Response to: Why RHIOs Aren't Working

There's lots of truth in both articles, but its both unfair and inappropriate to compare the US RHIO / NHIN progress, as flawed and ineffective as it is, to the Canadian Health Infoway project. The Canadian project has the singular ability to impose standards, consent directives, protections, and funding, all of which are presently lacking in our national initiatives. As both authors point out, US healthcare financial incentives are presently not aligned with national HIE objectives, and there's no question that data still equals market share in our competitive market.

HITSP is moving forward with consensus standards, and CCHIT continues to add to its repository of criteria for certification, but at the end of the day providers have no incentive to pay the extra cost to vendors for the HIE interfaces and changes in practice that such standardization requires.

What our country needs is a transition strategy to HIE that paves the way in consumable steps. If there is truly value in transportable health data, and there is value in shipping it around the country and populating it into many different repositories, that won't happen overnight, and it certainly won't happen in the absence of national progress toward a single standard for authentication, user provisioning, and protection of those following the standards.

As a provider who strives to do the right thing, I am not happy when people accuse the provider community of shunning data exchange simply for competitive reasons. That can't be farther from the truth. We have a very large private network that encompasses as many physicians as will subscribe to it because we want our physicians to have as much data about their patients as possible. No, its not competition we are afraid of.

Note the word "private". That's our present requirement, because of the litigious nature of our society, and especially in today's economy when inappropriately disclosed data can be the meal ticket of a lifetime. If HIE is to become truly widespread, there have to be standards and there have to be safe harbors for those of us willing to pay the necessary security costs to keep our patients' data out of the hands of those who would violate patient privacy mandates. The first prosecuted security breech of exchanged data will set the industry back 10 years. And you can bet that it will happen without nationally instituted standards and protections. So, who wants to be first?

Dave Minch
HIPAA/HIE Project Manager
John Muir Health
Walnut Creek, CA

Commentary - Why RHIOs Aren't Working

Electronic Healthcare, 6(4) 2008: 102-103

Why RHIOs Aren't Working: Views from an American Who Can See White Rock, British Columbia, from His Backyard
David E. Garets

Abstract:[Commentary on the article, US Regional Health Information Organizations and the Nationwide Health Information Network: Any Lessons for Canadians? by Denis Protti]

The problems with RHIOs (often referred to as health information exchanges) in the United States have as much to do with the structure of the American health "system" as they do with non-existent business models for funding them after the grant runs out and lack of interoperability standards.

Misaligned Incentives
Our "system" is "distinguished" by an incredible lack of aligned incentives.

• Insurance companies want to keep their insured consumers from engaging in expensive procedures or showing up in expensive venues (emergency departments) and have a reputation for looking for creative ways to not pay for medical services.
  Hospitals think they're the centre of the medical universe and make their money getting most of the sick people and providing as many services for them as are reimbursable by the tight-fisted insurers.
• Most American physicians are independent business people trying to maximize their incomes and attempting to gain leverage from hospital competition in their communities. Pharmaceutical companies, for the most part publicly held manufacturing firms, are intent on maximizing their profits and have figured out how to be successful - spend billions of dollars lobbying the US Congress to keep price controls and imported drugs out of the country while marketing directly to consumers.
• US residents, 47 million of whom are uninsured (approximately 16% of the population), are left to fend for themselves with competing doctors, hospitals, pharmaceutical companies eager to have them "ask your doctor whether whatever drug we're pushing today is right for you." In the United States, the costs for this madness are escalating far faster than inflation and presently comprise at least 15% of the US gross domestic product, a far higher percentage than in any other developed country, with poorer outcomes.
• And finally, employers, who fund a large percentage of the healthcare costs for employed Americans and their families, are furious at the increasingly large bite employee and retiree healthcare costs are taking out of their profits, making it increasingly difficult for many of them to be globally competitive. They're trying to get a handle on containing those costs. In large part, they attempt to manage this by shifting more of the costs to their employees.
  

I don't mean to be cynical, but RHIOs are the least of our worries!

Let Me Count the Hurdles
Let's look at what RHIOs are trying to do with that "system" in mind. As Professor Protti writes, they're trying to "facilitate the secure exchange of healthcare information to advance the effective and efficient delivery of healthcare for individuals and communities." A noble goal, but what's in the way? Let me count the hurdles:

1. About half the hospitals in the United States are located in communities where there are one or more competing hospitals in town. They mostly don't like each other and don't trust each other. I've had CEOs of competing hospitals tell me that they've spent millions of dollars building their electronic medical record systems (EMRs), and not for the purpose of sharing data with their competitors.
2. Private practice physicians want the best for their patients, but not to the extent of implementing ambulatory medical records systems to make the care they give more efficient, effective and safer. The overall penetration of those systems in the United States is below 20% in most of the studies of ambulatory EMR adoption. So that means that somewhere north of 80% of physicians in the United States still have paper clinical records (almost all of them have practice management systems to get their claims and bills out). Participating in a health information exchange or RHIO where the expectation is that the clinical data will be in digital form is a non-starter for many physicians, especially those in individual or small group practices.
3. The entities that benefit from the information a RHIO would provide aren't always the ones that are expected to pay for it, as Protti points out.
4. The lack of interoperability standards and the unwillingness of our legislators to mandate them cause problems for consumers. First, what comprises a personal health record (PHR)? Is it just laboratory test results and some demographic data? Or is it the Continuity of Care Document? Does the consumer have to key most of that information into the webbased and/or employer-provided PHR? For the majority of people who have PHRs, including me, the answer is yes.

Second, because many of the systems in American healthcare organizations (HCOs) are proprietary and there's no controlled medical vocabulary standard in the country, the data coming out of one HCO's systems won't be easily understood by an RHIO's federated or centralized databases.

Progress is being made, but it's slow. The losers? Consumers/ patients.

The information exchanges that will succeed are the ones that have their incentives aligned. One reason that Indiana's initiative works, and the ones from Tennessee and Louisiana show promise, is because they're providing services to not just cities, but in large measure to rural portions of their states. That's one source of the "supply" of patients needing specialized cancer treatment, for example, provided by larger urban and academic medical centers. They're not so much trying to hook together competing HCOs as they are facilitating supply chains that align limited services with people who need those services, a pragmatic solution.

The other type of information exchange that will be successful is the model proven by Inland Northwest Health Services in Spokane, Washington. In my opinion, they're not a RHIO, but rather a services provider, delivering healthcare IT services among others. They run a regional MEDITECH data centre more efficiently than the independent hospitals that are their customers could possibly manage on their own. They're an outsourcer to hospitals, and because they specialize in one hospital information system and have the ability to interface and integrate other existing applications owned by their customers for community access, they are able to facilitate the exchange of data between their hospital and physician office customers who wish to exchange data.

RHIOs and health information exchanges must focus on collecting and sharing minimal data sets that solve real healthcare delivery issues quickly and effectively. Then these can be incrementally expanded as successes are achieved. Most are trying to do too much too soon, exacerbating the mistrust among the stakeholders.

Be Thankful!

Be thankful you have a healthcare system as rational as it is. Your system of regional health authorities and a centralized, national funding source for innovation in healthcare IT (Canada Health Infoway) makes eminent sense. I think it's the model for other nations globally. Now if the United States would just get closer to the way you do it …

About the Author
David E. Garets, FHIMSS, is the president/CEO of HIMSS Analytics

Annual Survey of RHIOs Finds Funding Lagging

The Annual Survey of Regional Health Information Organization Finance, conducted by Healthcare IT Transition Group in 2006 and 2007, gathered financial data from U.S. RHIOs (also called Health Information Exchanges) at all stages of development, from earliest startup through the most mature production stage. The survey team’s report, Sustainable RHIO Funding and the Emerging Business Model. The sample included 23% of the U.S. RHIO cohort. Respondents were located in 28 U.S. states and territories; 52% reported being in the startup stage, 24% in a transition stage, and 24% in production.

The report’s financial analysis of the RHIO space includes an examination of revenue streams, service offerings, stakeholders as sources of revenue, value creation and capital development strategies. Investigators studied contributed, earned and other income, including loans and investor proceeds. The survey report includes 48 charts and tables that illustrate a broad and deep financial picture for this nascent segment of the healthcare and health information technology markets, but one that still remains hamstrung by various technological and non-technological trials.

A summary report is available here:

The full 79-page report is available at http://rhio.hittransition.com. Free public summary of the 2007 RHIO finance survey report is available here:

Zach Dunlap says he feels "pretty good," four months after he was declared brain dead and doctors were about to remove his organs for transplant.

Was this a patient error or adverse event? Would other patients in similar circumstances also been witmess to their declaration of death? Will organ transplant programs re-visit their policies and programs and related issues of medical ethics?

Dunlap, 21, said he has no recollection of his crash.

Dunlap was pronounced dead November 19 at United Regional Healthcare System in Wichita Falls, Texas, after he was injured in an all-terrain vehicle accident. His family approved having his organs harvested.

As family members were paying their last respects, he moved his foot and hand. He reacted to a pocketknife scraped across his foot and to pressure applied under a fingernail. After 48 days in the hospital, he was allowed to return home, where he continues to work on his recovery.

On Monday, he and his family were in New York, appearing on NBC's "Today."

"I feel pretty good. but it's just hard ... just ain't got the patience," Dunlap told NBC.

Dunlap, 21, of Frederick, Oklahoma, said he has no recollection of the crash.

"I remember a little bit that was about an hour before the accident happened. But then about six hours before that, I remember," he said.

Dunlap said one thing he does remember is hearing the doctors pronounce him dead.

"I'm glad I couldn't get up and do what I wanted to do," he said.

Asked if he would have wanted to get up and shake them and say he's alive, Dunlap responded: "Probably would have been a broken window that went out."

His father, Doug, said he saw the results of the brain scan.

"There was no activity at all, no blood flow at all."

Zach's mother, Pam, said that when she discovered he was still alive, "That was the most miraculous feeling."

"We had gone, like I said, from the lowest possible emotion that a parent could feel to the top of the mountains again," she said.

She said her son is doing "amazingly well," but still has problems with his memory as his brain heals from the traumatic injury.

"It may take a year or more ... before he completely recovers," she said. "But that's OK. It doesn't matter how long it takes. We're just all so thankful and blessed that we have him here."

Dunlap now has the pocketknife that was scraped across his foot, causing the first reaction.

"Just makes me thankful, makes me thankful that they didn't give up," he said. "Only the good die young, so I didn't go."

US Regional Health Information Organizations and the Nationwide Health Information Network: Any Lessons for Canadians?

Denis Protti Professor, School of Health Information Science, University of Victoria, British Columbia, and visiting professor, City University London, England.

The creation of regional clinical data exchanges (usually referred to as RHIOs) is a centrepiece of the US national healthcare information technology strategy. How well are they doing and what lessons can we learn that might be applied here in Canada?

Background and Definitions There seems to be general agreement in the United States that a Regional Health Information Organization (RHIO) is a neutral, non-governmental, multi-stakeholder organization that adheres to a defined governance structure to oversee the business and legal issues involved in facilitating the secure exchange of health information to advance the effective and efficient delivery of healthcare for individuals and communities. The geographic footprint of an RHIO can range from a local community to a large multi-state region. As regional networks of stakeholders mature, they often find the need for a formal independent organizational and governance structure (i.e., an RHIO) with systems to ensure accountability and sustainability for the benefit of all stakeholders. Experts maintain that RHIOs will help reduce administrative costs associated with paper-based patient records, provide quick access to automated test results and offer a consolidated view of a patient's history. The terms RHIO and Health Information Exchange (HIE) are often used interchangeably though most would see HIE as a "concept" relating to the mobilization of healthcare information electronically across organizations within a region or community as opposed to an "organization." Typically, an HIE is a project or initiative focused around electronic data exchange between two or more organizations or stakeholders. This exchange may include clinical, administrative and financial data across a medical and or business trading area. HIEs may or may not be represented through a legal business entity or a formal business agreement between the participating parties. Local Health Information Infrastructure (LHII) is a term occasionally used synonymously with RHIO. LHII was originally termed by the Office of the National Coordinator of Health Information Technology (ONCHIT) to describe the regional or local initiatives that are anticipated to be linked together to form an envisioned National Health Information Network (NHIN). The NHIN describes the technologies, standards, laws, policies, programs and practices that enable health information to be electronically shared among multiple stakeholders and decision makers to promote healthcare delivery. When completed, the NHIN will provide the foundation for an interoperable, standards- based network for the secure exchange of healthcare information in the United States. The development of the vision of the NHIN began originally with the National Health Information Infrastructure (NHII) described more than a decade ago in the Institute of Medicine report The Computer-Based Patient Record. The original idea behind the NHII was that it would be an initiative set forth to improve the effectiveness, efficiency and overall quality of health and healthcare in the United States. This would be accomplished through a comprehensive knowledge-based network consisting of interoperable systems of clinical, public health and personal health information that would improve decision-making by making health information available when and where it is needed. These interoperable systems would use a set of technologies, standards, applications, systems, values and laws that support all facets of individual health, healthcare and public health. The path toward reaching a NHIN is anticipated to be through the successful establishment of RHIOs. When completed, the envisioned NHIN will provide universal access to electronic health records. In 2004 - not surprisingly following a visit from British Prime Minister Tony Blair - President George Bush called for electronic health records to be widely available in the United States by 2014. The federal government has launched initiatives to establish interoperability standards, examine variations in state privacy laws, conduct demonstrations of the NHIN and fund studies of areas such as strategies for state governments. Organizations such as the eHealth Initiative and the Markle Foundation have brought together the diversity of healthcare stakeholders and communities to share experiences, create tools and identify policies and steps that will facilitate the achievements to date. RHIO Models and . . . . [to continue please click here]

Why RHIOs Aren't Working: Views from an American Who Can See White Rock, British Columbia, from His Backyard

David E. Garets FHIMSS, President & CEO, HIMSS Analytics

Misaligned Incentives

[This article responds to: US Regional Health Information Organizations and the Nationwide Health Information Network: Any Lessons . . . ?]

Our "system" is "distinguished" by an incredible lack of aligned incentives.

• Insurance companies want to keep their insured consumers from engaging in expensive procedures or showing up in expensive venues (emergency departments) and have a reputation for looking for creative ways to not pay for medical services.


• Hospitals think they're the centre of the medical universe and make their money getting most of the sick people and providing as many services for them as are reimbursable by the tight-fisted insurers.


• Most American physicians are independent business people trying to maximize their incomes and attempting to gain leverage from hospital competition in their communities.


• Pharmaceutical companies, for the most part publicly held manufacturing firms, are intent on maximizing their profits and have figured out how to be successful - spend billions of dollars lobbying the US Congress to keep price controls and imported drugs out of the country while marketing directly to consumers.


• US residents, 47 million of whom are uninsured (approximately 16% of the population), are left to fend for themselves with competing doctors, hospitals, pharmaceutical companies eager to have them "ask your doctor whether whatever drug we're pushing today is right for you." In the United States, the costs for this madness are escalating far faster than inflation and presently comprise at least 15% of the US gross domestic product, a far higher percentage than in any other developed country, with poorer outcomes.


• And finally, employers, who fund a large percentage of the healthcare costs for employed Americans and their families, are furious at the increasingly large bite employee and retiree healthcare costs are taking out of their profits, making it increasingly difficult for many of them to be globally competitive. They're trying to get a handle on containing those costs. In large part, they attempt to manage this by shifting more of the costs to their employees.

I don't mean to be cynical, but RHIOs are the least of our worries!

Let Me Count the Hurdles [ . . . to continue click here.]