Innovation Valley
Health Information Network 		Contact Information
HomeWho We AreBoard & SponsorsWhere We're GrowingOur Healthcare CommunityPhysician PortalPatient PortalEmployer Support
RHIOs Roll Out Across The State
HealthLeaders-InterStudy
Tennessee Summer 2006

By Don Mooradian

Tennessee’s three RHIO’s -- Regional Health Information Organizations – have similar goals and many of the same challenges, but are as different from each other as urban Memphis is from the verdant hills of the Tri-Cities area.

Each has the goal of electronic records and information sharing among regional health entities. And each is working with the involvement and support of the state and its largest insurer, BlueCross and BlueShield. But that’s where the similarity ends.

There are now hundreds of groups nationwide referring to themselves as RHIOs, which can be defined as a regional coalition of multiple, competing healthcare enterprises that agree to collaborate, build connectivity and move health information among themselves, for the purpose of serving patients.

In the Tri-Cities area, for instance, CareSpark grew out of a community-based healthcare coalition that began in the 1990’s, when providers, employers, insurers and others began working together to combat chronic illnesses prevalent in that area. With the formation of CareSpark and the adoption of an ambitious three-year development plan, it is moving towards creation of a full-fledged RHIO serving 17 counties in Tennessee and Virginia, 1,200 physicians and 18 hospitals.

East Tennessee is trying to roll out a 16-county collaborative effort called Innovation Valley Health Information Network. And in Memphis, the city’s fiercely competitive hospitals are only beginning to share limited amounts of information electronically.

West Tennessee. Dave Archer, chairman of Mid-South eHealth Alliance, serving the three-country Memphis metro area (Fayette, Shelby and Tipton counties), said the first hurdle was getting the area’s providers to come around the table to cooperate.

But in mid-June, five Memphis hospitals began sharing information that included lab results, imaging reports, patient history and physical results and discharge notes. The five participating are Baptist Memphis, Le Bonheur Children’s Hospital, Methodist University Hospital and the Regional Medical Center at Memphis, known as The Med. The Med, the city’s public hospital, is the only facility accessing the information at this time.

It takes 4-6 weeks to train and bring the operation up-to-speed, Archer explained, adding “You can’t just flip a switch to make this work.” At least three of the other participating hospitals are expected to be accessing information by the end of the year, he said.

The hospitals were quick to realize the value in reducing duplicate tests and so forth, especially for uninsured patients for which the hospitals received no reimbursement, Archer said. But even then, Archer admits the principals often have trouble getting along.

While the health plans and other providers are not plugged into the system, Archer said his group is discussing how to make this happen. “I suspect we’ll all learn how to work and play together,” he said.

“In the relationship between hospitals, we were able to take off competitive hats for a venture that will improve patient care. We do tend to have difficulty working with each other so having the state at the table has been helpful,” Archer said. “The state has been involved; they’ve been a great proponent of trying to set some guidelines. The council wants to play better together.”

But the snag is in the sharing and owning of records – a sticky matter in any competitive environment – and the glaring perennial question of finding a model that will work economically.

“The greatest challenge will be developing a sustainable model. I don’t think any of us have that answer to that question,” said Archer. “The great unanswered question is ‘What is the revenue stream?’’

“We and the other RHIOs are working with the state and work with BlueCross BlueShield of Tennessee in the claims environment,” said Archer, who said insurers stand to save the most from shared records and will want to be strong supporters “when we can show insurers how much can be saved.”

“Five or 10 years down the line, we might be interconnected by some grand statewide RHIO Internet,” Archer said, while admitting that such visions are just conjecture. “I sure don’t know because there are a lot of competitive forces and it’s still in its infancy. But we clearly believe in this is the way to go.”

East Tennessee. The Innovation Valley Health Information Network is in the process of planning, budgeting and designing a network that ultimately will serve 16 counties in east Tennessee with the overall goal “to increase patient safety and quality of care,” said Alan Hill, executive director.

There are about 1 million people in the service area where there are about 2,000 physicians and 15 hospital systems. Innovation Valley has partnered with the Texas-based Patient Safety Institute and is using a solution developed by a Patient Safety Institute and demonstrated in Seattle.

“Funding has been an obstacle to get us started,” Hill said, noting that the network is expected to cost $12-$14 million over the next two years to build the initial system. Getting the word out about the organization and building trust were other challenges. Hill said it will likely take a year to build the infrastructure, with the planning and design phase wrapping up this September. Phased implementation may start in October or November as individuals are asked to “opt in” to the system by allowing the sharing of their health records with authorized caregivers.

After a year’s operation, Hill said the plan is to evaluate the system’s value to all players – payors, administrators, providers and patients. “We would hope to determine who got value from this and how much, then, for those who got value so we can equitably allocate a value-based transaction fee for the future that is profitable and compelling to all parties,” Hill said, adding that payers and self-insured companies are but one of several groups who financially benefit from the network.

Hill said the group is in discussions with the insurers in the area including BlueCross BlueShield of Tennessee, Cigna, Cariten/PHP, Aetna, and John Deere/United Healthcare. “They’ll be intricately involved in providing claims-based data,” said Hill.

“Because few physician offices have EMRs, data has to be retrieved from alternative sources,” Hill said, adding that having money for physician EMRs is not required in the IVhin network to be successful. “Our network supports EMRs but does not require them. .”

“The ultimate goal,” said Hill, “would be a card in possession of the patient that tells the caregiver ‘I give you authority to get the information you need.’”

Tri-Cities. “RHIOs obviously are important. They are the best promise for overcoming competing interests. But nobody has yet pulled this together” said Liesa Jenkins, executive director of CareSpark. She described the group as a “zone of cooperation within a zone of competition.”

CareSpark was formed by participants in the decade-old Community Health Improvement Partnership, which has worked to improve the health and healthcare system in the region. Initiated as a RHIO in April 2005, CareSpark has been building a consensus amongst members regarding IT structure and the type of information to be gathered and shared, issues that are still being assessed.

“Our region may be a little different. No payor or provider dominates the market. So it’s competitive in that regard,” she said. “The impact of a RHIO will be to see if you can reduce the overhead and improve service. If we reduce tests by 1 percent or save 1 percent on using generics, we get a three to one savings on costs.”

“In the first year, we have calculated that we will have 200 physicians and a minimum of 50,000 patients involved, which does not get us to financial sustainability,” Jenkins said.  “In the second year, with another 250 physicians and another 150,000 patients engaged, we are showing a positive cash balance, which will continue to grow as we add an additional 250 physicians and 150,000 patients in year 3.”

After that, the organization anticipates growth will slow, adding perhaps 50 physicians and another 100,000 patients enrolled each year, “until we reach 900 of our 1,200 physicians and 600,000 of our 710,000 patients,” said Jenkins.

“Most everyone is looking for the health plans to pay a significant chunk of the cost of infrastructure,” said Jenkins, but she adding that the group is not forcing participation, “but hoping they participate voluntarily. It has to be a collective choice. We are building momentum moving on multiple fronts and parallel tracks.”

Exactly how much health plan participation is hard to say, but Jenkins said that 10 or 20 percent participation would not be near enough to make a RHIO effective. “There has to be critical mass. We’ve got to bring a critical mass along to make it work,” she said.

The RHIO covers a sprawling, mountainous 17-county area serving about 700,000 people. About two-thirds of that population lives in Tennessee and a third in North Carolina. There are also a few people from Kentucky and West Virginia. “Mountain geography determines where the roads go and people don’t select doctors or hospitals by what state they are in,” Jenkins said, explaining some of the out-of-state clientele.

The terrain and size of the market doesn’t help in other ways. “We’re not on the beaten path for foundations and government grants,” Jenkins said, adding that the process is “a lot slower than I thought but in a way faster because we are trying to do more.”

CareSpark is working with a $6 million budget. It has raised $2 million in cash and $1 million in in-kind contributions, leaving a balance of $3 million yet to raise. In the first year, the group estimates a budget of about $1.2 million in operating expenses and $4.5 million in capital expenses. The second year would be about the same amount of money but a different mix.

“Some RHIOs started sending information quickly. We don’t have a lot of money to throw out there and see what works,” Jenkins said, adding that the plan is to be operative in the first quarter of 2007.

As for the future, Jenkins said RHIOs might be so commonplace, they will hardly be noticed. “People don’t ask what’s behind an ATM or a cell phone, so if we’re really successful, we’ll be invisible,” Jenkins said. “It will just be the way we do business. RHIOs will have served their purpose.”

Pioneer. All three Tennessee RHIOs are working with RHIO pioneer Bruce Taffel, M.D., currently chief medical officer for Shared Health, a for-profit subsidiary of BlueCross BlueShield of Tennessee.

“I was one of the founders of CareSpark (in the Tri-Cities), and co-chaired the Governance Committee that designed CareSpark's current governance structure,” he said. BCBST provided $180,000 in funding to CareSpark along with in-kind support from several BCBST experts, he said.

Taffel said that BCBST was amongst the first organizations to sign a letter of support and cooperation with, what was then, East Tennessee Health Information Network. Since then, Shared Health has engaged in several meetings with what is now called Innovation Valley Health Information Network to work out details for participating in their efforts.

BCBST is also cooperating with Vanderbilt University’s Volunteer eHealth Initiative to outline the initial design for the Memphis Midsouth e-Health Initiative. Shared Health has been in discussions with the group to define ways that the two organizations can work together productively.

Within the discussions about RHIOs, some officials believe payors have the most to gain from improved efficiencies and, therefore, they should pay the most for the establishment and operation of the RHIOs.

“RHIOs are important as the vehicles for promoting health information technology in providers' offices and facilities and assuring that all constituencies are using systems supporting interoperability,” Taffel said. But Taffel says it’s wrong to assume payors are the only ones to benefit from information-sharing structures.

“We absolutely agree that health information technology and HIE will result in great benefits to the health care system as a whole, including payors who should bear some part of the costs,” Taffel said. “In addition, we feel that the benefits to the provider may be under-valued.”

Taffel pointed out that The BlueCross BlueShield Association has found many studies revealing a return-on-investment to providers through HIT.

“In other words, we believe that HIT has enormous potential for improving quality and reducing cost and that payors will benefit, but more real-time studies need to be done in order to truly understand the types of value, the quantity of savings and the parties to whom the value and savings truly accrue,” Taffel said.

The best RHOI scenario for a large insurer like BCBST, said Taffel, would be that RHIOs promote the adoption of interoperable systems throughout their provider community.

Taffel lauds the eHealth Advisory Council established by Gov. Phil Bredesen and its goal of coordinating electronic medical records. “We think the state is doing the right thing in trying to coordinate and connect the community projects,” he said. “We also believe that attention from the state will also help foster standards for interoperability and increase the level of understanding of EMR benefits for both consumers and providers.”

Paula Wade
HealthLeaders-InterStudy
210 12th Avenue South
Nashville, TN 37203
615.369.4806
Fax 615.385.4979