Monday, March 19, 2018

The ONC’s SAFER Patient Identification Self-Assessment Looks at Both Technology and Users

The Office of the National Coordinator for Health Information Technology (ONC) offers healthcare organizations a self-assessment for optimizing their use of electronic records in the area of patient identity. The patient identity self-assessment is actually one of nine areas offered on the SAFER (Safety Assurance Factors for EHR Resilience) platform. The patient identity self-assessment and others may be found on ONC’s website at, or by searching for “ONC safer guides” on Google. The guides are also downloadable as PDFs. Each self-assessment begins with a checklist of recommended practices, followed by a “practice worksheet” that gives rationales for and examples of how to implement each recommended practice.

Three domains organize the recommendations. Within the first domain, Safe Health IT, it is recommended that an enterprise-wide master patient index that includes patients’ demographic information and medical record number be used to identify patients before importing data. Duplicate patient records are a common problem that the ONC wants to help address, and it explains that an enterprise-wide patient index “reduces the occurrence of duplicate patient records by increasing the likelihood that patients with previous encounters are identified.” As a practical matter, this could be a master patient index that employs an algorithm that uses patients’ first name, last name, date of birth and gender as well as other attributes (e.g., zip code, telephone number and the last four digits of a Social Security number). It could also involve policies and procedures to identify and prevent duplicate patient record creation and a means to integrate unintentional duplicate records into one complete record.

The self-assessment also recommends that users are warned (by the health IT system) when they attempt to create a new patient record (or look up a patient) whose first and last names are the same as another patient or when the user attempts to look up a patient and the search returns multiple patients with the same or similar names. Using automated EHR processes to prevent duplicate records is seen as a way to prevent unintentional human errors, getting at one of the big risks seen in managing patient records: Creating duplicate records or commingling two different patient records results in a serious patient safety risk. A system might display an alert or warning if that patient, or a patient with similar demographic data, already exists. It might also display in a visually distinct manner the patient names when multiple patients in the system have similar demographic data. There are a total of six recommended practices within the Safe Health IT domain.

Organized in the second domain, Using Health IT Safely, are a total of seven recommendations. For example, it is the recommended practice that patients be registered in a centralized, common database using standardized procedures (I would emphasize “standardized procedures”). As a rationale for this recommendation, the self-assessment notes that nonstandard registration practices and the lack of access to a common database are known causes of duplicate medical records for the same patient. What this might look like in practice would be an organizational policy that establishes standardized registration procedures and a common database to serve as the “source of truth” for determining if a record already exists on a person who presents for service. This might also include requiring a picture ID when verifying the identity of new patients, as well as training registration in consistent patient entry practices across the various points of entry (e.g. ER, inpatient, clinic, phone, internet). This practice of using standardized procedures might also include prompting the registrar when creating a new patient record to consider potential matches in the existing database. What I like about the discussion around this recommendation is the acknowledgment that technology alone will not get us where we want to be. Recognizing the human-user component is key, and training to common protocols for data entry is such an important part in the overall equation.

A process to assign a temporary unique patient ID (which is later merged into a permanent ID) for instances when the patient registration system is unavailable or the patient is not able to provide the required information is another recommended practice. Processes must be in place to address those instances when a patient needs to be cared for immediately without the normal registration process. Staff members should be trained in the creation and use of temporary IDs and how and when to merge temporary records into permanent ones.

Under the third domain, Monitoring Safety, it is recommended that the organization regularly monitor its patient database for patient identification errors and potential duplicate patients and records. Monitoring reduces the likelihood that patients will be misidentified and harmed as a result, and once identified, duplicate records should be deleted and merged. It seems that identifying duplications will also help identify weaknesses not only in the health IT system but also in protocols and training. What I would love to see more of from the ONC is, in fact, recognition that health IT will only succeed if it is built upon input from the user community and its investment is mirrored by a similar investment in the protocols and training that make a great team of users, from the frontline to the back office and the obvious clinical work in between. And to be fair, the SAFER self-assessment for patient identification acknowledges this in its introduction:

Processes related to patient identification are complex and require careful planning and attention to avoid errors. In the EHR-enabled healthcare environment, providers rely on technology to help support and manage these complex identification processes. Technology configurations alone cannot ensure accurate patient identification. Staff also must be supported with adequate training and reliable procedures.

I’ve highlighted only some of the recommendations of the SAFER self-assessment for patient identity. Taken in total, the recommended practices demonstrate how the ONC sees a very robust technology aiding in positive patient identification in the use of EHR. It should also be noted that the SAFER self-assessment for patient identity is very much intended to address patient identity issues in all settings, including the clinical setting, addressing risks associated with a clinician’s need to access patient data. Even with the ONC’s heavy reliance on IT solutions, the recommendations demonstrate the importance of policies and procedures and the need for initial and ongoing training throughout the organization. This is something that Patient Access knows well and that NAHAM has long championed.

And that’s the conclusion of a 2016 study published in the Online Research Journal, Perspectives in Health Information Management, “Why Patient Matching is a Challenge: Research on Master Patient Index (MPI) Data Discrepancies in Key Identifying Fields.” The report cites estimates that healthcare’s EHR system has an 8–12 percent rate of duplicate records (and it cites a RAND Corporation report that duplicate record rate in U.S. healthcare ranges from 8 percent to as much as 15 or 16 percent in larger healthcare systems). The study found numerous reasons for duplicate records, including lack of data standardization, frequently changing demographic data, required multiple demographic data points, and the prevalence of default and null values in key identifying fields.

As for its observations and recommendations, the study suggests to its health information management professionals “partnering with colleagues in Patient Access to establish standard policies and procedures, such as patient searching protocols, standard name entry conventions and questions that registrars can ask the patient in order to determine if the patient has ever been to the facility or practice before.” I would hope the financial managers and strategic planners of hospital systems large and small are engaging Patient Access on this important issue of positive patient identification, duplicate medical records and ensuring the clinical side is getting the right information for the right patient.

And echoing what’s been noted above, the study concludes:

No amount of advanced technologies or increased data capture will completely eliminate human errors. Creating policies and procedures for front-end and back-end staff to follow is foundational for the overall data integrity process. Training staff on standard policies and procedures will result in fewer duplicates on the front end and more accurate duplicate records record matching and merging on the back end.

The study cites among other works the Patient Identification and Matching Final Report prepared for the ONC in 2014. The report compiles the input of numerous organizations in the healthcare space, including NAHAM. Summarizing NAHAM’s input to the report seems a great place for me to end:

Positive patient identification is the first critical step in providing patient care. Incorrect patient identification through the registration process increases the potential for patient harm. Improved patient identification standards, processes and technology ensure safe and appropriate patient care and can eliminate duplicate medical records and fraudulent billing. NAHAM supports continuing efforts to create an environment of positive patient identity and believes that the standardization of patient identification protocols and technologies are important means to this goal. NAHAM supports the development of standards for data attributes in electronic systems, whether clinical or administrative and enhanced common capabilities for all healthcare data systems to input standardized data. Education and training are important parts of the solution for positive patient identity. Education and training are also important to ensure personnel at all levels understand the important roles patient data input and patient identification protocols serve in enhancing patient safety.

By Frank Moore, NAHAM's Government Relations Director

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