The Health Alliance of Greater Cincinnati has an integration problem similar to many other multihospital-care systems:
* Its six hospitals, spread throughout the region, must speak the same language and organize around services and patients instead of remaining self-contained facilities.
* Its 170-physician group practice, operating at 40 locations in southwest Ohio and northern Kentucky, needs access to information from the hospitals and communication among the practitioners.
* Its relationships with physicians include managing some who are salaried and some who remain independent, some who are high-volume admitters to the system's hospitals and others merely occasional admitters.
To solve these information challenges, Health Alliance has devised an inside/outside strategy, says William Finney, senior vice president and chief information officer. On the inside, the healthcare organization is in the fourth year of a campaign to standardize hospital information systems involving general business and clinical operations, delivered through a private network. On the outside, Health Alliance is relying on HealthBridge's regional intranet to connect physicians, reference laboratories, managed-care organizations and other healthcare organizations interacting with it.
For starters, the deployment of HealthBridge saved the cost of creating a remote network for physicians. Estimates for operating a high-speed private network for high-volume admitting physicians hovered around $180,000 per year, while a separate modem-access arrangement for low-volume admitters would have cost the health system about $45,000 annually.
In addition to conserving costs, the common network constitutes the single access point to any participating health system, greatly simplifying the connection equation for doctors and their staffs, says Robert Steffel, HealthBridge's executive director.
It wouldn't be quite as important to create a regional organization if most physicians operated solely within one healthcare system, Steffel says. But in the Cincinnati area there is "profound movement of physicians across systems."
The HealthBridge option, Finney says, allows doctors to use one Internet-connected computer like they would a television set. A TV viewer doesn't have to go to separate TVs for each channel, yet that's what the equivalent would be for doctors practicing at multiple hospitals if they had to access each institution through a separate network, he says.
"Now, with a simple browser, they can have access to the information of the entire community. And they like that," says Raymond Pierangeli, senior vice president and CIO of Mercy Health Partners, Cincinnati. HealthBridge had more than 3,500 registered users at the end of February, including about 600 residents and 440 attending physicians.
A recent study of the business case for HealthBridge compares the cost of setting up seven separate networks to reach independent physicians against the cost of reaching those same physicians with a collaborative network. The conclusion: a single network could cover the same ground for $2.2 million vs. a combined $5.5 million for the discrete networks, for a savings of $3.2 million in initial installation costs. Much of the cost savings is reaped by avoiding the duplication of network connections in physician offices.
Forging common ground
Over three years, HealthBridge has engineered access for registered users to one hospital information system after another. Remote access to laboratory, radiology and transcription reports is now available from Health Alliance, Mercy Health Partners and TriHealth, a two-hospital system in Cincinnati, along with Children's Hospital Medical Center in Cincinnati and St. Elizabeth Medical Center, a three-hospital system in northern Kentucky.
The regional service provider also has forged connections to two major managed-care organizations, Anthem and Choice Care/Humana, and to Envoy, a major claims clearinghouse for commercial insurance and managed-care companies. Also, the Envoy connection delivers eligibility and benefits information on Medicaid enrollees in Indiana, Kentucky and Ohio.
The network backbone to interconnect providers and managed-care plans was intended to extend the utilization of existing clinical and administrative applications of the sponsoring organizations, Steffel says. The $1.3 million cost of the internetworking project does not include the expense to participating organizations of installing their own telecommunications and networking equipment to use HealthBridge, he says.
But those expenses would have been incurred anyway, paying for less cost-effective methods of bringing together the facilities and practices of a diverse and geographically dispersed healthcare system, says Rick Moore, CIO of TriHealth. "We don't undervalue the need even within our own organizations to integrate," he says. "I can use HealthBridge to address my own enterprise needs."
A regional intranet increases access to desirable information whether or not a clinician is connected to a private network, Steffel says. At Health Alliance, for example, a physician employed by the organization can use the private network during the day but still have access through HealthBridge at night, he says. Physician usage peaks from 4: 30 p.m. to 1 a.m., and the prevailing daytime use is by nurses, he adds.
The next level
The impressive roster of accessible information systems brought proponents of the intranet much closer to their goal of making information regionally available. But clinicians and others still had to use multiple passwords to sign in and out of systems, and each system had its own look and particular way of storing and presenting patient information, Steffel says.
The more people who signed up, the more passwords had to be managed. And as more systems were hooked up, it became complicated for clinicians to retrieve the same types of information from multiple places for one patient, he says. The success of the networking phase created a new set of problems resulting from higher expectations for information use.
Moore says the next-level goal for HealthBridge is to make it easier for clinicians to practice in the Cincinnati area without having to jump from system to system. The implementation of a regional application for sending and receiving clinical messages is "hopefully the first of many" common vehicles for presenting data from multiple sources to one clinician, he says.
The clinical messaging system, called Elysium, presents a unified list of lab, radiology, transcription and patient demographic information to a physician regardless of the source of each bit of information. That cuts through the problem of multiple system interfaces.
Results are dispatched to physicians of record through Elysium without the doctors first requesting them, which reduces turnaround time for key information affecting patient treatment. It also avoids the necessity of building a master patient index for information searches, because data on patients are automatically routed to authorized destinations, Steffel says.
Once the messaging system and other existing intranet-based applications are implemented broadly, HealthBridge executives say the cost avoidance and economy of scale will accelerate. A recently completed study by V4 Consulting, an Indianapolis-based healthcare consulting firm, concludes that if physician offices receive routine reports and physician referral information through Elysium instead of paper and telephone methods, each office can save more than $200 per day per physician in staff time (See chart, p. 32).
Other systems in place to check insurance eligibility, request a referral and appeal a claim denial can save another $130 per day, according to the study. The combined annual savings is projected at $85,000 per physician per year.
The Cincinnati area had some things going for it in getting to this stage of collaboration, Finney says. "HealthBridge came about because it was a good idea at the right time among the group of people that had the right chemistry to resolve it," he says.
Other factors gave Cincinnati a fighting chance: The marketplace was the right size, and the three principal health systems represent 80% of the market. "You couldn't accomplish this in Chicago," he says.
In addition, HealthBridge was providing a new level of service that was not well developed at any of the participating organizations, so it wasn't facing the financial and political challenges of replacing or superseding information systems in which investments and choices already were made, he says. "It had a narrow enough focus with a tangible (enough) return that it became doable in people's minds."
Outside the provider ranks, Pierangeli says, "There were some expectations in the community that helped bring us together." For example, Steffel says, an active business coalition drove home to healthcare executives "that to the extent collaboration can reduce costs, it makes sense to go ahead and do it."
But just as significantly, some key participation from medical leaders in the formative stages of HealthBridge helped give it a boost, Steffel says. "Physicians are the sustaining force to make it work," he says, emphasizing that care of patients is the ultimate concern and the ultimate sell. "If you can put something in their hands that helps them do that, they will support it."
One prominent physician, Alfonso Barnes, M.D., took an early interest in the concept and eventually became chairman of the HealthBridge board of trustees. His prognosis is glowing: "Healthcare in the area of Cincinnati will never be the same once all the promises of HealthBridge are fulfilled."
But it took some of Barnes' patient focus to get participants past some early differences of opinion about issues such as organization and control, Steffel remembers.
Barnes, a gynecologic oncologist, told a story about a 23-year-old woman referred to him who came to the office distraught and looking to him for a clearer idea of her medical situation and what could be done about it. But as he sat down with her, he couldn't give her any counsel because he had no clinical information to go on -- none was provided beforehand by the referring physician. And Barnes didn't even have enough insurance information to make a decision on scheduling her next appointment.
All he could do was leave two phone messages on answering machines and send her home with her grief. That's what he wanted to avoid having to do ever again.
"That helped us refocus and get everyone on the exact same page," Steffel says. It led to a list of guiding principles that all sponsors agreed to refer to when impasses arise. And Barnes' experience with that woman still serves as the anecdotal explanation for what the initiative is all about.
"It was very powerful," Steffel says. "We share that story with everyone who comes into the HealthBridge family."