July 23, 2007

PHRs — Popping Up Everywhere
By Neil Versel
For The Record
Vol. 19 No. 15 P. 26

The number of companies that have developed personal health records continues to mount without a let-up in sight. This report spotlights a few of the major players and their plans to make a difference.

Look just about anywhere in HIT—even outside traditional channels—and you’re apt to find a personal health record (PHR) in one of its many shapes and forms.

Practically every week, some company announces a new or enhanced PHR offering. Legislation pending before Congress, which seeks to promote PHR usage by funneling private money to physicians as an incentive for adopting the technology, has the backing of business and consumer groups and healthcare providers.

Lately, the topic is high on the agenda at every major HIT conference in the United States and abroad. Earlier this year, health insurer Aetna even advertised its PHRs on Washington, D.C.’s Metrorail trains.

Indeed, payers, employers, health systems, and scores of technology vendors are falling over themselves to bring PHRs to market, with the stated goals of empowering patients, increasing efficiency, and improving the quality of care.

“Right now, there are a lot of companies jumping into this space,” notes Wendy Angst, general manager of CapMed, a Newtown, Pa.-based PHR subsidiary of Bio-Imaging Technologies, Inc., a company that manages digital medical images for clinical trials. CapMed has had a PHR application for more than a decade. Since 2002, the company has offered the PHR on an encrypted USB drive called HealthKey.

“We believe it’s the personal health record that will help accelerate the acceptance of the electronic medical record in the physician office,” says Wayne Gattinella, president and CEO of WebMD, the New York-based consumer health information giant that’s offered a PHR since 2002. Only this year, however, did WebMD make its PHR free, a sign of the growing competition for the hearts and minds of healthcare consumers.

Revolution Health, a company started by and supported with the substantial bankroll of AOL cofounder Steve Case, now offers free online “personal health homes.” For the past two years, Intuit has had a version of its popular consumer-finance software called Quicken Medical Expense Manager for tracking healthcare bills and spending and has announced plans to release a Web-based product called Quicken Health before the end of 2007.

The new Quicken title promises to incorporate clinical information and eventually be interoperable with health information exchanges. UnitedHealthcare and Cigna HealthCare are among the insurance companies pledging to sponsor Quicken Health for their enrollees.

Microsoft and Google also have indicated their interest in PHRs, particularly in the area of the “health URL,” essentially a patient’s medical home in cyberspace.

Long-standing rumors suggest that a simplified PHR called Google Scrapbook could emerge this year, but the Internet search leader remains characteristically silent. Still, Google keeps trotting out Vice President Adam Bosworth to speak about healthcare and occasionally drop hints about the company’s plans.

In March, at the Fourth Health Information Technology Summit in Washington, D.C., Bosworth indicated that Google users are asking four kinds of questions in healthcare: What may be wrong with them? What information is relevant to their conditions? Who can help treat an illness? How can patients with chronic diseases live with and manage their conditions?

“It is astonishingly hard to find that information,” Bosworth said. “And honestly, we don’t know how to answer these four questions just yet.”

Even though quality-improvement organizations and advocates for consumer-driven healthcare have been advising potential patients to research the number of times a physician or hospital has performed a certain procedure, that information is not readily available. “We’d like to deliver that,” Bosworth said, adding, “Search is a really good tool for finding relevant information.”

One month later, at another healthcare gathering in the nation’s capital, Bosworth continued on this track. “Honestly, the problem isn’t that there’s no data,” he said. “The problem is that the data isn’t flowing to doctors to help them make better decisions.” This conundrum, according to Bosworth, helped hasten his own mother’s death from cancer.

Bosworth also said those who are ill should have a personalized health URL where caregivers can go to share information and discuss treatment options. “This isn’t rocket science. It is Online Web Applications 101,” he said.

The idea of a health URL did not start with Google nor is it exclusive to Revolution Health. For example, MedCommons, a privately held company in Watertown, Mass., already has a product called Health URL, a secure, patient-controlled Web page that summarizes basic health status, including diagnoses, medication lists, and allergies, based on the continuity of care record (CCR) standard.

“It’s a patient-centered view of the world,” explains MedCommons Chief Science Officer Adrian Gropper, MD.

The CCR helps create interoperability, something Gropper believes is sorely lacking in health information these days. “We are CCR-native, so when people give us something, we can give it back,” Gropper says. Additionally, the Web helps encourage data sharing by incorporating relevant information around hyperlinks and RSS feeds, he adds.

The health URL is “really a dynamic and interactive concept,” says David Kibbe, MD, MBA, senior advisor to the American Academy of Family Physicians’ Center for Health Information Technology. A single online home for a patient’s information moves the focus of technology away from software to the control of data, much in the way that social networking sites like MySpace and Facebook do.

“I think the idea of social networking here is about taking control of health experiences,” Kibbe says. A health URL would provide access not only to basic health data but also to relevant documents, images, and video. “All of those things might be useful in taking more control of your health and healthcare,” Kibbe says.

The general consensus is that a PHR, in whatever form, is merely a subset of a true electronic health record. Where many of the PHR advocates diverge is in the source and scope of the content, as well as the physical form of the record.

“Our focus for the future is on portability,” says Gattinella, explaining why he believes a Web-based product makes the most sense. In a truly interoperable environment, the PHR will provide seamless integration into a healthcare provider’s systems. This means the patient won’t have to fill out a clipboard, and the doctor won’t have to go searching for the patient’s basic health and insurance information. “It’s an electronic version of what you’d typically be asked to fill out in a physician’s office,” Gattinella says.

This is such a sticking point with patients and providers that one PHR vendor in the crowded marketplace actually calls itself NoMoreClipboard. And one component of the medical profile—namely medication history—is so important that some companies are focusing their efforts right there.

MediModules, a year-old company in Brooklyn, N.Y., is one such vendor, offering the framework for a comprehensive, patient-centric medication list. “There’s only one person who truly knows about all [an individual’s] medications,” says MediModules President and CEO Abha Agrawal, MD. That person, of course, is the patient.

The company has two products: MediRecon for healthcare facilities and a patient portal called MyMediList. Both go beyond the typical hospital portal to permit patients to include drugs prescribed outside one particular health system. “Where we saw it from the beginning is that the patient has to be involved at every level,” explains Munish Khaneja, MD, MediModules’ chief medical officer.

With MyMediList, a master prescription list is loaded onto the site so there is no free-text entry, reducing the chance of selecting the wrong drug or dosage. With some PHRs, “I could type ‘strawberries’ for a medication I’m taking,” Agrawal says.

A complementary service, MediWallet produces a wallet-sized printed report of a patient’s MyMediList record. It is updated in real time, and the date is included on the printout so a doctor can know just how timely the list is. “We made it portable so even in the paper world, you still have some safety,” Agrawal says.

“Online access is not the only portability you need,” adds Khaneja.

CapMed has a similar mindset. The company’s strategy in the near term is to develop a PHR in three interchangeable formats: the USB key, a desktop version, and an online record. “The model is for the consumer to use any of these,” Angst says.

At the 2007 HIMSS conference, CapMed demonstrated how Bluetooth-enabled mobile phones could receive readings from home monitoring devices and send the same information to a PHR.

CapMed sells directly to consumers, although Angst sees greater opportunity in the business-to-business market. “CapMed’s had a lot of success in the hospital market, but we’ve had more with employers and health plans,” she says. “It seems like health plans and employers are the places to be right now.”

Employers in particular are making a lot of noise about PHRs, particularly those involved in Dossia, an ambitious project funded by Wal-Mart, Intel, Pitney Bowes, BP America, Applied Materials, and Cardinal Health. Dossia intends to provide “lifelong” PHRs to employees of each participating company, records that individuals will be allowed to take with them even if they change jobs or retire.

Announced with much fanfare last December, the not-for-profit Dossia will debut its Web-based technology over the next few months and may add up to four additional corporate partners before the end of the year. After the first 10 companies have their employee records online, Dossia may produce an offering to small businesses.

Omid Moghadam, director of PHR programs at Intel, says the computer chip maker spent 11/2 years looking at many of the more than 200 PHR options in the marketplace but nearly all were “tethered” to a single vendor, health system, insurer, or employer, and information was scattered. This set-up resulted in two significant roadblocks. “You have to go through nine or 10 different sources, and you can’t take it with you when you change jobs,” he says.

“Fragmentation is what we realized is the big problem,” adds Moghadam. “What that requires is for the individuals to gather and enter all the information themselves.”

He and others believe that it is unreasonable to expect all but the most conscientious patients to keep their records up-to-date, complete, and accurate.

“It’s another thing on the to-do list [for patients],” says PHR blogger Jean Henshaw. “Until they feel they absolutely need it, people won’t be doing it. People who don’t have health issues probably won’t use it. Folks who do have health issues will see that this is valuable.”

She says doctors are skeptical when they see her self-maintained record. “They think it’s cute,” says Henshaw. “It’s my personal health record so they don’t take it as seriously as their own records that they keep.”

Why would a physician ignore the information contained in a PHR? “Because doctors are extremely busy people, they are very specific about using things that help them do their jobs and ignoring things that don’t create value,” reasons Charles Kennedy, MD, vice president for HIT at health insurer WellPoint.

The Indianapolis-based company has enlisted WebMD to build PHRs for its members, starting with self-reported medical history information and data from billing claims and pharmacy records. Likewise, users of Dossia PHRs will have the option of keying in their own information to supplement what can be gathered from claims and, when available, electronic medical records.

“There is enough [existing] electronic data to make a pretty good record,” Moghadam says. “The combination of claims and pharmacy data will get you about 80% there.”

Health insurers are thinking along the same lines, working through the America’s Health Insurance Plans and the Blue Cross and Blue Shield Association to develop a standard for a “payer-based” PHR.

Some of the larger payers, including Aetna and numerous Blue Cross and Blue Shield plans, including WellPoint’s, offer various flavors of PHRs through their Web portals.

“The vast majority of data exists in the payer’s hands,” says John Capobianco, president and chief operating officer of Medecision. This Wayne, Pa.-based technology firm is working with many health insurers to create “patient clinical summaries,” essentially payer-created records that have been clinically verified for accuracy.

ActiveHealth Management, an Aetna subsidiary, does similar work with claims data. A new “supercomputer” to process the information puts clinical decision support behind both Aetna’s PHR and a standalone product sold to large, self-insured employers. “I think we’ve got one of the only PHRs that’s backed by clinical decision support,” says ActiveHealth Executive Vice President and Chief Information Officer Frank Norman.

“Without the decision support, it’s like having all the ingredients of a soufflé but not the recipe,” adds Lonny Reisman, MD, ActiveHealth’s CEO.

The same can be said not only for a payer-based record but for a PHR in general, according to Gattinella. “At the end of the day, the personal health record is a means to an end,” he says. “It’s the tools that surround it that make it relevant.”

— Neil Versel is a journalist in Chicago specializing in HIT.