# Presentation: 646476

## 
Dallas-Fort Worth Hospital Council 
Education & Research Foundation

Susan McBride, RN, PhD

**Dallas-Fort Worth Hospital Council **
**Education & Research Foundation**
**Susan McBride, RN, PhD**

**Dallas-Fort Worth****EMPI Record Linkage Project for:*****Improving Patient Safety, Quality & Health***

## DFWHC Data Initiative: Regional Collaboration

**Data Initiative started in 1997**
**Collected and reported data starting in 1998**
**The focus was on data and staying in front of public reporting initiatives and the issues surrounding the programs**
**Major Transition from the UB92/1450 format for exports to the HIPAA transactions format/Tx837**
**We now have over 8 years of data in the DI warehouse **
- 1999-2006
- Data 90 days out from close of quarter
- Approximately 6,000,000 million encounters in the DI warehouse to date
- Report on over 70 measures of patient safety and quality
**And,....The region recognizes:**
***The Power in collaboration!*****  **

## Value & Power in Collaborative Data

**Value & Power in Collaborative Data**

## EMPI Record Linkage Project:

**Applying advanced probabilistic matching algorithms to accurately link disparate person / patient records within and across healthcare organizations for improving patient safety, quality & health.**

***A Patient Safety & Quality Use Case***

## Linkage Project Overview

**Evaluated vendors**
**Narrowed to three vendors**
**Requested proof of concept**
**Two vendors agreed to proof of concept**
**Selected QuadraMed as a development partner for our Record Linkage project**
**Implementation is underway**

## Overview provided to Vendors

## QuadraMed Identity Management Solutions

**Smart Identity eXchange **
- Employs Probabilistic Technology to associate facility level identifiers to a person record within the DFWHC Data Warehouse
- Incorporates deterministic rules to evaluate external data to confirm or deny probable automatic record linkages
- Extensible data model to store DFWHC specific data elements
**InterSystems Ensemble - Universal Business Integration Platform**
- Integration Platform
- Extensive library of Adapters including: HL7, ANSI X.12 (e.g. 837), HIPAA and SQL Server
- Industry standard development: XML, SOAP, JAVA, EJB, COM, VB.NET, C++, etc.
- Industry Standard Access: ODBC, JDBC, Relational Gateway
**SmartMerge**
- Identity Management application for moderate to low probability linkages

## Getting Started: The Partnership Plan

**QuadraMed (up to 300 hours)**
- Perform SmartScan Weight File Generation
- Install Ensemble
- Implement Smart Identity eXchange
- Install SmartScan
- Install SmartMerge
- Provide Training on QuadraMed Products

**DFWHC **
- HIT/HIE Infrastructure
- Purchase Dedicated Windows Server
- Provide Remote Access to Smart Identity eXchange
- InterSystems Ensemble Training
- Staff support: Epidemiologist, SAS Data Analyst (Linkage Expertise), Sr. Leadership support, HIT Support
- Collaborative Committee Support

**Cooperatively Define Initial Auto Linking Process Rules**

## QuadraMed’s Part of the HIE Landscape

**GET**

**SEND**

- Source: © 2004 The Markle Foundation   Graphic adapted from Tom Benthin original.

**De-Identified****Data**

**Reporting**
**Router**

**Message**
**Transfer**

**FIND**

**QuadraMed**
** ****Smart Identity**
**eXchange**

**Provider asks if there are records for his/her patient**

**Index sends****location of****any records**

**Source****sends index****information**

**LOCATOR**

**Provider asks****for and receives records**

**Records****are sent to Provider**

**TING**

**Source may push data for reporting**

**REPOR**

**Data**
**Sources**

**Patients**

**Providers**

**Hospitals**

**Diagnostic**
**Services**

**Payors**

**Public Health****Providers**

**DATA**

**Individual**
**Care**
**Providers**

**Patients**

**Providers**

**Hospitals**

**Diagnostic**
**Services**

**Payors**

**Public Health****Providers**

**Public**
**Health**

**Notes:**
QuadraMed’s Smart Identity eXchange conforms to the Markle Foundations definition of a record locator service.

## Smart Identity Management Solutions

**Smart Identity Management Solutions**

**Complete**
**Identity**
**Management**
**Solution**

**Smart I/X® with SmartMerge®**
**& SmartManager®**

**SmartScan® Data Analytics**
**& MPI Cleanup Outsourcing**

**DFWHC EMPI Business Needs****	****     **** Solution Component**

**SmartPAL® Probabilistic**
**Matching Algorithm**

**SmartID® & SmartSwipe®**
**API  -  HL7 Q/R  –  Web Services**

**Record Matching Technology**

**Passive Indexing**

**Active Indexing**

**Remediation**

**Specialized**
**MPI Professional**
**Services**

**Technical **
**Solutions**

**Notes:**
The product set that QuadraMed offers utilizes a probabilistic matching algorithm called LinkSearch to accurately locate patient records along with all duplicated person records within a single MPI file and across multiple MPI files.  Using this technology within a single MPI we are able to accurately identify all possible duplicate patient records within a patient database. When this technology is employed across two or more MPI files we can accurately identify how to join patient records across multiple organizations to compile a common electronic patient record.  In summary there are four application components that the QuadraMed MPI Solutions Group provides; they are:

SmartScan Analysis – complete analysis of one or more MPI files employing probabilistic matching technology to identify duplicate patient records within a single MPI or overlapping patient records in two or more MPI files. 
Smart Identity eXchange (Smart I/X) – InterSystems Ensemble Server based application that monitors HL7 ADT messages to identify duplicate or overlapping patient records as soon as they are created within an organization’s MPI file(s). 
SmartMerge – Medical Records application that allows an organization to review and resolve duplicate or overlapping patient records identified by MPIspy. 
SmartID – Registration portal to employ probabilistic matching technology to accurately locate patient records to significantly reduce the risk of creating new duplicate records.  This tool can also be employed in an integrated delivery network to search multiple MPI files to facilitate the transfer of patient demographics from one MPI to another or to assist in linking of patient records across an enterprise.   SmartID has seven different scripting modules that it employs to automate the sending and receiving of information to third party healthcare applications; they are: 
3270 & 5250 terminal emulation scripting module  for mainframe based applications using the de facto HLLAPI integration standard with the Rumba and Attachmate terminal emulation packages
vt220 terminal emulation scripting module for mini-computer or UNIX based applications using the HLLAPI standards for Rumba and Visual Basic Script integration standards and Reflections terminal emulation packages.
The Windows scripting module that enables SmartID to integrate with Windows applications using non-invasive techniques defined (or exposed) by Microsoft.
The Java scripting module that allows SmartID to communicate to web-based applications that use Java for the user presentation layer.
The Meditech scripting module to enable SmartID to communicate to Meditech Magic and GUI based version of the Hospital Information System
HL7 scripting module provides a mechanism for SmartID to send HL7 messages to third party systems to create, modify patient records.  This module can also be used to initiate the merging or linking of two patient records together in third-party systems.
Direct Database scripting is also available to SmartID to allow it to programmatically access third-party system’s databases directly to retrieve or update information.
SmartSwipe Incorporate magnetic card and 2D Barcode readers to read encoded demographic information contained on State issued driver’s license, Credit Cards, Federal Department of Defense ID cards, and some insurance cards.

## Probabilistic matching1
Scientifically “Tunes” Itself To The Data Characteristics
45,000+ First Name Synonyms/Aliases
Accommodates For Common Data Entry Errors/Anomalies 
Mis-keys 
Mis-spellings 
Punctuation Errors
Abbreviations
Digit Rotations, Etc.
Phonetic Matching on First & Last Name and First Name Aliases
First Name / Last Name Transpositions
Adapts To Your Baby Naming Conventions
Advanced Probabilistic Blocking And Weighting
Other Advanced Person Matching Logic

**Scientifically “Tunes” Itself To The Data Characteristics**
**45,000+ First Name Synonyms/Aliases**
- Accommodates For Common Data Entry Errors/Anomalies
- Mis-keys
- Mis-spellings
- Punctuation Errors
- Abbreviations
- Digit Rotations, Etc.
- Phonetic Matching on First & Last Name and First Name Aliases
- First Name / Last Name Transpositions
- Adapts To Your Baby Naming Conventions
- Advanced Probabilistic Blocking And Weighting
- Other Advanced Person Matching Logic

**1****“Building an Enterprise Master Person Index” (AHIMA Practice Brief) January 2004**
**“****Surveying the **_**RHIO**_** Landscape: A Description of Current RHIO Models, **
**with a Focus on Patient Identification (AHIMA Practice Brief) January 2006**

**Diagnosis : Data Analysis**

**Notes:**
QuadraMed is only one of two vendors that incorporate the Fellegi-Sunter advanced probabilistic matching algorithm into a robust turnkey identity management solution.  QuadraMed has proven the accuracy of its implementation of the Fellegi-Sunter probabilistic theory through ten years of delivering its applications to numerous healthcare organizations.  The accuracy of the QuadraMed technology has also been verified multiple times to other leading vendors with similar products in pre-sales comparisons.

QuadraMed’s nickname/alias database significantly increases the probability of locating a person’s record regardless of the nickname used in previous registration events.  This one component truly set us apart from competitive solutions.

## Probabilistic Matching Criteria

**Data elements used for ****blocking ****& matching**
**First Name (Phonetic)**
**First Name Alias (Phonetic)**
**Last Name (Phonetic)**
**Middle Initial**
**Gender**
**Month-Day-Year of Birth **
**SSN**

**Phone Number**
**Mother’s Maiden Name**
**Address**
**City, State & ZIP**
**Race/Ethnicity**
**Marital Status**

**Query Flags** dynamically govern the types of records evaluated for each search by varying the logical conditions applied to the **blocking** **elements** used to select records for evaluation.

**Notes:**
QuadraMed’s uses an enhanced NYSIS phonetic encoding algorithm to block (determine what records in the MPI should be selected for analysis) and probabilistically score each record for search and matching purposes.
Query flags are used by the Smart Identity eXchange to dynamically constrict or expand the number and type of records evaluated for each search to optimize the speed and accuracy of the probabilistic search process.

## Configurability & Scalability

**Notes:**
Smart Identity Exchange can be deployed on a single server and yet is scalable to support a distributed architecture.

## QuadraMed Smart Identity Exchange

**Standard Data Elements:**
**Identifiers** – type, issuing authority, trusted vs non-trusted, effective dates
**Names** – type, prefix/suffix/degree, effective dates, identity unknown & confidentiality flags
**Addresses** – type, effective dates
**Contact Info** – type, effective dates, comments, telephone/email/IM, etc.
**Relationships** – type, person vs. organization, effective dates
**Demographics **– gender, MMN, birth & deceased info, marital & military status, religion, language(s), citizenship(s), race(s), ethnicity(s)
**Custom Attributes** – customer-defined, unlimited

## So what does this process look like,....

## Initial Process:

**Initial Data extracted from DFWHC Warehouse**
**Runs through Smart I/X and then extracted for SmartScan Analysis**
**SmartScan scientifically computes the probabilistic weights for all demographic database record elements and performs the initial detection of duplicates**
**Autolink will occur based on linkage weight and predetermined deterministic matching criteria**
**Moderate to Low Probability duplicate records will be output to SmartMerge for clerical review**

## Batch Processing

**Quarterly Extractions will flow through the same process as above**
**Will load into Smart I/X in real-time and will autolink in real-time**
**Again, records not meeting the weight threshold and criteria will be left for review in SmartMerge**
**NOTE:**
**All existing records based on site specific ID will be updated with the most current information.  **
**All updated records will be reevaluated to see if they represent a duplicate individual.**

## What do we intend to do with this data once the EMPI is available,....

## Plans for the future

**Link Inpatient to Outpatient Hospitalization Encounters**
**Link Multiple Outpatient Encounters**
**Calculate 30, 60. and 90 day Re-admission Rates**
**Develop episodic metrics & analytic capability to evaluate chronic illness models for congestive heart failure, pneumonia, and other identified chronic illnesses.**
**Link cardiovascular, stroke, and chronic disease research data  to our Inpatient and Outpatient databases**
**Support research activity to improve healthcare delivery**
**Improve patient safety and quality efforts**
**Track complication rates**
**Track infection rates**
**Evaluate ability to use the technology to address physician data integrity issues (Issues with UPIN, State Lincense #s, & Multiple Federal IDs)**

## Challenges Expected

**Resource to examine the duplication issues**
**Logic to automate linkage based on patterns seen in the cases that are in the pool for review in SmartMerge**
**Masking criteria protecting substance abuse and HIV create linkage challenges (SSN: 999.99.999; John & Jane Doe)**
**Dual development**
- Methods for using the data
- Methods for further automating autolinkage

## Statistics on Volumes

**Total discharges: 6,192,054      **
**Discharges missing SSN: 1,452,593      **
**Discharges with SSN: 4,739,461      **
**Unique SSNs: 2,196,685      **
**SSN with Single discharge: 1,225,145      **
**Range of SSN count: 1 to 180 **

## Questions & Discussion

**Contact information:**
**Susan G. McBride, RN, PhD**
**Sr. Vice President Dallas-Fort Worth Hospital Council**
**President of DFWHC Education & Research Foundation**
**972-717-4279, ext 5033**
_**[smcbride@dfwhc.org](mailto:smcbride@dfwhc.org)**__** **_