On Mar. 9, 2020, the U.S. Department of Health and Human Services (HHS) finalized “two transformative rules that will give patients unprecedented safe, secure access to their health data.” Issued by the Office of the National Coordinator for Health Information Technology (ONC) and Centers for Medicare & Medicaid Services (CMS), the Final Rules implement interoperability and patient access provisions of the 21st Century Cures Act and support President Trump’s MyHealthEData initiative.
In its release announcing the Final Rules, HHS noted that together “these final rules mark the most extensive healthcare data sharing policies the federal government has implemented, requiring both public and private entities to share health information between patients and other parties while keeping that information private and secure, a top priority for the Administration.”
Cures Act Final Rule implements the interoperability provisions of the 21st Century Cures Act, passed by Congress in 2016 to promote patient control over their own health information while still allowing providers to choose the IT tools that let them provide the best care for patients without excessive costs or technical barriers.
Specific to patient matching, the Cures Act Final Rule adopts as standard the first version of the United States Core Data for Interoperability (USCDI v1), making its use a requirement as part of the new application programming interface (API) certification criterion.
According to ONC, adoption of the USCDI standard “supports improved patient matching through the exchange of USCDI and its patient demographic data elements.” The Final Rule integrates additional data elements to the patient demographics data class to improve patient matching:
Phone Number Type
“Any improvement strategy must include data standardization and promote a more consistent, comprehensive collection of patient data at all entry points,” said Karen Proffitt, MHIIM, RHIA, CHP, vice president of industry relations and chief privacy officer, Just Associates. “The Final Rule requirement for adoption of USCDI standards, including historical data and more relevant data elements such as phone number and email address, represents a significant step toward improving interoperability and minimizing MPI errors overall.”
Interoperability and Patient Access Final Rule gives patients access to their health information when they most need it, in a way they can best use it. It is focused on driving interoperability and patient access to health information by leveraging CMS’s regulatory authority over Medicare Advantage, Medicaid, CHIP, QHP issuers and FFEs to free patient data.
Specific to patient matching, which was one of two requests for information included within the proposed rule, CMS noted that while “accurate patient identity management is critical to successfully delivering the right care to the correct patients,” patient matching challenges are beyond the scope of the current rule. However, the comments provided will be taken into consideration for potential future rulemaking.
“As a healthcare community, we must recognize the critical role improved data capture and MPI data quality play in enabling patients to have more comprehensive access to their health information by ensuring complete and accurate data is available for viewing or transmitting,” said Proffitt.
She adds, “any process to incorporate patient verification of data along the way could be very beneficial.”
By Beth Haenke Just, MBA, RHIA, FAHIMA, founder and CEO, and Karen Proffitt, MHIIM, RHIA, CHP, vice president of industry relations/CPO, Just Associates, Inc.
The introduction of overlays into a medical record system can be so subtle that they often go unnoticed until one causes an adverse event, HIPAA violation or billing error—making them a primary source of patient errors, expenses and lost revenues in hospitals today.
Caused when the information of two patients is co-mingled within one medical record, the dangers of overlays have intensified with the proliferation of electronic health record (EHR) systems, which accelerate the rate at which multiple internal and external systems can be infected with dirty data. Compounding the problem is an overreliance on technology-centric solutions to resolve possible duplicates.
The American Health Information Management Association (AHIMA) puts the average duplicate rate at between 8 percent and 12 percent. A more recent survey by Black Book found an average of 18 percent. Meanwhile, an analysis of EMPI cleanup projects Just Associates completed between 2012 and 2016 showed that as many as 1.3 percent of these possible duplicates are actually potential overlaid records.
When it comes to overlays, there are three challenges facing health information management (HIM) professionals tasked with maintaining the integrity of patient records: 1) identifying and resolving existing overlaid records, 2) determining the root cause(s) and 3) implementing policies and procedures that will prevent the creation of new ones.
The birth of an overlay
The most common way an overlay is created happens at the time of registration when an incorrect patient record is selected, core demographic information is changed, and a new visit is added. Occasionally, the records of two different patients are erroneously merged during the duplicate resolution process.
Overlay creation can also be traced back to multiple departments. A study in the Journal of AHIMA involving an eight-hospital, multi-state healthcare organization found that most of the errors happened in the emergency department (ED) and, to a lesser extent, in registration, scheduling and ancillary areas such as lab and radiology.
The hospital system that was the subject of the study had been tracking and keeping detailed statistics on overlay errors for five years, beginning with the implementation of an EHR system. This provided researchers with the rare opportunity to analyze a considerable sample size of 555 errors, from which they determined an error rate of one in every 10,734 admissions. That is the equivalent to more than nine errors per month, of which 97.5 percent were caused by user oversight. The study also identified an upward trend in overlays attributed to growth of the health system and higher utilization of error identification tools that reveal more issues than manual methods.
For example, 54 percent of overlays were found by registration users while data integrity change reports that made use of EHR tools found 31 percent. Clinicians were a distant third, identifying just 6 percent of errors. Patients also found overlay errors via patient portals, which could have allowed them inappropriate access to highly-sensitive protected health information (PHI) — access that could lead to HIPAA violations.
Proactive EHR tools found most overlays within 10 days of their occurrence, and most were corrected in 30 days. This is important because the longer an overlay goes undetected, the less likely it will be found. When it is found, the older overlaid record is much more time-consuming and expensive to correct.
The high cost of overlays
To determine just how costly overlays are, it is necessary to cast a wide net, as few studies have been done to establish industry averages. Factors contributing to the full financial impact of an overlay include denied and delayed claims, lost revenues and resources required to identify and correct the error.
Time is a huge factor in the costs associated with overlay correction resources. For paper-based overlays, it can take between 60 and 100 hours, while EHR-based errors can take months depending upon system complexity. A survey by the College of Healthcare Information Management Executives (CHIME) further found that respondents typically had at least two people dedicated to “data cleansing,” including overlay correction.