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Unique Health Identifier for Individuals

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Congress, through the HIPAA, has included provisions that constrain the use of a unique identifier, directing HHS to adopt "standards providing for a standard unique health identifier for each individual...for use in the health care system." and that the standards "shall specify the purposes for which a unique health identifier may be used." HHS would be forced to specify the purposes for which any unique identifier would be used and prohibited. The identifier would be used in health care treatment, payment and administrative activities but could be prohibited from use outside of the health care system.with that use being subject to penalty.

The President's Quality Commission outlined the uses of individual health care information that were consistent with the right to confidentiality and could be made without patient consent:

• - Health purposes, including provision of health care, payment for services, peer review, health promotion, disease management and quality assurance.
• - When there is clear legal basis for the disclosure in very limited circumstances; medical or health care research for which an institutional review board has determined anonymous records will not suffice, investigation of health care fraud and public health reporting.

The Secretary of HHS's recommendations for privacy legislation would allow use of a unique identifier without patient consent for:

• - Health care and payment
• - Health oversight of many types, including oversight by law enforcement, government agencies investigating or paying for health care, professional licensure and discipline systems, regulators such as insurance commissioners, and accreditation, standard-setting and quality review bodies.
• - Public health, including public health surveillance.
• - Health research, under certain limited conditions (for example, with approval of an institutional review board).
• - Emergency purposes
• - Health data collection by state agencies.

The President's Quality Commission and Secretary of HHS agree that the boundaries of the health care system cannot be drawn too narrowly to overly restrict use of the unique identifier.

There is not consensus on the criteria for selection of a unique health identifier. The American Society for Testing and Materials (ASTM) has published the Standard Guide for Properties of a Universal Healthcare Identifier (UHID). This publication provides 30 criteria to evaluate candidate identifiers and a sample identifier which illustrates these criteria. Four basic functions of an identifier are supported by these criteria:

• Positive identification of patients when clinical care is rendered
• Automated linkage of various computer-based records on the same patient for the creation of lifelong electronic health care files
• Provision of a mechanism to support data security for the protection of privileged clinical information (does not attempt to address all safety concerns).
• Use of technology for patient records handling to keep health care operating costs at a minimum.(from government White Paper on Unique Health Identifier published 7/2/98).

The 30 criteria are:

• Accessible
• Assignable
• Atomic (single data item - no subelements having meaning)
• Concise (as short as possible)
• Content-free
• Controllable
• Cost-effective (maximun functionality with minimum cost to create and maintain)
• Deployable
• Disidentifiable (possible to create a number of encrypted identifiers with same properties)
• Focused (created and maintained solely for supporting health care)
• Governed (has entity responsible for overseeing system)
• Incremental (can be phased in)
• Linkable (can link health records together in both automated and manual systems)
• Longevity
• Mappable (able to crreate bidirectional linkages between new and existing identifiers during incremental implementation of a new identifier)
• Mergeable (can merge duplicate identifiers to apply to the same individual)
• Networked (supported by a network that makes services available universally)
• Permanent (never to be reassigned, even after a holder's death)
• Public (meant to be an open data item - person can reveal it)
• Repository-based (secure, permanent repository exists to support functions)
• Retroactive (can assign identifiers to all existing individuals when system is implemented)
• Secure (secure encryption and decryption)
• Splittable (able to assign new identifier to one or both people if the same identifier is assigned to two people)
• Standard
• Unambiguous (minimizes risk of misinterpretation such as confusing number 0 with letter O)
• Unique (identifies one and only one individual)
• Universal (able to support every living person for the foreseeable future)
• Usable (processable by both manual and automated means)
• Verifiable (can determine validity without additional information) (from government White Paper on Unique Health Identifier published 7/2/98)

  The Standard Guide provides no way to weight the relative importance of each of the criteria.

  Six qualities of an ideal identifier were outlined by the Institute of Medicine's Committee on Regional Health Data Networks:

• It must be able to transition easily from the present record-keeping environment
• It must have error-control features
• It should have separate identification elements (to indicate who the individual is) and authentication elements (to allow validation of identity with high confidence levels using parameters other than the identification elements)
• It must work in any circumstances in which health care services are provided
• It must work anywhere and in any provider's facilities
• It must help minimize the opportunities for crime and abuse

TABLE OF CONTENTS