Interoperability demands a single national patient identifier
mark summers | electronic health reporter | 11 MAY 2015
At HIMSS this year, multiple speakers laid out visions for a future where parents could consult with a pediatrician via a telemedicine encounter during the middle of the night, take their children to receive immunization shots at a retail clinic, and have all of this information aggregated in their primary care provider’s record so that providing an up to date immunization record at the start of the next school year is as simple as logging into the PCP’s patient portal and printing out the immunization record. In short, multiple speakers presented visions of a truly interoperable future where patient information is exchanged seamlessly between providers, healthcare applications on smartphones, and insurers.
While initiatives such as the CommonWell Health Alliance, Epic’s Care Everywhere, and regional health information exchanges attempt to address the interoperability challenge, these fall short of fully supporting the future vision described above. Today’s solutions do not address smartphone applications and still require manual intervention to ensure that suggested record matches truly belong to the same patient before the records are linked. This process is costly but manageable in an environment where a low volume of patient records are matched between large provider organizations. In a future world where patient data is available from a multitude of websites, smartphone applications and traditional healthcare organizations, it would be cost prohibitive to manually review and verify all potential record matches.
Of course, one solution to this dilemma would be to improve patient matching algorithms and no longer require manual review of records before they are linked. However, for this to be possible, a standard set of data attributes would need to be captured by any application that would use or generate patient data. In a 2014 industry report to the Office of the National Coordinator for Health Information Technology, first name, last name, middle name, suffix, date of birth, current address, historical address, current phone number, historical phone number, and gender were identified as data attributes that should be standardized. Many of the suggestions in this report were incorporated into the Shared Nationwide Interoperability Roadmap that the ONC released in January 2015.
Unfortunately, when the promise of smartphone applications is that they are quick and easy to use, it is difficult to envision a scenario where consumers will take the time and effort to accurately enter all of these data elements before using a smartphone application. Instead, patients will rush through registration and inadvertently enter inaccurate information or they will abandon innovative smartphone applications and instead continue to receive healthcare through today’s channels. It would be a shame if innovative smartphone applications are not adopted because demographic data entry requirements become too challenging for patients to manage.
Even if smart phone applications are able to capture all of the above data elements and the matching error rate is reduced to 2.5 percent that means that there would be at least 8 million Americans with inaccurate medical records (the true figure is higher, given that it is an inaccurate assumption to assume that the same 2.5 percent of records are always mismatched). It is doubtful that clinicians would be willing to accept this error rate without having a manual review process in place before records are linked.
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Another potential solution to this dilemma would be to develop a framework where patients are responsible for linking their records between different healthcare providers, insurers and smartphone applications. While technically feasible, this solution is problematic as it requires patients to take the time and effort to link records. Some motivated patients undoubtedly would; however, the vast majority of patients are not likely to take the time and effort to link records between organizations. This would only be a feasible solution if all patients would consistently link their records.
What then is the practical answer to developing an environment where health information can be seamlessly shared between not only traditional health insurers and providers but also new, innovative healthcare smartphone applications? The simple solution is a single national patient identifier.
When HIPPA was originally conceived in 1996, it included a provision for establishing a national patient identifier to facilitate the sharing of health information. Ultimately, Congress effectively decided to ban a national patient identifier by refusing to pass appropriation funding in 1998, citing privacy concerns.
While this may have been the best decision in 1998, the environment has changed significantly since the late 1990s. Today, patient data not only supports individual care decisions but also big data efforts such as population health management. As a result, clinical and financial outcomes are at risk.
This is not to minimize the privacy and security challenges that would come with the implementation of a national patient identifier. Indeed, in today’s world where just a few Facebook likes provides enough information to accurately determine race, gender and sexual orientation privacy and security concerns must be addressed for a national patient identifier to be successfully adopted.
Estonia’s X-Road project provides a useful example of how such system could be managed. While available to all Estonian citizens, X-road is available to non-citizens on an opt-in basis. A similar concept could be used when developing a national patient identifier whereby patients who want the convenience such an identifier would afford can opt-in while those who have privacy concerns could choose not to participate. The X-Road project also protects data by using strong encryption and two factor authentication and in 10 years of operation has not had a data breach.
While the ONC has begun the push for interoperability, the ONC stops short of calling for a national patient identifier. Let’s acknowledge that we need a national patient identifier to achieve true interoperability and the vision so many have outlined. We can then have an informed discussion regarding the data and privacy concerns and work to ensure that appropriate legislative protections are enacted. Otherwise, until a reliable way to uniquely identify patients is accessible to all stakeholders in the healthcare industry, the visions outlined for a truly interoperable environment where information is shared seamlessly will not be realized.
Mark Summers is a healthcare expert at PA Consulting Group