Getting to Maybe

Getting to Maybe promises to make us effective agents of change by telling us how to improve the world by applying the science and process of social innovation.

The book begins with a brief story about Bob Geldof's historic response to the famine in Ethiopia. Here is a little-known musician who created a highly successful global initiative - the Live Aid Telethon - to raise awareness and money. This venture was about the power of one.

The authors then describe a movement of multiple interactions that took Brazil from a very high infection rate for HIV/AIDS to a very low rate. No one leader could be identified.

Getting to Maybe analyzes how such changes happen and tries to answer the question, "How can the impossible become possible?" But the title of the book gives the authors away: there isn't an answer. The authors say that "there is no road map for social innovation; it is not a route that can be mapped step by step." Darned. Yet, the book talks about vision, a sense of calling, developing possibilities and the need for intense interactions, networking and information exchange. These factors, mixed with talent and skill in identifying and removing barriers, the authors say, will get you to "maybe."

I am not so sure. For example, by reading about the post-World War II Dutch emigration movement, I was shown a direct path of social innovation that was repeated family after family and year after year. The book To All My Children, by Albert Van der Mey (Paideia Press), demonstrates emigrants' motivations, their often uninhabitable beginnings, their resolve to build a better life, their commitment to community and social fabric and their passion and resolve. These qualities were the foundation of their economic and social success that evolved not many years later. There was a clear path, one often repeated by subsequent waves of immigrants. There was no maybe.

The authors get to "maybe" because that, it appears, is what they set out to do. If they had developed these themes and taken some risks, they might have presented a road map, a strategy and perhaps even a blueprint.

Yet, the many stories about social entrepreneurs are worth reading and serve to inspire those who have the vision. If anything, the reader will understand the importance of identifying roadblocks and reframing these as opportunities. This approach, of course, is not unique to social innovation.

The book is worthwhile, if only to read and re-read a short section on the objective of introducing patient-centred care. It quotes Dr. Don Berwick - CEO of the Institute of Healthcare Improvement and a Harvard professor - describing the treatment of a patient who, he says, is no fool and has a lot to contribute to his own care - if the system would let him. Find out how the patient is patronized, kept in the dark, fed strange foods and pretty much ignored as his care providers do everything to him and never with him. This situation is a problem that can be restated as an opportunity, and so become the impetus to design much-improved patient-centred care, with or without IT.

And if you do not know the story of Linda Lundström (and others like her), read the book. Ms. Lundström designs and makes women's clothing. She grew up in a community that included many First Nation families. When as a youngster she was faced by the reality of racism, she was moved to act. She returned to her hometown and applied her knowledge, skill and drive to engage the women and children, to offer hope and opportunity. This is the beginning of social transformation. As I write this, Ms. Lundström is facing her own challenges in dealing with the globalization of the fashion industry. In some form, she will re-emerge; just read the back of every price tag attached to her products: "I have a strong belief in the power of positive energy that all women are capable of radiating towards those we know, each other and the rest of the world."

It is the stories in this book that work. The social entrepreneurs profiled provide the learning and the motivation. They are inspiring.

A post-note: How to change the world

If you are interested in social entrepreneurs, find a copy of How to Change the World: Social Entrepreneurs and the Power of New Ideas, by David Bornstein (Oxford 2004). The author is a compelling writer who has travelled around the globe to give readers a glimpse of individuals and movements that have changed the world. The stories he has selected are captivating. For example, he describes how Florence Nightingale was motivated by inexplicable obsession, action and orientation for growth with an unwavering belief in the rightness of her ideas - and so she was well suited to apply concentrated focus, practical creativity and long-term energy to advance system change.

Bornstein also writes about child protection in India, assisted living in Hungary, reforming healthcare in Brazil, care of AIDS patients in South Africa, micro credit and the Grameen Bank and the Child Survival Revolution attributed to James Grant, who headed UNICEF from 1980 to 1995.

At the end, Bornstein lists six qualities of successful social entrepreneurs, a blueprint that does not explain why people become social entrepreneurs but does make identifying them possible. And look, he says, at Changemakers.net, an initiative of Ashoka: Innovators for the Public, which focuses on the rapidly growing world of social innovation. It provides solutions and resources needed to help everyone become a "changemaker" and presents compelling stories that explore the fundamental principles of successful social innovation around the world.

Heart transplant patient survives thanks to tiny temporary pump

Montreal – April 4, 2008 Heart specialists at the McGill University Health Centre are the first in the world to implant a minimally-invasive cardiac support system called the Impella 5.0 into a patient who was suffering from acute rejection after a heart transplant. The procedure was performed in the heart catheterization lab by Dr. Renzo Cecere, Director of the MUHC Mechanical Heart Program, and Dr. Jean Phillipe Pelletier, an MUHC Interventional Cardiologist, on February 19.

"In the worldwide experience of about 300 implants of the Impella 5.0, this is the first case of its use in a heart transplant patient suffering from severe acute rejection,” states Dr. Cecere. “This device allowed us to stabilize the patient's condition until she responded to the powerful anti-rejection medications. Without this new technology, this patient would likely not have survived."

Already available in the US and Europe, the Impella 5.0 is most often used as a bridge to a moreHide all permanent therapy, allowing doctors more time to develop a definitive treatment strategy. It is designed to help restore cardiac stability in patients who develop heart failure after heart surgery and who have not responded to standard medical therapy. In this case however, the device was implanted in transplant patient where the main purpose was to take the pressure off the patient’s heart in order to allow it time to heal from the trauma of an acute rejection.

The Impella 5.0 is made up of a miniature pump which is mounted in a catheter and inserted through a small incision in the patient’s groin area. The catheter is advanced from the groin to the left ventricle of the heart, where it can stay for up to ten days.

"The Impella system is the most recent acquisition of the MUHC Mechanical Heart Program, and further expands our ability to offer state-of-the-art treatments to patients with advanced heart disease," says Dr. Cecere. Health Canada accepted the technology for use in this country in June, 2007.


About the McGill University Health Centre (MUHC)
The McGill University Health Centre (MUHC) is a comprehensive academic health institution with an international reputation for excellence in clinical programs, research and teaching. The MUHC is a merger of five teaching hospitals affiliated with the Faculty of Medicine at McGill University––the Montreal Children’s, Montreal General, Royal Victoria, and Montreal Neurological Institute and Hospital, as well as the Montreal Chest Institute. Building on the tradition of medical leadership of the founding hospitals, the goal of the MUHC is to provide patient care based on the most advanced knowledge in the health care field, and to contribute to the development of new knowledge.

Response to: Why RHIOs Aren't Working

I just read Mr Garets' article "Why RHIOs Aren't Working: Views from an American Who Can See White Rock, British Columbia, from His Backyard".

I was fascinated and, I assume, reliably informed of the systemic problems of RHIOs clarified by his analysis. Having a direct participant report is an irreplaceable antidote to information sources distorted by distance and perspective. Thank you for publishing it.

I wonder whether the author selected the title. If so, I think he might have had second thoughts about his views of Canada, when considering the metaphor (looking into a neighbour's yard across the fence) -- the grass always looks greener on the other side. The optical reason for that is that a side view of grass sees only what is sticking up, the greenly displayed part of the grass blades. The owner of the grass looks down at his feet where he stands, deeper down to the roots. All the dead grass and bare patches are painfully seen and felt. Side views are predictably false.

People like Michael Moore and, more moderately, your author might take that more into account when tempted to describe our extremely dysfunctional Canadian system in glowing terms. Apparently, the Americans have not yet figured out how to fix their system. We surely have not settled how to fix ours either. But let's be reasonable on both sides of the fence.

Sincerely,
Robert C. Gordon PhD MBA
London Ontario Canada

Collaborative research database set up to serve complementary and alternative medicine

March 31, 2008 - The McGill University Health Centre Research Institute and the University of Calgary in collaboration with Centennial College are launching the first-ever searchable database of outcome measures intended for complementary and alternative medicine (CAM) researchers - the IN-CAM Outcomes Database. This innovative initiative promises to improve the quality and the range of CAM research that will lead to more effective treatments in the future.

The project is funded by the Lotte & John Hecht Memorial Foundation and the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research (IN-CAM).

IN-CAM co-Directors Dr. Marja Verhoef and Dr. Heather Boon believe that a coordinated, interdisciplinary and collaborative effort is needed to address the many gaps that exist in CAM research, for example, the type of health benefits people are seeking from CAM and how these needs vary depending on a person's beliefs, culture and context. The IN-CAM Outcomes Database recognizes a range of outcome measures which address different health domains.

According to co-investigator Dr. Mark Ware, who is also Director of clinical research at the Pain Clinic of the McGill University Health Centre, this database provides CAM researchers with tools in an interactive forum to improve their research questions and methodology which, hopefully, will foster a community of CAM researchers who can use the IN-CAM Outcomes Database to rate and comment on outcome measures and to propose new measures to be added.

As one of the principal investigators, University of Calgary's Dr. Verhoef will launch the database at the International Conference for Complementary Medicine Research held in Australia from March 28 to 31.

----------------------------------------------------------------------
The Research Institute of the McGill University Health Centre (RI MUHC) is a biomedical and health-care hospital research centre. The institute supports over 600 researchers, nearly 1200 graduate and post-doctoral students and operates more than 300 laboratories devoted to a broad spectrum of fundamental and clinical research. The Research Institute is inextricably linked to the clinical programs of the MUHC, ensuring that patients benefit directly from the latest research-based knowledge. The Research Institute of the MUHC is supported in part by the Fonds de la recherche en santé du Québec. For further details visit: www.muhc.ca/research.

The Centennial College Applied Research Centre's mission is to enhance continuous learning, foster social transformation and innovation, increase employment and knowledge transfer, and build partnerships. ARC works closely with industry, communities and government stakeholders to support innovation and commercialization. www.centennialcollege.ca/arc.

Dr. Marja J. Verhoef (University of Calgary) was the first President of the Foundation of the International Society of Complementary Medicine Research (ISCMR).

----------------------------------------------------------------------
For more information please contact: isabelle.kling@muhc.mcgill.ca or tdryden@centennialcollege.ca

Simcoe Muskoka gets upgraded network infrastructure to improve patient care

TORONTO - March 31, 2008 - Smart Systems for Health Agency (SSHA) today announced that more than 20 of the largest health care organizations in the North Simcoe Muskoka Local Health Integration Network (LHIN) have received increased network bandwidth enabling them to improve health services to residents. The upgrade enhances care by enabling health care providers to transmit electronic digital images of patient x-rays, scans and ultrasounds over a private and secure network.

The enhancements come from Smart Systems for Health Agency (SSHA), an agency of the Ontario Ministry of Health and Long-Term Care responsible for electronically connecting health care professionals to each other and to patient information.

The ability to electronically transmit digital images helps reduce patient wait times for treatment and enables doctors to more quickly collaborate on a diagnosis. With the upgrade, physicians can now also streamline care by integrating their clinical and chronic disease management systems with hospitals and data from Community Care Access Centres.

According to Jean Trimnell, North Simcoe Muskoka LHIN's Chief Executive Officer, this will allow the region to dramatically increase the scale, reliability and speed of network-based connections and applications to services local residents.

The increased capacity has broadened the North Simcoe Muskoka region’s use of the Ontario Telemedicine Network and extended video conferencing services, eliminating the need for residents to travel to larger centres for care. Physicians can also utilize the technology to speak with experts across the province on a diagnosis.

This is the first LHIN to complete the upgrade of SSHA’s network to its largest health care partners and hospitals.

Depending on location and connection method, participating organizations are now experiencing bandwidth speeds of up to 200 Mbps, representing an increase of between three to 40 times previous speeds.

Organizations benefiting from the upgrade are:
Collingwood General and Marine Hospital, Collingwood · Huronia Medical Centre, Midland · Mental Health Centre Penetanguishene, Penetanguishene · Muskoka Algonquin Healthcare - Burk’s Falls & District Health Centre, Burk’s Falls · Muskoka Algonquin Healthcare - Huntsville District Memorial Hospital site, Huntsville · Muskoka Algonquin Healthcare - South Muskoka Memorial Hospital site, Huntsville · Ontario Telemedicine Network - Regional Office, Barrie · North Simcoe Hospital Alliance - Huronia District Hospital, Midland · North Simcoe Hospital Alliance - Penetanguishene General Hospital, Penetanguishene · North Simcoe Muskoka Community Care Access Centre - Main Office, Barrie · North Simcoe Muskoka Community Care Access Centre - Bracebridge · North Simcoe Muskoka Community Care Access Centre - Collingwood · North Simcoe Muskoka Community Care Access Centre - Midland · North Simcoe Muskoka Community Care Access Centre - Placement Coordination Service - Huntsville · North Simcoe Muskoka Local Health Integration Network, Orillia · Orillia Family Health Network, Orillia · Orillia Soldiers' Memorial Hospital, Orillia · Royal Victoria Hospital, Barrie · Simcoe - Muskoka District Health Unit - Head Office, Barrie · Simcoe - Muskoka District Health Unit, Huntsville · The Villa Care Centre, Jarlette Health Services, Barrie

Background
The North Simcoe Muskoka LHIN, with a total population of 435,000 people, is one of 14 LHINs across Ontario mandated to plan, integrate and fund local health services, including hospitals, community care access centres, community health centres, long-term care homes, mental health and addiction programs and a variety of community support services agencies. The LHINs oversee nearly two-thirds of the $37.9 billion health care budget in Ontario. For further information on the North Simcoe Muskoka LHIN, visit the LHIN here.

Smart Systems for Health Agency (SSHA) is an agency of the Ontario Ministry of Health and Long-Term Care, responsible for electronically connecting health care professionals to each other and to patient information. SSHA provides a common IT platform that helps health care providers access vital patient and health information they need to deliver better care. For more information, visit www.ssha.on.ca.

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]