Costs and Benefits of a Unique Patient Identifier for The U.S. Health Care System

In the healthcare industry, misidentification errors are not restricted to diagnostics and therapeutics but also may affect documentation. So, my earlier posts on semantics, ontologies, interoperability and the like notwithstanding, all is for naught when a given document doesn't provide information about a given patient. A chain is only as strong as its weakest link and patient identification is usually the first link in the healthcare chain.

Complicating the issue, not everybody can participate to the same degree or in the same way in the process of identifying a patient uniquely. Neonatal and senile patients are two groups where health providers and technology are on their own, when it comes to identifying the patient. Naturally, readers of this post fall into neither of these groups.

See, for example, Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk at

http://pediatrics.aappublications.org/cgi/reprint/117/1/e43.pdf

which provides a rather thorough study of errors in the first of these three groups.

The information that is used routinely for patient identification is frequently similar but often not recognizably unique.

In my November 20, 2009 post, Biometric and Other Identification Technologies, I discuss some leading technologies.

Although widely touted as “great” in security circles, all biometric devices (i.e., fingerprint, palm outline, iris, retina, et al) used for unique identification produce false positives and false negatives.



For example, an episode of Fox's "24" last season showed a White House visitor placing her thumb on a fingerprint scanner, a type of screening that is not typically used at the White House.

Fingerprint: false positives or negatives with scars, calluses, cracks in the skin, dirt, household cleaners and other variables.



Retina scan: susceptible to diseases such as glaucoma.



At the same time, non-biometric technologies have their own sources of error.



For a widely discussed examination of the costs and benefits of a unique patient identifier for the U.S. health care system, see

http://www.rand.org/pubs/monographs/2008/RAND_MG753.pdf

This recent study says using unique patient identification numbers for U.S. citizens would reduce medical errors, make electronic health records simpler and protect privacy.

The study says that despite a potential cost of $11 billion to create unique patient ID numbers, the effort "would likely return even more in benefits to the nation's health care system."

Most health care systems use statistical matching to find EHRs, according to the study by RAND Health, a research division of the RAND Corp. Statistical matching looks for demographic information, including names, birth dates and all or part of Social Security numbers.

See my November 17, 2009 post, Unique Patient Identification Numbers, Electronic Heath Records (EHR), Electronic Medical Records (EMR), and Social Security Numbers (SSN).

RAND researchers, who reviewed past studies, said that method causes errors or incomplete results about 8% of the time and leaves patients more exposed to privacy breaches.

"Assuming every health care system would have these [ID] numbers, then you'd be more likely to pick up all of the person's information," said Richard Hillestad, PhD, the study's lead author. "It would certainly make a lot of things easier."Using demographic information to locate EHRs causes errors or incomplete results about 8% of the time.

But critics expressed concerns.

"It's an absolutely terrible idea," said Deborah Peel, MD, a psychiatrist and chair of the Patient Privacy Rights Foundation, a watchdog group based in Austin, Texas. "Any database that has these numbers is bound to be a treasure trove for identity thieves."

The study was funded by a group of health information technology and IT companies, but Hillestad said that didn't influence the outcome. Dr. Peel is skeptical. "The combination [of data] is really deadly," she said. "That's why I say this is a data miner's dream."

The American Medical Association advocates prohibiting the sale and exchange of personally identifiable health information for commercial purposes without a patient's consent. The AMA also advocated in 1999 in favor of legislative action to repeal the portion of the Health Insurance Portability and Accountability Act of 1996 that mandated use of a unique patient identifier.

Hillestad said privacy is a big issue, but touted the ID numbers as a security boost.

"You're not sending all of the name and demographic information through the line to get connected," he said. "[Privacy] would depend on how much you protect the numbers."

Biometric and Other Identification Technologies

In my November 17 post, I began a discussion of the [proposed] unique patient identification numbers by looking at a de facto proxy, the Social Security number (SSN). In the present post, I will continue with a look at a few of the technologies available for getting information such as someone's identification into or out of a computerized system such as, but not limited to, those used to implement electronic health records (EHR).

Biometric Applications

Biometric verification is a technology which uses unique characteristic features of an individual to automatically identify a person. There are several biometric technologies including fingerprint, hand geometry, and retinal scan. Each of these verification techniques claims to provide positive identification of individuals. What's more, these forms of ID cannot be transferred, forgotten or lost. Anywhere personal identification is required (such as PIN numbers at financial institutions), biometric verification can be used.

The hardware needed for biometric verification is frequently installed at the entrance of a building or secured area and are the "keys" for entry. Fingerprint verifiers, for example, generally allow any finger on either hand to be used for positive identification. Usually an alternate finger is also chosen as a backup in case of injury (cut, scrape, etc.) to the first. Multiple fingerprint templates can be stored locally inside the fingerprint terminal or through a network on a host computer (e.g., in a database). Most vendors also include software that supports common security access features such as unauthorized overtime or early clocking in. In addition, many of these systems can be integrated with existing software packages. Therefore, usually, separate systems do not have to be maintained in order to record and restrict access.

Biometric applications are highly specialized and costly to install when compared to card recognition and other access systems. In addition, if a biometric unit such as a terminal goes down, the manufacturer is often the only source for replacement or repair. With other technologies, such as magnetic stripe, input devices are readily available and can be purchased from a variety of vendors. Biometric Identification, however, does have its benefit. When ultimate security is vital, biometric identification is sometimes proven to be the best solution. But, caveat emptor: as shown later in this post, errors do occur.

Voice Recognition

Although technically, voice recognition is part of biometric verification, its widest application is to convert speech into text and not principally for security or access control. Voice recognition has many advantages, most notably allowing people to keep their eyes and hands free while "voicing instructions" to the computer. Voice recognition is used in many professional fields including healthcare.

For a discussion of using the human voice for verification, see my article "Speech Authentication Strategies, Risk Mitigation, and Business Metrics" in the bibliography at the bottom of this blog.

http://www.developer.com/security/article.php/3684921/Speech-Authentication-Strategies-Risk-Mitigation-and-Business-Metrics.htm

For readers with a background in mathematics and statistics, see the papers

"Comparing Human and Automatic Face Recognition Performance" at

http://myslu.stlawu.edu/~msch/biometrics/papers/adler-schuckers-Human-Automatic-FR.pdf

and

"Statistical Evaluation and Estimation of Biometric-based Classification" at

http://myslu.stlawu.edu/~msch/biometrics/papers/SchuckersTIFSCorrelationStructurev3.pdf

Among the topics discussed here are

(1) false accept rate
(2) false reject rate
(3) false match rate
(4) false non-match rate
(5) biometric authentication,
(6) effective sample size
(7) confidence intervals

Note 1: A video in the right-hand column of this blog presents a brief introduction to confidence intervals.

Note 2: If 99.9% were good enough

• There would be a major plane crash every 3 days
• 12 babies would be given to the wrong parents each day
• There would be 37,000 ATM errors every hour

Nonetheless, technology-based systems in use today do yield the expected outcome less than 100% of the time.

So, it's important that you understand that, like their human counterparts, technologically-based methods are error prone. At the same time, it's also important that you know the cost of these errors to you (and those you serve) in the methodology you choose to use.

Optical laser Cards

These cutting-edge cards transform CD-ROM technology into a credit card form, capable of securely storing megabytes of personal information. For example, a patient ID card could hold an image, health care history, vaccination record, X-rays and more.

Card Based Access System

Controlling entry security to your facility (or computer system) is of vital importance, whether your facility is a high security area such as a hospital, airport, or bank, or even if it is an everyday situation such as an insurance office, school, or department store.

Visual Identification

The simplest access control systems use portrait ID or membership cards, which rely on a receptionist or colleagues at work to recognize interlopers by the absence of a valid, matching portrait card. Such systems require the printing of clear, easily visible, portrait cards. Unfortunately however, that alone is not enough, because with current PC and scanner technology, creating fake or counterfeit cards is all too easy.

Even simple door entry control systems need to use an anti-counterfeiting system which provides an overall security "watermark" feature which is proof against all attempts to copy it.
This type of access control is extremely cost-effective, and it may be all that many facilities need to achieve the security level they require.

Swipe Card Door Access Control Systems

If you need controlled access without relying on the presence of guards or reception staff, you may need to add swipe card readers and electronic locks to your controlled entrances. A higher level of security can be achieved by using mag-stripe readers.

Proximity Cards / Prox Card Access Control Systems

Proximity Cards, or "Prox" as they are often called, are standard size plastic ID cards which contain a coil antenna and a pre-programmed micro chip containing a unique code. When the prox card is within a foot or so of the Prox reader, the radio signal from the reader is picked up by the card antenna and used to power-up the micro chip which then replies with its own unique code.

The reader and its associated processor compare the code with a list of authorized entrants, and if it's OK, the door is opened and a record of entry is logged.

Prox cards must always be "personalized" with a portrait ID to eliminate the misuse of "loaned" or stolen cards.

Reference Books

For a good summary of the sources of problems (errors) and biometric performance, see



This book includes very readable material on

(1) Legal aspects of biometric technologies
(2) Selected technology error rates
(3) Resistance of the system to forgeries
(4) RFID applications
(5) Economics

and much else.

For a comprehensive introduction to RFID, see



Click here for a preview look at this book.

RFID and Bar Codes

For a discussion of the pros and cons of using RFID and bar codes for the identification of patients, staff and medications, in different use cases, see

http://geekdoctor.blogspot.com/2007/11/bar-codes-rfid-and-patient-safety.html

You will find there a summary of early work at Beth Israel Deaconess Medical Center in Boston to establish positive patient identification:

"For identification of most patients, we believe linear and two dimensional bar codes on wrist bands is robust, cost effective and standardized. For staff badges, linear bar codes work well. For NICU babies passive RFID enables scanning of swaddled infants without disturbing them.

For identification of medications, we believe linear bar codes of NDC numbers on heat sealable plastic bags provides a practical means to positively identification medications.

For identification of equipment, specifically for tracking location in real time, active RFID works well. Because of the size and expense of tags, we do not believe active RFID should be used for patient identification at this time.

Thus, a combination of bar codes, passive RFID and active RFID is working well in our various pilots. No one technology meets the needs of all use cases. Although we favor bar codes over passive RFID in the short term, we do expect to eventually replace bar codes with RFID once the technology is more robust, standardized and cost effective."