9. Identification based on Medical Record Number and Provider Prefix

I. Description of the Option

Peter Weagaman from Medical Record Institute (MRI) proposes that a patient identifier must first and foremost identify the patient record and the focus be directed away from patient identification to identification of the patient information. In order to achieve a unique patient database identification, the Medical Record Institute proposes the use of existing provider institution generated medical record number with a provider number prefix. The solution requires consensus on a practitioner identification system but eliminates the cost of creating, implementing and maintaining a nationwide (patient) numbering system. The unique provider ID would identify the location of the patient database and the medical record number would identify the patient's record within that database. The proposal also includes designation by the patient of a practitioner of choice to be the curator who functions as the gateway for linking and updating of information.

The Medical Record Institute's proposal in summary consists of:

  1. no mandate for a Unique Patient Identifier
  2. no change to the current practice of patient identification
  3. a recommended DHHS mandate to the primary care physician to be the curator for linking and updating of patient information from multiple treatment locations
  4. use of technology for linking and updating information from multiple locations without a Unique Patient Identifier.

II. Author/Proponent and Documentation

  1. This method is proposed by Mr. C. Peter Waegemann, Executive Director, Medical Record Institute. Medical Record Institute's position paper and articles provide details about the method.
  2. Medical Record Number is already a widely used identifier.

III. Compliance with ASTM Conceptual Characteristics

a) Functional Characteristics

Accessible: Access to obtain the Identifier can be handled by provider organizations themselves.

Assignable: Identifiers can be assigned by the provider organizations themselves. Identifiable: The institutional MPI can support this function.

Verifiable: Organizations with computerized issue of Medical Record Numbers have the check-digit verification capability. Check-digit verification can be implemented with this method.

Mergeable: Duplicate medical record numbers are one of the problems facing the current institutional MPIs. Prevention of the issue of multiple medical record numbers has been a challenge and the merger of the respective records have been a persistent problem in healthcare organizations. Merging duplicate number can be done via cross-referencing.

Splittable: The instances of the same medical record number assigned to multiple individuals are fewer in relation to duplicate issues. However, the ability to split the same medical record number assigned to multiple individuals faces the same problems as merging duplicate numbers and records. This can be accomplished by issuing new number to one or all individuals that have the same number.

b) Linkage of Lifelong Health Record

The Medical Record Institute supports the retention of life long health record of only important information and not all patient care information.

Linkable: This function requires the Primary Care Physician to function as the curator to keep track of the location of care of an individual in order to link and support the electronic exchange of patient information.

Mappable: This function requires the Primary Care Physician to function as the curator to keep track of the location of care of an individual in order to create bidirectional linkage between the Medical Record Number with Provider Prefix and existing identifiers.

c) Patient Confidentiality and Security

Content Free: The proposed Identifier includes the Medical Record Number and provider ID within its content.

Controllable: Does not use encryption or decryption scheme to hide the identity of the individual

Healthcare Focused: Medical Record Number with a Provider Prefix is healthcare focused.

Secure: Does not use encryption nor requires a trusted authority to enforce a secure identifier

Disidentifiable: Does not use encryption or decryption scheme to hide the identity of the individual

Public: Medical Record Number and Provider IDs are not public information and require security protection.

d) Compatibility with Standards and Technology

Based on Industry Standards: This option is not based on industry standard.

Deployable: This option does not indicate any barriers and is compatible with technologies such as bar code readers, scanners, etc.

Usable: There is no inherent barrier to its use as a patient identifier.

e) Design Characteristics

The Department of Health and Human Services mandate to the primary care physician needs to be addressed by appropriate executive action. Protocol and procedures relating to the primary care physician's role including his or her power must be defined. A change in the choice of primary care physician by the patient and a change in the practice or affiliations of the primary care physician must be taken into account. Computer and communication system must be developed to facilitate the prompt and accurate exchange of information

Unique: The method does not recommend a unique identifier.

Repository-based: This method depends on the existing institutional Master Patient Index (MPI) data base.

Atomic: The proposed Identifier includes the provider ID within its content. It can be considered as a single data element.

Concise: The Medical Record Number with Provider Prefix is concise.

Unambiguous: Existing organization based Medical Record Numbers consists of numeric digits. Zeros and ones may present some ambiguity with letters "o" and "l" respectively.

Permanent: Patients will have multiple identifiers each issued by different organizations that delivered care. Within the same institution the identifier will be unique.

Centrally governed: The issue and maintenance of the ID are managed by the provider organization itself and does not require a central governing body.

Networked: The ID is issued and maintained within the same organization. There are no barriers to implementing the identifier over a network.

Longevity: The scope of the Medical Record Number and its assignment to a Provider Prefix is limited to the issuing organization.

Retroactive: Does not apply. Medical Record Number is currently in use and not a new identifier proposal.

Universal: The scope of the organization-based Medical Record Number is not universal. It is intended only for patients visiting the organization. The Provider Prefix to the Medical Record Number is also organization based.

Incremental Implementation: Since this option is built upon the existing Medical Record Number it requires only the addition of the Provider Prefix which can be implemented incrementally.

f) Reduction of Cost and Enhanced Health Status

Cost-effectiveness: This option leaves the existing method of identification in tact except for the addition of the provider ID. Therefore, it will require minimum expenditure for implementation. However, its success and benefits depend on the ability of the Primary Care Provider who will function as the curator, and the computer's ability to exchange information without a unique identifier. It also depends on the feasibility of a DHHS mandate for the Primary Care Physician to function as the curator.

IV. Compliance with Unique Patient Identifier's Operational Characteristics and Readiness

Currently operational: Medical Record Number with a Provider Prefix is not currently operational. It is not a Unique Patient Identifier. Patients will receive multiple identifiers based on their choice of primary care physicians and provider organizations.

Existing infrastructure: Does not have existing administrative or technology infrastructure and the proposal does not address these requirements

Readiness of the required technology: The technology necessary to develop the infrastructure is available. The technology infrastructure including software applications, computer and communication systems must be developed to facilitate prompt and accurate exchange of information.

Timeliness: Medical Record Number with a Provider Prefix is not a Unique Patient Identifier. Medical Record Numbers are already in use. Therefore, addition of Provider Prefix should take relatively a short period of time. However, the provider prefix will require consensus on the choice of national provider identifier to be finalized first. In addition, an executive mandate by an appropriate authority must also be accomplished. Appropriate operating procedures, guidelines, technology and administrative infrastructures, etc. need to be created to handle situations involving multiple organization specific medical record numbers and choice to change primary care physicians, patient's relocation, etc. The final solution may require a substantial amount of time to implement.

Adequacy of identification information to support identification functions: The organization specific MPIs do not have information on a patient's other record locations or care provided by other organizations. This will be dependent on the ability of the primary care physician to function as a curator to keep track of all locations of care, past and present.

V. Compliance with Unique Patient Identifier's Components Requirements

Identifier

Medical Record Number is organization specific. It is unique only within the organization that issued it. Medical Record Number with a Provider Prefix is not a Unique Patient Identifier. The Provider Number is subject to change based on the patient's choice of a different primary care physician, health plan or provider organization.

Identification Information

The patient's demographic information collected and maintained by provider organizations is accessible for use only within the same organization. The Primary Care Physician has the responsibility to track and maintain separately previous episodes of care and record locations.

Index

The Master Patient Index currently used by provider organizations are specific to respective organizations. They are not mappable to the same individual's identifier in another organization. The Primary Care Physician has the responsibility to track and maintain separately previous episodes of care and record locations.

Mechanism to protect, mask or encrypt the identifier

Encryption is not part of the proposal.

Technology Infrastructure

The scope of the technology infrastructure is limited to operation within the same provider organization. Its nation-wide scope is not addressed by the proposal.

Administrative Infrastructure

Scope of the administrative infrastructure is limited to operation within the same provider organization. Its nation-wide scope is not addressed by the proposal.

VI. Compliance with Basic Functions Criteria

Access to geographically-distributed information requires the patient identifier to expand beyond an institutional level. The existing institution-based medical record numbers are adequate to manage the patient identification only within that institution. A robust identification method that can identify individuals uniquely across the nation and facilitate the linkage of their lifelong health record is the main objective of the Unique Patient Identifier. The institution-based Medical Record Number with provider prefix is not a Unique Patient Identifier. It does not fully comply with the Unique Patient Identifier's operational characteristics and component requirements. In the absence of these critical elements, the it lacks the ability to fulfill the basic functions discussed below.

Identification of individuals

Delivery of care functions: Medical Record Number with a provider prefix is not a Unique Patient Identifier that can support identification across multiple organizations. The positive identification of an individual is possible only within the organization that issued the identifier during the course of delivery of care.

Administrative functions: The identification for administrative functions required by practitioners, provider organizations, insurers, HMOs, federal health plan agencies, etc. is possible only within the organization that issued the identifier.

Identification of information

Coordination of multi-disciplinary care processes: The support for multi- disciplinary functions and coordination of care processes including, ordering of procedures, medications and tests and communication of results is possible only within the organization that issued the identifier.

Organization of patient information and medical record keeping: The support for manual medical record keeping and automated collection, storage and retrieval of information during the course of delivery of care is possible only within the organization that issued the identifier.

Manual and automated linkage of lifelong health records: The Medical Record Number lacks the ability to identify, organize and link information and records across multiple episodes of cares from multiple sites of care. This capability depends on the current primary care physician's ability to track, identify and link patient information from multiple organizations with multiple Medical Record Numbers and Provider IDs.

Aggregation of health information for analysis and research: The Medical Record Number lacks the ability to support the aggregation of health information across multiple episodes from multiple providers for research, planning and preventive measures. Once again, this capability depends on the current primary care physician's ability to track, identify and link patient information from multiple organizations with multiple Medical Record Numbers and Provider IDs.

Protection of privacy, confidentiality & security

Access Security: Access Security procedures are applicable only within the organization that issued the identifier. They are not addressed by the proposal.

Content-free Identifier: This option includes the primary care physician's Provider Identifier.

Mask/Hide/Encrypt/Protect/Disidentify: Does not use encryption

Improve health status and help reduce cost

The Medical Record Number with Provider Prefix is not a Unique Patent Identifier proposal. Its success is subject to the primary care physician's ability to track, identify and link patient information from multiple organizations with multiple Medical Record Numbers and Provider Identifiers and the development of the necessary technology solutions.

VII. Strengths and Weaknesses

Strengths:

  1. Fully meets 17 of the 30 ASTM conceptual characteristics and partly meets 1
  2. Uses existing identifier as part of the solution
  3. Relatively easy to implement
  4. Low cost of implementation
  5. Does not require a Central Trusted Authority
  6. Eliminates the effort, time and investment that will be required for developing and implementing a new identifier.

Weaknesses:

  1. The Medical Record Number with a provider prefix is not a Unique Patient Identifier. Patient's ID will change when they change the primacy care physician.
  2. Does not meet two of the five operational characteristics and a third is not adequately addressed
  3. Only partially meets four of the six Unique Patient Identifier components' requirements and a fifth is not addressed
  4. Only partially fulfills the basic functions of the Unique Patient Identifier
  5. The existing medical record numbers have not been able to support exchange of information across institutional boundaries. System vendors are required to develop enterprise-wide MPI and cross indexes to link information from different institutions for the same patient which in turn led the industry in search for a Unique Patient Identifier.
  6. Sophisticated computer tools and software have to be developed and introduced to address the exchange of information from multiple institutions with multiple identifiers for the same patient. This task has been an unfulfilled challenge for the industry.
  7. Adequate protection must be provided to assure accurate matching and secure transmission of patient information.
  8. Primary Care Physician's role has to be modified to include keeping track of the sites of care for individual patients.
  9. The tracking of a patient's other sites of care or record locations depends on the ability of the patient's primary care physician.
  10. A change in the choice of the Primary Care Physician by the patient or a change in the practice or affiliation by the Primary Care Physician can cause delay and difficulty in accessing information.

VIII. Potential Barriers & Challenges to Overcoming the Barriers

  1. Inclusion of missing identifier components and operational characteristics
  2. Executive action for the designation of a Primary Care Physician as the curator to assume the responsibility for tracking the patient's sites of care and site-specific identifiers
  3. Development of necessary communication technology and computer software to facilitate the exchange of information from multiple institutions with multiple identifiers for the same patient
  4. Existing MPI errors such as duplicate Medical Record Numbers, incorrect and/or outdated information
  5. Development of policies and procedures and implementation methodologies.

IX. Solutions to the Barriers:

  1. Finalize the Provider Identifier choice and related issues.
  2. Executive mandate relating to the Primary Care Physician's role as a curator for the linking and updating of information from multiple providers.
  3. The clean-up of existing errors in the organizational MPIs
  4. Development of the technology infrastructure including application software, computer and communication issues to support the primary care physician's ability to perform the record location functions and exchange of information.
  5. Development of implementation methodologies and policies and procedures.