Regional Health Information Organization (RHIO). That's the catchphrase of the year — maybe of the decade. Leading edge hospitals are reporting their success in RHIO deployments as their peers observe the movement with growing interest and lessening trepidation.

There is legitimate reason for concern. Attempting secure data exchange across multiple, unrelated provider systems can be a complicated and expensive endeavor…or not. The federated model could easily address the security, confidentiality and privacy issues that threaten to derail RHIO expansion.

New and Improved Technology

Data federation technology, which draws upon non-centralized repositories of patient data, has been around for more than a decade, but its adoption in the healthcare world has been slow until recently. Several variables influenced this change in behavior.

First, the growing demand for access to all relevant medical data at the point of care, as well as remotely, has led to the evolution of healthcare IT solutions that pull data from multiple applications to deliver a comprehensive, longitudinal view of the patient. These data-aggregating products allow physicians to access clinical notes, flow sheet views, radiology reports, lab results, clinic and OR schedules, e-mail, secure messaging and clinical content sources.

Second, the movement of the industry towards RHIOs and, eventually, the National Health Information Network (NHIN), has introduced significantly greater complexity. Past models included the heavy lifting and high cost of centralizing the patient data that was extracted from the various RHIO member organizations into a central (and duplicate) database. The politics of data ownership and the lack of confidence in the complex synchronization that this required often stalled projects before they even started. Additionally, there is no standardization of data access or usage policies among the various facilities, let alone within the industry. High cost, long lead times, the latency inherent in a complex database model, and the politics of data ownership in the central data repository model have opened the door for a more elegant solution.

Many predict that the next generation of patient-centric Web portal solutions, will not only draw from patient data within an enterprise, such as a RHIO, but also from the ubiquitous Internet itself.

The remedy to these ills is a "truly" federated data model, which does not demand that data be moved, replicated or modified; thus, eliminating the politics of data ownership and the lack of confidence in the newness and accuracy of the data. Instead, hospital physicians interact with a virtual, real-time, "single view" of patient data that resides in multiple, diverse databases. The seamless viewing experience is generated by a Web portal solution that adheres to the access rights set forth by the original database owner.

Some so-called federated models rely on centralization during the manipulation phase, which occurs after the data is drawn from the native applications and before pushing it out to the Web portal for viewing. This is not a true federated model and, as such, is still afflicted with the aforementioned data integrity and latency issues. A true federated model aggregates data to ensure that there is zero centralization of patient information. This translates into less risk of security, privacy or confidentiality breaches.

Another benefit of the federated data model is that there are no changes required to the legacy applications. Furthermore, because there is no need for complex back-end data integration, deployments can move rapidly with numerous rollouts in as soon as three months, as opposed to the three or more years for centralized data solutions. Moreover, the federated structure allows for easy integration of additional hospitals into the system as the RHIO expands.

Federated models also enable organizations to quickly and efficiently pull data for the purpose of evaluation of performance and quality improvement objectives. These are increasingly vital criteria as providers strive to meet the challenges set forth by the Centers for Medicare and Medicaid Services.

Don't Believe the Hype?

Naysayers question the long-term viability of the federated model in healthcare. Some argue that federated solutions cannot manage the complicated, discrete databases that are common within RHIOs. These databases, which are owned by separate towns, parishes or large hospital groups, may have their own management structures and internal policies. But successful deployments exist that have handled large quantities of database sources, each with different tax systems, lab applications and distinct operating platforms. This enterprisewide interoperability — once seen as unachievable — has now become one of the most valuable aspects of the federated data model solution.

The politics of data ownership and the lack of confidence in the complex synchronization that this required often stalled projects before they even started.

Another argument is that the solutions cannot handle large data volumes at one time. The twist to this claim is that these Web portal solutions process data requests using a role-focused filter, which aggregates the data according to the given user's access rights. The portal would rarely, if ever, need to extract a significant volume of data for one user's request; thus, making the debate essentially irrelevant.

Many have also decried the inherent problems with rolling out enterprisewide updates via these solutions. However, because the data always remains within the control and ownership of the native database owner, there would be no enterprisewide updates. Each organization would manage their own systems as they have done in the past. The federated Web portal solution runs its own software updates, which would not impact the client PCs or the native databases.

Best Practices of YouTube

There are lessons to be learned from business successes such as YouTube when it comes to data sharing and delivery. One lesson relates to "mash-ups," the user-generated videos that result from modifications of existing digital files using various audio, video and graphic or text elements. In the healthcare world, "mash-ups" refer to a slightly different process of combining content formats and delivery. Many predict that the next generation of patient-centric Web portal solutions, will not only draw from patient data within an enterprise, such as a RHIO, but also from the ubiquitous Internet itself. In other words, evidence-based medicine and best practices available via the Internet could be integrated real-time into Web portal solutions to further enhance clinical decision making at the point of care.

Technology and Telemedicine

We can embrace the era of telemedicine thanks to the evolution of federated technology. The ability to link healthcare providers across broad regions facilitates and improves the coordination of specialized care and collaboration between remote general physicians and specialists. Prior to this simultaneous, real-time access to patient data, rural physicians and their patients often had to wait for weeks to see a visiting specialist. Delays were further extended while waiting on files and release forms sent by mail. By using a federated Web portal solution, a specialist consultation can take place within 24 to 48 hours of the general physician's request.

One of the most powerful outcomes is the improvement in the health and welfare of communities that have suffered from lack of quality care and limited resources. "The expanded depth and continuity of care possible with federated Web portal solutions enables hospitals to serve people in underserved communities," says Jamie Welch, CIO of the Louisiana Rural Hospital Coalition.

"The resulting decrease in hospital length of stay and reduction of hospital admissions has resulted in significant budgetary savings," he says. "This is a tremendous boon for strapped, state-run hospitals that carry the burden of underinsured or uninsured citizens' care."

The Time is Now

The age of RHIOs has arrived, as we employ technology to link all of our patient data into a virtual, universal view. Yet, we have only just begun this journey with the ultimate destination of the NHIN still before us. We will continue to face challenges to preserve the integrity and vision of improved patient care as we balance technological opportunities and risks.

Implementing a RHIO: A mini-case history

According to the Louisiana Department of Health and Hospitals' 2007 Health Insurance survey, 21.2 percent of Louisiana residents are uninsured. Many of these residents live in rural, medically under-served areas and rely on state-run facilities for their primary healthcare. Consequently, they often travel to one of the state's 10 public hospitals for care, stretching the resources of those facilities to their limits. One such facility is Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S), the state's only remaining Level I trauma center after Hurricane Katrina closed Charity Hospital in New Orleans in 2005.

To ease the burden on its health system and improve access to specialist care in rural areas, the Louisiana Rural Hospital Coalition Inc. (LRHC) in conjunction with the LSUHSC-S developed a progressive eHealth initiative. By mid-2007, they had received $13 million in funding from the Louisiana legislature to create a statewide network that would enable 24 rural hospitals to access an integrated, patient-centric Web portal system to support a statewide telemedicine program, a cornerstone of their eHealth vision.

Previous attempts at telemedicine had been stymied by the lack of secure and timely access to patient data, as well as by the extended deployment time and cost for available centralized data solutions. "We originally envisioned using a centralized data model, but quickly realized that we would spend three years hammering out governance, privacy and data ownership issues," says Jamie Welch, CIO of the LRHC. "Hospitals are very protective of their patient data and do not wish to permit other facilities' physicians to alter that data."

After evaluating models used by other successful regional health information organizations (RHIOs), the LRHC and the LSUHSC-S concluded that the federated data model would address their concerns. Under that model, clinicians would access patient information without moving it from the clinical systems where it was stored; thus, allowing participating facilities to maintain control and ownership of their respective data. "In addition to requiring the federated data model, our RFP stated that there would be no storage of patient data during any point in the process in order to ensure a fast deployment, reduced risk to data integrity and improved security and privacy of patient data," says Welch.

The collaborating Louisiana healthcare organizations selected the secure open system Web portal solution jointly proposed by Carefx, CA Inc., IBM and Initiate Systems. IBM's Websphere and Carefx's Fusion would make up the portal framework while CA would provide user authentication and single sign-on, policy-based authorization, identity federation and auditing of access. Initiate Systems would implement the enterprise master person index (EMPI) for accurate patient identification.

On March 20, 2008, the RHIO went live, with all 24 participating facilities able to conduct teleconsultations with LSUHSC-S. Within the first year, seven of the 24 hospitals will utilize these systems to support teleconsultations. The comprehensive Web portal solution will be deployed in the remaining facilities within the next three years, with a total of 2,500 physician licenses to accommodate future growth.

In preparation for the portal deployment, the LSUHSC-S installed a secure VPN tunnel between the host computers at LSUHSC-S and the rural hospitals. In addition, the seven hospitals implemented picture archiving and communications systems and hospital information systems.

Even with the initial infrastructure investments, Louisiana leaders expect to reap significant savings through the state's telemedicine program and its accompanying Web portal platform. "Rural patients would often have to wait for three weeks or more to see a specialist and then the specialist would have 25 consultations in one day," says Welch. "In urgent medical situations, the patient would be driven to LSUHSC-S, delaying critical care for the patient and incurring additional costs for the state hospital. Now, we can set up a specialist teleconsultation within 1-2 days of the rural physician's request, which cost-effectively meets the medical needs of the rural community."

The Louisiana RHIO has already made great strides in realizing its dream of providing extensive specialist care to its underserved rural population. A total of 24 hospitals will benefit from real-time access to medical data to improve patient outcomes and an advanced telemedicine system that leads the nation in innovation. "Thanks to this innovative portal technology, we can now ensure proper care for our often forgotten rural citizens," says Welch.

Andy Hurd is chairman and CEO of Scottsdale, Ariz.-based Carefx Corp., a provider of information aggregation tools designed to streamline clinical workflow. He can be reached at ahurd@carefx.com.