HM312

1. © 2017 American Health Information Management Association© 2017 American Health Information Management Association
Health IT and EHRs:
Principles and Practice,
Sixth Edition
Chapter 17: Health IT for
Consumers

2. © 2017 American Health Information Management Association
Health IT for Consumers
• Personal health records
o Scanned documents
o Software supplied by vendors
• Offered by providers and others
• Acquired by consumer
• mHealth, aka digital health technology
o Screening kits
o Physiological monitoring
• Social media sites for health consumers

3. © 2017 American Health Information Management Association
PHR Definition – no standard
• AHIMA defines the PHR as “an electronic, universally
available, lifelong resource of health information needed by
individuals to make health decisions. Individuals own and
manage the information in the PHR, which comes from
healthcare providers and the individual. The PHR is
maintained in a secure and private environment, with the
individual determining rights of access. The PHR is separate
from and does not replace the legal record of any provider”
(AHIMA 2010)
• Connecting for Health observes that “PHRs encompass a
wide variety of applications that enable people to collect, view,
manage, or share copies of their health information or
transactions electronically” (2006).

4. © 2017 American Health Information Management Association
PHR Definition – no standard
(continued)
• Health IT.gov defines PHR as:
“An electronic application used by patients to maintain and manage their health information in a
private, secure, and confidential environment.”
PHRs:
– Are managed by patients
– Can include information from a variety of sources, including providers and patients
themselves
– Can help patients securely and confidentially store and monitor health information…
– Are separate from, and do not replace, the legal record of any health care provider
– Are distinct from portals that simply allow patients to view provider information or
communicate with providers
Properly designed and implemented, PHRs can help patients manage their health information and
become full partners in the quest for good health” (2013)
4

5. © 2017 American Health Information Management Association
PHR Dimensions and Attributes
From Connecting for Health
• Sponsor – supplier of PHR (provider, payer, employer, HIE,
professional organization, or disease-related group – which may be
non-profit or commercial)
• Integration
o Tethered – connected to sponsor (each of which may supply
data to or use data from a PHR in different ways)
o Standalone – independent of any sponsor
• Platform – how PHR is technologically supplied
• Data source – single sponsor supplies data; sources can be mixed
o Consumer should always be included as a data source, but
frequently is not when sponsor is a provider or payer
o Consumer should have the ability to exercise control over who
is provided access
• Business model – how PHR is funded
o Licensed, subscription, through advertisements, investment by sponsor

6. © 2017 American Health Information Management Association
PHR Attributes – no standard
• National Committee on Vital and Health Statistics notes that “PHRs are
broadly considered as a means by which an individual’s personal health
information can be collected, stored, and used for diverse health
management purposes. There is no uniform definition, and the concept
continues to evolve. NCVHS concluded that “it is not possible, or even
desirable, to attempt a unitary definition at this time” (NCVHS 2006).
• Health Level Seven (HL7) notes that its PHR-System Functional Model
(see next slide) does not attempt to define PHR, but rather identifies
features and functions necessary to create and manage an effective PHR.
HL7 also makes a clear distinction between a PHR and a PHR system,
where PHR is the underlying record that the software functionality of a PHR
system maintains.
• AHIMA organizes PHR attributes into six categories:
– Functionality
– Format and content
– Privacy, access, and control
– Maintenance and security
– Interoperability
– Ownership of the PHR

7. © 2017 American Health Information Management Association
HL7 PHR System Functional Model
Source: HL7 2014

8. © 2017 American Health Information Management Association
PHR Standards
• Continuity of Care Record (CCR) from ASTM International E31
Committee on Health Informatics, Massachusetts Medical
Society, American Academy of Family Physicians, and HIMSS
o CCR is a specification of content for an organized, transportable set of basic
patient information consisting of most relevant and timely facts about a patient’s
condition, especially for use in referrals and transfers of patients across the
continuum of care.
• It is not an EHR.
• It does not provide interactive clinical decision support.
• It is not universally accessible.
• It does not have a universal patient identifier or record locator service.
• It may be rendered in XML or as a document when combined with HL7 CDA.
• Clinical Document Architecture (CDA), from HL7, is a
document markup standard that specifies the structure and
semantics of clinical documents for the purpose of exchange. A
CDA document is a defined and complete information object that
can include text, images, sounds, and multimedia content.

9. © 2017 American Health Information Management Association
CCR + CDA = CCD
• HL7’s Clinical Document Architecture is a Web
Services Architecture (WSA) to support the exchange
of documents (See chapter 14).
• ASTM and HL7 have harmonized these content and
message standards to become the Continuity of Care
Document standard.
• Various types of document templates are being
created by HL7 and the consolidation of these
documents with the CCR content specification is
referred to as the Consolidated-Clinical Document
Architecture (C-CDA).

10. © 2017 American Health Information Management Association
Current Status of PHR Utilization
• More definitive information on PHR usage is needed.
• It is often not clear to the average consumer what a PHR is;
with those stating they have a PHR overwhelmingly
maintaining it via paper received from providers and
personal notes.
• Providers contribute to lack of understanding of PHR by
offering portals for scheduling appointments, paying bills,
exchanging emails, and providing (often limited) access to
a person’s health information, which they call a PHR.

11. © 2017 American Health Information Management Association
Benefits of PHRs
• Of strong interest to sponsors for different purposes, though mostly
associated with consumer engagement, which is believed to enhance
care coordination and improve patients. They are also of interest for the
ability to make more informed health decisions, and ultimately improve
health and lower the cost of health care.
• Physicians find PHRs valuable when information from disparate
sources is structured and legible. The American Academy of Family
Physicians identifies benefits as:
o Empowerment of patients
o Improved patient-provider relationships
o Increased patient safety
o Improved quality of care
o More efficient delivery of care
o Better safeguards on privacy
o Bigger cost savings as a result of improved documentation with PHRs lowering
malpractice costs (Endsley et al. 2006)

12. © 2017 American Health Information Management Association
Barriers to PHR Use
• Some concerns reflect an incomplete understanding of PHRs.
• Barriers and suggestions for addressing:
o Barrier: Are data faithfully and accurately maintained?
Suggestion: Ensure PHR data are appropriately sourced
o Barrier: No reimbursement for PHR review.
Suggestion: Move to patient entry of data via templates to move data to
EHRs
o Barrier: Liability for overlooking red-flag medical symptoms?
Suggestion: Ask patients to use their PHRs as a personal reference
o Barrier: Will patients understand the content of their health records?
Will there be risk of using unscrupulous sources?
Suggestion: Provider workflow changes to educate and explain results
saves downstream time. “Cyberseals” of approval can validate
legitimacy of websites
o Barrier: Are PHRs secure (like a flash drive or download from patient)?
Suggestion: Virus protection and other measures should be the norm
for all records

13. © 2017 American Health Information Management Association
Deeper Challenges with PHR Best Practices
• Should sensitive diagnoses be shared? (Yes, with appropriate
security measures.)
• Should entire medication list be shared? (Yes, with origin of
documentation and updates.)
• Should all lab results be shared? (Variations in workflow due to
state law restrictions noted, but CLIA requirements have
changed.)
• Should all clinical notes be shared? (Access should be supplied
on request.)
• Should patients be authenticated to access PHR? (Yes.)
• Should minors have access to PHRs, share access via proxies?
(Variations in state law prevail.)
• Policies and procedures should address these and other
issues

14. © 2017 American Health Information Management Association
Supporting Patient Use of PHR
• Blue Button
o Portal for Medicare benefits and services, as well as
information about acquiring a PHR (including reference
to myPHR.com.)
• MyHealtheVet
o Veterans Health Affairs portal for benefits and services,
including Personal Health Journal and prescription refill
requests; in the future, will be able to view portions of
their medical records.

15. © 2017 American Health Information Management Association
Ten Questions to Ask about PHRs

16. © 2017 American Health Information Management Association
Mobile Health Devices
• No significant differences across demographics of age, gender, income,
education, and geography with respect to use of or interest in digital health
technology.
• Activities:
o Integrated delivery networks enrolling patients in directed exchange
o Wearable fitness devices, personal testing tools, health apps, and
others, with caution for:
• Digital footprints left behind
• Interoperability (IEEE 11073 Health Informatics – Medical/Health Device
Communication Standards recognized by FDA for medical device
interoperability)
o Reliable and easy-to-understand information via the web
o Building communities in social media
o Privacy and security important issues
o Self-empowerment, often without the aid of their personal physicians

17. © 2017 American Health Information Management Association
Consumer Empowerment & Patient Engagement
• Consumer empowerment is the investment of power or authority
in those who purchase goods and services
o In healthcare, consumer empowerment is believed to make consumers more
financially responsible and accountable for their own healthcare.
o Consumer empowerment in healthcare is word of mouth enhanced through
digital and web technologies.
• Patient engagement is the actions individuals take to obtain the
greatest benefit from healthcare services available to them. The
National eHealth Collaborative Patient Engagement Framework
& Consumer eHealth Readiness Tool outlines five phases of
patient engagement:
o Inform me
o Engage me
o Empower me
o Partner with me
o Support my e-community

18. © 2017 American Health Information Management Association
Center for Advancing Health
Engagement Behavior Framework

19. © 2017 American Health Information Management Association
Federal Government Initiatives
• Consumers deserve to know the quality and
cost of their healthcare. Healthcare
transparency provides consumers with the
information necessary, and the incentive, to
choose health care providers based on value.
• Providing reliable cost and quality information
empowers consumer choice. Consumer choice
creates incentives at all levels, and motivates
the entire system to provide better care for less
money.

20. © 2017 American Health Information Management Association
Health Plan Initiatives
• Pioneers
o BlueCross BlueShield
o Aetna
• Payers are supplying providers and
consumers with:
o Patient data to populate a PHR (and EHR)
o Clinical analysis tools
o Best practice and best process protocols
o Reimbursement for e-visits

21. © 2017 American Health Information Management Association
Employer Initiatives
• The goal of employer-sponsored PHR is to let
employees compare costs, availability of
services, and to some extent performance
across care providers, putting more power into
their hands (and reduce costs for employer)
• Unique concerns associated with potential for
discrimination and rising premiums

22. © 2017 American Health Information Management Association
Vendor Initiatives
• Many vendors
o Internet, software, paper-based, wearable engraved
or electronic
o Product for purchase or free
• Unregulated, except
o Health Breach Notification requires vendors to
report breaches to Federal Trade Commission
• Watchdog groups have helped assure solid practices
o Center for Democracy and Technology
o Electronic Privacy Information Center