Sounding Board: Medicine Just Got Personal

MDNG Pediatrics, January 2007, Volume 5, Issue 3

MDNG's Editorial Board members examine issues facing physicians today. This month, Drs. Holly Miller and Betty Vandenbosch examine the world of Personal Health Records (PHRs) at the Cleveland Clinic.

Personal Health Records are an important component of electronic medical records that allow patients and physicians to communicate quickly and effi ciently, enabling patients to access the information they need to make better-informed decisions and take a more active role in their care. Here, two professionals discuss their experience with implementing such a system at the Cleveland Clinic.

Compared to other industries, such as banking and finance, healthcare has been slow to take advantage of the improvements in data storage and record keeping, automated customer service capabilities, and other services and functionality made possible by the rapid advances in computer technology in the last 20 years. But that may be about to change. Not only have many studies demonstrated the improvements in safety and quality that can be gained from employing an electronic medical record (EMR) in medical practice, but incorporating information technology into practice has recently been championed by a wide range of leaders and executives, culminating with President George Bush’s pronouncement of a national goal for all providers to use EMRs in caring for patients by 2015. Seeking to stay ahead of the curve, several leading institutions that have “e-transformed” their clinical practice through the use of an EMR system have also implemented a secure

personal health record (PHR), fully integrated to the EMR system, to meet the growing demands of their consumers.

Surveys over the last several years have demonstrated the growing desire of healthcare consumers to become more actively involved in managing their healthcare, communicate more frequently with their providers, and access healthrelated services online. Consumers have embraced the Internet and quickly become accustomed to ordering goods and services and conducting their banking online. Th e exponential growth of the Internet has fueled consumers’ desire for both the

convenience and empowerment that comes with having electronic personal health records (ePHRs). An ePHR provides information for patients, healthcare-related patient services, patient tools, and a secure means of communication with the patient’s provider. At the Cleveland Clinic, we implemented our EMR in 2000. The EMR is now used throughout our health system by more than 5,000 physicians, more than 1,500 fellows and residents, and 26,000 nurses and support staff . We began the implementation of an ePHR (fully integrated with our EMR) in 2003, and currently have more than 70,000 patients registered for the system. This integrated solution allows for the flow of information and messaging to our end-user constituents, enables secure patient messaging and lab and test result information, and the timely management of patient services, such as prescription renewal and appointment requests.

These services are delivered quickly, allowing for improved quality of care, tremendous practice effciencies, and improved patient satisfaction. In the world of paper charts, for example, a physician receives a paper lab or test result that has been transported from a printer in the lab to her “in” basket. After reviewing the result, the physician may want to review that patient’s record before she dictates a letter to the patient, so she requests a chart pull. After waiting for the chart to arrive, she reviews the record and dictates a letter to be typed by a staff member. The letter is transcribed, delivered to the physician, corrected by the physician, and signed

and mailed to the patient by the staff member. It is difficult to imagine the patient receiving the letter in less than a week or two. With the integrated EMR/ PHR, this process is dramatically simpliflied; the physician receives the result in her in-box, adds an explanatory comment for the patient and sends the result with the attached comment securely to the patient, who receives it nearly instantaneously. The patient receives an e-mail advising him or her that there is new information and prompting him or her to log on securely to the PHR. While online, the patient is able to explore his or her personal information, including diagnoses, age- and gender-specific health reminders, etc. and view upcoming appointments or request new appointments online when he or she is due for a test or procedure. The patient can also view a wealth of personalized, patient-friendly health information related to his or her diagnoses, medications, and results.

Practice efficiencies are realized because the system enables pertinent information to be securely “pushed” to the end-user constituents, rather than the end-users needing to “pull” information from a variety of sources. Patient result information is pushed to the physician’s in-box as soon as it is ready. The physician in turn is now able to push the result securely to the patient’s PHR, or at the very least send a message to the medical secretary to arrange a follow-up appointment with the patient. When the secretary receives the message, all of the required information to manage the next steps of the workfl ow is at his or her fingertips. The secretary can view the physician’s schedule to look for an open appointment, look up the patient’s phone number, or push a message to the patient through the PHR. The secretary may either call or send a message via the PHR to the patient to arrange the appointment. Along with any message sent through the PHR, an automated “tickler” e-mail including the URL of the encrypted PHR website is also pushed to the patient. The e-mail alerts the patient to log on to the PHR and informs him or her whenever new information has been pushed into the system. To maintain security and privacy the patient uses a personal user ID and password to log on.

Throughout our entire PHR system at the Cleveland Clinic, patients have access to context-sensitive personal information. For example, patients can look up a variety of articles pertaining to their diagnoses, view information explaining the rationale for their health maintenance tests, and read additional information that can help them better understand their medications or test results. The information is written in patient-friendly terms, and is provided either through mass personalization, context-sensitive system links, or as specific information for the patient delivered directly from his or her provider. Patients can even take online interactive patient education modules and respond to satisfaction surveys through the Clinic’s PHR.

When President Bush visited the Cleveland Clinic in January 2005, a patient who was on the podium with the President shared her experiences using our PHR system. The patient had recently been diagnosed with hyperlipidemia, and she used the PHR system to better understand her condition. In reviewing her record in the PHR, she recognized that she had slowly been gaining weight (about five pounds a year), and she had gotten to the point where she was considered obese. She used the diagnoses-related links provided in the PHR to find articles about hyperlipidemia, cholesterol, and obesity. Through the educational links, she found exercise and diet tips and advice that helped her control her weight. The patient also learned that she was at increased risk for type 2 diabetes, which further motivated her to exercise to lose weight. Using the PHR, she followed her weight loss and lipid results, and over the course of a year was able to lose weight and control her lipids without taking medication. She and many others who used the PHR system reported that it made them feel “empowered.”

Not all patients are ready for an online PHR. Our experience, as well as that of many other organizations that provide PHRs, shows that the number-one reason patients enroll in a PHR is because their doctor recommended it. At the Cleveland Clinic, patients who wish to sign up with the PHR must have a minimum level of experience with technology and the Internet and have reliable Internet access and an e-mail account. In order to activate their account, they must agree to a set of terms and conditions that requires them to always keep their e-mail address up-to-date to receive the e-mail “ticklers” and always log on to the PHR when they receive a prompt or message.

If you are thinking about implementing a PHR into your own practice, it is necessary to determine who among your patients responds well to this technology and who does not. For the most part, people adopt technology if they believe that they have suffi cient skills to do so, if they believe that there is a benefit to them personally, and if they are encouraged by important people in their lives and care about meeting the expectations of those people. Not surprisingly, the easier to use and the more useful a technology is perceived to be, the more likely patients are to have a positive intention toward using it. Of course, the more a patient uses the PHR system, the more his or her expertise and comfort level with the system will increase.

So, the challenge is to implement a PHR system that is easy to use and has the features and functions that the majority of patients want and will find useful and time saving. Then you have to encourage people to try the system and to keep using it. In addition, security of the site and patient information is paramount. In a business setting, employees are compelled to use the work-related computer systems even if they don’t like them because it’s important to their jobs and careers. Patients are not similarly compelled to use an electronic PHR system. If the system is diffi cult to use or is disappointing, patients may use the PHR but will probably continue to use more familiar methods, such as the telephone, to communicate with their physicians. If the patients try the system and have a positive experience it will build their confi dence, encourage them to use all of the features and functions of the PHR, and promote their continued use. Initial success and approval will cause patients to grow more accustomed to the system and more dependent on it.

Holly Miller, MD, MBA, is Managing Director of eCleveland Clinic. She also coordinates the development of Clinical Internet Strategy at the Cleveland Clinic and manages the development of e-Cleveland Clinic MyChart, MyMonitoring, and Virtual Visit projects throughout the Cleveland Clinic Health System. She is actively involved in funded clinical research about patients’ use of ePHR systems, and is a nationally recognized leader in health information technology.

Betty Vandenbosch, PhD, MBA, is Associate Dean of External Relations and Executive Education at the Weatherhead School of Management, Case Western Reserve University. She researches and writes about the impact of information technology on individual and organizational performance and has collaborated with the Cleveland Clinic Foundation to explore whether its ePHR system can serve as a surrogate for labor-intensive manual interventions and improve compliance and outcomes in patients.