Long-term trouble can start during a brief check-in. A rushed or incomplete search of the organization’s MPI can cause clinical registrars to create duplicate patient records or even select the wrong record.

Faulty information entered at check-in streams straight through the system, risking treatment errors and leading to eventual billing problems. Entities that participate in health information exchange will export bad information into their networks.

Error-ridden MPIs also hamper an organization’s ability to understand its patient population and its own performance, both for internal and external reporting. Patient information spread across multiple records can distort measures of patient severity and overall risk of mortality. And correcting errors consumes time.

HIM departments often are the hub of identifying and mitigating registration errors. HIM staff sift through the MPI, merging duplicate records and  separating out information that has been overlaid into the wrong patient account.

But what HIM learns about the types of MPI errors occurring in patient registration may never be shared with that department. Because HIM and registration are typically managed through different departments, there can be an information exchange disconnect between the two areas. If registration staff do not know what they are doing wrong, how can they correct it?

Some facilities have instituted registration improvement programs, which can feature cross-department committees whose purpose is to reduce registration errors and clean up the MPI.

Providing Feedback to Registration

Not only do these registration improvement processes eventually reduce work for HIM, they also give vital feedback to registration staff about how their actions directly impact the medical record and patient care, according to Gwyndle Kravec, MBA, RHIA, CCS, director of HIM and privacy officer at Peninsula Regional Medical Center, based in Salisbury, MD. Peninsula instituted a registration improvement program that has greatly reduced MPI errors.

“I think this program heightens the awareness that this is an issue of data quality and that these [duplicate MPIs] do impact patient safety,” Kravec says. “When you heighten awareness of what the downstream effects are of having a duplicate medical record, then I think [registrars] are more conscientious of what they are doing. They want to get it right.”

Registration improvement programs can be simple or elaborate, depending on what investment a facility feels is appropriate to clean up its MPI and registration processes.

The HIM department at Christiana Care Health System, based in Newark, DE, has worked with the facility’s registration areas for several years to improve registration processes and reduce MPI duplicates and overlays. The initiative is an important part of ensuring health records are complete and accurate, says Kathy Westhafer, RHIA, CHPS, program manager for clinical information.

“We are looking for that MPI to really be the focus of how we identify the patient, that we have one record for the patient within the health system,” Westhafer says.

Each day a team of Christiana Care HIM professionals uses a clinical system tool that identifies possible MPI duplicates and overlays. A notification tool is also available for all staff to report possible duplicate MPI accounts. HIM staff investigates these suggested cases, merging duplicate MPIs or separating out information in overlay cases.

“That team is doing the research and determining if it is a situation where two people were merged inappropriately, in an overlay situation, or if it is really one person that has multiple records,” Westhafer says.

Because each ancillary area at Christiana Care conducts patient registration, duplicate and overlay MPI cases are compiled by HIM and separated by the specific ancillary area where the error occurred. Reports describing the circumstances of the error are circulated monthly to the various registration area managers. The information is used to create better registration processes as well as develop specific education for registration staff, Westhafer says.

Providing feedback to the registration departments is key to the facility’s MPI cleanup efforts. Instead of HIM doing cleanup work solely on the back end, registration now can use the information to improve accuracy on the front end, Westhafer says.

Since Christiana Care started its improvement processes, registration errors have been significantly reduced. A recent audit showed the organization’s MPI duplication rate accounts for fewer than 2 percent of all MPI records, a typical industry benchmark for MPI best practices, Westhafer says.

“We felt really good that the processes that we have put in place over the years seem to have worked,” she says.

Direct Training for Dramatic Results

In other organizations, HIM may have a more hands-on role in registration improvement efforts. At Peninsula, MPI duplication rates were so high that in 2007 the HIM department staff formed a committee and began direct education with registrars.

At that time, Peninsula’s registration staff was not taking enough time to accurately select or create MPI numbers. HIM staff struggled to fix the resulting duplicate accounts being entered into the system each day.

“We were processing 60 duplicates a week,” Kravec recalls. “Some of those were expected as part of our [trauma] registration process, but a majority of them were errors. So we had to get together because [the registration department] were not taking accountability. They were creating the error, and HIM was cleaning it up.”

The resulting committee, made up of representatives from HIM, patient registration, finance, IT, and labs, meets monthly to review duplication creation rates, discuss trends in registration data errors, and create new processes to correct the mistakes. A registrar is also invited to each meeting to discuss how a registration error occurred and how it could be prevented in the future.

Through the program, HIM collects all MPI account duplicates and sends them to the registration department manager. The registration manager uses the information for educational training in the department and monitoring which registrars are habitually creating errors. Under a disciplinary action program, a registrar who creates three duplicate MPI accounts within a rolling one-year time period is terminated from the organization. The policy holds registrars accountable for their mistakes and has helped reduce the number of errors committed, Kravec says.
 
Also, once a month the HIM operational manager will visit the registration department and conduct quality training with the registrars. The manager provides registrars the recent duplicate MPI rates and shares specific examples of recent registration errors that HIM has found. The HIM manager also observes the registrars at work, watching for any shortcuts that could lead to registration errors, Kravec says.

“There were so many errors and missing information in different records that we knew we needed to get something done,” Kravec says. “So we built in this ad-hoc way to do it where the HIM manager goes up [to registration] and does training on a monthly basis and brings true live examples where they registered a patient incorrectly.”

The registration improvement program has drastically reduced the number of MPI account duplicates at Peninsula.

In the first year of the program, MPI duplication rates dropped 23 percent from the previous year. By the end of the second year, rates had dropped 57 percent compared to rates before the improvement program was implemented.

“It is less resources I’m using, and my identity coordinator can certainly use their time doing better things than merging duplicate records,” Kravec says. “It is not just with one system—we have 17 downstream systems that it impacts. We have to coordinate and synchronize these merges so that patient safety is not impacted in a negative way.”

The registration improvement program at Peninsula is vital in keeping the duplication rates under control. It holds people accountable for their actions, Kravec says. “You do betterwhen you think somebody is watching,” she says. “Now if we stopped the program or stopped the [training] on these, I can see these numbers reversing.”

How Registration Errors Occur

The cause of registration errors varies from simple accidents to negligence.

The turnover rate for registration department employees is especially high in many facilities. With new employees regularly starting work, education on proper MPI creation is constantly needed, Westhafer says.

The rush to register patients can also affect error rates. At Peninsula, the emergency department has a policy that patients should be registered within two minutes so treatment is not delayed. Nearly 65 percent of Peninsula’s patients are admitted through the ED.

Registering a patient within two minutes is a lot of pressure, Kravec says, and with both patients and registrars in such a hurry, mistakes can easily be made. 

The most common registration error at Peninsula is misspelling a patient’s name when searching the MPI. Because of this, the MPI duplication committee has asked registrars to confirm at least three unique identifiers in a patient’s record—such as name, Social Security number, and date of birth—before assuming they have found the correct file.

Many registration mistakes can be avoided by requiring registrars to ask patients if they have ever been to the hospital before. “That is very simple, but there were some registrars that never asked that,” Kravec says.

Technological problems are partly to blame for some registration errors at Christiana Care. The facility’s registration system is nearly 20 years old and in dire need of upgrade, Westhafer says. “There are inherent problems with a 20-year-old system in that you are very limited in how you can search [for MPI records],” she says.

The organization has decided to replace the registration system, and Westhafer says staff is looking for a system that makes it easier for registrars to look up MPI records.

One guideline at Christiana Care contributes to duplicate records, intentionally. Registrars are instructed to create a new record if they cannot confirm they have correctly matched a patient to an existing record. “We have told registers, ‘when in doubt—unless you are positive—it is better for you to create a duplicate than it would be to choose somebody incorrectly,’” Westhafer says. HIM staff would rather merge a duplicate record than sort out patient information from an incorrect account, Westhafer explains.

Getting Started

Improvement programs do not need to be elaborate. Merely sharing duplicate creation rates with registration staff can help reduce errors. Registration management can use the rates to help develop new registration procedures, train registrars, and track improvement progress.

Facilities looking to create programs should first track their duplication rates. Identifying specific MPI issues will help organize a response to the problem. Next, they can create a project assessment and determine which facility departments would be affected by a registration improvement program. Contact those parties and invite them to help develop the project, Kravec recommends.

Regardless of how the errors occur, an important part of a registration improvement program is educating registrars about the impact their work has on the rest of the facility. Registration’s impact on patient care is a focal point of the education sessions HIM conducts at Peninsula, Kravec says.

Just educating registrars on the importance of finding the correct patient MPI during registration can have a positive impact on their work.

“Registrars didn’t have the full picture before this program,” Kravec says. “Now they have the full picture.”

In particular, Sebelius singled out unequal care. AHRQ’s “2008 National Healthcare Disparities Report,” she told the House Ways and Means Committee, “highlights that severe and pervasive disparities continue to persist in this county. Minority patients still receive disproportionately poor care compared to their Caucasian neighbor.”

Solving healthcare disparities is complicated by a lack of comprehensive data about its prevalence.

Last month in the Journal, Jennifer Hornung Garvin and coauthors wrote, “At the heart of … efforts to develop effective strategies to address healthcare disparities is the need for accurate and complete data. However, data describing racial, ethnic, language, cultural, and socioeconomic characteristics are frequently inaccurate, incomplete, and lacking in detail in the healthcare setting. Sometimes they are not collected at all.”

Addressing healthcare disparities, the authors stress, “requires that providers capture better data about race, ethnicity, and socioeconomic status, an effort complicated by the sensitive nature of the data and the challenges of categorizing them appropriately.” They point to several data sets that providers can adopt to improve their collection of this so-called equity data in support of efforts to create equal care for all.

See “Data Collection and Reporting for Healthcare Disparities” in the April 2008 issue.

Given the difficulty of reporting performance measures from paper records, healthcare has been making do by using administrative data, the only data widely available in electronic form. The trade-off is the quality of the quality measures: administrative data produce a narrow and less reliable look at the care delivered.

(In the worst case, as a Boston Globe story on Google Health related earlier this month, poorly managed use of claims data can result in outright misrepresentation of care delivered. The Journal wrote about this danger in personal health records back in April 2007.)

An emerging, intermediate solution is to mix administrative data with the clinical data most likely to be available electronically now—laboratory and pharmacy information. The results are promising. Research sponsored by the Agency for Healthcare Research and Quality has shown that the blend improves the accuracy of the measures. (Also see “Improving the Quality of Quality Measures” from the Journal April 2009 print issue.)

NQF steering committee members are evaluating more than 100 potential measures on their scientific acceptability, usability, and feasibility, says Margaret Skurka, MS, RHIA, CCS, FAHIMA. Skurka, a steering committee member, is professor and director of the Department of Health Information Management at Indiana University Northwest in Gary. The group is focusing on “high-impact” measures that can improve routine care, she reports.

Skurka believes that HIM involvement has broadened the committee’s scope. For instance, physician members evaluate a measure on its ability to illustrate quality of care, and HIM expertise has helped evaluate “how easily that data piece is retrievable from coded data,” she says.

Once the group works its way through a review of each potential measure, it will submit the resulting list for public comment. NQF expects to announce the review this summer.

The QRDA initiative is developing CDA standards for reporting quality measure data across health IT systems that are EHR-compatible. Currently, the work is published in part as an HL7 draft standard for trial use and is being tested in pilot implementation.

In “Advancing Quality Measures Reporting in HIEs,” Randolph C. Barrows Jr. describes the use of the QRDA in the quality measure use case featured in the NHIN demonstrations earlier this year. The QRDA was used in drafting functional requirements to support the exchange of patient-level quality data from provider systems to quality data measurement and reporting facilities. It also factored in writing functional requirements for the exchange of population-level quality measures results from a measurement and reporting facility to quality data recipients.

In “Mining for Measures,” Ruth Carol profiles the Health Story Project, a consortium of EHR vendors, associations, and providers developing and promoting data standards that support the flow of information between text-based, narrative documents and electronic health records. Also working off the CDA, Health Story standards address consultation notes, history and physical, operative notes, and diagnostic imaging reports.

“The Health Story Project standards help bring important information produced through dictation and often needed for quality measures into the EHR, making that information more accessible and/or available to be included in QRDA reports of quality measure information,” says Joy Kuhl, director of health information technology for the Alliance for Pediatric Quality, a sponsor of the QRDA initiative.

The QRDA initiative is a private collaboration sponsored by the Alliance—a joint effort of the American Academy of Pediatrics, the American Board of Pediatrics, Child Health Corporation of America, and the National Association of Children’s Hospitals and Related Institutions.

The story is adapted from the broader AHIMA resource “Copy Functionality Tool Kit.” It offers sample policies, testing activities, case scenarios, and questions organizations can ask when considering the use of copy and paste.

You’ll find a lot of other good practice resources on that page.

HHS says that this is the first time it has compiled a comprehensive list of the quality measures in a single location. It intends the inventory as a step in the effort to advance collaboration and synchronization within the quality measurement community. The measures and specifications in the inventory were self-reported by HHS divisions.

The list is available as a spreadsheet, sortable through dropdown menus. HHS says it will be adding more sorting options in the coming months.

An overview of industry activity around data quality, quality management, and data content standards is available on AHIMA’s Web site.

Physician Cooperation

• Find a physician champion, since physicians will usually listen to other physicians. Approach those physicians with excellent documentation practices and an interest in coding issues.
• Start off the program slow, gradually integrating different departments and groups of physicians, says Linda Haynes, RHIT, documentation specialist with Legacy Health Systems, located in Portland, OR. Assure physicians you are not trying to change the way they practice medicine.
  Be persistent and patient. Some physicians will follow the CDIP for a while, then slack off answering queries, says Lori Schmitz, RHIA, the DRG coordinator with Mississippi Baptist Health System, based in Jackson, MI.
• Physician education is key. Attend their staff meetings; put up flyers and posters in the physician’s lounge and dictation areas. Create pocket cards with documentation reminders by specialty, Schmitz suggests.
• Illustrate how better documentation more accurately reflects risk of mortality and severity of illness, says Joan Enloe, RHIT, director of medical information, documentation integrity and utilization management at Greenville Memorial Hospital, in Greenville, SC. This shows that the CDIP is about more than reimbursement—it results in better care and a clearer physician report card.

Avoiding Turf Wars

• Getting clinical documentation specialists and coders to get along can be tricky. This may happen most frequently when the CDSs are nurses. Try using a facility’s coding auditor or coding specialist as the go-between. This has worked great at Legacy Health Systems, Haynes says, as the coding auditor is seen as an expert in both coding and clinical information.
• Hold a “meet and greet” session in neutral territory (perhaps off-site) so that coders and CDSs can get to know each other, recommends Joyce Leppo, CCS, inpatient coder with Gettysburg Hospital, in Gettysburg, PA.
• Show respect. Acknowledge that each side has something to learn from the other, says Betty Bean, RHIA, consultant with HealthPort, based in Clarksville, AR.
• Include both CDSs and coders in the program planning process. This builds teamwork from the start, says Colleen Lunski, RN, clinical documentation specialist at Altru Health System in Grand Folks, ND.

Measuring Success

• Track as much information as you can about your program, using statistics to mark improvements and downtrends, says Joan Enloe, RHIT, director of medical information, documentation integrity and utilization management at Greenville Memorial Hospital, in Greenville, SC.
• Track physician response rates and present those to the medical staff advisory board, Enloe says.
• Don’t measure productivity solely on the number of queries submitted. Fewer queries could mean physician acceptance of the program. More queries could mean less acceptance.
• Do a post-discharge review of the chart to ensure that all documentation obtained by query was considered for coding, Haynes says.