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PA Bulletin, Doc. No. 08-686


Reporting a Patient Identification Number

[38 Pa.B. 1783]
[Saturday, April 12, 2008]

   The act of July 20, 2007 (act) (40 P. S. §§ 1303.401--1303.411), establishes certain requirements relating to the surveillance, reporting, control and prevention of health care-associated infections. Under the reporting requirements for hospitals established in section 404(b)(2) of act (40 P. S. § 1303.404(b)(2)), a hospital is required to report health care-associated infection data to the United States Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), and its National Health Safety Network (NHSN), including the following:

Report[ing] patient-specific data to include, at a minimum, patient identification number, gender and date of birth. The patient identification number must be compatible with the patient identifier on the uniform billing forms submitted to the [Pennsylvania Health Care Cost Containment Council].

   In a letter from Stacy A. Mitchell, Acting Deputy Secretary for Quality Assurance, dated December 5, 2007, the Department of Health (Department) clarified that reporting of the ''patient identification number'' referenced in section 404(b)(2) of the act required the completion of three patient identifier fields as follows:

*   Patient ID No.--this is the primary field and should be completed with the patient identifier most useful to the facility's infection control efforts.
*   Secondary ID No.--this should be completed with the Patient Control Number. This is the patient's account billing number reported in Field 3a of the Universal Billing Form-04 (UB-04).
*   SSN--facilities must include the patient's social security number.

   Although the act does not require NHSN reporting until February 14, 2008, some hospitals began reporting as early as January 1, 2008. Early NHSN reporting has revealed that reporting the Patient Control Number (the patient's account billing number reported in Field 3a of the Universal Billing Form-04 (UB-04)) in NHSN's ''Secondary ID'' field overrides Patient Control Numbers entered previously in other events for that patient, and results in health care-associated infection reporting which does not comply with the requirements of the act. Unfortunately, the CDC was not aware of this override issue until it was brought to their attention by the Department in response to comments from hospitals conducting early reporting.

   To appropriately report patient identification numbers and allow for effective tracking of health care-associated infections in compliance with the act, a hospital is to report patient identification numbers as required under section 404(b)(2) of the act and Acting Deputy Secretary Mitchell's December 5, 2007, letter, with the exception that the information previously reported under the ''Secondary ID'' field is now to be reported in the ''Comments'' field.

   Only the Patient Control Number should be included in the ''Comments'' field. A hospital should not include any other data, text or information in the ''Comments'' field. To ensure data entered as part of early reporting complies with the requirements of the act, a hospital should edit data previously reported to NHSN under these requirements to move the Patient Control Number previously reported under the ''Secondary ID'' field to the ''Comments'' field. Hospitals should be aware that the Patient Safety Authority will establish similar requirements for the reporting of patient identification numbers under the provisions of section 405 of the act.

   The Department, the Health Care Cost Containment Council and the Patient Safety Authority will work with the CDC to create modifications to NHSN to allow reporting of the Patient Control Number in a separate patient ID field, and allow other data, text or information to be included in the ''Comments'' field.

   Pending the implementation of these modifications to NHSN, and in recognition of the fact that hospitals may have desired to use the ''Comments'' field to include information explaining why health care-associated infection data may not have been reported to NHSN in a timely manner as required by sections 404 and 405 of the act, the Department will not take action against a hospital under section 411 or the Health Care Facilities Act (35 P. S. § 448.411), as long as health care-associated infection data is reported in accordance with the act within 30 days of confirmation of the event. Any other noncompliance with the reporting requirements of sections 404 and 405 of the act may result in penalties as authorized in under section 411.

   Nothing in this notice shall relieve a hospital of timely complying with other requirements of the Medical Care Availability and Reduction of Error (MCARE) Act (40 P. S. § 1303.101--1030.910), including the reporting and notification requirements of sections 308 and 311 of the MCARE Act (40 P. S. §§ 1303.308 and 1303.311), except as those requirements may have been superseded, amended, or altered by Act 52.

   The Department will provide separate notice to hospitals when the necessary modifications to NHSN have been completed to allow reporting of the Patient Control Number in a separate patient ID field and release the ''Comments'' field for use by hospitals in including other data, text or information which they may desire to report.

   Persons with a disability who require an alternative format of this Notice (for example, large print, audiotape, Braille) should contact Will Cramer, Chief, Healthcare Associated Infection Prevention Section, Bureau of Managed Care, Room 912, Health and Welfare Building, 7th and Forster Streets, Harrisburg, PA 17120, (717) 787-5193 or for speech and/or hearing impaired persons V/TT (717) 783-6514 or the Pennsylvania AT&T Relay Services at (800) 654-5984.


[Pa.B. Doc. No. 08-686. Filed for public inspection April 11, 2008, 9:00 a.m.]

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