The recent faltering of a regional health information organization in Portland, Ore., and the outright folding of a RHIO in Scranton, Pa., may be indicative of a scaling back of some of the more ambitious goals of the RHIO movement, according to industry observers.
Are RHIOs like those proposed in Oregon and Pennsylvania between competing entities and multiple information technology systems dead?
"I'm definitely in the category of I don't know," said David Lansky, senior director of the health program at the Markle Foundation, who admits not having spent a lot of time tracking individual regional activities, but works primarily "one level up" on how regional networks communicate with each other. Markle was a participant in one of three consortia to present a prototype to HHS of a national health information network. The Markle collaborators moved electronic messages between RHIOs in Boston, Indianapolis and Mendocino County, Calif.
"It's not yet clear if the incentives exist for healthcare organizations to share information," he said. "So, I think it's become time to have more discussions about getting the incentives right. How? That's a deep question. Ultimately, it will be how we pay for healthcare."
One problem with RHIOs as they often are proposed is that they provide the bulk of their benefits to patients and health plans, people and entities that according to our current healthcare payment structure either don't pay at all for RHIO startup and operational costs or pay a disproportionately small share. For many areas, healthcare information exchanges need to address the limited business cases of the providers who will build and maintain these systems, according to John Regula, who served as chairman of the now-defunct Northeastern Pennsylvania Regional Health Information Organization, or NEPA RHIO.
"It does not make sense for a RHIO to have a consumer-centric model," said Regula, the chief information officer of Allied Services, Scranton, Pa., a not-for-profit provider of rehabilitation medicine, senior-care, home healthcare and vocational and residential services. "It's a noble idea to say put the patient first, but what you have to have are business plans within the provider community," he said. "Technology will be funded by two (entities), the federal government and the providers themselves that have a need for that."
Andy Davidson is president and chief executive officer of the Oregon Association of Hospitals and Health Systems. Davidson worked on the Portland RHIO, an effort backed by the business community to develop a Web-based portal and a record-locator service that would provide a clinical messaging service connecting hospitals and physicians in the 1.6 million-population Portland metro area. A board overseeing the project voted in May not to go forward with a $17 million, five-year funding plan. Asked whether he thought the RHIO was stalled or dead, Davidson said, "The honest answer is, I really don't know."
"Part of it is you have to step back and see what's going on nationally," Davidson said. "I've worked on other (RHIO) efforts in Seattle, Cleveland and Long Beach. The common theme in Seattle, Cleveland and Long Beach is that none of them got off the ground." But all of them faced different barriers, Davidson said. One key challenge is system usability at the provider level.
"If you build a system you've got to ensure it's valuable enough that physicians are going to use it," he said. "You've got health systems and hospitals investing huge amounts of money in their own IT systems, and they're not necessarily seeing a return on investment in those systems."
Another common stumbling block to RHIOs is an unwillingness of likely participants to collaborate because of provider and payer rivalry and mistrust, Davidson said.
"That's crushed so many others, but that was not an issue here," he said. "What was different about this city, not once did I hear the argument that people didn't want to share their data."
On the other hand, what was seemingly a strength in Portland, that "all of the systems are down the (IT) path, some further than others" created its own concerns. Some Portland RHIO members worried that the proposed architecture, which was to rely on a Web-accessible interface between the disparate systems, would produce a cumbersome tool physicians would be unwilling to use.
"If that's your design, and that's clearly the cheapest way to do it, from a physician workflow perspective, you've got to integrate this into my record, and even if it's a tab on my (electronic medical-record system), you still have to go to another spot and that's pretty much universally held as a problem," Davidson said. "Until there is a mandate that people have to use a common data format and common data standards, people will continue to look to add-on technology for the purpose of sharing information."
So the problem is not so much one of whether to connect, but how well, as well as "ensuring that existing (IT) investments are fully leveraged before you look to the next thing," Davidson said.
Regula said that NEPA RHIO involved "eight hospitals, a handful of docs and probably 75 or so active members of the communities." The group formally incorporated as a not-for-profit, selected and seated a board of directors and six months into the project, on June 6, the board met and voted the corporation out of existence.
Board members, Regula said, "realized that governance structure was wrong for what we wanted to do. Our biggest enemy was the fact that we did incorporate and we had all the paperwork issues to get a corporation running that it got in the way of our ability to collaborate."
"The corporation tried to initiate the model in reverse," Regula said in a written post-mortem. "That is, building an external model and imposing it on each entity. This model fails for two reasons. First, each entity is already managing an incredible list of internal priorities. Second, each entity currently operates at a different level of technological readiness. Through collaboration, without the restraints of a formal structure, our RHIO initiative is free to build partnerships through pilot projects among ready and interested entities without an impractical one-size-fits-all solution."
As such, Regula sees the Northeastern Pennsylvania effort as a success, not a failure.
"I think the biggest thing that NEPA RHIO did was open up communication between some of the providers where before there were barriers. The model that we walked away from NEPA RHIO (with) was that the people will find commonality where a business plan or a business need exists."
Janet Marchibroda is the CEO of the eHealth Initiative, a not-for-profit collaboration based in Washington, which is putting the final touches on its fourth annual report on the status of state and regional health information exchanges, due to be released next month.
According to last year's report, Marchibroda said, about 25 exchanges were operational and were actually swapping data among the 165 or so that existed in all states of development. "I think there are probably that many again this year," Marchibroda said. "We're seeing a handful of these initiatives closing their operations, but it's not an overwhelming number." In addition, she said, "About 20 new initiatives hit the radar screen."
"Nobody says this was easy, but I don't see an alternative," she said. "There is no quick fix here. I think we're learning as we go. Whatever we call them, we need regional efforts to improve our healthcare system. Absent national healthcare reform, we're going to need to move this locally one community at a time."
Joe Panther, executive vice president of Browsersoft, a Shawnee Mission, Kan.-based vendor of services supporting an open-source software product for local and regional health information exchanges, agrees with Regula that would-be RHIO developers need to think small and customize the approach and hit singles, not go for home runs, to start.
"They are sustainable, but you have to have a couple of wins," he said. "You need to start showing there is real, actual tangible benefit to exchanging information, then you have something to go with. Quit trying to build the A-bomb. This is a ground-up effort."
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