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Functionalities of personal health record (PHR) are evolving, and continued discussions about PHR functionalities need to be performed to keep it up-to-date. Technological issues such as nonfunctional requirements should also be discussed in the implementation of PHR.
This study systematically reviewed the main functionalities and issues in implementing the PHR.
This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search is performed using the online databases Scopus, ScienceDirect, IEEE, MEDLINE, CINAHL, and PubMed for English journal articles and conference proceedings published between 2015 and 2020.
A total of 105 articles were selected in the review. Seven function categories were identified in this review, which is grouped into basic and advanced functions. Health records and administrative records were grouped into basic functions. Medication management, communication, appointment management, education, and self-health monitoring were grouped into advanced functions. The issues found in this study include interoperability, security and privacy, usability, data quality, and personalization.
In addition to PHR basic and advanced functions, other supporting functionalities may also need to be developed based on the issues identified in this study. This paper provides an integrated PHR architectural model that describes the functional requirements and data sources of PHRs.
In health emergencies such as epidemics, natural disasters, or artificial disasters, access to reliable health information becomes crucial for the community [
The EHR aims to collect health data managed by health care providers, while the PHR aims to collect health data entered by individuals [
One of the important PHR research areas is PHR functionality [
Functions or features of PHRs are evolving [
This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [
The search is conducted using the online databases Scopus, ScienceDirect, IEEE Xplore, MEDLINE, CINAHL, and PubMed. Terms or keywords used to search the articles: (“phr” OR “personal health record” OR “personal medical record” OR “personal health information” OR “personally controlled electronic health record” OR “pcehr” OR “patient portal”) AND (“functionality” OR “features” OR “issues” OR “implementation”). The search was conducted for journal articles and conference proceedings published between January 2015 and December 2020 to ensure that the data were current because the functions of PHRs are evolving.
The authors defined inclusion criteria as the review guidelines for study selection. The articles included for this study must have full text available and written in English, be original research articles, focus on discussing the electronic PHR platform, and discuss functionalities and/or issues in the implementation of PHRs.
In this study, the PHRs discussed are all PHR types (stand-alone, tethered, and integrated) that provide access to health information or records to patients electronically. Therefore, papers with related terms such as patient health records or patient portals are also included in this review. The authors also reviewed PHRs at the design stage to include conceptual papers in this review.
The study selection consists of the following phases:
Keyword or search string was searched in each online database previously mentioned. Duplicated records were checked and removed.
The title and abstract of identified articles were selected based on the eligibility criteria. Articles that did not meet inclusion criteria were eliminated.
Articles that were not eliminated in the previous stage were read in full text to determine whether they should be included in the review based on the eligibility criteria. Reference lists of the included studies were also checked to identify additional relevant articles.
The first author screened the titles and abstracts based on the eligibility criteria. The same author reviewed full-text versions of the articles that were not excluded from the previous screening. The first author extracted data from selected studies and the second author reviewed the extracted data. Disagreements between the two authors were resolved through discussion. If an agreement could not be made, the third author would determine the decision. We were unable to consistently evaluate the risk of bias due to the variety of methodologies within the studies.
Data collection was performed manually using a data extraction form. Information extracted from each article consists of characteristics of selected articles, such as study location, PHR purpose, and methodology, and functionalities of PHRs and issues in PHR implementation
Authors categorized functionalities of PHRs based on their purpose as defined in Bouayad et al [
The database search results identified 2248 studies from 2015 to 2020. Next, duplicate records were removed, resulting in a total of 1511 studies; 124 studies were excluded after the title and abstract screening (articles that mentioned literature review and articles not related to PHRs, patient portals, or access to health records to patients were excluded at this stage). A total of 387 articles were assessed in full text, of which 297 were excluded because they did not meet the selection criteria. However, 15 additional studies were identified from reference lists checking, for a total of 105 studies included in this review (
Flow diagram for search results. IEEE: Institute of Electrical and Electronics Engineers; MEDLINE: Medical Literature Analysis and Retrieval System Online; CINAHL: Cumulative Index to Nursing and Allied Health Literature; PHR: personal health record.
The chosen articles showed that PHR research has mainly been done in developed countries such as the United States, Canada, and European countries compared to developing countries. This country classification was based on the United Nations World Economic Situation and Prospects 2020 [
The purposes of PHRs (
The study methods (
Countries involved in personal health record study.
Purposes of PHRsa.
Category | Description | Number of studies |
General | PHR designated not specific to any diseases, health status, or population. | 48 |
Chronic disease | PHR for chronic diseases such as cancer, diabetes, or cardiovascular disease. | 31 |
Hospital patients | PHR for patients who have visited the hospital, such as inpatients and outpatients. | 10 |
Older adults | PHR for patients with the age of more than 50 years. | 5 |
Women and child health | PHR for women, pregnancy, and pediatric health. | 4 |
Mental health | PHR for mental health diseases, such as bipolar disorder. | 4 |
Other populations | PHR for other specific populations, such as employees and foster youth. | 3 |
Total | —b | 105 |
aPHRs:patient health records.
bNot applicable.
Methods used in the studies.
Method | Type of study | Number of studies |
Qualitative | Interview and focus group discussion | 41 |
Quantitative | Questionnaire, cohort study, and randomized clinical trial | 33 |
Conceptual paper | —a | 16 |
Mixed method | — | 15 |
Total | — | 105 |
aNot applicable.
Basic functions identified in this study consist of the health record and administrative record. Advanced functions consist of medication management, communication, appointment management, education, and self-health monitoring (
Identified Functionalities in PHRa.
Function | Description | References | |
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Health record | Allows patients to view or access clinical documents from health providers’ EHRb. | [ |
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Administrative record | Allows patients to manage personal information and view information related to health providers and insurance. | [ |
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Medications management | Allows patients to manage information related to medications and prescriptions. | [ |
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Communication | Allows patients to interact and communicate with health care providers and others, such as support groups and families. | [ |
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Appointment management | Allows patients to manage appointments with health care providers. | [ |
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Education | Allows patients to access health-related education resources. | [ |
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Self-health monitoring | Allows patients to manage their self-health data through clinical measures. | [ |
aPHR: patient health record.
bEHR: electronic health record.
The health record function provides patients options to view clinical documents that can be retrieved from health providers’ EHR [
This function can also include information about medical history [
Test results menu in the health records module of PittPHR [
This function enables the patient to manage information about demographics or personal information [
Patients can also view health professionals’ information, such as name of health worker [
Health care team information menu [
Health care providers publish prescriptions to the patient’s PHR, while pharmacists dispense the prescribed medication [
This function also allows patients to view list of prescribed medications [
Medication management in My Chart in My Hand [
The patient can send messages to the health care provider to inform them of health condition [
Comments or questions page in myNYP.org [
Some PHRs may allow a patient to request or schedule appointments (
Appointment scheduling in mPHR [
The education function can include resources from trusted websites [
Education resources in Maternity Information Access Point [
Patients can manage their own health related to nutrition and diet information such as weight [
These clinical measures enable calculation such as BMI [
The monitoring of health data can be shown as a dashboard that visualizes data in graphs, charts, or diagrams [
MyHealthKeeper interface for patient’s lifestyle data [
Some issues must be considered in implementing PHRs because these issues can define additional functionalities that can support the main functionalities in PHRs. The issues identified included interoperability, security and privacy, usability, data quality, and personalization (
Issues in implementation of the PHRa.
Issues | Description | References |
Interoperability | Ability of PHR to share or exchange data with other systems | [ |
Security and privacy | Safeguarding of data and personal information in PHR | [ |
Usability | Whether users can use PHR effectively and efficiently | [ |
Data quality | Ensures consistency, completeness, accuracy, and timeliness of the PHR information | [ |
Personalization | Ability of PHR to be tailored and adapted to patient needs and preferences | [ |
aPHR: personal health record.
An important issue raised in several studies is PHR compatibility with other systems [
In the tethered or integrated PHR, patients may connect their PHR to the health care provider system [
It is necessary to create legislation to realize PHR interoperability [
PHRs contain personal and sensitive data [
To ensure the security of information, PHRs should use a single sign-on mechanism [
To address privacy concerns related to data sharing, PHRs should have the ability for patients to choose what information to share and who can see that information [
Some usability problems identified in selected studies include font or text size that are difficult to use [
A PHR may add a section to guide patients about the features in the PHR [
Developers should involve users in designing, updating, or improving PHR systems [
Health care providers may doubt patient-entered data in a PHR [
To ensure data quality of patient-generated data in PHRs, health care professionals need to take time to supervise the quality of information generated by patients in PHRs [
In tethered PHRs, which are tied to EHRs in health organizations, health information on the PHRs are created automatically from the original patient clinical reports to make this information more reliable [
Some users may have more health issues than others, such as older patients having more health issues, appointments, and information to manage [
PHR systems should provide medical information that can be dynamically adapted to patient preferences for simpler or more complex information [
Seven function categories of PHRs are identified as the main functionalities of PHRs, which are grouped into basic and advanced functions. Basic functions (health records and administrative records) provide essential information for patients in their health care. Health records could provide a complete summary of patient health status and condition. Information on this function could reduce health workers’ time gathering patient history and reduce redundant transactions and tests [
Advanced functions (medication management, communication, appointment management, education, and self-health monitoring) could support patient involvement in their health care. Involving patients in controlling their health information improves the chance that health providers would have a comprehensive view of patient health conditions [
In addition to these functionalities, other supporting functionalities may also need to be developed based on the issues identified in this study. To improve security and privacy, PHRs should implement access control, which includes authentication and authorization. PHRs can also provide a backup option to avoid data loss and audit logs to review who accessed the record and what data have been accessed. To improve usability, PHRs can provide quick access to the important information or functions that users frequently use and add a menu for help or a user guide about using features in the PHR. Customization options to show or hide specific health data according to patient health needs are also recommended to increase personalization.
Interoperability represents a key component of PHR architecture [
Integrated personal health record architecture.
The main functionalities described in this review, such as health records, administrative records, medication management, communication, appointment management, education, and self-health monitoring, have also been described in previous reviews [
The functionalities in PHRs can help health care providers and patients obtain useful health information during public health emergencies such as natural disasters and pandemics. For example, in the COVID-19 pandemic, hospital services experienced a crisis [
The Health Level 7 Personal Health Record System Functional Model (HL7 PHR-S FM) defines a standardized model of the functions present in PHR systems [
Health records, medication management, communication, education, and self-health monitoring can be categorized into personal health sections. Administrative records such as managing patient profiles can be categorized into a personal health section, while information about health professionals, hospitals, and insurance can be categorized as a supportive section. Supporting functions defined based on PHR implementation issues, namely sharing, access control, audit logs, backup options, and customization, can be categorized in the information infrastructure section. This section ensures the privacy and security of PHRs, promotes interoperability between PHRs and other systems, and enables PHR function to be accessible and easy to use [
Comparisons between functions.
Functions identified and ID | Functions defined in the HL7 PHR-S FMa | |||||
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Function name | Description | ||||
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PH.2.5 | Manage historical and current state data | Provide a summary of the patient’s current medical state and history | ||
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PH.1.2 | Manage PHRb account holder demographics | Capture the patient’s demographic information | ||
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S.1.3 | Manage health care provider information | Import or retrieval of data necessary to identify a health care provider | ||
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S.1.5 | Manage health care facility information | Import or retrieve of data necessary to identify a health care facility | ||
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S.2.1 | Capture and read health insurance account and benefit information | Request and/or receive and read the information on health insurance benefits | ||
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PH.3.4 | Manage medications | Help patients manage his or her medications | ||
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PH.6.3 | Communications between provider and/or the PHR account holder’s representative | Capture information in preparation for a consultation and maintain continuous communications with the health provider | ||
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IN.3.10 | Secure messaging | Enable secure electronic communication with health providers | ||
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PH.6.3 | Communications between provider and/or the PHR account holder’s representative | Capture information in preparation for a consultation and maintain continuous communications with the health provider | ||
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PH.4 | Manage health education | Provide proper medical education and patient-specific knowledge based on information in the PHR | ||
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PH.3.1 | Manage personal clinical measurements and observations | Provide the patient capability to enter personally sourced data and make it available to authorized health providers or other users or applications | ||
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IN.2 | Standards-based interoperability | Interoperability standards enable the sharing of information between PHRs and other systems | ||
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IN.3.3 | Entity access control | PHR must perform authentication and authorization of users or applications | ||
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IN.4 | Auditable records | Provide system access and use audit capabilities to indicate who accessed the record, how, and when the action was taken | ||
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IN.1.3 | Present ad hoc views of the health record | Provide ad hoc views of the PHR information | ||
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PH.1.1 | Identify and maintain a PHR account holder record | Offer user guide for the installation, initialization, registration, or operation of their PHR |
aHL7 PHR-S FM: Health Level 7 Personal Health Record System Functional Model.
bPHR: personal health record.
The functionality identified in this review covers the main section (PH, S, IN) in the HL7 PHR-S FM. However, functionalities and data elements found in this review are on the individual level that focuses on improving health care. Functions that are not included in this review are functions related to the secondary use of health data. Secondary health data use applies to personal health information for uses outside direct health care delivery [
Not all functions in the HL7 PHR-S FM were found in this review study because the HL7 PHR-S FM is universal and generic by design. There may be additional constraints in certain realms or regions. PHR developers or designers can create a functional profile to define a selected set of applicable functions for a particular purpose, group of users, degree of interoperability, or custodian [
This study is limited to reviewing the implementation of PHRs in research articles and does not address the implementation of commercial PHRs available on the internet. Thus, the functionalities and issues of the PHRs defined in this study may not reflect the state of the practice. This paper does not discuss which functions are more common or whether certain functions are used more frequently than others and does not discuss each function’s benefits and impact on health outcomes. We cannot determine which functionality should be prioritized in the implementation of PHR. We only discuss the functions that are generally mentioned in the selected paper. Each function’s data element may not be comprehensive and might not be generalizable to all patient populations. This is because each disease or condition has different specific data.
This systematic literature review paper discussed functionalities and issues in the implementation of PHRs. Seven function categories are identified in this review, which are grouped into basic and advanced functions. In addition to these functionalities, other supporting functionalities may also need to be developed based on the issues identified in this study. Based on the results, this paper provides an integrated PHR architectural model that describes the functional requirements and data sources of PHRs. This study can offer recommendations or guidance in implementing PHRs by health care facilities management, application developers, policymakers, or other related stakeholders. Functionalities (including data elements and subfunctions) listed in this study and architectural model (
PRISMA checklist.
Characteristics of the included studies.
Data elements and subfunctions.
electronic health record
Fast Healthcare Interoperability Resources
Health Level 7
Health Level 7 Personal Health Record System Functional Model
information infrastructure
personal health
personal health record
Preferred Reporting Items for Systematic reviews and Meta-analyses
supportive
This work is supported by grant NKB-3027/UN2.RST/HKP.05.00/2020 from the Pendidikan Magister Menuju Doktor untuk Sarjana Unggul and Ministry of Research, Technology, and Higher Education Republic of Indonesia.
None declared.