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MPI Data Integrity:
Costs, Causes, Complications
MPI Data Integrity:
Costs, Causes, Complications
Alan Soskel, RHIA
MPI Data Integrity Analyst
Dekalb Regional Health System
Greater Atlanta HIMA
Annual Meeting, May 8, 2015
MPI Data Integrity:
Costs, Causes, Complications
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:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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.
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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 Data Integrity:
Costs, Causes, Complications
MPI – the bigger picture
MPI /
EMPI
Regional /
National
HIEs
Facility
level
NHIN
MRN usually serves as
unique patient identifier
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.
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Impact of Poor MPI Data Integrity
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.
MPI Data Integrity:
Costs, Causes, Complications
Impact of Poor MPI Data Integrity
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
MPI Data Integrity:
Costs, Causes, Complications
Impact of Poor MPI Data Integrity
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
MPI Data Integrity:
Costs, Causes, Complications
Impact of Poor MPI Data Integrity
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
MPI Data Integrity:
Costs, Causes, Complications
Impact of Poor MPI Data Integrity
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.
MPI Data Integrity:
Costs, Causes, Complications
Moving on to the MRN
Ideally there should
be only one MRN per
patient serving as an
over-arching patient
identifier.
Each account represents a
single patient visit. There can
be many accounts for a patient
under the umbrella of a single
MRN.
Medical
Record
Number (MRN)
Account
Account
Account
Account
MPI Data Integrity:
Costs, Causes, Complications
“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…
MPI Data Integrity:
Costs, Causes, Complications
…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
MPI Data Integrity:
Costs, Causes, Complications
3 Types of MRN Data Errors
Duplicate 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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Duplicate MRNs and Overlap MRNs
Patient
MRNs
Accounts
/ Visits
Visit 1
MRN 1
Visit 2
Single
patient
MRN 2
Visit 1
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Overlay MRNs aka Compromised MRNs
MRN
Patients
Accounts /
Visits
Visit 1
Patient 1
Visit 3
Single MRN
Patient 2
Visit 2
MPI Data Integrity:
Costs, Causes, Complications
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?
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Computing Duplicate MRN Rates
Total Duplicate MRN Rate for static database =
𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑑𝑢𝑝 𝑀𝑅𝑁𝑠 𝑥 100
𝑇𝑜𝑡𝑎𝑙 # 𝑜𝑓 𝑀𝑃𝐼 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑟𝑒𝑐𝑜𝑟𝑑𝑠
A 500,000 record MPI file contains 15,000 duplicate pairs
involving 30,000 records. The duplicate rate is 3%.
15,000 𝑑𝑢𝑝𝑙𝑖𝑐𝑎𝑡𝑒𝑠 𝑥 100
500,000 𝑀𝑃𝐼 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑟𝑒𝑐𝑜𝑟𝑑𝑠
= 3% dup MRN rate
MPI Data Integrity:
Costs, Causes, Complications
Computing Duplicate MRN Rates
Creation Rate of Dup MRNs (daily, weekly, monthly, etc.)
# 𝑜𝑓 𝑑𝑢𝑝 𝑀𝑅𝑁𝑠 𝑐𝑟𝑒𝑎𝑡𝑒𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 𝑝𝑒𝑟𝑖𝑜𝑑 𝑥 100
# 𝑜𝑓 𝑠𝑐ℎ𝑒𝑑𝑢𝑙𝑒𝑑, 𝑃𝑟𝑒𝑟𝑒𝑔𝑠 𝑎𝑛𝑑 𝑎𝑑𝑚𝑖𝑠𝑠𝑖𝑜𝑛𝑠, 𝑠𝑎𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
Facility has 10,000 pre-regs and admissions per month.
250 duplicate records were created. The creation rate is 2.5%.
250 𝑑𝑢𝑝 𝑀𝑅𝑁𝑠 𝑐𝑟𝑒𝑎𝑡𝑒𝑑
10,000 𝑠𝑐ℎ𝑒𝑑𝑢𝑙𝑖𝑛𝑔,𝑟𝑒𝑔,𝑎𝑛𝑑 𝑎𝑑𝑚𝑖𝑡 𝑒𝑣𝑒𝑛𝑡𝑠
= 2.5% creation rate
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Cost of Duplicates, Correction Costs
Department Time Cost*
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
* Labor costs based on average wage rate of $15/hour
MPI Data Integrity:
Costs, Causes, Complications
Cost of Duplicates, Correction & Clinical Costs
Case study – Children’s Medical Center
Study performed on confirmed duplicates
1,000 Records included in Study
Costs Captured
• Readmissions with Bad
Debt
• Clinical Issues
• Treatment Delay
• Operational Costs for
Rework
Average Cost of Duplicates
Correction costs:
• $96.25 per duplicate record
Clinical and/or treatment issues:
• 4% of duplicates
• Average Cost per duplicate $1099
Bad Debt:
• 11% of duplicates
• Average Cost per duplicate $867
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Cost of Duplicates, Risk Costs
Estimated potential risk costs
Quality & Continuity of Patient Care
Duplication of Tests & Treatment
Success of Strategic Initiatives
Impact on Operations
Breach of Confidentiality
Liability Risk
Regulatory Noncompliance
Customer Dissatisfaction
> $100
> $100
Variable
$10 - $1,000
Variable
Variable
> $10,000
Variable
MPI Data Integrity:
Costs, Causes, Complications
HIM may manage the MPI and MRNs…
But where does MPI Data Integrity start?
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
HIM may manage the MPI and MRNs…
But where does MPI Data Integrity start?
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)
MPI Data Integrity:
Costs, Causes, Complications
Standard Search Workflow at DMC
Used by Patient Access and Scheduling departments
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb 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%
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb Medical - In What MRN Did Major Error Occur and
What Search Protocol Failed
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb Medical - In What MRN Did Major Error Occur and
What Search Protocol Failed
Same data as
above slide in
graphical form
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb 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
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb 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
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb 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
MPI Data Integrity:
Costs, Causes, Complications
Top Causes of Duplicate MRNs
Dekalb 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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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)
MPI Data Integrity:
Costs, Causes, Complications
Recommendations
Name 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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
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
MPI Data Integrity:
Costs, Causes, Complications
References
1. 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.