The Santa Barbara County Care

The Santa Barbara County Care Data Exchange was once one of the most ambitious and publicized U.S. health information exchange (HIE) efforts. Eight years after its inception, and several months after providing some data, the Santa Barbara Project shut down operations. Despite its developed HIE infrastructure, participants found no compelling value proposition in initial HIE services. Even with fewer technology delays and more community leadership, other regional health information organizations (RHIOs) may also stumble over HIE service-value propositions without some combination of grants, incentives, and mandates that develop initial RHIO infrastructure and services and ensure provision of unprofitable yet socially valuable services. [Health Affairs 26, no. 5 (2007): w568– w580 (published online 1 August 2007; 10.1377/hlthaff.26.5.w568)] The santa barbara county care data exchange was once considered one of the most ambitious and best-publicized health information exchange (HIE) efforts in the United States and a model for emerging regional health information organizations (RHIOs) elsewhere. Yet it shut down operations in December 2006, eight years after its development began. The board of the Santa Barbara Project (as it was commonly called) voted to shut down operations, even though the project had built a basic HIE infrastructure and started to provide data to clinical users. This report provides the history of the Santa Barbara Project, compares its experience with that of two other functioning RHIOs, and suggests some lessons learned. ! Information sources. To gather information for this report, we conducted more than forty interviews of current and former managers and staff in key participating organizations in the project—Santa Barbara County (California) health care organizations, CareScience (now part of Quovadx), and the California HealthCare Foundation (CHCF)—as well as key leaders in two functioning RHIOs (in the Indianapolis and Spokane areas). We analyzed interview transcriptions and detailed w 5 6 8 1 A u g u s t 2 0 0 7 H e a l t h I T DOI 10.1377/hlthaff.26.5.w568 ©2007 Project HOPE–The People-to-People Health Foundation, Inc. Robert Miller ([email protected]) is a professor at the Institute for Health and Aging, University of California, San Francisco. Bradley Miller (no relation to Robert Miller) is a physician research associate there. notes, project progress reports, other project and CHCF documents, and past presentations and articles on the Santa Barbara Project and the other RHIOs. We then used pattern-matching and explanation-building techniques to identify themes emerging from the data.1 ! The setting. Santa Barbara County, located about eighty miles north of Los Angeles, had a population of 400,000 in 2000. The county has three main cities: Santa Barbara (population 92,000), Santa Maria (population 77,000), and Lompoc (population 41,000), each with adjacent populated areas. The geographically separate cities have relatively self-contained health care systems, with one dominant hospital (system) in each city: the 600-bed Cottage Health System in Santa Barbara City and nearby Goleta, the 125-bed Marian Medical Center (part of the Catholic Healthcare West hospital system) in Santa Maria, and the 60-bed Lompoc District Hospital in Lompoc. History Of The Santa Barbara Project The project’s history is divided into several periods. An early organizing and planning period was followed by two periods in which technology was the key constraint on progress; thereafter, community organizations’ decision making, rather than vendor technology, became the key constraint on progress. ! Early evolution (late 1998 through summer 1999). Key organizations came together when the Santa Barbara Regional Health Authority (SBRHA), a countysponsored Medicaid health plan, approached the CHCF about health information technology (IT) funding opportunities and David Brailer, chief executive officer of Care Management Science (later CareScience), approached the CHCF about a possible HIE demonstration project. Brailer had previously conducted research on Community Health Information Networks (CHINs), regional HIE organizations with centralized databases whose promise in the early 1990s had faded.2 HIE proponents argued that communitywide electronic HIE could improve quality if a health care provider could go to one local Web portal, with one user sign-on, password, and uniform graphical user interface (GUI), to obtain all health care data for a patient across all community health care facilities and providers. HIE could provide more patient data that were more timely, legible, organized, and accessible, which could improve electronic lab and prescription ordering, reminders, lists of patients needing services, and performance reporting. HIE could reduce costs if it could eliminate paper results distribution; reduce duplicate lab tests; and help provide more appropriate primary, specialty, and emergency room care—and thus reduce use of health care services. In February 1999, the CHCF asked CareScience to study the feasibility of a Santa Barbara County HIE demonstration project. Brailer reported that a communitywide HIE system was feasible: interest and cooperation in the Santa Barbara community were sufficient, an HIE support structure could be built, and sufficient “off-the-shelf” software was available that could integrate health care S a n t a B a r b a r a P r o j e c t H E A L T H A F F A I R S ~ W e b E x c l u s i v e w 5 6 9 information systems with peer-to-peer networking technologies to enable countywide HIE. Product, culture, workflow, and financial barriers were believed to be surmountable. ! Organizing and planning (fall 1999 through winter 2000). In September 1999 the CHCF awarded a $10 million, three-year grant to CareScience and the Santa Barbara participants to create the Community-wide Health Information Demonstration Project, soon called the Santa Barbara County Care Data Exchange. The goal was to create an HIE model replicable in other communities.3 The CHCF contracted with CareScience to act as a Program Management Office to lead the effort—it would disburse funds, organize the participants, set up and staff governance structures, certify that vendors complied with standards, contract with vendors to obtain needed software, and more generally provide “products and services that address key barriers to success” for the Santa Barbara Project.4 To encourage cooperation, CareScience organized participants into four Care Data Alliances: groupings/clusters of Santa Barbara health care organizations with substantial clinical transactions among themselves. Each alliance had an anchor organization: Sansum Santa Barbara Medical Foundation (a large medical group) and SBRHA (a Medicaid health maintenance organization, or HMO) in Santa Barbara City, Mid-Coast Independent Practice Association (IPA) in Santa Maria, and Lompoc District Hospital in Lompoc. More than half of the $10 million was to go to alliance organizations to develop HIE interfaces between the Santa Barbara Project and the organizations’ “legacy” (older) data systems that were not designed for Web use and to help upgrade information systems in Santa Barbara organizations, to enable them to better participate in the project. The chief governance structure was the Care Data Exchange Council, to comprise high-level health care organization managers meeting monthly. Top technical experts and clinical leaders in a Technical Advisory Committee and Clinical Advisory Committee would advise the council. ! Technical concept development and prototyping: (winter 2000 to mid2003). Initially, CareScience believed that it could acquire much of the needed technology through purchasing “off-the-shelf” software or by contracting with technology vendors to adapt existing products. CareScience certified whether a vendor’s products were compliant with recognized technical standards and able to integrate with legacy information systems. Participating organizations were led to believe that the Santa Barbara Project could be developed rapidly. By fall 2000, in a crucial reversal of its initial findings, CareScience concluded that “off-the-shelf” software did not exist that would allow HIE to move forward and, in particular, that adapting existing “middleware” could not easily enable legacy health information systems to participate in a network system such as the project’s. In an important decision following this CareScience reversal, the CHCF agreed that CareScience should become the software developer and vendor, as w 5 7 0 1 A u g u s t 2 0 0 7 H e a l t h I T