Curbside Consult with Dr. Jayne 2/18/13

In the last several months, I’ve been involved in a lot of conversations around the concept of unique patient identifiers. A considerable amount of it has been due to our hospital’s participating in an accountable care organization.

We have a very good master patient index (MPI) in place, as well as other tools that allow most of our applications to use CCOW to share patient context as well as user context. Now the ACO is requiring us to tightly integrate with providers external to our owned facilities and employed medical group. That is giving a lot of people in our organization a fair amount of heartburn.

During nearly a decade of practice acquisitions and mergers, I’ve seen how people in various practices may (or may not) correctly identify patients. I’ve seen people perform patient searches using: the first three characters of both first and last name; first name, last name, and Social Security number; first initial, last name, and phone number; and various combinations of name, address, and date of birth. In consulting work, I’ve seen clients with both pristine MPIs and those clogged with duplicates.

The health of the MPI depends on not only the actual data integrity, but how the information is governed. The logic of the matching algorithm also plays a major role in minimizing erroneous matches or missed matches. If person merges are not performed in a timely manner (or if users don’t know how to request a merge when they find a duplicate patient) patient safety can be in jeopardy. In large health systems that have let their MPIs get out of control, it can take months to years for a cleanup effort to be successful.

Our organization is all too familiar with what happens when data isn’t as tightly governed as it is within our MPI. We’ve dealt with the pharmacy intermediaries that use ZIP codes for matching, which is a challenge for our transient patients. We’ve dealt with Sandy vs. Sandie vs. Sandi when the patient’s legal name is Sandra. We’ve dealt with marriages and divorces and the ensuing claim denials that result when names may not match.

There has been a lot of debate in the past about a national patient identifier. As fiercely independent Americans, we seem to fight it as an intrusion into our privacy. However, we willingly submit to a government identifier in order to pay taxes or receive government benefits (the Social Security number) or when we want to drive a car (the state-issued driver’s license number) or go to the Caribbean for spring break (the passport). Yet for the most personal situations (and possibly life-saving or life-threatening, depending on how you think of it), we resist a unique identifier.

I have to have a National Provider Identifier number if I want to receive anything other than a cash payment for my professional medical services. It took time and effort to update clinical, administrative, and payer systems with fields to track the NPI, but somehow we all survived. The same type of update would be needed to track a patient identifier, but the demands of Meaningful Use have proven that vendors can and will update systems based on government regulations.

There would also need to be a new government infrastructure created to issue identifiers and maintain the information. Meaningful Use has also demonstrated a willingness to accept additional layers of bureaucracy in the name of intended reform, so why not for a patient identifier?

Having a unique patient identifier would certainly make interoperability easier. It would also provide significant benefits to patient safety by reducing the possibility of duplicate or conflicting charts. Knowing exactly who we’re treating can also assist in preventing drug diversion and reducing healthcare and insurance fraud.

The original HIPAA Act of 1996 allowed for the creation of unique patient ID numbers, but Congress quickly blocked funding, citing privacy concerns, existing numbering systems, and concerns about government involvement in health care. A decade and a half later, however, those trains have long left the station. It’s time to reconsider.

There is significant support among the professional community. The American College of Cardiology has a nice position statement. Many other organizations cite the 2008 RAND Corporation study titled “Identity Crisis” in calling for support.  The RAND study also discusses the need to use both statistical matching and a unique identifier during the implementation process or if participation is voluntary.

Correct patient identification is essential for effective health information exchanges. There’s a lot of discussion around the Direct protocols for Meaningful Use Stage 2. Privacy rights advocates are pushing for patient-defined identifiers where patients can choose different identifiers in different situations depending on what data they want shared. Although this may allow some data to remain siloed in an effort to protect privacy, it also prevents creation of a true comprehensive patient record.

I support the ability of patients to receive care anonymously, but when patients do so, they should not be surprised that physicians and caregivers may not have the full picture of the patient’s health. Physicians and hospitals should not be held liable for negative outcomes when information is sequestered by the patient. For the rest of us, however, who want to ensure that our physicians have our entire health history present so we can receive the best care possible, this can’t happen too soon.

What do you think about a national patient identifier? E-mail me.

E-mail Dr. Jayne.