Since the Health Insurance Portability and Accountability (HIPAA) Act of 1996, interoperability has been a major goal for both the private and public sectors. Interoperability in the sense of creating an efficient and all-encompassing health care system that, quite simply, works for everyone. True interoperability is something entirely possible within our lifetimes, and the one thing that can accomplish this is something conceived back in the late 1990s: National Patient Identifiers (NPIs).
National Patient Identifiers are a proposed way to index patients on a national scale, under one system, much like Vehicle Identification Numbers and MAC addresses. It seems like the ultimate solution in interoperability, but since its proposal in 1996, there’s been a federal ban creating on NPIs. Why have NPIs, the potential silver bullet that may solve the health industry’s interoperable needs, been banned? Here’s our introduction to our ongoing series about NPIs.
Check out our other articles on interoperable solutions with HL7 FHIR, MARCA, and telemedicine.
The NPI’s Humble Beginnings
When looking at standards in health exchange and interoperability, we must harken back to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 America, which revolutionized the health care system. Not only did it give patients more control over their health information, it set standards for the privacy of health information. It also mandated the adoption of universal identifiers in health care; Title II Section 1173(b) of HIPPA states:
“The Secretary shall adopt standards providing for a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the healthcare system. In carrying out the preceding sentence for each health plan and health care provider, the Secretary shall take into account multiple uses for identifiers and multiple locations and specialty classifications for health care providers.”
HIPAA mandated the adoption of a unique identifier not only for patients, but also for employers, health plans, and providers. However, the debate over HIPAA’s release was focused on patient privacy. The Department of Health and Human Services (HHS) released a white paper, titled “Unique Identifiers for Individuals”, analyzing the benefits and drawbacks of NPIs. They recognized the “many benefits, including improved quality of care and reduced administrative costs. Being able to identify an individual unique is essential in both the delivery and administration of health care.” It seems like an essential part of ironclad health infrastructure, “having multiple identifiers for the same individual within or across organizations prevents or inhibits timely access to integrated information. Unique identifiers for individuals would facilitate ordering tests and reporting results; posting results, diagnoses, procedures, and observations to charts; updating, maintaining, and retrieving medical records…”
The HHS proposed implementing NPIs is many different ways, namely with unique identifiers based on an SSN, identifiers not based on an SSN, and even non-universal identifiers. Not only did they list various proposed methods, they listed the benefits and drawbacks of each respective method. However, NPIs were met with opposition as many argued against it based on a singular issue: privacy.
Concern over Breach of Privacy with NPIs
The main concern over having an NPI was the lack of patient privacy. The Clinton Administration’s President’s Quality Commission argued against NPIs, stating in the same white paper, “Having different identifiers for the same individual across organizations is sometimes perceived to be protective of individual privacy because potential linkages across data systems are impeded. Having all healthcare organizations use the same identifier increases the threat to privacy by facilitating unauthorized linkages of information about an individual within and across organizations.”
However, it’s worth noting that they also said: “This is why some believe that an electronic environment poses greater risks than one that relies on paper records.”
Other organizations also voiced concern over the lack of privacy an NPI would bring. The National Committee on Vital and Health Statistics gave its opinion: “it would be unwise and premature to proceed to select and implement such an identifier in the absence of legislation to assure the confidentiality of individually identifiable health information and to preserve an individual’s right to privacy.”
The debate over NPIs ranged over a considerable amount of time. However, the final nail in the coffin was Vice President Gore’s press release in 1999 where he stated, “Because the availability of these identifiers without strong privacy protections in place raises serious privacy concerns, the Administration is committed to not implementing the identifiers until such protections are in place.”
Since 1998, the HHS has been banned from working on a solution to NPIs.
A Possible Future for NPIs
It’s been 18 years since the ban on NPIs, but interest in it has not waned, rather it has grown. One of the data architects of HL7 FHIR, Graham Grieve, believes that a single patient identifier through an MPI (Master Patient Index) is “unavoidable.”
Standards such as HL7 FHIR are not enough, as Forbes’ Dan Murno notes, “FHIR may well be the HTML of healthcare, but we still need an MPI for any system to determine ‘who the hell we are.’ Anyone can generate an MPI of course and every electronic health record solution includes an MPI, but each one is different. There is no standard (and none pending) for this critical field used throughout the entire healthcare delivery ecosystem.” It’s important to note that, only the patient identifier was defunded. The National Provider Identifier is a thing—the CMS began issuing NPI’s in October of 2006.
The conversation over NPI’s has been steadily increasing, with both industry and political support, NPIs seem to be on drawing more attention. Stay tuned for Part 2 of our series where we look at NPIs in the present and analyze the benefits and drawbacks of NPIs.