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Monday, May 23, 2011

Spinning the RHIO Story

A recent publication in the Annals of Internal Medicine has gotten quite a bit of attention in Health IT related media:
A quick summary of the reporting tells me that few if any actually read the report, since most only reported data available in the abstract.  I won't bother repeating the abstract, simply read it for yourself.

Age of the data?  The Survey data was gathered between December 2009 and March of 2010.  Where are we now?  May of 2011.  This study is based on data more than a year old.

On RHIO criteria for Meaningful Use, which is alluded in many of the article titles:  There isn't any, at least in the Meaningful Use Standards and Certification Rule or in the Incentives Rule.  That's right.  There is NO criteria specified for what an HIE / RHIO must do under any of these rules.  Nor are there any incentives being given to RHIOs/HIEs by CMS.  Yes, there were public funds made available by ONC, about 1/2 a billion dollars.  The study clearly acknowledges this, even if the reporting on it does not.

The next is the spin on financial viability.  Of 75 organizations, 1/3 (25 / 75 = 1/3) are financially viable, and another 20 expect to be so in the future.  Of startups with a product for sale in a specific sector, 1/3 are financially viable?  That sounds like positive news to me, not negative -- where do I invest?

Of new startups in a sector, over 40% (75 / 179) have a product in the market in the Health IT sector?  That also sounds positive to me.

In that group of new startups, around 17% (13 / 75) meet the current market need (Meaningful Use)?  Also positive, even if none meet the Comprehensive criteria that their expert panel put together.  New markets rarely produce the "perfect" product in early years.

Some other factoids:  The number of RHIOs continues to increase over time when compared to similar studies by the authors in mid 2008 and early 2007. The rate of increase seems to be slowing somewhat, but the number of RHIOs now defunct has been shrinking over that same time period.  It is now less than half of its 2007 numbers.   There are a couple of confounding factors that could influence the observed rate of growth, including the effect of ONC State HIE grants and Meaningful Use regulation on the industry, but the study doesn't address that these.

What were the biggest challenges for RHIOs according to the study?  In the core set, reporting quality measures, supported by slightly less than a quarter of the operational RHIOs.  In the menu set, reporting to public health (immunizations, syndromic surveillance, and electronic laboratory reporting) as an aggregate was the weakest.  A quarter of operational RHIOs were able to support that.  A critical observation that I would make here is that public health needs to get more engaged with RHIO initiatives.

The strengths?  Exchange of summary patient data (core) and laboratory reporting (menu-set) was supported by more than half of the operational RHIOs.

The funniest statement in the article?  "Most EHRs do not automatically enable the types of HIE required to achieve meaningful use..."  Have the authors looked here?  Or perhaps here and here?

The authors' conclusion? These findings call into question whether RHIOs in their current form can be self-sustaining and effective in helping U.S. physicians and hospitals engage in robust HIE to improve the quality and efficiency of care.

Yes, it does "call the question", but the study doesn't answer it, and it wasn't designed to do so.   Compare these findings to that of any other nascent industry that started in the last century. I think you'll find that we are in better shape than some, and worse than others.  The authors would be advised to compare this new industry with others.  This is my biggest issue with the study.  I didn't find it badly done as other studies on Health IT were, just under-analyzed and very poorly reported.

If we want to understand how well RHIOs are doing, we should compare them to other new businesses that have been "invented" or even "re-invented" in the past few decades. One example would be alternative fuels or electric/hybrid cars -- both recipients of government incentives.  We could compare this initiative to the failure of similar initiatives in the past (see this article on CHINs from 1994), or to others being done internationally (e.g., Canada Health Infoway, or the NHS program).  I'm sure others can find similar examples.  Doing so would provide some analysis about how we are fairing compared to other industries and  initiatives.  It also might set some realistic expectations about how soon we can expect results and what those results might look like.