RHIO Governance Models

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Models for Connected Communities


tend to include large, “self-sufficient” enterprises agreeing to network, share, allow access to information they maintain on peer-to-peer basis. They may develop a system of indexing and/or locating data (e.g., state or region-wide master patient index (MPI)).


tend to includes mostly smaller enterprises agreeing to pool resources and create a combined, common data repository. They may share technology and administrative overhead.


are a combination of Federations and Co-ops and tend to agree to network, share, allow access to information they maintain on peer-to-peer basis; allowing for aggregation across large areas (statewide or regional). Hybrids may be required for statewide initiatives.

The two primary roles of the connected community’s organizational structure are ==Utility== or ==Neutral/Convener/Facilitator==. The ==Utility== RHIN/RHIO provides functions such as:

  • Centralized database
  • Patient information exchange
  • Clearinghouse
  • Patient information locator service

The ==Neutral/Convener/Facilitator== RHIN/RHIO

  • Builds consensus policies
  • Brings together competitive enterprises
  • Bridges multiple RHIN/RHIOs in geographic location
  • Seeks an open-standards approach – non vendor specific

An example of a RHIO that has taken on a utility role is that of the Santa Barbara County Care Data Exchange (SBCCDE) They have developed technology for patient information exchange which includes a patient information locator service. CalRHIO on the other hand is serving in more of a neutral/convener/facilitator role and building statewide consensus policies and bringing together competitive hospitals for projects like the emergency department linkage effort. As CalRHIO matures, they will most likely work to bridge multiple RHIN/RHIOs across the state of California.

Challenges and Potential Solutions


  • ==General==
  • Lack of trust and accountability
  • Politics – finding “neutral” ground
  • Pride of ownership
  • Fear of loss of advantage
  • Maintenance of interest and buy-in
  • Individual stakeholder priorities
  • Costs
  • Motivation
  • ==Business / Policy Issues==
  • Competition between stakeholders
  • Consensus of common policies and procedures
  • Consumer privacy concerns
  • Transparency of process
  • Uncertainties regarding liability
  • Difficulty in reaching multi-enterprise agreements for exchanging information
  • Decreasing debt capacity
  • Return on investment
  • Governance and leadership
  • Sustainability
  • Costs –Financial and personnel – especially for Small/Rural providers
  • Physician and payer incentives
  • Economic Factors
  • ==Technical / Security Issues==
  • Interoperability among multiple parties
  • Standards
  • Authentication
  • Auditability
  • Security and legal issues
  • ==Internal to the Institution / Network==
  • Competition for resources
  • Dilution of Effort: Project competing against other pressing needs
  • Preservation of previous investments
  • Increased cost of IT (perceived or real)
  • ==External to the Institution / Network==
  • Security – Data & Physical Resources
  • Rights in Data – who “owns’ the data and who can make changes (tracking changes)
  • Reliability of Data – potential mismatching of patients & data corruption
  • Linking Outside: Standards, reliability, controls
  • Business Continuity: Destruction/Recoverability of critical resources
  • Lack of Accountability & Control (perceived or real)

Overcome Challenges

  • Don’t allow the long list of challenges overwhelm you
  • Obtain buy-in from the highest level of each participating entity
  • Engage State leadership and leaders of healthcare organizations to continue to support dialogue/education on the issue
  • View challenges as opportunities for improvement
  • Identify effective leaders and “champions”
  • Identify financial incentives and provider investments in their internal systems
  • Identify funding sources for information technology and RHIN/RHIOs
  • Identify funding assistance for rural and small providers
  • Educate and communicate with providers and the public
  • Recognize opportunities
  • Recognize improved ease of inter-institution partnering
  • Identify the value and benefits that accrues to each participant
  • Establish standards
  • Leverage the efforts of the larger health systems – collaboration not competition
  • Reduce the number of barriers posed by state and federal regulations (HIPAA, Stark, etc.)
  • Adopt common terminology
  • Address adjudication of liability

Recommendations for Success

  • Involve major players in planning – CEOs, COOs CMOs, CIOs, nurse executives, legal, risk management/compliance, etc ~ avoid “one champion” or pure tech view
  • Ensure leaders of the RHIN/RHIO are accountable to the community, not their individual interests
  • Establish a shared vision and common goals
  • Plan for governance from the beginning
  • Keep patient and security and privacy of information at front
  • Identify all stakeholders and invite everyone to the table
  • Prepare stakeholders for real collaboration
  • Establish a mission and set measurable and achievable goals
  • Address governance accountability and sustainability concerns
  • recognize that discussion dialogue and debate are part of the process
  • Build trust
  • Plan some quick “wins”
  • Demonstrate value and quality, safety, and cost benefits
  • Share stories and data of success with the reluctant and encourage them to join the collaborative
  • Secure the services of an experienced legal firm and keep them informed
  • Address and implement the agreement structure early
  • Spell out all interface & data specifications in excruciating detail, and hold everyone to them
  • Communicate expectations and hold all accountable for their obligations.

From Chritina's Considerations Based on the writings of Holt Anderson