SummaryPhysicians at the Palo Alto Medical Foundation, a large multispecialty group practice, use a comprehensive, integrated electronic and personal health record system to gain immediate access to each patient's full medical record during visits, provide patient education, write prescriptions, monitor patient progress, and complete other tasks. Using MyHealthOnline, the practice's patient portal, patients have secure access to key components of their medical records; can get customized health information; and can request appointments, renew prescriptions, and communicate with their physicians electronically. Authorized caregivers, as proxy users, can review the health records of dependents and older adults who need help managing their own health care. Patients report being more engaged, knowledgeable, and motivated as a result of the system, while physicians report that it helps them to practice more efficiently. Patients, caregivers, and physicians also report high levels of satisfaction with the system.Suggestive: The evidence consists of post-implementation feedback from periodic surveys of physicians, patients, and caregivers.
Developing OrganizationsEpic Systems Corporation; Palo Alto Medical Foundation; Sutter Health
Date First Implemented2001
Palo Alto Medical Foundation implemented the electronic health record (EHR) system in 1999 and the personal health record (PHR) system in 2001.
Patient PopulationThis program serves a diverse population in the San Francisco Bay area who receive care from the Palo Alto Medical Foundation.
Problem AddressedPhysicians and patients who rely on paper-based medical records face limitations in terms of quick access to clinical data, convenient exchange of information, and timely completion of screenings, treatment, and followup care. In order to engage and empower patients to take a more active role in their health, patients must also have convenient, online access to their information.
- Inefficient for physicians: The well-documented shortcomings of paper-based records include difficulty locating paper charts, costly transcription of notes, delays in scheduling recommended screenings, and errors in prescribing. Medical practices that use EHRs have significant advantages over those using paper records, but physicians cannot realize the full benefits of electronic data access unless an integrated PHR system gives patients access to their records and hence the ability to participate more fully in their own care.
- Inconvenient for patients: Many patients have access only to paper charts, and even those using PHRs often do not have access to the full functionality that comes with an integrated system. Some PHR systems rely on standalone software applications, thus requiring patients to manually enter their own medical information. This cumbersome process often results in incomplete, inaccurate PHRs that providers cannot access. More commonly, PHR systems allow the patient to use a portal to get to information from a single provider’s electronic records. Many patients, however, have multiple providers with separate medical records that tend to remain fragmented and difficult to access.1 In addition, when patients change providers, they typically lose electronic access to their previous records.
- Inadequate data security: Unlike physician-maintained records, PHR services offered by third parties do not have to comply with federal laws that protect the security of personal medical information.2
- Limited ability to engage patients, change health behavior: A PHR that does not provide a comprehensive, patient-focused summary of key medical information, including guidance from physicians, has limited ability to enhance patient–provider collaboration, guide self-care, and promote healthy behaviors.1
Description of the Innovative ActivityPhysicians at the Palo Alto Medical Foundation use a comprehensive, integrated electronic and personal health record system in their daily interactions with patients. Physicians use the system to gain immediate access to each patient's full medical record during visits, provide patient education, write prescriptions, monitor patient progress, and complete other tasks. Using MyHealthOnline, patients have secure access to key components of their medical records, can get customized health information, and can request appointments, renew prescriptions, and communicate with their physicians electronically. Proxy access lets authorized caregivers review the health records of young children, elderly family members, or others who need help managing their own health care. Key elements of the integrated EHR/PHR system include the following:
- Efficient, paperless patient care: Physicians can quickly access each patient's electronic chart via computers in examination rooms and throughout the clinic. Through secure remote access, physicians can access the EHR any time they need the information to make patient care decisions (including from the physician's home or while on call). Using the system, they can use features of the EHR system to order medications and tests, retrieve test results, document patient visits, provide customized educational materials, and perform other clinical tasks. The PHR component of the integrated system supports ongoing communication with patients via secure messaging, encourages patients to stay involved in their own care, and promotes adherence to prescribed medication regimens and recommended behavior changes.
- Secure, online patient access to medical data: Patients can review most of their medical records online, except for progress notes, through MyHealthOnline. This system consolidates clinical records from all practices, including specialists, affiliated with the Palo Alto Medical Foundation. The PHR includes a current general health summary, medical history, laboratory results (with graphing capability), medications, and other key information. Multiple security features ensure confidentiality of each patient's data. Currently, approximately three-fourths of the practice's adult patients are using MyHealthOnline.
- Comprehensive online health services: MyHealthOnline offers patients a comprehensive set of Web-based health services, including the ability to schedule appointments, view test results, renew prescriptions, obtain customized education materials, receive personalized health news and information, and access other resources and services, including the following:
- Electronic reminders: Patients can sign up to receive automatic reminders about required tests, appointments, and other needed health services and activities.
- Electronic communication with providers: Patients can exchange secure messages online with their physicians and advice nurses.
- Caregiver and family access: Spouses, adult children, legal guardians, conservators, and other caregivers can be authorized to have proxy access to the health records of young children, elderly family members, or others who need help managing their own health care. If the patient has subscribed to the messaging service, the proxy representative can communicate electronically with the patient's physician.3
Context of the InnovationA large, not-for-profit, multispecialty group practice with headquarters in Palo Alto, CA, the Palo Alto Medical Foundation serves a relatively affluent patient population, including many employees of high-tech firms in the Silicon Valley. The organization has more than 1,000 physicians who collectively serve more than 700,000 patients, making it one of the largest medical groups in the San Francisco Bay area. Since 1993, the foundation has been part of Sutter Health, a not-for-profit health system located mainly in California. In 2008, the foundation's three group practices merged to form a single medical group serving patients in Alameda, San Mateo, Santa Clara, and Santa Cruz counties. The Palo Alto Medical Foundation's interest in using advanced information technology led to its decision to implement an EHR system and a closely integrated PHR system to support patient care.
ResultsPatients report being more engaged, knowledgeable, and motivated as a result of the system, while physicians report that it helps them to practice more efficiently. Patients, caregivers, and physicians also report high levels of satisfaction with the system. Fears that the system might be overused by some patients, and that it might create a "digital divide" between the elderly and younger patients, generally have not been realized.
Suggestive: The evidence consists of post-implementation feedback from periodic surveys of physicians, patients, and caregivers.
- More engaged, knowledgeable, and motivated patients: Many patients reported that having convenient access to their medical records has improved their understanding of their health status, the quality of communication and their sense of connection with their provider, and the degree to which they feel empowered to improve their own health. One in five patients reported that having access to MyHealthOnline has led them to change health-related behaviors. Physicians generally concur, noting that the system has helped their patients to become more involved and engaged in their care.
- More efficient care provision: Physicians surveyed reported that the close integration of the PHR with the clinical data system serves to enhance their efficiency due to the workflow process improvements inherent with an electronic system (e.g., quicker access to clinical records, easier communication with patients, and enhanced ability to provide timely screening, treatment, and followup care).
- High satisfaction: Patients, caregivers, and physicians report high levels of satisfaction with the system, as outlined below:
- Patients: In a recent survey, 94 percent of patients using MyHealthOnline reported being satisfied with the system. Popular features include clinical messaging (rated as the most valuable feature, despite the annual fee requirement) and having access to test results (including graphics that show changes in laboratory results over time) and online prescription renewal (which shortened the typical turnaround time for securing a renewal from 1 to 2 days to a few hours).
- Caregivers: Proxy users of the system also reported high levels of satisfaction, with 100 percent indicating they would recommend it to others. Three-fourths of proxy users indicated that the system improved the quality of patient care by making appointment scheduling easier and offering convenient access to test results and prescription refills. A similar percentage reported that the proxy access option gives the Palo Alto Medical Foundation an edge over other practices.
- Physicians: Among physicians, 90 percent reported being satisfied with the PHR.
- Fears about potential negative impact not realized: Fears that some patients might overuse the system and that others, particularly the elderly, might be reluctant to use it, have largely not come to pass, as outlined below:
- No evidence of overuse: Initially, some physicians worried that patients might overuse the PHR system, particularly the option of unlimited clinical messaging. However, these fears have largely not materialized, as 92 percent of surveyed physicians report that their patients use the system either as much or less than expected. In addition, those using the system heavily appear to be substituting electronic messaging for more time-consuming phone calls and office visits. An analysis of a random sample of clinical messages suggests that the potential savings from fewer office visits would more than offset the cost of the electronic consultations.4
- Substantial participation by the elderly: More than one-third of patients in their 60s, one-fourth of patients in their 70s and 11 percent of patients over 90 have enrolled in MyHealthOnline. These findings have allayed concerns that the PHR could lead to an age-based "digital divide" that would disadvantage elderly patients.
- Ongoing evaluation of clinical impact: Ongoing trials are testing the system's ability to help patients manage diabetes and other chronic medical conditions. (See the Adoption Considerations section for more details.)
Planning and Development ProcessKey steps in the planning and development process included the following:
- Implementation of EHR system: In 1999, the Palo Alto Medical Foundation began using an EHR system in some of its clinics. Dr. Tang, who had previously implemented such a system at Northwestern Memorial Hospital in Chicago, led the effort to implement an electronic health record from Epic Systems Corporation (a company he had worked with at Northwestern). The foundation completed its transition to EHRs in 2002.
- Strategic planning for online services: During a mid-2000 retreat, the foundation's board of trustees decided that the organization should provide patients with online access to many services. Several factors influenced the decision, as outlined below:
- Significant demand for online services: A market analysis suggested that increasing Internet use had created an opportunity to use online services to support patient care. In focus group sessions, middle-aged, busy professionals expressed particular interest in online health care services. By contrast, demand tended to be weaker among young, healthy consumers, while older patients expressed a preference for face-to-face visits. As a result, the board decided to target patients 40 to 65 years of age during the initial phases of the project.5
- Need for process improvements: By transitioning to online services, the board hoped to increase operational efficiency by eliminating inefficient, paper-based procedures.
- Development of PHR system: The practice's effort to provide online health care services got underway during the early phases of the EHR implementation. Key steps included the following:
- Defining functional requirements: Based on focus group findings and published surveys, the foundation decided to focus initial efforts on letting patients access a health summary, view test results, request medical advice and prescription renewals, make appointments, update demographic information, and access physician-endorsed health information.
- Building an integrated system: To ensure a smooth transition, online communication with patients had to dovetail with the workflow of the EHR system. In 1999, Epic Systems began developing MyChart, a PHR system that integrates with Epic's EHR system. Dr. Tang and his colleagues collaborated with Epic to further refine this system, which they called PAMFOnline. (It was renamed MyHealthOnline in 2010, when Sutter decided to implement it systemwide.) In 2001, the foundation became the first medical practice in the country to implement MyChart.
- Adding new features: Over time, new features have been added to MyHealthOnline, including wireless uploading of home monitoring data (e.g., glucometer readings, blood pressure, weight, pedometer steps), submission of previsit questionnaires, automated ordering of health maintenance procedures, and automated processing of prescription renewals.
Resources Used and Skills Needed
- Staffing: Eight full-time staff members, most of whom were trainer/analysts, were involved in deploying the initial system. Currently, the PHR and EHR system is used by physicians as part of their normal work and maintained by IT staff as part of their regular work.
- Costs: The initial implementation costs of the EHR system are estimated at $4.5 million. The additional implementation-only costs for the integrated PHR are difficult to estimate since the Palo Alto Medical Foundation was a co-developer.
Funding SourcesPalo Alto Medical Foundation; Sutter Health
The PHR is provided to patients without charge, with the costs being covered out of the foundation's operating budget.
Tools and Other ResourcesInformation on MyChart, developed by Epic Systems, is available at http://www.epic.com/software-phr.php.
More information on Healthwise materials can be found at http://www.healthwise.org.
Getting Started with This Innovation
- Identify and recruit physician leaders: Implementation of EHR and PHR systems represents a major cultural change that must be led by physician leaders with medical informatics and implementation management expertise. "It's not an IT project," Dr. Tang said. "Ideally, a chief medical information officer should lead the project, because it needs to be clinically led."
- Expect a learning curve: Productivity may decline after introduction of a clinical data system, as it takes time for people to learn the system. Providers will usually return to full productivity within a few weeks, but it may take as much as a year to become proficient. The learning curve for a PHR system is less steep and hence "the payback is felt much sooner," Dr. Tang notes.
- Aim for system integration: A successful system requires close integration of the electronic records that clinicians and patients use. Given the typical lack of interoperability of many health data systems, "it can become a real chore for patients to get information into a standalone PHR," Dr. Tang notes. With an integrated system, however, laboratory results and other data flow automatically into the PHR.
- Define what data will be shared (and how): Providers must decide what information to share, such as problem lists, medication lists, allergy lists, and test results. Data available to the patient should be presented in a way that a layperson can understand, with links to additional information as needed.
- Promote communication: A well-designed system leads to improved communication. "That's where a lot of the power and synergy come in, with patients joining their health care team," Dr. Tang said. Operating off a shared health record with convenient communication channels to their physicians makes the relationship more continuous.
- Offset professional costs: Reimbursing providers for "non–visit-based" care can help ensure that PHRs are financially sustainable. When Palo Alto Medical Foundation physicians use the clinical messaging system to communicate with patients, they use "tracking codes" to log the level of effort.
Sustaining This Innovation
- Survey users: Regularly survey patients and providers to gain insights to guide ongoing development and enhancement of the system.
- Document benefits: Documenting early experiences with PHRs (including their benefits) can help to improve such systems and promote their use.
- Assess clinical value: As noted, Dr. Tang and his colleagues are planning a series of clinical trials called EMPOWER (Engage and Motivate Patients Online With Enhanced Resources) to test the ability of the system to improve health and manage chronic diseases. In the initial study, EMPOWER-Diabetes, glucometer data is wirelessly uploaded to the provider via the patient's cell phone. Readings can be correlated with a patient's notes on dietary intake and physical activity. The nurse care manager can utilize targeted educational materials addressing specific issues, such as hypoglycemia.
Spreading This InnovationMany organizations expressed interest in PAMFOnline (now MyHealthOnline) after its launch in 2001. The system's success has led other organizations, including Kaiser Permanente and Stanford University, to implement Epic's MyChart system. According to Dr. Tang, PHR systems are becoming "a standard of care for integrated delivery systems."
References/Related ArticlesInformation about Palo Alto Medical Foundation's PHR and EHR systems can be found at http://www.pamf.org/ehr.
Tang PC, Lansky D. The missing link: bridging the patient–provider health information gap. Health Aff (Millwood). 2005;24(5):1290-1295. [PubMed] Available at: http://content.healthaffairs.org/content/24/5/1290.full
Cross M. Online Records Get Personalized. Health Data Management Magazine, July 2007. Available at: http://www.healthdatamanagement.com/issues/20070701/15397-1.html
Tang PC, Lee TH. Your doctor's office or the Internet? Two paths to personal health records. N Engl J Med. 2009;360:1276-8. [PubMed]
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Original publication: February 16, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 13, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.