This is a multi-part message in MIME format. --------------E413C96ED09D566A53D5339C Content-Type: text/plain; charset=us-ascii Content-Transfer-Encoding: 7bit file:///0/Temporary%20Items/nscomm40/tmp/tmp1/edt1.html --------------E413C96ED09D566A53D5339C Content-Type: text/html; charset=us-ascii; x-mac-type="54455854"; x-mac-creator="4D4F5353"; name="edt1.html" Content-Transfer-Encoding: 7bit Content-Disposition: inline; filename="edt1.html" Content-Base: "file:///0/Temporary%20Items/nscomm40/t mp/tmp1/edt1.html" <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">Action Plan for Implementing a Unique Health Identifier
Action Plan for Implementing a Unique Health Identifier
BACKGROUND
This paper presents an action plan of the Computer-based Patient Record Institute (CPRI) for adopting a unique health identifier.CPRI is a nonprofit membership organization committed to advancing improvements in health care quality, cost, and access through use of information technology. It serves as a neutral forum for bringing together diverse interests of health care stakeholders to develop common solutions. CPRI was established in 1992 as a result of the recommendation of an Institute of Medicine (IOM) study: The Computer-based Patient Record: An Essential Technology for Health Care (National Academy Press, 1991).
A computer-based patient record is electronically maintained information about an individual's lifetime health status and health care. It replaces the paper medical record as the primary record of care, meeting all clinical, legal and administrative requirements. It also serves the providers and patients better than a paper medical record. For example, a computer-based patient record system can facilitate access to health data stored in multiple, dispersed locations, when authorized by the patient, to provide complete and accurate data for continuity of care. A computer-based patient record system also provides reminders and alerts, linkages with knowledge sources for decision support, and data for outcomes research and improved management of the health care delivery. Computer-based patient record systems that include properly designed and monitored security features can provide greater protection of confidentiality for individually identifiable health information than paper-based records.
The term unique health identifier should be understood to mean a number (or other identifying code) that identifies one, and only one, person, used for the purpose of managing all health information. Other terms, such universal patient identifier (Evaluation of Candidates for Universal Patient Identifier, CPRI, 1995), unique personal identifier (Final Report of the Task Force on the Privacy of Private-Sector Health Records, Contract HHS-100-92-0036, Kunitz and Associates, Inc., September 1995), universal healthcare identifier (Guide for the Properties of a Universal Healthcare Identifier ASTM, E1714, 1995), or national citizen identifier may be used synonymously.
STATEMENT OF POSITION
The CPRI is developing this action plan to achieve the benefits of computer-based patient record systems which require unique identification of individuals receiving health care. The urgency attached to this issue is due to the increasing number of providers involved in an individual's care (all pursuing courses of treatment that are documented in separate records), and the rising cost associated with merging patient records as health care providers integrate delivery systems.While the need for a unique health identifier is generally agreed upon, and various options have been debated, no breakthrough strategy for a specific solution has been advanced.
In 1993, CPRI published a position paper recommending that the social security number (SSN), with modifications in the number and the process for issuing it, be adopted immediately as a "universal patient identifier." At the same time, several other organizations, such as the Work Group on Electronic Data Interchange (WEDI), the National Association of Health Data Organizations (NAHDO), and the American Medical Informatics Association (AMIA) also supported the SSN for this purpose. More recently, several states have mandated the use of SSN for state data reporting and have required process changes to facilitate issuance of numbers.
WHY A UNIQUE HEALTH IDENTIFIER?
In the days of a town doctor making house calls, a patient was identified by sight and from memory. As populations grew, health care providers cared for more patients and patients received their care from more than one provider. Providers developed their own identifiers to meet their own needs. Today, new models of health care delivery, particularly managed care, call for integration of care among many providers. These new models of integrated care can only be fully supported through an integrated, electronic information system. The concept of a lifetime health record, logically containing health data from all sources, when authorized by the patient, is key to delivering high quality, cost-effective care. In order to achieve this integration, a system must be able to unequivocally match information from another system to the correct patient. Identifying each person and the person's health data with a unique health identifier is the most reliable method of making sure that only the correct data for a given patient is merged. This ensures that health care providers have accurate and complete information upon which to base their patient care decisions. The lack of a unique health identifier frequently leads to patient data not being properly matched to a patient's record or causes data from the wrong patient to be merged into a record.ALTERNATIVE IDENTIFIERS
Many alternatives to the SSN have been suggested. Several organizations support creation of a new numbering system to be used as the identifier. There are many algorithms proposed to create such a number involving various pieces of demographic information about an individual. ASTM's Guide for the Properties of a Universal Healthcare Identifier outlines many of the limitations of using the current SSN and issuance policies. For example, SSNs are not issued at birth, not everyone receiving health care in the US is eligible for a SSN, some individuals have more than one SSN, and in some cases one SSN has been issued to more than one individual. A technical deficiency in the existing SSN is the lack of a check digit. Use of a check digit is an important tool to help catch transcription errors. Clearly these issues would need to be addressed in any proposal for a unique health identifier based on the SSN.Biometric identifiers, such as retinal scans, DNA prints, and thumb prints, are generally capable of uniquely identifying the patient at the time of treatment. While cost and reliability of such systems are issues, the primary issue is availability of the biometric identifier when services are needed. It is estimated that 80 percent of the cases where access to patient specific information is required do not involve a patient's physical presence, such as transferring medical records from one physician to another for consultation and handling phone calls from the patient to the provider. Thus a biometric identifier would need to be turned into a character string essentially becoming an alternative number.
Proponents of a new number point out that it would be linked only to health records and associated databases. Any identifier has as its key attribute the ability to link information. With appropriate security procedures and legislation that provides sanctions for breaches of confidentiality, the SSN can be used in as secure a manner as any other identifier. But because the SSN is available today, it can be implemented at lower cost than an entirely new system. In addition, most providers currently record the SSN of their patients, so it is available as part of many existing systems thereby reducing the implementation costs to providers.
In light of concern raised by some over the adoption of the SSN as the unique health identifier, CPRI established a task force in 1994 to reevaluate the SSN in this role. This task force devoted significant effort evaluating different identification schemes and concluded that with modifications to the SSN and important changes to the process of issuing SSNs, a unique health identifier based on the SSN is the most feasible option.
CONSIDERATIONS FOR ADOPTING THE SSN
To ensure both acceptance and functionality of a modified SSN as the unique health identifier, several considerations related to implementation and performance must be addressed. These include issues of confidentiality and security, procedures for issuing unique health identifiers by a "trusted authority," the requirement of uniqueness, cost of implementation, and the need to educate the public on the role of the unique health identifier.Confidentiality and Security
A unique health identifier is essential to implementing a computer-based patient record. Using a unique health identifier to link patient data, however, must be accompanied by enforceable policies that protect the confidentiality of identifiable patient data. Confidentiality and security are largely policy issues, enforcement of which may be accomplished using technology tools and functions. The CPRI has consistently held that establishing guidelines enforceable by law for maintaining strict confidentiality of patient records is crucial to implementing the computer-based patient record.A primary concern for the use of SSN is the potential for using it to link other non-health care data. Any numbering system, however, may be used to link other data. Preventing unlawful linkage lies not in the number itself, but in privacy protection law, anti-discrimination law, and use of system security features that prevent unauthorized access to confidential data. There must be explicit constraints regarding linking of health data, and appropriate penalties for breach of confidentiality and discriminatory practices. Encryption, secure networks, and other such technology provide means of securing the data itself.
Trusted Authority
Equally important in the confidentiality and security issue is the identity and the responsibilities of the trusted authority that administers a unique health identifier system. Establishing a trusted authority is a choice between creating a new organization or incorporating the function into the charter of an existing organization. Any such organization will necessarily require the public trust. As such, it must incorporate both public and private interests. The cost and time required to set up a new organization with the accompanying infrastructure would far exceed the cost of using an existing organization.A logical choice for an existing entity is the Social Security Administration (SSA). It has over thirteen hundred offices nationwide, and is beginning to process requests for SSNs in real time. However, for the SSA to effectively administer SSNs as a unique health identifier, there must be significant changes to SSA procedures for issuing the numbers. There must be increased funding and specific tasking of the SSA to clean up existing duplication, multiple assignments, and other errors. Fortunately, these actions would benefit all users of the SSN. The SSA will ultimately face the challenge of lack of capacity if the SSN is limited to numbers only. This limitation could be handled by converting digits to alpha characters, as being proposed for the universal provider identifier. In addition, there must be legislation permitting the use of SSNs for health identification purposes. There must also be a mechanism whereby identifiers can be assigned to those without an SSN. Finally, there must be an authentication algorithm used to establish the identity and authority of the organization requesting a number.
Uniqueness
Health Data in the Information Age (Institute of Medicine, National Academy Press, 1994) delineates characteristics it believes critical to any unique health identifier, including: easy transition to the number, built in error control features, ability to identify and verify the person's identity, universal applicability which never impedes access or delivery of health care, full functionality to link events occurring at multiple providers, and minimization of opportunities for crime and abuse.One helpful characteristic of a unique health identifier is the inclusion of a check digit. A check digit is used to determine the accuracy of the data entry process. The Verhoeff method (Error detecting decimal codes, Mathematical Centre Tract 29, 1969, The Mathematical Center, Amsterdam) detects approximately 99.8 percent of the transcription errors associated with entering a SSN. Check digit methods provide a high level of immunity from data input errors. The check digit does not have to be stored.
Cost/Benefit
Availability of the SSN makes it the most cost-effective solution. Initial estimates indicate that the overall cost of creating a new identification system would be considerably greater than adopting the SSN with a check digit and process improvements at the SSA. Many health care organizations, including the Department of Veterans Affairs, and Health Care Financing Administration (HCFA), already use the SSN in their identifiers, or at least collect it as part of patient demographics. Finally, improving SSN issuance would have a significant impact on fraud and abuse in the entire system of entitlements which relies on SSN for identification purposes.Education
The 1993 Health Information Privacy Survey conducted for Equifax by Louis Harris and Associates showed strong support for use of the SSN as the unique health identifier. The report reads "Were such a personal ID number introduced, there is a clear preference for it being the same number as the SSN. A strong majority of leaders (72%) and the public (67%) favors using the SSN as their health care identification card." Although the results of this survey indicate a generally favorable opinion about use of the SSN as the patient identifier, CPRI recommends developing a program of public education describing the potential advantages of a unique health identifier and the measures that ensure protection of personal health data.SUMMARY OF RECOMMENDATIONS
CPRI calls upon the National Committee on Vital and Health Statistics to immediately recommend to the Secretary of the Department of Health and Human Services (DHHS) the adoption of a unique health identifier based on the SSN. The following steps outline a course of specific actions that are necessary to meet this objective:CPRI endorsement of position papers does not necessarily imply endorsement by individual CPRI member organizations.
- Enact legislation to fund and task the SSA to add a check digit to the SSN and modify the process of issuing SSNs so that it may be used as the unique health identifier.
- Enact federal preemptive legislation to provide uniform protection of the confidentiality of health information, as called for in Public Law 104-191.
- Develop and promote a public education program outlining the importance of a unique health identifier and describing how access to individually identifiable health information will be protected and controlled.
For answers to frequently asked questions, see the Unique Health Identifier FAQ.
Computer-based Patient Record Institute
4915 St. Elmo Avenue, Suite 401
Bethesda, MD 20814Copyright, CPRI
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