Seven Keys to RHIO Success: The eHealthTrust Model

In a recent interview with NHIN Watch, I indicated that a complete RHIO must have:

  • All medical information available in electronic form
  • Stakeholder cooperation
  • Financial sustainability
  • Public trust
  • To achieve these goals, I described seven key requirements to RHIO success:

    1) financial incentives to clinicians who use EHR’s (electronic health records)

    2) central repository for data to allow rapid access and offline searching for public health and research

    3) having patients as the source of requests for information

    4) asking consumers (patients) to pay for their records to be electronic (about $5 per month)

    5) releasing medical information ONLY with patient approval

    6) establishing a community non-profit organization with independent privacy oversight to build and operate the system

    7) using a trustworthy technical architecture so consumers/patients can be sure that their information is safe and carefully protected against loss or improper release

    So how do you implement a RHIO that meets these requirements?

    Use the eHealthTrust model.

    The eHealthTrust makes complete patient information available when and where needed by serving as the community custodian of the complete medical records for everyone.

    Each person controls all access to his/her records, and is charged about $60/year ($5/month) for the service (which may be and should be reimbursed as an allowable medical expense).

    The eHealthTrust pays physicians about $3 for the “deposit” of each standardized electronic report of an outpatient encounter, thereby creating potential new revenue of about $15,000/year for physicians with EHR systems (and providing the needed incentives for their acquisition and use).

    Since the patients explicitly provide consent for the eHealthTrust record keeping activities, cooperation of all health care stakeholders in providing information is assured (since medical records must be provided on patient request under the Federal HIPAA statute). The eHealthTrust model assures public trust by putting the patient in control of his/her information.

    How does the eHealthTrust address the seven key requirements?

    1) financial incentives to clinicians for EHR (electronic health record) use

    The eHealthTrust uses the bulk of the fees from consumer/patients to pay clinicians to deposit standardized electronic reports from outpatient encounters. These reports must be generated from EHR systems; therefore, clinicians that have EHRs can receive substantial additional revenue (e.g. $15,000/year), which they need to pay for the systems (which may cost $40,000). The eHealthTrust is the only proposed business model for RHIOs that includes such financial incentives, thereby ensuring that the records of outpatient visits are electronic and thus can be easily available when needed.

    2) central repository for data to allow rapid access and offline searching for public health and research

    A central repository provides fast response time, and a searchable (offline) copy of the medical records for public health and research. By using an architecture that is trustworthy (see 7 below) and putting the patients in control of their information (see 5 below), it is possible to use this easy, low-cost solution. The alternative “scattered model,” which retrieves information from its existing locations only when needed, suffers from high cost, lack of reliability, and slow response time, and also does not readily allow the information to be searched for public health and research purposes.

    3) having patients as the source of requests for information

    In the eHealthTrust, patients submit a standing request for their medical information. This ensures the cooperation of the stakeholders, since the Federal HIPAA statute requires release of medical information when the patient requests it. Lack of such cooperation has been a major issue for many RHIOs.

    4) asking consumers/patients to pay for their records to be electronic (about $5/month)

    In a recent survey, 52% of consumers indicated that they would be willing to pay $5/month or more for their records to be electronic. This provides an immediately available source of funding – which is critical to financial sustainability.

    5) releasing medical information ONLY with the approval of the patient

    Medical information should be controlled by the consumer/patient – this is the central guiding principle of the eHealthTrust. An overwhelming majority (79%) of consumers support this (see my December posting for more details). Trust in the system depends on consumers/patients having control over their information – which they should have!

    6) establishing a community non-profit organization with independent privacy oversight to build and operate the system

    It is important to create an organization with representation from all the stakeholders and open, transparent processes. A community non-profit is the easiest way to accomplish this. An independent privacy oversight committee is needed to ensure that the information is properly protected and never misused.

    7) using a trustworthy technical architecture so consumers/patients can be sure that their information is safe and carefully protected against loss or improper release

    In an eHealthTrust, there are two separate repositories of information. One would provide access to the clinical records. Using a special, ultra-secure operating system, an authorized user would only be able to access a single person’s record before being logged off. This “cubbyhole” system would have no capability for searching or retrieving more than one record. By having the information in a central repository, it is easier to apply state-of-the-art computer security techniques since you know where the information is at all times.

    There would be a second offline repository of the medical records that would be used for public health and research. It would have no phone lines or network connections, and therefore would not be subject to improper electronic access. Only authorized personnel in the same room would be able to perform searches. Personnel would be carefully screened, and their activities closely monitored.

    In summary, the eHealthTrust provides a solution to building a RHIO that meets all the key requirements.

    Next time: The first eHealthTrust system in a community

    5 Responses to “Seven Keys to RHIO Success: The eHealthTrust Model”

    1. DaveRoss says:

      While I agree with the 7 keys to success, I think it’s worth pointing out what to many may be the obvious. That is, a superordinate success factor lies in how the need for the RHIO/eHealthTrust and the functions it serves is communicated to providers and patients. I’m curious why you chose to leave that aspect off the key success factors?

    2. Christina says:

      I like your keys to success! For item 4, the patient ultimately does pay even if not directly. As for item 5, I agree, but don’t want the approval process to get in the way of timely care being provided. This one will take a great deal of upfront planning.

    3. felicia martinez says:

      What other impact and challenges are for RHIO’S with EHR ?
      Are RHIO incorporated in all or part of this transition from regular paper material to all electronic and how is going to be funded?

    4. jnferree says:

      The recent study from Avalere, “Evolution of State Health Information Exchange: A Study of Vision, Strategy, and Progress,” was authored by Sheera Rosenfeld, Shannah Koss, Greg Fuller, and Karen Caruth, all of Avalere Health is an excellent overview of the challenges and lessons learned from early to mature RHIO projects.

      http://www.avalerehealth.net/wm/show.php?c=1&id=714

      At the end of the day, the long term viability of any Community HIE or RHIO is dependent upon (2) critical factors of success:

      1. Consumer Privacy and Protection
      2. Sustainable (break-even) business model

      As a healthcare consumer of (HSA, Medicaid, HMOP/PPO) services, unless I am convinced my ePHI being accessed by a CE or BA that I trust will not use this info in any way that could harm me, I would be VERY reluctant to avail my personal health information.

      Amazingly, very few of the RHIO’s that participated in the Avalere study have connected the dots on the value a biometric smart card platform brings to the table. I predict this will change very soon.

    5. [...] The scattered model requires that every system holding medical information be able to respond immediately to queries. This would need to be done in addition to the routine tasks being addressed by each system. Both software to process the queries and additional hardware to prevent the slowdown of the primary work of the system would therefore be needed. Indeed, for large systems that would be queried often (such as those in hospitals), there would need to be a separate server with a copy of the data to handle the queries. Otherwise, the hospital would find it difficult to guarantee adequate response time for internal access to its own records. This additional hardware and software has a cost — which would be borne by every medical information system in the community. These costs would be especially burdensome to physicians, who already are struggling with the high cost of electronic health record systems for their offices — this is one of the key obstacles to widespread adoption (see Seven Keys to RHIO Success). [...]

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