The California Health Care Foundation (CHCF) has published the results of a study to determine why its pilot program to develop a RHIO (Regional Health Information Organization) failed in Santa Barbara. The report is clear, well-written, and instructive.
The goal was admirable: CHCF wanted to create a centralized database of patient information that was readily available to hospitals, physicians, and other providers as they delivered medical services to area residents. It was hoped that this RHIO would become a model for similar efforts around the country.
In its summary, CHCF cites “lack of a compelling business case, distorted economic incentives, passive leadership among participants, vendor limitations, software delays, and privacy and security issues as factors that played a significant role in the project’s eventual closure.”
But the report itself (caution: pdf) is even more interesting. Dr. David Brailer, who led the software company engaged for the project, later went on to head President Bush’s technology initiative. One report described him as the man whose “job was to sell Bush’s rewiring of American medicine.”
Dr. Brailer is a brilliant and innovative man, and the authors say that the project suffered from the loss of his charismatic leadership after he went to Washington. But they also suggest that either he or his organization (CareScience) oversold their own capabilities and the available technology, and undersold the difficulties involved – no doubt unintentionally.
The authors also say that Dr. Brailer differed other stakeholders in CareScience over the extent to which the company should supplement CHCF’s initial investment as a form of R&D for its own products – which CHCF had hoped would result from this project.
Reading the report, a couple of other possible reasons for its failure come to mind – reasons that help explain that “passive leadership” and some of the other problems:
Failure to understand participants’ motives
Each of the participants in the health economy have reasons for participating in it. These are primarily, but not exclusively, economic. They also have well-ingrained behaviors. This extends from physicians and senior hospital administrators to ward clerks and front desk staff. Failure to examine the motives of each of the players led to an unwillingness to either assume new expense, which the authors note.
What they don’t note, but is also significant, is that these participants won’t change their behavior unless they are given reasons to do so that make sense to them – and speak to their economic, social, and personal motivations.
More research into these motivations is needed, and practical suggestions for changing them need to be developed.
The behavioral dynamics of medical care
It’s very difficult to persuade physicians – or patients – to change long-standing methods of interacting with one another. For the RHIO concept to be fully successful, physicians need to become comfortable with pausing to retrieve information from a computer. That may mean teaching them new behavior – or, emphasizing PDAs and other less-intrusive handheld technologies. As an alternative, office staff might be trained to retrieve the information and give it to the doctor before the patient arrives.
Further research in the sociology and anthropology of physician/patient behavior could help solve this problem.
Forgetting to heed the “cui bono” principle
Because the U.S. healthcare system is economically decentralized, changes in one area may result in financial benefits elsewhere. In this case, the theory behind the CHCF initiative was that care would improve and operating efficiencies would increase under a working RHIO.
But, as the lawyers ask, “Cui bono?” Who benefits? In this case, a broad array of private insurers could save money from better efficiencies and outcomes. But these payers weren’t brought in as stakeholders in the process. To complicate matters further, additional investment today may save future insurers money – and we can’t know who those future insurers might be. This is one of the reasons why wellness programs have taken so long to find a foothold.
Additional research should be conducted into alternative funding models for RHIOs that involve private and public payers.
One large-scale payer was involved as a stakeholder: The Santa Barbara County Health Care Initiative, which pays Medi-Cal claims in the area. The report’s authors don’t provide much detail on the Initiative’s role in this effort.*
The report’s authors do a fine job of detailing many other problems with the project, but these two areas might deserve further study at some point.
* Conflict-of-interest alert: I worked as a Systems Analyst for the vendor that set up the Santa Barbara County Health Initiative under an HMO-like data model – way back in 1982.