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The post-mortem on the Santa Barbara RHIO shows the technology case was placed before the business case. Will the NHIN plan follow suit?
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The health policy journal Health Affairs has an interesting set of papers written by a number of experts on the lessons learned from the Santa Barbara County Care Data Exchange, which was one of the first attempts in the nation to institute a Regional Health Information Organization in the 1990s and which shut its doors for good in December 2006.
The most interesting from my view is the one by David Brailer, the first national coordinator for health IT. He actually helped set up the SBCCDE, and says its experience was fundamental to many of the activities and projects he promoted while in his job at the HHS. He's now the chair of Health Evolution Partners in San Francisco, which he founded.
The lessons of Santa Barbara were clear as far back as 2002, he writes, well before the decision was made to shutter it, and it was those lessons and not the original assumptions behind the SBCCDE that were applied to federal policy.
Here's the "nut graph" that I think explains everything that went wrong with the SBCCDE, and which points to the approach Brailer himself took while at the HHS, and which informs most of the current leading thought about RHIOs:
The developers of the Santa Barbara Project, including myself, were obsessed with the latest technology, devices, connectivity, and many other technical variables. There was a strong interest in applying peer-to-peer Internet methodologies (for example, Napster-like information sharing) to health care information. This resulted in an overengineered, overly complicated product that had little regard for how physicians and consumers would use it. Human factors, workflow, and how information fit into the broader goals of the community were not considered. In other words, this was a typical 1990s health IT project. The gap in the Santa Barbara Project between the technical imperative and users' needs was never closed. It was a similar "undue technology focus" that drove much of the national health IT policy, Brailer said, and it was only an extraordinary effort that convinced leaders in the health community to put more authority over policy into the hands of users and to keep it out of those of techies who thought they knew better.
David Holmquest, who is chief executive of the California Regional Health Information Organization (CalRHIO), takes this argument one step further, saying that the critical argument about what value RHIOs deliver was one that the SBCCDE managed to dodge, at least early in its existence. A $10 million grant from the California Health Care Foundation that funded the SBCCDE from the beginning actually promoted that thinking, he argues, and concludes:
The outcome of the Santa Barbara Project, however, suggests that other local efforts to create health information exchanges would do well to address the value question upfront, at the beginning of their work. Today, creating a sustainable business model--and particularly a model that will support the initial costs of constructing information exchange platforms and linking local providers and other entities--is one of the biggest challenges for nascent health information exchange (HIE) efforts. This GHIT article published last year gives some of the thinking of insiders' perspectives of the then clearly struggling SBCCDE. There was still some hope that it could right itself, but the Health Affairs articles show that it had probably already died some time before.
Anyway, a fascinating if rather dry read about what will be one of the early chapters in whatever book about US healthcare and its relation to IT is eventually written.
By Brian Robinson, GHIT Contributing Writer
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