Patient Generated Health Data Requires New Protocols for Use and Documentation

Technology continues to change the practice of medicine and the nature of patient communication. From telehealth to EHRs to patient portals, tools and capabilities are constantly evolving, impacting the doctor-patient relationship, delivery of care and the official medical record. Now, as reported by Patient Engagement HIT, existing and emerging technologies make it possible for patients to introduce their own notes and data into the process.

This patient generated health data (PGHD) can aid in care decisions and inform discussions between patients and physicians. While this adds a new – and ideally helpful – dimension to practice management, it’s also important to examine PGHD from a risk management perspective, including the need for protocols to utilize and document the data effectively and safely.

What is patient generated health data?

Patient Engagement HIT says, “PGHD can take virtually any form, ranging from sophisticated reads from a patient’s blood glucose monitor all the way down to a handwritten list of symptoms. The former is becoming more common than the latter, and with the rise in both patient- and provider-facing technology, it is also easier to use.” The publication cites the Agency for Healthcare Research and Quality (AHRQ) in differentiating PGHD from “clinical data collected by a provider because it originates with the patient or a family caregiver.”

The AHRQ lists these as common examples of PGHD:

• health history
• treatment history
• biometric data
• symptoms
• lifestyle choices

What does patient generated health data mean for my practice?

When patients can give physicians detailed insights in these areas, says Patient Engagement HIT, it “unlocks an important view into patient disease management.” However, how and when this information is collected and applied will vary by physician and setting, and Patient Engagement HIT reports that its use is “still limited.”

Early data presented in a 2017 HIMSS conference indicates that it may have a “good impact on patient health” and help patients feel more engaged, but both patients and physicians have been slow to incorporate PGHD. Reasons include the patient burden of data collection, resistance to digital monitoring, technical challenges (including poor integration with EHRs) and data overload. 

MLMIC encourages policyholders to assess the value of PGHD and what technologies are available – to both patients and physicians – to incorporate it into their practices. In all cases, detailed protocols and proper documentation are important to ensure patient safety and limit medical liability.