AHIP Coverage (March/April 2006)
Implementing Personal Health Records
Health Plans Take the Lead in Developing a New Tool for Patients and Providers
By Mari Edlin
The health care industry has long been awash in acronyms–HMOs, PPOs, PBMs–that are used so frequently as to become commonplace.
As health care information technology evolves, another group of acronyms has started working its way into everyday vernacular: personal health records (PHRs); electronic medical records (EMRs), which include detailed doctor’s notes related to patient encounters, test results and diagnoses; and electronic health records (EHRs), the brainchild of the national health information technology coordinator, Dr. David Brailer, who foresees a system of Internet-based individual health care records linked together into a national health information network.
Although all three approaches have advocates, most health insurance plans are dipping their toes into the technological waters by developing a consumer-oriented, payer-based PHR.
PULL QUOTESThe most successful PHRs are ones that insurers automatically populate with information from their own systems and jump start members to add information–rather than requiring patients to populate the record on their own.Industry leaders agree that there would be great advantages to securely transporting patient information from one health plan to another to ensure continuity of care, as well as sharing historical medical information to be used as a vehicle for care management. But such widespread portability–except for the ability to print a record off a computer and take it with you–is just now moving beyond the talking stages.No matter who populates the PHR, health insurance plans agree that patient information is owned by members who hold responsibility for sharing it with whomever they choose. |
“As a broad concept, PHRs have different approaches depending on how they are used and what value they bring to users; no one design is the solution,” says David Lansky, senior director of the Health Program for New York City-based Markle Foundation, stressing that a PHR in which patients control access and content will likely be more complete and longitudinal than an EMR maintained by a single physician.
Enhancing Consumer Responsibility
Scott Myers, managing partner at Accenture, emphasizes that a PHR serves as a valuable tool in helping consumers assume more responsibility for their health, while an EMR with richer and timelier clinical data is a more important tool for physicians. Concurring with Myers, many health insurers say that PHRs have evolved in the wake of consumer-driven health plans and the desire to provide consumers with the information they need to assume more personal responsibility for their health care.
Ray Murphy, senior vice president and chief information officer for Capital District Physicians’ Health Plan (CDPHP), Albany, N.Y., which is two-thirds on its way to developing a PHR, foresees that the record will become more patient-centric as consumers take on additional responsibility for their health. “We believe that patients should own the information and it is difficult to do so if they don’t have it,” he says. “The health plan is the logical place to house it; however, the insurer should only have access to that information which enables it to process a claim, rather than detailed clinical data.”
A survey conducted last September by Public Opinion Strategies, Alexandria, Va., for the Markle Foundation, reveals that 60 percent of the 800 adults polled support creation of a secure online PHR, primarily to check and fill prescriptions (68 percent), check for mistakes in their medical record (69 percent), retrieve results over the internet (58 percent) and conduct secure and private e-mail communication with their doctors (57 percent), while 19 percent say they would not use a PHR for any of these items.
“Health insurers would like to take advantage of information they already have and make it available to their members,” Lansky says. He notes that the most successful PHRs are ones that insurers automatically populate with information from their own systems and jump start members to add information–rather than requiring patients to populate the record on their own. “Not only are they not motivated to do so, but many members do not even have sufficient information,” he says.
The development of PHRs sponsored by health insurance plans run the continuum from records populated by members only to those populated by medical and pharmaceutical claims data and physician input to the more sophisticated PHRs, combining medical and health information from both members, providers and claims data. The more mature PHRs also link to self-management tools designed specifically for members with chronic disease and critical risk factors, such as smoking or obesity, and provide a communication vehicle between physician and patient.
But no matter who populates the PHR, health insurance plans agree that patient information is owned by members who hold responsibility for sharing it with whomever they choose.
Linking Claims and Personal Data
Alan Sokolow, M.D., chief medical officer for Empire BlueCross Blue Shield in New York City, is quite decisive when he says that his members own the data in their PHRs, have full access to it, the right to maintain whatever information they desire and full discretion as to whom has access and what they are allowed to view. “They can even grant access to one doctor and not to another,” he adds.
Members create My Health Record, accessed through Empire’s website, where they connect to WebMD Health’s PHR feature. Information about prescription drug use, physician and hospital visits, diagnoses, lab test results and other claims and administrative data are automatically populated into the PHR on a regular basis.
This data is supplemented by patient input including family history; health risks–which can be provided through a health risk assessment (HRA)–allergies; over-the-counter medications and vitamins; and screenings, immunizations and drug histories which may not show up as claims if they occurred outside the network. The PHR contains two years of claims history so that if a patient wants to maintain a full record, they have to do some legwork, Dr. Sokolow says. Since the end of December 2005, as many as 30,000 members are using the PHR capabilities.
He points out that Empire’s PHR applies logic to claims so that members are not suddenly presented with sensitive information without understanding its significance. For example, if lab values are included in the PHR, they are accompanied by the normal ranges so that patients can put their own results into perspective. Information in the PHR also triggers reminders for screenings and immunizations, as well as drug interactions.
Empire, like many other plans that support PHRs, urges it members to take the record along to doctor visits–even though doctors may already have their own electronic version–and recommends specific questions for the physician. At the end of the dialogue, the member receives a summary of the discussion and visit.
For Empire, the PHR represents a market differentiation, a value-added for its members, as well as a tool for managing consumer-driven health care.
CIGNA HealthCare headquartered in Bloomfield, Conn., developed a secure consumer web portal, myCIGNA.com in 2002, enabling members to input personal health data–allergies, medications, surgeries and immunizations–complemented by claims and administrative data from the plan but only if the member gives permission. The PHR also is linked to a HRA.
During the first nine months of 2005, myCIGNA.com averaged 3000 users a month who completed an HRA; by October and November, the number had quadrupled per month.
In conjunction with the PHR and HRA, patients’ home pages on the site provide personalized information based on the data they have input. The portal also connects members to Condition Centers that provide evidence-based treatment guidelines for more than 35 medical conditions. Members have full control of their records and are encouraged to use the information as a basis of discussion with their physicians.
“With the end of gatekeepers, we have become a fragmented health care delivery system,” says Andrea Gelzer, M.D., senior vice president, clinical public affairs for CIGNA. “Once members understand they have access to a repository of information, a private and secure place to store it and a way to track their health care, there will be an astronomical increase in usage.”
Although quality of care is what health insurers say is their number one priority, cost savings run a close second. Dr. Gelzer says that the use of a PHR provides only soft savings and is more beneficial as a tool for engaging members in their health care which results in smarter consumers.
UnitedHealthcare pre-populates a PHR for its members with information on allergies, lab tests, office visits, medical conditions and procedures, while also allowing members to input their doctor appointments, medical histories and physician visits; however, members are limited to indicators established in a template available online through the Personal Health Manager link at myuhc.com.
“The record also can be used as a dynamic tool to push targeted information to members–condition-specific alerts and appointment reminders,” says Archelle Georgiou, M.D., executive vice president, strategic relations for Optum/UnitedHealth Group in Minneapolis.
“The records will enhance communication between doctors and patients, and improve case management and quality of care by avoiding medication duplications and contraindications and unnecessary costs,” she says.
Members of UnitedHealthcare can grant physicians permission to view their entire PHR and add to it, or can limit access without the ability to modify anything in the record. They also have full discretion to open their records to family members.
Dr. Georgiou notes the importance of integrating a PHR and EMR to obtain a complete picture of a member’s health, but knows it won’t be a reality until standards are established. Right now, she praises the PHR for providing a two-way communications vehicle for physicians, giving them insight into the entire care experience beyond the office visit.
The PHR/EMR Connection
Group Health Cooperative in Seattle launched its PHR in 2000, with limited functionality but today that PHR has evolved into a much more sophisticated record called MyGroupHealth. Unlike many other PHRs, MyGroupHealth interconnects with an EMR and allows members to view their online medical records; order and renew prescriptions; schedule and cancel appointments; communicate with their physicians via secure e-mail; and review their lab results, an explanation of the results and immunization histories.
After each patient visit, doctors prepare visit summaries including vital signs, reason for the appointment, prescriptions, lab orders and treatment instructions, which patients receive in person or via the Internet.
Ted Eytan, M.D., medical director, health initiatives and web services for Group Health, is quick to point out that the PHR is controlled by the patient, who should be able to access as much information as possible and manipulate the data. “The future calls for full transparency,” he says.
“The PHR empowers members to handle their own health care and that confidence in managing it makes for a healthier person,” Dr. Eytan continues. “When we are able to make the right health care choices, we will do it.”
Group Heath also sponsors an online HRA, whose information is entered into the PHR. Thus far, one-third of adults receiving care from Group Health have established a PHR.
Dr. Eytan says some physicians are concerned that the PHR will discourage doctor/patient communication but “MyGroupHealth enhances the relationship; it doesn’t replace it,” he says. “The record is used where it makes sense.” He believes that a PHR can encourage accuracy and make providers more diligent because they know that their patients will have access to the records.
In addition, the PHR/EMR system analyzes claims and can identify members with chronic disease and link them to specific information. MyGroupHealth also links to the Healthwise Knowledgebase for self-care suggestions.
The nest steps, says Dr. Eytan, are what he calls a “shared health record,” in which patients and their doctors record information together, and portability, which presents a technical challenge yet to be surmounted.
Self- or Clinician-populated PHR?
My Health Connection, established in 2002, is the portal allowing members of Excellus BlueCross BlueShield in Albany, N.Y., to create their PHRs–a comprehensive personal health tracking tool that holds a patient’s list of medications, allergies, adverse drug interactions, medical histories, active medical problems, preventive health care such as screenings and immunizations, lifestyle habits, social and family histories and health care proxy contacts.
Members may choose which information they would like to include, as well as deciding who can access their records including clinicians and family members. The site prompts members to input certain information, such as over-the-counter medications and herbal remedies that would not show up in an EMR. “Few members can populate the record at the get-go; they need updates and reminders,” says Jamie Kerr, M.D., medical director for Excellus, ”It is important to have the record available at the point-of-care.”
Two of the plan’s goals are to pre-populate the PHR and add prescription claims. Since fall 2002, 8,000 Excellus members have created PHRs. They are encouraged to use the PHR as a basis of discussion with their physicians.
At the heart of Kaiser Permanente’s health record system is Kaiser Permanente HealthConnect, which provides an EHR. Members may view their medical records containing immunization and medication histories, health conditions and allergies through a secure web portal.
Although members “own” the information and have control over those accessing it, Marshall explains that they may not amend or add information to the EHR; it is populated by clinicians and staff in the medical centers and hospitals.
Marshall says that by the end of the year, members in most regions will be able to look at lab and x-ray results and an explanation of them, schedule appointments, refill prescriptions and even have access to their physician’s notes as a reminder of what medications to take or foods to avoid with certain medications. Right now, no one region has deployed every functionality.
“After a visit, you may not remember everything that happened,” Marshall says, “but KP HealthConnect populates the EHR and prevents errors and dated, inaccurate information. When members visit their doctors, they both have the same information in hand, giving patients the confidence to take care of themselves.”
Can’t Take it With You
Industry leaders agree that there would be great advantages to securely transporting patient information from one health plan to another to ensure continuity of care, as well as sharing historical medical information to be used as a vehicle for care management. But such widespread portability–except for the ability to print a record off a computer and take it with you–is just now moving beyond the talking stages.
Helen Darling, president of the National Business Group on Health in Washington, D.C., emphasizes the importance of portability. “Employees own the record, but if they leave a company or change health plans, they can’t take it with them,” she says. “We need this ability in our mobile society.”
“Gaps in quality of care which lead to medication and other errors make a case for having portable health records,” Excellus’ Kerr says. “But until there is interoperability and standardized protocols, it will be difficult.”
Stakeholders in the sharing of information agree that privacy is a key issue, one that health insurance plans have taken seriously by ensuring that information remains secure and confidential by following HIPAA industry standards, including user names, passwords and encryption.
Another survey conducted by Public Opinion Strategies for the Markle Foundation last September reveals that 72 percent of respondents favor the establishment of a nationwide electronic information exchange that would allow a patient’s health information to be shared with authorized individuals securely, privately and immediately over the Internet.
“Secure” and “private” are the operative words, as 79 percent say that making sure their records are shared only if they have provided permission is a top priority. As many as 91 percent say they require confirmation of the identity of anyone using the electronic system, and 68 percent frown upon employers having access to the information.
Even their most ardent proponents would concede that implementation of PHRs is still in its infancy. But America’s health insurance plans are clearly leading the way in developing this new tool.
Mari Edlin is a freelance health care journalist living in Sonoma, Calif.
