Organizational and Legal Issues Developing organization and governance models for HIE

1
Organizational and Legal Issues-- Developing
organization and governance models for HIE

• Day 2 -Track 5 FIRST SESSION RHIO GOVERNANCE
• CONNECTING COMMUNITIES for BETTER HEALTH
• 2nd Annual Learning Forum and Exhibition
• WALTER SUAREZ, MD, MPH
• PRESIDENT, PUBLIC HEALTH DATA
• STANDARDS CONSORTIUM

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• Governance Issues
• Most models call for involvement of all
  stakeholders, including
• Providers (through their local professional
  associations)
• Individuals (MDs, RNs, RPh, Others)
• Institutional (Hospitals, Nursing Homes, others)
• Plans (individually and/or through their local
  trade association)
• Private (HMOs, others)
• Public (Medicaid, Medicare)
• Purchasers
• Private employers/employer coalitions
• Public employers (state, local)
• Public Health
• Quality Improvement Organizations (QIOs)
• And then also.
• Patients (consumers/unions)

3

• Governance Issues
• There are unique issues across states
• Relative strength of key components (public
  health purchasers health plans providers)
• Market consolidation/fragmentation
• State regulatory constrains
• Geography
• The significance (and challenge) of getting all
  members at the table
• RHIO Organization must have a defined role/goal
  that is addresses each members needs
• Providers connectivity to support clinical
  care, quality improvement, patient safety
• Plans improve business processes to support
  plan administration
• Purchasers quality measurement, accountability,
  value-based purchasing and P4P
• Public Health improving health of population
  enhancing monitoring and surveillance providing
  population-based reference data for clinical
  decision making
• QIOs New business role under Medicare/CMS Scope
  of Work
• What about patients? Researchers? Vendors?

4

• Why RHIOs Need to Discover/Invent Themselves
• No cookie-cutter approach. When youve seen
  one. Youve seen one
• Internal market dynamics drive process for
  establishing a regional initiative
• While at the end regional organizations might
  look somewhat similar (independent
  multi-stakeholder non-profit), each community
  needs to go through the organizing process from
  start to end
• Process validates the need/value of regional
  effort
• Process allows establishment of trust
• Process ensures buy-in by participating
  organizations
• Process ensures ongoing commitment from
  organizations
• There are state laws that will affect the
  formation of regional organizations
• Privacy
• Health plan regulations
• Provider regulations
• Public health laws

5

• Building a Sustainable Business Model
• Governance need to be established first
• Will decide the mission and purpose of RHIO
• The Governance will then need to determine WHAT
  is the RHIO going to DO and HOW is the RHIO going
  to do it?
• Convener/Facilitator/Educator on Standards
• Pilot tester/Prototype developer
• Buyer vs Builder of infrastructure (vs leveraging
  existing private infrastructure and Internet)
• Buyer vs Builder of value-added services
• Aggregator of data (repository)
• Transaction switcher/router
• Administrator of cross-system patient linkage
  system
• Clinical support systems
• Role in establishing privacy and security
• Role in disseminating information
• Role/product/service for consumers/patients?

6

• Building a Sustainable Business Model
• The Governance will need to create a business
  plan including timeline of implementation,
  start-up/maintenance costs, and methods for
  paying for these costs (upfront contributions
  from participants, grants, ongoing fees, state
  funding, etc)
• Differences between existing vs new organizations
• Existing organizations will need to re-purpose
  their mission to adopt/adapt to new role
  business plan would then follow
• New organization will need to establish
  governance, determine purpose and scope of
  activities, develop funding

7

• The TRUST Factor
• Three levels of Trust
• Within competing constituencies (i.e. among
  hospitals or among health plans in the region)
• Between represented constituencies (i.e. between
  providers and payers or payers and
  purchasers/employers)
• With the public (in the community)
• Organized patient/consumer advocates
• Consumers/patients at large
• Significance of trust with public will depend on
  the ROLES of the organization
• What is the interaction with the public?
• Does the public know (care?) what the regional
  organization is about?

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• Public Representation, Non-Profit Status and
  Trust
• Representation of The Public is one of the
  hardest issues to deal with
• We all represent The Public (providers, plans,
  employers, public health)
• Employers represent The Public (their
  employees)
• Government represents the Public (public
  health, public programs)
• Consumers REALLY represent The Public
• Who to select? (individuals advocates unions)
• Non-profit Status Does Not Ensure Public Trust
• In many states most/all hospitals and health
  plans are non-profit!
• Public Health CAN serve as a neutral, trusted
  convener party
• Transition out of role as convener after
  founding organizations establish
  mission/goals/priorities for group and define
  organizational approach (independent non-profit)

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• Statewide vs Community-based Organizations
• Are the roles and responsibilities different?
• Depending on their inter-dependencies and
  relationship, one might become an overseer and
  the other be responsible for operationalizing the
  core components of the RHIO in a smaller
  region/area.
• Is there a need for both levels?
• It all depends on the market/region
• In some states, a statewide organization can
  suffice
• In other states, there might not be a statewide
  organization, and community-based organization
  might need to be formed
• Yet in other states, a statewide organization
  (RHIO?) might be formed to oversee activities,
  and community-based organizations in areas within
  the state might exist to operationalize
  components of the RHIO.
• There might be also areas where a regional
  community-based organization is formed to covered
  various states, and within each state there are
  either statewide organizations or smaller
  community-based organizations that operationalize
  the components of the RHIO

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• Statewide vs Community-based Organizations
• Need for further federal action
• Federal guidelines can be provided to explain the
  possible scenarios and reinforce the co-existance
  of multiple models for RHIO development
• Federal guidelines should not define a single
  approach to RHIO formations and models.

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• Financial Models and Financial Incentives
• Financial Models will depend on WHAT regional
  organization is doing
• Convener/Educator/Standards facilitator
• Financial Approach Membership-based
• Innovator/Pilot Developer
• Financial Approach Grants
• Products and services
• Financial Approach User fees
• Financial Incentives
• RHIOs might facilitate/promote the use of
  financial incentives to support the adoption of
  HIT/Standards in the market
• RHIOs should stay away from standardizing the
  contractual relationships between payers and
  providers related to financial incentives and pay
  for performance
• Might constitute restriction of trade
• Could result in stiffening innovation in quality
  management
• Creates conflicting dual roles as
  convener/facilitator/promoter of the adoption of
  standards, and at the same time, measuring and
  having a financial impact on those organizations
  that are members