Tuesday, February 26, 2013

It’s Time for a National Patient Identifier

Here's a guest post from  Meg Aranow, Principal at Aranow Consulting LLC.

Some of us remember that the early HIPAA discussions included the concept of a national patient identifier.   As legislators and administrators attempted to find the right balance between the risks and rewards of automation, ultimately the patient identifier was thought to pose too much privacy risk.  I think that was the right decision in 1998.  But is it right in 2013?

The risk-reward playing field has been significantly altered by the infusion of federal stimulus money to hasten the implementation of data exchange among collaborating providers of care.   Clinically misidentified patients are patients who are not associated with their own medical histories or are mistakenly associated with someone else’s medical histories.  These patients have a heightened risk for inappropriate and potentially dangerous care provision.  This potential has always existed within our institutions, but the prevalence increases as our collaborative models are extended.  When clinic records are shared with the collaborating specialty clinic, and then shared with hospital and then the post- acute facilities we increase both the opportunity to deliver great care, and the risk of misidentification occurring somewhere in the chain.

Washington administrators are considering a new set of standards to routinize matching algorithms in an attempt to reduce patient mismatches.  To dictate standard matching criteria will compromise the very privacy safeguards they sought to maintain by eliminating the patient identifier in the first place.  Standardized criteria is a weak substitute for an identifier – it weakens privacy protections  and doesn’t actually solve the underlying problems of errant patient identification which stems from intentional or unintentional misreporting and recording of patient demographics.

Undoubtedly there are risks with a national patient identifier.  We need to continue our efforts to bolster security and privacy.  Unfortunately today security awareness and breaches both seem to be on the rise.   Most CIO’s are acutely aware of the security standards they must meet and report that they are making incremental progress against multi-year agendas…perhaps foreshadowing a point in the future where breaches of PHI will become increasingly rare.   Additionally, medical identity theft is estimated in the billions – Ponemon Institute suggests a high end of $30B per year.  Making more money available for preventative measures rather than paying for the penalties and remedies for the lapses seems like a worthy paradigm shift.  Strong, reasonably funded security and privacy requirements with repercussions for mistakes and abuse may be the path to finding the new balance of risk and benefit for a collaborative medical system based on a national patient identifier.

A patient identifier, separate and distinct from the social security number, and used as one factor in multi-factor authentication at the point of registration for services would assist in the accurate identification of patients at the point of care.  The persistent use of the patient identifier in the private and public HIEs will streamline and make more accurate efforts to share data among collaborating clinicians and public health entities.


Joe Stewart said...

I couldn't agree more. The landscape has changed over the past decade and I share the view that the risks relating to mis-identification and the costs related to inadequate patient identification outweigh the objections to a national patient id. It's time to adopt a national patient id.

Unknown said...

+1 from the TITLE alone...reading now...

José Morais Antas said...

The problem is (has been/will be) there is no such simple thing as a "National Patient Identifier".
The problem is that, as every human being has the potential to become a patient, what you are really talking about here is a "National Personal Identifier".
An identifier that, unlike the SSN, would need to be even more precise and unequivocal. Because health care systems are critical systems and by definition "minor" errors in such systems - such as a "mis-identification" - would potentially incur in mortality or, at least, morbidity.
And I will not even delve in the "minor problem" of the non-healthcare potential of a "National Personal Identifier" that is dead on (pun intended) precise and unequivocal...

XML4Pharma said...

National Patient Identifiers have been implemented in most european countries. Some countries (such as Austria) use the social security number (99.9% of the people in these countries have one), other (like the Netherlands) have a so-called social-fiscal number (assigned at birth or immigration) which is used for as well tax matters, social security as patient identification. Even other countries (e.g. Belgium) have a NPI which is used for almost anything that has to do with government (although I am not sure whether it is also used as a patient identifier in Belgium).
Not knowing the US system very well, what is the problem with the SS? Is it not unique or unequivocal?
I very well understand it is also a cultural matter whether introduction of such an identifier is accepted by the population. I remember the heavy protest in Britain when they tried to introduce idendity cards, whereas in Belgium or France everyone always have it in its wallet.

Adrian Gropper said...

Patients are people and deserve transparency and consent rather than tracking.

Probabilistic matching is both opaque to the person and coercive. A national ID might be transparent but is still coercive.

Globally unique voluntary person IDs are in use every day in the form of phone numbers and email addresses. Meaningful Use Stage 2 includes Direct secure email addresses that are accessible to everyone. It also allows for self-signed certificates that can be completely person-controlled.

There are many other advantages to a Direct email as a patient ID including the ability to notify the patient, to deliver signed, secure messages and to support bi-directional communications with the care team.

HealthITGuru said...

John, can you write a blog post about the BIDMC EMPI strategy? I would like to know the approach you use. Patient identification is more complex than a number. patient matching against first name, last name, DOB, sex, zip code and last 4 of ssn has an error rate of 1 in 40 million (false positive). Drop the last 4 of ssn and it is 1 in 80,000 (still 99.999%).

Rob Macmillan said...

We at Global Patient Identifiers, Inc. believe that the implementation of a National Patient Identifier must address two key issues from the outset or it will be doomed to failure.
Firstly, it must empower the patient to be able to make decisions about the privacy of his or her healthcare record. It must allow the patient to decide that while part of the record may be “open” (meaning available to all providers), other parts may be “private” and available only to those as specified by a privacy policy selected by the patient. It may indeed be necessary to have multiple privacy policies for different kinds of information.
Secondly, it must be implemented by the private sector and patients must be able to decide if and when they will acquire an identifier. In other words, the implementation must be voluntary.
We believe that the combination of these two factors will drive nearly universal patient acceptance of a unique healthcare identifier.

Edward J. Larkin said...

Why not use ones own thumbprint? If you want a drivers license in Texas, you are required to provide this. If you want to rent a storage unit in the state of Arizona you will also need to provide this. Its easy, its simple and its impossible to duplicate!

XML4Pharma said...

Impossible to duplicate?
You can find Dr. Schauble's (the German finance minister) fingerprints on the internet. See http://www.focus.de/digital/multimedia/tid-9383/chaos-computer-club_aid_267520.html
A security breach has been found at the Frankfurt airport where fingerprint was used to provide access to the security zone without further control for coworkers. It was found to be easy to copy someone elses fingerprint and getting access using a rubber duplicate.
I do not know about the US, but acceptance by the population is extremely low in Europe ("big brother" fear).

Unknown said...

A patient person-controlled identifier s lerveraging Direct Addresses seems to be a great way to get around the "coercive" objection and the cultural resistance to a Universal ID. We explored the mechanics of this in the Chatham Connect with Direct ONC sponsored Consumer Innovation Challenge project. The difficult part assuming that we can overcome the policy and mechanical problems will still be getting patients to adopt Direct Addresses and use them. How do patient come to see that value? Patient engagement in healthcare is the key to so many problems.