PROVIDENCE – Driving along Thurber’s Avenue Curve north on Route 95, did you ever wonder: why was the highway engineered in such a dangerous fashion, with a severe curve, the scene of so many accidents and fatalities?

It’s a good question. The official answer, much like the actual curve in the roadway, is not straightforward. It wasn’t because of engineering, design or safety concerns; Thurber’s Avenue Curve was apparently built that way because of cost concerns over a proposed land deal.

One account says that the state decided not to buy a gasoline storage tank and raze it during the right-of-way acquisition begun in 1958, because it was allegedly deemed too expensive. [Another, perhaps apocryphal account, had the decision where to build the highway connected to who owned the land, land that had been recently purchased by an elected official.]

The end result: a dangerous, man-made curve was built. Six decades later, the ongoing costs of the “poor” engineering of the Thurber’s Avenue Curve have continued to pile up. 

Like the Big Blue Bug, the Thurber’s Avenue Curve has become an iconic Rhode Island landmark, serving as a convenient reference point for traffic jam reporters. It even survived the Route 195 highway relocation.

One takeaway from Thurber’s Avenue Curve is how enduring and long-lasting the results can be from poor decisions, based upon a short-term cost calculus, in building new infrastructure.

Today, the lessons of Thurber’s Avenue Curve can serve as a caution sign, a yellow flashing light, as Rhode Island continues to build out its new electronic health IT highway infrastructure.

To do so, much like a person entering recovery, the first step will be to recognize and admit to some inconvenient truths about the state’s past health IT failures. The roots of those failures are revealed in the story that follows.

The electronic health IT highway
To get started on this journey, please strap on your policy wonk helmet again.

To make the dive into the murky waters surrounding the nuclear-powered aircraft carrier that is our nation’s health care delivery system as it attempts to change course, to borrow the metaphor used by a commercial insurance spokeswoman, we need to illuminate the context.

In health care, a new national electronic health IT highway is being built, much of it with federal taxpayer dollars, health insurance ratepayer premiums, and hospital system investments.

As of March 2013, some $1.6 trillion has been invested to build the health IT infrastructure, according to Stephen Soumerai, professor of population medicine at Harvard Medical School.

The optimistic view of that investment in health IT infrastructure and electronic health records, building an interconnected health IT highway, is that it will serve as an important tool in the heath care industry’s toolbox to cut costs, increase affordability and improve patient outcomes – the triple aim.

According to Dr. Farzad Mostashari, the former national coordinator of health information technology [ONC] at the U.S. Department of Health and Human Services, the new health IT infrastructure is “the bottom floor” in creating standards to move from mere billing and data collection into a transformative force in the way that health care is delivered – the way it is paid for, and the manner in which patients are engaged.

At a conference in Boston in 2013, Soumerai challenged Mostashari’s view, saying that the trillion-dollar investment was unsupported by any research evidence that it would create the predicted return on investment, or evidence that the promised changes in delivery, outcomes, quality and cost-savings could be achieved.

However, the move toward bundled payments and away from fee-for-service is directly tied to the implementation of health IT networks across hospital system platforms – what’s known as population health management analytics. [See links to ConvergenceRI stories below].

“You can’t have an Accountable Care Organization if you can’t count,” said Dr. Ken Mandl, director of the Intelligent Health Laboratory at Boston Children’s Hospital, at the same 2013 conference, finding the middle ground between Soumerai and Mostashari.

Here in Rhode Island, a statewide compact of health leaders organized by Sen. Sheldon Whitehouse and Rhode Island Foundation President and CEO Neil Steinberg has promised to move toward a self-imposed deadline of having 80 percent of all reimbursements tied to the global payment business model by 2019. The Centers for Medicare and Medicaid recently announced new goals to have 50 percent of all reimbursements paid through Accountable Care Organizations by 2018. [See links to ConvergenceRI articles below.]

As a result of the shift in business models, the larger hospital systems have invested billions in new health IT systems. In Boston, Partners Healthcare is implementing a $1.2 billion Epic health IT system for its network of 10 hospitals and 6,000 doctors. The system is projected to hold medical records for as many as 4 million patients.

Here in Rhode Island, Lifespan [for about $100 million] and Care New England [for about $50 million], CVS Health [for its entire system, at an undisclosed cost, following its move into the retail clinic business] are implementing Epic health IT systems. Care New England is rolling out its system, beginning with ambulatory care; Lifespan is planning a “big bang” implementation [for both in-patient and out-patient care] on March 29. [See links to Convergence article below.] Southcoast Health hospital system in New Bedford has also embarked on the journey to implement Epic.

While Epic has emerged as the preferred top-shelf health IT platform for many major hospital systems, the Microsoft of the hospital world, there are other competing hardware and software solutions.

Athenahealth of Watertown, Mass., recently purchased the hospital software system designed by Dr. John D. Halamka, the chief information officer at Beth Israel Deaconess. The health IT system, called webOMR, will become part of the Athenahealth’s cloud-based system, which it says can be easily downloaded and shared with providers both inside and outside competing health care networks.

At the crux of the technology conflict moving forward is the issue of interoperability: how systems share – or don’t share – data across competing IT platforms in a nimble – or clunky – fashion.

Interoperability becomes the critical functionality in the world of health care where population health management is the key to getting paid: if you are being paid to treat the patient within a continuum of care, you can’t manage the costs unless you can connect to the emergency rooms, urgent care centers, hospitals and specialists outside of your internal network.

Further, for primary care of patients with chronic conditions, early intervention in a collaborative, patient-centric, team-based framework, supported by an interconnected health IT system, is key to achieving cost savings and bending the cost curve – and improving health outcomes.

The gold to be found in health IT systems is in the flow and content of the data, not in the competing hardware and software systems – and the capability of providers to perform the analytics on that data in real time, in treating patients.

The rub is: who gets to capture the wealth in any shared savings achieved. Is it the hospital systems? Health insurers? Large group practices? The state’s general revenue fund for managed Medicaid programs? Or, providers and the facilities that are performing the actual work? And, of course, how, if and when those savings are shared with patients.

There’s a much longer discussion about whether investments at the front-end of the health care delivery system – in nutrition, in wellness, in healthy housing, at the neighborhood and community level – can achieve a greater ROI in terms of outcomes and reductions in costs. But that’s a deeper dive for another day.

As Deep Throat once told reporters Bob Woodward and Carl Bernstein during their investigation into the Watergate burglary and cover up, “Follow the money.”

Following the money
Here in Rhode Island, a major effort to jumpstart the changeover from paper to electronic records, begun in 2005, led by many of the state’s top health care CEOs, floundered and ran aground in 2011.

A new entity, a corporation, named EHRRI, Inc. [Electronic Health Record of Rhode Island], was created. It set up shop to invest and advocate for an EHR product created by a Massachusetts software company, eClinicalWorks, as the best choice for Rhode Island hospitals, group practices and providers, offering rebates of $5,000 to physicians that chose the software package.

EHRRI quietly went out business in 2011, transferring its assets to the Massachusetts e-Health Collaborative. As a result, millions of dollars, including a reported $1 million investment by Blue Cross & Blue Shield of Rhode Island to support EHRRI, were effectively flushed down the drain.

It’s a story that has not been told publicly, though; like the background in the deals surrounding the construction of Route 95, the facts are known but talked about in private.

And, as with the poorly designed Thurber’s Avenue Curve, the repercussions – the costs to taxpayers, health care insurance customers and the overall health care delivery system – continue to grow and be magnified by what happened with EHRRI.

Much of the story happened 10 years ago, but the record has been preserved, as revealed in a series of detailed minutes of meetings of the Rhode Island Quality Institute, the quasi-public agency created by Sen. Sheldon Whitehouse when he served as the R.I. Attorney General.

It is a public record that was hidden in plain sight.

Unlike the debacle of 38 Studios, the rise and fall of EHRRI has never created a sense of public outrage. Why it didn’t is also part of the story – allegedly in part because of the fear of retribution by powerful players within Rhode Island’s political and health industry establishment.

As a result, there were few if any apparent consequences for those responsible that took a big gamble on a commercial software package, and lost.

Some of the players have moved on or retired – George Vecchione of Lifespan, Jim Purcell of Blue Cross & Blue Shield of Rhode Island, John Hynes of Care New England, Christopher F. Koller, the former R.I. Health Insurance Commissioner, and Edward Quinlan of the Hospital Association of Rhode Island.

There is new leadership at many of key Rhode Island health institutions, including Blue Cross, Care New England, and Lifespan.

But many are still active: Laura Adams, president and CEO of the Rhode Island Quality Institute [who also served on the board of EHRRI], Maria Montanaro, then head of Thundermist community health center, now nominated to serve as director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals [who also served as a founder and board member of EHRRI], Stephen Farrell, president of UnitedHealthcare of New England; Amy Zimmerman, the state Health Information Technology Coordinator at the R.I. Executive Offices of Health and Human Services, and Sen. Whitehouse.

Even Gov. Gina Raimondo surfaces in the minutes as someone interested in making a potential business investment in EHRRI: “Laura Adams stated that she had been contacted by Gina Raimondo, a venture capitalist from Point Judith Capital, who has expressed an interest in meeting and discussing possibilities,” reads the minutes from the R.I. Quality Institute board meeting on June 1, 2005.

More significantly, the story about the rise and fall of EHRRI provides insights into the current problems with Currentcare, the state’s health information exchange, managed by the R.I. Quality Institute.

The saga begins
This is a long story. Feel free to take coffee breaks and exercise breaks while reading, a walk around the block. It is, like the Russian proverb about work, not a wolf that will run away into the woods.

Our saga begins the first week in January of 2005, more than 10 years ago.

On Jan. 6, 2005, the Clinical IT Leadership Committee, under the auspices of the R.I. Quality Institute, met to discuss strategies for volume-based purchases to be made by Rhode Island-based physicians and hospitals of electronic health record, or EHR software, from vendors.

At that meeting, the groundwork was laid to create a group-purchasing vehicle, which later became EHRRI. The rationale, as reported in the minutes, was this:

• There must be a mechanism for bringing the physicians together to formulate Rhode Island’s approach to group purchasing of EHRs.

• The R.I. Quality Institute does not have the name-recognition, structure or history in the Rhode Island physician community to be the broker of a purchasing option on behalf of physicians.

• To create the best opportunity for this high level of collaboration to emerge, a group should be formed under the umbrella of [the Quality Institute].

• This group would develop and achieve consensus on Rhode Island’s approach to EHR group purchasing.

The initial proposed committee was to consist of the CEOs from the New England Physician’s Alliance, including physician groups from Rhode Island, Miriam and Newport hospitals, the physician group for Women & Infants Hospital, the R.I. Community Health Centers, and others to be specified by the R.I. Quality Institute board.

It was discussed that negotiations with vendors “must go past purchasing and include the life-cycle of the product,” including service, maintenance and upgrades.

A short list of vendors invited to present to the group was approved, including: A4, Allscripts, GE Centricity, Physician Microsystems, NextGen, EpiChart, and Amicore.

Who was there at the Jan. 6, 2005 meeting? The folks attending the meeting included: Laura Adams, Mike Batty, Dr. Nathan Beraha, Anchor Medical; Dr. Reid Coleman, Lifespan; Chris Dooley, Women and Infants’ PSO; Dr. Michael Felder, University Medical Foundation; Dr. Steven Freedman, Ear, Nose and Throat Specialists; Dr. Peter Friedman, Rhode Island Hospital; Dr. Deidre Gifford, Quality Partners of Rhode Island; Dr. David Gorelick, Aquidneck Medical Associates; Dr. Steven Graff, Orthopedic Group, Inc.; Dr. Mack Johnston, Neighborhood Health Plan of R.I.; Dr. Gus Mannochia, Blue Cross & Blue Shield of Rhode Island; Mark Pezza, Thundermist Health Center, Dr. Cedric Priebe, Care New England; Dr. Al Puerini, Rhode Island Primary Care; Dr. Andrew Snyder, Hasbro Children’s Hospital; Newell Warde, Rhode Island Medical Society; and Amy Zimmerman, Rhode Island Department of Health

Concept for a new company emerges
At the April 6, 2005, board meeting of the R.I. Quality Institute, more details emerged about the planning for a new company to facilitate group purchases, in the report by the Clinical IT Leadership Committee by Dr. Snyder.

Snyder said that the Group Purchasing Committee, narrowed from its initial membership to include Coastal Medical, Lifespan PSO, Care New England PHO, University Medicine Foundation and Thundermist Health Center, had met on March 15 to further explore how best to move forward with the collective purchasing of EHRs in Rhode Island.

Snyder said that one of the “rewards” of collective purchasing would be to lower the costs and complexity of connecting to the Master Patient Index, the initial name of the state’s health information exchange now known as Currentcare.

Another advantage was the potential to negotiate lower prices for EHR products. Snyder acknowledged that there would be some risks but argued that the need to mitigate costs was an overriding factor.

“If we were able to narrow the list down to a single vendor for a group-purchasing agreement, provided that vendor had full functionality, flexibility and a strong track record, it could afford significant advantages,” he told the board, according to the minutes.

The Group Purchasing Committee, Snyder continued, had formulated a concept that would include selecting a single vendor and pooling resources to lower the costs of acquisition.

Snyder sketched out the vision for the new company that would be enabled by “significant investments from physician groups statewide,” according to the minutes.

Snyder optimistically estimated that it would take about 400 physicians to break even, and then that every physician added after that would lower the overall cost. Cost savings, Snyder continued, “would be in the magnitude of 10.”

Further, support services for the first year could be purchased from the vendor, and then, perhaps, after that, it could migrate “to home grow our local support” moving forward.

Snyder underscored that the concept required agreement on one vendor, and that it would also require outside financial backing.

Dr. Mark Jacobs of Coastal Medical enthusiastically endorsed the concept, saying it would allow Rhode Island “to stand out nationally.” Dealing with a single vendor, Jacobs continued, would make the “building of the interface” with the statewide health exchange less complicated and less costly.

[Ironically, even today, interoperability between eClinicalWorks, the sole vendor chosen by EHRRI, and Currentcare, remains at best problematic and costly, according to sources.]

Who was there at the April 6, 2005 meeting? At that meeting, as members of the R.I. Quality Institute board, were: Laura Adams, Rhode Island Quality Institute; Dr. Frank Basile, University Medicine Foundation; Dr Richard Besdine, Brown Medical School; Dr. Nitin Damle, South County Internal Medicine, Dr. Yul Ejnes, Rhode Island Medical Society; Stephen Farrell, UnitedHealthCare; Charles Fogarty, R.I. Lt. Governor; Dr. David Gifford, director of the R.I. Department of Health; Jane Hayward, the R.I. Office of Health and Human Services; John Hynes, Care New England; Dr. Mark Jacobs, Coastal Medical; Jeff Johnson, Central Rhode Island Chamber of Commerce; Mary Jones, consumer; Christopher Koller, R.I. Health Insurance Commissioner, Donald Letendre, University of Rhode Island; Pamela McCue, Rhode Island State Nurses Association; Marcia Petrillo, Quality Partners of Rhode Island; James Purcell, Blue Cross and Blue Shield of Rhode Island; Edward Quinlan, Hospital Association of Rhode Island; Marti Rosenberg, Ocean State Action; George Vecchione, Lifespan; and Sheldon Whitehouse, Esq..

The participants included: Dr. Robert Baute, Kent Hospital; Tom Collins, Cranston; Elaine Desmarais, South County Hospital; Cathy Duquette, Hospital Association of Rhode Island; Bobbie Fay, South County Medical Center; Dr. Jerald Fingerut, Blackstone Valley Community Health Care; Linn Freedman, Nixon Peabody; Sam Havens, consultant; Deb Hogan, R.I. Manufacturing Extension Partnership; Dr. Paul Gertman, Middletown; Elaina Goldstein, URI College of Pharmacy; Celia Gomes McGillivray, R.I. Community Health Center Association; Dr. Lynn McNicoll, Quality Partners of Rhode Island; Lisa Smolski, Rhode Island Free Clinic; Dr. Andrew Snyder, Lifespan/Physicians PSO, and Amy Zimmerman, R.I. Department of Health

The founding of EHRRI
From the minutes of R.I. Quality Institute board meeting on May 4, 2005, the name, EHR of Rhode Island, first emerges, as well as a discussion of the benefits of having such an organization in Rhode Island.

The discussion also begins to focus on the differences between the Quality Institute and the new entity. As part of the discussion, Laura Adams raised the issue of whether or not to build the state’s health information network in a way that would allow for the statewide aggregation of data. This could significantly affect funding sources, as aggregated data of this type “would have considerable value for population-based research, quality improvement and the biosciences.”

If it were decided to build the capacity to aggregate, Adams continued, discussions would have to take place with EHR of Rhode Island, since if this organization is launched successfully, they “will have access to substantial amounts of significant clinical data.”

The next night, on May 5, 2005, the Clinical IT Leadership Committee met, and the discussions rambled on about EHR Rhode Island. Most revealing were the following items:

• Dr. Jacobs said that if the new company, EHR of Rhode Island, was to succeed, it could provide substantial help to very small and medium practices. “It could provide access to a very high quality product at a substantial discount,” reducing the cost of interfacing with the statewide health information exchange.

Jacobs also said there was “an amazing amount chemistry and collaboration” when the core group that was planning EHR of Rhode Island – representatives of Lifespan PSO, Coastal Medical, Thundermist, University Medicine Foundation and Care New England’s Women and Infant’s PHO – met on April 20, 2005.

At that meeting, according to Jacobs, the group agreed on many details about EHR of Rhode Island, including the corporate structure, investment, governance, finance, and operating principles. The group even sketched out the board membership of the new entity: two seats each for the five founding members, the Quality Institute would have a seat, with the rest filled by outside investors, one seat per investor.

•  Market pressures for health care entities to make a decision in buying their own new health IT system were beginning to conflict with the aspirations of the new group, EHR of Rhode Island, which sought to have the task of gaining physician’s adoption of EHRs in Rhode Island transferred to the new group. 

The minutes revealed that Jacobs said he had actually slowed down [emphasis added] Coastal’s internal decision-making process “in favor of the greater good,” but that Coastal needed the process to move quickly. Maria Montanaro said that Thundermist wanted to complete their selection and purchase of a new system by the end of 2005. Care New England was reported to be examining the vendor products being considered by EHR of Rhode Island and vetting them for the capability to meet the needs of their physicians as well as be integrated with the hospital system’s IT infrastructure.

•   The targets for outside investment in EHR of Rhode Island were identified: health insurers, malpractice insurers, government agencies, and health care organizations.

•   The need for a communications strategy was identified by Dr. John Bossian to get the word out to large numbers of physicians. But Montanaro cautioned against this, saying the group was not ready to initiate large-scale messaging.

•  A conflict surfaced around the decision made by EHR of Rhode Island to pursue a one-vendor-fits-all strategy. Dr. Al Puerini, who had developed his own EHR software for physicians, EpiChart, argued that the door needed to remain open for viable alternatives needed to exist in the marketplace. Dr. Jonathon Leviss of Thundermist [who would later become the chief medical officer at the R.I. Quality Institute] countered that while no one wanted to impose a system on anyone, the experience of Kaiser lent credence to mandating a single-system approach.

•  A potential partnership with the Massachusetts eHealth Collaborative is first broached, with the idea that Rhode Island could join with Massachusetts in creating a purchasing collaborative for EHR vendors. Laura Adams said that she was planning to meet with Micky Tripathi, the CEO, the week of May 22. [In 2011, when EHRRI collapsed, the Massachusetts eHealth Collaborative would assume its assets.]