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September 5, 2005

RHIOs: Building Blocks of National Healthcare IT Network
By Laura Gater
Radiology Today
Vol. 6 No. 18 P. 18

Regional health information organization (RHIO), regional health information network, community health information network, and local health information infrastructure. These terms are basically all the same concept—a networked community of healthcare providers and perhaps insurance providers and vendors. The idea has been around for a while but has recently become a hot topic thanks to President Bush’s 10-year plan to construct a nationwide healthcare infrastructure.

David J. Brailer, MD, PhD, national coordinator for health information technology, has stated that fostering regional collaboration through RHIOs is one of three strategies for achieving the goal of interconnecting healthcare information. The idea behind RHIOs is improving healthcare quality, safety, and efficiency through interconnected information networks. Supporters hope RHIOs will eventually revolutionize healthcare by allowing healthcare providers access to clinical information for all patients in a given area or region, across a decentralized technology environment. The expansion of RHIOs links directly to radiology because digital images in DICOM format would be part of the proposed system of interoperable networks.

Identifying and linking medical records—including digital images—throughout the RHIO’s geographic area is the first technological challenge, and an imperative one, to exchanging data the way Brailer and the administration envision. That goal remains a long way off in the future.

“Defining RHIOs right now is a major challenge,” says W. Holt Anderson, executive director at the North Carolina Healthcare Information and Communications Alliance. “People think they are part of a RHIO or say they are setting one up, but there are no defining characteristics of a RHIO. It could be a transitory phrase, but a RHIO is a connected community.”

Anderson defines a RHIO as “two or more very strong hospitals or hospital systems that are self-sufficient and not likely to share clinical databases because of competitive reasons. They share legal, agreement-driven models to allow them to share information on a counter basis, but not from a business standpoint.”

RHIO Models
The three models of RHIOs are the co-op model, the federated model, and a combination, or hybrid, model. The co-op model usually consists of at least one rural hospital that lacks monetary or technological resources sharing overhead and technological resources with other hospitals. The hospitals in a co-op model have good reason to collaborate and combine resources. Federations are strong health systems that join together; they may or may not share their master patient indexes (MPIs). The hybrid model merges both previous models, according to Anderson.

“A RHIO is a connected community that serves different functions in different parts of the country,” explains Anderson.

The federated model is the most technologically advanced, says Deborah Kohn, MPH, RHIA, CHE, CPHIMS, FHIMSS, principal of Dak Systems Consulting. Some technologies in a federated RHIO system are centralized, similar to the U.S. government, but each stakeholder in a RHIO has its own technology system, like state governments, and processes its own transactions.

“The important technologies, like the enterprise master patient index [EMPI], are centralized, but each institution keeps its own MPI, which all feeds into the EMPI. The RHIO links them all,” explains Kohn.

Jonathan Leviss, MD, medical director of healthcare strategies for identity management systems developer Sentillion, Inc., notes that the way a RHIO is organized depends mainly on what kind of information the organization is trying to share. If the stakeholders don’t strategize effectively, then the organization and structure won’t be successful.

“RHIOs need a technology strategy,” states Chris Callahan, product director for Misys Optimum. “The architecture of such a system would be similar to the way the Internet is set up. The central data resides in the endpoint of the network.”

Integration models and technologies do exist today that enable the interoperability of existing information systems without having to rewrite current systems.

Jim Stowe, program director for MA-SHARE, which is seeking to improve healthcare connectivity in Massachusetts, notes that MA-SHARE’s technology is flexible, based on a distribution data model without central access. Patient record information remains stored electronically at each local healthcare facility and will not be aggregated into a central repository.

“As we think about building these RHIOs, we need to talk about the population we can serve. We need to get hospitals in [strategic] areas to join,” says Anderson. “This is about serving patients. If we do it right in local areas, the interconnectivity among RHIOs ought to take flight.”

Building a RHIO
Perhaps the best way to build a RHIO, as with any other organization, is to learn from others.

“Learn from history to figure out what not to do,” says Callahan. “Learn as much as you can from everyone else who has built a RHIO. A RHIO taps competitors to collaborate. Self-interest won’t get anyone anywhere. The current incentive structure needs to be changed—financial as well as clinical. From a basic project management perspective, program management really needs to be brought into RHIOs to help get things done. I think a lot of governing models for RHIOs will emerge.”

Sentillion advocates the establishment of RHIOs as franchises, which would minimize their variability yet promote local creativity and management.

A RHIO is a business, according to Kohn, and should be organized and structured as such.

“It takes a tremendous amount of effort, from financial, government, legal, and technology perspectives, although technology is the least important,” she explains. “It’s just like building a brand new business, bringing together a lot of stakeholders, like hospitals, physician offices, reference labs, to try to share information and trying to get a board of directors to agree on stakeholder contracts. They have to agree on all kinds of things. Competition is tremendous. Stakeholders may form a RHIO and become your competitors.”

Anderson points out that a RHIO should be built from the local area upward, not from a national area down to the local.

“Build a community, then a large community, then a larger national infrastructure,” he says. “RHIOs are going to continue to evolve. They can’t stand still. As technologies evolve, as capabilities evolve, RHIOs will change. Small providers, such as rural hospitals and single physician practices will need incentives to encourage them to get electronic medical records [EMRs]. Large employers are the real beneficiaries of EMRs and RHIOs. Smaller companies are not sure that RHIOs will be beneficial to their bottom-line health plan. RHIOs need to offer technology and training support to rural physicians, clinics, and hospitals.”

The organization needs to define itself first, says Leviss, before creating a strategy for development. A technology strategy needs to be developed because it is the gateway to support physicians. A RHIO also needs to develop standards by which all vendors would abide. Technology decisions have to follow organizational strategy, and organizational strategy follows organizational identity.

One of the most successful RHIOs is the Indiana Health Information Exchange, Inc. (IHIE), a nonprofit corporation that shares clinical information among healthcare providers and other healthcare entities in the state, using a secure information exchange designed to protect patient privacy. Providers have access to patient information, which is housed in a broad clinical database at participating hospitals, for treatment purposes. The IHIE is comprised of the major hospitals in Indianapolis—Clarian Health Partners, Health and Hospital Corporation of Marion County, Indiana University School of Medicine, St. Francis Hospital and Health Centers, St. Vincent Health, and Wishard Health Services.

Identity Management
Sentillion’s Leviss believes the biggest aspect of a RHIO is identity management. Who has a right to access information and how is that right controlled? Identity and access management solutions are necessary to establish trust that the RHIO’s health information systems are secure and that patient information in those systems are protected.

Technical barriers to patient identification in a RHIO include accuracy, security control, performance, scale, and nonstandardized data. Matches located in a database search must represent the correct individual; encryption and flexible data stewardship are components of security control that must be enacted; a new patient record added to the system must be searchable immediately; RHIO technology will need to scale as participation increases; and the amount of variation in the data collected in healthcare settings presents a challenge because of format variation, and/or sporadic capture of certain data.

The federated RHIO model relies on a decentralized system of record management, where patient information is only accessed when needed and clinical data is stored only where it’s created, which can overcome the political, technology, and cultural barriers that may hamper RHIOs.

“RHIOs need to make sure that data from a prescription, blood test, EKG [electrocardiogram], or x-ray, is managed so that the correct test is matched with the correct patient. This is a real issue,” says Leviss. “How does a RHIO embark on sharing information with all different kinds of people? Different technologies are being developed for identity management, but healthcare is just beginning to look at it. One common issue is that hospitals have a huge number of computer users. If RHIOs are not strategic about addressing who has access to identity management, the public will lose confidence in them.”

In many RHIOs, patient information is now stored in different systems, such as pharmacy, pathology, EMR, often with a different name each time for the same patient (eg, William Brown, William E. Brown, Bill Brown, Bill E. Brown, W.E. Brown), notes Leviss. Technology can be utilized to create a master patient list so records can be identified so a physician (or anyone authorized) can log into “merger” to tie all the records together for one patient.

Accurate patient identification and linking is the foundation of health technology that is implemented in a RHIO or any similar network that shares patient information. Without accurate patient identification, patient safety is compromised, along with patient care and trust.

No Definite Timetable
RHIOs, like any other business, take a long time to establish. There is no definite timeline, except perhaps for deadlines imposed by grants and funding from another organization.

“Everything takes five times longer than you think, plus privacy, security, and technology issues,” says Stowe, whose organization, MA-SHARE, is currently implementing patient prescription history.

Callahan says to expect a greater than five-year timeframe for establishing a RHIO. “Absolutely. People who anticipate being set up in 12 to 18 months are going to be very disappointed,” he says.

According to Kohn, the timetable “totally depends” on a variety of factors, similar to starting any other business. “How long does it take to start a company?” she asks. “You have to approach grant organizations to get the funding to begin a RHIO, you have to go through the process to get money. You need to have strong determination and leadership to get funding.”

Costs of Doing Business
The costs involved with implementing a RHIO can be controlled through careful planning and organization, just like with any other business start-up, according to Callahan.

“Make sure that everyone involved agrees on what they’re going to do and when before you start; otherwise, you’ll have a lot of reworks,” he says. “Cost is a function of time. The longer it takes, the more it will cost.”

Efficient project management is the key to saving money, notes Leviss. “Efficient project management starts at the beginning of a project,” he says. “Your strategy or plan has to be completed within the timeframe indicated. Use legitimate timetables and also make sure that all projects are feasible within time limits.”

The efficiency of a RHIO helps reduce many costs in the long run. “Currently, to exchange information between stakeholders in organizations is labor-intensive, error-producing, and all being done manually by paper,” explains Kohn. “RHIOs can reduce costs. The use of paper is extremely costly, labor-intensive, and error-generating. RHIOs utilize electronic, digital communication and eliminate paper. The efficiency from the technology and the cost, in the long run, is great. The hard part is getting everyone to collaborate, and to get used to the technology.”

MA-SHARE saves funds by seeking the best possible prices from vendors. “By using economies of scale, we are building a comprehensive statewide solution, spreading costs across a wide system of users. How we control costs in operating the RHIO depends on our contractors and our funders [grant providers] and hardware and software vendors, who offer us the opportunity to get favorable terms,” Stowe says.

It’s not easy to figure out the return on investment in a RHIO, according to Anderson, who cites Inland Northwest Health Services in Spokane, Wash., as the best example of a RHIO that is cost effective. Inland Northwest has managed to be cost effective and a viable organization by sharing technical resources and overhead costs.

As RHIOs or any community-based health information networks evolve and improve, they may prove to be valuable stepping stones on the road to a national network which a patient’s medical record will be available anywhere, anytime.

— Laura Gater’s medical and business trade articles have been published in Medical Imaging, 24x7, Podiatry Management, Veterinary Forum, Corrections Forum, and other national and online publications.

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