Regional health information organizations (RHIOs) have cemented their place in the rush to health information technology, but it's not clear how to make them successful. Although a good number of them have been formed, most of them have struggled for traction.

A recent study by market watcher Forrester Research, for example, counted hundreds of RHIOs in the talking stage, but only seven that could be called operational.

Reports by First Consulting Group were harsher. Its surveys concluded that only two RHIOs " HealthBridge, serving the Greater Cincinnati area in Ohio, Kentucky and Indiana, and the Indiana Health Information Exchange " were self-sustaining or close to it. The rest are dependent on grant money.

Yet Dr. David Brailer, the outgoing national coordinator for health IT at the Department of Health and Human Services, has called RHIOs an essential element in the formation of a National Health Information Network. At the annual Healthcare Information and Management Systems Society conference earlier this year, he said statewide RHIOs could be necessary umbrella organizations for local data exchange networks and gateways to NHIN.

At the same time, he seemed to acknowledge the current state of uncertainty about RHIOs when he said his office intended to fund an assessment of the organizations, including a gap analysis of their current status and develop a set of best-practice guidelines.

So just what does it take to ensure a RHIO's success? It's probably still too early for definitive answers, but there's been enough time for experts to form some robust opinions.

Take small steps, push for early success
Thinking big was the first mistake the founders of the Santa Barbara County Care Data Exchange (SBCCDE) made, said Sam Karp, chief program officer at the California Healthcare Foundation (CHCF), one of the principal investors in the exchange.

Its founders opted to try to pull everything together at once, which meant having to wrestle with a wide range of technology, funding and governance issues. It was overwhelming.

Although the SBCCDE is finally set to open its doors this summer, Karp said he believes the eight-year effort would have been a lot easier if it had started with smaller ambitions.

"If we had begun it incrementally, then we would have been able to move things along much faster," Karp said. "If any major error was made it was in trying to accomplish too much at once."

It's a matter of building momentum and a culture of success, said Robert Steffel, executive director of Greater Cincinnati HealthBridge. Establishing a RHIO means persuading organizations that are otherwise fierce competitors in the health care field to collaborate with one another.

If you can't show these competitors early on that a RHIO will provide returns such as lower costs or higher efficiencies, then it's unlikely to progress, he said.

"The [community health information network] efforts of the late 1980s and early 1990s mostly failed because they had bad business models and high expenses," Steffel said. "One of the costliest issues was insisting that they first pull together single databases covering the whole of a community."

The lesson learned from that was to set limits early for what RHIOs could do and aim for early and relatively limited successes, he said.

Health care is generally a conservative activity, and providers have concerns about moving from the known and safe way of doing things, said Jan Root, assistant executive director of the Utah Health Information Network (UHIN). So you have to start with a simple, direct message.

With the pressure to reduce sky-high health care costs, focusing on something that will quickly have an impact is best, she said.

"Pick something teeny that people can see an immediate value in," she said. "It needs to be something that people will buy and use, something that they will pay money for but that also provides a demonstrable value."

Get physicians on board early
Ed Ewen, director of clinical informatics at Christiana Care Health System and a member of the Delaware Health Information Network's technology committee, said he believes one of the big problems most RHIOs have is the lack of early physician participation.

Most RHIOs are dominated by large hospitals, he told the audience at a recent health care connectivity conference in Portland, Ore. That's natural enough, he said, because they have the resources to devote to the task of forming RHIOs, but it also means that few other voices are heard.

That's a pity because physicians bring a vital perspective to the table that's at the core of a RHIO's mission, he said.

"In many ways, they already have information-sharing networks set up with their patients through their human-to-human interface," he said. "If they could be made to work together electronically, some kind of RHIO would automatically be put in place."

However, he said, by the time physicians are invited in, the RHIO's electronic interfaces have often already been defined. So, particularly for the early physician adopters of health IT, the RHIO offers nothing more than another potential interface with the patient, so they generally don't have much interest, he said.

In addition, physicians, not IT workers, are the best people to persuade other physicians to use health IT, Steffel said. He cited the example of HealthBridge bringing a doctor from California to show an audience of physicians how he could maintain his workflow by scheduling visits and examining patient data from a computer in Cincinnati.

"Physicians in the audience were convinced when they saw [that] this doctor could do all of that from a thousand miles away when they couldn't do any of it sitting in their own offices," he said.

Get local skin in the game
The saying that the best things in life are free doesn't necessarily apply to participation in a RHIO.

The Cincinnati community funded the HealthBridge project without the need for any major government grant, Steffel said. That boosted the eventual success of the project because the people had an incentive to ensure that the project worked.

"The mind-set has to be that people feel they have enough invested in the project that they have to be involved, but not so much that they'll be risking the health of their organization if it fails," he said.

RHIO stakeholders will act in their own best interests, he said, so the reason they are involved has to be more than an expectation that the RHIO will increase the quality of care. That has to be translated into a tangible return for stakeholders, he said.

For RHIO stakeholders to be actively involved, they have to be concerned about the organization's ultimate worthiness, said Howard Burde, chairman of law firm Blank Rome's Health Law sector. And that involvement has proven sustainable only when they put some real "skin" into the project.

"That can be broader than a simple dollar investment, but ultimately there should be a monetary impact," he said. "My sense is that it's these types of arrangements that really work."

Get government involved, but carefully
Generally, whenever industry bodies of any kind get involved in projects they feel the need to keep government at extreme arm's length, but so far that's not been the case with health data exchange programs.

A common theme that's emerging from efforts to establish RHIOs is the positive influence of early involvement by government, said Mark Frisse, director of regional informatics programs at Vanderbilt University's Center for Better Health, which is a major player in e-health initiatives in Tennessee.

Even more important than the kind of seed money it can provide for these efforts, he said, government is valuable as a convener that can use its authority to