Medical Records
Will PHRs rule the waves or roll out with the tide?
Rick Schooler, vice president and chief information officer of the Orlando (Fla.) Regional Health System, a seven-hospital network, has high hopes for electronic personal health records. In the future, he believes, portable, patient-controlled, Web-based PHRs will form the basis for regional and national health information networks and give providers access to comprehensive health data on each patient.
But he’s skeptical that they’ll catch on with the public anytime soon. For that to happen, he says, the government needs to create PHR standards for data transfers and privacy, vendors have to make the information understandable to consumers, payers have to pressure providers to transfer clinical data to PHRs, and employers and health plans have to give consumers incentives to use PHRs to manage their health. “There’s got to be a motivating factor to cause the individual to want to make use of the record,” Schooler says.
The entrance of Microsoft, Google and other well-financed players into the PHR space—as well as a Medicare pilot in South Carolina—undoubtedly will raise the visibility of the service. But while more than 200 different models are available on the Web today, only 1 percent to 4 percent of the population takes advantage of them, according to consumer research polls from the Markle Foundation and Harris Interactive.
One reason is privacy. Although 65 percent of respondents to a 2006 Markle Foundation survey said they “would like access to all of their own medical information” online, 80 percent worried about the privacy of electronic records and that their health care information might be misused or sold. When asked by Harris Interactive in 2006 to rank their top concerns regarding online health information, 68 percent of respondents put privacy as their top worry, followed closely by security at 66 percent.
While those polls look broadly at the topic of electronic records, the Markle Foundation, in a survey released in June, asked specifically about PHRs and found a high level of concern: 57 percent of people who said they were not interested in opening a PHR ranked privacy and confidentiality as their primary concerns.
It’s also unclear what type of PHR will gain public acceptance. Records that consist mainly of patient-entered data have gotten little uptake. Even when PHRs are prepopulated with claims data, as they are for 70 million consumers who have insurer- or employer-provided records, just 1 percent to 7 percent of people use them, according to industry observers.
The most substantial use of PHRs to date has occurred in big group practices like those of Cleveland Clinic, Group Health Cooperative and Kaiser Permanente. In those groups, patients have access to PHRs mirroring the electronic medical records of their physicians, as well as to secure messaging services that connect them with the practices.
To some observers, a method of linking doctors to patients online is a prerequisite for a PHR to gain any degree of consumer acceptance. “The PHR that doesn’t connect into your doctor is like an ATM without any money in it,” declares Ed Fotsch, M.D., president and CEO of Medem, which offers a PHR that includes secure online messaging.
Similarly, John Halamka, M.D., chief information officer of Beth Israel Deaconess Medical Center in Boston, which has offered its PatientSite PHR for eight years, views the doctor-patient link as indispensable. “From our perspective, you can’t separate the PHR and the messaging. If I’m going to share a lab result with you, and you have a question, you need to have the loop closed with me.”
Some experts disagree. “It’s a mistake for us to prejudge and formalize what the desirable features of these new applications will be,” says David Lansky, president and CEO of the Pacific Business Group on Health. “There may be huge numbers of people who get great benefit to their health [from a PHR] in ways that don’t involve connectivity to the health care system, and we should encourage that, not inhibit it.”
Over the next decade, Lansky believes, the information network that will replace what is now termed a PHR could transform health care by empowering consumers to seek more care from sources other than their doctor and hospital, thus challenging those providers to offer value-added services.
“Some people want doctors and nurses to interpret the data, but other people are going to use it themselves,” he says. “People want to look at their lab results right away, and a lot of people who have been managing chronic illness for decades know as much about their results as any professional who might look at a printout.”
He draws a parallel to the way online investing allows consumers to bypass stockbrokers. “Traditional institutions will change how they interact with patients and families, and new market entrants will redefine what those relationships can be like,” he suggests.
The tension between these two attitudes—that PHRs’ success depends on their role in the doctor-patient relationship, or that they will transform the system by transferring power from physicians to patients—lies at the heart of the current debate over PHRs and the impact they might have in coming years.
Cutting PHRs Loose from Organizations
Aside from records that contain mainly consumer-entered data, most current PHRs are centered around organizations rather than patients. These tethered PHRs are typically offered by larger health care systems, multispecialty groups and insurance companies. Their biggest limitation is that they’re based on partial health records. The health care systems are not the only places where their patients get care, and the insurers only have claims data, plus test results from some labs. Moreover, about 30 percent of health plan members switch carriers every year.
Despite the flaws and omissions of claims-based PHRs, they do offer a view of what’s being done in physician offices.
The new untethered paradigm, embraced by Google, Microsoft and Dossia, a consortium of large employers, offers or facilitates a patient-centered, portable PHR that’s capable of integrating data from a wide variety of sources, including the patient, insurers, providers, pharmacies and others. In fact, both Google and Microsoft are trying to sign up health care systems that are willing to integrate their data with the technology giants’ new “platforms.”
If a hospital has the capability to connect with, say, Google Health, and the patient requests it, a particular subset of his or her information—for instance, lab results—can be automatically uploaded to the PHR. The patient can then decide whether to share that information with any number of people, including family members, a caregiver and her physicians. The difference between this approach and the tethered model is that the patient controls the PHR, adds data to it from a variety of sources, and decides with whom to share it.
But there’s a significant barrier to making these PHRs truly dynamic: just 17 percent of physicians working in ambulatory care put patient information into electronic health records, according to a June New England Journal of Medicine study. So those physicians may have no way to view and download data to the PHR—or to do the opposite and pull patient-entered data into the official medical record.
Converting Physicians
Even if physicians are well-connected, there’s scant evidence to show how they would use the PHR. For starters, there’s a suggestion that physicians don’t place much faith in patient-entered data or claims data, and they also have issues with data that comes from outside their practice or organization. “You could go to a Cleveland Clinic or a Kaiser group with a perfectly organized record from one of the other places of that kind, and they’d throw it all out and start over again,” says David Kibbe, M.D., a consultant and former director of the Center for Health Information Technology of the American Academy of Family Physicians.
Martin Harris, M.D., CIO at the Cleveland Clinic, which conducted a two-month pilot this spring with Google Health involving 1,600 patients, says that is a “very broad statement. It would depend on what the test was.” Cleveland Clinic physicians do import some of the information they get from Google Health into a patient’s EMR. Problems generally arise with such things as MRIs and other specialized tests that were ordered or done elsewhere.
“You’ll hear physicians say about an MRI, ‘They haven’t had the quality of MRI that I would need in order to operate on a patient,’ ” he says.
Can Entrepreneurs Lure Consumers?
The new players in the PHR space aren’t waiting for physician support to kick-start their efforts. They’re going directly to consumers, betting that the marketplace will drive adoption.
Microsoft officials say they aren’t even building a PHR. It sees HealthVault as a data storage site with a set of interfaces that allows consumers to collect and share their health information. The company is counting on other vendors to provide the applications that will make the data useful to consumers. Among its initial partners are companies that offer home monitoring devices, patient education and wellness programs. “Several dozen” health systems are also in various stages of integrating with the Microsoft platform, according to Grad Conn, senior director of product marketing for HealthVault.
Microsoft has also contracted with the Mayo Clinic to provide educational content and to create a next-generation information appliance. Philip Hagen, M.D., the medical director for Mayo Clinic Health Solutions, says Mayo doesn’t yet know what form this tool will take, but he’s sure that it will help physicians and patients work together more effectively.
While the Google Health product is distinctly a PHR, the company also encourages independent vendors to supply services that will rely on the personal data that patients choose to share with them. “We are an open platform that third parties can build on,” says Missy Krasner, product marketing manager for Google Health. “For example, we will probably never get into the business of disease management because that’s not Google’s core competency. We can see a lot of third parties that specialize in diabetes or congestive heart failure building on top of Google Health. And if the consumer trusts that third party and wants to deal directly with them, they can share the information they have in their Google Health profile. In exchange, the service will provide personalized content or service.”
Neither Google nor Microsoft is linking its PHR platform directly to its search business. But both companies hope their new health care projects will increase the use of advertised supported services, including health-related searches, on other parts of their Web sites. They’re not charging either health care providers or service vendors to use their platforms.
Marrying Claims and Clinical Data
The not-yet-launched Dossia PHR will depend partly on claims data held by the insurers that administer health plans for its founding companies, including Applied Materials, AT&T, BP America, Cardinal Health, Intel, Pitney Bowes, Sanofi Aventis and Wal-Mart. Dossia has partnered with both Microsoft and Google and will also gather clinical information for its patient-controlled, portable PHR, says Colin Evans, the company’s president. Unlike the data in current health plan PHRs, all of this information will go with employees when they leave Dossia companies. Evans admits, however, that it will be problematic for the patient to keep the record updated if he or she moves to a non-Dossia firm.
Evans also acknowledges that claims data is often incomplete. It only covers members for the period that they are enrolled in the plan, it doesn’t include prescriptions and treatments that aren’t covered, such as a flu shot at a health fair, and may have coding errors. “If we get clinical data from a provider, clearly we’d rank that as having a higher probability of being correct, and position it as such in the record.”
WebMD and Revolution Health, which is the brainchild of AOL founder Steve Case, are also planning to add clinical data to their current PHRs. WebMD already has some lab data in the claims-based records that it sells to employers. (It also offers a free PHR to consumers on its Web site.)
A big selling point for sites like WebMD and Google Health is that the data can be used to generate alerts such as adverse drug interactions—not just notifications reminding patients to take a medication or drink more water.
Revolution Health will augment its patient-entered PHRs with clinical data after companies like Microsoft and Google solve the connectivity problems, says Brad Jacobs, M.D., medical director of the Internet health information services provider.
So What Does it Mean to Hospitals?
The biggest potential benefit of PHRs to hospitals, says Orlando Regional’s Schooler, is that they might enable clinicians to access data from other providers when a patient is admitted to the hospital, comes to the ER, or visits a hospital-owned physician office. But for this approach to work, he emphasizes, providers must be required to send particular data to patients’ PHRs, and it must be in a standard format.
Halamka, of Beth Israel Deaconess, chairs a government-appointed panel that recommended PHR standards to the Department of Health & Human Services. “Over the last two years, [the panel] has created the mechanism, the format and the standards that allow data to be copied between EMRs and PHRs,” he says. The main building block is the continuity of care document, or CCD, an HL7-approved format for patient data summaries. Within a year or two, notes Halamka, the major health information system vendors are expected to offer programs that allow CCDs to be exported to EMRs and PHRs from other companies.
Say consumers suddenly decide that they want PHRs, perhaps because of all the new possibilities that Microsoft and Google open up to them. If they ask hospitals to provide data from their electronic records, how should health care systems respond?
The main problem that hospitals will encounter, Kibbe says, is that “they don’t have much capability to gather health information from different systems into a single file.” In other words, even if they have some method of extracting data from their disparate systems, they won’t be able to easily summarize it as a CCD. The process can be facilitated if a hospital already posts patient data on a physician portal.
Many hospitals, however, are not that far along. Even those that have made the leap into EMRs may not be ready to expand that to PHRs. For example, the CGH Medical Center in rural Sterling, Ill., purchased a NextGen EMR for its family practice and is also leasing it to a multispecialty group that includes most of the other physicians in town. The employed group has just started e-prescribing, and the independent group is busy customizing the EMR templates for its specialties. It will be another year or two before either group is ready to consider adding NextGen’s patient portal, let alone a PHR, says Ray Sharp, CGH’s CIO.
In contrast, St. Vincent Health System, a subsidiary of Ascension Health, recently agreed to introduce Medem’s iHealthRecord in all of its 18 acute care facilities and 85 physician practice sites in Indiana. Initially, says Alan Snell, M.D., chief medical informatics officer of St. Vincent, the PHRs will incorporate data extracted from its Allscripts ambulatory EMR and the Eclipsys system that’s being rolled out to its hospitals. But down the line, the Indiana Health Information Exchange, a regional health information organization that’s rapidly expanding across the state, will help populate the PHRs by pushing data to the system’s EMRs; eventually, it may feed data directly to the PHRs.
The advantage that the RHIO has over the Microsoft and Google approach, Snell notes, is that it’s likely to incorporate most local providers. “Medicine is practiced at a local level,” he says. “It’s not like you can go to eight or 10 or 20 large national companies and have 60 to 70 percent of the data. It doesn’t happen that way.”—Ken Terry is a writer in Fanwood, N.J.
This article 1st appeared in the August 2008 issue of HHN Magazine.
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