Setting new standards: insurers are working to bring portable personal health records closer to reality.

[ILLUSTRATION OMITTED]

Imagine walking into your physician's office armed with your full medical history, on a piece of paper that you printed out from your home computer.

That "what-if" situation is quickly becoming more of a reality as use of personal health records--PHRs--continues to climb.

Now the health insurance industry is trying to take patients' personal records a step further by making them portable.

National health insurance trade association America's Health Insurance Plans and the Blue Cross Blue Shield Association hope to meet the industry's goal to incorporate the record's core data elements and implement portability standards by the end of this year.

A Personal Approach

Health plans are playing an integral role in helping meet that goal.

Over the past several years, a number of carriers have implemented their own versions of the records, or are planning how to set up these records.

Today, more than 90 million consumers have access to these records through their insurers, said AHIP spokeswoman Susan Pisano. But are consumers taking advantage?

Not yet, according to a 2005 survey by market research and advisory services company Health Industry Insights. It found 82% of consumers said they were "uncertain" about when they would use a PHR, with only 3% indicating they would use it in the next one to six months. Eight percent plan to never use one.

While momentum slowly grows, confusion still exists about these type of health records. Often, the records mean different things to different people.

PHRs differ from electronic medical records in that they're used by individual consumers who control use of the data and designate who has access to it. They contain a core set of medical information, such as physician office visits, lab results, medications, illnesses and hospitalizations, family medical history and care alerts. Electronic health records, on the other hand, are used by providers and contain detailed clinical information about patients.

Electronic records have garnered national attention over the past five years. In 2004, President Bush announced a comprehensive initiative to digitize the health care system and issued an executive order calling for most Americans to have a personal electronic medical record within 10 years.

Making Connections

Until now, information stored in PHRs lacked consistency. Patients were unable to take their records with them if they left one health plan and went with another, said Jeanette Thornton, director of health informatics for AHIR 

Consumers and providers are demanding the industry change that. They're looking for plans to conform to a single standard for content, she said.

In 2006, AHIP and the Blues Association agreed to begin working with member plans to standardize information. They conducted consumer and physician focus groups to identify key information from claims and administrative data, along with consumer information, that should be included in PHRs.

[ILLUSTRATION OMITTED]

Results unveiled the need for portability for consumers so they can take information in their records with them if they change jobs, switch health coverage or become eligible for Medicare.

As part of the process, 10 health plans pilot-tested standards and demonstrated that the model works.

"The goal was to make sure health plans are able to take the information, package it in a standard way and send it to plans so they could read the information," said Thornton.

One of the 10 pilot plans was conducted by Horizon Blue Cross Blue Shield of New Jersey, which introduced its first-generation PHR several years ago to allow members to populate data. Jeff Kaminski, manager of product development for the Newark, N.J.-based health plan, said it will take "time, resources and budget, along with commitment from many companies to help members to accomplish the [AHIP/BCBSA] model."

Horizon is in the planning phases to extend its PHR offering by unveiling a more robust personal record. The future version would use claims data to provide evidence-based recommendations to members, and grant providers permission to access patient information, he said.

Moving Ahead

In November 2007, AHIP, in partnership with the Blue Cross Blue Shield Association, completed its second phase of work, focused on standardizing member-entered data such as over-the-counter medications and health risk factors, "as well as what standards we would agree to for lab test results," said Thornton. "It will take additional time for implementation because they're more complex."

AHIP and the Blues Association also adopted guidelines recently that require individuals to approve the transfer of their record data from one insurer to another. The new rules permit the transfer to take place only after the individual is enrolled in the new plan.

In December 2007, the two associations, along with Health Level Seven Inc.--a nonprofit organization involved in developing international health care standards--signed a memorandum of understanding to create a collaborative process for the maintenance of portability standards for the records. The implementation guide contains technical standards, a data dictionary and operating rules for transferring the record data from one insurer to another.

HL7 will maintain the technical standards of the implementation guide along with the American National Standards Institute Accredited Standards Committee x 12 (ANSI ASC x12), which is the national standards body for the development and maintenance of electronic data interchange standards.

AHIP and the Blues Association also have announced partnerships with two standards development organizations for joint long-term maintenance of the transfer standard.

Widespread use of PHRs supports the goal of the Nationwide Health Information Network, a governmentled project to promote nationwide connectivity and interoperability.

Government also is getting involved in furthering their utilization, last year, eight health plans began participating in an 18-month federal pilot project to test the usefulness of online records for Medicare Advantage members. The Centers for Medicare and Medicaid Services, the federal pilot-sponsor, plans to use the results to help design a user-friendly system that will enable all 42 million Medicare beneficiaries to have their own records. That figure includes more than 8 million enrolled in Medicare Advantage plans and nearly 17 million in Prescription Drug Plans.

Following the Lead

A number of health plans are aligning with the industrywide portability and interoperability standards goal.

Cleveland-based Medical Mutual of Ohio recently began collaborating with its 23,000-physician network to promote its transportable record, called iHealth, which provides access to a patient's personal health information at the point of care. Patients manage and control access to their records, which can be updated with claims and drug data or integrated with an electronic medical record, iHealth, with 1.6 million members, is powered by San Francisco-based Medem.

"iHealth empowers patients to take a more active role in their health care and improves accuracy of information across the continuum of care," said Bob Man, vice president of eBusiness for Medical Mutual. The PHR fulfills AHIP/BCBSA and National Committee for Quality Assurance standards.

"Doctors can use iHealth for all their patients, regardless of carrier, and Medical Mutual is offering a PHR that members can keep for life. If a member leaves the plan, their comprehensive information goes with them," said Mau.

He added that, while the average PHR adoption rate for health plans is about 1%, PHR adoption can be as high as 40% if a physician asks a patient to fill it out.

WellPoint's Anthem Blue Cross and Blue Shield of Ohio is moving beyond the AHIP/BCBSA guidance by working with Kettering Health Network in Ohio, which includes two major medical centers, three other hospitals and a college of medical arts, on an Individual Health Record pilot. The program is supported by technology provider CentriHealth, which provides the infrastructure and clinical applications.

In the unique pilot, a member's Individual Health Record is automatically updated with claims information and true clinical data, such as radiology results, lab results and pharmacy information. Consumers and physicians also receive care alerts to specific health events and opportunities to maximize compliance with evidence-based medical interventions, such as notification of preventive screenings and exams.

The system is able to recognize duplicate data sets, such as claim data and clinical data for the same event, and it rationalizes them into a single record, said Dr. Charles Kennedy, vice president of health information technology.

WellPoint's outcome research company, Healthcare, is working with pharmaceutical firm Novartis to look for evidence of improvements in clinical effectiveness, efficiency of care delivery, safety gains and other clinical measures, he said.

Today, more than 10,000 members and about 1,000 physicians have access to the Individual Health Record in the greater Dayton, Ohio, area. Kennedy said physicians are recognizing the value of the Individual Health Record "because the system provides easy access to a detailed summary of all relevant clinical information, all care management strategies being used by all physicians involved in the care of the patient, evidence-based medicine guidelines applied real-time to each new piece of patient data, and a new way to monitor patient disease exacerbations at home."

Anthem also is combining the Individual Health Record with pay-for-performance incentives, which is also piquing physicians' interest, he said.

"The benefit for members is that they get a layman's view into the same data and rule sets the physicians are using to manage their disease state," Kennedy said. "Members feel empowered to take better care of themselves and feel more connected to their physician care-management plans."

Horizon also is eyeing record portability. But it will work closely with its partner WebMD, which powers Horizon's member health and wellness portal (My Health Manager) and its PHR, "to help us with portability of the records," said Kaminski.

Thornton is excited about what standardized records will bring to the industry, including "the opportunity to provide great service for consumers. In a way that eliminates the need for each plan to develop its own method of doing it," she said.

"One reason many people said it would be a challenge for plans to implement PHRs is because individuals often change insurers," Thornton said. "Having the ability to have information portable--if they're interested in that--adds much value to health plan membership."

Standards also will help integrate records into care management to help consumers make healthier lifestyle changes, Thornton said. It's then up to each plan to decide what features and functions they want to incorporate in their health records, she said.

[ILLUSTRATION OMITTED]

Already, PHRs are a game changer in the industry by helping close the gaps of care. "We would be able to send specific secure messaging to members, allowing for stronger interventions to benefit them," Kaminski said. For instance, if a patient has diabetes, and he opts to share the PHR information with his physician, the record can alert the doctor to the patient's lack of medication compliance. The record also would notify the patient if he is overdue for an annual eye exam.

Kennedy said that records also can help avoid poor patient outcomes in select care settings, such as emergency rooms, by giving physicians a baseline set of information for patients they may have never met before. "By having access to a PHR in these settings, it's possible to avoid complications and duplication of services, resulting in significant cost savings," he said.

Looking Ahead

"Eventually, we foresee members being able to load information from home-based devices, such as glucometers, into their personal health records," said Kaminski. But value-adds like that will take time. "We don't expect a lot of quick wins from PHRs, but longer-term results will help save lives and dollars," he said.

Kaminski believes within the next five to 10 years, "portability will be worked out and every plan will have its own unique version of an automated PHR that will be a nice linchpin for members to use to make better health care decisions"

AHIP and the Blues Association now am working with members toward implementing an industrywide PHR transfer standard in December, said Thornton.

"It's always a challenge with a new technology to increase consumer uptake," she said. "As plans begin to roll out PHRs, the next step is ensuring they have an effective communication plan in place, are working to increase uptake and making people more aware of what's available to them."

The ultimate goal in the industry is to eventually make PHRs, electronic medical records and electronic claims information interoperable.

Thornton said AHIP is looking to the federal government to help make that happen.

In the meantime, Pisano said, it won't be long until many more consumers recognize the potential of having their own record of their health.

"We need an engaged population to improve health care quality," Pisano said. "Halt" of America now lives with a major chronic disease that requires individuals to participate daily in managing their condition. We need tools and help to ensure we're doing things we should be doing."

* State of the Market: Utilization of personal health records continues to slowly grow.

* What's Being Done: America's Health Insurance Plans and the Blue Cross Blue Shield Association are working toward implementation of an industrywide PHR transfer standard by the end of the year.

* What Lies Ahead: More health plans will continue to develop their own versions of PHRs.

Personal Health Records' Link to Life Insurance

While personal health records have proven their value in the health care arena, some industry experts believe they also may have a future home in life insurance.

"Technology will be the game changer for the evolution of distribution of life products," said Robert Kerzner, president and chief executive officer of life insurance and financial services trade associations Limra International and Loma. "One particular area that has great potential is the ability to have clients' medical records available, in real time, in one location."

[ILLUSTRATION OMITTED]

He said that could potentially cut weeks or even months off of underwriting. "Today, we write and issue checks to three to five physicians and often wait six to 12 weeks for a response. If we could instantly collect that data, it could have a systemic impact on distribution and increase producer productivity."

Not only that. "This could the missing link to get us to a world with instant issue of life insurance and other risk products in real time, but at very competitive rates," Kerzner said.

Personal health records also would reduce underwriting costs significantly, he said. "Consumers would more likely be placed in the right class, allowing us to charge each individual as fairly as possible to the risk due to more complete records."

He also believes the records have the potential to speed up the payment of disability claims. "It's often a lengthy, time-consuming process to ascertain medical history to verify issues such as disability," he said. "Having individuals' personal health information would allow us to reduce time and expense dramatically, associated with paying those claims."

But life insurers will first have to dispel consumers' privacy concerns when it comes to their confidential medical information, he said. "As an industry, we'll have to go to great lengths to make certain consumers and their medical data are well protected."

He said the Veterans Administration is a model for demonstrating the value of electronic patient records. Several years ago, the VA developed a secure patient portal known as My HealtheVet to allow U.S. veterans access to a PHR, online health assessment tools, mechanisms for prescription refills and making appointments, and access to high-quality health information.

"A decade ago, the VA's medical care wasn't viewed as very good, but today is rated among the highest, The difference? Instant access to all medical records of patients" he said.

"That kind of availability in real-time could be a huge change for the life insurance business."

Learn More

Anthem BCBS 

Partnership Plan Inc.

A.M. Best Company # 64855

Distribution: Broker/agents. consultants, internal sales, direct

Horizon Healthcare

Services Inc.

A.M. Best Company # 64022

Distribution: Brokers, benefit consultants, direct

Medical Mutual of Ohio

A.M. Best Company # 04693

Distribution: Brokers, in-house sales

For ratings and other financial strength information visit wwvw.ambest.com.