Why PHRs Are Part of Meaningful Use
How time flies. Not that long ago, James Brown created similar lyrics about War. Now, we are looking at a battle to create digital standards and achieve adoption, the so-called meaningful use. *See Correction Below.
Reaching over a year into the past, May 2007, iHealthBeat presented an article on EHRs and PHRs. Michael Zaroukian, M.D., PhD, chief medical officer at Michigan State University was concerned about PHRs because of a) accuracy, completeness, usefulness, and volume of data, and b) uncompensated time for physicians to sift records, and c) potential for a misdiagnosis if a crucial element in the PHR is overlooked. Often, he said, "PHR information is poorly organized."
Joseph Heyman, M.D., and AMA Trustee, of PHRs contrasted the PHR being a "snapshot of the patient and their most important demographics" to the entirely different "entire medical history for life."
"Making sense of unorganized or complicated PHRs can take up to four or five hours---paper or electronic,: noted Dr. Peter Basch of MedStar Health, Washington, DC. Said Basch: "A two or three-minute oral history during the physician visit can be more helpful than an extensive PHR."
Yes, time flies, but attitudes change more slowly, partially because a majority of physicians have no EMR with the familiarity that comes with digitized work flow and partially because, as my Dean once told me: "if you are not up on something, you will be down on it."
In fairness to those quoted above, nearly two years of IT change have created second and third generation software platforms with little resemblance to PHRs of their comments. Taken one at a time:
- There are several good PHRs, the characteristics of which are automatic coding, orderly and directed entry patterns, prompts, integrated data bases for drugs both branded and generic, integration with EMRs and interoperability with devices. They create summaries of abnormal entries and summarize current drugs and allergies. They send and receive data digitally, by FAX and PDA phone. They have storage for files, reports, wills, directives---and they graph results. They have many of the features of a good EMR.
- The mental picture of a harried physician leafing through dog-eared pages is more likely that of a physician digging into a paper chart than one using a modern PHR.
- Before or after looking at a PHR, or after receiving the report of an Aide who looked at the PHR, the physician is quite likely to ask better questions during the physical exam.
- And indeed, the PHR can be an accurate reflection of the patients entire history, or using the summary of abnormal entries, it can be a snapshot of illness as well as medications, allergies and statement of present illness. Additionally, the PHR can contain documents: CT and MRI reports, laboratory values, visitation privileges and health care directives.
- A seldom-mentioned benefit to the physician is that, for purposes of coding compliance, the PHR can provide a dated, time-stamped proof that history was received and checked.
- For the chronically ill, a rule of thumb is that the patient comes to know a great deal about that illness, sometimes rivaling the knowlege of his/her physicians. Many such patients carry extensive records---a few well organized but many more quite fragmented. The PHR offers an orderly chronology, offers graphing, and if the PHR is web-based and integrated with digital reconciliation software, a human interface can quickly eliminate duplications and errors both in the PHR and in the physician record.
- Web-based information in a secure cloud, offers the additional benefit of being everywhere portable and accessible. The PHR is ideal for "adult children" who care for elderly parents at a distance of many miles. A distant ER report can be scanned and FAXED to the PHR in minutes.
- With regard to privacy, it is the patient who owns the PHR and controls its entries. To those who say, "How can you believe what a patient enters," one can perhaps best respond using Doctor William Osler's phrases. "It is more important to know what sort of patient has a disease than what disease a patient has." The PHR, misconceptions included, tells much about patients' views of themselves. It is, as always, left to the physician to make sense of the history. "Listen to the patient carefully, and they will tell you the diagnosis," said Osler. And, it is the feature of ownership that allows the patient to use the PHR to deal with HIPAA most effectively.
For the quick visit, the PHR is a quick refresher for allergies and medication changes. One need only to ask when it was updated, inquiring about changes. For the complex, long visit, the PHR points quickly to the systems most important about which to seek more information. And, the filing cabinet features allow for review of physicians dictation and discharge summaries.
What is different about PHRs since 2007 is that they are like EMRs, built on flexible interactive platforms, with full integration into portals, medical devices, Internet, and telecommunications. They will save physician time and be yet another instance whereby information systems provide safer treatments.
This is Part I of three parts. In Part II, we will review the fine recent article by John Moore and in Part III review the part played by PHRs in Population Health.
*Correction: "War" is a song written by Norman Whitfield and Barrett Strong in 1969. Editor
