PHRs are now in hospitals; what does this mean for quality?
Experts see benefits for safety, as well as increased patient involvement
Although they've been around for a while, personal health records, or PHRs, have been grabbing bigger headlines recently with the launch of Google Health, bringing the two largest brands on the Internet (Microsoft already had launched its HealthVault product) squarely into the health care arena. But even more significant for hospital quality managers, two big names in the health care world — The Cleveland Clinic and Beth Israel Deaconess Medical Center — have become Google integration partners. That means that with the permission of their patients, these systems will have access to all the medical information those patients have stored on Google Health.
As this new world of healthcare information technology begins to be explored on the hospital and health system levels, questions are naturally arising: Does this raise privacy concerns? What about HIPAA? What impact will this have on quality? With a reported 200 PHRs available, how does a hospital decide which ones it wants as partners?
Just what is a PHR?
With so many acronyms flying around such as EMRs (electronic medical records) and RHIOs (regional health information organizations), it's important to distinguish a PHR from these other types of systems.
"The notion of a PHR is that a patient can be the steward of their own medical information," explains John Halamka, MD, chief information officer at Beth Israel Deaconess in Boston. "You can go online and see your credit card statement the same day as you charge something, but how many people can go online and see their last cholesterol test results? In the interest of quality, patients should be able to see the tests, all their medications, and be able to hand off that information to the next provider. A PHR is really that vehicle."
"The most effective PHRs allow patients to pull together all of their medical information from all different places and locate them in one central virtual place," adds Jon White, MD, director of health IT at the Agency for Healthcare Research and Quality (AHRQ)."They will also allow you to do things with it once you pull the information together, such as seek out the best treatment for what you have and find the best provider — hospital or doctor."
PHRs also help people around that patient do a better job of taking care of his or her health, he continues. "That could be a hospital; if they are connected to the PHR it gives them access to the person's health care information from places outside," he offers. "It could also be the family caregiver."
So, for example, if a patient lands in the ED or is admitted to the hospital, his or her providers won't have to go to all the patient's doctors and labs and pharmacies to get the information they need. However, cautions White, "I can't say that any of these PHRs do it perfectly yet."
Better quality?
Does immediate access to all this information mean better quality — and ultimately, better outcomes — for hospital patients?
"What if, every time you went to the ED, that doctor had a comprehensive list of all your meds?" Halamka asks rhetorically. "What if they knew that five different doctors were writing you meds that combined together could kill you? I'd say that information would be pretty helpful."
In addition, he notes, PHRs can eliminate redundancies and save money. "Let's say you get a $2,500 MRI, then go across town and get another because that second hospital did not have your records," he poses. "The PHR enables the patient to move that data simply by giving permission to do so and indicate with whom the information can be shared. This reduces cost, and engages the patient."
"Anything that encourages transparency and gives the patient more access to information about their health will help quality," asserts Paul Tang, MD, MS, an internist and vice president, chief medical information officer at the Palo Alto (CA) Medical Foundation. "It also encourages them to take a more active role, and that's what PHRs do. One of the things we've found out is that people look up information frequently — particularly lab results."
One of the most powerful aspects of a PHR, Tang continues, is that it gives the patient the ability to graph results. "It lets you see how changing your health behavior can change your test results," he observes.
"No. 1, if a PHR is used properly, there is no substitute for having a patient engaged and informed about the care they are receiving," says White. "Secondarily, it gives access to information about the patient that the provider might not otherwise have had. It allows those who decide about their care to obtain better quality information, and it improves communication with the patient."
It can also benefit the hospitals that provide superior care, he continues. "If a patient uses their PHR as means of seeking the best care, a hospital can engage the public through that vehicle. They can shine if they do well; that information will be made accessible to patients that have the PHR, and they will seek out those facilities that perform well on their condition."
"It's the connectivity that makes it so useful," adds Halamka."You can push a button and all the patient's life experiences come together automatically."
Privacy concerns?
How do patients feel about all of their life experiences flashing before someone's eyes? And what about HIPAA? "If the patient is the one who can move the information, the hospital is out of the loop," says White. "It removes liability concerns."
The better systems, he says, are more secure than paper records. "However, people who use them should have their eyes wide open and read the fine print about what these companies can do with the information," he cautions. "But Google and Microsoft, for example, have been very aggressive about adopting policies to ensure privacy."
"HIPAA is designed for providers, so systems like Google are not covered," adds Halamka. "This is no different than having a patient go to the health records management department and getting a paper record, then handing it off to another caregiver."
"Typically, something within the actual site handles requests for information," adds Tang. "You check a box that says so and so can have all, part, or none of your information. The good ones will go to the level of an item-by-item selection."
As for security, says Halamka, Google has set up separate secure servers, so as not to commingle the information with, for example, YouTube or gmail. "There is a separate infrastructure just for health, and they have their own security people, who are quite good," says Halamka.
Tang agrees that most PHRs are very secure. "The weakest link has been patients sharing passwords," he notes.
As for patients, they seem pleased with their experiences. "Patients really like it; our satisfaction rate is 94%," says Tang. Two of their favorite features, he says, are access to test results and communicating with their doctors. "We have secure patient messaging so they can communicate directly to the doctor," he explains.
"We have 40,000 patients on our own personal health record; we offered [Google Health] to them and about 5,000 have chosen to sign up," says Halamka. Google Health, he adds, "brings together all your test data, labs, and pharmacies, and then you also get decision support, information about drug interactions, monographs about diseases, and so on," he says. "All of this is totally controlled by the patient; we don't transfer information — they say send the data to Google."
"There are signs, and some evidence, that PHRs do improve patient satisfaction," adds White. "Being from AHRQ, I care about quality, and satisfaction is one piece of it. I think PHRs will help; we are in the process of generating more evidence."
How do you choose?
With so many PHRs to choose from, selecting one (or three) seems like a daunting task. "I would only do it when the patients ask for it," says Halamka. "We will transfer our data to any secure location a patient asks us to."
In terms of specific providers, he continues, "you should look at their privacy policies to make sure they say they won't sell the data — that they will keep the patient in charge."
Getting his information system to "talk" to Google Health, he notes, "was not that hard; we did it in a couple of weeks." Then, on the center's own PHR, the patients were told the service was available and were given a place to click if they wanted to enroll.
But, White cautions, "your information systems have to be in a state where they can do this." In addition, he notes, your own internal policy about the sharing of information should be revisited. "On some levels it should be a no-brainer; the patient asks for the information and they make it available — no HIPAA issue there. But there are usually [internal] policies about how information gets shared, and that needs consideration."
As for whether to link up with a specific PHR, your patients should be the main consideration. "Go out and ask them," Tang advises. "Look at the patient population you serve. See what kinds of things appeal to them."
An added bonus, he says, is that "your hospital can rise in stature in the community's eyes if you are proactive in getting patients new ways to help them take care of themselves."
Typically, he adds, there is no charge for a hospital to link up with a PHR. "There would, or course, be IT costs to set up the infrastructure," he notes.
As for the patients, says White, "there is not a fee for Google Health or Microsoft's HealthVault; others have fees, but they are not exorbitant."
Looking to the future
"Over time we will see patients get more and more data from more and more providers, assuring better quality of care, drug interaction warnings, and less redundant testing," Halamka predicts. Specialty clinics, he says, will particularly benefit. "In one MS clinic we have 100% of the patients on it, because there are very complex medication regimens," he explains. "In a primary care clinic, we only have about 25%."
"There seems to be an increasing number of groups trying to do this; it will only get bigger," says Tang. The big issue in the future, he says, will be interoperability. "This way, you wouldn't have to connect to the various PHRs one by one," he explains. "But everything would still require consent."
[For more information, contact:
John Halamka, MD, MS, Chief Information Officer, Beth Israel Deaconess Medical Center, Boston. Phone: (617) 306-9886. E-mail: [email protected].
Paul Tang, MD, MS, Vice President, Chief Medical Information Officer, Palo Alto Medical Foundation, Palo Alto, CA. E-mail: [email protected]
Jon White, MD, Director of Health IT, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 2000, Rockville, MD 20850. Phone: (301) 427-1364.]
Although they've been around for a while, personal health records, or PHRs, have been grabbing bigger headlines recently with the launch of Google Health, bringing the two largest brands on the Internet (Microsoft already had launched its HealthVault product) squarely into the health care arena.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content