An EMR is an electronic health record system that keeps track of patient’s medical history specific to particular provider. It’s a digital version of paper charts maintained by providers. People who are in patient care(doctor, clinician, radiologist, pharmacist etc.) will access EMR to view and update medical records frequently.

An EHR is an electronic health record system that keeps track of patient’s medical history from more than one providers.

A Personal health record (PHR) is a tool used to collect, track and share past and current about your health or the health of someone in your care.

EHR and PHR are similar in nature (conforms to interoperable standards) but with some differences. EHR fully managed by providers whereas PHR is fully managed, shared and controlled by patient and can aggregate data from multiple sources. EHR’s are available to multiple providers without patient consent whereas PHR is available only on patient’s consent.

PHR are of two types based on who owns and controls the data, tethered PHR and interoperable. Tethered PHR is linked with EHR of multiple providers whereas interoperable PHR is independent of health providers and are more specific to the patient.

Hospitals maintains patient’s health records with EMR software which are fully controlled and managed by them and are specific in nature. This type of record management unless implemented part of EMR software have the following limitations when addressing patient’s needs. Most EMR’s available in the market doesn’t provide these features and are expensive to develop.

1) Lack of co-ordinated care of patient

The people engaged in patient care often have to access latest updated patient’s information for quick diagnosis and preventive medication. This information may come from various sources such as health devices, external health providers, and care team (doctors, clinicians, and radiologist).

2) Lack of sharing patient’s health records with other health providers

When patient attends another health provider, sometimes patient’s medical history from various hospitals attended is required to diagnose medical conditions.

3) Lack of patient’s ability to access medical history at any time

Patient have to access last hospital visit information and view medical history from time to time.

4) Lack of access to patient’s medical histories from different hospitals at one place

Patients may visit more than one hospital in their life time. With each visit, patient medical information is recorded. These records are not easily accessible from each provider to aggregate and store them at one place.

5) Lack of real time health monitoring updates from patient and care team

Often patient have to be monitored for chronic conditions with health devices such as blood glucose monitor, blood pressure monitor, heart rate monitor, pedometer etc. for diagnostic purposes.

Why PHR is preferred than EHR for addressing patient information needs inside and outside hospitals

Hospitals when addressing patient information needs to overcome the EMR limitations, usually can adopt EHR or PHR. EHR is specific to one or more providers and doesn’t provide interoperability with other hospitals. Still a patient can view and schedule appointments with EHR but restricted from doing any updates to their health information records.

I studied some research papers of some EHR implementations in hospitals, the results are as follows

· Hospitals were more likely to have implemented EHR if they were Larger Institutions, major teaching hospitals, Part of a larger hospital system, located in urban areas, or had dedicated coronary care units.

· No meaningful relationship was found between adoption levels of EHR and Ownership Status of the hospital in terms Public vs Private hospitals.

· Most commonly reported barriers were: inadequate capital for purchases (74%), concerns about maintenance costs (44%), resistance from physicians (36%), unclear return on investment (32%), and lack of staff with IT skills (30%).

· Among hospital that implemented EHRs, these factors were mentioned as having positive effects: additional reimbursement for EHR use (82%), financial incentives for adoption (75%), availability of IT implementation technical support (47%), objective third-party evaluation of EHR products (35%).

· Although adoption levels were low, a significant proportion of hospitals reported to have already used electronic format of laboratory and radiologic reports, radiologic images, medication lists, and some decision-support functions.

· Interoperability issues can also be noticed as barrier. Lack of health information exchange between hospitals has reduced the potential value of these systems.

· From a policy perspective, creating incentives for use of EHRs and creating disincentives for not using these systems can be a potential facilitator.

· Finally, it is important to notice that this study was focused on adoption levels of EHRs in US hospitals, and did not study the actual effectiveness of these systems.

PHR addresses patient needs more than EHR. It helps the patient to keep latest up-to-date information collected from various sources at one place.

Based on my study on PHR case studies, some of the PHR findings are

· Laboratory test results were the most commonly used feature. Scheduled visits, medical conditions, and current medications were among other frequently accessed features.

· Test results were populated to PHR with a delay of ten days to allow clinician review prior to patient access. However, it is concluded that patients want results to be simultaneously populated in their PHR.

· In terms of clinical information, Provider Profiles were the most accessed pages.

· More than 80% agreed that the PHR helped them manage their medical problems, get better prepared for their scheduled visits, and take charge of their healthcare.

· Although more than two-thirds of patients agreed the information was accurate and complete, a significant number of patients believed inaccuracies in current medications (25%) and medical conditions (32%).

· It is observed that patients desired PHR as a convenient tool of information exchange, and found it useful, particularly for laboratory test results, medication list, medical conditions lists, and links to information resources.

Why Health Vault PHR

There are several PHR solutions available in the market. Currently Health Vault PHR is the best PHR solution among the other PHR solutions. My selection of Health Vault solution is based on the following reasons for the evaluation

· Free with no licence fee but with affordable integration costs

· Bi directional (two way) updates with EMR

· interoperable with standards

· Cloud based scalable web solution

· Accessed through various mediums and devices such as tablet, mobile, health device, web services.

· Integrated with 20+ health devices

· Secure communication between parties

· Patient centred with controlled access

· Extensible with custom applications and services

· Customizable local storage

· Pluggable authentication providers such as Open ID providers specific to hospital

I decided to use triangular model evaluation framework for the evaluation of Health Vault application for use in hospitals.

S.No

Criteria

Description

1

Organisation

Refers to hospital

2

Provider user

Refers to individual service providers in the hospital such as doctor, clinician and radiologist

3

Technology

Refers to Health Vault PHR

4

Patient needs

Refers to patient needs inside and outside hospital

I used some ratings based on functionality and accessing information in each criteria

1) Fully implemented 2) Partially implemented 3) Not implemented

Feature

Rating

Provide functionality to import or export Continuity of care document (CCD) and Continuity of care (CCR) documents

1

Secure authentication

1

Accessible via various mediums and devices (tablet, mobile, web)

1

Adheres to privacy principles

2

Ability to view and store medication history

1

Ability to view and store DICOM images

1

Ability to view and store family details

1

Ability to view and store miscellaneous files

1

Ability to view and store Allergies data

1

Ability to view and store immunization records

1

Ability to add and maintain health devices used for monitoring

1

Ability to maintain health profiles

1

Ability to share and print profiles

1

Ability to view and store procedures

1

Ability to view and store various health measurements

1

Ability to view access and update history

1

Ability to view and store family details and contacts

1

Ability to share and import information through email

1

Health Vault case studies

I have studied case studies of some hospitals using EMR software and integrated with PHR applications. The underlying principles and architecture is same for every PHR. Thus, I collected and studied some research papers on PHR general use in hospitals not specific to Health Vault.

Few hospitals who integrated Health Vault PHR with their EMR software as listed below

1) Maudsley NHS Foundation trust , UK

Maudsley foundation trust is the largest mental health service with over 35000 patients in Europe. Maudsley implemented a project called MyHealthBox which includes Health Vault integration to provide Summary Care Record to all patients

2) Mason General Hospital, WA, US

MyMasonHealth is a patient online solution implemented at Mason general hospital which integrates Health Vault with existing EMR using Microsoft Health Vault community connect to engage patients with improved experience in emergency rooms and clinics.

3) Brooks rehabilitation, Jacksonville, Florida, US

Brooks rehabilitation implemented a project Brooks Health Connect which integrated Health Vault with existing EMR. At Brooks, 90% of patients comes from referring acute care hospitals and are placed in various care settings within first 60 days. To improve patient experience and reduce the times between the team, Continuity of care solution is required to facilitate.

4) Steward Health Care System , Boston, US

5) Lucile Packard Children’s Hospital , Stanford, US

Lucile Packard Children’s hospital is a major referral center for severely ill children. The patients who visit the hospital are referred by Primary care provider outside LPCH are at 90% of overall visits. The remaining 10% patients visit directly to the hospital and its clinics. Hospital receives patient referrals from over 30 states. LPCH implemented an interoperable PHR like Health Vault to overcome the issues related to sharing and co-ordinated care.

6) PeaceHealth – St. Joseph Medical Center, Bellingham, Washington

Comprehensive preregistration and discharge process using HealthVault community connect.

Concerns

Some concerns below related to usage of Health Vault PHR (or any general PHR) in hospitals, most of them addressed by industry expects

PHR records may not be accurate with current health status

I agree patient can modify health records which may not be true with current or past health history. Hospitals should not fully depend on PHR information. The main use of PHR is to provide up to date information of patient’s last visit and scheduling appointments. In my study, all the hospitals who integrated Health Vault PHR already implemented bi-directional updates with EMR and health vault. This means anything that is recorded in EMR will be synced to Health Vault and vice versa. On patient’s next visit, doctor access patient information from hospital EMR not Health Vault directly.

But if the patient visits another hospital (not linked to previous hospital) by modifying health vault information which is rare and if there is no record that is pointing to previous hospital, new hospital may fail in collecting previous medical history and may depends on Health Vault information.

Patient’s privacy

Health Vault or any other interoperable PHR is a patient controlled health record (PCHR). Patients can allow or deny access to their health records to any provider user at any time. Every hospital access is different and acted as a separate client for accessing the data.

Information Security

How safely and securely information communicated between various stake holders through Health Vault.

The communication between Health Vault and other parties is always secured and encrypted using industry standard protocols. Health Vault communication mainly done by patient, EMR system and provider users through https protocol and email.

Health Vault is a cloud deployed solution accessed by anyone using secure hypertext transfer protocol (https) through a web browser. Https is a standard secured protocol used by everyone and is done through digital certificates. Encryption and decryption done through private and public keys. At one end, the information is encrypted by a private key and other end the information is decrypted by public key. Client apps and services also have to do communication using https protocol to connect to Health Vault cloud.

Email is the other form of communication used by provider users. This communication is done using direct messaging protocol. Direct messaging protocol is a standards protocol which encrypts and secure a message. Each health vault user is allocated with a direct project email address when registering a health vault account. Currently Microsoft is offering this feature only for users registered in US instance.

References

Rebecca Todd, Maudsley launches Health Vault based PHR, 2012, E-Health insider (UK),

Arash Anoshiravani, Gregory Gaskin, Ed Kopetsky, Christy Sandborg, and Christopher A. Longhurst, Implementing an Interoperable Personal Health Record in Pediatrics: LessonsLearned at an Academic Children’s Hospital, 2011, J Particip Med

Health Systems Choose Microsoft HealthVault Community Connect to Improve Care Coordination, Engage Patients and Families, 2011, Microsoft

Lingxia Liao, Min Chen, Son Vuong, Xiaorong Lai, Novel Web-enabled Healthcare Solution on HealthVault System, 2012, Dept. of Computer Science, Univ. of British Columbia, V6T 1Z4, Canada

Bruno Alvesa, Henning Müllerab, David Godela, Omar Abu Khaleda, Michael Schumachera, Interoperability prototype between hospitals and general practitioners in Switzerland, 2010, University of Applied Sciences Western Switzerland (HES-SO), Sierre & Fribourg, Switzerland and Medical Informatics Service, University & Hospitals of Geneva, Switzerland

Nhan V Do, Rick Barnhill, Kimberly A Heermann-Do, Keith L Salzman,Ronald W Gimbel4, The military health system’s personal health record pilot with Microsoft HealthVault and Google Health, 2011,J Am Med Inform Assoc

Care Coordination Approaches with Microsoft Technologies, 2011, Microsoft

New Microsoft Health Solution Connects Hospitals with Patients and Referring Physicians to Improve Coordination of Care, 2010, Microsoft

Microsoft Health Vault https://www.healthvault.com/au

http://blogs.msdn.com/b/wwhealthit/archive/2011/02/28/microsoft-healthvault-community-connect.aspx

http://www.med.umich.edu/him/myphr.pdf

http://www.healthit.gov/policy-researchers-implementers/direct-project

A Personal health record (PHR) is a tool used to collect, track and share past and current about your health or the health of someone in your care.

PHR’s are categorized into two types based on its data ownership and control

1) Tethered PHR

  • Linked to EHR of multiple providers
  • Provider owns and manages patient information
  • Extension of the provider’s health system EMR
  • Allows the patient to view information stored in EMR
  • Allows the patient to communicate via email or online appointment systems
  • Patients cannot share information electronically with outside providers
  • Patients cannot import and integrate their data from external sources

2) Interoperable PHR

  • Patient owns and manages his own health information
  • Stored in a central repository, accessible to all on consent
  • Electronic linkages with multiple providers, health systems and pharmacies
  • Integrated with provider’s health system EMR
  • Easily accessible and controllable
  • Patients can share information electronically with outside providers
  • Patients can import and integrate their data from external sources