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7. Lifetime Human Service & Treatment Record (LHSTR) Number based on Birth Certificate

I. Description of the Identifier

Edward F. Hernandez, Bureau of Records and Statistics, San Francisco Department of Public Health recommends a Lifetime Human Service & Treatment Record Number which will serve as a Unique Patient Identifier. Birth Certificates are personally specific and uniquely enumerated. The national civil registration consists of three components. They are:

1) registration in birthing hospitals (Birth Certificate)

2) "Official Report of Birth" in the case of an US citizen giving birth or fathering or adopting a child outside the territorial boundaries of US

3) alien registration document or "green card" and other forms of the U.S.Visa issued by the Department of State.

Of these three disparate components, the Birth Certificate is the largest and the other two serve as its surrogate. Although each one of them uses different enumeration method, all of their documents exist in both paper and electronic formats. Mr. Hernandez' proposal consists of linking these documents to a randomly assigned 16- digit number. A personal identification number or "PIN" chosen by individuals or their designee would also be included. A 16-digit ID number can support 1015 (ten quadrillion) individual numbers and a 16-position alphanumeric ID can support 1616 individual unique Identifiers. The above three components that provide factual basis for the establishment of a LHSTR are divided into three breeder (document) types. The method also includes a six-digit check-digit verification and a public- key/private-key based encryption on an as needed basis.

The LHSTR file structure includes a three tier approach. A set of seven core data elements forms the first order of document. It consists of:

1. sixteen (16) position randomly assigned permanent identifier (LHSTR Number)
2. the full name of the individual as stated in the document
3. date of birth as stated in the document
4. place of birth as stated in the document
5. mother's name as stated in the document
6. enumerator on the document
7. type of the document.

The second order documents includes a longitudinal component supplementing the basic record to corroborate over time to protect against error or fraud of the association between the individual and the record. They include U.S. passport, social security record, a state driver license, military ID, etc. The third order of documents consists of medical or social service record. The purpose is to facilitate event-by-event tracking of all health and human services provided to an individual on an explicit and consensual basis. The content includes type of service, provider ID and date and time of service. The event-by-event data can be captured through a point-of-sale (POS) terminal with the recipient using a card and PIN or manual entry in the POS terminal. The third order of documents may also include those documents that were created on the basis of the second order of documents such as a membership card, ATM Card, library card, etc. In the case of an emergency, if identifiers are not available, a temporary record must be created and resolved later after the identity is established. Mr. Hernandez is currently working on improving this model further. He recommends the creation of a national level organization to oversee the LHSTR operation . He suggests that the current Association of Vital Records and Health Statistics that exists in the 50 states can be organized into a United States Vital Health Records Trust to function as a Central Trusted Authority. He also recommends the United States Postal Service, SSA, Local Public Health Authorities, etc. as other possible options.

II. Author/Proponent and Documentation

1. Edward F. Hernandez, Director Bureau of Records and Statistics, San Francisco Department of Public Health UHID is the proponent of this method.
2. Mr. Hernandez has provided a document that outlines his method in detail.

III. Compliance with ASTM Conceptual Characteristics

a) Functional Characteristics

Accessible: The LHSTR Number requires a Central Trusted Authority for its issue and maintenance.

Assignable: The LHSTR Number proposal includes a Central Trusted Authority for its assignment. However, the necessary policies and procedures for its access and assignment, the required specifications, design, development and testing for its implementation, the establishment of a local and international authority and the definition of their functions and responsibilities are yet to be planned.

Identifiable: LHSTR Number will be supported by three levels of patient identification data including tracking of event-by-event healthcare service rendered along with provider information.

Verifiable: The proposal includes a six (6) digit check-digit verification process.

Mergeable: Duplicate LHSTR Numbers can be merged at the Central Trusted Authority level with appropriate policies and procedures via cross-referencing.

Splittable: Same ID issued to more than one individual can be handled by issuing new IDs to both or one of the individual.

b) Linkage of Lifelong Health Record

Linkable: The LHSTR Number can be used to link patient records from multiple sources.

Mappable: Bidirectional linkage is possible between the LHSTR Number and the existing Identifiers.

c) Patient Confidentiality and Access Security

Content Free: The LHSTR Number is free of information about the individual.

Controllable: The public-key/private-key information and encryption scheme can be controlled at the Central Trusted Authority level.

Healthcare Focused: The LHSTR Number is solely for the purpose of healthcare.

Secure: The public-key/private-key information and encryption scheme can be controlled at the Central Trusted Authority level.

Disidentifiable: The initial LHSTR Number draft proposal uses encryption based on public-key/private-key.

Public: The LHSTR Number is content-free. The public disclosure of the Unique Patient Identifier without risk to privacy and confidentiality of patient information is not discussed in the proposal. However, patient identifiers are not public information.

d) Compatibility with Standards and Technology

Based on Industry Standards: The Identifier is not based on existing standards.

Deployable: The LHSTR Number is capable of implementation in a variety of technologies such as scanners, bar code readers, etc.

Usable: The LHSTR Number is capable of implementation in a variety of technologies such as scanners, bar code readers, etc. The 22 digit identifier will be difficult for manual use.

e. Design Characteristics

Unique: The LHSTR Number is intended to be a unique number nationally.

Repository-based: LHSTR Number is repository-based. It is supported by three levels of patient identification data including the tracking of event-by-event healthcare service rendered along with provider information.

Atomic: The LHSTR Number can function as a single data element.

Concise: The 22 digit length is not concise for manual use and memory.

Unambiguous: The LHSTR Number proposal provides a choice of numeric and alphanumeric characters. Zeros and ones could present some ambiguity with alphabets "o" and "l".

Permanent: The LHSTR Number is intended as a permanent identifier. It can support 1616 unique numbers.

Centrally governed: The LHSTR Number approach requires a Central Trusted Authority and its proponent, Mr. Hernandez recommends the creation of an organization called United States Vital Health Records Trust.

Networked: The LHSTR Number can be operated on a computer network.

Longevity: Can support patient identification for a foreseeable future. The sixteen digit numbering system can support 1616 unique IDs.

Retroactive: Has the capacity for retroactive assignment of the LHSTR Number to each person in the United States.

Universal: Can support identification of all living individuals for a foreseeable future.

Incremental Implementation: The LHSTR Number can be implemented on an incremental basis. With the development and use of appropriate procedures both the LHSTR Number and existing patient identifiers can co-exist during the time of transition with the establishment of necessary bidirectional mapping.

f) Reduction of Cost and Enhanced Health Status

Cost-effectiveness: The LHSTR Number has the potential to support the identifier functions and enhance the health status of the nation through efficient record keeping and management, sharing of information, reduced cost of integration and optimum use of technology. The establishment of both the administrative and technology infrastructures, the creation of the Trusted Authority, the design and development of computer software and hardware, and the design and development of communication networks and security measures will require substantial expenditure.

IV. Compliance with Operational Characteristics and Readiness

Currently operational: The LHSTR Number is not currently operational.

Existing infrastructure: Does not have existing administrative and technical infrastructures.

Readiness of the required technology: The necessary technology and methodologies are ready and available for use.

Timeliness: The LHSTR proposal consists of randomly assigning a 16 digit identifier to each of the three existing civil breeder records without the need for the participation of individuals. The individuals will pick a personal identification number (PIN) similar to the PIN used with ATM Bank Cards to guard against unauthorized use. However, the implementation of an entirely new system including the creation of administrative and technology infrastructures (Central Trusted Authority, software, hardware, communication network, etc.) and development of policies and operating procedures requires substantial amount of time and resource.

Adequacy of identification information to support identification functions: The LHSTR Number proposal includes a three tier identification information that includes 1) identification information about an individual that does not change, (DOB, Mothers Name, etc.) 2) those that are acquired longitudinally (e.g.. SSN, Drivers License Number, etc.) and 3) medical service data (provider ID, type of service, date of service, etc.).

V. Compliance with Unique Patient Identifier Components Requirements

Identifier

The LHSTR proposal includes a 16 digit randomly assigned identifier, a 6 digit check-digit and a six digit optional encryption scheme.

Identification Information

LHSTR Number proposal includes a three tier identification information that includes 1) permanent identification information that do not change, 2) those that are acquired over one's life time and 3) medical service data (provider ID, date of service, etc.).

Index

The LHSTR serves as the index.

Mechanism to protect, mask or encrypt the identifier

A public-key/private-key based encryption is included in the proposal with the option to choose a different method if needed.

Technology Infrastructure

The technology infrastructure such as software, communication network, hardware, etc has not been addressed.

Administrative Infrastructure

Mr. Hernandez recommends that the current Association of Vital Records and Health Statistics that exists in the 50 states can be organized into a United States Vital Health Records Trust to function as a Central Trusted Authority. He also lists the USPS, SSA, local public health authorities, etc. as possible options.

VI. Compliance with Basic Functions Criteria

Compliance with the basic functions criteria depends upon the identifier's compliance with operational characteristics and the identifier components requirements. The LHSTR Number proposal complies with 2 of the 5 operational characteristics more than 4 of the 6 identifier component requirements. The proposal must comply with all of the components and operational characteristics to fulfill the basic functions discussed below. LHSTR 29/22 character length is unsuitable for manual use. Therefore, at best it can only partially meet the Unique Patient Identifier's basic functions.

Identification of individuals

Delivery of care functions: The LHSTR Number has the potential to support the positive identification of an individual required during the course of active treatment subject to the successful implementation of remaining components and operational requirements. However, the length of the identifier will be difficult for patients to remember and users to process manually.

Administrative functions: The LHSTR Number has the potential to support the identification for administrative functions required by practitioners, provider organizations, insurers, HMOs, federal health plan agencies, etc. subject to the successful implementation of remaining components and operational requirements. However, the length of the identifier will not be conducive to manual use by patients, providers, payers, etc.

Identification of information

Coordination of multi-disciplinary care processes: The LHSTR Number has the potential to support multi-disciplinary functions and coordination of care processes including, ordering of procedures, medications and tests, communication of results and consultations subject to the successful implementation of remaining components and operational requirements. However, the length of the identifier will present difficulty in manual use, such as verbal communication, telephone enquiry and personal interactions.

Organization of patient information and medical record keeping: The LHSTR Number has the potential to support automated collection, storage and retrieval of information subject to the successful implementation of remaining components and operational requirements. However, the length of the identifier will not be conducive to manual use. Currently, most of the provider organizations are required to maintain manual medical records in addition to electronic information.

Manual and automated linkage of lifelong health records: The LHSTR Number has the ability to identify, organize and link information and records across multiple episodes of cares and multiple sites of care subject to the successful implementation of remaining components and operational requirements.

Aggregation of health information for analysis and research: The LHSTR Number has the ability to support the aggregation of health information on the basis of groups of patients, regions, diseases, treatments, outcomes, etc. for research, planning and preventive measures subject to the successful implementation of remaining components and operational requirements.

Support the protection of privacy, confidentiality & security

Access Security: The Access Security and the authentication procedures needed to access the patient care information are not addressed.

Content-free Identifier: The LHSTR Number is a content-free identifier.

Mask/Hide/Encrypt/Protect/Disidentify: The LHSTR Number proposal includes encryption to protect the Identifier. This capability subject to the successful implementation of remaining components and operational requirements.

Improve health status and help reduce cost

The LHSTR Number has the potential to support the functions of a Unique Patient Identifier. It is contingent upon the establishment of both the administrative and technology infrastructures, the creation of the Trusted Authority, the design and development of computer software, hardware and communication networks and the implementation of security measures which will require substantial investment of resource, time and effort.

VII. Strengths and Weaknesses

Strengths:

1. The LHSTR Number meets most of the ASTM conceptual characteristics effectively (of the 30 requirements, fully meets 24 and partly meets 2). .
2. It meets three of the five operational characteristics.
3. It meets four of the six identifier components' requirements. It also meets the fifth one partially.
4. It meets both the basic functions criteria and the privacy, confidentiality and security criteria effectively.
5. Avoids crossover problems from an existing system that need to be corrected or those that cannot be corrected retrospectively.
6. The three (3) components of the civil registration namely, birthing hospital registries, the official report of birth and the alien registration documents together have the maximum potential to enumerate all individuals living in the nation for the issue of the 16 digit LHSTR Number.
7. The three (3) level data segments that support the LHSTR Number can provide both a reliable identification with a high degree of accuracy and the necessary information about a patient's previous episodes of care and medical records relating to them.
8. This is the only option that provides patient participation with PIN security.
9. Provides an opportunity to design an identification system that can take advantage of emerging technologies and available resources
10. Offers capacity to handle the nation's population for a foreseeable future.

Weaknesses:

1. LHSTR Number is at a conceptual level.
2. Untested - implementing a brand new system nationwide has inherent risk for its success.
3. Lack of existing infrastructure - technology and administrative infrastructures need to be established afresh.
4. Lack of existing plan and procedures - LHSTR Number requires the development of an implementation plan for the establishment of necessary infrastructure including the establishment of a trusted authority, definition of its power, organizational structure, operating procedures, etc.
5. Significant cost - planning, design, development and implementation of the LHSTR Number will require a substantial investment of resources, a huge effort and a longer time frame.

VIII. Potential Barriers & Challenges to Overcoming the Barriers

1. Establishment of a Central Trusted Authority
2. Substantial investment
3. Timeliness.

IX. Solutions to the Barriers:

1. The LHSTR Number is at a conceptual stage. It will present several challenges to completing the various preliminary tasks including the nation-wide system design, development and implementation.
2. Development of identifier specifications, design, etc.
3. Establishment of a Central Trusted Authority
4. Development of the necessary technology infrastructure including software, hardware and communication protocols
5. Development of implementation methodologies, policies and procedures.
6. Analysis of the cost-effectiveness and feasibility of timely implementation.

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