One of the "basic challenges that we face," says Jack Wolf, Montefiore Medical Center's chief information officer, "is the lack of a unique patient identifier."

Montefiore delivers care to some 2 million people in the Bronx and beyond, in its hospitals and some 100 ambulatory sites, including more than 20 Montefiore Medical Group locations.

It has long taken a keen interest in spurring better population health, seeking novel ways to tackle chronic disease, through various public health programs, including community-based health fairs, informational workshops and more.

Partnering with various agencies and community groups is an essential component of Montefiore's education and outreach. But when it comes to the brass tacks of care delivery, there are hurdles, says Wolf – specifically when it comes to tracking patients.
as they move among various care settings beyond the Montefiore system.

"When you start to talk about population health, and start to talk about the population in the Bronx, our patients make their decisions about where they want to go for their own healthcare, and it's not always to the same provider each time," he says.

"An individual might show up to an emergency room that's not part of our system, but we might be at risk for their healthcare," he adds. "Or it might just be that they decide that they want to go to a different provider or a different specialist, outside or inside of our network. And when they move from one location to another, it's difficult to say that Jack Wolf is the same Jack Wolf in the Montefiore system, now presenting in the emergency room of a Bronx-Lebanon or a Saint Barnabas.

"When you get into population health, tracking these patients is very dependent on being able to uniquely identify that it is the same patient," says Wolf. "Obviously when you get into certain areas it's critical you're certain you have the right person for allergies and medications."

The argument over the establishment of universal patient identifiers is a long and passionate one, of course. And Wolf recognizes this: "One person could say its more important to have access to your health record in a critical situation because it could save your life. Another might say, 'Well that's my decision, not your decision.'"

Still, despite that lack of a UPI, and the fact that New York is an opt-in state with regard to health information exchanges and regional health information organizations, Montefiore has been looking toward novel ways to solve the challenges of keeping patients identified as they move through different provider sites, locally and statewide.

"There are ways that you can identify the patient and still meet all the concerns (about) privacy," he says. "That's where I believe – and this is Jack Wolf's personal opinion – that the power of the HIEs and the RHIOs comes into play.

"Within our own environment at Montefiore, we have a master patient index for all of the patients that travel and receive care in the system," he explains. "If you go into the Bronx-Lebanon delivery system, they have their own master patient index.

"At the RHIO level, we could create a higher-level MPI, between Bronx-Lebanon and Montefiore. That RHIO could become a router – knowing that Jack Wolfe is 11111 medical record at Montefiore and 99999 medical record at Bronx-Lebanon, but anywhere I present, when it goes up and connects with the RHIO, the RHIO router says Jack Wolf also has records here and here and it is the same person – and therefore collects the health records."

Even beyond that, "you could take that up another level, to an HIE at the state level, where, Jack Wolf presents, let's say, in Albany, and all of a sudden the state HIE has that same MPI at the state level," he says. "You could keep aggregating it up."

No question, he says, "there are a lot of challenges in this, that we'd have to work very diligently with the state, and with the other provider organizations, to deal with. But I do believe there are ways around just creating a healthcare ID."

Toward that end, "we're working closely with the RHIOs, working closely as the HIEs are starting to evolve."
 
But the state opt-in law is also "one of the challenges that really hits us," says Wolf.

"For example, if we have a patient who's in a Montefiore-affiliated location, and their primary care physician is in that system, and all of a sudden we want to refer them down into the Bronx for our cardiology center of excellence, or our asthma or diabetes program, or for cancer care, we would have to get a signed consent form from the patient to allow a specialist to view their record – even for a consultation."

That, he says, "creates a lot of added work – and in some cases it even precludes the referral, until such time as you can get the consent form. As you move through different systems and really focus on population health, on creating care plans and populating medical records, it makes it very difficult."

Telescoping in from the sprawl of a statewide HIE, however, Wolf focuses on one simple fact: "The best way to share clinical information among providers is to have that information in the electronic medical record, easily accessible."

For example, "a physician in the emergency room would be logged onto our EMR at Montefiore," he says. "If a patient presents there, and we realize that patient has been receiving their primary care at another institution, with the connection capabilities of the RHIOs we can go pull that clinical data.

"But in today's world that clinician has to go into a separate system to view that data. If we could put that data into the EMR the physician is working on we could save a lot of time, we can save a lot of costs and we can prevent a lot of additional costs by having that information at the fingertips of the ER provider."

That, says Wolf, "is why this concept of being able to identify the patient and share the data right up front creates a much more fluent workflow for the providers."