A journey to RHIO: regional health information organizations are starting to gear providers up for electronic health records--and nursing homes are invited.

As electronic health records (EHRs) and integrated clinical information systems become commonplace, more healthcare provider organizations are beginning to come together to create the next step in healthcare information technology--regional health information organizations, or RHIOs. They offer the promise of improved patient care and enhanced provider organization efficiency. What's more, the federal government is promoting the concept of RHIOs as a key element in the ultimate drive towards a National Health Information Network (NHIN).

Where is the place for nursing homes in this new interconnected world? To date, only a handful of RHIOs are actually up and running and sharing clinical data, so the horizon is still a bit distant for this concept to apply to nursing homes. But within the next year, according to numerous surveys, dozens of RHIOs may be up and sharing data in real time. And, though only a very small number of long-term care executives say they are actively involved in RHIO development, that number, too, could leap ahead fairly quickly in the next couple of years.

For physicians with patients who are nursing home residents, the potential for better and smoother hospital admission and discharge processes seems likely because of RHIO-based data availability, while nursing homes themselves could benefit from regionally, and eventually nationally, shared clinical data to improve coordination with hospitals and overall patient care.

What's going on with RHIOs right now? A small number of nursing home executives are actively involved in some level of RHIO-related planning or activity. One is Gary Kelso, president and chairman, Mission Health Care Services, a system of four nursing homes, based in Huntsville, Utah. As president of the Utah Health Care Association (UHCA) and a member of the Health Information Technology Committee (HIT) for the American Health Care Association (AHCA), Kelso has naturally become involved in working with other long-term care executives, as well as executives from all sectors of healthcare, to bring his own organization and his state and national associations into collaborative initiatives. Describing himself as "something of a geek," Kelso says it's clear that technology cooperation will be essential to overcoming those staffing, cost-inflation, and reimbursement crises in which long-term care is perpetually enmeshed.

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"We've got to do things faster, smarter, cheaper," he says. "I wanted to get involved in a process, so I got involved with the HIT committee. Before that I had formed a committee with the Utah association, working with the state department of health. We wanted to make sure that long-term care was not a 'stepchild' as RHIOs were developed. So I met with our local RHIO, explored what they're doing, and asked how we could become involved."

The statewide RHIO, called the Utah Health Information Network (www.uhin.com), has been live since 1994 (it started out as a community health information network, or CHIN, back in the 1990s, when CHINs were popular). It already connects all the state's hospitals, 95% of its physicians, all its labs and psychiatric hospitals, and long-term care for claims purposes, notes Jan Root, PhD, UHIN's director. The next step, and one in which Kelso and other UHCA member-organization executives will be involved, is to create a statewide clinical network under the RHIO's sponsorship that will begin exchanging clinical data among providers. The software that Kelso and his colleagues at Mission Health Services are codeveloping with a vendor, the Salt Lake City-based BlueStep, Inc., will provide a platform for nursing homes to share data with acute-care and other providers.

At the same time, UHIN is working "very quickly" with [the Salt Lake City-based] Intermountain Healthcare and Utah Department of Health to create full-fledged statewide provider clinical data exchange, Root says. "We don't want to be left out in the cold; we want to have the ability to be linked in with either e-prescribing or e-medical records. For example, with this software, if a resident moves from one building to another, part of the file can immediately be transferred to whoever needs it."

The RHIO is starting out modestly with a transorganizational messaging system (i.e., focusing on messages that often need to be documented on paper by hand) for clinicians, Root says. "Right now, we have just three sites--one clinic, one hospital, and one health plan," all exchanging electronic messages around clinical information. Root's organization hopes to move beyond this initial pilot this autumn and, she says, nursing homes are welcome to participate along with other providers. Sometime next year Root hopes to convert this "early-adopter" project into a statewide clinical messaging system that will pay its way through some sort of per-message fee system.

In fact, across the United States, a wide variety of business and operational models are emerging among the RHIOs being developed. In Virginia, for instance, the Richmond-based MedVirginia, operating as a for-profit entity but with primary sponsorship from the Marriottsville-based Bon Secours Health System, Inc., is already processing more than one million messages a month, and already has more than 370,000 unique patients in its database, according to MedVirginia CEO Michael Matthews. "And we just see the data becoming richer as time goes on and we get additional data suppliers into the system. Our model is a community utility," he adds, and says he welcomes participation by all types of providers in the state, including long-term care.

MedVirginia operates thusly: "Fees are charged to data suppliers to have their data in our clinical data repository, because they're able to reduce some of their costs of data transfer. The physicians can view data at no charge." Physicians do pay for some subscription-based services, such as "interfacing with their practice management systems, electronic pre-scribing, etc." He adds, "We've focused on what physicians need day to day, but we haven't forgotten about long-term care or nursing homes." Indeed, he believes nursing homes will find participation in the network useful and meaningful.

As things stand as of press time, no RHIO has yet incorporated regular, active data exchange involving nursing homes, according to Clement J. McDonald, MD. He is director of the Indianapolis-based Regenstrief Institute and a prime mover in the Indiana Health Information Exchange (IHIE), an Indianapolis-based RHIO that is among a handful of RHIOs nationwide that are fully live and actively sharing large amounts of data among participants. "We do have a nursing home attached to the county hospital here, so their data is a part of our database," McDonald says. "But I'm not aware of a nursing home actively using data in a RHIO as yet."

A recent survey of leaders of 50 RHIOs nationwide does seem to indicate, however, that long-term care executives are becoming actively involved in the planning of some RHIOs. According to the report "Funding RHIO Startup and Financing for Life: The Survey of Regional Health Information Organization Finance," released in June 2006, 14% of survey respondents indicated that nursing home/long-term care organizations have been involved at the startup phase (compared with 74% of respondents who said so of hospital organizations and 58% who said so of physician groups); 13% said nursing home organizations have been involved in the transition (preparation) phase, and 13% in the production (ready to go live) phase. Author Michael Christopher, a development analyst at the Tulsa, Oklahoma-based Healthcare IT Transition Group, says that although nursing homes, like physician groups, tend to lack the financial resources of hospitals and health plans, their leaders are evidently realizing the importance of becoming involved in RHIOs despite this.

Nursing homes in general will inevitably be pulled into the RHIO orbit for good healthcare policy and self-interest reasons, says Mark Pavlovich, director, operations analysis, at Sava Senior Care, Atlanta, Georgia. Pavlovich, who is chairman of AHCA's Health Information Technology Committee, says that "nursing homes are so essentially tiedinto the continuum of health-care that we really are at a place where we have to exchange in formation electronically, not only with everyone who refers to us, but also those to whom we refer. I see information in a RHIO helping in so many ways." Indeed, Pavlovich sees RHIO participation as essential for nursing homes.

Will it be easy? Certainly not. Will it hap-pen very quickly? Not likely. But everyone agrees, the trend toward EHRs is clear, and nursing home executives should begin learning now how to participate in their regions' RHIOs to make sure the trends work to the benefit of their residents and of their organizations as the future unfolds.

Mark Hagland is an independent healthcare writer based in Chicago. To send your comments to the author and editors, please e-mail hagland1106@ nursinghomesmagazine.com.