July / August 2007
EHRs, PHRs, and ePrescribing: How Do the Pieces Fit Together?
Consider the following medical care scenarios…
You are in a car accident and are transported, unconscious, to the emergency room (ER) of the local hospital. Luckily, you are a relatively healthy person but you are on a blood pressure medicine and an anti-depressant. You are also allergic to some antibiotics. How will the ER physician know what medications you are on? How will he know your medical history? How will he give you the best care possible?
Your father spends the winter months in a warmer climate and has a multitude of health conditions including diabetes, heart disease, and a recent bout with cancer. He has located a physician near his winter home but wants to make sure that all the important information can be transported and that his primary care physician in his home state stays informed. What does he need to know? How can he make sure he will be taken care of all year round?
Your family has moved and your child needs yet another camp physical. What are the dates of those immunizations? When was his or her last physical? How can you get fast, accurate information?
What links these scenarios together is the need for health information that is accurate, complete, and available in “real time.” How challenging is it for a provider and his patient to get needed and timely information? What is the process for requesting and getting patient data? Should the patient be keeping track of his healthcare information, his parents’ information, and his children’s information? What are healthcare organizations and companies doing to help? This article provides a discussion of basic health information exchange (HIE) concepts, how these concepts inter-relate, and ongoing challenges.
EHRs and EMRs
An electronic health record (EHR) is a secure, real-time digital medical record stored on a computer or over a network. The EHR supports clinical decision-making by providing access to a patient’s health information history at the point of care. Sometimes, the acronym EHR is used interchangeably with EMR although an EMR is an electronic medical record, typically a hospital record. An important distinction between EHRs and EMRs is that an EMR is considered a type of EHR, and an EHR may be comprised of several EMRs (http://www.myphr.com). Today, most EHRs are maintained by providers. However, a significant barrier for physicians using an EHR is financial; most physicians cannot afford the implementation of an EHR unless it is subsidized. In the United States, only about 10% of physician practices have an EHR (RWJF, 2006). The benefits of EHRs to consumers are significant in terms of up-to-date information, and EHRs may include information regarding current history and chronology of presenting problems, lab results, radiology reports, hospitalizations, office visits, referrals, medications, and allergies.
While EHR “uptake” is limited, several innovative projects are underway in Massachusetts. PatientSite, an EHR system developed by the Beth Israel Deaconess Medical Center in Boston, Massachusetts, is a good example of a patient-accessible EHR (https://www.patientsite.org). Patient Gateway is a secure, web-based portal developed by Partners Healthcare System for its patients that includes, for example, e-mail, appointment and prescription requests, and access to a “Health Library” (https://www.patientgateway.org). The Massachusetts e-Health Collaborative (MAeHC, http://www.maehc.org), with $50 million funding over 5 years from Blue Cross Blue Shield of Massachusetts, has implemented EHRs in three Massachusetts communities: Brockton, Newburyport, and North Adams. Physicians in these communities have been given hardware, software, technical support, and the infrastructure to share healthcare information electronically within the communities. Education and communication are significant ongoing components of the implementation process. One of these communities is currently developing a patient-centered information portal to operate side by side with the EHR implementation.
Personal health records (PHRs) are collections of important information about an individual’s health, family history, and other pertinent, known, and available health information that can be actively maintained and updated by the patient. The source of the information for a PHR may be a healthcare provider (via an EHR) or the patient or payer claims payment statements. Two in five adults keep personal or family health records, according to a nationwide survey conducted by Harris Interactive and published in Health Care News (2004). The report also noted that there are many “good reasons” to keep a PHR. The top three included the ability to provide doctors with useful information (78%), the ability to look back and recall what care was received (78%), and the ability to have access to the record in case of emergency (77%). The goal of PHRs is to facilitate communication between patients and their healthcare team. It is more than an information repository. It is actually a platform from which one can manage his/her own care or the care of family members. “Without patients and their care team working together, PHRs are the sound of one hand clapping” (Nobel, 2007).
The benefits of linking a PHR to an EHR include the ability for the consumer/patient to have an informed discussion with clinicians, provide sufficient information to caregivers, record progress individually, and provide remote access when traveling. Consumers/patients may also be able to refer to clinician instructions, prescriptions — current and history — allergies, insurance claims, appointments, vaccinations, wellness goals, and healthcare services.
PHRs are still maturing. That is, questions remain regarding their residency, ownership, control, portability, lifespan, reconciliation with EHRs, emendation, etc. While a number of healthcare entities currently offer a version of EHR/PHR — including providers, employers, health plans, and stand-alone vendors — a significant concern centers on ownership and control of the data. For example, if an employer has offered an EHR/PHR, does that mean that it can “suggest” preventive and/or chronic condition management to employees (Business Week, 2007)? If the information is held by the health plan, can it use the information to make decisions about future insurance? If the data is managed by a stand-alone or third-party vendor, where is the assurance that the vendor will be in business in 5 years? Will they be able to use or sell the information?
What can consumers do if they want to start a PHR? An obvious place to start is with one’s primary care physician and, if available, information from an EHR. A set of “consumer principles” has been put forward by a diverse group of national consumer advocacy organizations. These include requirements for consumer access, information use, control over information sharing, system security and privacy, and transparency and accountability of health information administration (National Partnership for Women & Families, 2006).
The American Health Information Management Association (2007) has identified key elements of a PHR/EHR:
- Allergies/serious adverse event (SAE)
- Clinical notes
- Discharge summaries
- Surgical reports/pathology
- Family history
- Medications/medication history
- Doctor contact information: PCP, specialists
- Any other pertinent information you believe would help your healthcare provider gain a greater understanding of you as a whole.
Electronic prescribing (ePrescribing) is the use of computer devices by a healthcare provider to enter, modify, review, and communicate prescription information; it provides secure, bi-directional electronic data interchange (EDI) connectivity between clinicians and dispensing pharmacies. SureScripts, founded by the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA), has initiated electronic prescribing adoption programs in states across the United States (http://www.surescripts.com). In addition to the transmission of prescriptions, ePrescribing can provide clinical decision support for the provider, including patient medication history, allergy information, drug interaction alerts, formulary, and benefits eligibility information. ePrescribing is efficient and accurate because the system is entirely electronic (Halamka, et al., 2006).
The Institute for Safe Medication Practices (2000) reports that prescription errors may result from miscommunication due to illegible handwriting, unclear abbreviations, and dose designations, unclear telephone or verbal orders, or ambiguous orders and fax-related problems. In addition, the pharmacist does not need to re-key the prescription information into his or her system. There are cost-savings for the providers and pharmacies from the reduction in calls to patients, better prescriber knowledge of formulary, and fewer data-entry errors (Tufts Health Plan, 2006).
EHRs, PHRs, and ePrescribing are each evolving independently because different stakeholders have different emphases and perspectives on increasing market share, adding services, improving efficiency, increasing revenue, improving care quality and safety, and reducing costs.
Benefits and Risks
It is difficult to have a discussion about ways to hold and use electronic health information without addressing the benefits and risks.
President Bush, in his 2006 State of the Union address, talked about the need for electronic health information (http://www.whitehouse.gov/stateoftheunion/2006). The aftermath of Hurricane Katrina is testimony to the critical need for electronic health information, with scenes of physicians desperately drying paper records as they try to decipher the medications that their patients require. Electronic health information is necessary for an aging mobile society with increasingly complex co-morbidities and healthcare needs. It is no longer easy for a provider, a patient, or a healthcare proxy to manage the many pieces of data and knowledge that comprise our healthcare records. Electronic health information gives us a tool that can help.
Although potential benefits may be clear, there are a number of concerns that consumers commonly have about electronic health information. Security is an important issue for most consumers. Newspapers routinely report the loss of personal information from electronic databases (Abelson, 2007). Although the security of paper records is also at risk, the scale of a potential breach is not comparable. Breaches of paper records may result in the loss of a single or a small number of records, affecting a few people. Electronic breaches, however, can be orders of magnitude greater. In general, the security procedures for electronic health systems surpass those of paper records and typically include access-level controls via secure passwords. Large-scale breaches, such as that of the Veterans’ Health Administration, often result from the transport of the data on a laptop — a violation of standard security protocol (Yen, 2006). Consumers who are comfortable with Web-based banking and ATM activity, for example, will need to make similar risk/benefit assessments with regard to their health information.
Privacy is another primary concern of consumers. Much attention and thought is being given to the best means of providing protection through a consumer consent process that anchors the transmission of health information in those situations where the Federal HIPAA rules do not explicitly address the information exchange (treatment, payment, or operations). On the back end, electronic health records offer the ability to audit the record so that patients can find out who has had access to their records. According to a consumer advocate with Health Care For All (www.hcfama.org), “Transparency, health record accessibility and control, and easily understandable information are key to consumer support. As long as the organization or provider is clear about the privacy and security protections risks, and consumers are given access to and control of their information, they will likely be supportive of and even enthusiastic about computerized connected health records” (Lisa Fenichel, personal communication, April, 2007).
Massachusetts is part of a national privacy project called the Health Information Security and Privacy Collaboration (HISPC) that has been accomplished by the Massachusetts Health Data Consortium. The Consortium has gathered together a diverse group of stakeholders to look at common privacy practices in the Commonwealth as well as the challenges to implementing electronic health information exchange (RTI, 2007). MA-HISPC identified consent management and protection of sensitive information (psychotropic medications and those for HIV/AIDS and substance abuse) as two key issues requiring follow-up action.
Given the advances in electronic communication in the world around them, many healthcare consumers already think that physicians have all their patients’ health information in electronic format and readily available. Patients believe that their physicians can have instant recall about them, or easy access to their data, and are surprised when their physician asks them to provide a summary of their status, including tests, medications, and diagnoses. The physician has not necessarily collected nor maintained summary data, and it is not easily available when it would be helpful. The current paper medical record only works if the physician has access to it, and sometimes it is not easy to obtain.
Currently, there are many ongoing activities related to EHRs, PHRs, and ePrescribing. The list of projects mentioned below is not exhaustive but, in addition to the projects we have already mentioned, provide a “snapshot” of activities in this domain.
Masspro supports primary care provider adoption of EHRs with education and training programs throughout Massachusetts (http://www.masspro.org/HIT/index.php).
EMC Corp. believes that it can create a healthy workforce by helping employees and family members improve overall health through meaningful targeted Health Management Programs via a Web-based EHR/PHR.
Dossia is a Web-based program that developed as a result of collaboration between Applied Materials, BP America, Inc., Intel Corp., Pitney Bowes, Inc., and Wal-Mart. Dossia will allow members to create their PHR by entering the data or asking the software to search and add the information from various sources. The participating companies hope that EHR/PHRs will save money by removing unnecessary paperwork, duplicate tests, and medical errors (Los Angeles Times, 2006).
The RxGateway is a MA-SHARE initiative (www.mahealthdata.org/ma-share/projects/e-prescribinggateway.html) to offer end-to-end ePrescribing including prescriptions, eligibility and formulary checks, and allergy information. The project’s goal is to improve the speed of adoption, accuracy, and value of ePrescribing applications by electronically linking them with all major payers, prescription benefit managers, and prescription dispensing locations, including retail pharmacies and mail order services.
Partners Healthcare System, working with Recombinant Data Corporation, helped develop a clinical data warehouse and a reporting portal that supports quality reporting. The portal seamlessly integrates these reports with the electronic medical record system at Partners, so a doctor can navigate from the reports to the EMR with one click (Abend, et al., 2007).
A well thought-out integration of electronic health records and personal health records offers the promise of empowering consumers with access to timely and relevant personal health information that is linked to decision support systems to provide guidance, options, and choices for the consumer to take an active role in managing their care. As our population ages and becomes increasingly mobile, it will be critical to maintain complete health information for ourselves, our children, and our parents. We are not there yet; the challenge is to create a thoughtful, protected, long-term linkage between medical records and the richness of information held by the consumer.
Jerilyn Heinold is a biostatistician and healthcare consultant for the Massachusetts Health Data Consortium with interests in health information technology, EHR implementation, ePrescribing, and HIT for behavioral health. She can be reached at email@example.com.
Laura Allen is the communications coordinator for the Massachusetts Health Data Consortium.
Diane Stone is the project director for the Massachusetts Health Information Security and Privacy Collaboration (HISPC) project with interests in advancing health information exchange (HIE) through expanded stakeholder collaboration. She can be reached at firstname.lastname@example.org.
Abelson, J. (2007, March 29). Breach of data at TJX is called the biggest ever. Boston Globe. Available at www.boston.com/business/globe/articles/2007/03/29/
Abend, A. H., Einbinder, J. S., & Housman, D. (2007, March 23). A data warehouse and portal for clinical quality reporting. Innovator Spotlight Series. Massachusetts Health Data Consortium.
American Health Information Management Association (AHIMA). (2007). My Personal Health Record: A guide to understanding your personal health information. Available at www.myphr.com
Dimitropoulos, L., et al. (2007, March 5Ç7). Comfort in paper: Bringing stakeholders to the table to discuss private and secure eHIE. National HISPC Meeting, Bethesda, MD. Available at http://www.rti.org/page.cfm?objectid=
Get healthy or else. (2007, February 26). Business Week.
Halamka, J., Heinold, J., Fournier, G., Stone, D., & Berry, K. (2006). E-prescribing in Massachusetts: Collaboration leads to success. Patient Safety & Quality Healthcare, 3(5), 26-30. Available at http://www.psqh.com/sepoct06/e-prescribing.html
Institute for Safe Medication Practices. (2000). Electronic prescribing can reduce medication errors. Available at www.ismp.org/newsletters/acutecare/
Los Angeles Times. (2006, December 7). Companies join forces on “medical internet.” In The Boston Globe. Available at www.boston.com/business/technology/articles/2006/12/07/
Markle Foundation. (2003). The personal health working group final report. Connecting for Health.
Massachusetts Health Data Consortium. (2007). MA-Share. Available at www.mahealthdata.org/ma-share/projects/
Masspro. (2007). Doq-it/HIT services. Available at www.masspro.org/HIT/index.php
National Partnership for Women & Families. (2006). Health information technology — Consumer principles. Available at www.nationalpartnership.org/site/DocServer/HIT_20-
Nobel, J. (2007, February). Massachusetts Health Data Consortium Special Newsletter.
RTI. (2007). RTI International supports national health information security and privacy collaboration (HISPC). Available at www.rti.org/page.cfm?nav=7&objectid=
Robert Wood Johnson Foundation (RWJF). (2006). Health information technology in the United States: The information base for progress. Available at www.rwjf.org/files/publications/other/EHRReport0609.pdf?gsa=1
Tufts Health Plan. (2006). ePrescribing collaborative boots patient safety with 8,000 prescriptions changed in June. Available at www.tufts-healthplan.com/about.php?_
Two in five adults keep personal or family health record and almost everybody thinks this is a good idea. (2004). Health Care News, 4(13).
Yen, H. (2006, June 6). Figures on stolen VA data increased. About 2.2 million personnel affected, government says. Boston Globe. Available at www.boston.com/news/nation/washington/articles/2006/06/07/