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| George T. Schwend |
With demonstrated presidential and congressional support for the creation of a national health information network (NHIN), the industry has turned its attention to the regional health information organization concept, widely seen as a gateway to the broader national network.
RHIOs allow providers to exchange health and patient information within a specified geographic area and empower patients to change providers without fear of losing or delaying their medical records.
Additionally, RHIOs and the NHIN are seen as foundational structures for a unified public health surveillance system; performance and quality monitoring of patient care; and improved dissemination of clinical research to practitioners, researchers, sponsors and the Food and Drug Administration. The real-time delivery of scientific discoveries would speed communication of research to clinicians at the point of care through integration with national databases of clinical decision support.
David Brailer, M.D., Ph.D., former national coordinator for health information technology, stated at the 2006 annual conference of the Healthcare Information and Management Systems Society that he envisions RHIOs in every state, where they would provide guidance for the development of health care IT applications. State RHIOs would act as parent organizations for local RHIOs.
But critics and fans alike are pausing to ask, “Will this new iteration of health care data exchange finally deliver the promised cost efficiencies and improved quality of care?”
To answer the question, it’s helpful to examine one of the most commonly known models of the early community health information movement to determine its weak links and analyze the lessons learned from its failure.
What Worked, What Didn’t
Community health information networks (CHINs), often called the “network of networks,” was a popular concept in the mid-1990s. The model found initial success with its focus on administrative simplification and communication links between health care stakeholders without the need for data centralization.
However, its market penetration was limited by challenges in several areas:
- Lack of industry standards for electronic data exchange
- Immature technology that was unable to adequately address inter-enterprise connectivity and interoperability issues
- Stakeholder politics that prevented competitive health care organizations from working cooperatively
- Health care providers’ lack of trust in the overall process, combined with a fear of loss of control over patient information, particularly regarding privacy and security of patient data
- Lack of clear ownership over data systems and information,
- Uncertainty in sustainable funding and value delivery
Although CHINs and other pioneering community health information models did not gain full acceptance, increasing health care costs for all stakeholders and top-down encouragement from the federal government has fanned the flames for continuing a community-based health care exchange experiment with the hope of attaining significant improvements in the quality, safety and cost-effectiveness of health care.
The Future Is Wired
Advancements in technology have addressed many of the obstacles that CHINs were unable to overcome. One of the most significant technological breakthroughs was the widespread adoption of the Internet. As both a medium of data exchange and an interactive communications tool, the Internet’s market penetration has greatly contributed to the elimination of organizational silos and cultures of isolationism.
Equally important is the establishment of industry standards such as HL7, a messaging standard that enables disparate health care applications to exchange clinical and administrative data and has led to the development of groundbreaking technologies that ensure interoperability among various intra- and inter-organizational networks.
These technologies include language and integration engines that allow and support centralized control access to medical terminology standards and generate mapping to create a common pool of standardized codes and concepts. Moreover, these solutions provide standards for modeling, storing, updating and distributing information accurately, consistently and securely for interoperability between the constituents of a RHIO and between other RHIOs under the NHIN umbrella.
Further, the passage of HIPAA has required vendors to supply IT solutions that maintain a level of privacy and security that not only meets regulatory requirements but also provides a sense of confidence among health care providers and consumers. This growing trust and improving attitude toward sharing secure, private information with other RHIO members has increased clinician adoption of new solutions.
The financial model continues to be debated. The Department of Health and Human Services has agreed to spend $139 million over five years on direct assistance to select pilot RHIOs and support for their activities. However, the government prefers that ongoing funding be sustained by the RHIOs themselves.
Many RHIOs have found success in requiring members to invest in the fixed costs, as opposed to charging a transaction or service fee. Participants leverage economies of scale by sharing the upfront fixed costs and other costs associated with the launch of community connectivity, as opposed to proceeding with individual, often redundant, non-interoperable solutions.
Lastly, health care leaders have realized that creating communitywide connectivity requires more than new technology: it requires the human elements of leadership, vision and a dedication to achieving tangible return on investment. With this in mind, successful RHIOs have embraced the following strategies:
Slow is better: When establishing a RHIO, incremental steps should be taken when addressing the multitude of challenges within technology, funding and governance.
Focus on small wins first: Members of a RHIO are typically enterprises responsible for obtaining a respectable return on their investment of time, training and other resources. The RHIO rollout should include quick, initial wins to create goodwill, strengthen commitment and demonstrate value.
Make physicians champions early on: Physicians offer unique, reality-based perspectives on patient care that enhance the creation of RHIO processes and standards. To encourage physician participation, the benefits of improved efficiency, quality and safety of patient care should be clearly communicated. Physicians will then embrace the opportunity to champion the RHIO model, thereby providing the most efficient method of increasing clinician adoption and participation in the organization.
Require investment by RHIO stakeholders: Mirroring human nature, organizations will put forth more effort into the RHIO development and success if they have personally invested in the venture.
Get government involvement for positive benefits: Government plays an important role in creating a functional national network. By identifying and requiring the adoption of and adherence to industry standards pertaining to RHIOs, the government creates the “playground rules” that help ensure interoperability among the various health care IT solutions utilized by RHIOs--and, more importantly, between the RHIOs themselves as they eventually form the NHIN. Moreover, the government may offer seed money and provide influence to encourage collaboration among competitors as well as increase awareness and support within the industry.
Complement staff with professionals from all sectors: Professionals from both inside and outside the organization often bring technical expertise, business acumen and strong health care industry involvement, all of which complement the strengths of the RHIO staff.
Don’t underestimate privacy concerns: Every stakeholder, from the provider to the consumer, is concerned about the security and confidentiality of patient data. By consistently and clearly communicating all efforts being taken to preserve privacy, consumers may be less likely to push for restrictive legislation requiring opt-in requirements for RHIOs. To complement this strategy, RHIOs could also focus on soliciting positive feedback and tacit approval from physicians and pharmacists, both of whom are perceived as the most trusted sources of medical advice by consumers.
As the nation’s health care stakeholders evaluate the various solutions proposed to improve the delivery, safety and quality of health care, community health information models continue to rise to the top. Due to the latest technological advancements, the RHIO concept now has real potential to allow secure sharing of patient data--in real time--across expansive geographical areas without necessitating a centralized, community-based data repository.
RHIOs also benefit from the hard-won wisdom of past health care models such as CHINs, empowering new RHIO members with established best practices for this next stage of health care delivery.
George T. Schwend is president and CEO of Health Language Inc., Aurora, Colo.
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This article first appeared on April 18, 2007 in HHN's Magazine online site.
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