17 Dec Healthcare IT: In wake of Harvard study, experts call for new RHIO funding model
Madison, Wis. – A recent Harvard University report chronicling the slow pace of progress on Regional Health Information Organizations comes as no surprise to several healthcare IT observers, some of whom have been outspoken in predicting their failure and the need for a new financial model.
The study, based on a survey of 145 RHIOs, paints a bleak picture of the progress the organizations are making in advancing electronic patient data exchange. Electronic patient data exchange between hospitals and other clinical settings has been cited as a critical component of improving medical care, especially in emergency room settings, but the report raises fresh doubts about whether the goal is achievable unless changes are made.
“It really is the wrong concept at the wrong time,” said Peter Strombom, co-founder of the College of Health Information Management Executives and former CIO of Meriter Hospital in Madison.
Degree of difficulty
According to the report, one-quarter of the nation’s RHIOs are defunct and only 20 programs, at the time of the survey, had grown to a modest size and were exchanging at least some patient data. Five of those organizations were exchanging data for a specific patient population such as Medicaid enrollees, and only 15 shared clinical data across a broader range of patient types.
Julia Adler-Milstein, a doctoral candidate in health policy at Harvard and the study’s lead author, told Modern Healthcare that the findings indicate that comprehensive, nationwide electronic patient data exchange will be more difficult than anyone imagined. The degree of difficulty stems from the lack of public investment, which is basically been limited to start-up grants. The primary barrier is a lack of public investments to cover large upfront costs, and lukewarm interest from private stakeholders.
Many RHIOs initially are funded by grants, but when the grants dry up, project momentum is lost, which is why some have called for a more sustainable funding model.
John Wade, vice president of Saint Luke’s Health System in Kansas City and chairman of the Healthcare Information and Management Systems Society, said some RHIOs have attempted to act like a business without having done the due diligence expected from any business entity.
“You can’t run RHIOs on goodwill, and you can’t plan to fund them with only grant funds,” Wade said. “It’s like building a castle on quicksand.”
Wade compared the RHIO experience with the wagon train trek to California. Some made it in good shape, some made it after suffering great hardships, and some never made it, especially the early pioneers. “Nothing in the [Harvard] report is surprising because it’s exactly what KC REE has encountered as we’ve been trying to get our RHIO running,” he said, referring to the Kansas City Regional Electronic Exchange.
Dr. Barry Chaiken, associate chief medical officer of BearingPoint and chairman of WTN’s 2008 Digital Healthcare Conference, said a more robust public-private partnership is needed. He said healthcare is unique in that improvements made by one stakeholder don’t necessarily benefit all stakeholders, which means not every stakeholder has the same incentive to advance technology.
If an organization invests million in an electronic medical record, those who benefit include the patients and the insurance companies that pay for care, but the insurers are not required to give the provider organizations any money to implement the EMR. The same thing applies to RHIOs, he said.
“One payer that is altruistic may want to invest in this technology, but may pause because all other payers may choose to get a free ride and not make the investment,” Chaiken said.
Dr. William Yasnoff, managing partner of National Health Information Infrastructure Advisors, said if RHIOs are to be successful, they must address several complex and interdependent problems at the same time. The issues are related to network interoperability, establishing public trust, assuring stakeholder cooperation, and financial sustainability.
Yasnoff, founder of the eHealth Trust Initiative and the Health Record Banking Alliance, has promoted health record banking as the approach that best addresses all these issues. Under the banking method, states or regions create a central repository, or bank, for all electronic health records. Healthcare organizations would interface with the banking system, not with each other.
Consumers, meanwhile, would elect to have key elements of their medical records, from all sources, deposited in a health record bank, and the banks would allow aggregated copies of each consumer’s medical information to be shared when and where they are needed.
The banks would be financed with small monthly fees charged to consumers, who would consent to have their medical information shared electronically. Legal agreements would be set up between the consumer and the entity holding the record, which would be enlisted to act in the interest of the consumer – much like a legal trust relationship.
Whatever the eventual model looks like, Yasnoff said people who advocate any health information structure have an obligation to present a “clear and convincing” description of how it would operate when completed. “So far,” he said, “only the health record banking approach provides such a description.”
Yasnoff, a former senior advisor to the Department of Health and Human Services, is recommending several bills now before Congress that would set up or accommodate health record trusts.
At this stage, Adler-Milstein indicated that RHIOs have been successful with an incremental approach, and have found the clearest return on investment from exchanging test results from laboratories and imaging centers.
Perhaps mindful of state failures on large information technology implementations, some of which occurred due to overly ambitious project timetables, the state of Wisconsin appears content with an incremental approach to patient data exchange. One example is the Wisconsin Health Information Exchange, a RHIO established for healthcare facilities in southeastern Wisconsin.
WHIE’s first step will be to launch an Emergency Department Linking Project during the first quarter of 2008. The ED Linking project will provide emergency room physicians with specific patient information and contribute to qualitative improvements such as decreased testing redundancy, improved clinical decision-making, and fewer medical errors.
Dr. John Barthell, co-founder of WHIE, acknowledged the organization is working incrementally, trying to make sure it has “buy-in” among member facilities, engaging payer groups, and carefully evaluating each step. With the financially challenged state government limited in what it is willing to offer, which includes a $110,000 eHealth initiative contract for WHIE, the ED Linking Project has thus far been funded by a Medicaid transformation grant, by the five major health systems in the region, and with sponsorship help from Microsoft.
While testing ED Linking, Barthell said WHIE is evaluating the next piece – sharing lab results – and he expects the health systems to partially fund each incremental step.
He compared the sharing of electronic patient information between hospitals and clinics to the painful expansion of the railroad industry. A lot of the players failed, he noted, but that did not stop survivors from criss-crossing the nation with tracks.
“I’m aware that some of the [RHIO] efforts didn’t find any legs and closed shop,” he said. “Clearly, some underestimated the amount of effort it takes to make this happen.”
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