Smart cards are set to revolutionize health care
But so far, it’s a tough sell to U.S. hospitals
An elderly accident victim is wheeled unconscious into the hospital emergency department, and the questions begin. Who is he? Is he insured? On Medicare? Medicaid? What about allergies? Has he visited this hospital before?
An ambulance technician hands over a small plastic card from the patient’s wallet, which is inserted into a personal computer (PC) port. In seconds, the screen fills with information telling medical staff that the 65-year-old man is on Medicare, in the care of a doctor on staff, diabetic, and an organ donor. All of that information, including his medical record, is stored on the patient’s plastic card.
That’s not a scene from a sci-fi movie. It’s happening now at a handful of American hospitals and could be coming to your hospital soon.
Celebration Health, the hospital serving Walt Disney’s Celebration, a planned community in Orlando, FL, and 11 hospitals in Oklahoma City have seen the value of smart cards for storing patients’ medical information. The Oklahoma hospitals already are using smart cards, and Celebra-tion Health plans to start using them next August.
Whether your records are stored mostly on paper or your organization is well on its way to a completely computer-based medical record, it’s important to understand and prepare for the coming revolution in information storage and management offered by smart cards. If proponents of the technology are correct, this system could revolutionize health care and health information management by providing up-to-the-minute medical information in a format that is easily accessible to authorized personnel yet secure from prying eyes.
Introduced about 20 years ago, a smart card resembles a credit card but contains an embedded microchip that can store significantly more data than the familiar magnetic strip you see on the back of credit and ATM cards. That chip essentially is a tiny computer, which is capable of making data processing decisions the reason the cards were dubbed "smart."
Smart cards have been used primarily as value-storage vehicles such as phone cards and, more recently, cash cards. In Europe, several countries are beginning to use the cards in health care, mainly to store insurance and personal information rather than actual medical records.
Insured patients in France can use the cards to pay medical expenses consultation fees, lab test charges, or pharmacy bills upfront and then file claims for reimbursement. In Germany, 73 million people are using them, and 110,000 physicians have been issued card scanners and printers. Everyone who seeks medical services must have his or her card scanned at each office visit. At present, the cards carry only about eight items of information, such as insurance carrier, name, and address. Spain is planning a combined health and social security card, which will use fingerprint technology for secure identification.
Change is on the way
Despite these developments, the idea of storing patient medical records on smart cards that patients carry in their wallets has been very slow to catch on in the fragmented American health care system. But as the Oklahoma and Florida hospitals show, that is about to change.
"The technology is absolutely here," says Randy Bednar, vice president of marketing for Precis Smart Card Systems in Oklahoma City, whose Precis Health Card System card is used by 7,000 cardholders, 11 hospitals, 57 doctors, 20 pharmacies, and two ambulance companies. "When you look at the American health care system with its different computer systems and different health plans we have all these different systems out there it becomes quite daunting to interface all that technology. There is no standardization across the board. But it’s not an either/or message. Smart cards absolutely will be an integral part of health care in the next century."
The Precis card carries personal information such as name, address, and phone number, as well as organ donor, allergy, and insurance information. But its most innovative feature is the medical information it stores. That includes a record of the patient’s last hospital visit, medical procedures performed, diagnostic notes, and medications prescribed.
The Precis system runs on Microsoft Windows software. Hospitals, doctors, and pharmacists have scanners that read the cards. When a patient makes an office visit, the smart card is read by a scanner attached by a port to a PC. Information categories are displayed on a one-page computer screen. Users click on categories to access specific information, Bednar says. For example, a click on the "medications" option reveals a patient’s current prescriptions.
A new prescription can be entered by the doctor during a visit although more often doctors jot the information down and give it to a clerk to input. "A doctor’s not going to type stuff in a computer," he observes. Once input, the information can be printed out.
If given a new prescription, the patient can take the printout to the pharmacist to be filled. Or the pharmacist simply can scan the patient’s smart card with updated information into a card reader and view the new prescription information.
Ambulance companies that use the smart cards carry a palm-top card reader on board. Their systems are read-only, Bednar says.
Security concerns
At present, the Precis cards, which have been in use only about a year, don’t use personal identification numbers (PIN) or any other type of security mechanism. "We can PIN-protect if we wanted to, but there are not enough readers out there" for security concerns, Bednar says. Because of this, if a patient loses a smart card, there is very little chance that anyone could access the medical information stored on it.
Once the technology takes off and more health care system participants have scanners, security measures will be added to the cards, he says. That could include patient signatures, hand scans, thumb prints, or eye scans, which must match what is embedded on the smart card to "unlock" the information.
Security measures are no small matter when it comes to storing medical information, but smart card proponents argue that personal information is safer from prying eyes stored on smart cards than on computer networks. Many people have access to computer networks, but smart cards permit access only to those who are authorized to "unlock" the information, those with designated readers and where security measures are used, Bednar argues.
At Celebration Health, set to open in November, use of smart cards for storing medical records is still in the planning stages, says George Stuart, president of Leapfrog Smart Products Inc., which is providing the systems integration technology for its SmartMed cards.
In a multiphase project planned with SunTrust Bank and VISA USA and scheduled to begin in February, Celebration residents will be able to use smart cards to shop, bank, and gain access to community common areas such as golf courses and tennis courts.
One card does it all
In Phase II of the project, which is set to roll out next August, residents’ medical records will be added to the information stored on their smart cards, Stuart says.
SmartMed cards will carry about 8K of memory on their microchip enough space for "all of the active medical information on a patient, up to and including notes from 10 doctor visits," Stuart says. "It’s like you’re carrying around a computer. You have as much computing power in your pocket as the old Commodore 64." By comparison, phone cards typically carry only about 1K or 2K of memory. Eventually, cards will carry as much as 32K of memory, he predicts.
There are about 46 million smart cards used worldwide to store some type of health information, according to the Smart Card Forum, the McLean, VA-based trade association. So far, they’re used predominantly to store insurance and personal information, not entire medical records.
As the technology catches on, smart cards are expected to offer many benefits to the health care field. "I think the card will have benefits in areas where you’re managing a particular disease that requires follow-up visits, like oncology or kidney dialysis. Treatment plans could be put on the card," Stuart says.
Leapfrog’s SmartMed cards are still in pro-totype form, but here’s how they will work. The cards will store patients’ medical, personal, and insurance information. They also will act as a secure electronic key to other remote or local data bases that will store patients’ entire medical histories. Card readers will allow medical personnel to view the stored medical information.
Some card readers will have write capabilities, enabling medical personnel to update patient information on the card. Others will have read-only capabilities. A central database will store all the medical record information. Access to the data will be available only to authorized users. Several layers of security, including the smart cards themselves, will ensure the privacy of that information.
Readers will become commonplace
Because the technology is so new, it’s difficult to pinpoint the price of a card reader. And like all new technology, that price will fall over time. For now, the readers are separate from PCs, linked by a port. Soon readers will come installed in PCs, just as floppy disk readers are now. As for the cards, price varies between as little as 80 cents apiece to as high as $1.15, depending on storage capacity, according to the Smart Card Forum.
Thus far, U.S. hospitals are proving a tough sell for the new technology. "Conceptually, it’s very easy to sell the idea," Bednar says. "But [hospitals] don’t do it. When you have a perception of new technology, everybody waits for somebody else to do it."
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