CHOS-WG Scenario: Patient identification

Version 0.3, 25 May 2009, Etienne Saliez,

Generic scenario dealing with the opening of a patient record, the very first step is here to retrieve the right patient record.

Since it not known if a record already exist for the patient, the first step is always to try to retrieve an archived record.
In large medical centers of large cities, personal recognition is no more possible. Be careful, identification imply responsibilities which may be potentially even more critical than confidentiality issues.

A number or code pointing exclusively to one unique patient record.
A number makes sense in the context of an "Information Space", which must always be known in an unambiguous way, e.g. inside a given department of a given hospital, inside a given hospital, inside the national system of a given country.
In some systems a patient could have more than one identifications. As far as pointing to a unique patient several aliases may exist and could be useful.
Remark: depending of the cultural environment, some countries allow or do not allow the use of their national ID number for medical purposes.

Moreover in order to reduce the risk of typing error it is recommended to require to type some redundant check information, as a check digit and/or initials of first and last name (which oblige people to read not only the number but also the names).
If available reading an electronic card.

However the user is still responsible to check that the presented card indeed belong to the patient, particularly in case of children and elderly patients. In countries where some people do not have any insurance, a card could have been borrowed.

The problem is here that none of these descriptors is unique. The association of these descriptors reduce the risk of error to a very low level, which in practice is usually accepted although never perfectly safe.
What in case of incomplete information?

The hight probability level cannot be met, and it should not be allowed to search in the database. However in order to avoid to disturb the work, a unique patient ID nr may be created, but not merged to any preexisting record in the data base.
In practice a question of policy and a responsibility of the medical director. Some lazy medical centers retrieve patient only on a first and a last name. This should be strongly discouraged and forbidden by the software.

If 0 candidate, the patient does not exist in the database and a new record should be created.
If 1 or more candidates, look carefully at a few additional information, as e.g. address, date of latest contact, etc...

It is sometimes possible that none of the candidates would really correspond to the patient arriving at the reception. Two patient having the same descriptor is never absolutely excluded.
In case of doubt 2 errors are possible:

To create a second record for the same patient. The safest attitude because the lack of integration is just a little annoying and not worse than the old paper based administration.
To have 2 patients sharing the same record. A dangerous risk because information of one patient could be applied to the other one. For example the blood group of one given to the other.

After careful control, it should become possible to solve problems of temporary record and occasional error, but merge and unmerge of patient records are here out of the scope of the current basic version. A job reserved to a few responsible persons.

A short list of patients is proposed. For example a list of patients having an appointment, or being on the working list of a lab, etc...
A click on an entry in such a list, will open the record.

Anyhow an echo of the full identification of the patient plus few additional information (address, ..),is presented and the user is responsible to accept the proposal of the computer.
If necessary a new patient record is created.

Although not strictly a part of the identification, a set of administrative information is usually required, as:

Address, telephone, ...
Mandate for the Care Team, and who is the main referent doctor according to the choice of the patient.
Health insurance information:
Optionally if the patient agree some family links as partner, parent, children (NB: remember that the system works primarily on birth names).
...

As long as some information is missing, questions will appear. Of course when a new record is created, but even later if not yet available.
Adaptations can be made at any time if necessary. Moreover maybe after a predefined delay, a reminder asking to confirm that the information is still valid.

The patient should be recommended to carry a medical identification document.
If no such document is available nor some kind of official Social Security card, a card should be given to the patient.
A simple approach is to print a label and to set it on a small card with the address of the organization. The patient number is unique inside the organization, i.e. the "information space".
This label could contain a few more practical information, as full names, address, insurance, referent doctor, ...

So far we have a valid patient identification from an administrative point of view, but not yet the next steps as:

To check the authorization to access the medical content of the record : Access-Control.html .
To activate to medical software components.