pulled from the multiple repositories.
That way, an emergency physician can still punch up pertinent patient data from another network by communicating over the CHIN to a competitor's data repository. "The (regional) network is what's shared, but the record isn't," Mr. Wakerly said.
Think of it as putting in a request for items stocked at a distribution facility and having someone at the facility fill an authorized order. Sharing a common repository, on the other hand, could be akin to giving the item-seeker the run of the warehouse.
Well-run and item-rich "warehouses" of data are a competitive advantage for both hospitals and physicians, Mr. Wakerly said.
Physicians want to have good access to patient records but don't want to share patients with competing physicians. Keeping that information within the confines of the corporation can relieve some of the doctors' anxiety about connecting electronically to a network, Mr. Wakerly said. It also can ease resistance stemming from patient-confidentiality concerns.
But it makes sense to keep other kinds of information freely available on the regional network, he said. Eligibility and insurance information are examples of data that help cut down on duplication and provide no competitive advantage.
The software and cabling links between payers and providers also are components to be shared instead of duplicated. "A lot of the connectivity and infrastructure could be invested many times over by hospitals," Mr. Wakerly said.
The Milwaukee-based Wisconsin Health Information Network, formed in 1992 and generally regarded as one of the more well-developed CHINs, is emphasizing connections and information-sharing among participants, but it doesn't have a data repository.
Leaders of the communitywide effort in the Chicago area are holding off on consideration of a data repository, preferring to emphasize connections and not "get bogged down" by questions that would have to be answered in any quest for a centralized data base, said Karen Hackett, vice president of the Metropolitan Chicago Healthcare Council.
Private vs. regional links.Connections among healthcare facilities are another bundle of strategic considerations. In some cases, hospitals may want to forge a direct link to remote locations. In other cases, it may be better to wait for the CHIN to develop. Mr. Wakerly described three scenarios calling for different decisions:
A physician's office is in the building next to the hospital that contains the health plan's computer nerve center. Generally, a physician practicing in the hospital's office building is loyal and valuable, and a direct link is probably worth the expense. Factors to consider include the physician's practice volume, how tightly coupled the practice is to the health plan, and the cost of the connection and ongoing computer support.
A physician in a practice several blocks from the hospital splits admissions 50/50 with another health network, doesn't do a lot of volume and may be compelled in the future to choose one network or another. The payback may not be worth the communications link, which includes a personal computer, software, and the cost of sending crews to hook up and maintain the connection. "That doctor should be supported by a community network," Mr. Wakerly said.
A community hospital has a small information-systems staff and a limited budget but has a physician referral network of 100 offices. Direct connections would be cost-prohibitive, but getting a CHIN established could result in communication with all the offices at a cost shared by all participants in the regional network.
CHIN obstacles.Getting that CHIN established may reap benefits, but getting competitors to join hands may be harder than joining computer systems. Obstacles to cooperation already have prompted at least one vendor of regional-network computerization to scale back ambitious assumptions about how to sell to a market.
Ameritech Health Connections had been trying to get prospective clients to commit to a regional effort as part of any agreement to receive Ameritech's package of computer-integration software and connections. Ameritech was seeking markets in which it eventually would hook up (and collect usage fees from) a significant majority of the providers and other interests that would comprise a regional information-transfer network.
But now Ameritech is bending to the proprietary and even exclusionary interests of individual hospitals or care networks in a market. The new tack concedes that cooperation with competitors may be too much to ask of prospective clients at this stage of the healthcare-reform scramble. In insisting on regional cooperation, the company was "predetermining what the customers needed in every instance," said John Slotterback, the Ameritech unit's president.
Mr. Slotterback said competition will yield a shakeout as institutions close and healthcare markets shrink to a scale that parallels demand for services. "In time, there will be a network for the winner," he said. "When the time is right, everyone can be hooked up to the network."
The Milwaukee regional network, which Ameritech helped establish in partnership with the four-hospital Aurora Health Care system (May 4, 1992, p. 30), is "a wonderful example of what could happen, but it's more an exception than the rule," Mr. Slotterback said.
The Wisconsin network currently has five hospitals and more than 600 physicians connected and participating. By the end of the summer, it expects to add another four hospitals, a home healthcare agency, four billing services and Wisconsin's Medicare fiscal intermediary, said Frank Hoban, the network's general manager. Connecting the intermediary will make information available to participants on Medicare claims status and eligibility for benefits, Mr. Hoban said.
So far, the expense involved in establishing the network has been "less than $10 million," Mr. Hoban said. He wouldn't get more specific.
A stake in networks.
Notwithstanding the Chicago initiative, CHINs are more likely to get off the ground when a local integrated network "puts a stake in the ground" and brings the CHIN to town, said Dennis Gallitano, chairman of the healthcare information systems and technology department of Coffield, Ungaretti & Harris, a Chicago law firm.
Vendors are trying to make inroads in major markets, he said, but "the buyers are dictating the time, tempo and pace of these formations."
However, much of what it takes to run a CHIN-linkage to physician offices and other network points, and coordinated transfer of data among the points-is the same for running an integrated, multiple-site health plan on a smaller scale, Mr. Gallitano said. That means hospitals and their healthcare partners can bring the technology to town for their own purposes while getting into position for CHIN construction down the line.
Integrated health plans that invest in such technology can introduce physicians to the benefits of two-way connections, help them provide better care and reduce resistance to sharing data in wider circles later on.
One vendor of CHIN technology, Integrated Medical Systems, based in Golden, Colo., concentrated initially on putting physicians on a two-way link with hospitals to which they refer patients.
The networks will have to expand and diversify in the future, but providing this first step "gets outlying offices into data exchange in a very non-threatening way," said Walt Zerrenner, senior vice president and chief information officer at Methodist Hospital of Indiana, Indianapolis.
Methodist is developing a regional network in partnership with IMS (Oct. 11, 1993, p. 44). So far, it has 250 physicians on the network receiving information such as laboratory and radiology results, electrocardiograms, patient demographics and transcriptions for correction and electronic signature.
Forging such links also could put the investing hospital in the driver's seat when deciding on the scope of the regional network. Hospitals that have done their brainstorming and consensus-building beforehand will be equipped to pursue their interests when the CHIN's chief sponsors start laying out a blueprint.
