Smart Cards for Healthcare

Smart cards for healthcare are well established in France, Germany and Taiwan, but they have received minimal attention in the United States. Benefits of a smart card include faster registration of patients, portability of medical records and potential data support for existing electronic health records.

When used in healthcare, smart cards contain medical data for the patient they represent. Rather than a paper chart or an electronic health record stored and transported over the Internet, this wallet-sized card contains a computer chip loaded with pertinent medical information. The chip interacts with a computer system to make stored health information available.¹

The exact type of smart card varies based on the type of chip in the card and how it is read.² Operating systems within the computer chip vary from fixed file structures to dynamic application systems; the latter is the most versatile at updating, managing and running different operating system applications.²

Smart cards are used for a variety of purposes – as identification cards for employees, financial institutions, colleges and universities, and as citizenship records.²

The amount of data storable on a magnetic stripe card (140 bytes) is considerably smaller than what is available on a smart card (1 KB to 4.9 MB).³ Most smart cards used for healthcare are integrated circuit processor cards, and they have a data capacity of 8 KB to 128 KB.³

Security for smart cards incorporates a photographic image of the user or biometric information such as digitized iris or fingerprints.¹ Two concerns for use with electronic health information are the amount of data storage and the security of the smart card itself. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires protection of personal health information. When health information is available on a wallet-sized card, how can you ensure the security of health records should the card be lost or stolen? Furthermore, who is held liable should the technology fail: the purchaser, the healthcare facility or the distributor of the technology?

Operating systems may contribute to security, but they may need to be available as supplementary points of data storage as well. Patients with chronic or complex conditions may require more data storage for completeness of their medical records. Compatible operating systems could store additional medical information relevant for particular patients. It may be prudent to keep emergent medical information as fixed data on the card and to use erasable storage space for communication between facilities (prescriptions, diagnostic imaging, etc.).

Use of the Technology
The most rigorous use of smart cards as portable medical health records is in Taiwan. In 2003, cards were issued to all members of the national health insurance program – more than 22 million people.²

In France, the use of smart cards dates back to field testing in 1982. This makes it the country with the longest history of smartcard use.⁴ France now has about 50,000 users.⁴ Germany is the largest European user of smart cards, boasting almost 80 million card users.¹

In the United States, pilot programs have been launched in a variety of locations. The most notable was the Health Passport Project (HPP), which ran from 1999 to 2002 in Bismarck, N.D., Cheyenne, Wyo., and Reno, Nev.¹ The HPP included 8,000 participants who received smart cards containing demographic, financial and medical information to be used for Women, Infants and Children benefits, healthcare services, Head Start programs, public health services, and immunizations.¹ The card could be used for accessing services such as cashless purchases and for scheduling of clinic appointments.¹

The smart card was also tested at Heritage Valley Health System in Beaver, Pa., with 40 kiosks in six outpatient locations.⁵ Both patients and staff reported benefits, and an estimated $1,400 was saved daily via the expediting of patient processing.⁵ Another localized use of smart cards is in El Paso, Texas, where patients can purchase their own cards at local hospitals and pharmacies for approximately $71 to assist in managing their own health information.¹

The usefulness of smart cards has been tested most recently in an emergency department in Australia. This cross-sectional survey of three tertiary emergency departments queried 270 patients and staff about the use and effectiveness of smart cards.⁶ The respondents cited advantages including assistance during emergencies, reduction in workload and time demands for staff (for patient registration), more accurate and complete information, avoidance of confusion, and improvements in communication.⁶ Eighty percent of patients said they believed it would save them time vs. 60% of staff.⁶

The use of smart cards is slowly growing in Canada, Latin America and the United States for healthcare, business and financial purposes, but growth is not standardized for a particular industry or country. Belgium is the first country to standardize smart card use, requiring each citizen to use one as an identification card.¹ Bulgaria provides healthcare smart cards for all military personnel and their families.¹

Taiwan’s national health system began using the smart card in 2003 as part of its national health insurance program. The cards are now used in 70% of clinics and hospitals.⁷ The switch from a paper card to a smart card was well supported by the strong technological foundation of electronic health records in Taiwan, as well as the presence of the national health insurance program.⁷ The cards contain photographs of the user, store 32 KB of information and are replaced approximately every 5 to 7 years.⁷

Smart Cards for the U.S.
Data storage, network security and technological infrastructure can make rapid interchange of sensitive health information between facilities difficult. This is where a smart card could have a role in improving U.S. healthcare.⁸ These portable media devices work well for healthcare because they can be easily updated and are just as easily transported as moving your wallet from place to place.⁸ The best combination of electronic health records and smart cards is to combine network-stored information with information available to be saved on a smart card. Smart cards cannot sufficiently contain the entire medical records of all patients, nor would it be safe to do so.⁸

The 32 KB of data storage on the smart cards could contain basic registration information, primary care provider contact information, allergies, immunizations, current prescriptions and chronic conditions. Additionally, medical facility usage could be accessed for troubleshooting medical and provider usage, such as determining pharmacy trends and avoiding dangers associated with polypharmacy.

Along the lines of a healthcare home, smart cards could contain all important medical information and could be used to limit or encourage patients to confer with their primary care provider. The card could also help provide expedited processing in emergency departments and with specialists, as well as assist in coordination of medication prescriptions. The gatekeeper model could be built into the card itself, in that the card would be swiped for every medical use and the provider would know the patient’s habits with regard to emergency services and filling (or not filling) prescriptions.

The benefits of a smart card can combine with the benefits of electronic health records to assist in data transport between facilities. Risks include the potential monopoly for smart card distributors and loss of revenue during the installation phase of cards, card readers and supportive technology.

The use of smart card technology could assist in managing healthcare data and usage. Once a critical mass of healthcare providers and consumers has been reached, the benefits of smart cards may expand to include improved outcomes and greater return on investment. The ultimate goals are to encourage a gatekeeper relationship with each patient’s primary care provider and to improve patient outcomes.

Ruth Ann Madden is a family nurse practitioner at Manassas Internal Medicine in Manassas, Va.

References

1. Ward SR. Health Smart Cards. Merging technology and medical information. Medical Reference Services Quarterly. 2003;22(1):57-65.
2. Smartcard basics. http://www.smartcardbasics.com/cardtypes.html. Accessed Sept. 30, 2011.
3. Oracle. Java Card Technology. http://www.oracle.com/us/technologies/java/javacard-135146.html. Accessed Oct. 4, 2011.
4. Jacquinot Consulting, Inc. Smart Card Overview. http://www.jacquinot.com/smartcards/smartcard_overview.htm. Accessed Sept. 30, 2011.
5. Kearns S. Care card technology improves health system’s patient flow and waiting time. http://www.healthleadersmedia.com/content/TEC-235448/Care-Card-Technology-Improves-Health-Systems-Patient-Flow-and-Waiting-Time.html. Accessed Oct. 4, 2011.
6. Mohd R, et al. Health smart cards: differing perceptions of emergency department patients and staff. Australian Health Review. 2009;33(1):136-143.
7. Smartcard Alliance. About smart cards. http://www.smartcardalliance.org/pages/smart-cards. Accessed Oct. 4, 2011.
8. Kardas GK, Tunali ET. Design and Implementation of a smart card based health information system. Computer Methods and Programs in Biomedicine. 2006;81:66-78.