Card Technology in Healthcare

Daniel L. Maloney

Director of Emerging Technologies

Department of Veterans Affairs, VHA OI

1335 East West Highway, Suite 300

Silver Spring, MD 20910

U.S.A.

CardTech/SecurTech 2001

May 16, 2001

Card Technology in Healthcare

Daniel L. Maloney

#### Director of Emerging Technologies

Department of Veterans Affairs, VHA OI

1335 East West Highway, Suite 300

Silver Spring, MD 20910, U.S.A.

phone: 301-734-0107, fax: 301-734-0111

email: daniel.maloney@med.va.gov

VA WWW - http://www.va.gov/card/

1\. Introduction:

There continues to be a lot of activity in the fields of medical
informatics, the Internet and smart cards. The French continue to move
ahead with their smart card initiatives in healthcare. The Netlink
project demonstrated the ability for viewers developed by different
groups in different countries to read data from smart cards with a
defined data set. The Western Governor's Association Health Passport
Project is demonstrating that data can be entered once and shared
between multiple programs of different organizations in multiple
locations. The U.S. military has been testing their new smart
identification card as they phase out the plastic identification cards
in favor of a chip-based multi-application smart card with Public Key
Infrastructure (PKI) capability. MedicAlert is exploring a smart card
that contains data and connects to more information stored on the web. A
recently introduced product measures blood cholesterol levels and stores
the results on a smart card and on a web site.

The Health Insurance Portability and Accountability Act (HIPAA) passed
by the U.S. Congress in 1996, is designed to improve payer/provider
communications of clinical information and reduce administrative and
overhead expenses. Healthcare providers, payers and healthcare
clearinghouses are subject to the provisions of HIPPA and will be
required to comply with their requirements. Because security and patient
privacy are included in the scope of the act, there has been an
increased level of interest in these topics and potential solutions to
address these problems.

As more people use the Internet, an expanding number of people would
like to have better electronic identification, authentication, privacy
and confidentiality. Privacy and Security are becoming issues often seen
in today's popular press. As more and more of our individual data become
available electronically, privacy and security of data are issues of
concern for every individual. It is becoming an issue of concern for
more people as more of our personal data becomes available
electronically. The new cards with cryptographic capabilities can
perform encryption calculations while protecting private keys.

In a non-medical area, both American Express and VISA are issuing smart
cards that have capabilities that go beyond the normal credit card
functions. The chip on the American Express Blue Card carries a
certificate and added security features to unlock an internet
"electronic wallet" that carries personal information used to
automatically fill out web forms when purchasing. There will be multiple
varieties of the VISA smart card because VISA provides a set of tools
that their members can customize to deliver various capabilities. One
VISA card allows the user to complete electronic forms on the web based
upon data stored on the card. This VISA card also allows the user to
store passwords that are used to access computer systems. Both companies
have given the user free smart card readers.

The Washington D.C metro system is using a proximity smart card with an
electronic purse application for paying metro fares and metro parking

The costs of biometrics fingerprint readers are decreasing while they
are becoming more accurate. This will leads to more opportunities for
systems access control including smart cards that store the fingerprint
parameters. Support also continues to grow for the Java card. More
powerful cards and card with more memory will continue to be introduced.
All of these improvements will make it easier to create and support a
variety of applications in medical and non medical areas.

2\. Pressures on Healthcare

Healthcare is not immune to the downsizing pressures that are pervasive
in our world wide economy. Efficiency and profitability are becoming
increasingly important in all types of healthcare organizations.
Insurance and government organizations are concentrating on cutting
healthcare costs and fraud. The healthcare provider is often frustrated
by their inability to access appropriate, accurate and complete
information about the patient's condition and treatment. Many patients
would like to have more access to and control over their patient record.
They would like more open and free access to their own medical records,
but they fear unauthorized access to their medical records

As more and more people use the World Wide Web as part of their daily
activities, access to data continues to become easier. Most people will
support open access to general educational health information that
allows the individual to better understand a disease or improve their
health. However, inappropriate access to an individual's private medical
data is a very different matter. The public debate will continue to heat
up as individual information is made available. It is easy to find
someone's phone number and address. There have been multiple reports of
hackers breaking into e-commerce Web sites and obtaining copies of
thousands of credit card numbers. While we are beginning to expect that
the information we need will be instantly available, we want individual
specific information to only be available to those that have a right to
see that data. People are beginning to worry about information
accessible on open networks that is only protected by passwords and
PIN's since these passwords can be discovered by hackers. More
sophisticated methods of user authentication will be demanded and
required. One solution to this privacy problem is to have all individual
data stored on web systems protected using sophisticated encryption
techniques. Only the user would have the keys to decrypt their data.
Only the user could grant access to other strongly authenticated
individuals. That access could be granted to portions of the data for a
limited period of time as identified by the owner of the data. While it
is easy to envision the technical solution, it is much more difficult to
implement that solution on a wide scale.

3\. Cards as part of the solution

Cards can play an important role in delivering healthcare solutions to
the patients. Cards can meet business needs with either low technology
or high technology solutions. Both patient cards and healthcare provider
cards need to be considered as a part of the system. Cards should not be
thought of as a stand-alone device. The network and the card are more
effective if they are combined to work together. A card can carry a
visually readable and an electronically readable identifier to speed
patient information lookup. This can lead to decreased paper work and
decreased administrative costs, decreased date entry error, and better,
faster delivery of services and benefits. Information can be retrieved
more easily and more quickly when the card is used as the key for data
lookup, or when the card is used to store the data. Faster access to
data can result in improved service, increased patient convenience and
improved patient satisfaction. When the card is used as a factor in
establishing patient identity, fraud can be decreased. Using smart cards
containing more advanced technology, public/ private keys and
certificates can be securely transported and used as part of the system
for Secure Access to On-line Data. This will become a major enabler for
electronic service delivery projects. These cards can also carry some
essential and some convenience data. In the same way, keys carried on
cards can enable secure and private communications as well as Digital
Signatures of documents. In some cases, cards can be used as evidence of
eligibility for treatment and to support financial transactions.

4\. Functions of Healthcare Cards

There are many functions of a medical cards including the following:

-   Identification - Cards are used to simplify identification either
    visually or by using electronically readable content. Data would
    include patient id, name, issuer, etc.

-   Access Control - Cards can play a roll in accessing data on local
    systems, on networked information systems, or in another card.

-   Data Carrier - Data can be carried on a card and read at different
    locations. In this way, the same information can be given to
    organizations that otherwise might not exchange data because of lack
    of connections, technical incompatibility or different
    organizational reporting structures. Data examples include
    administrative, emergency, medical specialty data bases,
    prescriptions, allergies, immunization history, treatment locations,
    pointers to data, primary physician, preventative healthcare, etc.

-   Information Transfer - Information on the card is transferred to
    computer systems or transferred to required paper records.
    Information is transferred to paper either mechanically, or
    electronically by reading the card information and printing it on a
    form.

-   Authentication - Cards can carry keys and certificates used for
    encryption and digital signatures. An individual's private key is
    used to create a digital signature for a document. Electronic
    communications systems use digital signatures to authenticate the
    sender and demonstrate message integrity. Electronic keys carried on
    smart cards are considered more secure than keys carried on other
    medium, such as floppy disks.

-   Encryption / Decryption -- Some encryption can be performed on a
    smart card. A system using a card with encryption capabilities is
    more secure since any secret keys do not need to be copied to the
    terminal device.

5\. Healthcare Uses of Card Technology

5.1 Projects in the United States

There are many examples of excellent card programs in the US including
the following:

In 1997, the Department of Veterans Affairs (VA) medical division, the
Veterans Health Administration, implemented a nationwide upgrade of
their patient card from a simple plastic embossed card to one that has
an electronically readable magnetic stripe. The cards, which are
currently in use, are plastic with embossing, magnetic stripe, bar code
with a black and white picture. The cards function as an identifier and
as a data carrier for a small amount of information. The cards are
produced at each facility with name and other non changing information
which is downloaded from the Hospital Information System. The patient
picture is taken and the card is produced in about one minute. The card
is used as an electronically readable identifier to speed patient
medical record look-up on the facility's medical information system. The
installation of multiple capture stations and embossers at over 171
facilities was completed in 1997. About 2.5 million cards are produced
each year with equipment at the 171 VA facilities. The program has been
reviewed and enhancements are being tested.

The new VA Express card is in the testing phase. The VA Express card
will be one card for the veteran that will be recognized by all segments
of the VA. The enhancement is envisioned to decrease time and simplify
registration at a medical center, make limited emergency data available
on the card, and improve data quality by allowing the veteran to view
and print their own data on a facility Kiosk. When the back-end
applications are available, it will also enable electronic transactions
from the web enabled Kiosk using electronic PKI keys on the card. The
cards are smart cards with magnetic stripe, bar code, a color picture
and PKI capabilities. The VA Express Card project involves the 2 pilot
sites in Milwaukee, Wisconsin and Iron Mountain, Michigan. 10,000 cards
were distributed in April 2001. Additional cards will be distributed
from the medical centers with an approximate total of 50,000 by the end
of the year. The initial direction to implement a smart card for the
veterans came from the acting Secretary in May, 2000. In August 2000, a
demonstration was given of the registration, the kiosk data view and the
digitally signed form functions. An additional function includes a "form
filler" or "embossing removal" application to be used at the facility.
This application reads data from a computer chip in the card, places the
information in the proper location on multiple forms, and prints them
out. A centralized directory has been established that contains basic
patient information, their picture and information about the cards that
they have been issued. This directory is updated when a card is issued.
Basic administrative data and emergency contact information is
compatible with the G-8 / Netlink specification. The data is PIN
protected.

A small smart card pilot involves virtual private networking (VPN)
technology. The purpose of this pilot is to test the safety and
usability of VPN technology to allow selected users to have limited
access to corporate resources from the Internet. The pilot encrypts all
traffic across the Internet and allows access control by person, by
protocol, and by target resource down to the file or URL. The selected
virtual private networking technology uses strong authentication to
authenticate the user. Strong authentication involves two factors to
identify a user: something you know (a PIN) and something you have (a
key protected by the smart card). Currently, about 100 users are
involved with the test.

VA developed a demonstration implementation of the G-8 Healthcare Data
Card interoperability specification. Our goal was to demonstrate
interoperability with other implementations of this specification such
as the Netlink project sites in France, Italy and Quebec. This was
successfully demonstrated at CardTech SecurTech 2000 and in Rome at a
Netlink meeting on September 27, 2000. Portions of the data that were
designated for read access, such as emergency data, were able to be
viewed by viewing software developed by the different countries. This
interoperable implementation was used as the basis for the architecture
of the G-8 compatible portion of the VA Express card. VA would also like
to investigate the feasibility of using the PKI keys stored on this G-8
card to access copies of the patient's health record.

The Western Governors Association (WGA) is sponsoring the Health
Passport Project in three communities in the western United States with
a focus on Preventative Health. . This project is the largest
demonstration for state based, health-related smart cards in the
country. The objectives of the project are to improve delivery of
benefits from multiple organizations to the residents of the western
states by lowering administrative barriers to care, and to improve data
sharing between programs. Other goals include reduced healthcare costs
and improved access to preventative health information. Multiple
programs and multiple agencies are sharing information under the Health
Passport Project. Participants in the demonstration include pregnant
women, mothers and children eligible for a number of public health
programs, including Women's Infant and Children (WIC), Immunizations,
Medicaid (EPSDT), Head Start, Maternal and Child Health services. WGA
launched the project in Bismarck North Dakota in June, 1999, in
Cheyenne, Wyoming in June, and in Reno Nevada in the fall of 1999. More
than 25,000 smart cards are being issued to parents. The cards function
as an identifier and as a data carrier. The cardholder protects the
information on the card through the use of a personal identification
number (PIN). The project includes smart cards, terminals, readers,
software and Kiosks. Healthcare providers will also have a card
requiring activation by a PIN which will allow them to view only that
information they need to perform their job.

Working with multiple organizations is often difficult. The design and
development was so successful that 10 of the thirteen applications
interfaced very nicely with the Health Passport card so that writing to
the card and the program software became transparent. Also added was a
\"pending update" feature that allows the user to go out an pick up
information (such as tests) at a later date, but before the next service
visit. The participants can also use kiosks to make hard copies of data
on the card. The Urban Institute will complete their evaluation and
present their report at the Governors\' meeting this summer. A follow on
phase of the project will involve access to data on the network.
Additional information is located at URL
[http://www.westgov.org/wga/initiatives/hpp/default.htm]{.underline}

West Virginia University in Morgantown, West Virginia designed and
developed a smart card system for rural healthcare facilities in the
state of West Virginia as part of a research project investigating
technologies and applications for secure telemedicine. A National
Library of Medicine Grant supported this effort in order to better
understand secure and private Telemedicine systems and the associated
policy, administration, regulation and technology issues. Patient Cards
were based on the G-8 Healthcare Interoperability Specifications and
carried a compatible emergency data set. Health Professional cards were
required for the use of the secure telemedicine applications, enabling
authentication based on Digital Certificates and providing role-based
information from patient cards. The project included upgrading the
applications to enable Emergency Room physicians to have web-based
access to their patient's electronic medical records and for
patient-approved notification of E/R visits. Although the development
project was successfully, the system was not implemented.

U.S. military's MARC Card initiative is a highly successful
multi-function and multi-technology card project. The cards function as
an identifier and as a data carrier. The testing and deployment has
taken place in Hawaii. There are over 40,000 cards in use. The
technology of the card includes a smart card, bar code, magnetic stripe,
picture, signature block and embossed characters. The non medical
functions of the card include manifesting and deployment, food services
and building access security. Medical information content includes
identification, emergency data, blood type, immunizations, allergies and
registration information. The U.S. military is currently identifying
additional functionality and evaluating options for a Person
Identification Carrier (PIC).

The big news in DoD is that in September 1999, the U.S. military
announced that they will phase out plastic identification cards in favor
of chip-based multi-application smart cards. The new cards are called
Common Access Cards (CAC). DoD has distributed a number of cards at
their test facilities and will begin to issue these cards on a large
scale in May 2001. The new photo ID card is expected to interact with
their network and carry keys compatible with their evolving Public Key
Infrastructure as well as physical access. The phased implementation is
expected to be complete by 2002. The DoD card will also provide support
for existing card applications.
([**http://www.dmdc.osd.mil/smartcard/owa/ShowPage?p=index**](http://www.dmdc.osd.mil/smartcard/owa/ShowPage?p=index)
)

5.2 European and Canadian Projects

Europe has many examples of excellent card programs. Organizations in
Europe have more experience with smart card technologies than
organizations in the U.S. The following are some of those activities:

The largest, recent implementation in the medical field has been in
France where smart cards are being distributed to both individuals and
healthcare providers. A very important date in the history of French
SESAM Vitale program was April 1996. On this date, the law was passed
that established the legal foundation for many functions of the French
health smart card: digital signature in the health sector and electronic
reimbursement claims for health expenses.

From the 80\'s to 1996, SESAM-Vitale card had been just a \"pilot
project\" supported by the health insurance bodies. The original Sesam
Vitale project began in 1985 and included a family card for insurance
entitlement. The current family insurance card is called Carte Vitale.
During 1998 and 1999, 42 million of the Carte Vitale family insurance
cards were distributed. These cards contain identification and
administrative data and are used to simplify insurance billing
procedures. This is an incredible accomplishment with approximately 5
million cards being distributed per month from 4 suppliers. During 2001
& 2002, France will be distributing an individual Vitale card to all
person that are 16 years are above. This will mean more that 10 million
cards will be distributed. These cards will have exactly the same
technology as the existing Vitale

The French are also designing the Vitale 2 card. This is an individual
card that will contain medical data in addition to the existing
identification and insurance data found on Vitale 1. A call for tenders
was launched in December 2000 for the development of the Vitale 2 mask
(operating systems). Additional calls for tenders for the cards will be
launched during 2001. The French plan to launch the deployment of the
Vitale 2 cards 1Q 2004 and complete the distribution approximately 18
months later. The Health data stored in the Vitale 2 cards will probably
be compatible with the G-8 / Netlink data model but these decisions have
not been finalized by the French Ministry of Health. A working group has
been established to address the definition of this part of the card. The
law covering this card does exist. Some additional regulations that
define the data model, access control rules, etc. have not yet been
published.

France is also distributing smart cards to each of France's 300,000
Healthcare Professionals. This Healthcare Professional Card (or CPS) was
distributed to 160,000 health care professionals and 120,000 assistants
by March 2001. Plans are to distribute these cards to all French
healthcare professionals and assistants. This card contains a
cryptographic chip and securely stores private keys. The card are being
used to control access to the French Healthcare Network, to digitally
sign documents, to control access to healthcare data on the network, to
control access to data contained on patient cards and to vastly improve
the security and confidentiality of communications between healthcare
professionals. Updated information on the distribution of the CPS card
can be found at URL
[**http://www.gip-cps.fr/**](http://www.gip-cps.fr/).

The CPS card is used to digitally sign electronic health reimbursement
claims. Statistics for the transmission of health reimbursement claims
between the healthcare providers and the insurance bodies include the
facts that 75,000 providers are using the system and 15% of the health
reimbursement claims being submitted electronically. This is more than
1,000,000 electronic submissions per day. Additional information can be
found at URL
[**http://www.sesam-vitale.fr/**](http://www.sesam-vitale.fr/).

France established a Healthcare Network in November 1998 to facilitate
communications among healthcare providers and insurers. This Healthcare
Network is called Réseau Santé Social (RSS) and uses the Healthcare
Professional Card to control access to the information on the network.
The purpose is to provide a secure network with sufficient capacity to
meet the various needs of the health community. The current major use is
for secure administrative transactions. Additional information can be
found at URL
[**http://www.cegetel.rss.fr/**](http://www.cegetel.rss.fr/).

Germany has completed a project distributing 80 million cards to all
citizens during 1994 and 1995, along with the reader/printer
infrastructure. These cards function as an identifier and as a data
carrier. The German cards are serial memory chip cards used primarily
for insurance identification. This was a major national initiative that
was extremely well planned and executed. The reader/printer system
allows patient data contained on the card to be automatically printed as
a completed insurance form. The data can also be transferred to a
personal computer. There are options to generate and send an electronic
submission directly to the insurance fund, eliminating the paper portion
of the transaction. Additional upgrades are planned and several smart
card pilots are being conducted. Germany will participate in the
multi-country Netlink Pilot. A German Healthcare Provider Card is being
planned.

Netlink is a coordinated action to ensure implementation of
interoperable data card systems and Internet solutions. Netlink is an EU
funded Project that began in 1998. It is a multi-country pilot of
interoperable Patient cards and Healthcare Provider Cards. There are
pilot sites in France, Germany, Italy and Quebec, Canada. Benefits
include secure and easy communication of sensitive data across borders.
Technical architecture documents were completed in mid 1999. Test cards
were made available to the project offices and implementation began in
2000. Systems developed in Italy, France, and Quebec were shown to be
interoperable. 130,000 cards were distributed in northern Italy.
(<http://www.sesam-vitale.fr/html/projets/netlink/index.htm>)

The government of Quebec in Canada has similar plans for patient and
healthcare provider cards. The Rimouski Pilot was active from 1993 to
1995 and involved both administrative and clinical data. The Quebec
government would like to implement a smart card that will be compatible
with the card in Europe. If the initiative is approved, Quebec will
eventually distribute 7 million cards.

Quebec is participating in the Netlink project by sponsoring a pilot in
the Laval region. The pilot will use smart cards for authentication of
patients and healthcare professionals. Information will be stored in
anonymous databases for the creation of shared patient records. The
patient will control the access to their clinical data. The project will
involve 1,000 healthcare professionals, 9000 patients and 400
workstations.

In late March at the Global Forum in Naples, Italy, it was announced
that the first Italian Identity cards had been officially issued. These
cards include the health area that is compliant with the Netlink
specifications. The initial experimentation includes 100,000 smart cards
containing a chip and a laser stripe. The cards contain x509 v3
compatible digital signature keys and certificates. The plan includes an
additional call for tender that should be announced later this year. The
Identity cards would be distributed to all the Italian population of 58
million. Additional information can be found at URL
[**http://www.anci.it/cie/**](http://www.anci.it/cie/). Other Italian
projects include "Regional Services Card" in the Lombardia region that
is also Netlink compliant. In the Lecco area, 300,000 cards are being
distributed that have interfaces to Doctor's packages and hospital
information systems, and are also Netlink compatible.

In Germany, the QuaSi Niere Renal Dialysis Card Project is a smart card
project focusing on quality assurance and renal dialysis treatment. The
cards function as an identifier and as a data carrier, as well as a
carrier of keys for user authentication. This project is sponsored by
the Medical Association in Berlin which is part of the German Ministry
of Health. The project was operational with over 35,000 cards in use in
March 1997and currently involves 50,000 patients and 3,000 doctors. The
project includes a depersonalized, indexed data base that is used by
approved health statisticians to identify successful methods used to
improve the quality of care. The project includes both providers and
patients authentication cards.

5.3 Framework Projects

Framework initiatives describe a structure for creating compatible card
systems. They are considered to be a set of guidelines for Health card
projects that will lead to interoperability. These framework initiatives
do not result in card systems that are distributed, but they do result
in a set of agreements or strategies for implementing compatible card
systems.

EUROCARDS is a European Union (EU) Advanced Informatics in Medicine
(AIM) Concerted Action on Data Card Applications in the Healthcare
system. The project was created in late 1993 and delivered the final
reports in 1995. The project developed a technical, social and legal
framework for data card applications in Europe. There is a framework for
professional and patient cards. The Healthcare Professional Cards
includes electronic identification, access control to information
systems (local and remote), keys for digital signatures for stored and
transmitted electronic documents, access control to patient data bases
and the possession of cryptographic class keys indicating certain
professional status. EUROCARDS identified the following priorities for
implementation: Administrative Cards and the creation of the
infrastructure (readers, workstations), Healthcare Professional Cards as
a means of enhancing Security, Emergency Cards for national and
international purposes, and Patient Cards containing medical and
pharmaceutical information, and pointers to additional data. The
EUROCARD framework is described in the book "Healthcare Card Systems,
EUROCARDS Concerted Action Results and Recommendations" by A. Pernice,
H. Doare and O. Rienhoff, (IOS Press, 218 pages)

The TrustHealth Initiative is a framework to demonstrate trustworthy
telematic systems using modern security techniques in an open systems
connectivity environment with trans-European interoperability. The
framework uses smart cards and RSA asymmetric encryption to enhance
healthcare information security. Aspects of the framework include user
authentication, digital signatures and exchange of session keys for
confidentiality protection, proof of professional registration and as
access control devices. The European Commission sponsored and started
the project in 1995. An infrastructure of National Trusted Third Parties
is a component that is necessary to issue cards that contain keys and to
maintain the link between the user and the public key. The project
involved 9 countries and multiple suppliers. SPRI in Sweden played a
major part in TrustHealth development.

The G-8 Healthcare Data Card Project was one of 6 healthcare
international cooperative initiatives to demonstrate the positive
potential of the Global Information Society. First initiated at the
Ministerial Conference held in Brussels on February 25-26, 1995, the G-7
(later became G-8) and the European Commission established a number of
projects where international cooperation could be an asset. This
project's goals were to demonstrate:

-   an international emergency card that would provide the essential
    medical information that is vital for an emergency situation, as
    well as

-   an international harmonized administrative data set, and

-   an international professional card that will allow the secure
    identification of healthcare professionals when accessing medical
    data and network services

A major emphasis was placed upon developing technical interoperability
so that all cards from all participating manufacturers can read in the
different participating countries. The specifications were completed and
are available at URL
<http://www.sesam-vitale.fr/html/projets/g8/index.htm>. In May of 2000,
the G-8 organization congratulated this work group for making the most
substantive progress of all the groups, but decided that they would no
longer sponsor the efforts. The workgroup is continuing their efforts
and is currently called The Global Healthcare Applications Program,
formally the G-8 Healthcare Data Card Workgroup.

6.  Conclusion

The impact of Internet connectivity continues to be felt by
organizations throughout the world. Instant access to published
information, such as product specifications, is becoming a daily
business tool. Businesses are using the Internet for direct on-line
ordering, as well as access to personal and business data. Because of
the importance of privacy and security in all aspects of healthcare
data, these developments will be of great interest to individuals and
healthcare providers.

Card technologies of all types are being used in the healthcare field to
meet business needs. From the simplest to the most complex need, there
is a combination of card technologies that can be used to deliver an
appropriate solution for the user and the healthcare facility. As new
needs are identified, there is usually a smooth migration path to the
solution involving more advanced technologies. While the majority of US
organizations continue to rely on traditional card technologies, some
are investigating the suitability of the newer technologies.

In the US, there is a growing interest in techniques to increase
healthcare data privacy, confidentiality and security, as more medical
information is electronically stored and accessible from widely
available networks. A potential solution to this problem would involve
public private key systems with keys being securely stored and used on
portable smart cards. This would allow the user to interact securely
from any connection on the network including the doctor's office, work,
home, the library or the public kiosk in the mall.

In the past, the interest in using a card as a portable data carrier has
been of more interest in other countries than in the US. However, it is
very useful to have essential data stored on the card, such as
electronic keys, identification information and emergency data. Data
which is useful or which simplifies the daily interactions with the
healthcare establishments should also be placed on the card.