CEO SUMMARY: Forget CHINs from the 1990s and RHIOs from this decade. The future of regional health data repositories may turn out to be a patient-controlled model, often called a “Health Record Bank” (HRB). Here is the lab industry’s first look at this nascent movement. HRBs are under development in Louisville, Kentucky, the State of Oregon (for the state’s Medicaid beneficiaries), and the State of Washington. Other notable HRB advocates investing in the concept are Microsoft and Google.
ANY DISCUSSION OF SHARING HEALTHCARE DATA at the community, regional, or state level portends major threats and opportunities for laboratories serving patients within that geography. After all, laboratory test data comprises the overwhelming majority of information in a patient’s long-term clinical record.
There is widespread agreement from most healthcare stakeholders that health-care would benefit from some form of a single health repository. In the 1990s, the favored term was CHIN—Community Health Information Network. In this decade, the most common term is RHIO—Regional Health Information Organization. HIE—Health Information Exchange—is another way to describe this data repository model.
However, progress on creating such health data repositories at the community or regional level is proving problematic. The first challenge is to develop a funding model that sustains the data repository. The second challenge is to gain agreement among the participants on the technology to assemble, store, and make data available, along with the operating protocols of the HIE. The third challenge is getting all classes of providers, including hospitals and large clinics, to participate in the healthcare data repository. Many entities see their heath data as a proprietary asset. Thus, these providers are cagey about “supporting” the RHIO in their area while working to retain control over how data they hold are used.
Health Record Bank
Enter the “Health Record Bank” (HRB). This is a healthcare data repository concept which borrows from the financial banking model. Both patients and providers choose a health record bank, pay a fee and establish an account. Next, each time a patient visits a provider, the provider would feed information from that encounter into the patient’s HRB. Of course, patients can also submit their own health data into the HRB.
Credible efforts are already under way to create the nation’s first HRBs. For the past two years, in Louisville, Kentucky, the Louisville Health Information Exchange (LouHIE) has raised funding and developed a business plan. It expects to select a vendor this fall and initiate the first pilot project in the second quarter of 2009. It is targeting system build-out for 2010.
In Oregon, during 2007, the state received a $5.5 million federal grant specifically to develop an HRB for the 400,000 patients covered by the Oregon Health Plan, which is the state’s Medicaid Program. The data warehouse for this HRB is under development.
HRBs In Washington State
Next door to Oregon, the State of Washington is providing $3.4 million in seed money to help several communities organize and operate their own HRBs. Several large health systems are involved in this project. State officials hope to have the first community HRBs operational by February 2009.
The three examples presented above represent just one dimension in the gathering effort to make HRBs the dominant form of regional health information exchanges. As clients and long-time readers of THE DARK REPORT know, Microsoft Corporation and Google both launched well-financed, much publicized health record banks during the past 12 months. Because Microsoft and Google are both respected as strategic leaders in business uses of the Internet, their decision to enter the healthcare informatics marketplace by developing health records banks gives this concept added credibility. (See TDR, May 27, 2008.)
Both Microsoft and Google see the HRB business model as a natural extension of their primary businesses. Further, Microsoft and Google have a sophisticated understanding of how consumers currently use the Internet and why a health records bank service is likely to be both successful and financially lucrative down the road.
There are simple and obvious reasons why interest in the HRB approach is growing. The complexities of creating RHIOs, frustrate RHIO organizers and those health-care providers in a region who must participate if the proposed RHIO is to function effectively. RHIOs need to get agreements on technology, to create operating rules, and to interface with all participating providers.
For example, as officials looked at progress to create RHIOs in the Pacific Northwest, these daunting challenges drove the decision in Washington State to develop health record banks. “To be frank, we don’t think that [the RHIO model] is sustainable or feasible,” says Juan Alaniz, Manager of the HRB project for the Washington State Health Care Authority in Olympia. “We think the real change will come from consumers having control over their healthcare information and sharing it with whomever they want to. The health record bank could be the disruptive technology to change the paradigm.”
One leading advocate for health record banks argues that simplicity is the strength of HRBs. “You don’t have endless meetings and discussions and data-sharing agreements and millions of dollars in legal fees,” declared William Yasnoff, M.D., Ph.D., and the Founder of the Health Banking Alliance. “By using this simple construct—which is consistent with individual medical privacy—you are able to eliminate this whole layer of just maddeningly complex policy discussions about who should see what when.”
Critics of HRBs
There are plenty of critics of HRBs, who say that consumers must step up and take responsibility for establishing their patient record in the HBR if this data model is to succeed. There must also be a large enough proportion of patients in a region participating in the HRB to motivate providers to access their patients’ health records from the HRB.
Another criticism of HRBs is the possibility that some patients would manipulate the data in their personal health record. For example, how would a physician know whether a patient was withholding information that, if known by the physician, would influence treatment?
“The idea of giving control to the patient, for a lot of my colleagues, was a really hard one for them to wrap their heads around,” stated James Hereford, who chaired the Health Information Infrastructure Advisory Board (HIIAB) that was created to advise Washington State legislators on options for creating a regional electronic patient health record solution.
Treating Data Appropriately
In developing the HRB concept, Washington State will provide ways that physicians can see the sources of data in a patient’s record so that they can treat that data appropriately. Yasnoff suggests the HRB can be structured so that providers can deposit data into the health record bank that cannot be modified by the patient—but the patient could add notes in the record which providers would view when they access that data.
Because the concept of the health records bank represents one more approach toward creating a centralized repository of patient health data, laboratory directors and pathologists will need to track its emergence and progress. That’s because laboratory test data comprise an overwhelming proportion of the long term patient medical record. Thus, the HRB model will directly change both how physicians and patients access laboratory test data and how they use it.
CHINs, Then RHIOs
Further, as noted earlier, CHINS in the 1990s proved unworkable and too complex. In this decade, RHIOs, the next generation in thinking about how to create regional health repositories, are proving equally challenging and expensive. Thus, it should be no surprise that a consumer-centric approach to regional health repositories is emerging. However, the health record bank (HRB) model will generate its own controversies until a real-world demonstration project shows that this concept can work.
Health Info Exchange Has Three Business Models
FOR SEVERAL DECADES, efforts to organize regional health data repositories have used the distributed (federal) model or the centralized model. Health record banks represent a third business model.
Distributed (Federal) Model:
Writing in the Group Practice Journal (Vol. 55, No. 2, Page 38, February 2006) authors Victor Plavner, M.D., and Peter van der Grinten wrote about the distributed model common to RHIOs (regional health organizations), stating that “typical RHIO architectures rely on the use of a central data repository that, in turn, requires extensive integration and mapping of data from disparate systems to allow end-users to access and view the data across the network. For providers who have endured expensive data integration projects in their own organizations, the prospect of repeating the process in a network setting can appear daunting.”
In a story for the American Health Information Association (AHIA), writer Chris Dimick describes the centralized model as where “…participating organizations store a patient’s data on a centralized data base. They form a community that links to the data base for health information exchange, submitting and withdrawing records. Though the centralized repository is similar to that of the health record bank model, control over the record lies with the providers, who own and manage the record.”
Health Record Bank Model:
Advocates of the health record bank (HRB) point out that organizing the health data repository along similar lines as a commercial bank greatly simplifies the technical complexity and expense. Because one format is used to keep patient data in the HRB, it is simpler for providers to build the interface to the HRB. That single interface allows them to access the patient’s record when needed, and to pass new clinical data into the patient’s health record.