Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the U.S. Health Care System

By: Richard Hillestad, James H. Bigelow, Basit Chaudhry, Paul Dreyer, Michael D. Greenberg, Robin C. Meili, M. Susan Ridgely, Jeff Rothenberg, Roger Taylor

A national health information network, or NHIN, that enables disparate health care information systems across the United States to allow authorized users to easily and quickly share critical health information has the potential to enhance safety and dramatically improve the quality and efficiency of the national health care system. A unique patient identifier (UPI) to use as a singular key to accurately link, file, and retrieve individual health records was seen as an important element of the national system and was mandated as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation. However, privacy and security concerns about electronically sharing patient information have completely sidetracked the development of standards for a UPI and threaten to delay the development of the NHIN.

Correctly linking patients to their health data is a vital step in achieving quality health care. The two primary approaches to this linking are the UPI and statistical matching based on multiple personal attributes, such as name, address, and Social Security number (SSN). Lacking a UPI, most of the U.S. health care system uses statistical matching methods. There are important health, efficiency, security, and safety reasons for moving the country away from the inherent uncertainties of statistical approaches and toward a UPI for health care.

This monograph examines the operational advantages and disadvantages, compares the errors, examines the costs, and discusses the privacy issues associated with the UPI and its alternatives. Our analysis indicates that a health care system in which every patient has a unique, nondisclosing (i.e., containing no personal information) patient identifier is clearly desirable for reducing errors, simplifying interoperability, increasing efficiency, improving patient confidence, promoting NHIN architectural flexibility, and protecting patient privacy. A one-time cost of $1.5 to $11.1 billion for a UPI, to remove the systemic errors in health-records retrieval, is small by comparison with the value a potential efficiency savings of $77 billion per year at the 90-percent level of adoption (with additional safety and health values that could double these benefits) that previous studies estimated for connected Electronic Health Record (EHR) systems. Prohibiting development of a UPI actually sidesteps the larger problem: the development of a NHIN without first establishing a legal environment that best protects privacy while also encouraging the advances that interoperability of EMR systems between providers would bring to health care quality and efficiency. Continuing de facto endorsement of statistical matching as the only practicable approach to linking patients to their electronic health records will inhibit the effective development of the national health information network.

This monograph should be of interest to health care IT professionals, other health care executives and researchers, and officials in the government responsible for health policy.

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