Personal Health Records-Altering the Future of Health Care

Jessica A. Smith, Assistant Editor

As increasing numbers of health care providers are jumping on board the health information technology (HIT) bandwagon, patients are following closely behind in the parade. For those in the industry, electronic health records (EHRs) provide a way of streamlining operations to save time and money while increasing efficiency, not to mention snagging a piece of the $19-billion HIT stimulus package pie. Although patients do not enjoy the financial incentives offered to health care providers, many are realizing other benefits by taking advantage of personal health record (PHR) providers like Google Health and Microsoft HealthVault. The trend is one that helps to foster a more participatory role on the part of the patient, which in turn can help clinicians to see better outcomes.

Growing Numbers Seeing Benefits

A health care provider and not-for-profit health plan, Kaiser Permanente recently announced that more than 3 million members are taking advantage of its PHR, My Health Manager. The provider stated that the number continues to grow and touted the benefits of the PHR. "My Health Manager increases a patient's access to caregivers and health information," said Anna- Lisa Silvestre, Kaiser Permanente's vice president of online services. "This level of access enhances the doctor-patient relationship and facilitates collaboration, which ultimately results in better health outcomes."

Last year, about 7 million individuals throughout the country had used a PHR, and more than 70 million were interested in doing so, according to a 2008 consumer study by Manhattan Research. Some PHR providers offer the service for free, taking away cost as one of a number of factors for patients deciding whether to use one or not.

Google, Microsoft, and Others Offer Array of Features

Tech giants Google and Microsoft are the 2 most well-known free PHR providers. Microsoft HealthVault launched first in October 2007, with Google Health following suit in May 2008. The 2 companies offer many of the same services through their PHRs, with only a few slight differences. Both have lengthy lists of partnerships that allow for interoperability between the PHR and a given system. For example, Microsoft HealthVault partnered with the Mayo Clinic to power its Mayo Clinic Health Manager, which is free to all and offers a number of services not found by using HealthVault alone. Google Health has joined forces with CVS Pharmacy and CVS Caremark.

A common denominator of PHRs is that they put the patient in control, allowing for a secure, private, digital health record comprised of a range of health information. Bringing together data from physicians, hospitals, pharmacies, and patients provides a comprehensive picture of a user's health stored in one location, with the ability to be accessed from any location.

"Our focus is entirely on the user/ consumer/patient and personal health in formation needs," said Missy Krasner, Google Health product manager. "Every day, people are already coming to Google to search for health informa- tion. Google Health is an extension of Google's mission to organize the world's information and make it universally accessible and useful. Google Health provides a central place for users to collect, store, manage, and share their personal health information."

A patient's health information can be entered manually, imported from clinicians or insurance companies, scanned from paper documents, or uploaded from health or fitness devices. Aside from medical records, prescription histories and test results also can be added to the information contained in a PHR. Both Google Health and Microsoft HealthVault offer the ability to track progress, whether in the realm of a medical condition or a fitness goal. By creating graphs with information gleaned from test results, medical devices, or fitness equipment, the PHRs provide a concrete way for users to monitor their standing in terms of health objectives. The value of a well-assembled PHR does not stop at the patient whose information it contains. With consent from the patient, the record can be shared with a range of clinicians, family, friends, or other caregivers. When taken a step further to include coaches, personal trainers, and others who could put the health information to good use for a patient's benefit, the possibilities seem endless. "We let users decide who has access to the information in their Google Health profile by letting them choose who views or adds information to their profile and allowing them to revoke access at any time," said Krasner. Whether sharing information in the PHR or keeping it to oneself, useful features like health information links, personalized recommendations, and scheduled reminders for dosage times and appointments allow for greater patient autonomy and initiative.

Implications for Pharmacy

As much as pharmacists might like to spend extensive amounts of time counseling patients toward better outcomes, the sad reality is that time constraints stand in the way. Even with the time- saving automation innovations that are cropping up in pharmacies everywhere, it remains difficult to give patients the in-depth counseling they often need. The participatory role fostered by PHRs helps to bridge the gap. Perhaps one of the most important applications offered by PHRs is the detection of drug, disease, and allergy interactions. In Google Health, when patients add a new medication to their profiles, potential drug interactions are brought to their attention through a warning alert that appears on the screen. This helps to alleviate the possibility for adverse events, especially in cases when the pharmacist is not privy to a patient's full medication history or other crucial information. When a patient shares access to a PHR, a pharmacist has the ability to take a more holistic approach. Armed with knowledge about the patient's complete medical history, as well as current conditions, fitness levels, and other information that is not typically accessible, pharmacists can provide more tailored, effective care. Even for patients who are not particularly conscientious about tracking things like blood sugar, for example, if they link a blood pressure monitor to their PHR, a pharmacist can get useful data regarding adherence and overall condition. Depending on the PHR provider and whether it is in partnership with a given pharmacy, patients also may be able to order prescription refills through their PHR.

PHR Pitfalls

Probably the most talked about patient problem with PHRs was the case of Dave deBronkart. A kidney cancer survivor, deBronkart was hit with a few unpleasant surprises when he imported his medical data into

Google Health from Beth Israel Deaconess Medical Center in Boston. Aside from finding no dates listed alongside his conditions, deBronkart found that the record included conditions he never had, including such alarming diagnoses as aortic aneurysm and metastases to the brain and spine. Word of the inaccuracy issues spread quickly after deBronkart blogged of his experience. It turned out that the reason for the false information was that insurance billing codes were transmitted to deBronkart's Google Health account. Insurance billing systems are often not far-reaching enough to include codes for every condition, or for a test to rule out a given condition, which some- times results in data being categorized incorrectly. Google and Beth Israel have since resolved the issue. The hospital will no longer send insurance billing codes to PHRs; instead, it will use the written text entered by doctors. Beth Israel sought a new coding system that would be of greater clinical use.

When patients discover incorrect information in a PHR, they can go in and change it. Although Google cor- rected their system, the situation raises the question of whether such mistakes in other PHR providers could cause medical or prescription errors.

Privacy is another concern for patients considering using PHRs. Both Google Health and Microsoft HealthVault have extensive security and privacy con- trols, but other providers may not offer the same. Due to falling outside of regulation under the Health Insurance Portability and Accountability Act of 1996, the potential exists for privacy issues with PHRs.

Another issue is with the possible difficulties one might encounter while assembling a PHR. Health care providers must be contacted and asked to upload patient information to the record, which can take time. Some might not yet possess the technological capability to do so. Beyond the problems a computer-savvy patient might face are the ones someone without technological knowledge might see as far too daunting. Such individuals could opt to forgo a PHR altogether, deeming it too labor-intensive. "Education and awareness building will be critical in establishing the need for a PHR in the mind of American consumers," said Erika Fishman, director of research at Manhattan Research.

Embracing the Trend

When one considers President Obama's goal of digitizing all medical records by 2014, along with the growing prevalence of electronic prescribing, PHRs are yet another important piece of the HIT puzzle. If patients, pharmacists, and other clinicians can endure a few bumps in the road as they work toward using PHRs to their full potential, every- one involved will benefit.