The Bay Area HIE a Case Study in Connecting Stakeholders

focus Health IT and the Economic Stimulus

The Bay Area HIE A Case Study in Connecting Stakeholders

Eric Saff; Craig Lanway; Armando Chenyek; and Dave Morgan

he exchange of patient health related infor- Keywords mation is a prerequisite for everything Health information exchange, HIE, meaningful use, physician from data aggregation in electronic health health system, IPA, interoperability, connectivity, SaaS, care T records to the evolution of population-based chron- coordination, patient access. ic care management. Set in motion 10 years ago by Abstract the Institute of Medicine’s seminal, To Err is Human; The core philosophy of health information exchanges is to bring driven by needs ranging from cost reduction and together industry stakeholders to facilitate the movement of actionable healthcare information within or across organizations. quality improvement to threats of bioterrorism and One workable model for automating the HIE is the virtual health pandemics; facilitated by technological innovation; exchange. It allows an organization to satisfy its electronic and, now, accelerated by the financial incentives of data exchange needs, while positioning it for HIO/RHIO and Nationwide Health Information Network inclusion. Four the American Recovery and Reinvestment Act of healthcare organizations in the San Francisco bay area offer 2009 (ARRA), health information exchange (HIE) a unique case study of this emerging model and a distinctive is fast becoming a reality. technology strategy using HIPAA-compliant SaaS online connectivity. The article will explore the foundational elements States, regions, healthcare organizations and a host of public such as platform connectivity solutions and services that meet and private entities are establishing the networks—organiza- the federal HIT Policy Committee’s approved recommendation of tional, local, regional, national and international—over which this “meaningful use” 2011 criteria for exchange health information. data exchange will occur. Several ambulatory solutions are integrated into the data and The recent enactment of ARRA promises to accelerate HIE workflow. The Bay Area HIE consists of John Muir Health, development with an unprecedented $19 billion program pro- a private health system; Hill Physicians Medical Group, an moting adoption and use of health IT, especially electronic health independent physicians’ organization; Alta Bates Medical Group, records (EHR). While ARRA’s health IT components—collectively labeled HITECH—reflect the general conviction that elec- a 600-physician IPA; San Ramon Regional Medical Center, a tronic information systems are essential to improving the health 123-bed, acute-care hospital; and University of California, San and healthcare of Americans, few U.S. doctors or hospitals—17 Francisco (UCSF), a large academic health system. Collectively, percent and 10 percent, respectively—have even basic EHRs.1 2,800-plus physicians, 900,000 patients, numerous reference Moreover, there are significant barriers to EHR adoption and use, labs and interoperability among several health IT vendors including cost; a perceived lack of financial return from investing are involved. Providers and hospitals are exchanging data in them; technical and logistical challenges involved in installing, and 136,000 patients have connected online to their records. maintaining, and updating them; and consumers’ and physicians’ Connected physicians have access to online services, e.g., concerns about the privacy and security of electronic health infor- results management, messaging, colleague-to-colleague mation.2 However, the objective clinical and financial benefits of messaging, referrals, and eprescribing. Patients are offered HIE are significant. secure messaging, including preventive care reminders, PHRs, lab results, script renewals, bill payment, appointment requests, Benefits of HIE referrals and education services. Revealed are resulting care Inaccessibility of paper records and lack of inoperability between coordination and practice operational improvements. legacy systems contributes to medical errors, which, according the Institute of Medicine’s To Err is Human report, kills as many as

www.himss.org volume 24 / number 1 n winter 2010 n jhim 25 98,000 Americans every year.3 Adoption of digital health record exchange processes to accommodate resistant physicians is systems—made viable by HIE—could reduce the number of expensive and time consuming. deaths due to medical errors by at least 70 percent.4 • Developing and managing an enterprise master patient index HIE will have a substantial impact on healthcare system costs, (eMPI) is expensive. saving approximately $80 billion annually, while reducing medi- However, the equation is changing for large health systems, cal errors and improving quality.5 According to The Center for which now can achieve a highly beneficial end state of aligned Information Technology Leadership (CITL), widespread use of physicians exchanging health information among themselves and personal health records (PHR) via HIE could save the U.S. health- with their patients in a multi-vendor environment. Three factors care industry as much as $21 billion a year.6 are causing this change: According to eHealth Initiative’s (eHI) Sixth Annual Survey of 1. Business demands, from lowering transaction costs to retain- Health Information Exchange, 40 operational initiatives reported ing physicians and increasing referrals. Primary care physi- cost savings resulting from HIE in the following areas:7 cians are the dominant source consumers use to find special- • Reduced staff time spent on handling lab and radiology results. ists and choose facilities. Almost seven in 10 specialist shop- • Reduced staff time spent on clerical administration and filing. pers rely on physician referrals and nearly three in four con- • Decreased dollars spent on redundant tests. sumers undergoing a procedure choose the hospital based • Decreased cost of care for chronic care patients. on recommendation or referral of the physician performing • Reduced medication errors. the procedure.9 Physician retention is critical given consider- Another important benefit of HIE is physician satisfac- ing the estimated cost to replace a single physician: $200,000 tion, a prerequisite for recruitment and retention. Simplified, from lost fees, recruitment and re-establishing the practice.10 affordable access to data and applications is a key differentia- Pay-for-performance (P4P) is another business driver. tor and a valuable offering to engage and retain physicians in According to Dr. David Lee, Vice President of healthcare an increasingly competitive environment. HIE allows physi- management for Anthem BlueCross and BlueShield of Indi- cian practices to become more efficient without disrupting ana, creating successful P4P programs is difficult because care. The eHI survey reports HIE’s impact on physician prac- claims data is an inadequate way to evaluate care; health- tice in the following areas:8 care is fragmented; scale is important to making programs • Improved access to test results and resultant efficiencies to practice. attractive to physicians; and physicians mistrust the data.11 • Improved quality of life. For physicians wary of P4P programs, HIE provides access • Reduced staff time spent on handling lab and radiology results. to reliable clinical data for providers, hospitals, pharmacies and • Reduced staff time spent on clerical administration and filing. laboratories, and, as a function of a respected RHIO, can alleviate physicians’ mistrust of the data used in these programs.12 Operational challenges of HIE 2. Government’s new, proactive role at all levels: Grants are fund- At its most fundamental level, HIE is the movement of healthcare ing regional HIEs and development of a robust set of interoper- information within or across organizations in support of care ability standards defined by the Federal Health Architecture. coordination, delivering the information at the right time to the HITECH provisions in ARRA — $36 billion in Medicare and Med- right individual to facilitate higher quality and more cost-effective icaid health IT incentives over five years—will motivate healthcare. Examples include interactions with a hospital lab for order- care organizations to achieve “meaningful use” of EHRs and HIE ing tests and receiving results, transmission of a prescription necessary for their viability. Between 2011, when early adopters from a physician to a pharmacy, sharing of patient health history receive the biggest payouts, and 2015, when late adopters start between two physicians, relaying data from a patient’s personal paying penalties, ARRA incentives can total as much as $48,400 health device to a physician and giving patients access to their for eligible professionals and up to $11 million for hospitals. health information. This information movement can happen at 3. The advent of virtual delivery models: Funding and business the community, regional and/or national level. demand may be driving HIE growth, but satisfying that demand Unfortunately, conducting effective HIE has proven challeng- calls for a viable delivery model. ‘Cloud-sourced’ health informa- ing for a myriad of reasons: tion exchange is an emerging model that offers a low-cost, scal- • Deploying traditional centralized data solutions requires sig- able and highly networked solution. The most effective virtual nificant time and money. delivery models combine four foundational elements—platform, • Resolving governance, privacy and data ownership issues is applications, connectivity solutions and services—to create a data difficult. exchange foundation that can cost-effectively satisfy the majority • Establishing connectivity is problematic given the plethora of of an organization’s electronic data sharing needs, while building a physician office clinical systems and homegrown solutions, viable platform for the regional- and national-level needs to come. with hundreds of disparate technical automation approaches. • Eliminating competition and adopting common semantics is The Health Information Delivery Network critical for interoperability. A virtual delivery model serves as a powerful, scalable and • Leveraging the Internet’s network connectivity capabilities is cost-effective foundation for all levels of health informa- difficult with vendors’ point-to-point connectivity solutions. tion exchange: community, regional, national and individual • Maintaining parallel manual and automated information patient. Consequently, it allows an organization to satisfy its

26 jhim n Winter 2010 n volume 24 / Number 1 www.himss.org current data exchange needs, while positioning it for HIO/ complete solution for all participants in the health system, includ- RHIO and NHIN inclusion. ing the patient whose data can be released to the PHR. Practices When evaluating virtual delivery models, it is important to that don’t have an EHR/PHR review data online via browser examine four foundational elements: platform, application, con- through applications on the HIE. nectivity solutions and services: Services: Services comprise datacenter operations, servers and Platform: Software-as-a-Service (SaaS) technology infrastruc- networks that organizations access, as well as application mainte- ture is ideal for deploying workflow and connectivity solutions. nance (i.e., regular service upgrades). SaaS also streamlines—and thus, improves—connectivity between Satisfying both current and future data exchange requirements a healthcare organization and other entities with which it exchanges calls for an affordable, effective HIE model with the appropriate information. The healthcare organization connects to the platform; platform, comprehensive applications, connectivity solutions the platform connects to everything else, centralizing access. This and proficient services. It should meet an organization’s current positions the patient record in one virtual location, which allows health information exchange needs, while enabling connectivity data from multiple sources to aggregate in one place. to regional and national networks. From a patient’s perspective, this means one record filled A working example of an operational HIE utilizing the model with data from any provider within the network. The data view described above can be found in the San Francisco Bay area, where is patient-centered, but the data collection is patient-indifferent a group of healthcare organizations have deployed RelayHealth’s — aggregation happens whether the patient is connected to the Virtual Information Exchange strategy™. platform or not. Organizations neither purchase nor install a SaaS HIE. Rather, it lives in the ‘cloud,’ where the vendor regularly CASE STUDY: THE SAN FRANCISCO BAY AREA HIE improves it, expands it and delivers it via a monthly subscription. Primary participants in the San Francisco Bay Area HIE include: Organizations benefit from a predictable cost structure, lower • University of California, San Francisco (UCSF): A 600-bed cost of ownership, quick return on investment, minimal internal tertiary and quaternary regional referral medical center for IT costs and the ability to treat the costs as an operational expense Northern and Central California. It is integrated with the Uni- (as opposed to a capital one). A rapid development cycle ensures versity of California San Francisco Medical School, Nursing an innovative platform as features and functions are improved School, Pharmacy School and Dental School. USCF averaged over time. 740,000 ambulatory visits in 2008. Another benefit of this model is sustainability. The SaaS • John Muir Health: A not-for-profit organization that includes approach offers organizations the ability to purchase modular John Muir Medical Center – Walnut Creek Campus, a 327-bed subscriptions for services that address their specific business medical center that serves as Contra Costa County’s only needs, without investing in infrastructure and managing costly designated trauma center; and John Muir Medical Center – installation and upgrades. Concord Campus, a 254-bed medical center in Concord; the Furthermore, by leveraging those investments to connect to John Muir Behavioral Health Center; the John Muir Physician other organzations in the community, region or across the coun- Network; and outpatient centers in Brentwood and Rossmoor. try, they are not required to fund specific HIE infrastructure • Hill Physicians Medical Group: One of the nation’s largest efforts to provide the effective connectivity required for meaning- independent physician associations (IPAs) and a recognized ful use. This approach will become very important when stimulus leader in innovative managed health care. The Standards of funding ends. Excellence Program of the California Association of Physician Applications: The ideal HIE includes clinical applications Groups recognizes Hill Physicians as a state-wide leader in care to coordinate care and financial applications to streamline pay- management practices, health information technology, account- ment. Powerful as stand-alone options, their true value rests in ability and transparency. Nearly 300,000 people in seven North- their ability to connect to a variety of ambulatory and acute care ern California counties have selected Hill Physicians care platforms. Virtual applications should interoperate with—not providers for their primary and specialized care. replace—existing HIT investments. A Services Oriented Archi- • Alta Bates Medical Group: A 600- physician IPA founded in tecture (SOA) framework allows these applications to be embed- 1983 that serves 50,000 health plan members and patients in ded within the context of existing workflows. Applications are Oakland, Berkeley and the greater East Bay. connected with data exchange through transaction standards • San Ramon Regional Medical Center: A 123-bed acute care (e.g., HL7 and C32/CCD) for clinical/administrative data. The hospital founded in 1990. result is rapid deployment, support for physicians’ existing elec- Currently, the collaborative model comprises: tronic medical record (EMR) solutions—and increased physi- • Five health organizations. cian alignment. • More than 2,800 physicians. Connectivity solutions: Within this information exchange • More than 900,000 patients. system, hospitals and practices can share clinical data in network- • Numerous reference labs. based connectivity models. Participating systems do not main- • Interoperability among several major health IT vendors. tain separate connection points to each community, regional or This San Francisco Bay area HIE addresses three of the big- national network. Rather they connect once to the platform. The gest challenges facing healthcare today: Physicians (recruitment, best connectivity solutions work directly with the HIE to create a retention and satisfaction), patient access to their caregivers and

www.himss.org volume 24 / number 1 n winter 2010 n jhim 27 clinical information, and EHR meaningful use. The following In the first six months of HIE roll out, 25 percent of 1,600 regis- chronicles the current progress of four organizations. tered patients were active adopters, as were 52 enrolled providers UCSF Medical Center: Physicians at academic institutions and 123 staff members. serve as clinicians, researchers and teachers. Not surprisingly, Hill Physicians Medical Group: An eight-year veteran of this ternary role can make it difficult for them to communicate health information exchange, Hill Physicians, became part of the with patients before, after or in lieu of a physical visit. At UCSF, Bay Area HIE in 2002. In its early years of online connectivity, this communication shortfall was evident, appearing as the num- Hill Physicians co-developed an e-referral management solution ber one issue in monthly patient satisfaction surveys. to manage referrals from its more than 3,000 physicians spread The organization has a 45-person call center that can send across 1,500 practice locations in nine counties. Today, nearly electronic notifications. If physicians respond to the notifica- 14,000 referral messages are transmitted monthly between prac- tions but cannot reach their patients, they leave messages. The tices, physicians and patients. patient responds by calling the call center, creating and continu- Referral management—an important HIE capability—enhances ing an inefficient communication cycle. Additionally, as a regional care continuity while eliminating problems created when patients referral source, UCSF understands the importance of improving arrive at a specialist’s office without proper referral information. its relationships with referring physicians. However, a survey of Physicians use an online connection to transmit the necessary referring physicians indicated that UCSF was not communicating forms and the patient’s personal health records, medical reports about referred patients in a timely manner. and other electronic files, which is a more reliable alternative to UCSF concluded HIE was one method to address these chal- faxing, photocopying and filing referral documents. The service lenges, offering secure messaging to improve patient communi- sends referrals electronically to connected providers, while retain- cations and electronic links to a large number of referring physi- ing the fax option for providers not enrolled with the service. cians and other stakeholders associated with the larger area phy- The HIE allows Hill physicians to get test results from national sician networks. In addition, HIE would allow UCSF to compete commercial labs, LabCorp and Quest Diagnostics, and from a effectively with nearby healthcare organizations that had begun regional lab operated by Catholic Health West, HealthCare Clini- offering e-connectivity to patients. Recognizing that HIE simply cal Laboratories. The IPA also receives results from Muir Lab, the made operational and economic sense, UCSF joined the Bay Area outreach laboratory service of John Muir Health, which is also a HIE in March 2009. member of the Bay Area HIE. Later this year San Ramon Regional Patient-to-physician and physician-to-physician secure mes- Medical Center will the next healthcare system joining the HIE saging was one of the first two features UCSF implemented; test to electronically exchange lab results with Hill Physicians and the results reporting, the other. Together, these two features allow other Northern California participants. physicians to review results, comment on them and then share The areas covered by John Muir Health and Hill Physicians in the their findings with patients and/or other physicians via email. East Bay overlap. In the community of 4 million people they serve When offered the opportunity to join the HIE, 25 percent of UCSF in Northern California, patients see physicians from both groups patients said they would. With quicker physician access to results and use the hospitals for inpatient/outpatient care. Realizing the and more expedient communication of them, UCSF anticipates importance of shared patient data to achieve continuity of care, the operational cost reductions from a significant reduction in call vol- former competitors became collaborators, extending their respec- ume — 30 percent of which is from patients. Electronic prescrib- tive virtual information exchanges to share results data. ing has also been implemented. By using eprescribing, physicians A SaaS-based platform provides a non-partisan conduit that links have cut in half the time it takes to process daily medication refill the two organizations and enables clinical information exchange requests such as eliminating the hassle of phone tag with patients, over a wide geography, creating a true community-wide continuum and improved formulary compliance. of care. Physicians, regardless of their affiliation, can receive results USCF’s initial HIE strategy is to take small steps and get it right, from John Muir Health via a results viewer, or populate their elec- given the critical need for patient privacy and accuracy in delivery tronic medical records with the data automatically, further reduc- of lab results to ordering physicians and patients. In the short- ing inefficiencies and costs associated with paper-based reports. term, the health system will work with Hill Physicians Medical Moving paper lab reports to a practice previously took days. The Group and John Muir Health’s physician networks to pass diag- electronic exchange shortens this tedious process to mere seconds. nostic test results. Their long-term strategy is to pass pre-appoint- For the ambulatory physician, easy access to complete, near ment medical information from the referring physician and then real-time clinical data from previous hospital visits means more send back post consult, procedure and hospitalization informa- informed decisions, fewer redundant tests and better manage- tion. The goals: enhanced continuity of care for every patient and ment of chronic conditions. For Hill physicians members, data fewer redundant tests. exchange is a secure transport mechanism that adds value to To further increase patient satisfaction, UCSF is considering practice EHRs. This broad, real-time access to results will mini- implementing electronic bill pay, which would consolidate patient mize test duplication, improve productivity and enhance team bills, then make them viewable online. The medical center also is care collaboration. Soon, doctors will be able to send orders back interested in automating the referral process to improve patient to MuirLab and exchange information with UCSF Medical Group, intake and streamline the now cumbersome process of referral whose physicians become participating members of Hill Physi- management for physicians and their staffs. cians in January 2010.

28 jhim n Winter 2010 n volume 24 / Number 1 www.himss.org In addition, the HIE helps Hill Physicians improve the patient patients and expanding over the next few years to encompass experience. Nearly 98,000—more than 30 percent — of Hill Physi- millions across a larger region. To this end, the medical center’s cians’ 300,000 patients have registered on the network to use the short-term goal is to build a robust PHR by exchanging patient HIE. With secure messaging, patients can reach out to physicians data electronically, establishing a data depository and increasing and physicians can reach out to patients or to other physicians the number of physicians—across the HIE—receiving lab results. about patients. As of third quarter 2009, patients initiated more Alta Bates Medical Group: For physician practices with one to than 7,000 messages, while providers initiated 16,468, increases of three physicians, deploying an EHR can be prohibitive. Accord- 88 percent and 62 percent, respectively, over 2008. There are 6,608 ing to a recent study, practice size and physician age are key driv- registered, enrolled and/or active providers. ers of EHR adoption and use.13 Sixteen percent of solo practices The most significant patient-centered HIE usage, however, is and 20 percent of dual practices reported full/partial use of EHRs, physicians’ e-prescribing. For the month of August 2009, physi- compared to 25.3 percent of practices of three to five, 33.8 percent cian e-prescribing transactions totaled 50,391—nearly 73 percent of practices of six to ten and 46.1 percent of practices with 11 or more than the year before. The total includes 18,535 e-scripts sent more physicians.14 In terms of age, physicians aged 55–64 years electronically and 20, 665 e-renewals received from pharmacies. represented the lowest percentage of EHR users at 18.1 percent.15 Total transaction volume for Hill Physicians increased 75.6 per- Forty-four percent of physicians under 35 years, 27.2 percent ages cent since last year, reaching 129,872 in August 2009. Next steps 35–44 years and 25.1 percent of those aged 45–54 years reported include transmitting orders to Muir Lab and linking to Alta Bates similar EHR use levels.16 Medical Group, another Bay Area HIE IPA. These numbers are especially relevant for Alta Bates Medi- John Muir Health: John Muir Health joined this Bay Area HIE in cal Group. Of the 90 primary care physician practices in Alta 2007 to simplify the difficult job of coordinating community care. Bates, more than 60 percent are solo practitioners and more Concerned about patient safety and the potential for medi- than 30 percent are group practices with fewer than six phy- cal error in the provision of care services across the continuum sicians. The average physician age in the IPA’s service area is of care, John Muir Health uses the HIE as a bridge to electronic 55 years and the average practice size is two physicians. Given patient records, both the EHR and the PHR. The Bay Area HIE these demographics, the high dollar and resource costs to is unique in its ability to give patients the ability to access and implement an EHR and the absence of a compelling reason to update the HIE’s PHR, which, in turn, passes the data to physi- change the way they deliver care, physicians might continue cians’ EHRs. John Muir Health has made HIE connectivity and providing care as they always had, simply biding their time access available to more than 700 physicians in its owned practic- until retirement. es and an affiliated IPA. Nearly 200 of these physicians use John Six years ago, Alta Bates saw the HIE as a way to propel reluc- Muir Health’s EHR, while 100 or more use the EHRs they have. tant physicians into electronic records. In 2008, the IPA made A superfluity of EMR-based patient portals in the community secure e-prescribing, e-messaging and results ordering/sharing made it difficult to engage physicians fully in PHR use because available to its 650 physicians. It also is working with LabCorp to patients were not able to use one PHR to access all their physi- begin sharing test results with physicians. cians across the community. Standardizing on the HIE’s patient For Alta Bates, critical mass—30 percent of engaged physicians portal allowed John Muir Health to provide critical data to all phy- exchanging data—is the ROI tipping point for its HIE involve- sicians. Patients/consumers, physicians and participating payment. Despite slow adoption—to date, only 20 percent of physi- ors can use the HIE portal as an online entry point to exchange cians are connected to the Bay Area HIE—Alta Bates believes information. This single Web access makes more comprehensive such new features as the ability to share results with patients will patient coordination possible to caregivers at multiple community help spur adoption. locations and improves provider-to-provider communication. As a result, between January 2009 and August 2009, the number of LESSONS LEARNED self-registered patient connections increased 75 percent, while the According to Bay Area participants, key HIE success factors include: number of provider-initiated messages rose more than 46 percent. Moving from a competitive to a collaborative model: Citing Plans are underway to add allergies, medications and problem both business and ethical reasons for information sharing, partici- lists as well as routine patient interactions (e.g., online consulta- pants agree that an HIE is in the best interest of the patient. While tions, appointment scheduling, etc.). they think economic stimulus opportunities will drive some coop- An estimated half a million lab results, radiology reports and eration, they believe quality continuity of care demands a true sea transcribed documents are transferred monthly from John Muir change from the current models of competition to a future model Health and MuirLab to physicians associated with both John of collaboration, in which all healthcare stakeholders accede to Muir Health and Hill Physicians. Potentially 500 doctors in their transparency and putting the patient first. community can receive results. Ranked among the top 10 hospital EHR/PHR integration: The ideal state for an HIE is a com- outreach laboratories in the nation, MuirLab operates 27 labora- mon, shared EHR. The reality is convergence will bring techno- tory draw sites communitywide and serves more than 18 counties logical dissonance. Nevertheless, any system that collects any in Northern California. data on any patient at any care juncture must be able to populate John Muir Health’s ultimate goal is to populate the EHR with both the PHR and ultimately the EHR, be it a shared entity or an as many patients as possible, starting now with 150,000 localized assortment of interoperable ones. Technical standards exist (and

www.himss.org volume 24 / number 1 n winter 2010 n jhim 29 are evolving) to create a true continuous record and funding via data is adopted, the cost of creating and maintaining multiple plat- ARRA will encourage additional development. forms will impede real connectivity and data sharing progress. Extensive testing: Technological formats must be defined. The The transmission of data between acute and ambulatory settings information being exchanged uses differing formats, from images will be a future core competency. Having a common intermediary to lab transcripts. Because patient safety depends on data arriv- will minimize the resources required by all sides. JHIM ing in the proper format and going to the appropriate person(s), a significant testing effort is vital. Armando Chenyek is Director of Marketing and Provider Services at Alta Bates Physician education/engagement: Physicians are the prima- Medical Group. He leads all aspects of marketing initiatives including promoting ry source of care data. Therefore, their engagement is the primary physician adoption of health information technologies. determinant of HIE success. Until an HIE initiative achieves critical mass of adoption, its value will be limited. Dave Morgan is Executive Director of Ambulatory Services at UCSF Medical Center. He oversees the operations of 96 physician practices totaling 1,200 CONCLUSION physicians and the medical center’s ambulatory services. As ARRA compels computerization of healthcare operations, it will become increasingly clear that HIE viability depends on rep- Craig Lanway is Chief Information Officer at Hill Physicians Medical Group. He licable, shared-platform connectivity across various settings and manages the information services and technology functions, including EHR, HIE multiple markets that is easy and cost-effective to maintain. and electronic commerce strategies. While the primary beneficiary of this approach is the solo prac- titioner or small practice lacking IT infrastructure and capital, Eric Saff is Senior Vice President, CIO and Chief Security Officer at John Muir the burden of building the infrastructure will fall on hospital and Health. He oversees many innovative initiatives, including visual integration, physician organizations. Until a single standard for transmitting communication fusion and partnerships enabling community-wide data exchange.

References 9. Tu HT, Lauer J. Word of Mouth and Physician Referrals Still Drive Health Care Provider Choice. Center for Studying Health System Change, Research Brief 1. Blumenthal D. Stimulating the adoption of health information technology. No. 9. December 2008. Accessed November 18, 2009. Available at: http://www. N Engl J Med. 2009;360(15):1477-9. hschange.org/CONTENT/1028/#ib2. 2. Ibid. 10. Valancy J. Recruiting and retaining the right physicians. Fam Pract Manag. 3. Kohn LT, Corrigan JM, Donaldson, M. To Err Is Human: Building a Safer Health 2007;14(9):28-33. Accessed November 18, 2009. Available at: http://www. System. Institute of Medicine, 2000. medscape.com/HIEwarticle/565814. 4. Klein M. HHS Secretary calls for $550 million health care fund to reduce 11. Ackerman K. RHIOs Critical to Pay-for-Performance Programs. iHealthBeat. deaths caused by medical errors. Wisconsin Technology Network. June 8, 2004. 2009 Nov. Accessed November 18, 2009. Available at: http://www. Available at http://www.wistechnology.com/article.php?id=905. worldcongress.com/events/nw610/pdf/iHealthBeatarticleWHITC.pdf. 5. Health Information Technology in the United States: Where We Stand, 12. Ibid. 2008. The George Washington University, Massachusetts General Hospital, 13. Health Information Technology in the United States: The Information Base for Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/files/ Progress. The George Washington University, Massachusetts General Hospital, research/062508.hit.exsummary.pdf. Robert Wood Johnson Foundation. http://gwumc.gwu.edu/sphhs/departments/ 6. Kaelber DC, Shah S, Vincent A, Pan E, Hook JM, Johnston D, Bates DW, healthpolicy/CHPR/downloads/EHR_annual_report_2006.pdf. 2006. Middleton B. (2008) The Value of Personal Health Records CITL. 2008. Accessed 14. Ibid. November 18, 2009. Available at: http://www.citl.org/_pdf/CITL_PHR_Report.pdf. 15. Ibid. 7. eHealth Initiative. Migrating Toward Meaningful Use: The State of Health Information Exchange eHealth Initiative’s Sixth Annual Survey. (2009) 16. Ibid. 8. Ibid.

30 jhim n Winter 2010 n volume 24 / Number 1 www.himss.org