In 1993, the computer-based Patient Record Institute (CPRI) recommended that SSN with modifications in the number and its process of issuing, be adopted immediately as a "Universal Patient Identifier". Several other organizations such as AMIA, ACMI, ACS, WEDI, ASC X12, NADHO, etc. have also recommended the use of SSN as a Unique Patient Identifier. In 1996, CPRI released an action plan for implementing an Enhanced SSN. CPRI's recommendations for the Enhanced SSN include :
1) confidentiality and security procedures for issuing Unique Patient Identifier by a "trusted authority"
2) federal legislation to provide uniform protection of the confidentiality of health information
3) federal legislation permitting the use of SSN for healthcare purposes
4) mechanism to handle patients without an SSN
5) uniqueness
6) temporary number for emergencies
7) use of demographic information data base to support identification functions
8) use of check-digit verification to ensure accuracy
9) penalties for breach of confidentiality and explicit constraints regarding linkage of health data
10) encryption
11) authentication to verify the identity of the organization requesting a number
12) clean-up of existing duplication, multiple assignments and other errors
13) change in the format of the number to facilitate capacity
14) public education program on Unique Patient Identifier.
In response to the immigration and welfare reform law passed in 1996, the Social Security Administration (SSA) has submitted a report in September, 1997 to the US Congress on options available for enhancing the Social Security Card. SSA studied different methods for improving the Social Security card application process. SSA's report includes evaluation of various options to issue a counterfeit-resistant ID card with improved security features and functionality. They include:
1) plastic card
2) card with picture
3) secure bar code stripe
4) optical memory stripe
5) magnetic strip
6) magnetic stripe/picture
7) microprocessor/magnetic stripe/picture.
Cost to the government to implement these options in a 3 or 5 or 10 year time period and issue new cards to the 277 million current card holders will range from $3.9 billion to $9.2 billion.
There are about 1300 Social Security offices in the US. SSNs are assigned centrally at SSA Headquarters in Baltimore, Maryland. Applications are handled in Field Offices and Offices of International Operations. SSN is assigned within 24 hours of processing of the application. It has been pointed out even by critics that with 1300 Social Security Offices, well-trained personnel, detailed standard procedural guidelines and an electronic network in place, the SSN can be used as the patient's identifier on relatively short notice. SSN is a demonstrated success as patient identifier in large systems such as Veterans Administration. A majority of the citizens already has SSNs and it is currently used as a patient identifier for about 20% of the population. Other points frequently mentioned in favor of SSN include 1) SSN is the de facto linkage, 2) it already has broad distribution and widespread use, 3) SSN with check-digit is less expensive to implement than a new identifier, 5) people are used to it, 6) systems are accustomed to handling it, 7) SSA continues to make improvements to SSN, 8) government bears the burden of administering the system, 9) used as Medicare ID and 10) relatively easy to adopt.
The initial Social Security Law was passed in 1935. It was called Social Security Account Number (SSAN). In 1943, President Franklin Roosevelt signed an executive order requiring federal agencies to use the SSN whenever a new record system was to be established. The DOD adopted SSN as a military identifier during World War II, and in 1960 the IRS adopted SSN as the tax payer identification number. When the Medicare legislation was passed in 1960, the government adopted the SSN plus an appended letter as the Medicare identification number. The Privacy Act of 1974 prohibited states from using the SSN for enumeration systems other than by authority of the Congress; however, states that were already using it were allowed to continue. The Tax Reform Act of 1976 authorized the states to use the SSN for a variety of systems including state and local tax authorities, welfare systems, driver's license systems, department of motor vehicles and systems for tracking delinquent child support parents. The SSN is in widespread use as a personal identifier.
1. SSN is already used as an identifier in both healthcare and other
industries.
2. SSN is sponsored by several organizations including CPRI,
AMIA, ACM, ACS,WEDI, ASC X12 and NADHO. Formal Documentation, 1300 Social
Security Offices, well-trained personnel, detailed standard procedural
guidelines and an electronic network are in place.
Accessible: SSA is accessible throughout the nation with its numerous field offices.
Assignable: SSN is assigned within 24 hours, and the postal delivery takes 7 to 10 days. About 1300 field offices provide adequate capability to handle the assignment regardless of the date or place of request. CPRI's recommendation for the Enhanced SSN include improved procedure to process requests for SSN in real time.
Identifiable: SSA maintains a set of identification information on each individual. The amount of identification information collected and stored by the SSA is currently not sufficient to provide the positive identification of an individual for healthcare functions. The Enhanced SSN proposal recommends a data base of individuals' demographic information to support this.
Verifiable: The inclusion of check-digits in the Enhanced SSN has the potential to support the verification process.
Mergeable: SSN's current operating policies and procedures address this function. Multiple numbers have links and cross-references to increase its capability further.
Splittable: SSN's current operating policies and procedures address this function. Currently, a new number is issued upon request . The Enhanced SSN proposal recommends new procedures for the issue and management of the identifier to handle the unique requirements of the healthcare industry.
Linkable: SSN is currently used as the patient identifier in large healthcare systems, such as the VA Hospitals and Department of Defense. SSN is used to support the linkage of health records in both a manual and automated environment.
Mappable: SSN is widely used as a secondary identifier by healthcare organizations. Most of the medical record charts include the SSN as a data item. Therefore, it is possible to map SSN to the existing identifiers. This unique capability can also facilitate the mapping of the same individual's medical record in multiple institutions to increase its capability further.
Content Free: The SSN in its current form includes the location and time of issue information. Enhanced SSN proposal recommends changes to the current format.
Controllable: The necessary administrative and technical infrastructures are in place and can provide the control and security necessary for the encryption and decryption functions being proposed for the Enhanced SSN.
Healthcare Focused: The SSN was not created for the use of healthcare. The proposed Enhanced SSN includes check-digits, encryption, improved procedure for the security and issue of SSN, federal privacy legislation against the unauthorized access and misuse of patient information, and appropriate access control. With these additions, the Enhanced SSN has the potential to address the concerns of the healthcare industry adequately.
Secure: The proposed Enhanced SSN encryption and decryption scheme is intended to aid the access security without compromising an individual's privacy. SSA has the necessary administrative and technical infrastructure in place and has the potential to function as the Trusted Authority to govern the policies relating to the encryption and decryption of the identifier. The Enhanced SSN proposal recommends new procedures for the issue and management of the identifier to handle the unique requirements of the healthcare industry.
Disidentifiable: The proposed encryption scheme for the Enhanced SSN enables hiding the identity of the individual that the SSN identifies.
Public: SSN is used widely. It has the potential for encouraging linkages to individuals' social and financial information which can cause harm to them. To address this potential problem, CPRI's proposal for the Enhanced SSN recommends confidentiality and security measures, federal legislation against the misuse of patient identifiers and discrimination based on health information.
Based on Industry Standards: SSN is not based on a industry standard. It is considered to be the de facto standard for personal identification.
Deployable: SSN is currently used in various computer files and formats. It is compatible with technologies such as scanners, bar code readers, etc. The Enhanced SSN proposal includes new procedures for the issue and management of the identifier to increase its capability further.
Usable: SSN is used currently both in manual and automated modes. Enhanced SSN proposal does not indicate any inhibition to manual or automated use.
Unique: Under special situations and upon request, SSA's procedures allow the issue of a new number, for example, to protect the identity of the requesting individual. The CPRI's Enhanced SSN proposal includes check digits, encryption and confidentiality and security procedures for issuing Unique Patient Identifiers by a "trusted authority" to assure its uniqueness. These enhancements have the potential to increase SSN's capabilities further.
Repository-based: The Social Security Administration (SSA) maintains a data base of identification information supported by computer networks. The Enhanced SSN proposal includes a data base of individuals' demographic information to support the requirements of healthcare identification functions.
Atomic: SSN can be used as one atomic data element.
Concise: SSN is concise.
Unambiguous: The current SSN includes only numeric characters. The Enhanced SSN proposal recommends an alphanumeric format. This capability will depend on the specifications and design of the proposed enhancements.
Permanent: Enhanced SSN is a permanent identifier.
Centrally governed: The Enhanced SSN proposal requires legislation to fund and task SSA to add check-digit, modify the process of issuing SSN, etc. SSA is well positioned to function as a Central Authority with its 1300 field offices, extensive computer networks, trained personnel and operating procedures already in place. It has the potential to provide the control and security necessary for the encryption and decryption functions, identification and disidentification functions, check-digit verification and other support functions. The proposed enhancements have the potential to increase its repository capability and strengthen the integrity of its identification system as a whole.
Networked: There are about 1300 nation-wide SSA offices with the necessary computer network links already in place.
Longevity: CPRI's Enhanced SSN proposal addresses the SSN's lack of capacity to cover the population for a foreseeable future.
Retroactive: Enhanced SSN is aimed at issuing identifiers to all existing individuals.
Universal: CPRI's Enhanced SSN proposal addresses the SSN's lack of capacity to cover the population for a foreseeable future.
Incremental Implementation: SSN is used as a patient identifier by 20% of the population. Most of the medical records in healthcare organizations already use SSN as a secondary identifier. Therefore, this provides a basis for parallel use and incremental implementation of the Enhanced SSN by healthcare organizations.
Cost-effectiveness: SSN is viewed by many as the most realistic option. Its administrative and technology infrastructures are already in place. With implementation of the recommended enhancements such as check-digits, encryption schemes, increased security and improved issuing procedure, Enhanced SSN is likely to be less expensive than other options. It has the potential to function as a Unique Patient Identifier and enhance the health status of the nation through efficient record keeping, sharing of information, reduced cost of integration and optimum use of technology.
Currently operational: SSN is currently operational. It is used as a Unique Patient Identifier in healthcare for about 20% of the population and as a secondary patient identifier by most of the healthcare organizations. It is used in VA hospitals, Department of Defense and Medicare.
Existing infrastructure: SSA is well positioned to function as a Central Authority with its 1300 field offices, extensive computer networks, trained personnel and operating procedures already in place.
Readiness of the required technology: SSN is currently operational. The necessary encryption technology and check-digit methodologies are ready and available for implementing the proposed enhancements.
Timeliness: With the administrative and technology infrastructures and policies and procedures that are in place, Enhanced SSN can be implemented in the shortest time frame.
Adequacy of information to support identification functions: The Enhanced SSN proposal includes the use of a patient's demographic information for supporting the identification functions. In order to link information from previous episodes and different sites of care, record locations and provider information would be needed.
Identifier: The current SSN has the XXX-XX-XXXX format. The Enhanced SSN proposal includes the addition of alphanumeric characters to increase capacity, and check-digit verification to improve accuracy.
Identification Information: The Enhanced SSN proposal includes the use of a patient's demographic information for supporting the identification functions. In order to link information from previous episodes and different sites of care, record locations and provider information must be addressed by the proposal.
Index: SSA maintains a nation-wide data base of individual's identification information indexed by their SSN.
Mechanism to protect, mask or encrypt the identifier: The Enhanced SSN proposal includes encryption to hide the identifier.
Technology Infrastructure: SSA has a nation-wide technology infrastructure and computer networks to administer the issue and maintenance of the SSN.
Administrative Infrastructure: SSA has 1300 field offices, trained personnel and operating procedures currently in place.
Compliance with the basic functions criteria depends on compliance with operational characteristics and the identifier component requirements. SSN is in compliance with both of these requirements.
Delivery of care functions: Enhanced SSN can support manual and automated verification of the positive identification of an individual required for the active treatment procedures. VA Hospitals and the Department of Defense are currently using SSN for these purposes.
Administrative functions: Enhanced SSN can support the identification functions required of practitioners, provider organizations and secondary users such as insurers, HMOs, federal health plan agencies, etc. for administrative purposes. SSN is currently used by VA Hospitals, the Department of Defense and others for these purposes.
Coordination of multi-disciplinary care processes: Enhanced SSN can support multi-disciplinary functions and coordination of care processes including ordering of procedures, medications and tests, communication of results and consultations. These functions are currently supported by SSN in organizations such as VA Hospitals and the Department of Defense Medical Centers.
Organization of patient information and medical record keeping: Enhanced SSN can support manual medical record keeping and automated collection, storage and retrieval of information. VA Hospitals and the Department of Defense are currently using SSN for these purposes.
Manual and automated linkage of lifelong health records: Enhanced SSN can be used to identify, organize and link information and records across multiple episodes and sites of care. VA Hospitals and the Department of Defense are currently using SSN for these purposes.
Aggregation of health information for analysis and research: Enhanced SSN can support the aggregation of health information on groups of patients, regions, diseases, treatments, outcomes, etc. for research, planning and preventive measures.
Support the protection of privacy, confidentiality & security
Access security: Enhanced SSN recommends access security and authentication procedures for the use of SSN and the protection of patient care information. It can facilitate patient identification without granting access to the patient care information.
Content-free Identifier: SSN in its current format has its location and time of issue. Enhanced SSN proposal recommends changes to both the content and format of SSN to improve security and capacity.
Mask/Hide/Encrypt/Protect/Disidentify: Enhanced SSN proposal includes encryption to protect the Identifier.
Enhanced SSN currently has administrative and technology infrastructures in place. With implementation of the recommended enhancements, such as check-digits, encryption schemes, increased security and improved issuing procedure, it is likely to be less expensive than other options. It has the potential to function as a Unique Patient Identifier and enhance the health status of the nation through efficient record keeping, sharing of information, reduced cost of integration and optimum use of technology.
1. The Enhanced SSN proposal by CPRI meets:
a) almost all of the ASTM Conceptual Characteristics (of the 30 requirements, fully meets 27 and partly meets 1),
b) all of the Operational Characteristics,
c) Unique Patient Identifier Component requirements and
d) Basic Functions Criteria.
2. The Enhanced SSN's strength also includes:
a) Existing infrastructure
b) Trained Staff
c) Policies, procedures and guidelines in place
d) Ongoing improvements by the SSA
3. CPRI has identified SSN's limitations due to its current structured format and the potential for problems due to its widespread use and provided recommendations to eliminate them. Proposed enhancements to eliminate deficiencies and improve capabilities include:
a) encryption scheme
b) addition of check-digits
c) improvement to issuing procedures
d) clean-up of existing duplications, multiple assignments and other errors.
d) confidentiality and security measures
e) legislation to prevent misuse and discrimination
f) mechanism to handle patients without SSN
g) temporary ID for emergency use
h) change in the format to facilitate capacity
4. Several approaches described in the ASTM Guide including the encryption
scheme can be used in conjunction with the Enhanced SSN to yield the same
benefit as a UHID (e.g. multiple Encrypted IDs with links to the Enhanced SSN).
5. Already used by 20% of the public
6. Least expensive to implement
7.
Relatively easy to adopt - people are used to it and systems are accustomed to
handling it.
8. Speed of implementation
9. According to Harris poll,
the majority of the American population and organizational leaders favor SSN as
a patient identifier
The weakness relates mainly to those SSN's problems already being addressed in the CPRI's Enhanced SSN proposal. They are:
In summary, the barriers relating to SSN fall under the three major categories listed below:
1) Inadequate administration for healthcare purposes, i.e. existing error level, incomplete issue, lack of mechanism for emergency issue, lack of check digit and capacity for future growth.
2) Privacy and confidentiality risks due to SSN's use in non-healthcare areas in the absence of legislation and legal protection.
3) Cost, length of time and complexity involved in correcting and enhancing SSN problems.
4) Enactment of the necessary federal legislation (both privacy legislation and legislation permitting SSN's use in healthcare).
The Enhanced SSN proposal includes these solutions. Upon implementation, they have the potential to effectively overcome the barriers and eliminate the weaknesses listed above.