The Social Security number (SSN) has evolved over the years from an identification number used primarily when enrolling for Social Security benefits to its present status as the de facto national identifier-and a prime target for identity thieves.
Widely used in healthcare as a patient identifier, the SSN nonetheless creates numerous risks for patients, including privacy and security, identity theft, and identity fraud. Indeed, these risks were considered significant enough to prompt the Office of the Inspector General (OIG) to assess how hospitals were using and protecting patient SSNs.
Desiring to mitigate these risks and better protect its patient population, Peninsula Regional Medical Center (PRMC) has determined it was time to transition away from the use of SSNs as its primary patient identifier to a unique, system-generated medical record number (MRN).
Located in Salisbury, Md., PRMC is a nonprofit, 358-bed tertiary care facility that serves as the hub of the Peninsula Regional Health System. Joint Commission accredited, PRMC's 330 physicians and 3,000 healthcare professionals provide inpatient, outpatient, diagnostic, sub-acute, and emergency/trauma services to nearly 500,000 patients each year. That includes more than 80,000 people seeking emergency care, nearly 14,500 surgical procedures using robotics and minimally invasive techniques, and more than 21,000 inpatient admissions.
Recognized nationally for clinical excellence in a number of specialties, PRMC earned the Distinguished Hospital for Clinical Excellence Award and the 2010-2011 HealthGrades Women's Health Excellence Award, its second consecutive year for that recognition. PRMC also received the Beacon Award for Critical Care Excellence from the American Association of Critical-Care Nurses.
PRMC has earned national recognition for its health IT implementation and adoption, including the American Hospital Association's 2010 Most Wired Most Improved in 2010 and the AMDIS Award from the Association of Medical Directors of Information Systems for its dedication to improving the practice of medicine through direct physician use of IT. It also received the McKesson Celebrating CPOE Success Award for its 85-percent CPOE adoption rate.
A MULTI-FACETED CHALLENGE
With an organization as large as PRMC's, it was critical that the conversion to the new identifier system be done in a manner that would have minimal impact on patient care and business processes to preserve patient safety and minimize any financial disruptions. This was especially difficult with the facility's high repeat admission rate, which means that patient records rarely become inactive. Further, 75 percent of the estimated 450,000 patient records that utilized SSNs would need to be migrated to the new MRN-based patient identification systems.
IT WAS CRITICAL THAT THE CONVERSION TO THE NEW IDENTIFIER SYSTEM BE DONE IN A MANNER THAT WOULD HAVE MINIMAL IMPACT ON PATIENT CARE AND BUSINESS PROCESSES TO PRESERVE PATIENT SAFETY AND MINIMIZE ANY FINANCIAL DISRUPTIONS.
Potential workflow disruptions were also significant because of the multiple ways the SSN patient identifier is used throughout the PRMC system, from surgical schedules to care plans and discharge instructions. It was also used for such things as mammography follow-up visits, cancer treatments and physical and occupational therapy appointments that are scheduled as a series. This challenge was exacerbated by the conversion's projected effect on more than 25 downstream information systems, including registration, clinical, ancillary, and financial systems.
Finally, the transition project required a funding commitment from the highest levels to ensure that the projected $250,000 cost would be covered.
A STRATEGIC SOLUTION
The first step in the transition process was to establish a multidisciplinary steering committee capable of taking a holistic view of the project to ensure equal representation of all interests. One of the committee's primary responsibilities was to conduct a comprehensive analysis of the impact that an MRN conversion would have on 25 downstream systems to determine the potential risks and vulnerabilities as they related to patient safety and business operations.
The committee was also charged with implementing and maintaining an effective ongoing program of risk assessment to downstream systems regarding the timing of the update. It was responsible for determining system integration capabilities and limitations as well as validation and quality review.
Recognizing that it did not possess the internal resources or expertise to accomplish the full scope of the project with limited disruptions, PRMC brought in Just Associates Inc., a consulting firm that specializes in patient data integrity solutions. The Centennial, Colo.-based firm was selected because of its expertise in patient identification management, data integrity, and the electronic linking of patient records to design and manage the conversion and to avoid complications. A key determinant in the firm's selection was its depth of knowledge on the intricacies of data integration between legacy and downstream systems.
To minimize the potential for workflow disruptions, a critical first step was to develop a comprehensive understanding of the multiple ways in which the patient identification number was being used across the PRMC system. Just Associates began by conducting a comprehensive evaluation and assessment of the interface engine that supported the patient identifier, including examining every point-to-point interface that sent or received the SSN identifier.
Just Associates also looked at how the SSN was entered into the registration and scheduling systems and sent to all downstream, clinical, ancillary, and financial systems and whether downstream systems utilized the patient identifier within their databases as a primary record key. The final piece to this process was determining how the systems read inbound message transactions and utilized the SSN to determine whether the transaction should add a new record or update an existing one.
Throughout this process, extensive interviews were conducted with the integration team and members of each department that utilized systems impacted by the patient identifier. By understanding exactly how the identifier was used, Just Associates was able to develop a workflow process that traced the movement of the patient identification number from entry point (registration) through exit point (discharge) and every possible formation in which that number would reside (paper files, electronic spreadsheets, etc.).
The impacted systems were then ranked according to specific risk levels. This led to the development of a strategy for conversion with specific recommendations for approaching conversion within each system.
IMPLEMENTATION AND BENEFITS
The detailed mapping and strategy process made it possible to effectively design and run software scripts to automate conversion to the MRN system. Just Associates developed scenarios for error trapping and for identifying potential failure points to ensure a smooth process and minimal disruption. The firm also established estimated timeframes for executing the conversion process, established audit logs to track progress in downstream systems and set quality assurance and error thresholds.
That, coupled with a carefully planned strategic approach, has kept the project moving forward. In August 2010, PRMC went live with the use of MRNs in all 25-plus applications. There were minimal disruptions to clinical systems and departments-even in the midst of a deployment of a new clinical information system.
EXTENSIVE INTERVIEWS WERE CONDUCTED WITH THE INTEGRATION TEAM AND MEMBERS OF EACH DEPARTMENT THAT UTILIZED SYSTEMS IMPACTED BY THE PATIENT IDENTIFIER.
This unique approach resulted in significant savings of both costs and resources. In addition to reducing the IT staff's workload, it also reduced workloads in the impacted clinical and ancillary departments. The need to bring in additional temporary staff was minimized.
Equally important, developing and running test scripts to confirm conversion accuracy helped ensure system-wide confidence in the project. PRMC and its patients also benefit from heightened security, as well as improved compliance with HIPAA, Maryland's Personal Information Protection Act (PIPA), and federal Red Flag Rules.
Overall, the migration to a new medical record numbering system was conducted in an efficient and cost-effective manner, and the conversion process helped PRMC gained a better understanding of how data and information flow through the entire organization. This is proving to be invaluable as the facility continues its migration to a new information system.
Gwyndle Kravec, MBA, RHIA, CCS, is the health information management privacy officer for Peninsula Regional Medical Center ( www.peninsula.org). She has been in the health information management field for 23 years. She can be reached at [email protected]. Healthcare Informatics 2011 August;28(8):49-51