No small change for the health information economy.

n engl j med 360;13 nejm.org march 26, 2009 1278 cumstances (such as when a vendor creates a PHR specifically for a covered entity), vendors such as Microsoft and Google are not covered by HIPAA. Microsoft says it will seek patients’ consent before sharing data with third parties, but none of these application suppliers are covered by HIPAA. Whatever the business model for PHRs, lawmakers should require that the consumer user be clearly informed about the identity of the system’s operator and the financial terms of any direct or indirect use of patient data. It’s difficult to predict what roles Google, Microsoft, and health plans will play in the PHR marketplace in the long run. There aren’t major technical barriers to entry, but data sharing will require the development and adoption of technical and content standards — and a desire on the part of physicians and patients to contribute information to commercial repositories, with their growing contingents of third-party application developers. Since the majority of physicians still don’t have electronic medical records, and patients often seek care outside their providers’ delivery system, these standalone PHRs may serve as data intermediaries. However, if the Obama initiative to replace paper records with interoperable EHRs in the next 5 years succeeds, the landscape will change dramatically, and the need for intermediaries may disappear. Users of integrated PHRs have demonstrated that creating shared records for patients and their health care team can enhance patients’ ability to become active partners in their own health care.5 This is a try-it-you’ll-like-it type of innovation. As physicians increasingly adopt EHRs, we expect community interest in PHRs to grow organically. Ultimately, it will no doubt become difficult for physician groups to survive in the marketplace without them. Dr. Tang reports serving on the Google Health advisory council. No other potential conflict of interest relevant to this article was reported.