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Smarter than you think: although many European and Asian countries embrace smart cards with personal health information, U.S. healthcare organizations are slow to adopt them - Authentication/Biometrics
Phil ReynoldsDaily life is becoming more mobile, including in healthcare. It seems like everyone carries his own cellphone, and laptops and personal digital assistants (PDAs) allow physicians to get anytime, anywhere access to patient information.
Comfortable with the mobility and efficiency that new technologies offer, many European and Asian countries have provided smart cards with personal health information to their citizens, but U.S. healthcare organizations (HCOs) have been slow to get onboard with the secure, portable devices (Figure 1). It's unusual behavior for a country that considers itself to be a technology leader.
The Grass Is Always Greener ...
The standard healthcare smart card is a credit card-size plastic card that contains an embedded microprocessor chip and memory, so compressed, encrypted data can be written to and read from the card. Memory size is as high as 64 KB, which permits storage of about 500 pages of text, but no significant graphical information. Larger memory allows additional functionality such as making copayments or verifying a stored personal identification number, and some cards display a photograph or a biometric thumbprint to help identify the cardholder.
All of the cards, though, contain some kind of basic health information such as a person's name, allergies and an emergency contact--data extracted by card software from a healthcare information system or entered directly into the application.
Early this summer, Taiwan issued a 32 KB card with personal health information to more than 22 million citizens. The European Commission has proposed June 1, 2004, as the launch date for a common health insurance smart card to facilitate health treatment that European Union citizens might need during a temporary stay in a member country. France got an early start with smart cards in 1993 with its Sesam-Vitale card that began as a health insurance card containing only administrative data, but later became a health card also holding personal health information.
In contrast, there have been a number of U.S. healthcare smart card deployments in the past decade, but most were government or pilot programs of limited scope. The Department of Defense began issuing MARCs (Multi-Technology Automated Reader Cards) as multifunctional IDs in 1994 to nearly 200,000 troops. The Western Governor's Association distributed cards to about 25,000 pregnant women, mothers and children in public health programs during the first phase of its 1999 pilot Health Passport Project. In January, The New England Partners Project awarded a contract for its pilot that includes about 10,000 people participating in public health and human services programs.
On the private side, Precis Smart Card Systems conducted a 1994 pilot in Oklahoma City that involved physician practices, hospitals, ambulances, pharmacies and about 3,000 patients, but it suffered from a lack of computer-based patient record data. The University of Pittsburgh Medical Center rolled out its Healthcare Passport card to 300 UPMC Health Plan members in 2001; it has since issued 10 times that number of cards to other patients.
"Our federal government is investing in an infrastructure initially being used as an ID card, but it's establishing a platform to take the costs out of services such as healthcare that it provides to its employees," says Randy Vanderhoof, executive director of the Smart Card Alliance. "The major challenge in healthcare is that the motivations for patients, doctors and insurance companies are not going to benefits everyone at the same level."
Why Not Healthcare?
As in other countries, smart cards are more widely used for finance, transportation and mobile communications in the U.S., so why not healthcare? There are several factors:
Government. Unlike many European and Asian countries, the U.S. has no national healthcare system. U.S. healthcare is provided primarily by private, manage care organizations with competing interests. "Our government took the first step in healthcare with HIPAA regulations, but that's far from the type of influence the Taiwanes and French governments have had," Vanderhoof says.
Professional culture. HCOs want to remove inefficiencies to be more profitable, but there is no over-seeing entity driving them to implement smart cards. One theory is that if payers don't endorse smart cards, it discourages HCOs from using them. "If smart cards facilitate faster claims processing, insurance companies would have to pay off doctors more quickly," Vanderhoof says.
Cost. Typically, the costs of smart cards and readers have been prohibitive for anything but a government program or the smallest pilot, but as technology advances, the cost of cards decreases and their price-to-performance ratios improve. The typical card now costs about $1 and a USB-connectible reader costs about $10. HCOs that don't want to foot the bills themselves for a wide-scale deployment will have to seek government or private funding--or charge consumers directly.
Infrastructure. Smart cards require readers, and few healthcare providers have them. Given the popularity of both desktop and mobile computers, some vendors now manufacture PCs, laptops and PDAs with built-in card readers. "Connectivity and getting users to use readers was an overwhelming obstacle, but this will become less of a problem as time goes on," Vanderhoof says.
Interoperability. Since vendors are utilizing different operating systems for their smart cards, it is difficult to ensure that the cards can be used at varied sites, which is crucial for wide-scale deployments. However, industry executives have formed committees to discuss setting standards for smart cards, including a common application programming interface such as Java--perhaps the most widely used operating system worldwide.
Privacy. Americans are much more concerned about privacy than Europeans and Asians, so anything that challenges their privacy is considered threatening. "The privacy advocates are a very strong voice, and they're all against the government being able to identify us. They want anonymity, which is considered to be a basic right of our society," Vanderhoof says.
Social culture. Smart card technology use is prevalent in Europe, so Europeans are used to it and they understand it. Americans aren't, and they haven't been provided with a logical case of what smart cards would offer them. "You don't sell the customer on the technology, but on the benefits of the technology. That's the approach healthcare providers should be making to their customers." Vanderhoof says.
Despite these challenges, HCOs and providers across the nation continue to demonstrate their interest in and dedication to smart cards.
Showing One Cares
When Dan Dietrich, M.D., was diagnosed with cancer in 2000, he experienced what many patients experience when they visit different physicians and facilities: repeatedly filling out paperwork to provide his medical history, including an allergy to penicillin.
Frustrated with having to answer the same questions over and over again, Dietrich co-founded the company Health Data Card (HDC) in Omaha, Neb., in June 2001 to provide a smart card of the same name with basic but important health information on a secure, portable device that people could present to healthcare providers.
Last year, HDC began a pilot program involving Dietrich's Alegent Health Family Care Clinic in Omaha. Dietrich bought the cards for about 500 of his patients and charged them nothing. He entered the patient's demographics, immunizations, allergies, emergency information and current medications into the HDC system. Dietrich printed all of this information for the patient to verify before he issued a 16 KB card with the encrypted, compressed data.
Physicians in his consultant group get the read/write software and readers free. "It gives nurses a jumpstart in getting information from a patient," he says. "From a doctor's standpoint, it's a way of saying that they really care about their patients by giving the cards to them free."
However, many cardholders were disappointed when they learned that most of Omaha's emergency rooms (ERs) could not read the cards, so HDC began providing the ERs with free read-only software and card readers. HDC also gave the software and readers gratis to local emergency response units, which knew when someone had a card by a sticker on that person's home or vehicle window. Also, HDC offered the software and readers to physicians outside of the Omaha area such as those who treat cardholders spending the winter in Florida.
Use of the card meets HIPAA regulations, since its information is not moving directly from doctor to doctor. "As a physician, it took a big worry out of my hands because the patient is in control of his own information. There's a blind consent when giving the card to another doctor," Dietrich says.
Since the software and readers are licensed only to medical professionals, the card does not require user authentication, according to Dietrich. "I think people have trust in our system," he says. "The chip is much more secure than paper records, and we didn't want to put any more responsibilty on doctors. Patients are more concerned about people hacking into Internet-based information rather than a card in their possession."
Making Information Mobile
To provide better care for more than 1 million ER and ambulatory care visits by many patients who do not speak English, Queens Health Network (QHN) in New York City began issuing smart cards with health information in August. QHN comprises Elmhurst and Queens Hospital Centers, 15 community-based medical centers and practices, and six school-based health centers.
Elmhurst Health Connection Cards will be issued to about 10,000 patients of the Adult Primary Care service at Elmhurst Hospital during the next year, as the first phase of a pilot program, it is the first step in trying to share more patient information with physicians in the NYC Health and Hospitals Corp., of which QHN is a member, so that smart cards become part of the organization's information infrastructure, according to Al Marino, QHN's CIO.
The health network has provided free read-only software and card readers to the ERs at 10 other NYC hospitals, and it hopes to work with local hospitals as well as ambulance systems so they get the software and readers. QHN has spent about $200,000 on the program since July 2002, and it hopes to get grant money to expand the program to areas such as Women's Health services.
"We're trying to change our focus to improving health outcomes by moving information better," Marino says. "We want to be able to share information not just within our own health system, but within the community, and so patients have access to their information. We're excited about a patient being able to provide their information in an emergency situation."
Each card, manufactured by Redwood City, Calif.-based Gemplus Corp., consists of the patient's photo ID and a 64 KB chip that contains compressed text data such as name, address, emergency contact, allergies, current medications and recent lab results. The cards are updated automatically each patient visit through Elmhurst's adult mary Care service.
QHN complies with HIPAA regulations by patients that their cards contain personal health information and that they need to take caution in using the cards. "Patients can choose to give their card to whomever they want," Marino says. "That's their permission being granted when they give it to someone."
Although the cards do not require user authentication at participating hospitals, additional security measures could be developed for other settings such as a community health clinic or a kiosk, where a patient could access his card directly. Potentially, read/write software and readers could be given free to patients for use in their homes as part of a home healthcare program. "Patients are interested in the cards, and they can see a benefit in them," Marino says. "So far, the program looks positive."
Improving Community Health
Munroe Regional Medical Center (VRMC), a not-for-profit, 422-bed acute care hospital in Ocala, Fla., started using smart cards in 2000 to promote a healthier community. MRMC partnered with Grand Rapids, Mich.-based Conduit Healthcare Solutions as a beta site to provide the Medical Data Card to members of its Prestige 55 program, which offers vascular, cholesterol and diabetes screenings, mammograms and other preventative tests to seniors. The program began with more than 2,000 participants, but now almost 16,500 Prestige 55 members carry the card.
"Prestige 55 is the largest program at Munroe, and it was the easiest way to get a group into a pilot program," says Jennifer Wood, executive director of Volunteer and Senior Services at MRMC. "I was looking for something that could decrease staff workload and increase members' interaction with us. I felt smart cards would be the best way to go in the long run to provide services and information. They're certainly better than using bar codes or magnetic strip cards."
The 8 KB microprocessor chip card uses text files to store the last three results of each screening, as well as the member's MRMC medical records number, health plan information, primary care doctor, chronic medical history, allergies, emergency directives and living will contact. Prestige 55's annual $8 membership fees exclusively fund the card program.
Although the cards can be read only via her staff's laptops, Wood is working on getting readers into MRMC's ER and a local ambulance service. She also is considering implementing a kiosk system, perhaps at satellite locations, so that cardholders can read designated information on their cards.
"One of the troublesome areas for us is portability. Until smart cards are being used extensively in other parts of the country, ours are only good in our area," Wood says. "Smart card technology is not as prevalent in our country compared to other countries, but I'd like to see it happen here."
Members voiced their displeasure in not being able to use their cards during the 18-month period beginning in early 2002 when Wood suspended the cards' use while she investigated their compliance with HIPAA regulations. Now, if a member wants to give his card's information to a physician, the member must first sign a permission form before the card's information is printed.
Wood has experienced frustration with the smart card program, but only because she and her staff have been unable to devote a sufficient amount of time to improving it further. "We didn't realize it would grow so far," she says. "Our progress would have gone faster if we had a team devoted to implementing it, but we don't have the time to plan and market it."
Realizing the Future
For smart cards to become a commonplace healthcare device in the U.S., it will require the cooperation of diverse, competitive and complementary interests.
"We will see healthcare consortiums such as regional entities moving to this technology and implementations on an individual basis. They will become models for other groups to follow suit. If they control all of the pieces, then they can get a quicker ROI, but if they have to go outside of the homogenous system, it could be more difficult for them due to possible different technology being used," Vanderhoof says. "Healthcare providers could have individual health information on a national ID card that serves other purposes, using the U.S. government as a model, but there isn't a political will to do so."
Figure 1: Healthcare Smart Cards, Worldwide
North America
Millions of % of
Year Units Shipped Revenues
2000 0.02 0.1
2001 0.08 0.5
2002 * 0.22 1.6
2003 * 1.08 8.0
2004 * 2.66 12.3
2005 * 5.12 14.0
Europe
Millions of % of
Year Units Shipped Revenues
2000 41.10 98.3
2001 19.70 88.1
2002 * 15.20 80.7
2003 * 12.30 67.4
2004 * 17.50 60.8
2005 * 26.60 53.6
Asia/Pacific
Millions of % of
Year Units Shipped Revenues
2000 0.65 1.6
2001 3.14 11.4
2002 * 5.39 17.7
2003 * 9.68 24.5
2004 * 18.22 26.8
2005 * 38.31 32.4
All figures are rounded. Base year is 2001. * = projected.
Source: Frost & Sullivan, 2002 Study.
For more information about smart cards from Conduit. www.rsleads.com/312ht-201
For more information about smart cards from Gemplus, www.rsleads.com/312ht-202
For more information about smart cards from HDC, www.rsleads.com/312ht-203
COPYRIGHT 2003 Nelson Publishing
COPYRIGHT 2004 Gale Group
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