Dean's Newsletter

Archive of previous newsletters

Rochester Regional Health Information Organization (RHIO)

June 22, 2006

Last Saturday morning, a middle-aged man presented to our emergency room with mild abdominal pain that had persisted for several weeks. He reported that he was told he had "an aneurysm" 3 weeks earlier, based on an abdominal CT scan at an independent radiology facility. A repeat CT scan was performed and showed an abdominal aortic aneurysm of 5.3 cm. In general, concern about aneurysm rupture increases as the aneurysm diameter expands, and a threshold for significant concern is 5.0 cm. In addition, there was some evidence that the aneurism had begun to dissect the vessel wall, another bad sign.

What should be done? Is this patient at immediate risk, requiring immediate surgery? Or can it wait until Monday, when the specialized surgical team needed to perform this operation in an optimal fashion would be available? The key information is whether the aneurysm had grown in the past 3 weeks since the last CT scan, and whether the appearance of dissection was new. This information, however, was not available on Saturday, as the radiology facility was closed. The decision was made to admit the patient for observation, with a plan to evaluate him by the full vascular team on Monday morning, but with on-call readiness to perform the surgery on an emergency basis over the weekend if symptoms worsened.

Suppose we knew that the aneurysm was only 2.5 cm three weeks ago with no evidence of dissection. Would that have changed the plan to immediate operation? On the other hand, suppose that the aneurysm looked exactly the same three weeks ago; in that case, could the patient have been sent home with an appointment to see the vascular team on Monday morning, preserving the availability of a bed in an already crowded hospital? The medical information contained in records at another facility was critical in answering these questions.

Let's now generalize the example and recognize that similar scenarios play out every day. In our emergency rooms, and in our clinics and faculty practice offices, patients are seen who have prior medical records in other health systems. Under these circumstances, how can our physicians and nurses obtain the data they need to determine the diagnosis and best treatment plan? Surely, a history and physical exam goes a long way, but additional information is often needed, and critical time may be lost in trying to acquire medical data—lab tests, imaging studies, office notes--from another system. We often have little choice but to repeat key lab tests and/or imaging studies, a process that wastes money and produces a delay in diagnosis and treatment that may impact on the patient's response to treatment. Parallel problems occur when URMC patients show up in non-URMC facilities.

What can be done to facilitate the exchange of key medical information across systems? The Federal Government (Department of Health and Human Services) is promoting the development of "Regional Health Information Organizations," or "RHIOs," to connect health data in a region into a virtual patient record. In NYS, about $53 million has been set aside for such regional health care networks as Phase 1 of a program called Heal NY. In response to an RFA, 26 NYS community initiatives were funded. In our region, the Rochester RHIO, which evolved out of the now-closed Rochester Health Commission, was awarded a grant of $4.4 million in late May, to be matched with an additional $1.9 million raised from several local health systems, insurers and businesses, including URMC, RIT, Excellus, Preferred Care, physician groups and Unity Health System. The consortium of local businesses include: Bausch & Lomb, Jasco Tools, Kodak, M&T Bank, Xerox, and Wegmans.

Phase I of the Rochester RHIO project will extend over 18 months; its goal is the design and implementation of a centralized and secure health information exchange (HIE) that will serve health care providers--and their patients--in our 9 county region. The HIE will provide the foundational architecture for the exchange of digitally generated patient information, which includes medication history, imaging reports, lab results, and demographic data. Within a number of years, the HIE has the potential to integrate the clinical data used and sourced by over 870 physicians, 195 pharmacies, 5 labs, 15 hospitals, 3 independent labs, and 5 imaging centers.

An economic model to estimate the savings for our community was developed by a health economics consultant, Health Alliant, with significant input from members of our community. According to the model, the Rochester RHIO can reduce annual medical costs up to $75 million across the community by the 5th year of the project. Estimated savings based on this analysis from Health Alliant are shown below. The savings are projected to accrue largely by reducing redundancy of medical testing, increasing the use of generic drugs, reducing adverse drug events, and reducing time and administrative expense to access and distribute images and results.

It can be seen that the key savings driver is the projected increase in the use of generic drugs. As noted in a previous Newsletter (February 24, 2006), this is an important community and URMC goal that will likely be addressed through a number of different strategies. One must be quite cautious, however, in interpreting the projected savings from generic drugs through the Rochester RHIO, since most ambulatory e-prescribing in use today (e.g., Allscripts) uses ambulatory payor formulary compliance, which is also effectively directed at this goal. Likewise, through the Pharmacy Benefits Management (PBM) process (what happens when you actually present a prescription to be filled at any pharmacy), most drugs written as "brand" and not specifically marked DAW are already substituted for generics or lower cost alternate brands under pharmacy/PBM contracts. Given the rising prices of brand-name drugs, as well as the roll-out of the Medicare prescription plan, total medication expenditures will no doubt increase, and the projected "savings" will represent a reduction in the amount of increase. That said, the role of the Rochester RHIO in furthering the use of generic drugs will be welcomed, and it will be important to measure its specific impact in this area.

It is intuitive that the quality of medical care will also be improved as a consequence of better and more uniform access to medical data. Some of the quality measures that will be monitored include:

• More accurate diagnosis with key information available "24/7"
• Reduction in unnecessary hospitalizations
• Reduction in unnecessary emergency department visits
• Reduction in length of stay
• Reduction in "busted appointments" because information not available
• Reduction in cycle time to complete diagnosis and embark treatment plan
• Improved "handoffs" between physicians
• Increased frequency of access to prior images for comparison
• Improved employee satisfaction of physicians, nurses and staff

As the RHIO is planned, a key goal will be to protect the privacy of patients while providing those with a "need to know" the mechanism to obtain critical medical data in an efficient, secure manner.

A large number of people with diverse backgrounds and interests came together to work successfully in obtaining the funding needed to start the Rochester RHIO. Here are some perspectives from a few of these individuals regarding the potential benefits and challenges of designing and implementing a regional health information network:

Dawn Deperrior, Consultant and RHIO Project Manager: "The greater Rochester community has an opportunity to achieve significant qualitative and quantitative benefits already demonstrated by similar initiatives with shared access to patient-centric electronic health records. Examples range from the nationwide Veterans Administration model, communitywide Cincinnati HealthBridge model, down to Dr. Alice Lovey's local pediatric practice EMR connection to immediate electronic lab results from each local lab."

Martin Hickey, MD, Sr. Vice President for Health Care Affairs, Excellus

Martin Hickey, MD, Sr. Vice President for Health Care Affairs, Excellus: "RHIOs not only have the potential to save health care costs (20% lab duplication, increased penetration of Generics to 70%, reduction of adverse drug events by up to 50%, etc.), but they will significantly increase the opportunity to coordinate all care. RHIOs also will form much of the foundation of the personal health record, which should assist in further engaging the patient in his or her own care. Finally, with its centralized multiple patient index, the RHIO should be of immense value in undertaking epidemiologic and other clinical research.

 

 

Al Kinel, Director of Alliances, Kodak

Al Kinel, Director of Alliances, Kodak, and initiator of Rochester RHIO: "Healthcare institutions in our community have expended significant resources to build high quality information systems that add tremendous value and help our professionals deliver high quality care. However, these institution-centric systems and associated work processes are not effective or efficient in obtaining or sharing information with other institutions. The RHIO will augment the institution-centric systems with a public utility that links facilities to provide clinicians with a single patient view, regardless of where the patient has been treated. Over time, our RHIO will also connect to other community initiatives throughout the state and country, forming a nationwide network that supports patients that travel or move. Kodak is pleased to support the RHIO to ensure that image-intensive specialists, PCPs and radiologists can easily obtain all relevant images and information to improve care and reduce costs."

David Krusch, MD, Associate Professor of Surgery and Director of Medical Informatics at URMC

David Krusch, MD, Associate Professor of Surgery and Director of Medical Informatics at URMC: "The Rochester RHIO will provide an essential infrastructure for the exchange of continuity of care medical information between all providers caring for a patient. In effect, this epitomizes the notion of the "patient centric record." Having community wide common access to these high value resources, such as ambulatory medication lists, problem lists, allergy history, and laboratory values will result in increased safety and more efficient care delivery by all providers. As we embrace Electronic Health Care Systems, such as Allscripts, we are strategically positioning ourselves to leverage the RHIO as it evolves."

 

Bob Panzer, MD, Chief Quality Officer, URMC

Bob Panzer, MD, Chief Quality Officer, URMC: "The safety of patient care improves dramatically when key information is available at any time, from any place. For example, with our Allscripts ambulatory care EMR, covering physicians can see the patient's entire record even when they are calling the patient from home. Yet today, that information is only available for physicians to manage patients within 'their system'. The RHIO will provide the platform for higher quality, safer care for all patients in the region."

Information technology is transforming health care for the better, and the RHIOs represent yet additional examples. Through electronic medical records (Dean's Newsletter April 14, 2006) and RHIOs, health care personnel have more efficient and thorough access to medical information about their patients, and through open-access journal publications (Dean's Newsletters July 1 and July 8, 2005), they are better informed of new knowledge and technology. For their part, well-informed patients are better equipped to participate actively in their own care and decision-making. The transition from general information on the internet to a true personalized health record—with the ability to gather specific information tailored to their risk profile and illness history—promises to add further justification to the use of the word "revolutionary" as applied to the impact of IT on health.

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry