Testimony by Pat Wise for the January 27-28, 2003 NCVHS Workgroup onNational Health Information Infrastructure


National Committee on Vital and Health Statistics
Department of Health and Human Services
Hubert Humphrey Building
Washington, DC. 20001

National Health Information Infrastructure Working Group

January 27-28, 2003

Statement on Personal Health Dimension
Healthcare Information and Management Systems Society

Pat Wise
Director, Electronic Health Record Initiative

Good Morning. My name is Pat Wise. I am the staff liaison for the Electronic Health Record and the NHII Initiative for HIMSS.

Founded in 1961, HIMSS is the healthcare information industry’s largest society and trade association-representing more than 13,000 individuals and 110 plus corporations. With five offices nationwide, 43 chapters, and 20 special interest groups, HIMSS exists to improve human health through the effective use of information technology and management systems.

During the summer of 2002, the HIMSS Board of Directors unanimously voted to adopt the National Health Information Infrastructure as the Society’s top strategic policy issue. At that time, it chartered the formation of the NHII Task Force, which is chaired by Dr. C. Martin Harris of The Cleveland Clinic Foundation.

The HIMSS NHII Task Force includes representatives from provider organizations, supplier and consulting firms, your parent committee, the National Committee on Vital and Health Statistics, the Centers for Medicare and Medicaid, the Centers for Disease Control, the Department of Defense, and the Veterans Administration. The purpose of the NHII Task Force is to drive the country toward the creation and universal adoption of a national health information infrastructure.

Recognizing that the NHII will not be achieved through the efforts of any one entity, our initiative works collaboratively with other organizations to harness the depth and breadth of our collective memberships. We are committed to providing extensive education opportunities for members and the industry at large, as well as conducting proactive outreach to both Legislative and Executive branches of our government.

One of our early initial projects for the HIMSS NHII Task Force was a comprehensive audio education program, presented by Jeff Blair, providing an overview and tutorial of the creation of the NHII concept, the vision of NCVHS, and recommendations for realizing that vision. Additional early efforts include creating an inventory of existing technologies and practices, writing a position statement and gap analysis on developmental needs and encouraging multiple sources of increased funding that could help the industry create an NHII; and actively supporting state initiatives that may serve as test beds for a national initiative.

As this nation builds a healthcare information infrastructure for the 21st century, HIMSS applauds the efforts of this Work Group in addressing the issues related to linking individuals to their personal health information. In preparing for today’s testimony, HIMSS sent inquiries to its individual and corporate members to more fully assess the implementation of enterprise MPI. The responses were surprising.

Currently, the majority of health care in the United States is documented on paper, and exists at the source of the care provided. These locations range from 24 hour store front acute care settings, urban and rural private practice settings, community hospitals, specialty clinics, and academic medical centers. Even within the same enterprise, it is not unusual to find “convenience” files, or duplicate files, located in clinic settings and practitioners’ desk drawers. This results in a fragmented picture of individuals’ health needs and health histories. The potential for electronic health records to improve efficiency, safety, and the quality of care is recognized throughout the industry.

Access to appropriate information at the time of care delivery is essential; clinicians and consumers need the right information at the right time. Electronic health records and the transmission of personal health information can provide the link necessary to connect the weekend visit to the clinic, with the visit to the family practitioner for a chronic ailment, with the clinicians in the medical center treating a complication. Integrated electronic health record systems allow providers immediate access to essential clinical information and provide consumers with the capacity to provide essential information about their health care to the providers of their choice at any time.

The benefits to integrated electronic health records are substantial for both consumers and providers and include;

  • Reduced numbers of adverse events caused by lack of information about health consumers at the point of care
  • Reduced duplication of diagnostic tests due to the inability to locate the results or a practitioner being unaware that a colleague had recently ordered the same test.
  • Efficiencies gained in the system when practitioners do not have to “hunt” for clinical information
  • Enhanced decision making through online clinical support software
  • Individual consumers being confident that subject to appropriate privacy controls, regardless of where or when they seek health care the professional treating them has access to relevant clinical histories and treatment information

The enterprise master patient index (EMPI) is more relevant than ever to health information systems .Healthcare organizations may have several systems handling various different data processing needs from laboratory to billing, or from ADT to Image Manager. In today’s world, each system will likely have its own patient database and its own identification schemes. When data must be transferred or correlated between domains, the ID numbers on the two systems may be different. Additionally, the same ID may exist in both domains but identify different people, preventing access or matching up of the data, or more importantly raising the possibility of mismatched data. Errors in patient identification or variation in medical record numbers can undermine the system leading to fragmented information or co-mingling of patients’ information. An EMPI provides access to patient care data, medical records and billing information while improving internal efficiencies, clinical and financial outcomes.

Upon querying its membership HIMSS determined that large healthcare organizations have done the most work with EMPI models. These models facilitate the organization of clinical data for clinicians; most have no provision for consumer access. No advanced models were identified through our inquiries. In community hospitals and private practice settings EMPI appears to be in early development or non-existent. Most linking across providers today is between laboratories and physician offices and hospitals. Social Security Number (SSN) is the common identifier used. Even within this fledgling linking, problems exist in correlating test codes.

The majority of physician practices are not automated and of those that are, only the large ones have the sophistication to exchange information electronically and those are only pulling information, not pushing out information from their own electronic health record (EHR). Accessibility of information for the consumer was not a factor in their design.

Community hospitals are for the most part still faxing laboratory results and other information to physician offices as well as providing dial-in to an enterprise EMR for on-line review of patient information by the physician. Information is not pushed to physician offices electronically at this time. The healthcare information is not reviewed by a patient consumer except upon direct request and at that time the information is converted to a paper record.

In the state of Delaware, the health care commission has approved the development of a “utility” that will provide an index indicating which providers in a community have information on a patient. This Utility is a long range vision that will implement a standard way for patient care stakeholders to electronically exchange information in a secure and timely fashion. The Utility would establish standards for patient identification, secure electronic Internet data transfer, data content and legal agreements for utility use. It would implement these standards so that patient authorized providers can use the Utility to electronically request information from data contributors. The Utility does not store patient information, rather it stores who has information. The encounter registry stores provider encrypted patient identification numbers which will be cross referenced for future use in requesting information. Patients will have to authorize data contributors sharing of information.

Studies indicate that implementing electronic sharing of information can reduce the administrative costs of healthcare by 50-80%. The Wisconsin Health Information Network experienced between $17,000 and $68,000 savings per physician practice by electronically requesting and obtaining information requests from hospital departments.[1]

HIMSS membership was consistent in advocating for the development of a national framework that promotes the use of electronic health records and the patient authorized sharing of relevant clinical components. This health information is extremely personal and consumers need to be confident that their information is valued, their privacy will be respected, and the information will be used to improve their own health or that of the public at large.

Currently in its fourth year of implementation, Integrating the Healthcare Enterprise (IHE) is a HIMSS led initiative that brings together clinicians, information technology professionals and industry representatives to implement standards for communicating patient information efficiently throughout the enterprise. IHE achieves its objectives by fostering integration through coordinated implementation of established standards. IHE is not an effort to develop new standards. Rather IHE depends on the existence of stable clinical data standards such as Health Level Seven (HL7) and DICOM, widely accepted by users and industry. These standards provide the tools and technologies. IHE specifies how to apply such standards to real world scenarios and integration problems.  This initiative is currently expanding it’s technical framework to include the functionality needed to support the IT Infrastructure including EMPI, Query/Display and Synchronized Patient View. A description of the proposed work of the IHE IT Infrastructure Committee relative to EMPI is found in Attachment I of this statement.

The HIMSS community is very pleased and supportive of today’s meeting. In preparing this testimony, we learned that our assumptions about the use of EMPI across the nation were quite overstated. There is a great need for groups, such as those in the room today, to work together to achieve symmetry within an EMPI, as well as create a reality in which an EMPI is the norm, not the exception. HIMSS looks forward to the realization and the promise of electronic health records. We take seriously our intent to drive, frame, and lead initiatives of national import. To this end, we have developed the following work plan to launch these efforts.

Work Plan

A detailed prospectus will be developed based on feedback from the EHR Steering Committee, IHE experts and other key stakeholders.  Key elements include the following:

  1. Roll out a robust EHR Initiative program of value to the corporate community.
  2. Promote healthcare standards development that supports EHR.  Participate in the Institute of Medicine panel on Patient Safety Data Standards Initiatives.
  3. Identify standards-based solutions to integrate systems necessary to populate information in the EHR and solicit comment in a publicly available format.
  4. Define the necessary attributes of an electronic health record. Publish a position statement on the attributes of a fully functional EHR.  Prioritize elements of the EHR in key domains. Galvanize industry involvement, support and participation.
  5. Create an EHR Demonstration Project. Utilize consensus process to refine, develop, and document EHR technical framework. Organize industry implementation and testing process to prepare for public demonstrations. Schedule demonstrations at key industry meetings to showcase implementation of an EHR technical framework.
  6. Document the business case for an EHR.
  7. Advocate public policies that provide financial incentives and grants for EHR implementation and research.
  8. Increase adoption of the EHR through case studies, research, presentations, and websites.
  9. Establish HIMSS as a clearinghouse of information, research, and other EHR materials. Develop, maintain, and grow a comprehensive EHR Implementation Toolkit.
  10. Utilize the Davies Award process to identify, showcase, and educate regarding real-world EHR implementations. Update the current enterprise Threshold Criteria. Launch the “Small Practice” Davies.

Results Expected

A tangible, real world integration model will provide a rich source of lessons learned, best practices and educational opportunities. The impact on patient safety and quality improvement outcomes can be identified, quantified, and publicized. Utilizing the collaboration of clinicians, vendors, and industry stakeholders, with a unified vision and documented strategy, the long-term goal of actualization of the ubiquitous electronic health record can be realized.

On behalf of the HIMSS NHII Task Force, and the Society as a whole, thank you for the opportunity provided this morning

About the Healthcare Information and Management Systems Society

The Healthcare Information and Management Systems Society (HIMSS) provides leadership in healthcare for the advancement and management of information technology.  Headquartered in Chicago, HIMSS provides services to more than 13,000 members, including IT healthcare corporations, firms and professionals from around the globe. Through the collaboration of 42 chapters and 19 special interest groups, HIMSS directs and shapes the healthcare industry, encourages emerging technology and promotes public policies that will improve healthcare delivery. For more information, visit HIMSS at www.himss.org.

Attachment I

Enterprise Master Patient Index (EMPI)

Description of the Problem:

An EMPI is generally used to manage patient identification numbers and cross-reference them across disparate systems. Healthcare organizations may have several systems handling various different data processing needs, from laboratory to billing, or from ADT to Image Manager. For example, each system may have its own person database and its own person identifier numbering schemes. Even the same type of system may be used to manage tasks at different “entities”, i.e., between two enterprises that may have distinguished historical Patient IDs. Each of these can be called an ID Domain.

When data must be transferred or correlated between domains, the ID numbers on the two systems may be different. This is becoming more common as better connectivity and more distributed workflows and data systems are implemented. Additionally, the same ID may exist in both domains but identify different people, preventing accessing or matching up of the data, or more importantly raising the possibility of mismatched data.

Use Cases:

The goal is to address the ability to handle multi-system, multi-site or multi-entity functionality, using a local ID for all actors within the local site (or entity) and to allowing access to results from other sites (entities) for that patient.

Use cases include situations where:

  • patients are transferred from one ID domain to another and there is a desire to integrate their data from a previous ID domain
  • multiple ID domains exist within an enterprise and patient data from multiple domains needs to be accessed and collected together for diagnosis and treatment
  • the ID used for the healthcare side of the organization needs to be translated to the ID used for the financial and payer side of the system.

Recommended Approach & Relevant Standards:

An EMPI can function as a Correlation Manager between these domains, providing a cross-reference of person identifiers across each of the domains. It can be called a correlation domain. Typically an EMPI will also have one universal or enterprise identifier that uniquely identifies the person in the EMPI itself.  Note that the correlation may have several different scopes: multi-system, multi-department, multi-site or multi-enterprise.

EMPI functionality also typically includes methods or services to provide a unique identifier for a person, from a set of traits or demographics for that person. An example of the use of EMPI is for a client system to query the EMPI for a person given a set of demographics. The EMPI uses matching algorithms to find possible matching persons, and returns to the client system none or possible candidates. The user can choose the good candidate or create the new person with the set of traits.

This type of functionality is typically used to drive patient information reconciliation. However it is always a qualified person who chooses at last the possible candidate of the matching.

EMPI may be included within an ADT actor or OP actor, which is used for the other functions (admit for ADT, healthcare and nursing or emergency for OP).

Patient information is propagated from the EMPI down to other actors (ADT included) locally as defined in existing transactions, possibly making use of HL7-PID and HL7-PV1 messages. In fact, the transactions are only used between ADT actors and EMPI actors when neither synchronous transactions/services between the two actors, nor the total integration of EMPI actors in ADT actors is possible (see section 4.2 page 45 in Technical Framework 5.3).

New actors would include an EMPI Manager to receive/collect patient information for multiple sites and provide correlation of multiple IDs for a single patient, and an EMPI Lookup actor to query the EMPI Manager to determine list of IDs for a patient for cross-site access. The Manager would likely be grouped with one of the key workflow actors and the Lookup would be grouped with actors that need access to data in other domains.

Synchronization of the EMPI aware systems could be done through either a Peer-to-Peer architecture or a Federation architecture.


The recommendation is to initially concentrate on the case where ID for a patient may be different between entities or sites but is the same for ALL systems/actors within single entity. (A more detailed proposal is available on the RSNA ftp site as MPI_Integration.doc)

[1] A WHINing Information Exchange “The Physicians Advocate”, 1998 2(10)