# Presentation: 551108

## Evolution of Health Care Cards& Networks in EUROPE

**Otfrid P. Schaefer, MD.**
- Central Research Institute of Ambulatory Health Care in Germany (ZI)

## In Germany

- the "Versichertenkarte" (Insurance Card)   was implemented by Federal Law (1989)
- delivered to 73 Million Members of 1200   different legal sickness funds within 15   month until 31st of December 1995
-  ***was the biggest field test with chip cards******    in heatlh service world-wide so far***

## The German Insurance Card

- based on a memory IC   with only 256 byte   capacity
- is strictly an  administrativ card
- containing only eight   items:
- The name of insurance

- ID-number of the ins.
- Name, title and
- address of  the insured
- his birthday
- his insurance status
- and his I D
- Date of exspiry of    Card

## In GermanyThe Insurance Card

- In GermanyThe Insurance Card

- is improving transparency of health  services
- is rationalizing administrative work
- is fully accepted by patients
- is daily routine in hospitals and doctor's   offices nation-wide

## Introduction of Insurance Card in Germany

## Germany after the introduction of a nationwide insurance card and the European projects:

- Thirteen different card projects with medicaldata have been proposed  in 1996
- Three of them have been defined in 1993

## German Health Care Card Projects  (1)

**German Health Care**** Card Projects  (1)**

**1.    A-Card for electronic prescription (Pharmacists)**
**2.    DEFICARD   - a card for patients with implanted****      defibrillator, first pilot project in Hannover and ****      now in the  University Hospital Bochum ****      (realized since 1993)**
**3.    DENTCARD  - a card for dental treatment****      and follow up (pilot project Bühl)**

## German Health Care Card Projects  (2)

**German Health Care**** Card Projects  (2)**

**4.    DIABCARD - a European project, 2 pilot sites****      (since 1994)**
**5.    HEALTHCARD ("Gesundheitskarte" by  ****      Bayer, a Hybrid Card with Chip and CD-****      ROM (pilot project starting 1997 in****      Leverkusen))**
**6.    HEALTHPASSPORT (Gesundheitspass)****      Berlin (not pursued)**

## German Health Care Card Projects (3)

**German Health Care**** Card Projects (3)**

**7.    PATIENTCARD "Patientenkarte" with ****      "A-Card", storing patient history and drug****      prescription (started 1996 in Koblenz,****      Neuwied, Andernach) run by ****Zi**
**8.    SANACARD (small pilot project in Koblenz)**
**9.    SANATURA Card in Saxonia****      (storing preventive medical data, ****      vaccinations etc. (at present not active))**

## German Health Care Card Projects (4)

**German Health Care**** Card Projects (4)**

**10.  ONKOCARD (small pilot project, card****      for follow up of patients with cancer)**
**11.  ****QUASINIERE**** a card for quality management****       in kidney replacement therapy using a Patient ****      Card, a Network and the Health Professional****      Card (1997)**
**12.  VISITCARD (CD-ROM-Card to store X-rays, ****      (terminated)**
**13.  VITALCARD (not purpused)**

## The Koblenz Consent

## Declaration of consent

**No card duplicates**
**The storage of medical data is restricted to the ****   card (Obligation of physicians and software****   producer)**
**Use of cards is  strictly voluntary**
**Data may only be read in physicians offices, ****   hospitals and pharmacies**
**Patients are entitled to review (delete) the data****  stored on their cards at any time**

## Medical Patient Data CardKoblenz (Neuwied) / A-Card

**Card {Chip-} type**
- Processor Card (SLE44C80, CardOs, ST16F48,  MPCOS, each 8 Kb)
**Access**
- Doctors in the 1. step may only _read_ all data
- Pharmacists may only _read and write_ drugs/ adresses, data are compressed

## Joint Panel on Health Cardswith 6 Working groups

- Health Professional Card
- Checklist
- Security infrastructure
- Data structure
- Multifunctional cardterminal
- Evolution of the administrative card   (VK)

## Members of the Joint Panel (1)

- Representatives of statutory sickness funds
- Representatives of physicians associations
- Representatives of the Ministry of Health   and Ministry of Research
- Representatives of Research Institutes of   German Universities

## Members of the Joint Panel (2)

- Representatives of the Federal and State  Commissioners for Data Protection
- Representatives of the Federal Office for  Data Security in Information Technology
- Representatives of Patient Organizations
- Members of project teams and their  industrial partners

## Many European Smart Health Card Projects

- have been running within the last ten years
- have demonstrated functional and organi-  zational benefits in health care
- have been researched and testet for adminis-  trativ as well as for specific medical appli-  cations
- None of them have been compatible with   each other

## EU - Telematics Program

- CARDLINK
- DIABCARD
- TRUST HEALTH

## DIABCARD

## CARDLINK

## Numerous administrative and Health Care Card Projects have been proposed and are in the status of planning or implementation in many European countries within the last two years

## Proposed and ongoing Health Card Projects in Europe (1)

- Austria	Pilot of social security card and access		to care in 2 provinces (field trial in 1997, 		8 Mio. cards nation-wide, 50,000 cards  		with cryptocontroller)  		Pilot on health card by Ministry of                   Defense
- 			Nationwide implementation of card		system in preparation

## Proposed and ongoing Health Card Projects in Europe (2)

- Belgium	Card for Social Security and access to          	care (1996: 10 Mio. cards)   	 	Professional Card (1997: 500,000 		cards with cryptocontroller)
- Finland	Pilots for healthcare cards,		 participation in CARDLINK** **** **

## Proposed and ongoing Health Card Projects in Europe (3)

- France   1. Step 7/97: 10 Mio. (familiy) Social Security 	       Cards (Carte Santé)
- 	      	       2. Step 3/99: 60 Mio. Health Care Cards,	       (SESAM VITAL)
- 	      	       Health Professional card (GIP/CPS) 	       introduction 1998
- 		       Several pilot projects on Health Care Cards	       since 1985 participation in CARDLINK.	       NETLINK proposal (1997)

## Proposed and ongoing Health Card Projects in Europe (4)

- Germany   73 Mio. Insurance Cards (memory IC)	           issued to 90% of the total population	           in 1994/95
- 			1997 discussion of second generation of 		insurance card as multifunctional Smart		Card, to be delivered in the year 2000
- 			Several pilots of card systems for		primary care and chronic diseases		associated to CARDLINK.		NETLINK subcontractor

## Proposed and ongoing Health Card Projects in Europe (5)

- Greece  	Social security card for seamen 		(proposal, card with microcontroller or		hybrid card) 		Social security card (announced)		Pilots for healthcare and emergency		cards (CARDLINK)
- Ireland	Primary care and emergency card, 		main pilot site of CARDLINK

## Proposed and ongoing Health Card Projects in Europe (6)

- Italy	Several niche projects (primary care,		chronic diseases, prescriptions)		Pilots of a multifunction citizens' card		Two regions praticipating in		CARDLINK, NETLINK partner
- The 	Insurandce cards for private insurance    Nether-    (1997: 1 Mio. cards), emergency card      lands	pilot (CARDLINK)		Organizer of "Health Cards '97"		Nov. 12-14, Amsterdam

## Proposed and ongoing Health Card Projects in Europe (7)

- Spain	1995/96 pilot of a national Social 		Security Card in Andalucia,		nation-wide extension in 1997/98		Healthcare and emergency card		pilots, also CARDLINK
- Sweden	Card as patient identifier for access to 		care (definiton phase)		Pilots for medical and professional 		cards (TRUSTHEALTH project)		ID card (plan)

## Proposed and ongoing Health Card Projects in Europe (8)

- United	    Two pilots in early 1990's    Kingdom      (Exeter Care Card pilot, PANACEA)		    Green Paper on ID card suggests		    including medical information for		    emergency

## Eastern Europe Card Systems planned or in real preparation

- Bulgaria	  	  Health insurance card
- Czech Republic    Health care / insurance
- Estonia     		  Health care card
- Hungary   	  	  Selected diagnose related cards
- Poland    	  	  Health care card
- Slovakia   	 	  Health insurance card
- Slovenia	 	  Health insurance card 			  	  (1997: 2 Mio. cards)
- Lithunia    	  Social security card in discussion

## Health Insurance Card in Slovenia

- Population		2 Million
- nation-wide  implementation	 1998-1999
- investment costs 	17.4 Mio. US$
- only _one_ Health Insurance Institute !

## Health Insurance Card inCzech Republic

- Population		10.3 Million
- nation-wide  implementation	 1998-1999
- investment costs 	 97.0 Mio. US$
- 14 Health Insurance Institutions

## Partners in Pilot Project Mácha

- Ministry of Health, CR
- General Health Insurance Office, CR
- IMA Ltd., CR
- APROKS Ltd., CR
- ORGA Card Systems GmbH, Germany
- European Commission - PHARE, CEN,   EUROCARDS

## Data Structure Health Card System Czech Republic

## Technical Background (1) Health Card System Czech Republic

- physical parameters		ISO 7816-1					ISO 7816-2					ISO 7810
- electric signals		ISO 7816-3

## Technical Background (2) Health Card System Czech Republic

- Microprocessor module:   MOTOROLA SC21
-  processor MC68HC05SC21
-  3     KByte EEPROM
-  6     KByte ROM
-  128 Byte RAM
-  16   Byte security read-only EEPROM

## Initiatives at the European Union (EU) Level (1)

- European Parliament           Initiative for a European Health Passport 	 (to be issued by Member States 1999 on 	 a voluntary basis), LEOPARDI
- Eurocards           Non-official framework for coordination,	 hamonization of data sets, promotion of 		 interoperability, promotion of standarization	(CEN)	8 Working groups:

## Initiatives at the EU-Level (2)

- Eurocard working groups:
- 1.	Administrative cards
- 2.	Emergency cards
- 3.	Medical data cards
- 4. 	Health professional cards
- 5.	Technical interoperability
- 6.	Users acceptance
- 7.	Legal issues
- 8.	Project validation methology

## Initiatives at the EU-Level (3)

- TESS: Telematics for social security;    	      intersonnection of social	      security systems (refunding)
- 4th Framework Program:
- 		       -	NETLINK proposal, Cross Border 	          Project, France / Germany / Italy /	          Canada	       -  VITAL wwwSERVICES Proposal,             nine European Telematic Projects	          under one umbrella

## 70 European Telemedicine Projects 1994 - 1998 (1)

- Actual call for proposals within 7 clusters:
- Cluster 1: (umbrella projects) Coordination of 		  activities to consilidate results of		  projects and maximize impact on		  industry and health services
- Cluster 2: Applications for Health Care		  Professionals
- Cluster 3: Health Care Networks for Health		  Care Management

## European Telemedicine Projects (2)

- Cluster 4: Integrated emergency systems 		  and mobile communications
- Cluster 5: Information services for citizens		 and healthcare workers
- Cluster 6: Advanced application research
- Cluster 7: Industrial user groups		 exploritation of results and		 standards

## Candidates for the EU umbrella project VITAL wwwServices

- AMBULANCE
-  ET-ASSISST
-  HERMES
-  HOMER-D
-  MERMAID
-  NIVEMES
-  OPHTEL
-  RECOVER

## Interaction of Cards with Telematic Applications

- HPC and PDC combined with network accessible specialists or data bases meet the requirements concerning:
- identification
- authentication
- confidentiality
- privacy
- data integrity