Question

The patient presents to your office with a PHR.Develop a tool for providers to understand the PHR that includes:

How do you access it?

What obstacles might you identify?

Frequently Asked Questions

What advantages and disadvantages are there?

What do you as a clinician need to understand?

Answer 1

The PHR (personal health record) is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care. Sometimes this information can save you the money and inconvenience of repeating routine medical tests. Even when routine procedures do need to be repeated, your PHR can give medical care providers more insight into your personal health story.

Remember, you are ultimately responsible for making decisions about your health. A PHR can help you accomplish that.

Important points to know about a Personal Health Record:

• You should always have access to your complete health information.
• Information in your PHR should be accurate, reliable, and complete.
• You should have control over how your health information is accessed, used, and disclosed.
• A PHR may be separate from and does not normally replace the legal medical record of any provider.
• Medical records and your personal health record (PHR) are not the same thing. Medical records contain information about your health compiled and maintained by each of your healthcare providers. A PHR is information about your health compiled and maintained by you. The difference is in how you use your PHR to improve the quality of your healthcare.
• Take an active role in monitoring your health and healthcare by creating your own PHR. PHRs are an inevitable and critical step in the evolution of health information management (HIM). The book “The Personal Health Record” assists new users of PHRs in getting started, addressing current PHR trends and processes.

Reports Common to Most Health Records:

• Identification Sheet – A form originated at the time of registration or admission. This form lists your name, address, telephone number, insurance, and policy number.
• Problem List – A list of significant illnesses and operations.
• Medication Record – A list of medicines prescribed or given to you.
• History and Physical – A document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits, and current medications. It also states what the physician found when he or she examined you.
• Progress Notes – Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.
• Consultation – An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.
• Physician’s Orders – Your physician’s directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.
• Imaging and X-ray Reports – Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.
• Lab Reports – Describe the results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.
• Immunization Record – A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children’s immunization records with other important papers.
• Consent and Authorization Forms – Copies of consents for admission, treatment, surgery, and release of information.

Additional Reports Common to Hospital Stays or Surgery:

• Operative Report – A document that describes surgery performed and gives the names of surgeons and assistants.
• Pathology Report – Describes tissue removed during an operation and the diagnosis based on examination of that tissue.
• Discharge Summary – A concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.
• Your records may contain some or all of the documents above. Depending upon your illness or injury, you may use the services of the emergency room, intensive care unit, a physical therapist, or home health nurse. Often these specialized services have unique evaluation, measurement, and progress reports wich you may also find in your health record.

How is it useful?

The information in your medical record is used to monitor your health, coordinate the care you receive, and ensure that quality healthcare is being delivered—but that’s just the beginning. It also travels to many different places both inside and outside the healthcare system. Your information may be used for research, as a legal document in cases where evidence of care is needed, and to pay for the care you receive.

By healthcare providers:

Most healthcare organizations have quality assurance departments. People in these departments review patient information in order to monitor and improve the quality of care you receive. Your information may also be used for research and as a legal document in cases where evidence of care is needed. For the most part, anyone who wants to use it for any other purpose needs your permission first.

Hospitals can share information with family members without your authorization if you are unable to consent and a family member (such as spouse, parent, or child) is involved in providing your care. For example, your spouse or child may be involved in caring for you following a hospital stay (by helping you in and out of bed, to bathe, changing bandages, and similar activities). You can simplify things at the time you are admitted to the hospital (or nursing home) by specifying which family member you want to receive information about you.

By insurance companies:

After your health information is collected, it is used to bill for the services you received. Your patient data for billing purposes is usually transmitted electronically to those paying your bills, such as your insurance company, although the company may request paper documents in support of the bill. Your information is often identified by your name, patient identification number, address, phone number, and social security number. Your health insurance company receives your health information through the claims provided by the patient accounts/billing department at your healthcare facility. The coded data is then evaluated automatically to identify appropriate payment for the services you received. Your insurance company may ask your provider for more information to validate payment if the claims submitted were not complete enough to support what was being billed.

What is the use of PHR?

Use your PHR to assist with decision-making when it comes to potential health conditions, treatment options, costs of treatment, management of chronic conditions, healthy lifestyle choices, preventive actions, and monitoring the accuracy and security of your health information.

Individual-level Barriers to Personal Health Record Adoption

At the level of the individual, health care consumers must understand and accept their roles and responsibilities related to their own health care. The developers and users of EHRs and PHRs must understand individuals' and clinicians' mental models of health care processes, and the related workflows. An individual's PHR can only be useful if the person understands the importance of maintaining and coordinating health-related documentation and activities with health care providers. Consumer-related interface, technology, and access issues specific to PHRs are not yet well understood.

The workflow models for both providers and patients are poorly understood. While informaticians have studied clinical workflow models in some settings of care, evaluations of patient workflows in homes and in the community are rare. We will have to develop an understanding of how the PHR can fit into the flow of what individuals do on a day-to-day basis.

It is possible that PHRs will threaten the control, autonomy, and authority of some health care providers, based on traditional provider–patient roles. Providers and patients will need to develop different mindsets and levels of trust. Providers must learn to encourage patients to enter the information accurately and to trust that information appropriately. Consumers must trust that providers will only use the information for the individual's benefit.

Behavioral change is difficult. For PHR adoption, change management issues involve providers, consumers, and regulators. First, there must be a motivation to change. While it is intuitive that PHRs can help to improve health by offering additional information when it is needed, better objective evidence of efficiency and effectiveness of PHRs may be required before consumers, providers, and regulators will move toward the goal of PHR adoption.

Frequently Asked Questions

Where do I go if I can't find the information I need on your Web site?

If you are unable to find the answer to your question on this Web site, please visit our Helpful Links section for additional resources. You can also try contacting the director or manager of health information managementat your local hospital who may have additional suggestions.

How can I obtain copies of my health record?

Contact your doctors’ offices or the health information management or medical records staff at each facility where you received treatment. Find out if your provider has his/her own plan for helping patients to create personal health records (PHRs). Ask if your records are in an electronic format that you can access yourself, or if you need to request that they make copies for you. Also, ask your physician or health information management professional to help you determine which parts of your record you need. If you want medical records kept by your health plan, contact the plan’s customer service department.

Ask for an "authorization for the release of information" form. Complete the form and return it to the facility as directed. Most facilities do charge for copies. The fee can only include the cost of copying (including supplies and labor), as well as postage if you request the copy to be mailed. It can take up to 30 days to receive your medical records, so ask when you can expect to receive the information you requested.

Am I required to pay for copies of my health record?

Your healthcare provider is allowed to charge a reasonable fee for copies of your health record. The fee should only include the cost of copying (including supplies and labor), as well as postage if you request the copy to be mailed. If you request an explanation of this information, you may also be charged a fee for its preparation.

I need my immunization records and can't locate my physician. What should I do?

Even if your physician moved, retired, or died, his/her estate has an obligation to retain your records, including immunization records, for a period defined by federal and state law. Often this retention period is 7-10 years following your last visit (or until a child/patient is 21 years old). You may be able to locate your records by contacting:

• Your physician’s partners
• The health information manager at a nearby hospital where the physician practiced
• The local medical society
• The state medical association
• The state department of health
• If your efforts are unsuccessful, you may have to be re-immunized.

I am moving to a different state. How can I transfer my health record?

If you know the name of the new healthcare provider you may ask your current physician to send a copy of your health information. You may be asked to make the request in writing and to specify what information you want to have sent.

If you don’t know where you will be receiving care, you have two other options.

Once you have selected a new healthcare provider, go to his or her office and sign an authorization form, which the office staff will send to your previous provider requesting that copies of the information be sent.

Ask your current provider’s staff to make a copy of your records, and carry it with you to give to your new provider, when you choose/visit one. You will probably be asked to pay for the cost of copying records, so you may want to ask for help determining which records your new provider will need.

I don't know how to use a computer well. Do all PHRs need to be documented on a computer?

PHRs (personal health records) are not the same as EHRs (electronic health records). Therefore, you may store your PHR in the form of paper, computers, Internet, or portable devices such as CDs or jump drives.

Why would I want to keep a PHR?

Your health information is scattered across many different providers and facilities. Keeping your own complete, updated and easily accessible health record means you can play a more active role in your healthcare. You wouldn’t write checks without keeping a check register. The same level of responsibility makes sense for your healthcare.

A patient’s own PHR offers a different perspective, showing all your health-related information. It can include any information that you think affects your health, including information that your doctor may not have, such as your exercise routines, dietary habits, or glucose levels if you are diabetic.

Also, the PHR is a critical tool that enables you to partner with your providers.

It can reduce or eliminate duplicate procedures or processes, which saves healthcare dollars, your time, and the provider’s time. And the information you gather gives you knowledge that assists your preparation for appointments.

With your PHR, you can:

• Knowledgeably discuss your health with healthcare providers
• Provide information to new caregivers
• Have easy access to your health information while traveling
• Access your information when your doctor’s office is closed
• Record your progress toward specific health-related goals
• Refer to physician instructions, prescriptions, allergies, medications, insurance claims, etc.
• Track appointments, vaccinations, and numerous other wellness healthcare services

If I don't have access to a computer can I still keep a PHR?

Yes. A simple file folder with copies of your health records can be very valuable in documenting your health. Electronic PHRs may be more efficient than paper, especially now that more physicians have moved to electronic health records, but the important thing is to have a single source of your health information, in whatever format you choose to store it.

Do universities offer free PHRs to students?

Yes. Several universities now offer PHRs to enrolled students. Indiana University is providing free PHRs to students through a service called NoMoreClipboard.com, which allows students to import their health data from the school’s health system. Students can keep their PHR after graduation, if needed.

Should my PHR include emergency contact information?

Yes. For the best possible care in the case of an emergency, you should include emergency contact information in your PHR.

Can I access my PHR through my cell phone?

Yes. If your PHR is stored through an Internet service, it can be accessed. If your phone does not receive Internet access, you may install an application that allows you to print, backup, encrypt, and import data when connected to a computer. Later, when you’re on the go, your PHR can be accessed and edited through your mobile phone.

Personal Health Records: Advantages and Disadvantages
Personal Health Records are records of your personal health information stored on a system. They provide easier and faster access for patients to their information, which they can manage and control to their liking.

Advantages

• you can limit who can access your PHR online
• you can limit how much of your personal information people can access
• many different types of people can access them (i.e. your physicians, pharmacists, pharmacies, insurance companies, etc.)
• many different forms as website ones are stored on a secure, reliable server created by one of your personal health care providers
• Also, when a new doctor asks a patient for his medication history but he can’t remember it, he can go access the patient’s PHR online with his password and find it during an appointment

Disadvantages

• there is still no federal law right now stopping people from sharing or selling personal medical records to any marketing agencies or other 3rd parties without the patient’s consent
• companies often take patient data without their consent and the data is shared without taking out all unique identifiers in it that reveal a patient’s personal information
• It costs around $30,000 to implement an electronic record system in a health care facility
• all someone needs is the patient's password to access their entire PHR online as there is no furthur security protection
• the privacy settings in a Personal Health Record have not been fully developed yet

What do you as a clinician need to understand?

The changing healthcare environment includes significant opportunities for improving care by providing patients with increased access to and management of their health information and the health information of loved ones they care for. One example of this consumer empowerment is the increasing use of personal health records.

Benefits of PHR
Convenience

• PHRs can provide the patient a detailed record of their health history without having to remember or keep paper records of such information as immunization dates, injury and illness dates or treatments they have received.
• Should they choose to, the information in their PHR can be shared with clinicians so they can easily see what types of treatments the patient has undergone and what medications have been prescribed.
• With the increasing use of electronic record-keeping systems in clinical settings, PHRs that can connect to hospital or medical office information systems may simplify the patient registration process.

Education

• PHRs may include or link to educational resources and tools such as wellness programs and health risk assessments.
• PHRs may have features to help patients track chronic illnesses, diet, exercise and other everyday health behaviors.
• Access to life-saving information
• PHRs may help clinicians identify potentially harmful interactions between medications.
• Web-based PHRs can be an important source for critical information when patients are traveling, in need of emergency care or providing caregiver support to dependents who are elderly or away from home.

PHR Privacy and Access
Well-designed PHRs are private and secure. No one should be able to view a person’s PHR without appropriate consent. However, patients may be able to permit or specify special access and viewing permissions that would allow use of the PHR in a critical emergency situation. In this limited type of emergency situation, clinicians may be able to access patients’ medical history when patients are not able to provide urgently needed information. For example, emergency care clinicians should be able to learn if patients have allergies or are taking medications that may affect the care they deliver. The information contained in the PHR is meant to be available at all times, whenever and wherever the patient and their authorized users have access to the Web.