For every nascent RHIO, the involvement of large physician groups is crucial to building momentum. Yet it is still unusual for independent physician associations to take the lead in RHIO startups. Many IPAs operate with lean administrative staffing and don't have IT executives available to tackle interoperability issues. Others have been reluctant to make the investment in common infrastructure.

One exception that has garnered a lot of attention is Taconic IPA in Fishkill, N.Y., which has been instrumental in the development of the Taconic Health Information Network and Community (THINC) RHIO in the Hudson River Valley. Under the leadership of President and CEO John Blair, M.D., Taconic IPA was one of the first physician organizations in the country to lead a RHIO effort. But other less-well-known IPAs have quietly been playing the role of catalyst in clinical data-sharing efforts in their communities.

For Bill Beighe, CIO of the Physicians Medical Group (PMG) IPA, the Santa Cruz RHIO in California is like knitting together a huge quilt of the region's healthcare community. His IT group spends its time sewing together the data from clinics and labs to build a stronger network. "We're working toward as complete a record as possible," he says.

PMG, which has 275 physicians, was instrumental in the formation of the Santa Cruz RHIO. In 1996, it instigated efforts on local clinical messaging to improve the quality of care. It started using Lotus Notes software and later moved to the Internet, creating a health information exchange with software from Axolotl Corp. (Mountain View, Calif.). Besides the IPA, the Santa Cruz RHIO includes clinics, local laboratories and two community hospitals.

Adherence to standards makes interoperability possible, Beighe says. "There's very little proprietary system interfacing," he explains. "We are exchanging standard HL7 data." If a clinic's data can't be put in a standard format, then a PDF file of the report is attached to the patient's record.

One challenge is keeping up with software upgrades by vendors that feed data into the RHIO. "One clinic gets a new transcription company, and fields that should be populated come in blank," he says. "So that takes a fair amount of time to fix, and it's an ever-changing landscape we're dealing with."

Like the Santa Cruz RHIO, the Quality Health Network (QHN) RHIO in Grand Junction, Colo., is continually adding data sources, says Greg Reicks, M.D., president of the 204-member Mesa County Physicians IPA, who also serves as president of QHN.

Founded by the IPA and several regional partners two years ago with $2.5 million in seed money from a lawsuit settlement with the state of Colorado, QHN was able to hire an executive director and small IT staff." We found we needed local IT people on the ground to get the system up and running and for ongoing support," Reicks says. "We couldn't rely just on vendors."

Although most of its lab results come from two local hospitals, QHN is working on adding national reference labs such as Quest Diagnostics Inc. (Lyndhurst, N.J.). "We also are working on outpatient transcriptions," he says. "If a patient goes to a cardiologist, we are looking for a way to get those doctors' notes into the system."

Reicks says the network initially spent a lot of time and money on legal fees involving privacy and security. "The hospitals wanted more restricted access to their information because of security concerns," he says. "We wanted more access because we thought it would improve quality. We are still struggling with that in a way—who can access what information."

Some IPA executives working on data exchange have run into more obstacles. Rick Mac- Cornack, chief systems integration officer at the 420-member Northwest Physicians Network in Tacoma, Wash., says he believes RHIOs and the whole data exchange movement may be premature. "There's this largely invisible 70 percent of physicians who are in small group practices. They don't have the capital to invest in or much interest in data exchange," he says. "What they need is a way to simplify their administrative workload, which is a heavy burden."

MacCornack, whose IPA has worked with local hospitals, national labs and image providers to create the South Sound Health Communication Network—based on Soarian Community Access from Siemens Medical Solutions (Malvern, Pa.)—says the technical side of building and maintaining interfaces is complex. "They work splendidly once they're done, but it takes on average about 18 months to get from initial conversation with a lab to having the interface built." But he added that getting cooperation from area hospitals to share data has proven even more problematic. MacCornack says that RHIOs could be valuable tools, but attitudes about data sharing must change before they can be effective. "If you have a dysfunctional system, just turning it into electrons doesn't solve the problem.".