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The benefits of implementing the long-awaited individual health identifier — facilitating care delivery to the right patient, in the right place and at the right time — should far outweigh the cost of implementing this key enabler, writes Lloyd Mudiwa. The Irish health service is about to get a lot more efficient and safer, and at not too high a cost too, if the experience of the Epilepsy Patient Record (EPR) is anything to go by.

Speaking on Wednesday last week at the HSE’s proposed implementation of the eHealth strategy, with a focus on the individual health identifier (IHI), Dr Colin Doherty, National Clinical Lead for Epilepsy, said epileptics received care right across the health system (from general practices to any of the specialist six hospital centres countrywide).

But, if they have exacerbations or seizures out in the street they may be admitted to a hospital where there is no centre and their records are not kept.

The clinical experience

Led by Dr Mary Fitzsimons, HSE Clinical Programmes, they developed the EPR 10 years ago to ensure patients’ care was integrated.

“During this journey we have come across many problems which have made the health identifier the solution. For instance, if we have four patients with a common name like Sean Murphy — each of those four names is highlighted in red and it’s ‘please be aware this is the same name as for three other patients’, and we have to go down through various identifiers. If their dates of birth are the same then we have another level of trouble, so we have all of these governance structures to make sure we don’t make mistakes on those.

Dr Doherty said: “You can do that in a small project like epilepsy [there are 40,000 epilepsy patients in Ireland], but when you try to attack the whole of the health system, and all of the chronic diseases, especially when you get to the elderly group that have on average three chronic diseases at the age of over 65, it’s just not going to be possible to put in those safeguards …”

Dr Fitzsimons added: “The other day and I found a patient who had exactly the same name, exactly the same address and what I thought was exactly the same date of birth. But when I looked closely, the year of birth was actually different by 30 years …. It was a father and son.

Wrong information

“The problem with this is you can either end up putting the wrong information into the wrong record, or mistakenly think that these are two separate people and you create a new record ending up with a bit of information in each of the records, so the integrity of the information is reduced and that has huge implications for patient safety,” she added.

“Currently in hospitals, it’s very, very frequent that a patient will have more than one chart, added Dr Doherty.

“Maybe the patient is too sick to say that ‘I have been here before’ and they are issued with a new number.”

Fortunately for Dr Doherty’s patients and colleagues, the EPR will be a demonstrator project for the IHI and thus an early adopter of this key enabler from possibly as early as the end of this year.

“The benefits of this will be immediate because all of the redundant governance measures we have built into the system will fall away,” he commented.

Implementing IHIs

With up to 95 per cent of patients identified, the HSE expects to have created an IHI that uniquely and safely identifies every patient across the health or social care services, both public and private, by the summer, IMT has reported.

The plan to implement the IHI, which has been described by Dr Áine Carroll, HSE National Director for Clinical Programmes, as a key enabler for the implementation of the eHealth strategy, follows the decision taken after consultation in January to use the Primary Care Reimbursement Service (PCRS) technical infrastructure for the roll-out.

Dr Carroll said: “An individual identifier will help to break down traditional boundaries, enable sharing of information across the continuum of care and therefore facilitate integrated care.

“Evidence from other countries, such as Canada and the UK, tells us that unique identifiers also facilitate a reduction in medical errors, simplify the use of electronic medical records, increase overall efficiency and can help protect patient privacy.”

Richard Corbridge, the new Chief Information Officer of the HSE, said: “The IHI will also help in managing our health services more efficiently and ensure that health information can be shared safely, seamlessly across different healthcare organisations associated with patient care.”

There would also be a three-year programme to make IHIs available in the various clinical systems throughout the health service, with a target of autumn 2015 for the first systems.

ROI matrix These systems will be prioritised through the clinical benefit that can be released through having them in the systems, Corbridge stressed.

Implementation into each clinical setting will be considered against a ROI matrix that will consider patient safety, efficiency gains and clinical engagement, he elaborated, adding that new systems would have the IHI as part of core requirements.

He disclosed: “We are working to understand the GP system because we think that that will be useful in getting integrated care we wanted between primary care and secondary care.”

IHI will be available on referral letters from spring 2016 and incorporated in the national maternity and neonatal system in the summer of that year.

The IHI record

Describing it as an indexing system for patient records, the CIO said IHI would facilitate the planned future implementation of an electronic health record (EHR)—an electronic version of a patient’s medical history.

The IHI places the patient at the centre of integrated care, and along with the EHR and the Primary Care ICT Programme facilitates collaboration between the different systems and makes the most of the connected data to enable insight and facilitate service improvement. It will also be linked to recognised European standards.

The IHI record is a combination of a person’s IHI and other personal data that is used to safely identify them, separate from their Personal Public Service Number (PPSN) as it will only be used in the healthcare setting, and would also have to be used in the private healthcare setting, which would not be legally possible to do with the PPSN.

Based on international best practice, the Health Information and Quality Authority (HIQA) in 2009 recommended that the Minister for Health not use the current PPSN as the identifier in health and social care as this would open up significant information governance issues with other non-health related environments.

The Health Identifier Act 2014 allows for the following data to be collected and stored in a patient’s health identifier record: forenames, surname, date of birth, place of birth, sex, all former surnames, mother’s surname and all her former surnames, address, nationality, a PPSN (if any), date of death in case of a deceased individual, signature, and photograph.

Initially though, only basic demographics will be stored as part of the IHI.

Under the same Act, people will be automatically assigned an IHI. The introduction of a system of individual health identifiers drives improvements in patient safety and is to members of the public advantage when they access health or social care services in Ireland, Corbridge said, adding: “You will still receive care if you do not know or disclose your IHI.”

The HSE will provide an index service to the healthcare organisations that hold records about patients to enable their number to be applied.

While there is no need for a patient to know their number in order for them to receive healthcare — with the IHI not tied to their eligibility for care nor any social welfare benefits — there will be a process put in place where they can request it.

Safety, access

Corbridge said identification supported privacy, transparency and audit based on the premise that digital records were easier to safeguard and share, the identification of patients, as well as their individual clinicians and healthcare organisations, which would also be allocated with identifiers. This facilitated a governance model that allowed patient review of records accessed and ensured legitimate relationship between views of the record. Digital records also enable audit of access and traceability of clinical requirement.

A business unit within the HSE, the Health Identifiers Operator, will be responsible for the national register of individual health identifiers, which consists of people’s IHIs and other personal data.

The health services provider identifier (HSPI) for each provider that offers health services in Ireland will be held in the national register.

The Executive is currently working on how to implement the IHI system for all care settings.

Corbridge put the cost for providing the national IHI infrastructure and the data quality service resources required to run the system in year one at just under €1 million (€910,179).

Over five years the cost of licensing standards-based identifiers from globally recognised best practice would be circa €300,000, he mentioned.

Backing up the cost effectiveness of IHIs, Dr Doherty said: “By far and away the indirect costs of health are massive compared [to direct costs].”

Indirect costs include the time lost to productivity when patients attend hospital etc.

“The EPR has turned our service from one where we saw 95 per cent of our patients 10 years ago face-to-face, to where we are now: 60 per cent of what we do now is virtual. We can manage our patients directly, because we have their records right in front of us, when they ring us up.”

He added: “We haven’t done the figures yet, but I can tell you the change in the costs, particularly in around the indirect costs, is going to be absolutely massive… and these [set up] costs are miniscule compared to what we are saving.”

Next step

On the following day, HIQA began a public consultation on draft standards for public consultation, which lay the foundation for the introduction of IHIs.

HIQA’s Acting Director of Health Information Rachel Flynn said: “HIQA has developed these draft standards to support the introduction of health identifiers into the Irish healthcare system by providing information governance and management standards that the health identifier operators must put into practice.

“Implementing these standards will promote trust among the public and health service providers that the national registers have been established in accordance with the law and in line with international best practice.

“In turn, this creates confidence that health service providers can be uniquely identified and can uniquely identify the patients to whom they are providing services, which ultimately leads to improvements in patient safety.”

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Autor(en)/Author(s): Lloyd Mudiwa

Quelle/Source: Irish Medical Times, 19.05.2015

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