The U.S. Healthcare Problem and Emerging RHIO Model
The U.S healthcare system is the costliest and one of the most inefficient in the world. But leading thinkers, business leaders and government officials are modeling an emerging new, community-based solution called Regional Health Information Organizations.
How bad is the current system? On many significant measures the U.S. healthcare system underperforms the rest of the developed world, despite spending vastly more on healthcare than any other developed country. The population health status in the U.S. is 24th in the world, and we are 72nd in the efficiency with which we produce that population health status. The cost of healthcare in the U.S. is 2 to 3 times that of other developed countries and it is having a significant negative impact on jobs and the nation’s economy.
The U.S. also has significant issues with respect to access, safety and quality of care. Each year roughly 44 million Americans are “uninsured”, from 44,000 to 98,000 people die in hospitals due to preventable medical errors and over 700,000 people suffer needlessly from adverse drug events. Peer-reviewed published research indicates that patients receive the most appropriate care only 55 percent of the time.
Clearly, the U.S. healthcare system is beset by systemic problems, not isolated issues. Among the leading concerns cited frequently by public- and private-sector experts alike are flawed incentives, lack of information technology, lack of attention to evidence-based practices, limited access versus broad participation; high unit prices for drugs, devices, and services; safety issues; high administrative costs; and negative social factors affecting people, companies and the U.S. as a whole.
A key manifestation of the system’s failure is its inability to consistently support science-based, appropriate and cost-effective decision-making. For example, clinical approaches that cost more than other approaches but do not produce a better clinical outcome for a similar patient or population represent 30 percent of healthcare spending. That’s $500 billion in waste in 2003, and is projected to grow to $1 trillion by 2013.
Consensus is emerging that small incremental changes have not and will not adequately address these complex, inter-related issues.
There is a growing belief that progress is likely to include some combination of state or local governance, information technology, new incentive structures, and evidence-based medicine. Indeed, over 600 local coalitions throughout the U.S. have formed spontaneously to improve their healthcare system. Nationally, substantial emphasis, financial commitments and progress have been made with respect to healthcare information technology. Medicare, private insurers and employers are experimenting with many different incentive structures. These efforts are intended to create new models for organizing and delivering healthcare in the U.S. that can be replicated across the country.
The Federal government has stepped up to help facilitate this groundswell effort, launching an initiative known as the Framework for Strategic Action which aims to transform healthcare through information technology.
A cornerstone of the Framework involves the creation of Regional Healthcare Information Organizations (“RHIOs”) which are essentially regional collaborations that facilitate the development, implementation and application of secure health information exchange across care settings. The benefit to a local/regional community of this Federal initiative is twofold: 1) a great deal of thought and energy has gone into how to accomplish intelligent healthcare reform on a regional basis and this thinking can be leveraged and tailored to the unique needs of the community, and 2) the Federal government is highly supportive of such efforts, including providing partial funding to many projects.
Key Success Factors for Locally-Driven Solutions
A number of inter-related factors are critical to the success of healthcare system modernization and reform, including:
- Agreement – This is unquestionably a lynchpin and a highly challenging area. Local, volunteer efforts are often doomed because any stakeholder group can effectively block change it does not support. A foundation for consensus can be achieved by first articulating a shared vision of the desired end-state and the benefits to each stakeholder group. Broad-based inclusion is critical. Equally critical is the ability to navigate potential roadblocks through the presentation of solid business case analyses and a clear and actionable strategic plan.
- Commitment – There are three distinct forms of commitment necessary for success: First, there is the time and human resources commitment from every stakeholder/participant. Second, there is organizational commitment which must be supportive of the strategic implementation plans that are ultimately created, including data sharing. Finally, there is financial commitment. In many respects this is the ultimate form of “buy-in” as certain public and private entities invest capital in the modernization process.
- Business Case – A detailed business case analysis which takes into consideration different strategic alternatives, demonstrates which approaches are optimal and quantifies the net benefits to the system and to individual stakeholders is required to gain agreement and move forward. Such analyses help maintain directed and rational thinking among the stakeholders/participants, and provide a documented plan that gives confidence to funding sources that they should invest in the program.
- Process – This begins with consensus and coalition building, but follows through with creation of clear strategic plans for all to follow. Many previously-formed RHIO organizations have found that a neutral, expert advisory group is critical to the process of moving otherwise-entrenched parties toward common ground and innovative solutions.