SYNTEL, A U.S.-BASED IT SERVICE PROVIDER WITH

AN EXTENSIVE GLOBAL DELIVERY SERVICE, SUGGESTS

SPECIFIC BEST PRACTICES FOR REDUCING COSTS

AND IMPROVING BUSINESS PERFORMANCE GLEANED

FROM HUNDREDS OF APPLICATION MANAGEMENT

ENGAGEMENTS AMONG GLOBAL 2000 COMPANIES.

A P P L I C A T I O N SA W H I T E P A P E R S E R I E S

SSN Remediation Approaches for Healthcare Organizations

With the growing threat of identity theft and thepassage of a number of federal and state regulations (includingHIPAA) aimed at protecting the privacy of individuals, healthcareorganizations are facing tremendous pressures to address the use of Social SecurityNumbers (SSNs) as patient identifiers. This has led to proposals for an alternate Universal

Healthcare Identifier (UHID) to be used in place of SSNs throughout healthcare organi-

zations, including within their back-office business applications

Because of the serious implications of failing to protect patients’ privacy, healthcare organi-

zations need to act now to address this issue. Drawing upon its vast experience providing

healthcare industry solutions, Syntel has developed SSN Remediation options and can help

organizations customize and implement an approach that best suits their requirements.

By leveraging Syntel’s healthcare industry and IT expertise, healthcare organizations can

not only address these legislative requirements—they can realize ROI and evolve their

infrastructure to support the business agility and efficiency they need to compete effectively.

INTRODUCTION

ADDRESSING COMPLIANCY

UNIQUE HEALTHCARE IDENTIFIER: ALTERNATIVE TO SSN

SSN REMEDIATION APPROACHES AND SOLUTIONS

ADDED BENEFITS TO SSN REMEDIATION: OPPORTUNITY TO EVOLVE INFORMATION SYSTEMS

CONCLUSION

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SSN Remediation Approaches for Healthcare Organizations

1.INTRODUCTION

Most US healthcare industry databases that contain privateinformation about individuals are designed assuming theSocial Security Number (SSN) offers a number of qualitiesthat make it useful as a database key, namely the fact thatit is a unique identifier, universal, and secure. In fact,because it is so widely used, the SSN by nature cannot beconsidered secure. With SSNs appearing on a range ofrecords, from intake forms to medical bills, and within allrelated medical databases, these numbers can easily slipinto the wrong hands. The widespread public exposure ofSSNs has greatly contributed to increasing incidents offinancial and criminal identity theft, with identity theftbeing the number one form of consumer fraud. In 2003,42 percent of all complaints received by the Federal TradeCommission were related to identity theft.2

Threats to privacy within healthcare organizations

Medical records may contain personal information relatedto family relationships, sexual behavior, and substanceabuse issues. A number of parties—including insuranceand drug companies, employers, employees, and courts—have access to these records. A lack of consistent privacyprotection may result in unauthorized or unintendedaccess to this information. Furthermore, there is a pushwithin the healthcare industry to create a national medicalrecords data bank, which could create a centralized andeasy target for identity thieves. The victim of identity theftmay be denied loans, admission to educational institutions,employment. He or she may experience difficulty securinghealth and life insurance coverage at a reasonable rate, orsecuring it at all. Ultimately, the greatest impact may bethe loss of dignity and autonomy suffered by this personas the individual spends years and significant sums ofmoney to clear his or her name and credit record.

Regulations to protect privacy

Over the years, the federal government has implementeda variety of regulations to address protecting the privacyof individuals, many of which are closely linked to the useof SSNs (e.g., 1996 HIPAA Privacy and Security Lawsand the 1998 Identity Theft and Assumption DeterrenceAct). More recently, many state governments have recognized the need to reduce the risks associated withthe disclosure and misuse of SSNs by taking measures tolimit their use and display. In fact, California Law SB168specifies how and when SSNs may be used by businesses.3

2.ADDRESSING COMPLIANCY

Clearly, healthcare organizations (HCOs) must complywith federal and state legal protections aimed at protectingthe privacy rights of patients and stopping identity theft.Some HCOs have already instituted plans to ensure compliance. For instance, the Blue Cross Blue ShieldAssociation has mandated that no Blue Plan shall displaya member’s SSN on the member ID card; all Blue CrossBlue Shield organizations must be compliant by January 1, 2006.

Those HCOs that do not take measures to protect theprivacy of their members’ identity and medical records riskthe loss of consumer confidence and ultimately, business.Consider IBM’s request in early 2003 that all 150 of itshealth insurance providers stop using SSNs as an identifier.IBM warned these companies that it would take compliancewith the request into consideration during the annualrenewal process.4

Recommended best practices

The California Department of Consumer Affairs hasdeveloped a comprehensive set of recommended practicesfor protecting the confidentiality of SSNs. In summary,the recommendations are as follows:

• Reduce the collection of SSNs• Inform individuals of the intended use when

collecting SSNs, and the consequences of not providing it

• Eliminate the public display of SSNs• Control access to SSNs by only allowing access

when necessary• Protect SSNs with security safeguards• Ensure your organization is accountable for

protecting SSNs by providing training and conducting risk assessments and audits 5

Beyond implementing these best practices, Syntel recommends that healthcare organizations implement:

• An alternative to the SSN as an unique individual identifier

• Remediation steps as concerns affected business applications and computer systems

“The Social Security Number (SSN) has a unique status as a privacy risk. No other

form of personal identification plays such a significant role in linking records that

contain sensitive information that individuals generally wish to keep confidential”.1

— Mark Rotenberg, Executive Director, Electronic Privacy Information Center

Targeting the Healthcare Industry

“The fact that HIPAA privacyand security standards areseen as a challenge to somehackers makes the health-care industry a target…Thiswas precisely the nature ofthe hack at the University ofWashington Medical Centerin Seattle in December2000. A hacker… allegedlygained access to the medicalcenter’s network throughthe affiliated university net-work and was able to steal4,000 patient records contain-ing PHI, including patients’dates of birth, SocialSecurity numbers, heightand weight and recent medical procedures.” 6

SSN Security ConcernsExtend BeyondHealthcare

Beyond protecting the rightsof patients, organizationsmust keep in mind the far-reaching implications of pre-venting SSNs from beingused by anyone other than itsowner. “In today’s world inwhich terrorism is a real con-cern, the SSN is a valuablecommodity for criminals atall levels, as it allows individ-uals to integrate themselvesinto our society with relativeanonymity and commitcrimes or acts of terrorism,while avoiding detection”. 7

3.UNIQUE HEALTHCARE

IDENTIFIER: ALTERNATIVE TO SSN

HIPAA’s administrative simplification provisions includea requirement that the Secretary of Health and HumanServices (HHS) adopt a standard unique health identifierfor all related constituents in the health care system8.However the Department of Health and Human Serviceshas yet to publish a standard, and while a variety of proposals for a Unique Health Identifier (UHID) havebeen published by various organization, none have beenadopted as a standard. In fact, a universal standard maynever be adopted; instead, individual organizations mayneed to define their own UHIDs.

Evaluating UHID candidates

The American Society for Testing and Materials (ASTM),a standards development organization accredited by theAmerican National Standards Institute, has published theStandard Guide for Properties of a Universal HealthcareIdentifier (UHID), which provides 30 criteria for evaluatingany proposed UHID. The 30 criteria are designed to support the following four basic functions of a uniquehealthcare identifier:

1. Positive identification of patients when clinical care is rendered.

2. Automated linkage of various computer-based records on the same patient for the creation of lifelong electronic healthcare files.

3. Provision of a mechanism to support data security for the protection of privileged clinical information.

4. Use of technology for patient records handling to keep healthcare operating costs at a minimum.9

While these criteria are worthy of consideration, ultimately,the selection of an UHID format may be dictated by off-the-shelf tools that HCOs utilize to implement anSSN remediation initiative.

4.SSN REMEDIATION APPROACHES

AND SOLUTIONS

Completely replacing the SSN as an unique patient identifierwithin healthcare organizations is not a practical optionbecause healthcare organizations will need to reference itwhen conducting such tasks as running credit checks orverifying a patient’s identity over the phone. Furthermore,due to the sheer volume of existing records that containSSNs as identifiers, organizations will need to keep these inplace in order to link old and new IDs and records.

When assessing which technology applications needremediating in order to protect patients’ privacy, HCOsshould take a methodical approach. (See Figure 1.)

Syntel recommends two alternatives to the use of theSSN as a patient identifier. Regardless of which approachis chosen, each option requires that organizations generatea new UHID and map existing SSNs to this new UHID.The resulting “SSN-UHID” number will be translated asneeded to properly populate and interact with variousapplications (e.g., claims processing and ID card printing)throughout the organization.

With a UHID strategy in place, the next step is to integrate it into UHID Generation methods.

Approach one: Map and Swap

The first and most desirable approach is to use the SSNas one of many attributes associated with the patient togenerate the UHID, in which case the SSN would onlybe referenced internally to ensure the integrity of apatient’s records. For all computer processing related to a patient’s records and account, the UHID would be usedand only this identifier would be visible on any externaldocuments, records, Web sites, etc. The SSN would beswapped with the UHID for almost all transactions permanently, and except in some situations, a cross-refer-ence between the SSN and UHID may not have to be maintained at all.

Advances in data-base technology

Due to the massiveamounts of existing electronic medical records,HCOs must contend withthe technological issuessurrounding SSN remedia-tion. Fortunately, HCOs cantake advantage of the factthat today’s database technology enables the useof alternate means of identifying individuals.Healthcare providers andrelated entities can nowconduct searches on multi-ple identifiers in a timelymanner without boggingdown system resources.This capability paves theway for establishing aunique health identifier toreplace the use of the SSNas the patient identifier.

STEP 3 STEP 4

Second, identify the impacted entities throughout the organization— thisextends to policies, processes, and employees(including contractors); computer systems; andcustomers, providers, and vendors.

Finally, HCOs will need to evaluate and select the solution approachthat is most appropriate for their environmentand situation.

Third, once the compliancy issues and timeframeshave been mapped to the various entities, it is timeto establish a new UHID format, as well as rules forcross-referencing the UHID and SSN. Organizationswill benefit from referring to the criteria published bythe ASTM standard guide in choosing a new UHID format.

First, identify compliance issues and time-frame(s) applicable to the organization’ssetting(s). While all organizations must complywith federally-mandated regulations, additionalregulations vary by state and by healthcare entity.

STEP 1 STEP 2

Figure 1. Implementing Remediation Steps: SSN Remediation Timeline

Because the SSN would not be used for processing, littlechance exists that HCOs would expose it and violatepatient privacy rights. This fact alone makes the Map andSwap approach a highly desirable option that the entirehealthcare industry would benefit from. However, in theinterim, there will be situations in which the SSN willhave to be used so organizations must plan to graduallymove towards this model.

While a desirable option, healthcare organizations needto recognize the following implications of the Map andSwap approach. First, the technological impact will besignificant. Since the UHID will likely be alphanumericand may have a length of nine or more characters, health-care organizations’ computer systems will require extensivechanges (e.g., database field reprogramming). Second, dueto the number of systems impacted (see Figure 2), thisapproach will result in long testing cycles and conse-quently, long project cycles. Third, the significant systemimpact and long project cycles will make this the morecostly of the two approaches. (See Figure 3.)

Figure 3. In the Map and Swap approach, the SSN is not visible to the public.

Approach two: Map and Wrap

In the Map and Wrap approach, the SSN will continueto be used most of the time for internal processing; theUHID will only replace the SSN for external communi-cations. Because of this, only those systems that relate toexternal communications will need to be modified toaccommodate translating the SSN to the UHID or viceversa. With less impact on systems across the organization,this solution requires less testing and thus can be implemented more quickly and inexpensively.

At the same time, because the SSN will still be widelyused across systems, the possibility of exposing the SSNon some form of communication (and thus violating thepatient’s privacy) will still exist. Since the translation ofthe SSN to UHID or vice versa will need to be introducedat appropriate times during business processes (which will likely change over time), maintaining these routineswill become an on-going part of system administrationand maintenance.

In this approach, care must be taken to ensure that HCOrepresentatives never divulge or ask for the SSN in anunsecured communication and thereby compromise thepatient’s privacy. (See Figure 4.)

Figure 4. In the Map and Wrap approach, the SSN could possibly be exposed.

UHID generation methods

There are essentially two options for generating a UHID. Generate a random number for eachpatient or custom design a fuzzy logic withparameters such as Last Name, DOB, etc., to generate the UHID. Regardless of how the UHID isgenerated, healthcare organizations should keepsome related issues in mind. Groups may askinsurers to use custom and/or group-generatedIDs to replace SSNs as patient identifiers. Downthe line, state or federal mandates may requireorganizations to use an UHID completely differentin size and structure to the one an organizationchooses today. Mergers and Acquisitions willpose unique challenges in merging subscriberdatabases and ensuring consistency betweenunique identifiers. Finally, privacy of the alternateidentifiers is no less important. Care must betaken to ensure that, if the number is accessed byan unauthorized person, related personal and private information will not be easily accessible.Again, the selection of an UHID format may bedictated by the off-the-shelf tools used to generatethe UHID. Due to these issues, HCOs may want tochoose a solution that offers them the most flexi-bility to handle these future scenarios and thatprovides the best mechanism for protectingpatient privacy, regardless of which ID is used.

Sales andPricing

ID CardPrinting

SNN is swapped with UHIDpermanently for the most part

External World sees only UHID

External World sees only UHID

External World sees only UHIDExternal World sees only UHID

Internal WorldInternal World

SSN UHID

Referrals andAuthorization

FinancialsGL. AP.

Enrollment

ClaimsProcessing

ProviderCapitation

PremiumBilling

CustomerCare

FeeSchedule

ProviderContract

Contracts

SSN UHID

SNN is maintainedfor the most part

Figure 2. Healthcare payer processor model and SSN remediation impact.Not Likely to be impacted

Likely to be impacted

UHID generation tools

As HCOs evaluate the best way to implement an SSNremediation project, the decision will largely hinge on thesophistication required to generate the UHID. Forinstance, will a new UHID be generated and will a cross-reference with the SSN need to be maintained (as inSyntel’s Map and Swap approach)? Or will there be anon-going requirement to translate between the SSN andUHID (as in Syntel’s Map and Wrap approach)?Depending on the chosen approach and the organization’sunique requirements, healthcare organizations will alsowant to consider the relative importance of other features,such as a matching algorithm capability to accurately andquickly compare and link data from different sources.

Out-of-box Enterprise Master Person Index solutions

The Enterprise Master Person Index (EMPI) is a solution that supports the creation of a unique identifierand cross-references the various patient identifiers frommultiple systems throughout the enterprise. As opposedto the facility-centric view provided by the traditionalMaster Person Index (MPI), the EMPI provides an individual-focused view of patient activity across theorganization. Several out-of-box solutions based on theEMPI concept are available to generate the UHID asdescribed earlier, including the following:

• SeeBeyond™ eIndex™ Global Identifier *• McKesson Horizon Passport *• Siebel® Universal Customer Master *

Custom and in-house solutions

Some HCOs may consider handling an SSN remediationproject in-house. If so, they will want to assess the availability of sufficient technical resources to provide theinsight needed to determine the optimal solution, as wellas the ability to implement the solution. Additionally,

organizations will want to ensure their solution addressesboth immediate and future requirements, to ensure theoptimal return on investment.

HCOs could decide to simply issue new non-SSN IDsand handle old accounts separately, but the impact acrossenterprise-wide systems makes this an impractical andcostly approach. The result will be a hodge-podge solution that will only serve as a type of band-aid.

5.

ADDED BENEFITS TO SSN

REMEDIATION: OPPORTUNITY TO

EVOLVE INFORMATION SYSTEMS

As HCOs assess their options in protecting their patients’privacy, they will realize the opportunity to evolve theirenterprise information systems to keep pace with the latesttechnological innovations. This becomes increasinglyimportant to ensure that the data contained within legacysystems is accessible throughout the organization andeven via the Internet.

The Service-Oriented Architecture

While Service-Oriented Architecture (SOA) models haveexisted for some time, they are taking on new meaning inthis age of electronic interconnectedness. The SOA modelhelps organizations efficiently reuse application businesslogic across multiple channels. It also enables organizationsto logically and effectively connect legacy and new applications, providing a solid foundation for organizationsthat wish to move toward a real-time enterprise model.(See Figure 5.)

Figure 5. Migration to Service-Oriented Architecture helps HCOs seamlessly connect data and reuse business application logic.

SUBSCRIBE ADAPTERS

Service Broker

Enterprise

J2EE/.NETWS Container

PUBLISHER

Mainframe

AS/400

Windows and UNIX

TWS*

GWS**

*TWS — (Translator Web Service)

** GWS — (Generator Web Service)

AP

AP

AP

AP

AP

AP

HTTP(S)AGENT

AGENT

AGENT

Process andService

ServiceRepositor

Data Base

LDAPEntitlement

SSN UHID

* These product names, marks,logos, and symbols are trademarksof their respective owners.

Realizing the Real-Time Enterprise

Gartner’s definition of the real-time enterprise concept isthat it helps organizations achieve “competitive advantageby using up-to-date information to progressively removedelays in the management and execution of its criticalbusiness processes”.10 RTE techniques enable faster accessto patient information and quicker execution of businessprocesses, ultimately adding significant value to initiativessuch as data warehousing and customer relationship management (CRM). According to Gartner, healthcareorganizations must possess these characteristics to improvequality of care while reducing costs.

Benefits beyond compliance

By investing in new and emerging technologies to addressthe issue of ensuring patient health information privacy,organizations will not only meet legal requirements andindustry best practices, but will also realize a return oninvestment. Implementing an SSN remediation solutionwill provide healthcare organizations with insight intosystem interdependencies which they can leverage to support the implementation of other required HIPAAidentifiers (NPI, NHI, NEI, etc.) and other strategicbusiness initiatives. In fact, forward-looking organizationswill seize this opportunity to streamline business processes,workflows, and infrastructure usage.

While pursuing the vision of linking HCO systems tostrategic goals (such as ensuring patient health informa-tion privacy) may require an unforeseen budget allocation,the ultimate savings through efficiency should outweighthe initial costs. On an industry level, the White Houseestimated in 2002 that the healthcare industry would incurcosts of approximately $18 billion over a ten-year periodto implement privacy-related measures. It also estimatedthat the healthcare industry would realize almost $12 bil-lion in savings due to these measures. “Further, there willbe additional savings in the long term because patientswill have more faith in the health care system, so they willbe less likely to withhold vital information from theirdoctors, and will more readily seek care”.11

6.

CONCLUSION

As HCOs contend with compliance deadlines and complex system architectures, they will benefit from theexpertise and support of a skilled IT vendor. Healthcareorganizations can leverage Syntel’s extensive healthcareindustry experience and our unique perspective on thespecific process issues, technology implications, and regu-latory factors affecting healthcare providers to successfullyimplement technologies that meet requirements and drivebusiness results.

Syntel Offers SSN Secure Remediation Solution

Syntel has developed a comprehensive SSN Remediationoffering—SSN Secure—that helps healthcare organizationsassess their options and ultimately implement the most

appropriate solution, whether it is custom or out-of-the-box. The Syntel process consists of field-tested steps toensure a successful project. Each engagement consists ofSyntel working with the customer to:

• Complete an initial exposure assessment across both operational (i.e., policy, process, and people) and technical aspects of the organization.

• Establish project goals and objectives.• Create a project execution strategy that aligns

with the organization’s goals and objectives.• Create a communication and training plan that

will help the customer address the required cultural changes throughout its organization.

• Perform a detailed impact analysis that provides the customer with insight into the extent of changes throughout the enterprise systems.

• Assist with appropriate tools and technology selection.

• Define a solution approach that meets the organization’s goals and objectives.

• Implement the solution in accordance with the customer’s timeline.

Partnering with Syntel

As the first U.S.-based firm to launch a Global ServiceDelivery model in 1992, Syntel has perfected this modelto deliver reduced time-to-market, enhanced efficiencies,and quality improvements for large-scale IT projects inthe healthcare and insurance marketplaces. Syntel is able to deliver complex IT projects with outstanding qualityand competitive pricing.

Syntel has developed an internal Healthcare Center ofExcellence, through which it offers customized healthcareindustry services leveraging its experience across a varietyof healthcare industry functions. These services addressapplication development and management, enterpriseapplication integration, data warehousing, enterpriseresource management, customer relationship management,health plan solutions, digital healthcare, Medicaid solutions, and regulatory compliance. Syntel crafts eachsolution around its deep understanding of the issues facingHCOs across claims processing, enrollment, eligibility andbenefits, sales and marketing, premium billing, contractadministration, revenue cycle, supply chain, departmentalsystems, and clinical data systems functions.

To date, Syntel has helped numerous organizations onboth the payer and provider side—including Humana,First Health Services Corporation, Blue Cross BlueShield of Georgia, Aetna, HCA, and Hanger OrthopedicGroup Inc.—stay ahead of a wide range of technologydevelopments. In short, Syntel has the experience,methodologies, and consultant training to help yourorganization protect patient privacy rights while implementing an infrastructure that will enable businessagility and deliver measurable ROI.

See back cover for references.

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References

1 Mark Rotenberg, Executive Director, Electronic Privacy Information Center and Adjunct Professor, Georgetown University Law Center, Testimony and Statement for the Record, Joint Hearing on SSNs and Identity Theft,Subcommittee on Oversight and Investigations, CommitteeFinancial Services, and Subcommittee on Social Security, Committee on Ways and Means, U. S. House of Representatives, November 8, 2001,www.epic.org/privacy/ssn/testimony_11_08_2001.html

2 Federal Trade Commission, National and State Trends in Fraud & Identity Theft, January – December 2003,January 22, 2004,http://www.consumer.gov/sentinel/pubs/Top10Fraud2003.pdf

3 Fight Identity Theft, California Law SB 168 (Debra Bowen) Identity Theft Prevention Questions and Answers,http://www.fightidentitytheft.com/legislation_california_sb168.html

4 CSO Magazine, Five Ways to Fight ID Theft, March 2004,http://www.csoonline.com/read/030104/idtheft.html

5 California Department of Consumer Affairs, Office of Privacy Protection, Recommended Practices for Protecting the Confidentiality of Social Security Numbers, June 2002;revised January 2003, http://www.privacy.ca.gov/recommendations/ssnrecommendations.pdf

6 Computerworld Magazine, Do no harm: HIPAA’s role in preventing ID theft, June 12, 2003, http://www.computerworld.com/databasetopics/data/story/0,10801,82051,00.html

7 Social Security Administration, Office of the Inspector General, Social Security Number Misuse fact sheet,updated June 2003,http://www.ssa.gov/oig/executive_operations/factsheet1.htm

8 United States Department of Health & Human Services,Health Insurance Portability and Accountability Act of 1996,http://aspe.hhs.gov/admnsimp/pl104191.htm

9 Joint Healthcare Information Technology Alliance,National Health Identifier for Individual Issue Summary,http://www.jhita.org/identif.htm

10 Gartner, Inc., Architecture Agility for Healthcare or Life Science RTEs, March 3, 2004

11 Health Privacy Project, Myths and Facts about the HIPAAPrivacy Rule, updated September 22, 2003,http://www.healthprivacy.org/info-url_nocat2303/info-url_nocat_ show.htm?doc_id=173435