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For other articles and previous issues click here. April 10, 2006
Making RHIOs Work RHIOs strive for interoperability and fiscal sustainability. From the 30,000-foot view, it may appear that the one constant of regional health information organizations (RHIOs) is inconsistency. But a closer look at the technology and business models in place at several of the more successful RHIOs shows that while their differences may be many, they possess a number of common characteristics that should serve as examples for their emerging counterparts. The many differences are understandable; even though RHIOs are expected to become the building blocks for a national health information network (NHIN), their actual formation and potential for success are based on their ability to meet the unique needs of the community they are established to serve. As a result, the structure, funding, mission, and technology of each RHIO are ultimately determined by the needs, opportunities, and challenges inherent to the region. “It’s driven by the culture of the community, the needs of the community, and the resources of the community,” says Christina Thielst, a healthcare governance, administration, and management consultant and author of Forming a RHIO? Moving From a Collaborative to a Formal Organizational Structure With Authority and Accountability, a guide for groups charged with moving a health information exchange project to a more formal structure. “If you have a community collaborative that has identified diabetes support as a priority and you have stakeholders in the community who are willing and able to put in the necessary time and energy, then that project is likely to be more successful than one with significant need but no resources to make anything happen. “It has to be those two things coming together: the needs of the community and the resources,” she adds. “Cultures and resources are just very unique in each community.” According to “Accelerating Transformation through Health Information Technology” by the Center for Health Transformation (CHT), today’s RHIOs are based on models ranging from a co-op of organizations actively sharing consumer data to a single provider institution offering Application Service Provider-based technology services and electronic medical record (EMR) access, as well as a consortium that serves as a facilitator for competing providers and payors in a single area. The factors determining the final model upon which a RHIO is based include the types of participating institutions, their size and technological sophistication, the driving forces and leadership behind the RHIO, the geographic area, and the distance between providers. RHIOs also share common issues, according to the CHT. Those issues include the need to address technical issues to ensure that participants can efficiently and effectively transfer electronic data—including images—and to ensure interoperability and communications between the disparate systems of public and private healthcare providers. In fact, according to the CHT report, “Interoperability is in many ways the most complex and most important requirement in the formation of a RHIO, given the goal of supporting a national infrastructure for health information exchange.” The
Technology Dilemma While the homogeneous model has been successful for some RHIOs, it is the heterogeneous approach that is winning the most support for its ability to bring together organizations that are already utilizing different vendors’ EHR systems, as well as to address the customization needs of each participating organization. “Our model relies on interfaces; I don’t think there’s anyone who’s invented a way to get rid of interfaces,” says Rick MacCornack, PhD, chief systems integration officer at Northwest Physicians Network, a Tacoma, Wash.-based independent physicians association that recently teamed with St. Luke’s Health System in Boise, Idaho, to demonstrate a multistate health information network to facilitate the exchange of clinical health data across significant distances. “Interfaces get built for every installation. You can have the same EMR from the same vendor installed in 10 different clinics, but 10 different interfaces still need to be built because each clinic has customized their EMR for their clinical staff. That’s the reality, but it’s not the barrier that many imagine.” The South Sound Health Communication Network (The Network), which operates the connectivity solution in the Tacoma area, and St. Luke’s Regional Medical Center utilize Siemens’ Soarian Community Access to create a secure portal through which patient data is “pushed” from a source—such as a hospital, health department, laboratory, etc—to a physician on the network. Communication traffic inside the portal is managed by software from RMD Networks, allowing providers to efficiently communicate with each other and their patients to better coordinate care and improve outcomes. “Our model is a relatively inexpensive approach to providing the right functionality to benefit a majority of the physicians, and that is connectivity through a secure portal that enables them to talk with each other,” says MacCornack. “It’s an ASP model, so all you need is a PC and broadband connection. It is easily interfaced with EMRs, lab systems, pharmacy systems, you name it.” Another RHIO that has adopted the heterogeneous model is the Utah Health Information Network (UHIN), which was created in 1992 and has since been recognized by Health and Human Services as the first successful RHIO. UHIN connects 100% of the state’s hospitals, laboratories, local health centers, and mental health centers through platform-independent software architecture and tools that allow providers and payors to exchange information. The suite of software products supporting UHIN was developed by Columbus, Ohio-based HealthCare Transaction Processors, Inc. (HTP), which has since developed the modules into three software packages—HTP Transaction Manager for payors, HTP Sentinel for providers, and HTP MedRunner for RHIO administrators—that work together to connect all members of a RHIO community into a functioning network. According to HTP cofounder and chief technology officer Fred Richards, an open architecture is critical to a RHIO’s success, particularly as it begins to link into a national network, as are proper security and privacy controls. “If you just have a few organizations coming together to exchange information, then you can create your own homogeneous network. But that model won’t support expansion to a larger scale that incorporates all the information you need from the entire community,” he says. “Our system is very open in communication and architecture. In a couple of areas, we publish those communications protocols so anyone can write to them. We’re making our system as open as possible so that, as a platform, it becomes architecture-independent. It’s a better approach. If you don’t have an open set of standards that allows everybody to intercommunicate, then everyone can’t participate in the RHIO. “Whichever model you choose, security and privacy standards must be addressed early in the process,” Richards adds. “Ideally, consumers should be able to specify under what circumstances and by whom their information can be accessed.” In fact, the need for an open architecture has led many in the industry—including the CHT—to call for vendors to upgrade systems to incorporate a service-oriented architecture (SOA), which will enable data to be exchanged via Web services that dynamically exchange data between systems, based on agreed-upon standards, without the need for costly interfaces. “SOA is an excellent method for developing a ‘system of systems’ architecture because it leverages legacy systems by opening them up through Web services and doesn’t require a complete infrastructure update,” says David Clark, director of integration and interoperability for HIMSS, which recently announced the formation of the HIMSS RHIO Federation. “I believe this methodology will have a significant influence over interoperability, as it can save organizations thousands—if not millions—of dollars over the long term.” At the end of the day, it’s too early to tell which, if any, of the current technology models will be the most widely used and accepted, says Clark. “This is a major point of controversy, particularly in the data architecture area and identity management/mutual authentication,” he says. “Some proponents believe that a CDR, or centralized data repository, is best, while others feel that a decentralized architecture is better. Some are adopting a hybrid model where both methods are used for different purposes. “The technology doesn’t seem to be a barrier, except that RHIO leaders are in need of official direction on standards which ANSI HITSP will handle,” he adds. “Most RHIOs are dealing with business problems vs. technical problems at this point.” The
Business of RHIOs Most emerging RHIOs rely almost exclusively on grant funding as their primary revenue stream. In fact, according to “The Integrated Path: Incorporating Contributed Revenue in the RHIO Funding Mix” from the Healthcare IT Transition Group, all of the more than 100 full-blown RHIOs in the United States are currently (or were originally) partially or fully funded by grants from various public and private sources. Indeed, in its summary report, the CHT called for the federal government to dedicate 1% of all discretionary spending—approximately $47 billion per year—to health information technology, including RHIOs, and encouraged emerging RHIOs to pursue both public and private funding sources, including grants and loans for start-up capital. However, the push is on for RHIOs to begin adopting business models that are self-sustaining, which will require a shift away from a sole focus on what’s good for the community to one that is keyed to demonstrating real value to stakeholders. “The initial pulling of people together is based on the idea that this is the right thing to do, but you quickly start to look at ‘Well, OK, how are we going to pay for this? How are we going to make this happen?’” says Thielst. “So you quickly move from ‘This is the right thing to do and we want everyone to join with us around the table’ to ‘Let’s figure out how we’re going to do this.’ It’s a very quick transition to where the collaborative starts to look at a business plan.” Every RHIO needs to begin with planning for governance, she adds, which is the starting point of her “Forming a RHIO?” guide. In addition, the leadership needs to not only identify its stakeholders and how its model will benefit those stakeholders, but also whether those stakeholders are ready for true collaboration. Without those elements in place, moving to a sustainable model will be extremely difficult. “That’s the pressure on RHIOs right now. What is the business case? How is it going to be sustainable? Show us the numbers,” says Thielst. “Once RHIOs demonstrate value, they’ll see more stakeholders putting up money. Stakeholders have a responsibility to their own organization and governing body and they can’t just write a check without data that demonstrates it’s a wise use of their funds.” As with technology, one model has emerged that has demonstrated success in moving RHIOs toward sustainability: charging subscription and transaction fees. UHIN, for example, charges both payors and providers a modest subscription fee to use the service, then fees to payors for the various transactions conducted over the network. After demonstrating its ability to move administrative healthcare transactions, such as claims, benefit eligibility, and electronic payments, UHIN is expanding to handle clinical transactions such as electronic prescriptions, medication history records, lab results, and discharge notes. Now handling more than 3 million transactions per month, UHIN has attained sufficient revenues to sustain and grow its services. The key, according to Richards, is being able to demonstrate results before expecting stakeholders to pay up. And that, he says, comes from a pilot project—which is perhaps the best use for seed money. “You have to have a result,” he says. “When you start, you have to say, ‘This is the cost of doing this before and this is the cost of doing it afterward.’ Without that premise going into a pilot, it’s going to be hard to prove to the participants that they ought to pay for this service.” As a “medical information utility,” The Network charges the broad base of community physicians a small monthly fee for network access, similar to what a utility company may do. Community partners that push data into The Network are charged based on the savings derived through workflow improvement and reduced costs for communicating results to community providers. According to MacCornack, this model creates a rational and transparent basis for the business value derived. Physicians, for example, pay less than community partners such as hospitals, radiology groups, labs, etc, simply because the large-volume partners achieve a much higher return on investment than do physician practices. “The key is that community partners benefit by having the majority of the physicians in the community on The Network, so that they actually realize substantial savings. It therefore becomes a mutual incentive for everyone to participate. Everyone gains something advantageous,” says MacCornack. “Our model presumes that, in fact, we can shift the status quo and actually move the industry toward competing on service and quality—quality measured by real clinical data, not claims data,” he adds. After one year of operation, The Network has more than 800 users, including patients, physicians, and office staff, and has started securing participation from community partners, including several radiology groups, a national laboratory, and one hospital system. “We’re getting through a chicken-egg hurdle now so that once clinical data is pushed in the next two months, more physicians will be attracted to join,” MacCornack says. “Further, we can now demonstrate that a typical primary care practice can save about $4,000 a year in simple office workflow improvements by using The Network. This is operating cash we encourage the physician to set aside for an EMR.” Time
Will Tell “Generally, the state of RHIOs is the incubation state, if you compare it to the myriad technology startups in the late 90s,” says Clark. “The RHIO Boom, as I like to call it, has many of the same characteristics as the dot-com boom. [There is] lots of interest by the venture capital community, many grassroot efforts, various business/financial models and the entire industry is trying to figure out where the money is for both long- and short-term investment and sustainability.” However, he adds, RHIOs should not lose sight of their role as the foundation of the NHIN. At some point, they will need to begin linking together and they need to plan for that eventuality. “RHIOs will need to not only consider their data and architecture models internally, but also how they will eventually connect to an NHIN,” says Clark. “Their focus is on local interoperability, but RHIOs will save a lot of money and time if they begin to consider the ramifications of connecting to NHIN down the road.” —
Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing
in healthcare and health information technology.
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