New computer networks offer a revolution at your fingertips

From the June 1995 ACP Observer, copyright © 1995 by the American College of Physicians.

By Edward Doyle

Throughout the country, a quiet revolution is taking place that promises to change the way physicians get information from hospitals, payers and related organizations.

In health care markets of all sizes, community health information networks, better known as CHINs, are being formed to electronically join physicians, hospitals and payers. For physicians using these systems, the benefits are great; with just a few keystrokes, they have access to all kinds of information that they need to run their practices--everything from hospital lab reports to referral information from HMOs. And for the communities at large, these networks promise to offer a wider range of services such as telemedicine services for rural populations and databases to measure the quality of health care plans and the health status of the population.

What exactly is a CHIN? In simple terms, it is a large network that links much smaller networks created by hospitals and insurers in a community. A small, independent network, like the one at St. Vincent's Health Center in Jacksonville, Fla., typically gives physicians access to billing information and patient data. At St. Vincent's, nearly 200 doctors tap into the hospital's network to get information such as lab reports, lists of physicians on staff at the hospital and referral information for health plans. Physicians provide the computer and modem; the hospital provides the software and service free of charge.

But the problem with St. Vincent's independent network--and others like it--is that it is open only to physicians on staff at the hospital. Physicians using the system cannot communicate with other hospitals and insurers or with colleagues who are not on staff at the hospital. Even worse, physicians who want to communicate with more than one hospital or payer need different software--and sometimes even separate computers--for each network they use.

This is where CHINs come in. By connecting different hospitals, payers and health care organizations all on a single network, CHINs allow physicians to communicate with many different organizations using a single computer equipped with one program. Using a CHIN, a physician could, for example, get lab reports from three hospitals and billing information from an insurance company, send prescription refills to a pharmacy and e-mail a colleague, all without ever switching computers and all while using the same software.

The Wisconsin Health Information Network (WHIN), one of the best known CHINs in the country, offers its 1,200 physician users access to more than 15 major hospitals and seven large payers, including Medicare and Medicaid. Physicians using the network supply their own modem and computer. The service costs $30 a month plus $25 for each computer linked to the service.

Mark Clemence, ACP Member, a general internist in Hales Corners, Wis., said that he finds the network's links to local hospitals the most helpful aspect of the service. By searching hospital records for patient information via the network from his home or office, he can spend less time in the hospital. "I can keep closer tabs on what's going on with my patients, rather than finding out the next day and spending more time in the hospital catching up," he said. And when he sees a new patient in the hospital, he goes to the network for past charts, old lab tests and prescriptions to get some background on the patient.

Last year, the two-year-old Wisconsin network began offering physicians precertification and referral authorization, as well as general claims information. "Often times I can no longer pick the specialist of choice," Dr. Clemence explained. "It's up to third-party payers. With WHIN I can access patient information in terms of what insurance they're carrying and what HMO they belong to."

But sophisticated CHINs do more than simply provide links to multiple hospitals and payers. The Wisconsin network is preparing to offer physicians direct links to area pharmacies so they can order prescriptions online and check if patients are actually filling their prescriptions. Plans are also under way to offer physicians direct access to an immunization database created by the state. And the network recently began offering Internet access and will soon carry commercial online services for physicians that offer free access to Medline and drug-interaction programs.

Getting physicians involved

The Wisconsin network is typical of the most common type of CHIN: It is a for-profit organization that is partially owned by the company that set it up. This model is popular; one CHIN vendor has set up and owns nearly 50 networks across the country.

But in the fast-moving world of information technology, the vendor-driven CHIN may soon be replaced by a bigger and better network: the community-based CHIN. In cities where hospitals and insurers have already created their own networks, health care leaders are joining to put these individual networks into larger CHINs.

That's the goal of the Northern New England Health Informatics Initiative, which is coordinating the creation of a community-based CHIN of nearly 30 different health care networks in the tri-state area of Maine, New Hampshire and Vermont. Michael Caputo, project executive, explained that it is important to act now. "Three or four years from now when it really makes sense for these groups to be communicating with each other, they are going to be so far entrenched in their own proprietary systems that they are not going to be able to do this very cheaply or effectively," he explained.

And in Cincinnati, when two vendors announced that they intended to create competing CHINs, the health care community jumped into the action. A variety of health care organizations, including physicians, payers and hospitals, joined forces to create a single community-owned CHIN, driving out the vendors. "It made more sense for health care organizations in the city to work together," explained Michael Rosen, MD, an orthopedic surgeon spearheading the city's CHIN effort. "CHINs should not be competitive."

This new breed of community-based network poses some definite benefits for physicians. For one, physicians tend to get more involved in their creation than in vendor-driven models; CHINs being created in Chicago, Cincinnati and South Carolina are partially or fully owned by state medical societies.

As a result of physician involvement, these community-based networks tend to cater to physicians' needs. While the traditional vendor-driven CHINs will only work with physicians who already have the necessary hardware (usually a 386 or faster PC), many of these new community-based networks are planning to provide physicians some technical assistance. In New England, where a high percentage of the state's 2,500 physicians work in rural areas, this is of particular concern. "Rural physicians don't have access to bandwidth, so we need to bring everyone up to a minimum level of connectivity," Mr. Caputo explained, "probably 28.8 speed modems."

Community-based CHINs also promise to offer more than lab reports and claims information. In New England, CHINs may eventually provide video links to large academic institutions for rural practices that cannot afford telemedicine technology. And in Minnesota, where 18 different organizations are forming a CHIN, the goal is to use information carried on the network for public health purposes. The state agency coordinating the creation of the CHIN may use information from the network to create report cards on health plans and even build a statewide pediatric immunization database.

Building a bridge

But in their quest to use and not just distribute data, most community-based CHINs will not act as large repositories. Rather than storing hospital and payer data in large databases, most CHINs will simply provide the connections between networks.

It's an important point, because the notion of storing so much patient data in one place makes people nervous, explained Ralph Wakerly, national director of CHINs for First Consulting Group in Chicago. All CHINs use some form of security measures to keep patient data from getting into the wrong hands, but competing health care organizations still prefer to keep patient data on their own computers where they can keep a close eye on it. "The parties that are participating in CHINs are still competitors," Mr. Wakerly said. "Do you think that Blue Cross and the Travelers want to share a list of their subscribers in a central repository? That's their customer base."

As a result, most CHINs simply provide users such as physicians the connection between various networks; all data on these networks is kept and maintained by the organization that owns it. But this creates its own set of problems, particularly for physicians searching for information. If a patient has been in three different emergency rooms, had prescriptions filled at two different pharmacies and had X-rays performed as an outpatient at yet another hospital, the physician looking for information would have to go separately to each network to discover all that. An even bigger problem: How would the physician even know where to look for the information?

The obvious solution would be to create an electronic medical record containing a broad range of information on all patients in the network, but such a solution would require that standards for collecting and reporting such information are agreed upon and followed, something which is still in the future.

Developers of the community-based CHIN in Chicago are working on a temporary solution. Mr. Wakerly, the Chicago consultant, explained that vendors are working on technology that would actually find all information about a certain patient from various insurers and hospitals and automatically bring it back to the physician using the network. One possible scenario: If an internist wanted information on a patient, he would enter the patient's name and relevant information such as birthdate and Social Security number, and the system would automatically collect and report all information that it found in different networks on the CHIN.

Pipe dreams?

Despite these ambitious plans, CHINs still face some obstacles. Technical issues aside, there is the issue of critical mass: Until enough other individuals or organizations begin using a particular service, there is not enough information to make it of much value. Only when there are enough physicians, hospitals and payers participating can any of the users get value from the service.

Frank Hoban, general manager of the Wisconsin CHIN, said that networks need to offer information on about 50% of the covered lives in an area to really be useful to physicians. After more than two years of operation, the Wisconsin network has information on only 35% of covered lives in the state. (He expects to reach the 50% mark sometime later this year.) Unlike the Wisconsin CHIN, however, community-based networks have buy-in from many segments of the community and have greater potential to reach the 50% mark much more quickly than vendor-owned CHINs.

But because these large projects have yet to be implemented, no one knows how readily they will be embraced. "Everybody paints the vision, everybody shows you the charts," explained Mr. Wakerly, "but nobody has delivered on the vision. Nobody has taken all the pieces and put them together into one comprehensive network with all the functions and all the players on the same network."

Even if takes a few years to introduce some of the advanced features, CHINs with basic functions--joining payers and hospitals and physicians who might otherwise never link up--are clearly on their way. As Dale Shaller of the Minnesota Health Data Institute, the group coordinating that state's CHIN, explained: "The wires already exist, it's a matter of agreeing to the connections that will make them all function all as a common network."

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