Moving Toward An Identity and Patient Records Locator

Last week, five health IT vendors came together to announce the CommonWell Health Alliance, a nonprofit focused on developing a national secure network and standards that will:

  1. Unambiguously identify patients
  2. Provide a national, secure record locator service. For treatment purposes, providers can know where a patient’s records are located.
  3. Enable peer-to-peer sharing of patient records requested via a targeted (or directed) query
  4. Enable patients and consumers to withhold consent / authorization for participation in the network

Unambiguous patient identity matters

In banking, without certainty about identity, ATM machines would not give out cash.  And in healthcare without certainty about identity, physicians are working with one hand tied behind their backs.

This problem will never be solved by the Feds. In fact, Congress has restricted any spending on it by the government at all.  Industry working together may be the only practical alternative.

CommonWell doesn’t intend to create a national patient identifier.  Instead it will use practical, robust identity mechanisms that a patient or consumer could provide to each physician or caregiver.  That might be based on a one-way hash of a cell phone number, an email address or a swipe of a driver’s license.  The Alliance members will decide on this as part of its standards.

Locating data is critical to clinical decisions

Imagine a cancer patient with a primary care doc they visit in a family practice, a surgical oncologist in private practice, a plastic surgeon and medical oncologist at one academic medical center and a second opinion oncology team at yet another academic medical center.

Chances are those caregivers all using different EHRs, and they may even be in different geographies.  The physicians don’t know where the records are.  Yet each physician needs real-time access to ALL of the patient’s information with critical clinical decisions hanging in the balance.

CommonWell intends to address these gaps by delivering a secure national record locator service and standards for peer-to-peer targeted queries.  Data that is returned to the physician are not stored on the CommonWell network, nor is the data normalized.

Founding members want every health IT vendor to join CommonWell Health Alliance

Those of us in the Alliance are aligned in our desire to be inclusive and welcoming to all.  The founding members are making significant commitments of money and product developer time for the good of each patient and physician.

I have personally worked with the thought leaders of this effort over several years on ONC initiatives, including the Direct Project and Meaningful Use standards for Stage 2, and I can vouch for their integrity, goals and expertise.  They’ve thought this approach through carefully, not only technically, but also in connection with governance, policy, privacy and security.

Allscripts and the CommonWell Health Alliance are committed to practical, standards-based solutions that can make healthcare safer and more responsive to the physician and patient.  To that end, the Alliance looks forward to working collaboratively with the Office of the National Coordinator for Health IT, other vendors and with standards bodies to achieve these objectives.

Rich Elmore is Vice President for Strategic Initiatives at Allscripts.

13 replies »

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  2. “…one-way hash of a cell phone number, an email address or a swipe of a driver’s license.”

    Well, I hope they consider identifiers that will work for pediatric specialties, and even neonatal…

  3. I’m worried that this alliance is merely a cartel, established by market leaders in the legacy EHR business to protect their investments against an obvious market shift toward interoperability (which negates their business model of locking clients into a proprietary system with high switching costs).

    There are no real technical barriers to most of the issues mentioned, unless you choose to consider legacy EHRs as having a divine right to stay in the market no matter where technology goes.

    The only reason the federal government can’t do this, nor anyone else who ever tried, is that this cartel lobbies heavily, and in effect dictates the rules for MU and other HIT policy. There are plenty of examples from other industries and other countries to counter the need to hand over this important layer of HIT infrastructure to a cartel of big companies whose motive is simply to sustain their stranglehold over the market.

  4. The locality of healthcare is incredibly important as a protective element or genius loci. That’s because the locality matters in the healing nature of the architecture duly noted by Vitruvius in terms of site location for the askepilon. The network itself is more organic than tcp-ip nicely depicted in the movie Avatar. Meaningful use is a brilliant tool to avoid wasted resources as exemplified by Alexander Pope who describes its role in leveraging the genius loci in the organic human centric healing network..

    ‘Tis use alone that sanctifies expense,
    And splendour borrows all her rays from sense

    This is not about franchise doc in the box that is about monoculture but the intelligent building of value in the locality so that it attracts value due to the terroir. One can buy sparkling wine but only Champagne is champagne.

    The fact is that bigger is better has come to natural limits in food and healthcare. It’s much easier for the flagellum of pathogenetic E. coli to distribute itself in very large monoculture food chain that mixes and distributes millions of pounds of bulk ground meat. Obviously food costs have gone down due to systemic efficiencies but also dumping antibiotics into the food chain likely results in resistant bacteria. The spread of prions almost automatically calls for borders and biosurveillance. Recently this has led to some horse sense in common markets regarding the mixing and labeling rather than local cultural norms where people intelligently adapted to evolutionary conditions like adding iodine to salt. The inherent value of salt from Afar is the clue to origins of trading (no one wants to live there) but it forms the basis of medical information from afar. To drill down to the information in a sea of noise is to realize we are creating our own systemic problems by solving other systemic problems at enormous scale, if one blasts messages to consume things our brain craves on a constant basis like HFCS the results are obvious in terms of costs. In colonial times people drank beer for breakfast.

  5. May I ask how Surescripts is able to conduct hundreds of millions of prescription transactions between hundreds of thousands of providers, without a National Patient Identifier?
    Why is this not good enough? How often is it clinically imperative to obtain all medical records for a patient, from unknown sources, in an emergency situation, where offline requests for a push are impossible?

    To Steve’s comment at the very top, lack of a national patient identifier is absolutely not the reason why the “competing” hospital down the street will not share data with you.

    I don’t see why the Feds should not be the ones charged with such departure from current process. The Feds should, and this should go through Congress and get and up or down public vote.

    I am not certain that an Alliance of private, for-profit corporations should be enabled to make these decisions for the entire nation. I don’t mean to imply anything about the integrity of all involved, all of whom I greatly respect, but this is just wrong.

    I understand the need of entrepreneurs and all sorts of other entities, but I am not certain of the medical reasons for someone in Florida to routinely query medical records of folks in Washington State. And please, let’s leave out the 1 in a million use cases.
    Data mining, even for rare and pure purposes is supposed to be just secondary use of data. Shouldn’t we first take care of the primary problem?
    Is our primary problem inability for non health care providers to mine health data? Is our primary problem the 5 minutes it takes a patient to fill out intake forms multiple times? Is it the inability of the world renown surgeon at Mayo to get all of the patient’s records in under 50 seconds?
    We don’t need anything of this magnitude just so a handful of medical facilities within a 20 miles radius can exchange information about this or that patient. Health care is still local. Although other things are not.

  6. The medical Internet has apparently been founded.

    Like the general Internet, which has enjoyed and still does enjoy broad and persistent success, the Alliance is a plurality of separate and even competing entities with an offering to bring in still others, and appears to cultivate broad and inclusive governance, yet not control too deeply the actual transactions or storage of data. Also – thankfully – it is not a governmental institution.

    Had this not come when it did, the HIT movement could have faltered and even dissolved at a weak point without the coveted interoperability it needs to thrive…or worse, the government (or a dominant single industry player) would have had to come in and establish a bureaucratic equivalent of an exchange conduit.

    It is in all our interest to carefully and prayerfully watch this new body develop, and be as engaged as possible from our respective constituencies. As a practicing physician, I hope we doctors step up and participate in this most critical evolution with the guiding leadership incumbent on us from our Hippocratic duties. And I would urge the Alliance to make us welcome in all levels of the new entity, for the greater good of patients.

  7. I have to agree that patient identity is not going to solved by the Feds. However there are are multiple existing solutions of which one is voluntary patient ID described by the ASTM standard on the subject is in fact was supported by the RAND report on the subject. The fact this already a part of the ISO X.500 Directory is obvious along with client certificates. I have joked with the NSTIC IDESG privacy experts that we might have to put the entire country through the witness protection / privacy protection program in terms of massive deindentification first however to scrub their existing linkable attributes.! A patient ID should be meaningless but valid, mine are and I simply had them assigned by a privacy officer. Like an ATM or credit card. The number is not your identity and can or should be changeable whenever the patient wants. That requires a level of integration in NWHIN superior to pro ballistic matching and no more risk.

  8. It’s nice to see some specifics. It enables open discussion and could lead to open governance.

    1 – We all seek unambiguous patient ID. The three methods you suggest could all be acceptable. However, the ID strategy needs to respect people’s privacy by not being coercive. Involuntary IDs, be they probabilistic master patient indexes or biometric “tattoos” that we can’t escape are not going to work on a regional or national scale regardless of federal funding. If we can’t wait for NSTIC / IDESG to reach some conclusions for citizens as opposed to patients, then the patient ID discussion needs to be extremely open and inclusive. Patient Privacy Rights stands out as one participant that represents 10 Million concerned citizens and should probably be at the table.

    2 – A secure record locator service was envisioned by PCAST and is now at the forefront of our health information exchange discussions in Massachusetts. To run an RLS, CommonWell, or the HIE, or anyone, needs to have the patient’s consent and honor their authorizations and revocations. To participate in national-scale exchange (as opposed to local or regional federations), EHR vendors need to communicate the patient’s authorization to whatever RLS services are operated by state authorities, communities or vendor consortia. Our state HIE is seeking guidance from the EHR vendors as to how they would like to communicate patient consent to us.

    3 – Targeted or directed query is already possible and required under Meaningful Use Stage 2 Direct (aka Blue Button+ Push) and CommonWell adds nothing here unless they intend to lower the bar for everyone by providing an open source reference implementation. That would be super cool!

    4 – Citizens need to be able to do more than just provide authorization to a private network. We need the data-holders to support substitutable networks (CommonWell, state HIE, PHRs, homemade apps, etc…) and to give the power of connection to the individual physician acting as the patient’s agent without any technical interference from the vendor or the institution that happens to host the physician. Patient Privacy Rights testimony on HIE governance has more detail on how this could be done. http://patientprivacyrights.org/wp-content/uploads/2013/02/2013-01-29-PPR-Testimony-1-29.pdf

    The people involved in CommonWell are indeed the most dedicated and honorable people in our industry. Let’s hope that the open governance, inclusiveness and open source generosity that has been their hallmark so far continues under the CommonWell trademark.


  9. Rich, I applaud your efforts.

    It all goes back to fragmentation of the healthcare system, which is a big driver of inefficiencies, as everybody knows (even if at the same time many among the ‘everybody’ consciously make profit from that fragmentation.)

    Less attention is paid to how that fragmentation threatens peoples’ sense of identity (and therefore safety, comfort, and other ‘healthy’ things).

    That’s in part because we lack an easy, uniform way to identify patients and link them to their health data, doctors, hospitals, pharmacies, insurance plans and others.

    The Babylon of patient-identity numbers are bogging down our medical-records system, which threatens care as well as innovation by entrepreneurs such as Lybba (the nonprofit healthcare design organization I run) that are trying to link patients to new kinds of information and tools.

    Best of luck.

    David Fore

  10. If a pt has a stress test at a local competing hospital, I cannot obtain the results from them. I can hope that I can obtain them, usually with lots of delay, from their cardiologist. If it is an EKG or a blood test, I just have them repeated. It is much faster and more certain. If this can be fixed, it will be a major boon for all of us. We really need a universal (organized) record for everyone that is accessible.