A National HIE Leader on Patient Matching, TEFCA and the Future of Health Information Exchanges

Sept. 6, 2018
San Diego Health Connect’s CEO speaks to Healthcare Informatics about a variety of interoperability and health information exchange issues

It’s no secret that healthcare and health IT experts feel that the lack of a nationwide patient matching strategy remains one of the largest unresolved issues in the safe and secure electronic exchange of medical data.

What’s especially troubling is that electronic health records (EHRs) across hospitals and health systems nationwide are riddled with duplicate records. According to a recent Black Book survey, the average duplicate rate across healthcare organizations is 18 percent.

What’s more, for health information exchanges (HIEs) across the U.S. today, matching and linking patient identities pose an enormous challenge due to the diversity and independence of the institutions they serve. As such, HIE leaders, such as Dan Chavez, CEO of San Diego Health Connect (SDHC), the metro area’s regional HIE, are tasked with finding a solution to the patient matching problem.

To this end, in 2016, San Diego Health Connected announced it would be using a patient matching platform from Virginia-based health technology company Verato. The HIE agreed to implement the Verato solution after a pilot employing Verato technology successfully increased the number of matched records in SDHC’s MPI (master patient index) by 110 percent, cutting down the time this outcome would typically take from years to a few short weeks.

The SDHC MPI manages the identifying information for millions of people across the San Diego region, aiming to ensure that the records belong to the correct patients. According to officials, due to stringent matching criteria, SDHC’s MPI matching algorithm excluded 187,000 patients because of unresolved patient identification. Once these same records were run through Verato, 75 percent of those mismatches were resolved. Verato then outperformed expectations when it found an additional 126,000 patient matches that the MPI had originally missed.

SDHC’s Chavez recently spoke with Healthcare Informatics about this patient matching issue, as well as broader HIE topics such as sustainability and TEFCA—the government’s proposed Trusted Exchange Framework and Common Agreement, a plan to spur interoperability among providers. Below are excerpts of that interview.

Can you outline the problem of providers not being able to properly match patients, and why this is a specific and unique challenge for HIEs?

What happens at the point of care is when a care provider is trying to provide care and pull up a record, depending on the EHR, the application, or the workflow—which all may be separate, distinct, or the same—whenever that happens, what’s presented may cause an interesting caregiver-patient interaction.

So, are you the Dan Chavez on 123 Main Street? Or do you live on street X? Are you born in 1975 or 1957? In this day and age, we expect that you should know who I am, regardless of the system you’re looking at. I can do that on Facebook and on Uber, so why are we having that conversation [in healthcare]? How can the doctor, nurse, or caregiver not know who I am? That’s an interesting conversation which can get uncomfortable. The provider might say that the system doesn’t allow for that information, or he or she doesn’t have the proper information on the patient. It’s usually some silly excuse.

But the doctor knows that the patient has been to provider X or Y, so how can you not have that information? So therein lies part of this challenge—why aren’t you seeing this information? And that could lead to a credibility issue, too. Why am I here for treatment and what treatment am I here for?

Dan Chavez

How is San Diego Health Connect working to solve this problem?

We involve the community. For a solution to be accurate, successful and well-implemented, it requires people, process and technology. We have a very engaged medical records workgroup and they work to make sure that our [medical records] are as streamlined, easy to use and factual as possible, through the HIE.

There might be as many as five patients [with the same name] in your [system]. Our goal is ideally to get that down to one. In our world, the worst case would be three, though we do have the anomaly of a five- or seven-name pick list. We work very hard to get it to one. And if we don’t have the information, it could be that the patient didn’t consent. So our goal is to take the gray and obscurity out of this process. When we do get that pick list of three, many times two of those three are the same person and we just have to combine those records. But we are diligent in removing duplications and feeding that back to the committee, along with problem information, names and organizations, and getting that pick list as short as possible.

What results can you speak to from using Verato?

We have an exception queue and it’s oscillating. Every time we add a new major [organization] with more than 10,000 patients to the HIE, it impacts the queue. We just added a health plan and that has added 4 million lives to the master patient index record locator service. So that will be a big bump to the queue and we have to socialize that participant into the MPI record locator service. Much of that is done automatically. That’s the beauty and also the challenge of an HIE—it’s a change management exercise and it never goes away. So even though you are achieving good results, once you add someone new, you blow up.

Going forward, it’s mostly about onboarding new participants to the process. Health plans now have patient volumes in six and seven figure numbers joining the HIE, so there are lessons learned based on the last health plan we added. We keep getting better every time we onboard. Every time we add a new player, there will be duplications, things will get gray and then adjustments will have to be made. But overall, we have about 98 or 99 percent [patient matching rate].

How you feel about TEFCA and its impact on HIEs such as your own?

TEFCA makes a lot of sense and we appreciate the intent; we support it. We hope it’s not too disruptive and takes advantage of the infrastructure, process, and lessons learned from what we have invested so far. How much will TEFCA formally incorporate—and we are all different—what we have done in San Diego, in the ultimate final ruling that is published? Our input is that you need a better scenario assessment of what’s out there, evaluate it, look at best practices, and incorporate as much of those good investments that have occurred as possible.

Are you concerned about the future viability of HIEs?

I can’t speak for the rest of the country; only California at best, and within there, San Diego. Dr. John Halamka [CIO, Boston-based Beth Israel Deaconess Medical Center] was out here recently speaking, and I was asking questions to him about HIEs, to which he said they are valuable, but immature. I thought that was very telling.

There was recently an article published by the CIO of Cedars-Sinai Medical Center in Los Angeles, Darren Dworkin, and the focus of the conversation was the return on investment for your EHR. He said that there are two things that maximize the ROI of an EHR, which takes 10 years to [achieve]. The two things that maximize that value are: interoperability, which is what HIEs are all about; and the second is data analytics and decision support. But you cannot get that data unless you have the interoperability.

So in my mind, and yes, it’s my job, but I fully believe that HIEs have tremendous value. It’s that commitment to the HIE in the community and how committed that community is that determines the evolution, maturity and the corresponding ROI. And that includes public health and the EHR—not just hospitals, doctors, and payers. The more that the entire ecosystem is involved, the greater utilization, sustainability, and value [for the HIE].

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