March-April 2021

Feds Go Postal to Address Patient-Matching Shortcomings
By Lisa A. Eramo, MA
For The Record
Vol. 33 No. 2 P. 16

ONC’s Project US@ creates a unified, industrywide address specification for patient matching.

Patient matching has long plagued the health care industry. However, during the current COVID-19 pandemic, the ability to match patient identities could not be more important.

“Patient matching is demonstrably important during this time of increased testing, vaccination, and contact tracing,” an Office of the National Coordinator for Health Information Technology (ONC) spokesperson told For The Record in an e-mail statement. “We have heard from stakeholders that patient misidentification in diagnostic laboratory testing prior to the pandemic was an issue that has been exacerbated by the current increased volume of patients.”

What’s one data element that can potentially help clear up the confusion? Patient address.

A 2019 Journal of American Medical Informatics Association study found that applying the US Postal Service (USPS) Postal Addressing Standards can increase matching by up to 3%. “If you multiply 3% by billions of health care transactions daily, there’s the potential to augment millions of health care observations,” says Shaun Grannis, MD, vice president of data and analytics at the Regenstrief Institute.

Address Standardization on the Horizon
Most recently, the ONC announced Project US@, an initiative to create a unified, industrywide health care specification for patient mailing addresses. The initiative is being launched in collaboration with Health Level Seven International, the National Council for Prescription Drug Programs, X12, other standards development organizations, and members of the Health Standards Collaborative, as well as other federal and private partners. The timeline? Before the end of this year.

“We are engaging with a wide range of standards development organizations and other partners to ensure that there is a broad agreement on the approach, support for the solution, and commitment to implement these standards from across the health care and health IT industry,” according to the ONC spokesperson. “We believe this will ensure there is voluntary widespread adoption of the new implementation specifications across use cases, settings, and systems throughout the health care community.”

In a blog post about the initiative, Steven Posnack, MS, MHS, deputy national coordinator at ONC, wrote the following: “Among the outliers and edge cases there are some things on which we really do need to agree across the health care ecosystem and implement consistently. How we represent a patient’s address is one of them. In particular, as mundane as address may seem, it is often one of the key elements used for the purposes of patient matching and linking records, though other data like e-mail and cell phone number are gaining in their use. … Project US@ is reflective of how subtle improvements in health IT can have a big impact when implemented at a national scale. By doing this together, we will be able to establish a lasting, industrywide approach to representing patient address that is consistent across a spectrum of clinical and administrative transactions.”

Why focus on patient mailing addresses?

There’s significant variation in how health care providers capture mailing addresses, Grannis says. For example, some might capture Drive vs Dr. or Apartment 7 vs Apt. #7. With variation comes an inability to rely on that information with confidence when matching patients, Grannis points out.

“However, one caveat is that you’re still relying on the patient to give you the right information,” says Keith Olenik, MA, RHIA, CHP, vice president of revenue cycle services at Pivot Point Consulting. For example, patients may unintentionally make a mistake when providing their address because they’re not feeling well, or they may intentionally provide an incorrect address to avoid receiving a bill. In some cases, the data field may be left blank.

“Because Social Security numbers are used much less frequently in patient matching than in the past to protect patient privacy, this makes it even more important that other data elements are accurate and complete and that our matching algorithms understand how to evaluate them, even when they change over time,” says Joaquim Neto, chief product officer at Verato. “It’s also important to note that people move, and unless organizations have the ability to update addresses quickly in patients’ medical records, match rates will suffer. To improve match rates, we must assure not only the integrity of address data but also the integrity of other demographic data elements that verify an individual’s identity.”

Olenik agrees. “The issues we have in matching extend to a lot of different data attributes. Address is just one of them,” he says. “We support any initiative that gives us more data, but we’re also trying to set the expectation that it won’t be a game-changer. This is a building block. It’s part of the bigger picture, and it’s a key piece that could help make a difference from a patient care standpoint.”

Experts agree that address standardization couldn’t come at a better time. Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, told The New York Times that approximately 80% of coronavirus test results are missing demographic information and 50% do not have addresses.

These data gaps not only make it more difficult to match patients but also add administrative burden, says Dan Cidon, cofounder of NextGate. “These types of delays are not only frustrating but also downright dangerous,” he says. “Contact tracers have to spend valuable time manually searching for data to locate individuals who may be unknowingly spreading the virus.”

COVID-19 has undoubtedly highlighted the longstanding problem of patient matching. However, there’s also another important development propelling patient matching into the national spotlight: an ONC report due to Congress on the topic of current technological and operational methods to improve patient matching. The Further Consolidated Appropriations Act enacted into law on December 19, 2020, states the following: “The report shall evaluate the effectiveness of current methods and recommend actions that increase the likelihood of an accurate match of patients to their health care data. Such recommendations may or may not include a standard for a unique patient health identifier. The report shall include the risks and benefits to privacy and security of patient information.”

As of press time, the ONC report had not yet been released. However, it comes in the wake of several ONC patient-matching efforts currently underway. To date, ONC has established USCDI standards for several demographic fields: birth sex, race, ethnicity, and language. In the 21st Century Cures Act, it finalized the addition of current address, previous address, phone number, phone number type, and e-mail address.

“ONC is realizing we need a strategy—whether it’s a unique identifier or augmenting existing algorithms—we need to do something to make this better for patient safety,” Grannis says. “Even if we do implement a unique patient identifier, it’s going to take some time in a $4 trillion industry. Health care services are highly personal, sensitive, expensive, and complicated. There’s resistance to change, and there’s significant variation in processes across the United States.”

Overcoming Challenges
As part of Project US@, experts say ONC and its collaborators will likely address a variety of questions and challenges to achieve industrywide consensus on a standard for capturing patient mailing addresses. For example, will there be three or four address lines? A minimum and a maximum number of characters? Use of punctuation and special characters? A requirement to include a postal code extension?

Each of these decisions has implications for IT systems. For example, how might address standardization affect proprietary matching algorithms used by third-party data cleanup and patient-matching solutions?

In addition, many EHR vendors may need to revise their products, Olenik says. “For some older systems or systems that have a broader customer base, it’s extremely difficult to retrofit something that seems like it should be so simple,” he says.

“What would be helpful to examine more closely is how this field is treated today by EHR vendors and look at a reasonable compliance timeline for both providers and vendors,” says Cassie Leonard, director of congressional affairs at the College of Healthcare Information Management Executives (CHIME).

CHIME is a founding member of the Patient ID Now coalition (NextGate and Verato also are members), which is fighting for repeal of an appropriations ban that prevents Health and Human Services from using federal funds to create a unique patient identifier.

“Although the ONC effort doesn't completely solve the patient-matching problem in its entirety, it is clear that this sets the nation on a course to prioritizing patient safety, identification, and matching,” Leonard says.

The specifics of Project US@ have yet to be announced. Interestingly, the Patient Matching Improvement Act of 2020, introduced in August and referred to the US Senate Committee on Health, Education, Labor, and Pensions, seeks to ensure health care organizations have access to the USPS address-formatting tool to improve patient matching. The Patient Matching Improvement Act would open the free USPS tool to the health care industry to improve patient record matching among providers and strengthen the country’s COVID-19 response efforts.

However, the 21st Century Cures Act outlines several limitations with using the USPS standard. More specifically, the rule states the following: “While the US Postal Service Postal Addressing Standards include a single representation for certain data elements (such as rendering apartment as apt, building as bldg, floor as fl, etc), they also allow variations for other data elements, such as ‘acceptable’ and ‘preferred’ spellings and abbreviations for street and city names. This may result in multiple ‘valid’ addresses. … Because of the variation, the required use of reference files, and the manual reconciliation necessary for implementation, we have not adopted the US Postal Service Postal Addressing Standards as a required standard for the address Data Elements within the USCDI.”

“With that being said, USPS does significantly reduce variation. Any reduction in unnecessary variation can improve matching accuracy,” Grannis says.

How Hospitals Can Prepare
Although the details of Project US@ have yet to be announced, Olenik says organizations can start thinking ahead by identifying all systems that capture patient addresses. For example, will the organization’s telehealth or patient engagement platforms incorporate the new standard? What about system-owned physician practice EHRs that differ from the one the hospital uses?

“It will only result in added confusion if you have systems that can’t incorporate the standard,” Olenik says. “You’re going to have inconsistencies when you go in and try to do a match.”

In addition, organizations can plan to provide systemwide education, Olenik says. Anyone who captures patient addresses should be aware of the new standard and how it affects their workflow. This includes physicians and other providers, registration staff, community outreach coordinators (eg, those conducting community health fairs or support groups), and emergency medical service responders, according to Olenik.

Looking Ahead
Experts agree that address standardization is but one of many steps needed to achieve accurate patient matching.

“The Project US@ initiative cannot eliminate patient mismatches entirely, and other improvements will be needed in the longer term, but this effort from ONC represents a critical opportunity to better use data already collected in patients’ files to accurately match their records,” wrote Ben Moscovitch, director of The Pew Charitable Trusts’ HIT initiative. “By taking this important step focused on address standardization, ONC is rightly prioritizing a data-driven approach to improve record matching in the near term to help patients get better and quicker care.”

Moscovitch suggests the federal government can do more to advance address standardization, including permitting USPS to allow health care providers to use its converter as outlined in the Patient Matching Improvement Act. Current USPS terms and conditions limit the use of their application programming interfaces to mailing purposes only.

Cidon says address verification combined with geocoding (ie, translating a text-based address to an actual location) would enable organizations to not only improve patient matching but also support population health management.

“With geocoding, you’re also ensuring that if you send a bill or some other type of really important communication, that it will actually be delivered,” he says. “That certainly has a value well beyond patient matching.”

Data analytics will also benefit from geocoding, Cidon notes. “In some cases, there are huge populations covered by a single ZIP code, and if you want to get down to the street level in terms of health disparities due to economic or even environmental factors, you need the geocoded data,” he says. “It’s high time for us to make some progress on patient matching because the approaches we have today are leaving a significant part of the population at risk of misidentification.”

Grannis agrees. “Lack of a consistent identity strategy has been a gaping hole in our fundamental e-health infrastructure,” he says. “Project US@ is an effort toward filling that gap.”

— Lisa A. Eramo, MA, is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.