ISO 16527:2023 健康情報学 | ページ 3

0.3.1 Personal Health Record (PHR) Versus a Personal Health Record System (PHR-S)

The PHR WG makes a clear distinction between a PHR and a PHR System (PHR-S). The PHR is the underlying record (e.g., data, information, pictures, sounds, graphs, or videos) that the software functionality of a PHR-S maintains. There has been much discussion surrounding the definition of a personal health record. The PHR-S FM does not attempt to define the PHR, but rather to identify system features and functions necessary to create and effectively manage PHRs. The PHR-S FM offers examples of data elements, but is not intended to provide details necessary to specify a data model.

The overarching theme of a PHR-S involves a patient-centric tool that is controlled, for the most part, by the individual PHR Account Holder. A PHR-S should be immediately available electronically and able to link to other systems. The PHR-S provides functionality to help an individual maintain a longitudinal view of his or her health history, and may be comprised of information from a number of sources – e.g., from providers and health plans, as well as from the individual. Data collected by the system is administrative and/or clinical, and the tool may provide access to health-related forms (e.g., Advance Directives) and advice (e.g., diet, exercise, or disease management). A PHR-S might also help the individual collect behavioral health, public health, patient-entered and patient-accessed data (including medical monitoring devices), medication information, care management plans and the like, and might be connected to providers, laboratories, pharmacies, nursing homes, hospitals and other institutions and clinical resources. This PHR-S-FM is universal and therefore generic by design. There may be additional constraints in certain realms or regions. For example, in the US Realm, the management of laboratory results is subject to the Clinical Laboratory Improvement Amendments (CLIA) federal regulation.

At its core, the PHR-S should provide the ability for the individual to capture and maintain demographic, insurance coverage, and provider information. It should also provide the ability to capture health history in the form of a health summary, problems, conditions, symptoms, allergies, medications, laboratory and other test results, immunizations and encounters. Additionally, personal care planning features such as Advance Directives and care plans should be available. The system must be secure and have appropriate identity and access management capabilities, and must use standard nomenclature, coding and data exchange standards for consistency and interoperability. A host of optional features have been addressed over the course of this initiative, including secure messaging, graphical presentation of test results, patient education, guideline-based reminders, appointment scheduling and reminders, drug-drug interactions, formulary management, health care cost comparisons, document storage and clinical trial eligibility.

The effective use of a PHR-S is a key point for improving healthcare in terms of effective self-management, patient-provider communication and quality objectives.