Simulaci´ on “Ranking 10 % v/s PSU”

Drivers for introduction

A popular theme in discussions about PHRs suggests that a well-informed public – well aware of the changes which the Internet can provide, and familiar with policies about the rights of patients – is pushing healthcare providers to offer flexible access to information: “Public demand for flexible access to health information and services is growing, encouraged by internet trends and policies

promoting patient rights and empowerment” (Pagliari, Detmer, & Singleton, 2007, p. 330) and that PHRs are highly sought after: “…many consumers have high satisfaction levels with existing early versions of PHRs. In particular, consumers place value on easy access to test results and better communication with clinicians.” (Tang et al., 2006, p. 123)

Promised benefits

The reasons for the implementation of a PHR system in a particular setting may be explicitly de- scribed, often in an extensive business case. In other cases, the motivation may be less clear. Early implementations of PHRs were conducted in a spirit of exploratory research, intended to determ- ine whether it was feasible to provide a patient with access to his record. Clinicians who were famil- iar with the use of technology and anxious to communicate more effectively with their patients at- tempted small scale implementation of PHR functionality. The market for ehealth software de- pends to a significant extent on new software and new functionality, and a new opportunity for pa- tient-facing systems was seen as a business opportunity, and widely promoted. In the US, ‘meaning- ful use’ criteria mandated the provision of PHR functionality as a requirement for certification. Eventually, public discussions about PHRs and their benefits resulted in the emergence of demands from a discerning public for online access to their records, at least among technically literate pa- tients, and by 2010, there was a widespread view that the use of personal health records (PHRs) offered a range of benefits to patients, to healthcare providers, and to organisations.

…there is both a clinical and societal rationale for ensuring that underserved populations have ready access to PHRs. From the clinical perspective, PHRs can lead to active engagement in health affairs for a segment of the population that has high rates of chronic disease. From a societal perspective, PHRs may aid in the public health goal of ensuring improved health and health conditions throughout the country.

(Horan, Botts, & Burkhard, 2010) The various benefits offered by PHRs have been identified as being able to assist with many of the challenges facing healthcare, although the identification of those benefits may not necessarily have

preceded the the move towards widespread implementation. A range of possible benefits have been identified in the literature, a number of which are outlined below.

Better data and information

Use of PHRs can expose diagnostic and medication errors, integrate disparate clinical records, and improve the accuracy of records (Pagliari et al., 2007), as well as enhancing the quality and timeli- ness of health information (NEHTA, 2011). PHRs will also support emergency department care, by providing immediate access to a patient’s prior history (Tang & Lansky, 2005). Better availability of information within integrated PHRs will also offer the prospect of improvements in interactions between patients and their healthcare providers. Practitioners will spend less time taking the pa- tient’s history, and more time in detailed exploration of the patient’s questions and concerns. Email communication will support direct communication at the patient’s and doctor’s convenience, in- stead of playing ‘telephone tag’ (Detmer et al., 2008). Patients will also be able to enter additional data into their record, thus helping their clinicians to make better decisions (Tang et al., 2006). Patient-provider communication

PHRs will improve communication between patients and providers (NEHTA, 2011) and increase the level of trust between them, and support shared decision making (between patients and pro- viders) (Pagliari et al., 2007). This improved communication means that it will be easier for patients to ask questions, schedule visits, and ask for repeat prescriptions. The improved connection between patient and provider will mean a continuous, rather than an episodic relationship (Tang et al., 2006).

Empowerment of patients

A number of the benefits provided by personal health records are seen as contributing to the em- powerment of patients. The improved access to health data, information and knowledge which PHRs can provide will help them to improve their health and manage their illness (Pagliari et al., 2007; Tang et al., 2006).

The PHR may also become a conduit for improved sharing of medical records. Patients who are more engaged in their health are more active participants in the therapeutic alliance, for example, when patients with chronic conditions collaboratively manage their illnesses with clinicians to reduce pain, improve functional outcomes, and improve medication adherence.

(Tang et al., 2006, p. 124) PHRs will also allow patients to secure more control over their health information, allowing joint management of the record, and foster patient-oriented decision support (Detmer et al., 2008). Use of a PHR will also provide for better decision making, both by healthcare providers and by patients (NEHTA, 2011).

‘Virtual’ care

The use of personal health records can reduce geographical barriers to care (Pagliari et al., 2007). A PHR can collect data from monitoring equipment in the patient’s home, provide a link to patient support groups, and deliver on-line coaching, allowing face to face visits to be replaced by on line consultations (Detmer et al., 2008).

Health self-management

Personal health records will help patients with self care, give them more confidence, and improve their compliance with treatment (Pagliari et al., 2007), as well as helping with the management of stable chronic disease (NEHTA, 2011). Tang et al note that “…[p]atients with chronic illnesses will be able to track their diseases in conjunction with their providers, promoting earlier interventions when they encounter a deviation or problem.” (Tang et al., 2006, p. 123)

Education and lifestyle changes

Personal health records can provide educational materials explaining current clinical practice for specific diseases (S. Kahn & Hickner, 2009), and interactive health evaluations and reminders about preventive services, which can support changes in lifestyle (Kaiser Permanente, 2007).

System and organisation goals

Personal health records also provide benefits for health provider organisations, and for the health system overall. They can improve the use of scarce resources (NEHTA, 2011), reduce the cost of managing chronic disease, and reduce the cost of medications and wellness programs (Tang et al., 2006). Use of PHRs will also lead to a decrease in hospital admissions, and result in better policy development (NEHTA, 2011).

Demonstrated benefits

Although PHRs have been in routine use in some settings for a number of years, evidence about improvements in patient outcomes is slow to emerge. Many of the benefits reported in studies of PHR adoption and use relate to process measures, such as the frequency of PHR use by patients (Wagner et al., 2012), their satisfaction with the communication process (Lin, Wittevrongel, Moore, Beaty, & Ross, 2005), the provision of preventive services, or the number of times that patients at- tend a clinic (Druss, Ji, Glick, & von Esenwein, 2014). However, some evidence is emerging that there are real benefits to be obtained through the use of PHRs. When 83 patients with Type 2 dia- betes (with an HbA1c of 7% or above) were randomised to receive either Internet based care man- agement or usual care for 12 months, those in the intervention group showed a 0.7% reduction in HbA1c, compared to controls (Ralston et al., 2009). Another pilot study supplemented home mon- itoring of hypertension, using the chronic care model, with advice from a pharmacist via the Inter- net. Pharmacist advice increased the proportion of patients whose blood pressure was deemed to be controlled (Green et al., 2008).

It is not yet clear whether the potential benefits which might result from the use of a PHR are equitably distributed among all patients, or more likely to be experienced by less disadvantaged pa- tients.