Public Health in an Era of Personal Health Records: Opportunities for Innovation and New Partnerships

Published in the Journal of Medical Internet Research (2010;12(3):e33), this article explores the implications of electronic personal health records (PHRs). As the authors explain, in the near future, United States (US) citizens will be able to control and manage their own health information through PHR systems and tools. They note that the clinical benefits of this innovation, such as cost savings, error reduction, and improved communication, have been discussed in the literature and public forums, as have issues related to privacy and confidentiality. However, far less attention has been paid to the benefits these tools will have for public health.

The introductory section explores electronic PHRs and their capabilities. As explained here, such a PHR can take multiple forms, ranging from stand-alone software for one's computer to secure websites tethered to a specific practice or organisation to general secure websites as platforms to integrate various kinds of health information. Each of these approaches supports different health needs such as tracking visits and costs, enabling secure email with physicians, scheduling appointments, refilling medications, and/or integrating clinical care. Some PHRs offer "read-only" access to one's medical record, while others allow individuals to control who gets to view what within their record.

The authors highlight the potential benefits of PHRs in terms of 5 core public health services:

1. Monitoring population health status: "For example, through PHRs, individuals could easily, cheaply, and en masse share their health data anonymously with public health agencies, in essence creating 'sentinel citizen' networks. Such networks could be both passive, where population data is anonymously analyzed in order to assess the prevalence of health issues, and active, where citizens elect to share targeted health information of interest to public health agencies." The authors suggest that this sharing "opens the door to a new kind of bidirectional relationship between individuals and public health". They cite the example of one of the few survey systems in the US that has a bidirectional relationship with participants: the CDC's National Health and Nutrition Examination Survey (NHANES). A routine part of the NHANES process is to synthesise survey findings and package them with a participant's own health information as a "report of findings", which is then sent through the mail to the NHANES participant. The authors contend that PHRs have the potential to streamline this process by offering to provide a participant's health information in electronic form for integration with their other personal health data. Finally, they explain that PHRs have the ability to put some data management processes into the hands of individuals, allowing them to play a key role in maintaining the accuracy of their own personal health information.
2. Investigating outbreaks: "Combining PHRs with current and anticipated tools (e.g., location-tagged mobile phone pictures linked to personal health information) could make it much easier for individuals to assist public health with real-time reporting during and after outbreaks and disasters." Furthermore, a feedback loop could be created whereby individuals could get back information of value (timely, personalised, and localised public health alerts and notifications) in return for sharing their information with public health.
3. Informing, educating, and empowering: "PHRs offer the potential for deeply tailored health promotion opportunities that could go far beyond current strategies to improve health behaviors. Strategies include, for example, Web-based programs to improve self-management of diabetes or support tobacco use cessation....[N]ew tools could be designed to use existing PHR data to allow individuals to monitor their data and benchmark their health against those in their zip code, county, state, and nation."
4. Linking people to services: Using the example of influenza vaccination, the authors argue that, through PHRs, alerts could be sent directly to individuals who should receive a vaccination, along with a localised map of nearby clinics offering this service with information on hours, languages spoken, and costs. "By sending this information via a mobile device, public health could harness the power of immediacy...Taking this a step further, PHRs could enable individuals to immediately report receipt of a vaccination (with date, time, and geographic location) to public health monitoring systems, allowing for a more nuanced picture of vaccination behavior trends."
5. Performing research: "For example, PHRs could support the ability to build longitudinal research panels that could support public health research....Additionally, individual self-report data and information...could be used to identify subtle aspects of contextual health behavior and develop more nuanced public health interventions, recommendations, and policies. Such innovation could result in a strengthened relationship with citizens as partners in the public health research process."

While highlighting benefits, the authors also acknowledge challenges, such as the need for public health agencies to contribute more to research focusing on how these tools improve care for at-risk populations. In addition, there are questions of workforce readiness and capacity to take advantage of such tools.