One vendor at the core

Healthcare leaders in more than 100 communities across the U.S. are exploring ways to share patient information through regional health information organizations.

Getting all the players, many of whom are business rivals, to take information technology out of the competition is a big problem for some RHIO organizers. So is developing a business model, for those willing to cooperate.

Apart from that, the technical hurdles of data interchange in an era in which implementation guidelines for a plethora of healthcare data transmission standards are still being developed remain formidable.

One way providers in several communities have tried to achieve interoperability is by agreeing on using one main healthcare information technology system to serve their needs, creating what might be called vendor-centric RHIOs.

One of the oldest and most extensive examples of this rare breed is an exchange served by Inland Northwest Health Services, a not-for-profit corporation formed in 1994 by four Spokane, Wash., hospitals looking to collaborate. Today, INHS supplies outsourced IT to 38 hospitals and more than 1,000 office-based physicians in Idaho, Washington, and, most recently, California.

INHS uses as its "basic core" the enterprise hospital IT system from Medical Information Technology, or Meditech, Westwood, Mass. INHS also supports a physician office electronic health-record system from GE Healthcare, although the service organization will work with a multitude of other software products for its provider clients, according to Thomas Fritz, INHS' chief executive officer.

INHS' first foray into IT was in billing, Fritz said, but most Spokane doctors have admitting privileges to multiple hospitals and were irked by having to use different records systems. "The doctors were helpful in making us see we could get greater value in creating a community asset and share that asset with anyone who wants to be a part of it."

At the time, only one of the hospitals was a Meditech customer, so convincing the leaders and staff at the other three founder hospitals to adopt the same system was "a hard decision to make, absolutely," Fritz said. "It really created shock waves around the community. People who work with one hospital system for a long time were really loyal to (that) one system. We had to have a lot of meetings about values and culture and moving away from one hospital's system to bring value and community and to serve patients better."

INHS client hospitals range in size from 25 beds to more than 600, all using a central data repository and servers in Spokane that dish the software using an application service provider, or ASP, model.

No panacea

Using one core IT system isn't a panacea for interoperability, Fritz said. "Anytime you're just using a single (vendor), you're going to have limitations because they don't have all the products," he said. For example, Fritz said, Meditech doesn't offer a picture archiving and communications/radiology information system, or PACS/RIS, while smaller hospitals will use fewer modules of the Meditech system than larger ones.

"No matter where you are, you're going to have multiple vendors," he said. "We're hoping with the setting of interoperability standards, you'll be able to use multiple vendors easier." But Fritz said: "There is no doubt about it, the fewer vendors the better, because that means fewer interfaces."

INHS doesn't bargain with Meditech for reduced prices on software licensing, leaving those negotiations to the individual hospitals, but Fritz said that by pooling resources and sharing expenses, the providers do save money. INHS has 225 employees working in IT and a $35 million IT budget spread across 38 hospitals.

Jay Linney, vice president of state and regional health initiatives for Kansas City, Mo.-based Cerner Corp., said the idea of a vendor-centric RHIO is "an interesting premise" and "logical and valid" on its face, but if systems were truly integrated and not merely interfaced, "the ability to fire alerts into the community would be greater. We could be much more proactive in terms of pushing knowledge out into the community."

Still, Linney said, Cerner's ability to create interfaces with a customer's existing systems is company strength. And in today's market, there are a bunch of considerations that healthcare IT system buyers wrestle with -- besides communitywide interoperability. "We've also had experiences where health systems have made opposite decisions, where there is not a strong, vested interest in sharing information across the street," and hospitals have chosen not to buy the same IT system as a key competitor, Linney said.

Cerner has "a couple of markets where it has a strong footprint," noting that in Kansas City, Jacksonville, Fla., and Seattle, it has multiple installations. But even in its hometown Kansas City, two hospitals have other vendors' IT systems.

Cerner, already a player in remote data hosting, has spent $70 million on a new data center in Kansas City, which will be used in part to host its several personal health record projects, including one set up in partnership with Blue Cross Blue Shield of Tennessee for the TennCare (Medicaid) program. Cerner also will be the IT provider for a Web-based, employer-sponsored community health record consortium in the Kansas City area called Healthe Mid-America.

So far, 21 area employers have committed to join Healthe Mid-America, providing free community health records for their 100,000 employees and dependents, according to Jim Hansen, CEO for Healthe Mid-America. Cerner is scheduled to launch a pilot of the service for its own employees Jan. 31, with rollouts to two or three other employers expected before spring.

The group estimates employer members will save $15.6 million over five years in lower healthcare costs through the system, Hansen said.

"We wouldn't be doing this if we couldn't create a budget that would be in alignment with those revenues and costs," he said.

The initial records will be created using insurance claims data, medication histories from pharmacy benefit managers, or PBMs, and immunization records from state registries, Linney said. The goal is to augment that information with data from the IT systems of local providers, including lab results, discharge summaries and other clinical information. Providers will access the records via the Web.

"What we're seeing in the Kansas City employers coming together is where we see the market will evolve," Linney said. "Employers, because of their vested interest and their funding such a large percentage of the healthcare costs, they're going to see that a system (of interoperability) is created."

Epic Systems Corp., Verona, Wis., has locked up all of the hospitals and several of the large medical groups in nearby Madison. Working with its Madison customers, Epic is developing a "programming package" to create an exchange capability for fellow Epic system users, according to Carl Dvorak, chief operating officer. "It's being done here in Madison, and we've got a couple of other (places) that are looking at it," Dvorak said.

Dvorak said he doubts vendor-centric RHIOs will dominate the healthcare IT landscape. "Most areas have a number of vendors already in place," he said, but, "we are seeing in a number of geographical areas where there are enough Epic sites together to give them a jump start to the exchange of data. We're tapping Epic-to-Epic sites in advance of national standards because it's easy for us to do that. We can maintain both ends of the connection."

The interchange will allow a provider at one Madison hospital or medical group to do a simple request for patient information stored on the IT system of another facility in the community. The first exchanges will be limited to basic information such as medication histories, allergies, immunizations and a summary of recent visits.

"Obviously, it isn't going to be the complete medical record," said Peter Strombom, vice president of information services at Meriter Health Service, Madison, a participant in the exchange pilot. Strombom notes that developing a viable business case has been a major hurdle for most RHIOs, but it won't be a problem in Madison. Because it's peer-to-peer, "we believe we don't need the infrastructure that an independent RHIO requires," he said. "The unique thing about Epic's plan is you don't need a financial plan to implement this and make it work."

Strombom said the project was launched about six weeks ago during a meeting of Madison-area healthcare IT leaders. "We hope to have a test environment up and running by Jan. 8," he said. "Having common vendors makes it easier."

But interoperability wasn't why Meriter bought Epic, Strombom said.

"We made the decision in 2002 and at that stage, interoperability was not on the drawing board," he said. And interoperability wasn't a selling point at Dean Health System, either, according to Jerry Roberts, vice president of information technology at the 500-physician multi-specialty group based in Madison and an Epic user since 2003.

Roberts, like Strombom, said the group decided on Epic based on the system's merits for internal use. Interconnectivity with other systems is only now becoming an issue, a bonus, he said.

"I actually think from a public health and public policy perspective, you want to make (vendor selection) agnostic and open," Roberts said. "You don't want to have anyone excluded." But in Madison, "you have 100% of the hospitals and 95% of the outpatients going though some form of EPIC system. It contributes to the six aims of the IOM (Institute of Medicine) faster and cheaper than if you had something more open and broader.

'Healthcare is local'

"By and large, healthcare is local," he said. In Madison, "most of the care is provided with the systems and affiliates. It really isn't a RHIO in a sense of any other RHIO because there is no central repository where it is ported for collective viewing. All it (will do) is open a window into the systems."

St. Louis-based SSM Health Care, the parent of St. Mary's Hospital Medical Center in Madison, didn't pick a vendor for its systemwide clinical IT program until about 15 months ago -- after most of the hospitals and major physician groups in Madison had chosen their IT vendor.

"There was a complex and thorough evaluation and selection process," said Frank Byrne, the 289-bed hospital's president. "But the experience of our key physician partners (at St. Mary's) was certainly one factor, which worked out well with us in Madison because our physician partners at Dean (Health System) had already selected Epic and were already on the way in implementing it."

Like Linney, Byrne said, "In traveling about the country, I still encounter the healthcare leader who sees that a proprietary EHR will give them a competitive advantage." According to Byrne, that's the wrong approach. "I feel the medical record belongs to the patient. Since we're all going to be on the Epic platform, we're looking at how we can accelerate the process and improve the care for the people we serve."

The key aims of Electronic Health Record of Rhode Island at its creation were to give physicians pricing leverage with software vendors though group purchasing, help them obtain financial support for their IT systems by negotiating subsidies from payers and medical malpractice carriers, and making the technical aspects of connectivity easier.

The company, founded in 2005, aimed to select, buy, install and operate just one EHR system for every physician in the state, according to Mark Jacobs, CEO of Providence-based Coastal Medical Inc., one of five EHRRI founding physician groups. Jacobs is chairman of the board of EHRRI, whose members also include the physicians at Lifespan Hospital group, Woman and Infants Hospital, Kent Hospital, and Thundermist Health Associates.

Between them, the five groups represent more than 1,400 Rhode Island physicians, roughly 40% of all doctors in the state providing direct patient care, according to American Medical Association figures.

The initial plan was to use the groups' size to negotiate EHR subsidies with Rhode Island payers and medical malpractice carriers, arguing that physician conversion to the new technology would benefit both payers and carriers financially.

"We were overly optimistic about that," Jacobs said. Blue Cross Blue Shield of Rhode Island, the dominant payer, has approved "some money" for infrastructure and individual physician subsidies, he said, but the other major payer, UnitedHealthcare, has not. Meanwhile, the med mal carrier for Coastal has attributed a portion of its recent 18% rate reduction for the group to its EHR installation, which Costal began in June, but Jacobs said there is no clear way to parse the EHR portion from the discount based on the group's claims experience and other med mal market factors.

EHRRI also moved forward on picking one system, the practice management and EHR suite from eClinical Works, Westborough, Mass.

"We have 90 implementations in progress, and we have another 60 to 65 pending contract," Jacobs said, although some of the physicians are going with a practice management system, not the full suite. Coastal, which is the first of the founding five groups to implement the EHR, has 85 provides working across 16 care sites. It has an interface developed with its own lab system and is working on links to two outside labs.

"All the interfaces are a big deal," he said. "They're difficult. They're slow, and you've got to get them right." But by using just one vendor's EHR, the interfaces only need to be developed once.

Also, by group purchasing, Jacobs said he thinks EHRRI can offer member physicians a better price.

"The figures nationally of what it costs per physician are in the $30,000 to $35,000 range," he said. "Ours are in the $20,000 to $25,000 range." Even with the Blues' subsidy, "the majority of the costs are still with the physician." EHRRI even has local competitor, Polaris Medical Management, a management service organization based in Cranston, R.I., that developed its own EHR and practice management suite it sells as part of an IT service to physicians in Rhode Island and Massachusetts.

Originally, Jacobs said he thought cost was the biggest barrier to physician adoption of IT, Jacobs said. "I think that's changed."

The way Jacobs sees it now, for physicians in small offices, "I don't think the value proposition is compelling enough yet." Vendors say that physicians will save money by lowering dictation and personnel costs for file storage, but not from Jacobs' own experience.

"Our office is completely electronic," he said, and yet, "I can't say that any of those things translate into benefits. Yes, you can see dictation costs go down if you use Dragon (a version of speech recognition software), but if you lose a file clerk, you add a scanning clerk. If you have a small office, you can't get rid of half an employee because people are multi-tasking already. You're asking doctors to step up without any clear return," he said.

Jacobs said he believes the EHRRI approach is replicable by other physician groups wanting to pool their resources, "but you know, you have to convince the docs" to accept change, and that, he said he's learned, is the hardest part.

"I'm 57 years old," Jacobs said. "This conversion to electronic medical records is one of the hardest things I've done since I left medical school. It's an enormous amount of work, especially during the first three or four months. It's very stressful. As one of my partners said, 'You take a difficult job and make it tougher.'

"I've been live for six months and you couldn't tear it away from me," Jacobs said. "I wouldn't go back, but it's been a tough six months and that's what EHR Rhode Island and any organization faces when it goes to the physician community and said, 'Would you like to go to an electronic medical record?'"

Like other vendors' executives interviewed for this story, Hoda Sayed-Friel, Meditech's vice president of marketing, is skeptical that vendor-centric RHIOs will be a dominant form of data exchange. "No one model of RHIO will dominate," she adds. "Everyone's definition is different. The stakeholders and the personalities across the country are all different."