Editorial: RHIO's and the Illusion of Health IT Success

For example, the announcement of a hospital going 'all digital' or rollout of a multi-million dollar record system makes great press releases but is it actually working years after the parade is over?

Another example is a worker or representative at a local hospital replying "yes" to the question of does their hospital or large clinic have an interoperable Electronic Medical Record (EMR) or Computerized Order Entry (CPOE) system? But do they really? They may 'have it' but is it being used? Have they actually tested interoperability with other organizations or do they just have 'agreements'? Could it be that they actually have a nasty hybrid of paper records and EMR or an EMR that few people actually use? Or worse, do they not even want to talk about the real issues because of millions of dollars and large amounts of time wasted on a failed implementation?

There is historic precedence for the illusion of Health IT success in the United States. For example, only a few years ago, 'paperless' prescription writing was touted as being right around the corner by media and companies. Weekly or monthly, there was news of a startup company that was going to accomplish the goal of point of care prescription writing by some device such as a handheld. So far it hasn't happened on any large scale with two exceptions mentioned below.

One of the greatest success illusions of 2005 and 2006 may be the RHIO phenomenon. RHIO's are purported to be popping up like mushrooms, probably in anticipation of federal dollars. However, is anyone examining that they may be based on a flawed premise and, if historic experience is taken into account, doomed to failure? The premise is that somehow, by getting disparate healthcare groups to hold meetings about interoperability and agreements to share data that this will make it happen. Maybe, but there are a number of problems with this approach.

First, it's been tried before. Without looking at the date of publication, try reading this article entitled 'Smart technology, stunted policy: developing health information networks' by Paul Starr. If you read it you will notice that it speaks about many of the issues facing us today and in fact could have been a current article. The only problem is that it was written 8 years ago. What has changed since then? Why do we expect RHIO's will work now?

Second, RHIO's makes disparate, local healthcare entities into mini-standards organizations. This is something they are almost always ill-prepared to do. RHIO's will make strategic decisions (if they are able to make decisions at all) based on local politics, local needs and whatever information they can muster at the moment. Vulnerability to a good sales pitch at the time of decision can ensure a sub-optimal solution.

At best, a successful RHIO will create an island of interoperability which may be incompatible with another RHIO island that has made different strategic choices. While HL7 (a messaging standard) may be the thing that lashes the whole thing together, it also creates its own set of problems. Success of RHIO's will merely push the problem of multiple, incompatible clinical computing systems to the user interface level where health-care workers that work in more than one setting or change jobs will be treated to the nightmare of having to learn or re-learn multiple user interfaces that essentially do the same thing.

So what is the solution? Perhaps trying things that are already known to work on a national or at least state wide scale. Only two systems have emerged as having functional large scale clinical computing software: Kaiser Permanente which uses the proprietary Epic system and the Veterans Affairs VistA system. Both are not health-IT computing nirvana, but both appear to work adequately. Like VistA, Epic is based on the MUMPS programming language, but suffers from being a proprietary system. VistA has its own problems. However, VistA is in the public domain and is actively being supported by many organizations in the private sector.

Despite these large-scale systems already working in the real-world, they are seemingly ignored in favor of piecemeal efforts like RHIO's or local micro-environment choices. This is much like the situation that existed prior to the adoption of the railroad standard gauge. Unlike the railroad standard gauge, clinical computing standards are very complex.

The cycle of illusion of success followed by reality of failure continues on. When a rosy picture of health-IT implementation is reported, ask the question if this is really the case or only window dressing for multi-million dollar wishful thinking? If the RHIO's go bust, as seems likely, the next question will be how to keep the cycle of initial enthusiasm from progressing to the usual failure.

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