February 18 , 2008
If personal health records (PHRs) and electronic health records (EHRs) are to reach their full potential for adding value to the healthcare system, they must have widespread adoption and usage—and they must be fully integrated. Since integration is considered crucial, many providers, payers, employers, and vendors have already begun to assume that it will happen—albeit gradually—within the next three to five years.
Key players have now begun to focus on obtaining a return on investment (ROI), making information actionable once it is in the health record, and building innovative tools and services wrapped around a PHR to engage users. Even though significant barriers to integration remain, vignettes of successful efforts offer hope for the future of EHR/PHR integration.
Barriers to Adoption
The forecasting firm Datamonitor envisions a future where “every hospital and physician office will have its own EHR and where EHRs from different hospitals and physician offices will be interoperable to promote local, regional, and/or national (perhaps even global) sharing of information.” EHR users will include providers (hospitals, ambulatory care clinics, primary care offices, physicians, and nurses) and ancillary departments (radiology, laboratory, pharmacies, public health departments, and payers). Removing the barriers to attain this vision will require leadership, education, funding, and collaboration among vendors, payers, providers, medical groups, associations, and government entities. Among the most common barriers are the following:
• Lack of consensus on standards related to issues such as privacy, technology security, and primary care. Key decision makers continue to debate which standard should and will be used across the healthcare industry. Alternatives have ranged from Health Level Seven’s (HL7) offering to the American Society for Testing and Materials’ (ASTM) Continuity of Care Record (CCR) to a harmonized standard reflecting the input of both the ASTM and HL7. “Unable to predict which standard will win out as the best or most appropriate, vendors are left with the expensive task of having to maintain every standard demanded by the market to optimize integration with available data sources,” says Robert Barker, manager of interoperability and standards at Horsham, Pa.-based NextGen, an EHR and practice management systems developer.
Selection of a single standard would result in greater cost-effectiveness and across-the-board interoperability. Support is needed for working groups such as HL7, the ASTM, and the Certification Commission for Healthcare Information Technology. Working together with PHR and EHR vendors and potential users, these groups can explore issues such as how standards may affect innovation, required PHR features, and emerging CCR uses.
• Some organizations have been reluctant to offer PHRs. The apprehension of some healthcare organizations may be rooted in their confusion about the varied features and benefits of EHRs and PHRs. Will EHRs increase provider efficiency, reduce medical errors, cut costs, enhance productivity, improve patient care and satisfaction, and increase revenues?
And what of the patient or member? Few people question PHR features and functions, but can the PHR deliver on sponsor expectations of improved outcomes and consumer expectations related to control, flexibility, convenience, accessibility, prevention, and health maintenance? Potential adopters also need to know how the patient-centric health record relates to the workings of payers, health information exchanges, public health departments, pharmacies, and research groups. In the end, providers may hesitate to change how they practice medicine and stay “skeptical of available technologies, especially in regard to patient privacy and physician autonomy,” according to Datamonitor.
• EHR adoption is relatively low among certain groups. Just 27% of the more than 2,000 respondents to a November 2007 survey by Harris Interactive said they had an EHR. Of those, the majority claimed that their physician maintained the EHR, while 4% of respondents said they maintained their own. A July 2006 HIMSS survey of HIT professionals reported that, while a majority of Americans have never heard of PHRs, physicians have the power to encourage PHR usage.
Most consumers fail to understand the nature and benefits of PHRs and still worry about out-of-pocket costs, privacy, and security. They are less likely to trust PHR sponsors such as employers, health plans, and special interest groups and more likely to trust physicians, hospitals, and pharmacies.
Much of the solution rests in education. While the healthcare system trumpets the values of individual responsibility and accountability, consumers have yet to internalize their pivotal role in illness and injury prevention and chronic care management. A 2008 research brief from the Employee Benefits Research Institute reports that the consumer-driven health movement “relies upon fully educated health consumers taking self-initiated actions.” In promoting PHR adoption and usage, organizations must consider consumers’ needs, goals, health literacy, and Internet access, as well how they use varied tools, including PHRs, to enhance health.
• Funding is an ongoing problem. “Integration projects have lacked adequate seed funding, as well as financial and other incentives aligned with quality goals,” says Barker. For example, the Office of the National Coordinator for Health Information Technology was handed a fiscal 2008 budget of just $61.3 million—the same as 2007—causing it to postpone work on PHR architecture.
Organizations need to evaluate the role of incentives such as points programs, premium reductions, or other financial carrots. In addition, they must implement multipronged incentives involving PHR usage and other behaviors that demonstrate ongoing involvement with health improvement.
Overall, PHR and EHR integration is slowed by the lack of answers to the following key questions:
• What is the relationship between the PHR and health risk assessment? How can these tools be better integrated?
• How can the PHR be best bundled with other healthcare services and tools?
• What’s the best strategy for controlling and verifying data sources?
• How is data security and privacy best maintained?
• Who has access to the data within the record? For example, who is able to mine data?
• What is the record’s ROI, and how is that ROI calculated?
• How is the PHR used? For example, is it used to store personal health information?
• How can data within the PHR be made more actionable for users?
• How can consumers be educated and motivated to enter and manage data?
• Who has the responsibility to respond to information that is entered into PHRs by consumers?
• Who pays for the PHR and for PHR/EHR integration?
• As more choices become available, how does someone prevent PHR silos that display data tied only to the sponsor?
• How does the PHR become an integral part of overall patient care across the care continuum?
Despite these unanswered questions, many providers and other organization are forging ahead. Some programs are larger than others, but most are reporting success. A few programs are hopeful that their successful forays into providing patients with PHRs will eventually lead to EHR integration projects. Here are a few of the many success stories:
• Eugenia Marcus, MD, is one physician who has become a staunch supporter of PHRs. At Pediatric Health Care at Newton-Wellesley Hospital outside Boston, Marcus downloads clinical information from electronic charts into the PHRs of select patients. Her patients, who currently use a CapMed Personal HealthKey (a PHR residing on a USB flash drive), have a comprehensive record that includes data from the EHR and information that is entered from home monitoring devices or is self-entered. Marcus has been an early innovator with PHRs and continues to look at additional ways to use the PHR to help improve communication with her patients and other members of her patients’ care team.
• Massachusetts-based Masspro is working to reduce barriers among professionals by serving as a pilot for the Centers for Medicare & Medicaid Services’ Doctor’s Office Quality Information Technology initiative. Thousands of physicians have implemented EHRs in response to Masspro’s program.
• Jacksonville-based Blue Cross and Blue Shield of Florida has enhanced patient safety and quality of care through a complete longitudinal and horizontal care record. The record includes a hospital and health system EHR, a group and solo practice EHR (problems/symptoms, allergies, medications, labs, images), a blended PHR/personal health information manager (history, drugs. allergies, alternative treatments), and a record for health plans, pharmacies, labs, and diagnostic centers.
• The Ann Arbor (Mich.) Area Health Information Exchange has implemented NextGen’s Community Health Solution, a data aggregator for multiple systems. Data accumulated at one physician’s office is sent to a central data repository or data aggregator and then shared with other providers. This is accomplished with patient permission but no intervention from the physician.
• Wilmington, Del.-based Christiana Care Health System has enhanced patient satisfaction, information control, and access for 250 of its cancer patients by providing them with PHRs housed on CapMed HealthKeys. Patients participated in free training sessions about PHR use, as well as monthly surveys on issues such as ease of use and doctor/patient relationships. The results were positive. In fact, many patients wanted more room on their HealthKey to store memory-intensive information such as radiological images.
Working with the Delaware Health Information Network, which facilitates patient access to information from all providers in the state, Christiana is now looking to automate downloads to patients’ USB drives and educating patients and physicians with online tutorials.
These pockets of success are being repeated throughout the country. The general feeling among vendors and providers, backed up by patient reaction, is that integration of PHRs and EHRs is inevitable. However, there are many steps providers, payers, vendors, and employers can take to facilitate integration, including the following:
• Support PHR/EHR integration on organizational, industry, and policy levels.
• Champion seed funding and realistic incentives for patients, professionals, and other data sources.
• Advocate a free marketplace while also developing practical vehicles for collaboration and community.
• Share integration success stories and best practices at conferences, within work groups, and by publishing in magazines and journals.
• Educate professionals and consumers about the features and short- and long-term benefits of EHRs and PHRs.
• Invest in research that addresses PHR/EHR issues, such as ROI and the use of records within varied populations.
• Facilitate more PHR/EHR demonstration projects.
— Wendy Angst is general manager of CapMed, a division of Bio-Imaging Technologies, Inc. and a provider of interactive personal health management solutions for hospitals and healthcare systems, providers’ offices, managed care organizations, and pharmaceutical companies.