I recently read an article (which I can’t find now) that said, We don’t log in to check our health data as much as we do our financial data. This was a pretty interesting statement considering a few days back I posted this tweet about PHR and being an active patient:

I want to spend some time thinking about the motivation for a healthy individual to become an active patient. #PHR #ePatient

February 25, 2011 11:15 pm via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

Figuring out the right motivation for someone to use a PHR has been something that’s been on my mind for quite a while. You may remember my post about requesting an appointment and sending your medical record using a PHR where I was asking some similar questions.

There’s certainly a place for software that connects patients with their doctors for things like scheduling an appointment, paying their bills, requesting prescription refills, and even doing e-visits. In fact, one of my advertisers recently launched an enterprise patient portal that has these types of features (check out this video which describes their feature set).

There’s no arguing that these types of connections to doctors are valued and something that patients would love to have. Many doctors are still on the fence about them, but I’m sure we’ll be seeing more and more of these types of services over time. However, while being really great features they still don’t solve the problem of a healthy patient wanting to log in to this portal regularly.

I think one game changer when it comes to PHR will likely be around an emerging set of devices which track our health. For example, over on Smart Phone Healthcare I recently wrote about Tracking Fitness and Activity Levels on Your Smartphone. These devices will track your steps, calories, heart rate, and sleep data and upload it to a centralized location where you can see all that data and watch your fitness and activity levels change over time. Plus, I believe we’re just getting started with collecting this type of data. You can easily see this moving to blood sugar levels, cholesterol, blood pressure, etc.

Now imagine that all of this data was available in your PHR. This type of data would be constantly updated and seeing the graphs of this health data over time is something that I’d login to check as much as I do my financial data.

Previously, I’d always been a bit down on these types of tracking devices. I’ve argued that we’re missing that link for doctors to be able to do something with the data that patients are collecting. I still think this is the case, but just because your doctor might not use the data a patient collects doesn’t mean it can’t be valuable to the patient to collect and see that data regularly. Plus, once EHR software and doctors are ready to digest the data, you’ll be ready as well.

As is often my Sunday tradition, I love to post some healthcare IT related polls. Today’s poll is prompted by this tweet I sent out earlier this weekend:

I want to spend some time thinking about the motivation for a healthy individual to become an active patient. #PHR #ePatient

February 25, 2011 11:15 pm via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

On that note, I’d love to see how many of my readers use a Personal Health Record (PHR) and more specifically if you update your PHR or not. Of course, this poll will be completely bias since it’s industry people right. Which is why if the results say that few people in the healthcare IT industry are updating their PHR info, then maybe PHR has some issues to be dealt with.

There’s a pretty fierce battle going on right now between all the various stakeholders interested in exchanging patient data. The stakeholders range from very large companies to government initiatives to startup companies. One of the major problems that I see is that it’s not completely clear which model of patient data exchange will win out. In fact, let’s not be surprised if a number of different options take hold.

With this said, I found it interesting that my favorite open source healthcare IT advocate, Fred Trotter, has chosen to get behind the Direct Project. In Fred’s post describing the challenges with the IHE-protocol HIE model approach is flawed and that the direct exchange of healthcare information is the way to go. In fact, he provides the following two illustrations in his post to show the difference:

HIE Model (click on the image to see it full size)

Direct Model (click on the image to see it full size)

Fred then offers this incredibly interesting conclusion:

At every level, organizations are deciding whether to invest in Direct or IHE-based exchange. At this point, I believe the only viable option is for a local exchange to either support Direct only, or both Direct and IHE. IHE is simply going to be too heavy weight for early adoption. Eventually, IHE may become dominate but for now Direct is much simpler, and puts the patient right in the center of everything. If you are a policy maker, you should be asking anyone involved with an HIE process to detail what their Direct-strategy is. If any effort is ignoring Direct and going with IHE-only I would lay odds that they will be broke and defunct before the decade is out.

Moreover, an IHE-only strategy is going to exclude direct participation from patients at this stage. If you care about patient empowerment, I recommend that you advocate for the Direct project at every level, including in your local HIE and REC.

Lots to consider with this complex challenge.

I guess you could say that the direct model is the patient centric model. Although, one could easily argue that the direct model doesn’t have the patient as the center of the model, but instead is a PHR centric model. So, the direct model will be a patient centered model only as much as the PHR software allows the patient to be involved.

Thus, it makes since why Microsoft HealthVault and Google Health are heavily involved in the Direct Project. Of course, they want to be involved in a project that puts them at the center of the communication.

The real question even with the direct model is what incentive do the various PHR vendors have to make this interaction happen? What will be the “cost” that PHR vendors pass on to consumers and/or doctors that use the PHR centric model? Basically, what’s the business model of the PHR vendors?

Unless we can find a PHR centric business model that works for the PHR vendor while still empowering the patient, even the direct model will fail or have adverse outcomes.

I was looking through the HIMSS session titles and saw one about the Usability of PHR, which prompted me sending out the following tweet:

Usability of PHR? First, shouldn’t we address the reason to use PHR?

January 14, 2011 1:53 pm via webReplyRetweetFavorite

@techguy

John Lynn

Then, a smart HIT journalist named Neil Versel sent his comment on my tweet:

Amen! #healthit #PHR RT @techguy: Usability of PHR? First, shouldn’t we address the reason to use PHR?

January 14, 2011 2:55 pm via ÜberSocialOrigReplyRetweetFavorite

@nversel

Neil Versel

Something to think about this weekend.

I recently got a message from Jerry Theis of MyCrisisRecords. He sent me a story that I thought was a great way to start off the new year. It talks about the value of health care data interoperability and in this case a device and PHR with a person’s health information. Enjoy the story!

Yesterday, one of my members called me to tell me she was taken to the emergency room suffering combinations of complications caused by a rare condition, Polymorphous along with a flare up of fibromyalgia which caused to her go into cardiac arrest. The ER doctors were able to effectively treat her because she had her digital device which provided them all of her medications, conditions, allergies (she is allergic to latex). Because of this rare condition and her acute distress she was told by the doctors had she not had this device there would have been adverse events, medical errors and it would have been fatal.

The ER doctors read the article I had downloaded in the device about Polymorphous. She, the patient educated the doctors who said they had never treated or seen this rare condition. The ER doctors consulted with Mayo Clinic and an expert on Polymorphous consulted with them and spoke to the patient while reviewing the transmittal of her PHR sent to him. She consented to be injected with a drug that had to be sent from Mayo (2hrs). It relieved her of the severe pain and swelling in her throat.

I share this with you because it meant so much to me to hear her testimonial and how thankful she was and how grateful she said the doctors were about what I created. I am a psychotherapist and she is a patient of mine who has a Bi Polar condition. The doctors said they may have had discarded her presentation because of her psychiatric condition had they not had the complete PHR. Another primary reason why I relentlessly developed this technology, for the special needs populations.

An interesting discussion happened in the comments about HIPAA secure fax services in regards to the security of email. Being a tech person who formerly managed a few different corporate email systems, sometimes I forget that many people don’t understand some of the details about the security (or lack of security) that’s provided by email.

The short story is: Email is NOT HIPAA Secure (at least in 99% of cases)

There is a way to encrypt email sent between 2 email systems, but so far a standard and mechanism for encryption between all the vast number of email providers has not been established. I won’t go into the details of why this is the case (cost of encryption, standards for encryption, etc), but suffice it to say that almost none of the email systems send encrypted email that would satisfy the HIPAA requirements.

In fact, most times when an EMR, PHR or other patient portal wants to send a secure email/message to someone they send an email which contains a link to an encrypted website that has a unique login. The reason they do this is because there’s no recognized and adopted standard for encryption of email. However, presenting Protected Health Information (PHI) through an encrypted webpage where someone has a unique login is HIPAA compliant and doesn’t require the receiving email system to understand the encryption. It’s a pain, but it’s the reality of privacy of health information right now.

One of the major reasons that many people think that email is secured is that a number of email providers (Gmail being the most famous for this) turned on encryption for all of their users. The misunderstanding is that this encryption is just for users logging in to check, read and send their email. It does not encrypt the email as it it sent from Gmail to the destination email system. Aleks, from Sfax described it similar to a postcard. It’s open where anyone listening can see what’s in the email with no traces left behind.

The only security email partially offers in this manner is the volume of emails that are sent. There’s such a huge volume of useless emails that there’s some security by obscurity benefits. Although, that security doesn’t meet well with the HIPAA requirements. Plus, remember that one thing that computers are great at doing is crunching large amounts of data.

One minor exception that I might make is that if you’re sending email in an internal email system, then it’s possible to set up email encryption. This is possible because you control the email system for the sender and the receiver and so there are ways to do this. However, I know very few people that have actually set this arrangement up. Probably because if they are on your internal email system they usually have access to your EMR and all the PHI can remain in the EMR instead of your email system.

Now many have said that you shouldn’t use the free email providers like Gmail. After reading this it should be clear. You shouldn’t use ANY email provider for sending PHI. So, whether you use Gmail or some other free email provider it shouldn’t matter since I’m sure you won’t be sending any PHI through email any more.

Of course, I’d recommend you use the free Google Apps version of Gmail since DrSmith@yourpractice.com is so much more professional than DrSmith985373@gmail.com. Although, that’s kind of a topic for a different discussion.

I recently sat down with Jeff Donnell from NoMoreClipboard. We had a fascinating all around conversation, but one of the most fascinating things he told me was the story of his last visit to his doctor’s office. I’ll do my best to recount what he told me.

When he decided he needed to go see the doctor for a visit his wife suggested that he call the doctor to make an appointment. Of course, Jeff “eats his own dog food” and decided that instead of calling for an appointment, he’d request an appointment through NoMoreClipboard. So, he logged into his account and sent off the request for an appointment with his PHR attached. Pretty interesting idea no?

Don’t ask me why, but when possible I’d much rather request something through my computer. Maybe it’s sitting on hold while you wait to talk to someone that’s turned me off to the phone call, but the idea that I could request an appointment online even if the doctor isn’t on NoMoreClipboard is a pretty attractive feature for a PHR.

Of course, since Jeff’s doctor wasn’t on NoMoreClipboard, his appointment request and health record were faxed to his doctor’s office. He got a call from the doctor and scheduled his appointment. The story certainly doesn’t end there.

When he arrived at the doctor’s office he wondered if they’d have his record or not. They handed him the standard clipboard to fill out all the paperwork. He still said nothing and dutifully filled out the paperwork. No one said anything about the record he’d sent until he was with the doctor and the doctor realized that Jeff was the one that sent in his PHR. I guess it was the talk of the office when that fax came in.

Obviously, the idea of requesting an appointment and faxing in your health record using a PHR still has a ways to go. In fact, NoMoreClipboard’s goal is to work with doctor’s offices like these so that the office gets the person’s health record on the forms that the doctor’s are use to getting it on. I think that’s a smart strategy. Not to mention the idea of the patients driving their doctors to use and work with a PHR provider. I think they call that Word of Mouth advertising right?

I’ve been thinking about this for a while when I recently talked with someone from Microsoft’s HealthVault division. I quite frankly asked this gentleman why I should use a PHR. Obviously, if I was a patient with a chronic or complicated illness I could see a compelling use case. However, what’s the use case that will drive and motivate healthy individuals to use a PHR. So far I really haven’t heard a good answer.

Requesting an appointment and not having to fill out that same lengthy cumbersome paperwork is the closest I’ve thought of.

One of the really interesting things that I’ve heard at the Mobile Health Expo has been the use of text messages to assist with patient compliance.

I think this is at least the third time at this conference that I’ve been hearing about the use of text messages in healthcare as a way to remind patients of their need to comply with the doctors instructions.

In one case, NoMoreClipboard is working with a hospital to use medical minutes (basically subsidizing their cell phone plan) for participants in a diabetes program. In this program, users would access the NoMoreClipboard PHR through their cell phone where they can update their blood glucose levels or other information as designed by their hospital.

This is pretty cool, but the interesting part is the way they’re using text messages together with the PHR. For example, if the patient doesn’t check in with their information, then a text message is sent reminding them to do so. Plus, once they enter in their information, they can get proactive messages about how they should deal with various blood sugar levels. For example, if their levels are low it might instruct them to eat or drink something to raise that level (although in a nice medically appropriate way).

I should have written down the exact numbers, but in the above case they found that they saved about $18,500 in treatment costs for a compliant patient vs. the non-compliant patient.

I of course had to ask if this could actually be a problem for the hospital. Sure, it improves healthcare, which is incredibly valuable. However, would this impact the revenue that a hospital was receiving previously to treat patients? Sure, it’s a bit ominous to think this way, but let’s be honest that the hospital revenue is an important factor.

Jeff Donnell from NoMoreClipboard brought up a good point that in many cases these patients were ones who had no health insurance and so the hospital was often not making money from treating these patients, but in fact was having to pay for these patients. So, being able to lower these costs is a huge benefit on top of the clinical benefits.

Of course, this is just one example of the usages of text messages in healthcare. I’m really finding it fascinating. Text messages seem to be one of the most innovative technology I’ve heard discussed and not all the various “Apps” that are out there. Yep, the simple text message is being used in all sorts of creative ways. Plus, text messages tied to a PHR or some other web source is really interesting as well.

Of course, I can’t help but imagine how text messages could be integrated into an EMR. Appointments is one obvious area. Patient compliance is another interesting one. What other areas of an EMR could benefit from the implementation of text messages?

One speaker said that on average text messages are read within 4 minutes. There has to be a way to leverage this attention in healthcare and EMR.

In this Sunday’s HUH? news we have a report by Healthcare IT news that Google may be considering using their Google Wave technology for EHR. Of course, I think the writer at Healthcare IT news must have had a deadline or something since the paper written by Google engineers Shirley Gaw and Umesh Shankar about representing “Individual Health Records” that are aggregating from “multiple sources” which sounds a lot more like a PHR to me than an EHR

That minor verbiage aside, it’s hard for me to imagine Google Wave used as a PHR or an EHR. Ok, I get the idea that it would be interesting to see all the clinical data elements added to a patients history in real time (basically what Google Wave does). This is an innovation that is needed. I just think that re-architecting the very consumer focused Google Wave product isn’t going to get us there.

Not to mention, Google has chosen to stop supporting Google Wave. I think Google probably has enough to do with health with Google Health. I’ll be very surprised if we really see the Google Wave technology used in healthcare.

One of my readers emailed me about a presentation he was looking at doing about EMR software and consumers. I was really intrigued by the idea of presenting on the benefits of an EMR to the consumer (Translation: Patients). I’d spent quite a bit of time thinking about the benefits of an EMR to doctors, but I hadn’t put as much thought and effort into the benefits of an EMR to patients.

Here’s our initial brainstorm on the benefits of an EMR to patients. Feel free to add to the list in the comments:
-Online Appt Scheduling
-Online Prescription Refills
-Online Patient Information
-Online Forms (possibly pulled in from a PHR)
-e-Visits (this is a controversial one)
-Secure communication with doctor
-Recall/Reminders Electronically
-Patient participation in health record (ie. diet journals)
-Better point of care
-Clinical decision support
-Better access to your health records
-Less errors
-Lower cost
-Better collaboration and communication between primary care and specialty Drs

No doubt some of these benefits should have a ? mark by them. Although, I like the idea of looking at the EMR from the patient perspective. I do after all think that consumers might be the key to “forcing” broad EMR adoption.