A Cleveland-area community health information network has been open for business for months, but it hasn't attracted a single subscriber or forged the links to insurance companies that could make it worth the price of admission.
Instead, representatives of the business community, key hospitals and the local medical society are questioning the Greater Cleveland Hospital Association's decision to negotiate the boundaries of the CHIN deal with a vendor first and then try to sell it to the four primary constituencies. Those are hospitals, physicians, healthcare purchasers and consumers.
In December 1994, the hospital association announced it had reached agreement with Ameritech Corp. to invest in and own the infrastructure involved in a network to be called theInformation systems
Regional Health Information Network of Northern Ohio, or RHINNO (Jan. 2, p. 16).
By avoiding the time and complexity of formal bidding for the CHIN project, association representatives said at the time that they'd be able to get the initiative off the ground more quickly.
But although two dozen hospitals submitted expressions of interest in response to an association mailing, none has signed up yet, said Philip Mazanec, the association's senior vice president.
Prominent provider organizations such as Cleveland Clinic and University Hospitals of Cleveland are withholding their participation.
"The whole thing seems to be in a stall right now," said Rand Lennox, chief information officer of University Hospitals. "We have a need to have a lot of payers on the network for it to be of value to us. The value has not been created yet."
Ameritech originally came in with a fee structure based on flat rates by size of an organization. But that meant the first subscribers would be paying up front for a network that had no traffic, he said. The fees have been restructured around per-transaction charges, he added.
But the problem goes deeper than price, said John Clough, M.D., director of health affairs for Cleveland Clinic.
"One of the mistakes that was made was sort of springing this without much support from the stakeholders in the community," said Clough.
In the wake of the agreement with Ameritech, businesses represented by the Health Action Council of Northeast Ohio "felt left out and were pretty upset about it." The same reaction came from the Cleveland Academy of Medicine, he said.
The situation "created some political problems that wouldn't have had to occur. I think it's a tactical mistake," Clough said. "To the hospital association's credit, they are really trying to patch this up and bring these people in."
A CHIN initiative in Chicago took a year to decide on a vendor coalition and a plan of action, but it spent much of that time lining up consensus among various interest groups before selecting the vendor in November 1994. It also put payers on the governing board as well as on the ground floor of the project.
A strong preference for broad-based planning and ownership of a CHIN was voiced by respondents to MODERN HEALTHCARE's 1995 survey of healthcare information systems trends (Feb. 13, p. 74). More than half the respondents said the CHIN should be owned by a consortium of hospitals, physicians, payers and business interests, compared with 6% who thought a vendor should own it.
Greater Cleveland Hospital Association representatives said they acted after conducting discussions with a range of medical and community interests. "We still feel we have the buy-in" from those interests, said Mazanec.
A community-based governing structure was conceived as part of the agreement with Ameritech. But the governing board was to be formed by subscribers to the CHIN, on the presumption that there was enough interest to quickly build a subscriber membership, he said.
By April, the Health Action Council had come out against the RHINNO because of a feeling that the business community wasn't going to be represented, said Patrick Casey, the group's executive director.
A written statement criticized the hospital association's "relationship with a specific vendor to create a proprietary venture," and it concluded that a vendor-owned, for-profit structure wasn't the best approach to serve "the complex and divergent needs of purchasers, physicians and consumers of care in northeast Ohio."
Meanwhile, the physician group is expressing similar concerns about how community oriented the CHIN would be. Russell W. Hardy Jr., M.D., president-elect of the Academy of Medicine, said that regardless of whether the CHIN is owned or just governed by local interests, physicians "want to be sure there's significant community involvement."
Both Lennox and Clough said they didn't have any qualms about Ameritech's technology and the CHIN's capabilities, and the business and physician reps said they're solidly behind the idea and its potential to do their constituencies a lot of good.
Indeed, the final terms of the CHIN initiative might have ended up the same way if all options were talked out beforehand, but everyone would be on board by now, said Clough. "The big lesson from this is it's better if you get all the stakeholders involved up front," he said.
Hospital association representatives said a previous consensus-building effort between hospitals and the Health Action Council should have smoothed the way for quick resolution of the CHIN concerns about competition and cooperation. The Cleveland Health Quality Choice project involved getting about 30 providers to submit price and quality data for businesses to do comparison shopping.
But Clough said the success of that project wasn't because of amity among competing healthcare interests but because hospitals had to participate or risk losing business. "It's not a great example of diminished competition among hospitals. There's still fierce competition."
With Blue Cross and Blue Shield of Northern Ohio, the area's dominant payer, moving into the provider business, and other hospitals getting into the insurance business, the idea of sharing payer and provider information may be an obstacle in itself to acceptance of the CHIN, Lennox said.
"In general, people aren't standing in line to make their competitors more efficient," he said. "In retrospect, (the hospital association) might have been better off trying to understand the market better."
All the factors-competition, community involvement and value-are influencing decisions even at places where the CHIN could contribute to immediate needs to integrate facilities, Clough said. At the Cleveland Clinic, the subscriber contract is "on the desk with the pen poised above it, and I imagine the same is true at a lot of other places."