Regional Health Information Organization
A Regional Health Information Organization (RHIO, pronounced rio), also called a Health Information Exchange Organization, is a multistakeholder organization created to facilitate a health information exchange (HIE) – the transfer of healthcare information electronically across organizations – among stakeholders of that region's healthcare system. The ultimate objective is to improve the safety, quality, and efficiency of healthcare as well as access to healthcare through the efficient application of health information technology. RHIOs are also intended to support secondary use of clinical data for research as well as institution/provider quality assessment and improvement. RHIO stakeholders include smaller clinics, hospitals, medical societies, major employers and payers.
The US system of Healthcare is highly complex and fragmented, with use of multiple information technology systems and vendors incorporating different standards. In contrast with other developed nations, healthcare accounts for a disproportionate percentage of the US GDP, and there is a concern about the economic viability of Medicare. Despite this significant expenditure, there is evidence of inefficiency, waste and medical errors, with a 2001 estimate by the Institute of Medicine of between 44,000-98,000 annual deaths due to medical errors. While numerous possible causes for this situation exist, much waste (e.g., duplication of laboratory tests) and medical errors (e.g., adverse drug reactions) are traceable to inability of healthcare providers (who are not the patients' primary providers) to access patients' existing medical information in a timely manner when needed: better and more ubiquitous health information technology might be part of the overall solution.
In 2004 President George Bush issued an executive order for the development and nationwide implementation of an interoperable health information technology infrastructure to improve the quality and efficiency of health care with the goal that most Americans will have an EHR by 2014. In July 2004 the United States Department of Health and Human Services released their vision of how America’s healthcare system could be rebuilt during the next decade. An aspect of the federal effort is the creation of the Office of the National Coordinator for Health Information Technology. One of the roles of ONC is to facilitate RHIO development.
The planning stage of RHIO formation involves 1) identification of a shared vision/motivation,2) creating a governance structure 3) identifying a technology and network infrastructure for data integration, 4) defining standards for data sharing, protection of data, and business practices to ensure patient protection during data exchange 5) defining educational and business strategies to ensure sustainability of the effort. Finally, RHIOs must implement the proposed strategies.
Types of RHIO Architecture 
The two broad types of architecture, Centralized and Federated, correspond to the "Data Warehouse" and "Federated database system" models of data integration. In the Centralized configuration (e.g., The Santa Cruz Community and the Michigan UP Network), all providers send their data to the RHIO's central repository on a periodic basis (daily), while in the Federated model or Record Locator service, the data stays at its original location, and the RHIO only has a "pointer" to that information.
The pros and cons of each architecture follow from the approaches. For the Centralized design, once data is centralized and restructured into a uniform data model, it is easier to query and analyze: however, because movement and restructuring is generally a complex batch process involving the well-known steps of "extract, transform, load", the centralized data may be somewhat out of date if the (logistically challenging) target of daily updates is not achieved. Also, there may be concerns among the individual RHIO participants who originate the raw data that they are giving up "control" and "ownership" once the data is copied to a central site. Also, creation of the central repository requires close collaboration to determine exactly what data will be centralized and how it will be structured.
Federated systems, where the RHIO software merely has information on which patient's data is available at what locations, are often more politically feasible than Centralized systems. However, designing a protocol by which the RHIO can query (heterogeneously structured) individual provider data stores is technically challenging, and the software at the individual sites must ensure authenticate electronic requests to ensure that they are legitimate and authorized: no standards that can be used for this purpose currently exist. A federated setup requires greater network bandwidth than the centralized approach, because a request by a user of the central RHIO software can be farmed out to multiple provider systems.
The Centralized and Federated approaches are not mutually exclusive, and hybrid setups can be employed. In one proposed hybrid model, the health record trust), all data for each patient would stay in a single repository (the data bank), but patients could choose which data bank to use for their records.
Current Status 
Of the more than 190 RHIOs in various stages of development (2009), a 2009 survey found that 57 RHIOs actively exchange data used by healthcare stakeholders. RHIO initiatives exist at two levels, larger (statewide) and smaller (local and rural).
Compared to local RHIOs, state-level initiatives, because of the larger number of stakeholders and patient base, and consequent financial strength, have a greater likelihood of being able to utilize national-level expertise both in health IT and policy-making. Most operational RHIO efforts tend to be larger efforts, though the risk of political battles and consequent failure is also amplified if several large stakeholders choose not to cooperate with each other.
Compared to state-level RHIOs, stakeholders tend to be more heterogeneous with respect to line of business, use of technology and size. Rural RHIOs have a subscriber base of less than 100,000. The presence of numerous, smaller organizations with relatively limited IT budgets translates to numerous challenges due to the diseconomies of small scale. There is limited access to skilled technology professions, and health IT vendors pay less attention to small customers. Many stakeholders continue to deploy legacy software from long-defunct vendors and some may not deploy IT at all. In addition, stakeholders may be less IT-savvy, and even availability of high-speed Internet connectivity may not be assured. A significant sustainability challenge for smaller RHIOs involves funding. Some support models (e.g., used by Northwest, Louisville KY) are based on shared, subscription-based use of commercial health information software, and the shared use of scarce resources such as information technology professionals, who are unaffordable for smaller organizations acting individually.
Irrespective of size, certain challenges remain, such as interoperability standards, as well as consistent standards with respect to privacy, security and appropriate use of the data. Currently, privacy/security issues vary across states, and federal efforts to ensure uniformity are desirable.
Examples of RHIOs 
INPC/ IHIE 
The Indianapolis Network for Patient Care (INPC), operational since 1994, connects all five major hospital systems in greater Indianapolis. All INPC participants now deliver registration records, all laboratory tests, text reports, mediciation history and all UB92 records (diagnosis, length of stay, and procedure codes) for hospital admissions and emergency room visits to separate electronic medical record vaults in a central INPC server using a federated data store model. The message exchange standard that is used is HL7. The computer system standardizes all clinical data as it arrives at the INPC vault, laboratory, radiology, and other study test results are mapped to a set of common test codes LOINC with standard units of measure, and patients with multiple medical record numbers are linked.
Implementation has been simplified because each participating institution uses the same data model and term dictionary which contain the codes, names (and other attributes) for tests, drugs, coded answers, etc. The data for any participating patient seen in any of the region's 11 emergency rooms can be presented as one virtual medical record.. Stakeholders/ participants in this RHIO include: major and regional hospital systems, regional and national reference laboratories, state, federal, and private payors, pharmacy benefit management claims respository services, major physician practice organizations, individual providers, state government (Dept. of Health), major academic research institutions, and others.
The statewide Indiana Health Information Exchange, which uses the expertise of the same medical informatics/IT team as the INPC, combines clinical data in combination with administrative (claims) data to support electronic delivery of test reports to physician offices using faxes, printers, and e-mail, as well as Clinical Quality Services, which provide a "report card" (and incentives) on established quality messures to physicians, practice groups, employers, and payers. The IHIE is a rare example of a self-sustaining HIE (not reliant on government grants). Stakeholder satisfaction with this RHIO is apparently high
CalRHIO is an example of an RHIO failure due to political/turf battles: it became defunct as of January 8, 2010. Following over a year of feuding with California e-Health Collaborative (CAeHC) for California State designation of a state-wide HIE entity, both organizations were turned down by the state government in December 2009; large stakeholders such as Medicity Inc. and Kaiser Permanente subsequently followed suit and withdrew financial support. Reasons for CalRHIO's failure have been attributed to a limited business model dependent on state-entity designation.
Other States 
In some states (e.g., Kansas), an alternative to a stakeholder-consortium-based state-level RHIO is being considered, namely direct involvement of the state governments in creating the RHIO infrastructure. This approach builds on the strengths of state governments as major employers and purchasers of healthcare services (e.g., University of Alabama, Birmingham, is Alabama's largest employer). Similarly, TennCare in Tennessee has roots in addressing the state’s uninsured/underinsured population and is consequently more state driven. Utah’s efforts are based on the state’s prior efforts to process healthcare claims.
Recent federal efforts (e.g., at the Veterans Administration) are aimed at creating a federal employee based electronic health record system, which might be considered a national RHIO.
- "What is Health Information Exchange?". American College of Rheumatology.
- White House website Transforming Health Care: The President’s Health Information Technology Plan, Promoting Innovation and Competitiveness: A new generation of innovation, April 27, 2004.
- CNN.com U.S. health costs on unyielding rise, Associated Press, February 22, 2006.
- L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, eds., To Err Is Human: Building a Safer Health System. Institute of Medicine. 2000. Washington, D.C: National Academy Press.
- "Office of the National Coordinator for Health Information Technology (ONC)". United States Department of Health & Human Services. October 8, 2006.
- The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care, Tommy Thompson and Dr. David Brailer, Department of Health and Human Services, July 21, 2004.
- ONC Office of the National Coordinator for Health Information Technology
- Castro, Daniel, “Improving Health Care: How a Dose of IT May Be Just What the Doctor Ordered”, The Information Technology and Innovation Foundation, October, 2007, http://www.itif.org/files/HealthIT.pdf
- eHealth Initiative Migrating Toward Meaningful Use: The State of Health Information Exchange A Report Based on the Results of the eHealth Initiative’s 2009 Sixth Annual Survey of Health Information Exchange.
- Why these doctors love their RHIO. Medical Economics, url: http://www.memag.com/memag/article/articleDetail.jsp?id=182803
- Rauber, Chris (January 10, 2010). "CalRHIO closes, but board to help state on IT".
- Office of the National Coordinator for Health Information Technology
- AHRQ National Resource Center for Health Information Technology
- Core RHIO Business Requirements
Current RHIOs 
Some of the currently self-sustaining RHIOs to date (Source: First Consulting Group):
- Healthcare Information Xchange of New York (HIXNY) http://www.hixny.org
- Long Island Patient Exchange (LIPIX) http://www.lipix.org
- http://www.grrhio.org/ Rochester, New York
- HealthBridge, Greater Cincinnati area (Ohio, Kentucky and Indiana)
- Indiana Health Information Exchange
- Indianapolis Network for Patient Care- Regenstrief INPC
- [Adirondack Regional Community Health Information Exchange or ARCHIE http://www.archiehealthexchange.org/]
- e-Health Network of Long Island www.ehealthnetworkli.org
- Medical Information Network – North Sound www.min-ns.org
- Bronx Regional Health Information Organization www.bronxrhio.org
- Colorado Regional Health Information Organization www.corhio.org
- Keystone Health Information Exchange (KeyHIE) 
- Maryland's Chesapeake Regional Information Systems for our Patients 
- Michigan UP Healthcare Network
- MidSouth eHealth Alliance
- Massachusetts SHARE (Simplifying Healthcare Among Regional Entities) 
- Santa Barbara County Care Data Exchange
- Santa Cruz Physician Medical Group (IPA)
- Southern Tier HealthLink New York
- Taconic Health Information Network and Community (IPA) (New York)
- Quality Health Network, Grand Junction, CO
- CareSpark (Central Appalachian Region – VA, TN, NC and KY)
- PeaceHealth (Alaska, Oregon and Washington)
- Western New York Clinical Information Exchange (WNYCIE) - HealtheLink 
- East Kern County Integrated Technology Association (EKCITA)