Personal Health Records (PHR) on the Rise Again

In last several years, the term PHR has risen, fallen and then risen again. What caused the rise in interest in PHRs again? Where is the interest coming from?

 

●      What is a PHR?

●      What functionality can a PHR have?

○      What value does a PHR bring?

●      Can I mix my PHR with my EHR

○      Tethered

○      Not tethered

●      What are the different PHRs out there?

●      Is it part of meeting meaningful use?

 

What is a PHR?

This is a quote taken directly from the CMS website, “In general, a Personal Health Record (PHR) is controlled by the individual, and can be shared with others, including caregivers, family members and providers.  This is different from a provider's electronic health record, which is controlled by the provider just as paper medical records are today.  Ideally, a PHR will have a fairly complete summary of an individual's health and medical history based on data from many sources, including information entered by the individual (allergies, over the counter medications, family history, etc).”[i]  So in summary a PHR is a way for patients to input their own health data and review it. A step closer to the Medical Home concept (also known as Patient-Centered Medical Home[ii])

 

What Functionality can a PHR have?

PHRs can have all different sorts of functionality, just like an EHR. Here is a list of different functionalities that can be found in PHRs currently:

●      Entering Med History

●      Entering Allergies (Med & Environmental)

●      Present Medication Alerts

○      Drug to Drug Reactions

○      Drug Dosage

○      Drug duplications

○      Drug reactions to allergies

●      Entering Past Social History

●      Immunization Records

●      Entering Family History

●      Entering Medical Device information

○      Automatically

○      Manually

●      Scheduling/rescheduling for doctor visits

●      Renewing Medication Requests

●      Send communications to hospital staff

○      Doctor

○      Triage Team

○      Etc

●      Update Demographic information

○      Share data with others

●      Can share with such entities as the Genomix research link

●      Link to Pharmacies to receive up to date medication information

●      Test Results Viewable

●      Access to radiology reports

●      View portions medical chart

 

With this list of possible functionality, we can start to see the value that a PHR can bring. If a patient updates their medication list or has a direct link to the pharmacies that he or she uses, such as CVS, Walgreens, etc their medication lists can update automatically, and in turn, update their med list in their physicians EHR as unverified meds. The physician can then verify the medications at the patient’s next visit. There are multiple values to be found just in this aspect alone: patients have a medication list up to date, physicians have the medication list up to date, clinical intake time decreases with having to type out, find, and entering medications in the EHR. Another aspect that can save time and increase patient health is that if the patient is traveling or has to go to the hospital, they can give access to the ER physician to see all of their PHR data. And/or the patient could wear a PHR bracelet and the physician could use an emergency physician code to get the data if the patient is unconscious.  The patient would have to allow this type of access.
 

Another value adding functionality is the scheduling and rescheduling function that a PHR can offer. This functionality will cut down the amount of calls and work required by the front desk.   Additionally this would also cut down confusion and time delays with patients, with having a single source to find when and where their appointments were.

 

Can I mix my PHR with my EHR

There is a lot of value to be found in a PHR, but that value really only can be amplified when a PHR is linked (tethered) to the physicians EHR/PMS.  Without this link, a PHR is only a tool for a patient to collect and store medical information, which in itself is not a bad thing, but does not bring as much value to the Medical Home concept as a linked PHR. Many EHR vendors offer a PHR that will link to their system however many  of them offer limited integration . Be sure to review the capabilities/functionality before picking a PHR to link with your system.

 

What are the different PHRs out there?

As mentioned there are a number of PHRs out there: below are some examples. 

GoogleHeath - https://www.google.com/health

Microsoft’s HealthVault - http://www.healthvault.com/

Dossia – http://www.dossia.org

MyChart - http://www.epic.com/software-phr.php

Indivo- http://indivohealth.org

MyHealtheVet – (Used by VA) – http://www.health-evet.va.gov

iHealth – http://medfusion.net/ihealthrecord/

 

Is it part of meeting meaningful use?

With meaningful use coming into play, we need to know where a PHR fits.  According to the 2011 Objectives[iii] (listed on the Meaningful Use Matrix):

 

The goal is to electronically capture in coded format, and to report health information and to use that information to track key clinical conditions

●      Provide patients with electronic copy of- or electronic access to- clinical information (including lab results, problem list, medication lists, allergies) per patient preference (e.g., through PHR) [OP, IP]

 

With that stated, a PHR is required by 2011 to meet ‘meaningful use’.

 

In closing, it is clear that a PHR will be part of your HIT role out either to meet meaningful use and/or to bring value to both patients and your organization. In upcoming blogs we will discuss PHRs in more detail, and perhaps provide comparative analysis..

 

 

[i] http://www.cms.gov/PerHealthRecords/

[ii] http://www.medicalhomeinfo.org/

[iii]http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_11113_872719_0_0_18/Meaningful%20Use%20Matrix.pdf

 

Meaningful Use

How should Organizations define the budget, resources and timeline to achieve meaningful use criteria and quality for stimulus payments? Physicians with Electronic Health Records (EHR) that can show “meaningful use” in 2011 are eligible for $44,000 over 5 years through Medicare and $65,000 over 6 years through Medicaid. The Centers for Medicare and Medicaid Services (CMS) published the revised meaningful use criteria on January 13, 2010. An overwhelming amount of public comment has been provided in regards to the criteria not being achievable and unrealistic for the timeframe. The Government does not intend for every healthcare organization to achieve the meaningful use payments because there would be budget deficits similar to the cash for clunkers program in 2009. The challenging meaningful use criteria will motivate a large percentage of early adopters and those already in the implementation process. These early adopters will likely receive the payments, as they should, while those organizations that did not take the risk prior to ARRA may be able to qualify in a future stage or just avoid penalties. Regardless of the state of the organization there are 3 essential management tools that must be in place to achieve meaningful use in every organization. These tools include a visual timeline, a resource matrix and a meaningful use dashboard.

1. Visual Timeline
The visual timeline is typically created in Excel or in other software applications. The Excel worksheet is typically configured with calendar months on top and applications down the left side with merged cells that represent duration for implementation projects, upgrades and integration projects. We recommend adding bold lines vertically corresponding to the calendar months with each meaningful use stage. The objective of the visual timeline is to provide a visual representation of the program to be implemented to meet each stage for stimulus payments.

2. Resource Matrix
The resource matrix should be combined with the visual timeline. In order for the timeline to be achievable, resources must be procured to complete the work. Resource effort should be estimated to match the duration in the visual timeline. The cost of the resource may also be added which will be a key input into budgeting for meaningful use.

3. Meaningful Use Dashboard
The third tool is a dashboard with meaningful use criteria by stage to track whether the metric has been achieved and calculates an organization’s percentage of completion by stage. The dashboard provides an executive review of progress to these strategic initiatives and planning for metrics that are at risk of not being achieved.

Whether the organization is already live or just beginning the journey, these tools are essential for an accurate timeline, budget, resources and dashboard to achieve meaningful use. For more information regarding these tools and approach please contact us at information@projectnavigation.com or 610-590-0336.

Training Strategies for Minimizing Impact to Physician Productivity:

The training experience is one of many critical components that help determine the level of success of migrating to an EHR. A poor training experience can leave a provider confused, frustrated and less willing to embrace the change thrust upon him. When looking at training impact on productivity of providers alone, there are several items worth considering:

1. How to maximize classroom time

a. Strong facilitator and trainer

b. Workflow and role based training with real scenarios

c. Confirm room and training devices are ready prior to the start of the training session

d. Clearly communicate location, parking, training session start and end times

2. Communication prior to training session

a. Basic understanding of the project

b. The Vision

c. Realistic Expectations

d. Phasing

e. Reasons for Change

f. Online tutorials

3. Consider offering training during non peak patient hours

a. Early Morning

b. Early Evening

c. Weekends

4. Understand the level of complexity of the material and scope of change

a. Allot appropriate amount of training time given the specific software and functionality being introduced - If a session only needs to be 60 minutes, don’t schedule 3 hours as well the reverse

b. Avoid spending too much time on components that are relatively intuitive, and focus on those items that are significantly changing critical to daily workflow

5. Schedule sessions close to when the EHR will get used in a live setting

6. Expect that coaches will be necessary the first few days that providers use the new system and processes

As part of the overall training experience, classroom time away from patients must be well spent. Along with many other components, well planned training will help minimize impact to Physician productivity during the initial implementation of an EHR.

EHR Resource Planning (4) – Resource Calendar and Task Relationships

Creating a resource calendar and determining the relationships between tasks is the forth blog in the multi-blog series on estimating resources for an electronic health record (EHR) project. The first blog, Introduction, describes the basis for these blogs and the series of blogs that will follow. The second blog, Defining Resources, discuses how to create the tasks and designate the resources roles assigned to the task in a resource assignment matrix (RAM). The third blog, Estimating Task Work and Duration, explained how to use the RAM created in blog two estimate work and duration for each task. The forth blog will continue to expand on the third blog and move into assigning calendars and tasks relationships to the project plan.

We use calendars in our everyday life to document import events that we don’t want to forget. In project management a calendar is used document a block of time that is available to complete a task. There are 3 types of calendars project, resource, and task. Essentially a calendar can be assigned to an entire project, a specific resource, or a specific task. A calendar should capture the following information work week start day and time, work week end day and time, holidays, vacation days and any exceptions to a typical work week. Once the calendar is defined, the next step is to assign it to the entire project, a specific resource or a specific task. In some projects it may be necessary to create several calendars and have calendars assigned to all three levels. Note that there is a hierarchy to the calendars: task then resource then project. The task level calendar trumps all other calendars, the resource is the next in line and finally the project level calendar is applied to each task.

Once the calendar is created we can start to define the relationships between tasks. What is a relationship in project management terms? Think of it as defining the logical order in which tasks must be completed. The idea is to document the relationship between tasks to create the logical association. There are four types of relationships: finish to start, finish to finish, start to start and start to finish. Finish to start requires that the predecessor task is completed before the successor can begin. Finish to finish requires that the predecessor task is complete before the successor can be completed. Start to start requires the predecessor to start before the success can start. Finally, start to finish requires the predecessor to start before the successor can be completed. It is essential that all tasks have a predecessor and successor. This allows the movement of a task’s start date and finish date to propagate throughout the entire plan based on relationships created. For example, if a task requires an increase to the duration the successor tasks start and finish date will automatically update based on the relationship created to the predecessor task.

At this point you now have a complete project plan. The next challenge is disseminating this information to all the resources and stakeholders. Many organizations choose not to buy an expensive project management software licenses for all their employees. In the next blog we will discuss options on how to distribute a project plan and build custom reports with Microsoft Project and Office.

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EHR Resource Planning (3) – Estimating Task Work and Duration

Estimating the work effort is the third blog in the multi-blog series on estimating resources for an electronic health record (EHR) project. The first blog, Introduction, describes the basis for these blogs and the series of blogs that will follow. The second blog, Defining Resources, discuses how to create the tasks and designate the resources roles assigned to the task in a resource assignment matrix (RAM). The third blog will use the RAM created in blog two and add work, duration and resources to the tasks.

Let's take a look at how to use your RAM to add work and duration for each task. The RAM (Appendix 1) lists all the tasks and resources needed to complete the tasks. The tasks from the RAM should be copied into a project management software application, such as Microsoft Project (Appendix 2). An additional tool to assist with estimating duration is a risk register (Appendix 3) which contains the identified risks. A risk is a positive or negative event that may impact the ability to meet the project objective. For example, if a particular task has a high risk probability then the duration or work for that task may need to be increased.

There are several task duration and work estimating techniques however we will focus on three which include: expert judgment, historical performance, and three point estimating. Expert judgment is generally used when no historical data is available from past projects and involves requesting individual team members to provide work and duration estimates. The second estimation technique, analogous estimating, uses historical information as the source for estimating duration and work. The last estimation technique, three-point estimating, involves gathering three estimates for each task: most likely, optimistic, and pessimistic. The next step is to combine all three estimates to come up with one single value. The most common method of obtaining an accurate single estimate is by using the Program Evaluation and Review Technique (PERT). PERT uses a formula in Microsoft Project that places an emphasis on the most likely estimate but still takes into account the pessimistic and optimistic estimates (Appendix 4). Microsoft Project only supports estimating duration with PERT however you may create an Excel spreadsheet and average the likeliest, optimistic and pessimistic work estimates and enter that value into the work column in Microsoft Project. Three point estimates will be more accurate than single point estimation and is recommended for estimating work or duration for tasks without expert judgment or historical performance baselines.

The next step is to attach the resources to your tasks. In order to complete this step the resource sheet in Microsoft Project must be populated from the resource names in the RAM (Appendix 5). Once the resource names have been transfer to the resource sheet than attaching the resource to a task is easy. From the Gantt view click the cell below resource name and the list of resources from the resource sheet will present. Select a resource name the resource will be assigned to the task (Appendix 6).

At this point, the RAM has been used to populate tasks and the resource sheet within Microsoft Project. Three estimating techniques for work and duration were discussed and resources have been assigned to tasks. The fourth blog in this five blog series will discuss resource calendar and task relationships to finalize the EHR project schedule.

Appendix 1 – Resource Assignment Matrix (RAM)

Task	Clinical		Technical			Clinical W/Technical Skills			Administrative
	Tom	John	Sue	Terry	Bob	Carol	Susie	Nick	George	Brian
Establish VPN connectivity			A	C	R				I
Review EHR vendor statement of work	C		C			C	C	I	A	R
Finalize future state workflows	A	R	C			I
Finalize interface specifications			A	R		C
Test all Interfaces	S		A	R		S

Appendix 2 – Copy tasks from RAM into Microsoft Project and add Resources

Appendix 3 – Risk Register

Appendix 4: Adding the PERT Analysis Toolbar

Appendix 4a: PERT Analysis View

Appendix 4b: PERT Analysis with duration estimates

Appendix 4c: Calculate duration based on PERT Analysis

Appendix 5: Populating Resource Sheet in Microsoft Project

Appendix 6: Assigning resources to a task in Microsoft Project (Click the cell under resource name)

Transitioning from Paper to an EHR

Achieving a goal to become truly paperless is not realistic. Not all systems from all hospitals, clinics, imaging centers and laboratories that touch your patients are fully electronic, and even if they were: they don't all willingly or otherwise integrate with one another yet. Interoperability makes for interesting discussions, but demands a period of definition, evolution, more definition, acceptance and finally adoption before we see true interoperability. Paper (even if scanned) will continue to be part of the patient/ provider experience for quite some time. Phasing the implementation should be considered when guiding providers and clinical staff on their path to become paperless. The learning curve and initial productivity impact of a new system can be minimized by following appropriate plans unique and specific to your existing processes, tools and overall tolerance for change. When implementing an EHR, it is important to pick the right components at the right time to leverage synergies and improve adoption.

There are many components that need to be considered, ranked and slotted in the rollout plan. Picking your battles and prioritizing are important while achieving implementation and "meaningful use" goals as quickly as possible.

The Components:

1. Data conversion options need to be confirmed. What historical data can be converted at what cost and in what time frame? How useful is the historical data and how far back do you really want to go considering storage and potential performance impact.
   
2. All potential real-time interfaces need to be confirmed and weighed based on clinical relevance, cost and resource availability to build and test. Which interfaces provide the biggest bang?
   
3. A decision needs to be made regarding the cost/ benefit of back scanning and whether to back scan at all using your own or third party resources. Third party resources tend to shorten the duration of a back scan project.
   
4. A Go-forward scanning solution of critical clinical patient information not available electronically needs to be defined.
   
5. Pre-population of current medication, problem, allergy and immunization list should be considered as well. Are there resources available to assist with this to ease the transition for providers?
   
6. Transcription – see previous blog entry regarding transcription options.
   

Contact us for more details regarding strategies that will help you align your short and long term focus with the most effective transition to less paper.