I’m embarrassed to admit this, but over the last week I’ve become addicted to a hideously cute little iPhone app called Shopkick.  The app locates where you are geographically, spits out a list of retailers for you, and when you click on the retailer’s name, typically rewards you with “kickbucks.”

The more kickbucks you get, the higher “level” you’re at, whatever that means — and when you collect, say, thousands of points you can get a $25 gift card. (Yippee!)  In truth, the rewards Shopkick offers probably average out to about 3 cents an hour. Who cares?  I keep playing with the stupid app until I’m out of offers to click.

Now can anyone tell me why the same type of scheme wouldn’t motivate at least some consumers to add data to their PHR on a regular basis?  Small cash rewards are already proving effective at improving medication compliance, after all, and for most people, updating their PHR would be no harder than taking a pill.

In the past, I’ve scoffed mightily at online schemes which reward people for participating in communities, filling out forms or otherwise doing what they’re told.  After all, why should anyone care if a site names them an “explorer” or a “champion” or a “grand poobah”?  But there I am, getting psyched when Shopkick promotes me from level 3 to level 4.  Hey, I can’t help it — every time you level up you get such a cute little chime and a big green bubble to pop…  (Yes, I am otherwise a mature, responsible adult.)

But I’m being taught, by playing with this app, that rewarding people — even with very small incentives — can do an amazing job of getting them to repeat behavior.  Offer patients relevant reinforcement and patients are likely to take the PHR maintenance job more seriously.   What if, for example, a health plan teamed up with a pharmacy retailer to offer discounts on products if patients maintained their data? It could be huge.

But don’t make the rewards too exciting. Hey, you might have to keep releasing new, updated versions of your gaming system to satisfy fans.

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.

An electronic medical record (EMR) is a computerized medical record created in an organization that delivers care, such as a hospital and doctor’s surgery. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.

So, there you have ‘em — the two major terms that compete for attention in our business.  The top definition comes from HIMSS and the second, from Wikipedia.

In the circles where I travel, “EMR” and “EHR” are used interchangeably, but not everyone agrees they should be.  In my mind, for example, the two terms shouldn’t exist — only EMR does the trick.

Why?  To my knowledge, the term “medical record” has a widely-accepted definition, but the term “health record” has no formal place in medical care. And there’s no reason to toss an imprecisely-defined term into the mix when we’re struggling to define so much about digital healthcare. (For what it’s worth, Wikipedia defines the EHR as an “evolving concept.”)

Good Lord, toss in the even more poorly defined term “PHR” and you’ve officially created a conceptual traffic loop which could create traffic crashes for years to come.

But  I know not everyone cares about terminology the way a slightly-obsessed editor does.  What do you folks think?  Do you care which acronym the industry uses?  Does it matter?

Recently, I wrote a piece for this blog arguing that the PHR model was at a turning point — and didn’t hide my doubts that this approach had much of a future.

In response, one of our readers was kind enough to tip us off to a massive PHR project which had never shown up on my radar. Apparently, the Australian government is well into building the infrastructure to support a nationally-available PCEHR (personally controlled electronic health record).

The $467 million project, which is undergoing its second wave of testing and development, will make PCEHRs available to consumers by July 1, 2012.  Nine sites are running related projects, including:

*   A system making prescribing and dispensing data available to 2 million citizens and their providers

*   A project targeting data sharing among palliative care patients and clinicians

*   A site focused on improved health for a population of about 9,000 mothers and newborns

*   A consumer-oriented portal, serving chronically-ill patients, integrating patient-entered medical data into a “Health Book”

The PCEHR project comes as Australian health officials undertake a package of national health reforms, including efforts to increase access to primary care and a $20 billion investment in improving public hospitals.

While I still doubt that the current US approach to personal health records makes sense — who decided consumers would bother with a sort of “extra” set of records designed to make key data available in a poorly-defined emergency situation? — rolling out PHRs aggressively as a key component of a primary care-oriented national health reform makes a great deal of sense.

I’m eager to see how Aussie citizens respond next year when the PCEHR goes live.  If consumers are convinced that the personal record is the key to better health, I’m sure they’ll jump on board.

So,  Google is going through some internal upheaval as co-founder Larry Page prepares to take over the reigns as CEO.  According to an piece appearing in today’s Wall Street Journal, Page is aggressively reviewing existing projects and is likely to take an axe to those that don’t seem to be working. Does it surprise any of you that one of the programs facing cutbacks may be Google Health and its faltering PHR?

As HIT expert Shahid Shah notes, Google has created some decent PHR technology — but despite having a vast reach and rich resources, hasn’t figured out how to grow its user community.  Even with its massive bank account, I’m not surprised to see that it hasn’t turned healthcare into a major income source. Google just isn’t that great at going outside of its box.

Then, consider that Microsoft doesn’t seem to be pushing Health Vault very hard these days, and you’ve got to wonder whether the whole “massive tech company builds PHR” thing can possibly work.   Yes, I realize I might get flamed by Microsoft execs saying this, but let’s get real here.  Microsoft isn’t great at connecting to markets it doesn’t monopolize either.

Oh the other hand, evidence is mounting that PHRs may be popular when driven by a provider and its own EMR.  Perhaps the highest-profile example of this may be Kaiser Permanente’s EMR/PHR ecosystem.  Its “My Health Manager” PHR system is closely integrated with its Epic EMR installation and now has millions of users.

Why is Kaiser succeeding at generating PHR interest where Google has failed? It’s largely because rather than offering a mixed bag of apps and options, as tech vendors have been doing, My Health Manager allows patients to securely exchange messages with physicians, refill prescriptions, review test results and schedule medical appointments.  Patients aren’t being asked to become updater and curator of their medical information, but rather, to use it. This just makes sense.

As I see it, the whole notion of a PHR as a freestanding app is basically circling the drain.  Realistically, patients have little incentive to interact with their health data unless it has some immediate impact on their lives.  An EMR/PHR combination, on the other hand, has tremendous potential, as it connects patients to both their providers and their health data effectively.  If I were Microsoft or Google, I’d just throw in the towel at this point.

I found an interesting article on Fast Company talking about the Facebook for Patients. Of course, I’m a sucker for anything that says Facebook and patients, so I had to check it out.

Turns out the article talks about a new Medical Social Network from IBM. Officially it’s being called the IBM Patient Empowerment System. From the description, it’s an interesting mix of PHR functions where you record your health information, patient to patient interaction like PatientsLikeMe, patient to doctor interaction, and even FDA alerts and drug checking.

Of course, I wanted to try this IBM patient empowerment system out myself, but the article didn’t have a link to it. So, I headed to Google and found no website, but the first result was this video about the IBM PHR along with some press releases:

Pretty hard to judge a system if you can’t use it. Plus, it’s hard to interact with other patients if patients can’t find the portal.

I suspect that the reason I can’t find the portal is that it seems like they’re doing a beta test of the website with Gacheon University Gil Hospital in Korea. It doesn’t seem like they’ve opened up the system to everyone yet. It will be interesting to see if they continue to do a partner based approach for rolling out the IBM PHR or if they choose to open it up to anyone and everyone that wants to join.

I’d say the most controversial part of what they’re doing is probably the FDA alerts and drug checking. This tweet by Neil Versel, blogger at Meaningful Health IT news, describes why these types of alerts and information is going to require a change:

Attitude adjustment needed, stat! RT @amednews: Only 8% of doctors say online research done by patients is helpful http://bit.ly/g5Yrzq

March 12, 2011 8:15 am via ÜberSocialReplyRetweetFavorite

@nversel

Neil Versel

The challenge to doctors is whether IBM does it or someone else, the empowered patient is already happening. IBM’s Facebook for Patients is just one piece in the puzzle.

Tonight, I checked out the always-interesting #HITsm TweetChat, which attracted a nice group of informed HIT experts. (It takes place from 8PM to 9PM Central Time on Mondays — I highly recommend you attend sometime.)

While the conversation wandered, as professional chats always do, one theme that came up a few times was the importance of PHRs in the overall healthcare data picture. I watched with interest, since I’m a real PHR skeptic and wondered if anyone had a  breakthrough idea on the subject.

One poster — if I understood him correctly — noted that while he didn’t trust Google or Microsoft PHRs, he’d manage his own health data gladly if it was stored on a very secure, easy-to-populate tool like financial site Mint.com.  I thought this was a tremendously good idea.

For those who haven’t used it, Mint.com allows consumers to suck data from bank and credit card accounts, loans and more into a single interface, making it easy to check on and edit the data with a few clicks.  Not only that, it allows you to create analytical charts, monitor for problems and set goals.  Just imagine how useful those functions could be for personal health maintenance.

Having used Mint.com happily for my personal finances, I yearn for the day when health data is equally accessible and manageable.  It’s easy to imagine — though admittedly, a tall order technically — interesting consumers in building out PHRs if they had access to a simple interface and secure connections to all needed data.

Unfortunately, I don’t know of any PHR that’s quite this sophisticated. Is it time for Intuit (Mint’s owner) to go into the PHR business?

I recently was contacted by a guy named Matt from Poland who had built a simple web application that tracked Blood Pressure called Blood Pressure Chart. If you want to really see what he’s created in action, you can see his own Blood Pressure records, chart and statistics.

I really like the simple implementation of such a niche item such as Blood Pressure. It seems like niche applications for things like Blood Pressure or even blood sugar levels for diabetes could be very useful. I think that many people are just overwhelmed by the idea of using a full PHR software system, but they would be likely to use a simple application like this to track a specific health problem they’re trying to track.

Some work and thought still needs to go into how the doctor and patient will access and document a website like this, but it’s interesting to see the application of technology into such a tight niche problem area. Maybe the focus of an all encompassing PHR product is the wrong direction and instead the focus should be tighter niche products that don’t overwhelm the patient.

I was really interested to read John Moore’s post about the irrelevancy of Google Health leading to its demise. It’s a great post that’s worth a read for anyone interested in the PHR space and in particular Google’s participation in healthcare. I’m a little reticent to bet against Google, but the lack of commitment on Google’s part to healthcare says something. I mean, Google has quite a bit going on with cell phones (Android), web browsers (Chrome), and operating systems (Chrome) just to name a few. You can see why Google Health isn’t high on their priority list. Oh yes, and of course they still have to maintain their dominance in search and all the other products they have (gmail, google docs, calendar, etc etc etc).

With that said, some of the most interesting things were found in the comments of Chilmark’s post. Here’s a couple excerpts:

My college health class used car upkeep as a metaphor for how we take care of our health. With my car, I know I should pay more attention to everything: it’d probably run better if I looked at it more, kept up with the latest from my manufacturer (hey, actually read my owner’s manual).
But honestly? I’m just as happy to pay a mechanic to keep track of what I need, when I need it. The money I pay is as much to escape the tedium of keeping up with all that knowledge as it is for the service itself. I’m willing to bet a lot of people feel that way about health: they probably believe they should be involved, but when push comes to shove they’d rather just pay someone else to worry about it.

This rings far too true. We care, but not enough to really care (at least until we really need to care).

I belive what we are seing here is the end of the B2C direction for PHR. John Moore was the 1st to say that PHR is for B2B model. Google designed it’s solution for B2C (login to data through Google). this was wrong. if you see real addade value apps in the market they are offred as B2B under Microsoft HealthVault.

PHR = B2B Very important lesson learned.

Anyone that works in Healthcare IT knows who John Halamka is and so of course I was interested in his post of his top 10 impressions after HIMSS. It’s an interesting list and I think he does a pretty good job of looking at things from a very high level. Here they are as posted on his blog:

1. Meaningful Use is everywhere. Vendors are promising EHRs, modules, appliances, and services to help clinicians achieve it. I had dinner on Monday night in a small Indian vegetarian restaurant. Sitting next to me were 3 engineers from Bangalore who were arguing about the details of Meaningful Use in between bites of vegetable curry. I could not escape Meaningful Use anywhere!

2. Certification is everywhere. It’s particularly ironic that many vendors claimed their systems were certified, even though the certification NPRM was just released today, making compliance with the new certification process in time for HIMSS impossible.

3. Cloud computing, Software as a Service and ASP models are popular tactics to accelerate EHR rollouts. There are still lingering concerns about how to ensure privacy in a cloud environment.

4. Several firms such as Intersystems, Axolotol, and Medicity are offering HIE platforms that include many of the standards noted in the IFR. The marketplace for HIE products is just emerging and it’s hard to predict who will become the market leader.

5. The Continuity of Care Document is gaining traction. I found many vendors supporting CCD exports from their EHRs. A company called M*Modal , has developed natural language processing technology that captures dictated content in its original context (ontology-driven
rules) as a CDA document.

6. Consultants abound. It’s clear that Regional Extension Centers and Health Information Exchanges will require expertise and staffing from professional firms. They all had large booths at HIMSS.

7. 30,000 people attended, including 10,000 I did not recognize (just kidding). It’s clear to me that many IT professionals, even those with limited healthcare domain expertise, attended HIMSS to better understand how they could participate in the euphoria of HITECH stimulus dollars.

8. Self service kiosks for patient identification and self-registration are now mainstream. Just as we print our airline boarding passes, we can now use credit cards or biometrics to check into ambulatory care appointments and automatically settle all co-pay balances.

9. Image exchange in the cloud is being offered by several vendors. As I mentioned in Monday’s blog, Symantec announced an appliance for small clinician offices that cloud enables all imaging modalities using a facebook-like social networking invitation to share/view images.

10. PHRs and patient engagement are becoming more mainstream. Google and Microsoft continue to innovate in the non-tethered PHR marketplace.

There’s no doubt that Practice Fusion has been making a big splash in the world of EMR. They were the first EMR company that I’d seen that was pioneering the “free” ad based EMR on the web. You can read more about my first impressions of their free EMR offering on EMR and HIPAA. This interview with the CEO of Practice Fusion is pretty interesting as well.

Now Practice Fusion has made the next logical step and added a PHR front end for patients to be able to access their clinical record. From the look of the screenshots (see below), I’m not seeing anything particularly special about the PHR. In fact, I’d likely say that this isn’t much more than an initial PHR offering. Since it is their initial offering, I guess that makes sense. Certainly they’ll be building it out over time.

What I find more interesting about this new PHR is that Practice Fusion built the PHR on top of Sales Force. SaleseForce.com recently made an investment in Practice Fusion and so this seems to be an extension of that partnership. I see this as a really interesting move for Practice Fusion to build a healthcare application on top of the Force.com cloud. It also will be interesting for SalesForce.com to enter the healthcare space.

Check out the following screenshots of the PHR application: