Innovate to Integrate

In California, as in many other areas of the country, an individual’s health information is scattered throughout the community among different healthcare providers in paper records and in computer systems that can’t talk with each other. This is a major problem that can have serious repercussions, as Donald Holmquest, President and CEO of the California Regional Health Organization (CalRHIO), explains: “We all know that it’s hard to find our own health information, and if you’re a doctor it’s often difficult to find patient information.

“In fact, I was in my own doctor’s office recently for an annual physical and he kept asking me about this particular procedure I had some time ago. He wanted to know the data but he kept giving me a date that didn’t match. Finally, we realized that somebody else’s record had been put into my paper record. I was not only missing medical information, but I was being given completely the wrong patient data.”

As a doctor himself, Holmquest was intuitive enough to realize the problem and its potential consequences, an incorrect prescription. However, he worries about the average patient and their inability, understandably, to identify such issues. And this is just in doctor’s offices, where patients are treated by physicians who know them and usually have at least some records on them. Holmquest points out that the most challenging environments for good care in the United States are the emergency departments of hospitals, where almost every patient is a stranger who is being treated by doctors and nurses who don’t know them.

Widespread problem

To highlight the scale of the problem, Holmquest recalls the results of a study carried out in 2005 by the University of Colorado in Denver. Researchers at the university discovered that when an independent evaluator made assessments on a sample population’s clinic visits they found that in about one out of seven instances, charts had clinical information missing. Further evaluation revealed that in half of these occasions, the patient got either the wrong drug, the wrong treatment or a diagnosis was dismissed. “Therefore, the patient could have come to some harm from that visit just because of missing information,” says Holmquest.

“This was not the result of a bad doctor or a bad clinic. It’s just that information wasn’t there that should and could have been. This works out to be six percent of the ambulatory visits in a very fine university ambulatory setting, which is probably a much better setting than many others that we deal with. The worrying thing is that six percent of the time when patients in the United States go to see their doctor they are at risk of being harmed, or getting a suboptimal result – getting a drug that interacts with another drug they’re already taking but the doctor doesn’t know they’re taking.”

Holmquest considers how these figures can be related to the state of California. “The state has a population of 37 million, with about one million people visiting the hospital every day. Therefore, every day at least 50,000 people are at risk from missing patient information.”

Bringing together the various healthcare stakeholders around the shared vision of using information technology to make healthcare safer and more efficient throughout California is something that CalRHIO is continuously striving to achieve. Holmquest explains how the organization began in 2005 to build a consensus around what it should do. “We raised a substantial amount of money and spent this in educational efforts and holding meetings all around the state. We had about 100 healthcare related organizations and about 450 individuals participating in work groups. They considered what kind of clinical information is important and what technology should be used to connect to thousands of information systems around the state. In addition, more than 1000 people attended statewide educational summits.”

Holmquest says the team worked hard to ensure as many people as possible were consulted about moving forward. “The end result of this effort was the selection of a stakeholder board of 24 positions, which we filled with representatives from hospitals, medical groups, risk-taking medical organizations, consumers, privacy advocates, state and local governments, health plans, insurance companies, safety net providers and other regional health information efforts. It is, therefore, a broad stakeholder board, and that’s how we brought the various stakeholders together on a continuing basis. Our goal is to make the best decisions on behalf of the public – the residents of the state of California.”

Exchange projects

One of the projects that CalRHIO is pursuing is to help safety net providers and their communities plan and expand health information exchange projects. The organization was given a substantial grant from the Blue Shield of California Foundation. This funding enabled them to offer free technical consulting service to various safety net providers throughout the state. A huge amount of healthcare in California is provided by community clinics – free clinics – some state qualified, some federally qualified, some both, and public hospitals, and it is with these people that the organization works to provide free consultation on technology projects.

“We also provided grants to four safety net organizations to help them expand their health information technology projects,” recalls Holmquest. “That work is still ongoing. We would love to continue this type of work. We have found that many of these organizations need basic help in planning their IT roadmap to understand where they are today and how to get where they want to be in the short-term and farther out.”

Challenges and opportunities

One of the biggest challenges for the organization in the long term will be its business case. As Holmquest points out, organizations like CalRHIO need to be able to sustain themselves beyond initial start up. “You cannot rely forever on grants,” he says, “whether they’re federal grants, state grants or private grants. You have got to come up with a sustainable business model.

“The technology is well understood. There are huge ongoing national efforts aimed at achieving interoperability. We’ve been engaged in these activities, but what is most critical to us is finding a financial model that makes it possible for us to sustain our operation and grow. When starting any business, you might have a great idea, but if you can’t monetize it then you’re not going to go anywhere with it.”

Depending on healthcare organizations to finance the initial build-out and startup places undue financial burden on early adopters and has demonstrated little success to date, Holmquest says. The financing model for the CalRHIO Health Information Exchange is designed so that participants (health plans, hospitals, medical groups, individual physicians) are not paying for initial deployment. CalRHIO is borrowing private capital to get the system up and running, which will be repaid through revenue collected from its medical information query service. “It’s utility model. Those who benefit pay only for the services they need and use,” Holmquest points out. “We believe this approach will greatly enhance participation and adoption of health information exchange and help to rapidly connect people in California.”

CalRHIO is starting its deployment in emergency departments, initially providing data from national sources on medication history, laboratory reports and clinical claims data from payers. Currently ED physicians have no patient data. The information provided through the CalRHIO system will help them make better care decisions and save the cost of redundant tests. It will also improve safety. For example, by having medication history, a physician can determine whether a prescription might adversely interact with what the patient is already taking. Because health plans and their members will be the primary beneficiaries, health plans are being asked to pay for medical information queries to the system on behalf of their members. Deployment to physicians’ offices will come once the EDs are connected.

An interesting final point Holmquest makes is that the estimates from organizations that have looked at health information technology generally reveal they can save about five percent of the cost of healthcare by just reducing duplicate tests and getting better outcomes.

“5% of what we spend on healthcare is huge amount of money,” stresses Holmquest. “In California, that five percent number translates to about $10 billion to $15 billion every single year. The benefits are therefore self-explanatory – we can save huge amounts of money and keep 50,000 people every day from getting a bad result. There is nowhere else in the healthcare system today where such savings are as certain, affordable and supported by technology that already exists.

“It would be a serious mistake not to tackle this problem and solve it, because it is the only simple solution today for saving a significant amount of money in healthcare. Changing the healthcare system in the United States will take decades and will cost trillions of dollars. What we’re talking about doing is achievable relatively speaking with a small amount of money and we will see enormous savings and enormous benefits for patients as a result. It’s time to get this thing going.”