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Should the country adopt
use of federally-issued patient identification numbers? The question has been the focus of
much attention lately, as Health and Human Services Department officials begin work on a
massive new system [GCN, Sept. 7, Page 82].


I want to use the issue to make a broader point about framing complicated information
policy problems. No matter what kind of information system you operate, you will
ultimately have to confront a challenge involving overlapping, conflicting and poorly
defined goals.


Let’s begin with the background. In 1996, Congress passed the Health Insurance
Portability and Accountability Act. The law included provisions designed to increase the
electronic transfer of health information among health plans, providers and
intermediaries.


The lack of standards for electronic transactions was widely recognized as a barrier to
efficiency and cost reduction. Savings could be billions of dollars annually. Assigning
standard identification numbers to health plans, health care providers and employers was a
key first step. Congress left the details to the HHS secretary.


The process of selecting identifiers for the health care entities is now under way. It
is mostly technical and has generated little public interest and only a few privacy
concerns. The fireworks didn’t start until work began on an identifier for
individuals.


The secretary was aware of the privacy implications of a new patient ID number. For the
other mandated identifiers, HHS jumped directly into rule-making. But for the patient ID,
the department was much more tentative. Rather than propose rules straight away, the
patient ID process began with a notice of intent, several steps removed from any actual
rule-making.


The secretary asked an advisory committee to hold hearings. The National Committee on
Vital and Health Statistics (NCVHS) held its first hearing in July. The notice of intent
was not yet ready so the department issued a white paper—which you can read at http://aspe.os.dhhs.gov/admnsimp/nprm/noiwp1.htm—to
focus the debate.


The paper took a narrow perspective on the patient ID issue. The attitude was that
Congress had mandated a patient identifier, so the issue to be decided was which
identifier to select. The paper offers several alternatives. It discusses other approaches
as well, but the main questions relate directly to the selection and implementation of an
identifier.


As a member of NCVHS, I can tell you the first hearing sparked tremendous controversy
across the nation. One major concern is that a new health identifier will quickly be
adopted for use in welfare, tax, credit and other purposes. It will likely make the Social
Security number obsolete.


You may not be able to work, travel or function without a government-issued health ID
card in your possession. There are other concerns as well, but I am not arguing about
their substance today.


At the hearings, two things quickly became apparent. First, there is no consensus on
which identifier should be selected. Opinions range all over the place. That was no real
surprise.


The second point was more interesting. The lack of agreement extends to the basic role
of identification in the health care system. Some opposed any new identifier. Existing
linkage techniques that do not use identifiers might solve the problem. Others argued that
many health care activities could be conducted without using identification at all. In
other words, it is not simply that people disagree on the appropriate identifier, they
disagree on the function of identifiers in the first place.


HHS followed the congressional direction to pick a patient identifier. That was the
wrong starting point. So much for letting Congress define the problem. The assumption that
a patient identifier is a good thing and is necessary to support linkage of patient
records may be wrong.


If we can articulate our underlying goals clearly, we may find that different solutions
will work at lower cost and with fewer risks to important values such as privacy. It all
remains to be seen, but we will never get anywhere if we don’t frame the questions
correctly.


The broader lesson is that as the world grows more interrelated and interconnected, we
have to make sure that we are looking for answers to the right questions. Don’t let
simplistic assumptions warp your thinking. Next time you are faced with a major revision
to your agency’s information system, see if you can define the goals and the needs
from a different perspective. It could save you a lot of time and produce a better
result. 


Robert Gellman, former chief counsel to the House Government Operations
Subcommittee on Information, Justice, Transportation and Agriculture, is a Washington
privacy and information policy consultant. His e-mail address is rgellman@cais.com.

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