Personal Health Records
and Personal Health
Record Systems
A Report Recommendation
from the National Committee
on Vital and Health Statistics
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
National Institutes of Health
National Cancer Institute
National Center for Health Statistics
Centers for Disease Control and Prevention
Personal Health Records and
Personal Health Record Systems
A Report and Recommendations from
the National Committee on Vital and Health Statistics
U.S. Department of Health and Human Services
National Cancer Institute
National Institutes of Health
National Center for Health Statistics
Centers for Disease Control and Prevention
Washington, D.C.
February 2006
Personal Health Records and Personal Health Record Systems
1
Acknowledgements
Executive Summary
Background
Personal Health Records are Evolving
in Concept and Practice
Recommendations 1-2
Personal Health Record Systems’ Value
Depends on Users, Sponsors, and Functionality
Privacy
Recommendations 3-7
Security Requirements
Recommendations 8-9
Interoperability
Recommendations 10-14
Federal Roles in PHR Systems, Internal and External
Recommendations 15-16
Advancing Research and Evaluation on PHR Systems
Recommendations 17-20
Next Steps for NCVHS
Contents
2
Personal Health Records and Personal Health Record Systems
Acknowledgements
Executive Secretary
Marjorie S. Greenberg
Chief
Classifications & Public Health Data Standards Staff
Office of the Director
National Center for Health Statistics,
HHS Centers for Disease Control and Prevention
Hyattsville, Maryland
HHS Executive Staff
Director
James Scanlon
Deputy Assistant Secretary
Office of Science and Data Policy
Office of the Assistant Secretary
for Planning and Evaluation,
Department of Health and Human
Services (HHS)
Washington, D.C.
Chairman
Simon P. Cohn, M.D., M.P.H.
Associate Executive Director
The Permanente Federation
Kaiser Permanente
Oakland, Californiaia
This report was developed by the Workgroup on the National Health Information Infrastructure (NHII) of the National
Committee on Vital and Health Statistics (NCVHS), the statutory public advisory body on health information policy to
the Secretary of Health and Human Services. All the members of the full National Committee, and particularly those
who serve on the Subcommittee on Standards and Security and the Subcommittee on Privacy and Confidentiality,
contributed to the final report. It is based on a letter report that was approved by the full Committee in September
2005 and sent to the Secretary. The letter report is available on the NCVHS Web site (http://ncvhs.hhs.gov/050909lt.
htm). It has been slightly modified (but not substantively changed) to serve the wider audience interested in personal
health records and systems. The Workgroup is grateful to the many experts and organizations whose invaluable
suggestions contributed to the findings and shaped the recommendations.
Development of this report was coordinated and supported by the National Cancer Institute’s Center
for Bioinformatics, which provides the lead staff for the Workgroup. Workgroup staff and staff from
the National Center for Health Statistics, which serves as Executive Secretary to NCVHS, provided
invaluable assistance.
National Committee on Vital and Health Statistics
October 2005
Personal Health Records and Personal Health Record Systems
3
Membership
Jeffrey S. Blair, M.B.A.
Vice President
Medical Records Institute
Albuquerque, New Mexico
John P. Houston, J.D.
Director, ISD; Privacy Officer; Assistant Counsel
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Robert W. Hungate
Principal
Physician Patient Partnerships for Health
Wellesley, Massachusetts
Carol J. McCall, F.S.A., M.A.A.A.
Vice President
Humana
Center for Health Metrics
Louisville, Kentucky
Mark A. Rothstein, J.D.
Herbert F. Boehl Chair of Law and Medicine
Director, Institute for Bioethics, Health Policy
and Law
University of Louisville School of Medicine
Louisville, Kentucky
Donald M. Steinwachs, Ph.D.
Professor and Director
The Johns Hopkins University
Bloomberg School of Public Health
Department of Health Policy and Management
Baltimore, Maryland
Paul Tang, M.D.
Chief Medical Information Officer
Palo Alto Medical Foundation
Palo Alto, California
Justine M. Carr, M.D.
Director, Clinical Resource Management
Health Care Quality
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Stanley M. Huff, M.D.
Professor, Medical Informatics
University of Utah
College of Medicine
Intermountain Health Care
Salt Lake City, Utah
A. Russell Localio, Esq., M.A., M.P.H., M.S.
Assistant Professor of Biostatistics
University of Pennsylvania School of Medicine
Center for Clinical Epidemiology and Biostatistics
Philadelphia, Pennsylvania
Harry Reynolds
Vice President
Blue Cross Blue Shield of North Carolina
Durham, North Carolina
William J. Scanlon, Ph.D.
Health Policy R&D
Washington, D.C.
C. Eugene Steuerle, Ph.D.
Senior Fellow
The Urban Institute
Washington, D.C.
Kevin C. Vigilante, M.D., M.P.H.
Principal
Booz-Allen & Hamilton
Rockville, Maryland
Judith Warren, Ph.D., R.N.
Associate Professor
School of Nursing
University of Kansas
Kansas City, Kansas
4
Personal Health Records and Personal Health Record Systems
Liaison Representatives
Virginia S. Cain, Ph.D.
Acting Associate Director for Behavioral and
Social Sciences Research
HHS National Institutes of Health
Bethesda, Maryland
June E. O’Neill, Ph.D
Co-Chair, NCHS Board of Scientific Counselors
Director
Department of Economics and Finance
Zicklin School, Baruch College
New York, New York
Steven J. Steindel, Ph.D.
Senior Advisor
Standards and Vocabulary Resource
Information Resources Management Office
HHS Centers for Disease Control and Prevention
Atlanta, Georgia
J. Michael Fitzmaurice, Ph.D.
Senior Science Advisor for
Information Technology
HHS Agency for Healthcare Research and Quality
Rockville, Maryland
Edward J. Sondik, Ph.D.
Director
National Center for Health Statistics
Centers for Disease Control and Prevention
Hyattsville, Maryland
Karen Trudel
Deputy Director
Office of E-Health Standards & Security
HHS Centers for Medicare and Medicaid Services
Baltimore, Maryland
Staff of the Centers for Disease
Control and Prevention,
National Center
for Health Statistics
Debbie Jackson
Katherine Jones
Jeannine Christiani
NCVHS Workgroup on the National
Health Information Infrastructure
Simon P. Cohn, M.D., Chair
Jeffrey S. Blair, M.B.A.
Richard K. Harding, M.D.*
John P. Houston, J.D.
Stanley M. Huff, M.D.
Robert W. Hungate
C. Eugene Steuerle, Ph.D.
Paul Tang, M.D.
Kevin C. Vigilante, M.D., M.P.H.
* Member during Report development
Personal Health Records and Personal Health Record Systems
5
Workgroup Staff
Mary Jo Deering, Ph.D., National Center for Bioinformatics,
National Cancer Institute, National Institutes of Health,
U.S. Department of Health and Human Services (HHS),
NHII Workgroup Lead Staff and Project Manager
for the Report
Cynthia Baur, Ph.D., HHS Office of Public Health and Science
Jay Crowley, HHS Food and Drug Administration
Linda Fischetti, RN, MS, Department of Veterans Affairs
Kathleen Fyffe, HHS Office of the National Health
Information Technology Coordinator
Robert Kambic, HHS Centers for Medicare and
Medicaid Services
Eduardo Ortiz, M.D., M.P.H., Department of Veterans Affairs
Anna Poker, HHS Agency for Healthcare Research and Quality
Steven J. Steindel, Ph.D., HHS Centers for Disease Control
and Prevention (CDC)
Cynthia Wark, MSN, RN, HHS Centers for Medicare and
Medicaid Services
Michelle Williamson, HHS/CDC National Center for
Health Statistics
Susan Baird Kanaan, Consultant Writer
NCVHS Web site: www.ncvhs.hhs.gov
President Bush and Secretary Leavitt have put forward a vision that, in the Secretary’s words, “would create a
personal health record that patients, doctors and other health care providers could securely access through the
Internet no matter where a patient is seeking medical care.” The National Health Information Infrastructure
Workgroup of the National Committee on Vital and Health Statistics (NCVHS)
1
held six hearings on personal health
records (PHRs) and PHR systems in 2002-2005. On the basis of those hearings, the Workgroup developed a letter
report with twenty recommendations that it sent to the Secretary in September 2005.
2
Citing the role PHR systems
could play in improving health and healthcare and furthering the broad health information technology agenda, the
letter report urges the Secretary to exercise leadership and give priority to developing PHRs and PHR systems, con-
sistent with the Committee’s recommendations. The present report is a slightly expanded version of the letter report
sent to the Secretary. Although substantively unchanged, it adds clarifying information for a broader audience.
1 NCVHS is the statutory public advisory Committee on health information policy to the Secretary of Health and Human Services.
2 http://www.ncvhs.hhs.gov/050909lt.htm
6
Personal Health Records and Personal Health Record Systems
Executive Summary
Currently, PHRs and their associated health
management tools are heterogeneous and evolving.
There is no uniform definition of “personal health
record” in industry or government. The following
attributes can vary:
n the scope or nature of the information/
contents
n the source of the information
n the features and functions offered
n the custodian of the record
n the storage location of the contents
n the technical approach
n the party who authorizes access to
the information
The Committee concluded that while this variety
reflects the current stage of innovation, it makes
collaboration and policy-making difficult. The Com-
mittee recommended development of a descriptive
framework to facilitate nuanced discussion and
policy-making in this area, and proposed the attri-
butes listed above as a starting point (see page 11).
Although the consumer/patient is the primary ben-
eficiary and user of PHRs, other stakeholders stand
to benefit from their use, as well. The table below
summarizes potential benefits from the perspective of
various roles. (These perceived benefits may not align
with any specific PHR or PHR system, and the same
users may play different roles at different times.)
Personal Health Records and Personal Health Record Systems
7
Key Potential Benefits of PHRs and PHR Systems
Roles Benefits
Consumers,
Patients and their Caregivers
Support wellness activities
Improve understanding of health issues
Increase sense of control over health
Increase control over access to personal health information
Support timely, appropriate preventive services
Support healthcare decisions and responsibility for care
Strengthen communication with providers
Verify accuracy of information in provider records
Support home monitoring for chronic diseases
Support understanding and appropriate use of medications
Support continuity of care across time and providers
Manage insurance benefits and claims
Avoid duplicate tests
Reduce adverse drug interactions and allergic reactions
Reduce hassle through online appointment scheduling and prescription refills
Increase access to providers via e-visits
Healthcare Providers
Improve access to data from other providers and the patients themselves
Increase knowledge of potential drug interactions and allergies
Avoid duplicate tests
Improve medication compliance
Provide information to patients for both healthcare and patient services purposes
Provide patients with convenient access to specific information or services
(e.g., lab results, Rx refills, e-visits)
Improve documentation of communication with patients
Payers Improve customer service (transactions and information)
Promote portability of patient information across plan
Support wellness and preventive care
Provide information and education to beneficiaries
Employers Support wellness and preventive care
Provide convenient service
Improve workforce productivity
Promote empowered healthcare consumers
Use aggregate data to manage employee health
Societal/Population
Health Benefits
Strengthen health promotion and disease prevention
Improve the health of populations
Expand health education opportunities
8
Personal Health Records and Personal Health Record Systems
These and other benefits are not assured, however. To realize
the potential of PHRs and PHR systems to improve health
and healthcare, significant steps are needed in the areas
of privacy, security, and interoperability, in particular, as
recommended in this report. The Committee’s key findings
include the following:
n It is important to clarify the respective rights,
obligations, and potential liabilities of consum-
ers, patients, providers, and other stakeholders in
PHR systems.
n Consumers should have the right to make an
informed choice concerning the uses of their
personal information when signing up to use any
personal health record products or services.
n Security is a critical component of a PHR system,
especially if it is accessible via the Internet.
n The full potential of PHR systems will not be
realized until they are capable of widespread
exchange of information with Electronic Health
Records (EHRs) and other sources of personal and
other health data.
The Committee also identified broad areas for research and
evaluation for PHR systems. They include consumer, health
services, and technical research and the development of
metrics to assess the implementation and impact of PHR
systems on multiple dimensions of health and healthcare.
Most of the National Committee’s recommendations (which
are listed below and discussed further in the full report) are
directed to the U.S. Department of Health and Human
Services (HHS). Some also call for action by other federal
agencies, standards development organizations, PHR
vendors, health care organizations, and pilot project contrac-
tors. All the recommended steps require coordination among
stakeholders and between the public and private sectors.
They also require federal leadership. The Committee recom-
mends that, similar to its role in stimulating EHR adoption,
the Department encourage and actively participate in a
public/private partnership that facilitates standards-based
approaches to PHR systems in a harmonized legal and
regulatory environment across geopolitical boundaries.
NCVHS Recommendations on PHRs
and PHR Systems
Recommendations on Evolving
Terms and Practices
1: Consensus framework. NCVHS recommends that HHS
support the development of and promote public-private
consensus on a framework for characterizing personal health
record systems, building on this initial framework (see p.11).
2: Education. HHS and others should use the agreed-upon
framework as a basis for education efforts highlighting the
benefits and risks of various types of PHRs, aimed not only
at consumers and patients but also at healthcare providers
(e.g., physicians and nurses) and other stakeholders.
Recommendations on Privacy
3: Education about privacy. In any public education
program about PHR systems, HHS and other parties should
inform consumers about the importance of understanding the
privacy policies and practices of PHR system vendors,
including the enumeration of potential secondary uses
and disclosures of personally identifiable health information.
4: Best practices. HHS should identify and promote best
practices with respect to privacy policies and practices for
PHR systems, and models for plain language wording of
notices describing these policies and practices. These best
practices and models should also address translations into
other languages.
5: Privacy in HHS-sponsored activities. For any HHS-
sponsored pilot projects, and any contractual relationship
that CMS undertakes with entities intending to utilize CMS
data in PHRs, HHS should require that those PHR systems
provide advance notice to consumers of any uses or disclo-
sures of personally identifiable health information. In those
situations where HIPAA does not apply, uses or disclosures
of information in PHRs should not be allowed without the
express consent of the consumer.
6: Privacy in activities by entities not covered by
HIPAA. Entities not covered by HIPAA that offer PHR systems
should voluntarily adopt strict privacy policies and practices
and should provide clear advance notice to consumers of
Personal Health Records and Personal Health Record Systems
9
these policies and practices. This notice should specifically
include a full description of all uses of PHR data. In addition,
NCVHS recommends that no health information in a PHR be
used without the express consent of the consumer, which
may be obtained in conjunction with the notice.
7: Assessment. HHS should collaborate with other Federal
agencies as appropriate to review and assess issues related
to privacy and other consumer protections for PHR systems.
Such a review should evaluate existing authorities and
mechanisms for addressing potential problems; it should also
identify gaps and recommend appropriate action.
Recommendations on Security
8: Security standards framework. HHS should work
with relevant stakeholders to develop and promote a stan-
dards framework for authentication, access control, authori-
zation, and auditability based on the following principals:
n All PHR systems should provide consumers
with terms and conditions of use.
n All PHR systems should provide functionality that
enables a consumer to audit who has accessed the
consumer’s information within the PHR.
n All PHR systems should be based on industry-
standard security and authentication schemes.
This should not preclude vendors from making
additional security protections available at the
option of the consumer. The decision to adopt
additional security technologies should take into
consideration portability, supportability and cost
of such solutions.
n PHR systems should include functionality that
provides a consumer with the ability to control
who accesses the consumer’s information within
the PHR. This would include the ability for the
consumer to restrict access to specific subsets of
information within the PHR.
9: Security in HHS activities. For any HHS-sponsored pilot
projects and any HHS contracts to produce PHR systems,
HHS should require that security protections consistent with
the HIPAA Security Rule be implemented.
Recommendations on Interoperability
10: Addressing standards gaps. Standards development
efforts should be expanded to address issues related
to authentication, identification of the data source, non-
repudiation, communication to/from PHR systems, mapping to
consumer-oriented concepts and terms, and the enabling of
consumer-controlled access.
11: Consistency of EHR and PHR standards. HHS should
encourage standards development organizations, wherever
possible, to adopt for the PHR those standards that are used
to promote interoperability of EHRs.
12: PHR data sets. HHS should encourage standards
development organizations, wherever possible, to identify
data sets for PHR systems that are consistent with those
used for EHRs.
13: Standards for HHS-sponsored activities. For any
HHS-sponsored pilot projects and any contractual relation-
ship that CMS undertakes with entities intending to
utilize CMS data in PHR systems, HHS should require that
PHR vendors and health care organizations adopt data
content and exchange standards that are based upon
standards accepted for EHRs, as a way of improving the
interoperability of the systems.
14: Standards for private-sector activities. Private sector
PHR vendors and health care organizations should voluntarily
adopt data content and exchange standards that are based
upon standards accepted for EHRs, as a way of improving
the interoperability of the systems.
Recommendations on the Federal Role
15: Federal roles. Federal agencies should assess how they
can more fully explore and appropriately promote the benefits
of PHR systems across their respective roles.
16: Considerations for underserved populations.
The Federal government should identify and address the
information technology access and use barriers that limit the
dissemination of PHR systems, particularly to underserved
populations. HHS also should address health literacy issues
that could limit the use of PHR systems by the most
vulnerable populations.
10
Personal Health Records and Personal Health Record Systems
Recommendations on Research
and Evaluation
17: HHS research. The Secretary should request that all
agencies review their research portfolios and program opera-
tions and report to the Secretary the ways they could contrib-
ute to the research and evaluation of PHR systems.
18: OPM pilots. HHS should collaborate with the Office
of Personnel Management to help implement pilot studies
of PHR systems with payers and beneficiaries of the Federal
Employees Health Benefits Plan.
19: AHRQ research. The Agency for Healthcare Research
and Quality (AHRQ) should expand its evolving health
information technology research portfolio to support health
services research and the development of metrics to assess
the impact of PHR systems on quality of care, patient safety,
and patient outcomes.
20: CMS pilots. The Centers for Medicare and Medicaid
Services (CMS) should conduct pilot studies of PHR usage
for chronic diseases to evaluate utility and cost effectiveness
for beneficiaries, providers and payers.
Next Steps for NCVHS
NCVHS will continue to gather information on this dynamic
field. It plans to release additional recommendations on
privacy, confidentiality and the NHIN. In addition, it will
provide a forum for exploring several issues that arose from
the initial hearings:
n The role of CMS
n Ownership and control of data within PHR systems
n The ability of PHR systems to obtain data from
external sources such as provider systems,
claims clearinghouses, health plans
and similar sources
n Non-repudiation (authenticating the integrity of the
contents and exchange of information)
n Potential liability for providers associated with the
use of incomplete or inaccurate data within a PHR
n Privacy policy practices, including notice
Personal Health Records and Personal Health Record Systems
11
Background
President Bush and Secretary Leavitt have put forward a vision that, in the Secretary’s words, “would create
a personal health record that patients, doctors and other health care providers could securely access through the
Internet no matter where a patient is seeking medical care.” Responding to this vision, the National Committee on
Vital and Health Statistics (NCVHS) submitted a letter report on Personal Health Record (PHR) systems in September,
2005. The letter report describes initial findings from national hearings covering the many types of systems referred
to as “Personal Health Records,” suggests areas for further exploration, and offers twenty recommendations. It urges
the Secretary to exercise leadership and to give this area the priority it deserves, in view of the role PHR systems could
play in improving health and healthcare and furthering the broad health information technology agenda. The present
report is a slightly expanded version of the letter report sent to the Secretary. Although substantively unchanged,
it adds clarifying information for a broader audience.
In its 2001 report,
Information for Health: A Strategy
for Building the National Health Information
Infrastructure, NCVHS identified three primary areas
or dimensions that comprise a national health infor-
mation infrastructure (NHII): information to support
the needs of patient care, population health, and per-
sonal health. The healthcare provider (patient care)
area promotes quality patient care by providing ac-
cess to more complete and accurate patient data on
the spot, around the clock. It includes provider notes,
clinical orders, decision-support programs, electronic
prescribing programs, and practice guidelines. The
second area, population health, makes it possible for
public health officials and other data users at local,
State, and national levels to identify and track health
threats, assess population health, and create and
monitor programs and services. This area includes
information on both the health of the population and
influences on it. Finally, the personal health area of
the NHII supports individuals in managing their own
wellness and healthcare decision making. It includes
a personal health record that is created and con-
trolled by the individual or family, plus information
and tools such as health status reports, self-care
trackers and directories of healthcare and public
health service providers.
In this vision of the NHII, the three primary areas are
equally important, and the goal for the infrastruc-
ture as a whole is to promote optimum information
exchange among them. The heart of the vision is
sharing information and knowledge as appropri-
ate so it is available to people when they need it
to make the best possible health decisions. Ready
access to relevant, reliable information and secure
modes of communication will enable consumers,
patients, healthcare and public health professionals,
public agencies, and others to address personal and
community health concerns far more effectively.
Ready access to relevant, reliable
information and secure modes of
communication will enable consumers,
patients, healthcare and public health
professionals, public agencies, and
others to address personal and
community health concerns far
more effectively.
12
Personal Health Records and Personal Health Record Systems
Following publication of the 2001 NCHVS report,
considerable work got underway on many fronts to develop
the provider and population health dimensions of the NHII,
much of it spurred by federal policy. In these two areas,
infrastructure development has been paired with progress
toward standards and privacy protection. However, there
was less federal attention to the development of technolo-
gies, content, connections and protections for the personal
dimension of the NHII. The NCVHS Workgroup on the
National Health Information Infrastructure (NHII) decided to
hold a series of hearings to learn more about PHRs and PHR
systems (described below) because of their importance for
Source: National Committee on Vital and Health Statistics, Information for Health:
A
Strategy for Building the National Health Information Infrastructure, Washington, D.C., 2001.
The diagram below, from the 2001 NCVHS report, shows how
some information needs are unique to one dimension of
activity and users, some are shared by two, and some are
shared by all three. The list of information types below is
intended to be illustrative and is not exhaustive.
Personal Health Records and Personal Health Record Systems
13
empowering consumers and patients to manage their health
and partner with their healthcare providers.
By April 2005, the Workgroup had held six open hearings on
information needs and activities related to personal health,
and personal health records in particular. The hearings
covered PHR models, data sets, standards, identification,
authentication, barriers to adoption, privacy, policy issues
and business issues. The invited presenters included
consumers, government, health care organizations, nonprofit
and commercial sponsors, Federal staff, standards and policy
experts, healthcare providers, payers, and economists.
The Workgroup was also informed about the work done on
personal health records/personal health management tools
by the HHS Office of Disease Prevention and Health
Promotion and the Markle Foundation’s Connecting for
Health Collaborative, as well as about the Veterans Health
Administration experience with MyHealtheVet, a personal
health record already deployed for veterans.
The Workgroup identified seven issues where specific
measures, collaboration and leadership are needed to assure
that stakeholders’ investments yield the desired benefits.
These issues, discussed below, include evolving conceptions
of PHRs; varying perspectives on their benefits; privacy;
security requirements; interoperability requirements; the
federal role; and research evaluation needs.
3 See Lansky, D., Kanaan, S., Lemieux, J. April 15, 2005. Identifying Appropriate Federal Roles in the Development of Electronic Personal Health
Records. Results of a Key Informant Process. Submitted to the Office of Disease Prevention and Health Promotion, OPHS, U.S. Department of
Health and Human Services; and Connecting for Health, July 2004.
Connecting Americans to their Healthcare. Final Report. Working Group
on Policies for Electronic Information Sharing Between Doctors and Patients. Markle Foundation and Robert Wood Johnson Foundation.
http://www.connectingforhealth.org/resources/wg_eis_final_report_0704.pdf
3
The Committee proposes adopting
the term “personal health record”
to refer to the health or medical
record that includes clinical data,
and the term “personal health
record systems” to refer to the
multi-function tools that include
PHRs among a battery of functions.
There is no uniform definition
of “personal health record”
in industry or government,
and the concept continues to
evolve. This lack of consensus
makes collaboration, coordination
and policymaking difficult.
14
Personal Health Records and Personal Health Record Systems
Personal health records are broadly considered as means by which an individual’s personal health information
can be collected, stored, and used for diverse health management purposes. However, NCVHS found that there
is no uniform definition of “personal health record” in industry or government, and the concept continues to evolve.
In some concepts, the PHR includes the patient’s interface to a healthcare provider’s electronic health record (EHR).
In others, PHRs are any consumer/patient-managed health record. This lack of consensus makes collaboration,
coordination and policymaking difficult. It is quite
possible now for people to talk about PHRs without
realizing that their respective notions of them may
be quite different. Recognizing the variety of attri-
butes and possibilities and being very specific about
what is being discussed would enable those engaged
in collaboration and policymaking to conduct more
nuanced discussions of PHRs and to collaborate
more effectively.
Personal Health Records
are Evolving in Concept
and Practice
The first step in this direction is to catalog the
variety of types of PHRs and PHR systems in
existence and the varied uses of the terminology.
This section summarizes the different perspectives
of PHRs that the Workgroup observed throughout
its process and recommends a way HHS could
promote greater clarity.
The term “record” in “personal health record” may
itself be limiting, as it suggests a singular static
repository of personal data. The Committee found
that a critical success factor for PHRs is the provi-
sion of software tools that help consumers and
patients participate in the management of their own
health conditions. A “personal health record system”
provides these additional software tools. The Com-
mittee proposes adopting the term “personal health
record” to refer to the collection of information
about an individual’s health and health care, stored
in electronic format. The term “personal health re-
cord system” refers to the addition of computerized
tools that help an individual understand and manage
NCVHS believes that establishing
a framework for characterizing and
describing the attributes of PHRs and
PHR systems would be extremely helpful
in promoting a better understanding and
appropriate use of any given PHR
system. A consensus framework would
also provide a foundation for public
education efforts.
Personal Health Records and Personal Health Record Systems
15
the information contained in a PHR. These terms are analogous
to the terms “electronic health record” and “electronic health
record systems” that have been adopted by the standards
development organization HL7, which is leading the standards
activity in this area. The PHR and the PHR system are intended
for use by consumers, patients or their informal caregivers,
in contrast with EHR systems that are intended for use by
healthcare providers.
Despite the heterogeneity of PHRs and PHR systems at pres-
ent, NCVHS concluded that it is not possible, or even desir-
able, to attempt a unitary definition at this time. However, the
Committee believes it is possible as well as useful to charac-
terize them by their attributes: specifically, the scope or nature
of their information/contents, the source of their information,
the features and functions they offer, the custodian of the
record, the storage location of the content, the technical ap-
proach to security, and the party who authorizes access to the
information.
NCVHS believes that establishing a framework for char-
acterizing and describing the attributes of PHRs and PHR
systems would be extremely helpful in promoting a better
understanding and appropriate use of any given PHR system.
Some of the approaches to each of the attributes, as heard
by the Committee, are listed below in a framework that the
Committee offers as a starting point for such an effort. The
consensus-building process around such a framework should
take into consideration the work that standards development
organizations are doing to define the functional attributes of
PHR systems. A consensus framework would also provide a
foundation for public education efforts, which many speakers
called for, to highlight the benefits and risks of various types
of PHRs, aimed not only at consumers and patients but also
at healthcare providers and other stakeholders.
Initial framework of PHR
and PHR systems attributes
n Scope and nature of content
Some PHR systems just have consumer
health information, personal health
journals, or information about
benefits and/or providers, but no
clinical data about the individual.
Some PHR systems have clinical informa-
tion. Of these, some are disease specific,
some include subsets of information
such as lab reports, and some are
comprehensive.
n Source of information
Data in PHR systems may come from the
consumer, patient, caregiver, healthcare
provider, payer, or all of these.
Some PHR systems are populated with
data by EHRs.
n Features and functions
PHR systems offer a wide variety of
features, including the ability to
view personal health data, exchange
secure messages with providers, schedule
appointments, renew prescriptions, and
enter personal health data; decision support
(such as medication interaction alerts or
reminders about needed preventive
services); the ability to transfer data to or
from an electronic health record;
and the ability to track and manage
health plan benefits and services.
n Custodian of the record
The physical record may be operated by a
number of parties, including the consumer
or patient, an independent third party, a
healthcare provider, an insurance
company, or an employer.
Recommendations on Evolving
Terminology and Functions:
1. Consensus Framework
2. Education
16
Personal Health Records and Personal Health Record Systems
n Data storage
Data may be stored in a variety of locations,
including an Internet-accessible database,
a provider’s EHR, the consumer/patient’s
home computer, a portable device such as
a smart card or thumb drive, or a privately
maintained database.
n Technical approaches
Current PHRs and PHR systems are
generally not interoperable (with the
exception of the PHRs that are “views”
into the EHR, and they vary in how
they handle security, authentication,
and other technical issues.
n Party controlling access to the data
While consumers or patients always have
access to their own data, they do not
always determine who else may access it.
For example, PHRs that are “views” into
a provider’s EHR follow the access rules
set up by the provider. In some cases,
consumers do have exclusive control.
Recommendation 1:
Consensus framework.
NCVHS recommends that HHS support the development
of and promote public-private consensus on a framework for
characterizing personal health record systems, building on
this initial framework.
Recommendation 2:
Education.
HHS and others should use the agreed-upon framework
as a basis for education efforts highlighting the benefits and
risks of various types of PHRs, aimed not only at consumers
and patients but also at healthcare providers (e.g., physicians
and nurses) and other stakeholders.
PHR systems create different
kinds of value for a range of
individual, institutional and
societal stakeholders.
Personal Health Records and Personal Health Record Systems
17
Personal Health Record
Systems’ Value Depends
on Users, Sponsors,
and Functionality
Testimony to NCVHS indicated that PHR systems create
different kinds of value for a range of individual, institutional
and societal stakeholders. The table below summarizes po-
tential benefits from the perspective of various roles. Given
the heterogeneity of concepts of PHRs and PHR systems,
these perceived benefits may not align with any specific PHR
or PHR system. Also, it is worth pointing out that the same
users may play different roles at different times.
18
Personal Health Records and Personal Health Record Systems
Roles Benefits
Key Potential Benefits of PHRs and PHR Systems
Consumers,
Patients and their Caregivers
Support wellness activities
Improve understanding of health issues
Increase sense of control over health
Increase control over access to personal health information
Support timely, appropriate preventive services
Support healthcare decisions and responsibility for care
Strengthen communication with providers
Verify accuracy of information in provider records
Support home monitoring for chronic diseases
Support understanding and appropriate use of medications
Support continuity of care across time and providers
Manage insurance benefits and claims
Avoid duplicate tests
Reduce adverse drug interactions and allergic reactions
Reduce hassle through online appointment scheduling and prescription refills
Increase access to providers via e-visits
Improve documentation of communication with patients
Healthcare Providers
Improve access to data from other providers and the patients themselves
Increase knowledge of potential drug interactions and allergies
Avoid duplicate tests
Improve medication compliance
Provide information to patients for both healthcare and patient services purposes
Provide patients with convenient access to specific information or services (e.g., lab
results, Rx refills, e-visits)
Improve documentation of communication with patients
Payers Improve customer service (transactions and information)
Promote portability of patient information across plan
Support wellness and preventive care
Provide information and education to beneficiaries
Employers Support wellness and preventive care
Provide convenient service
Improve workforce productivity
Promote empowered healthcare consumers
Use aggregate data to manage employee health
Societal/Population
Health Benefits
Strengthen health promotion and disease prevention
Improve the health of populations
Expand health education opportunities
Consumers and patients who use
PHR systems express strong
support for them. Even those who
are not familiar with them are
interested in their potential benefits.
The Committee believes that the
emerging market for PHR systems
needs to be monitored.
Personal Health Records and Personal Health Record Systems
19
Consumers and patients who use PHR systems express
strong support for them. They appreciate having access to
their personal health information to manage their own health
and health care and to share information with their provid-
ers. While surveys confirm that most of the general popula-
tion is unaware of PHR systems, they also show that even
those who are not familiar with them are interested in their
potential benefits. Specific areas of interest include access
to their health information (e.g., diagnoses, medications, test
results), communicating with their physicians, scheduling ap-
pointments, renewing prescriptions, tracking immunizations,
noting mistakes in the medical record, transferring informa-
tion to new doctors, and getting test results.
The Committee heard testimony that people with chronic
conditions are more likely to use PHR systems, including
disease-specific PHR systems. It also heard of growing inter-
est from payers, providers, and employers to sponsor PHR
systems for their members, patients, or employees.
Many presenters (consumers, policy analysts, economists,
health system executives) observed that PHR systems bring
health care in line with electronic and automated services in
other consumer sectors. Several raised the possibility that
Health Savings Accounts and other “consumer-driven health
plans” may provide a stimulus for PHR systems. However,
these insurance approaches are too new to draw conclusions
from them.
NCVHS heard testimony that the market for stand-alone
PHRs offered for sale or subscription as commercial products
or through non-healthcare third party entities is fairly new.
While the number of products is growing, sales and usage
statistics are limited.
Among the potential market drivers of PHR systems are the
following: chronic disease management; improved access to
personal health data; improved customer service and con-
venience; strengthened market position through increased
loyalty (to the sponsoring entity); promotion of wellness,
prevention and self-care; and improved care delivery and
coordination through timely access to information.
On a cautionary note, the Committee believes that relying
entirely on market forces to determine the nature and direc-
tion of PHR systems could cause personal health information
to be exploited for its economic value without adequate
consumer controls. While this is addressed more fully in the
section below on Privacy, the Committee believes that the
emerging market for PHR systems needs to be monitored.
As the market evolves, there may be occasions when the
government needs to set standards or limits that formally
recognize certain consumer rights. Otherwise, a breach of
confidence in PHRs and PHR systems could harm the con-
sumer and undermine consumers’ trust in electronic health
records and the National Health Information Network.
All PHR systems are based on
consumers having access to
their health information, and
some are based on consumers
having exclusive control of the
information in their PHR. It will
be important to clarify the
respective rights, obligations,
and potential liabilities of
consumers, patients, providers,
and other stakeholders
in PHR systems.
Consumers should have the
right to make an informed choice
concerning the uses of their
personal information when
signing up to use any personal
health record products
or services.
20
Personal Health Records and Personal Health Record Systems
The Committee views privacy and security as closely entwined, with technical security measures being
designed to implement privacy policies and practices. The Committee’s findings on security follow this
section on privacy.
The privacy considerations of PHR systems are complex, yet addressing them adequately is essential if PHR
systems are to become widely accepted and used. Consumers want to be able to control access to their
personal health information. As noted above, all PHR systems are based on consumers having access to
their health information, and some are based on consumers having exclusive control of the information in
their PHR. Some presenters raised the issue of consum-
ers’ ownership of their personal health information.
Some identified a difference between legal control
and ownership of the institutional medical record,
on one hand, and consumer control and ownership
of personal information and of a PHR, on the other.
NCVHS observed that although the issues of health
record ownership and access control are not new,
they take on added dimensions with the emergence
of PHR systems. Moreover, while ownership per
se may not be as relevant as control, it will nev-
ertheless be important to clarify the respective
rights, obligations, and potential liabilities of con-
sumers, patients, providers, and other stakeholders
in PHR systems.
Privacy
The Committee notes that unique privacy issues arise
in relation to PHR systems offered by third parties,
including some emerging systems that warehouse
and mine personal health data for secondary uses.
The Committee is concerned that some business
models involving third-party data warehouses could
be predicated on the secondary use (including sale
or barter) of consumer data. Consumers using these
PHR systems may have little control over second-
ary uses by the PHR vendor. Although there are
Privacy measures at least equal to
those in HIPAA should apply to all
PHR systems, whether or not they
are managed by covered entities.
Recommendations
on Privacy:
3. Education about privacy
4. Best practices
5. Privacy in HHS-sponsored
activities
6. Privacy in activities by
entities not covered by HIPAA
7. Assessment
Personal Health Records and Personal Health Record Systems
21
beneficial secondary uses of data, such as post-marketing
surveillance of adverse events from prescription drugs
or population health monitoring, other secondary uses
(e.g., targeted marketing) may not be desired by the con-
sumer. Consumers should have the right to make an informed
choice concerning the uses of their personal information
when signing up to use any of these personal health record
products or services.
While HIPAA compels covered entities to provide notice of
their privacy practices to consumers, not all PHR vendors are
“covered entities” as defined under HIPAA. The Committee
is unaware of any requirement that compels PHR vendors
not covered by HIPAA to provide to consumers the terms and
conditions governing the privacy of their personal data. While
the Committee does not suggest that HIPAA or a HIPAA-like
framework is necessarily the most appropriate for
safeguarding privacy in PHR systems, it does believe that
privacy measures at least equal to those in HIPAA should
apply to all PHR systems, whether or not they are managed
by covered entities. The Committee also believes that it is
vital for PHR systems vendors to provide clearly stated,
easily understood, up-front privacy notices to consumers of
their privacy policies and practices, and that these notices
should be translated into other languages.
The recommendations below indicate some initial steps that
should be undertaken to address these concerns. However,
the Committee believes that these issues are entwined with,
though not necessarily identical to, the privacy and
confidentiality issues that must be addressed within the
context of the National Health Information Network (NHIN).
The NCVHS Subcommittee on Privacy and Confidentiality
has been conducting hearings on privacy and confidentiality
and the NHIN, and additional recommendations will
be forthcoming.
Recommendation 3:
Education about privacy. In any public education program
about PHR systems, HHS and other parties should inform
consumers about the importance of understanding the pri-
vacy policies and practices of PHR system vendors, including
the enumeration of potential secondary uses and disclosures
of personally identifiable health information.
(See Recommendation 2.)
Recommendation 4:
Best practices. HHS should identify and promote best
practices with respect to privacy policies and practices for
PHR systems, and models for plain language wording of
notices describing these policies and practices. These best
practices and models should also address translations into
other languages.
Recommendation 5:
Privacy in HHS-sponsored activities. For any HHS-
sponsored pilot projects, and any contractual relationship
that CMS undertakes with entities intending to utilize CMS
data in PHRs, HHS should require that those PHR systems
provide advance notice to consumers of any uses or disclo-
sures of personally identifiable health information. In those
situations where HIPAA does not apply, uses or disclosures
of information in PHRs should not be allowed without the
express consent of the consumer.
22
Personal Health Records and Personal Health Record Systems
Recommendation 6:
Privacy in activities by entities not covered
by HIPAA. Entities not covered by HIPAA that offer PHR
systems should voluntarily adopt strict privacy policies and
practices and should provide clear advance notice to con-
sumers of these policies and practices. This notice should
specifically include a full description of all uses of PHR data.
In addition, NCVHS recommends that no health information in
a PHR be used without the express consent of the consumer,
which may be obtained in conjunction with the notice.
Recommendation 7:
Assessment. HHS should collaborate with other Federal
agencies as appropriate to review and assess issues related
to privacy and other consumer protections for PHR systems.
Such a review should evaluate existing authorities and
mechanisms for addressing potential problems; it should also
identify gaps and recommend appropriate action.
Security is a critical component
of a PHR system, especially if it is
accessible via the Internet.
With an Internet-based PHR
system, multiple individuals,
such as family members and
caregivers, may view and
contribute patient information.
Ensuring authentication and
access control in this context
represents a major challenge.
Personal Health Records and Personal Health Record Systems
23
Security Requirements
NCVHS noted that security is a critical component of a PHR system, especially if it is accessible via the Internet.
Appropriate security measures must be employed to minimize the risk that an unauthorized person could gain
access to an individual’s information contained within a PHR. Survey and focus group research presented to the
Workgroup indicates that widespread adoption of PHRs is not likely to happen until consumers are confident that
they have adequate security protections. This confidence seems to depend on having the ability to control access
to personal information and to audit who has seen it. As noted, the Committee found that PHR systems may exist
in a variety of forms. Some of these may be within the exclusive control of the individual, such as a smart-card or
thumb-drive based system. The large majority are currently Internet-based, such as those sponsored by healthcare
providers, health insurers, or commercial ventures. New technical approaches may be needed to promote and
achieve personal control over the creation, management, and exchange of personal health information contained
within PHRs. The HIPAA Security Rule, as noted, has limited application. However, there is broad validity to its
observation that specific security requirements will vary
over time based both on threats, available security tech-
nologies and requirements inherent to a particular PHR.
As noted above, the HIPAA Security Rule only applies to
covered entities.
In a healthcare setting, the provider can control
the access of employees and affiliated staff to a
patient’s information in an EHR. With an Internet-
based PHR system, in contrast, multiple individu-
als, such as family members and caregivers, may
view and contribute patient information. Ensuring
authentication and access control in this context
thus represents a major challenge. Further, while
healthcare providers can use a variety of advanced
technologies to secure an EHR, there is some ques-
tion as to whether consumers generally are willing
to accept the burdens or costs associated with the
use of enhanced security technologies. The wide-
scale adoption of such technologies for PHR systems
will therefore be problematic, and security for PHR
systems will probably be limited to technologies
that are generally available for desktop operating
systems. Further complexity is added by the multiple
sources for information on the individual, includ-
ing provider EHRs and external laboratory systems
providing test results. Ensuring that the source of
the information and the contents are authenticated
and can not subsequently be changed (i.e., can not
Recommendations
on Security:
8. Security standards framework
9. Security in HHS activities
24
Personal Health Records and Personal Health Record Systems
be repudiated) is part of the challenge. The Committee plans
to explore the issue of non-repudiation (i.e., authenticating
the integrity of the contents and exchange of information) as
it relates to PHR systems. Here it offers recommendations
pertinent to the other issues raised above.
Recommendation 8:
Security standards framework. HHS should work with
relevant stakeholders to develop and promote a standards
framework for authentication, access control, authorization,
and auditability based on the following principals:
n All PHR systems should provide consumers with
terms and conditions of use.
n All PHR systems should provide functionality
that enables a consumer to audit who has
accessed the consumer’s information
within the PHR.
n All PHR systems should be based on industry-
standard security and authentication schemes.
This should not preclude vendors from making
additional security protections available
at the option of the consumer. The decision to
adopt additional security technologies should take
into consideration portability, supportability and
cost of such solutions.
n PHR systems should include functionality that
provides a consumer with the ability to control
who accesses the consumer’s information
within the PHR. This would include the ability
for the consumer to restrict access to specific
subsets of information within the PHR.
Recommendation 9:
Security in HHS activities. For any HHS-sponsored pilot
projects and any HHS contracts to produce PHR systems,
HHS should require that security protections consistent with
the HIPAA Security Rule be implemented.
Interoperability is limited in
a number of ways.
The greatest opportunities for
improving health and health care
lie in enabling information
exchange between the three
dimensions (areas) of the national
health information infrastructure.
The full potential of PHR systems
will not be realized until they are
capable of widespread exchange
of information with EHRs and
other sources of personal and
other health data.
Personal Health Records and Personal Health Record Systems
25
Interoperability
As observed at the beginning of this report, the greatest opportunities for improving health and health care lie
in enabling information exchange between the three dimensions (areas) of the national health information infra-
structure. Consumers, providers, and those responsible
for population health use much of the same informa-
tion, but they do so for different purposes: respectively,
to manage personal and family health, to care for
patients, and to protect and promote the health of
the community and the nation. The overlapping areas
shown in the diagram on page 12 illustrate the types
of information that will be shared and the need for
interoperability. Interoperability is the term used to
describe the technical capacity for this exchange
of data between different information systems.
The full potential of PHR systems will not be realized
until they are capable of widespread exchange of
information with EHRs and other sources of personal
and other health data.
Currently, interoperability is limited in a number
of ways. First, most PHR systems in use today are
integrated with one provider’s EHR system, in effect
serving as a portal view into the EHR. This provides
tight integration between what the patient sees and
what the provider sees. However, if EHR systems
are not interoperable, the content would be primar-
ily limited to what is stored in that provider’s EHR.
In all likelihood, the data from other providers or
other data sources would not be accessible to the
patient’s PHR. Hence under those conditions, the
value to consumers exists only in the narrow context
of their treatment relationship to that provider.
Interoperability is even more limited at present
for most stand-alone PHR systems, which require
consumers to manually enter their health data.
None currently exchanges information with EHRs
electronically, although some pilot projects to do
so are underway in both the Federal and private
sectors. While stand-alone PHR systems could
potentially contain data from multiple EHRs, the
current lack of interoperability standards impedes
the flow of information between any one EHR and
a stand-alone PHR.
Recommendations
on Interoperability:
10. Addressing standards gaps
11. Consistency of EHR and
PHR standards
12. PHR data sets
13. Standards for HHS-
sponsored activities
14. Standards for private-
sector activities
Standards development efforts to date
have not focused on certain key areas
that would be necessary for optimum
PHR implementation.
26
Personal Health Records and Personal Health Record Systems
Standards development efforts to date have not focused on
certain key areas that would be necessary for optimum PHR
implementation. Significant work is needed on the following
issues: user authentication, identification of the data source
(consumer, family member, caregiver, provider, other), non-
repudiation, communication to and from PHR systems,
mapping of medical jargon to consumer-oriented information
and terms, and enabling consumer-controlled access.
The Committee heard broad agreement that a core or limited
set of personal health data is important for PHR utility,
although there was no consensus on a particular data set.
Agreement on a specific minimum or core data set could
help promote interoperability.
Recommendation 10:
Addressing standards gaps. Standards development
efforts should be expanded to address issues related to
authentication, identification of the data source, non-repu-
diation, communication to/from PHR systems, mapping to
consumer-oriented concepts and terms, and the enabling of
consumer-controlled access.
Recommendation 11:
Consistency of EHR and PHR standards. HHS should
encourage standards development organizations, wherever
possible, to adopt for the PHR those standards that are used
to promote interoperability of EHRs.
Recommendation 12:
PHR data sets. HHS should encourage standards develop-
ment organizations, wherever possible, to identify data
sets for PHR systems that are consistent with those used
for EHRs.
Recommendation 13:
Standards for HHS-sponsored activities. For any HHS-
sponsored pilot projects and any contractual relationship that
CMS undertakes with entities intending to utilize CMS data
in PHR systems, HHS should require that PHR vendors and
health care organizations adopt data content and exchange
standards that are based upon standards accepted for EHRs,
as a way of improving the interoperability of the systems.
Recommendation 14:
Standards for private-sector activities. Private sector
PHR vendors and health care organizations should voluntarily
adopt data content and exchange standards that are based
upon standards accepted for EHRs, as a way of improving the
interoperability of the systems.
The Federal government can offer
vision and strategic leadership for
PHR development and dissemination
across its many roles in the health
sector. NCVHS believes that HHS
can encourage and actively participate
in a public/private partnership
that facilitates standards-based
approaches in a harmonized legal
and regulatory environment across
geopolitical boundaries.
Personal Health Records and Personal Health Record Systems
27
The Committee heard testimony that the Federal government can offer vision and strategic leadership for PHR develop-
ment and dissemination across its many roles in the health sector—that is, its roles as policy maker, healthcare provider,
payer, employer, and sponsor of research and public education. The Committee notes that a number of documents
already exist that can help identify specific opportunities, including the report cited on page 12 of this Report. Several
Federal agencies are already pursuing the use of or interaction with PHR systems to support their own missions (e.g.,
CDC and CMS, DoD and VA). Development of harmonized definitions for PHR systems and EHR systems will help coordi-
nate these efforts with other Federal agencies, thereby
preventing unwanted duplication and confusion among
users and promoting needed interoperability. NCVHS
believes that HHS can model its role on the one it plays
with respect to EHR adoption. That is, it can encourage
and actively participate in a public/private partnership
that facilitates standards-based approaches in a harmo-
nized legal and regulatory environment across geopoliti-
cal boundaries. The Committee heard that the Federal
Employee Health Benefits Plan could provide a vehicle
for encouraging PHR system use and assessment. An
additional federal role is to provide for experimentation
and research to facilitate the evolution of PHR systems,
as described below.
Federal Roles in PHR
Systems, Internal
and External
Recommendations
on the Federal Role:
15. Assess Federal roles
16. Considerations for
underserved populations
28
Personal Health Records and Personal Health Record Systems
Recommendation 15:
Federal roles. Federal agencies should assess how they can
more fully explore and appropriately promote the benefits of
PHR systems across their respective roles.
Recommendation 16:
Considerations for underserved populations.
The Federal government should identify and address the
information technology access and use barriers that limit the
dissemination of PHR systems, particularly to underserved
populations. HHS also should address health literacy issues
that could limit the use of PHR systems by the most vulner-
able populations.
NCVHS observed that the ability of people to easily connect to
their health information source, either by the Internet or other
means, will be a determining factor in the widespread success
of PHR systems. There are limited examples of PHR systems
supporting underserved populations in rural and urban areas.
The Committee identified broad areas for
research and evaluation for PHR systems.
These areas include consumer, health
services, and technical research and the
development of metrics to assess the
implementation and impact of PHR
systems on multiple dimensions of
health and healthcare.
Personal Health Records and Personal Health Record Systems
29
The hearings identified numerous issues regarding PHR systems that require further research and evaluation—for
example, who uses them and how, interactions with health services, and impacts. NCVHS found that much of the
currently available information about PHR systems is based on expert opinion and focus groups. It concludes that a
variety of research, evaluation, and pilot studies are necessary to answer key questions and allow comparison of PHR
system types and approaches. Findings from rigorous research and evaluation studies will increase the evidence base
for the effective implementation and use of PHR systems. At least some of the needed research may be conducted as
an extension of current and planned research into EHR systems. The Committee estimates that the amount of funding
required for PHR systems research would be a mod-
est percentage of ongoing and future health IT and
EHR research efforts.
The Committee identified broad areas for research
and evaluation for PHR systems. These areas include
consumer, health services, and technical research and
the development of metrics to assess the implemen-
tation and impact of PHR systems on multiple dimen-
sions of health and healthcare.
Advancing Research
and Evaluation
on PHR Systems
Consumer Research
Consumer research should identify who is adopting PHR
systems; how individuals use the systems; barriers to adop-
tion and successful use; and access, pricing and usability
issues, among other things. Identification of these factors
can inform decisions about the functions and drivers for
PHR systems adoption. When overlaid with the different
types of PHR systems that the Committee has identified, the
health care and technology industries can design successful
products that will match consumers’ needs and preferences,
and the Federal government can more easily identify the best
purposes for any Federally-sponsored or Federally-promoted
PHR system.
Health Services Research
Health services research should address issues
related to PHR systems’ impact on workflow,
particularly its effects on efficiency and utilization.
While there are presumptive positive relationships
between PHR systems and patient safety, healthcare
quality, costs, and individual and population health,
the actual impact is unknown. Some areas for fur-
ther research with respect to patient management
include whether and how PHR systems change the
way individuals relate to healthcare providers and
the healthcare system; whether PHR systems lead
to better self-management of chronic conditions;
Recommendations on Advancing
Research and Evaluation:
17. HHS research
18. OPM pilots
19. AHRQ research
20. CMS pilots
30
Personal Health Records and Personal Health Record Systems
Next Steps for NCVHS
Recommendation 18:
OPM pilots. HHS should collaborate with the Office of
Personnel Management to help implement pilot studies of
PHR systems with payers and beneficiaries of the Federal
Employees Health Benefits Plan.
Recommendation 19:
AHRQ research. The Agency for Healthcare Research and
Quality (AHRQ) should expand its evolving health information
technology research portfolio to support health services re-
search and the development of metrics to assess the impact
of PHR systems on quality of care, patient safety, and patient
outcomes.
Recommendation 20:
CMS pilots. The Centers for Medicare and Medicaid Ser-
vices (CMS) should conduct pilot studies of PHR usage for
chronic diseases to evaluate utility and cost effectiveness for
beneficiaries, providers and payers.
whether PHR systems improve the availability of clinically
relevant information before, during and after encounters;
and whether PHR systems contribute to modifying unhealthy
life-style behaviors such as smoking, lack of exercise, and
poor diet.
Technical Research
Technical research would examine methods to optimize the
interface between PHR and EHR systems; the optimization
of standards for interoperability; approaches to authentica-
tion, identification, and role-based permissions; and the
ability to execute data-source annotation.
Metrics
NCVHS concludes that a series of metrics around PHR
system usage, processes, outcomes, and impacts should
be identified and tested. Metrics should also monitor the
quality, validity and reliability of records management of PHR
system data, including the concordance of consumer/patient-
entered and provider-entered data.
Recommendation 17:
HHS research. The Secretary should request that all agen-
cies review their research portfolios and program operations
and report to the Secretary the ways they could contribute
to the research and evaluation of PHR systems.
Personal Health Records and Personal Health Record Systems
31
The National Committee will continue to gather information on this dynamic field. In particular, it plans to release
additional recommendations on privacy, confidentiality and the NHIN. In addition, it will provide a forum for exploring
the following issues that arose from the initial hearings:
n The role of CMS
n Ownership and control of data within PHR systems
n The ability of PHR systems to obtain data from external sources such as provider systems, claims
clearinghouses, health plans and similar sources
n Non-repudiation (authenticating the integrity of the contents and exchange of information)
n Potential liability for providers associated with the use of incomplete or inaccurate data within a PHR
n Privacy policy practices, including notice
Next Steps for NCVHS
32
Personal Health Records and Personal Health Record Systems
Notes
Personal Health Records
and Personal Health
Record Systems
