To tether or not to tether, that is… just another question in the PHR world

IMHO (In My Humble Opinion), John Moore, from Chilmark Research, is the best analyst following Personal Health Records and consumer-directed health IT. Ask me my opinion on most things PHR related, and my inclination is to check John’s excellent blog ( before answering, just in case. In the vast majority of instances, I should just reduce my answer to “WJS”—What John Said.

The other day, John and I were talking about the impact that the recent proposed criteria for Meaningful Use will have on the market for PHRs. Looking at these requirements, particularly the requirement that all health care providers allow patients access to Personal Health Records by 2013, and even allowing for some evolution before finalization, it’s impossible to reach a conclusion other than that some form of interoperable Personal Health Records is coming in the near future.

So John asked: “How effectively do you think untethered PHR systems like yours will compete with tethered PHR systems offered by EMR/EHR vendors?”

Although I didn’t fess up at the time, I was knocked a bit off kilter by John’s question because I thought my opinion on this was lifted straight from John’s own excellent post earlier in the year. After stumbling through the call, I did a quick search and sure enough—WJS. Here’s a link to John’s post titled “Siloed Tethered PHRs are a dead end.”

I don’t think I can improve on John’s comments, but perhaps I can extend them a bit.

From a vendor’s perspective, there is no doubt that acquiring a tethered PHR as either a free-bee or at a modest cost from an existing EMR / EHR vendor is an easy decision for many providers. Indeed, for many patients, who see only one provider and who have relatively little need for close monitoring between the patient and the provider, these are probably sufficient.

However, for people and families living with chronic and severe medical conditions such as congestive heart failure, diabetes, cancer and other conditions, siloed, tethered PHR solutions simply don’t work.

The other day, I visited a large cardiology practice in a community that has a fairly well developed health information exchange. Doctors at the cardiology practice can see information from the primary care physicians’ group, and both can see information from the regional hospital, and vice versa.

I asked if they offer a PHR. They said “Oh yes, it’s really starting to see some traction. Our patients like it.” So I asked if their patients had access through their PHR to information in the other provider EMR systems, visibility that the doctors themselves have on behalf of the patient. They answered “Oh no. The patients can only see what we have. They have to go to each separate provider’s web site to see each separate set of information.”

So, if a patient has more than one chronic condition, say diabetes and congestive heart failure, he or she needs to have at least two separate tethered PHR accounts, and probably three to include the hospital, in order to paint a comprehensive picture that is comparable to what any one of those providers can see.

That is a failed model.

There is an interesting precedent from the financial services industry. About 10 years ago, we saw the emergence of online bill payment services like Bluegill and CheckFree (Checkfree acquired Bluegill). In the earliest days, you could only pay your bill online by going to the web site of the specific vendor. Paying your electric bill, your insurance and perhaps your telephone, required visits with separate user names and passwords at three different web sites. Over time, banks and other independent vendors offered a consolidated bill payment service.

From a market perspective, most people today use a consolidated bill payment service, often provided by their bank, but a fair percent still prefer to pay directly at the specific vendor’s site. It is really a question of convenience with no inherent value beyond that.

We expect to see a similar progression in PHRs where tethered phrs are analogous to the direct vendor payment sites, and untethered PHRs are analogous to the consolidated bill paying services—but with one HUGE difference: Other than the bank accounts from which the banks are paid, there is no relationship between one vendor and another that warrants consolidation. Paying for your phone bill has nothing to do with paying for your water bill. It’s just a matter of convenience and personal preference. On the other hand, your personal health information is itself one single, consolidated set of information. Every transaction or record with every provider could have an impact on every other provider and on your health profile as a whole. That makes a compelling case for an untethered PHR.

So, there’s pretty good evidence for how this could roll out. Initially, as traction develops, we will see success for both tethered and untethered PHR systems. However, as we see sophisticated PHR solutions emerge that are targeted at specific chronic medical conditions, where their success dictates communication between the patient and multiple providers, the requirement for untethered PHRs will be inescapable—at least for that part of the population dealing with chronic medical conditions—which is the whole point of the exercise in the first place.

So, when it comes to the question “to tether or not to tether?”, my answer is clear: WJS and then some.

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