AHIP Coverage (March/April 2007)
You Can Take It With You
Portability, access to information 24/7 and wherever needed, patients taking a more active role in their health and health care. This vision of personal health records is becoming reality thanks to recent initiatives.
By Mari Edlin
Health care’s mantra—the right care at the right place at the right time—continues to hold true, but as the industry embraces health information technology, that philosophy is taking on new meaning. The new challenge for 21st-century health care is to quickly and securely get the right health information wherever and whenever it is needed.
There is consensus among stakeholders that the widespread adoption of health information technology will lead to safer, more effective health care. Experts believe adoption of technology will reduce preventable errors, such as medication errors; increase compliance by patients with recommended treatments; improve treatment for people with chronic disease; and contribute to lower health care costs.
In support of these goals, America’s Health Insurance Plans (AHIP) and the Blue Cross and Blue Shield Association (BCBSA) have developed a model for health-plan-based, personal health records (PHR). It is designed to provide consumers with greater access to the information they need to optimize their health and health care. The model includes the core key elements that medical groups have indicated every consumer’s personal health record should include —physician encounters, names of clinicians, recent patient histories, medications, immunizations, and lab tests and screenings. Physicians encouraged insurers to adopt a consistent set of core PHR data.
PHRs are distinct from electronic medical records (EMRs), which providers use to store and manage detailed clinical information. PHRs are designed for use by individual consumers, who control use of the data and designate who has access to it.
Since most of the information needed for consumer-centric PHRs can be derived from the data that health plans have as a result of claims filed on behalf of consumers, the health insurance community decided that it was in a position to offer a service many believe will be an important building block in the nation’s move to full interoperability.
“Efforts such as those by health insurance plans to provide consumers with portable PHRs are a step forward in the national health IT agenda,” said Robert M. Kolodner, M.D., interim national coordinator for health information technology at the U.S. Department of Health and Human Services, at an event in Washington, D.C., last December to announce the initiative.
One reason the insurance industry work has such promise is its scope: The members of the two trade groups provide coverage for more than 200 million Americans, 100 million of whom already have access to some type of PHR through their plans.
In addition to identifying the core elements for PHRs, the industry, working with an experienced consulting firm, developed the portability standards needed to allow consumers to bring their personal health information with them after enrollment in a new health plan. Consumers have consistently indicated that PHRs increase in value when they are portable from insurer to insurer and don’t need to be rebuilt each time they change insurance coverage.
Ten health care organizations, including Shared Health, Horizon Blue Cross and Blue Shield, Aetna, and Health Care Service Corporation, participated in a pilot to test the portability standards. The pilot proved successful, demonstrating that PHRs can now be transferred plan-to-plan. But market research told the health insurance community that consumers wanted something else: added assurances about how the data will be used. So the health insurance community adopted a new guideline: PHRs will only be transferred after a consumer has been enrolled in a new health plan and given permission for the transfer to take place.
PHR Evolution
The adoption of PHRs is picking up steam, starting with the first-generation records that are populated by members themselves, graduating to those populated with medical and pharmaceutical claims data and physician input, with the most sophisticated PHRs combining medical and health information from members, providers, and claims data. The more mature PHRs also link to self-management, decision-support tools designed to enhance communication between physician and patient.
Matthew Guldin, senior research analyst for Frost & Sullivan, says adoption of PHRs is being driven by their viability as a competitive strategy; an increase in chronic diseases; Americans’ predilection for a “digital lifestyle”; and the federal government’s embrace of health information technology. PHRs also have evolved in the wake of consumer-driven health plans and the philosophy that consumers require tools and information to make well-informed health and health care decisions.
Nowhere is that philosophy embraced more firmly than at the National Health Council (NHC), an organization that represents voluntary health groups such as the American Cancer Society, the American Diabetes Association, and the American Heart Association. According to its president, Myrl Weinberg, PHRs are critical to optimizing the health of people with chronic conditions, who must play a role in their own care on a daily basis.
“PHRs can help improve health care delivery, especially for people with chronic illness and disabilities, but interoperability—where all entities agree on core data, common language, and infrastructure that can be shared across any provider and any health care system—is the biggest challenge,” Weinberg says.
Weinberg announced at the December event that NHC would partner with AHIP in a pilot program to promote awareness of the value of PHRs among the consumers their local organizations serve in Massachusetts and Northern California, and to speed their adoption. Many consumers have been slow to embrace PHRs, and hearing about their value from trusted sources such as the local chapters of the cancer, lung, and heart groups can only help. NHC is also playing a critical role in providing input to help shape PHRs as they develop within the industry.
Joe LaMountain, a consultant to NHC, anticipates that NHC’s partnerships with respected trade organizations will create a significant amount of credibility, putting patients more at ease about privacy concerns.
“There is an opportunity for patients and plans to create something useful so that members can access their own medical records and easily manage their care,” says LaMountain. “At the end of the day, we will have developed a product with a natural constituency.”
Pat Kennedy, with Washington, D.C.-based PJ Consulting Inc., acknowledges that consumers have been slow to build PHRs themselves, partially because they cannot remember their entire medical histories. He says that three years ago, a group of self-insured employers discussed how to make PHRs a valuable tool for their employees. The consensus was that employees need to be financially motivated (through discounted premiums or lower copayments) to complete their own PHRs. AHIP research has suggested that consumers do not want to populate their own records and would prefer reviewing pre-populated PHRs, and they value that aspect of the service being offered by insurers.
Kennedy says that payer-based health records with medical and pharmacy claims data—a snapshot of a patient’s medical history to share with doctors—developed several years ago can be used as a way to urge patients to add to information that has already been entered by the payer. “A true patient health record would be a combination of a PHR and a payer-based record, even if it’s not electronic. In 10 years, we can look forward to an electronic health record, making all health care information available to the treating physician,” he says.
In September 2005, the Markle Foundation, New York City, commissioned a survey to gauge consumer interest in PHRs. The results indicated that consumers would use their own secure, online PHRs to check and fill prescriptions (68 percent), check for mistakes in their medical records (69 percent), and retrieve test results over the Internet (58 percent).
A little more than a year later, the foundation commissioned another survey, which showed interest in PHRs is building: As many as 97 percent of respondents think it’s important for their doctors to be able to access all of their medical records to provide the best care, and 96 percent believe it is important for individuals to access their medical records to optimize health self-management. The results were released last December at the second annual Connecting Americans to Their Health Care conference in Washington, D.C.
David Lansky, senior director of the foundation’s health program, says he is pleasantly surprised at how many respondents made a direct correlation between PHRs and improved health care.
“Last year, there was an emphasis on the value of electronic health records as a tool for people to access their tests results and other personal health care information. This year, we are hearing that people also see value in EHRs as a means of helping our society use health care more appropriately,” Lansky says. “We are looking at how to build a common framework for sharing information among organizations that hold health care data and to address how patients can access data and exercise control over sharing it. As people become more mobile and more accountable for their health care, information has to follow.”
The Robert Wood Johnson Foundation, Princeton, New Jersey, is rallying behind growing interest in helping consumers use information technology to better manage their health and to navigate the health care system. The foundation recently announced Project HealthDesign, a $4.4 million initiative giving nine multidisciplinary teams an opportunity to build tools to advance the field of PHR systems.
Piloting Standards and Data Exchange
“If PHRs are to be truly personal, provide real value to stakeholders, and belong to the consumer, they should be portable,” says Jana Skewes, president and CEO of Shared Health in Chattanooga, Tennessee, which participated in AHIP’s pilot on data sets and transfer standards. “Portability and interoperability in health information technology are critical in creating a value-based health system, where the system itself is connected to exchange data. This should enable quality measurement and also provide a platform for measuring and publishing the price of health care.” Skewes says that the ultimate goal is integrating a PHR into care management and health information strategies to help consumers make lifestyle changes.
Health Care Service Corporation (which operates the Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma, and Texas) partnered with Shared Health during the AHIP/BCBSA pilot. Hayes Abrams, senior director of managed health care delivery for the insurer based in Chicago, says the pilot enabled his plan to exchange member information by meshing standards with other payers.
Gaining trust from members and ensuring the privacy of health care information—allowing it to be seen only by those selected by a patient—are two critical elements of successful PHRs, Abrams says. “We want to provide tools that guide members in making the best health care decisions. The more trust they have, the more apt they are to use PHRs.”
He sees PHRs as the key to how payers and members ultimately connect with multiple providers and plans via EHRs—digital records compiled from multiple, disparate clinical systems creating a longitudinal and aggregate display of that data for clinicians and patients. “Definitions of PHRs, EMRs, and EHRs are used interchangeably, which clouds the issue,” he says.
Abrams believes that the pathway created by the industry PHR project is a stepping stone in establishing harmony between PHRs and EHRs—and ultimately toward a fully interoperable health care system. Development is moving from patient-populated fields and claims data to data populated from multiple sources to interoperability among plans and providers. In his mind, the inevitable goal—eight to 10 years away¬—is a seamless integrated PHR-EHR with multiple plans and providers.
“A record is just a so-called piece of paper but once it is recognized as a means for helping patients make more informed decisions, a PHR will become a daily part of life,” adds Michael Rosenfield at CIGNA HealthCare, Bloomfield, Connecticut.
BlueCross BlueShield of Tennessee, Chattanooga, also a pilot participant, is taking advantage of Shared Health’s services by using the company’s Clinical Health Record (CHR) solution. It is currently available to the insurer’s 600,000 fully funded group members, as well as to all members covered by the state’s Medicaid (TennCare) program. Nissan North America also is providing the solution to its 24,000 employees and dependents in Tennessee.
The CHR, a secure Web-based health record, aggregates payer encounter data—patient demographic information and medical diagnoses and procedures—with core clinical data sets, including medication histories and lab results. The patient-centric information is available to clinicians at the point of care. Shared Health also offers the CHR-Consumer View, which allows consumers to view the same information as their providers, improving coordination of care and communication between doctor and patient.
“Our long-term plan is to combine input from providers, patients, and the insurer,” says Paul Kulpa, senior program manager, consumer-driven health plans for BCBST. “We want to empower and engage consumers, improve quality of care, and lower costs.”
Archelle Georgiou, executive vice president, strategic relations for a division of UnitedHealth Group, is not surprised by the outcome of the AHIP standards pilot. “Each plan may have its own format for a PHR, but the elements are consistent,” she says, “since many PHRs are populated by the plan from claims data. What the pilot did not address is the interoperability of self-reported data.” AHIP plans to address this as a future enhancement.
Introduced at the end of 2005, the PHR offered by UnitedHealthcare has evolved over the past year, becoming more interactive and dynamic by integrating the results of health risk assessments and by adding messaging capabilities to alert members about opportunities to improve their health, such as highlighting potential complications from medications and sending reminders about necessary screenings. “The PHR doesn’t just sit out in cyberspace; it provides an experience for members and helps them navigate the health care system with tools and resources,” Georgiou says.
In the first-generation PHR offered by Horizon Blue Cross Blue Shield of New Jersey, members populate the data. Claims data and automatic integration of health risk appraisals will be available this year. “We are continually looking to utilize new information technologies, such as PHRs, to empower our members to receive the highest quality of care,” said William J. Marino, president and CEO of Horizon BCBSNJ, who participated in the December announcement of the AHIP/BCBSA initiative.
By next year, Vidya Raman-Tangella, Horizon’s clinical innovations executive, anticipates that a more robust PHR will use claims data to provide evidence-based recommendations to members (e.g., clinical messaging to apprise members of necessary screenings and unfilled prescriptions) and grant providers permission to access patient information. A fourth-generation PHR should enable members to input data gleaned from devices, such as electric scales and blood pressure cuffs.
Horizon, headquartered in Newark, and a participant in AHIP’s standardization pilot, also is testing the value of tying claims data to clinical recommendations. It is conducting a pilot program that allows some hospital emergency departments access to patient information for consumers with conditions that put them at risk for trips to the ER, perhaps under circumstances that would make it difficult or impossible for the patients to convey needed information to doctors and nurses once there. Data are provided by the insurer through a Radio Frequency Identification (RFID) chip implanted in the patient’s upper arm. The goals are to enhance emergency patient management and patient safety and to create a platform for collaboration between health plans and hospitals, says Raman-Tangella.
The Core of Decision Support
There are many players in the marketplace, from health insurers designing their own PHRs to vendors producing models that fit member needs. The PHRs serve as the foundation of a suite of decision-support tools for members as the move to self-management, a need for information on cost and quality, and an emphasis on physician-patient relationships all dictate that the patient have access to these tools. Some industry optimists even imagine computers arriving with built-in PHR software in the near future.
“We consider a PHR to be the centerpiece of a person’s health care decisions,” says Craig Froude, executive vice president, WebMD Health Services, which offers health management applications so users can make more informed and cost-effective decisions.
“We hope our PHR will become ubiquitous so it can serve patients and physicians across health plans,” says Lonny Reisman, M.D., CEO and founder of ActiveHealth Management Inc., New York City, a clinically based, technology-driven health management services company. A new entry into the PHR scene is MyActiveHealth PHR powered by Active Health’s proprietary CareEngine System.
As information from either a member or from claims becomes available, the CareEngine, a clinical decision-support technology, reviews the member-specific data and compares it to the most current evidence-based literature to identify discrepancies in care. Actionable recommendations and alerts—potentially adverse drug interactions and missing lab tests, for example—are transmitted to the PHR and to the physician.
One of the largest differentiators of the CareEngine will be its ability to deliver a clinical analysis in real time by mid-2007. The CareEngine is the system behind Aetna’s PHR, which was piloted by the Hartford, Connecticut-based insurer in February. “The PHR is at the core of online resources to help members find a better state of health,” says Daniel Greden, head of product management for Aetna’s e-health. “Consumers have so much medical data residing in different places, so bringing it all together online with additional online resources will further empower members.”
“PHRs may be one of our most important contributions to helping improve health care in the U.S.,” said Ronald A. Williams, chairman, CEO, and president of Aetna, at the December event.
“Health care is a team sport,” says George Bennett, CEO of Health Dialog, Boston, a care management company that promotes the use of health coaches to work with plan members and their physicians. “We have to build a database so all participants can see the same things through the same lens at the same time.” But he offers one stipulation: The consumer lens can be unplugged from the major database and become portable. “It’s the individual’s record to share with whomever he or she wants.”
Highmark in Pittsburgh is parlaying its emphasis on consumerism into a PHR tailored by Health Dialog to the insurer and its members. Launched in February, it provides an opportunity to share information among patients, physicians, and the plan to better care for people, says Don Fischer, M.D., chief medical officer for Highmark. “Members need the tool to take a greater role in their health care,” he explains. He is concerned, however, about consumers’ diligence in inputting data and believes there may need to be incentives to facilitate uptake.
While there has been some evidence that consumers do not use these tools, Highmark has integrated its PHR into its clinical programs, such as care and chronic disease management, to encourage member participation. Highmark wanted to develop functionality, such as access to coaching, that encourages members to use the record.
Fischer foresees that every three to six months, Highmark’s PHR will be enhanced, starting with claims data followed by information entered by the member, tools to track weight and diet, access to exercise and nutrition programs, and eventually messaging alerts.
“We want to ensure that the PHR is interoperable, but it won’t be portable at first,” Fischer says. “We could have bought an off-the-shelf model but instead, we wanted to develop one that had more clinical relevance. It was essential for us to build a PHR with a partner in clinical management.”
Kaiser Permanente has rolled out its electronic health record to seven of its eight regions, allowing most members to access lab results, schedule appointments, refill prescriptions, e-mail physicians, and receive physician notes about medications. Kate Christensen, M.D., medical director for the Internet Services Group and for kp.org, a member portal, says that although patients have not been deluging doctors with e-mails, several online functions, such as “e-mail your doctor” and checking lab results, have enhanced provider/member communication.
“There is more to a PHR than providing bare bones claims data,” Christensen says. “The important step is attaching the health record information to interactive tools and putting information where members can access it.”
Amid the swirl of activity surrounding the evolution of electronic health records, it could be easy to miss the significance of any one advance. But one individual flagged the AHIP/BCBSA initiative with a profound statement. “This is an important red-letter day for patient care,” said David Kibbe, director, American Academy of Family Physicians Center for Health Information Technology, at the December announcement. And that, after all, is what it is all about.
Mari Edlin is a freelance health care journalist in Sonoma, California.
