Additional Comments

Advanced Integrated PHR/EMR Technology Definition

A Personal Health Record (PHR) is a digital record created by the patient. An Electronic Medical Record (EMR) is a digital record of the healthcare provider(HCP)-patient encounter. Our advanced integrated PHR/EMR contains the following features many that are unique that can enact disruptive changes described below.

  • Web-based PHR/EMR. The PHR and EMR are online, thus can be accessed anywhere anytime there is Internet connection. The EMR is an Application Service Provider (ASP). The HCP just needs to be online to access the EMR, minimizing hardware requirements and IT support.
  • Patient Generated Medical History (PGMH). The PGMH is the linchpin of the medical history in the PHR and EMR and is based on adaptive questionnaire technology. With the adaptive questionnaire, the patient is asked a general question. Positive responses result in follow-up questions, creating a customized questionnaire and producing a comprehensive medical history. Previous studies and our experience show that patients can be very candid when communicating through a computer. More than 400 students have completed the PGMH at the BentonHarborHigh School school-based clinic without difficulty. In my practice, the patient’s ability to complete the PGMH without help is related to age than socioeconomic status; young patients can complete it without help while older patients may need assistance.

In a paper questionnaire, the patient answers “yes” with the ambiguity of what exactly the patient is saying yes to... cigarettes, cigars, snuff, or chew tobacco?

These questions are asked by the adaptive expert questionnaire only if a patient says yes to smoking. (Note these questions are presented to the patient one at a time.)

  • Using the PGMH, the patient is empowered to tell his or her story and the workload of obtaining a medical history is transferred to the patient. The HCP merely edits and appends the history.This history is very comprehensive, i.e., diabetics are asked if they check their feet or walk barefoot. (The significance of this will be discussed below.) The PGMH contains more than 11,000 questions and covers more than a dozen specialties. The PGMH can be presented in various languages so citizens can perform it in their native language.
  • Accurate medication lists are notoriously difficult and obviously needed to provide optimal patient care. Patients completing this listat home, with all their medications in front of them, increase the likelihood of making an accurate list. How these lists can be employed will be discussed below.
  • In PGMH, the patient is asked a series of questions about high-risk behavior. Since the adaptive questionnaire asks whether the patient has experienced adverse consequences of a high-risk behavior, the patient is made aware of these consequences. Then the patient is asked if he or she is interested in quitting. At the end of the PHR, based on the patient responses, the patient can be offered various options discussed below. During a clinic visit, the patient’s awareness and using the patient’s own responses in the discussion, enhances high-risk-behavior counseling. One goal of medicine is to change patients’ high-risk behaviors.

The Client Expert module allows system administrators to create their own set of questions. These new questionnaires can be used in:

  • Public health surveys – questions concerning the specific circumstances surrounding a disease outbreak.
  • Clinical trials.
  • Specialty clinics.
  • Integrated PHR/EMR.Since the PGMH is used by both the PHR and EMR, the data structures of the PHR and EMR are identical, facilitating bidirectional communication of the patient’s past medical history (PMH). A patient’s PMH includes a list of the patient’s diseases, medications, allergies, surgeries, hospitalizations, drug, alcohol, and smoking history, etc.

When a patient sees a healthcare provider using EMR (EncounterSuite), the Core PMH is loaded into the EMR, where the HCP can edit and append the PMH based on the clinic visit.

At the end of the clinic visit, the updated Core PMR updates the PHR and a text copy of the complete encounter is added to the PHR’s chart.

A patient’s PHR and EMR would constantly update each other,

so both remain current.

If a patient, who did not have a PHR, saw a HCP with the integrated EMR, he or she would perform the EMR’s PGMH and at the end of the visit, a PHR would be created for the patient.

Because PHDs often serve patients who have interactions with social workers and other agencies, the PHR definition can be expanded to include their documentation.

The integrated PHR/EMR is a very unique feature.

  • EMR designed by HCPfor HCPs. Critical to the plan described below is that HCPs would want to use the EMR. Besides the PGMH, it contains many additional HCP-friendly features including:
  • Adaptable physical exam. Abnormal physical findings are carried forward and there are no rigid templates.
  • Assessment/Plan is a working problem list. Keeping track of the patient’s medical conditions is easy.
  • Wellness guidelines and disease management alerts. The HCP is alerted when established guidelines should be applied to the patient, making conforming to quality guidelines easier.
  • Treatment Favorites. Complex orders for a problem can be saved and recalled with a click. The HCP can then edit the orders as needed. Treatment Favorites based on guidelines can be created so that applying the suggested guideline to a patient is simple. In addition, Treatment Favorites are the means for new medical knowledge to be applied to the clinic visit. For many HCPs, not following guidelines is not a conscious decision but rather the result of not knowing what the latest guidelines are and how to incorporate them into their practices.
  • Prescription Favorites. Commonly prescribed prescriptions can be written with a click.
  • Assessment/Plan is a working problem list. Following a patient’s medical conditions is easy.
  • Diagnostic equivalence. All patients with a given disease will be identified regardless of how they are labeled. In a simplistic example, patients with hypertension can be labeled has having high blood pressure or hypertension. Diagnostic equivalence will identify both groups of patients. This feature is essential for epidemiological research, disease management guidelines, and the prospective clinical trial alerting system (see below). Similar technology can automatically produce a differential diagnostic list based on a patient’s reported symptoms.
  • Robust reporting. Responses made in the PHR and EMR produce discrete database entries. Since there is only one version of the PHR and EMR, data across sites and patients can be combined. This fact and diagnostic equivalence enable robust reporting. These reports would be useful in understanding the needs of clinic populations, epidemiological studies, and clinical trials.

Report Showing How Many Patients Made a Particular Response.

Report Listing Individual Patients Who Made a Specific Response.In this case, because the response was a fill-in, what responses were made. (Patient demographics are de-identified.)

  • Facilitating performance of clinical trials. Facilitating clinical trial performance would decrease the cost of a trial and thus allow more trials to be performed, expanding medical knowledge and identifying new drugs. Many of the EMR’sfeatures would facilitate the performance of clinical trials, including:
  • Consistent discrete historical data points across sites enable more accurate, more frequent, and more reliable data. Using the Client Expert Module, an adaptive questionnaire can be created concerning a drug’s efficacy and potential side effects. Because the questions are asked the same way to every trial subject, site-to-site variation is reduced. (One clinical investigator’s loose stool is another’s diarrhea.) Since the trial subject can answer these questions at home, more frequent and contemporaneous responses can be obtained, producing more accurate data. Reports can be generated summarizing: how many subjects made a particular response; who those subjects were; and what they wrote.
  • Prospective clinical trial alert system. Based on diagnostic equivalence, the HCP is alerted when the patient being seen qualifies for a particular trial The alert contains a description of the trial and a point of contact. This system has several important implications:
  • The HCP does not have to be informed of a clinical trial beforehand.
  • Patients can be screened against a large number of trials simultaneously.
  • Improved subject recruitment and decreased subject dropout. In most clinical trials, about 30% of the subjects drop out. Let the trial administrator explain the importance of the trial, convey the researchers’ passions, describe what participation requires, and thank the subject for his or her participation. As the trialprogresses, the administrator can describe the next step in the trial, preliminary results, and thank the subjects.
  • Retrospective clinical trial reports listing patients previously seen are also based on diagnostic equivalence.
  • Treatment Favorites. Treatment favorites are the means to place a complex series of orders with a single click. This facilitates compliance with the clinical trial protocol. An order remains in the Inbox until the result comes back or is completed, thus labs and other tests in the trial protocol are not forgotten.
  • Web-based. The centralized structure facilitates clinical trial administration.

*****************************************************

Context for Disruption:

APHDdistributes the PHRto its citizens and sells the integrated EMR to the HCOs and HCPs.

A wide-scale PHRwould offer many benefits:

  • More patient involvement with his or her healthcare.Patients fill out their histories in the PHR. Patient can be immediately shown how to improve and be more responsible for their health. As a result, they becomemore vested and involved in their health and healthcare. This would increase wellness and patient compliance.
  • Citizens have a portable, readily accessible medical record that can be used in their HCP visits, improving the quality of their medical care.
  • Citizens would have portal for health access and information. Based on the patient’s responses, an individualized report can be created to educate the patient on how to improve his or her health and provide access to medical examinations, preventive testing, high-risk-behavior clinics, etc. with links to make online appointments.
  • Increasing the access of its citizens to healthcare. After completing the PHRs, the patients can view a report and action sheet created based on their responses. They can immediately act on the findings and suggestions. These suggestions would include making appointment(s)for medical exams, screening tests, counseling, smoke-enders, weight loss/nutrition clinics, etc.
  • Links to online appointment systems for the various clinics, information sheets downloads, and links to multimedia presentationscan be part of the report. Multimedia presentationscan include informational videos about diseases, wellness, testimonials of former addicts, etc.Online testimonials would provide emotional support for those with high-risk behaviors and offer ways to overcome them.
  • Wellness guidelines and disease management guidelines. These would be based on the patient's demographics, medical conditions and responses. For example, if a diabetic answers that he or she does not check their feet, a link to a short video/animation on the how and why of diabetic foot hygiene is presented.
  • Multimedia education about medical conditions. Studies show that when people both hear and read information, they retain much more than if they only hear or read it. Adding images and animation would augment the learning process so that patients can understand their medical conditions. As a result, patient compliance with treatment improves. The PHD can approach the local television cable company and ask if it would be willing to place these videosin its on-demand video offerings.
  • Interactive online counseling. Previous studies and our experience show that patients can be very candid when communicating through a computer. Based on their PHR responses, subscribers can be offered various counseling services online or through local agencies. One advantage is that inspirational testimonials by patients who have overcome a problem can be brought to each subscriber with that problem. Online counseling is very convenient, improves compliance, and is relatively inexpensive. These programs can include:
  • Nutritional/weight loss counseling.This is a very effective program when coupled with digital diaries to record real-time food intake and to identify alternatives.
  • Drug and alcohol counseling for the addict/alcoholic and their families. Online testimonials can play an instrumental role.
  • Exercise programs.
  • Physical therapy. Videos of how to perform the exercises, perhaps coupled with animation explaining the purpose of each exercise, is better than 2-dimensional paper handouts. Points made by the physical therapist can be forgotten when the patient is home doing the exercises.
  • Accurate medication lists. These are difficult to achieve. Having a patient sitting down in front of the computer at home with all his or her medications would increase the accuracy of the medication list. With this list, the PHDcan:
  • Detect drug interactions or contraindications.
  • Inform patients about FDA alerts on medications they are taking.
  • Ascertain compliance. Comparing the medication list with the list of filled prescriptions would indicate the level of compliance. If noncompliance were an issue, the patient can be counseled.
  • Suggest generic alternatives. Examine the medication list and determine if there were generic alternatives. The patients would be told that these are only suggestions, which they should discuss with their HCPs.
  • Enroll patients in a medication reminder program.The PHD candevelop a messaging program to remind patients when to take their medications either by text messaging or text paging. This would improve patient compliance with medication, which has been shown to reduce illness and costs.
  • Public health departments have two main responsibilities in disasters.
  • Coordinate the response to emergency disasters. The PHDs, using the integrated PHR/EMR, can improve their response in several ways:
  • First responders canprovide better, more efficient care. If paramedics and emergency HCPs had their patients’medical histories and medication list, they can provide better care more quickly since they would not have to obtain a medical history.

PHR use in a Disaster.

  • Continuity of medical care after Hurricane Katrina-like disasters: If some disaster destroyed the regional infrastructure, an online medical EMR/PHR would enable continuity of care for residents. EMR/PHR data would reside on servers throughout the country insuring data redundancy and therefore availability.
  • The public health department has even greater responsibilities for the special needs population. This population includes hearing impaired, vision impaired, limited English-proficiency populations, homeless, etc.
  • Identifying these patients.
  • Notifying these patients of an evacuation in the event of a disaster.
  • Assuring transportation/evacuation. This means transportation requirements given a patient’s special medical conditions must be identified a priori.
  • Continuing delivery of health/medical care. There must be continuity of medical care for special needs patients in the event of an evacuation. Specific equipment and facility requirements for each special needs patient must be identified. Special need patients must be sent to locations where the appropriate medical equipment and facilities is available.

Using the Client Expert module, an adaptive questionnaire can be created to identify the special needs patients and catalogue their particular requirements. The reporting system can create reports listing the patients and their needs to facilitate evacuation planning. In the event of a disaster, the special need patients’ PHR would facilitate continuity of care during the transfer to the new facility.

The integrated EMR would offer many benefits:

  • Healthcare would improve.
  • HCPs would have up-to-date medical histories to work from, enabling them to spend their time counseling, not interrogating, patients as described above.
  • The EMR can contain similar health information, links, and multimedia education as described above.
  • Wellness and disease management guidelines can be incorporated into the guideline alerting system so that HCPs can easily apply them to their patients.
  • Clinical trials can be run through the EMR providing another source of income for PHDs and HCPs.
  • Epidemiological surveillance. Discrete data that can be collected across sites and diagnostic equivalence would enable powerful epidemiological reporting, which can be applied to these applications:
  • Real-time disease surveillance. Monitoring various clinical sites across a region can provide this data.
  • Pharmacoepidemiological data. How HCPs prescribe medications for various diseases is an important topic that is not well understood.
  • In the EMR, when a HCP prescribes a medication for a patient during an encounter, he or she must access the e-prescribing pad through one of the patient’s problems, thus establishing a link between that prescription and that problem. The HCP has the opportunity to associate the medications with other problems.
  • Post-marketing drug surveillance. For many drugs, the incidence of complications is very low. Thus for complications to appear, a large number of patients must be taking the drug. This occurs after the FDA has approved a drug for market. Therefore, post-marketing surveillance of drugs is important to detect complications.