are regional health information

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