mpi data integrity: costs, causes, complications alan soskel, rhia mpi data integrity analyst dekalb...

MPI Data Integrity:Costs, Causes, Complications

Alan Soskel, RHIAMPI Data Integrity Analyst

Dekalb Regional Health System

Greater Atlanta HIMAAnnual Meeting, May 8, 2015


Agenda• MPI definitions• Implications of MPI data integrity• MRNs

• Types of errors• Statistics• Calculating error rates• Costs• Control of MPI / MRNs• Causes• Recommendations


MPI Data Integrity and Accuracy – why does it matter?• Profit

• Typical dup MRN costs $121 to correct• Even one lawsuit can be devastating

• Risk• Patient care and safety• Patient & family satisfaction• Every duplicate and compromised MRN is a risk

for loss to the organization

• Loss• PA, Scheduling, HIM, Billing confusion / time• Clinical confusion / time• Operational efficiency


Definition of MPI

• The Master Patient Index (MPI) identifies all patients treated within a single healthcare facility together with associated physician groups and services. • The Enterprise Master Patient Index (EMPI) identifies

all patients treated within an enterprise, or group of related healthcare facilities together with associated physician groups and services.• Each patient should have a unique Identifier.


Definition of MPI

• Used by scheduling & registration applications to ensure that patient is represented only once with the same set of demographic data

• Link that tracks patients within an organization and across patient care setting

• Facilitates the coordination of care and provides access to the patient’s history of previous encounters


Evolution of the MPI


Card file

Facility master patient index (MPI)

Enterprise master patient index (EMPI)

Electronic health records (EHR)

Health information exchange (HIE)

National Health Information Network (NHIN)

MPI – the bigger picture


MPI / EMPI

Regional / National

HIEs

Need for a regional/national unique patient identifier. Use of Record Locator Service. Percent of MPI inaccuracies within each entity

exponentially increases the number of errors in the HIE environment.

NHIN

Facility level

MRN usually serves as unique patient identifier

Impact of Poor MPI Data Integrity

Clinical implications: can’t find data, patient care & safety• Staff working with partial information on patients• Inability of clinicians to access vital patient records in the

event of an emergency• Risks of negative drug interactions because physicians do

not know a patient’s current condition or medications• Delays critical diagnosis• Exposes patients to unnecessary invasive procedures



Community and patient relations:

• Patient dissatisfaction caused by staff confusion, extra wait time, delayed scheduling and billing issues.

• Bad publicity caused by lawsuits, breaches, etc.

• Medical identity theft.



Community and patient relations:

Case study – Children’s Medical Center• Registration Delays• Longer wait in ED while staff searched for previous record• Blood sample taken again for repeat test• Initial antibiotics changed after organism ID’d on 2nd test• Paid for 2 prescriptions• Sick for additional 2 days—missed work, lost wages• Follow-up visit at doctor confused due to duplicate test results from ED• Time spent clarifying billing with insurance company



Physician relations:

• Lack of Confidence & Frustration

Case study – Children’s Medical Center

• 45% routinely found duplicate medical record numbers

• 30% re-ordered tests due to inability to find results in record

• 25% felt duplicate records impacted the quality of care they were able to deliver



Operational efficiency:

• Increased costs, wasted time, staff confusion

• Errors create enormous waste and additional expense

• Increased number of tests being re-run because the original results cannot be located



Confidentiality Breaches:• Wrong patient is billed• Wrong next of kin is notified in an emergency• Wrong protected health information is sent in

response to a request for disclosure.


Moving on to the MRN


Each account represents a single patient visit. There can

be many accounts for a patient under the umbrella of a single

MRN.

Ideally there should be only one MRN per patient serving as an over-arching patient

identifier.

Medical Record

Number (MRN)

Account Account Account Account

“Duplicate medical records occur when one patient is associated with more than one Medical Record Number, or MRN. The existence of duplicate records in a healthcare system is one of the most critical issues currently facing health information technology (HIT) departments. Duplicate medical records are often erroneously created as a result of inaccurate data entry. These duplicates, or dupes, can have negative impacts on registration and billing systems, but more importantly on patient safety. 5 Ctd…


…With the existence of multiple records for a single patient, it is likely that healthcare providers will miss critical information because it is located in the duplicate. In addition, the existence of a duplicate record can lead to unnecessary replication of lab orders and tests causing the cost of treatment for an individual patient to rise”5

5Duplicate Medical Records: A Survey of Twin Cities Healthcare Organizations, Molly A. McClellan, University of Minnesota, Minneapolis, MN


3 Types of MRN Data ErrorsDuplicate records: a patient has two or more assigned MRNs. I refer to the first MRN created as the “Original MRN” with all other MRNs called “Duplicate MRNs”

Overlap records: a patient has different MRNs in separate facilities that are linked in one EMPI

Overlay records aka compromised records: one MRN contains information on two or more patients


Duplicate MRNs and Overlap MRNs

Same patient

2 or more MRNs

Image from: AHIMA - MPI Clean Up: It’s a Must! Webinar July 21, 2009


MRN1 MRN2

Duplicate MRNs and Overlap MRNs


Accounts / VisitsMRNsPatient

Single patient

MRN 1Visit 1

Visit 2

MRN 2 Visit 1

Overlay MRNs aka Compromised MRNs

Records that seem to match :

same name, similar DOB

2 patients

1 MRN

Image from: AHIMA - MPI Clean Up: It’s a Must! Webinar July 21, 2009


Only 1 MRN

Overlay MRNs aka Compromised MRNs


Accounts / VisitsPatientsMRN

Single MRN

Patient 1Visit 1

Visit 3

Patient 2 Visit 2

Duplicate MRN Statistics

• Quiz: How many times will a patient come back to the facility before a dup MRN is discovered?

• Quiz: what is the average dup MRN rate?


Duplicate MRN Statistics

• Average hospital MPI contains 500,000+ patient records

• The average duplicate MRN rate is 8% - 12% 2

• Best practice duplicate MRN rate is suggested to be below 5% (depends on hospital facility)

• HFMA recommends duplicate MRN rate of 0.5%

• Duplicate MRN rate can increase to 25% or more where patient records from different EHRs are shared among caregivers, such as among HIEs and Accountable Care Organizations (ACOs). 3


Clinical Statistics6

• 30% - physicians could not find data previously recorded

• 11% - same drug or radiology exam ordered, half of which ended up being performed

• Physicians not aware of 1 in 4 prescriptions (25%)

• 1 in 7 admissions and 1 in 5 lab/radiology exams ordered due to retrieval barriers

• Data collection transfer costs range from $12-$28 per visit


Computing Duplicate MRN Rates

Total Duplicate MRN Rate for static database =

A 500,000 record MPI file contains 15,000 duplicate pairs involving 30,000 records. The duplicate rate is 3%.

= 3% dup MRN rate


Computing Duplicate MRN Rates

Creation Rate of Dup MRNs (daily, weekly, monthly, etc.)

Facility has 10,000 pre-regs and admissions per month.250 duplicate records were created. The creation rate is

2.5%. = 2.5% creation rate


Duplicates are Costly

Duplicates/Overlaps: $121 +• Time & materials wasted by creating dup MRNs• Time & materials wasted by researching, identifying &

correcting “on demand”• Delays in billing & accounts receivable• Duplicate tests and treatments• Missing clinical information• Bad debt


Cost of Duplicates, Correction CostsDepartment Time Cost*

* Labor costs based on average wage rate of $15/hour


Department Time Cost

HIM Dept. 30 - 240 min $8- $60

Patient Access/Scheduling 15 - 30 min $4- $8

Radiology 15 - 90 min $4 - $23

Laboratory 15 – 60 min $4 - $15

Business office 30 – 60 min $8 - $15

Total correction cost per dup MRN 105 – 480 min $28 - $121

Cost of Duplicates, Correction & Clinical Costs

Costs Captured• Readmissions with Bad

Debt• Clinical Issues• Treatment Delay• Operational Costs for

Rework


Average Cost of DuplicatesCorrection costs:• $96.25 per duplicate recordClinical and/or treatment issues:• 4% of duplicates• Average Cost per duplicate $1099Bad Debt:• 11% of duplicates• Average Cost per duplicate $867

Case study – Children’s Medical CenterStudy performed on confirmed duplicates1,000 Records included in Study

Duplicates are Costly

Case study - Dekalb Medical Center:Correction cost per week and year

• Creation rate = 26 Dup MRNs/week

• Correction cost = 26 x $121 = $3,146/week $163,592/year


Cost of Duplicates, Risk Costs

Estimated potential risk costsQuality & Continuity of Patient Care > $100

Duplication of Tests & Treatment > $100

Success of Strategic Initiatives Variable

Impact on Operations $10 - $1,000

Breach of Confidentiality Variable

Liability Risk Variable

Regulatory Noncompliance > $10,000

Customer Dissatisfaction Variable


HIM may manage the MPI and MRNs…But where does MPI Data Integrity start?




Sources of MPI Data Integrity Errors

• Patients – unresponsive, unwilling, no IDs

• Physicians and staff – calling / faxing orders

• EMS – John/Jane Does, combative patients

• Hospital staff – Scheduling and Patient Access



Patient Demographic fields in Allscripts used by DMC

Current fields used in DMC searches • First Name (FN)• Last name (LN)• DOB• Gender• SSN

Fields to be considered in DMC searches to decrease dup MRNs• Driver’s License number• Address• Mother’s maiden name• Partial SSN (last 4 digits)

Standard Search Workflow at DMCUsed by Patient Access and Scheduling departments


Causes of Duplicate MRNs• Lack of standardized data dictionaries with uniform conventions for

handling data elements such as middle initials, titles (e.g., Reverend, etc.), hyphenated names, and suffixes

• Discrepancies in name, gender, DOB• Misspellings, transpositions, typos, , variation in name order• Using nicknames instead of full names• Confusion caused due to marriages and divorces; inconsistent use of a mother's

maiden name as a middle name• Not capturing correct SSN or wrong SSN

• Typos• Guarantor SSNs• Insurance sponsor SSns


Causes of Duplicate MRNs

• Missing or garbage data from EMS, patients and physicians

• Undefined or inadequate processes for patient scheduling, registration, pre-reg, financial counseling

• Prior data conversions

• Poor system integration, design and data definitions


Causes of Duplicate MRNs

• Approximately 25% of ALL records have errors in at least one of four key data fields:• LN, FN, DOB or Gender

• >80% of duplicate MRNs have a discrepancy in one or more of six key data fields: • LN, FN, DOB, Gender, MN or SSN• Approximately 40% have a discrepancy in first or last name


Top Causes of Duplicate MRNsDekalb Medical - Results based on PA workflow

SSN same – did not find original MRN – 6.22%

Name, DOB and Gender same – did not find original MRN – 22.01%

SSN, Name, DOB and Gender same – did not find original MRN – 2.15%

Incorrect / missing data cause duplicate MRN – 69.62%


Top Causes of Duplicate MRNsDekalb Medical - In What MRN Did Major Error Occur and

What Search Protocol Failed



Top Causes of Duplicate MRNsDekalb Medical - In What MRN Did Major Error Occur and

What Search Protocol Failed

Same data as above slide in graphical form


Top Causes of Duplicate MRNsDekalb Medical - Detailed Causes of Duplicate MRNs

# color cause

1 dark blue

SSN missing in dup MRN; Used name from ID other than D/L

2 maroon SSN missing in dup MRN; First name spelling

3 green SSN typo

4 purple SSN missing in original MRN; Last name spelling

5 light blue

SSN missing in original MRN; Reversed first, last names

6 orange SSN missing in original MRN; DOB typo; New married/ divorced name not updated

Top Causes of Duplicate MRNsDekalb Medical - Top 11 SSN errors


1.Missing leading digit

2.10 or more digits entered

3.SSN Missing in original MRN

4.SSN Missing in dup MRN

5.SSN Missing from both MRNs

6.Used parent , spouse other SSN

7.Used sponsor SSN from Medicare or Champus card

8.SSN-A on Medicare card in Insurance tab does not match SSN in demos tab

9.Registration switched SSN to Guarantor SSN

10.Born at DMC and SSN not assigned yet

11. Baby without SSN presents for care

Top Causes of Duplicate MRNsDekalb Medical - Most Common Name errors

• Last name spelling• First name spelling• Middle name spelling• Middle initial vs full middle name• Used middle name as first name• Hyphen vs no hyphen in last name• Reversed first and last name• Reversed middle and last name• Suffix in last name field not suffix

field• Inconsistent maiden-married name

use

• Maiden and last name combined• New married / divorced name not

updated• Used name from ID other than D/L• Name changed • Difficult foreign name• Formal vs informal (nickname) first

name• Baby name not updated in original

MRN• Used Guarantor name


Top Causes of Duplicate MRNsDekalb Medical - Other errors

• John/Jane Doe into ER• Gender• Date of Birth:

• typos, patient gave wrong DOB, wrong on D/L

• EMS gave wrong / no info: • DOB, SSN, Name spelling

• Provider gave wrong / no info: • DOB, SSN, Name spelling, Wrong patient

• Patient gave wrong info: • DOB, SSN, Name spelling, refused to provide, unable to provide, said

never been here before


Recommendations

Practices that support accurate patient identification9:• Obtain copies of a government-issued picture identification (such as a

driver's license, passport, or official identity card) and insurance card each time a patient registers.

• Develop a customer-friendly script for requesting patient identification and verification information.

• Define a set of attributes that will be used consistently for patient identification.

• Build effective business processes and quality checks with clear standards, policies, and procedures into patient ID activities

• Improve the accuracy of patient matching by collecting additional data elements such as mother's maiden name


Recommendations

IT changes:• Work with vendor to properly define SSN field

• 9 digits• all zeros not allowed• Format field as 999-99-9999• Separate SSN field for “refused”, “unknown” etc.

• Give HIM ability to delete “bad names” from “Other Names” list – this list is searchable and contributes to duplicate / compromised MRNs


Recommendations

SSN errors:• Until IT can correctly define and format SSN field:

• 9 digits – watch for missing leading digit and entering 10+ digits• all zeros not allowed

• Educate staff re: • Medicare #’s / attached suffix• Tricare # = SSN• Guarantor relationship to patient• Using sponsor SSN• Provide HIC suffix handout from SSA (see notes below)


RecommendationsName errors:• Use military style of repeating back spelling of names – C as

in Charlie, E as in Echo, etc.• Create and follow naming and nomenclature policies:

• Full middle name vs Middle initial• Hyphenated last names or no hyphen• Consistent maiden-married name format• Use of formal name vs nickname• Suffix not to be entered in last name field• Consistent use of D/L as ID for name, address, DOB confirmation


Recommendations

Search Protocols: • Educate staff to be able to play “detective” • Teach expanded search practices• Reduce age range in searches• Expand search fields to include D/L #, last 4 digits of

SSN, address 1, mother’s maiden name• Scan all possible IDs at time of registration


Recommendations

Physician Offices:• Get copies of both D/L and Insurance cards• Educate office staffs about our naming and

nomenclature policies• Do not schedule procedures without all needed data• Provide fillable electronic order forms


Recommendations

Performance Standards and Credentials:• Add quality factor to performance standards• # registration / scheduling events - # dup MRNs created

• Hire more PA staff with CPAR credential• Managers to review causes of dup MRN with staff


References1. AHIMA: MPI Clean Up: It’s a Must! Webinar, July 21, 2009

2. Hillestad, R., Bigelow, J.H., Chaudhry, B., et al., Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the U.S. Health Care System, RAND Corporation, 2008.

3. Brochure: ARGO Duplicate Profile Analysis Service www.argodata.com

4. MPI Clean Up: It’s a Must! Webinar July 21, 2009

5. Duplicate Medical Records: A Survey of Twin Cities Healthcare Organizations, Molly A. McClellan, University of Minnesota, Minneapolis, MN

6. Electronic Medical Records – Getting it Right and Going to Scale. Commonwealth Fund background paper , Jan. 2004

7. “Managing the Integrity of Patient Identity in Health Information Exchange”, AHIMA Practice Brief, July 2009.

8. Technology Influence on Data Integrity & Impact on Patient Safety, Privacy & Security. AHIMA Convention Proceedings, September 2008.

9. AHIMA. "Limiting the Use of the Social Security Number in Healthcare." Journal of AHIMA 82, no.6 (June 2011): 52-56.


http://www.argodata.com/

mpi data integrity: costs, causes, complications alan soskel, rhia mpi data integrity analyst dekalb...

Documents

mpi mpi data integrity

definition of mpi

percent of mpi inaccuracies

patient relations

patient dissatisfaction

patient care setting

vital patient records

patient care safety