Support for Personal Health Records as Part of an Electronic Health
Record by Rural Health Care Providers in Upstate New York
A Dissertation
Presented to the
Faculty of the
School of Health and Public Administration
Warren National University
In Partial Fulfillment
Of the Requirements for the Degree of
Doctor of Philosophy
In Health Administration
David G. Curry, RN, MSN
Plattsburgh, New York
ABSTRACT
In general, Americans depend on their healthcare providers to keep their
medical records, resulting in bits of information in multiple locations and
without a single repository. This creates a situation in which errors can
occur, as no one is exercising oversight. A Personal Health Record (PHR)
for every American is a partial solution that is recommended to help
decrease preventable medical errors. This dissertation reports a
descriptive survey conducted with the medical providers in the
Plattsburgh, New York area to determine how far advanced they were in
adopting Electronic Health Record (EHRs) systems for their offices,
whether they were familiar with PHRs and whether they would promote
PHRs with their patients. The major barriers to adoption of EHRs were
financial ones – initial cost, ongoing cost, and loss of productivity and
training. The major limitation of this study, other than the response rate, is
the unique, rural geographic location of the study population. The financial
barriers identified are consistent with other studies on the topic of EHR
adoption. Since adoption of PHRs has potential to be of great benefit to
patients and the health care system alike, incentives to adoption must be
put in place. In summary, rural medical providers in Plattsburgh, NY do not
appear ready to promote PHRs if it requires using their own resources.
ii
TABLE OF CONTENTS
CHAPTER 1
CHAPTER 2
CHAPTER 3
INTRODUCTION
Statement of the Problem
1
Case Study
3
Purpose of the Study
7
Importance of the Study
8
Scope of the Study
9
Rationale of the Study
12
Definition of Terms
14
Overview of the Study
16
REVIEW OF THE LITERATURE
Depth of the Problem
19
The Role of the PHR
22
Perceived value of a PHR
31
Lack of single standard
39
The Future for PHRs
44
Summary
55
METHODOLOGY
Approach
57
iii
Data Gathering Method
58
Database of Study
59
Validity of Data
60
Originality and Limitations of Study
62
Summary
64
CHAPTER 4
DATA ANALYSIS
65
CHAPTER 5
SUMMARY, CONCLUSION AND
90
RECOMMENDATIONS
Barriers to EHR Implementation
98
Study Support of Hypotheses
112
Limitations of the Study
117
Recommendations for Study Improvement
122
Challenges Implementing EHRs
125
Challenges Facing PHRs
139
Recommendations for Future Research
147
BIBLIOGRAPHY
154
Appendix A – Survey Instrument
161
Cover letter for survey
167
iv
List of Tables
Table 1 – How many MDs in Practice
93
Table 2 – Barriers to implementation of Electronic Health Records 105
Table 3 – Effect of Personal Health Record on Medical Practice
v
114
List of Figures
Figure 1
Types of PHRs
24
Figure 2
NextGen Interface
134
vi
Chapter 1: Introduction
Statement of the Problem
As a group, Americans are not very conscientious in caring for their
personal health information. A recent Harris Interactive survey showed
only about 42% of Americans keep any personal health records (PHRs)
(Taylor, 2004). Contrast this with their oversight of their personal banking
records. 57% of Americans reconcile their checkbooks (Bankrate.com,
2007).
In general, Americans depend on their healthcare providers to keep
their medical records. This reflects in part the paternalistic organization of
healthcare delivery in the United States, where the providers, generally
physicians, instruct the patient in what to do and expect unquestioned
compliance. The patients generally comply with few if any questions. In
addition, the historical belief was that health records were the property of
the healthcare provider and a physical asset of the organization to be
bought and sold with the medical practice. Even today, patients can
expect to pay for copies of their own medical records (Privacy Rights
Clearinghouse, 2007).
1
The result is fragmentation of personal health information, with bits
of information in multiple locations and without a single repository. A
second result is the inability of a patient to access the sum of their health
information even if they desired. Together, this creates a situation in which
errors can and do occur, as no one person or medical practice is
exercising oversight of the sum total of information.
In 1999, the Institute of Medicine released the report “To Err is
Human: building a safer health system” and shocked the healthcare
industry with estimates of 46,000 to 98,000 preventable deaths per year
from medical errors (Kohn, Corrigan, & Donaldson, 2000). Their research,
based on analysis of previous studies, placed the total national cost of
medical errors at between $17 and $29 billion per year (Kohn et al., 2000).
While most medical errors result from system problems – similar
medication names, similar packaging of different drugs or dosages, etc –
some errors could be avoided if patients or their families were more
involved or aware. A PHR for every American is a partial solution that is
recommended to help decrease preventable medical errors (Wolter &
Friedman, 2005).
2
Case Study
Jane Doe is a 38-year-old divorced mother of 2 teenaged
daughters. Her daughters are covered by her ex-husband’s health
insurance until they finish college, but with the divorce last year, she was
forced to return to work so she could afford health insurance for herself.
Her individual policy is not as good as the coverage she had while
married, but she is still able to have annual gynecologic exams with Pap
smears with a reasonable co-payment. Her long-time gynecologist
accepts her new insurance, but she was forced to change primary care
providers, as her internist did not. When she changed primary care
providers, only a medical summary of her old records was sent as her old
internist charged $0.75 per page for copying records – money she could
not afford.
On the date in question, Jane arrives at her gynecologist for her
annual exam accompanied by her 17-year-old daughter, Joan, who will be
having her first gynecologic exam. As mentioned, Joan is covered by her
father’s insurance. His insurance company has an online Personal Health
Record (PHR) for its insured patients and Jane has been keeping
information on the children since they were born. Jane printed a copy
today to bring to the first visit with this new provider for Joan. There is a
3
complete record of Joan’s immunizations and all acute visits with dates. It
is noted in this record that Joan has a questionable allergy to penicillin
dating back to age 5. Apparently, Joan developed a fine red rash on the
6th day of amoxicillin for a strep throat. Joan’s PHR also lists the fact she
is on an oral contraceptive for severe acne, prescribed by her
dermatologist.
Jane has been seeing this gynecologist since before her children
were born, and all her records have been kept by her gynecologist and her
primary health care provider. She has not kept her own PHR. Even if she
had, she could no longer access it since the divorce and change of
insurance. Since she first came to this gynecologist and gave her first
family history for their records, two of her mother’s older sisters have been
diagnosed with breast cancer. This information is not in her records;
however, since it occurred after her family history was taken. It is in her
daughter Joan’s PHR, however, since Jane added the information when
the diagnoses were made.
On this day, the provider sees Jane Doe first and on examination
finds a slight vaginal discharge and cervical inflammation. Since Jane has
a new sex partner, the provider suspects a Chlamydia infection and gives
her empiric treatment with ciprofloxacin (Cipro) and azithromycin. The
4
gynecologist’s records show no known allergies, but unknown to her, Jane
had been given Cipro by her old primary care provider years before for a
urinary tract infection and a rash and swollen tongue had developed. That
information was not in the medical summary Jane received from her old
internist, and Jane did not remember the event when this new prescription
was written. In addition, because Jane is not yet 40 years old, and her old
family history does not include those cases of breast cancer, the provider
does not consider a mammogram at this visit, as it would not be covered
by insurance.
The provider next sees daughter, Joan. She is impressed with the
print out of the PHR that Joan brings with her. She is also struck by the
family history of breast cancer reported there, as updated by Jane, and
realizes Jane has a significant risk of breast cancer, even though she is
under age 40. After completing her examination of Joan, she returns to
explain to Jane that she needs a mammogram right away given the
history, and that if the gynecologist had been aware of the family history,
would have done a baseline examination years before. Based on the
family history, the gynecologist obtains a prior authorization from Jane’s
new insurer for a mammogram even though she is not yet 40, the usual
minimum age for first mammogram.
5
Jane and Joan leave the office visit having learned the value of the
PHR, as did the gynecologist. Jane takes both antibiotics and has a
reaction. However, as they are only a single dose treatment of each drug,
has only a mild reaction, a rash and mild throat tightness, which clears
without major complications. She tells the doctor about it on her return,
and after inquiring at her old internist’s office, realizes she has an allergy
to ciprofloxacin. That information is entered in her record when she returns
to her gynecologist to find out her mammogram is within normal limits. At
this point, Jane begins keeping her own PHR on her personal computer.
This case study, while fictional, is not an exaggeration of how most
patients deal with their personal health information. In general, parents do
an excellent job of overseeing the health information for their children, but
less so when caring for their own information. This case study also deals
with a healthy mother and daughter. Consider that most health care needs
occur as people age and develop chronic illnesses. The amount of
medical information that can result, and the medications required to treat
the illnesses, increases with time. Further, the number of possible
locations, from hospitals to specialty physicians and therapists, to multiple
pharmacies, both local and mail-away, increases as well. The information
is scattered among many databases, but still belongs to the patient. The
6
patient has the greatest interest in the accuracy of the information, but
often leaves the task of maintaining that information to others. A Personal
Health Record, with only occasional updating, can make a substantial
difference in the quality of the health care one receives, especially when
seeing more than one provider.
In addition, providers, like the gynecologist in the case study,
currently depend on their patient’s memory to supply necessary medical
history. Unfortunately, a person’s memory is subject to errors. One can
forget even important past events or remember them incorrectly. This too,
can result in errors.
Purpose of the Study
The purpose of this study is to determine whether healthcare
providers in a rural community in upstate New York recognize Personal
Health Records as an important part of the Electronic Health Record
(EHR) for every patient and whether they are willing to invest in an EHR
that will integrate with a PHR. Further, it is hoped to determine whether
the rural providers will act as advocates for PHRs, since patients look to
their providers for medical guidance.
7
Importance of the Study
Examination of the literature since the release of the IOM report
shows that when patients are made aware of PHRs, they generally see
the value of keeping one (Taylor, 2004). The problem at this time is a low
level of awareness within the general population concerning the value and
availability of PHRs. An online survey at MyPHR.com (American Health
Information Management Association, 2006) retrieved on January 28,
2007 showed 42% of respondents kept no personal health records, 42%
kept paper records, 12% kept records on their personal computer, and 2%
used an online service like myPHR.com (total number of respondents was
not reported – just percents). Unlike the Harris Interactive poll mentioned
earlier, this is a convenience survey of visitors to the website –
experienced computer users. Even in this group, only 58% kept PHRs in
some form or another.
One cannot trust the healthcare system to keep ones records.
Healthcare in America is fragmented with multiple competing interests. An
individual can expect to have information about their health in every
physician’s office they have ever visited, every hospital they have visited,
the local medical laboratory (which may be a national company with a
huge database), their local health department, if they were ever bitten by a
8
dog or had a reportable disease, for example, every insurance company
with whom they ever had health or life insurance, every pharmacy at
which they filled a prescription and more. Each location represents
another possibility for inaccuracies.
Personal oversight of one’s medical information is as important as
one’s regular checking of their credit history for fraud or inaccuracies. A
PHR is the vehicle to that oversight. One’s personal physician could be
the authority figure who could promote the use of PHRs with their own
patients.
Scope of the Study
Plattsburgh, population 18,000, is the smallest “small city” in New
York State, located in Clinton County, population 88,000, bordered by
Canada on the North, Lake Champlain, and Vermont on the East and the
Adirondack Mountains and Park to the South. Champlain Valley
Physicians Hospital Medical Center or CVPH, as it is generally called, is a
341-bed acute care hospital serving the local population. It has a medical
staff of 156 members, with 92% board-certified in a specialty (CVPH
Medical Center, 2007).
9
CVPH is the largest local employer as well. The local economy is
otherwise dependent largely on timber and paper industry and state
employment at the many prisons or at the State University of New York
College at Plattsburgh. The Plattsburgh Air Force Base closed in 1995
with resulting loss of population in the 1990s of 2,759 (-12.8%) (CityData.com, 2007).
Because of its geographically remote location within the state, and
its sparse population, Health Maintenance Organizations do not find the
area profitable, and fee-for-service healthcare services are predominant.
As a result, many of the local providers, including specialists, are in singleprovider or small group practices, as opposed to the large multi-specialty
group practices found in larger, urban areas. Thus, a patient in Plattsburgh
will have separate medical records at every specialist’s office they go to, in
addition to their record at CVPH, where most laboratory services are
obtained. They will have a separate medication list kept by each of these
providers and each will have their own list of the patient’s allergies,
previous surgeries, etc.
It is possible that patients in Plattsburgh will use more than one
pharmacy for their prescriptions, and military veterans will often use
Veterans Health Administration facilities for some, though seldom all, their
10
care or prescription drugs. In other words, there are multiple redundant
copies of personal health information throughout the healthcare
community, obtained separately, usually through an interview by each
provider, and each with the potential for errors of transcription, omission,
or accuracy.
A recent telephone survey of the local private practices conducted
by CVPH Medical Center revealed that eight (26.7%) of thirty practices
report having an EHR for their patient records. Of those EHRs named,
none currently support integration with a PHR (J. Rafferty, personal
communication, January 19, 2007). This survey included medical
practices with providers not on the hospital medical staff.
The plan for this study is to perform a more complete informational
survey of the local providers, in cooperation with CVPH, to determine their
knowledge and understanding regarding EHRs and PHRs. Once they
have been educated about PHRs, through definitions in the survey,
questions will be asked to determine whether they will advocate the use of
PHRs to their patients by investing in EHRs that integrate with PHRs and
by educating their patient population.
11
Rationale of the Study
Since the IOM report, there have been many calls for
standardization of healthcare recordkeeping and funds to promote projects
aimed at increased use of information technology for standardization are
available at the federal and state level. However, implementation of that
technology happens at the provider level. Individual providers must
evaluate the many products available and decide which product meets
their particular wants and needs.
At the same time, it has become clear that patients must take more
responsibility for their own health and healthcare. They must exercise
oversight of their health information, for while the actual medical record,
whether paper or electronic, is owned by the provider; the data it contains
is the property of the patient. Therefore, both patient and provider should
recognize the value of patient access to that data through the mechanism
of a PHR.
However, do they? Specifically, this project sets out to determine
whether providers in a rural, predominantly private practice (as opposed to
large group practice) community recognize not just the value of an
12
Electronic Medical Record, but of the integration of an EMR with a
Personal Health Record.
Hypothesis one: “providers in rural private practice perceive the
Personal Health Record as having no additional value in an Electronic
Medical Record.”
Cost is a factor in the decision-making regarding EHRs as shown in
a 2005 Massachusetts study (Simon, Kaushal et al. 2007). Not all EHRs
can support PHRs, so when choosing a product, would providers pay
more for an EMR that can support a PHR? It is not the intent of this study
to compare specific EHRs. That said:
Hypothesis two: “providers in a rural private practice would not be
willing to pay any additional cost for an EHR that supports a PHR.” In
other words, if they see the value of the PHR, they are not willing to pay
for it.
Finally, healthcare providers operate in a regulated environment
where their income is determined by how many patients they see. Unlike
lawyers who can bill for every minute spent with an individual client,
physicians and other providers will only be paid what the third-party
payers determine for a visit regardless of length of time. While patients are
13
less likely now than in the past to take their providers words as gospel,
they still look to the providers for their recommendations. Since more
patients is more money to providers:
Hypothesis three: “providers in rural private practice will not be
willing to spend time advocating for Personal Health Records for their
patients.”
Definition of Terms
Continuity of Care Record (CCR) - a health record standard specification
under development by ASTM International, the Massachusetts Medical
Society (MMS), the Health Information Management and Systems Society
(HIMSS), the American Academy of Family Physicians (AAFP), and the
American Academy of Pediatrics to create flexible documents that contain
the most relevant and timely core health information about a patient. The
goal is to create a CCR that will enable the next provider to easily access
information at the beginning of a first encounter and easily update the
information when the patient goes on to another provider, in order to
support the safety, quality, and continuity of patient care (Medical Records
Institute, 2006).
14
Electronic Health Record (EHR) - a secure, real-time, point-of-care,
patientcentric information resource for clinicians. The EHR aids clinicians’
decision-making by providing access to patient health record information
where and when they need it and by incorporating evidence-based
decision support (Handler, Holtmeier et al., 2003).
Electronic Medical Record (EMR) – a medical record in digital format. In
health informatics, an EMR is one of several types of EHR. Confusion
between the two terms exists. EMRs typically include a problem list,
medication list, allergy list, notes, health maintenance information, and
results retrieval (for laboratory, radiology, and other testing results) (Bates,
Ebell et al., 2003).
Institute of Medicine (IOM) Report – “To Err is Human: building a safer
health system.” While several hundred reports have been issued since this
one came out in 1999, reference to “the IOM report” in this paper is
synonymous with this particular report, as it is in many health care
providers’ minds (Stafford, 2000).
Personal Health Record (PHR) - a health record that is initiated and
maintained by an individual. An ideal PHR would provide a complete and
accurate summary of the health and medical history of an individual by
15
gathering data from many sources (American Health Information
Management Association, 2006).
Provider – while primarily indicating physicians, the term includes nonphysician providers of healthcare such as podiatrists, chiropractors,
physical therapists, nurse practitioners, physician assistants, nurses, and
others.
Overview of the Study
CVPH Medical Center submitted a grant request in Spring 2007 to
the State of New York for funding to support Electronic Medical Records
(EMRs) in physicians’ offices throughout Clinton County, New York that
can share information with the hospital systems. This funding for Health
Information Technology (HIT) is available through the Health Care
Efficiency and Affordability Law for New Yorkers Capital Grant Program,
or HEAL NY, as it is known (American Health Information Management
Association, 2006; New York State Department of Health, 2006). The
EMR proposed in the grant is NextGen EMR from NextGen Healthcare
Information Systems, Inc. (R. Miller, personal communication, February
12, 2007). This EMR boasts an integrated Continuity of Care Record
16
(CCR) – one form of a Personal Health Record (Medical Records Institute,
2006).
The hospital has already conducted a limited telephone survey of
most physician offices in Plattsburgh (not the entire county) and has
determined that 8 of the 39, or 26.7% of practices surveyed have an
electronic medical record (J. Rafferty, personal communication, January
19, 2007). This actually compares favorably with a survey conducted in
Massachusetts in 2005, where 23% of practices were found to have
EMRs. The most frequently cited barriers to adoption of EMRs found in
that study were start-up costs, ongoing costs, and loss of productivity
(Simon et al., 2007).
The possibility of funds to support their adoption of electronic
medical recordkeeping tools will lead the 73% of provider offices in
Plattsburgh without an EMR to consider purchase options. Not all currently
available EMRs can integrate with PHRs. Nor are all EMRs equally priced.
While CVPH would prefer all providers chose a single EMR, such
as NextGen as proposed in the grant, the strengths and weaknesses of
the various products will undoubtedly lead to the choice of a number of
different systems across the many offices not yet having an EMR. The
17
factors that go into those choices are of importance to CVPH and to the
patients who will be served by these next-generation medical records
systems. As pointed out previously, inclusion of a Personal Health Record
component will allow patients to oversee their health information.
To determine how the local providers go about making choices in
the crowded field of Electronic Medical Records, working with the
Information Systems department of CVPH Medical Center, a survey will
be developed and distributed to the medical staff of the hospital. The
survey will be structured in such a way that terms such as Personal Health
Record and Electronic Health Record will be defined and the attitude of
the providers toward those items will be elicited. The survey will include
questions on whether the provider would be willing to pay more for an
Electronic Health Record that included a Personal Health Record, and if
so, how much more. The perceived barriers to implementation of
electronic records will also be explored.
18
Chapter 2: Review of the Literature
Depth of the Problem
To Err is Human: Building a Safer Health System was issued by
the Quality of Health Care in America Committee of the Institute of
Medicine (IOM) in September, 1999 (Kohn, Corrigan & Donaldson,
2000). This 200-page report re-examined two previous studies, one in
Utah and Colorado, the other in New York, and announced a finding that
shook the healthcare community. Extrapolating the findings of those
previous studies to the 33.6 million hospitalizations nationwide, the
calculation was made that between 44,000 and 98,000 preventable
deaths occur in hospitals annually from medical errors. This exceeds the
number of Americans killed in motor vehicle accidents in 1999 (43,458),
with a cost estimate of between $17 and $29 billion dollars for the
preventable events (Kohn et al., 2000).
The IOM report finds that most errors are caused by system
problems, not bad apples that can be removed. Human error is,
however, probably the leading cause of errors. However, a human error
can be precipitated by floating a nurse to a unit in a hospital without
proper orientation to specialty procedures, or by stocking two different
19
medications with similar names side-by-side. Yes, the error might be
made by one single person, but it is possible it was preventable with a
better system.
In order to design better systems, the IOM report has a number of
recommendations in Chapter 8. The first recommendation of relevance
to this project is, “include the patient in safety design and the process of
care” (Kohn et al., 2000, p. 173). In healthcare, the results of an error fall
on the patient, not the healthcare worker, or the workplace. Patients,
therefore, have the greatest interest in safety, yet for the most part, they
give themselves over to the system with few questions. The next
recommendation of relevance is, “improve access to accurate and timely
information” (Kohn et al., 2000, p. 177). This translates into computerbased patient records (CPRs) as part of the solution (Mjoseth, 2000).
Yet, at the same time that the United States spends
approximately 16% of its gross domestic product on health care, double
that of the median spending of industrialized nations, the US fails to lead
in health information technology (HIT) utilization (Schoen, Davis et al.
2006). In 2002, the United States still ranked last among twenty-three
industrialized nations in infant mortality (Schoen, 2006, p. w459). And
seven years after the IOM report discussed above, the United States still
20
has no reporting system to assess care delivered or point to areas for
improvement (Schoen, 2006, p. w463). Money alone cannot lead to
better, safer healthcare.
Information systems have the potential to improve healthcare
delivery and reduce errors and duplication, as well as track and assess
care. However, Electronic Medical Records (EMRs) are routinely used
by fewer than twenty percent of US physicians (Schoen, 2006, p. w470).
This compares poorly with the 60 to 90 percent rate of utilization in the
leading countries. This translates into the inability to generate lists of
patients by diagnosis or, if a medication were recalled, to identify all the
patients in a practice to whom that medication was prescribed. This lack
of computer support also means providers have no prompting of
potential drug interactions when prescribing new medications (Schoen,
2006).
The authors of the Scorecard study have a number of
recommendations to improve both quality and access to care. They first
note that many of the deficiencies in access, quality, and cost are
interrelated. “Lack of access to primary care, poor quality in hospitals
and nursing homes or during transitions, and inadequate information
systems contribute to duplicate efforts, inefficient use of specialized care,
21
and higher rates of hospital admission and readmission, which raises the
costs of care and lead to poorer outcomes” (Schoen, 2006, p. w.473).
Investment in research and information systems are the two areas the
authors emphasize as holding the key to improvements in our health
care delivery systems.
The Role of the PHR
One means to improving information management is the Personal
Health Record. A PHR can come in many forms from paper-based to
electronic format, either on a personal computer or on a network
database (Sprague, 2006). In its simplest form, a patient keeps a card on
their person listing known diagnoses, allergies, and current medications.
A more sophisticated one can be found on the Internet. MyPHR.com,
http://www.myPHR.com, has information on how to proceed with
developing a PHR (American Health Information Management
Association, 2006).
However, access to a PHR does not translate into actual use.
Consumers must see the value to themselves before they will invest the
effort in starting and maintaining a PHR. The American Health
Information Management Association (AHIMA) is taking a leading role in
22
promoting PHR use. In fact, AHIMA is the lead organization that
launched MyPHR.com in October of 2003 (Burrington-Brown et al,
2005a). One thing that is clear from examining the website is that there
are many ways to fulfill the functions of a Personal Health Record and
educating consumers on the many options is the first and most critical
task to increase PHR utilization.
MyPHR has information for consumers on why one should
maintain a PHR as well as how to obtain one’s health information from
providers. It has sections on consumer health information rights, which
includes who may or may not access one’s personal health information,
http://myphr.com/your_record/index.asp, and a section for Frequently
Asked Questions. The website also points consumers to various
products, included paper forms, online products and personal computer
based PHRs, that one can search to find the product best suited to one’s
resources and abilities at http://myphr.com/resources/phr_search.asp.
Another online PHR source may be one’s own health insurance
company. According to America’s Health Insurance Plans (AHIP) as
reported in Sprague’s article (2006), 70 million Americans have access
to a PHR through their various insurance plans (p. 3). A PHR maintained
by one’s insurer is referred to as “tethered” (Sprague, 2006). This refers
23
to the fact that it is not portable. In response to concerns this lack of
portability raise, AHIP is pursuing implementation of data standards to
allow transfer of data between health plans.
Figure 1 – Sprague, 2006, p. 4
24
Untethered, or patient-maintained PHRs, may raise concerns in
providers’ minds about trusting the data a patient brings to visits
(Sprague, 2006). Until recently, the patient has always been the primary
source of his or her own historical health data, but as databases in
hospitals and insurance companies grow, potentially more accurate
sources of information become available. A patient who arrives with a
PHR listing chronic pain and multiple allergies to pain medications will
likely provoke suspicion, just as they would if that were the verbal history
they gave. If that same information came from a “tethered” PHR,
suspicion would be less likely.
There are other issues regarding PHRs that must be considered
also. Who has access to your PHR and who can alter the data it
contains, for example? The access question gets very complicated when
dealing with minors, especially teenagers, who may currently have some
privacy protection around reproductive issues. In such a case, even their
parents might be restricted from accessing their Personal Health Record.
The privacy and access issues are also complicated by the fact
the Health Insurance Portability and Accountability Act (HIPAA) of 1996,
which was designed to protect personal health information, would not
apply to private vendors of PHR software (Sprague, 2006, p. 9).
25
Insurance company PHRs would be covered by HIPAA, since insurance
companies are “covered entities” but private vendors are neither covered
entities nor agents of a covered entity, so privacy protection would not
attach under HIPAA as currently written. A recent proposal from the
National Committee on Vital and Health Statistics (2006) would remedy
that oversight, but legislative action is required. Such action is not yet on
the horizon.
Why a Personal Health Record? Fragmentation of our personal
healthcare is the primary reason. Personal oversight of our healthcare
information becomes critical when a complex medical condition occurs.
Deborah Ribis, a nurse who suffered a workplace back injury, has written
a book describing the information one needs to keep and the steps one
needs to take to advocate for oneself in the healthcare system (Ribis,
2006). While not specifically naming the product a Personal Health
Record, she devotes an entire chapter to recordkeeping (Ribis, 2006,
pp.42-50). A work-related injury is particularly complex because it
involves both the healthcare system and the government. But even just
within healthcare, one can expect to see several doctors and therapists,
some of whom are working for you and some for the workers
compensation system.
26
That might be the most important point in her book – the only
person you can be certain has your best interest in mind is you. Even
your personal doctor has a complex agenda regarding your care. He or
she isn’t directly paid by you, but rather is paid by some third-party
probably with a co-pay from you. But regardless of who pays,
“Remember, medicine is a business, and you are a customer” (Ribis,
2006, p. 51). One’s self-interest, therefore, drives the need for personal
recordkeeping.
The issues of personal healthcare recordkeeping have been
extensively researched by the Working Group on Policies for Electronic
Information Sharing Between Doctors and Patients of the Markle
Foundation (Working Group on Policies for Electronic Information
Sharing between Doctors and Patients 2004). It can be accessed online
at
http://www.connectingforhealth.org/resources/wg_eis_final_report_0704.
pdf . The principal recommendations of the Working Group for the years
2004-2006 are:
27
(“Connecting Americans to Their Healthcare: final report,” 2004, p. 1)
Recommendation 1 translates to ‘educate the public about
Personal Health Records’. A PHR provides a mechanism for patients not
only to oversee their health information, but enables electronic
communication with their providers of care. Increased public
understanding must come first and foremost from the healthcare
providers themselves. Patients listen to the recommendations of their
providers. That is why they are there in the first place; to get advice on
their health. While that advice is often in the form of a medication, it
should also be guidance on safety and prevention of illness or injury. A
PHR can prevent injuries in the form of errors, thus making their
endorsement an appropriate recommendation of providers. Whether
rural providers see the value of a PHR, are willing to make a financial
investment in a PHR and endorse a PHR to their patients’ forms the
basis of the hypotheses in this study.
28
The 2004 Markle Report examines PHRs in detail. The essential
elements they identify for inclusion are as follows:

Name and demographic information

Emergency contacts, next of kin

Family history

Insurance information

Problem list (diseases and conditions)

Medications (Rx, OTC, vitamins, herbals and other
alternative therapies)

Allergies and reactions Immunizations

Labs and tests

Hospitalizations/surgeries

Other therapeutic modalities (counseling, occupational
therapy, etc)

Visit summaries

Advance directive form

Spiritual affiliation/considerations

Other concerns – free text field to explain other things you
want your doctor to know

Goals, next step or disease management plan
29
Optional elements include:

Links to patient education, self-care content and consensus
guidelines

Secure messaging

Doctor’s notes and other narrative information

Standardized intake questionnaires

Appointment scheduling and reminders

Preventive service reminders

Adherence messaging

Patient diaries (pain, symptoms, side effects)

Longitudinal health tracking tools (charts, graphs)

Drug interactions checking

Rx refills

Financial information, such as Explanation of Benefits

Scanned images, such as CT scans
(“Connecting Americans to their healthcare,” 2004, p. 28)
At this time, however, there are no national, international or industry
standards for Personal Health Records. The above elements are currently
just recommendations.
30
Perceived Value of a PHR
The Markle Foundation issued a number of other reports including
Connecting Americans to Their Health Care: A Common Framework for
Networking Personal Health Information in December, 2006. This paper
looks at the recent explosion of information technology in many areas of
society, from information searches (with Google now becoming a verb)
to online personal banking to personal music players with custom
playlists, and proposes an approach to networked PHRs. The goal is to
improve consumer access to and confidentiality of one’s own health
information (Lemieux, Nicholson, Shirky & Lansky, 2006, p. 4). This will
require both consumers and providers being open to changes in
relationships and responsibilities.
The arguments for a networked PHR are based on six principles
for handling personal health information offered by the Personal Health
Technology Council of the Markle Foundation. These principles are:
1. Individuals should be guaranteed access to their own health
information.
2. Individuals should be able to access their personally identifiable
health information conveniently and affordably.
31
3. Individuals should know how their personally identifiable health
information may be used and who has access to it.
4. Individuals should have control over whether and how their
personally identifiable health information is shared.
5. Systems for health information exchange must protect the
integrity, security, and confidentiality of an individual’s information.
6. The governance and administration of health information
exchange networks should be transparent and publicly
accountable.
The authors conclude that only a “networked PHR” is capable of
delivering on those principles for patients (Lemieux, Nicholson et al.
2006).
Another Markle Foundation initiative, with a resulting final report,
concerned KatrinaHealth – the online service created in the aftermath of
Hurricane Katrina to enable evacuees to obtain records of their
medication histories by working with their healthcare providers (Weisfeld,
2006). KatrinaHealth.org was made possible by the combined efforts of
the Markle Foundation and several pharmacy-related businesses: Gold
32
Standard, a business that managed the Medicaid prescriptions for the
state of Mississippi, RxHub, a company that electronically managed
communication of electronic prescriptions and pharmacy benefit
information for over 150 million Americans, and SureScripts, an eprescribing network connecting over 90% of the nation’s pharmacies.
Subsequently, the Veterans Health Administration, with many recipients
of services evacuated from the disaster area, was included in the
coalition. Many veterans obtain their health care from both the VA and
other public and private sources, and the VA information system is so
robust and comprehensive that their recipients were the only evacuees
who lost no health care information from the storm.
The magnitude of the need for the KatrinaHealth service is
evident from the fact that an estimated 40% of evacuees were taking one
or more prescription medications at the time of the disaster (Weisfeld,
2006, p. 4). As a result of the stresses of the storm and the evacuation,
many more individuals required treatment after the fact. Connecting
people to their medication history was essential for treating the many
chronically ill and elderly who lost everything in the storm.
As helpful as the KatrinaHealth effort was, there were distinct
gaps in the service. One gap concerned authentication of medical
33
providers. Without a method of authentication, there could be no security
on the personal health care information being released. The American
Medical Association (AMA) was engaged to assist with authenticating its
members, but mid-level prescribers such as Physicians Assistants and
Nurse Practitioners could not be authenticated, as they are not tracked
by the AMA (Weisfeld, 2006, p. 10). In the end, KatrinaHealth could
successfully give authenticated providers the medication histories they
requested for only about 30% of the requests made. Still, the
coordination and cooperation needed to get the system operational was
enormous, so this should be viewed as a very successful operation and
a model for future disaster recovery.
But rather than disaster recovery, one should aim toward
information integrity and security at all times. Since more than 40% of
Americans have one or more chronic illnesses, accounting for over 60%
of all medical expenses (Shine 2002), patients should claim
responsibility for oversight of their health care. In a small study of
patients with inflammatory bowel disease (IBD), subjects were shown
samples of Electronic Medical Record pages and asked for their
impressions of the utility of the page and its function (Winkelman,
34
Leonard, & Rossos, 2005). They were also asked how they might design
their own EMR to aid in the management of their IBD.
Results showed that merely providing the patients with access to
their records did not hold any perceived value to the subjects. The
subjects expressed interest in communication tools, such as email,
bulletin boards, and chat rooms. They expressed the desire for two-way
communication with their providers to discuss disease-related issues,
thus establishing a partnership as well as a tangible record of the
communication (Winkelman, Leonard et al., 2005).
The generalizability of this study is very limited due first, to the
small sample size, second, to the specificity of the disease process
involved and finally, to the interpretive nature of the methodology.
However, given the increasing prevalence of chronic disease with the
aging of America, one can expect similar findings were the study
repeated with other disease conditions.
In fact, surveys have shown that the patients most supportive of
Personal Health Records are those with chronic diseases (National
Committee on Vital and Health Statistics, 2006). Those are the
individuals who may need to see multiple providers and are on multiple
35
medications. They are at greatest risk of medication interactions or
treatment errors from failure to have current accurate information at
every provider interaction.
How do providers view the tools available with the growth of
healthcare information technology? The 2003 Report from the Boston
Consulting Group was based on data collected from 400 physicians and
10,000 patients on their feelings regarding information technology in
healthcare (Von Knoop, Lovich, Silverstein & Tutty, 2003). 90% of the
physicians surveyed said they use the Internet to research clinical
conditions (Von Knoop, Lovich et al. 2003). 43% stated their preferred
access point to health information online was via a professional
association website, such as the American Academy of Family Practice,
the American Academy of Pediatrics or the American Medical
Association (Von Knoop et al., 2003, p.12). WebMD, Medscape and
Physicians Online followed, at 23%, 14% and 11% respectively.
Of greater interest was the finding that 65% of physicians
surveyed had referred patients to health-related websites. More that 1/3
of physicians had recommended professional association websites,
while over 1/5 had recommended WebMD (Von Knoop et al., 2003, p.
13). The authors refer to this as a “convergence” of the two audiences
36
that should encourage the developers of the websites to create
consistent messages for both groups (Von Knoop et al., 2003, p. 13).
The Boston Consulting Group study also reports that the fastest
growing electronic tool for patient care is e-prescribing (Von Knoop et al.,
2003, p. 14). It not only allows accurate prescribing of medications, but
automatically checks new medications for possible drug interactions with
other patient medications and against insurance formularies to assure
insurance coverage. This application of information technology provides
immediate returns to the provider – fewer calls from pharmacists to
clarify prescriptions. The value of this technology is made clear by the
fact that 1/3 of the physicians surveyed who were users of e-prescribing
paid for it themselves (Von Knoop et al., 2003, p. 14).
This study also found that Electronic Medical Records, while
growing in popularity, tend to be installed in medical practices with higher
revenues due to the cost of implementation (Von Knoop et al., 2003, p.
16). In this survey, while 43% of physicians in practices with more than
25 providers used EMRs, only 19% of physicians in smaller practices
were using them.
37
More recently, physicians in Massachusetts were surveyed about
their attitudes toward Electronic Health Records (Simon et al., 2007).
While this study found that 45% of physicians in Massachusetts were
using an EHR, only 23% of physician practices had EHRs. What this
means is the bulk of physicians using EHRs were in larger group
practices (52% of practices with 7 or more physicians had EHRs), not
solo (only 14% had EHRs) or small group practices (Simon et al, 2007).
In the proposed study in Plattsburgh, there were no group practices with
7 or more providers, physician or non-physician (NP or PA) at the time
the original proposal was submitted. By the time the survey was
conducted, one group practice, an ophthalmology group, added their
seventh provider.
In the Simon study, the most commonly cited barrier to adoption
or expansion of an EHR by 90% of the non-adopters was “start-up
financial costs” (Simon et al., 2007, p. 114). “Ongoing financial costs”
and “loss of productivity” were cited by 88% and 86% of non-adopters as
additional barriers to adoption. As mentioned above, the non-adopters
were predominantly the solo or small group practices. Thus, it is
expected that in the proposed Plattsburgh study, cost and productivity
will be significant barriers as well.
38
The final questionnaire in the Massachusetts study was based on
a systematic review of the literature regarding barriers to implementation
of electronic health records, with a focus on ambulatory applications
(Simon et al., 2007, p. 111). That questionnaire has been obtained from
the authors. With their permission, some items in this current project will
be based on questions from the Massachusetts survey to allow for
comparisons between study populations.
A recent telephone survey of physician practices in the
Plattsburgh area by Champlain Valley Physicians Hospital found that
eight (20.5%) of the 39 practices contacted reported using an EHR (J.
Rafferty, personal communication, January 19, 2007). This falls within
the range found in the studies cited above.
Lack of a single standard
One other problem that has shown up in the review of the
literature is the lack of a single standard for Personal Health Records. As
mentioned above, a PHR can be as simple as a piece of paper carried in
one’s wallet listing diagnoses, allergies and medications. CVPH Medical
Center has already developed a Vital Link Medication List form, in
conjunction with the local health department, that they recommend for
39
senior citizens to keep on their refrigerators for easy access by rescue or
ambulance personnel in the event of a medical emergency (CVPH
Medical Center, 2004). This Vital Link form is a PHR at its most basic,
with information on medications, current medical problems, and
advanced directives.
Once one moves online, there are many choices, from a simple
spreadsheet kept on one’s computer to an online PHR maintained by
one’s insurer. Various proprietary PHR systems may resist
interoperability in order to maintain market share for related products
sold by their company. Just as Microsoft doesn’t always make Internet
Explorer source code work well with webpages written to Netscape
standards, NextGen EMR has little economic incentive to make their
product interface with Chartmaker or Medi-e-notes – competing EMR
products.
In this conflict, various medical groups have weighed in to lobby the
federal government to support a single standard. That standard is the
Continuity of Care Record or CCR and the many medical groups include:
American Academy of Dermatology Association
American Academy of Family Physicians
American Academy of Ophthalmology
American Academy of Pediatrics
40
American College of Emergency Physicians
American College of Obstetricians and Gynecologists
American College of Osteopathic Internists
American College of Osteopathic Family Physicians
American Gastroenterological Association
American Medical Association
American Osteopathic Association
Massachusetts Medical Society
In a 2005 letter to the Secretary of Health and Human Services, Mr.
Mike Leavitt, they wrote, “the undersigned physician membership and
national medical associations urge AHIC to recommend the use of the
Continuity of Care Record, CCR, standard (American Society for Testing
and Materials (ASTM) E2369-05 Standard Specification for the Continuity
of Care) as the basis of a national PHR breakthrough project or projects.”
(American Academy of Dermatology Association and et al., 2005).
The multiple medical organizations that signed the letter offer a
number of reasons to use the CCR as a basis for a universal Personal
Health Record. First, as mentioned in the quote above, the authors noted
that the CCR format has been approved as a standard by the American
Society for Testing and Materials. It has also been integrated into some
existing Electronic Health Record products already on the market,
including the NextGen EMR (www.nextgen.com) being considered by
41
Champlain Valley Physicians Hospital Medical Center for implementation
through a HEAL NY grant.
Further, the authors emphasize the CCR standard is
comprehensive, with sixteen components, such as demographics,
diagnoses, medications, etc (American Academy of Dermatology
Association and et al. 2005). Since these components are optional, they
can be used or not for a complete or partial PHR. Also, the CCR standard
uses Extensible Markup Language (XML) standards for storage and
display of data elements (American Academy of Dermatology Association
and et al. 2005). This subset of the Hypertext Markup Language (HTML)
of the internet assures interoperability and ease of data transfer between
programs utilizing the standard.
Finally, the authors emphasize that the CCR standard is free of
licensing fees, making its use freely available to any EHR vendors. ASTM
is working to assure interoperability with electronic prescription software
through ongoing discussions with the National Council on Prescription
Drug Programs among others (American Academy of Dermatology, 2005,
page 3).
42
But ASTM is not the only standards organization, and medical
groups are not the only health care providers with an interest in Personal
Health Records. Nurses have a long history of not only providing health
care, but also of advocating for their patients on health care issues. The
College of Nursing at the University of Iowa has lead the way in
establishing standards for nursing practice and documentation. These
standards are known as Nursing Intervention Classification (NIC) and
Nursing Outcomes Classification (NOC). Members of the faculty in
conjunction with graduate students have extended their expertise to
develop a Personal Health Record that reflects a nursing orientation
(Lee, Delaney et al., 2006).
Called the IowaPHR, the tool the authors are developing includes
terms from Nursing Outcomes Classification, though some terms had to
be converted to language more familiar to the average layperson (Lee et
al., 2006, page 28). This need to convert terminology points out one of
the potential problems with any PHR – use of language too sophisticated
or technical for the average American. Initial testing done by the authors
shows a panel of experts giving IowaPHR high marks on site
presentation, ease of navigation, usefulness of information saved for
43
healthcare providers in the future and ability to find desired information
(Lee et al., 2006, page 27).
The IowaPHR also has sections that deal with child health,
community mental health and cancer prevention (Lee et al., 2006, page
26) – all significant health related issues that often aren’t well addressed
in our current treatment-oriented health care system. These are areas in
which nursing, as advocate for patients, seeks to collect information that
can later be used by other providers to improve the health care status of
the individual. Further testing of the tool is underway, but the IowaPHR
provides a concrete example of how important many data sources can
be to providing comprehensive health care to individuals.
The Future for PHRs
In April, 2004, President Bush spoke to the American Association of
Community Colleges in Minneapolis, Minnesota and announced his plan
to digitize the records of the American health care system in ten years
(Office of the Press Secretary, 2004). This project would include a
“personal electronic medical record” for every American. The key to
meeting this goal, according to the President, was the development of
standards to assure these records could communicate with each other.
44
The other necessary requirement was the ability to assure the privacy of
those electronic records for all Americans.
While this announcement elevated the stature of Personal Health
Records, progress toward that goal has not moved forward as quickly as
one might hope, given that three years of those ten have now passed.
More players have entered the PHR arena, but as mentioned in the
previous section, the standards have not yet been realized. In some ways,
this has further complicated the issue of fragmentation of patient
information and lead to confusion among consumers regarding their
multiple choices – tethered versus untethered, personal versus webbased, etc.
Because the current state of Personal Health Records is one of
growth and development, predictions about its future for the next three to
five years are extremely useful to this discussion. A recent report from the
California HealthCare Foundation contained interviews with six experts
with six varied perspectives on PHRs and their thoughts on what PHRs
would, or rather could, look like within five years (Gearon, 2007). These
experts present the views of technologist, informed patient, physician,
employer and the public health sector.
45
Dr. Patricia Flatley Brennan presents the view of the technologist.
She is a nurse with joint appointments to the faculty of the School of
Nursing and the College of Engineering at the University of WisconsinMadison and national program director for the Robert Wood Johnson
Foundation’s Project HealthDesign. She sees two paths along which
PHRs will evolve. One will involve better links between information kept by
patients, such as that acquired by personal glucose meters, and the
records kept in personal provider’s offices in Electronic Health Records
(Gearon, 2007, p. 7).
The other path will include the development of more and better
home-monitoring equipment and alert systems. These might include
scales that report daily weights and body-mass index (BMI), or a treadmill
that reports exercise output, directly into a PHR. But information could
also flow from the PHR to the patient. For example, the PHR could alert a
patient to the need for a prescription refill.
Dr. Brennan points out that one of the major concerns with such a
distributed information model is security of information (Gearon, 2007, p.
8). She points out that two necessary steps for success are better
education of health professionals regarding basic information science and
increased health literacy beginning with elementary school children. These
46
two steps will enable consumers and providers to make informed
decisions regarding access to health information.
In addition, Dr. Brennan suggests that financial incentives for
consumers be developed to promote PHR use. Since consumers are
becoming increasingly responsible for managing their health information,
especially as it applies to claims processing, it makes sense their
participation should be encouraged through rewards. Currently, the health
care financing system only rewards the providers and the payers (Gearon,
2007, p. 9).
Interestingly, the expert advocating for the consumer, David
Lansky, Ph.D., executive director of the Markle Foundation’s Personal
Health Technology Initiative, does not mention financial rewards to the
consumer as an incentive to PHR adoption. While intimately involved in
PHR development, his perspective is truly that of a consumer, having had
both orthopedic and cardiac events in the previous year (Gearon, 2007,
p.10). He observed firsthand the fragmentation and duplication of
information and reports that he now chooses his providers based on
whether they have and use Electronic Health Records.
47
Unfortunately, he reports that none of his current crop of providers,
including two large, sophisticated hospitals, can deal with his PHR simply
and directly (Gearon, 2007, p. 11). Of course, he also reports that his
medical needs have led him to create a PHR that is somewhat unique and
individualized, and contains elements of several. Therefore, he must add
some bits of information manually. That need for individualizing of PHRs
will continue to challenge the system for the short term he feels.
Dr. Lansky also notes that while insurance claims data has some
utility, especially to payers and providers, it has little use to him. It is not,
after all, a reflection of his health (Gearon, 2007, p. 12). Claims reports
merely describe his interactions with the health care system. His true
‘personal’ needs are overlooked by tracking the claims, yet this is the data
that is easily accessible.
His feeling is that a truly personal PHR is perhaps ten years away.
He believes individuals like him will not be the driving force for PHR
development. Rather, the large health care institutions, recognizing the
value of an informed, empowered consumer market, and online service
providers, like Quicken or Google, will team up to create the environment
necessary for PHR development (Gearon, 2007). Only then can the
48
information fragmentation problem be successfully addressed in a way
consumers will appreciate.
Daniel Sands, MD, MPH presents his expert views on behalf of
physician providers. With his background as a primary care physician in a
large practice affiliated with Beth Israel Deaconess Medical Center in
Boston and as senior medical informatics director for the Internet Business
Solutions Group at Cisco Systems, he sees the problem of PHR adoption
from both sides (Gearon, 2007, p. 13).
Dr. Sands reports that approximately one-quarter of the patients he
cares for use the services of PatientSite – a tethered PHR maintained by
Beth Israel Deaconess Medical Center that allows patients to
communicate with their providers via secure email, request prescription
refills, referrals or appointments, and enter and track their own health
information (Gearon, 2007, p. 14). He finds this tool to help him maximize
his most precious resource – time. In addition, he feels this asynchronous
communication medium, for non-urgent matters, actually builds a closer
provider-patient relationship.
49
But Dr. Sands feels PHRs are still in their infancy and their future is
far from clear. He feels there are two possible paths that may be followed.
In the first, PHRs will wither, while in the other, they will flourish.
In the more pessimistic scenario, a business model prevails in
which PHRs are sold to patients, or, like insurance, given to patients by
employers. There are few incentives for patients to maintain or update the
information, and inadequate standards do nothing to encourage providers
to adopt collaborative EHRs (Gearon, 2007, p. 15). The lack of userfriendly integration coupled with declining reimbursements for providers
result in barriers to universal adoption. In this scenario, PHRs fail to
realize their potential.
On the other optimistic path, robust information standards are
developed and information sharing technologies mature. Legislation
promoting security and educational initiatives of consumers lead to
increased comfort with the use of PHRs by patients and providers. This
leads to closer patient-provider relationships. Indicators of improved
quality of care lead to increased demand for PHRs and the system
flourishes (Gearon, 2007, p. 16).
50
However, there is another provider perspective to consider,
presented by David Kibbe, MD, MBA. He is another family physician, and
senior advisor to the Center for Health Information Technology at the
American Academy of Family Physicians. His concern is that PHRs can
become another unfunded mandate, with associated bureaucratic
problems and costs.
To realize the benefits of PHRs, effective standards must be
developed to address the transport and sharing of personal health
information between computer systems. Currently, there are no financial
incentives to help providers make the transition from paper to electronic
records (Gearon, 2007, p. 17). One potential barrier to those incentives
that must be addressed are issues of Safe Harbors (Office of Inspector
General and Department of Health and Human Services 2006).
Another barrier, mentioned time and time again, is the issue of
effective standards. As a representative of the American Academy of
Family Practice, Dr. Kibbe is a proponent of the Continuity of Care Record
or CCR (Gearon, 2007, p. 18). This iteration of a PHR uses Extensible
Markup Language (XML) as a standard for storage and sharing of data
over the Internet and standardized categories of information, making
sharing between PHRs and EHRs more uniform.
51
But the issue of costs remains paramount in Dr. Kibbe’s analysis.
With all the system pressures to reduce cost, where will the money come
from to pay for implementation of PHRs and EHRs? This is the basis of
his fear of the unfunded mandate – an unanswered question. While
various legislative solutions have been advanced in both the Senate and
the House of Representatives, consensus has not yet been reached on
how to pay for all the uninsured Americans, much less how to pay for
PHRs. Dr. Kibbe closes his thoughts with the idea that the solution might
come from Google or Yahoo – a standardized, low-cost PHR from a
widely-accepted technologically-advanced company with a solid
reputation.
Another interesting perspective that may also include Google or
Yahoo is presented by Michael Barrett, JD. He is a managing partner in
Critical Mass Consulting, a company that analyzes health and benefit
portals for Fortune 500 companies. His experience with these companies
reveals the presence of another layer of PHRs – those internal PHRs
maintained by large companies as part of their employee wellness
programs. These programs have been developed with the goal of
improving employees’ health status, not for the employees, but to benefit
52
the company’s bottom line through lower absenteeism, fewer on-the-job
injuries, etc (Gearon, 2007, p. 20).
As these tools develop internally, some companies share the
results of the health risk assessments with their employees. These tools
may or may not be useful as a foundation of a separate PHR that the
employee can take with them. But perhaps they will be more useful in the
future for their ability to interface with other commercial tools or
databases.
Specifically, Mr. Barrett discusses the new product from Quicken
called Quicken for Health Care (Gearon, 2007, p. 21). This was
announced in 2006 as a joint venture between Intuit, maker of Quicken
financial software, and Ingenix, a unit of UnitedHealth Group. The goal is
to create a Personal Health Record starting with financial data, such as
medical and pharmacy claims, with co-payment and deductible
information, rather than clinical data. However, Mr. Barrett ads the closing
thought that “tracking blood pressure may never be as much fun as
tracking an investment portfolio” (Gearon, 2007, p. 22). Ultimately, that
lack of individual reward may be one huge barrier to consumers/patients
universally adopting PHRs. Once more, a financial incentive may need to
be applied.
53
The final perspective on the future of PHRs is given by Jeremy
Nobel, MD, MPH. He is an adjunct faculty member of the Harvard School
of Public Health and sees PHRs as having significant potential on cost
containment of health care spending. Further, he sees the opportunity with
well-designed PHRs to provider patients with culturally sensitive
educational information and advice (Gearon, 2007, p. 23).
Dr. Nobel notes that PHRs hold the potential to gather health data
on hundreds of thousands or even millions of users. Once cleaned of
personal identification, the data can be used to spot health trends like
disease outbreaks or other public health risks. The data could point to
areas of the country with over-utilization of services or areas lacking in
basic health care services. This type of research using aggregate patient
data holds great potential for cost savings across the entire health care
system.
Once more, the issue of consumer education is mentioned by Dr.
Nobel as a barrier. He also suggests that incentives to consumers may
increase the acceptance and use of PHRs, especially if the incentives can
be tied to a cost savings. The example he gives is of a reduction in a
patient’s pharmacy copay for diabetes medications if the patient shows
compliance with his treatment regimen. Since better diabetes
54
management yields lower overall medical costs, this financial incentive
and reward to the patient would result in an overall cost savings to the
system (Gearon, 2007, p. 24).
Summary
Health care delivery is a fragmented process involving multiple
providers at different locations keeping potentially duplicate information.
This provides many opportunities for errors or inaccuracies to occur. A
Personal Health Record, maintained by the patient or parent, returns
control of this vital information to the person with the greatest interest in its
accuracy. The value of PHRs is not in dispute, nor is the interest of
patients in having PHRs, once they are made aware of them. The
problems are lack of awareness by patients and providers in this valuable
tool, and lack of a mechanism to implement PHRs when desired.
The goal of this study is to ascertain the level of awareness about
Electronic Health Records and Personal Health Records by rural health
care providers in upstate New York. Further, the study will seek to
determine whether those providers would use their valuable time to
educate their patients on Personal Health Records and finally, whether
55
they would actually invest in an Electronic Health Record that would
support a Personal Health Record.
56
Chapter 3: Methodology
Approach
The plan for this study is to survey the entire medical staff of
Champlain Valley Physicians Hospital Medical Center for their attitude
on Electronic Health Records and Personal Health Records. This will be
a descriptive survey. Specifically, the medical staff, as a group of rural
providers in solo or small group practices, will be surveyed regarding
perceived barriers to implementation of EHRs and PHRs. This part
essentially duplicates the work of Simon et al. (2007), but in a population
of providers that are exclusively in small group or solo practices. In the
next part of the survey, they will be asked whether they perceive a
benefit for themselves or their patients from a PHR integrated in an EHR
(hypothesis one), whether they would be willing to pay a premium for an
EHR that will support integration with a PHR (hypothesis two) and finally,
whether they would be willing to encourage their patients to use a PHR
(hypothesis three).
The survey (see Appendix A) will collect background data on
location and size of medical practice as well as years in practice and will
include questions on current Healthcare Information Technology
57
utilization by the provider. The major terms used in this study, EHR,
PHR, CCR, etc., will be defined for the participants and questions
regarding their attitudes toward the various items will be elicited.
Data will be analyzed using standard statistical calculations of
central tendency and range. Correlations with size of practice and other
demographic variables will be analyzed, though the size of subsamples
of the total population may not yield levels of statistical significance.
Data Gathering Method
The survey will be distributed to the medical staff through several
routes. First, there will be a paper version that will be placed in the
hospital mailboxes of all medical staff members. Second, there will be an
online version of the survey that will be advertised by email to those
medical staff members that use that communications tool. Finally, nonresponders will be contacted by telephone and asked to participate
directly.
A cover letter will be included that will assure participants of the
confidentiality of the information. Their consent will be inferred by their
return of the survey. Participants will be informed that the data in the
aggregate will be shared with CVPH Medical Center. CVPH will be using
58
the data for the purpose of planning for the HEAL NY grant being
submitted in Spring, 2007.
See Appendix A for a draft of the survey instrument and cover
letter.
Database of the Study
This study will be based on a written survey presented to the
members of the medical staff of Champlain Valley Physicians Hospital
Medical Center in Plattsburgh, NY. The survey will assess the providers’
attitudes toward Electronic Medical Records and Personal Health
Records with regard to issues of cost, productivity and relative value as
compared to the traditional paper-based medical record keeping
systems.
While CVPH Medical Center reports the medical staff as having
156 members, with 92% board-certified in a specialty (CVPH Medical
Center 2007), that includes a number of Physicians, Nurse Practitioners,
Physicians Assistants and Nurse Anesthetists who work exclusively
within the hospital, either in the Emergency Department or the Operating
Rooms, and not in private practice. These medical staff members will be
59
excluded. As the data is acquired, the exact number of eligible
participants will be determined.
According to the 2005 survey conducted by the Center for Health
Workforce Studies of the University at Albany, Clinton County, New York
has 190 practicing physicians (Armstrong & Forte, 2006). Their average
age is 51 and 20% are female. This would mean the population of
physicians on staff at CVPH Medical Center is the largest concentration
of physicians in the county. Unfortunately, there is no simple way to
identify the remaining physicians in the county who are not affiliated with
CVPH to include them in the study.
Validity of Data
The medical staff of Champlain Valley Physicians Hospital
Medical Center (CVPH) represents a tight, almost closed, medical
ecosystem. Most medical and surgical specialties are represented, and
most providers make specialty referrals within this community. This is
largely due to geographical factors. CVPH is the largest hospital within a
30 miles radius and the next larger hospital, Fletcher Allen Health Care
(FAHC), an affiliate of the University of Vermont, is a $20 ferry ride away
on the other side of Lake Champlain. Since FAHC is in another state,
60
referrals from New York insurance companies often require a prior
authorization, and in general, local patients prefer not to travel if the
service is available locally.
While this close knit health care delivery system might seem an
ideal environment for implementation of a Personal Health Record, the
experience from Massachusetts shows that solo and small group
medical practices are slow to adopt Electronic Medical Records.
Financial and productivity concerns are most often cited (Simon, 2007).
The CVPH medical community is completely composed of solo and
small group practices. None had seven providers at the time of the study
proposal.
The experimental population, therefore, has all the incentives for
adoption and the disincentives for non-adoption. To date, the very
cursory survey of practice managers done by CVPH shows adoption of
EHRs at about the rate found in other studies – less than 30% (J.
Rafferty, personal communication, January 19, 2007). This study,
however, will go directly to the providers rather than practice managers,
to study their views of EHRs and PHRs. They are ultimately the decisionmakers within the various practices.
61
Originality & Limitations of Data
While this study is modeled on previous surveys of medical
providers to elicit barriers to adoption of Electronic Health Records, this
study goes beyond that to examine provider attitudes toward Personal
Health Records. Ultimately, the decision to adopt an EHR is made by the
owner of a medical practice, since the investment of money and time
must be weighed against any perceived return. In a solo or small group
practice, the owner is very sensitive to the financial and productivity
issues, as the decision to adopt an EHR will directly impact his or her
workload and income. In larger practices, ownership may be held by only
a few partners whose decision to adopt an EHR will impact the other
members of the practice without them having a voice in the decision.
The solo and small group practices in the CVPH environment will
be extremely sensitive to the financial and productivity issues brought on
by adopting an EHR. At the same time, the providers are becoming
aware of potential returns on this investment in terms of accuracy of
information resulting in errors avoided. While the benefits of adopting an
EHR will generally be seen by informed medical providers, the benefits
to the providers of a PHR will be less obvious. An integrated Personal
Health Record can improve accuracy and reduce errors while potentially
62
improving productivity, but these benefits are still theoretical, since PHR
implementation is still quite low. The question to be explored in this study
is whether providers can imagine those benefits and are willing to invest
to realize them.
The major limitation of the study is the population to be studied.
The medical providers in the catchment area of CVPH Medical Center
are somewhat unique in that they are exclusively working in solo or small
group practices. Few areas of the United States have so little penetration
by group practices or Health Maintenance Organizations. The sparse
local population and its location on the Canadian border, with the 6
million acre Adirondack Park (the largest wilderness area east of the
Mississippi River) to the South and Lake Champlain to the East, create a
unique geographic and health care environment. Further, the local
medical community is predominantly Caucasian and male, with few
foreign medical graduates – another unique aspect of the local health
care environment. Thus, one cannot generalize the findings to other
populations of health care providers.
The study is further limited by the small size of the population of
providers. CVPH claims a medical staff of 156 members (CVPH Medical
63
Center, 2007). The goal is to sample all of this relatively small population
in order to minimize the limitation of small numbers.
Summary of Chapter 3
The purpose of this study is to investigate the attitudes of rural solo
and small group medical providers toward Electronic Health Records.
Specifically, the goal is to determine whether the health care providers
working in the catchment area of Champlain Valley Physicians Hospital
Medical Center are willing to invest in EHRs and if they are, will they
invest extra in an EHR that supports a Personal Health Record. Further,
the study seeks to determine how these providers view PHRs and whether
they will promote PHRs among their patient population.
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Chapter 4: Data Analysis
The survey (Appendix A) was distributed to the medical staff of
Champlain Valley Physicians Hospital Medical Center on April 2, 2007.
While the proposal was to survey the entire medical staff, the intent of the
project was to determine how physicians that maintain patient records
viewed Personal Health Records. At the time of survey distribution, it was
clear that a number of medical staff members do not maintain patient
records and were therefore excluded from the survey. These are mostly
the physicians who are directly employed by Champlain Valley Physicians
Hospital Medical Center.
The medical staff groups that do not maintain separate office
records include pathologists, anesthesiologists, radiologists, emergency
department physicians, and cardiac surgeons (whose main office is in
Albany, 155 miles south). In addition, because they are not decisionmakers in the practices where they work, Nurse Practitioners and
Physicians Assistants were not surveyed either. Many of the mid-level
practitioners (NPs and PAs) on the medical staff are also employees of
the medical center, either in the Emergency Department or in the surgical
services.
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After removing those providers mentioned above, 110 surveys were
distributed to the remaining medical staff members via their medical staff
mailbox at the hospital. This is the routine method by which all
correspondence, both personal and confidential, is sent to the medical
staff by both the hospital and its departments and by other medical staff
members. It is, therefore, quite reliable.
While respondents were not asked for their names, the surveys
were identified by a number assigned to each provider before they were
distributed. A cover letter (Appendix A) explaining the purpose of the
study, and assuring participants their responses would remain
anonymous, and a business card from the primary investigator was
attached. Surveys were to be returned to the medical staff mailbox of the
primary investigator, who is also a member of the medical staff at CVPH.
Consent to participate was inferred upon return of the survey by the
selected participants.
9 surveys were returned in the first week, 9 in the second week, 7
in the third week and 4 in the fourth week. In week 2 a reminder letter was
placed in the mailbox of non-responders and in week 3 an announcement
regarding the value of the survey to the hospital and thanking responders
was made at the quarterly medical staff meeting. In weeks 3 and 4
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telephone calls were placed to the offices of several non-responders
requesting to speak to the physicians with the intent of offering to conduct
the survey by telephone. None of the physicians were available to speak
at the time of the call and none made return phone calls. Due to the lack
of human resources and difficulty with these attempts at direct contact, the
telephone survey option was abandoned.
No further surveys were returned after week 4 and on May 4, 2007
(final business day of week 5), data collection was closed with a total of 29
responders from the 110 surveys distributed. All the surveys returned
were the originals. Based on handwriting on the surveys, they all
appeared to have been completed by the medical provider to whom they
were distributed.
Those 29 responders yield an overall response rate for the survey
of 26.4%. They represented twenty-four different medical practices and
fourteen different medical specialties in the community. The specialties
represented were Internal Medicine (6 responders, 5 practices), Family
Practice (1 responder,1 practice), Obstetrics/Gynecology (4 responders, 3
practices), Pulmonary Medicine (3 responders, 2 practices), Cardiology (2
responders, 1 practice), Pediatrics (3 responders, 2 practices), Neurology
(2 responders, 2 practices), Nephrology (1 responder, 1 practice), Ear,
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Nose and Throat (1 responder, 1 practice), Podiatry (2 responders, 2
practices), Ophthalmology (1 responder, 1 practice), Gastroenterology (1
responder, 1 practice), Urology (1 responder, 1 practice) and Oncology (1
responder, 1 practice). The information on practice type was determined
by identifying the respondent by the number on the survey.
The following is a presentation of the analysis of the data returned
on the surveys using descriptive analysis of frequency of responses.
Because of the relatively small number of responses, comparisons could
not be performed between subgroups based on gender, age or medical
specialty. For that reason, analysis is restricted to measures of central
tendency and standard deviation. SPSS software, version 14.0 for
Windows, was used for all statistical analyses (SPSS, 2005).
Demographic information was collected in Section VI of the survey.
Twenty-one (72.4%) of the responders were male and eight (27.6%) were
female. Their average birth year was 1958 with a standard deviation of
plus or minus 8 years. The range of birth years for respondents was from
1946 to 1972. This translates to an average age for the respondents of 49
plus or minus 8. The average year they started in their current practice
was 1991 plus or minus 9 years. This demographic data helped to confirm
68
that the survey was indeed completed by the person to whom the number
on the survey had been assigned.
There were additional unrepresented practices in several of the
specialties listed above, but these 29 responders represent 24 different
medical practices in the community. Medical specialties with providers that
were given surveys but without responders were Orthopedic Surgery,
General Surgery, Plastic Surgery, Dermatology, Psychiatry and Physical
Medicine and Rehabilitation (PM+R). These groups have somewhat
unique patient information needs. Their absence from the study will be
discussed later.
Section I of the survey concerned information about the
respondents’ current practice.
Survey question 1 asked “how would you best characterize your
practice?” Of the 24 practices represented, 11 (45.8%) are solo practices
with 5 of those reported to be primary care and 6 solo practices in
specialty care. The other 13 (54.2%) practices are either primary care
group practices or single specialty group practice or partnerships.
Question 2 asked how long the respondent had been associated
with their current practice. The mean time in the current practice was 12
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years. There was a range of 1 to 30 years and a standard deviation of 7.9
years.
Question 3 concerned ownership of the medical practice in which
they worked. Fourteen (48.3%) of the 29 responders reported they were
sole owners of their practices. Eleven (37.9%) of the responders stated
they were part-owners, while four (13.8%) were not owners.
Question 4 asked how many full- and part-time providers there
were in the practice. These were identified as either physicians or midlevel nurse practitioners or physician’s assistants. Respondents reported a
mean number of physicians of 1.69 with a range of 1 to 7 and a standard
deviation of 1.7. They reported from 0 to 5 mid-level providers in the
practices with a mean of 1.07 and a standard deviation of 1.41.
Question 5 of the survey asked the number of outpatient visits they
personally had in a typical week. The individual providers claim to see an
average of 83 outpatients per week with a standard deviation of plus or
minus 34.
Question 6 was a 3-part question concerning how easily the
respondent could generate information about their patients using their
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current medical record system. There were two non-responders for this
question making N=27.
Part a asked how easily they could generate a list of patients by
diagnosis or health risk (e.g., diabetes). The scoring was from 1 for “very
easy” to 5 for “cannot.” The mean for part a was 3.2 with SD 1.7 with six
(22.2%) reporting 1-very easy, five (18.5%) reporting 2-easy, one (3.7%)
reporting 3, five (18.5%) reporting 4-difficult, and ten (37.0%) reporting 5cannot.
Part b asked their ability to list patients by laboratory results (e.g.,
patients with abnormal H&H). For the same scoring range, two (7.4%)
reported 1-easy, no one (0%) reported 2, three (11.1%)reported 3, three
(11.1%) reported 4 and nineteen (70.4%) reported 5-cannot. The mean for
part b was 4.4 with SD of 1.2.
Part c asked about how easily they could list patients by
medications they currently take (e.g., patients on warfarin). Again the
same scoring range was used with N=27, and five (18.5%) reported 1-very
easy, one (3.7%) reported 2, five (18.5%) reported 3, two (7.4%) reported
2 and fourteen (51.9%) reported 5-cannot. The mean was 3.7 with SD of
1.6.
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Question 7 was a 4-part question asking the respondents to rate
several measures of personal and professional satisfaction or stress. The
responses were on a scale of 1 to 4: not a problem, slight problem,
moderate problem or serious problem. All twenty-nine respondents
answered this question.
Part 1 asked about isolation for colleagues. Nineteen (65.5%)
responded this was not a problem; five (17.2%) felt this was a slight
problem; three (10.4%) that it was a moderate problem and two (6.9%)
that isolation from colleagues was a serious problem. Using the number
values for these responses, the mean was 1.59 with a standard deviation
of 0.95.
Part 2 asked how much of a problem personal or professional
stress was to the respondents. Two (6.9%) felt it was not a problem;
seven (24.1%) reported it was a slight problem; fifteen (51.7%) felt it was a
moderate problem and five (17.2%) reported that personal or professional
stress was a serious problem. Using number values for these responses,
the mean is 2.79 with a standard deviation of 0.82.
Part 3 asked respondents how much of a problem having to work
long hours to meet practice demands was to them. Three (10.4%)
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reported this was not a problem; four (13.8%) reported this was a slight
problem; thirteen (44.8%) felt this was a moderate problem and nine
(31.0%) reported working long hours was a serious problem. Using
number values, the mean was 2.97 with a standard deviation of 0.94.
Part 4 asked respondents whether they were feeling demoralized
about the state of medical practice in general. Four (13.8%) reported they
felt this was not a problem; nine (31.0%) reported this was a slight
problem; seven (24.1%) felt this was a moderate problem and nine
(31.0%) reported that feeling demoralized about the state of medical
practice in general was a serious problem. Using number values, the
mean was 2.72 with a standard deviation of 1.07.
Question 8 asked, “Overall, how satisfied are you with your current
practice situation?” This was scored from one to four, with one = very
satisfied, 2 = generally satisfied, 3 = somewhat dissatisfied and 4 = very
dissatisfied. Three (10.3%) respondents were very satisfied, fifteen
(51.7%) were generally satisfied, eight (27.6%) were somewhat
dissatisfied and three (10.3%) were very dissatisfied. Using the number
values, the mean for this question was 2.38 with a standard deviation of
0.82.
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The next section of the survey, Section II, dealt specifically with
Health Information Technology.
Question 9 asked, “Does your practice use a computerized
scheduling system?” Twenty-five (86.2%) respondents answered yes,
while four (13.8%) answered no. Of the twenty-five answering yes, twentythree answered the second part of the question, which asked, “If yes, for
how many years?” The range of responses was from one to fifteen years
with a mean of 8.52 years with a standard deviation of 4.09. Presumably
those answering no are still using a written scheduling system or
appointment book.
Question 10 asked respondents “Upon completion of a typical office
visit, how do you generate medication prescriptions?” The choices were,
1. computerized with decision support (e.g., drug interaction alerts); 2.
computerized, but no decision support: 3. handwritten or 4. other, with a
blank line to describe. Twenty-three (79.3%) respondents handwrite
prescription. Four (13.8%) respondents generated prescription by
computer with decision support and two (6.9%) generated their
prescriptions without decision support. All respondents reported one of
those three choices.
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Question 11 asked, “Does your practice have any components of
any electronic health record (EHR), that is, an integrated clinical
information system that tracks patient health data, and may include such
functions as visit notes, prescriptions, lab orders, etc.?” Only four (13.8%)
respondents answered yes, while twenty-five (86.2%) answered no. The
second part of this question asked the respondents who answered ‘no’,
“when do you plan to implement an EHR?” The choices were, 1. within the
next twelve months, 2. within the next two years, 3. within the next 3-5
years or 4. no specific plans.
Of the twenty-five respondents who answered no to part one, four
(13.8%) stated they were planning EHR implementation within twelve
months; three (10.3%) reported they were planning implementation within
the next two years; five (17.2%) reported planning implementation within
three to five years; eleven (37.9%) reported no specific plans and two
(6.9%) did not respond.
Questions 12 through 14 were directed to those who answered
‘yes’ to question 11. Question 12 asked for the name of the EHR used.
Two of four respondents answering yes reported using Medinotes and two
reported using Encounter. The two respondents using Encounter worked
in the same practice, so the four respondents actually represented only
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three medical practices. Since twenty-four practices were represented in
the response to the survey, this indicates only 12.5% of practices
surveyed are using EHRs in the Plattsburgh, New York area. The two
practices using Medinotes were found to be solo practices. All three
practices using EHRs are medical specialties – pediatrics, neurology and
pulmonary medicine.
Question 13 asked when the ‘yes’ respondents had begun using
their EHR by month and year. The two providers using Encounter, who
are in the same group pediatric practice, agreed they had begun in March
of 2006. One of the Medinotes users began in July of 2004, while the
other began in October of 2006. One respondent who answered ‘no’ to
question 12 added the comment here that they were using Medent billing
software, but not the EHR.
Question 14 was a multi-part question to determine which EHR
functions the respondents used. It asked respondents which EHR
functions were available to them and which functions they were actually
using. Specifically, the survey asked whether their EHR contained
laboratory test result, laboratory order entry, radiology test results,
radiology order entry, electronic visit notes, reminders for care activities
(e.g., health maintenance), electronic medication lists, electronic problem
76
lists, transmission of prescriptions electronically or via fax and electronic
referrals or clinical messaging (secure email between providers).
Of the four respondents reporting they had an EHR in their practice,
one of the Medinote users did not respond to question 14 and the two
Encounter users, who both worked in the same practice, had very different
answers to availability and use of the laboratory and radiology features in
the EHR. The three responders with EHRs did agree on the availability of
the remaining features in both EHRs, however, and made some or regular
use of them all.
Question 15 was for all responders and addressed barriers to
beginning or expanding the use of computer technology in their practices.
Ten barriers, or potential barriers were listed. They were:

Computer skills of you and/or colleagues/staff

Computer technical support

Lack of time to acquire knowledge about
systems

Start-up financial costs

Ongoing financial costs

Training and productivity loss
77

Physician skepticism

Privacy and security concerns

Lack of uniform standards within industry

Technical limitations of the systems
Response choices to the potential barriers listed above were ‘not a
barrier’, ‘minor barrier’ or ‘major barrier’. 28 respondents gave answers to
all the potential barriers. The results are also presented in tabular format
in Table 1, Appendix C.
Regarding computer skills of self/staff, 13 (44.8%) respondents
reported this was not a barrier, 13 (44.8%) reported this to be a minor
barrier and only 2 (6.9%) reported this to be a major barrier.
Lack of time to acquire knowledge was reported not to be a barrier
by 7 (24.1%) respondents, a minor barrier by 9 (31.0%) respondents and
a major barrier by 12 (41.4%) respondents.
Start up financial costs were perceived by 2 (6.9%) respondents not
to be a barrier, a minor barrier by 6 (20.7%) respondents and a major
barrier by 20 (69.0%) respondents.
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Ongoing financial costs were seen as not a barrier by 2 (6.9%)
respondents, a minor barrier by 12 (41.4%) respondents and a major
barrier by 14 (48.3%) respondents.
Respondents reported training and productivity loss as not a barrier
by 4 (13.8%) respondents, a minor barrier by 13 (44.8%) respondents and
a major barrier by 10 (34.5%) respondents. There was one additional nonresponder for this item.
Physician skepticism is not a barrier according to 11 (37.9%)
respondents, a minor barrier for 11 (37.9%) respondents and a major
barrier for 6 (20.7%) respondents.
Computer technical support is not a barrier according to 8 (27.6%)
respondents, a minor barrier for 13 (44.8%) respondents and a major
barrier for 7 (24.1%) respondents.
Privacy and security concerns were reported by 19 (65.5%)
respondents not to be a barrier, a minor barrier according to 6 (20.7%)
respondents and a major barrier according to 3 (10.3%) respondents.
Lack of uniform standards were reported not to be a barrier by 9
(31.0%) respondents, a minor barrier according to 8 (27.6%) respondents
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and a major barrier according to 10 (34.5%) respondents. There was one
additional non-responder for this item.
Technical limitations of systems are not a barrier according to 6
(20.7%) respondents, a minor barrier according to 10 (34.5%)
respondents and a major barrier according to 10 (34.5%) of respondents.
There were two additional non-responders for this item, for a total of
10.3%.
Section III addresses personal computer experience of the
respondents. Question 16 asked how often respondents use the internet
for personal and/or professional use, including email from home work or
another location. Nineteen (65.5%) respondents report using the internet
several times a day. Eight (27.6%) respondents report using the internet
daily, while two (6.9%) report using it weekly. None reported using the
internet monthly or less than monthly.
Question 17 asks what type of internet connection respondents
have at their practices. Twenty-five (86.2%) respondents report they have
broadband connections, e.g., DSL or cable modem, or faster at their
practices. Three (10.3%) respondents report having dial-up modem
connections and one (3.4%) respondent did not know the type of
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connection. None (0%) reported not having internet access at their
medical practice location.
Question 18 asks whether respondents have email for their medical
practices. Twenty (69.0%) report they do have email, while nine (31.0%)
report they do not.
Section IV asks respondents their opinion of the effect of computers
in healthcare. This includes the impact of Personal Health Records
(PHRs).
Question 19 is a multi-part question asking the effect of computers
on:

Controlling healthcare costs

Quality of health care

Interactions within the health care team

Patient-provider communication

Patient privacy

Providers’ access to up-to-date knowledge

Efficiency of providing care

Medication errors
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Results are scored on a scale of one to five with one being very
positive, two is somewhat positive, three being no effect, four represents
somewhat negative and five is very negative. There was one nonresponder to all parts of this question.
Regarding the effect of computers on controlling healthcare costs,
four (13.8%) respondents felt the effect was very positive, fifteen (51.7%)
felt the effect was somewhat positive, six (20.7%) felt computers had no
effect, two (6.9%) felt computers had a somewhat negative effect on
controlling costs, while one (3.4%) felt the effect on controlling costs was
very negative.
The effect of computers on quality of healthcare was felt to be very
positive by fourteen (48.3%) respondents, somewhat positive by twelve
(41.4%) respondents, one (3.4%) respondent chose no effect on quality of
healthcare, one (3.4%) chose somewhat negative and none (0%) chose
very negative.
The effect of computers on interactions within the health care team
was felt by fourteen (48.3%) respondents to be very positive, somewhat
positive by eleven (37.9%) respondents, and no effect by three (10.3%)
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respondents. None (0%) of the respondents chose somewhat negative or
very negative.
The effect of computers on patient-provider communication was felt
to be very positive by six (20.7%) respondents, somewhat positive by
fourteen (48.3%) respondents, no effect by five (17.2%) respondents, and
somewhat negative by three (10.3%) respondents. None (0%) of the
respondents selected very negative.
The effect of computers on patient-provider communication was
reported as very positive by one (3.4%) respondent, somewhat positive by
five (17.2%) respondents, having no effect according to twelve (41.4%)
respondents, somewhat negative effect by nine (31.0%) respondents and
very negative effect according to one (3.4%) respondent.
The effect of computers on the ability to access up-to-date
knowledge was reported as very positive by fifteen (51.7%) respondents,
somewhat positive by twelve (41.4%) respondents and having no effect
according to 1 (3.4%) respondent. No respondents (0%) reported the
effect of computers on access to up-to-date knowledge as somewhat
negative or very negative.
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The effect of computers on the efficiency of providing care was
viewed as very positive by sixteen (55.2%) respondents, somewhat
positive according to five (17.2%) respondents, having no effect according
to two (6.9%) respondents, somewhat negative according to three (10.3%)
respondents and having a very negative effect according to two (6.9%)
respondents.
Finally, the effect of computers on medication errors was seen as
very positive by eighteen (62.1%) respondents, somewhat positive
according to six (20.7%) respondents, and having no effect on medication
errors according to four (13.8%) respondents. No respondents (0%)
reported the effect of computers on medication errors as having somewhat
negative or very negative effect.
Part one of question 20 simply asked respondents whether or not
they were familiar with the concept of a Personal Health Record (PHR).
The question included the definition of a PHR as “a health record initiated
and maintained by the individual patient that can integrate with, and be
accessed from an Electronic Health Record (EHR). In addition, they can
enable secure email messaging between patient and provider.” Twentyfour (82.8%) respondents answered yes, four answered no (13.8% and
one (3.4%) respondent left this question unanswered.
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The second part of question 20 asked respondents to respond to
statements concerning PHRs. The statements were to be answered
agree, disagree or don’t know. The results of this part of question 20 are
available in tabular form in Table 2, Appendix C.
The first statement was “a PHR is a valuable addition to an EHR.”
Twenty (69.0%) respondents agreed, three (10.3%) respondents
disagreed, five (17.2%) respondents said they did not know and one
(3.4%) did not respond.
The second statement said “a PHR can improve the quality of care
delivered.” Seventeen (58.6%) respondents agreed, two (6.9%)
respondents disagreed, nine (31.9%) reported they did not know and one
(3.4%) did not respond.
Statement three was “a PHR can reduce medication errors.”
Twenty (69.0%) respondents agreed with that statement, while three
(10.3%) disagreed and five (17.2%) did not know. One (3.4%) did not
respond.
The fourth statement said “a PHR can improve the efficiency of my
practice.” Fourteen (48.3%) respondents agreed, six (20.7%) disagreed
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and eight (27.6%) did not know. Again, one (3.4%) respondent did not
answer this part.
Finally, the last statement in this question said “a PHR would be
welcomed by my patients.” Nine (31.0%) respondents agreed with that
statement, two (6.9%) disagreed and seventeen (58.6%) did not know.
One (3.4%) respondent did not answer this part.
Question 21 asked respondents to consider whether they would
consider paying “a one-time dividend of 5% for an EHR that would
integrate with a PHR.” Seven (24.1%) respondents answered yes, fifteen
(51.7%) answered no and there were seven (24.1%) respondents who did
not answer this question. There were several comments written on the
survey regarding this question – the most succinct was “5% of what?” This
question and the poor response will be discussed at length in Chapter 5.
Question 22 asked “given that a PHR is a new concept to the
general public, would you be willing to invest time in educating your
patients on its use and value?” Fifteen (51.7%) respondents answered
yes, while fourteen (48.3%) answered no. There were no non-responders
for this question.
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Section V of the survey concerned “The Office Practice
Environment” and was a single multi-part question. In the Simon study,
this was also called “office culture” (Simon et al., 2007). Question 23
asked survey participants to “indicate your agreement or disagreement
with the following statements:”

The office staff are innovative

The provider(s) are innovative

Among my colleagues, I am usually one of the
first to find out about a new diagnostic test or treatment

We are actively doing things to improve quality
of care

After we make changes to improve quality, we
evaluate their effectiveness

We have quality problems in our practice

Our procedures and systems are good at
preventing errors from occurring
The statements were scored from 1 to 5, with 1 being strongly
agree and 5 being strongly disagree. There were no non-responders for
any part of this question.
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With statement one, office staff are innovative, four (13.8%)
respondents strongly agreed, seven (24.1%) agreed, thirteen (44.8%)
neither agreed nor disagreed, and five (17.2%) disagreed. None (0%) of
the respondents strongly disagreed with the statement.
Statement two, providers are innovative, found five (17.2%)
respondents strongly agreeing, nine (31.0%) agreeing, ten (34.5%) neither
agreed nor disagreed, four (13.8%) disagreed and one (3.4%) strongly
disagreed with the statement.
Statement three, I am usually one of the first to find out about a
new diagnostic test or treatment, four (13.8%) respondents strongly
agreed, ten (34.5%) respondents agreed, nine (31.0%) neither agreed nor
disagreed, and six (20.7%) disagreed. None (0%) of the respondents
strongly disagreed with this statement.
With statement four, we are actively doing things to improve quality
of care, nine (31.0%) respondents strongly agreed, nine (31.0%) agreed,
nine (31.0%) neither agreed nor disagreed and two (6.9%) disagreed with
the statement. None (0%) of the respondents strongly disagreed with this
statement.
88
For statement five, after we make changes to improve quality, we
evaluate their effectiveness, seven (24.1%) respondents strongly agreed,
seven (24.1%) agreed, eight (27.6%) neither agreed nor disagreed, six
(20.7%) disagreed and one (3.4%) strongly disagreed.
Statement six, we have quality problems in our practice, found one
(3.4%) respondent strongly agreeing, six (20.7%) agreeing, six (20.7%)
neither agreeing nor disagreeing, eleven (37.9%) respondents disagreeing
and five (17.2%) strongly disagreeing.
The final statement, our procedures and systems are good at
preventing errors from occurring, had two (6.9%) respondents strongly
agreeing, seven (24.1%) agreeing, twelve (41.4%) neither agreeing nor
disagreeing, six (20.7%) disagreeing and two (6.9%) respondents strongly
disagreeing.
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Chapter 5: Summary, Conclusions and Recommendations
The plan for this study was to survey the entire medical staff of
Champlain Valley Physicians Hospital Medical Center for their attitudes
toward Electronic Health Records (EHRs) and Personal Health Records
(PHRs). This was done with a descriptive survey found in Appendix A.
Specifically, the medical staff, as a group of rural providers in solo or
small group practices residing in Clinton County, New York, was
surveyed regarding perceived barriers to implementation of EHRs and
PHRs. This part essentially duplicates the work of Simon et al. (2007),
but in a population of providers that are exclusively in small group or solo
practices. In the next part of the survey, they were asked whether they
perceive a benefit for themselves or their patients from a PHR integrated
in an EHR (hypothesis one), whether they are willing to pay a premium
for an EHR that will support integration with a PHR (hypothesis two) and
finally, whether they are willing to encourage their patients to use a PHR
(hypothesis three).
While CVPH Medical Center reports the medical staff as having
156 members, with 92% board-certified in a specialty or subspecialty
(CVPH Medical Center, 2007), that includes a number of Physicians,
Nurse Practitioners, Physicians Assistants and Nurse Anesthetists who
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work exclusively within the hospital, either in the Emergency Department
or the Operating Rooms, and not in private practice, thus not having their
own medical record systems. Those individuals would have no clear
motivation for considering either EHRs or PHRs and thus would
confound data interpretation. Forty-six members of the medical staff
were determined ineligible based on that criteria, leaving 110 members
to whom surveys were distributed.
The survey was distributed in hard copy via their mailboxes at
Champlain Valley Physician’s Hospital Medical Center (CVPH) on April
2, 2007. A cover letter and business card from the primary investigator
explaining the purpose of the survey, reassuring participants of their
anonymity, and proving contact information should they have questions
(Appendix A) was included.
While the initial plan was to have a secondary distribution of the
survey electronically, or an optional posting of the survey online, CVPH
does not have a comprehensive list of email addresses for the medical
staff. This plan was therefore abandoned. Further, the plan for follow-up
phone surveys of non-responders was tried, but also abandoned for lack
of time and resources. Telephone contact with busy physicians for a 10minute survey was not feasible and no calls were returned.
91
Twenty-nine (26.4%) physicians returned the survey by the time
data collection was closed after five weeks on May 4, 2007. While this
response rate is low compared to the 71% response rate in the study
conducted in Massachusetts, it should be noted that providers there
were surveyed under the auspices of the Massachusetts e-Health
Collaborative and participants were given a $20 honorarium for their time
(Simon et al., 2007). The administration of CVPH felt a 26% return rate
was quite good in their experience with surveys of this particular
physician population (R. Miller, personal communication, May 7, 2007).
The Simon study also sent a second and third mailing to nonresponders to increase response. They also conducted telephone
surveys with non-responders that resulted in one percent of their total
valid responses. These options were not available for this survey due to
resource constraints, however, should another survey of this population
be designed, a second hardcopy of the survey should be distributed to
non-responders at the end of the second week. This was the point at
which initial responses dropped off significantly and a second copy might
have returned additional responses.
These twenty-nine physicians represented twenty-four different
practices in fourteen different medical specialties or subspecialties.
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Given that eleven (37.9%) of the responders were in solo practice,
though several did have mid-level NP or PA assistants, that leaves
eighteen responders representing thirteen group medical practices. It
appears, therefore, that in some cases, a conscious decision may have
been made for one provider to submit a survey on behalf of the entire
group. There is no way to confirm this, however.
Table 1: How many MDs in practice
Number
per practice
Valid 1
2
3
4
5
6
7
Total
Total
Frequency number
11
11
5
10
3
9
7
28
1
5
1
6
1
7
29
76
Valid
Percent
37.9
17.2
10.3
24.1
3.4
3.4
3.4
100.0
Cumulative
Percent
37.9
55.2
65.5
89.7
93.1
96.6
100.0
The group practices represented range in size from two to seven
MDs or DOs. There were five practices with two physicians, three with
three, seven with four, one with five, one with six and one with seven.
(The largest group of seven is an ophthalmology group that added
another physician after this survey was proposed, as at the time of the
proposal, there were no groups that large in Plattsburgh) Totaling these
numbers, the respondents potentially represent as many as sixty-five
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physicians in the various Plattsburgh group practices, however, five of
the respondents (29 respondents minus 24 medical practices = 5) are in
the same practices with other respondents, thus giving potentially
duplicate responses for their groups. In the one instance where it is
certain from the data that two providers were in the same practice, their
responses showed minimal differences concerning their views of
technology.
Six specialties available in the community had no responders.
Those were Orthopedic Surgery, General Surgery, Plastic Surgery,
Dermatology, Psychiatry and Physical Medicine and Rehabilitation
(PM+R). The surgical specialties have unique medical record needs,
since much of their work is done within the hospital and care is very
episodic, but their feedback would have been helpful. Should a similar
study be done in the future, a method for encouraging broader
participation will be needed. An honorarium is one method that has been
shown to be quite successful (Simon, 2007).
Psychiatry also has unique recordkeeping needs. Psychiatrists
are much more concerned with confidentiality, but at the same time,
have greater problems with patient-management related to changing
medications, multiple drug allergies and recurrent admissions for
94
inpatient treatment of acute exacerbations of their various psychiatric
illnesses. Their records are also of a more narrative, less objective,
nature. This group, while having the potential to realize great benefit
from PHRs, would probably require a separate survey instrument. Their
concerns with confidentiality might limit their desire for connectivity in
their medical record systems and might outweigh concerns they might
have regarding initial or ongoing costs.
The demographic data returned shows twenty-one (72.4%) of
respondents were male and eight (27.6%) were female with an average
age for the respondents of 49. Comparable data on the entire physician
population of New York in 2005 was 71% male and 29% female with an
average age of 51 (Armstrong & Forte, 2006). Comparison data for
Michigan, another geographically large and diverse state was. In their
2005 survey, 85% of physicians were male and 15% were female, with
an average age of 52 (Michigan State Medical Society, 2005).
According to the 2005 survey conducted by the Center for Health
Workforce Studies of the University at Albany, Clinton County, New York
has 190 practicing physicians. Their average age is 51 and 20% are
female (Armstrong & Forte, 2006, p. CO-21). This would indicate that the
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twenty-nine respondents to this survey were a fair reflection of the
physician population of the area at least according to gender and age.
This also shows that the 156 practicing physicians on staff at CVPH
Medical Center comprise more than 75% of all the physicians in the
county. The twenty-nine respondents actually represent 15.3% of the
entire county physician population. However, it is impossible to generalize
the results of this survey to all the physicians in the county (the thirty-four
who are licensed with addresses in Clinton County, but not on staff at
CVPH), since their practice environments are unknown.
The New York report did not present data on technology use. Its
information was obtained from re-licensing information supplied by all
physicians. The Michigan study did have such technology data, however.
They found that 26% of respondents were using computers for medical
records (Michigan State Medical Society, 2005). While they did not
specifically ask about Electronic Health Records, their results are in line
with the Simon result of 23%, but much higher than the National
Ambulatory Medical Care Survey: 2003 summary (Hing, Cherry &
Woodwell, 2005). This survey showed only 17.6% of practices using
EHRs nationally.
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The survey served two purposes. First, it attempted to determine
the barriers to implementation of EHRs within a rural population of solo
and small group medical providers. This was not meant to identify new
barriers, but rather to build on research done in Massachusetts by Simon
et al. (2007). That part of the survey was modeled on their tool that was
graciously supplied by Dr. Simon. This part of the survey will be of great
value to the local medical community and to the planning process at
CVPH Medical Center. It also provided a foundation for the second
purpose.
The second purpose of the survey was new research to determine
the attitudes of the local rural providers regarding the value of Personal
Health Records and to discover whether they would invest time or
money in supporting the concept with their patients. This focus was
based on the literature showing PHRs have great potential value to
improve patient care, but remain poorly understood by most patients and
many providers as well. The literature also shows patients look to their
medical providers for recommendations regarding their healthcare. This
was the basis for the hypotheses tested in the survey.
97
Barriers to EHR Implementation
Implementation of an EHR, or planning toward implementation, is
fundamental to the hypotheses of this study because without an EHR, a
Personal Health Record is less useful to the physicians and their
practices. While a printed version of a PHR has some utility, it is of
maximal value when the data can be integrated into the EHR. In this
study, only three of the twenty-four practices (12.5%) represented had
electronic medical records. Unlike the Simon study where large groups
(seven or more providers) were more likely to have EHRs, in
Plattsburgh, these practices with EHRs were two solo practices and one
group of four physicians and one mid-level provider. This makes sense,
however, since there is only one medical practice in the community of
seven or more providers, thus, there are no “large” groups.
While only three practices using EHRs were identified in this
study, CVPH Medical Center had previously done an informal telephone
survey of 39 local medical practices (J. Rafferty, personal
communication, January 19, 2007) that showed eight (20.5%) medical
practices claiming to have EHRs. This telephone survey would have
been with office managers, rather than owners or medical providers, and
careful review of this data shows it included a psychology (non-medical)
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practice and a medical practice with a physician not on the medical staff
of CVPH. Neither of these practices were included in this study
population bringing their comparable results from Rafferty down to six
(16.2%) practices with EHRs in 37 practices surveyed. This compares
somewhat more favorably with the results of this study in which 3
(12.5%) practices of the 24 who responded reported having EHRs.
By eliminating these two confounding practices from the Rafferty
data, the results of the two Plattsburgh studies reveal a much lower
adoption of EHRs than was found in Massachusetts, where 23% of
practices were found to have EHRs. It must be repeated, however, that
in Massachusetts, this 23% adoption rate was heavily influenced by the
much greater adoption rate among large (greater than seven providers)
medical practices, while there are no practices of that size in Plattsburgh
at this time.
While the Plattsburgh physicians are not adopting EHRs, they are
using other electronic technologies, including electronic scheduling.
Twenty-five (86.2%) of respondents had been using electronic
scheduling for an average of 8.5 years. And nineteen (65.5%)
respondents reported using the internet several times a day, with twentyfive (86.2%) having high-speed internet connections in their medical
99
practices. Thus, they are not naive to electronic technologies available to
them, nor do they appear uncomfortable with using these technologies,
but rather it appears physicians are making conscious decisions about
which technologies to adopt.
One electronic technology they have not adopted is electronic
prescribing, or e-prescribing for short. There are a number of standalone
e-prescribing software packages available, such as DrFirst from Rcopia
(https://www.rcopia.com/drfirst_index.jsp) or eRx NOW from the National
ePrescribing Patient Safety Initiative (NEPSI)
(http://www.nationalerx.com/). In both these software programs, the
patient data is stored on secure servers maintained by the vendors and
accessed via the Internet. Users pay an annual subscription fee of $800
to use the DrFirst service (B. Schiller, personal communication, April 1,
2007), while the eRx NOW product is currently free to use, though there
is a fee to upload patient demographics.
These products only require the uploading of demographic
information regarding the provider’s individual patients to use. This data
can easily be obtained from the electronic billing and scheduling
software that are reported to be used by the physicians in this study.
Once uploaded, the provider logs onto the secure server and can view,
100
download or print a list of a patient’s current medication from any and all
providers. They can easily modify or cancel an existing prescription or
can electronically “write” a new prescription. The prescription can then
be printed, or better, sent electronically to the pharmacy of choice.
Pharmacies that participate include the large national chains such as
Wal-Mart, Walgreens and Eckerds and national mail-in prescription
services like CareMark or Medco.
Surprisingly, e-prescribing, with its multiple benefits to both patient
and provider, is only used by six (20.7%) of the survey respondents.
Four of those six were the only providers who are also currently using an
EHR, leaving only two (6.9%) who have adopted e-prescribing
independent of EHR implementation. This compares reasonably well
with the results from the Massachusetts study, where 21% of offices
overall used e-prescribing – with 50% of EHR adopters using it while
only 12% on non-adopters reported using e-prescribing software (Simon
et al., 2007).
As mentioned above, eRx NOW software is currently free to use.
Why then are electronic tools like these not more commonly used?
Identifying the barriers to adoption of electronic technologies, including
EHRs and PHRs, is the key to promoting their use.
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The use of an e-prescribing product gives providers one way to
track all of their patients who are taking a given medication. The question
was asked in this survey how easily the respondents could list all of their
patients taking a given medication. The example used in question 6c
was warfarin, a vitamin K agonist used to prevent blood clots. Fourteen
(51.9%) reported they could not currently track patients taking that
medication. Unfortunately, warfarin is a very common, but dangerous,
medication in the elderly population who are at high risk for atrial
fibrillation – a heart condition associated with blood clots and strokes. It
is a medication that must be discontinued prior to procedures that may
cause bleeding, like colonoscopies or dental extractions and requires
frequent blood testing to assess its effect on blood clotting.
Those physicians that prescribe it frequently may have a paper
record-keeping system to track these patients. Therefore, it is likely that
had the example been a medication like digoxin, another medication
given for atrial fibrillation, the number reporting they could not list all their
patients taking a given medication would have been higher. Should this
survey question be used again, another medication, such as digoxin,
should be listed as the example.
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Another function supplied by an e-prescribing program is the
ability to proactively check for drug-drug interactions. In fact, the function
is performed automatically when prescribing a new medication. The
software compares the new medication to the current medications the
patient is taking and automatically alerts the provider to any interactions,
thus, preventing the possibility of untoward side effects or adverse
events (B. Schiller, personal communication, April 1, 2007).
Question 6, with its parts on listing patients by diagnosis,
laboratory result and medication, was included to stimulate the
respondents to think about this basic function for sorting patients that is
not available in a paper system, as well as to obtain the actual ability of
the respondents to complete the task. The hardest task for them to
perform, with nineteen (70.4%) reporting they could not, was list patients
by laboratory results. In a paper system, laboratory results are merely
initialed by the provider as being reviewed and then filed in the chart.
Any ability to retrieve patients is dependent on the memory of the
provider. With an EHR, laboratory results can be downloaded directly to
the correct test in the EHR, allowing retrieval of results for all BMPs.
As in the Simon study, financial costs were the major barrier cited
to implementation of EHRs. Start-up costs were reported to be the
103
greatest barrier by CVPH physicians, with twenty respondents (69%)
citing it as a major barrier (Table 2). Ongoing financial costs ranked
second with 48.3% or fourteen respondents citing it as a major barrier.
Lack of time to acquire knowledge ranked third as a major barrier by
twelve (41.4%) respondents. This would make sense, since any time
spent learning about EHRs, in order to make an informed choice, would
detract from the primary mission of the medical practice – providing
patient care and generating revenue.
The emphasis on financial cost might explain in part the rationale
for not using e-prescribing. Since handwriting prescriptions has been the
normal operating procedure for most providers since their days in
training, and now that New York State supplies all prescription blanks
free to every provider, the cost of e-prescribing must appear to outweigh
any benefit in tracking patients. In addition, there would be the learning
curve to adopt the technology. If the study is repeated, clarification of the
providers’ perceived barriers to e-prescribing would be of great interest
since e-prescribing is a stand-alone piece of technology that could be
adopted much more easily than an entire EHR.
E-prescribing is also a software package that could benefit a
hospital, such as CVPH. If adopted in the Emergency Department and
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associated hospital clinics, providers in those settings would have
access to all medications prescribed to the patients they see, regardless
of what provider actually wrote the prescription. This would prevent time
lost in attempting to confirm medications with calls to pharmacies and
would prevent duplication of medications for patients, resulting in cost
savings for them. This happens because the e-prescribing software
accesses national databases called Pharmacy Benefit Managers (PBMs)
like RxHub (http://www.rxhub.net/) to populate their own databases with
medication information.
Table 2: Barriers to implementation of Electronic Health Records
Barrier to
Not a Minor Major Major+ No
implementation
barrier barrier barrier Minor response
Computer skills of
13
13
2
15
1
self/staff
44.8% 44.8% 6.9%
51.7% 3.4%
Lack of time to
7
9
12
21
1
acquire knowledge
24.1% 31.0% 41.4% 72.4% 3.4%
Start-up financial
2
6
20
26
1
costs
6.9%
20.7% 69.0% 89.7% 3.4%
Ongoing financial
2
12
14
26
1
costs
6.9%
41.4% 48.3% 89.7% 3.4%
Training/productivity 4
13
10
23
2
Loss
13.8% 44.8% 34.5% 79.3% 6.9%
Physician
11
11
6
17
1
skepticism
37.9% 37.9% 20.7% 58.6% 3.4%
Computer technical 8
13
7
20
1
Support
27.6% 44.8% 24.1% 70.0% 3.4%
Privacy/security
19
6
3
9
1
Concerns
65.5% 20.7% 10.3% 31.0% 3.4%
Lack of uniform
9
8
10
18
2
Standards
31.0% 27.6% 34.5% 62.1% 6.9%
Technical limitations 6
10
10
20
3
of systems
20.7% 34.5% 34.5% 70.0% 10.3%
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Total
29
100%
29
100%
29
100%
29
100%
29
100%
29
100%
29
100%
29
100%
29
100%
29
100%
In the Simon study, results were separated for EHR adopters and
non-adopters as well as reporting the overall percentages. In the CVPH
population, however, there were only four adopters, and two of those
from the same pediatric practice had been using their EHR for only one
year. Thus, in Table 2, adopters and non-adopters for CVPH physicians
are reported together as the number of adopters is too small to analyze
separately, and thus, too small for any comparative statistical analysis.
When CVPH respondents’ reports of major and minor barriers are
combined, start up costs and ongoing financial costs share first place as
the leading barriers with 89.7%. This corresponds well with the findings
from Massachusetts of 90% and 88% for EHR non-adopters on start up
costs and ongoing financial costs respectively (Simon et al., 2007). Only
64% and 63% of EHR adopters, who would have a better knowledge of
actual start-up and ongoing costs, reported these to be a barrier in the
Simon study. Again, in the current study, there were too few EHR
adopters to compare.
Most other perceived barriers that were surveyed in both studies
came within ten percentage points or less of each other. Loss of
106
productivity and training costs ranked behind start-up and ongoing
financial costs with 81% reporting it to be a barrier in the Massachusetts
survey. 79.3% of respondents in the CVPH survey made this item the
third ranked barrier also. This is essentially another financial measure of
the cost of EHR implementation.
In the Simon study, the 77% of combined respondents reported
lack of time to acquire knowledge as a barrier compared to 72.4% in this
study. For CVPH physician respondents, this ranked as the fourth
barrier. Tied for fifth were computer technical support and technical
limitations of the systems with twenty (70%) CVPH physicians reporting
these as minor or major barriers for each. In the Simon study, these
were perceived as barriers by 66% and 79% respectively.
59% reported lack of computer skills as a barrier in Simon
compared to 51.7% in this study. Physician skepticism was reported as a
barrier by 58.6% of CVPH physicians compared to 57% in the Simon
study. However, two survey items showed differences greater than 10%
between the two survey populations – privacy and security concerns and
lack of uniform standards.
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The major difference in perceived barriers to EHR adoption
between the Simon study and the current study concerned privacy or
security concerns. In Table 2, only nine (31.0%) CVPH physicians
reported privacy or security concerns as a minor or major barrier to
implementation of an EHR. In the Massachusetts study, 55% of
respondents (47% of EHR adopters and 58% of EHR non-adopters)
reported privacy or security concerns as a minor or major barrier. While it
is not possible to calculate a statistical significance to this difference due
to lack of the raw data, only reported percentages, from the Simon study,
the magnitude of the difference, given the close correspondence of other
measures in the two studies, would suggest there is a real difference.
It is likely that the major difference between the studies is the
small, virtually closed, community of Plattsburgh, New York within which
the CVPH physician population operates. This contrasts with the
experience of physicians across the entire state of Massachusetts in
many different practice environments. While the Plattsburgh physicians
see patients from outside the (small) city of Plattsburgh, population
18,000, most patients they would see still visit Plattsburgh for shopping,
entertainment, etc. Thus, physicians in Plattsburgh are constantly
meeting their patients out in the community. This leads to a more relaxed
108
concern regarding confidentiality issues due to the closeness of the
community.
In larger population areas, chance meetings with one’s physician
are less likely due to more venues for shopping, etc. In a less intimate
community, protection of one’s privacy, and a corresponding concern as
reflected in the results of the Simon study, would be expected. Since
violations of medical privacy or record security can have serious
implications in our litigious society, it would be interesting to explore the
difference in attitude between the providers in Plattsburgh and
Massachusetts. While well beyond the scope and intent of this study,
future research into providers’ perceptions of privacy and security in our
new electronic age, and between small and large communities, should
be designed and carried out to see if significant differences do indeed
exist.
The other question with a large difference in respondents between
the Simon study and the CVPH physician population, though not as large
as on security and privacy, concerned ‘lack of uniform standards’.
Eighteen (62.1%) of the CVPH physician responders felt the lack of
uniform standards for electronic record systems represented either a
major or minor barrier to implementation. In the Simon study, 81% of
109
non-adopters and 68% of adopters felt this was a major or minor barrier.
When combined, 78% of the Massachusetts respondents felt this was a
major or minor barrier. This is a 16% difference on this survey item
between the two overall populations, but 19% if one compares
Plattsburgh with the non-adopters in Massachusetts.
The 13% difference between adopters and non-adopters in the
Simon survey regarding lack of standards is close to the average his
group found for the various survey items. The likely reflects the
increased knowledge about and comfort with the technology once one
has actually researched and implemented an electronic record system.
Once actually using an electronic record system, the presence of at least
individual product standards become obvious. However, at the time
Simon et al. conducted their research, not all vendors had adopted some
of the national standards, nor had all applied for, or been certified by, the
Certification Commission for Healthcare Information Technology
(CCHIT). This lack of universal adoption of industry standards is likely
the reason adopters still perceive lack of standards as a substantial
barrier.
This should change, however, since the three leading HIT industry
associations – the American Health Information Management
110
Association (AHIMA), the Healthcare Information and Management
Systems Society (HIMSS) and The National Alliance for Health
Information Technology (Alliance) – joined forces in July 2004 to launch
CCHIT as a voluntary, private-sector organization to certify HIT products.
Currently there are approximately 88 CCHIT-certified ambulatory EHRs
on the market (Certification Commission for Healthcare Information
Technology (CCHIT), 2007). As the presence of CCHIT standards and
the certification process becomes more universally known, this
perception of lack of standards should decline among both adopters and
non-adopters of the technology.
One possible explanation for the 16% difference between the two
survey populations, with the CVPH physicians reporting a lower
perception of lack of standards as a barrier, may actually be a result of
the dissemination of knowledge about CCHIT standards. That would
mean that the CVPH population was staying up-to-date on activity in the
HIT sector. However, since twenty-one (72.4%) reported lack of time to
acquire knowledge as a major or minor barrier, increased knowledge of
industry standards by the CVPH providers seems unlikely to be the
explanation of the difference.
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It seems more likely that the opposite, lack of knowledge
regarding HIT industry standards by the CVPH population, explains why
they don’t perceive this to be as great a concern as the Massachusetts
population. The rural nature of their practices, combined with the time
constraints of small-group or solo practices has left them less
knowledgeable of industry standards than their Massachusetts
colleagues. This lack of knowledge makes them less concerned on this
matter than they otherwise would or should be. Should this study, or one
like it, be repeated, a question regarding provider familiarity with CCHIT
standards by the study population might help clarify the difference on this
item between the two studies.
Study Support of Hypotheses
The second purpose of the survey was new research to determine
the attitudes of the local rural providers regarding the value of Personal
Health Records and to discover whether they would invest time or
money in supporting the concept with their patients. This focus was
based on the literature showing PHRs have great potential value to
improve patient care, but remain poorly understood by most patients and
many providers as well. This was the basis for the hypotheses tested in
the survey.
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Hypothesis one: “providers in rural private practice perceive the
Personal Health Record as having no additional value in an Electronic
Medical Record.” Question 20 of the survey speaks to this hypothesis
directly and indirectly. First, after giving a definition of a PHR as “a health
record initiated and maintained by the individual patient that can
integrate with, and be accessed from an Electronic Health Record
(EHR),” the respondent is asked if he or she has heard or read about the
concept. Twenty-four (82.8%) respondents answered in the affirmative,
four (13.8%) responded no and one (3.4%) did not respond.
The question went on to ask their opinion regarding five aspects
of a PHR, including the direct question, “A PHR is a valuable addition to
an EHR.” The results are presented in Table 3 below.
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Table 3: Effect of Personal Health Record on medical practice
PHR attribute
Agree
Disagree
PHR is a valuable part of
EHR
PHR improves quality of
Care
PHR reduces medication
Errors
PHR improves practice
Efficiency
PHR is welcomed by
Patients
20
69.0%
17
58.6%
20
69.0%
14
48.3%
9
31.0%
3
10.3%
2
6.9%
3
10.3%
6
20.7%
2
6.9%
Don’t
know
5
17.2%
9
31.0%
5
17.2%
8
27.6%
17
58.6%
No
response
1
3.4%
1
3.4%
1
3.4%
1
3.4%
1
3.4%
total
29
100%
29
100%
29
100%
29
100%
29
100%
While 69% of respondents agree the PHR is a valuable addition to
an EHR, it was not tested for statistical significance, though it does show
a trend. If the responses of those four who were not familiar with a PHR
and the one non-responder are removed, then 19 of 24 (79.2%) agree
with the statement, 3 of 24 (12.5%) disagree and only 2 of 24 (8.3%)
don’t know. This shows four out of five responders reject the hypothesis
that a PHR bring no additional value to an EHR. It does indicate a
significant trend to reject Hypothesis 1. Had the survey response been
greater, results might have been stronger.
Hypothesis 2 states “providers in a rural private practice would not
be willing to pay any additional cost for an EHR that supports a PHR.”
Question 21 speaks directly to this hypothesis asking “Given the financial
investment necessary to implement an EHR, would you be willing to pay
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a one-time dividend of 5% for an EHR that would integrate with a PHR?”
Unfortunately, the wording of this question caused some confusion
among respondents resulting in seven (24.1%) non-responders to this
question. It appears the choice of the word “dividend” obfuscated the
intent of the question. In addition, the 5% price tag wasn’t clear as
evidenced by the written response “5% of what?” written on the first
survey returned in the first week.
This question was designed with the intent of setting a single price
for a PHR – in this case 5% of the base price of the EHR. The intent was
to have a single question directed toward hypothesis 2, rather than
asking multiple questions, such as “would you be willing to pay more for
an EHR that integrates with a PHR? 2% more? 5% more? 10% more?” It
would appear that multiple questions would have been preferable and
clearer to the participants.
While the survey was proofread, it would have benefited from
being piloted with several physicians. They would likely have seen the
difficulty in interpreting the question and adjustments could have been
made. As it stands, the results for this question do not provide sufficient
reliable data to speak to the second hypothesis, nor do they indicate a
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trend. Hypothesis 2 therefore cannot be answered from the data
collected.
Hypothesis three states, “providers in rural private practice will not
be willing to spend time advocating for Personal Health Records for their
patients.” The thought behind this hypothesis and the question was that if
providers would not spend money promoting PHRs with their patients,
perhaps they would spend some time. Question 22, “Given that a PHR is
a new concept to the general public, would you be willing to invest time in
educating your patients on its uses and value?” spoke directly to this
hypothesis.
While there was no confusion evident in the responses to this
question, with fifteen (51.7%) responding yes and fourteen (48.3%)
responding no, one responder wrote “staff time” on the survey, indicating
that the physician would not spend their own time, but would delegate the
task. This would indicate that perhaps several questions should have been
used on this hypothesis and again, it is likely that piloting the survey would
have been helpful in determining the best wording and should be done
with future surveys. Hypothesis 3 is therefore supported by the study “providers in rural private practice will not be willing to spend time
advocating for Personal Health Records for their patients.”
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The response rates for “no” on both questions 21 and 22 were
approximately 50%, giving the appearance of some relationship between
the answers to these two questions. In fact, only seventeen (58.6%)
respondents gave the same answer, either yes or no, to both questions.
Only eleven (37.9%) answered no to both questions and six (20.7%)
answered yes to both. The seven non-responders to question 21 no doubt
kept this correlation lower than it would have been had question 21 been
better received.
Limitations of the study
The major limitation of this survey is the response rate of 26.4%
or N=29. While the primary investigator and CVPH Medical Center are
satisfied that this response rate meets the immediate goals of both, it
severely limits the ability to generalize the results to the entire local
medical community. Furthermore, given the unique medical environment
of the Plattsburgh, NY area, with many solo practices and no large group
practices, this low response makes the data very difficult to compare to
other data sets.
It is likely that one reason for the low response is the relative
value of the subject’s time. In ten minutes, the time projected for the
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survey, a physician could complete a patient visit that could net $50 or
more. Future research with high-income subjects should include a
budget for an honorarium.
Response rate could also likely have been improved with second
and third distributions of the survey to non-responders. This would have
required more time and clerical support than was available, however.
Future research with this population should include budgeting for
additional survey distribution to non-responders.
Alternatively, sample selection could have been aimed at a single
subject in each medical practice in the community, rather than
attempting to survey the entire medical community. This was the
methodology used by Simon et al., with results weighted according to
number of providers per respondent in the practice (2006). It appears
from the surveys returned that in some practices, a single physician
returned the survey for the group. However, given the small size of the
medical community, this would not have necessarily resulted in a better
overall number of returns.
Finally, it is likely the response rate would have been better had
one of their peers, specifically a physician, been a co-investigator on this
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survey. While the primary investigator is nominally a member of the
medical staff of CVPH and known to most of the local physicians, he is
not a physician. A physician champion on the medical staff would likely
have improved the response.
A second limitation on generalizability of the survey was the
restriction of the study to physician members of the CVPH medical staff.
There are at least 34 other physicians within Clinton County who are not
members of the medical staff and thus were not considered for inclusion
(Armstrong & Forte, 2006). While the number is small, these physicians
provide care to the same patient population, and therefore have the same
information-sharing needs, especially when referring patients to specialists
on the CVPH medical staff. Should this study be repeated, an effort should
be made to identify these physicians and include them in the study
population.
In addition to including other physicians from Clinton County, there
are several other adjacent New York counties that share the rural
character of Clinton County. Physicians in those counties would increase
the study population, but are not affiliated with CVPH, so would alter some
of the utility of the results for future planning by CVPH.
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A third limitation to the generalizability of the findings of this survey
is the unique geographic attributes of the Plattsburgh, New York location.
CVPH Medical Center, with its medical staff of 156 physicians, nurse
practitioners, physicians’ assistants and nurse anesthetists, is located
thirty miles south of the Canadian border on the western shore of Lake
Champlain. To the South and West lies the six million acre Adirondack
Park (the largest wilderness area east of the Mississippi River). The next
largest hospital, Fletcher Allen Health Care, is thirty miles away, but the
trip includes a $20 ferry ride across Lake Champlain to Burlington,
Vermont. Not all New York insurances are accepted in Vermont, which is
one of the incentives patients have for confining their medical care to
providers affiliated with CVPH Medical Center.
The next largest hospital in New York is 110 miles south in Glens
Falls, New York. While a larger hospital than CVPH, its services are not
much greater than what is available in Plattsburgh. Most referrals from
CVPH go to St. Peter’s Hospital in Albany, New York, 155 miles south of
Plattsburgh, or 2 ½ hours by ambulance.
This unique geographic location results in a reimbursement
situation where solo or small group practices can survive, while large
groups have no incentive. Health Maintenance Organizations can’t obtain
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the necessary economies-of-scale so they are absent from the area. While
there are certainly other similar medical environments within the
continental United States, they are the exception, rather than the rule.
Thus this survey, while useful in Plattsburgh, will have little application
elsewhere.
Also, the lack of participation by members of the specialties of
General Surgery, Orthopedic Surgery, Plastic Surgery, Dermatology,
Psychiatry and Physical Medicine and Rehabilitation restrict the ability to
extend the findings to those specialty practices. While they all have unique
record keeping needs, and don’t provide primary care for any patients,
Personal Health Records would assist them in providing higher quality
care to those patients they do see. Their views on the topic of PHRs would
therefore be of interest.
Regarding respondents’ plans to implement EHRs within their
practices, eleven reported no specific plans for implementation. Review of
the data shows no significant correlation between this response and their
year of birth (age), but it is possible these respondents are not considering
an EHR as they intend to retire from medical practice within the next five
years. If this is the case, they would not be able to recoup their financial
investment in an EHR. A question regarding retirement plans of the
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respondents would have been helpful in clarifying this item and should be
considered for future surveys.
Given the levels of personal and professional stress reported in this
survey, with twenty-two (75.9%) reporting they felt it was a moderate or
serious problem, retirement might be on the minds of many of the
respondents. In addition, twenty-two (75.9%) also reported the long hours
to meet practice demands were a moderate or serious problem. Given the
average age of 49, it would be an early retirement they would be
considering, but it would be useful to clarify why they have no specific
plans to implement an EHR.
Recommendations for Study Improvement
There are two groups of recommendations that can be developed
from this study. The first group concerns improvements that could be
made if the study is replicated. The second group of recommendations
concerns how implementation of Electronic Health Records and Personal
Health Records can be facilitated in a rural health care setting.
Regarding recommendations should the study be replicated, the
major improvement needed is a better response rate. Twenty-nine
respondents across fourteen medical specialties results in too many
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independent variables to do more than report descriptive statistics on the
responses.
Response rate could be improved in several ways. First, a coinvestigator who is a peer member of the group to be surveyed, rather
than a subordinate member as this author is, would be beneficial. This
would provide an incentive not to disappoint the peer by failing to compete
the survey.
Second, an honorarium should be offered. This could be monetary
but could also be something as simple as a meal voucher valid in the
hospital cafeteria. Since this survey was done with some benefit derived
by CVPH Medical Center, their participation in providing some support
could have been solicited to cover the honorarium.
Third, additional surveys could have been distributed to nonresponders. Two weeks after the initial survey distribution, a second copy
could have been distributed to the mailboxes of the non-responders. The
bulk of the surveys were returned within the first two weeks, so those that
hadn’t responded might have been motivated to participate by a second
copy of the survey. If the second round of surveys had a strong response,
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a third round could have been attempted, though this would have required
keeping the data collection window open a week or two longer.
With a more web-connected group, an online or email survey might
have been a viable alternative. With the medical staff of CVPH, a
comprehensive email list was not available. Currently, the hospital does
not use email to communicate with physicians outside their employment.
In other words, the physicians and mid-level providers eliminated from the
sample because they do not keep separate medical records are the only
ones the hospital currently communicates with by email.
Besides response rate, the other area that must be improved if the
study is replicated is the survey itself. Questions 21 and 22 need
improvement in order to return the desired information on the respondents’
feelings on PHRs. Also, question 6c would benefit from a different choice
of medications as mentioned earlier – one that might not routinely be
tracked with a paper system.
Question 21 should read, “Given the financial investment necessary
to implement an EHR, would you be willing to pay more for an EHR that
would integrate with a PHR?” Then the question can have a second part
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that asks how much more and could have multiple choice amounts as
percentages.
Question 22 should read, “Given that a PHR is a new concept to
the general public, would you be willing to invest time, either yours or your
office staffs, in educating your patients on its uses and value?” In the end,
time is money, so in some ways, these two questions are just alternate
ways of asking the same question. But having the office staff as the
potential educators provides a cheaper option for the responders to
consider.
One additional recommendation that should have been performed
was to pilot the study with several typical providers before general
distribution. The problems with the questions above would probably have
revealed themselves. The questions could have been improved
beforehand, making the above recommendations moot.
Challenges Implementing EHRs
While the finding that solo and small group medical practices face
major barriers to implementation of EHRs is not a new finding, this study is
useful to the medical community in Plattsburgh, New York. CVPH Medical
Center, the single community hospital in town, is reviewing this data with
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an eye to finding ways they can facilitate electronic record implementation.
It is clearly in the self-interest of the hospital to have providers able to
receive electronic transfer of patient data.
As an example, in the current paper medical record environment, if
a patient arrives for an appointment and had a laboratory or radiologic test
within the last two days, a paper copy of the results probably hasn’t
arrived at the provider’s office. It is probably sitting in the physician’s
mailbox at the hospital (because of the size of the community, most
laboratory and radiologic examinations are done at the hospital).
Someone in the physician’s office must call the hospital, be transferred to
the appropriate department and ask that a copy of the examination result
be faxed to the provider’s office. Because of confidentiality issues, results
are only given over the telephone if results show a medically dangerous
condition, since the caller can’t be identified as someone authorized to
have the information. The laboratory and radiology departments have all
the correct fax numbers for providers’ offices.
This procedure for obtaining recent information will consume five
minutes or more of both office staff and hospital staff time – more if either
end is particularly busy. Repeat this procedure several times a day for
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every medical practice not using any electronic record systems and the
cost savings, mostly in employee time, is substantial.
While the hospital is not in a position to provide financial support to
private practices, due to concerns regarding Safe Harbors regulations
issued by the Office of Inspector General of the Department of Health and
Human Services in August, 2006 (Office of Inspector General, 2006), they
can provide assistance with finding financial support. They are currently
pursuing that option with a grant submission to the State of New York for
funding to support Electronic Medical Records (EMRs) in physicians’
offices throughout Clinton County, New York that can share information
with the hospital systems. This funding for Health Information Technology
(HIT) is available through the Health Care Efficiency and Affordability Law
for New Yorkers Capital Grant Program, or HEAL NY, as it is known (New
York State Department of Health 2006). The EMR proposed in the grant is
NextGen EMR from NextGen Healthcare Information Systems, Inc. (R.
Miller, personal communication, February 12, 2007). This EMR boasts an
integrated Continuity of Care Record (CCR) – one form of a Personal
Health Record (Medical Records Institute, 2006) and is CCHIT certified.
The only potential problem that may arise should the HEAL grant
be awarded would be promoting the acceptance of the NextGen EMR by
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the majority of the physicians not currently using or committed to another
system. While the NextGen EMR is a very robust system, very few CVPH
physicians were involved in the grant process. The nature of the solo or
small group provider is that of an entrepreneur. They value their
independence, and in this instance, that translates into making their own
decisions on product selection. While 72.4% of survey respondents
claimed lack of time to acquire knowledge was a barrier to EHR
implementation (Table 1), that doesn’t necessarily mean they are willing to
accept a product chosen for them.
The greatest benefit to both the hospital and the community can be
derived from a uniform product across many medical practices. This will
allow easier data transfer from the hospital to the medical practices, as a
single computer interface will be needed. While none of the current EHR
users have NextGen EMR, should the HEAL grant materialize, there are
enough non-users currently to provide economies of scale if most can be
convinced of the merits of the NextGen product. This will be the greatest
challenge facing the hospital – to overcome physician resistance since
most of the physicians were not involved in the selection decision at the
time of the grant writing.
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CVPH Medical Center, or any hospital in a similar situation, can
explore other avenues for aiding their community physicians with
implementation of EHRs, however. One of the barriers to implementation
not measured in this survey is the need to digitize existing records. While
this may sound like a simple proposition, scanning the existing paper
record into a digital format, it’s not at all that simple.
First, a scanned document is essentially a digital photograph or
image of the paper original. It can only be manipulated like a photograph –
rotated, enlarged or resized, lightened or darkened, etc. And like a copy of
a photograph, any defects in the original, like poor ink quality or the lines
resulting from a bad fax machine, will be reproduced and to some degree
exaggerated in the scanned copy.
If one wishes to take data from the document to enter it into a graph
or spreadsheet, the document must be run through an optical character
recognition (OCR) program to extract the actual text or numbers. If the
scanned copy is crooked or has handwriting or fax lines, the optical
character recognition software will make its best guess. The old adage
“garbage in, garbage out” would apply here. In some cases, the scanned
document is best left as an image and viewed only in its original form. This
may be the safest choice.
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This is also the fastest choice. Running a scanned document
through optical character recognition takes more time and computing
power than scanning the original document in the first place. Thus,
keeping the document as an image will allow the transfer from paper to
electronic record to continue moving at a reasonable speed. These files
would then be stored in an image format like .jpg or .bmp. But speed isn’t
the only problem with the transfer.
Once a document has been scanned, it is now a computer file. That
file must be named and the name must be useful to those who will want to
view that file later. As an example, let us use a laboratory report of a Basic
Metabolic Panel (BMP) usually reported on a single sheet of paper. A
BMP is a group of seven or eight routine blood chemistry tests, including a
blood sugar (BS), blood urea nitrogen (BUN), creatinine, sodium,
potassium, chloride and CO2. It may also include a calculated glomerular
filtration rate (GFR). This laboratory report also has at least two significant
dates and times on it – the date and time the specimen was taken and the
date and time the laboratory report was issued. The time the specimen
was obtained determines whether or not the blood sugar was a fasting or
random specimen and aids in interpreting the result.
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So what should the file be named? BMP_fasting_05052007.jpg,
with laboratory test and date in the file name, would be one naming
protocol. Someone – a clerical person for cost-effectiveness – would have
to select and name the file. The ‘fasting’ could be based on a specimen
obtained before 9am, or the laboratory might have reported that in the
results. But the naming of the file will still require the person to examine
the file and extract test name, date and time and enter them accurately as
the file name.
But what if one or more of the laboratory results are abnormal? Can
the file name reflect that? Or perhaps more importantly, should it reflect
the presence of abnormal results? Clearly the provider who will be using
the medical record would like to be cued to the presence of abnormals. In
a world of paper records, providers unconsciously train themselves to
scan pages of laboratory reports and based on experience, with a
consistent page format for a given laboratory, can find the abnormals
without difficulty, and mentally discard the slightly abnormal from the
significantly abnormal. In other words, just identifying abnormal laboratory
values is not useful without some interpretation that can only be done by
the provider.
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Again using the Basic Metabolic Panel, a blood sugar obtained at
6am is most likely a fasting specimen and should be below 100 milligrams
per deciliter (mg/dl). So if the reported result for a fasting blood sugar is
110 mg/dl, that would be abnormal. But if that patient is a known diabetic,
that result would be acceptable. If the filename for that BMP included
some marker that an abnormal result was included, say
BMP_fasting_05052007_abnlBS.jpg (for ‘abnormal blood sugar’), the
provider might take the time to open that file only to find a result with
which they were quite happy for their diabetic patient.
The naming problems can become more difficult when several
abnormals are involved or even when several separate laboratory tests
are included in a single report. An example of that might be the
combination of a thyroid stimulating hormone (TSH), cholesterol panel and
prostate specific antigen (PSA) for a male patient’s annual examination. If
the provider is to know what is contained in that image file the name might
be TSH_lipids_PSA_05052007.jpg. Unlike the paper copy, where the
provider can quickly scan the page and move on, the file must first be
opened to view. At least by including the laboratory test names in the
filename, the provider knows if it is of immediate interest or not. But this
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assumes their clerical help is conscientious in their work and has named
the file correctly.
The second level to this problem after naming the files properly is to
store them in the EHR correctly. While a paper medical record may have
just a few chart sections to store data, a provider scanning their own paper
records can browse a chart quickly and visually separate office visit notes
from consultation notes or hospital discharge summaries from admission
histories. In an electronic record, one can only browse folders or file
names. The documents they represent are hidden until opened. In order to
easily find the exact document you want, they must be stored efficiently.
This results in many tabs or file folders in which to store the many different
types of documents that make up a medical record. If one wants to find
that BMP mentioned above, it would be filed under laboratory data in a
subdirectory for serum chemistry tests.
Current generation electronic health records facilitate a search like
this with color-coded tabs for various chart sections. Still, such a search,
and opening the files found, takes a bit more time than flipping pages in a
paper record. Furthermore, given the limited size of a computer screen,
the provider can only view at most two documents at the same time
(assuming one splits the screen). Thus, the provider must click tabs to
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move between pages if comparing results from different dates. While this
is not that different from what one would do with a paper medical record, it
is a bit slower. See the NextGen interface below to see how crowded the
screen appears and the multiple tabs under which scanned data would
have to be placed for ease of retrieval.
Figure 1: NextGen interface (retrieved from www.nextgen.com on
May 28, 2007)
The above discussion only applies to the scanned historical
documents, however, and specifically just to laboratory reports. Once the
EMR is operating properly and the hospital and the medical provider have
optimized their electronic interface, laboratory data can flow from the
laboratory at the hospital, or any other laboratory with the proper interface,
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to populate a flowsheet in the EMR that will separate the data by test and
can highlight abnormals by color. Unfortunately, the historical scanned
data will not be displayed in this manner. That would require each old test
result to be re-entered in the proper data fields manually – a costprohibitive operation.
So how can CVPH help the local providers with their
implementation challenges? The scanning issue is one area in which the
hospital’s resources can be a great help. Since the bulk of the scanning
process of existing paper records is a one-time event, and therefore onetime expense, the hospital could purchase a high-speed scanner that
could be loaned to medical practices as needed. Medical practices that
are in the process of implementing EHRs could borrow the scanner for the
week or two needed to convert existing records to digital format.
Figuring just twenty-five pages per record and 4000 records for a
small, solo medical practice, (a relatively conservative estimate) that
represents 100,000 pages needing to be scanned. While the scanner
could probably handle that volume in a 40-hour workweek, since that is
only 42 pages per minute and a high-speed scanner can handle up to 200
pages per minute, the staff probably could not. Each chart will have to be
taken apart and sections scanned separately so the pages can be named
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and filed properly (see discussion above on naming files). Then the files
would need to be properly put back together for continued use until full
implementation of the electronic record system was complete. The staff,
therefore, would probably require at least two weeks – 80 hours for two
people or 160 man-hours – to complete the conversion of those 4000
charts to electronic format.
Another way CVPH can assist with implementation, therefore, is to
supply trained staff who are trained in medical record maintenance. These
individuals could significantly speed up the scanning process since they
would require little additional training and could accompany the scanner
from one medical practice to the next. This might be more than the
hospital could afford, however, so instead, they could provide training to
the staff within the medical practice on operation of the high-speed
scanner and on the most efficient naming protocols for the various
sections of the records.
Another level of support CVPH Medical Center, or any community
hospital interested in moving implementation of electronic health records
forward, could provider would be centralized data storage or backup.
CVPH could become the primary data repository for the community
practices with remote access to the data via the internet. This would be
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made easier if many providers used a single data format, such as
NextGen EMR, but this wouldn’t be absolutely necessary. The data
storage would have to be securely partitioned to prevent access to other
provider’s patient’s data, but that would be relatively easy. This service
could be provided for a monthly fee that would cover the hospital’s
employee and equipment costs and would certainly be less expensive that
the cost an individual provider might incur for the same date storage
onsite.
The independent physicians would then only need personal
computers with high-speed internet access. Right now, twenty-five
(86.2%) of the twenty-nine respondents in this survey have broadband or
faster internet access at their offices. One must presume they have a
computer with internet access as well, otherwise, why have high-speed
access?
This would fall under the ASP (application service provider) model
of computer services delivery. This has the primary advantage to the
individual physician of freeing him from having the need for onsite data
storage equipment operating twenty-four hours a day, seven days a week.
24/7 operation would be necessary for the physician to access his files
from home, for example.
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The ASP model provides economies of scale for CVPH by diluting
the operating costs of the storage equipment and the personnel over
multiple separate medical practices. In addition, should most of the
medical practices choose a common product, such as NextGen EMR,
product updates could be installed for all users in a uniform manner at a
convenient time, minimizing service interruptions.
The downside to the ASP model is individual loss of control over
their sensitive patient data. For those providers who weren’t comfortable
with CVPH storing all their patient data for them, the providers could set
up their own primary storage systems onsite. CVPH could then provide
secure off-site backup of sensitive patient data. This would require the
physician to have either a great deal of personal computer expertise or a
service contract with a computer firm to maintain the server for on-site
patient data storage. This arrangement would assure access to patient
data in the event of some failure of the local internet connections.
However, as mentioned above, the advantages gained by 24/7 access to
patient data would place the burden of technical support on the providers
to maintain equipment, rather than on CVPH Medical Center, should they
choose onsite data storage.
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Challenges Facing PHRs
While 82.4% of the physicians responding to this survey reported
knowing something about Personal Health Records, only one-half were
willing to spend additional money for an EHR that supported or integrated
with a PHR and only half were willing to spend time educating their
patients about PHRs. While there were problems with the survey
questions (discussed above), and conclusions must therefore be qualified
in the presence of those problems, the trend is clear. Based on this study,
if PHRs are to be advanced to the patient population in Plattsburgh, New
York, one should not expect the physician population to be the champions
of the movement.
Who then will promote PHRs? The federal government has
recommended more patient participation in their own care and the
Personal Health Record has been shown to be a device that can help fulfill
that recommendation, but educating the medical consumers on the
adoption and use of a PHR has not been adequately addressed. In the
Plattsburgh, New York community, this may be another place where
CVPH Medical Center can provide some leadership.
139
At the most basic level, CVPH can institute community education
on the value and use of PHRs. This can be done with Public Service
Announcements (PSAs) on the local media outlets as a first step. They
have already developed a Vital Link Medication List form, in conjunction
with the local health department, that they recommend for senior citizens
to keep on their refrigerators for easy access by rescue or ambulance
personnel in the event of a medical emergency (CVPH Medical Center
2004). This Vital Link form is a PHR at its most basic, with information on
medications, current medical problems, and advanced directives, and can
provide the foundation for the educational PSAs.
At the next level, CVPH Medical Center can examine possible ways
the hospital can begin to issue paper PHRs to patients on hospital or
emergency department discharge. As the only hospital for thirty miles, and
the largest facility in New York State for over 100 miles, they are the
facility-of-choice for most local residents. They already give every
discharged patient an instruction sheet whether leaving the Emergency
department or the inpatient part of the facility. It would be a short step to
produce a brief paper PHR for the patients to carry with them and share
with future medical providers.
140
The next step would be to work on creating some form of an
electronic PHR linked to the hospital’s information system. CVPH currently
uses Siemens (http://www.medical.siemens.com) software for its Hospital
Information Systems. Siemens is a working in collaboration with NextGen
Healthcare to:

Achieve interoperability and workflow across acute and ambulatory
practice settings to maximize efficiency and minimize redundancy

Offer physicians immediate access to acute and ambulatory
images, protocols, and data - anytime, anywhere.

Streamline the patient experience across the continuum of care

Broaden clinical content knowledge and clinical data exchange
capabilities

Improve patient safety, accuracy, and completeness of clinical data
exchange across the continuum of care
(Siemens Medical Solutions USA, 2007).
This is the same NextGen Healthcare Information Systems, Inc.
whose product CVPH is proposing in the HEAL grant submitted by CVPH
(R. Miller, personal communication, February 12, 2007). This system
supports a PHR in the form of a Continuity of Care Record (CCR) as well.
141
It might be feasible for CVPH to explore the possibility of unbundling the
CCR from the NextGen EHR for use in the community and promote the
introduction of the CCR in conjunction with their Siemens system. Such an
effort by CVPH might help local providers decide to choose the NextGen
product for implementation in their practices, whether the HEAL grant is
funded or not. One problem with this is the fact that currently, all CVPH
patient data is stored remotely on servers maintained by Siemens in
Malvern, PA. Thus, Siemens would have to be an active participant in
such a product enhancement and there would undoubtedly be costs
incurred by the medical center.
Another option for the hospital to consider would be to set up a
central PHR or CCR of their own for the community. This PHR would be
located on a server which they would maintain and would be independent
of the Siemens system but accessible to all medical providers in the
community. The PHR software would ideally be purchased from a
commercial, CCHIT-certified vendor in order to guarantee good integration
with EHRs in the medical providers’ offices. Authentication of those
attempting to access the database would require additional software as
well. This solution would have its own range of expenses in order to
142
maintain twenty-four hour-a-day access to the database and therefore
might not be a viable option for the hospital.
Finally, CVPH and the local medical community could approach
the major insurance companies serving the upstate New York area to see
what they might be willing and able to provide in support. As discussed in
Chapter 2, many insurance companies are offering “tethered” PHRs
(Sprague, 2006) to their clients. There may be issues related to the Safe
Harbors regulations (Office of Inspector General, 2006) that need to be
resolved, but the insurance companies have already developed the PHR
product, so promotion by the hospital to the local community would benefit
all stakeholders.
In summary, it appears likely that CVPH Medical Center will have to
do most of the work to promote PHRs in the Plattsburgh, New York
community. While there will immediate and direct expenses, improvement
in continuity-of-care and decreased medication errors will eventually yield
financial benefits to the hospital.
But there is a second level to the problem of Personal Health
Records. That is, what should one look like? While the question of
standards for EHRs has been addressed by CCHIT, that same question
143
regarding Personal Health Records has not. In fact, since the proposal for
this current study was drafted, Project HealthDesign leaders are working
to move toward a broader vision of PHRs. The PHRs they are working to
develop with nine multi-disciplinary demonstration projects will help
selected patient-populations make better day-to-day health decisions
(Project HealthDesign e-Primer 1, 2007). These are not the rather simple
PHRs envisioned by this study investigator in the original proposal, but
rather a second- or third-generation product that is individualized to the
patient and provides functionality and not just data storage.
Vanderbilt University Medical Center is one of the demonstration
project sites. They are working to develop a three-part PHR to improve
medication administration to children with cystic fibrosis who are attending
school. Their PHR, when completed, will include patient-specific data and
information on the child’s school environment and will incorporate textmessages to older children and other communication tools to send just-intime messages to caregivers (Robert Wood Johnson Foundation and
Project HealthDesign 2007).
In a brief article by Mark Frisse in the Project HealthDesign EPrimer 1 report, he compares the first generation PHRs to horseless
carriages – literally a carriage with an engine added (Frisse 2007). He
144
sees the mission of Project HealthDesign to jump beyond the mere design
of a better horseless carriage and instead design the entire transportation
system. While such work is challenging and exciting, to continue with Dr.
Frisse’s analogy, it is difficult for most of us to grasp where the Interstate
Highway System will take us when most of us have not yet sat in a
horseless carriage, much less driven one.
For the time being, implementation of PHRs needs to begin with
acceptance of basic functionality – storage of personal data on
medications, medical problems/diagnoses, allergies, etc. There are
challenges to be addressed just at this level of acceptance. In a recent
article published on Modern Healthcare Online, the concerns of a number
of physicians were presented (Robeznieks 2007). Dr. Michael Zaroukian,
who is chief medical information officer at Michigan State University, lists a
number of reasons for concern. These include: the accuracy,
completeness, usefulness and volume of the records physicians receive
from patients; the hours of uncompensated work it will take to slog through
them; and the potential for a misdiagnosis if something important was
overlooked (Robeznieks, 2007). Another physician expressed concern
over being given a disc with a years worth of blood pressure readings
taken every four hours. How does one go about analyzing that volume of
145
data in a meaningful way, especially if there were medication or lifestyle
changes during that time?
Time spent evaluating the data in a PHR can only be billed in the
context of an actual office visit. This is in contrast to lawyers, for example,
who can bill for every minute spent working on a client’s behalf. In
healthcare, only actual services or procedures are billable. The larger the
PHR, the more information must be evaluated without reimbursement.
Furthermore, there is the question of liability should a provider
assist a patient with a PHR and bad outcome result somehow from the
data it contained. This could happen if an important bit of information was
buried in the sheer volume of data presented. This particular problem of
liability can be compounded when the data is transferred between multiple
providers. This question remains unanswered and will probably remain so
until it is decided in court, though the development of standards for PHRs
would perhaps help avoid some concerns about liability.
Physicians are not the only ones concerned about PHRs. In a
national survey, 67% of those consumers surveyed were either “very
concerned” (36%) or “somewhat concerned” (31%) about the privacy of
their personal health information (Bishop, Holmes et al. 2005). The very
146
portability of a Personal Health Record puts the privacy of ones health
information at risk. Once again, standards for PHRs, in addition to
education of consumers, is essential to successful dissemination and use
of PHRs. Only then can the full benefits of Personal Health Records as
part of Electronic Health Records be realized.
Recommendations for Future Research
As noted in Chapter 2, educating consumers on the many options
regarding the forms and functions of a Personal Health Record is the first
and most critical task to increased PHR utilization. How then does one
educate consumers? The intent of this study was to determine whether
rural health care providers in the Plattsburgh, New York area would be the
ones to provide the education. It appears from the results of this study,
flawed as it may be, that the local providers are not willing to invest their
resources of time and money to promote Personal Health Records to their
patients.
Currently, Champlain Valley Medical Center is providing a paper
form, called Vital Link, that performs the basic functions of a Personal
Health Record (CVPH Medical Center, 2004). This form allows patients to
record information on medications, current medical problems and
147
advanced directives in one place. CVPH also makes the recommendation
to keep Vital Link on one’s refrigerator where emergency personnel can
easily find it. Vital Link is quietly promoted by the hospital and the Clinton
County Health Department, but the key word is ‘quietly’.
At the other end of the PHR spectrum, Project HealthDesign is
working to create second-generation Personal Health Records that
function beyond a simple data repository (Robert Wood Johnson
Foundation & Project HealthDesign, 2007). These PHRs will have the
ability to perform tasks, like sending reminder messages to patients. This
level of functionality will truly put the ‘personal’ in Personal Health
Records.
But as of 2004, only about 40% of Americans keep any kind of
Personal Health Record (Taylor, 2004). And with the multitude of choices
available, from paper PHRs to online products to tethered PHRs offered
by insurance companies, who will perform the consumer education that is
so badly needed? This is the area where future research into PHR
implementation should be directed.
While one would expect self-interest would be a driving force for the
necessary education to occur, this study would seem to indicate that self-
148
interest alone is not enough. Physicians can see the value of a Personal
Health Record as evidenced by their responses, but the cost to them in
time and money to educate their patients appears to outweigh the
perceived value of the PHR.
One area for future research therefore would be to see if the
physician population would respond to financial incentives to provide the
adoption of and education regarding Personal Health Records. Where the
incentives would come from is an issue that would also need to be
addressed, but if research showed incentives would work, the money
might be easier to find. It must be remembered that the ultimate goal here
is not the PHR but rather the improvement of the safety of the American
health care system (Wolter and Friedman 2005).
While a limited example of financial incentives to providers exists in
the pay-for-performance incentives currently being offered to providers
that show evidence from their electronic records of improved patient
outcomes (Endsley 2003), incentives for PHR promotion would be more
difficult to tie to outcomes. This is especially true given the potential
workload issues facing providers when given a patient-managed PHR.
149
What the patient considers important and documents at great
length in their PHR, such as a rash on their elbows that gets worse every
Winter, might be of no significance to anyone other than that patient’s
dermatologist. But the data may end up in the EHR of every provider that
patient visits and may distract from more important information like an
elevated blood sugar done using their spouse’s glucometer and recorded
only once in the PHR. Providers are rightly concerned with missing a
critical data element that might open them up to a charge of malpractice –
in this case, missing the diagnosis of diabetes.
Incentives should not be restricted to the physicians, either. Since
the ultimate beneficiary of improvements in medical care and safety is the
individual patient, consideration should be given to how some of the
potential cost savings resulting from the implementation of PHRs and
EHRs can be used to encourage the individual consumers through
incentives to demand these technologies for themselves. These incentives
might be offered in the form of a “free” PHR with the patient expected to
maintain it. This marketing model works well with glucometers currently,
as many companies give away the glucometer knowing they will make
their money on the test strips.
150
Individual patients can also be encouraged to use PHRs by giving
reductions in the cost of copays for laboratory tests or medications. In both
these instances, the incentives would probably come from the payers –
insurance companies or the government in the form of Medicare or
Medicaid. How would individual patients respond to these types of
incentives? Would they think the effort worth the compensation? These
are questions that must be answered with appropriate research since the
pressure is on to make patients more responsible for their own health and
health information.
Another level of individual patient incentive depends on the
integration of future medical devices. Obese patients might be given a
scale or even a treadmill that would report its results right to a PHR, much
like glucometers are capable of doing. The individual would be able to
track their weight and exercise regimen and share results with their
healthcare provider. The first level of research would determine whether
this type of financial incentive would appeal to consumers. The next level
of research would focus on whether patients were able to improve their
health through such an application of technology on behavior.
A payer such as an insurance company might also fund an
incentive of this type. This would be similar to the payments currently
151
made for smoking cessation or bariatric surgery – an investment now for a
financial return to the payer later. This type of research would explore the
PHRs envisioned by Dr. Brennan and being developed by Project
HealthDesign (Gearon, 2007) – PHRs that are more than just data
repositories, and can help patients make health decisions.
In the short term, however, education is the key to successful
implementation of Personal Health Records throughout the healthcare
system. If we are to meet the goal set forth by President Bush of a
personal electronic medical record by 2014, this must include better basic
information science education for health care professionals as well as
increased health literacy education for children in elementary schools
(Gearon, 2007, p. 9).
But until such time as this next generation of providers and
consumers comes of age, our current consumers will be looking to their
existing medical providers for guidance on selection and implementation
of Personal Health Record products and services. The results of this
study, flawed as they may be, indicate the necessary education and
guidance will not be coming to the consumers in the Plattsburgh, New
York area from the health care providers on the medical staff of CVPH
152
Medical Center. It appears the costs, direct and indirect, are the major
barriers perceived by these rural providers to performing this education.
153
BIBLIOGRAPHY
American Academy of Dermatology Association and et al. (2005,
November 10, 2005). "Letter regarding Personal Health Records."
Letter regarding the use of CCR Retrieved February 5, 2007, from
http://www.centerforhit.org/PreBuilt/chit_phrleavittltr.pdf.
American Health Information Management Association. (2006). "My
Personal Health Record." Retrieved January 28, 2007, from
http://www.myphr.com.
Bankrate.com. (2007). "Maintain good money habits." Retrieved
February 3, 2007, from
http://www.bankrate.com/gookeyword/news/advice/resolutions/debt
/habits.asp.
Bates, D. W., M. Ebell, et al. (2003). "A Proposal for Electronic Medical
Records in U.S. Primary Care." J Am Med Inform Assoc. 10(1)(JanFeb, 2003): 1-10.
Bishop, L., B. Holmes, et al. (2005). National Consumer Health Privacy
Survey 2005, California HealthCare Foundation.
Bush, G. W. (2004). "President unveils tech initiatives for energy, health
care, Internet." Retrieved June 9, 2007, from Office of the Press
Secretary, The White House at
154
http://www.whitehouse.gov/news/releases/2004/04/200404266.html.
Certification Commission for Healthcare Information Technology (CCHIT).
(2007). "CCHIT Certified Ambulatory Electronic Health Record EHR
Products by Company." Retrieved June 2, 2007, from
http://www.cchit.org/certified/2006/CCHIT+Certified+Products+by+
Company.htm.
City-Data.com. (2007). "Plattsburgh, New York." Retrieved June 20,
2007, from http://www.city-data.com/city/Plattsburgh-NewYork.html.
CVPH Medical Center. (2004). "Vital Link Medication Safety." from
http://www.cvph.org/aboutcvph/vitallink.asp.
CVPH Medical Center. (2007). "Facts about CVPH." Retrieved January
28, 2007, from
http://www.cvph.org/aboutcvph/facts.asp?pageval=hm.
Endsley, S. (2003). Pay for Performance: issues and opportunities.
Phoenix, Health Services Advisory Group.
Frisse, M. E. (2007) "Personal Health Records Must First Be Personal."
Project HealthDesign E-Primer 1 Volume, DOI:
Gearon, C. J. (2007). Perspective on the Future of Personal Health
Records, California HealthCare Foundation: 25.
155
Handler, T., R. Holtmeier, et al. (2003). "Electronic Health Record
Definition, Attributes and Essential Requirements." Retrieved
January 28, 2007, from
http://www.himss.org/content/files/EHRAttributes.pdf.
Lee, M., C. Delaney, et al. (2006). Building a Personal Health Record from
Nursing Perspective. Consumer-Centered Computer-Supported
Care for Health People. H. A. Park and et al., IOS Press: 25-29.
Lemieux, J., D. Nicholson, et al. (2006). Connecting Americans to Their
Health Care: a common framework for networked personal health
information. The Connecting for Health Common Framework,
Markle Foundation. P9.
Medical Records Institute. (2006). "The Concept Paper of the CCR version 3." Retrieved January 28, 2007, from
http://www.medrecinst.com/pages/about.asp?id=54.
National Committee on Vital and Health Statistics (2006). Personal Health
Records and Personal Health Record Systems. Washington, DC.
New York State Department of Health. (2006). "Health Information
Technology." Retrieved February 3, 2007, from
http://www.health.state.ny.us/technology/.
Office of Inspector General and Department of Health and Human
Services (2006). Medicare and State Health Care Programs: Fraud
156
and Abuse; Safe Harbors for Certain Electronic Prescribing and
Electronic Health Records Arrangements Under the Anti-Kickback
Statute; Final Rule. D. o. H. a. H. S. Office of Inspector General,
Federal Register. 71: 45110-45137.
Office of the Press Secretary. (2004). "President unveils tech initiatives for
energy, health care, Internet." Retrieved June 9, 2007, from Office
of the Press Secretary, The White House at
http://www.whitehouse.gov/news/releases/2004/04/200404266.html.
Privacy Rights Clearinghouse. (2007). "Medical Privacy: frequently asked
questions." Retrieved January 28, 2007, from
http://www.privacyrights.org/fs/fs8b-MedFAQ.htm.
Ribis, D. L. (2006). Get Back on Your Feet! what every injured and ill
person needs to know. Williston, VT 05495, Women in Print.
Robert Wood Johnson Foundation and Project HealthDesign (2007).
Project HealthDesign E-Primer 1: rethinking the power and
potential of Personal Health Records. P. F. Brennan. Madison, WI,
Robert Wood Johnson Foundation.
Robeznieks, A. (2007) "PHR data overload, legal liability concern docs."
Modern Healthcare Online Volume, DOI:
157
Schoen, C., K. Davis, et al. (2006). "U.S Health System Performance: a
national scorecard." Health Affairs 25(6): w457-w475.
Shine, K. I. (2002). "Health care quality and how to achieve it." Academic
Medicine 77(1): 91-99.
Siemens Medical Solutions USA. (2007). "NextGen Healthcare Solutions."
Retrieved June 2, 2007, from
http://www.medical.siemens.com/webapp/wcs/stores/servlet/Produ
ctDisplay~q_catalogId~e_1~a_catTree~e_100010,1008631,1007111,1007092,1007102,1007
182~a_langId~e_1~a_productId~e_173534~a_storeId~e_10001.htm.
Simon, S. R., R. Kaushal, et al. (2007). "Correlates of Electronic Health
Record Adoption in Office Practices: A Statewide Survey." J Am
Med Inform Assoc. 14: 110-117.
Sprague, L. (2006). "Personal health records: the people's choice?" NHPF
Issue Brief(820): 1-13.
Stafford, M. (2000). ""To Err is Human: building a safer health system":
nursing's response to IOM report on medical errors." Chart 97(7).
Von Knoop, C., D. Lovich, et al. (2003). Vital Signs: e-health in the United
States. Vital Signs. Boston, MA, The Boston Consulting Group: 44.
158
Weisfeld, V. D. (2006). Lessons from KatrinaHealth. M. Foundation,
Markle Foundation: 39.
Winkelman, W., K. Leonard, et al. (2005). "Patient-Perceived Usefulness
of Online Electronic Medical Records: Employing Grounded Theory
in the Development of Information and Communication
Technologies for Use by Patients Living with Chronic Illness." J Am
Med Inform Assoc. 12(3): 306-314.
Wolter, J. and B. Friedman (2005). "Health Records for the People: touting
the benefits of the consumer-based personal health record."
Journal of AHIMA 76(10): 29-32.
Working Group on Policies for Electronic Information Sharing between
Doctors and Patients (2004). Connecting Americans to Their
Healthcare: final report. Connecting for Health, Markle Foundation.
159
Appendix A
Final draft of survey
161
Cover letter for survey
167
160
Survey of Healthcare Providers on Computer Technology
This survey asks about your medical practice and factors related to the use of certain computer
technology, particularly electronic health records (EHRs) and personal health records (PHRs). It
will take about 10 minutes to complete.
All responses are private and confidential. Results will be analyzed on in the aggregate and
individual responses will not be reported.
Section 1: Practice Characteristics
1.
How would you best characterize your practice? (please check only one)
 Solo, primary care
 Solo specialty care
 Primary care group
 Single specialty group or partnership
2.
How long have you been associated with your current practice?
______ years
3.
Are you a:
 Full-owner
 Part-owner
 Not an owner of the practice
4.
Considering all full- and part-time clinicians at your practice, including yourself, how
many
Physicians ________
Nurse practitioners/physician assistants __________
5.
Please estimate the number of outpatient visits you have in a typical week:
___________ outpatient visits
6.
With your current medical record system (paper and/or electronic), how easy would it
be for you or your staff to generate the following information about your patients?
a. list of patients by diagnosis or health risk
(e.g., diabetes)
b. list of patients by laboratory results (e.g.,
patients with abnormal H&H)
c.
list of patients by medications they currently
take (e.g., patients on warfarin)
161
very easy –> cannot
1 2 3 4 5
1
2
3
4
5
1
2
3
4
5
7.
8.
Please indicate how much of a problem each of the following is for you (check only
one for each item):
Isolation from colleagues
not

slight

moderate

serious

Personal or professional stress




Having to work long hours to
Meet practice demands




Feeling demoralized about the state 
Of medical practice in general



Overall, how satisfied are you with your current practice situation?
 Very satisfied
 Generally satisfied
 Somewhat dissatisfied
 Very dissatisfied
Section II: Health Information Technology
The next set of questions will ask you about the computers and health information technology in
your office practice. Please select the answer that best describes your practice.
9.
Does your practice use a computerized scheduling system?
 Yes
 No
10.
If yes, for how many years? ________
Upon completing a typical office visit, how do you generate medication prescriptions?
 Computerized, with decision support (e.g., drug interaction alerts)
 Computerized, but no decision support
 Handwritten
 Other (describe: ______________________________________)
11.
Does your practice have any components of any electronic health record (EHR), that
is, an integrated clinical information system that tracks patient health data, and may
include such functions as visit notes, prescriptions, lab orders, etc.?
 Yes
 No
If no, please answer question 11 a and skip to question 15
a. When do you plan to implement an EHR?
 Within the next 12 months
 Within the next 2 years
 Within the next 3-5 years
 No specific plans
162
12.
What is the name of your EHR system (e.g. Medinotes, etc)?
______________________________________________
13.
Please indicate when your practice began using an EHR:
_______/_______________ (month/year)
14.
Please indicate all the features of the EHR that you have available in your practice.
For those features you have, indicate the extent to which you use them:
Available
Use
Yes no don’t
Know
don’t some regular
use use
use
Laboratory test results






Laboratory order entry






Radiology test results






Radiology order entry






Electronic visit notes






Reminders for care activities
(e.g., health maintenance)






Electronic medication lists






Electronic problem list






Transmission of prescriptions
Electronically or via fax






Electronic referrals or clinical
Messaging (secure email between
Providers)






15. How much of a barrier is each of the following to beginning or expanding the use of
computer technology in your practice?
Not a barrier | minor barrier | major barrier
Computer skills of you and/or colleagues/staff



Computer technical support



163
Not a barrier | minor barrier | major barrier
Lack of time to acquire knowledge about systems



Start-up financial costs



Ongoing financial costs



Training and productivity loss



Physician skepticism



Privacy and security concerns



Lack of uniform standards within industry



Technical limitations of the systems



Section III: Personal Computer Experience
16. How often do you use the internet for personal and/or professional use, including email
from home, work or another location? (check only one)





Several times a day
Daily
Weekly
Monthly
Less than monthly or not at all
17. What type of internet connection do you have at your practice? (please check only one)




Do not have internet connection at work
Dial-up modem connection
Broadband (e.g., DSL or cable modem) or faster
Don’t know
18. Does your practice have email?
 Yes
 No
 Don’t know
164
Section IV: Computers and Health care
19. For each outcome listed below, indicate whether you think the effect of computers is,
or would be, very positive, somewhat positive, etc.
Effect of computers on:
very
somewhat no somewhat very
Positive positive effect negative negative
Controlling healthcare costs





Quality of health care





Interactions within the health
Care team





Patient-provider communication





Patient privacy





Providers’ access to up-to-date
Knowledge





Efficiency of providing care





Medication errors





20.
A Personal Health Record (PHR) is a health record initiated and maintained by the
individual patient that can integrate with, and be accessed from an Electronic Health
Record (EHR). In addition, they can enable secure email messaging between patient
and provider. Have you heard or read about this concept?
 Yes
 No
Please respond to the following statements regarding Personal Health Records (PHRs) with
either agree, disagree or don’t know:
A PHR:
Agree | Disagree| Don’t know
is a valuable addition to an EHR



can improve the quality of care delivered



can reduce medication errors



can improve the efficiency of my practice



would be welcomed by my patients



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21. Given the financial investment necessary to implement an EHR, would you be willing to
pay a one-time dividend of 5% for an EHR that would integrate with a PHR?
 Yes
 No
22. Given that a PHR is a new concept to the general public, would you be willing to invest
time in educating your patients on its uses and value?
 Yes
 No
Section V: The Office Practice Environment
23. Please indicate your agreement or disagreement with the following statements:
Strongly agree - - - > strongly disagree
1
2
3
4
5
the office staff are innovative





the provider(s) are innovative





among my colleagues, I am usually
one of the first to find out about a new
diagnostic test or treatment





we are actively doing things to improve
quality of care





after we make changes to improve
quality, we evaluate their effectiveness





we have quality problems in our practice





our procedures and systems are good
at preventing errors from occurring





Section VI: Personal Characteristics
These are a few general questions that may help us interpret the survey findings:
In what year did you begin practice?
In what year were you born?
___________________
_____________________
What is your gender?
 Male
 Female
Thank you for your participation.
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David G. Curry, RN-C, MSN
Associate Professor
Department of Nursing and Nutrition
SUNY Plattsburgh
April 2, 2007
Dear CVPH Medical Staff member:
Attached is a survey on Healthcare Information Technology (HIT) that will serve two
purposes. First, it is being done in partial fulfillment of the requirements for my doctoral
degree in Health Administration, and second, it will help CVPH Medical Center plan for
future implementation of HIT that will be of value to the local medical community.
This survey will help to determine the level of knowledge regarding Electronic Health
Records (EHRs) and Personal Health Records (PHRs) and the perceived barriers to the
purchase and implementation of various Healthcare Information Technologies. While the
results of individual responses will be confidential, the data in the aggregate and the final
report will be available to any who ask.
The results of this survey, along with the recent Grand Rounds done by Dr. Patricia Hale
(which can be viewed on videotape from the CVPH Medical Library), will be extremely
helpful for individual medical practices, as well as CVPH, in planning for the inevitable
move to computerized medical records for all of us.
Feel free to contact me with any questions you may have at curryd@plattsburgh.edu or at
my Plattsburgh State office, 518-564-4245. I appreciate your assistance in this venture
and will reciprocate with any assistance I can offer in planning for computerizing your
medical records.
Please return the completed survey to my medical staff mailbox - - and thanks!!
Sincerely,
David G. Curry, NP
Attachments: HIT survey, business card
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