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Julia Adler-Milstein, Andrew P. McAfee, David W. Bates, and Ashish K. Jha The State Of Regional Health Information Organizations: Current Activities And Financing Health Affairs, January/February 2008; 27(1): w60-w69. [Abstract] [Full Text] [Figures Only] [PDF] [Technical Appendix] [Reprints & Permissions]

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The Problem Is Not RHIOs, It's Sequencing And Business Case

Peter Basch   ( 13 December 2007 )

RHIO Business Models

Donald L. Holmquest   ( 13 December 2007 )

The Future of RHIOs in New York

Rainu Kaushal, Jason S. Shapiro, Lisa M. Kern   ( 6 May 2008 )

The Problem Is Not RHIOs, It's Sequencing And Business Case 13 December 2007
Peter Basch, Medical Director, Ambulatory Clinical Systems MedStar Health Send letter to journal: Re: The Problem Is Not RHIOs, It's Sequencing And Business Case peter.basch{at}medstar.net Peter Basch	For a field that is too often defined by hyperbole and unbridled enthusiasm, I congratulate the authors on this sober analysis. While they are correct that the current market-oriented approach to health information exchange is experiencing great challenges, and may even be described as failing, I believe it is incorrect to assume that this approach per se is necessarily wrong. Rather, I believe we are experiencing this paradox of what should be successful not being successful, because of a problem with sequencing, and the current lack of a sustainable business case for health information and quality. The authors state that “the appeal of electronic health information exchange in general, and RHIOs in particular, is evident.” This is not entirely true. The appeal of electronic resulting is clear to physicians who practice with EHRs. For the majority of physicians who still use paper records, electronic resulting may actually lead to less efficient workflows and inappropriate conclusions and actions taken on results seen out of full context. And it should thus be expected that these physicians would not pay for something that was perceived as not useful, or even detrimental to their practices. But electronic health information exchange (HIE) is more than electronic resulting. HIE takes the additional step in aggregating (or virtually aggregating) information on a patient-centric level. This means that when a doctor views results in an HIE, the doctor is exposed to far more than what he/she ordered. He/she would see all information about that patient. Leaving aside (for the moment) the very real concerns of information overload, information out of context, care delivery confusion (e.g., unwanted multiple opinions), and unintended expansion of liability, what may appear to be a societal good to policymakers does not yet have a business case in medical practice. Until the payment schema for health care services extends beyond payment for episodes of care, and creates a better balance between payment for thinking and payment for doing, the market for health information exchange will be marginal to nonexistent. However, when the market for information mobility changes, the unsolvable dilemma of private funding for a public good goes away. Consider the emerging concept of the Patient-Centered Medical Home. A physician who practices within such a model practices under very different expectations, has longitudinal and cross-physician responsibilities, and is paid very differently. Under this model, one could reasonably expect that a physician would gladly pay for the enabling infrastructure of HIEs; without it, his/her work would be far less efficient. Conversely, the value proposition for a physician to engage with HIEs outside of such a model might be to pay for information that adds uncompensated work and unintended expansion of liability (e.g., the physician pays the HIE for the privilege of being an uncompensated medical home). The problem, then, is not with RHIOs and not with HIEs. In a health care system where all (or most) physicians used EHRs, and there was a sustainable and compelling business case for information management and quality, there would be a ready market for secure mobilization of health information. And once such a market existed, there would a clear and irrefutable business case for HIEs, and perhaps even for RHIOs.
RHIO Business Models 13 December 2007
Donald L. Holmquest, President and CEO California Regional Health Information Organization (CalRHIO) Send letter to journal: Re: RHIO Business Models dholmquest{at}calrhio.org Donald L. Holmquest	This article provides an excellent documentation of the issues and challenges facing health information exchange (HIE) efforts around the country. The lack of sustainable business models for HIE should not be surprising. While few would dispute the importance of having critical patient information available when and where it is needed, the question of who should pay for the service is still unresolved in the minds of many stakeholders. When CalRHIO began its developmental work in 2005, it was clear from the Santa Barbara experience that profitability and value creation were necessary elements to support the effort long-term. While CalRHIO spent more than a year and much of its resources developing the prerequisite consensus among a wide universe of stakeholders, the majority of its focus since that time has been to develop a sustainable business model. Grants and gifts from a number of benevolent organizations have been critical in providing CalRHIO with the capacity to research stakeholder needs and find a technology solution and value proposition that meets them. However, the future for California and for all other states and regions is dependent on stakeholders paying for the benefits they derive from HIE. The irony is that HIE benefits everyone -- those who receive health care (patients), those who pay for it (purchasers and payers, including governments), those who use it to speed the delivery of diagnostic results, and those who use immediate results to make better decisions about which medical services to deliver (providers). At CalRHIO, we believe that those who benefit from HIE should contribute direct financial support proportional to the benefits received. The other principle we subscribe to is that unless alternative sources of financing are developed, front-loaded expenses associated with construction of the HIE will penalize early adopters and reward those that sit on the sidelines. CalRHIO’s financing model is unique in that the ultimate users of the services are not asked to underwrite the initial development and implementation of the exchange; instead, they will pay only when services that they want to use become available, and as they use these services. If providing secure access to medical records at the point of care were easy, it would already be done. It is important to acknowledge that most of the struggling organizations surveyed in this report have envisioned HIE as a critical step in quality and safety improvements and a driver of new efficiencies. They launched their efforts, knowing the obstacles, because these benefits greatly outweighed the costs in a broad social calculus. While surely no slight was intended, none of these organizations deserve to be viewed as failures or novices. Rather, they should be recognized as the pioneers they are. As with any other emerging industry group, the early phases are always challenging, and the business models, market entry strategies, and services themselves evolve rapidly during this period. In the absence of federal or state grants to underwrite the costs of HIE service deployment, we believe that it will be difficult for most early efforts to transition from the stage of convening stakeholders to the actual launch of full HIE services because of the lack of serviceable business models. This is the challenge that CalRHIO has taken on. As a wise soul once said, the decision to go into battle can only be justified if one of two conditions exists: either victory is certain or the battle is worth losing. These pioneering organizations, as well as those that come after, should be acknowledged for their willingness to engage. In mid-battle, however, the task is always to assess the field and determine the strategies that will ensure ultimate success.
The Future of RHIOs in New York 6 May 2008
Rainu Kaushal, Associate Professor Cornell University, Jason S. Shapiro, Lisa M. Kern Send letter to journal: Re: The Future of RHIOs in New York rak2007{at}med.cornell.edu Rainu Kaushal, et al.	This article presented significant challenges facing regional health information organizations (RHIOs) and their subsequent high rate of failure. Challenges to RHIOs include achieving financial sustainability, obtaining adequate stakeholder buy-in, and developing privacy policies that protect patients while allowing health information to flow easily between authorized providers. Through the Healthcare Efficiency and Affordability Law (HEAL NY), New York State is approaching these challenges in five ways: 1) committing $200 million in implementation contracts to health information technology (IT) projects across the state; 2) establishing the New York eHealth Collaborative (NYeC), a public-private partnership to address policy issues surrounding health IT; 3) developing a statewide privacy policy; 4) establishing the Health Information Technology Evaluation Collaborative (HITEC) for New York State to perform rigorous, independent evaluations of grantee projects; and 5) developing an operational definition of a RHIO and common services for a Statewide Health Information Network of New York (SHIN-NY). Through the SHIN-NY, health information will be shared among the RHIOs for clinical care and be made available to appropriate parties for biosurveillance, quality measurement, and other population health initiatives. The SHIN-NY will also allow for state-level integration with future nationwide health information network (NHIN) standards. No doubt some RHIOs will succeed while others fail. Although many in health care and related fields believe a priori that widespread health information exchange and interoperable electronic health records should improve efficiency and quality, this remains to be proven. It is essential that adequate funding and policy guidance be provided to RHIOs to optimize their likelihood of success. It is also essential that adequate funding be directed toward rigorous evaluation of RHIOs’ efforts, in order to maximize understanding of what worked, what did not, and why.