The what, why and how of implementing Personal Healh Record Systems

Electronic health record (EHR) systems have greatly improved efficiency and safety in health care delivery: consolidating patient information, tracking prescription use, and enabling decision support.  These systems are controlled by the healthcare providers, some of whom can and do make patient information available to them electronically or via specially requested printed reports.  Patient health record (PHR) systems, introduced in the last couple of years, are a new development, allowing patients improved ability to access their health record at any time outside the care setting, and to even control information and access to that information.  While there are obvious concerns about privacy, control, and legitimacy, the attraction of PHRs to providers and policy makers is the ability to engage patients in their care and, in doing so, to improve care as well as control costs. The PHR market is still very immature, but there are a number of approaches and developments already underway internationally, with vendors offering a range of possibilities.  Two reports may be useful to those considering the why, what and how of implementing a PHR system:

A 2008 report: The Value of Personal Health Records, by the Center for Information Technology Leadership (CITL), synthesized the best-available evidence and expert opinion into a simulation model of costs and benefits in different PHR scenarios to develop the value proposition of a PHR system.

CITL considered two primary components in a PHR system: infrastructure and applications utilizing the infrastructure. The PHR infrastructure included components and functions that would allow patients to collect and share their health information. Privacy and security functionality are expected to be embedded throughout the PHR system in both infrastructure and applications. The CITL model estimated costs to develop the PHR infrastructure; and the applications to support:

• information sharing (medication history and test results);
• information self-management (remote monitoring, web-based educational support); and
• information exchange (medication renewals, appointment scheduling, e-visits).

Although the model has only been validated by a consensus review process among domain experts and so may differ dramatically from what will actually be experienced, CITI hopes that this will provide a framework for analysis and that extrapolation from the model can facilitate predictions of potential value to those considering employment of PHRs.

A more recent report by Alberta Health Services: Engaging the patient in healthcare: an overview of Personal Health Record Systems and Implications for Alberta, presents a very through and useful overview of PHRs, evaluation of PHR capabilities, a comparison of vendors and benefits and caveats of PHR systems.

There are three distinct categories of PHRs, differentiated by their underlying IT architectures:

• Stand alone: For example, WebMD and RevolutionHealth: that offer an external user interface and data repository, allow patients to create profiles based on their medical history,  health-tracking that can identify patient risk factors for a range of diseases,  and enable users to connect directly with one another , but they don’t automatically interact with EHRs.
• Tethered: Offered by large healthcare IT vendors that are predominantly focused on EMR/EHR solutions, for example: Eclipsys Sunrise, Epic Systems MyChart, Cerner Health Connections, and McKesson HorizonWP, who offer a PHR system as an extension of the provider’s health information system, allowing patients to view their personal information through a patient portal. These modules can include tools that enhance patient-provider interaction (e.g., e-scheduling, e-visits, pharmacy requests), disease/health management (via dashboards), and financial services. They offer limited decision-support and social networking capabilities, but most vendors are partnering with services such as GoogleHealth and Microsoft HealthVault to broaden the range of services and make patient data portable beyond the provider’s internal systems. Recently, Telus acquired an application by Sunnybrook Health Sciences Centre in Toronto: MYchart that enables patient access to health records, messaging to providers and clinicians, and limited health-management trackers. However, it apparently offers little ability to scale and interact with multiple systems.
• Interconnected: Google Health, Dossia, Microsoft Health Vault, and Telus HealthSpace (in Canada) are the major players in this market, which is just getting started.  The  interconnected PHR.combines elements of stand-alone and tethered PHR systems, providing an external repository of health information that users can control and to which health systems can connect. The PHR functions as the user interface for a broad set of IT functions that can be linked to or built into the PHR through the vendor’s development tools. These systems can also collect data from multiple repositories across multiple settings or health systems. Telus HealthSpace is a licensed version of Microsofl HealthVault, but data is stored in Canada. Also, while most major players currently in the interconnected PHR systems market offer their solutions for free, Telus will charge health systems to build onto HealthSpace.

Apparently an interconnected PHR need not necessarily replace a tethered PHR, but be used in addition, to provide the user interface and access point for patients, with the tethered PHR system providing the connection with other IT capabilities (e.g., secure physician email). The most successful PHRs implemented at large health systems today have taken this approach (e.g., Kaiser Permanente, Cleveland Clinic, Beth Israel Deaconess Medical Center).

This white paper is the result of a two-week investigation, which included interviews with McKinsey experts in global healthcare and IT, and an expansive literature review, and analysis of industry and market research.  As the report points out, there are over 200 vendors in the fledgling, but rapidly growing PHR market, so there is a high degree of variability in both the nature and scope of product offerings.  This value of this report, therefore, is in understanding what is available, what is possible, and how to make the choice between alternative systems.