This video really put into perscpetive the number of players involved, some of which include: insurance companies, health providers, software companies, and pharmacies.  With the number of PHRs expanding in the market, one of the primary concerns addressed was the idea of standardization.  Standardization includes the issues surrounding uniform data exchange (challanging because of the the various flavors of stand alone PHRs available and their unique functions).  

Another significant barrier focused on here was the idea of security or privacy of the medical information.  Surveys presented in the video highlighted the importance of security to patients.  For this reason, it is an important consideration in the development of privacy standards.  Interesting comments were made in regards to actual versus perceived privacy to end users as well as the need for consistent legislation to be developed in this area.

Overall, the most interesting portion of the video was the discussion of the potential benefits of the PHR.  While several of the logistics including full implementation are not well defined at this time, the driving forces are already in place.  The final goal being patients with full access to their medical history available in a standard format.  Once this is in place, the further ambition of generating more accurate population based heatlh statistics becomes a realistic goal.

" The science associating genomes and disease therapy is evolving repaidly.  Personlized medicine is here."

This quote summarized many of the points that Dr. Halamka made.  In particular, his talk provided some great insight on what current sequencing technology can potentially bring to the healthcare industry.  His discussed that the incorporation of this information can lead to more personalized (and preventative) care.  He also emphasized the importance of standards in the heatlh care industry, both in terms of medical records and in the representation of genomic data.

Patricia Flatley Brennan: Personal Health Record Systems of the Future: A Bold Vision

"Provide a window on the day-to-day happenings in a person's life"

Dr. Brennan presented a very interesting outlook on PHRs primarily from a research perspective.  She discussed a lot of the aspects that make a PHR successful.  In particular, the importance of engaging the patient in the process including getting an accurate assessment of the patient's lifestyle and preferences.  This information according to her, in addition to excellent data and robust data exchange can really enhance the value of a PHR.

Blackford Middleton: EHRs and PHRs: Impact on Patient Safety, Healthcare Quality, and Costs

"Lots of information in handwritten notes...but no data gathered" 

Dr. Middleton's quote seems to be an excellent summary of exactly why electronic health records are so important.  The generation of information in the written form has not necessarily led to actual data collection or improved care for the patient. In his talk, he takes time to define exactly what EMRs, EHRs, and PHRs are.  In addition, he explains their unique role and importance in closing the gap in knowledge between, not only between the clinician and the patient.

Paul Tang: Personlizing Health Care: Getting Patients Together Online

"Patients do seek information about diagnosis and treatment plan (including alternatives)." 

Dr. Tang opened the conference with some interesting insight on patient's perspectives.  The above quote which may seem obvious tries to point out that patients want additional information and will seek outside opntions.  In particular, he discussed the enhanced connection to the information and decision-making process experienced by the patient when they have access to this information readily (in electronic form).

 “ We should put patient in the picture” Paul Tang. He explains this to emphasis looking into patient needs in PHR.

" Cultural waves are similar to tsunami waves and legislative is reacting to a cultural push in health care."   David J. Brailer. It is an uphill task to deliver EHR and PHR in a health care system.

 “ Electronic record technologies could help to transform practice of healthcare using information and knowledge management” Blackford Middleton. We are seeing that as a evolution of the health care industry.

Some members of the group are:

• “Retail” PHR providers (e.g., WebMD, Intuit, Medem)

• Consumer portals (e.g., Google, Yahoo)

• Data clearinghouses (e.g., SureScripts)

• Retail pharmacies (e.g., Walgreens, Wal-Mart)

• Health plans (e.g., AHIP, BCBS)

• Provider organizations (e.g., VA, Kaiser Permanente)

This is really an exciting period in the healthcare industry. It is a whole revolution. They had cover Policy Framework for Consumer Access Service which is critical for developing the Networked personal Health Information. They had deliver PHR and some the expectation and feature we are expected to see. Using PatientSite, they had shown what PHR can actually deliver. Standardization of systems and architecture of healthcare systems seems to be a constant challenge. Practice and standards for other area like hospitals, pharmacies, labs, suppliers and equipment manufacturers, software developers, vendors, employers, insurance companies and the government are some of the area to set the standards in. This is seen as something everyone hopes to see in the near future.

The speakers spoke of the availability of various PHR’s including institutional and web based PHR’s like those offered through Google and Microsoft.  They shared insight of how the major health stake holders can interrelate to provide a rich PHR environment that could offer benefits for all involved.  Halamka described and shared his experiences and lab values with his own PHR to illustrate the benefits the PHR can offer a person.

The public health as a whole could benefit from population statistics developed from anonymous PHR information.  The possibilities are endless in the utopian environment of exchanging, sharing and accessing medical data.  Our president has committed our country to a goal for all health records to be electronic and exchangeable by 2014.

Policies and standards are currently developing for this fast paced entity.  Privacy is tantamount to these standards.  There are many barriers to achieving the ideal which include the individuals as patients, the physicians, the institutions, i.e. hospitals, pharmacies, labs, suppliers and equipment manufacturers, software developers, vendors, employers, insurance companies and the government.  Individuals are especially sensitive where privacy and confidentiality are concerned.  It also takes much time and would require ready access to an electronic device to implement. Physicians and institutions realize the disruption in work flow and the tremendous capital outlay that would be involved for their work places to convert to electronic records.  Another barrier currently is that most EHRs are stand alone entities.  A major boost to improve salience of the PHR would be for the development of software/IT solutions to integrate the stand alone software options currently available.  A central bank or repository was also discussed.  This would streamline access and portability of an individual’s medical records.

This video presented quite a vision for the future and was an excellent preparatory tool for the course in Boston.

Ideally, the goal would be for all information to be electronically transferred to a central repository so that the patient can have access or allow someone who they think should be able to access in order to provide better service to them.  It was amazing to hear that Bush announced that every American should have access to their PEHR record by 2014 and being half way towards this time frame, we are no where near that goal.  This thought has really challenged the way the industry will go about implementing.  The Department of Health and Human Health Services launched AHIC - Americas Health Information Community to try and find out how to stimulate this progress.  Congress has given this topic a lot of attention and various ideas are under way.  One congress man proposed incentives to doctors if doctors would insure that their patients had access to PHR’s.  Another thought it might be a good idea to have federal employees have access to a PHR through their health insurance plan.  Another made mention of the idea of creating health record banks.  The Major National Health Insurance Plans the big private health insurance under AHIC (bluecross/blueshield) said they would have a standard for portability of PHR of information which cover about 100 million people.  This is a great launch pad to get this process started.  Corporations such as Microsoft and Google are announcing a platform to give access for general internet services to large employers such as IBM.  By doing so, they will collect PHR data to aggregate information.

Services that PHR offer are provided in various forms. There is not one product that offers all of these services.  Some of the services are as follows:  Educating patients by helping them take care of themselves or family members through their home.  Secure messaging to their doctor. Availability of certain transactions such as making appointments or setting up reminders. Refilling prescriptions. Reminders to stay on track with drugs or exercise programs.  Allowing patients to keep track of their own information of interest such as monitoring pain levels or tracking side effects from medications or combination of drugs.Keeping track of long term health trends and checking for drug interactions that can be sent back directly to patient instead of having to go back to dr. or pharmacy.

It will be very exciting to see what the conference has to offer in terms of obtaining a better understanding of thes e services and the difficulties associated with the implementation process.

2)      Victor Strecher PHD, MPH:  “Must tailor to each patient so it is not everything for everybody… as one size doesn’t fit all!”  He felt that tailoring was the most effective means for achieving positive behavioral changes to impact a person’s health.  This has always been my approach and goal with each of my patients.  Even though the same technique may be used – that technique is used for different reasons which are dependant on each individual’s needs related to their “chief complaint” and/or what they want to see different about their smile.  Our motto is that we customize our patient’s treatment to give them the best possible result.  However, I have not seen many physicians take this approach until recently when my daughter had surgery to remove cysts on her ovaries.  The type of cysts were unknown, however, the surgeon gave several differentials.  The usual approach for this type of surgery is to utilize an abdominal incision.  However, since the surgeon is my daughter’s good friend and knows how active my daughter is physically – she described using a minimally invasive technique to allow my daughter to be back to gyrotonic instruction within a week.  This surgeon did an excellent job at tailoring the surgery to fit my daughter’s profession and lifestyle.

3)      David Hotkiss and Donald Wald:  ‘People with serious illnesses go to the MD first…those with minor illnesses go online first”.  This statement literally hit “home” as last month my husband came home one night complaining of a stomach ache.  He had previously talked about how several of his employees had either gone home early or called in sick with the stomach flu earlier in the week – he thought that he was coming down with the same flu.  He did a web search for symptoms, virulence and for what he could expect if he had the flu. Of course, I had to give him my opinion of several differential diagnoses for his stomach pain – which he took with a grain of salt.  However, when he woke up in the morning he complained that the pain was much worse.  Again, I suggested that it might be appendicitis as the pain was now centered around his navel and asked if I could do the classic appendix test.   He wasn’t having pain on his right side and had read that appendicitis  was uncommon in men his age – so he declined my offer and my suggestions (I’m only a dentist!).  By noon – he was moaning so loud due to the pain that I insisted that I take him to the hospital.  He wanted to talk to his doctor first.  I called her, told her the symptoms and she told him to get to the hospital STAT.  Guess what – he had a ruptured appendix!  The surgeon asked me how I could let him wait so long, especially with my background!  When my husband thought it was the stomach flu he looked up info online.  When he   thought it might be more than the flu he wanted to talk with his doctor. 

     BTW: We just opened the bill up tonight - $53,197.00!!! for less than 24 hours in   

     the hospital!

4)      Eric Pan, MD, MSC and David Kaelber, MD, PhD: “The system (to bring the latest guidelines to influence care and quality) can anticipate actions, but is predicated on the clinical decision support system (CDSS), i.e. if have an EMR without CPOE (eRx) won’t have the necessary info needed”.  This was another statement that reminded me of my daughter’s surgery in January.  While she was in the first recovery area she was given and effective analgesic.  When she was brought to the second recovery area (where we could join her) she complained of pain and was given a different and uneffective analgesic. (BTW:  My daughter is a doctor and her surgeon is one of her patients and good friend.    Before the surgeon left for another surgery she said she completed the EMR and informed the nurse to take great care of her friend.)  However, the nursing staff changed and the new nurse was only aware of the analgesic ordered for the second recovery room and refused to give another medication.  The EMR could not be accessed in the recovery room – go figure!  There was a paper record that they would fill in the blanks with when they could get a copy of the EMR from surgical services.  I did suggest to the nurse that she call the surgeon assuring her that the surgeon would agree to give my daughter the first medication – the nurse had to hold the phone an arm length from her ear when she reached the doctor for the scolding she received about not having the orders sooner.  (I won’t tell you what that bill cost!)   This was a classic example of how the system must improve to benefit the nursing staff as well as the patients.

This was a terrific course – very well organized, with superb presenters  who are leaders in their field.  The students were a joy to be around.  Thanks to Mrs. Feldman for  organizing the exhaustive details of the trip and accommodations and for being a shepherd for the students, as well as to Dr. Horan for his vision and for his support of enlightening his students with this powerful course offering.

Elizabeth Mort, MD, MPH

Workshop address: Using an Electronic Health Record for Population Health Management.

The reason I like this quote is because it is really true that training for effectively using a system is a must; so, we get the most of it. This is simply because it is useless to build a system (or LMR in this case) while health providers and physicians are not able to effectively use it. Such ability is only obtained by training. In case of untrained users, having the system or not will be equally the same. Meanwhile, thinking about a system’s workflow and how to get tasks processed more efficiently is a privilege. This is simply because this will lead to the best quality if the system in use. Moreover, analyzing the workflow leads to the right training programs. Therefore, workflow and training are necessary processes to achieve a valuable system.

David Z. Sands MD, MPH

Panel Presentation address: Avoiding Pitfalls to Implementation of eHealth Solutions: Do as I say, Not as I’ve Done

The value of any system lies in the value of its information. Therefore, I believe it is really important that physicians who are more involved with patients should participate in updating their patients’ data because they know their patients much better than anyone else who may be far from those patients and with limited medical background. Moreover, hiring people, to update patient’s data, who are not familiar with patients, may lead to data missing, misuse of data, and poor quality data. This will eventually weaken quality of the whole system.

David J. Brailer, MD, PhD.

Keynote Address: 2nd Annual Warner Slack Keynote Lecture-Digital Medicine in the Era of Health Reform.

I thought this quote reflects a fact which can’t be denied. This fact is the cultural difference and how it may impact the success of any system, especially when we are talking about a system of a global use. However, even locally, there are still some differences between regions within the same country which may lead to several impacts due to cultural differences. Talking about US and its health care system, legislations are different from one state to another and this makes it more complicated  adapting to too many various legislations in order to get an integrated health care system. Also, culture plays a role in shaping the community’s interests which might be reflected in its interests in PHR adoption.

Charles H. Weiss, MD

Panel Presentation address: Patients’ Perspectives on eHealth

I think it is very important for patients to understand that email is just a tool that can be used to arrange for doctors visits, and to request helps in emergency cases. Physicians have concerns about long emails, and they have right. This is because patients may think that they can send whatever information they want, but at the end it maybe irrelevant. So, this will take more time for physicians to read all emails from many patients. Moreover, email is an unsecured tool to communicate with physicians about confidential data. Therefore, patients should keep it short and into the main point to help physicians to give high quality services.