COMMENTARY

Readers' and Author's Responses to "Electronic Personal Health Records: Should Doctors Worry?"

Terry J. Hannan, MBBS, FRACP, FACHI, FACMI; Vojtech Huser, MD, PhD; Matthew K. Wynia, MD, MPH, FACP

Disclosures

October 31, 2008

To the Editor:

I am writing in response to Dr. Matthew Wynia's Webcast on Medscape on electronic personal health records.[1] Having personally been involved internationally in implementing electronic health records since the 1980s, the clearest message is that patients want to take an active part in their health information management, and they want clinicians to be able to do this also.[2] Then the question of ownership of the record information can be discussed at length. Professor L. Weed emphasized the importance of patient involvement in a plenary presentation at an informatics conference in Canada in 1989. He concluded with the following statement:

 

Patients do not specialize, and they or their families are in charge of all the relevant variables 24 hours a day, every day. They must be given the right tools to work with. They are the most neglected source of better quality and savings in the whole health care system. After all: They are highly motivated, and if they are not, nothing works in the long run anyway. They do not charge. They even pay to help. There is one for every member of the population.[3]

I have found that through the use of simple technologies (Microsoft™ Office applications) and email[4] that the patient involvement in the content, documentation, and use of an electronic summary patient record (SPR) is not such a steep learning curve as indicated by Dr. Wynia in his dissertation. I have adapted from established SPR formats a fill-in template that records the patient's total medical management. A prominent feature of this SPR is the patient's involvement in its content and accuracy of the patient-doctor encounter.[5] Some features of this record are described below:

  1. The patient verifies the record content;

  2. The patient contributes directly to the record by emailing confirmation of receipt of the record. (or receives a printed copy);

  3. Further contributions are made by emailing preformatted MS Excel© charts with FBSL [free basic script language] (with averages of their daily BSL [blood sugar level] readings and HbA1C [glycated hemoglobin] levels) and blood pressure readings;

  4. There are preformatted templates inserted for insulin adjustments, enoxaparin travel protocols, and for many other clinical states;

  5. All communications with the patient and responses are stored in the SPR by time and date; and

  6. Educational materials are provided by Web hyperlinks from the record to the Web, or printed if no email facilities.

Approximately 30% of patients use the SPR email facilities with an age range of 16-94 years. I found no excessive use of the email facilities by patients, and there are several instances in which real-time communications have prevented the patient having to come to the hospital for evaluation. In conclusion, there seems to be clear evidence of patient empowerment with these SPR formats, and the learning curve(s) are not necessarily steep.

Terry J. Hannan, MBBS, FRACP, FACHI, FACMI
Department of Medicine
President Australian College of Health Informatics
Launceston General Hospital
terry.hannan@dhhs.tas.gov.au

References

  1. Wynia MK. Electronic personal health records: should doctors worry? Medscape J Med. 2008;10:204. Available at: http://journal.medscape.com/viewarticle/579181 Accessed October 20, 2008.

  2. Tierney WM, Rotich JK, Hannan TJ, et al. The AMPATH medical record system: creating, implementing, and sustaining an electronic medical record system to support HIV/AIDS care in western Kenya. Stud Health Technol Inform. 2007;129:372-376. Abstract

  3. Weed L. New premises and tools for medical care and medical education. Methods Inf Med. 1989;28:207-214. Abstract

  4. Sands DZ. Help for physicians contemplating use of e-mail with patients. J Am Med Inform Assoc. 2004;11:268-269. Abstract

  5. Bart S, Hannan T. The use of existing low-cost technologies to enhance the medical record documentation using a summary patient record [SPR]. Stud Health Technol Inform. 2007;129:350-353. Abstract

To the Editor:

I read with interest Dr. Wynia's editorial about challenges in personal health records (PHRs).[1] I completely agree with the suggested PHR's benefits of educating patients, reducing duplication, and preventing errors. I also acknowledge the challenges described. However, I would like to add a more positive stance on PHR's future and point to some opportunities.

I view a PHR system as yet another tool for nonpaternalistic medicine that the patient-physician team simply decides to use or not use.[2] A mutual agreement also decides the degree to which all potential PHR features are utilized. The author expressed concern about patients' control over what clinical records are shared with other doctors. It is important to point out that even in a no-PHR context, patients can hide important information by simply not telling a complete story during the exam or purposely not describing complete relevant past history. An unmentioned PHR challenge, which I consider very important, is general agreement on permissible, unbiased, and well-disclosed financial models, which pay for maintaining and developing PHRs.[3]

It is also important to mention clinical informatics and consumer health informatics opportunities of PHRs. It is more likely that PHRs will be adopted by younger patients and younger physicians. PHR systems can serve them as an important new communication channel. Such users are already using this channel heavily in banking, shopping, and entertainment. Young health consumers may want to set up health alerts and reminders in similar fashion as their credit card balance alerts via email or cell phone text message. Designers of computerized decision support modules for clinicians are already experimenting with PHR counterparts of such modules.[4] Recommendations displayed not only to clinicians in an EHR [electronic health record] system, but also to patients within a PHR system, have a much higher chance of resulting in improved care and lower long-term healthcare costs. Another PHR domain in which our learning curve will be steep but exciting to explore is designing patient-friendly medical knowledge content using newest semantic Web technologies that build on consumer and medical ontologies.[5]

I agree with the conclusion that PHRs have security, confidentiality, and usability challenges, but I think their general future is bright. They represent an important tool in a shift away from paternalistic medicine and also a potential instrument to affect rising healthcare costs through patient-targeted interventions.

Vojtech Huser, MD, PhD
Adjunct Post-Doctoral Research Fellow
Biomedical Informatics Research Center
Marshfield Clinic Research Foundation
Marshfield, Wisconsin
huser.vojtech@marshfieldclinic.org

References

  1. Wynia MK. Electronic personal health records: should doctors worry? Medscape J Med. 2008;10:204. Available at: http://www.medscape.com/viewarticle/579181 Accessed October 20, 2008.

  2. Leonard KJ, Wiljer D. Patients are destined to manage their care. Healthc Q. 2007;10:76-78.

  3. Abdolrasulnia M, Menachemi N, Shewchuk RM, Ginter PM, Duncan WJ, Brooks RG. Market effects on electronic health record adoption by physicians. Health Care Manage Rev. 2008;33:243-252. Abstract

  4. My Marshfield Clinic: PHR system of Marshfield Clinic and Security Health Plan. Available at: https://marshfieldclinic.org/mymarshfieldclinic Accessed October 20, 2008.

  5. Sachinopoulou A, Leppanen J, Kaijanranta H, Lahteenmaki J. Ontology-based approach for managing personal health and wellness information. Program and abstracts of the 29th Annual International Conference of the IEEE; August 22-26, 2007; Lyon, France.

Author's Reply:

To the Editor:

Both letter writers have added important information to my brief editorial essay. I am glad to have sparked additional conversation. One lesson from these 2 letters, taken together, is that some uses of PHRs will require a great deal more learning and adaptation than others. Still, like Drs. Huser and Hannan, I think PHRs [personal health records] generally hold great promise, and the changes they portend are exciting, even if I also see them as sometimes daunting. I look forward to seeing how patients, physicians, and the developers of PHRs will work together to create useful tools for improving care.

Matthew K. Wynia, MD, MPH, FACP
Director, The Institute for Ethics
American Medical Association
Chicago, Illinois
matthew.wynia@ama-assn.org

 


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