Modern PHRs beyond Meaningful Use

The State of Patient-Facing Health IT

Robert Rowley, MD, Healthcare and health IT consultant, practicing family physician

Patient-facing health IT has come a long way, but is also poised to make another significant leap forward. Last week, the final rules for Stage 2 Meaningful Use were released, and even though these rules address what physicians and hospitals must do to receive incentive payments for demonstrating “meaningful use of certified healthcare technology,” some of these rules impact how patient-facing technology (PHRs, or Personal Health Records) will evolve.

The new Stage 2 rules won’t come into play until 2014, but they signal how patient-facing technology will be influenced by Electronic Health Records (EHRs). Two of the new core criteria address patient engagement: providing patients with online access to their health information, and providing secure messaging between patients and providers. There are minimum thresholds for each of these (5%), meaning that actual patient engagement is something that physicians must demonstrate in order to be eligible for Stage 2 Meaningful Use money.

Even though these rules put pressure on providing patient-facing portals to a physician’s EHR, the initiative is still physician (or health system) centered. It is worthwhile to examine the state of patient-facing health IT from a patient-centric perspective, and outline a new vision for this area of technology – one which must come, regardless of the Meaningful Use program.

The new PHR dilemma – too many portals
Legacy PHRs emerged in the mid-2000s, and were disconnected, free-standing products that patients could sign up for directly. Notable giants in this field were Microsoft’s Health Vault and Google Health, though many other companies emerged at the time (now all gone). They had a great vision – a personal record of health that was longitudinal, attached to a patient rather than a doctor, and were something you could take with you as you navigated through the health system.

Connectivity was limited and setup proved difficult. This was at a time when few physicians had EHRs (adoption of EHRs by physicians at the time was <7%), and so the main data sources available were hospitals, health plans and labs. What did emerge from these products was exposure of how inaccurate such data sources were (the e-Patient Dave experience). Not surprisingly, these products suffered from low adoption and engagement, and almost all of them have vanished from the horizon.

The current generation of PHRs is tethered to a data source, and automatically populated by that data source. Three different kinds of data sources exist, and thus we have 3 different kinds of products (and product-development thinking):

  1. Portals to EHRs. This is what one usually thinks about when “PHR” is mentioned in a modern context. The data resides in a physician’s (or hospital’s) EHR system, and segments of that data are exposed via a portal. Some are quite sophisticated, and allow good two-way communication with the doctor’s office, viewing one’s health data found in the doctor’s system, and uploading one’s past medical history. Stage 2 of Meaningful Use will require that all certified EHRs have this capability.
  2. Portals to employer wellness (or Third Party Administrator) data. There are also some good patient portals out there, showing employer, health plan and lab data. A good example here is Dossia, which is an employer consortium that hosts a patient portal for employee wellness. These portals are separate from EHR data, just like how employer wellness programs have been separate from traditional health care (sickness care).
  3. Consumer sites, with device or self-entered data. These are generally web sites that contain consumer-derived data, and are socially sharable. The data is outside the reach of HIPAA (it is created by consumers themselves, and not by health care providers), and has enjoyed popularity precisely because it is socially sharable – witness Facebook apps like RunTracker, or FitBit pedometers. Such sites are popular among fitness enthusiasts, runners, etc. Engagement here is pretty high.

So here is the dilemma of modern PHRs: now that most physicians have EHRs (over 60% state they have now have some form of EHR in their practice), consumers are facing the problem of multiple logins needed for multiple portals, one for each doctor with an EHR (not to mention any employer-based portals). This was not an issue a few years ago, when few doctors had EHRs, but that has changed.

This is a step forward – patient data is more accurate (the EHR data that physicians use in their own records is clinically-derived, not billing-derived). But the segmented, siloed nature of health data becomes apparent when a patient is faced with many tethered-PHR logins to each segment of their overall health story. Very chaotic (just like health care itself).

A new vision – the Universal PHR
Clearly, then, we have a need for a unified personal health record that can combine all the different data sources in one central place, yet behave as though it were tethered to each. This would re-capture the original vision of legacy PHRs (perhaps it was a concept before its time, before the tide to ubiquity of EHRs had risen), by being patient-owned and portable. A cradle-to-grave record that you could take with you as you changed doctors, health insurance, employers, etc., yet be easily connected with the various parts of the health care system you were engaging at the time – that is the new vision.

Where might such a newly-envisioned technology emerge? From EHRs that already have patient portals (PHRs tethered to their own EHR product)? From employer-based wellness portals who are thus not indebted to any specific EHR (but are not connected to any, either)? From a new company altogether?

My sense is that such a Universal PHR will not come from an EHR vendor, as their focus and vision is centered around physician (or hospital) workflows, as it should be, and not on a patient-centered product. In fact, the tendency of some EHR vendors to create products that are “walled gardens” is a problem that can get in the way of an external, portable Universal PHR.

The strategic issues and challenges are significant. But we are at a stage of health IT connectivity where such a product is possible, and in fact is the imperative for the next generation of patient-facing health IT. Data-format standardization from EHRs (as is specified in the Stage 2 Meaningful Use regulations), the increasing use of EHRs by doctors and hospitals, and the emergence of Health Information Exchanges (both public/regional as well as health-system-confined private ones) all point to a feasibility that was not previously present.

This is an area that I am becoming very interested in focusing upon. I think it is the next “big thing” in health IT, and will be exciting to watch it develop.

Robert Rowley is a practicing family physician and healthcare information technology consultant. From its inception through 2012, Dr. Rowley had been Practice Fusion’s Chief Medical Officer, having created the underlying technology in his own practice, and using that as the original foundation of the Practice Fusion web-based EHR. This article was first published on Dr. Rowley’s web site