Regional Health Information Organizations:
Progress and Challenges
Julia Adler-Milstein
Academy Health
June 30, 2009
Overview
30 billion
transactions per year
Context

Regional Health Information Organizations
(RHIOs) are:


“organizations that facilitate electronic HIE
between independent entities in a defined
geographic region to improve health and care”
If RHIOs are to serve as the foundation for
nationwide health information exchange, it is
critical to understand:



progress
successful models
obstacles and challenges
Today’s Presentation

RHIOs Census I
Summarize results of first RHIOs census conducted in early 2007

RHIOs Census II
Describe in detail follow-up census conducted in mid-2008

RHIO Success Factors
Summarize results of multivariate analyses using census II data

RHIO Participation among Hospitals
Describe in detail study looking at RHIO penetration among hospitals and
characteristics that distinguish hospitals that participate in RHIOs from
non-participants
RHIOs Census I

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals

Census of US RHIOs; conducted in early 2007

Key Findings


High failure rate

Few operational

Narrow scope of activities

Uncertain business model
Open Questions

Premature assessment of viability?

RHIO growth over time?
Adler-Milstein et al, 2007
RHIOs Census II

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals

Has the number of RHIOs that are operational increased in
the 17 months since our last survey?

What types of entities participate in RHIOs and what types of
data are they exchanging?

How many RHIOs are self-sustaining and how optimistic are
the others that they will eventually become so?

What are the self-perceived barriers to successful, selfsustaining RHIOs?

Have RHIOs that were operational in our 2007 survey grown
over time?
Methods


RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Identification of RHIOs



eHealth Initiative Directory: 102 from initial survey plus
105 new to directory as of May 2008
Survey Development

2007 version; new financial questions and questions about
obstacles to development

Cognitive testing with small subset of RHIOs
Survey Administration

June-August 2008

Web-based
Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
207 Organizations
Identified
36 Unable to
Determine
Status
40 Never
Pursued HIE
131 Were/Are
Pursuing HIE
28
Operational
as of 1/1/07
As of
6/1/08
23
Operational
3
Stalled
14 Did Not
Respond to
2007 Survey
41 Planning
as of 1/1/07
2
No Longer
Pursuing HIE
6
Operational
16
Planning
55
Operational
as of 6/1/08
19
No Longer
Pursuing HIE
6
Operational
42
Planning as
of 6/1/08
5
Planning
48 Not
Surveyed in
2007
3
No Longer
Pursuing HIE
34
No Longer
Pursuing HIE
as of 6/1/08
20
Operational
18
Planning
10
No Longer
Pursuing HIE
Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Types of Entities Providing and Receiving/Viewing Data (n=44)
Data Providers
Data Receivers/Viewers
100%
86%
84%
Percent of RHIOs
80%
73%
70%
68%
57%
60%
39%
40%
34%
32%
34%34%
34%
25%
20%
20%
18%
11%
0%
Hospital
Ambulatory
MD/Clinic
Lab
Imaging
Center
Pharmacy
Public Health
Payer
(public and
Dept
private)
PBM
Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Types of Clinical Data Exchanged (n=44)
90%
84%
80%
70%
Percent of RHIOs
70%
66%
64%
60%
50%
40%
30%
20%
14%
10%
0%
Test results
Inpatient data
Medication history
Outpatient data
Public health reports
Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Forms of Support After Initiation of Clinical Data Exchange (n=44)
Results
Covering expenses*
Months to viability

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Planning
Operational
11%
41%
22 months
25 months
* Covering operating expenses with revenue from participating entities
Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Likelihood that RHIO will break-even with revenue from
participating entities among those that have not already done so
70%
61%
60%
Percent of RHIOs
50%
44%
40%
Planning
28%
30%
22%
Operational
20%
20%
13%
8%
10%
4%
0%
Definitely or Probably
Not
Maybe
Probably or Definitely
Will
Don’t Know
n=23 planning; n=25 operational
Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Barriers to Development
n=27 planning; n=44 operational
Results--Longitudinal

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
41 Planning
as of 1/1/07
Few RHIOs planning in 2007
became operational in 2008
6
Operational


16
Planning
Among 20 operational RHIOs in 2007:

17 still operational

No significant growth in breadth of activities

Some changes in sources of support
19
No Longer
Pursuing HIE
Summary of Key Findings

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals

Growing number of operational RHIOs

For every RHIO that became operational, more
than three “failed”

Focus on exchange of tests results and medication
histories; no evidence that RHIOs expand breadth
of activities over time

Minority of operational RHIOs appear financially
stable and remaining RHIOs very pessimistic
Policy Implications

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals

Disconnect between expectations/beliefs of RHIO
progress and the reality

Progress towards nationwide HIE slow and
significant uncertainty as to whether RHIOs will
serve as the foundation

Lack of rigorous evaluations is one likely cause

However, paving the road for RHIO success
requires addressing a wide array of barriers
Limitations

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals

Incomplete set of RHIOs

RHIOs classified as defunct may still be operating

Growth measured by breadth rather than depth

Self-reported data
RHIOs Success Factors –
Summary Results

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation among
Hospitals
Operational




Broad participants
Narrow types of data
Financially Viable



Early support from participants
Ambulatory providers as data receiver
Hospitals as data receiver
Characteristics of Hospitals
that Participate in RHIOs

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals
RHIO success dependent on stakeholder
willingness to share data



Hospitals and ambulatory providers key stakeholder
groups
Conflicting incentives for stakeholder participation
(Grossman et al., 2008)

Research Questions:


To what extent are hospitals participating in RHIOs?
What differentiates hospitals that participate in RHIOs
from those that do not?
Methods

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals
American Hospital Association Annual Survey: IT Supplement





Sent to all acute care general medical and surgical member hospitals
March 2008-September 2008
63.1% response rate; 3,049 hospitals (2,952 US non-federal)
HIE Survey Questions


RHIO participation
Type of data exchanged with unaffiliated hospitals and providers

Descriptive Statistics – RHIO penetration (hospital and HRR level)

Bivariate and Multivariate Analyses – Characteristics of RHIO
Participants vs. Non-Participants

A priori list of characteristics: size, profit status, IT infrastructure, other
technology, system affiliation, teaching status, and percent Medicaid
Results – RHIO Penetration

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals

269 hospitals (9.1%) reported participating in a RHIO and exchanging
at least 1 type of data with an unaffiliated entity

134 of 304 (44%) Health Referral Regions (HRRs) had at least 1
hospital participating in a RHIO

Median number of participating hospitals per HRR: 1
Median percent of participating hospitals per HRR: 14%


HRRs with highest RHIO participation (>1/3 hospitals) and at least the
median number of hospitals responding to survey per HRR (>=7)





Asheville, NC
Spokane, WA
Cincinnati, OH
Albany, NY
Indianapolis, IN
86% (6 of 7 responding hospitals)
50% (13 of 26)
46% (6 of 13)
40% (6 of 15)
39% (13 of 33)
Results –
Characteristics of
Participating Hospitals
Hospital Size
Small (N=1,402)
Medium (N=1,262)
Large (N=288)
Ownership
Private, For-profit (N=422)
Private, Non-profit (N=1,832)
Government, Non-profit (N=698)
Teaching Status
Major Teaching (N=223)
Minor Teaching (N=482)
Non-teaching (N=2,247)
Presence of Cardiac ICU (N=964)
No CICU (N=1,799)
System Affiliated (N=1,260)
Not System Affiliated (N=1,692)
Percentage of Medicaid Patients
First Quartile
Second Quartile
Third Quartile
Fourth Quartile
IT Infrastructure
Have No EHR (N= 2,685)
Have Basic EHR* (N=221)
Have Comprehensive EHR (N=46)
Participates and shares data
N=269 (9.1%)
Percent
8
9
13
4
11
8
16
10
8
11
9
10
9

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals
P-Value
0.030
<0.001
<0.001
0.040
0.24
9
10
10
8
0.73
8
19
20
<0.001
Results –
Characteristics of
Participating Hospitals
Hospital Size
Ownership
Teaching Status
Other Technology
System Affiliation
Medicaid Percentage
IT Infrastructure
Small (6-99 beds)
Medium (100-399)
Large (more than 400)
Private, non-profit
Private, for-profit
Government, Non-profit
Not teaching
Minor Teaching
Major Teaching
Without Cardiac ICU
With Cardiac ICU
Part of a System
Not Part of a System
Quartiles 1-3
Highest Quartile
No EHR
Basic EHR
Advanced EHR

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals
Adjusted Performance
95% Confidence
Odds Ratio
Interval
Reference
1.01
[0.70 - 1.45]
0.92
[0.49 - 1.72]
Reference
0.37
[0.19 - 0.70]
0.76
[0.53 - 1.08]
Reference
1.08
[0.76 - 1.61]
1.91
[1.06 - 3.45]
Reference
0.91
[0.67 - 1.24]
Reference
0.88
[0.67 - 1.16]
Reference
0.85
[0.61 - 1.18]
Reference
2.47
[1.69 – 3.61]
2.51
[1.13 – 5.59]
P-Value
0.94
0.005
0.087
0.57
0.38
0.33
<0.001
Summary of Key Findings

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals
RHIO penetration among hospitals is low





Few hospitals actively participating in data exchange via
RHIOs
Less than half of HRRs have at least one participating
hospitals
Within HRRs with RHIOs, majority of hospitals do not
participate
Hospitals that participate in RHIOs differ from
those that do not along two key dimensions


More likely to be not-for-profit
More likely to have advanced IT infrastructure
Policy Implications

RHIOs Census I

RHIOs Census II

RHIO Success Factors

RHIO Participation
among Hospitals

Current efforts to engage hospitals in health information
exchange have not had broad penetration

Low rates of RHIO participation among for-profit
hospitals suggest that competition and fear of loss of
market share may be holding them back

Incentives are likely needed to garner greater
enthusiasm to actively exchange clinical data with
unaffiliated providers

Greater adoption and use of HIT are likely to further spur
participation as hospitals realize greater gains from
availability of electronic data
Thank You!
Julia Adler-Milstein
jadlermilstein@hbs.edu