By Neysa Noreen, RHIA; Katherine Lusk, MHSM, RHIA; and Lesley Kadlec, MA, RHIA, CHDA
Why is patient matching important? Why is information governance (IG) important?
And how are the two linked together?
IG starts at the creation of information and patient matching starts at the time the patient information is being created. Part of resolving the problem with patient matching is using industry-recognized standards of information governance.
When a child is registered to go to school, the full legal name is used to track their education to ensure the correct child gets the credit for the education. Healthcare is just as, if not more, important. The same rigor needs to be applied to our medical records. Every encounter in a medical record is a chapter in the patient’s life. The only way to ensure all chapters are captured is to manage and govern them in a standardized manner.
This is one reason why AHIMA has launched the MyHealthID advocacy campaign, which features a petition to the federal government to make unique patient identification a priority and lift a ban that currently prohibits even the discussion of a patient identifier at the federal level. For more information, and to sign the petition, click here.
Information governance starts with the creation of the information. The patient record starts at registration. Use of a standardized naming convention ensures all registrations follow the same guidelines. Applying information governance at the initiation of the patient encounter ensures that all information is collected in a consistent manner, enabling a platform for linking across organizations.
Nationally if we were all to agree to use the patient’s full legal name when registering a patient it would improve electronic connectivity and remove the manual burden of managing the records across organizations. Lack of this standardization results in manual human intervention with transitions of care and e-referrals to link the record to the correct patient.
This manual intervention is costly. The Office of the National Coordinator for Health IT estimates that it costs $60/record to merge internally.1 The same costs occur when we try to match patients across disparate systems and organizations. We are increasing the volume of work exponentially and likewise increasing the cost.
Lack of Information governance creates a patient safety risk. From a patient safety standpoint, it is critical that patients can be linked across care settings. We must prevent exposing patients to unnecessary care, such as additional radiation, needle pricks, inappropriate medications, etc. Patient matching allows us to support the provision of appropriate clinical care.
IG provides the foundation to mitigate risk to patients because of incomplete information.
Information governance truly starts within each healthcare organization. Information is collected in numerous locations and circumstances. IG doesn’t stop within the boundaries of the physical walls of the organization, it crosses the bricks and mortar to help us exchange information electronically. This can only be done if the standards are the same. IG extends beyond the vendor. It is not an algorithm, it is not vendor-specific. IG provides data integrity and standardized practices.
The patient identity component of IG is not a vendor responsibility. We as HIM leaders need to take ownership and tell our vendors how the systems should work. We recognize that IG is a leadership initiative requiring partnering with vendors, setting the strategic tone and direction to both vendors and policy makers.
A mature organization has practices in place that captures patient information in the same way, every day, all day, using industry-recognized standards. To move forward, however, we need to expand these practices beyond the bounds of a mature organization to proliferate within a mature healthcare ecosystem overall.
IG requires an ongoing culture change. Registering our children for school with their full legal name has become part of our culture, it needs to become just as important to use the same information when we register patients at our organizations. IG with patient ID improves patient safety, increases the efficiency of healthcare delivery, and decreases administrative cost. Eliminating the manual effort to link patients can be accomplished with IG allowing linking electronically. IG with patient identity matching supports the triple aim of improving patient safety, increasing efficiency, and decreasing cost.2
For more information on what you can do to improve patient identification, visit AHIMA’s MyHealthID website here.
- Office of the National Coordinator for Health Information Technology. Patient Identification and Matching Final Report. 2014. https://www.healthit.gov/sites/default/files/patient_identification_matching_final_report.pdf.
- Institute for Healthcare Improvement. IHI Triple Aim Initiative. http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx.
Neysa Noreen (email@example.com) is data integrity and applications manager at the Children’s Hospital and Clinics of Minnesota.
Katherine Lusk (Katherine.Lusk@childrens.com) is chief health information management and exchange officer for Children’s Health System of Texas. She is an active AHIMA member focusing her attention on patient identity, health information exchange, standard development, and information governance.
Lesley Kadlec (firstname.lastname@example.org) is a director of HIM practice excellence at AHIMA.
Noreen, Neysa; Lusk, Katherine; Kadlec, Lesley.
"IG and Patient ID: A Perfect Match"
(Journal of AHIMA website),