Tuesday, March 06, 2007

Are PHRs the chicken or the egg?

Interesting shifts in the focus of national HIT spending.

Federal attention (and presumably resources) has turned from EHRs and HIEs to personal health records (PHRs). The following report refers to comments by Dr. Robert Kolodner, President Bush's head of health IT:

Kolodner said that most Americans will have EHRs by 2014, and personal health records will drive that effort. Progress will increase in pace as a tipping point toward healthcare IT adoption is reached, Kolodner said.

You can see the whole report here: ONC fields tough questions Town Hall meeting.

ONC plans on backing these words with resources. The next round of federal contracts for health information networks are due out in April, and according to Kolodner, the next projects will be required to "empower patients to manage their own data." Speaking further, Kolodner said:
They have to enable the patient to identify how they wish to view their own information, to choose how the trust to share data, to control access to data by others, and for how long.... Individuals will also be able to correct errors in their health information. The actual correction process will at first be manual, but in the future it will hopefully be automated.
You can see the whole report here: Majority of market now adopting value-driven healthcare, Leavitt says.

This is somewhat of a shift in priorities from the original vision laid out by Kolodner's predecessor, David Brailer. The original Framework for Strategic Action created in 2004 had PHRs as the third goal, behind EHRs and HIEs.

I've written before about my belief that PHRs can't be the driver of HIT. EHR penetration is so low at present, and hospital systems are so hard to connect to, that there isn't enough electronic data available yet to make PHRs interesting to consumers (please see You can't get blood (or data) out of a stone and Hi, I'm from Wal-Mart and I'm here to help....).

Further, by framing this goal as having "most Americans" rather than "most physicians" on an EHR by 2014, ONC is going after the highest hanging fruit. According to the National Ambulatory Care Survey, 90% of outpatient visits happen in small practices, yet, according to the CDC, penetration of "good" EHRs is only around 9% generally, and much much lower in small practices.

I hope I'm proven wrong, because the point is to get it done in any way that works. Maybe we can get consumers to pound the table for PHRs. And maybe that pounding will get physicians to feel the urgency to get EHRs in order to meet their patients' demands for data to populate these PHRs. And maybe substantial federal dollars focused in this way can create a market.

With all due respect to Dr. Kolodner and his tremendous efforts and vision, I think it will be an enormous challenge to have most Americans on an EHR by 2014 even if we funded EHRs directly. Getting to that goal indirectly through demand generated by PHRs will be even more challenging.


Mark Singh MD said...

This is a great point. It really is a chicken or egg issue. If "all" patients were to use a PHR, then, doctors will likely follow through with EMR adoption. But if there is only a 10% PHR adoption by patients (which would actually be huge in terms of numbers), it may not be enough to drive up EMR adoption. Especially because interoperability between EMRs and PHRs may be less than useful. Things really need to start at the center and work their way to the outside in terms of connectivity. Start with the data sources: labs, hospitals, move out to the doctors (EMRs), then to the patients (PHRs).

Micky Tripathi said...

Thanks Mark. My view, and the approach we've taken at MAeHC, is as you suggest. Focus efforts on getting the clinical side set up first. The PHR (or patient portal) will then have something meaningful to draw from. "Sustainability" of HIEs is sketchy at best right now; seems like an even further stretch to expect that patients will pay for PHRs (or portals) that are little more than an elaborate facade on scant information.

DirectHealthAccess said...


I agree with your assessment that PHRs will have a harder time driving the physicians and institutions to adopt EHRs, with one caveat. I believe there's a general assumption that a PHR can only be effective if it incorporates, right from the get go, fully interoperable clinical data exchange. As with most great undertakings of this kind, I think we have to walk before we can run.

For nearly two years I have served as a community presenter in the American Health Information Management Association's outreach effforts to teach consumers about the benefits of maintaining a personal health record. I have delivered numerous presentations around Massachusetts, and I can (at least anecdotally) confirm the findings of the Markle Foundation and the Harris Interactive survey - people DO see the value in possessing and maintaining their medical record. Even if it's not fully electronic. If individual health consumers acquire and update their medical, dental and eye records, they benefit by being more prepared for appointments with their doctors, being able to provide a specialist with the whole picture if their PCP has not forwarded records in a timely fashion, etc.

How can this be accomplished? Over the past fifteen years, significant achievements have been attained in other industries to take control of the paper mess by using scanning technology. Banks now routinely scan all checks under the Check 21 Act, insurance companies scan and process paper-based medical claims, mortgage loan applications and supporting documents are scanned and routed through the approval process, and public records at all levels of government are now scanned and available via the Web. Standard data formats such as TIFF and PDF make viewing of these files ubiquitous. And these industries all have found ways to secure the data as necessary to protect their business interests or the public. But these measures were not fully hatched all at once. They took the baby steps necessary to formulate the benefits they have now realized over the longer term.

To be sure, this is not the end game in the health care space. But until standards organizations and the Federal government come to a final determination on the exchange format: HL7, the CCR, the CCD or something yet to be adopted, why is it necessary to hinder forward movement at all levels?

If the basic target is to provide better, safer care by having information available to support a diagnosis, and to limit the need for performing duplicative tests, having scanned medical records will at least allow consumers and physicians to begin getting comfortable with the electronic health record.

Sorry for being so long-winded.