Monday, November 26, 2007

Are Regional Health Information Organizations (RHIOs) Sustainable?

As CEO of the Massachusetts Regional Health Information Organization (RHIO) called MA-SHARE, I have spent 4 years working with stakeholders in Massachusetts to create a sustainable business model for health information exchange.

MA-SHARE’s first effort in 2004 was the MedsInfo project, a state-wide medication history exchange pilot based on payer claims data. We learned a great deal about privacy, workflow, data expectations, and health information exchange operations. The project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations given the lack of integration of the data into clinician workflow and the inherent incompleteness of the data (only 66% of patients had medication data in our regional payer databases as of 2004). As of 2007, the two largest national e-Prescribing exchanges, RxHub and SureScripts, have much more complete networks and we've integrated the former MedsInfo functionality into our e-Prescribing utility, described below.

In 2005 and 2006, working with the Markle Foundation and the Office of the National Coordinator, we developed a Nationwide Health Information Network implementation pilot based on a state-wide master patient index called the Record Locator Service. The pilot demonstrated the value of the emerging clinical data exchange architecture to support provider-to-provider data exchange, personal health records, and biosurveillance. The architecture worked well, but the project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations required to maintain the Record Locator Service.

In 2006 and 2007, we implemented a state-wide e-Prescribing gateway. We've transmitted over 100,000 electronic prescription transactions through our exchange and we are live with formulary enforcement, eligibility checking, dispensed medication history including drug/drug interaction checking and routing to retail/mail order pharmacies. The stakeholders have found value in paying for the cost of ongoing operations of this infrastructure since it reduces costs to the payers by enhancing the use of generics/formulary medications, it reduces costs to pharmacies by eliminating paper workflows and it improves workflow for providers by streamlining renewal workflow. We've implemented our e-Prescribing gateway at CareGroup, Partners and soon Children's Hospital. We will work in 2008 to expand the use of the gateway to connect to vendor systems such as Cerner and Meditech, as well as to encourage its use in more institutions.

In 2007, we implemented our "push pilot" using national standards to share discharge summaries and emergency department summaries among caregivers. We use the same software application that routes prescriptions between providers and pharmacies to securely route documents provider to provider. This clinical data exchange approach is truly low cost and simple. All that is required is a sender which can summarize tabular and narrative data in the format specified by HITSP and an organization which can receive this data via direct integration into an electronic health record, secure email or fax. Cerner, MEDITECH, eClinicalWorks and GE Centricity are among the EMR vendors supporting the design and implementation of this project. We are optimistic that the value to the stakeholders of exchanging clinical summaries will be sustainable based on cost avoidance. By eliminating the expense of chart copying, mailing, and paper-based record storage, hospitals seem willing to fund health information exchange of summaries out of projected cost savings. It's also a great political win for the hospital, since pushing clinical summaries keeps the primary caregivers and referring physicians well informed, enhancing their satisfaction. It provides care continuity by ensuring all caregivers (inpatient, outpatient, Emergency Department, rehabilitation, and long term care facilities) are given a consistent medication list, problem list, laboratory summary, and discharge narrative. As personal health record services such as Microsoft HealthVault, Google's Health efforts and Dossia through Indivo Health are more widely deployed, we may also push data directly into personal health repositories at patient request.

MA-SHARE’s budget in 2008 is approaching the same kind of sustainablity we've achieved with our financial data exchange, NEHEN. All 'lights on' operations are funded by the stakeholders plus $250,000 is available each year for new projects and enhancements. No grant funding or soft money source will be used in 2008. Our hope is that more stakeholders will sign up to participate in MA-SHARE over time, further funding research and development of high value health information exchange products for our community. The big lesson learned in our statewide initiatives, MA-Share and NEHEN, is that grant funding and large stakeholder (academic medical centers/payers) contributions precede sustainability. To achieve sustainability, the initial efforts must be expanded to meet the needs of the common marketplace. We believe our push model addresses this issue.

Health Information Exchanges in the US are in tenuous financial shape. We've been exploring sustainable business models in Massachusetts for 4 years. Many RHIOs still depend on grants, which eventually end and thus are not a good business model. I believe that Health Information Exchanges will evolve to meet the local business needs of many communities but that a nationwide health information network linking together these local exchanges will not be widely deployed until more consistent funding is available. In many ways, data exchange is a public good, which is hard to support entirely from local stakeholders. Additional funding from federal and state sources would help. The level of investment in healthcare information exchange in Canada and the UK far exceeds that in the US. I hope that Bush's 2004 commitment to have every clinician in the country wired by 2014 will be met with increases in funding to support it.