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  Editorial: RHIO's and the Illusion of Health IT Success
Health-IT Failures Posted by Ignacio H. Valdes, MD, MS on Monday December 12, 2005 @ 04:19 PM
from the Health-IT-failures dept.
(Slightly updated: 12/12/05) Does it bother anyone that for years, Health Information Technology (IT) successes implied by the news and even in casual conversation may largely be an illusion? Does it bother anyone that Regional Health Information Organization (RHIO)'s might be failing at a very high rate? It is important to ask the question given the United States rich history of failure and two notable successes with large scale Health IT. Digg this article

For example, the announcement of a hospital going 'all digital' or rollout of a multi-million dollar record system makes great press releases but is it actually working years after the parade is over?

Another example is a worker or representative at a local hospital replying "yes" to the question of does their hospital or large clinic have an interoperable Electronic Medical Record (EMR) or Computerized Order Entry (CPOE) system? But do they really? They may 'have it' but is it being used? Have they actually tested interoperability with other organizations or do they just have 'agreements'? Could it be that they actually have a nasty hybrid of paper records and EMR or an EMR that few people actually use? Or worse, do they not even want to talk about the real issues because of millions of dollars and large amounts of time wasted on a failed implementation?

There is historic precedence for the illusion of Health IT success in the United States. For example, only a few years ago, 'paperless' prescription writing was touted as being right around the corner by media and companies. Weekly or monthly, there was news of a startup company that was going to accomplish the goal of point of care prescription writing by some device such as a handheld. So far it hasn't happened on any large scale with two exceptions mentioned below.

One of the greatest success illusions of 2005 and 2006 may be the RHIO phenomenon. RHIO's are purported to be popping up like mushrooms, probably in anticipation of federal dollars. However, is anyone examining that they may be based on a flawed premise and, if historic experience is taken into account, doomed to failure? The premise is that somehow, by getting disparate healthcare groups to hold meetings about interoperability and agreements to share data that this will make it happen. Maybe, but there are a number of problems with this approach.

First, it's been tried before. Without looking at the date of publication, try reading this article entitled 'Smart technology, stunted policy: developing health information networks' by Paul Starr. If you read it you will notice that it speaks about many of the issues facing us today and in fact could have been a current article. The only problem is that it was written 8 years ago. What has changed since then? Why do we expect RHIO's will work now?

Second, RHIO's makes disparate, local healthcare entities into mini-standards organizations. This is something they are almost always ill-prepared to do. RHIO's will make strategic decisions (if they are able to make decisions at all) based on local politics, local needs and whatever information they can muster at the moment. Vulnerability to a good sales pitch at the time of decision can ensure a sub-optimal solution.

At best, a successful RHIO will create an island of interoperability which may be incompatible with another RHIO island that has made different strategic choices. While HL7 (a messaging standard) may be the thing that lashes the whole thing together, it also creates its own set of problems. Success of RHIO's will merely push the problem of multiple, incompatible clinical computing systems to the user interface level where health-care workers that work in more than one setting or change jobs will be treated to the nightmare of having to learn or re-learn multiple user interfaces that essentially do the same thing.

So what is the solution? Perhaps trying things that are already known to work on a national or at least state wide scale. Only two systems have emerged as having functional large scale clinical computing software: Kaiser Permanente which uses the proprietary Epic system and the Veterans Affairs VistA system. Both are not health-IT computing nirvana, but both appear to work adequately. Like VistA, Epic is based on the MUMPS programming language, but suffers from being a proprietary system. VistA has its own problems. However, VistA is in the public domain and is actively being supported by many organizations in the private sector.

Despite these large-scale systems already working in the real-world, they are seemingly ignored in favor of piecemeal efforts like RHIO's or local micro-environment choices. This is much like the situation that existed prior to the adoption of the railroad standard gauge. Unlike the railroad standard gauge, clinical computing standards are very complex.

The cycle of illusion of success followed by reality of failure continues on. When a rosy picture of health-IT implementation is reported, ask the question if this is really the case or only window dressing for multi-million dollar wishful thinking? If the RHIO's go bust, as seems likely, the next question will be how to keep the cycle of initial enthusiasm from progressing to the usual failure.

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  • The Fine Print: The following comments are owned by whoever posted them.
    ( Reply )

    Re: Editorial: RHIO's and the Illusion of Health I
    by Gunther Schadow on Monday December 12, 2005 @ 09:18 PM

    thanks for this editorial. I agree with you that much of the talk on HIT successes may indeed be marketing pitch, and I completely agree that "it's been tried before. [...] 8 years ago [and didn't work]. What has changed since then? Why do we expect RHIO's will work now?". Indeed the nagging interoperability problems are still a big practical concern. And I completely agree that if RHIOs turn into mini-standard organizations it is a lot of effort wasted.

    However, I disagree with how you move on from there. You are saying that (a) HL7 doesn't cut it and that (b) the only thing that works is VA's Vista and Kaiser's Epic implementation.

    Let me take it one by one:

    (a) HL7 is our only realistic chance, in fact, without a single comprehensive interoperability standard that specifies all relevant data conceptualizations and representations including data-structures and terminology as well as remote transactions the idea of RHIOs will never materialize. Without such standards you will never create ubiquitous HIT infrastructure, since no one has the power to decree a single system (and IMO noone should try that, because it would be stifling innovation and would ultimately harm HIT cost & quality). So, to connect the islands, a standard is the only way. And HL7 is the only standard that begins to have adoption basis, relevant domain content, and addresses the broad spectrum of issues.

    (b) VA's Vista and Kaiser's Epic installation are not the only things that work. For one, both VA's Vista and Kaiser's Epic are simply a single large institution's EMR system, a large island of data to use your terms. In addition, Kaiser's Epic is operational only since very few years, so that's not a great example.

    When it comes to RHIOs at the very least you need to mention the Regenstrief Medical Record System (RMRS) which connect almost the entire city of Indianapolis and is rapidly growing to cover the whole state of Indiana. As far as I know Salt Lake City is also pretty well connected and so might be Boston. Those regional networks are real and operational for a long time.

    I agree that the shallow integration using web-portals are not the same as a deep data integration, and I agree that this can be a big usability drawback (but then the RMRS is not just a surface integration). But this only goes to show that there is still a lot to be done and no silver bullet has yet been found. I think that at the present time anyone stepping up and touting their system as the only credible solution or even the most credible solution is at least premature.

    [ Reply to this ]
    • Re: Editorial: RHIO's and the Illusion of Health I
      by Ignacio H. Valdes, MD, MS on Monday December 12, 2005 @ 09:44 PM
      I would not use the term 'doesn't cut it'. While it is a start, HL7 has nothing to say about things like user-interfaces. I realize that's like saying that a tire doesn't cut it as a steering wheel but TCP/IP existed long before Netscape the browser but TCP/IP wasn't everywhere until after the browser. I'm not anti-HL7, in fact, I am a member. However, data interoperability isn't the only problem.

      One of the reasons why FOSS should work pretty well is that with FOSS, the software IS the standard.

      VistA is the only one that has worked on a national scale. It has the largest number of patients, is already written, frequently updated, is in the public domain, and does HL7. Why not simply use that instead of fragmenting the world and false-starting with RHIO's? I know many of the answers to that question like the infrastructure to support it in the private sector is currently being built. But, in the end you are still left with the first sentence of this paragraph. Perhaps RHIO's are a way of keeping people occupied until the infrastructure is built?

      -- IV

      [ Reply to this ]
      • Re: Editorial: RHIO's and the Illusion of Health I
        by Gunther Schadow on Monday December 12, 2005 @ 10:16 PM

        I agree that data integration is not the only problem. But no user interface and no decision support function can work sufficiently without data. Indeed it has been the sense of the people who built the RMRS, that you first need to give physicians useful data before you can ask them to enter data (as notes or orders.) So, while data is not the only problem, it is the most crucial problem.

        "The software is the standard" sounds catchy, almost like "the message is the standard" as it had been said by the XML (then SGML) proponents in the past. Neither is really true, because you need to interpret the XML message and interpretation of non-trivial content is not self-evident. The same is true for software. Any large software project, the RMRS not exempt, has a big problem with rules of interpretation of data being hidden in program code. The key of a standard is that it lays these rules open. As the data and the rules for their interpretation get more complicated, it is not an easy thing to do even for a standard.

        But the most important point about a standard is that it is implementation independent. I can overload any data with my software so that it works beautifully, but I cannot expect anyone else to do the same tricks, if I even understand those myself.

        I think the right approach for VistA is to find an adopter in one of the new RHIO projects that are presently ongoing. I think the excercise of transplanting VistA to a truely new organization will be a great way to make that point. Are you not involved with any of the federally funded RHIO projects? I think you should.

        I agree that it might be a lot more effective for struggling RHIO consortia who spend millions of $ on meeting and consulting fees to instead forge ahead with a VistA implementation. But I do not think that a federal mandate that requires the use of VistA should be considered, and I don't think you mean to say that.

        I agree with your last sentence. There is a lot of activism to do something even before that is reasonably possible. With really useful HIT we are still in an era akin to the time when people tried to build contraptions that would allow them to fly. There were many beautiful devices, some even worked a little, but it took all that to figure out how best to fly. Let's not try to establish an FAA to regulate the early efforts of the Wright brothers. ;)

        [ Reply to this ]
        • Re: Editorial: RHIO's and the Illusion of Health I
          by Ignacio H. Valdes, MD, MS on Monday December 12, 2005 @ 10:31 PM

          I'd like to be involved with a local Houston RHIO, but for whatever reason, I don't know them and they do not know me. The biggest reason for me is time, time, time and a history of local agitation over many years that went nowhere. The sayings 'you can't be a prophet in your home town' and an expert is someone from out of town, so far is true. As well, now is as good a time and place as ever to disclose my recent involvement with Sequence Managers Software: http://www.linuxmednews.com/disclosure

          -- IV

          [ Reply to this ]
          • Re: Editorial: RHIO's and the Illusion of Health I
            by Scot M. Silverstein, MD on Monday December 12, 2005 @ 10:52 PM

            In fact, it's inflated claims and promises that reduce chances for health IT success, through clinician disillusionment. These claims of cybernetic medical miracles have been made for decades (perhaps since the days of vaccuum-tube-based, mercury delay column-memory computers)...

            In fact, I sat on the technology committee of the Delaware RHIO (Delaware Health Information Network) of the state health care commission for several years and contributed substantially to the initial planning phases. However, leadership elected to higher positions of authority the very people in charge of clinical computing at the hospital where I was Director of Informatics. If other RHIO's import such people, then they are destined to have the same (or lower) success rates as hospital-based clinical computing.

            My thoughts on these issues are at http://home.aol.com/medinformaticsmd/failurecases.htm and have resided there for about seven years now.



            [ Reply to this ]
      • Re: Editorial: RHIO's and the Illusion of Health I
        by J. Marc Overhage on Tuesday December 20, 2005 @ 03:27 AM
        A few notes.
        First, while the Vista application is used nationwide it is not really different from the Siemens Invision system whicih is also used nationwide. The VA does not have nationwide interoperability today. You can peak at another VA medical centers data but you cannot use data from there for decisions upport. There are hundreds of Siemen's Invison customers (I use them only as an example that I have direct experience with -- there are others) who use the same software with substantially the same interfac across the country but without data integration.

        More directly, there is absolutely ZERO probability that we will see a single application across any substantial fraction of our fragmented healthcare enterprise anytime in the next several decades. For better or worse we have a widely distributed healthcare "system" and each component of that system has its own contraints and challenges. While VISTA is available to physician practices for example, it provides very little support for pediatricians and so isn't suitable for them. Further, while there is some work going on to address this, I can't imagine how VISTA could work for the 2 person practice which dominates our healthcare environment. I do want to be clear that I think the VA has done great work creating and implementing VISTA and I'm not bashing it just pointing out why a single solution is unlikely in healthcare just as it is unlikely in retail. You could ask the same questiion about why every POS (point of sale) system doens't work exactly the same way avoiding works having to relearn an interface when they change jobs from Starbucks to McDonalds to the Gap.
        [ Reply to this ]
        • Re: Editorial: RHIO's and the Illusion of Health I
          by Ignacio Valdes, MD, MS on Tuesday December 20, 2005 @ 04:54 AM
          What healthcare system uses Siemens Invision exclusively, nationwide?

          In what way does the VA not have nationwide interoperability today?

          Why zero probability?

          How is healthcare the same as Starbucks/McDonalds/Gap?

          -- IV
          [ Reply to this ]
          • Re: Editorial: RHIO's and the Illusion of Health I
            by J. Marc Overhage on Tuesday December 20, 2005 @ 05:07 AM
            Its not that any particulary "system" uses Siemen's Invision just that there isn't anything "special" about a particular application being used in many sites across the country. I would be happy to be corrected but to my knowledge DATA from one VA medical center cannot flow to another VA medical center today. You can open a view into some data from another medical center but data does not move so in view they are not interoperable.

            the reason I say zero probability is that there is no compelling reason for thousands and thousands or healthcare organizations to switch from their existing systems that they spent millions to purchase and implement at some risk to their organization. They are not going to change without compelling reasons and even if they decided to we don't have the manpower to implement a different system nationwide.

            Maybe I misunderstood your point but I thought you were suggesting that everyone in healthcare adopt the same interface and I was asking why that would happen in healthcare when it hasn't happenedin these much less complicated service industries.
            [ Reply to this ]
    Re: Editorial: RHIO's and the Illusion of Health I
    by David Szabo on Friday December 16, 2005 @ 01:00 AM
    While not all RHIOs will succeed, I think you are shortchanging many of the efforts going on around the United States. The New England Healthcare EDI Network (NEHEN) uses the HIPAA transaction standards to link payors and providers to lower the cost of confirming eligibility, authorizing referrals and paying claims. NEHEN started several years ago with five dues paying members (inlcuding both providers and health plans), and now has more than 25 large healthcare organizations as members, with more growth to come. NEHEN has lowered the administrative costs incurred by its members significantly. MA-SHARE, LLC is developing a record locator service and gateway that will facilitate e-prescribing, medication history lookup and the exchange of data among disparate EMR systems. It recently completed a proof of concept pilot to deliver medication history from PBMs to hospital emergency departments and is now developing a more functional replacement system designed to improve physicians' access to their patients medication histories. Eventually, it plans to develop the infrastructure that will allow physicians to locate their patient's health records from a variety of sources, all in compliance with privacy laws and security standards. RHIOS can't be based on the idea that all particpants will use the same software. They need to use tools that will locate information and link disparate systems using common standards. HHS is working hard to encourage the development and adoption of standards. Laws such as HIPAA admin. simp. and the Medicare Modernization Act are putting standards into action. These laws can create a framework for local cooperation, if communities find the will to act. This work is far from completed. There are many barriers to be identified and overcome. Don't predict failure --- work for success!
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