Physicians should establish rules with their patients before using a PHR

These days, it seems that for every consumer advocate out there who promotes the personal health record (PHR) as The Patient Empowerment Ubertool, there’s at least 10 physicians worried sick that the technology will further complicate their frazzled work lives.

The fear and loathing derives from an increasingly common and distinctly distasteful experience in which a patient presents the physician with a thumb-drive, computer disk or Web-link to a site containing a Biblical flood of his blood pressure recordings, summaries of every headache, joint click and wheeze he’s ever had, and other gobbledygook which he blithely refers to as “his PHR.”

It’s the gift that keeps on giving and the problem for providers isn’t just the amount of information contained in the PHR or the oftentimes unorganized way in which it is presented. It’s that physicians are rarely reimbursed for time spent deciphering PHR data, and their concern that they will be sued should they miss the morsel of clinical pertinence amid the torrent of health minutiae.

“Folks like me are terrified of personal health records and what patients will bring to us,” internist Michael Zaroukian confided earlier this year in a panel discussion covered by Modern Healthcare. “In some ways, it’s simply an electronic extrapolation of what we’ve seen in the paper world,” added Zaroukian, who is also the Chief Medical Information Officer at Michigan State. “The greater the volume, the more likely it is that relevant data will be lost.”

Zaroukian actually takes time to help his patients organize their input so it can be useful to him, but the problem will overwhelm even the most intrepid physicians if currently low levels of PHR utilization were to blow-up, especially if every single PHR vendor continues to display patient data in its own idiosyncratic way. Imagine dealing with PHR info from 500 patients using 10 different PHRs!

The lack of reimbursement for such dealings adds rock salt to the wound. “With personal health records, one of the issues is the core problem of financing healthcare where information management and discussions with patients are poorly reimbursable in the context of an office visit,” Peter Basch said. “Those are currently seen as an uncompensated burden on physicians.”

“There’s no payer who will say: ‘Sure, I’ll pay you for your time’; they’ll say ‘Too bad, learn how to do it in 60 seconds.’”

The liability concerns appear to be real, as well. “Do patients have the right to delete something from a PHR?” asks Steven Waldren, director of the American Academy of Family Physicians’ Center for Health Information Technology. “If they do, do they have to notify physicians that something is missing?”

Probably yes, but according to Geoffrey Gifford, an attorney who specializes in medical negligence and product liability, the same legal standards apply whether a patient delivers a box of paper files or a PHR to the physician. Either way, physicians “have a duty to look at them if the records are pertinent to the treatment you’re rendering.”

Translation: the PHR needs to be reviewed for information that is relevant to the patient’s visit to the doctor.

One technique that can help in this regard is to ask patients, “What’s important in here and why is it important to you?” Debra McBride, vice president of Aon Risk Services told Modern Healthcare. Physicians are not receiving all that information “in a vacuum. They’re getting it from a patient who’s sitting in front of them. Ask for some guideposts.”

Elaborating on this point, Edward Fotsch, CEO of PHR provider Medem said physicians should establish ground rules with their patients before empowering them to use the tool.

“If I’m a physician and I offer you a PHR and you make changes on your own—or you go to some other doctor who makes changes—and I call in a wrong prescription, am I liable?” Fotsch asks. “No, I’m not, but only if—when I issued the personal health record—I set the rules of the road that I need to be notified of changes. You don’t say to a patient ‘Here’s a bottle of medicine. Good luck.’ ”

When it’s all said and done, PHRs do have enormous potential to improve care, but it’s not clear that potential will be realized. The tools need to be properly incorporated into a patient-physician partnership in which good communication channels have already been established.

Glenn Laffel is a cardiologist who blogs at Pizaazz.

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  • Justin

    It seems like it was only at state psych hospitals where records would be amassed for decades on patients, kept in the same place and be readily accessible. Now, with the EMR and PHR’s the amount of data on every patient is going to gigantic. This poses the problem of data being so buried it is not found.

    e.g. At the VA, the EMR goes back to the early 1990′s, and some patients have thousands of notes. And it has only been 20 years. Imagine a patient who goes to the VA at age 22, right after being discharged from the service. He could live to be 92. That is going to be 70 years of electronic records to dig through. If he is a generally healthy person, not a big deal, maybe. If he has psychiatric problems, he is going to have massive amounts of notes from day one. At what point are physicians going to be expected to dig through these decades of records? Who is going to pay for the time it is going to take?

  • J.T. Wenting

    It gets worse. Was the data collected using correct methods, always in the same way, etc.
    In other words, is the data (even without having to assume it’s incomplete) trustworthy at all.

    If there’s for example a spike somewhere in a heart rythm, is it arythmia or was the patient startled by a loud noise, or was he watchign a horror movie at the time?
    Who determines if the heart rythm monitor used was actually in working order in the first place and not recording random noise? And that it was used correctly and at repeatable intervals.

  • pinky black

    yeah, very well discussed. doctors should set certain rules with their patients in using PHR. doctors’ rights should also be protected. any error committed on the PHR is the doctors’ liability to patient. what if the error wasn’t caused by the doctor. e.g., the patient consulted other doctors. since there is no clear rules on PHR yet. doctors should establish rules in using PHR.

  • PICUDoc

    I think unfortunately the world of CPT, billing, and coding has not caught up with new health 2.0 technologies. I think we should move to flat rate billing by time like the lawyers do. Charge a premium for subspeciality time (higher training) and for procedural time (higher risk).

  • epatient

    Referring to my medical history and personal observations as ‘gobbleygook’ is offensive and possibly negligent. This post summarizes several foundational issues with how care providers can squeltch otherwise productive interactions with patients. #1 of course you need to review the health information I provide thats just part of delivering the care that you are getting paid to deliver. #2 you should review it in advance of my visit in order to be properly prepared for the appointment. #3 If the information provided is suspect or extraneous, then tell me so we can have a conversation about what to do about it. #4 you don’t own my medical information. I do and will use my best judgement hopefully in consultation with you about what to do with it.

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