10 22 2008 Steve Ross MD University of Colorado Denver Division of General Internal Medicine Explore key informatics issues of PHRs through medications in care transitions use case Types of PHRs PHR platforms Regional Health Information Organizations User centered design The role of standards 1 10 22 2008 Conceivably paper but generally electronic in informatics context Markle Foundation Connecting for Health Report An electronic application through which individuals can access manage and share their health information in a private secure and confidential environment Three basic types Standalone Tethered patient portal Interoperable Improve portability of health information In personal emergency In disaster e g Katrina In our fragmented health care system Get rid of the clipboard Empower patients Better adherence to e g to medication regimens Patient as driver of quality of care provided preventive care chronic disease management Improve self care 2 10 22 2008 Enter information yourself Formats Paper PC based load to mobile device Internet hosted www drkoop com WebMD Portable storage HealthMeans Smart Card MedicAlert e HealthKey 3 10 22 2008 You have to enter all the information Your doctors may not use it after all Can t read it Doesn t trust it Doesn t want to be bothered Also known as patient portal Most common form of PHR Often Offered by larger institutions e g VA My Health eVet Kaiser May be bundled with EMR e g Epic MyChart May include Secure electronic messaging Administrative functions scheduling refills Clinical information meds test results Consumer health information Chronic disease management tools 4 10 22 2008 Advantages Autopopulated don t have to enter data yourself Suite of useful tools Has a business model Disadvantages Not comprehensive You can t control release can t take it with you You can t control content The holy grail Comprehensive Portable Owned by the patient Controlled by the patient Able to interact with widgets 5 10 22 2008 From Middleton B The Value of PHR in the Clinical Setting Microsoft HealthVault Major focus on device connectivity capitalize on support of devices in Windows Relies on vendor UIs Business model ad revenue when search used Google Health Less device connectivity more emphasis on developing relationships with info suppliers Offers its own UI Business model also based on searches Dossia Based on nonproprietary Indivo platform Sponsored by employers e g Wal Mart 6 10 22 2008 Probably not Data sharing agreements are very sensitive Health care organization is better authenticator of PHR user than RHIO No business model for RHIO no membership or transaction fees PHR RHIO Record Locator Service Security protecting privacy Maintaining patient control But ensuring some release And providing emergency access Exchanging information Transmission standards HL7 Content standards Could save as PDF images Better to use ASTM Continuity of Care Record CCR 7 10 22 2008 From Liora Alschuler 2006 LTC Summit Shows XML encoding of CCR Readable with style sheet Potentially computable 8 10 22 2008 Header Body Readable required Computable optional 25 Rx Concept Unique Identifier RXCUI Semantic Clinical Drug SCD RXCUI Semantic NDC Codes Branded Drug Component Higher levels of abstraction enable decision support SBDC e g identifying duplicate 24 Hr diltiazem 120 mg extended release capsule 284264 Ingredients Drug classes calcium channel 64455 797 30 Cardizem CD 120 mg blockers 64455 797 42 Indications blood pressure 64455 797 49 313959 medications Diltia XT 120 mg 284264 Lower levels of abstraction can link to Tiazac 120 mg 208261 DISPENSED FULFILLED pictures consumer health information PRESCRIBED From pharmacy systems SureScripts RxHub Can assess adherence Can t tell if active or not Includes NDC code Med Hx only available if electronic prescribing used From electronic medical records Can t assess adherence Can tell if active Uses abstract medication identifier or arbitrary NDC code Med Hx only available if EMR used 9 10 22 2008 From IT Pro IEEE Sept Oct 2005 http www nlm nih gov researc h umls rxnorm RxNorm pdf 10 10 22 2008 Care transition Moving from one setting of care to another esp hospital home Abrupt information overload Risk of readmission or worse Wrong meds taken Wrong care of wounds catheters intravenous lines Not sure what to look out for Not sure who to follow up with and when Care transition coach and paper PHR to address four pillars 1 Medication list 2 Follow up plans 3 Self care 4 Red flags 11 10 22 2008 Many patients identify medications by shape size and color not name Drug names are redundant and inscrutable easy to unintentionally duplicate medications Tiazac and Cardizem are the same ingredient Norvasc and Plendil are slightly different ingredients in the same class Authoritative drug information isn t accessible For individual medications For drug regimen Intended medication list isn t always clear Provide pictures Prevent duplication of medications Make it easy to get authoritative information Help patients build and reconcile medication lists by linking to sources of personal medication information User studies confirmed that patients highly value pictures of medications To know what picture to show must know what has been dispensed must have NDC code Using a Micromedex database indexed by NDC code Making sure not to be thrown off by arbitrary NDC codes NLM is working on non proprietary image set 12 10 22 2008 Pharmacist experts confirmed that this is a common problem Can identify duplicate ingredients if you normalize to a common generic name or code Identifying duplicate classes such as calcium channel blockers requires proprietary medication knowledge applications e g ThomsonReuters Micromedex Wolters Kluwer Medi Span First Data Bank Patients have a lot of concerns especially related to possibility that medications could cause loss of autonomy Common concerns Will this medication cause a side effect I m not feeling well could it be one of my medications Will it hurt my body to take so many medications Are the medications safe to take together Information sources Internet Lots of information but not authoritative Doctor Little opportunity in busy visit don t want to bother the doctor Pharmacist Highly valued but only interact when getting meds Information on individual medications Proprietary as above Non proprietary from NLM DailyMed MedlinePlus Information on medication regimens Proprietary applications as above Google Health