Rhode Island is a state with 15 hospitals, 3,942 physicians and 1,545 square miles. You can drive across it on the diagonal-all 59 miles from Westerly to Woonsocket-in just 67 minutes.
But it is a state with giant ambitions in deploying healthcare information technology, a complex activity in which Rhode Island's tiny size gives it major advantages over its sister states, according to key players in the IT drive.
A coalition composed of many of Rhode Island's top healthcare leaders is working to connect every provider and, eventually, every patient's home in the state, to a universal healthcare information infrastructure.
These leaders, typically 20 to 25 people at each monthly meeting, have convened for more than two years as members of the Rhode Island Quality Institute, a not-for-profit organization based in Providence
that is coordinating the ambitious interconnectivity scheme.
"All the key players in the state are there," said Edward Quinlan, president of the Hospital Association of Rhode Island, and an institute member from its inception. "You have leaders from providers to employers to payers, all at the table meeting for a common cause. I think a state of our size, a million residents, one dominant payer, the ability to traverse the state in an hour, we're an ideal laboratory."
While clusters of connectivity to the degree envisioned by the Rhode Island leaders are developing elsewhere on a regional level, few, if any, have been planned from the start as a statewide enterprise and none have reached, on a percentage basis, the penetration level that Rhode Island is about to achieve with one of its efforts, e-prescribing.
Those planning regional connectivity efforts would do well to study the Rhode Island experience, if only for inspiration, but there is a lesson in methodology here, too.
Bring people together, face to face, and over time "you have people getting together on what they can do and not retreating to what they can't do," Quinlan said.
One key element of the Rhode Island effort, participants say, is a supportive state government. It is represented at institute meetings by Lt. Gov. Charles Fogarty and Health Department Director Patricia Nolan, a physician, both institute board members, and Nolan's deputy, William Waters, who oversees the state's public data-reporting program.
As a legislator, Fogarty sponsored the 1998 Rhode Island law that requires hospitals to gather and publicly disclose quality data. He has been an institute member since it was incorporated in May 2002. Healthcare, he said, is the state's largest industry, with state government spending on healthcare totaling somewhere between 30% and 40% of a $5.9 billion state budget.
Fogarty said some of the state's major healthcare players are already taking big steps into healthcare IT.
Lifespan, for example, a Providence-based four-hospital health system, has a computerized physician order-entry system fully deployed in one of its hospitals and has CPOE rollouts well under way at two others. Its affiliated physicians can access patient records via its LifeLinks Web portal; its medical informatics director, Reid Coleman, a physician, recently won a national award for excellence in applied informatics from the Association of Medical Directors of Information Systems, for leading clinicians through these and other IT projects.
On May 18, Fogarty testified before a state House committee in support of a $250,000 appropriation to pay for designing "a statewide interoperable healthcare information infrastructure." The bill also would create a state healthcare IT infrastructure advisory committee, and the institute "could actually be the vehicle to drive this forward," Fogarty said.
The bill has had a similar hearing before a Senate committee. It has not been reported out of either committee, said Susan Pegden, a Fogarty spokeswoman.
Starting with e-prescriptions
About nine months ago, taking baby steps toward the institute's broad connectivity goals, the first of what are now 245 physicians began writing electronic prescriptions-with a notable enhancement.
In most other places, e-scripts end up being converted to faxes because the computers at the receiving pharmacies can't interface with the numerous script-writing tools on the market. What makes the Rhode Island e-Rx project exceptional is that physicians' prescriptions are delivered electronically from the physician's computerized script-writing tool into the computer systems-not the fax machines-of Rhode Island pharmacies.
In collaboration with the institute, SureScripts, a joint venture of retail pharmacy organizations, created a key interface between the pharmacy computers and the physicians' script-writing tools, completing the last link in the chain of electronic prescription writing.
The quality institute and SureScripts have induced about 70% of Rhode Island pharmacies to upgrade their computers to receive the e-prescriptions through the interface, said Laura Adams, president and CEO of the institute. These early adopting pharmacies handle about 90% of retail prescriptions in the state, Adams said, but the institute is going after the rest.
In a few weeks, another 600 physicians will be joining the program, Adams said. When that happens, "We're about halfway home," she said, noting there are about 1,800 physicians actively prescribing in the state.
Adams studied under quality-improvement guru W. Edwards Deming and serves as a faculty member of the Institute for Healthcare Improvement headed by Donald Berwick, a physician and a member of the Institute of Medicine's Committee on Quality Health Care in America. Adams said she initially came to Rhode Island as a consultant to help get the institute up and running, but stayed on and is its only full-time employee.
The institute had a budget of $400,000 last year. "It's inadequate funding," she said. "I don't want to leave people with the impression you can do this with that amount of money. I'm exhausted."
The institute is applying for two grants from the Agency for Healthcare Research and Quality, which announced in April it was looking to fund statewide or regional connectivity pilot projects.
One grant request, for $200,000, will be submitted by the institute for planning future IT efforts. The second request, for $1 million annually over five years, is being submitted by the Rhode Island Department of Health in collaboration with the institute. That money will be used to create a master patient index for the entire state, Adams said. The index will be the foundation for future connectivity, she said.
Coleman, the Lifespan physician informaticist, said the conceptual model for the future Rhode Island connectivity system is a switchboard, routing access to the databases of the participants, and not the creation of one central database.
Access, Adams said, will be controlled through a "lockbox" with digital "keys" from both the patient and the provider needed to gain entry.
The Rhode Island Quality Institute is a remnant of the failed merger between the state's two largest provider networks, Lifespan and three-hospital Care New England, Providence.
'It's the right thing to do'
Lifespan CEO George Vecchione said he and Care New England CEO John Hynes sought to assure the public, and then-Attorney General Sheldon Whitehouse, who was wary, that the combination would be good for Rhode Island. Founding an institute devoted to quality would embody the commitment of the two groups to improving patient care, Vecchione said. When the merger plans were withdrawn in September 2000, Whitehouse suggested that planning for the institute continue. Whitehouse, Vecchione and Hynes remain as board members. Vecchione is board chairman; Hynes is vice president.
Vecchione said the primary motivation for Lifespan's involvement in the massive connectivity effort is that "it's the right thing to do." At this point, with no cost estimates or funding sources identified, any estimates of the system's return on investment would be as visionary are the project's goals. But there is a business case for going forward, he said.
"We have a projected shortfall in hospital beds over the next 10 to 15 years," he said. "So we either invest in bricks and mortar or redesign the delivery system and eliminate the inefficiencies and overlay it with evidence-based medicine. That's where the savings will come from."
"We don't have a firm source of funding at this point," Vecchione said. "There's going to be sizable investments needed, not only for new (IT), but also for maintenance."
Payers, including the government, are likely funding participants, he said.
Coleman said there is no solid timeline for implementing the full, statewide connectivity project, although total connectivity is probably a decade away. "There are a couple of major things we have to contend with, just mastering the technology and figuring out how to finance it," Coleman said. "The AHRQ grant requires that this effort be sustainable and I think it is. The question is, do the sometimes competing healthcare providers have the will to work together, and that answer, in Rhode Island, is yes."