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Dynamic Chiropractic – June 17, 2008, Vol. 26, Issue 13

Personal Health Records: How Digital Increases Responsibility

By Steven Kraus, DC, DIBCN, CCSP, FASA, FICC

Personal health records (PHRs) - it's a new acronym used to describe the future revolution in health care data management. PHRs are revolutionary because they place patients in charge of managing their own health records on a completely digital interface.

Just a couple of years ago, electronic health records (EHRs) seemed like science fiction. Now we're talking about patients walking out of our offices with their exam findings and SOAP notes in hand, not on paper but on their flash stick or sent encrypted via the Internet. The digital age is here!

I bring up PHRs not because of their novelty, but because they illustrate a critical point: Electronic health records should create greater efficiency and better clinic management, but they also require more responsibility and allow more scrutiny than we've ever faced. It's not enough just to be digital. We have to ensure our EHRs lead us to better evaluate patients, render more consistent care and help prove our clinical worth.

In a rapidly approaching age in which our exams and care plans will be accessible to whomever the patient authorizes, anything less is going to hinder chiropractic progress. When the rest of health care looks into the chiropractic window, we want to make sure they see how good we really are. That requires preparing for tomorrow's adoption of PHRs with chiropractic physician EHRs now.

EMR vs. EHR vs. PHR?

Health care acronyms can be puzzling, and the situation is about to get more muddy. Let's clear up any confusion about what language is proper for digital clinics. According to the Office of Health Information Technology (U.S. Department of Health and Human Services), the official wording for a digital, interoperable patient record that contains all the documents pertinent to care is electronic health record (EHR). In some places, it used to be called an electronic medical record (EMR). EHR has replaced EMR in official federal language. 

EHRs shouldn't be mistakenly referred to as digital patient notes. Digital patient notes, or digital SOAP notes, are contained or stored within the EHR, but they are only one component of the record. It's best to refer to the complete patient record or patient chart as an EHR.

Personal health records are one likely development of digital documentation. PHRs will be enabled by universal and compatible EHR programs. Essentially, PHRs are the integration of the patient's entire health care history and data into a single electronic record the patient manages or to which the patient authorizes provider access. It's essentially a lifetime EHR the patient owns. The EHR is managed by the physician or clinic. The PHR concept and software currently are in development and available in basic formats.

PHRs on the Way?

The two most prominent companies involved in the development of personal health information are Microsoft and Google. Microsoft's HealthVault and Google's Google Health are meant to be free, Web-based sites that allow users to upload health information received from providers. We might joke about Dr. Google and our reliance on the Internet as a reference shortcut, but the name couldn't be more appropriate.

Both companies aren't just going to host space for users to store data. They're creating interactive Web sites that respond to the information stored within the patient's PHR. For example, do you have patients on anti-hypertensive medication? Google Health will tell them everything about the drug, side effects, possible interactions and why maintaining proper blood pressure is important. While the details of these programs haven't been unveiled, it's easy to imagine all of the possible features.

PHRs and Health Care Transparency

I think it's safe to say our patients are going to be more informed than ever. It's an intimidating proposition for most health care providers, including chiropractors. Every ICD-9 and CPT code we use potentially will be referenced through a PHR, not only by the patient and Dr. Google, but also by their internist, cardiologist, neurologist and family practitioner. Patients will know exactly what the CPT code encompasses and face-to-face time factors associated with a code. It makes one wonder: Is the Google database going to agree with our diagnosis?

Ultimately, PHRs are going to mean a lot more transparency in health care. If we're doing our jobs right, more transparency should be good for everyone, especially the patient. It's harder to hide mistakes when the patient has their own charts and Dr. Google to consult.

What Do PHRs Tell Us?

It's important to note that truly operable personal health records still are in the theoretical stage. Still, the fact that it's in the works can tell us important things about our patients and about our future in a digitally based, health care environment.

Patients are motivated to understand health care decisions and know their options. They want information. The success of Web sites like WebMD and Web-based medical-support forums, and the popularity of alternative health Web sites suggest people are hungry for health care information. They self-diagnose and find treatment options before they even make an appointment with their family physician. They're using sites such as HealthGrades to check up on their medical doctor's reputation and to decide which hospital is rated highest for the procedure their internist is recommending. The up-and-coming DCConsult Web site (FCER) has a database of more than 33,000 published articles to use as a tool to validate evidence-based care. This is available to chiropractors to use in managing patient care. Technology gives instantaneous information. Both doctors and patients are using, and expecting, more technology in health care.

PHRs that interact with the EHRs established in your office would be an evolutionary tool in the access to health care information. Now the patient will be able to integrate their personal health history into their search for information and treatment options. If you understand this need, you'll be empowering patients with access to their records by using an interoperable EHR system. For now, simply e-mailing an encrypted copy of the patient records from your EHR to the patient, allowing them to manage their own data inside their PHR, is the method of choice.

Patients want technology and the control it offers. Preference will go to providers who understand this. The possible growth of PHRs is going to place more pressure on family practices to embrace electronic health records. As more hospitals adopt EHRs, the non-adopting family provider will get further behind the curve. A functional PHR will only make this technology gap more obvious. The patient-managed PHR is going to include histories and treatments associated with local hospitals, teaching institutions and EHR-based providers. Those who refuse to integrate into this data stream, for whatever reason, probably are going to lose preference from patients and third-party payers due to the simple fact they can no longer keep up with this new standard of care.

A patient-managed record opens the door to greater scrutiny and even greater opportunity. The portability and instantaneous access offered by EHRs already have raised the opportunities for third-party scrutiny. For example, I've previously written about the possibility of submitting bills to third-party payers with the SOAP note attached from that visit. The PHR concept takes the EHR visibility even further.

When the patient becomes a primary gatekeeper in communication between providers, any record we've signed off on is now fair game for review. What a reason to document perfectly! The possibility of patient-managed records reinforces the challenges and opportunities created by portable electronic records. The possibility of PHRs should lead us to:

  • accurately communicate how effective chiropractic care can be, especially for the kinds of patients and conditions that best respond to care;
  • gather clinical data that supports the patient's demand for more access to chiropractic physicians;
  • show our willingness to become primary adopters of EHR across the profession; and
  • justify our involvement with the patient and document the unique aspects to our patient management, including functional goals, co-morbidities that affect outcomes and the concept of maintenance care.

Transparency Requires EHR

This can only be accomplished if we choose an EHR system that actually improves the quality of our documentation and encourages greater consistency in care. Our patient records are the benchmarks by which the entire health care industry is going to judge our worthiness. Just having a basic digital SOAP note isn't going to prepare us for the future of patient-managed records and the health care transparency we'll face. The portability of EHRs and upcoming PHRs is creating opportunities to demonstrate chiropractic efficacy in a way we can't ignore by waiting for this trend to pass us by or until national and state laws force us to act.

We can influence patients with our documentation. We knew our documentation would influence claim reviewers, other health care providers and Medicare, but we actually can influence patient choices for continuing care through our documentation they review in their PHR. It comes down to the simple inquisitive nature in all of us: What are you writing about me? Many patients will read what you document.

If PHRs really are coming, all talk that places electronic health records somewhere in the future already is obsolete. When it comes time for patients to start managing their own records, my dream is that chiropractic already will be setting the standard for what defines a quality and relevant clinical record - a record that will stand inspection by any other provider and present them with the evidence of the patient's improvement under our care. This is a future in which I believe all chiropractors can flourish and grow by helping more people naturally.


Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.

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