JAC: We want to position our members to be ready for the day when people are able to share clinical information electronically. In October 2005 we formed a task force with members from a wide cross-section of expertise, which recommended to our board of trustees that we go ahead with a feasibility study. We have the first draft of a cross-industry business plan, and I’m meeting with various stakeholder groups to gauge what their involvement would be, and what adjustments we should make. Our goal is to submit this to our board by the end of September.

Our hospitals, despite a lot of the financial woes they’ve had with being under-reimbursed for services, are really trying to figure out how they could do a better job serving their patients and communities. They’re struggling with trying to get information as real-time as they can for patients who present in an emergency room. People trying to render care need to ask a lot of questions, such as: What medications are you on? When people are in an emergent situation, they may not be thinking clearly, and they don’t necessarily have their meds with them, or good documentation. A lot of times clinicians in an emergency department, an admitting department, or even in a physician’s office have to do a lot of research before they can start to treat the patient. Our hospitals see this as an opportunity to improve care, improve efficiency and reduce wait times.

JAC: There a lot of variations. Some groups in other states share information from a tumor registry, or an immunization registry. We’ve set the bar much higher - we want to have available to whomever renders care, in a secured place, all the clinical data that could exist for an individual patient. We see a RHIO, not being a hospital, physician or payor organization, but really being a health care organization - a 501(c)(3) nonprofit with a board of trustees coming from various sectors of industry - including physicians, employers and patient advocacy groups. The organization’s mission would be to share as much clinical information as possible, safely and securely, to ensure safe, high-quality, high-efficiency, cost-effective patient care.

JAC: There are four potential uses out of the gate. The first is a patient locator, or master patient index. You’ve got to be able to ensure that you are collecting information for the right person, and know what other physicians are in that patient’s continuum of care. The second is medication history - what current meds have been prescribed, filled and are in the patient’s possession. There’s a lot of information out there today in pharmacy chain and payor databases, and we need to identify it. The third use is to share electronic medical/health records. That’s going to be harder to come by. It may be years before everybody has 100 percent of their medical record available, but we don’t need 100 percent. Maybe five or ten pages in a medical record would be of great value to a physician or hospital emergency department when they’re trying to render care. We’ve got to get as much of that clinical information together as we can and organize it into a way that allows physicians to access quickly the things they care most about. The fourth use is to develop continuum of care transfer information, including long-term care facilities and nursing homes. Any one of those four uses, you could argue, would be a big hit, but we’re going to go for all four in the first five years, and hope that we can get progressively better at them. That’s the goal of our business plan.

JAC: Let me describe a problem that we’ve uncovered and how this RHIO might help. Massachusetts reported that 50 percent of patients who leave a hospital setting never fill their prescriptions. Think about the kind of patients who leave a hospital - the chronically ill, people who have hypertension, diabetes - these are conditions for which you can’t do without your meds. In New Jersey, we find that 50 percent is the low end. Some payors are experiencing as high as 75 percent. Those patients may be suffering greatly and probably go back to a hospital. One of the first things this RHIO will have is a medication history, as soon as we can identify who the patients and caregivers are. The primary care physician with a diabetic patient who has hypertension can check the patient’s pharmacy feed in the RHIO to see if that patient even filled their script. If they didn’t, the physician’s assistant or office manager can call to find out why not. If we can leverage this knowledge, maybe there are things we can do to address it, for example, maybe giving that patient a six-month supply of medications when they leave the hospital. Do the math of what the cost savings would be to the health care system, what the efficiency would be, and what the quality of life would be for the patient - who otherwise is going to end up back in the hospital.

Another benefit is that physicians won’t have to be mindreaders, and can go into a master patient index to see all the patient’s other physicians. He has a heart doctor? The physician may not have even been aware that the patient has a heart problem! Even if the RHIO achieves only the first two uses - here’s John Doe, here are all the places he’s gotten care, here are the meds he’s on and who prescribed them - think about how that could remove the misinformation or lack of information for a lot of physicians, and what value that would bring them. There was a recent national study that said that 20 percent of diagnostic tests are duplicative. If half of those could be avoided because people have access to that data, that could be a significant cost and time savings. A physician could look up those test results immediately and rule something out.

Another thing is improving the relationship between the patient and the physician. A chronically ill patient with a RHIO record can grant physicians access to their chart to get an opinion or a referral, and may not have to go into the office. The RHIO could create a lot of good dialogue and put the patient in better control of what kind of care is being rendered.

JAC: One school of thought says you need one master mega-database. A database like that would be too huge and costly. Another approach is the opposite: that you need to keep all the information at its origins, and a RHIO would be like a search engine pointing people to various data across the continuum of care - maybe just having a master patient index. But a chain is only as strong as its weakest link, and there could be a lot of weak links if you do that. I think the ultimate solution is a hybrid model of those two: there is some information in a central database that you would want to keep, and it would be small and manageable enough where you can have things like master patient index, medication history, allergies, and enough clinical data points to be of value to a physician. We could have a link from that database to the data’s origin, whether it be a physician’s office, a hospital or some other place, to make more complete data available if needed. For this model, a consensus decision needs to be made about which data should be centralized and which should be at the various locations. You’ve got to provide software to the people who maintain that data on a server someplace in their own facility to protect it, encrypt it and transmit it. Where possible, you want to also build a private network for that data, with a major feed going from a hospital "A" to the RHIO, without going across the Internet. There are five or six RHIO vendors who do it that way. Every hospital has various vendors that work within that hospital, and they all share a protocol called the HL7 standard, and every hospital has an interface engine that helps coordinate the data. Something like that is going to need to be done when you go across the state, or between states. There are some unofficial RHIO efforts currently moving forward in New Jersey, where large health systems are trying to tie physicians together. My hope is that these standards will help make data secure and interoperable across RHIOs.

JAC: It would be statewide or an umbrella, so that if you had various RHIOs in other regions of the state, they would coordinate access to data among patients, physicians and hospitals outside of their RHIO. There would be interoperability with some sort of statewide RHIO mechanism.

JAC: The number one barrier is going to be the cost. It’s not going to be cheap. We estimate this is going to be at least a $35 million to $40 million endeavor over the first five years. Right now, our hospitals and physicians are really strapped. The second barrier is getting everybody across the industry to come together and work on this. Hospitals are not used to sitting down and working with payors on a collaboration of this magnitude. There is a lot of distrust, whether it’s warranted or not. Just the fact that Horizon Blue Cross Blue Shield and NJHA got together on this speaks volumes about its importance and value. They have partnered with us in terms of funding and building the business plan. A myriad of stakeholders across the state have come to the table every two weeks, for at least two to three hours, for the last six months to build this business plan. I think that everyone agrees that sharing real-time clinical information is going to improve quality and efficiency, and reduce cost. It’s just a matter of what they are willing to do to get there. Privacy and security are pretty far down the list of barriers. Several mechanisms exist - for example, you can give out cards that generate a new password every 30 seconds which you would need to know, in addition to username, password and an authorized IP connection from your computer.

JAC: Physician technology adoption is certainly an obstacle. If I didn’t know what the system is going to bring me, I don’t know if I’d want to invest. That’s the predicament that they’ve been in, especially if they’re a smaller independent practice. And even if a physician has the money and thought that this might work, they’ve got a time investment to make. What I would hope for with this RHIO is that we could do some things that are significant enough so that all the physician needs to do is subscribe to the RHIO. If they don’t have the wherewithal or the money or the time to get automated, but they do have access to the Internet and do see the value of going online and finding their patients’ medical information and other physicians - along with their phone numbers and everything else that they would need to quickly identify and call them - my hope is that physicians would see that all it cost them was an Internet connection and a subscription to the RHIO. As they get access to clinical information, physicians need to store it in something, and perhaps the RHIO would provide an "electronic medical record lite" for physicians to at least see what the value of such a system is. We’re talking about having a subcommittee focused on how to drive adoption in the physician community.

JAC: We asked ourselves that question many times and concluded that it is an unfair question at this point in time. Here’s a better question that we thought we’d need to answer: What is a critical mass for getting enough hospitals and payors to make enough data available to physicians? I believe that physicians are going to want to have access to that kind of information and, if it’s affordable and it’s not a huge learning curve to get access to it, my guess is that physicians will come. But it would be unfair to put a limit or a number as a criterion if there’s nothing for them to get access to.