June 25, 2007

Hardly Elementary: Creating a Successful RHIO
By Selena Chavis
For The Record
Vol. 19 No. 13 P. 12

Complicated organisms that can fall victim to infighting and inflated egos, RHIOs can also be powerful tools capable of sparking interoperability. Learn from these industry experts, who share their experiences on how to set up a winning team.

It has been touted by some as the first recognized regional healthcare information organization (RHIO)—and also as one of interoperability’s biggest success stories. Since the mid-1990s, the Utah Health Information Network (UHIN) has evolved so it now connects 100% of the hospitals, laboratories, local health departments, and mental health centers in the state to its working RHIO.

Add to that the fact that 95% of doctors are also connected and an overwhelming 85% of commercial claims are now paid within seven days, and it’s no surprise that Utah achieves healthcare costs at 25% below the national average.

While there is little dispute among industry experts as to the potential benefits that RHIOs can bring to a national healthcare framework, re-creating success stories like Utah’s has not been simple. According to industry experts such as Fred Richards of Ohio-based HTP, a technology company involved in the creation of UHIN and other RHIOs, there are currently high expectations and much discussion regarding the potential RHIOs bring as a first-wave effort toward building a national health information network (NHIN).

Richards says recent research indicates that as much as 20% to 25% of the U.S. population is currently “covered by a working health information exchange [HIE]” in some form. And while the movement is taking shape as these entities sprout up across the nation, he also acknowledges that it has not been without its setbacks as numerous RHIOs—some high profile, such as the Santa Barbara, Calif., project—have been laid to rest or are struggling to get off the ground as a viable, working organization.
So, what does it take to create an effective RHIO? Several industry professionals weigh in on their experiences—both successes and difficulties—in creating these complex entities.

A Clear Definition?
According to the HIMSS RHIO Federation Definitions Workgroup, the definition of a RHIO is “a group of organizations and stakeholders that has come together for the purpose of electronic data exchange and is focused on improving the quality, safety, and efficiency of healthcare delivery.”

According to HIMSS, a RHIO may also be legally defined as a “neutral organization that adheres to a defined governance structure which is composed of and facilitates collaboration among the stakeholders in a given medical trading area, community, or region through secure electronic health information exchange to advance the effective and efficient delivery of healthcare for individuals and communities.” The organization also denotes that the terms HIE and RHIO may be used interchangeably.

While definitions offer a broad understanding of these entities, the way they ultimately evolve and become defined depends on the resources and needs of a particular region, according to Laura Adams, president and CEO of the Rhode Island Quality Institute (RIQI), the governing body for the state’s RHIO. “The term region is so poorly defined,” she says. “For us, the RHIO really is the technological system that moves data from point A to point B … and the governance that surrounds it.”

Because the size of the state lends to a more close-knit geographic territory, the Rhode Island RHIO is much like that of the newly formed Bronx RHIO in that the region is clearly defined. Barbara Radin, executive director of the Bronx RHIO, says defining the geographic territory in their region is much simpler than what she sees happening in other areas of the state. “For us, it’s simply an HIE that is going to connect the health providers in the Bronx electronically,” she notes. “Looking at what’s going on around New York, it varies. It may be several large hospitals that aren’t necessarily geographically close.”

Richards points out that the definition of a RHIO does not specify whether the patient information exchanged is clinical or administrative, adding that many initiatives underway across the country are working toward clinical objectives without considering the administrative possibilities.

Laying the Ground Work
“Don’t send your lieutenants” was the early message sent by the RIQI, and, according to Adams, it has been the most important principle behind its success. “[The stakeholders] have been together a good six years, and the coalition is stronger than ever,” she emphasizes, adding that the stakeholders are made up of CEO-level movers and shakers in Rhode Island healthcare. “If you can keep the highest level people there, you can cut so much red tape.”

Alongside an influential board of directors is the need for a strong, neutral director of the initiative, says Richards. “I have not yet seen a successful RHIO that didn’t hire someone from the outside,” he recalls, adding that if it is solely volunteer driven, the work won’t get done. “You need to hire someone to drive the volunteers and keep them focused on the original mission.”

Visionary is the word used by numerous professionals to describe the type of person who should lead the process of getting a RHIO off the ground. Noting that he has witnessed executives with varied skills prove successful in this role, Richards points out that it’s not so much about the individual’s background. “It’s more about the person having the vision to bring it together … ensuring that things get done,” he says.

Radin concurs, adding that some RHIOs get too caught up in the initiative’s technology component. “It’s much more than understanding the technology,” she says about the need to understand the RHIO’s various players. “You’re building a system that works in a context, and you have to build something that’s going to work wherever you put it.”
The Rhode Island coalition realized early on the importance of garnering community support. “Most [RHIOs] miss that at the outset,” Adams asserts.

Groups that utilized the system frequently—such as older adults and parents of children with chronic conditions—were strongly in favor of the Rhode Island initiative from the outset, says Adams. For others, it took more time and education for them to realize the value.

Adams notes that the RIQI was also caught off guard during the early formation stages when a number of community and social services groups, such as the American Civil Liberties Union, mental health centers, and domestic violence groups, expressed opposition. “It became apparent that we would have to codevelop this,” she recalls. “We wanted those people at the table. It’s made the process harder, but we would not do it any other way.”

Establishing communication with state regulatory groups is also key to laying the foundation, notes Radin. Citing that the rules, regulations, and laws around privacy were written well before RHIOs were becoming mainstream, she says building something that conforms to those rules can be tricky, especially since the rules tend to be vaguely written.

“As we go forward, we are going to have to get approvals from the state and other entities,” she points out.

Baby Steps First
Establish a clear message and don’t try to tackle everything at once is advice offered by a number of functioning RHIOs. “Develop a business plan with a business ROI [return on investment],” says Richards. “If you start there, you will be successful.”

In the case of the Bronx RHIO, Radin notes that a passionate top-down approach has created a strong commitment to the project throughout the region. “The people on the board have an incredible commitment to this project and believe it’s an important component to improving health for patients in the Bronx,” she emphasizes, adding that the enthusiasm that starts at the top filters into committees and subcommittees. “The fact that we have the senior level people makes it a very clear message.”

Adams concurs, suggesting that “it takes a couple of well-respected leaders to say, ‘This is the direction we need to go.’”

To move forward as a functioning entity, Adams says a RHIO needs to have enough early funding to finance the first two to three years. While the bulk of the funding will likely come from participating parties, Radin says that some payers have provided or promised financial support for the Bronx RHIO. “We’ve convinced them that it will benefit them,” she says. “Coming from the payer side myself, I have an appreciation for the benefits to them … but ultimately, it’s not about finances. It’s about quality improvement.”

Begin the process with one focal point is the advice offered in unison by a number of experts. Using the HealthBridge and Indianapolis RHIOs as examples, Richards notes that those organizations began their initiative by focusing on an area—laboratory data—that could provide measurable results. “It has to be a return that all parties can expect to gain by working together,” he says.

In the case of the RIQI, Adams says the group’s first initiative centered around e-prescribing, and the state became the first to electronically link physicians to most of the pharmacies within its borders. According to Adams, 85% of pharmacies in the state are currently connected.

The Trust Factor
RHIOs are easy to launch but hard to maintain, according to Adams, who points out that “the reason they are hard to sustain is that organizations don’t build trust over short periods of time.”

Experts agree that the trust factor between organizations can be the make-or-break factor in the longevity of a community-based initiative. For Rhode Island, the answer was found by establishing a transparent approach to running the organization. “You would be hard pressed at one of our board meetings to tell who’s on the board and who isn’t,” she says. “If there is anything secretive, you can’t expect people to trust you.”

In the Bronx, the main thrust of the trust factor rested in how entities of varying sizes would come together as a unit. “One of the questions was who would have the influence. We decided everyone would have one vote,” Radin recalls. “Each entity has a vote, no matter the size or complexity.”

While that approach may work in more urban, closely knit regions, Richards points out that the issue of influence becomes more complex in rural areas, where the geographic boundaries of a RHIO are not as clearly defined.

He notes that often a large tertiary-care hospital may drive the initial formation of the RHIO, and “he who is funding the project is going to have more vote.

“A lot of RHIOs that are popping up are not as community-based but are more self-centered,” Richards says, noting a primary difference between urban and rural geographic settings. “They almost have to trust each other because they depend on each other.”

Richards says that building trust becomes more of an issue in urban environments where a region may have several highly competitive organizations that are reluctant to release clinical information because they want to keep close ties with certain specialty groups. In this case, Richards recommends starting the process of implementing a RHIO with an administrative function such as claims. Then, as the organization builds approval among its members, the RHIO can begin tackling the clinical environment.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

Expect the Unexpected
When the Rhode Island Quality Institute (RIQI) pulled together a number of influential physicians to begin discussions and make recommendations about electronic medical record (EMR) technology and adoption, no one could have predicted what would happen next, says Laura Adams, the group’s president and CEO, which serves as the governing body for the state’s RHIO.

After forming the Clinical IT Leadership Committee, the group short-listed vendors and decided to go into business together and sell EMR software. “They not only got together, they got enthused,” she recalls. “It sounds great unless you are looking through the eyes of another doctor.”

After receiving numerous letters from angry and concerned physicians, the RIQI decided the issue would create too much turmoil within the coalition, ultimately diminishing the efforts to build trust among members. “We had to put some distance between ourselves and that company,” Adams notes.

Fortunately, the group was able to separate itself from the newly formed EMR company without alienating members of the original group, Adams says.

— SC