TopBackground
While RHIOs are the organizations that currently provide HIE as a service, they are not the first. There have been several waves of organizations offering HIE as a service. (Vest & Gamm, 2010). In contrast to their predecessors, RHIOs show significant variation in their organizational structure and process (Adler-Milstein, Bates, & Jha, 2009)
In the first generation (early to mid 1990s), RHIOs were typified by Community Health Management Information System (CHMIS) that were funded through private grants (initiated by the Hartford Foundation through grants to seven states and cities (Vest & Gamm, 2010)) and functioned as a centralized data repository for a geographically defined community and a transaction system for information exchange as well as billing and patient eligibility information retrieval (Vest & Gamm, 2010). An example was the IOWA CHMIS (described in (Stark, Gregan, & Allen, 1996)). These first generation organizations faced and overcame several challenges. They developed new technology to suit HIE needs, and promoted its use among care providers (Adler-Milstein et al., 2009; Vest & Gamm, 2010). In spite of these early successes, CHMISs could not overcome important problems (such as security and privacy concerns from patients, control and usage concerns from providers, lack of cooperation and consensus between competing providers (Vest & Gamm, 2010), and eventually could not sustain themselves because they could not easily transition from a grant funding model to a self-sustaining revenue model that leveraged the services they provided (Vest & Gamm, 2010).
The second generation (late 1990s) saw RHIOs take the form of Community Health Information Networks (CHINs). CHINs were commercial endeavors designed to offer cost-savings via HIE without any commitment to make public community health level data available (Vest & Gamm, 2010). An example was the Metropolitan Healthcare Council (described in Bergman, 1994). These organizations eschewed a central RHIO-managed repository in favor of a transaction-based federated data storage where independent providers maintained their own database (Vest & Gamm, 2010). Although this architecture did allay concerns of healthcare providers about surrendering their data (Bergman, 1994), many CHINs failed as competing providers limited the exchange of their information and competing technology vendors fostered schisms in the network (Bergman, 1994; Vest & Gamm, 2010).