Health Information Technology in Massachusetts Forum

Health Information Technology in Massachusetts: Private/Public Partnership? What Should the State's Role Be in Facilitating HIT Adoption?"

I recently attended this forum held in downtown Boston last week. The purpose of the form was to discuss the states role in health information technology adoption. There was an impressive panel made up of the top Healthcare IT leaders of the state, who also happen to be leaders at the national level as well. This panel included John Glaser, Ph.D; John Halamka, MD, Micky Tripathi and Janet Marchibroda.

The full list of speakers included: Secretary JudyAnn Bigby, MD; David Blumenthal, MD; Ray Campbell, Chris Gabrieli; John Glaser, Ph.D; John Halamka, MD; Jay Himmelstein, MD; Phil Johnston; Janet Marchibroda; John McDonough; Sen. Richard Moore; James Roosevelt, Jr.; and Micky Tripathi.


Here are some points made by the speakers at the forum which I found relevant:

Chris Gabrieli, Chairman of the Board Massachusetts Health Data Consortium
Chris worked for an EMR company in 1981 as part of a pilot. This system actually had decision support and clinical alerting. However when the pilot was completed, the medical clinic did not want to pay to have the system. As a result, the EMR equipment taken out of the clinic and the project was scrapped.

He spoke about the importance of patients being able to have a seamless transition when moving between healthcare providers. He compared it to how we can switch seamlessly from one cell phone provider to another while maintaining the same phone number.

John Glaser, Ph.D, CIO Partners HealthCare
Spoke about the need to broadly adopt healthcare IT technology.

The digital divide that is developing between the large hospitals/physician groups and the smaller healthcare organizations.

Partners Healthcare’s Telehealth programs and the benefits realized in managing CHF patients.

The need to get healthcare data exchanges up-and-running by aligning financial incentives between organizations.

Mentioned that MA-SHARE has gone as far as it can go and that now it needs broader support



Mickey Tripathi, CEO Mass eHealth Collaborative

EMR is a seen as a pure cost currently. The actual return on investment is seen much later.

Benefits of an EMR play out in a complicated manner over time. This is the reason why it's hard to establish a return on investment for EMRs using conventional methodologies.

John Halamka MD, CIO CareGroup Health System, and Dean for Technology at Harvard Medical School, CEO MA-SHARE

Spoke about the difficulties faced in trying save waste from the healthcare system by eliminating redundancy: "One man's redundancy is another man's country club".

Spoke of the problems of sustainability for RHIOs. He talked about how health-care providers will not pay if there is no infrastructure. In other words healthcare providers do not see the health information exchange as an investment. The challenge is how to build the infrastructure without the capital. John implied that the providers would see value and pay if there is a live health information exchange.


Janet Marchibroda MBA , Chief Executive Officer of the eHealth Initiative
The greatest challenge to RHIOs is building sustainability.

She mentioned that based on a recent survey on health information exchanges, the largest source of revenue is now coming from hospitals, not government grants.

The health information exchanges that are operational are exchanging Lab data, emergency department and outpatient clinical summaries.


Byron Byfield has written about the event on his blog.

RHIOs are still relevant according to Dr Brailer

Neil Versel, who is also a fellow health IT blogger listed on HITSphere, just wrote an article, for Digital HealthCare & Productivity: "Brailer Insists RHIOs Remain Important".
Dr Brailer still remains bullish on the prospects of RHIOs. He admits that RHIOs are undergoing a shakedown. I also believe this is the case.

Take the dot-com boom as an example. The initial exuberance was followed by people questioning whether the Internet could actually produce a sustainable business model. Well, since then we have seen the likes of Amazon.com, Google.com, youTube.com, and the list keeps growing.

RHIOs too, I believe will follow a similar path. Just as with the dot-coms, when funding was abundant, there was a "spend-spend" mentality without regards to sustainability. RHIOs, like the dot-coms, had been flush with significant funding, mainly from state and federal grants. In fact, there is a term for these grant-dependent entities: "Beltway bandits – a group of people who live off government grants", "grant babies" (see HISTalk)

The Santa Barbara RHIO is a good example, where it did not take long to burn through $10M in funding, only to learn in the end, that there really did not seem to be a need for such an entity in their community. Just recently, we learned of the shutting down of the Oregon RHIO, which did so only after spending nearly $500K just to find out that their RHIO was going to be to expensive.

Once you start hiring those consultants and lawyers, and start setting up committees, money can dry up very fast. RHIOs need to evolve, I believe from an entrepreneurial model that enabled the small technology start-ups in the 80s and 90's to beat the larger companies. After all, it was this model that allowed IBM to develop the now famous IBM Personal Computer (IBM-PC). IBM, in the early 80s, after learning from the success of Apple Computer, used a "small start-up company" model to develop the IBM-PC.

RHIOs will start to succeed once they focus on sustainable models that meet true business needs rather than needs decided by committees. They will need to adopt a "start-up" model, depend less on government funding (handouts), and rely more on self-funding and private investments.

Cross Enterprise Document Sharing: IHE XDS Integration

Microsoft IHE XDS Reference Implementation
I will be sharing information on Cross enterprise document sharing which is an important topic in the area of Health Information Exchanges and RHIOs. This model would equally apply to single organiziation document sharing as well.

Microsoft has recently released the IHE, XDS Reference implementation .

Roberto Ruggeri (a Senior Technical Strategist with Microsoft Worldwide Health) has an excellent introduction to IHE XDS on his blog.

Roborto writes:

"Integrating the Healthcare
Enterprise (IHE) is an organization
operating in the Health Information and Communication Technology area. The main
purpose of IHE is to create Interoperability Profiles that simplify integration
scenarios in healthcare."

"Arguably one of the most successful IHE profiles
is Cross-Enterprise Document Sharing or XDS. The profile focuses of the
publication, storage and retrieval of documents for the purpose of exchange
within a network of trusted participants (Affinity
Domain)."

IHE IT Infrastructure Technical Framework
Microsoft IHE, XDS Reference implementation

I found the presentations listed below useful for understanding IHE XDS basics concepts. It would be useful to review these documents before diving into Microsoft IHE, XDS Reference implementation .

IHE Canada, XDS Integration Profile, Technical Discussion

IHE XDS, Presentation by Jonathon L. Ellion MD (Heartlab): Very good , dynamic powerpoint introduction to IHE XDS

Leveraging IHE to Build RHIO Interoperability, Charles Parisot's (GE Healthcare) presentation discusses IHE issues as they relate to RHIOs

This article discusses a strategy for extending the IHE XDS for support of a federated architecture.
Enhancing IHE XDS for Federated Clinical Affinity Domain Support

Setting up an XDS Affinity Domain using IHE Components: This is an IBM Healthcare and Life Sciences document. It's a good practical guide to setting up a theoretical deployment. It addresses the architectural issues involved. Some of the points discussed are:

1. Patient Identity Cross Reference Manager

2. Security and Auditing

3. Physical and Logical Topology

4. Document Sharing Scenarios

HIE/RHIO Resources:

MA-SHARE Record Locator Service Technical Document
RHIO Reference Architecture Very good technical discussion of a RHIO architecture. Includes discussions on the use of BizTalk and data flow in a federated architecture model.

Future of RHIO Movement

Since the recent demise of several RHIOs, there has been a lot of interesting material on the net. I just received an eHealth smartBrief which had several RHIO items, Oregon RHIO plan stalls and RHIO experts talk problems, future of movement.

I have commented items from RHIO experts talk problems, future of movement that really made sense.

With our RHIO, SEMRHIO, based in South Eastern Massachusetts, our focus is on creating value to the physicians. Physicians are the ones actually taking care of patients directly and whose decisions can save and improve their patient's lives.

In order for a RHIO to have value to a physician, it must improve physician work flow by making critical patient data available at the right time in order to make the best clinical decision.

"One problem with RHIOs as they often are proposed is that they provide the bulk
of their benefits to patients and health plans, people and entities that
according to our current healthcare payment structure either don't pay at all
for RHIO startup and operational costs or pay a disproportionately small share."

It seem that many if not most RHIOs are the creation of non-physicians, such as health plans, business groups. They follow the typical game plan of seeking funding for setting up an organization and developing a governance structure. Unfortunately, only after spending substantial funds, they end up with a model that depends on grant funding for sustainability. As a result, several RHIOs have shutdown.

"For many areas, healthcare information exchanges need to address the limited business cases of the providers who will build and maintain these systems, according to John Regula, who served as chairman of the now-defunct Northeastern Pennsylvania Regional Health Information Organization, or NEPA RHIO."

This again highlights the issue that an HIE or RHIO needs to address the business needs of the physician/providers. After all, it is the providers that will use the system on a daily basis for day-to-day patient care.

"It does not make sense for a RHIO to have a consumer-centric model," said Regula, the chief information officer of Allied Services, Scranton, Pa...

"... "It's a noble idea to say put the patient first, but what you have to have are business plans within the provider community," he said. "

Exactly. Too many RHIOs try taking the "High road" of being consumer or patient centric. The only problem is, patients cannot be expected to micro-manage their data within the RHIO. As a physician, my patients expect that I manage their health data, test results, medication and problem lists. Sure, some of my patients do take an active role in this process, but in the end, there is an expectation that I ultimately am responsible for these tasks.

So for a RHIO to have a workable model, it must address the needs of the physicians. Physicians need to make critical patient care decisions based on data. There must be no hindrance to the flow of this data to the physician. For example, if I am prescribing my patient an antibiotic, it is important for me to know if my patient is on Warfarin. If this information is not readily available, I will not be able to safely prescribe medications for my patients.

We just presented at Microsoft MSHUG Tech Conference

We just presented our RHIO project, semrhio.org at MS-HUG, the Microsoft Healthcare Users group Tech Conference in Redmond. Our topic was "Winning Trust and Minimizing IT Resources".

Roberto Ruggeri , a Senior Technical Strategist with Microsoft Worldwide Health gave a review of our presentation on his blog. Roberto was very helpful and we would like to give him our thanks

Eric Stott, our "famous" BizTalk architect, was with us and commented on his blog. Byron Byfield, a fine specialist in healthcare payor-side data analytics, promises he will have something to say soon on his new blog.

I was joined in the presentation by Kate Sullivan, who provided an excellent background on SEMRHIO and the current RHIO climate.

The topic was on how choosing the "right" Trust model for data sharing and minimizing IT resources by centralizing common services, there is a greater chance for getting buy-in from competing community hospitals to join to form a RHIO, since the two main barriers to forming a RHIO, trust and IT infrastructure can be overcome to a large degree.

Typically, cost and security issues end up being why many RHIO fail to go beyond the planning phase. In fact, several RHIOs, after spending anywhere from $500,000 to a few million, end up closing their operations. A few weeks ago, the Portland RHIO, and a few months ago, the very high profile Sanata Barabara RHIO.