Personal Health Record (PHR) Systems and Return on Investment (ROI)

Shepherdstown 04 December 2008Meeting the health care needs of people in an effective and efficient manner is becoming an ever-more challenging proposition as costs rise, reimbursement goes down, quality accountability goes up, and demands for new treatments increase. Professionals, politicians, and patients are realizing that the current health care system, despite all its strengths, is broken and must be transformed.

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Simply put, the current health care system must continue to evolve from the doctor-centered production system of today to a more holistic, integrated person-centered system of the future. In many ways, people are becoming their own "ConsumerMD", supported by advanced information systems, technologies, and processes that enable self-care. The rise of personal health record (PHR) systems will play a key role in this transformation of our health care system that is underway.

The personal health record (PHR) is an electronic, lifelong record of health information that is maintained by individual citizens. These individuals own and manage the information in the PHR, which comes from both their health care providers and the individuals themselves. In this article, we focus on the steady growth in use of the personal health record (PHR) and reports to date on the cost/benefits or return on investment (ROI) related to their use based on a wide range of previously published articles and papers.

Background

In early 2000, the number of articles on PHR systems began to increase significantly as the number of these systems began to proliferate and be implemented by more and more health care provider organizations.

In January 2005, American Health Information Management Association (AHIMA) formed an electronic health information management workgroup to examine the role of the PHR in relation to the electronic health record (EHR). Based on research of current industry activities, AHIMA and the American Medical Informatics Association (AMIA) now advocate empowering individuals to manage their health care through the use of a personal health record (PHR).

In February 2006, NCVHS released a comprehensive report and recommendations on "Personal Health Records and Personal Health Record Systems" that bears reading. See http://www.ncvhs.hhs.gov/0602nhiirpt.pdf

In 2008, we saw both Microsoft and Google enter the PHR market place already populated by a range of fairly successful systems offered by Revolution Health, WebMD, Medem and others.

Finally, a 2008 survey commissioned by the Markle Foundations found that 2.7 percent of adults currently have some form of an electronic PHR, representing about 6.1 million persons. The numbers are slowly growing.

PHR Principles & Functionality

Basic principles and functionality of Personal Health Record (PHR) systems have been well documented in a recent joint report issued by AHIMA and AMIA. The report points out that the PHR should contain a wide range of information relevant to an individual's health. It states that a PHR should contain the following information:
  • Personal identification, including name and birth date
  • People to contact in case of emergency
  • Names, addresses, and phone numbers of your physicians, dentists, and specialists
  • Health insurance information
  • Living wills, advance directives, or medical power of attorney
  • Organ donor authorization
  • A list and dates of significant illnesses and surgical procedures
  • Current medications and dosages
  • Immunizations and their dates
  • Allergies or sensitivities to drugs or materials, such as latex
  • Important events, dates, and hereditary conditions in your family history
  • Results from recent physical examinations
  • Opinions and notes of clinical specialists
  • Important tests results; eye and dental records
  • Correspondence between an individual and his or her health care provider
  • Current educational materials, or appropriate web links, relating to one's health

In addition to medical information such as test results and treatments, a PHR should probably include diet and exercise logs, in addition to a list of over-the-counter (OTC) medications. PHR systems should provide a range of other services that meet the needs of patients such as:

  • Allow scheduling of clinical appointments online, as needed
  • Provide wireless access to public and private health and medical knowledge bases
  • Allow authorized access to your PHR anywhere, especially in an emergency
  • Allow you to buy needed health and medical related products online
  • Monitor and record nutrition intake, exercise, and other health related activities
  • eRx services that allow a patient to request Rx refills and manage prescribed or OTC products
  • Order or obtain selected services from your preferred physician or health care system
  • Have your PHR updated real-time from wearable or implanted biometric sensors
  • Access an array of other services tailored to your medical condition

For more information see http://www.amia.org/inside/releases/2006/ahima-amiaphrstatement.pdf

Selected Examples of Available PHR Systems

The following are brief descriptions of just a few of the many collaborative projects, activities, and organizations involving the development and implementation of personal health record (PHR) systems. We have focused heavily on those projects that involve open source solutions, but also include Commercial-Off-The-Shelf (COTS) solutions.

AHIMA and myPHR

The American Health Information Management Association (AHIMA) is a national nonprofit professional association, founded in 1928, dedicated to the effective management of personal health information needed to deliver quality health care to the public. It has put together a Web site with a set of procedures and forms you can use to construct your own personal health record. See information on myPHR at http://www.myphr.com/.

My HealtheVet

My HealtheVet (MHV) is the gateway to veteran health benefits and services. It has been developed and deployed by the U.S. Department of Veterans Affairs (VA) and provides access to trusted health information, links to federal and VA benefits and resources, the Personal Health Journal, and now online VA prescription refill. In the future, MHV registrants will be able to view appointments, co-pay balances, key portions of their VA medical records online, and much more. It has been deployed at all VA medical centers across the country, and hundreds of thousands of veterans are now using this PHR system. See http://www.myhealth.va.gov/.

iHealth Record - http://www.ihealthrecord.org/

The iHealth Record was released in May 2005 by Medem. It was a joint venture of the American Medical Association (AMA) and other key health care organizations. Features included:

  • No cost to patients. The service is funded by physician and hospital groups who license the service for their patients.
  • Online consultations for patients paid for by health plans.
  • Email capabilities between doctors and their patients.
  • Includes current medical conditions, medications, past surgeries and allergies, and end-of-life directives.
  • Health information is securely stored on the Medem network and cannot be sold or provided to any third parties without a patient's permission.
  • Additional resources include education programs, automated reminders regarding medications, and other services.
  • Patients decide which physicians will have access to view the record, and for what period of time that access is granted.

Consumers have many choices when selecting a PHR system that meets their needs. Their health care providers, employers, or insurers may offer them a PHR at little or no cost. They can also select from a growing number of PHR vendors who offer either a software application or online service. Links to some other examples of Open Source and Commercial-Off-The-Shelf (COTS) personal health record systems include:

Consumers should take the time to understand the advantages and disadvantages of the various types of PHR system providers. I recommend reading "12 Questions Consumers Should Ask When Choosing a PHR", by AHIMA.

PHR Cost/Benefits & Return On Investment (ROI)

Hard data on the cost/benefits or Return On Investment for PHR systems have been fairly hard to find. The following is a summary of various reports and white papers published in the last few years on this topic. Studies to date y tend to focus on potential benefits versus actual benefits.

"Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption", JAMIA, December 2005

According to a White Paper published in the Journal of the American Medical Informatics Association, PHR systems offer a number of potential benefits. See http://www.jamia.org/cgi/content/full/13/2/121

PHR Benefits for Consumers

  • One of the most important PHR benefits is greater patient access to a wide array of credible health information, data, and knowledge. Patients can leverage that access to improve their health and manage their diseases.
  • Patients with chronic illnesses will be able to track their diseases in conjunction with their providers, promoting earlier interventions when they encounter a deviation or problem.
  • Improved communication using a PHR system will make it easier for patients and caregivers to ask questions, to set up appointments, to request refills and referrals, and to report problems.
  • PHR systems can make it easier for proxy caregivers, such as family members, to better care for patients.
  • PHR systems can provide an ongoing connection between patient and physician. Patients value being able to readily access test results and better communication with clinicians.

PHR Benefits for Clinicians

  • Patients entering data into their health records can elect to submit the data into their clinicians' EHRs. Having more data helps clinicians to make better decisions.
  • The PHR may also become a conduit for improved sharing of medical records. Patients who are more engaged in their health are more active participants in the therapeutic process.
  • PHR-mediated electronic communication between patients and members of their health care teams can free clinicians from the limitations of telephone and face-to-face communication and improve the efficiency of such personal contacts.

PHR Benefits for Others

  • Potential benefits of PHRs to payers and purchasers of health care may include lower chronic disease management costs, lower medication costs, and lower wellness program costs.

American Academy of Family Physicians (AAFP) published a report in May 2006 on the cost/benefits of personal health records (PHR). It identified a number of potential benefits these systems offer to patients, their physicians and the health care system. These included:

  • Empowerment of patients
  • Improved patient-provider relationships
  • Increased patient safety
  • Improved quality of care
  • More efficient delivery of care
  • Better safeguards on health information privacy
  • Bigger cost savings

For more information, see www.aafp.org/fpm/20060500/57anin.html

National Committee on Vital and Health Statistics (NCVHS) also identified the many potential benefits of using PHR systems in a 2006 report. See http://www.ncvhs.hhs.gov/0602nhiirpt.pdf

Benefits identified in the report for consumers, clinicians, payers, employees and others included an extensive list of specific benefits for the following groups:

  • Benefits for Consumers, Patients and their Caregivers
  • Benefits for Healthcare Providers
  • Benefits for Payers
  • Benefits for Employers
  • Societal/Population Health Benefits

Value Realization and ROI - September 2006

See http://www2.amia.org/gotehr/docs/phrwhitepaperdraftvfinal.pdf?dbp

Health IT investments usually require justification based on quantifiable benefits in terms of avoided cost, improved efficiency or increased revenue. The health IT business case needs to take into consideration the one-time infrastructure costs, labor costs for implementation, as well as ongoing system support costs. However, according to this draft AMIA report:

  • There is a lack of empirical evidence in health care and informatics literature to quantify the PHR value proposition;
  • Although many of the perceived PHR benefits accrue to consumers, it is not clear that they are willing to pay or subsidize the cost of electronic health records;
  • Within the current business model, savings under non-capitated reimbursement arrangements tend to accrue to payers rather that the entity that invests in the technology;
  • To date, benefits such as patient satisfaction, improved communication, and consumer engagement have proven hard to quantify.

Employer Perspectives on PHRs - Oct 2006

The following are findings from a survey of major U.S. Employers on the use, tangible benefits and concerns related to PHR systems for employers - See http://www.phrconference.org/conf_resources/presentations/dec7/latest_consumer.pdf

  • 75% of employers don't yet offer a PHR but >50% plan to within 3 years
  • 50% plan to put financial incentives behind PHR adoption
  • Top value of PHRs as seen by employers:
    • Access to information in an emergency (80%)
    • Delivering information and disease management to employees (80%)
    • Sharing information with health care providers at the time of care (80%)
  • Top PHR concerns by employers:
    • Security & privacy (90%)
    • Employee and provider willingness to use PHRs (85%)
  • Top impact of PHRs on health care as seen by employers:
    • Improved safety and quality (>90%)
    • Improved direct employee engagement in their own care & health (90%)

VA eHealth Strategy & My HealtheVet White Paper - 2002

Extensive research, analysis and testing of various Department of Veterans Affairs (VA) initiatives indicated potential for significant cost-savings. Highlights of several ROI studies produced by the VA as it began moving toward development of its My HealtheVet Personal Health Record (PHR) system and electronic service delivery are profiled below.

  • MyHealtheVet - This integrated suite of online web-based information and applications has begun to serve as a major destination point for all veterans to access health information and interact with the VA. One initial area of ROI promised by My HealtheVet is in the expansion of the self-care where office visits could be reduced by 11% or more due to phone calls to a call center staffed by triage nurses. As My HealtheVet evolves to include personalized information on medical conditions, test results, billing information, pharmacy profiles and much more, the tangible savings could be further increased. Fewer calls to schedule clinic appointments, reduced mailing costs between the VA and veterans, reduced administrative fees related to manually processing forms, all offer tremendous potential cost saving.
  • 1010 EZ Registration Forms - Based on utilization data in June 2001, it was projected that 190,000 veterans will have used an online version of the 1010 EZ patient registration form. Using conservative savings estimates this was projected to equate to $168,000 in annual savings and achieves an ROI after two years, given the $400,000 cost of instituting the fully web enabled versions of the forms.
  • CHAMPVA Form Set - An analysis of the conversion of the CHAMPVA form to an online offering conservatively projected savings of $704,184 over a five-year period. This assumed that only 25% of veterans use the designated forms. The study estimated that an ROI would occur in less than 4 years. In a review of their methodology and assumptions, this was considered an extremely conservative estimate.
  • AudioCare e-Service - In 2002, the AudioCare interactive voice response system installed at almost all VA medical centers was accessed by veterans more than 60 million times to query the VistA systems at VA medical centers. These queries focused primarily on upcoming clinic appointments, the status of prescriptions, prescription refill requests, and co-pay balances. Handling 60 million 3-minute phone calls by staff at the VA would have cost $45M. It took less than one year to achieve full payback for the cost of the system.
  • WebCare eService - The companion WebCare module that would allow veterans to use a lower cost online self-service tool via the Internet was estimated to result in even greater savings. One internal estimate indicated that, with more than 50% of veterans today having access to the Internet that an additional 20 million queries a year could be handled via the Web, thus reducing the number of 3 minute phone calls to hospital staff to the tune of an additional $15M in savings in the first year.

VA, DoD, Kaiser Permanente and other organizations implementing PHR systems and electronic service delivery are continuing to conduct internal ROI and cost/benefit studies of each new feature as they move forward.

ROI on Wellness Programs and PHR Systems, September 2008 - See http://employeewellness.blogspot.com/search/label/ROI%20of%20wellness%20programs

Many PHR systems include health and wellness software applications, tools and information. "In 2001-05, medical claims for 1,900 Highmark employees who participated in its wellness programs were compared with the claims of employees with similar health risks who did not participate. The analysis shows that the company actually saved $1.3 million during the time of the study, mainly because its annual health care expenses for participating employees were $176 lower per employee."

Angel Investing, PHRs and ROI - August 2008

Research has shown that 78% of the public are very interested in having a Personal Health Record (PHR), but do not know how or where to obtain this item. Having a PHR addresses a major concern of the public - currently 63% are somewhat or not very confident that the health care professional has a complete picture of their health. To date, only 2.7% of people have an electronic health record available on the internet. Recent reports have shown that actual Return On Investment (ROI) for companies that incorporate a Personal Health Record have been as large as 8:1, based on per member per month reduction in claims paid. See http://go4funding.com/Angle-investor(s)-for-healthcare-business_Great-ROI_limited-openings/P9937.html

PHRs Could Save $21 Billion Annually

A November 17, 2008, article in FierceHealthIT Weekly reports on a new study from the Center for Information Technology Leadership at Partners Healthcare System in Boston that has come up with a detailed analysis of how much money interoperable PHRs could save annually. The study, which examined the costs and benefits of increasing the adoption of PHRs to 80 percent of the U.S. population, found that it would cost $3.7 billion in startup costs and $1.9 billion annually in maintenance costs. However, it also found that it would save up to $21 billion annually. See http://www.fiercehealthit.com/story/adoption-phrs-could-save-21-billion-annually/2008-11-17

HIMSS Reports on PHR Use and Benefits

HIMSS offers a range of articles and white papers on the topic of PHR systems and potential cost/benefits. They can be obtained from the following HIMSS web sites. See http://www.himss.org/digital_office/20071127_DigitalOffice.htm and http://himss.org/ASP/topics_FocusDynamic.asp?faid=204

Finally, a very recent detailed article on the benefits of Integrated PHR Systems published in 2008 by BioMed Central that is well worth reading. See http://www.biomedcentral.com/content/pdf/1472-6947-8-45.pdf

Conclusions

The following are some conclusions reported by various organizations that have been observing the PHR market place.

According to a PHR Market Overview by Frost & Sullivan, over the past decade vendors have been offering their personal health record (PHR) solutions directly to individual health care consumers. However, employers, health insurers, and health care providers have recently begun to offer PHR solutions to their respective constituencies as an essential part of their corporate competitive strategies. See http://www.frost.com/prod/servlet/report-brochure.pag?id=N0FF-01-00-00-00

Hospitals & Health Networks (HHN) recently published their annual list of the nation's "Most Wired" hospitals. They report that about 80% of the most wired hospitals have begun to offer access to PHR systems. For more information, see http://www.hittransition.com/arc_HITSync/arc0037.htm#037empowered

There was widespread consensus at a recent AMIA College of Medical Informatics symposium about the potential value of PHR systems and their potential to transform patient-provider relationships, especially when PHRs are integrated with provider EHR systems. They also identified many technical, social, organizational, legal, and financial challenges that warrant further study.

A report by Chillmark Research in April 2008 states that the PHR market appears to be robust, but most buying is still being done on faith rather than hard, demonstrable metrics on the ROI of PHR deployments by employers, providers and health plans. See http://chilmarkresearch.com/2008/04/21/whcc-day-one/

Fortunately, the number of studies reporting on actual cost/benefits or ROI on PHR systems is continuing to grow, as we have tried to show in this article. Look for new studies and findings to emerge shortly from the Veterans Health Administration (VA), Kaiser Permanente, CapMed and others that now have multi-year experience in deploying and using PHR systems.

Recommended Next Steps

The following recommendations and next steps are offered based on lessons learned to date:
  • Establish an Interdisciplinary Workgroup to identify functional requirements and/or potential uses of PHR systems by physicians and patients.
  • Identify Partners to collaborate on the development and deployment of PHRs (e.g., research, development, pilot projects).
  • Conduct a Feasibility Study and cost-benefit analysis for any PHR initiative you are considering.
  • Establish a Pilot Project to acquire, develop, and test a PHR system for your health care organization.
  • Integrate your EHR and PHR systems in order to get the most value out of your systems for your organization and your patients.
  • Educate and Engage Customers: Identify groups of patients/customers with selected long term medical conditions and develop an educational program and materials about the benefits of PHR systems.
  • Profile Clinical and Business Process Changes and the paradigm shift that takes place when patients assume control of their medical records through use of electronic PHR systems.

Most health care organizations are currently focused on electronic health record (EHR) systems and health information exchange (HIE) solutions. Investment in PHR systems is proceeding at a lesser pace. However, real transformation of our health care system will take place when personal health record (PHR) systems are more widely deployed and used across the country. So, get moving!

Author:

Peter J. Groen is on the faculty of the Computer & Information Science Department at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation - see www.shepherd.edu/surc


Peter Groen

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