In the July issue of the JAMIA, Peggy Wagner et al provide an interesting report on the use of personal health records (PHR) in an effort to improve hypertension control. In this well-designed study, 446 patients were randomized to either receive access to a PHR connected to the patient’s electronic medical record or usual care (i.e. no PHR). Physicians were from ambulatory practices in either family medicine or internal medicine. Metrics included blood pressure, body mass index, the Patient Activation Measure (PAM), Patient Empowerment Scale, Patient Assessment of Chronic Illness Care (PACIC), Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CAHPS) and utilization measures (e.g. hospital days, emergency department visits, and outpatient visits). The PHR functions available included secure messaging, access to educational materials, medication interaction checking, recording/monitoring of health measures such as blood pressure, viewing of some EMR data, and some goal setting and health diaries.
So… what were the results?
- Patients in family medicine were more likely to use the PHR
- As age increased, PHR usage decreased
- PHR use increased with self-reported Internet use, higher average diastolic blood pressure, and higher provider scores on CAHPS communication measures
- A greater number of inpatient days was associated with lower PHR use
But… only 26% of the patients used the PHR frequently. There were no statistically significant changes regarding patient activation, improvement in outcomes, satisfaction with care, or change in the use of medical services. The authors write:
This underscores the necessity to consider the immediate health outcome potential of subsequent stage 2 implementation plans for meaningful use criteria which require that patients are provided with information access after inpatient and clinical encounters with expectations that 20% will use a portal at least once. Our results suggest stage 2 implementation may not produce changes in patient health outcomes. Whether this is due to limited likelihood of patient use or limited impact when used is not yet understood.
Of course, this is only one study and whether these findings can be generalized is difficult to determine. The authors do cite other studies that also noted infrequent use of PHRs. They also point out that patients who were the most frequent PHR users did reduce their diastolic blood pressure by 5.25 points and almost 4 points in the systolic blood pressure — but they could not determine whether these results were related to PHR use, greater motivation for change, or other factors. As for the overall results, it isn’t clear whether the lack of PHR usage was the reason for the lack of benefit, but the fact that 54% of patients used the PHR less than two times in 9–12 months (and 20% accessed it only 3–5 times) might indicate a gap between the enthusiasm for PHRs expressed by some and the actual interest level of patients.
Should these findings influence the implementation of Stages 2 and 3 of Meaningful Use? There are four policy priorities for Meaningful Use:
- Improve quality, safety, efficiency, and reducing health disparities
- Engage patients and families in their care
- Improve care coordination
- Improve population and public health
Use of portals, PHRs, and other strategies related to patient/family interaction with health information and eligible professionals are in priority #2. The proposed stage 2 Meaningful Use metrics for patient engagement — presumably through a patient portal or connected PHR — include the following core objectives and measures:
- Provide patients the ability to view online, download, and transmit their health information within four business days of the information being available to the eligible professional. The measures are: a) more than 50% of all unique patients seen by the EP during the reporting period are provided timely online access; b) more than 10% of all unique patients seen by the EP during the reporting period view, download, or transmit to a third party their health information.
- Use secure electronic messaging to communicate with patients on relevant health information. The measure is: a secure message was sent using the electronic messaging function of certified EHR technology by more than 10% of unique patients seen during the EHR reporting period.
The current working document for Meaningful Use stage 3 from the Health Information Technology Policy Committee Meaningful Use Workgroup (of which I am a member) includes the following patient engagement related objectives and measures:
- View/Download/Transmit/Report, including ability to upload or report data to primary place of choice by patient (PHR, Portal, care team member, EHR, etc.); EP to choose one or more objectives according to what is most appropriate to their practice/facility. Some options listed: provide patients with the ability to self-report information such as: a) family history; caregiver status and role; functional status; patient-created health goals; medical device information (e.g., glucose levels; blood pressure).
- Provide 50% of patients the ability to designate to whom and when a summary of care document is sent to specific care team members (across settings/providers) and the ability of providers to review/accept updates.
- Create the capacity to accept pre-visit prep tools into the EHR (without a use requirement).
- Offer 10% of patients the ability to reconcile information — correct errors, add addenda (without requiring usage — just the ability to offer this option; no threshold for percentage of patients that take action or use it).
- More than 15% of patients use secure electronic messaging to communicate with EPs.
Most physicians and practices would likely agree with the need to better engage patients and families in their care — and that many of these objectives are worthy of attention and implementation. The question is one of balancing these priorities with the finite capacity of practices to implement and satisfy a growing number of objectives, escalating expectations of performance on earlier measures, and a number of other “distractions” (e.g. e-Prescribing penalties, physician quality reporting system, ICD-10 implementation, and payer-specific performance-based compensation programs).
Is the effort to drive patient engagement through Meaningful Use criteria ahead of the evidence? Should more testing and experimentation take place before adding new criteria and/or raising thresholds to satisfy Meaningful Use objectives for patient/family engagement?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.