While regional health information organizations, or RHIOs, are still uncommon-numbering only about 100 nationwide according to a recent survey of the realm-their growth has been rapid and is accelerating. What is far more rare than a RHIO, however, is a RHIO with financial stability.
Most of the RHIOs in various stages of development have yet to find a business model that weans them from the public and private grants most used to fund their startup and initial operating costs, according to the not-for-profit eHealth Initiative Foundation in its second annual survey report. Thus, the long-term survival of RHIOs remains in doubt.
There are exceptions, however.
In Indianapolis, the Indiana Health Information Exchange, or IHIE, which celebrated its first birthday earlier this year, has parlayed decades of pioneering work in healthcare IT by the venerable Regenstrief Institute at the Indiana University School of Medicine to launch what may become a fiscally sound RHIO connecting about two dozen hospitals and nearly 3,000 physicians in only its second year of existence.
Meanwhile, about 35 miles southwest of Indianapolis, in Shelbyville, Ind., 58-bed Major Hospital solved one technical problem inherent with hospital-physician communication by joining county and city government in buying two local Internet service providers and stringing its own fiber-optic network around the city of about 18,000 people (See story, p. 30).
In the Pacific Northwest, 226-bed St. Joseph Hospital, a PeaceHealth system facility in Bellingham, Wash., has led the extension of a successful healthcare IT system across Whatcom County, an area twice the size of Rhode Island that hugs the Canadian border (See story, p. 29).
"Yes, these are really going to happen," says physician informaticist J. Marc Overhage, chief executive officer of the Indianapolis network as well as a Regenstrief researcher and practicing internist. "This is the way we're going to take the next leap forward. Our health system is so incredibly fragmented and yet the information we need to take care of patients, we need all of it."
The Indianapolis organization was incorporated in February 2004 and has expanded to include 21 hospitals in five hospital systems while bringing online about 100 central Indiana physicians per week, Overhage says. Expenses for 2005 will be about $2 million, Overhage predicts, and if the IHIE lands a few more paying contracts with labs and other providers, it will finish the year in the black, he says. Regenstrief was founded in 1969 and began deploying an early electronic medical-records system in 1972 at Wishard Memorial Hospital, Indianapolis, so, "in reality, we're building on 30 years of work from the Regenstrief Institute," Overhage says.
"Good things are hard to birth," says Regenstrief Director Clement McDonald, a physician who has been with the institute since 1972. McDonald traces the IHIE's roots to a data-sharing agreement between Wishard and just one other Indianapolis hospital, Community East, in 1994. "Then we went to all the hospitals and said, `Let's do this on a fuller scale. I thought they'd throw me out because it wasn't good for their business," McDonald says.
But strategic barriers were not an issue. "Instead, the CEOs of three other major Indianapolis systems embraced the idea," McDonald says. The effort grew into the Indianapolis Network for Patient Care, or INPC, a project to provide basic patient data to all hospital emergency rooms in the city.
That gave rise to the IHIE, whose five founding Indianapolis-based healthcare systems are Clarian Health Partners, Community Health Network, St. Francis Hospital and Health System, St. Vincent Health and Wishard Health Services. Also joining the IHIE are ICareConnect, a physician-led IT effort, and BioCrossroads, a public-private partnership that includes the consolidated city-county government of Indianapolis and Marion County; Indiana and Purdue universities; and a number of corporations-including Indianapolis-based pharmaceutical giant Eli Lilly & Co.-to promote academic and industry collaboration in the life sciences.
The hospitals have signed four-year contracts to share patient information with each other through a communications network that also makes the data accessible to researchers as well as physicians and other providers. The information includes lab and pathology results, radiology and electrocardiogram reports, and transcriptions. The network also has access to prescription drug data from local pharmacies and RxHub, the data network developed by a national coalition of three large pharmacy-benefit-management companies.
So far, payers have kept their distance from the Indianapolis RHIO, but McDonald says that eliminates a problem of potential conflicts of interest regarding the use and sharing of the data that led to the failure of the community health-information network movement of the mid-'90s.
"The CHINs said, `Give us all your data and then we'll hit you over the head with it, " McDonald says. "We promised that the hospitals and the physicians won't get hurt with it."
Overhage says local control is one reason regional networks have a better chance at success compared with a national framework. "The trust relationships in order to share this information have to be built at the local level," Overhage says. "It's going to be a long time before some country doctor is going to allow his records to be taken care of in New York or the patients are going to allow that to happen."
An independent board of directors runs the IHIE, whose 15 members include the hospital systems' leaders as well as the dean of the IU School of Medicine, the state health commission and the mayor of Indianapolis.
Data from the hospitals are transmitted to central databases for each participant. The databases are controlled by the INPC, the Regenstrief project, but are accessible by the IHIE. Regenstrief, under contract with the IHIE, provides its proprietary Docs4Docs messaging interface that delivers the clinical reports in a common format to the providers using the IHIE system. Regenstrief also translates the input from the different IT systems into a common terminology, a task far harder than distributing the outputs to the physicians and hospitals, McDonald says.
Physicians and participating central Indiana hospitals can access their patients' clinical reports from any of the hospitals where the physicians have privileges. The doctors also may see the data at home through an Internet portal. Physicians who receive the clinical information don't pay for the service. Hospitals and other healthcare providers, such as specialists, who want to use the network to send clinical messages-for example, radiology reports or clinical consults-will be charged a fee per record sent.
"The approach that we've taken is a very simple one, that is, find the first service that someone is willing to write a check for and do it as best as we can," Overhage says. "Hospitals spend 81 cents on every result they send to the doctor's office. We do it for 25 cents, so it's a no-brainer to support that."
"It's a very simple business model," he says. "The return on investment is almost immediate, in just a couple of months. And the physician office, all they have to do is have a PC to get this information. It gives us a foothold to build on. It's very incremental."
Edward Koschka Jr., chief information officer for the five-hospital Community Health Network and a former director of ICareConnect, says his hospitals have not cut medical records staff as a result of their participation in the shared data exchange, but there have been other savings. He serves on a CIO advisory panel for the IHIE that meets once a month to provide guidance to the organization and its board.
"When we started, we were printing 3,700 pages a day and (sending) that out to the physicians' offices. We've reduced that to 1,000 pages a day. We'll be able to reduce our courier costs per physician, but I can't give you a number yet."
Internally, Koschka says, the hospital spends about $3.50 per chart pull. It bills its employed physicians less than $2 per record accessed electronically, Koschka says. Billing its own physicians for access to records is a cost-allocation practice Community started in 2000 before it joined the IHIE, he says. Most independent, office-based physicians aren't charged for the electronic clinical-messaging service, Koschka says, but that's not a new financial burden for the hospital.
"We were paying the load before, so what we're doing is moving from five different systems to one," he says. "We saved a little money and made life better for the physicians. I can't guarantee you that we're going to save a lot of money, but you move to technology if you know there's going to be some. The CEOs took a leap of faith."
McDonald's advice to RHIO planners across the country is to use a centralized data repository, at least until the government gets further along overseeing the development of interoperability standards and "start with messaging."
McDonald foresees RHIOs as a likely provider of EMRs to physician offices, where high prices remain a barrier to widespread use. "The cheapest way to give physician offices an EMR is to have one system in the center of the city. I think hospitals are going to be very strongly at the center of it."
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Regenstrief Institute, Indianapolis
Indiana Health Information Exchange
Service area: Indianapolis; nine central Indiana counties
Population in service area: 1.7 million
Physicians: Approximately 3,000
IT vendors: Regenstrief Institute/multiple hospital IT systems