Personal Health Record Usage and Medical Practices

Patients say they want transparency and instant access to their healthcare information, yet most remain on the sidelines when it comes to using these tools. Maybe that's no surprise when many physicians are still getting up to speed on EHRs. That may change - and soon. Stage 2 of the federal EHR meaningful use incentive programs requires that eligible providers make more healthcare information available electronically to more patients starting in 2014 - personal health records (PHRs) can help physicians reach that goal.

Still, meaningful use is not the primary motivator for PHR adoption, say medical practices using the technology successfully. Instead, it is driven by patient expectations, adept integration of information systems, and demands for value from physicians, patients, and payers.

So far, the PHR installations that seem to gain the quickest acceptance from patients share three elements: user-friendly technology, tie-in to a medical practice's website, and the encouragement of physician advocates.

Here's more information on what's driving the adoption of PHRs, what value they bring to practices and patients, and key tips for implementing them and encouraging patients to use them.

Patient expectations

Although recent surveys indicate disinterest in PHRs among patients - about 10 percent of Americans used them in 2011, according to Deloitte Center for Health Solutions - Brock Morris, chief information officer at Redmond, Wash.-based Pediatric Associates, hears a different story from parents of the practice's patients. That's probably no surprise, he says. Many of the parents bringing their children to the 85-physician multisite practice also work for the city's top private employer, Microsoft Corporation. "The parents of our patients tend to be a technically-minded demographic," Morris says. "We get asked all the time: 'What new services and solutions can you provide us?'"

PHRs, he adds, are a natural extension of his patients' parents' everyday experiences. "The parents are used to having information at their fingertips and being able to control it. They are frustrated when they want their child's immunizations or a growth chart and are told they have to wait a few days. In almost every other environment today, people get information quickly and can manage it themselves."

As younger, more tech-savvy patients become more active users of medical practices, the drive toward PHR adoption will increase. Indeed, Morris notes that younger generations of patients, including the parents he hears from at Pediatric Associates, gravitate to websites, text messaging, and other forms of communication.

Improved capabilities

Pediatric Associates is one of several practices around the nation involved in pilot testing interfaces between Microsoft's Web-based HealthVault PHR and their EHRs - Greenway's EHR in the case of Pediatric Associates. The approach aims to tie PHRs to EHRs via websites and, potentially, tie both to the medical devices patients use at home.

Morris says the beta version his practice is trying out allows parents to pull continuity-of-care documents (CCDs) about their child's care from the EHR and into HealthVault. Parents also can hook up their child's glucose monitor - and soon, other home health devices - to electronically enter data into the PHR to share with the child's medical team.

The pilot projects hope to overcome a barrier hobbling the prospects of free-standing, or "untethered," PHRs - lack of tight integration with a patient's clinical records and his provider's website.

Any individual can use HealthVault on the Web or via apps to create untethered accounts. But because HealthVault also supports common exchange formats, like CCDs, it essentially becomes a tethered system capable of electronically connecting with home health devices and a configured EHR. 

Information-rich source

When a PHR system is tied to a practice's EHR via a website it becomes a powerful tool, capable of drawing in patients to schedule appointments, view test results, renew prescriptions, and send messages to their physicians, says Johnathan Samples, executive vice president of research and development for Greenway Medical, which focuses its product line on the ambulatory care market.

"We're seeing the personal health record grow from just a single standalone repository of information to a system that is interoperable with other devices and mobile applications," Samples says. "The inputs are coming from a multitude of entities, not just the electronic health record."

Indeed, health systems that have implemented PHRs, such as Kaiser Permanente and the Cleveland Clinic, are now trying to tie together home medical devices, appointment scheduling applications, test results delivery, patient-physician e-mail, and other features. The result, they hope, will be a PHR that supports a coordinated, information-rich virtual medical home for each patient.

"A lot of the patient-centered care models and accountable care models center around getting the patient engaged and communicating with the patient," Samples says. "The personal health record is a perfect way to do that."

Meaningful use

Although not a primary driver of PHR adoption at present, meaningful use will make more inroads on the 90 percent of patients yet to embrace the technology. To qualify for meaningful use payments, eligible providers must provide at least half of their patients with electronic copies of their health information (including diagnostic test results and problem lists) upon request, as well as clinical summaries for each office visit.

In Stage 2, providers can expect more fuel for the growth of the PHR market. New criteria include secure patient-physician messaging, and enabling patients to view, download, and transmit their health information online.

Also setting the tone is the Federal Health IT Strategic Plan: 2011-2015, in which the government asserts a goal of empowering individuals with information about their health in an electronic format.

Ease of use

PHR usage among patients doesn't just happen; it must be promoted. And there's no better promotion than having a powerful, useable, and well-connected system ready for patients to use, says Pamela Larson, director of consumer health at Kaiser Permanente Internet Services Group.

By June 2012, some 3.9 million of Kaiser's 9 million members were registered for My Health Manager, a home-grown PHR tied into the health system's patient portal. While not every registrant is a frequent user, usage rates in the first half of 2012 are encouraging:

• 2.5 million lab results are viewed by patients online monthly;

• 1 million e-mails are sent by patients between patients and physicians monthly;

• 827,000 prescriptions are refilled online by patients monthly; and

• 230,000 appointments are scheduled by patients monthly. {C}

My Health Manager users gain 24/7 secure online access to their lab test results, eligibility and benefits information, and secure e-mail messaging. The organization's Epic-built EHR, Kaiser Permanente HealthConnect, ties into the PHR.

"By making these tools and resources available to our members, we are able to see a level of engagement that we were not able to see in the pen and pencil world," Larson says.

While a well-designed PHR helps patients stay in touch with their physicians, Kaiser's internal feedback indicates that convenience is the biggest attraction for patients, she says.

In early 2012, the multistate health system upped the ante by optimizing its website for convenient viewing from smartphones, tablets, and other mobile devices. The result? In just the first five months of 2012, some 6.4 million visits to the Kaiser website. Sixteen percent of its total traffic in that period came from mobile users.

"People definitely want to do things on the Web, but the convenience of having your handheld device wherever you are in the world just adds to the benefit the PHR brings to patients," Larson says. "If usability is not working, it drives people away."

Success factors

Samples, of Greenway, says there are three crucial steps when it comes to engaging patients on PHRs:

1. Promotion. "Physicians and staff have to talk about the PHR to patients," he says.

2. Integration. "The PHR should allow patients to complete forms online, request appointments, ask for medication refills - functions that provide convenience," he says.

3. Provider utilization. "Secure communication with the physician is important because the patients will eventually leave (the PHR) if there is no conversation going on with the physician," he says.

Prior to promoting its PHR, like Kaiser, the Cleveland Clinic also spent time determining what aspects of a PHR would appeal most to patients, says internist Martin Harris, chief information officer, Cleveland Clinic. First, the clinic engaged physicians in the PHR's design. Then, it formed patient focus groups to determine what features to offer.

But it didn't stop there. It promoted the system through its website, printed materials, and signs in medical offices. Patients also received verbal encouragement to sign up during visits; and others were drawn in by kiosks conveniently placed in offices.

Harris says that promotion and focus on ease of use paid off. Its PHR, MyChart, blossomed from a small pilot study with 3,000 patients in 2005, to a system with 450,000 users in June 2012. Each month, between 5,000 and 7,000 new users sign up, he says.

Information flow

A chief concern of physicians early on at the Cleveland Clinic was whether the PHR would give patients the ability to see test results or other diagnostic findings before their physicians had a chance to review them, says Harris. The initial usage guideline called for a five-day delay when releasing test results. That was reduced to three days after patients complained about the time lag. Now, except for new diagnoses of cancer or other sensitive matters, the system automatically populates the PHR after two days, regardless of whether the physician has seen test results. Physicians can also choose to release information sooner or put it on hold.

"It's important for all patients to be informed, but this information has real value, too, for the acutely ill," Harris says. "The office encounters can be very complex, with several events in a short period of time. With the PHR, the physician has a way to get more information and send reminders to the ill patients without requiring them to come in every time." {C}

A PHR can also erase the potential delays and missed opportunities when patients and physicians cannot meet face to face for important follow-up conversations. For instance, Harris credits the PHR, patient portal, and Web-accessible EHR for helping him quickly follow up with a patient after a concerning health issue surfaced in an office visit. By the time the patient's test results returned from the lab, the patient was off to Germany and Harris was on his way to San Diego. Harris was able to log in to the patient's record in the EHR from San Diego, assess the concerning test results, and then contact the patient in Germany for timely follow-up. That beats playing transcontinental phone tag, Harris says.

A more commonplace use of the PHR and its messaging capabilities involves stroke patients, Harris says. After discharge from the hospital, each stroke patient is signed up in MyChart so that the PHR can send patients functional status questionnaires to complete and return. "Formerly, the patients had to come into the office, but now we have the ability to get that information at the intervals we desire, and the patients don't have to leave their homes," Harris says.

Time-savings

Harris says the PHR has already reduced incoming phone call volume at many Cleveland Clinic medical practice offices.

"[MyChart] actually makes the office more efficient because the telephone has less demand and people who are calling in about an acute illness are getting through faster because their calls do not get backed up behind people asking for prescription renewals," he says.

But while PHRs and practice websites lead to smoother internal work flow, for instance, for patients the real benefit is clinical, Harris says. For example, scheduling is a Web-portal tool many patients wish to use. "The health information technology industry has always defined scheduling as an administrative tool, but at the Cleveland Clinic we think of it as a clinical tool, important to giving the physicians and patients a common understanding of what comes next," Harris says.

Types of PHRs

Personal Health Records (PHRs) are offered through employers, health insurers, health providers, and independent vendors. To get an idea of what's on the market and how many vendors there are, visit PHRsToday (http://www.phrstoday.com/ ), which includes reviews and other resources.

Here's an overview of some of the key types of PHRs available:

Tethered PHR. These PHRs are integrated or connected with the information system of the provider organization, health plan, or employer. They allow users to view portions of their clinical record or an abstract of their health record or claims data. Some systems allow patients to add information about their health status, workouts, etc.

EHR-, website-powered PHRs. These systems give users access to portions of their clinical record through their provider's website. Functions can include secure messaging to physicians, appointment scheduling, prescription refills, and patient-generated requests for documents, such as immunization records.

Untethered (also called "standalone") PHRs. With no direct connection to the provider's or health organization's EHR, the user must type in, scan, or download the health information he wishes to track. Patients can move the system and its information with them if they change physicians, insurance companies, or employers. The information is not necessarily available to the patient's provider.

In Summary

Although public and private incentive programs are moving more medical practices to offer PHRs, the momentum also includes patient expectations and well-integrated information systems. Practices considering integrating PHRs should consider the following:

• The need for staff to promote the benefits of PHRs to patients

• Increased patient engagement in their own health

• Ease of access to medical information for both providers and patients

Robert Redling is a freelance writer based in Tacoma, Wash. He has been practice management editor for Physicians Practice, Web content editor and senior writer for the Medical Group Management Association, and a speechwriter for the American Academy of Family Physicians. He can be reached via editor@physicianspractice.com.

This article originally appeared in the October 2012 issue of Physicians Practice.