Personal Health Records

Good afternoon, everyone, and welcome to all of our participants for today's webinar. My name is Kris Denick, and I work for the National Human Research Center, and I'll be the moderator for today's webcast. At this time, I would like to introduce Keisha Johnson from the HRSA Office of Health Information Technology. Keisha? Thank you, Chris.

Happy Friday, everyone. Thank you for joining us today for another OHIT-sponsored webcast. In response to feedback from many of you, we have asked today's speakers, Greg Wolverton, Dr. Jim Kahn, and Kathy Ficco to present today's webinar entitled "Personal Health Records." Today's session is one of many efforts our office is making to better provide assistance to HRSA-supported programs on effective adoption and use of health information technology.

Additional efforts include structuring the HIT Technical Assistance Center to coordinate HIT/TA resources across HRSA. And with outside partners, and the development of web-based toolkits customized to meet the needs of HRSA's many program grantees. Teleconferences such as this one will be just one of the many resources that will be made available to you through this TA Center. Our overarching goal is to provide the type of assistance that will empower you to address issues related to the planning, implementation, or evaluation of HIT applications and become educated HIT consumers.

I do hope that you find the following presentation useful and interesting and will participate in the question-and-answer session immediately following the presentation, as well as an online poll on which you can give us feedback on the presentation. Your comments and suggestions will allow us to be responsive to your specific needs and facilitate a broad sharing of HIT knowledge among HRSA-supported communities. In addition, later this afternoon, a discussion board will be opened on this topic on the HRSA Health IT community. I am now pleased to introduce to you our speakers.

First we have Greg Wolverton, CIO at White River Health Rural Health Center. Over the past 20 years, Greg has been employed in technology-related work for private and government entities. In 2002, Greg was selected as CIO for White River Rural Health Center, the largest federally-qualified health center in Arkansas, with 19 medical facilities, three oral health facilities, two wellness centers, and two retail pharmacies. During that time, he has been the technology leader for the organization, with a nearly four-year journey to system-wide PHR throughout the 6800 square miles it covers.

Most recently, PHRs were added to allow patient access to medical information. In 2008, under Greg's leadership, White River Rural Health Center was awarded the prestigious Nicholas Davis Award of Excellence for health information technology. Congratulations, Greg. Greg currently serves as a member of HRSA's national quality faculty, as well as a senior examiner on the board of examiners of the Governor's Quality Award, the Arkansas Institute for Performance Excellence, Arkansas Malcolm Baldridge Award.

Next we have Dr. Jim Kahn. Dr. Kahn is a professor of medicine at the University of California, San Francisco campus, specializing in patient-oriented research in the areas of HIV, pathogenesis, disease modeling, and the development of EHR systems applications.

Dr. Kahn joined the University of California/San Francisco's AIDS program at San Francisco General Hospital in 1987. He has received a career award from the American Cancer Society and two career awards from the NIH. Dr.

Kahn received one of 12 NIH Reengineering Clinical Research awards, and he has provided the clinical leadership for several NIH-funded innovative programs, including the Primary HIV. And Section and Post Exposure Prevention Projects and for the Center for AIDS Research Networks of Integrated Clinical Science projects. He led the development of an EHR system called HERO, which stands for Healthcare Evaluation Record Organizer, and linked the PHR system called myHERO, for the dual purpose of providing a platform for clinical care research. The expansion of clinical data elements and the ongoing creation and harmonization of data elements is the focus of Dr.

Kahn's scholarly activities. Last but not least, we have Kathy Ficco. Ms. Ficco is an RN and executive director for the St.

Joseph Health System Sonoma County Community Health Clinics and Program. She has served as the executive director since 1996 and is responsible for administration, management, and supervision of comprehensive access to care programs that she has fostered, developed, and matured. Ms. Ficco has worked over 30 years in health care and 20 years to increase access to the health care medically underserved population.

The health care senior program received a Best Practice in Community Health award from the Public Health Institute. She received a Community Partnership of the Year award from Santa Rosa City Schools and her leadership of S. Ellen High School Health Center. She has skill and expertise and collaborations that have garnered significant resources in serving vulnerable populations in our community.

In September of 2007, Ms. Ficco was honored to receive the North California Center of Wellbeing Leadership award in health and wellness. Ms. Ficco is the honored recipient of the Sonoma County Public Health Department 2006 Public Health Champion Award for outstanding accomplishments [audio break] accessibility of health services for workers and families among the most underserved in the community.

I would like to welcome all of our presenters today, and I will now turn it back over to Chris. Thank you, Chris. Thank you so much, Keisha. And I would just like to go over, at this point, some of the logistics in regards to the WebEx to all the attendees.

As far as all the attendees, we would like to thank them for taking time from their schedule and participating in this webinar. As far as all the attendees, their phones would be on mute during the duration of this webinar, and they could certainly ask their questions that they would like to be addressed during Q&A via either the chat feature or the Q&A. We would really appreciate if all the presenters do actually -- all the attendees actually address all their questions to all panelists in the drop down just so, you know, all the panelists would receive the listing of your questions, and at that point, what we would do is we would have Chris, who is going to be moderating the Q&A, have an appropriate presenter, have that question addressed, and also while attendees who are on the phone, if they do have a question during the Q&A session and would like to ask it via the phone, they could certainly use the "Raise hand" feature through WebEx, and at which point we will go ahead and unmute their phone lines. And also, all the materials that we are using for this webinar, as well as the recording of this webinar, would be made available on the HRSA Health IT web portal, and we will provide instructions for those who don't have all the -- or using them in the past webinar, where you could send an e-mail and get your user name and password.

And also, we would make that available within about two to three business days from today. With everything said, I would go ahead and like to hand it over to Greg Wolverton, who is going to be one of our first presenters. Well, thank you very much, and I appreciate it. Keisha, thank you for that warm introduction, and Chris, thank you.

At White River, one of the things that we really looked at was, how do we build into personal health records. Well, with it being personal, where do you want to go, how do you want to do it? We're looking at -- just kind of our thought was that -- when we first delved into this, nobody really understood it. But what I want to start with is kind of an overview and utilization of what we're looking at. What is a PHR really? I just went out and looked.

There's all kinds of definitions. But basically, Wikipedia defines it as a personal health record. It's typically a health record that is initiated and maintained by an individual. An ideal PHR would provide a complete and accurate summary of the health and medical history of an individual by gathering data from many sources and making this information accessible online to anyone who has the necessary electronic credentials to view that information.

When I looked at this, I was really intrigued by this definition, because I've really never -- I've seen them similar to this. I've underlined a few things there that really stood out to me and stood out to us at White River while we were looking at ours. You know, specifically the challenge areas were being initiated and maintained by an individual. How do we really get around that with the literacy limitations? How do we provide the patients with tools to do that? Not to mention, overall decision making.

It was really difficult for a lot of the literacy levels on our patient population. Secondarily, we come to a complete and accurate summary. And I think accurate, I'd much rather have accurate than complete any day, I think, when we're looking at, you know, an information perspective. But how does the customer, in this case the patient, do this? How do they make sure their information is accurate? How do they know? Once again, we all tie back into the education and literacy, again, as far as the health literacy.

And how do we gather the data from many sources? How do we bring together many people to the table? We can bring our side, but then other people can bring their side. It's getting everybody together. And then how does the customer -- it was very important to us, how does the customer decide what's important, what's important to them to keep in a personal health record? And how do we decide what necessary credentials are needed for access? Who, what, when, where, and how is access chosen? We may have one patient that says, "Well, my ex-significant other works at this facility, so I do not want my information to go to this facility, but I would want it to go to this facility." So I think there was a lot of challenges that was brought up, and at least in areas to be able to define, and it was really hard to look at. At White River we created what we called -- we looked at the best ways, and we thought, how can we do this? Our views were long, so we created an organizational continuum, as we defined it, and realized that really and truly the way we should be is we have our customer.

They can be external and internal, and we have all of these operations, health information technology, finance, clinical, administrative, everything revolving around our customers, and we should be able to get that information to them. Now where we're at now is to think that a lot of our information that we have is secondary to the patient. I think one of the first things we see is we work around our practice management system and say what it is that we can do in billing or what is it we can do in clinical or case management or pharmacy or anything around our practice management system, and we detract a patient out of that, actually. Where we need to be is, once again, going back to that continuum model where we should put our customer in the center, not be just patient focused, but we should be customer driven and bring everything together and allow them to get their information that they need to be able to complete their record.

I think some and I think see there's a question here. I'm going to answer it. Daniel says, "Do you believe all information at EMR/EHR should be available for the patient via PHR?" My answer to that is, no, and as I get through this, and I can tell you why there are some reasons that you would not want to give the patient's information automatically. Obviously, there's going to be a good example.

An HIV diagnosis would be one that you wouldn't want to put up on the portal for them to see themselves, obviously, without counseling and meeting with the physician, things of that nature. But we do want to give the customer what information we have with their provider of choice through a secure web-based portal. Why not give them lab results after they've been reviewed by the physician, imaging results. Once again, everything is after a review process.

And when we looked at this, we were thinking it needs to be generated by the provider, what information a provider feels comfortable with, even though it's the patient's information. We still need to make sure the provider is being able to work with that patient and get the information out so we don't have any miscommunication. Appointment information is very important, medication information by assessment. What meds am I taking because of my hypertension, or what meds do I have because of my diabetes? That's very important in some of the areas where the literacy levels are low.

And referral information, where do I go, or where do I normally go or my provider normally send me through handle internal medicine affairs, or where do I go for my heart test, et cetera? All this information was very important to us to put it into one place. Now getting all this together, we thought, well, what is the big solution? Well, we want the customer be able to interact. They are very much a stakeholder. You know, we were thinking for a while that we were the only one responsible for their care and we had more of our patients come up and say, "Well, why can't I be responsible for my care?" And throughout all of history, we've been told that that can't happen.

But we took that to heart and said, "Well, let's allow the customer to interact. Why not? Let's let them request appointments. Let's let them request med refills. Let's let them message the provider, request to message the provider.

Let's let them request when it's time for labs if they feel like the need, and also the ability to chart results on their own by pulling up charts and graphs and things of that nature such as hemoglobin A1C." The operative word here is request. We do not want anybody to actually be able to do that because, once again, let's send that back around to the provider and the other people that's responsible for the care. We need to make sure that's all in a continuum as well and we just can't absolutely go out there willy-nilly, if you will, allowing the patients and the customers to go out there to make those direct functions. At the same time, we actually wanted White River Rural Health to be able to interact with our patient.

We wanted to be able to send e-mail notifications of new test results that the provider made available out there by simple checkmarks. We wanted to be able to send appointment reminders via e-mail, via text, via phone calls, that we're able to call the patients. We wanted them to be able to view their statements and, of course, the financial things would be also pay their bills and also recall notifications. We felt that being very important in terms of annual exams for female patients, and pulling up things that are age-specific and anything that could involve a recall.

Those were all important items for us to be able to interact. I think some of the barriers in that was educating the providers on the service availability. It proved a little bit tough for us to get our providers educated to say, "This is what information you can really send out to the patients," the ones that are web enabled and they have the access to determine which access do they want to give them, what exactly do they want to see. The other side was educating our customers that we it have available but also at the same time making sure that they didn't understand that this was a, as one patient put it, a big bubble thing, but this information was strictly to White River, and pre-marketing around that to say, "Yes, you can have access to your records without having to request permission and without having to go through nine steps to get the information." And one of the ideas that we had was to put it out, first, for medications, and actually it proved itself for one of our patients who was out of the country and for some reason had lost their medications.

Well, they were able to sign in and see what their medications were and be able to have those re-prescribed for them and pick them up. So that one case right there was really, really, really, a boon for us because it really told us that people would use it for that. And I think the key thing was awareness. It was about engaging people to assist in making them healthier.

And for us that was very important. At White River, we're a community health center, we have patients that -- some have up to 18 chronic disease states. So it really was just trying to create that level of continuity between us and the patient and the other things they were -- the other side of it is we were trying to engage the patient in a way to get them ready for more personal health records from the standpoint of being able to utilize a RIO. Or some mechanism of sharing with their permission so we could put this information out there and get them used to this sharing aspect.

And that was very important, and we found that so far that seems to be working real good for us. You know we've tweaked our server delivery. We've tweaked the way we deliver it, and I think it's all part of, you know, the process of progress. To give you an idea of what our -- in exchange this is an old screen shot.

We've customized it a little bit more, and, you know, if you look to the left of this slide, you'll see it's kind of in an Outlook format where the patient has in-boxes. They can look at the messages. They can manage their personal information. They can update it for us.

And all that is live time back and forth, so it goes back. They can put in additional information, health history forms. They can do this all completely online. They can add surgical histories and allergies.

They can request a new appointment. One of the things that we found that patients are liking a whole lot is the ability to be able to look and see when the current appointments are scheduled, anything at all, and so they'll be able to keep up with it. And at the same time, we also could not only send an e-mail reminding them of their appointments or text message, we also have an automated system that places a phone call to them and, you know, reminds them of their appointments, which is very integral to us in terms of the chronic care. I think that under the request -- and you'll notice when we look at things, we set it up as requests, and that's very important.

We don't want people to -- we want them to request a refill, not complete a refill. And that was very important the way we worded that. So they could click on that and request a refill. And it would actually pull up a list of their current meds, and they get to click on it and see which ones they would like to request.

Also, if they feel it's time for them to come into their labs or do a lab request or referral request, they could do that as well. But certainly in the review, we felt it important to include the lab and diagnostic reports for one reason and one reason only -- access. They're the patients' records and we want them to be able to see and be able to feel when they're able to look at something and see that they're really getting improvement. They've gone from an 8.6 On a hemoglobin A1C and they're at a 7.2.

That's real progress, and we want them to be able to track it and see it and what they can lay their hands on and they can see and touch makes a big difference. And obviously, we want them to be able to pay their bills and see their current statements as well, so we certainly put current statements and the ability for past statements, and for some of our patients, when they're looking at for income tax time and things like this, this really has saved our front office and billing department a tremendous amount of work because patients are enabled now. They can click on it and pull the information of what they have paid and the care they've gotten. And that's really making a big difference.

So at the center of the page you'll see, obviously, a welcome statement, but it will tell you that you've got new messages and it will tell you the reminders, and these are all done through different clinical decision and support mechanisms, as well as standards that we do based on when somebody needs to have a specific lab, and it will tell you when it was last done, it will tell you when another one is due, and it will also send an e-mail reminding them that they've also got labs due or, once again, you know, it's time for you to make your appointment. You haven't made it, and you know because you're chronic care or because you're diabetic we need to really get you in -- or hypoglycemic because we need to get you in every three months, and so we can set those parameters, and those things are very important and automated. I will say looking at this, this is one record that I set up for myself, and you will see because I'm a male and I'm 47 years old that the system does not show a PSA, so it's saying your PSA is there, you need to have this PSA. And, you know, also the referral reminders, we made them a referral that they did not keep, so it's saying.

This right here is just the way -- kind of a dashboard, if you will, for them to look at their reminders. They can click on it and also they can schedule. These reminders show up in the request for an appointment as well for the reason. So it's going to say, "Do you want to handle your basically chronic care?" And it was very important for us to make sure that we have all the services available.

Now one of the things that we do share -- that we could share is that at this time we're setting up to looking at doing some health exchange -- by using this portal we could link multiple providers together for the information and go out and poll this information and come back, and I think that's where we're coming next. But I think we're real excited at this point about the overview. And the other side of it is that at White River we just really didn't think that anybody would use a memory stick, or a Flash drive to put a record on and take it to and from, back and forth, because the one thing we lack is a complete standard to bring that information back from my system to somebody else's system to somebody else's system that would mean anything to the patient, and, certainly, it would be easy to navigate and to work. So at White River that was our approach to simplify things for our patients and just make things overly easy.

We're fixing to redesign this, which we should roll out with our new website here in the next 60 to 90 days. It's really going to make it a little more interactive and be able to tie into some patient education with some mechanisms of videos and things like that based on what their assessments are and be able to assist and manage it. So we feel like it's a very, very powerful tool that we want to put out there for the patient to let them assist us and help us better the health care. And I'm going to turn it back over to, I guess, Chris.

Thank you for that. I'd like to pass it over to our next presenters, which is Dr. Kahn, please. First -- let me pull up the first slide.

Good. So I'm going to be talking about technology to improve health and focus on personal health records and, you know, my work has been on the public health side and has received support from the NIH. And from the following granting agencies, the Commonwealth Fund, Blue Shield Foundation, the California Health Care Foundation, and a recent grant from AHRQ. So let me present some conclusions that I'll have you consider, and then I'll go through my presentation and see if I could confirm the conclusions.

One is that new tools are necessary to improve health care. The second is that personal health records are intended to provide patients and their caregivers with information to improve self-management; that PHRs are equally important for all patients, not just patients with insurance. At San Francisco General Hospital we developed a PHR that we called myHERO, which is also the core link for HIV/AIDS. Patients, but it's used for anyone now.

Our goal is to reduce the digital divide and show that PHRs can improve health outcomes. And we're looking at personal health records as a potential mHealth application. MHealth is an abbreviation for Mobile Health. That is, we imagine doing this so that the personal health record is free of Internet but available on cellular wireless technology.

So let's talk about the case for improvement. In an article a few years ago, it was quite clear that whether you were looking at orthopedic problems, cardiology problems, infectious disease problems, diabetes, that outpatients were only receiving 55 percent of the recommended care, and it seemed to be just across the board wherever you looked. The Institute of Medicine undertook a very important study and published it in 2001 -- "Crossing the Quality Chasm." The residents I work with really liked this quote a lot. They say, "Improvements in care cannot be achieved by further stressing current systems of care.

The current systems can't do the job. Trying harder will not work." That's a line they really loved. So we tried to look at information systems and what characterized them. And we first looked at the systems, you know, what is owned by the system and what's in it, and some examples of what the system's own data could include financial information, demographics, notes, immunization records, labs, medications, images, consults, reports, and important documents.

These are electronic medical records, and what characterizes them is they're populated with data from reliable sources. Well, it's a system on some information on patient's own personal health records. And the challenge is to make personal health records feel like they're reliable. And the way that we thought to do that is to automatically populate.

And we took the same information that's in systems, whether it's financial information, demographics, diagnoses, immunization, labs, medications, images, consults, reports, and important documents, and populated those so that patients could then respond. Now we don't put notes in here, but we do put in almost everything else. And the philosophy we have behind this, the guiding principle, is the distinction between shared decision making and self-management. So shared decision making is the process that involves patients and decision making and planning.

This is sitting in the room with patients and giving them options. On the other hand -- can you advance to the next slide for me? Sure.  Just a moment, please. All of a sudden the slide advancement petered out.

Just give me one second. There it is. The self-management support is a broader process of engaging in activating patients to more fully participate in their care. Next slide.

So the philosophy behind this is what you do and what you know, and you hope that there's some proportionality to that; that is, if you know more, then you can do more. At least that's what we're hoping. That's why we do the research and try and do better efficacy. What transformative technology does is it tries to let you do more without necessarily knowing more, because you're better at it.

Of course in the real world there's not really a relationship between what you do and what you know, and sometimes you actually do worse. So the real challenge is how do you make things better? How do you go from better growth between what you do and what you know? And really, there's some classic information about this, but there's only really two ways you can do it. You can incentivize the process, and in the case of medicine, you pay clinicians to do the right thing, and paper results, it classically does get the job done. But the other way you can do things, and research is now very clear on this, is you can empower the consumers to demand more.

So why develop the personal health record? We think it promotes self-management by providing information through dual communication, giving patients and consumers up-to-date information. They have the opportunity to monitor with new devices, and there's a convenient storage of information. We also believe we can reduce the digital divide to more egalitarian access to information. We can improve the experience of care.

We can reduce people's travel to the clinic if they are coming for laboratory results. We can improve the health of populations by sending out broadcast information, especially about information for troubled medication or time for the flu shot. We can reduce the per-capita cost of health. But we also know that health literacy is vital, as we've already stated, to understand the information and create an action plan based on information.

Now we know that there's some low-hanging fruit here, and we think that, you know, we can do well with this low-hanging fruit, but there's always some serpent in there. There's always some kind of challenge to this knowledge, so let me try and talk about that. We're kind of at an interesting place. In a publication about a year ago on "How America Searches," and this is how through American search for health information, the Internet, for the first time, outpaced the doctor as the primary source of -- as the leading source of information.

You can see what other sources there were. So if the Internet is used more than the doctor, how can we use the Internet and technology? Well, we can give patients what they want. Here is a graph of what people want access to and why and what they do have access to. We can see patients want e-mail access, but very few of them do e-mail their clinicians.

They want access to their test results. Very few have them. They want access to their medical record. Again, very few want them.

So this is really supply and demand. If patients want it, our job is, I think, to give it to them. In fact, many people can do this, as this very famous quote from William Gibson said, "The future is already here, it's just not evenly distributed." And our job is to try to evenly distribute it. This is a screen shot of our personal health record that we have for patients.

We have tried to bring patients into the design of it. One thing that you can see is there's a lot of open space; that it's kind of clean lines. We don't try and put too much information. This is looking at an account.

But one of the things that we have done is recognize that patients need to share their record that we have. So one thing that we've done with helping the California Health Care Foundation is we've created a "Share My Health Record" module where we use standard terminologies and technology so that in this case patients who have a group of health accounts, for instance, can upload their information automatically from our personal health record directly to their Google health record. In a sense, we're using Google like a RIO, because from Google Health they can download it to the Cleveland Clinic or wherever else they want to get care. And they can share all of their information or part of their information.

Again, this gives power and authority to the patients. They could send all their medicines or part of their medicines, and then we're also trying to assess in surveys to patients before they come to clinic what is the state of their health. We have the satisfaction survey; that is, are they satisfied with their service. We have a depression survey, and hopefully through some grant support we'll launch some newer activities, including domestic violence prevention tools and ways to actually not just get the reports of your X-rays or CT scans but actually store your studies and have them viewed by the consulting clinician.

In terms of what's happening with our personal health record, you can see that there's been a pretty good and steady uptake in the number of users for the personal health record. This is a complex slide -- let me just take one second to go over it. On the left-hand side you see number of patients on the Y axis. On the right-handed Y axis you can see the average session length in minutes, and on the X axis you can see the session count.

So what you can see is that patients spend about 12 to 10 minutes the first couple of sessions, but then their session time goes down as they get better at it, and we have some people who only have a few sessions, but we have one guy who looked at his personal health record 110 times in the first couple of months of the year. And we have a diagnostic tool built into the personal health record, so although we can't see who's on it, we do know how many times a page is hit, and we do know with some satisfaction surveys what people like. So, of course, summary page comes up, but laboratory results is by far and away the most often linked page, and you can see how many times it's been accessed. In our case, because of our population of HIV-infected patients, they would like to see their CD4 cells and viral load.

I'm sure that if we had a diabetes clinic, it would be the hemoglobin A1C that would be seen the most. Our patients assess whether it's complete and accurate. And what we found is that patients don't always think their medications are accurate. So we did kind of do some exploration around this, and what we've realized is that since information flows from the electronic health record to the personal health record, that our clinicians were not keeping their medication list up to date.

In fact, this has been a really important case study showing that a personal health record that shows patients all their information acts as a motivator to help clinicians keep their information up to date. They do think their information is confidential. They do think that this is shared. And most important, if you look at the last line, patients said it helps them manage and take charge of their care, which is really the model that we're trying to achieve.

Now we are, in terms of innovation, we're way to the left here. We're at the early innovators. But we hope that, like many new innovations, our patients will see the importance of this technology as we build tools and applications that they want to have. So we're very consumer-driven in this regard.

Now I will say just a few things about mHealth. Not all patients, at least in our clinics, have equal access to the Internet, but nearly everyone has a cell phone, and the devices are becoming more common, less expensive, and more powerful with a growing number of applications. So we're trying to use this as a way to send short message service device messages, the SMS, to let people know, "Go to your site.  You've got new information," so they don't get Internet exhaustion and keep looking and looking and looking for new information, only to see that nothing is there.

We also can send alerts and reminders to patients, "Take your medication.  Come for clinic." We can inform patients of new information in disasters. We can improve management for health and wellness through this alert system, and we believe in our research that we'll have international implications. Just to give you some small inkling, imagine that there's an earthquake in the Indian Ocean somewhere and it propagates a big wave going east and west, and there's no tsunami warning system.

But if we knew that that earthquake was there, which we do, and we have a few minutes to send out a broadcast e-mail SMS message using a health tool that's just to move a hundred yards away from the beach, just imagine how many hundreds of thousands of lives that potentially could have saved. So our SMS function includes immunization, appointments, Pap smears, medication adherence, and notification to patients. So what are some of the potential challenges? Well, patients might not understand the value of a PHR and they might worry about sinister motives. We've heard from a number of patients, "You want my health information on the web," and that makes them very nervous.

Some have limited access to Internet or limited literacy, so even in the best of worlds, presenting information that they don't understand is just the same as not presenting it at all. Also, patients might not feel like that they have the right functionality, that they're looking for something more. And if you don't listen and give them what they want, they won't use it. Many of my patients are worried about costs and have complicated two-step tasks, so we have to try and keep it simple.

And, of course, the technology might not work as anticipated. It could be technology for you, there could be technology overload, and patients might simply give up because it's not working. So you have to always set the bar relatively low and make sure it's successful. From a clinician side, clinicians might not understand PHR.

They could ascribe sinister motives just by patients, like, "This is going to be more work for me. Now I have to e-mail my patients too." Of course, there is some data to suggest that the more patients e-mail, the less they telephone, which is important, because if you have to return a call and no one's there, you don't want to leave a message because you don't know how confidential it is. There's often multiple phone calls, whereas e-mail is password protected. You may not give the clinicians the right functionality; that is, they may decide that they don't want their patient to know that they've given someone a diagnosis of borderline personality.

This was an issue in our clinic as well. Strangely enough, it was our psychiatrist who came up and said, "If you give your patient a diagnosis of depression and you treat them for depression, why wouldn't you want them to know that you think they're depressed?" And it's the same with some borderline personality issues. There could be costs involved, and again, you don't want to complicate the clinicians' life by giving them more tasks, and for the same reasons, technology might fail, technology might be overloaded and it may not work the way you said it would work, and this could be a terrific problem for clinicians. It also might require changing their workflow, which I think most of us would agree is going to be the principal barrier for any technology adoption.

What are some of the potential challenges to this system? Well, if it's a HIPAA violation, you're sunk. You've got to make sure it's going to prevent HIPAA problems. The system's data might be used by a competitor or make it easier to lose a customer. So if someone could compare outcomes of heart attack between the ETFS in Kaiser and one is better than the other, and you can now get at your data from this other source, even if it's from a personal health record, it could be used inappropriately.

The costs might be prohibitive. The technology might not work as anticipated. But I think the most important thing that we have to be worried about is they might actually succeed, and success might create new demands on the technology, and new expectations from patients and change our patients really from being more pathless obtainer of information to really consumers of information. I mean, after all -- you know, when we buy a car, we don't just go to the lot, listen to one salesman and take what they say.

We often do Internet searches. So a final thought is that, you know, what you're doing here is that you're trying to see what's not there right now. And there's a lot that you're not seeing. But I appreciate that you're here to learn more about it.

And I will say that success is the ability to go from failure to failure without losing your enthusiasm. And I appreciate that you're involved in understanding personal health records and what it might mean to your patients. Bill Gates has one of the best quotes I always use. He said, "We always overestimate what will change in the next two years, and underestimate what will change in the next ten." So you may not have a personal health record or plans in the next year or two, but I think that their day is here and they're coming, so thank you for your attention.

Thank you so much for the wonderful presentation, Dr. Kahn. I would like to hand it over to Kathy, to proceed with her presentation.  Thanks.

Thank you for this wonderful opportunity, and I think I need a little help finding my presentation. I apologize. Give me one minute. How's everyone doing this wonderful afternoon? All righty.

Thank you. So I'm going to tell you about our story, which is using a personal health record for vulnerable populations. This is a collaborative project of our own St. Joseph Health System Sonoma County as the health partner Community Health Resource and Development Center, the technology partner with the media software, and these worker services and social service agency working in the Sonoma Valley.

And this was a grant-funded project through the California Endowment and the Rural Community Assistance Corporation to link health care to unaccompanied migrant workers in the Sonoma Valley. And so I think I'm going to need a little help driving. I don't know why I'm being challenged right now. I can take over.

Okay. So as you've heard from the other speakers, you know, I think you've heard very well what are personal health records? They encompass a wide variety of applications. They allow people to collect, view, manage, or share copies of their health information, or health-related transactions electronically. The first generation was to view information with manual data entry, and it's un-networked.

That's kind of our media project. It's been a work in progress. Future generations will be networked to aggregate data across multiple sources, help users with specific tasks, such as ordering medications, communicating directly with clinicians, and with scheduling appointments. Next slide, please.

Of course, as we said before, PHRs, personal health records, they're not electronic health records. So an EHR is a tool for a health professional. They're designed to improve upon the paper medical record chart. Clinicians have a legal and professional obligation to maintain their patients' records, and they own them.

In the case of a personal health record, they're really truly tools for the consumers, and consumers have no similar legal obligation and, of course, a PHR do not replace EHRs with paper charts; however, they may include copies of data from the electronic health record. Go ahead. As we all know, the Internet has transformed much of modern life as it relates to communication, doing searches on the Internet, seeking content with E-commerce, personal finance, and of course, entertainment. Next slide.

So what is the MiVIA? It is a patient-owned electronic personal health record that we originally designed with input actually from a farm worker advisory committee to enroll and engage migrant agricultural workers in their health care, and so our clinic is a mobile medical clinic that goes to a variety of high need types throughout the county, and the migrant workers are one population that we serve. We very soon saw the opportunity to expand the enrollment to include commerce that we serve, clients with special needs, served by both our medical clinic, as well as our dental clinic, women and children. So the MiVIA is web-based. It's secure and HIPAA compliant, and access is granted to clinicians by the MiVIA number.

They're in control of it. Next slide. The MiVIA PHR stores medical and dental health information. It provides a photo ID and emergency card with some basic health information on it, and in a future slide, you'll see what that looks like.

It included an e-mail account to offer a permanent address for a mobile population, and this was kind of an incentive to enroll people in the project. It also provides wonderful information and resources with automatic links to MedlinePlus and other health resources. And you can enroll one individual or up to eight members of a family with a single MiVIA enrollment. And it included the clinician portal for professional entry and verification, and this was based on our piloting the project and working with clinicians who said, "Well, you know, I'm a little skeptical about the information that the patient is putting in there, and if I knew my patient was seen by another clinician, I'd value that information perhaps a little more.

I'd want to know exactly what that clinician said or had to say," and so what the clinician enters in their portal becomes read only and cannot be edited by the patient or the client. Whatever the client enters, of course, can be edited. It is their record. Next slide, please.

So we've been doing this since -- well, we were in planning pretty much the first year in 2003. But 2004, we actually started enrolling people, and we realized that our patients access a variety of health providers, and in so doing, MiVIA serves as the bridge or personal RIO between disparate health care systems. Clinic X may have one kind of a practice management system, the hospital has another. We send the patient to the specialist, they have different information.

And, of course, if the patient has that information at their fingertips, then they are the person that can share it with all the different providers, they or the families, and in so doing, help to promote continuity of care and sharing of information. And our hope is that by doing this, we're improving the efficiency of our medical system by reducing duplication of diagnostic studies unnecessarily. And what we've really seen over and over is that we've been able to engage and empower the patient as an active partner in their health care. And also, having a PHR provides new levels of transparency, as was stated by Jim and Greg in their presentations.

Go ahead, please. So how do we go about it, and I really want to start by acknowledging our promotores who are lay health professionals, peer educators who really started working with the basics with the clients. And they said, "Okay, tell me where you're from in Mexico," and they go to Google Earth and show where Mexico was their hometown, and they would be so enchanted by seeing their hometown that they would really say, "Wow, show me more." And then they'd start showing them what the computer was for. We were really surprised to find out that a lot of our clients have had some introduction to either the Internet or a computer.

Of course, some had not had access. So what we would do is provide everyone with a little overview of the Internet, the links that are available on MiVIA, explaining to them how important the MiVIA purpose is in terms of having a safe place for their information, and however, these years that we've been involved with the project we have over 6,000 clients enrolled right here in Sonoma County. For people that are beginners in understanding the Internet, we realized the training can be a little intense, so since we see them in health care in our mobile clinics, the promotores would revisit that with them at subsequent visits. And of course, the more they started getting involved in putting their own data in, the more it created better understanding of their data, sharing data with others, and putting data on their families.

Next slide, please. So here's what the clients told us, and we observed. That it was reducing digital disparities. It provided them access to health and community services, clinics, libraries, and ESL classes, and here is what happened.

We would work with local community-based organizations to bring people to resources so that they knew if we started the training on the computer that they could go to the Resource Center or to the library. Many of them didn't know a library existed in their community, and now they're able to go there to access the MiVIA and to start getting books for their families, ESL classes for themselves. It really empowered them to be involved in their health condition. They would ask questions upon seeing the clinicians for different diagnoses.

They would ask the promotore, "If my child has asthma, what does that mean?  I'm on this medication?" And so the promotores would say, "Well, bring your medications, and we'll show you how you can learn more information about them." And they would introduce them to the website of MedlinePlus, which I'm sure a lot of you are aware have tutorials in Spanish and English and a lot of great information to help them gain more knowledge and control of their own health condition. And a lot of patients would just tell us, you know, I have the peace of mind now knowing that I can go visit my son in a another community, and that if I were to get sick, I could provide that clinician with my MiVIA account, and they would know that I'm a diabetic and they would know what medications I'm taking. Next slide, please. For the homeless we have some really interesting lessons learned.

Many were thrilled to have a concise place to store their health information and just as Jim stated before, some of them were a little skeptical. They were concerned about Big Brother and who might be viewing their information. We also learned that homeless shelters enter data on their clients into a HUD HIMS database that includes a photo ID. And some relevant demographic information, and we were able to copy and paste some of that same information with the client's permission into their MiVIA account.

And in the case of our local homeless shelter in Petaluma, a MiVIA photo ID allowed them to pick up their prescriptions at a local pharmacy using a voucher program. Next slide. As I mentioned before, a local dental clinic works very closely with the Welfare Regional Center with patients with special needs, and just as the mother of invention for the MiVIA, Cynthia Solomon, the software developer found out and started this whole process with her own son with a special medical condition. These moms have kids with unique conditions.

They're seeing very many specialists and doctors. They're very busy with their appointments. Frequently, they were carrying their child's record in small suitcases, and now they had the ability to have their information at their fingertips in a safe secure place that could follow them and be easily accessed wherever they went. Next slide.

This is an example of the web page for the MiVIA. Any of you can go online, www.MiVIA.Org to see it better. I know web shots are always so hard to see, and we even have a little video clip there. Next slide.

This is an example of the photo ID card. We went kind of low tech, printing it out on paper, cutting it, and laminating it. Our social service agency, the aid worker services created a plastic laminated card, more like a credit card. There were really some unintended benefits from the photo ID card.

You have to remember we're serving a population that may not have documentation. They're working in the fields and the wineries seasonally in the grape vineyards, and now they have a photo ID that actually tells other people who they are. We had to document on it that it was not a legal ID. I'm an ER nurse.

I knew the importance of including on there medications they take regularly, any allergies, name of their emergency contacts, et cetera, and that's all put on the MiVIA and can be updated very easily. In the Sonoma Valley, they were able to use their photo ID to cash their checks, to gain employment, show their employer where their residence was, and at the library to get library cards, so it was really exciting. Next slide. And this was an example of a medical office visit, with input from the nurse practitioners using this, we thought, "Well, how can we make it a little more user friendly in kind of an EMR light?" So we created an office visit that kind of followed the same format, so if the clinician wanted to they could actually type that visit and print it, and then put it into the patient record.

We're moving towards EMR with our regular community health coalition partners, but we aren't scheduled to go live for a year or so yet, so we're still on paper in our mobile clinic. Next slide, please. This was an example of a summary medical report. So the patient has, and the clinician, different screens where they can enter information, but it all goes into a summary medical record report, and this can serve as a continuity of care record.

The client could, if they wanted to, print this and take this to their office to the provider. Next slide. So this just is a diagram to show that the MiVIA, how the information flows. There's one MiVIA account and record; however, the patient has a portal for their advocate, and the clinician has their own portal.

They can both view all of the information in there. It's just that the information is entered and if it's entered by a clinician, that clinician is noted by name and, you know, and MD, nurse practitioner, RN, et cetera. Next slide, please. So people always ask, "Great that you're enrolling all these people, Kathy, but tell us what they're doing with it." So our promontor called 613 clients and found out that 40 percent of them stated they were using their MiVIA on a regular basis.

Of these, 58 had no prior computer experience and had to receive a lot of basic computer training. And 87 percent of them did not have their own home computer, so that meant they were using resources in the community that we had helped to link them to. That's very exciting. Next slide, please.

The MiVIA has expanded from the Sonoma Valley and our little project with our mobile clinics to the Alliance Clinic in Healdsburg, a federally-qualified health center. We have a family practice residency program that has a bridge clinic for clients with diabetes, and they were working with a community health outreach worker program through the San Rosa Junior College that was providing home visits, and they were helping to enroll clients in the MiVIA, and, of course, our homeless center and the VWS Resource Center. In Hood River, Oregon, there is a hospital, a mobile medical clinic, and a rural clinic, and they are actually using it as their own EMR light where they're providing every patient or enrolling every one of their patients in the MiVIA, but not really for the PHR purpose so much as for their purpose to be able to share information from the mobile site to the hospital and from the free-standing site. San Joaquin, the California Human Development Corporation recently was awarded a United PacifiCare Grant.

They are working to enroll farm workers in the community, and they actually have a mobile unit that is equipped with computers because their focus is job training and skills for people, and they're making great strides in that regard. Kern County, Delano Medical Center is using it. Humboldt County, they're actually using it to do case management of patients with congestive heart failure. And in Finger Lakes, New York, they're using it with their specialty voucher system and linking to it a Telemedicine project.

Next slide. We've actually been part of a research project with the Kay E- Health Center, and their mission is to advance scientific understanding and public policy improvements, as you can see from this slide. And their preliminary findings were there are innovative approaches to improving disability determination and health management in both disability and vulnerable populations that can and should be fostered. And they recommended federal and local policy support as necessary to achieve these desired systems.

And there's more information on their research project on their website. So the Markle Foundation did a consumer survey in 2008 to demonstrate how consumers see value in PHRs. So the percent of consumers who believe PHRs would improve their abilities to check for errors or mistakes in their health records, 87 percent, track health-related expenses 87 percent. So really high percentages in all of these different elements to avoid duplicated testing, keeping the doctors informed, more easily move from doctor to doctor, and we see that, as I'm sure others in health care throughout the nation, with this downturn in the economy, more people are losing their employer-sponsored health insurance, which is resulting in changing clinicians and providers seeing them, and what's unfortunate is that frequently that expensive workup and all their health information resides with those clinicians, but fails to follow the patient, so that's very important and one of the advantages of a personal health record.

Of course they can manage the health of family members, get treatments tailored to the user's health status, help to manage, as Dr. Kahn said before, that their own behavior and lifestyle needs, and almost half of the public say they are interested in joining a free online PHR system. Next slide. So that concludes my presentation, and I thank you all so much for this opportunity.

Thank you all so much for your wonderful presentations. I would now like to hand it over to Johanna Barraza-Cannon from HRSA to moderate the Q&A session. Hello? Hello. I'm sorry.

Can everyone hear me? Yeah. Okay. Good. This is Johanna Barraza-Cannon at HRSA.

I wanted to thank everyone again for these presentations that were all very informative. Just to remind you, these presentations will be available on the HRSA HIT community if you want to go back and listen to some of the portions. There have been some questions, just repeats of some of the presentation topics. So we will go through some of the questions that were generated through the WebEx, and also if folks have other questions, please submit those through the Q&A function on WebEx.

The first question I wanted to ask all of the participants is based on one of the statistics that Kathy provided about how many folks have access to personal computers in their homes, and there are other ways to access this information from a computer, perhaps a library or another area, but for all of the participants, can you talk about any training or information that you have given to patients about how to access the personal health record on their own time from other locations? And we can start with Greg. I would say here, yes, absolutely. What we do is -- we provide, we have got a literacy center and also an education center. And in every one of our wellness centers we have Internet lounges, if you will, kiosks that are available, and also the local libraries are available.

But we try to provide for it. But we actually did a survey where actually 44 percent of our patients actually had Internet, which really surprised us. 92 Percent had cell phones, so it was really an interesting survey that they had that. But what we do is try to help them as much as we can and even so advise them to go to the library and take other measures too.

This is Jim Kahn. What we have is we have a wireless technology in our clinic, so we're relatively free. We have three desktop computers and several laptop computers. We did purchase, you know, those screen protectors so that if you're just like an inch or two off the screen, you can't see anything.

And then we have our staff work with educators. We also give people a list of what's available for free Internet access. We update this monthly, so these are like community-based organizations, libraries, even some Internet cafes, and, you know, it takes us about two to three minutes to take someone who has never been on a computer and teach them how to mouse and how to use a URL. And that's really all they need, in part, because we designed our personal health record not to enter data but simply to mouse around and click and drag.

So once they know how to click and drag, they're set to go. As I stated in my presentation, we partnered with other community-based organizations in each of the communities that our mobile clinic travels to. And our mobile clinic is equipped with laptop computers that have wireless air cards, so we did have Internet access. And the promotores carry their laptops with them.

And I failed to mention too, our promotores are also certified application assisters. So frequently when they were enrolling children and families with children in the different health insurance for which they might be eligible, in the course of that conversation, the mom might share that the child had a particular ailment or condition, and that would provide another entree to enrolling the family into the MiVIA account. So thank you. From the WebEx we have some questions submitted.

One of the questions is a request to please repeat the site mentioned where patients can go to read  disease information in different languages. So if someone could repeat that information, but also as a follow up, what are the different sites that you reference in your PHRs? Are there any others that are in different languages? I guess I'll go first on that. If you go to the www.MiVIA.Org website, you will see the link to the resources there. And it's called MedlinePlus.

It was developed by the National State of Health and has a whole array of topics, medications. It's a great resource for families to get information. I know it's in Spanish and English. I don't know if any other languages are available.

And then the other resource links we have on our website include how to find a clinician. Because we were serving migrant farm workers initially, we knew they might be going from community to community and need to establish themselves at another clinic, so we included a link to the primary health care where they could find a clinic. All right. At San Francisco General you can see our site.

To the public, it's http://myhero.Sfdph -- for San Francisco Department of Public Health -- .Org, and our resources are there. And I agree with Kathy -- MedlinePlus is a terrific resource. It is in English and Spanish. It has a lot of tutorials.

It's operated by the National Library of Medicine within the NIH. If you are a programmer or an architect, it's not all that helpful because they don't have an ontology of their information. It almost has to be -- we had to do a lot of one-on-one mapping. But I think it's a great resource, probably the best resource available.

The literacy level is pretty high. You have to probably have an eighth- or ninth-grade education to get through the different materials. Greg, did you have anything to add? Well, and we do, we use Medline, but we also are using hADM as well that's specific to them. We're fixing to roll out a new website that's going to be out there that's going to be truly interactive for those.

We're going to have some Flash videos on those as well. But for the basic patient education and things like that, we still really are feeling that our patients are still really liking that piece of paper that they go to that they're given by the provider or the nurse or the case manager and they're able to go through all that with them, not only for their meds but also their chronic illness. Thank you. We had a question for Kathy.

Can patients who come and go from Mexico also access their health record? Have you heard of instances where this is facilitated care across the border. It is my -- yes. You can, as long as you have Internet access and the client has their, you know, password and shares limited access with their provider, it can follow them anywhere. An early version of the MiVIA was translated into Spanish, but the most recent version is not.

And the reason is that most of our clinicians are English speaking, bilingual that if you go to the hospitals the specialists and nurses, you're going to see it in English primarily. But, yes, it was set up with the goal that it could travel internationally or across the nation or county to county in our own state to transfer that information. A follow up for Kathy. Since the PHRs are meant to be consumer-oriented, can the webpages in MiVIA be presented in the consumer selected native language? As I stated, right now the newest version is in English.

An older version was in Spanish. Certainly those things are doable but it takes resources to do that, and the MiVIA is -- the technology partner is a non-profit, so they're kind of reliant on grants to expand and enhance, with input from those they serve. This is a question for the group from the chat. Do any of you know of PHR systems which integrate cost observances with quality measures so consumers can make informed decisions about their health-care choices? So this gets to the transparency issue and consumers making choices about care based on cost and quality.

This is Jim Kahn. I don't know of any resource that does that. I think AHRQ provides information to clinicians. But very few sources are providing information to patients.

This is Greg. I'll piggyback on that as well what Jim said. We really looked at that, but we had a real hard time in finding those that would want to engage in that interactively with us. I know that the technology partner has this on their radar screen, but I don't believe we're there yet.

But we do know that consumers are interested in where, say, for example, pharmacies, where could they get the best price for the prescription they just received from their physician? So I know that's on the drawing board, but it's not available at this time. Thank you. Another question we have on the chat. Are the solutions that were presented off-the-shelf products or individual-developed solutions? Well, for White River it's a little bit of both.

Right. And I think the question for folks is how do I do this and where would I get software like this? Would I have to create it from scratch? This is Jim Kahn. I don't think you have to create it from scratch. I think you just have to look around and see what might work for you.

And, you know, part of it is really assessing what do your patients want and what do you want a system to do. And I think doing a needs assessment is really the first step in trying to figure out what kind of system you need. And then I need to test it for your consumer, your clinician, and the stakeholders that are your administrators. I think that's what you really need to do.

In the case of MiVIA, we have a sponsorship methodology, meaning that the health entities that were listed on one of my slides have all either attained grand things, or perhaps in our case at St. Joseph, we have continued our effort to our community benefit. However, so you could certainly contact the technology partner if you're interested in doing that for your own organization. If you, as a consumer are interested in your own, the following platform is what the MiVIA was built on, and so you could go to that website, and there's an annual subscription to maintain your own personal health record.

Thank you. Another question. There was some information presented on noting who was entering the information. Was it patient-entered or physician-entered? Could you all talk about some of the tension or conflict that comes up when you have patient-entered data and whether or not the physician would want to use it? Yeah.

So this is Jim, so for instance, the kinds of data that clinicians mainly want to use is, again, it has to do with reliability factors, but there are some scales, just simple scales of weight that use wireless technology, record the weight, and upload it into the database into the personal health record. So the patients aren't transcribing anything. There are also Glucometers that you can buy that will update your glucose directly into a database, and you can see it that way. Most cardiologists are very happy using wire transmitted EKGs, so they're not recording from their machines but there are devices that will record from home.

So this is the kind of data that a lot of people will reliably use. What we may have more problems using is symptom reporting or the data that has a two step process; that is, you record it from the device, and then the patient has to hand enter it into a personal health record. Well, I think for White River what we're doing is really focusing on the aspect of delivering what the provider has already put in through the electronic record. So what people are viewing, with the exception of their histories and their demographic information, right now at this time, we do not ask the patient to enter anything, although we can change to allow things like self-blood pressure checks and things like that for hypertensive patients.

We do allow that once we know that the patient's entering in at least worthwhile information. In the case of the MiVIA, the patient or their advocate do enter their own information, and there is a pain and symptom diary, and clients do actually use that. They write the date and the time and the symptom of what they're experiencing, especially those that suffer from migraine headaches or may have some other condition that the doctor's a little challenged to treat them for and also as a way to see if the medication is working for them. So in our case, both the patient is entering information and/or their advocate, a mother or promotor might be helping them.

And the clinician is viewing that information. And I have had questions before from people, "Well, how can you really trust that what they're entering in their PHR is accurate and meaningful?" And I said, "Well, it's kind of like the same way when you're a physician or a clinician taking a history from a patient in the exam room." I mean, we don't do a lie detector test. We are taking them at their word when they're communicating with us their past medical history and what their signs and symptoms are and how long they have had that particular ailment or condition. And then we're moving forward on a diagnostic workup and a treatment plan.

So I hope that kind of helps answer your question a little. Thank you. That does. Thank you.

We have one last question from the Q&A, and then I'll ask if folks have closing thoughts. There's a question to Jim related to the HIV/AIDS population and is there a possibility of segmenting the electronic medical record, or perhaps in your case, the personal health record, based on sensitive health information realizing the technology may not be available to do that, or that providers of care may want the entire EMR. So this gets back to the issue of sensitive information being available. Yeah.

And I wrote an IM back to one of the participants. A lot of this has to do with your local laws. In the State of California, there are four things that can't appear in the personal health record. You can't have results of an HIV antibody test, you can't have Hepatitis-C antibody results, you can't have past reports for products of conception, and you can't have domestic violence.

The reason for the last one is they worried that the perpetrators of violence can look over their victim's shoulder, and if they see that personal violence is listed as a problem, that they'll actually perpetrate more violence. So with that said, T-cells and viral loads, two key markers of biologic health for our AIDS patients are allowed on personal health records. Hepatitis, products of conception are not allowed. We don't put any password filters on here.

So what I'm saying is you do have to take a look at state and national laws to see what is and is not. In general, our patients want everything. They don't want a limited knowledge based on the limited database. We used to have a 30-day wait period between the time last populated your electronic health record and then populated the personal health record.

That then got moved down to two weeks, and then to three days, and now it's instantaneous because, in fact, patients keep calling and saying, "I want the results.  I want the results." And if we gave a patient -- a clinician too long to look at it, patients were just more anxious. So we took the stand to say to all of our clinicians, "You better be looking at your patients' labs all the time because the patients will have access to them." So if you want to prevent a gotcha, then you have to know what the labs are. And now there's no time limits.

Also, Jim, I would add that I just learned from our lab director that it is possible now for patients to directly refer themselves to the lab for some tests like glucose, I think, if they have diabetes and some other things without a physician order. That's interesting, Kathy. I didn't know that. I wouldn't be surprised.

If you can do it at home with a Glucometer, why wouldn't you be able to map to the lab? Well, our time is just about run out. I want to thank our presenters for their presentations today. I found them all very interesting, and I'm glad to have this information out for us and for everyone on the call. Are there any closing thoughts? I will say that personal health records can be transformative technology.

It can help you manage patients. Also, I'll give you one other thought. I think, like Kathy had said, we were surprised by the capability of our patients and their Internet savviness. People who we thought can barely get themselves to a shelter were actually able to go and use the Internet.

So I would emphasize don't underestimate what your patients can do with motivation and training. I would underscore what you just said, Jim. That's so right on. It really truly empowers the person to be involved.

It's a strength-based tool. The Internet really is engaging people and empowering them. All right. I want to thank everyone for your participation again, and thanks for the audience for staying on our call.

I would hope that folks will go ahead and fill out the poll and let us know how you liked the webinar. We do look at the survey results very closely to try to determine future webinar topics and to make sure that we're meeting everyone's needs. So please take a quick look at the poll, and thanks, everyone, and have a great weekend. Thank you.

Thank you..