Lessons Learned from the Santa Barbara County Care Data Exchange

The Santa Barbara County Care Data Exchange (SBCCDE) — one of the first local regional health information organizations (RHIO) in the country — began in 1999. Eight years later, it was history.

SBCCDE had a hopeful beginning, starting up with $10 million from the California HealthCare Foundation (CHCF) and another $4 million from the federal government. The plan, initiated by CHCF, was to develop a digital framework to exchange confidential clinical information among Santa Barbara (Calif.) physicians, hospitals, laboratories and pharmacies. Developers predicted eventual linkage to other information networks, perhaps including EMS, though EMS wasn’t asked to participate in the SBCCDE. Phillip Greene, the chairman of the project says, “EMS data would have been minuscule.”

Dr. Angelo Salvucci, medical director for both Santa Barbara and Ventura counties EMS, says any project that does include EMS would require a fresh look at data collection. “What is most important in understanding and improving EMS medical care is to link the prehospital assessment with the emergency department and/or hospital diagnosis. Unfortunately, simply looking at the discharge diagnosis, a commonly stated goal of data projects, isn’t adequate. The most important discharge diagnosis may not be the highest priority for prehospital treatment. Only by having the hospital personnel enter focused feedback into an EMS CQI system can we really know if the EMS assessment and treatment were correct.”

SBCCDE quietly discontinued operations in December 2006. Greene says the top three reasons the project shut down were:

1. Financial support for 2007 was uncertain.
2. Second generation technology systems for electronic medical records looked better than SBCCDE’s software.
3. No one was using the data; there wasn’t enough data in the system to be useful.”ž”ž”ž

The difficulty of developing a system with all the necessary privacy safeguards was daunting. Hospitals were concerned about liability for data errors. Some hospital attorneys wanted architectural changes to the software that would have involved great expense and a long time to implement, according to Greene.

Though patients had to agree to participate in the system, HIPAA compliance was a major concern. A 2007 report from the California HealthCare Foundation cites long software development time as a cause for low participation from medical providers.

In the summer of 2006, only two entities in Santa Barbara submitted data to the SBCCDE: Cottage Health System and the Santa Barbara Regional Health Authority (a county-sponsored Medicaid health plan). There was already a system that allowed doctors access to medical records at Cottage Health. There was little or no perceived value to SDCCDE as it existed.

Again from the CHCF report: there were concerns that organizations making an investment in the system would bear disproportional financial burdens. Health plans could save money if tests were not duplicated, but they were not expected to contribute to the cost of the system. Sole practitioners and small medical groups were not contributing, either, though theoretically they would be able to access data supplied by large medical practices.

According to the CHCF report, participants in SBCCDE were focused on the short-term private value proposition of viewing medical data by the time the project neared its end. They were looking at the benefits only to the investors. However, the system had the potential to be a long-term social value proposition: one that benefited all participants. Data collection from many sources could have improved health services across the board or provided data and software services to help people who manage their health care.

By 2006, CHCF was concerned enough about the slow progress of the project that future funding wasn’t ensured. Because the system did not have enough information to be useful, local medical entities had little interest in funding the project. None felt they had an investment that needed protection and advancement.

Greene feels in retrospect the top-down approach to the system was a mistake. Rather than the CHCF coming to Santa Barbara, “We should have gone to CHCF,” he said.

In addition to the CHCF report, several papers have addressed the lessons learned from the SBCCDE. Everyone seems to agree these are valuable lessons that have already contributed to the success of other RHIOs across the country and the national health IT project. David Brailer, the first national coordinator for health IT, was SBCCDE’s program manager and chief executive officer of the company that developed the system’s software. “[SBCCDE] shaped nearly every aspect of the federal approach to health IT,” he said.

So what are the lessons learned from the SBCCDE?

• Communities have more of a stake in the project’s success if they help fund it from the beginning.
• Privacy and liability issues need to be part of the early technology planning, instead of being dealt with as they come up.
• A bottom-up approach with local leadership is more effective than a top-down approach with strict schedules and centralized control imposed from outside the community.
• It takes time to build trust in the project within the community.
• The case must be made for medium- and long-term private and social value propositions.”ž”ž”ž

Although there are currently no plans to revitalize SBCCDE, we shouldn’t see it as a failure because the lessons learned have already benefited other areas. Rather, it was an experiment that delivered results different than the planners envisioned — as many experiments do. “Early adapter are often late to revisit an idea, because they are still stinging from their frustrations,” Salvucci said.