EDUCATIONAL REPORT SPONSORED BY Imprivata. The Value of Precise Patient Identification

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1 The Value of Precise Patient Identification

2 Many hospitals and health systems rely on manual processes to identify patients at registration, as well as modalities like armbands and barcodes to identify patients during the care experience. They also follow protocols, such as using at least two patient identifiers when giving medication, drawing blood, or performing other care interventions. However, these strategies are not always foolproof. Despite the best intentions, organizations can struggle to consistently and reliably collect precise patient information and match individuals to their medical records. The consequences of patient misidentification and mismatching can be severe, ranging from medical errors to adverse effects on the bottom line. In this context, this HFMA Education Report, sponsored by Imprivata, discusses specific risks of misidentifying patients and examines various improvement strategies. Understanding the Metrics When trying to gauge the scope of patient identification and matching errors, healthcare leaders look at two key metrics: overlays and duplicate medical records. Overlays occur when staff choose the wrong patient from the master patient index (MPI), causing an intermingling of two patients medical histories. Duplicate medical records are when organizations have more than one medical history for the same patient. Duplicate medical records are much more common than overlays. The average duplicate medical record rate is 8 percent and is often higher in larger health systems, according to a 2008 study by RAND Corp. For a number of organizations, the emergency department (ED) is a major source of duplicates because patients may not be able to identify themselves, and physicians want to treat the patients as soon as possible. There is a lot of pressure on the registrar in the ED to identify the patient quickly, says Jim Schwamb, former vice president of patient financial services for BayCare Health System in Clearwater, Fla. However, there may be several records with similar names, and the registrar does not want to pick the wrong patient because the fallout from inadvertently merging two patient records can be significant. To avoid this, he or she will sometimes opt to create a new, duplicate record instead. The Risks of Poor Patient Identification Inadequate patient identification and the resulting overlays and duplicates can compromise patient care and have a negative downstream effect on the revenue cycle. The following are several risks that emerge when patient identification and matching fall short. Patient safety lapses. Proper selection of the medical record at the time of registration is essential for organizations to realize the clinical benefits of their electronic health records (EHRs), says Scott Phillips, senior director of patient access services for Texas Health Resources a 24-hospital system based in Arlington, Texas, that has more than 1 million patient registrations per year. The EHR has become such a part of treatment now, he says. If the physician does not have all of a patient s history because we give the patient a new medical record or worse, we overlay that patient into another patient s record there is a deficit of information, which impedes the physician s ability to make proper decisions. This can result in duplicate therapies, wrong-site or wrong-person surgery, potential allergic reactions, medication dosing errors, and other patient safety issues. Liability. Incorrectly identifying a patient can expose an organization to considerable liability, says David L. Feldman, MD, MBA, CPE, FACS, senior vice president and chief medical officer for Hospitals Insurance Company (HIC) in White Plains, N.Y. Doing the wrong procedure on the wrong patient there is no way to defend that, Feldman says. It just shouldn t happen. Denials and take-backs. Duplicate records and overlays are not only safety and risk-management concerns, but they also can lead to downstream problems in the revenue cycle, 2 April Healthcare Financial Management Association hfma.org

3 including denials and insurance take-backs. Payers will not reimburse for errors, so you have to think of accurate patient identification as the beginning of the revenue cycle, says Schwamb, formerly of BayCare. For example, a physician may order a second imaging test if the original test is documented in a different record. Payers will not cover the cost of the second test, so the hospital has to write off the charges. In some cases, insurance companies may even seek to recoup payment for duplicate services that were already paid. Reduced productivity. When you create a duplicate, it affects so many layers, says Patricia Consolver, CHAM, senior director for patient access services at Texas Health Resources. You re creating more work for the insurance verification staff to pre-register the patient, who may have already been registered. The clinical staff also has to document on two records because you have created two accounts. Overlays can be even more difficult to fix, each taking a substantial amount of staff time to correct. It can be very time-consuming to go back to payers and everyone who has treated the patient, including hospital-based physicians who do their own billing such as radiologists, pathologists, and cardiologists and tell them there is a major error in the record, Schwamb says. Secondary information systems that have their own patient indexing system, like those in radiology, also need to be fixed. Costly cleanups. Duplicate medical records can reduce the efficiency and accuracy of an organization s MPI, requiring a cleanup effort. However, scrubbing for duplicates and overlays can be a costly process, whether it is handled in-house or by an outside consultant. Organizations may spend six to seven figures to clean up their MPI. Having a clean MPI is especially important for integrated health systems that are moving to the same EHR. Leaders at Denver-based Centura are bringing their 16 hospitals and 100-plus physician practices onto the same EHR platform, a process they expect to complete in One goal of moving to a shared EHR is to improve the coordination of care across the continuum, says Stephanie Benintendi, corporate director, patient access. Before they can leverage their EHR investment, however, they need to clean up their patient index. Right now, we have teams of people working to consolidate and merge accounts together, Benintendi says. Currently, the duplicate rate at Centura is between 6 and 7 percent, which we hope to bring down to 3 percent by May, when the first phase of our EHR conversion is complete. Poor preparation for population health management. Your duplicate medical record rate, and, in some cases, your overlays, could really affect your performance in value-based care, Benintendi says. When you accept a risk-based contract with a payer, it basically means that you are responsible for the patient s care for pre- and post-treatment. If you have not identified the patient properly, then you could be duplicating services, such as radiology studies and lab work for tests that providers couldn t find in the original medical record. That is inefficient and drives up costs. Not identifying patients correctly also makes it difficult for organizations to track their costs and determine the total cost of care in risk-based arrangements, Benintendi adds. If you have several medical record numbers for a patient, you won t be able to run accurate reports, she says. This is an issue for all organizations trying to gauge their performance in an era of shrinking margins. Regardless of where you are on the value-based continuum, if you are doing unnecessary tests on patients, you are increasing costs and changing your efficiency ratio. Instead, you could be filling your schedule with new patients, which could have a positive effect on your market share. Insurance card and medical identity fraud. It is crucial to have strong patient identification processes at registration, otherwise you can make it easier for patients to provide false names and wrong addresses so they avoid getting their bills. At the same time, a lax patient identification policy may make it easier for a criminal to steal another patient s medical identity and receive services while the bill goes to someone else. HFMA EDUCATIONAL REPORT 3

4 Privacy concerns. Incorrect identification also leads to lapses in patient privacy, which can have substantial consequences. For example, communicating protected patient information to the incorrect person or sending the wrong bill to the wrong patient can result in costly fines, which can be easily avoided. Strategies for More Accurate Patient Identification Given the abovementioned risks, having a reliable patient identification process is a shared goal that physicians, finance leaders, and patients can and should get behind. To that end, the following improvement strategies can help organizations enhance patient identification and reduce the risks of misidentification. Standardize processes. Like many other aspects of health care, patient identification can benefit from standardization. Organizations frequently use a combination of centralized and decentralized scheduling, as well as different patient identification workflows across their departments leading to a less-than-consistent process. However, some organizations, including Centura, are looking to make a change. When the health system s new EHR is implemented, patient identification processes will become more standardized, Benintendi says. We will combine the scheduling, registration, and patient identification processes, so when staff in our centralized and decentralized areas generate an appointment, they will select the patient s medical record number, she says. It will be seamless. They will search for the patient, select the patient, create the appointment, and complete the registration as one workflow. To further reduce the risk of inaccurate patient identification, Centura plans to add the patient s photograph to the medical record. A photograph will pop up in the workflow to help prevent the wrong order from being written for that patient, Benintendi says. Centura s new EHR will not only eliminate steps that can introduce patient identification errors, but it also will enable faster insurance verification. The revenue cycle staff will have access to demographics, insurance coverage, and actual procedure code information sooner so they can get a jump on verifying benefits and authorizing services, Benintendi says. They also will be able to let patients know their out-ofpocket responsibility. We are expecting 80 to 90 percent of patients to have this pre-clearance process completed seven to 10 days before their date of service. Developing standards with physician offices. As more organizations step up their ambulatory care initiatives, they may struggle to standardize patient identification processes across settings. Texas Health Resources s Consolver says ensuring consistent patient identification in the organization s more than 250 physician offices has been challenging. Now that we have physician practices under our umbrella, we are seeing their quality assurance measures may not be the same as ours, Consolver says. For example, registrars in the hospitals may record patients legal first names, but the physician offices may request patients nicknames. This ambulatory patient data feeds directly into Texas Health Resources s main MPI, creating unnecessary duplicates. To address this issue, leaders at Texas Health Resources convened a patient identification standards development committee that includes representatives from IT, health information management (HIM), patient access, data integrity, the central business office, and the physician groups. Until the practices fully convert to our EHR, they may have system issues that can compromise patient identification, Phillips says. For example, in our EHR, we have different fields to list the patient s legal name and the name on their insurance card. In the practices systems, they may only have one name field. They will tend to use the name on the patient s insurance card so they don t get a denial. To fix this, we have developed an initial standard to identify patients, but we still need to address issues that come up without causing too much grief and suffering. 4 April Healthcare Financial Management Association hfma.org

5 Track trends regularly. Keeping a close watch on the reliability and accuracy of patient identification is essential. Five years ago, leaders at Texas Health Resources developed their own scorecard that includes 76 key performance indicators (KPIs), which cover a variety of areas including patient access, patient satisfaction, collections, duplicates, overlays, and registration quality. Each month, members of the organization s revenue cycle committee, which includes leaders from HIM, patient access, revenue cycle, as well as the CFO, review the scorecard. The report is color-coded green, yellow, and red the latter suggesting poor performance. It has been a huge driver for our patient access leaders to not have a lot of red on their scorecard, Phillips says. The most important KPIs for patient identification are the organization s duplicate medical record rate and volume of overlays, says Texas Health Resources s Consolver. Both metrics help leaders identify opportunities to improve. Ideally, we do not want overlays at all, but when they occur, we can address them in patient safety rounds and learn from it, she says. Collaborating with data integrity. Working with the data integrity team in HIM has helped patient access leaders at Texas Health Resources cut their duplicate record rate by 21 percent over six years. Today, only 0.3 percent of records are duplicates. The data integrity team is responsible for merging duplicate records and cleaning up the database. Patient access keeps an open line of communication with the data integrity group. For example, patient access will call them when a registrar in the ED likely creates a duplicate because of incomplete information or if there s a need to treat the patient quickly. Previously, patient access might make a duplicate, and HIM would not know about it until they were working the problem, Consolver says. Now we pick up the phone, and they know about it almost immediately. In addition, the data integrity team generates a monthly report that identifies where duplicate records occur. Reporting lets you identify trends early on, Phillips says. For example, the last thing you should be doing is putting new registrars on the triage desk in the ED. They need time to learn the process and the tools. Yet, one of our hospitals was consistently putting newly trained admissions staff at the triage desk in the emergency room. We could tell from the report that when the new people were working, we would have five or six duplicates. This could have gone on for years if we had not talked with the patient access leaders at the hospital. Engaging the CFO. Because HIM and patient access both report to finance in most organizations, CFOs can emphasize the value of precise patient identification across the enterprise, Phillips says. The CFO can get everyone on board and ensure they realize this is a priority, he says. For example, when Texas Health Resources hired an outside consultant to lead a major cleanup of duplicates in the organization s MPI in 2009, finance leaders made it clear that they did not want to repeat the investment in the future. Everyone in the organization understood that this was the one time we were investing in outside resources to improve the record s integrity, Phillips says. Going forward, it was going to be up to us to keep the MPI clean. Leverage software tools. Oftentimes, technology can enhance the reliability of patient identification. For instance, after the MPI cleanup was completed, leaders at Texas Health Resources invested in a third-party tool to boost the accuracy of patient identification at the time of registration. The tool uses an algorithm that searches the database for key data elements, such as name, sex, date of birth, and Social Security number. The tool then provides the registrar with potential patient matches. Medical records with the best match are labeled green. Less likely matches are labeled yellow, and unlikely matches are coded with red. Although Phillips credits the tool for helping reduce the duplicate record rate, he concedes it is not perfect. For this reason, they have been HFMA EDUCATIONAL REPORT 5

6 making adjustments to the tool over the past five years. The last thing you want when you are searching for the patient is to get three green options, he says. You have to refine the tool so that when you are using it, it is very clear what the right answer is. Consider a biometric solution. To elevate the reliability of their patient identification processes, some organizations have implemented biometric systems that scan the patient s palm at the time of registration and before care delivery. For instance, 12 New York hospitals served by Hospitals Insurance Company implemented a biometric solution that integrates with their EHR. The hospitals first focused on using the technology to correctly identify radiation oncology patients. We asked a group of radiation oncologists what kept them up at night, and they said it was radiating the wrong patient, HIC s Feldman says. It s rare, but if it does happen, it is a disaster for patients. The hospitals ruled out other identification systems, preferring the advantages of a biometric solution. Using barcoding or photographs to identify radiation patients, for instance, is not ideal, Feldman says. Because radiation is an outpatient procedure, we didn t think armbands were the best choice because patients needed to keep coming back for treatment and would not likely leave their armband on. In addition, photographs aren t always reliable, especially for patients who may be having radiation to their head or neck, which could change their appearance. Using biometrics also makes errors less probable if someone has the wrong armband, or cannot speak, or has a cognitive disability. To use the system, the patient puts his or her right palm on the reader so it can be scanned into the system. The technology uses subcutaneous vein patterns in the palm to create an encrypted digital file that is linked to the patient s medical record. The next time the patient comes in for treatment, he or she places his or her palm on a reader at the registration desk or a kiosk and verifies his or her date of birth. By adding the date of birth, the chances of misidentifying a patient become one in several million, Feldman says. Biometric systems significantly reduce the likelihood that the wrong patient receives radiation and prevent duplicate medical records. In the future, biometrics also could be used to identify patients immediately before surgery or when giving medication. In 2008, BayCare installed biometric palm scanners at every registration point throughout the enterprise. Patients were concerned about using their Social Security numbers when they registered, Schwamb says. Using a biometric system allowed us to remove Social Security numbers from our screens to reduce fraud and identify theft. More important to our patients, using a biometric system helped improve patient safety. Texas Health Resources also uses palm vein technology for patient identification. Address human factors. Although technology can create better systems to prevent humans from making mistakes, it is only part of the solution, HIC s Feldman says. Improving how staff work together is also critical. The 12 hospitals HIC serves follow the TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) crew resource management model that the Department of Defense and the Agency for Healthcare Research and Quality developed. The original idea was to break down hierarchies in airline cockpits that could compromise safety, which are similar to the hierarchies we have in health care, Feldman says. Using models such as TeamSTEPPS, healthcare organizations can learn to improve how different disciplines work together to reduce errors, including misidentifying patients, and elevate safety and quality. Investing in your patient access team. Patient access gets the brunt of the blame for patient identification problems, but it all comes down to education, pay, and what resources you give the team to be successful, Centura s Benintendi says. 6 April Healthcare Financial Management Association hfma.org

7 OUR SPONSOR SPEAKS LEVERAGING TECHNOLOGY TO ENHANCE PATIENT IDENTIFICATION David Wiener, general manager for Imprivata s PatientSecure Products Group, discusses how biometric solutions elevate the accuracy and reliability of patient identification. QWhy is biometric patient identification a key driver in improving safety and revenue cycle efficiency? Health care can only be effective if the right care is provided to the correct patient using the correct patient information. However, many healthcare organizations today struggle with cumbersome, manual patient identification processes that are compromised by human error and insurance fraud risk, affecting the accuracy of master patient indexes. As a result, everyone suffers. Staff can match patients with the wrong records or they may not be able to find a patient record, requiring them to create a duplicate. These errors result in incomplete and inaccurate medical histories, which jeopardize patient safety, significantly increasing the likelihood of adverse events. The downstream effects include insurance denials and take backs that impact hospital revenue cycle efficiency. Plus, an organization can experience an unrealized return on its EHR investment. Biometric patient identification is more accurate than in-person identification and stops the creation of duplicate and overlaid medical records at the source, improving overall patient safety and revenue cycle throughput. Patients can be immediately and accurately identified upon registration or even in emergency situations where they are unconscious or disoriented. Biometric technologies can also provide additional benefits, such as preventing the risks of identity theft and insurance fraud. According to our customers, palm vein biometrics are the most accepted by patients, with more than a 99 percent acceptance rate. Overall, we have seen our customers leverage this non-intrusive and highly accurate technology to transform patient identification. Source: Imprivata Registrars are typically one of the lowest-paid administrative functions in an organization, yet their role is the most important for patient identification. Organizations need to address the problem by providing adequate ongoing training and resources, rather than pointing fingers. As Centura s EHR conversion approaches, the patient access team will receive a combination of online and classroom training on the new EHR and relevant workflows. In addition, registrars in decentralized areas that currently handle their own scheduling, such as physical therapy, will undergo the same formal training that centralized registrars receive. Making staff accountable. Benintendi says organizations need to establish clear policies so patient access teams know the consequences of creating duplicates and overlays. This could mean anything from additional training and education to losing access to creating or selecting patient records from the MPI, if they have certain error rates that are determined to be avoidable. The key is making sure you have a system developed that supports the registrar and does not focus on punitive outcomes for a bad process or design. Encouraging self-reporting. Although accountability is important, organizations also should create a culture in which HFMA EDUCATIONAL REPORT 7

8 patient access staff feel comfortable reporting patient identification errors. There should be no fear in self-reporting duplicates because it is essential to share that information quickly, says Texas Health Resources s Consolver. Simply having patient access directors who acknowledge that duplicates happen, particularly in the ED, can help staff overcome their fear of punitive action for reporting errors. There are times, such as in the ED, when staff create a duplicate because they are trying to do the best thing for the patient they have in front of them, says Texas Health Resources s Phillips. Staff do get corrective action if we identify trends, but they should not be punished if it is just the nature of the business. Imprivata (NYSE: IMPR), the healthcare IT security company, provides healthcare organizations globally with a security and identity platform that delivers authentication management, fast access to patient information, secure communications, and positive patient identification. Imprivata enables care providers to securely and efficiently access, communicate, and transact patient health information to address critical compliance and security challenges while improving productivity and the patient experience. A United Front It is vital for leaders not to become overwhelmed as they try to clean up their databases and improve patient identification. People get scared by the numbers, Centura s Benintendi says. Even if your duplicate rate is only 3 percent, if you have a patient population with 1 million unique identifiers, that is still a lot of duplicates. From a tactical standpoint, don t let the size of the numbers overwhelm you to the point where you feel like you cannot make a difference. Her advice is to foster collaboration among clinical, quality, financial, patient access, and HIM teams. Improving patient identification should come across to the organization as a unified team effort, Benintendi says. You want everyone to realize that you can t have a high duplicate medical record rate, especially as organizations move toward value-based care. Everything hinges on accurate patient identification. About HFMA Educational Reports HFMA is the nation s leading membership organization for more than 40,000 healthcare financial management professionals employed by hospitals, integrated delivery systems, and other organizations. HFMA s purpose is to define, realize, and advance the financial management of health care. HFMA educational reports are funded through sponsorships with leading solution providers. For more information, call HFMA, ext This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA. 8 April Healthcare Financial Management Association hfma.org