USA - Is the Industry Ready to Get Personal?

Six years ago, Women's Care Florida, a 13-physician group practice, thought it was leaping into the future when it implemented an ambulatory EHR.

The software enables physicians to document their care, process labs and write prescriptions. "We had paper charts everywhere and it was a nightmare to find patient information," recalls practice member Matthew Mervis, M.D. "But we realized as we got further into the transition, we weren't doing the patient side. They were still calling us to get lab results, to ask follow-up questions, and to make their next appointment. Every telephone call represented another piece of paper. We got the office converted but we still had to figure out how to convert the patients."

Like a growing number of practices, Women's Care Florida turned to a patient portal, in this case one embedded in its ambulatory software package, from Greenway Medical Technologies. At first, the practice used the portal to publish care-related pamphlets. Then it added service-oriented transactions, which caused the popularity of the software to spike.

Now, patients can book appointments, ask routine follow-up questions, request medication refills, see their lab results and even pay bills online, all behind the firewall of a secure Web site, Mervis says. "Nearly all of our patients use it," he says. "It works out very well for the practice from an efficiency standpoint."

But there's one portion of the portal patients rarely touch, adds Lisa Mangan, R.N., administrator and practice manager at Women's Care. That's the section where patients can enter their own data into a free-standing personal health record. In theory, patients could add other data into the PHR, and dispatch it to their physician through the portal's secure messaging function. But that rarely happens. "The patients just don't use the PHR," Mangan says. "They don't understand what it's for, since they know our doctors are keeping track of their care for them."

When it comes to portals and PHRs, Women's Care Florida typifies a conundrum for the broader industry. Not long ago, PHRs were the darlings of venture capitalists. Patient-controlled records, it was predicted, would not only plug communications gaps but also grant patients the ability to take charge of their health. Google was one of many companies that launched PHRs, via its GoogleHealth initiative, with those lofty goals in mind. Problem is, the vast majority of patients weren't and still aren't interested in being their own record-keepers-let alone asserting any type of authority over caregivers.

The ostensible "authority" granted to patients proved to be mere nuisance. Eventually Google dissolved its business line and many other PHR wannabes quietly folded (see sidebar, page 26). "The market has never taken off for PHRs as an independent platform," says John Moore, founder, Chilmark Research, which tracks the health care I.T. industry. "GoogleHealth was a noble attempt at trying to make it easy. But consumers were not engaged in trying to gather their records and import them into a PHR."

That's not to say the importance of patient connectivity went away. While patient-controlled (sometimes called "untethered") PHRs have thus far proven to be marginal components of care, the patient portal model has steadily gained traction. Industrywide, there has been a surge in patient portals, which sport a variety of features and functions similar to those in use at Women's Care Florida. Many observers refer to the patient portal as a "tethered PHR," meaning it remains under the jurisdiction of the provider. Patients gain direct access to their provider's electronic record, and while they're limited in their ability to add data or transport the record to other providers, the messaging and scheduling functions are appealing nonetheless. "The real basic stuff patients want to do online with physicians can't be done with the PHR, but can be done with the newer portals," says Moore.

Portal limitations

But even portal advocates recognize the limitations of the model. They acknowledge that, despite the growing numbers of features offered by portals, some variation of the PHR-perhaps one connected via a health information exchange-will likely be needed to fill care gaps beyond their reach. These include between-visit care data for patients with chronic conditions, such as diabetes. Linking to specialists outside the reach of the health-system driven portal is another portal shortcoming potentially overcome by an untethered PHR.

What's driving the boom in portals? Reimbursement factors in as much as the ideal of patient authority. Under emerging payment models of accountable care, providers will be compensated on how well they manage patients with chronic conditions. For many, the portal represents a communications tool that can play a big role in staying in touch with at-risk patients between visits.

And as Moore points out, the march to value-based purchasing by health insurers, most notably Medicare, is sparking a spate of consolidation in the industry as large providers as well as payers acquire practices "to better control the full patient experience and better manage chronic care patients. We will see a greater aggregation of patient records into select entities and that will lead to a more longitudinal record accessible through a conventional portal," Moore adds. Furthermore, to qualify for meaningful use payments, providers have to provide patients an electronic copy of their chart upon request-a task greatly simplified by the patient portal.

Portal appeal aside, consumers have been slow to adopt PHRs due to a lack of incentives, says Harry Greenspun, M.D., a senior advisor in the Deloitte Center for Health Solutions, Washington, D.C. "PHRs were the rage mainly among PHR vendors," he says. According to Deloitte's annual survey of consumer attitudes about health I.T., just over 10 percent of the population maintains a PHR-which the survey defines as using a computer or Web site to maintain a personal health history. "Anything from a spread sheet to a full-bore electronic record," Greenspun says. "We don't distinguish between tethered and untethered."

It's the untethered variety that providers most commonly associate with PHRs-think GoogleHealth. The technology's inconvenience creates the biggest impediment to consumer adoption, many say. David Voran, M.D., medical director at St. Joseph, Mo.-based Heartland Health's Innovation Clinic, says he tried to create his own PHR using free-standing commercial software. "It got to be a nuisance. It involves continual reconciliation of the record. When I ask patients about PHRs, they say they're not worth the effort."Instead, the clinic offers patients connectivity via a portal linking directly to its EHR, from Cerner. The Cerner portal offers transactions and features beyond the reach of most PHRs-such as granting chart access. "They can schedule visits and communicate with physicians," he says. "The majority of patients don't use the portal, but among chronic patients, 80 percent do."

Many patients with chronic conditions use the portal to query their physician about minor problems, rather than booking appointments.

"We're not billing for that and they save a ton of money" by avoiding office visits, Voran says. It's direct access to their official record that lures patients, he adds. "Patients want to use the record their doctor sees."

The University of Pittsburgh Medical Center tried in vain to introduce PHRs into its workflow. Running more than 20 hospitals (including eight at the HIMSS Analytics Stage 6 of EHR adoption), UPMC was an early partner with GoogleHealth, recalls G. Daniel Martich, M.D., chief medical information officer.

"We tried to promote Google, but patients didn't want to go there. They voted with their feet and we abandoned that approach." The problem, Martich summarizes, is the lack of connectivity between the PHR and the regular record. "If you want to see your appointment list, you can't," he explains.

Pushing ahead

Undeterred by lack of interest in its PHR offering, UPMC has pushed on with its patient portal, a secure-access site that is part of its Epic EHR. Called HealthTrak by UPMC, about 87,000 patients use the portal, Martich says, launching into a list of features and functions. "Patients can see a summary view of old and new meds, make refill requests, see lab and radiology results, and view upcoming appointments," he says. "We also have e-visits."

E-visits are most commonly for minor complaints such as sore throats and headaches, although they can also tackle impotence and birth control-related questions. UPMC conducts about 150 monthly e-visits through its portal, requiring a co-pay from patients to participate.

In the set-up, patients log in, check off a standard disclaimer about the visit being a non-emergency, then proceed to describe their problem from standard pull-down list of problems. Based on the problem, the system walks patients through a list of standardized questions, which are driven by a behind-the-scenes algorithm, gauging the response and then pushing out the next appropriate question. Most of the time, the question goes directly to a primary care physician assigned to the patient's group, Martich says. "The patient usually receives a response within three hours," he says, with most replies coming by secure messaging containing advice about how to proceed.

Martich says the portal also helps keeps patients with chronic conditions engaged in their care. "We're trying to make office visits more transparent with more data sharing," he says. For example, using the portal, diabetic patients can track lab values and clinical measures online, graphing their lab scores and cholesterol counts. Seeing those values helps patients take more responsibility for their own outcomes, he says. "The portal helps patients manage their problems."

Many EHRs now include portal and PHR applications, but some hospitals have opted to build their own patient interfaces. Sharp HealthCare, San Diego, looked at commercial portals five years ago and decided it needed to build its own, says Anthony Sacks, M.D., a family physician at Sharp Rees-Stealy Medical Group, a 350-physician group practice mandated to use the portal to communicate with their patients. About 30,000 patients have registered to use the portal, which offers secure messaging, online bill payments, appointment scheduling and access to portions of the patient chart (an Allscripts EHR). Sharp did maintain a connection with the old GoogleHealth, which enabled patients to transfer certain information from the Allscripts system into their private PHR. But after Google closed shop, Sharp has not considered adding other PHRs to the mix, Sacks says. "PHRs seem like a vehicle for advertising," he says.

A tangled environment

For many in the industry, Google's withdrawal from the PHR business reflects the difficulty of entering the health care industry as much as limitations of the technology. The health care information stream is both tangled and highly regulated, causing some organizations to avoid embracing PHRs.

Heartland Health considered a project that would push out data from its in-house EHR chart to a PHR, says Voran, the medical director, but "the compliance officer said that would raise too many hackles," he recalls. "We would be pushing out HIPAA-protected data and creating all these possible use scenarios. We would have no assurance that unauthorized data mining was not taking place."

The downslide for PHRs dismays many technology proponents-but does not necessarily surprise them. "The ideal of a portable record, under patient control, which seamlessly connects with places where the patient gets care, turns out to be a challenge on a number of levels," says Daniel Sands, M.D., one of the pioneers of the patient portal. "Patients are not willing to enter many things on their own. With a portal, you are giving the patient a view that is already there, that's already structured and reconciled."

Sands now serves a chief medical informatics officer at Cisco Inc., having reduced his medical practice to a part-time primary care role at Beth Israel Deaconess, Boston. In 2000, Sands helped the hospital launch PatientSite, one of the industry's first patient portals. Still in use, the portal enables any number of transactions and grants access to the patient's EHR. "People are adopting the tethered PHR because that's where it's easier to get it right," he says. "All the major EHR vendors have embraced the patient portal module. None of the free-standing PHR vendors has been very successful."

The principal drawback to the hospital-controlled portal is the limited portability of the record, Sands acknowledges. "When patients sever ties with the institution, they can't take their information with them," he says. "We don't have EHR connections across the country to make it easier."

In the short run, that lack of portability won't affect many patients, Sands contends. "Increasingly, there's consolidation among provider groups to large systems. The portal is going to be the only thing you need. As the industry consolidates, the portal will be fine for the majority of patients-unless they move. We need to figure out how to connect our disconnected system through health information exchanges, so patients will have access to their own data through them."

As the industry moves away from fee-for-service to outcomes-based reimbursement models, the need to maintain connectivity with patients becomes even greater.

The shifting payment landscape is a big driver behind patient portals. Practices like Women's Care Florida need to run as efficiently as possible-and automating transactions via the portal is a timesaver for patient and provider alike, according to Mervis and Mangan. Using the Greenway portal, patients can fill in customized forms online prior to the visit, information which ports to the task list in the EHR.

"The staff can compare the old history with the new before accepting," Mangan says. Each year, the practice completes some 8,000 appointment requests and 2,500 prescription refills through the portal, transactions which once required phone calls and paper notes. Inevitably, during those calls, staff would small talk with patients, protracting the call needlessly, Mervis adds. "There's no more chit-chat with the staff when they call now."

Other practices are looking to combine a portal with embedded PHR capabilities to keep tabs on patients with chronic conditions. The Santa Clara (Calif.) County Independent Practice Association is a consortium of 800 physicians and treats over 100,000 patients, with many enrolled in commercial ACO plans, says Wayne Pan, M.D., the chief medical officer.

The IPA has deployed an administrative portal for its physicians, which collects and adjudicates referrals automatically with an adjoining messaging feature. The home-grown case management system, called Access Express, is supplemented by a clinical hub, from AxSys Technology, Scotland. The clinical hub includes a portal which gives patients the ability to enter in certain data into a PHR, which can be shared with providers, says Pan.

"There have been many false starts with PHRs," says Pan. "So we are taking a disease-specific approach. We are starting with the most difficult diabetic patients." With its limited initial purpose, Pan hopes the PHR will catch on with patients. "When we talk to patients, there is not an onslaught of requests to connect to commercial PHRs. But they are looking for tools to manage their disease process."

Portals also figure in meaningful use payouts. Some 140 physicians strong, Worchester, Mass.-based Reliant Medical Group (formerly the Fallon Clinic), has received nearly $2 million in incentive payments, says Larry Garber, M.D., medical director, informatics. "As part of meaningful use, we must give patients access to their record, their test results and allow them to get electronic copies," he explains. Using Reliant's portal, which is part of its Epic EHR, patients can download a Continuity of Care Document, or CCD, which summarizes key clinical measures, thus enabling Reliant to meet that meaningful use requirement.

At UPMC, patients can see their data from the ambulatory setting and inpatient alike, notes Martich, the CMIO. Its portal is housed in its ambulatory system, but any inpatient discharge summaries, ED reports, and operative reports are conveyed to the patient's individual HealthTrak account, he adds.

Enter accountable care

That kind of data sharing will be critical to the success of accountable care, says Mary Ann Holt, R.N., a partner at IMA Consulting. "The PHR is a way to provide a cohesive longitudinal record for any consumer," she says. "In the high-deductible era, there are more financial demands on patients. We have to get out of the mode that we enable consumers to not be responsible for their care. The PHR would help transition some responsibility to the consumers."

Holt understands the limitations of untethered PHRs, explaining that there will always be interface issues between a standalone record derived from an EHR-driven patient portal and a portable PHR controlled by patients. The central limitation to the portal is the inability of providers outside a given hospital network to see the data in it. And high-risk patients, the kind targeted first by accountable care, often see a multitude of specialists. A diabetic patient may have multiple specialists, Holt notes. "If they're not connected to the health system sponsoring the patient portal, giving them access to a PHR helps with coordinating care."

There are ways around the medical staff privilege limitations of a provider-controlled patient portal. At UPMC, for example, patients can grant proxy access to their HealthTrak PHR, says Martich the CMIO. "They could grant it to family members or to other physicians," he says. UPMC is also in the early stages of enabling patients to enter their own data to their PHR. Right now, patients can send data directly to their physicians via the secure messaging system and ask them to add the new data, Martich says. This coming summer, patients will be given the ability to update their charts directly, but any changes must be approved by the physician. "It is a way to insure the quality of data is at a certain medical standard," the CMIO explains.

One of the biggest gaps in the provider-controlled patient portal is its ability to capture between-visit care data, such as blood sugar scores for diabetics or weight for CHF patients. Mike Lee, M.D., director of clinical informatics at Newton, Mass.-based Atrius Health, says in the future the PHR can help with "patient stealth management," or monitoring clinical data between visits in areas such as weight loss.

Atrius Health spans six large group practices (Reliant Medical Group among them), totaling more than 1,000 physicians, treating about half of its patients on an at-risk basis through various ACO-like contracts. Atrius has more than 200,000 active users of its patient portal, which is part of its Epic EHR. The portal offers a wide array of services, including appointment requests, secure messaging, and delivery of test results.

Thanks to promotion of the service by physicians, enrollment has grown rapidly-from 25,000 patients at the end of 2008, Lee says. "Tethered portals have done much better than anyone expected," he says. "Patients are using them since they are tied directly to their physician."

Atrius hopes to capitalize on the popularity of its portal and expand its reach. "We are trying to figure out how to reduce morbidity and get patients to change their behavior in the time they are not at the doctor's office," Lee says. "There is a huge market in smart phones for patient self-management tools. The trick is trying to integrate the data in any sensible way with the patient portal or the EHR."

Using a freestanding PHR, Reliant Medical Group is attempting to close the gap between the patient portal and between-visit care, says Garber, the informatics director. It currently has a pilot project underway involving HealthVault, PHR software offered by Microsoft, in which diabetic patients will be monitored remotely (see sidebar, page 24). Garber says more needs to be done with patient connectivity. "Downloading a CCD is only half the value," he says.

The next Holy Grail?

PHR-enabled, two-way data exchange with patients may prove to the Holy Grail of the industry. In Los Angeles, one federally qualified health centre is attempting to attain it. Targeting underserved patients, AltaMed Health Services includes about 100 providers, mostly primary care, says Martin Serota, M.D., chief medical officer. By combining EHR, PHR and health information exchange technology, Serota says the center is hoping to build "a more robust model" of patient connectivity.

According to the plan, patients would access certain data generated from AltaMed's EHR, from NextGen, by using a portal from HealthAccess Solutions. That data will feed a PHR embedded in the portal. At first, AltaMed would populate the PHR with lab results, clinical messages and X-ray results. Then, it will build out bi-directional capabilities, enabling patients to ask for appointments and med refills. AltaMed also is building a data exchange. Three partner hospitals, via the HIE, will send data to discrete fields in the PHR.

The PHR as Device Connector

A group of a dozen diabetic patients at Worchester, Mass.-based Reliant Medical Group is participating in a pilot project aimed at tackling one of the industry's thorniest problems-tracking patient progress between office visits. In the pilot, the patients will capture their blood pressure scores, using cuffs from Omron Inc., which will feed data directly into a PHR, from Microsoft Corp. In turn, the HealthVault PHR will feed data directly into the practice's ambulatory EHR, from Epic. If the project works as anticipated, both patients and physicians will be better served, says Larry Garber, M.D., medical director, informatics at the 250-physician group practice.

The participating patients will be a group of high-risk patients-diabetics whose blood pressures are not in control. Prior to the Microsoft project, the patients had two ways to report their blood pressure readings to their providers. "They would call us and tell us the readings," Garber says. "That was not very efficient for either the patient or us." Alternatively, the patient could enter the data themselves via the practice's portal, a step that "was better for the practice, but not very efficient for the patient. We wanted to improve data collection for both of us. We wanted to automate the process."

Microsoft's HealthVault platform has built-in interfaces to a growing list of commonly used medical devices, Garber says. By using HealthVault, the practice sidesteps having to build multiple interfaces to its EHR in order to trap data from medical devices used in the home, he points out. "HealthVault will be our aggregator of devices."

In the set-up, any data gathered via the Microsoft PHR will flow directly into Epic. The Epic system will be configured to send a message to a clinician after two weeks' worth of data have been entered. If a value comes across in a dangerous abnormal range, it will send an alert. A nurse can review the data in Epic and the patient can gain similar access through the practice's EHR portal. The patient could also use HealthVault-a potential repository for other data-but they are not obliged to, Garber says. "HealthVault is the conduit."

Once the practice moves beyond the pilot, it will analyze other devices to monitor via HealthVault. Monitoring weight remotely would be valuable for congestive heart failure patients, Garber says, noting that weight fluctuations can signal problems with the heart. "If patients are more engaged in their day to day care, and we are part of that, they will be healthier," Garber says, adding that half of the patients the practice treats are seen under shared-risk contracts, which reimburse in part on outcomes.

Still Bullish on Free-standing PHRs

Six years ago, after he became president of NoMoreClipBoard.com, Jeff Donnell did a market analysis of the PHR competition. "There were about 150 PHR competitors," he says. "By now, most have either gone belly up or been acquired. There has been so much churn because these companies were either focused on the clinician, or the consumer, but not on both. One reason we have been able to survive is that we are striving for a balance in value."

When NoMoreClipBoard.com first launched, Donnell says the company focused on the direct-to-consumer market. "We figured everyone would want their own PHR," he recalls. "We were early to that party." The company recast its strategy, and now offers its PHR-still a patient-controlled, portable record-to health systems and group practices, which sponsor the product on behalf of their patients. About 400 group practices and 25 health systems use the service, which is branded by the sponsoring organization and is often integrated with the local EHR. Donnell is quick to distinguish NoMoreClipBoard.com's PHR from EHR access granted by most patient portals. "Most of those tethered portals are little more than a window to the practice's EHR," he contends. "In most cases, patients can't add data to it or take it across town to another physician. The idea that if I see three physicians and have to use three portals is ludicrous."

The company relies on fees from participating practices, and charges nothing to patients for maintaining their personal record. If a patient leaves the practice, they can still take their PHR with them, Donnell says. In addition, the PHR can accept Continuity of Care Documents from local EHRs. He won't disclose the number of patients who have created PHRs.

Gary Baldwin

healthdatamanagement.com

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