From Struggles to Success

Perhaps it might be a bit "Zen" (or Dickensian)—sounding to say it, but from all the evidence at hand, now may be both the best of times and the worst of times for regional health information organizations (RHIOs). For while more RHIOs than ever have sprouted up across the country (no one can say definitively how many RHIOs exist, but there are certainly dozens in at least the initial stages of development), many seem to be in trouble or struggling, and a number have already shut down operations. All this is happening just a few years after the RHIO concept rocketed onto the main stage of healthcare industry attention.

RHIOs in Santa Barbara, Calif., and Maryland have shut down, while others are doing relatively well. Of course, there are nearly as many types of RHIOs as there are RHIOs, which makes assessing what's going on even more complicated.

Certainly, industry experts agree, the first, heady days of the RHIO boom are over, and it's harder sledding from now on. Has the healthcare industry been riding a RHIOs hype rollercoaster? "Absolutely," says Keith MacDonald, "there's been no bigger one since HIPAA" (the preparation for the implementation of the federal Health Insurance Portability and Accountability Act of 1996).

And now, says MacDonald — a research director in the Lexington, Mass.-based Emerging Practice Group at First Consulting Group (Long Beach, Calif.) — "There are some real concerns. The initial funding was plentiful for a few years. But now there's a lack of ongoing funding and, in addition, there is the challenge of really making these things work from a governance perspective."

In fact, MacDonald says, more of FCG's clients lately have been integrated health systems and networks, and individual hospitals, all creating health information exchange with their physician group and laboratory trading partners, rather than what are normally considered to be RHIOs. Why? "Because it's hard. The governance issues, and getting multiple stakeholders to agree on the business model, the governance model, and a common data set, are all proving very difficult."

That's not to say there aren't fully functioning RHIOs that are doing well. For example, in southeast Wisconsin, the five major hospital systems in Milwaukee County came together in 2005, along with state public health authorities and Redmond, Wash.-based Microsoft Corporation (through Azyxxi, a company Microsoft had recently acquired) to create an emergency department-focused RHIO. The first three Milwaukee hospitals went live this summer, sharing information on ED visits and patients (many of whom have no established primary care physicians and are Medicaid enrollees or uninsured). The Southeast Wisconsin RHIO is transitioning to a mix of provider and health insurer subscription funding (while retaining some state grant money).

In Colorado, care quality improvement has been the focus of a RHIO based in Grand Junction that has brought together major hospitals, small critical-access hospitals, medical groups, and health plans, across the vast, largely rural, expanse of western Colorado. Participants in that RHIO have been exchanging data actively since October 2005.

And in Massachusetts, two whole communities — Brockton and Newberryport — have crated community-wide RHIOs to exchange patient information, RHIOs that also encompass a PHR (personal health record) aspect that is consumer-centric.

Back to school

So what are the lessons being learned from these successful RHIOs, as well as from RHIO failures? Focus, purpose, business and governance model viability, broad stakeholder buy-in and commitment are the absolute keys to RHIO success, say all those involved. In contrast, RHIOs that have collapsed have been weak in one or more of those areas.

For example, a statewide Maryland RHIO that ran out of steam earlier this year, the MD/DC Collaborative for Healthcare IT, began back in 2002 and puttered out this May. What happened? Though, "The basic goal was to create a patient-enabling information exchange capability, so that a patient would have data portability," says Satish Jha, principal of JM Consulting, LLC, Bethesda, Md., in practice, says Jha, who was an at-large member of the RHIO's board, "No data was ultimately exchanged. The hospital CIOs were afraid that it would expose the weaknesses of their information systems. So they kept finding ways to delay progress."

The Maryland RHIO' demise offers a few key lessons, says Thomas Durel, a former CIO of Blue Cross Blue Shield of Maryland (based in Owings Mills) and an IT professional who manages a few different outsourced IT departments across the country.

"When RHIOs are talked about as being for the benefit of the community and from an altruistic viewpoint, you get a lot of cooperation and people going to meetings and so on. But when it comes time to fund it and determine what benefits specific entities will get from it, it essentially falls apart," says the Rockville, Md.-based Durel. board, "The benefit proposition just hold water to different constituencies. Probably the largest benefit goes to the vendors. The hospitals have the challenge of integrating things themselves."

However, when the goals and vision are specific, an exchange can be successful, says Edward Barthell, M.D., an emergency physician who is helping to lead the Wisconsin Health Information Exchange (WHIE), Milwaukee, the Southeast Wisconsin RHIO focused on emergency department visits.

In WHIE's case, getting the CEOs of all the major health systems in the Milwaukee metropolitan area to commit to the project, through the Milwaukee Health Partnership, has been "invaluable. The chief medical officers tend to get it right away, they tend to be very supportive. They understand the problems the clinicians are having," says Barthell.

Convincing the hospital CIOs to participate takes more effort, he concedes. But if the benefits are clearly focused and laid out for all stakeholders, sustained success is possible.

"The success criteria need to be pretty focused and stay focused," agrees Dick Thompson, executive director of the Grand Junction-based Quality Health Network (QHN), the quality improvement organization that is sponsoring the Western Colorado RHIO. "Try not to be all things to all people."

For example, QHN, when preparing to connect a potential new physician practice to the network, meets with that practice' leaders to ensure they get specific benefits of value from joining the network.

And though numerous RHIOs can be expected to fail in the next couple of years, a large number will succeed as well, natural, says Sumit Nagpal, which is only founder and CEO of Wellogic, a Cambridge, Mass.-based interop-erability and health information exchange company that is helping to operate eight live RHIOs, including the Brockton and Newberryport, Mass. community-wide RHIOs.

"Many RHIOs will simply fail, that's just a given," Nagpal says. "And I agree with the assertion that for RHIOs to succeed, they need to have very strong business models that are real businesses, and not dependent on continued handouts."

In addition, those RHIOs that do succeed will have strong governance models that engage collaboration across communities, and that provide real value, Nagpal says. And, he adds, being ambitious enough to ensure that coded data is at the foundation of a RHIO's data exchange is essential. He questions whether general, non-coded clinical data (which can't be manipulated or easily shared) is worth passing around in the first place.

On a positive note, he adds, "This is the most exciting phase of RHIO development, because the solutions we're trying to reach for are very hard, and achieving scale is very challenging. We need many experiments to complete, which will either succeed or fail; and then there will be some consolidation. But this is a moment of creativity and invention right now in this industry."

Mark Hagland is a contributing writer based in Chicago

Sidebar

RHIO Steps to Success—A Sarcastic Look

Are the real RHIO keys to success more about hot air than about healthcare?

The following comes from Mr. HIStalk's blog, http://www.histalk.com.

Guide to RHIOs for CIOs, in easy steps:

Participate eagerly in meetings with your competitors as they talk about sharing data, making sure to speak in generalities and offering no participation beyond attending more meetings.
Go back to your co-workers and sneer at how stupid your competitors are and how backward their systems are compared to yours.
Report back to your fellow VPs that there's really nothing in it for your organization, but that you'll listen politely and avoid all commitments just so no one gets mad.
Respond to latest of 100 surveys asking about RHIOs, making sure to wax poetic about the wonderful possibilities that will result from the electronic hand-holding that RHIOs will bring, knowing full well it won't happen until benefits are offered to those involved.
Go back to your co-workers and make fun of all the folks who've forgotten CHINs and therefore are doomed to repeat history.
Ignore sales pitches from vendor RHIO participants who got involved only to troll for new business.
Go back to your co-workers and make fun of the IT organization of the local IPA or medical society, consisting of one doctor's brother-in-law armed with an AA degree and an A-Plus certificate.
Prioritize your IT shop's involvement in RHIO work somewhere between "get rid of all the cubes and give everyone an office" and "seriously consider moving all desktops and servers to open source operating systems."
Go back to your co-workers and explain to the bright-eyed among them who ask about RHIOs that it's "no margin, no mission" and that it will be a cold day in hell when you voluntarily share your exquisitely created and managed information with the clueless barbarians across town with their pathetic IT systems.
Get on the speaking circuit and HIMSS advocacy groups to make sure your attendance at RHIO meetings is rewarded with industry visibility as a RHIO thought leader.