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Lowering the duplicate patient record rate increases revenue cycle efficiency by improving the accuracy of information used to submit claims, collect payments, and provide care. Texas Health Resources, a 13-hospital system with more than 1 million patient registrations per year, reduced its duplicate patient record rate to 0.36 percent over six years—far less than an 8 percent duplicate record benchmark found in a 2008 RAND Corporation study.a Texas Health has also established an ongoing process to prevent the creation of duplicate records.
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Duplicate records detract from patient safety by giving providers a fragmented view of the patient’s medical history, thereby increasing the chances of medical error. The negative effect of a high duplicate record rate on the revenue cycle is not as widely recognized. Duplicate records affect a number of downstream financial activities as well as other key initiatives a hospital or health system may undertake, such as the implementation of an electronic health record (EHR) or a new patient registration system.
Direct impacts on payment. Incorrect identification of patients by registering a nickname, for example, instead of the legal name used on the health insurance policy, may result in denials, subsequent appeals, and delayed payments. Duplicate records may also lead to the repetition of lab or diagnostic tests already performed but documented in a different record. If the costs of these tests already have been paid by the insurance company, they will not be covered a second time, resulting in unreimbursed care for which the hospital cannot collect.
Obstacles to achieving meaningful use. Meaningful use provides another motivation for achieving a clean master patient index (MPI). It is strongly recommended that a medical record clean-up be done before attempting to qualify for meaningful use. Also, because Stage 1 incentives are tied to the number of unique patients served, duplicate patient records result in an inflated list of patients across a health system. This artificially increased number of patients makes it more difficult to prepare for meaningful use. For example, the Stage 1 measure related to maintaining an active medication list requires that 80 percent of unique patients have at least one medication entry recorded as structured data. For 1 million unique patients as identified by patient records, an organization must prove an active medication entry for 800,000 patients. However, if the duplicate rate is 8 percent and those duplicates are eliminated, then only 736,000 records would have to demonstrate an active medication entry to reach the meaningful use standard.
EHR and IT upgrade readiness. In preparation for EHR implementation, Texas Health initiated an MPI cleanup and developed a streamlined, ongoing process to reduce the creation of duplicate records. Texas Health also sought to reduce duplicate records ahead of a transition to a single registration system that would replace two different legacy systems. Together, these initiatives were slated for implementation over a two-year period.
Realizing the impact of duplicate records on its revenue cycle, Texas Health made the necessary commitment of time and money to put the right processes and technology in place. During the two-year transition to EHRs and the new patient registration system, four key steps were taken to eliminate duplicate records:
Scrubbing the MPI. A thorough, initial scrubbing of the existing MPI enabled the organization to get a handle on how many duplicates existed and identify problems that led to the creation of duplicates. The availability of data that documents root causes for duplicates makes it easier to correct improper registration habits. Detailed information about what is happening—as well as where and how often –—enables development of overall communications, education, and training programs for registration and medical records staff. Fixing a problem at registration saves considerable time and cost later in the revenue cycle.
At Texas Health, one common reason for duplicate records was an inconsistent approach to patient identification. For example, some Texas Health hospitals registered patients using legal names as they appeared on drivers’ licenses or insurance cards, while other hospitals used more commonly used nicknames. Patients who went by a middle name with friends and family were registered under the middle name instead of their legal first name. Suffixes such as junior or III were not always used, even though the suffix was part of a patient’s legal name.
Identifying and selecting the right patient records. Advanced probabilistic matching tools were incorporated into the patient record’s “search and selection” process to help registration and scheduling staff easily identify and select the right patient records. These tools ensure search results are sorted based on the likelihood that the records match. The results are presented in a ranked and color-coded display so that staff only needs to review the top choices and select the correct patient record.
In addition, technology that improves the process of merging duplicate records was implemented to save time when records were inadvertently duplicated.
Educating key stakeholders. Key staff members in both the registration and medical records departments were educated about issues related to duplicate records, the new system, and the steps needed to avoid duplicate creation. Staff education sessions were launched and the importance of using a full, legal name was addressed. The education sessions also provided strategies for minimizing patient wait times to keep satisfaction scores high and meet productivity goals.
Many staff did not realize how a simple error at the time of registration would affect downstream activities, so the sessions also focused on how duplicate records affect other areas. Examples include:
Monitoring performance. Data integrity teams were established to monitor records, identify trends that require re-education, and provide real-time support to registration staff when they encounter problems.
At Texas Health, the combination of technology that simplifies access to correct records and alerts staff to potential duplicates, thorough stakeholder education, and consistent follow-up training has resulted in outcomes that exceeded expectations. Texas Health’s initial goal of achieving a duplicate record rate of 0.9 percent or less has been surpassed; the actual rate has fallen to 0.36 percent over the period from 2006 to 2013, as shown in the exhibit below. The low duplicate record rate has contributed to a decrease in the number of A/R days—from 48.4 in 2006 to 38 in 2012. And the enhanced patient safety allowed Texas Health to go to a single EHR platform with clean data that helps ensure the validity of each patient’s medical record.
Texas Health’s new streamlined process involving registration data scrubbing, electronic identification readers, and real-time alerts to avoid potential duplicates positions the health system to improve patient safety and the organization’s financial health. Ongoing maintenance of a clean MPI, as well as technology that provides continuous monitoring and staff support, result in patient record accuracy levels that translate to cleaner claims and faster cash flow.
Patricia Consolver, CHAM, is corporate director of patient access, Texas Health Resources, Arlington, Texas, and a member of HFMA’s Lone Star Chapter.
a. 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.
Publication Date: Thursday, May 02, 2013
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