Patient identification and patient matching directly affect the quality, safety, and efficiency of healthcare delivery. However, in a digital era of electronic health records (EHRs) and patient portals, patient identification proves increasingly complex. Effective information governance can improve accuracy while addressing common risks and challenges.
Patient identification involves verifying the identity of persons seeking healthcare and matching them with the correct patient records. A rushed registration process or incorrect modifications can generate either duplicate patient records or single EHRs associated with multiple patients. Either problem can result in faulty care decisions and inhibit care coordination.
For example, when registering a patient with heart complications, a hospital employee found two patient records associated with the same EHR. Assuming one of the records was a mistake, they ignored it. However, two records for patients with the same name and similar birthdates had been mistakenly merged into the same EHR.
Not realizing the mistake, the hospital prescribed medication based on the second patient’s information. Because they did not properly verify patient identity, the patient receiving the medication suffered a life-threatening allergic reaction. The problem would have been avoided with proper patient verification and matching.
Accurate Patient Identification Proves Challenging
The problem with patient identification begins in the registration process. High registration staff turnover and inadequate training result in an error-prone process. Likewise, in the emergency department patient treatment takes priority over accurate registration.
Once the EHR has been created, each user with access rights to update patient information means additional possibilities for errors. For instance, incorrectly updating a patient birthdate can result in multiple errors and mismatching down the road.
Some common risks associated with patient identification include:
- Patient record duplication: This occurs when a patient has more than one medical record number (MRN) within or across healthcare systems. This can lead to incomplete or inaccurate patient information, fragmented care, redundant tests or procedures, medication errors or billing errors.
- Patient record overlay: This occurs when two or more patients share the same MRN, resulting in inaccurate medical history. This can lead to incorrect diagnosis or treatment, adverse events, legal liability or privacy breaches.
- Patient misidentification: This occurs when a patient is matched to the wrong record or when a record is not found for a patient. This can lead to delayed or denied care, clinical errors, and patient harm.
By improving processes around identity management, training employees, leveraging technology, and tightening access controls, healthcare facilities can minimize these risks.
Prevent Errors with Standardized Processes and Training
To begin with, healthcare organizations must define and enforce standardized policies and procedures around patient registration and EHR management. This includes collecting and updating data. It also includes the processes around resolving duplicates, as well as protecting and sharing information.
For instance, carefully checking name spelling and birthdate against the patient’s legal identification card will help avoid critical typos. Additionally, ensuring standardized methods of entering patient information, such as the order of names, will improve patient matching.
Even the best policies and procedures will fail if staff have not been trained to use them. Employees must understand the importance of proper patient identification and the potential risks involved. Ensure that all staff receive both formal training and just-in-time reminders. These may include visual reminders on employee desks or popup alerts in the system.
Updated technology will support standardized processes and minimize errors. For example, biometric scanners and RFID systems reduce the chance of misidentification. And software that uses AI-powered referential matching has proven very effective in reducing patient record duplication.
Improve Access Management
Because the patient record plays such an important role in care delivery, organizations need to take special care to protect access to this information. This includes first ensuring that authorized users have the correct permissions to create, update or delete patient records. Users should have no more access than required to complete their jobs.
It also includes authentication processes to verify the identity of anyone accessing the EHR. Laws like the Cures Act mandate that healthcare entities facilitate the access and exchange of electronic health information (EHI). To balance access with data security, however, systems need to definitively verify that those who access EHI are who they claim to be.
Information Governance in Healthcare Delivers Key Benefits
Information governance provides a structured approach to addressing the risks surrounding patient identification. By providing a framework for managing information throughout its lifecycle, information governance helps healthcare organizations ensure data quality, security, and compliance. It also covers the procedures around data collection, storage, and access.
Implementing an effective information governance strategy requires blending policies and practices with technology and training. Contact the information governance experts at Messaging Architects to start gaining control of critical patient data.