At the AHIMA19: Health Data and Information Conference, leaders in health information management (HIM) shared innovations in healthcare and addressed issues affecting patient access to their health records including the privacy, accuracy and interoperability of that information.
The annual meeting for the American Health Information Management Association (AHIMA), AHIMA19, also highlighted inspiring stories of perseverance, empowerment and shared details of AHIMA’s global leadership.
Patient advocate Doug Lindsay shared his gripping story of transitioning from a wheelchair to walking again; Alexandra Mugge, deputy chief health informatics officer at the Centers for Medicare & Medicaid Services (CMS), outlined the benefits of interoperability and patient access; healthcare innovators pitched their ideas to a panel of experts for a $5,000 prize; and exhibitors and industry speakers shared their spectrum of knowledge with attendees gathered from across the globe.
Nearly three thousand HIM professionals gathered for the annual conference in September, held at Chicago’s historic McCormick Place, the largest convention center in North America.
Information and Inspiration
Speakers addressed clinical documentation, data ownership, patient access to their medical records, interoperability and cybersecurity. These presentations provided important insights and updates on technology to help HIM professionals continue leading the industry in improving healthcare and changing lives.
Mugge told the crowd that interoperability and greater access to medical data is integral to improving healthcare outcomes for payers, patients, and providers.
“We believe electronic data exchange is the future of healthcare, and interoperability is the foundation of value-based care,” Mugge said. “Patients should know that the way they interact with the healthcare industry is changing. Patients are no longer passive participants in their care, they now have the ability to be empowered consumers of the healthcare industry through access to data that puts them in the driver’s seat to make the best and most informed decision about their health.”
Mugge assured attendees that privacy and security safeguards would remain in place as HIM professionals help shape the landscape of interoperability.
Lindsay found his own way to improve his health, seemingly against all odds. He was bedridden and home-bound for 11 years because of a debilitating illness that forced him to drop out of college at 21 years old.
Although Lindsay’s body was limited, his mind was strong and he was determined to walk again, and to live again.
That determination led Lindsay to create a surgery for what he learned was bilateral adrenal medullary hyperplasia. He then assembled a team of experts to perform the surgery, which eventually led to his recovery.
Any patient matching improvement strategy must look beyond technology and emphasize the people and processes that play a critical, yet often overlooked, role in ensuring data integrity. That was the message Just Associates, Inc., shared with the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) in response to requests for information on patient matching in conjunction with proposed rules to advance interoperability.
In its letter to the ONC, Just Associates noted that while it supports the focus on interoperability and usability and agrees with the importance of accurate patient matching, it does not believe that the concept of a “technology alone” solution is realistic. Any improvement strategy must also include data standardization and promote a more consistent, comprehensive collection of patient data at all entry points.
“Every technology has its flaws when it comes to patient matching and the importance of training staff, developing and maintaining comprehensive data governance policies, ensuring executive support for data governance and vigilant efforts on measuring and reporting data quality are critical. We cannot ignore the ‘people and process’ aspects to obtaining high levels data quality,” the letter stated.
Just Associates also provided feedback to the ONC on the importance of consistently defined and used format constraints and identified key issues that must be addressed to accurately measure algorithm performance. The suggestion was also made to align with the Children’s Hospital Association’s temporary demographic conventions for newborns to address the unique challenges with pediatric matching.
In its letter to CMS, Just Associates concurred with the suggestion that more standardized data elements be used across all appropriate programs to immediately enhance matching rates, noting that “data collection standards and their consistent application by health plans, providers and exchange organizations are critical for matching accuracy.
“Equally important,” the letter continued, “is the development of data definitions for these elements to ensure common understanding of exactly what data is being collected and in what format.”
Other advice offered by Just Associates in response to CMS suggestions included avoiding mandating the use of specific matching algorithms, data sources or software solutions, a move that would likely be premature and overly prescriptive. The firm also stated its support for implementation of a CMS-wide identifier, noting its potential to enhance accuracy and assist in duplicate record reconciliation verification processes.
By Susan DeCathelineau, vice president of global healthcare sales and services, Hyland Healthcare.
Healthcare interoperability continues to be a critical topic facing healthcare technology leaders. There’s no question that achieving true healthcare interoperability is key to moving the industry forward by enabling the type of information exchange that can streamline workflows, inform clinical decision making and enable precision medicine.
However, much of the current interoperability discussion is focused on ensuring core systems, i.e. Electronic Medical Records (EMRs) are compatible with one another. Yet there is one issue that is largely overlooked: the crucial role of integrating structured data with unstructured patient information.
For example, EMRs are designed to capture and manage structured patient data, and they do that job well. That is to say, they capture content using controlled vocabulary rather than narrative text. But the lack of structured data and standardization in the healthcare industry today creates major issues when sharing EMR content within and across healthcare organizations.
EMRs are not built to natively ingest the plethora of unstructured information that exists on a patient. This unstructured content includes things like diagnostic medical images, clinical documents and notes, visible light images and more. According to many industry estimates, as much as 75 percent of the information that exists on a patient lives outside of core applications like EHRs. Instead, this unstructured content is scattered in a multitude of legacy data silos.
Manage your unstructured clinical content
A recent whitepaper by Signify Research illustrates just how pervasive ineffective management of unstructured content is in today’s health systems, and just how vital this effort is to interoperability initiatives. In the paper, author Steve Holloway explains how the growth of healthcare networks resulting from merger and consolidation activity is driving the need for true interoperability. These ever-larger healthcare enterprises are increasing demand for incoming and outgoing information exchange between a diverse ecosystem of providers, patients and payers.
He continues to say that EMRs and health information exchanges have had “limited success in addressing the myriad of nuanced applications and unstructured content outside of core administrative patient records and financial billing processes.”
Holloway proposes that support for multi-disciplinary care and robust, multi-node interoperability will never be achieved without a more holistic approach to integrating structured and unstructured data.
Make the connection, see your whole patient
Providing a “holistic approach” to integrating structured and unstructured healthcare content is a core focus at Hyland Healthcare. Experience has shown that providing a suite of connected healthcare solutions allows healthcare providers to harness the unstructured content in every corner of their enterprise — whether it be a diagnostic medical image, clinical document, video file or audio recording — and link it to the core clinical or business applications they use every day. Addressing unstructured content needs is made possible by combining both a full suite of content services and enterprise imaging tools.
In short, healthcare providers – and by extension the entire healthcare enterprise – work best when it is possible to see your whole patient. By enhancing the EHR or other core clinical application with unstructured content that currently resides in disparate data silos, provider organizations can complete the patient picture. This delivers a truly comprehensive medical information repository at the fingertips of key healthcare stakeholders.
We live in a world where medical errors are the third leading cause of death behind cancer and cardiac disease, leading to more than 200,000 preventable deaths every year. We have an aging population growing at an unprecedented rate: 8.5 percent of people worldwide (617 million) are aged 65 and over, and this percentage is projected to jump to nearly 17 percent (1.6 billion) by 2050, leading to an anticipated physician shortage of more than 50,000 by 2025.
On top of all of this, healthcare costs are projected to increase to over 25 percent of GDP in the United States by 2025. The convergence of these events is pushing the entire industry to begin leveraging technology more than it has in the past.
Many of these challenges can be remedied by leveraging industrial IoT (IIoT) technology that’s been proven to solve similar challenges in other industries. Could an interoperable, connected healthcare platform that applies the principles of an IIoT connectivity architecture to share data throughout the healthcare system be the cure for our ailing healthcare system?
West Health, now the Center for Medical Interoperability, seems to think so. In 2013 they published a report showing how an interoperable, connected healthcare system could provide nearly $30 billion in industry savings while improving patient outcomes in the process. These connected healthcare platforms provide the foundation for innovation that is needed to make a meaningful data-driven change in healthcare. It’s these platforms that open the door to application developers everywhere to create modality-specific applications using artificial intelligence and machine learning.
So what exactly is a connected health platform and how does it provide a foundation for transformational change in healthcare? First, a connected health platform consists of hardware (gateways and servers) and embedded software components that are designed to take all of the data from any medical device (clinical or remote) and convert the data in a single usable format that gives providers access to a complete data set.
This connected platform will provide a variety of user interfaces, analytics and clinical applications to help users throughout the healthcare ecosystem distill value from this newly-gathered data. The applications range from the early detection of sepsis, to predicting cardiac arrest, to providing business analytics like bed and device utilization.
The connected health platform will become the center of an ecosystem for further application development, similar to that of an online app store — but with built-in medical-grade safety and security. The connected health platform must ensure data security and patient privacy by aligning to guidance provided by the FDA on cybersecurity, and meeting the standards defined by HIPAA.
However, these connected health platforms are only as effective as the data they capture, which is determined by the connectivity frameworks they are built upon. Many of the currently deployed platforms are not platforms at all, but a collection of disparate systems that provide silos of individual device data. These legacy systems have been built using internally-developed, proprietary, message-based communication technology.
As the first step towards the development of a connected health platform, modern web services-based communication has been deployed on top of the legacy technology to begin integrating all of the disparate data streams via onsite data centers or the cloud. Although this is a step in the right direction, these platforms are far from complete. Because of legacy communications infrastructure they are built upon, they are only able to aggregate a portion of the data making these systems a poor fit for true near-patient, real-time clinical decision support – the key to efficiently providing improved patient outcomes.
By Janak Joshi, senior vice president, chief technology officer and head of strategy, Life Image.
In December 2018, the FDA announced its new framework for the real world evidence (RWE) program, which would require including imaging data alongside claims, electronic health records (EHRs) and other datasets in clinical research. In issuing this new framework, regulators underlined the continued importance of using contextualized, quality datasets to make drug development faster, safer, more efficient and less expensive.
Because of this move to include authentic patient data in the drug development process, imaging data has become an essential part of RWE as it can accelerate the development cycle and improve the confidence in the final clinical arguments in support of drugs going to market.
Imaging data plays such a leading role in clinical decision-making because it is the most advanced diagnostic evidence for several diseases, and it can clearly show disease progression and drug impact across a variety of therapeutic areas, among other reasons. While EHRs and medical claims are the predominate sources of data, because they were initially designed for billing and payment purposes they do not have the depth and breadth needed to accurately capture the nuances of a patient’s full clinical history – nor do they contain imaging information.
Clinical researchers looking to achieve a holistic view of each patient’s healthcare journey by incorporating medical imaging into their RWE programs should avoid these three things.
Institutional bias stems from using data from a single health system, which tends to follow a uniform set of treatment protocols, leading to homogenous evidence data. A diverse dataset includes variation, for instance in geography, which can influence socioeconomic and environmental factors, level of education, healthcare access, payer mix and demographics.
The most effective RWE incorporates medical data, including imaging, from varied populations that include both research and non-research settings, AMCs and community hospitals, publicly and privately funded institutions, and a mix of highly insured and uninsured patients. The ultimate goal of RWE is to be representative of any and all patients across the globe.
A limited, siloed data pool
Small datasets do not accurately reflect the “real world,” therefore RWE requires very large databases with various datasets in order to ensure data integrity and credibly match patients to appropriate clinical trials. This poses a challenge since much of today’s data is siloed. To make RWE representative of outcomes and context, clinical researchers must break down siloes to achieve a large, interoperable pool of quality data from a breadth of sources, which they can normalize and match across sets for optimal results.
Take, for example, a new drug trial that needs to involve 500 individuals meeting specific real-world data standards. For each participant, researchers may require four years of prescription details, four years of imaging data, five years of blood test results, as well as genomics and other relevant data. However, consider that over the years many of these patients likely went to various pharmacies, switched health plans and/or providers, and had imaging and blood tests performed at various facilities or out-of-network sites. As a result, each patient’s information may be spread out over multiple EHR systems and may even be in non-digital, fax or CD formats.
The Department of Health and Human Services (HHS) filed its annual year-end report to Congress at the start of 2019. The 22-page report summarized nationwide trends in health information exchange in 2018, including the adoption of EHRs and other technologies that support electronic access to patient information. The most interesting takeaway has to do with the ever-elusive healthcare interoperability.
According to the report, HHS said it heard from stakeholders about several barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “These barriers impede the movement of health information to where it is needed across the care continuum,” the report said. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT.”
To better understand these barriers, HHS said it conducted multiple outreach efforts to engage the clinical community and health IT stakeholders to better understand these barriers. Based on these takeaways, HHS said it plans to support, through its policies, and that the health IT community as a whole can take to accelerate progress: Focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate, and move their health information using their smartphones (or other devices) and healthcare providers can easily send, receive, and analyze patient data; increase transparency in data sharing practices and strengthen technical capabilities of health IT so payers can access population-level clinical data to promote economic transparency and operational efficiency to lower the cost of care and administrative costs; and prioritize improving health IT and reducing documentation burden, time inefficiencies, and hassle for health care providers, so they can focus on their patients rather than their computers.
Additionally, HHS said it plans to leverage the 21st Century Cures Act to enhance innovation and promote access and use of electronic health information. The Cures Act includes provisions that can: promote the development and use of upgraded health IT capabilities; establish transparent expectations for data sharing, including through open application programming interfaces (APIs); and improve the health IT end user experience, including by reducing administrative burden.
“Patients, healthcare providers, and payers with appropriate access to health information can use modern computing solutions (e.g., machine learning and artificial intelligence) to benefit from the data,” HHS said in its report. “Improved interoperability can strengthen market competition, result in greater quality, safety and value for patients, payers, and the healthcare system generally, and enable patients, healthcare providers, and payers to experience the promised benefits of health IT.”
Interoperability barriers include:
Technical barriers: These limit interoperability through—for example—a lack of standards development, data quality, and patient and health care provider data matching. Addressing these technical barriers by coordinating to establish the technological foundation for standardizing electronic health information and by promoting exchange of that information can considerably remove these barriers.
Financial barriers: These relate to the costs of developing, implementing, and optimizing health IT to meet frequently changing requirements of health care programs. The cost to adjust health IT to meet these requirements can impact innovation and the timeliness of technical upgrades. Specific barriers include the lack of sufficient incentives for sharing information between health care providers, the need for enhanced business models for secondary uses of data, and the current business models for health systems or health care providers that do not adequately focus on improving data quality.
Trust barriers: Legal and business incentives to keep data from moving present challenges. Health information networks and their participants often treat individuals’ electronic health information as an asset that can be restricted to obtain or maintain competitive advantage.
Elsewhere, the Center for Medical Interoperability, located in Nashville, Tenn., is an organization that is working to promote plug-and-play interoperability. The center’s members include LifePoint Hospitals, Northwestern Memorial Healthcare, Hospital Corporation of America, Cedars-Sinai Health System, Hennepin Healthcare System, Ascension Health, Community Health Systems, Scripps Health, and UNC Health Care System.
Its mission is “to achieve plug-and-play interoperability by unifying healthcare organizations to compel change, building a lab to solve shared technical challenges, and pioneering innovative research and development.” The center stressed that the “lack of plug-and-play interoperability can compromise patient safety, impact care quality and outcomes, contribute to clinician fatigue and waste billions of dollars a year.”
More interoperability barriers identified
In a separate study, “Variation in Interoperability Among U.S. Non-federal Acute Care Hospitals in 2017,” showed additional difficulty integrating information into the EHR was the most common reason reported by hospitals for not using health information received electronically from sources outside their health system. Lack of timely information, unusable formats and difficulty finding specific, relevant information also made the list, according to the 2017 American Hospital Association (AHA) Annual Survey, Information Technology Supplement.
Among the explanations health systems provided for rarely or never using patient health information received electronically from providers or sources outside their health system:
Difficult to integrate information in EHR: 55 percent (percentage of hospitals citing this reason)
Information not always available when needed (e.g. timely): 47 percent
Information not presented in a useful format: 31 percent
Information that is specific and relevant is hard to find: 20 percent
Information available and integrated into the EHR but not part of clinicians’ workflow: 16 percent
Hospitals, when asked to explain their primary inability to send information though an electronic exchange, pointed to: Difficulty locating providers’ addresses. The combined reasons, ranked in order regardless of hospital classification (small, rural, CAH or national) include:
Difficult to find providers’ addresses
Exchange partners’ EHR system lacks capability to receive data
Exchange partners we would like to send data to do not have an EHR or other electronic system to receive data
Many recipients of care summaries report that the information is not useful
Cumbersome workflow to send the information from our EHR system
The complexity of state and federal privacy and security regulations makes it difficult for us to determine whether it is permissible to electronically exchange patient health information
Lack the technical capability to electronically send patient health information to outside providers or other sources
The report also details other barriers related to exchanging patient health information, citing the 2017 AHA survey:
Greater challenges exchanging data across different vendor platforms
Paying additional costs to exchange with organizations outside our system
[Need to] develop customized interfaces in order to electronically exchange health information
“Policies aimed at addressing these barriers will be particularly important for improving interoperable exchange in health care,” the report concluded. “The 2015 Edition of the health IT certification criteria includes updated technical requirements that allow for innovation to occur around application programming interfaces (APIs) and interoperability-focused standards such that data are accessible and can be more easily exchanged. The 21st Century Cures Act of 2016 further builds upon this work to improve data sharing by calling for the development of open APIs and a Trusted Exchange Framework and Common Agreement. These efforts, along with many others, should further improvements in interoperability.”
What healthcare leaders are saying about interoperability
While HHS said it conducted outreach efforts to engage health IT stakeholders to better understand these barriers, we did too. To further understand what’s currently going on with healthcare interoperability, read the following perspectives from some of the industry’s leaders. If there’s something more that you think must be done to improve healthcare interoperability, let us know:
How many doctors have you seen in your lifetime? Don’t know or remember? You’re not alone – the average American patient will see nearly 19 different doctors during their lifetime. Nineteen different offices. Nineteen different medical charts. Nineteen different phone numbers. Nineteen different calls to track down your records. Now, can you even remember your last five doctors?
The future: Imagine this, you visit your doctor – or any doctor for that matter – and they quickly pull up your medical history. Vaccinations when you were a child? Check. Currently on a hypertensive medication? Check. Pre-disposed to a medical condition? Yep, that’s in there, too. No more arriving 20 minutes early to the doctors’ office to fill out the industry-average seven pages of paper forms. Your records – past and present – are already being reviewed by your trusted provider.
Beyond the sheer convenience, the accuracy and completeness of having your entire medical history available at the fingertips of your provider can impact your well-being and scope of care. Can you accurately remember all procedures you’ve had? And when? Or all the medications you’ve ever taken? With dates? Imagine if you were a senior. Not just daunting, but nearly impossible. Instead of going over just snippets of what you actually remember, your doctor is empowered to holistically review your entire medical history with the potential to make more informed decisions about your health.
Seem like a pipedream? If you were to ask a mere decade ago, most would have agreed. As recently as 2007, 88 percent of physicians were still charting on paper. And those physicians on an EHR system – who were paying a premium – were almost exclusively using a localized, server based platform with no connectivity. For cost perspective, according to HealthIT.gov, the average upfront cost of implementing an EHR is $33,000 per provider plus an on-going fee of $4,000 yearly, a cost-prohibitive amount for most private practices.
Fast forward to 2009 and the passage of the HITECH Act which provided billions of dollars of incentives for providers to implement an electronic health record. In addition to the incentives, new vendors appeared on the market who provided electronic health record platforms completely free-of-charge, allowing providers to reinvest the incentives in their practice as additional staff, new equipment, etc.
Interoperability between healthcare’s disparate systems seems to be the stickiest of wickets, and a Holy Grail that every soul in the sphere is trying to find. Given the number of conversations about the topic, there’s often little discussed about its actual importance. Perhaps this is an assumed measure or an outcome that should be clearly understood as positive, but every relevant aspect of every story should be covered, not simply assumed. Because far better reporters and publications have done a far better job of describing the interoperability issue and its place in the current healthcare landscape, I decided to ask one question of the community, in an search of a foundational answer to: How is interoperability critical to healthcare innovation?
The prospective provided here, from some of healthcare’s most knowledgeable insiders, offers some interesting insight into a topic that seems more or less overlooked in the larger conversation of achieving interoperability or its capabilities.
Rick Valencia, senior vice president and general manager, Qualcomm Life Interoperability is the future of healthcare innovation, especially as we move toward an era of connected, team-based care. We need to create platforms and devices that enable the seamless, frictionless flow of data to allow doctors, patients, providers and care teams to collaborate efficiently to make critical care decisions. As care moves from the hospital to the home and more patients are remotely monitored, we need solutions that enable continuous care, informed interventions, and better management of at-risk populations. Without interoperability, we can’t innovate. Without innovation, we can’t improve the health of our nation.
Interoperability is critical to innovation in healthcare IT, particularly when it comes to connecting the care delivery ecosystem to provide safer transitions of care between acute and senior care. While some individuals may require short-term rehabilitative care, others may need home-based care, assisted living or long-term and hospice care. As seniors move through these different stages or between acute care and post-acute care, these transitions pose challenges for healthcare providers. Ideally, all the information that clinicians need to treat the individuals will be available when they arrive at their new destination. However, this is not always the case. Healthcare providers must invest in an infrastructure and emerging technologies, such as electronic health records and mobile communications, which support seamless transitions; interoperability plays a vital role. Compared to single-purpose or “best-of-breed” software solutions, comprehensive platforms can optimize many parts of the business, from enabling better-connected resident care and documentation, to delivering high quality data insights for financial management and risk mitigation. In the end, this will allow for better health outcomes, help reduce unnecessary hospital readmissions, ensure organizations are financially sound and keep healthcare costs down.
Interoperability in healthcare is critical for doctors to coordinate care for their patients and improve their health. However, if physicians are using proprietary software in their offices, interoperability becomes a very difficult and very expensive challenge. Without interoperability in healthcare, doctors cannot guarantee the data they sent to a specialist will be received or interpreted properly. Today, doctors have to rely on fax machines to exchange patient information. This is an outdated and un-secure form of communication to exchange patient information.
At the center of all this is the patient, whose medical records containing their most sensitive information is traversing across fax lines. ELXR Health will change healthcare by giving physicians a new way to coordinate care and exchange information. With the platform, patients can create and manage their medical consents anywhere on a smartphone or tablet. ELXR Health can transform and translate health data into multiple formats; doctors can seamlessly exchange patient information regardless of the EHR software they sent to, or receiving from.
The ELXR Health platform is cloud-based engine that translates and restructures electronic health records into a format easily readable by any doctor’s office. We center our solution around the patient by providing them a responsive web application to create and manage their consents. This doctor-patient collaborative system will improve coordination of care systems and dramatically increase patient outcomes.
Paul Emanuel, HCISPP, is the co-founder and CEO of ELXR Health. Emanuel has worked in healthcare technology for many years as a technician, a systems and security administrator, an EMR consultant and an HIE Engineer. His years of service in health IT enabled him to receive 14 IT certifications, and is a certified healthcare information security and privacy practitioner. He started his first company in 2008 helping rural health clinics adopt electronic health records and connect with state health information exchanges. He came up with his idea for ELXR Health from his years of experience in Health IT. ELXR Health was created to be the solution for doctors and patients to better coordinate care.
Marketing/promotion strategy Behavioral health organizations, managed care organizations, hospitals and private practices are looking for a cost-effective way to exchange patient data electronically while improving patient outcomes while adhering to their state laws. Our engine allows doctors to translate, restructure and validate health data so the data being sent is the data being received.
ELXR Health gives the patient the ability to manage their consents at their convenience from their smartphone or tablet. We also give developers the ability to integrate with our API to improve their software and provide better care systems for doctors and patients.
The College of Healthcare Information Management Executives (CHIME), the professional organization for chief information officers and senior IT executives, is calling on innovators throughout the U.S. to participate in the CHIME National Patient ID Challenge.
In an effort to find a universal solution for accurately matching patients with their healthcare information, CHIME will launch a $1 million challenge early this summer on the HeroX platform, co-founded by XPRIZE CEO Dr. Peter Diamandis.
The digitization of the U.S. healthcare system maintains that electronic health records must be able to seamlessly share and exchange information. According to CHIME, interoperability is not enough — to realize their full potential, patient data contained in the EHR must be accurate to support the requirements of coordinated, accountable, patient-centered care, the organization says.
“There is a growing consensus among payers and providers that a unique patient ID would radically reduce medical errors and save lives,” said CHIME CEO and president Russell P. Branzell, FCHIME, CHCIO.”Incomplete or duplicate health records present significant issues in terms of patient safety, and there is a pressing need for preventing, detecting and removing inaccurate records so hospitals can positively match the right data with the right patient in order to provide the best possible care.”
Duplicate or inaccurate patient records can occur from manual data entry errors, or when two or more individuals share the same name. This presents considerable concern for different individuals being identified as the same patient, potentially resulting in inadequate treatment or unintended injury.