Full medical jacket

The two military Cabinet departments — Defense and Veterans Affairs — thrive on obedience to a chain of command. In matters of health care, no less than in engineering or combat management, orders move from the top down. That’s why the departments’ joint development of personal health record systems is innovative and potentially revolutionary. Such records give patients a measure of control over their health care services and clinical records, and the systems are pushing service members and veterans toward the top of the health care chain of command. “We would like to deliver health care that is more patient-centric,” said Dr. Madhulika Agarwal, chief patient care services officer at VA’s Veterans Health Administration. “We want veterans to be more empowered about their own health care.”PHRs offer many functions, several of which might be included in any given system. The VA and DOD systems began as Web portals through which users could access health care information. PHRs can also act as electronic repositories in which patients can securely store or share health-related data with designated providers. Still other PHRs allow patients to refill prescriptions, set appointments and view their medical records.Secure e-mail messaging between patients and providers — a feature planned for but not activated in the VA and DOD systems — would allow physicians to answer routine questions, provide lab results, and authorize prescription refills without having to talk to patients on the phone or require an office visit. PHRs also provide more than convenience for patients and providers. Advocates say their use promotes patient involvement, responsibility and self-management — key factors for producing better results in the care of chronic diseases with high social costs, such as diabetes.At the annual State of the Military Health System Conference in January, Dr. Meera Kanhouwa, physician executive at Microsoft’s Health Solutions Group, said 50 percent of new diabetes cases could be prevented if people lost 10 percent to 15 percent of their body mass. “We’re talking about a chronic disease that could bankrupt economies in coming years,” she said. “Containing this disease entails personal responsibility.”VA’s PHR, My HealtheVet, was launched in November 2003, which makes it one of the oldest in existence. It is also one of the largest, with more than 500,000 active users. About 50,000 of them have signed up for upgraded accounts through which they can access enhanced features. The Web-based system has provided 5 million prescription refills since August 2005 and hosted more than 15 million visits since its launch.VA health executives consider My HealtheVet an enhancement to medical care. “The way we think of this technology is as an enabler and not to replace the current health system,” Agarwal said. “It complements the delivery of health care services that clinicians provide to patients.”At DOD, MHS’ Tricare Online also started as a health information portal. In December 2007, officials added PHR applications, and today it has about 375,000 active users. Although VA’s PHR has more advanced features than its DOD counterpart, both systems are still in their infancy. “The whole concept of Tricare Online was to get beneficiaries engaged in the health care system — not just the health care information system but the system in general,” said Col. David Gilbertson, AHLTA program manager at DOD’s Clinical Information Technology Program Office.Going beyond portal functions to more advanced PHR features requires that users undergo a registration and authentication process. Veterans who want an upgraded PHR account must appear at a VA facility to verify their identities. They are also required to watch an orientation video that explains their responsibilities for keeping their health information confidential.DOD has a simpler authentication solution via Common Access Cards, which all defense employees are required to carry. The electronic certificates embedded in the cards authenticate users, who can set up IDs and passwords for their PHRs in a matter of minutes. “Due to the sensitivity of the data displayed to a user, access to the PHR will only be available to users who log in to Tricare Online with their CAC,” Gilbertson said. CAC holders now have read-only access to their demographic, allergy and medication information via the Tricare Online PHR system. DOD officials are working on ways to make more and richer data available to patients, but first they must refine various business rules for the system. “There are legal, privacy and business considerations we have to work through first,” Gilbertson said. “A big stumbling block involves who has access to what information and how we ensure that we are not providing inadvertent access to someone who shouldn’t have it. We are also concerned about providing test results to patients without proper physician intervention and discussion.”VA and DOD are confronting the classic PHR conundrum: How much control should patients have over their clinical records? The primary concern is that too much patient involvement could compromise the integrity of the records. “A provider may not believe the information inputted by the patient,” Kanhouwa said. “The patient may not have complete information or may be hiding something.”The My HealtheVet PHR system encourages patients to enter their information, but VA has taken a number of steps to protect records. First, officials say they emphasize VA’s expectations regarding responsibility and accountability when users register. Future releases of My HealtheVet will include help files and online support to ensure that patients enter information accurately. Furthermore, health care providers who use My HealtheVet are encouraged to review patient-entered information in person with the patient. “The proviso is that the patient owns the information and has the right to say how much visibility will be given to clinicians, family, friends and advocates,” said Theresa Hancock, My HealtheVet program director.DOD’s Tricare Online also gives users the opportunity to correct erroneous information, usually involving personal or family medical histories. “We get patients involved in this part of the process to make sure that data is complete and accurate,” Gilbertson said.VA and DOD officials say they plan to add secure messaging to their PHR systems. VA’s messaging system would enable patients to request appointments, ask routine questions or request prescription renewals. Providers could use the feature to send lab results to patients. “This could take a huge burden off providers,” Hancock said. “Preliminary findings based on studies of other systems show that providing secure messaging reduces appointment no-show rates and reduces the number of necessary visits.”Gilbertson said he envisions a system that would enable patients to ask routine follow-up questions. “A patient may take a medication and wake up with red blotches the next morning,” he said. “He can message the provider to ask if this is normal. This way, the patient can get access to care without necessarily having to make an appointment.” My HealtheVet officials are testing secure messaging and an enhanced feature that would give patients access to lab results. After testing, the features will be launched incrementally, with the initial releases coming as early as the end of this year.“One VA hospital is not the same as another,” Hancock said. “We want to make sure we get it right to ensure clinical adoption. We want to make sure we do our homework and that the features are released when they are ready. It is not a question of implementing just functionality but a business process.” My HealtheVet has several other features on the drawing board, including one that would give patients limited access to VA’s electronic health record system, the Veterans Health Information Systems and Technology Architecture. Another feature would send automated clinical reminders to patients and providers. Hancock said VistA information available for patient viewing would include co-payment balances, radiology reports, physicians’ notes, admission and discharge summaries, vital statistics, and allergy information.The automated reminders would alert patients and providers to the need for appointments or tests. “When patients come in for a visit, they want to address whatever is bothering them at that moment,” Agarwal said. “But patients with chronic conditions need to have certain things taken care of periodically.” For example, diabetic patients and their health care providers might receive reminders to perform blood tests and eye and foot examinations, she said. DOD and VA are in the midst of a protracted effort to enable their electronic medical record systems to share information, with the ultimate goal of making them fully interoperable. The departments are also working on harmonizing their PHR systems, and officials want to standardize the processes and interfaces of the two systems. “We have been working with DOD, and we both sit on the same working groups to build and share the same policies, procedures, requirements, and training and outreach materials with each other,” Hancock said. “We are working toward the goal of a single access point so that veterans and wounded warriors could receive information from both portals.”