Correctly linking patients to their health data is a vital step in quality health care. The two primary approaches to this linking are the unique patient identifier (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. In this monograph, we compare the linking alternatives on the basis of errors, cost, privacy and information security, and political considerations. We also discuss operational efficiency, ease of implementation, and some implications for improved health care.

Preface
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.

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.

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.This research has been sponsored by grants from a generous consortium of health information technology companies: Cerner Corporation; CPSI; Intel; IBM; Microsoft; MISYS; Oracle; and Siemens. The right to publish results was retained by RAND. The research was conducted within RAND Health, a division of the RAND Corporation.

A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health.

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

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

Published 2008 by the RAND Corporation
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Conclusions
Broad Adoption of a UPI Should Enhance the U.S. Health Care System
Our analysis of the costs, benefits, and other aspects of a UPI described in this monograph indicates that a health care system in which every patient has a unique, nondisclosing patient identifier is clearly desirable for reducing errors, simplifying interoperability, increasing efficiency, improving patient confidence, promoting NHIN architectural flexibility, and protecting patient privacy.

A Hybrid System Utilizing Both Statistical Matching and a UPI Will Be Necessary for the Foreseeable Future
Such a system will be necessary when only some of the population has a UPI (as in a voluntary system), during the implementation of a UPI (which may take a number of years), and when a patient cannot provide his or her UPI and health services must be rendered. Depending only on statistical matching will perpetuate errors in health-records retrieval because of its reliance on nonpermanent and non-unique personal attributes. One possible approach is to begin phasing in a UPI as an additional attribute in statistical matching.

Security and Privacy Could Be Strengthened with a UPI
In the context of a networked health information system, security and privacy have much more to do with how access is managed and records maintained than with a specific identifier approach. Password protection and encryption of a UPI are relatively easy, whereas encryption of personal keys used in matching algorithms decreases the power of the algorithms. Repeated disclosure of personal information and linking that information to health information, required in statistical matching in a network, probably carry a greater security risk of disclosure of sensitive information than a UPI. Using demographic matching may also make it more difficult to recover from errors. Once a person’s health information is known and associated with the patient’s personal attributes, the option of giving the person a new identity with a new set of personal attributes does not generally exist.

Costs of a UPI Are Significant but Probably Much Less Than the Value Associated with Error Reduction, Efficiency, and Interconnectivity of the Health Care System
Costs depend on the scope of uniqueness and how strong and centrally managed the registration and authentication (verifying that a person is who he/she claims to be) processes are. To put the costs in perspective, previous studies of the value of connected Electronic Health Record (EHR) systems estimated 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 (Girosi, Meili, and Scoville, 2005). A one-time cost of $1.5 to $11.1 billion for a UPI, to remove the systemic errors in healthrecords retrieval, is small by comparison.

Implications for Public Policy
In this monograph, we further elaborate the importance of a unique patient identifier as an enabler of efficiency, quality, and privacy in a nationally connected health care system. HHS has not funded any development work on the UPI since the late 1990s.

Consequently, none of the NHIN-development contracts funded by HHS has employed a UPI approach, which limits a key purpose of the consortium process: to experiment with and develop the best approaches to interconnectivity and interoperability.

Privacy and security appear to be inadequate under current law and must be enhanced as the health care system becomes digitized and interconnected.4 However, 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.

Although it is beyond the scope of this monograph to suggest specific policy actions the government might take to ensure the privacy, access, and security of health care information, it is within its scope to recommend that Congress remove the current and clearly counterproductive constraints on HHS with regard to the UPI. Instead, Congress should be encouraging HHS to make a full assessment of the privacy, security, and operational implications of all the alternatives for linking patients to their health records within the NHIN.

These issues should be the subject of open study and debate in the vitally important process of developing the best interoperable U.S. health care system and reducing the errors and inefficiencies in that system. 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.

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