Smart cards: They’re not just for pay phones
So far, it’s a tough sell to U.S. hospitals
The 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 PC port. In seconds the screen fills with information telling medical staff that the 65-year-old male 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 happening in 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 are already using smart cards, and Celebration Health is preparing to start using them next August.
Whether your records are mostly stored on paper or your organization is well on its way toward 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 both easily accessible to authorized personnel and secure from prying eyes.
Introduced about 20 years ago, a smart card resembles a credit card but contains an embedded microchip which can store significantly more data than the familiar magnetic stripe you see on the back of credit and ATM cards. That chip is essentially a tiny computer, which is capable of making data processing decisions and 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 already beginning to use the cards in health care but 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 the cards, 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.
But so far the idea of storing patient medical records on smart cards that patients carry around 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." (For potential uses of Smart cards in health care, see p. 188.)
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 card scanners which 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 the information. "A doctor’s not going to type stuff in a computer," Bednar observes. Once inputted, 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 can simply scan the patient’s smart card with updated information into a card reader and view the new prescription information.
Ambulances that use the smart cards carry a palm top card reader on board. Their systems are read-only, Bednar says.
At present, the Precis cards, which have been in use only about a year, don’t use PIN numbers 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, Bednar says. That could include patient signatures, hand scans, thumb prints, or eye scans, which must match what is embedded on the smart card in order 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 stresses.
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, he adds. Eventually, cards will carry as much as 32K of memory, he predicts.
There are currently 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.
Although Leapfrog’s SmartMed cards are still in prototype form, here’s how they will work. The cards will store patient medical, personal, and insurance information. They’ll also act as a secure electronic key to other remote or local data bases that will store the patient’s entire medical history. Card readers will allow medical personnel to view the patient’s 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 those who are authorized users. Several layers of security, including the smart cards themselves, will insure the privacy of that information.
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 eighty 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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