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Curbside Consult with Dr. Jayne 2/18/13

February 18, 2013 Dr. Jayne 3 Comments

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.

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Currently there are "3 comments" on this Article:

  1. I think your right on track.. Doc are requried.. Payers may soon be requried to have a standard ID. The patient already had an ID but dont know it. The issue is once every Doc can reconize a patient based on picture… This will be a non issue! And if the X12 standard will allow for an ID that is not part of the SSN or Allow for POS ID of the patient this will go far!

    Thanks for the post!! Agree 100%

  2. This is spot on, however, we need to take a leap beyond data integrity. A single MPI is truly the ONLY way to have comprehensive patient clinicals and in turn provide comprehensive clinical care. The vendors spend all their time chest beating and declaring who is better which in turn keeps walls up around their data. I.e. There is no investment in this technology and shows they don’t really care about the provider or the patient. If they cared about this in the big picture they would be finding a way to a) aggregate data for true analytics/clinical decision support while still keeping the patient’s privacy in mind and b) aggregating patient clinicals in a comprehensive portal/vault/warehouse/whatever. Until HIT vendors can work learn to (or are forced to) work cooperatively in the space, the provider and patient will suffer.

  3. Dr Jayne

    I’ve spent some time thinking about this issue. You are correct: the US already has effective MPIs that it has effectively already implemented via social security and driver’s license numbers. However, the effectiveness of these MPIs in their fields doesn’t quite correlate to healthcare.

    SSN and DL numbers are relatively encapsulated, and actually mean almost nothing. Although they are unique people IDs, the IDs aren’t tied to much, and aren’t accessed by many government officials. Sure, the police look up your DL when you get a ticket, and the IRS looks up your SSN when distributing social security checks, but these databases really aren’t used by that many people in that many scenarios. Most of the time, they’re just in place so a computer can reference the right person. Rarely do people look at the data associated with DL or SSNs.

    In a single hospital admission, over a dozen people will need access to some portion of a patient’s chart. If the patient is transferred from the emergency department to the inpatient ward, another dozen will look at the patient’s chart. If the patient moves to another facility, another couple of dozen will get involved. Each of these people will need to review and scrutinize all of the data they’re presented with in order to do their jobs. Contrast this with social security, which is really just used to distribute money.

    As a technology enthusiast, I find the privacy advocates to be frustrating. They are getting in the way of progress. But they’re also right – we can’t be allowing hundreds of clinicians and administrators access to a patient’s record unless necessary. The consequences of the patient MPI would destroy any last shrivel of privacy in our FaceBook-connected world today

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