When he was US Health-IT czar, David Brailer stressed solving problems with interoperability, and as a result there are now several regional health information organizations (RHIO) in development. The good news is progress is being made facilitating information exchange between different organizations, but mostly among large organizations.

Unfortunately, the most important healthcare providers -- small physician clinics that deliver most care -- are essentially off the information grid. So is the next logical step for RHIOs to become application service providers (ASP)?

Jeff Rose, president of HealthAlliant, suggests that perhaps 20 percent  of RHIOs are looking at providing applications. There are already budding ASPs that look something like RHIOs. In Dayton, Ohio, the HIEx based at Wright State University is providing an ambulatory care record ASP to clinicians in both clinical and social service roles. The HIEx is designed as a public utility, and subscription costs are being kept very low. The goal is to be a community record for a nine-county area, combining Medicaid, social services, and clinical records.

Another consultant, Mark Renfro, Argus Technologies, believes that most big hospitals have little to gain from data exchange other than emergency-room information. Renfro is working with the Great Plains Healthcare Alliance, which is securing a USDA loan to provide shared lab, pharmacy, radiology, and EMR applications to 26 small hospitals and their attached clinics in Kansas.

While this model may make sense for rural providers, can a typical RHIO provide these services in a competitive market when local hospitals and technology vendors offer other options? The jury is still out. Although RHIOs have no experience in providing EMRs, for example, if RHIOs can subsidize the cost of an EMR, they may have an advantage. Rose notes that CareSpark, in rural Tennessee and Virginia, is doing this with funding from local employers and health plans.

On the other hand, Practice Fusion, a vendor of integrated services for physicians, is marketing its products via physician aggregators such as IPAs (independent practice associations). CEO Ryan Howard believes that the market doesn't realize how complex the synchronization of data between systems will be. He suggests that the ideal of the RHIO will require technology vendors to consolidate all data from their clients before exchange can realistically take place, and it's likely that many RHIOs will be reselling a preferred list of ASP solutions because otherwise their main task -- integrating data from different systems -- will be too difficult.

Rose is more optimistic about the prospects for data exchange, because the data sets required are not that complex. He says, "We're making this harder than it needs to be. The real problem is agreeing on how to describe bloodpressure, or CBC count. That's not a technology problem. What the RHIO is doing is collecting voices, making them heard, and arriving at those definitions."

So it appears likely that some RHIOs will be acting as ASPs for providers simply because they're well positioned to do so. But whether RHIOs will actually need to be providing applications to make data exchange real is still debatable.