RHIOs for beginners

A Regional Health Information Organization also called a Health Information Exchange Organization or RHIO, is a multistakeholder organization created to facilitate a health information exchange (HIE) – the transfer of healthcare information electronically across organizations – among stakeholders of that region’s healthcare system.

Many RHIO’s have pushed their way into healthcare systems but it is not clear how to actually make them a success.

Although many of them have formed with good intention, the struggle for traction is definitely there.

According to a recent study by market watcher Forrester Research, 100’s of RHIOs are in the talking stage, but only seven are actually operational.

In several surveys conducted by First Consulting Group, it was 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 many healthcare professionals such as 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 what exactly needs to be done to ensure the success of these RHIO’s?

It might be too early for a definitive answer, but there’s been enough time for experts to form some opinions.

Small Steps for early Success

The first and biggest mistake made by founders of the Santa Barbara County Care Data Exchange (SBCCDE) was thinking too big, 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 quickly became too overwhelming and seemingly impossible so the efforts slowed if not halted completely.

The SBCCDE will finally open its doors this summer, but 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).

In order to be successful, you have to start small and direct.

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.”

Physicians First

One of the big problems most RHIOs have is the lack of early physician participation, said Ed Ewen, director of clinical informatics at Christiana Care Health System and a member of the Delaware Health Information Network’s technology committee.

In a recent conference held in Portland, OR, he state that “most RHIOs are dominated by large hospitals.”

“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.”

He went on to say that it is a pity because physicians are a vital role and are at the core of a RHIO’s mission.

“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.

Local Support

The best things in life are free, as the saying goes, doesn’t 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.”

Government Involvement

Many industry efforts are done without the help of government, in fact whenever industry bodies of any kind get involved in projects they feel the need to keep government at extreme arm’s length.

This seems to be the opposite 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 bring people and organizations together regarding issues in which RHIOs are involved.

Not everyone is convinced that government should be involved in a RHIO’s early development. Burde said he believes that governments are probably the major force in organizing RHIOs, but he questions if that’s the way things should be.

“The way people relate to RHIOs will be different if governments are involved versus if the private sector is running things,” he said. “It’s probably best that government keep out of it, at least early on” in RHIO developments.

But governments do bring a presence and some badly needed expertise to the table, Root said. For starters, the state government in Utah is a legitimate stakeholder because it is a health care payer and provider through the Medicaid program, she said. And it can be a necessary foil on legal and other issues. “The state insurance commissioner is very involved [with UHIN] and attends every executive board meeting to ensure that we don’t participate in antitrust activities,” she said.

However, even when government gets involved to the point of paying start-up costs, the local medical community still should be taking the lead, she said.

“The community has to be involved with the pain of starting and developing RHIOs,” Root said. “Commitment comes from that.”

Hire a professional staff

As we’ve seen over and over again, simply having volunteers help with RHIO’s isn’t enough.

While yes, most RHIOs depend on volunteers at the beginning, hiring full-time paid employees as soon as possible is a key for success.

One of the lessons the SBCCDE’s developers learned was that you can’t rely on a volunteer committee to handle all of the work involved in putting a RHIO together, Karp said, not if you are serious about succeeding.

Developing a RHIO “takes a significant effort in terms of funding and the time given by clinicians, and we depended on volunteers for a long time at the SBCCDE,” he said. “To move things along we found you really need an independent staff to facilitate those efforts.”

That staff can also be a buffer against distrust.The trust that’s necessary among the various members of UHIN never fails, Root said, but the potential is always there.

The staff has become a vital part of the process of creating trust among UHIN members by smoothing bumps and providing an equal service to all of the community, she added.

Micro Networks

Ed Ewen, director of clinical informatics at Christiana Care Health System, said he believes regional health information organizations are not the best route to health data exchange networks. Instead, he touts what he calls micro health information organizations, or MHIOs, as the answer.

He said RHIOs don¹t fit the bill because they don¹t accommodate the natural connections between doctors and patients. In their current model, RHIOs cater mostly to the requirements of large hospitals and are ³disenfranchising for doctors and physicians,² he said.

Establishing RHIOs means going through a laborious process of building trust among the various members of the organization and managing the inevitable political conflicts, in addition to resolving financing issues.

One of the biggest problems for RHIOs is developing a viable business model and sustaining progress despite uncertain political and financial support during the years it takes to establish a successful RHIO, he said. At the Delaware Health Information Network, where Ewen is a member of the technology committee, it¹s been a matter of ³two steps forward and one step back² for the past nine years as members constantly revisit issues such as governance and trust, he said.

In Ewen¹s vision, MHIOs would eliminate many of those problems because they¹d build on the data interchanges that occur between doctors and patients, which are already at least partially automated through the use of fax machines and telephones.

All that¹s needed to elevate them to a fully electronic data interchange would be the ability to store, retrieve, import and export information between physicians¹ electronic health records (EHRs) and individuals¹ patient health records (PHRs), Ewen said. Current standards could handle that.

Patients would be able to freely opt in or out of such an arrangement, add or remove physicians, and block sensitive information, among other tasks, he said.

MHIOs would quickly form ³robust, redundant and dynamic networks facilitated by standards-driven PHR/EHR interoperability,² Ewen said.

In other words, they¹d do what RHIOs are intended to do.

Privacy Concerns

One final takeaway and perhaps the most important of all: pay special attention to protecting the privacy and confidentiality of data, Frisse said, because that will go a long way toward convincing a skeptical public about the viability of RHIOs and health data exchanges.

“Most of the public doesn’t know where their personal health care data goes now, and there are calls out there for legislation that will allow an opt-out/opt-in requirement for RHIOs,” he said. “Anything with an a priori opt-in requirement is destined to fail.”

To obviate that possibility, RHIOs should focus on convincing doctors and pharmacists about the organizations’ safety and usefulness, he said. The public trusts medical professionals, so if physicians feel that the data they use is well-guarded, then the public will also. “RHIOs should focus on convincing those people first,” Frisse said.


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