Regional Health Information Organization

Regional Health Information Organizations (RHIOs) are key to the US National Health Information Network (NHIN). [ [http://www.whitehouse.gov/infocus/technology/economic_policy200404/chap3.html White House website] Transforming Health Care: The President’s Health Information Technology Plan, Promoting Innovation and Competitiveness: A new generation of innovation, April 27, 2004.] The Office for the National Coordinator has contracted with the National Alliance for Health Information Technology to lead workgroups of national experts in defining key terms including RHIO and to solicit public comments. The effort began in late 2007 and has submitted their final definition for public comment in May 2008. The status of this definition process can be tracked at the website: http://definitions.nahit.org/. Based on this process national expertise has offered the following definition of a RHIO - "A health information organization [HIO] that brings together health care stakeholders within a defined geographic area and governs health information exchange [HIE] among them for the purpose of improving health and care in that community." Fundamental to this definition is the meanings of Health Information Exchange and Health Information Organization. A Health Information Organization (HIO) is "An organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards." Health information exchange (HIE) is "The electronic movement of health-related information among organizations according to nationally recognized standards". Much of the information that follows was developed prior to these definitions and provides insight into the evolution of the RHIO concept.

RHIOs are multistakeholder organizations expected to be responsible for motivating and causing integration and information exchange in the nation’s revamped healthcare system. Generally these stakeholders are developing a RHIO to affect the safety, quality, and efficiency of healthcare as well as access to healthcare as the result of health information technology. Regions in the US continue to use various definitions of "multistakeholder organizations." For instance, in Wichita, Kansas the Clinics Patient Index is a software architecture as well as support environment that facilitates integration among outpatient clinics and hospital emergency departments. Other RHIOs are forming with multiple hospitals, while still others might include medical societies, payers and major employers.

RHIOs are a specialization of health information exchanges (HIE). Health information exchange (HIE) is defined as the mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate healthcare information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care. HIEs also provide the infrastructure for secondary use of clinical data for purposes such as public health, clinical, biomedical, and consumer health informatics research as well as institution and provider quality assessment and improvement.

Background/Motivations

Healthcare systems are highly complex, fragmented and use multiple information technology systems and vendors incorporating different standards resulting in inefficiency, waste and medical errors. A patient’s medical information often gets trapped in silos of legacy systems, unable to be shared with members of the healthcare community.

With increasing healthcare costs and looming Medicare bankruptcy, President George Bush issued an executive order for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of health care with the goal that most Americans will have an EHR by 2014.

In July 2004 the United States Department of Health and Human Services released their vision of how America’s healthcare system could be rebuilt during the next decade. [The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care, Tommy Thompson and Dr. David Brailer, Department of Health and Human Services, July 21, 2004.] That vision is in the process of maturing and the lead in this effort is the Office of the National Coordinator for Health Information Technology. [ [http://www.os.dhhs.gov/healthit/ ONC] Office of the National Coordinator for Health Information Technology ]

There are several motivations driving an effort to encourage integration and information exchange among healthcare providers. The high cost of healthcare has been a concern for some time and has been cited as a reason firms such as Ford and GM have struggled. Projections are that healthcare may soon amount to 20% of our GDP. [ [http://www.cnn.com/2006/HEALTH/02/22/health.carecosts.ap/index.html CNN.com] U.S. health costs on unyielding rise, Associated Press, February 22, 2006.] Beyond cost, changes in the healthcare system and the push toward RHIOs and health information technology are being driven by the need to increase quality. In 2001 the Institute of Medicine released the ""study that identified the significant issues facing the American healthcare system. Along with other reports the details were disturbing. Each year between 44,000 and 98,000 people die as a result of medical errors, [L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, eds., To Err Is Human: Building a Safer Health System. Institute of Medicine. 2000. Washington, D.C: National Academy Press.] [Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995;21:541-548.] 770,000 are injured due to adverse drug events, [Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995;21:541-548.] [Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997;277:301-306] [Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997;25:1289-1297.] hundreds of physicians stop practicing because of the high rates of malpractice insurance, and there is a shortage of more than 400,000 nurses nationwide. [Peter I. Buerhaus, PhD, RN; Douglas O. Staiger, PhD; David I. Auerbach, MS, Implications of an Aging Registered Nurse Workforce, Journal of the American Medical Association, Jun 2000; 283: 2948 – 2954.] As a result of these studies many efforts began to alleviate these issues.

The NHIN is comprised of "information-rich" technologies guiding healthcare professionals, "consumer-centric" applications giving patients control and choice, and RHIOs to diffuse knowledge and construct regional technologies as well as interoperability [ [http://www.nlm.nih.gov/csi/csi_home.html National Library of Medicine] Commission on Systemic Interoperability, National Library of Medicine, on June 20, 2005.] ["American Health Information Community," Office of the National Coordinator for Health Information Technology (ONCHIT), June 6, 2005, [http://www.os.dhhs.gov/healthit/qa.html Dept. of HHS] , on June 20, 2005.] among technologies and providers.

Current status

While 2014 is still some time away, more than 150 RHIO-type organizations have been formed. [ [http://healthit.ahrq.gov/ AHRQ National Resource Center for Health Information Technology] ] Inland Northwest Health Systems/Northwest RHIO (Washington), Taconic Health Information Network and Community [ [http://ccbh.ehealthinitiative.org/Awardee_Taconic.mspx Taconic] ] (New York), and California Regional Health Information Organization (CalRHIO) [ [http://www.calrhio.org/ CalRHIO] ] are common examples. Each of these examples were formed around a set of common purposes: reducing the increasing cost of healthcare services, improve the quality of healthcare services, and/or offer better healthcare services as a result of a better informed patient or healthcare professional. While there is some similarity to the earlier Community Health Information Network (CHIN) of the early 1990s, collaborations of multistakeholders for RHIOs appear to better informed and motivated and are therefore staying together during the formation stage. [ [http://www.nhinwatch.com/news.cms?newsId=1007 Patty Enrado, “Perspective: Real progress at CalRHIO,” NHINWatch, 3/1/2006.] ]

There is a RHIO development process. RHIOs begin by establishing a governance structure as well as a shared vision or motivation.

RHIOs then establish strategies to achieve the vision. Several strategies are typically identified and include: 1) identifying a technology and network infrastructure that will create the desired integration, 2) defining standards for data sharing, protection of data, and business practices to ensure patient protection while facilitating greater information sharing, 3) defining educational and business strategies that ensure appropriate use of greater health information technology and the sustainability of the effort, and 4) other technical and non-technical strategies that create health information exchanges.

RHIOs then embark on efforts to implement the desired strategies. Of the more than 150 RHIOs being formed a recent study has indicated that only nine have actually moved to this stage of development where health data is actually exchanged. [ [http://www.healthcareitnews.com/story.cms?id=4644 Fred Bazzoli, Report: RHIOs long way from action’, Healthcare IT News, 3/13/2006.] ]

Recently the National Coordinator presented an interesting and evolving perspective of RHIOs. The Coordinator’s perception is that once RHIOs implement the technology-based health information exchange, the final stage of development will occur as RHIOs focus on other aspects of healthcare system change. In other words, the expectation is that RHIOs will continue to provide their technology-based health information exchange as a service without requiring constant oversight by the multistakeholders. Consequently, opportunities will exist to use RHIOs and more importantly the collaboration as the means to achieve other goals for a community or region.

The short history of RHIOs indicate they will be formed at two levels – statewide RHIOs and local RHIOs.

tate RHIOs

CalRHIO

States will form RHIOs that create information exchange that meet a "common good" and encourage, promote, facilitate the creation and operation of regional RHIOs. CalRHIO is typically cited as the best example of a state RHIO because of its accomplishments and the participation by a variety of stakeholders. A state RHIO takes on many of the tasks that are difficult for a local RHIO to control. For instance, standards for interoperability between systems for health information exchange would be identified by a state RHIO until such time as there is a national standard. The state RHIO would address issues of privacy and security since state laws currently are responsible for insuring proper use of personal data. There are also efforts at the national level to develop a federal law that supersedes all state laws to create consistency and encourage health information exchange. CalRHIO has also taken on the role of facilitating change by supporting and funding projects that test or demonstrate a strategy that will ultimately make up the framework for the entire state. The state RHIO may also take on the charge to develop a technology-based component that would be unlikely for each local RHIO to develop. For instance, a state RHIO might develop the web service technologies and protocols that complement requirements to inform the state’s quality reporting or public health system. A statewide master index of patients has been considered by some states.

INPC/ IHIE

Another often cited RHIO is the Indianapolis Network for Patient Care (INPC) [http://www.regenstrief.org/medinformatics/inpc/] [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=225997] [http://content.healthaffairs.org/cgi/gca?allch=&SEARCHID=1&FULLTEXT=Indiana+Network+For+Patient+Care&FIRSTINDEX=0&hits=10&RESULTFORMAT=&gca=healthaff%3B24%2F5%2F1214&allchb=] that has been in existence since 1994 connecting all five major hospital systems (and over 15 separate hospitals) in the greater Indianapolis area. All INPC participants now deliver registration records, all laboratory tests, text reports, mediciation history and all UB92 records (diagnosis, length of stay, and procedure codes) for hospital admissions and emergency room visits to separate electronic medical record vaults in a central INPC server using a federated data store model. The message exchange standard that is used is HL7. The computer system standardizes all clinical data as it arrives at the INPC vault, laboratory, radiology, and other study test results are mapped to a set of common test codes LOINC with standard units of measure, and patients with multiple medical record numbers are linked. Each institution has the same file structure and shares the same term dictionary which contain the codes, names (and other attributes) for tests, drugs, coded answers, etc. When a patient is seen in any of the 11 emergency rooms operated by the consortium hospitals, and the patient consents, the information from all of these institutions about one patient can be presented as one virtual medical record. [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1480174] . Major stakeholders/ participants in this RHIO include: major and regional hospital systems, regional and national reference laboratories, state, federal, and private payors, pharmacy benefit management claims respository services, major physician practice organizations, individual providers, state government (Dept. of Health), major academic research institutions, and others.

One of the largest, actively functioning, and few self-sustaining health information exchanges involves the same group of medical informaticists from the [http://www.regenstrief.org/ Regenstrief Institute] in collaboration with the major hospital systems in the region. It is called the [http://www.ihie.com/ Indiana Health Information Exchange] . The first services delivered by IHIE include electronic delivery of test reports to physician offices using faxes, printers, or an electronic/ web based mail box (DOCS4DOCS Clinical Messaging System). Additional services currently available include Clinical Quality Services, which provide a "report card" (and incentives) on established quality messures to physicians, practice groups, employers, and payers. This is perhaps the first known use of regional clinical data in combination with administrative (claims) data to form a more complete picture of clinical care events. It is also a rare example of a self-sustaining HIE (not reliant on government grants). In this instance, an HIE may be a combination of more than one RHIO. The value of this approach is to aggregrate more patient records than could be done in any one region with more diverse representation for use in various research endeavors.

To get a customer's perspective on the use of a RHIO see the Medical Economics article: [http://www.memag.com/memag/article/articleDetail.jsp?id=182803 "Why these doctors love their RHIO"]

Other States

See the [http://ccbh.ehealthinitiative.org/profiles/default.mspx eHealth Initiative Directory] for profiles of all major regional HIE efforts.

To achieve the expectations of a state RHIO most organize so that specific issues are addressed by working groups of experts from other organizations. These working groups tackle technical, legal, organizational, funding and other aspects and then formulate findings/reports back to an oversight board.

An alternative to a state RHIO is being used by some states. For instance, Kansas has decided to use their government created Health Policy and Financing office and Kansas Health Policy Authority as the means to drive statewide health information exchange. While this was not the recommendation of statewide experts who encouraged the CalRHIO type model, it has demonstrated the “muscle” that states have as major employers and purchasers of healthcare services. For instance, the state along with a single payer are implementing a health information exchange pilot in Wichita using a product developed by Cerner based on the Continuity of Care Record (CCR). Unlike CalRHIO where broad coalitions create change, in “state” driven efforts key stakeholders drive change. TennCare in Tennessee has roots in addressing the state’s uninsured/underinsured population and is consequently more state driven. Utah’s efforts are based on the state’s prior efforts to process healthcare claims. Recent discussions in the U.S. Congress are on the development of a federal employee based electronic health record system thus creating what might be considered a national RHIO.

Local RHIOs

Local RHIOs will be new or adapted organizations that serve a particular region (Northwest, Taconic). Unlike state RHIOs it is anticipated that multistakeholder, collaborative models will dominate. As a fundamental base local RHIOs will create the technology and services that cause health information exchange within a region and to the rest of the NHII. There are many models to consider but a majority seem to be separate organizations created as non profits or supporting organizations.

Funding has been the difficult issue for many of these local RHIOs as well as how best to govern their operation given the propriety and sensitivity of the data. Models are evolving that describe potential sustainability frameworks for these local RHIOs. For instance, the Northwest model evolved out of a successful ‘supporting organization” where hospitals in the state of Washington each gave up independent control of their own health information technology and instead “contracted” with a separate organization to provide that service. In 2004 approximately 30 hospitals contracted to use the service and each made use of the same MediTech health information system as well as similar clinical department systems. From a technical perspective health information exchange in this type of environment is less challenging than in a climate where hospitals may have disparate systems, but there are still a myriad of organizational, legal and consumer challenges. Taconic in New York had a similar beginning as did Midwest Data Systems in Hays, Kansas. In this case the model was also driven by the need to share costs and make efficient use scarce resources such as information technology professionals.

Louisville, Kentucky is an early entrant into a community in which hospitals and physicians have disparate rather than centralized systems. In this instance the local RHIO is using a health record banking model involving a central community health record bank. Individuals and organizations will "deposit" and "withdraw" information from the health record bank by permission, similar to deposits and withdrawals of money in financial banks. The central "health record bank" information will link to the disparate systems at hospitals, physicians offices etc. This approach will support more complete information at the point of care for physicians and patients, while potentially reducing errors and duplications, thereby reducing rising healthcare costs. The revenues to support the effort will be paid for through subscriptions by individuals and/or their sponsors such as employers. Additional revenues may be generated for the local RHIO by providing special services to hospitals, physicians and payers.

Rural RHIOs

RHIOs continue to evolve. In the original vision of the NHIN it was anticipated that "…the government can play an important role in supporting their formation. One role is to ensure that RHIOs are formed in the major market areas and, to the extent possible, in rural areas." [The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care, Tommy Thompson and Dr. David Brailer, Department of Health and Human Services, July 21, 2004, pp. 17-18.] Only a few of the RHIOs in process are rural and it is difficult to find information that addresses the unique needs faced by these rural regions. As a baseline a rural RHIO’s region could be considered any multistakeholder region where a single purchaser of health services does not dominate and the subscriber base is less than the 100,000 anticipated by the eHealthTrust model.

While only a handful of conceptual contributions have been made to the rural RHIO concept, these contributions have presented a widely divergent perception. For instance, an early perception was “Rural RHIO efforts tend to actually be easier because many are starting from the ground up and the pressing needs – reduce costs, improve patient access – are more universal and clear-cut.” [Brunner, Lincoln, “IT guru Melissa Chapman: how to make health IT work for the bottom line”, Wisconsin Technology Network, May 31, 2005, http://wistechnology.com/article.php?id=1872.] Unfortunately while rural RHIOs may have been starting from the ground up, which was true of many urban RHIOs, the multistakeholder organizations who would be forming and then relying on the rural RHIO had in fact established technologies.

These established technologies made the issue of health information exchange anything but easy. Instead, there was greater variability in the technology base across these providers. Some were using fairly new, comprehensive, predominantly financial systems. Others had very old, unsupported systems. While still others had nothing. Some instances were like Midwest Data Systems in Hays, Kansas where 25 or more hospitals were sharing the same technology from a centralized technology center very much like the Northwest model. Regardless of the technology base two other issues were shared by this group. First, they each paid a high price for their technology ranging from $3,000 to $15,000 per month. Second, these providers had limited access to information technology professionals to support their systems and to educate their staffs. Third, most were receiving inadequate support from the vendors of their technology base and in some very striking instances were using technology from a vendor that no longer even existed and who had made no provision for another vendor to support the system. Consequently, the rural RHIO climate is probably the most unusual and difficult to change rather than the easiest.

Rural RHIOs must meet the special needs of these areas. [Quality Through Collaboration: The Future of Rural Health Care, The National Academies Press, 2005.] These unique needs identified in the IOM report include:
* Adopting a rural focus in the NHII.
* Insuring high-speed access to the Internet.
* Developing consistent regulations and payment policies.
* Offer or identify strategies that offer financial strategies for EHRs.
* Assist collaborations and demonstrations in rural areas.
* Offer or identify strategies for ongoing educational assistance.

Strategies to address these needs have yet to be identified.

Types of RHIOs

Centralized

In this configuration, all providers send their data to a central repository on a periodic basis (daily). The Santa Cruz Community or the Michigan UP Network function on this model, and they have been quite successful.

Pros
* Uniform data format – great for interoperability, care/disease management
* Cohesive, centralized, “whole” system, easier to access, maintain and control (e.g. role-based access)
* Research, population studies, public health

Cons
* Political: medical data ownership and control in a central location
* More complex implementations
* Cost sharing implications
* Scalability
* Privacy & Security issues

Federated (Record Locator Service)

The data stays at the point of service, and the RHIO has and manages a pointer to that information.

Pros
* Easiest and quickest way to achieve the NHIN vision – less data exchange interface work
* No conflicts over data ownership

Cons
* How to ensure authorized and legitimate access to third-party system
* Data control and availability not guaranteed
* Standards and profiles still being defined

Hybrid

The best of both worlds, using centralized and federated models based on each RHIOs setup, socio-economic, political and geographic environments, size and so forth. This third approach is most likely what is expected to happen as more regional communities get connected.

One hybrid model is to use a health record data bank (also known as a health record trust). In this approach, all data for each patient stays in a single repository (the data bank), but patients can choose which data bank to use for their records. [Castro, Daniel, “Improving Health Care: How a Dose of IT May Be Just What the Doctor Ordered”, The Information Technology and Innovation Foundation, October, 2007, http://www.itif.org/files/HealthIT.pdf]

Vision

Many experts consider RHIOs essential to the vision of creating a National Health Information Network (NHIN), which will distribute a unified patient record based on data from different information systems, formats, organizations and locations without affecting systems in which information is shared across decentralized, heterogeneous technology environments including hospitals, clinics, and physician practices - in a complete, accurate, real-time data exchange environment.

References

External links

* [http://www.os.dhhs.gov/healthit/ Office of the National Coordinator for Health Information Technology]
* [http://healthit.ahrq.gov/ AHRQ National Resource Center for Health Information Technology]
* [http://www.healthunity.com/handbook_busreq.aspx Core RHIO Business Requirements]

Current RHIOs

Some of the currently self-sustaining RHIOs to date (Source: First Consulting Group):
* HealthBridge, Greater Cincinnati area (Ohio, Kentucky and Indiana)
* [http://www.ihie.com Indiana Health Information Exchange]
* [http://www.regenstrief.org/medinformatics/inpc/ Indianapolis Network for Patient Care- Regenstrief INPC]

Other RHIOs/CHINs/HIEs:
* Michigan UP Healthcare Network
* [http://www.midsoutheha.org MidSouth eHealth Alliance]
* Massachusetts SHARE (Simplifying Healthcare Among Regional Entities) [http://www.mahealthdata.org/ma-share]
* Santa Barbara County Care Data Exchange
* Santa Cruz Physician Medical Group (IPA)
* Taconic Health Information Network and Community (IPA) (New York)
* Quality Health Network, Grand Junction, CO
* CareSpark (Central Appalachian Region – VA, TN, NC and KY)
* PeaceHealth (Alaska, Oregon and Washington)
* Western New York Clinical Information Exchange (WNYCIE) - HealtheLink [http://www.wnyhealthelink.com]