From the December 2005 Issue
The toughest RHIO integration challenges are not technology-based.
By John Smaling
Remember how difficult it was to roll out enterprisewide orders and results, or group efforts to maximize adoption rates once CPOE went live? Who can forget the pain and suffering involved in bringing an e-MAR live? In their own ways, these were all Herculean efforts that transcended pure systems implementation and, ultimately, revealed themselves as lessons in human behavior and, in some cases, cat herding. Now, multiply those experiences by 10, sprinkle in a root canal and behold multiple attempts to launch regional healthcare information organizations, or RHIOs.
RHIOs are the feel-good story of the year that, collectively, are going to transform healthcare (no, we mean it this time). RHIOs represent the initiative wherein physicians, healthcare systems, payers and business at large are going to harmoniously play in the same sandbox, light scented candles and set aside individual interests for the collective good.
It’s easy to fall prey to a feel-good story. In spite of what the major players may think, there is definitely a herd mentality in healthcare. No one likes a bandwagon-jumping contest better than healthcare stakeholders. Even the most sterile imaginations should have no trouble envisioning hundreds of relatively simultaneous RHIO efforts pulling away from port on their maiden voyages.
A current inventory reports that on Sept. 10, 2005, roughly 150 individual RHIO-related initiatives were under way across 41 states. Sadly, a disproportionate number of these will not achieve long-term viability. Some that appeared in a blaze will vanish as quickly as they arrived.
This is most unfortunate, because the regionalization of healthcare information exchange is a terrific way to ultimately feed a national electronic health initiative. In the age of HL7, XML, LDAP, pervasive broadband presence and the real maturation of Web services, the technology needed to “wire” a RHIO is well within our grasp. But technology is not going to be the determining factor in bringing the RHIO concept to reality. We are: People are. RHIOs that strike an appropriate balance of incentives, trust, messaging and sense of community are those that hold the greatest promise for success.
A myriad of considerations must be managed and balanced in the care and feeding of a RHIO. Most have nothing to do with the technical aspects of systems integration, but all have a great deal to do with integrating the minds and interests of RHIO participants.
Retain an Effective Champion
Look at any successful organization; at its helm is an effective leader who can be described with words like strong, intelligent, decisive and determined. Those who serve as champions of RHIOs must possess all of these qualities—and more, and in very large measure, because of the dynamics of the stakeholder groups involved. RHIOs are comprised of highly diverse participating members who often have competing interests. The stereotypes behind these competing interests are widely known:
• providers are practicing irresponsible, costly healthcare;
• payers are overcharging businesses and paying too little to providers;
• businesses are charging employees too much for too little benefit.
Inherent in the stereotypes is an innate lack of trust, a critical requirement of RHIO-building success. Equally as challenging is the fact that among competitors, that which benefits one party is unlikely to benefit another. It may even be perceived as a loss or a direct hit.
These powerful complexities require a leader who possesses large measures of persuasiveness, diplomacy, business-sense, tenacity and charisma. “The most important aspect of my job is to integrate the hearts and minds of the people involved. Keeping the purpose of the RHIO front-and-center is a huge challenge,” says Laura Adams, president and CEO of the Rhode Island Quality Institute. “It’s very easy to get immersed in the latest technology challenge or funding complexity, but it’s imperative to raise as a constant reminder the real purpose of the RHIO.” Individuals capable of successfully shouldering the responsibilities of RHIO leadership are rare. Identifying the right person for the job is the primary key to success.
RHIO leadership is an extraordinarily difficult role, not to be underestimated by onlookers to the process. The constant struggle to balance the delicate trust between members, consistent mission and goal reinforcement, funding and incentives and community support is genuine and can wear down the strongest of leaders. Maintaining an interested and invested membership over the protracted period of time required for a RHIO to gain momentum might erode the mettle of the best of the best. Providing support, a confidential ear and other incentives to RHIOs champions will help to keep them at the helm where they are needed, leading the RHIOs.
Establish a Core Set of Goals
In an environment of diverse and possibly opposing interests, it is imperative that a set of unifying goals be established. These goals serve several purposes. They act as a litmus test by which all tactical initiatives can be gauged as in the common interest of the membership. They serve as a behavior moderator by calling out self-interested behavior that may be in conflict with the overall agreed upon goals. They also serve to measure the success of the RHIO.
Goal setting should be balanced and carefully crafted such that benefit is attainable for each constituent group. There must be something of benefit for everyone among the list of targeted outcomes. Goal setting must be based upon honest and open dialogue. The RHIO leader must promote direct discussion that clarifies each member’s interests, areas of competitiveness, and how far each one is willing to go financially and in expending effort to reach objectives. Navigating through these areas at this early stage helps the team understand each other’s thinking and also helps to identify if changes in team composition are warranted.
Goals must translate into actionable, well-defined initiatives. Sequence these in the spirit of a crawl, walk, run approach. Prioritize goals that provide a realistic blend of clear benefits and that are achievable in the shortest timeframe possible while, at the same time, represent manageable risk.
An overly complex goal can represent too great an effort for such a fragile team in its early stages. An example can be found in HL7’s formative history. Jim Gabler, research director at Gartner, was an integral part of the team credited for HL7’s success. “A key to HL7 gaining traction was the fact that we started with an area of standardization that people could do something with right away: a set of ADT transactions. A competing transaction standards body tried to start their initiative by creating standards for a worldwide medical record number. They failed, while HL7 succeeded.”
Consumers Need Privacy and Security
After several years of HIPAA efforts, players in the healthcare sector are very familiar with the terms security and privacy and what they mean for provider and payer organizations. However, a RHIO presents a more complex model. The transition from maintaining data within the virtual walls of a health system to a wider ranging set of participants will concern patients and their families.
When this level of information exchange occurs, the opportunity for an unwarranted event can arise. Other sectors that have achieved a high degree of e-commerce (remember those 1.2 million records “lost” by Bank of America?) can bear witness. Community education to help balance the risk/reward equation must be incorporated as part of the RHIO’s communication strategy.
RHIO payer, provider and business members should engage in closer and more frequent dialogue with the public so that they understand the benefits that the community derives in a higher quality of care at a more affordable level, because of this increased exchange of electronic information. Adams concurs. “The issues of privacy and security do keep me up at night. Systems must be developed that not only toggle share-ability off and on, but precisely what can be shared,” she says.
However, the notion of controlling “precisely what can be shared” raises complex issues. A principal tenet of a RHIO is to support the mission of improving patient safety. To optimize a clinician’s ability to accomplish this goal, isn’t a more complete clinical record necessary? By allowing exchange of only piecemeal information, do we elevate the opportunity for errors? This consideration certainly is supportive of the notion that, if you’re in, you’re in all the way. But does this concept risk lowering a patient’s willingness to participate in the RHIO?
Opting In or Out
The legal and philosophical considerations surrounding the RHIO’s right to leverage the data collected by its participating organizations are both complex and clouded. Many RHIOs today favor an opt-in strategy, in which patients are consulted on the use and value of information exchange and then asked to grant consent to allow their information to be shared.
Fundamental to the success of an opt-in strategy is the ability of the registrar or office staff member to communicate the value of such consent and to reassure the patient that their privacy and security is of great import to the RHIO. As a consequence, training healthcare personnel to communicate this message effectively is a necessary investment. Additionally, some of these conversations will take time, and the impact on the time required to register a patient should be of concern to healthcare organizations and physician practices.
Advocates of an opt-out strategy offer a different perspective. Mark Zielazinski, CIO at El Camino Hospital and a member of the Silicon Valley Joint Venture, believes that patients should be automatically considered “in” and should be discouraged from any other course. “Allowing people to opt-out is going to make it more costly for providers to make decisions based upon a lack of information. If a person decides to opt-out, he should have to pay for that privilege.”
Zielazinski makes an interesting point. Today, consumers are charged extra based upon the healthcare decisions they make. Smokers pay more for life insurance, as do people that participate in other high-risk activities. This concept, the notion that lifestyle choices should influence a consumer’s cost for healthcare, is clearly beginning to influence health insurance pricing. Why not include consumers’ decisions to share or withhold their health information in that cost equation?
Washington Wish List
The federal government, typically an easy target, and specifically ONC (Office of the National Coordinator for Health Information Technology), is following a rational and intelligent approach when it comes to a national electronic patient record. ONC has issued four specific RFPs that target compliance certification, privacy and security, NHIN infrastructure and standards harmonization. This attention from Washington represents an overwhelming reason to believe that RHIOs will succeed where CHINs failed.
Terrific dialogue is being exchanged at seminars and conventions across the country; most probably, it is also being advanced to Washington levels, heard and considered. Much of ONC’s efforts have been high-level strategic and organizational, but with the award of the four initiatives mentioned, more detailed work will begin that is vital to laying out the framework for interoperable EHRs.
While these efforts are encouraging and on point, two areas merit greater focus to help us to get it right the first time. Undeniably, transactional exchange between disparate systems increased dramatically after HL7 became a standard. More confident RHIO advancement should be promoted by the standardization encouraged by both NHIN and standards harmonization initiatives. Accordingly, ONC should accelerate the establishment of standards as much as responsibly possible.
On paper, it appears that they intend for the winning vendor of the standards harmonization project to work swiftly. Within 30 days of contract award, the vendor must submit a minimum of three use-cases for consideration to the Department of Health and Human Services. David Murray, standards and regulatory manager with the healthcare IT division of Siemens Medical Solutions, believes that these submissions will rapidly become reality. “Within the first year, we’ll likely see at least three implementation guides coming out of this effort, which is exceptionally ambitious.”
Promotion and Education
A number of health systems are anxiously awaiting a robust set of standards to be ratified before launching their RHIO efforts. However, many are moving forward without them. These pioneers are taking on the hard work of hammering through their own regional standards. Once national standards are established, early adopters will require a secondary round of effort to move their regionally standard environment to the national standard.
While varying levels of reinvestment will be required from region to region, many RHIOs have concerns about the nonstandard nature of their standards. The federal government needs to set aside a secondary round of funding to these early adopters to assist them in efforts to migrate to a national standard. This would be an excellent way to acknowledge their courageous work and perhaps encourage more creative and exploratory forays into expanding the RHIOs’ capabilities.
The second area that would benefit from further ONC engagement is the area of regional promotion and education. Communities of every size throughout the country would benefit from assistance in understanding the benefits of a RHIO, sample governance models, incentive strategies, goal setting and funding opportunities. ONC, or a funded designee, would be in a position to share RHIO success stories, and provide trend analysis and root cause for that which succeeds and fails.
As an added benefit, an associated repository of knowledge and listserv environment could be provided that encourages communication and idea sharing across regions. Region-to-region sharing of information can serve to reinforce successful disciplines and provide a lessons-learned base of knowledge to avoid common mistakes. Furthermore, establishing relationships outside of each individual region and promoting communication on a broader level seems consistent with establishing national information exchange. It can and should begin by promoting dialogue between and among RHIOs.
Launching and sustaining a RHIO is largely about bringing a diverse group of people together, building a set of common and achievable goals, and through constant communication and mission reinforcement, bringing those goals to fruition. A strong leader, appropriate goal setting, and earning community trust and participation will go a long way toward addressing the human aspects of this endeavor. Before anyone gets too carried away in the euphoria of following the herd, a healthy dose of RHIOlity will serve well.
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