by Chris Dimick
Keeping the organization’s master patient index clean leads some HIM departments all the way back to patient registration, where they collaborate to prevent errors before care starts. Accurate registration helps keep patient data complete and clean as it moves throughout the organization.
Long-term trouble can start during a brief check-in. A rushed or incomplete search of the organization’s MPI can cause clinical registrars to create duplicate patient records or even select the wrong record.
Faulty information entered at check-in streams straight through the system, risking treatment errors and leading to eventual billing problems. Entities that participate in health information exchange will export bad information into their networks.
Error-ridden MPIs also hamper an organization’s ability to understand its patient population and its own performance, both for internal and external reporting. Patient information spread across multiple records can distort measures of patient severity and overall risk of mortality. And correcting errors consumes time.
HIM departments often are the hub of identifying and mitigating registration errors. HIM staff sift through the MPI, merging duplicate records and separating out information that has been overlaid into the wrong patient account.
But what HIM learns about the types of MPI errors occurring in patient registration may never be shared with that department. Because HIM and registration are typically managed through different departments, there can be an information exchange disconnect between the two areas. If registration staff do not know what they are doing wrong, how can they correct it?
Some facilities have instituted registration improvement programs, which can feature cross-department committees whose purpose is to reduce registration errors and clean up the MPI.
Providing Feedback to Registration
Not only do these registration improvement processes eventually reduce work for HIM, they also give vital feedback to registration staff about how their actions directly impact the medical record and patient care, according to Gwyndle Kravec, MBA, RHIA, CCS, director of HIM and privacy officer at Peninsula Regional Medical Center, based in Salisbury, MD. Peninsula instituted a registration improvement program that has greatly reduced MPI errors.
“I think this program heightens the awareness that this is an issue of data quality and that these [duplicate MPIs] do impact patient safety,” Kravec says. “When you heighten awareness of what the downstream effects are of having a duplicate medical record, then I think [registrars] are more conscientious of what they are doing. They want to get it right.”
Registration improvement programs can be simple or elaborate, depending on what investment a facility feels is appropriate to clean up its MPI and registration processes.
The HIM department at Christiana Care Health System, based in Newark, DE, has worked with the facility’s registration areas for several years to improve registration processes and reduce MPI duplicates and overlays. The initiative is an important part of ensuring health records are complete and accurate, says Kathy Westhafer, RHIA, CHPS, program manager for clinical information.
“We are looking for that MPI to really be the focus of how we identify the patient, that we have one record for the patient within the health system,” Westhafer says.
Each day a team of Christiana Care HIM professionals uses a clinical system tool that identifies possible MPI duplicates and overlays. A notification tool is also available for all staff to report possible duplicate MPI accounts. HIM staff investigates these suggested cases, merging duplicate MPIs or separating out information in overlay cases.
“That team is doing the research and determining if it is a situation where two people were merged inappropriately, in an overlay situation, or if it is really one person that has multiple records,” Westhafer says.
Because each ancillary area at Christiana Care conducts patient registration, duplicate and overlay MPI cases are compiled by HIM and separated by the specific ancillary area where the error occurred. Reports describing the circumstances of the error are circulated monthly to the various registration area managers. The information is used to create better registration processes as well as develop specific education for registration staff, Westhafer says.
Providing feedback to the registration departments is key to the facility’s MPI cleanup efforts. Instead of HIM doing cleanup work solely on the back end, registration now can use the information to improve accuracy on the front end, Westhafer says.
Since Christiana Care started its improvement processes, registration errors have been significantly reduced. A recent audit showed the organization’s MPI duplication rate accounts for fewer than 2 percent of all MPI records, a typical industry benchmark for MPI best practices, Westhafer says.
“We felt really good that the processes that we have put in place over the years seem to have worked,” she says.
Direct Training for Dramatic Results
In other organizations, HIM may have a more hands-on role in registration improvement efforts. At Peninsula, MPI duplication rates were so high that in 2007 the HIM department staff formed a committee and began direct education with registrars.
At that time, Peninsula’s registration staff was not taking enough time to accurately select or create MPI numbers. HIM staff struggled to fix the resulting duplicate accounts being entered into the system each day.
“We were processing 60 duplicates a week,” Kravec recalls. “Some of those were expected as part of our [trauma] registration process, but a majority of them were errors. So we had to get together because [the registration department] were not taking accountability. They were creating the error, and HIM was cleaning it up.”
The resulting committee, made up of representatives from HIM, patient registration, finance, IT, and labs, meets monthly to review duplication creation rates, discuss trends in registration data errors, and create new processes to correct the mistakes. A registrar is also invited to each meeting to discuss how a registration error occurred and how it could be prevented in the future.
Through the program, HIM collects all MPI account duplicates and sends them to the registration department manager. The registration manager uses the information for educational training in the department and monitoring which registrars are habitually creating errors. Under a disciplinary action program, a registrar who creates three duplicate MPI accounts within a rolling one-year time period is terminated from the organization. The policy holds registrars accountable for their mistakes and has helped reduce the number of errors committed, Kravec says.
Also, once a month the HIM operational manager will visit the registration department and conduct quality training with the registrars. The manager provides registrars the recent duplicate MPI rates and shares specific examples of recent registration errors that HIM has found. The HIM manager also observes the registrars at work, watching for any shortcuts that could lead to registration errors, Kravec says.
“There were so many errors and missing information in different records that we knew we needed to get something done,” Kravec says. “So we built in this ad-hoc way to do it where the HIM manager goes up [to registration] and does training on a monthly basis and brings true live examples where they registered a patient incorrectly.”
The registration improvement program has drastically reduced the number of MPI account duplicates at Peninsula.
In the first year of the program, MPI duplication rates dropped 23 percent from the previous year. By the end of the second year, rates had dropped 57 percent compared to rates before the improvement program was implemented.
“It is less resources I’m using, and my identity coordinator can certainly use their time doing better things than merging duplicate records,” Kravec says. “It is not just with one system-we have 17 downstream systems that it impacts. We have to coordinate and synchronize these merges so that patient safety is not impacted in a negative way.”
The registration improvement program at Peninsula is vital in keeping the duplication rates under control. It holds people accountable for their actions, Kravec says. “You do betterwhen you think somebody is watching,” she says. “Now if we stopped the program or stopped the [training] on these, I can see these numbers reversing.”
How Registration Errors Occur
The cause of registration errors varies from simple accidents to negligence.
The turnover rate for registration department employees is especially high in many facilities. With new employees regularly starting work, education on proper MPI creation is constantly needed, Westhafer says.
The rush to register patients can also affect error rates. At Peninsula, the emergency department has a policy that patients should be registered within two minutes so treatment is not delayed. Nearly 65 percent of Peninsula’s patients are admitted through the ED.
Registering a patient within two minutes is a lot of pressure, Kravec says, and with both patients and registrars in such a hurry, mistakes can easily be made.
The most common registration error at Peninsula is misspelling a patient’s name when searching the MPI. Because of this, the MPI duplication committee has asked registrars to confirm at least three unique identifiers in a patient’s record-such as name, Social Security number, and date of birth-before assuming they have found the correct file.
Many registration mistakes can be avoided by requiring registrars to ask patients if they have ever been to the hospital before. “That is very simple, but there were some registrars that never asked that,” Kravec says.
Technological problems are partly to blame for some registration errors at Christiana Care. The facility’s registration system is nearly 20 years old and in dire need of upgrade, Westhafer says. “There are inherent problems with a 20-year-old system in that you are very limited in how you can search [for MPI records],” she says.
The organization has decided to replace the registration system, and Westhafer says staff is looking for a system that makes it easier for registrars to look up MPI records.
One guideline at Christiana Care contributes to duplicate records, intentionally. Registrars are instructed to create a new record if they cannot confirm they have correctly matched a patient to an existing record. “We have told registers, ‘when in doubt-unless you are positive-it is better for you to create a duplicate than it would be to choose somebody incorrectly,’” Westhafer says. HIM staff would rather merge a duplicate record than sort out patient information from an incorrect account, Westhafer explains.
Improvement programs do not need to be elaborate. Merely sharing duplicate creation rates with registration staff can help reduce errors. Registration management can use the rates to help develop new registration procedures, train registrars, and track improvement progress.
Facilities looking to create programs should first track their duplication rates. Identifying specific MPI issues will help organize a response to the problem. Next, they can create a project assessment and determine which facility departments would be affected by a registration improvement program. Contact those parties and invite them to help develop the project, Kravec recommends.
Regardless of how the errors occur, an important part of a registration improvement program is educating registrars about the impact their work has on the rest of the facility. Registration’s impact on patient care is a focal point of the education sessions HIM conducts at Peninsula, Kravec says.
Just educating registrars on the importance of finding the correct patient MPI during registration can have a positive impact on their work.
“Registrars didn’t have the full picture before this program,” Kravec says. “Now they have the full picture.”
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