EDUCATIONAL REPORT SPONSORED BY Imprivata
The Value of Precise Patient
Identification
EDUCATIONAL REPORT SPONSORED BY Imprivata
Many hospitals and health systems rely on manual processes
may be several records with similar names, and the registrar
to identify patients at registration, as well as modalities like
does not want to pick the wrong patient because the fallout
armbands and barcodes to identify patients during the care
from inadvertently merging two patient records can be sig-
experience. They also follow protocols, such as using at least
nificant. To avoid this, he or she will sometimes opt to create
two patient identifiers when giving medication, drawing
a new, duplicate record instead.”
blood, or performing other care interventions. However,
these strategies are not always foolproof. Despite the best
The Risks of Poor Patient Identification
intentions, organizations can struggle to consistently and
Inadequate patient identification—and the resulting overlays
reliably collect precise patient information and match indi-
and duplicates—can compromise patient care and have a
viduals to their medical records. The consequences of patient
negative downstream effect on the revenue cycle. The follow-
misidentification and mismatching can be severe, ranging
ing are several risks that emerge when patient identification
from medical errors to adverse effects on the bottom line.
and matching fall short.
In this context, this HFMA Education Report, sponsored by
Patient safety lapses. Proper selection of the medical record
Imprivata, discusses specific risks of misidentifying patients
at the time of registration is essential for organizations to
and examines various improvement strategies.
realize the clinical benefits of their electronic health records
Understanding the Metrics
When trying to gauge the scope of patient identification and
matching errors, healthcare leaders look at two key metrics:
overlays and duplicate medical records.
(EHRs), says Scott Phillips, senior director of patient access
services for Texas Health Resources—a 24-hospital system
based in Arlington, Texas, that has more than 1 million patient
registrations per year. “The EHR has become such a part of
treatment now,” he says. “If the physician does not have all of
a patient’s history because we give the patient a new medical
Overlays occur when staff choose the wrong patient from
record—or worse, we overlay that patient into another
the master patient index (MPI), causing an intermingling of
patient’s record—there is a deficit of information, which
two patients’ medical histories. Duplicate medical records
impedes the physician’s ability to make proper decisions.” This
are when organizations have more than one medical history
can result in duplicate therapies, wrong-site or wrong-person
for the same patient.
surgery, potential allergic reactions, medication dosing errors,
Duplicate medical records are much more common than
and other patient safety issues.
overlays. The average duplicate medical record rate is
Liability. Incorrectly identifying a patient can expose an
8 percent and is often higher in larger health systems,
organization to considerable liability, says David L. Feldman,
according to a 2008 study by RAND Corp.
MD, MBA, CPE, FACS, senior vice president and chief medical
For a number of organizations, the emergency department
officer for Hospitals Insurance Company (HIC) in White Plains,
(ED) is a major source of duplicates because patients may not
be able to identify themselves, and physicians want to treat
the patients as soon as possible. “There is a lot of pressure on
N.Y. “Doing the wrong procedure on the wrong patient—
there is no way to defend that,” Feldman says. “It just
shouldn’t happen.”
the registrar in the ED to identify the patient quickly,” says Jim
Denials and take-backs. Duplicate records and overlays are
Schwamb, former vice president of patient financial services
not only safety and risk-management concerns, but they
for BayCare Health System in Clearwater, Fla. “However, there
also can lead to downstream problems in the revenue cycle,
2 April 2016 © 2016 Healthcare Financial Management Association hfma.org
including denials and insurance take-backs. “Payers will not
the continuum, says Stephanie Benintendi, corporate director,
reimburse for errors, so you have to think of accurate patient
patient access. Before they can leverage their EHR investment,
identification as the beginning of the revenue cycle,” says
however, they need to clean up their patient index. “Right
Schwamb, formerly of BayCare. “For example, a physician may
now, we have teams of people working to consolidate and
order a second imaging test if the original test is documented
merge accounts together,” Benintendi says. “Currently, the
in a different record. Payers will not cover the cost of the
duplicate rate at Centura is between 6 and 7 percent, which
second test, so the hospital has to write off the charges. In
we hope to bring down to 3 percent by May, when the first
some cases, insurance companies may even seek to recoup
phase of our EHR conversion is complete.”
payment for duplicate services that were already paid.”
Poor preparation for population health management.
Reduced productivity. “When you create a duplicate, it
“Your duplicate medical record rate, and, in some cases, your
affects so many layers,” says Patricia Consolver, CHAM, senior
overlays, could really affect your performance in value-based
director for patient access services at Texas Health Resources.
care,” Benintendi says. “When you accept a risk-based contract
“You’re creating more work for the insurance verification
with a payer, it basically means that you are responsible for
staff to pre-register the patient, who may have already been
the patient’s care for pre- and post-treatment. If you have not
registered. The clinical staff also has to document on two
identified the patient properly, then you could be duplicating
records because you have created two accounts.”
services, such as radiology studies and lab work for tests that
Overlays can be even more difficult to fix, each taking a
providers couldn’t find in the original medical record. That is
substantial amount of staff time to correct. “It can be very
inefficient and drives up costs.”
time-consuming to go back to payers and everyone who has
Not identifying patients correctly also makes it difficult for
treated the patient, including hospital-based physicians who
organizations to track their costs and determine the total cost
do their own billing—such as radiologists, pathologists, and
of care in risk-based arrangements, Benintendi adds. “If you
cardiologists—and tell them there is a major error in the
have several medical record numbers for a patient, you won’t
record,” Schwamb says. “Secondary information systems that
be able to run accurate reports,” she says. “This is an issue for
have their own patient indexing system, like those in radiol-
all organizations trying to gauge their performance in an era
ogy, also need to be fixed.”
of shrinking margins. Regardless of where you are on the
Costly cleanups. Duplicate medical records can reduce the
value-based continuum, if you are doing unnecessary tests
efficiency and accuracy of an organization’s MPI, requiring a
on patients, you are increasing costs and changing your
cleanup effort. However, scrubbing for duplicates and over-
efficiency ratio. Instead, you could be filling your schedule
lays can be a costly process, whether it is handled in-house
with new patients, which could have a positive effect on
or by an outside consultant. Organizations may spend six
your market share.”
to seven figures to clean up their MPI.
Insurance card and medical identity fraud. It is crucial to
Having a clean MPI is especially important for integrated
have strong patient identification processes at registration,
health systems that are moving to the same EHR. Leaders
otherwise you can make it easier for patients to provide false
at Denver-based Centura are bringing their 16 hospitals and
names and wrong addresses so they avoid getting their bills.
100-plus physician practices onto the same EHR platform, a
At the same time, a lax patient identification policy may make
process they expect to complete in 2017. One goal of moving
it easier for a criminal to steal another patient’s medical iden-
to a shared EHR is to improve the coordination of care across
tity and receive services while the bill goes to someone else.
H F MA E D U C AT I O N A L R E P O R T 3
EDUCATIONAL REPORT SPONSORED BY Imprivata
Privacy concerns. Incorrect identification also leads to lapses
faster insurance verification. “The revenue cycle staff will have
in patient privacy, which can have substantial consequences.
access to demographics, insurance coverage, and actual
For example, communicating protected patient information
procedure code information sooner so they can get a jump
to the incorrect person or sending the wrong bill to the wrong
on verifying benefits and authorizing services,” Benintendi
patient can result in costly fines, which can be easily avoided.
says. “They also will be able to let patients know their out-of-
Strategies for More Accurate
Patient Identification
pocket responsibility. We are expecting 80 to 90 percent of
patients to have this pre-clearance process completed seven
to 10 days before their date of service.”
Given the abovementioned risks, having a reliable patient
Developing standards with physician offices. As more organiza-
identification process is a shared goal that physicians, finance
tions step up their ambulatory care initiatives, they may
leaders, and patients can and should get behind. To that end,
struggle to standardize patient identification processes across
the following improvement strategies can help organizations
settings. Texas Health Resources’s Consolver says ensuring
enhance patient identification and reduce the risks of
consistent patient identification in the organization’s more
misidentification.
than 250 physician offices has been challenging. “Now that
Standardize processes. Like many other aspects of health
we have physician practices under our umbrella, we are
care, patient identification can benefit from standardization.
seeing their quality assurance measures may not be the
Organizations frequently use a combination of centralized
same as ours,” Consolver says. “For example, registrars in
and decentralized scheduling, as well as different patient
the hospitals may record patients’ legal first names, but
identification workflows across their departments—leading
the physician offices may request patients’ nicknames. This
to a less-than-consistent process. However, some organiza-
ambulatory patient data feeds directly into Texas Health
tions, including Centura, are looking to make a change. When
Resources’s main MPI, creating unnecessary duplicates.”
the health system’s new EHR is implemented, patient identification processes will become more standardized, Benintendi
says. “We will combine the scheduling, registration, and
patient identification processes, so when staff in our centralized and decentralized areas generate an appointment, they
will select the patient’s medical record number,” she says.
“It will be seamless. They will search for the patient, select the
patient, create the appointment, and complete the registration as one workflow.” To further reduce the risk of inaccurate
patient identification, Centura plans to add the patient’s
photograph to the medical record. “A photograph will pop up
in the workflow to help prevent the wrong order from being
written for that patient,” Benintendi says.
To address this issue, leaders at Texas Health Resources
convened a patient identification standards development
committee that includes representatives from IT, health
information management (HIM), patient access, data integrity,
the central business office, and the physician groups. “Until
the practices fully convert to our EHR, they may have system
issues that can compromise patient identification,” Phillips
says. “For example, in our EHR, we have different fields to
list the patient’s legal name and the name on their insurance
card. In the practices’ systems, they may only have one name
field. They will tend to use the name on the patient’s insurance
card so they don’t get a denial. To fix this, we have developed
an initial standard to identify patients, but we still need to
Centura’s new EHR will not only eliminate steps that can
address issues that come up without causing too much grief
introduce patient identification errors, but it also will enable
and suffering.”
4 April 2016 © 2016 Healthcare Financial Management Association hfma.org
Track trends regularly. Keeping a close watch on the reli-
“Reporting lets you identify trends early on,” Phillips says. “For
ability and accuracy of patient identification is essential. Five
example, the last thing you should be doing is putting new
years ago, leaders at Texas Health Resources developed their
registrars on the triage desk in the ED. They need time to learn
own scorecard that includes 76 key performance indicators
the process and the tools. Yet, one of our hospitals was consis-
(KPIs), which cover a variety of areas including patient access,
tently putting newly trained admissions staff at the triage
patient satisfaction, collections, duplicates, overlays, and
desk in the emergency room. We could tell from the report
registration quality. Each month, members of the organiza-
that when the new people were working, we would have five
tion’s revenue cycle committee, which includes leaders from
or six duplicates. This could have gone on for years if we had
HIM, patient access, revenue cycle, as well as the CFO, review
not talked with the patient access leaders at the hospital.”
the scorecard. The report is color-coded green, yellow, and
red—the latter suggesting poor performance. “It has been
a huge driver for our patient access leaders to not have a lot
of red on their scorecard,” Phillips says.
Engaging the CFO. Because HIM and patient access both
report to finance in most organizations, CFOs can emphasize
the value of precise patient identification across the enterprise, Phillips says. “The CFO can get everyone on board and
The most important KPIs for patient identification are the
ensure they realize this is a priority,” he says. For example,
organization’s duplicate medical record rate and volume of
when Texas Health Resources hired an outside consultant to
overlays, says Texas Health Resources’s Consolver. Both metrics
lead a major cleanup of duplicates in the organization’s MPI
help leaders identify opportunities to improve. “Ideally, we do
in 2009, finance leaders made it clear that they did not want
not want overlays at all, but when they occur, we can address
to repeat the investment in the future. “Everyone in the
them in patient safety rounds and learn from it,” she says.
organization understood that this was the one time we were
Collaborating with data integrity. Working with the data
investing in outside resources to improve the record’s integ-
integrity team in HIM has helped patient access leaders at
rity,” Phillips says. “Going forward, it was going to be up to us
Texas Health Resources cut their duplicate record rate by
to keep the MPI clean.”
21 percent over six years. Today, only 0.3 percent of records
Leverage software tools. Oftentimes, technology can
are duplicates. The data integrity team is responsible for
enhance the reliability of patient identification. For instance,
merging duplicate records and cleaning up the database.
after the MPI cleanup was completed, leaders at Texas Health
Patient access keeps an open line of communication with
the data integrity group. For example, patient access will call
them when a registrar in the ED likely creates a duplicate
because of incomplete information or if there’s a need to treat
the patient quickly. “Previously, patient access might make a
duplicate, and HIM would not know about it until they were
working the problem,” Consolver says. “Now we pick up the
phone, and they know about it almost immediately.”
Resources invested in a third-party tool to boost the accuracy
of patient identification at the time of registration. The tool
uses an algorithm that searches the database for key data
elements, such as name, sex, date of birth, and Social Security
number. The tool then provides the registrar with potential
patient matches. Medical records with the best match are
labeled green. Less likely matches are labeled yellow, and
unlikely matches are coded with red. Although Phillips credits
In addition, the data integrity team generates a monthly
the tool for helping reduce the duplicate record rate, he
report that identifies where duplicate records occur.
concedes it is not perfect. For this reason, they have been
H F MA E D U C AT I O N A L R E P O R T 5
EDUCATIONAL REPORT SPONSORED BY Imprivata
making adjustments to the tool over the past five years.
desk or a kiosk and verifies his or her date of birth. “By
“The last thing you want when you are searching for the
adding the date of birth, the chances of misidentifying a
patient is to get three green options,” he says. “You have to
patient become one in several million,” Feldman says.
refine the tool so that when you are using it, it is very clear
“Biometric systems significantly reduce the likelihood that
what the right answer is.”
the wrong patient receives radiation and prevent duplicate
Consider a biometric solution. To elevate the reliability
of their patient identification processes, some organizations
have implemented biometric systems that scan the patient’s
medical records. In the future, biometrics also could be used
to identify patients immediately before surgery or when
giving medication.”
palm at the time of registration and before care delivery. For
In 2008, BayCare installed biometric palm scanners at every
instance, 12 New York hospitals served by Hospitals Insurance
registration point throughout the enterprise. “Patients were
Company implemented a biometric solution that integrates
concerned about using their Social Security numbers when
with their EHR. The hospitals first focused on using the tech-
they registered,” Schwamb says. “Using a biometric system
nology to correctly identify radiation oncology patients.
allowed us to remove Social Security numbers from our
“We asked a group of radiation oncologists what kept them
screens to reduce fraud and identify theft. More important
up at night, and they said it was radiating the wrong patient,”
to our patients, using a biometric system helped improve
HIC’s Feldman says. “It’s rare, but if it does happen, it is a
patient safety.” Texas Health Resources also uses palm vein
disaster for patients.”
technology for patient identification.
The hospitals ruled out other identification systems, prefer-
Address human factors. Although technology can create
ring the advantages of a biometric solution. “Using barcoding
better systems to prevent humans from making mistakes,
or photographs to identify radiation patients, for instance, is
it is only part of the solution, HIC’s Feldman says. Improving
not ideal,” Feldman says. “Because radiation is an outpatient
how staff work together is also critical.
procedure, we didn’t think armbands were the best choice
The 12 hospitals HIC serves follow the TeamSTEPPS (Strategies
because patients needed to keep coming back for treatment
and Tools to Enhance Performance and Patient Safety) crew
and would not likely leave their armband on. In addition,
resource management model that the Department of Defense
photographs aren’t always reliable, especially for patients
and the Agency for Healthcare Research and Quality devel-
who may be having radiation to their head or neck, which
oped. “The original idea was to break down hierarchies in airline
could change their appearance. Using biometrics also makes
cockpits that could compromise safety, which are similar to the
errors less probable if someone has the wrong armband, or
hierarchies we have in health care,” Feldman says. Using models
cannot speak, or has a cognitive disability.”
such as TeamSTEPPS, healthcare organizations can learn to
To use the system, the patient puts his or her right palm on
the reader so it can be scanned into the system. The technol-
improve how different disciplines work together to reduce errors,
including misidentifying patients, and elevate safety and quality.
ogy uses subcutaneous vein patterns in the palm to create
Investing in your patient access team. “Patient access gets the
an encrypted digital file that is linked to the patient’s medical
brunt of the blame for patient identification problems, but it
record. The next time the patient comes in for treatment, he
all comes down to education, pay, and what resources you
or she places his or her palm on a reader at the registration
give the team to be successful,” Centura’s Benintendi says.
6 April 2016 © 2016 Healthcare Financial Management Association hfma.org
OUR SPONSOR SPEAKS
LEVERAGING TECHNOLOGY TO ENHANCE
PATIENT IDENTIFICATION
David Wiener, general manager for Imprivata’s PatientSecure Products Group, discusses how biometric solutions
elevate the accuracy and reliability of patient identification.
Q
Why is biometric patient identification
Plus, an organization can experience an unrealized
a key driver in improving safety and
return on its EHR investment.
revenue cycle efficiency?
Biometric patient identification is more accurate than
Health care can only be effective if the right care is pro-
in-person identification and stops the creation of duplicate
vided to the correct patient using the correct patient
and overlaid medical records at the source, improving
information. However, many healthcare organizations
overall patient safety and revenue cycle throughput.
today struggle with cumbersome, manual patient identification processes that are compromised by human error
and insurance fraud risk, affecting the accuracy of master
patient indexes. As a result, everyone suffers. Staff can
match patients with the wrong records or they may not be
able to find a patient record, requiring them to create a
Patients can be immediately and accurately identified
upon registration or even in emergency situations where
they are unconscious or disoriented. Biometric technologies can also provide additional benefits, such as
preventing the risks of identity theft and insurance fraud.
duplicate. These errors result in incomplete and inaccurate
According to our customers, palm vein biometrics are the
medical histories, which jeopardize patient safety, signifi-
most accepted by patients, with more than a 99 percent
cantly increasing the likelihood of adverse events. The
acceptance rate. Overall, we have seen our customers
downstream effects include insurance denials and take
leverage this non-intrusive and highly accurate technology
backs that impact hospital revenue cycle efficiency.
to transform patient identification.
Source: Imprivata
“Registrars are typically one of the lowest-paid administrative
Making staff accountable. Benintendi says organizations
functions in an organization, yet their role is the most impor-
need to establish clear policies so patient access teams know
tant for patient identification. Organizations need to address
the consequences of creating duplicates and overlays. This
the problem by providing adequate ongoing training and
could mean anything from additional training and education
resources, rather than pointing fingers.”
to losing access to creating or selecting patient records from
As Centura’s EHR conversion approaches, the patient access
team will receive a combination of online and classroom
training on the new EHR and relevant workflows. In addition,
registrars in decentralized areas that currently handle their
the MPI, if they have certain error rates that are determined
to be avoidable. The key is making sure you have a system
developed that supports the registrar and does not focus
on punitive outcomes for a bad process or design.
own scheduling, such as physical therapy, will undergo the
Encouraging self-reporting. Although accountability is impor-
same formal training that centralized registrars receive.
tant, organizations also should create a culture in which
H F MA E D U C AT I O N A L R E P O R T 7
EDUCATIONAL REPORT SPONSORED BY Imprivata
patient access staff feel comfortable reporting patient
identification errors. “There should be no fear in self-reporting
duplicates because it is essential to share that information
quickly,” says Texas Health Resources’s Consolver.
Simply having patient access directors who acknowledge
that duplicates happen, particularly in the ED, can help staff
overcome their fear of punitive action for reporting errors.
“There are times, such as in the ED, when staff create a
duplicate because they are trying to do the best thing for
the patient they have in front of them,” says Texas Health
Imprivata® (NYSE: IMPR), the healthcare IT security
company, provides healthcare organizations globally
with a security and identity platform that delivers
authentication management, fast access to patient
information, secure communications, and positive patient
identification. Imprivata enables care providers to securely
and efficiently access, communicate, and transact patient
health information to address critical compliance and
security challenges while improving productivity and the
patient experience.
Resources’s Phillips. “Staff do get corrective action if we
identify trends, but they should not be punished if it is
just the nature of the business.”
A United Front
It is vital for leaders not to become overwhelmed as they try
to clean up their databases and improve patient identification.
“People get scared by the numbers,” Centura’s Benintendi
says. “Even if your duplicate rate is only 3 percent, if you have a
patient population with 1 million unique identifiers, that is still
a lot of duplicates. From a tactical standpoint, don’t let the size
of the numbers overwhelm you to the point where you feel
like you cannot make a difference.”
Her advice is to foster collaboration among clinical, quality,
About HFMA Educational Reports
financial, patient access, and HIM teams. “Improving patient
HFMA is the nation’s leading membership organization
for more than 40,000 healthcare financial management
professionals employed by hospitals, integrated delivery
systems, and other organizations. HFMA’s purpose is to
define, realize, and advance the financial management
of health care. HFMA educational reports are funded
through sponsorships with leading solution providers.
For more information, call 1.800.252.HFMA, ext. 330.
identification should come across to the organization as a
unified team effort,” Benintendi says. “You want everyone to
realize that you can’t have a high duplicate medical record
rate, especially as organizations move toward value-based
care. Everything hinges on accurate patient identification.”
This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are
those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.
8 April 2016 © 2016 Healthcare Financial Management Association hfma.org