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December 11, 2006

EMR and PHR: Healthcare’s Ultimate Connection
By Roger A. Edwards, ScD, and Dale L. Robinson, MS
For The Record
Vol. 18 No. 25 P. 18

The union of these technologies could result in years of bliss for patients, providers, and payors.

Healthcare delivery is evolving to respond to the ever-growing demands of aging Baby Boomers in the context of new treatments at affordable prices. Numerous platform technologies provide opportunities and challenges for creating and realizing the envisioned benefits to meet these expanding needs. The interface of personal health information with provider-based medical record information poses challenges from many perspectives. It’s important to identify pathways to address the conflicting and synergistic parameters that exist in this complex space.

The growing popularity of consumer-directed health plans (CDHPs) confirms that healthcare in the United States is moving toward a more patient-centric delivery system. In fact, CDHPs are being offered by more than 90% of health insurers.

The concept of a CDHP is to restore an individual’s financial responsibility in regard to their medical spending and gain a strong influence over his or her purchasing power. The rapid adoption of CDHPs will drive the need for a smooth integration of personal health records (PHRs) and electronic medical records (EMRs). A PHR is a vital component to effective CDHP acceptance and implementation, as it provides a tool for engaging consumers in their own healthcare.

At the same time, the EMR could also facilitate integration of EMR and PHR because providers are interested in engaging consumers if it can improve adherence to treatment regimens and facilitate behavior change. Furthermore, if pay-for-performance (P4P) approaches expand, they will require greater use of patient outcomes data, something EMRs can supply.

As consumers shoulder more responsibility for managing the costs of their healthcare, they will want to understand more about delivery options and the relative costs of those options. Consumers have historically lacked the tools for understanding options and costs. EMRs integrated with PHRs offer significant new capabilities to help consumers understand past relationships among health outcomes and healthcare use as well as provide insight that could guide future use.

EMRs vs. PHRs
The EMR is currently the patient’s medical record, controlled and maintained by the provider, while the PHR is health-related information the patient controls and maintains. In this context, the integration of EMRs and PHRs can have synergistic and conflicting outcomes.

Examples of synergies include the following:

• the PHR data augment physician-collected data;

• patients are motivated to be active participants in their own healthcare; and

• patients receive physician feedback on their personal health.

Examples of conflicts include the following:

• Would the patient role frustrate the provider?

• How does the provider get paid for interpreting PHR data?

• Can the provider trust PHR data?

• What about provider job satisfaction with changing workflows?

• What about patient satisfaction with greater responsibility?

Current Efforts
Health and Human Services has awarded four consortia $18.6 million for e-health demonstration projects “to develop an architecture and prototype network for the secure sharing of patient information among hospitals, labs, pharmacies, and physicians in the selected participating regional markets.”1

EMRs are implemented or in the implementation process in 40% of large physician practices (more than 20 physician full-time employees) and 24% of all practices. EMR features/capabilities implemented by more than 95% of these large practices include: patient demographics, visit/encounter notes, patient medication/prescriptions, presenting complaint, physical exam/review of systems, past medical history, problem lists, procedure/operative notes, and laboratory results.

In addition, more than 60% have drug interaction warnings, radiology/imaging results, consult/reports from specialists, referrals to specialists, drug reference information, immunization tracking, drug formularies, clinical guidelines and protocols, and integration with practice billing system.2

Hospital-based use of EMRs varies by function, ranging from 8% for some functions (eg, pharmacy order entry and lab order entry) to 80% for other functions (eg, viewing lab results, patient demographics, and medical history).3

PHRs have lower adoption rates, but several companies are trying to provide products and services to consumers. These products and services have the potential to change the balance of data “control” although they generally haven’t yet. The primary reason is that a significant shift in mindset is required to create this change since, historically, most health/healthcare data belonged to providers. Evidence is beginning to accumulate that that mindset may be changing.

Leaning Toward Patient Control
The evidence is compelling: healthcare unbound is rapidly expanding and consumers are becoming more comfortable with the Internet. As Forrester Research describes, the term healthcare unbound encompasses the trends toward self-care, mobile care, and home care and can be defined as the “technology in, on, and around the body that frees care from formal institutions.”

The premise is to improve basic access to the quality and cost efficacy of healthcare by transferring it directly to consumer households and work environments and away from institutions and doctor’s offices. Healthcare unbound facilitates the need for integration of PHRs and EMRs and is already a $500 million primarily self-pay market. Telehealth in the United States alone is poised to grow to $2 billion in 2009 and $34 billion in 2015.4,5

Vanguard boomers (aged 51 to 60) are “digital-ready consumers” who are “technology optimists,” of whom 17% use a personal computer to store and update personal health information in contrast to 6% of the U.S. population.6-9

In case there is any doubt about the patient’s readiness to embrace EMRs, one need only look at the growth of the Internet. Ease with electronic interactions is growing as noted in a recent Census Bureau report on Internet use.

In 2003, 55% of American households had access to the Internet and 32% of adult Internet users purchased products or services online; 86% of computer users have changed their online behavior in some way because of concerns about identity theft.10

For the healthcare system to capitalize on the opportunities presented by patient-directed healthcare, industry leaders must find a way to optimize EMR and PHR systems. One approach is to use a ‘Jobs-to-be-Done’ framework as described in Clayton Christensen’s The Innovator’s Solution: Creating and Sustaining Successful Growth.11

The framework helps characterize unmet customer needs and analyze innovation opportunities. It is a useful tool to examine these complex topics because it assists in identifying which product features are relevant. This view focuses on what customers are “hiring” the product to do—the circumstance—in contrast to market segment-oriented views that focus on the product or user characteristics.

Thus, the jobs-to-be-done view—in contrast to a “product” or “demographic”—addresses the complex issues associated with integrating personal health data with provider EMR data. (See Table 1).

The complexity of the issues surrounding the adoption of EMRs and PHRs will obviously require prioritization. One such method of reconciling the jobs-to-be-done requirements is the analysis of classical prisoner’s dilemma scenarios as shown in Table 3.

Pathways out of the prisoner’s dilemma include the following:

• Consumers will invest if they perceive and realize benefits.

• Providers will invest if they perceive and realize benefits.

• Payors will invest if they perceive and realize benefits.

• Providers and patients will learn new workflows if there are adequate perceived incentives—and competing priorities suggest that incentives aren’t always there.

• Not only do information and dollar flows change but so do health outcomes and healthcare delivery processes. However, these changes are not perceived as worth the investment.

Current Attempts to Integrate EMRs and PHRs
CDHPs and the Veteran’s Administration (VA) both align incentives for facilitating integration of PHRs and EMRs in different ways and provide pathways that help address the prisoner’s dilemma. CDHPs provide consumers with an incentive to track and understand their healthcare use and health outcomes. This capability and insight require PHR-EMR integration to obtain the full picture—a prerequisite to more effective implementation of the CDHP model. The VA also has a greater probability of enabling integration of PHRs and EMRs because it has the responsibility for healthcare of the veteran until death. Investments can be justified from a longer-term perspective as a result of this life-long care motivation.

A technology adoption risk analysis perspective (see Table 2) also highlights some challenges associated with integrating EMRs and PHRs. It offers a framework for organizing and understanding the variables associated with the diffusion of innovations.

Technology Issues
Potential integration solutions must overcome a wide range of technical and system challenges, including security of patient information, portability, secure storage for immediate, remote access to imaging and diagnostic data, patient control and authentication, and provider and payor-based systems with multiple and conflicting purposes.

The potential solutions will require adaptation of a range of rapidly evolving technologies, including wireless communications, biometrics-based identification, smart cards, and IT infrastructures. Optimal solutions may also require rapid development of enabling technologies that have not yet been defined.

Numerous functional technology challenges exist. Examples include the following:

• patient control and authentication;

• synchronization of patient and physician records;

• common data formats, storage, and rapid access to large data files;

• integration of PHR and data for diagnostic analysis; and

• easy-to-use formats for data entry.

Numerous enabling technologies also exist to address these technology challenges:

• easy-to-use, low-cost, reliable biometrics;

• data encryption smart cards;

• wireless communication devices and protocols;

• data compression for storage and retrieval of image-based data;

• algorithms for image analysis;

• handwriting recognition; and

• content management software for conversion of legacy data.

Likewise, Business Models Must Be ‘Fixed’
Besides technology issues, there are business model concerns as well. For example, it is necessary for healthcare payors and providers to define the win-win-win business model that provides health and financial benefits to patients, providers, and payors. It is also important to structure new reimbursement and payment policies/procedures for physicians and other healthcare providers as well as define the boundaries among data in the PHR, in the EMR, and across both.

Payors and providers should gain an agreement regarding the merging of PHR-EMR data for the patient’s health benefits. They should also incorporate employer participation and financial support, while clearly defining the business model.
However, there are programs that illustrate business practices that could enable newer business models. These include the following:

• My HealtheVet program — a secure and private Web-based system veterans use for information and other supplemental tools to increase their knowledge about health conditions, enhance communication between healthcare providers, and improve overall health.

• MinuteClinic business model — uses highly advanced and unique software systems to provide inexpensive and quick service to patients from healthcare kiosks in highly populated and convenient locations with leading retail partners (CVS, Target) and funding from leading investors (Bain and Tgap). It is based on the premise that patients don’t need to go to the doctor or hospital for simple primary care conditions.

• Existing telemedicine and telehealth demonstration projects — Numerous examples promote the extension of healthcare organizations over time and space by integrating information and telecommunications technologies to deliver a range of healthcare services.

• P4P models — P4P initiatives are programs that attempt to make the healthcare system more effective and efficient. They influence physicians to collect better data and deliver more accurate outcomes by offering financial incentives to drive their work.

• Existing payor disease management models — use Web-based assessment tools, clinical guidelines, call centre-based triage, best practices, formularies, customer relationship management applications, and other tools to provide more complete integration of healthcare services and better customer service. Disease management program infrastructures are managing more complex information used by various stakeholders.

• CDHPs — provide rewards that create incentives for cooperation of patients, providers, and payors—especially in the context of telehealth, disease management, and P4P.

Next Step
Recommendations to facilitate the integration of EMRs and PHRs in the process of implementing a new patient-directed healthcare paradigm are the following:

• Generate awareness about incentive alignments and misalignments by convening a national symposium to discuss perspectives of various stakeholders (private payors, the Centers for Medicare & Medicaid Services, and other public payors, provider associations, patient representatives, vendors, other regulators associated with the technology infrastructure).

• Conduct concept development and proof-of-principle evaluation of required technologies and devices.

• Collect voice-of-the-customer data from providers and patients to develop a systems concept for integrated PHRs and EMRs.

• Convene a symposium of network systems and service providers to identify existing and enabling technologies for data needs.

• Build national support through public dialogue among stakeholders.

While it is important to be aware of potential issues and challenges from integrating EMRs and PHRs into already existing CDHPs, this integration is necessary for companies to remain competitive.

— Roger A. Edwards, ScD, is a managing consultant in PA’s Life Sciences and Healthcare Practice.

— Dale L. Robinson, MS, is a member of PA’s Management Group and consults in PA’s Product & Process Engineering Practice.

References
1. McGee MK. “U.S. Awards Contracts Totalling $18.6 Million For E-health Projects.” GovernmentVAR. November 10, 2005.

2. Gans D, Kralewski J, Hammons T, et al. Medical groups’ adoption of electronic health records and information systems. Health Affairs. 2005;24(5):1323-1333.

3. Brailer DJ, Terasawa EL. “Use and Adoption of Computer-based Patient Records.” California HealthCare Foundation Report, October 2003.

4. “Telehealth”: The use of advanced telecommunication technologies to exchange health information and provide healthcare services across geographic, time, social and cultural barriers, while improving efficiency and overall quality.

5. Forrester Research, Inc. “Healthcare Unbound” 2004.

6. “Vanguard boomers”: The first 10-year cluster of Baby Boomers

7. “Digital-ready consumers” are familiar with wireless devices (cell phones, PDAs, etc), have a broadband connection or home network and consist of 27% of households; 13% of seniors *=(Forester)

8. “Technology optimists”: Consumers with an optimistic attitude toward technology that triggers their media consumption, online behavior, and attitude toward advertising, research and shopping including: (a) go online to bank, shop, download, and share; (b) 44% more likely (than pessimists) to go online and once online, they are three times more likely to download music files legally or listen to Internet radio; (c) twice as likely to research products for purchase, shop online, or send or receive photos via e-mail; and (d) more than twice as likely to check bank balances online and almost three times as likely to pay bills online.

9. Forrester Research, Inc. 2005.

10. http://www.consumerwebwatch.org

11. Christensen CM. The Innovator’s Solution. Boston: Harvard Business School Press; 2003.

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