As I have mentioned previously on this blog, and as is mentioned on the Certification Commission for Health Information Technology Website, I am Co-chair of CCHIT’s first Workgroup covering Personal Health Records this year, along with Lory Wood from the Good Health Network.

As you can tell from the list of members on the workgroup , the expertise represented is very impressive in its breadth, and its national scope, and we have all been working hard to support the first certification process for Personal Health Records in 2009. I encourage anyone interested in PHR Certification to follow its course through CCHIT communications on its web site and other venues; I won’t be discussing specifics of certification here.

What I am writing about is how this process is changing my understanding of the role of personal health records beyond the health system.

A great example is in the case of emergency responders - I recently posted my experience being one. Earlier this year, I commented on the value of a personal health record in another incident I was a part of, and it is interesting for me to look at what I said., which was around the value of a personal health record in preventing emergencies by promoting better patient engagement around their therapies. I still believe in that.

While that’s waiting to happen though, what about the times when an employee might have an emergency at the worksite or a person might suffer a car crash or other incident while traveling? It’s possible that in the incident I responded to earlier this year that the result would be a report back to family that their mother/father/daughter/son/brother/sister had died while co-workers and responders were frantically working to assess their medical condition.

Imagine what it might be like for an employee in a large big-box retailer to be able to identify parts of their medical history to be made available on an emergency basis to their employer, especially if the worksite is large enough that their personal effects are typically very far from where they work. Many of us fill out emergency contact information when we complete new-employment paperwork. Usually this is a piece of paper, and in most cases provides a thin buffer of hope that critical information about us will be available if it’s needed at a worksite emergency.

The same goes for automobile crashes, because a vehicle identification number by itself is often not enough to positively identify a crash victim or provide relevant medical information at a critical time of need. Several states (Florida and Ohio) and the automotive industry have thought about this. As Larry Williams explained to me, manufacturers have thought about the car ownership experience and their desire to provide support at its lowest point by providing methods for consumers to connect identification and emergency contact information to their vehicle IDs. The innovation in health care that comes from industries who are built on serving consumers primarily is interesting, isn’t it.

Both the American Health Information Community and IHE have produced a use case and white paper respectively, relevant to the potential role of a personal health record beyond a tethered connection to a primary care provider, that describe an ability for a person to tie their medical history to their vehicle’s identification number, for positive identification and medical attention. This is where a personal health record might integrate, at the discretion of the consumer.

All of this presumes appropriate privacy protections, of course, such that linkage and management of the information is under the control of the consumer.

This thinking is reinforcing in me the idea that a patient’s medical home is really the place where they live, work, and play. The promise of the personal health record is that people can leverage their personal health information at the right place and time to be enabled to do what’s most important to them, while being supported by a broad diversity of care providers, who at any given time are nurses, doctors, co-workers, emergency responders, families, and communities. This is a good thing to learn.

This is fourth of a multi-part series on a patient’s experience managing a chronic condition, in this case hypertension. A diagnosis has been made, and our patient has hopefully followed up and has hopefully been maintained on appropriate therapy (there is a 1 in 3 chance that this is happening). Now it is time for our patient’s health care sponsor (such as his employer) to review the health care benefit.

Click on the image to see it larger size

Patient Story (Frydman)

There is no patient story in this phase. At some point during the year, our patient’s employer will discuss provided health care coverage with a health plan or plan(s) who have set rates for coverage in the coming year. On the diagram, there’s no red dot indicating the presence of data because in many (most?) cases there is not a lot of data to guide this conversation. Many health plans have claims data, to show how many services and what types have been paid for throughout the year. They may not have data about the effectiveness of those services. For example, they may not know what percent of office visits for high blood pressure showed effective control. On the employers’ part, they may not have much data, either. If they are self-insured, they may have similar levels of claims data, but not measures of performance.

Even in health care organizations with advanced electronic medical records, the determination of “% patients with appropriate blood pressure control” may not be done in an automated fashion - a random selection of charts may be used to come up with this percentage. The electronic health record may facilitate the selection and review of charts, but nothing more. This is dependent on the health care environment being studied.

(If there are health plan and providers who would like to inform this part of the story, comments are open)

Clinical and Public Health pearls (Houston-Miller and Eytan)

• High blood pressure is one of the most costly conditions for employers, more than cancer, diabetes, heart disease, and behavioral health conditions. This does not take into account that hypertension is responsible for a significant amount of morbidity among patients with heart disease and diabetes. This post shows the costs of each. The first graph shows the cost per person with the condition. When you average the costs across an entire employed population, the large numbers of patients with hypertension escalates the cost of this condition above all others. For those people interested in the cost profile of chronic conditions to employers, The Center for Studying Health System Change hosted a forum where expert Ron Goetzel, Ph.D. provided an updated look at the data. It is compelling.
• Fewer than 10% of the cases of undetected or uncontrolled hypertension could be associated with lack of health care use. In other words, health plans and employers are already paying for this current state. It does not exist because patients are not getting enough health care.

Comment

Where is the data? and What’s Missing? In this case, there isn’t much data in the conversation. The conversation is around use of services, and in that setting, an assumption is typically made that more services is better. The result is that these stakeholders cannot engage at their potential to ensure that services are as effective as possible.

It is possible that a patient or provider may share data about the effectiveness of their blood pressure control services which are being purchased and paid for by employer and health plan respectively. Blood pressure control is already a HEDIS measure, and is a development Pay for Performance measure in California in 2009.

Next post, the yearly checkback, completing the cycle. Comments welcomed, of course

• What Should Employers Do about Health Care? — HBS Working Knowledge - A brief call to action to employers about going beyond cost management in benefit structure.

Shai, Iris, Dan Schwarzfuchs, Yaakov Henkin, Danit R. Shahar, Shula Witkow, Ilana Greenberg, et al. “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.” N Engl J Med 359, no. 3 (July 17, 2008): 229-241.

“The Employer as Health Coach,” October 11, 2007.

I initially reviewed this article for my interest in the question, “What kind of diet is best for losing weight?” (with good news for low carbohydrate and Mediterranean dieters), but I quickly became fascinated with the way this study was performed - on the worksite, at the Nuclear Research Center Negev, in Dimona Israel.

To quote:

As Okie recently suggested, using the employer as a health coach could be a cost-effective way to improve health. The model of intervention with the use of dietary group sessions, spousal support, food labels, and monthly weighing in the workplace within the framework of a health promotion campaign might yield weight reduction and long-term health benefits.

I think this is as significant as the weight loss intervention itself - that the study authors worked to modify the work environment to support the study aims. In the supplemental materials (linked here), you can see an example of the signage placed in the cafeteria to alert employees to the different food choices available, depending on which arm of the study they were in.

I think this fact of the study design is under-emphasized and marks an important trend in supporting interventions like this moving forward. With thanks to the Research Center in Dimona for teaching the world about more than nuclear science.

• Is worker wellness a privacy issue? - Nice article from Jane Sarasohn-Kahn. A reminder that people want to how the data is used to help them. Same thing with patient access - demonstrate how it helps care, and the balance of privacy and utility becomes more even.

I learned about this at the CCR workshop. The CCR accomodates elements of this, but CMS has not endorsed it yet as a standard.

AMCP.org - Comments on Standard SIG - The NCPDP was working on the standard for Med Sigs - a little background

I have been intrigued by EMC’s work in managing an employee personal health record - it seems above and beyond (in a good way) how an human resources function and grow and support talent. Also, time to upgrade Office for Mac. It went OK. I’ll update “my own CIO” tools list in the near future.

• Employers Find Benefits with PHRs - More info about EMC and its employee PHR
• News - - Gainesville.com: Dean admits student without backing - It’s interesting that this is posted in the entertainment section. That aside, this looks concerning. I don’t understand how a student is admitted to medical school on a personal recommendation, and without taking the MCAT. How will we have a diverse medi
• Event Calendar - A way to put upcoming events on a wordpress blog
• TimeDriver - Coming Soon! A revolutionary online personal appointment scheduler - A very high potential meeting scheduling package. Given that Timebridge only allows 5 slots to be determined, this looks very interesting.
• GE Healthcare-Press Release-NCHL and GE’s Institute for Transformational Leadership - I didn’t know about GE’s work in this area. It looks like they are doing work in LEAN as well as Six-Sigma, which they are known for.
• Report cites UA med school crisis | www.azstarnet.com ® - Sad news from my alma mater, related to the difficulties medical schools are having balancing revenue and their mission.
• D.C. Not-for-Profit Offers Model for IT Adoption - iHealthBeat - More progress in DCPCA’s EHR adoption efforts
• Burlington Free Press.com | Fletcher Allen’s new EHR - Fletcher Allen in Vermont gets approval to go ahead. I believe this is an Epic Systems install, bringing with it the possibility for excellent patient engagement with their health system as a result.
• Database Problem with Office 2008 for Mac - Office 2008 Install problems, just in case

I like how the advertising is different here, and I pay attention to advertising because it says something about the people who live here, and what can I say, I like to live in a place where people make things happen. In Seattle, advertising is more lifestyle oriented. Here it is more policy oriented, and I snapped a few shots of my favorite car company who are apparently doing a metro station “domination” (that’s the word the execs use) at Union Station, much as Kaiser Permanente did a very nice domination of Powell Street BART over the holidays (with a very cool nod to Kaiser Permanente’s excellence in supporting diversity).

The fun part is figuring out what’s behind this and what policy issue might be up for grabs that would make Toyota want to impress their commitment to the U.S. economy at this time. If anyone in the know knows, feel free to post a comment.

I’m adding one photo of the brand new Harris Teeter that’s about to open in my neighborhood. Apparently artsy photos are popular among the DC Flickr crowd. It’s a Web2.0 thing I guess.

February 20th through February 22nd:

• VA’s health IT gamble - Discussion of their efforts to centralize IT.
• Google your medical records? - Commentary in the Seattle-PI Health Blog. Innovation that helps health care be more patient-centered is goog. I mean good.
• Superfactory - Article: The Equally Important “Respect for People” Principle by Bob Emiliani - “A multi-lateral expression of the need for balanced, mutually respectful relationships, cooperation, and co-prosperity with these key stakeholders.” Thanks to mycolleague Lee for sending this on
• Cooking Light Best Cities: Washington, D.C. - Healthy Recipes and Menus - CookingLight.com - The description says it all. Great ways to eat healthy in this burgeoning food capital. Even for a non-foodie like me.

February 4th through February 6th:

• DC Moves for Safer Sidewalks - Get There - Washington government takes a step toward promoting walkability. Sidewalks stay open for business.Walkers rejoice!
• Apple //c - a photoset on Flickr - The OOB experience of an unopened AppleIIc computer. Remember when technology was fun? It still is. And I never even learned to program in Pascal.
• Ryanair’s Changing Altitude - Efficient cost management and charging for everything keeps margins high at RyanAir - a great example of “copy how we think” in terms of being like Southwest
• Running a hospital: More on fetching and work-arounds - BIDMC launches an improvement methodology called SPIRIT. Looks like it’s at least partially based on LEAN?
• The Health Care Blog: Bad Medicine: How The AMA Undermined Primary Care in America - Brian Klepper - Analysis of RBRVS and impact on primary care.
• The ethics of CEO blogging - Nice discussion from Paul Levy about the approach that a CEO takes to blogging. I’m in support!
• Insurers Begin To Reimburse for Online Visits, Concerns Remain - Nice profile of Kaiser Permanente’s program.
• Marriot Rolls Out Web-Based PHR System to Employees Nationwide - iHealthBeat - An employer-sponsored PHR. Will the lack of connection to the health care team be an issue?
• KUOW: Program Archive: Patient Safety, January, 2008 - Dr. Matt Handley, from Group Health Cooperative, is featured
• Best Companies 2008 - FORTUNE Magazine’s Top 100 Employers to Work For - The 2008 list is out. From an HR/Leadership perspective, it is interesting to look at some of the most important qualifications for being on the list, such as support for diversity.