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Regional Health Information Organizations: Business, Organizational and Legal Issues


CareSpark (Tennessee) Indiana. Massachusetts. 9. What Is CareSpark? ... State law privacy issues may present larger hurdles to project than HIPAA ... – PowerPoint PPT presentation

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Title: Regional Health Information Organizations: Business, Organizational and Legal Issues

Regional Health Information Organizations
Business, Organizational and Legal Issues
AHRQ Annual Meeting June 9, 2005
manatt manatt phelps phillips
William S. Bernstein, Esq. (
212) 830-7282
Table of Contents
  • Realities
  • RHIOs Emerging Policy Issues
  • RHIOs Emerging Business Plans
  • Emerging Models for Advancing HIT/HIE
  • RHIOs Financing, Formation and Governance
  • RHIOs Lessons From The Field

  • Framework for Strategic Action Issued but Federal
    Agenda Still Emerging
  • NHIN Waiting to hear federal response to
  • RHIOs Still nascent concept with great variation
    as to mission, goals and technology plans
  • If you have seen one RHIO, you have seen one
  • Funding Sources are Scarce, Especially for Early
    Development Stage, But Some Notable Exceptions
  • Big Question Whether Potential Benefits of
    HIT/HIE Can Overcome Competing Agendas and

RHIOs Emerging Policy Issues
  • No Federal guidelines at this point, but likely
    to emerge in the next several months field will
    evolve over time
  • Federal definition of RHIOs like to focus on four
  • Public Trust
  • Harmonization of State/Local Privacy Issues
  • Security
  • Aligned Financial Incentives

RHIOs Emerging Policy Issues
  • Key issues to be defined with respect to RHIOs
  • Geographic coverage
  • Requirements regarding numbers of
  • stakeholders/definition of community
  • Relationship to National Health Information
  • Network (NHIN)
  • Tax status of an entity
  • Availability of Federal funding
  • Certification/Accreditation
  • Requirements in Federal Contracts
  • State role in defining RHIOs

RHIOs Emerging Policy Issues
  • Federal role likely to be permissive encouraging
    innovation in marketplace, while seeking to
    promote federal goal of interoperability through
    National Health Information Network

RHIOs Emerging Business Plans
Regional Health Information Organization
RHIOs are regional entities which support the
development, implementation and application of
secure health information exchange
Information Technology
Clinical Process Improvement
Regulatory Decisions
Public Relations
Consumer Participation
  • Privacy and security standards
  • Operating standards
  • Core data set
  • Clinical protocols
  • Data use rules
  • Capital
  • Performance goals
  • Incentive structure
  • Coordination of payers and employers
  • Marketing Strategy
  • Communication Plan
  • Website management
  • Media management
  • Performance publication
  • Development
  • Operations
  • Security
  • Training
  • Support
  • NHIN Compliance
  • Clinical Guidelines
  • Operations
  • Implement
  • Training
  • Support
  • Patient advocacy
  • Patient involvement strategies

Potential Outsource Partners exist
Source HealthAlliant
RHIOs Emerging Business Plans
  • CareSpark (Tennessee)
  • Indiana
  • Massachusetts

What Is CareSpark?
  • CareSpark is a not for profit organization commit
    committed to better health in the central
    Appalachian region through collaboration,
    innovation, and wise use of health information
  • 10 year history of health improvement projects
  • Regional leaders concluded major improvements
    require regional health information exchange
  • 2 ½ years on current project 600,000 raised in
    9 months
  • Filed for 501c3 not for profit status

CareSpark Tactical Plan
  • To address health issues, we propose to provide
    technical capability and encourage clinical
    process improvement in the following areas
  • Prescription Medication
  • Diagnostic (lab, imaging) Services
  • Preventive Medicine (immunizations / screenings)
  • Chronic disease management

Regional Economic ImpactAverage of First Three
Project Years
Conservative Projections
CareSpark will help reduce unnecessary spending
through coordinated regional programs and
equitably share savings among participants and to
fund operations.
260 M
48 M
Source CareSpark
Indiana Health Information Exchange
Data access and use
Data management
  • Results delivery
  • Secure document transfer
  • Shared EMR
  • Credentialing
  • Eligibility checking

  • Results delivery
  • Secure document transfer
  • Shared EMR
  • CPOE
  • Credentialing
  • Eligibility checking

Health Information Exchange
  • Results delivery

Data repository
Network applications
  • Surveillance
  • Reportable conditions
  • Results delivery

Public health
Outpatient RX
  • Secure document transfer

Physician office
  • De-identified, longitudinal clinical data

Ambulatory centers
Public health
Source IHIE
Massachusetts Pilot Project in
3 Communities
Management coordination
  • Joint oversight and decision-making bodies
  • Structure, composition, process

Evaluation/ transformation
  • Quality measurement
  • Pilot evaluation
  • Transformation models
  • Quality
  • Cost
  • Productivity
  • Etc.

Intra-community connectivity
  • Clinical access to data
  • Data gathering and aggregation
  • Communication
  • Hardware/software
  • Implementation/tech support
  • Systems integration
  • Workflow redesign
  • Decision support

Clinical IT implementation/ support
Source MAeHC
Emerging Models for Advancing HIT/HIE
  • Grassroots
  • Convener
  • Catalyst
  • Operator

Emerging Models for Advancing HIT/HIE
  • Grassroots
  • No Statewide, Coordinated Effort
  • Driven entirely at local level truly allow a
    thousand flowers bloom
  • Examples
  • Connecting for Health
  • AHRQ Patient Safety and HIT Grantees

Emerging Models for Advancing HIT/HIE
  • Convener
  • Essential Tasks Educator, Convener, Information
    Clearinghouse, Researcher
  • Examples
  • North Carolina Health Information and
    Communications Alliance
  • MAShare
  • Maryland
  • Florida

Emerging Models for Advancing HIT/HIE
  • Catalyst
  • Essential Tasks Facilitate financing, provide
    technical assistance and project development
    support to spawn regional initiatives
  • Examples
  • Under consideration in New York
  • Kentucky
  • Health Tech/Manatt Report Spending Our Money
    Wisely Recommendations

Emerging Models for Advancing HIT/HIE
  • Operator
  • Essential Tasks Create financing vehicle and
    build infrastructure for information exchange
  • Examples
  • Indianapolis Regenstrief Institute
  • Massachusetts eHealth Collaborative

RHIOs Financing, Formation and Governance
  • Reviewing legal options necessitates a
    multi-faceted process involving an analysis of
  • The key business decisions that first need to be
    made in order to define the organizations
    mission and scope
  • The range of options facing the organization
    relative to
  • Governance Structure
  • Tax Status of Legal Entity
  • Terms and Conditions of Participant Agreements

RHIOs Financing, Formation and Governance
Medical Knowledge
50 of Cost 20 of Return
Patient Data
Source SBCCDE, CITL, Gordian Project analysis
RHIOs Financing, Formation and Governance
Private Payers Medicare Medicaid Self-insured Self
Ambulatory Computer-based Physician Order Entry
Source Center for Information Technology
Leadership, 2003
RHIOs Financing, Formation and Governance
Source HealthAlliant
RHIOs Financing, Formation and Governance
  • Classes of Membership -- Categories of
    interested participants (e.g., institutional
    providers, physicians and medical groups, other
    clinicians, managed care companies and insurers,
    local employers, public health agencies, public
    representatives) could be divided into classes
    and represented on the governing body by one or
    more representative members.
  • Restrictive Membership -- The governing body
    could consist of a limited number of members of
    diverse backgrounds chosen because of their
    leadership skills and standing in the community,
    their ability to articulate the views of various
    constituencies yet rise above those interests in
    determining the future of the project, etc.

RHIOs Financing, Formation and Governance
  • Virtual Model -- No new legal entity is formed
    rather, the project is operated under a
    contractual arrangement via (a) a hub-and-spoke
    format (see e.g., original Santa Barbara design),
    or (b) a single agreement among the participating
    parties (see e.g., original Indianapolis design).
  • Non-Profit Corporation Model -- A non-profit
    corporation is formed to be the development
    and/or operating company for the project. It
    could be organized to qualify as a 501(c)(3)
    tax-exempt organization or it could be a taxable
    non-profit. It could have only a governing
    board, or it could have "members" (comparable to
    stockholders) who elect the governing board
    and/or have the right to vote on certain (but not
    all) matters affecting the corporation/project.

RHIOs Financing, Formation and Governance
  • For-Profit Corporation Model -- A for-profit
    corporation is formed to be the development
    and/or operating company for the project. The
    corporation would have stockholders (who could
    consist of one or more classes - representing
    different levels of "investment", with different
    voting rights), who would in turn elect the
    members of the board of directors.
  • Limited Liability Company Model -- A limited
    liability company is formed to be the development
    and/or operating company for the project. The
    operating agreement for the company would provide
    who holds what economic interests in the entity
    and their respective rights, as well as the role
    of a governing body (if any) distinct from the
    equity owners.

RHIOs Lessons from the Field
  • Importance of Leadership and Creating Shared
    Vision Among Key Stakeholders
  • Organization of Project - Needs to be
    interdisciplinary and inclusive
  • Clinical
  • Legal/Organization
  • Financial
  • Technology
  • Communications
  • First step is creating strategic business plan
    this will drive all future steps
  • Structure of organizational vehicle may minimize
    legal complexity - multi-stakeholder
    not-for-profit structure, with independent
    decision making body, will significantly reduce
    concerns regarding fraud and abuse and antitrust

RHIOs Lessons from the Field
  • State law privacy issues may present larger
    hurdles to project than HIPAA
  • Largest and most complex issues involve
  • Defining role of RHIO as compared to and in
    relation to role of stakeholders contracting with
    the RHIO
  • Creating financing plan for the project Think
    of financing as occurring in three stages
  • Planning
  • Development
  • Operations
  • Note RHIO may enable financing of certain
    information technology investment by outside
    entities this capital/operating cost will be
    borne by the outside entities, not the RHIO

  • We are almost out of tricks here. The only
    thing left is to reduce the illness burden on
    society. Eliminating errors in the healthcare
    system through HIT is the best way to do that.
  • -Anonymous Commentator