Health system takes aim at duplicate numbers
By Lynne Gentry,
Registration Supervisor
MultiCare Health System
Tacoma, WA
In February 1996, MultiCare Health System in Tacoma, WA, began to address the problem of duplicate medical record numbers in the hospital information system.
About 150,000 of 787,000 medical record numbers in the master patient index (MPI) were identified as possible duplicate medical record numbers. An MPI conversion to a new hospital information system in 1993 and the decentralization of the admitting department in 1994 contributed to the increase in duplicate medical record numbers.
Not only were the registration responsibilities added to the unit secretary’s duties, but the birth of Washington state’s managed care Medicaid program also occurred in 1994. An ever-increasing number of managed care insurance plans added to the complication of the registration function now performed on the nursing units.
MultiCare Health System includes a medical center comprising two acute care hospitals totaling 388 beds, 34 outpatient clinics, 17 lab sites, and two day surgery centers for adults and children.
The health system also includes a third, off-campus, 66-bed hospital, 42 physician offices, six clinics, eight urgent care centers, and a physician residency family practice center. The hospital information system is used by the medical center and by the third hospital.
The project mission was to "design a process to establish and maintain the integrity of the medical record numbering system." MultiCare used a multidisciplinary approach to tackle this issue. The first phase of the project was to create a manageable set of recommendations that would solve the problem. The second phase would be to implement those recommendations.
An operations improvement team consisting of representatives from nursing administration, patient financial services, lab, radiology, patient registration, the emergency departments, health information management, information services (IS), and operations improvement made up the recommendation and implementation teams. Some representatives were asked to participate in both phases.
The recommendation team met eight times from February through May of 1996 and made the following recommendations:
• Create administrative policies and procedures.
• Create a communication strategy for referral sources to include a basic registration form with standardized and required critical data elements. Additional information to meet the needs of a specific department also could be included.
• Provide education to minimize duplication of medical record numbers.
• Create accountabilities.
• Create a standardized quality assurance procedure for registration.
• Provide "cheat sheets" at each registration area.
Team determined policy and procedure
The implementation team first met in June 1996. It was divided into subgroups to address five of the recommendations. The entire team addressed the development of the administrative policy and procedure that would be followed by the medical center. The team met every two weeks for five months; the subgroups met regularly based on the entire team’s critique of project status.
The policy and procedure proposal was ready for administrative committee approval in Nov em ber 1996 and became effective that December. The team created a referral source communication and registration data verification checklist, which was laminated and placed at all unit secretary stations. The team also developed a competency checklist.
The IS department began the task of the automatic merge of those duplicate numbers that met specific matching criteria. The education plan and quality monitoring plan also were approved. Written documentation was disbursed to 178 supervisors, managers, and directors, informing them of the expectations and accountabilities of the new process.
Before those performing registrations could be held accountable, there had to be an education mechanism to give them tools to reduce the creation of duplicate medical record numbers. The team’s education subgroup, led by a clinician from MultiCare’s center for clinical education, developed a computerized slide presentation, classes, and a video to be used in educating those who had registration responsibilities. The video was made using members of the task force portraying various registration scenarios.
Education now available
The education program is ongoing and available to new hires and existing staff who need further assistance. It was presented by our clinical nurse educator at Rutgers State University’s 16th Annual Nursing, Computer and Technology Conference, held recently in Orlando, FL.
A senior applications analyst from the IS department identified 77,000 duplicate numbers that were eligible for the automatic merge process, which occurs at the database level. This process began in December 1996. The 1997 target for the number of records to be merged was 31,000.
By November 1997, the actual number of duplicates merged had reached 56,221. Included in the merge process was the actual consolidation of the medical record charts by the hospital information management (HIM) department based on reports of merged records provided by IS. Those reports also were provided to ancillary departments to merge patient records manually in their clinical information systems.
By May 1998, a total of 75,752 records had been merged through this automatic process, and the second phase of the cleanup began. This phase includes the provision of additional reports to HIM, which lists those MPI records that may be duplicates, based on patient name and date of birth. HIM reviews information on the hospital information system and the actual medical record chart. If a merge is required, HIM completes the system and chart merge.
The plan for quality assurance involved a coordinated effort among IS, HIM, the quality registration department, and the center for clinical education. IS generates a daily report on the duplicate numbers created the previous day. Monitored by the quality registration department, the report lists the duplicates created, who created them, and on what day.
Statistics on system users who may need more education are maintained and distributed to directors. (This monitoring procedure also identified a common function employed by system users that prevented them from looking for established medical record numbers.)
For those who occasionally create a duplicate number, a reminder notice is sent containing techniques that will help deter the creation of duplicate numbers. Information is then relayed to HIM on those numbers that need to be merged in the hospital information system. A physical chart merge is performed after the patient information has been confirmed. Information is relayed to the registration and operations improvement departments for statistical purposes.
Without intervention, it was projected that duplications would have continued to escalate, possibly reaching 5,000 additional duplicate medical record numbers per year. The actual figures demonstrate a reduction in duplicate medical record numbers to an average of 27 per month in 1997 (out of an average of 23,268 new registrations created each month).
For the current year, January through June 1998, an average of 33 duplicate numbers have been created (out of an average of 27,084 new registrations per month) while operating at 100% capacity. More than 1,500 employees are authorized to perform registrations on the hospital information system and have the potential to create new patient records.
With that in mind, the duplicates created are remarkably few in number, especially considering that the registration functions are performed by multi-skilled staff at the point of service in an ever increasing managed care environment.
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