# Presentation: 659295

## Card Technology in Healthcare

**Daniel L. Maloney**
**Director, Emerging Technologies**
**Department of Veterans Affairs, VHA**
**Silver Spring, MD., U.S.A.**
**daniel.maloney@med.va.gov**
**http://www.va.gov/**
**http://www.va.gov/card/**

## Overview

**Major Issues**
**Pressures in Health Care**
**How Cards contribute to the solutions**
**Technical Developments**
**What is the VA doing?**
**Overview of Healthcare Card Projects**
**Summary**

## The Department of Veterans Affairs

**27 Million Veterans and 43 Million dependents**
**Nearly one-third of the nation’s population are potentially eligible for VA benefits, includes dependents**
**Second largest of the 14 Cabinet departments**
**Facilities in all 50 states, Washington D.C., Puerto Rico and the Philippines**
**Nation’s largest medical system with 159 hospitals, 129 nursing homes, 35 domiciliaries and 362 outpatient clinics**
**58 regional Benefit offices providing monetary, disability, pension, educational and vocational rehabilitation benefits**
**13 million home loans, and the nation’s largest insurance programs**
**114 national cemeteries**

## Functions of VA’s Public Domain Integrated Hospital Information System (VISTA / DHCP)

**Clinical and Administrative Support**
**Clinical Results Reporting**
**Order Processing**
**Patient’s Medical Record**
**Accounting and National Reporting**
**Medical Care Cost Recovery**
**Integrated Medical Images at pilot sites**
**60 Applications**
**National Electronic Network for inter facility Communication**

## Major Trends

**The Web Changes Everything**
**Electronic Service Delivery and EDI - saves time, money for corporation, and the customer**
**Major obstacle - Security, Privacy and User authentication**
**Major solution - Keys - Public /Private Key Infrastructure and Digital Signature**
**Carry keys on smart card**
**Multi-application cards reduce the cost per program**
**Customer Convenience /Humanize Interactions**
**User Opt In**

## Major Concepts

**Card functions as part of the System**
**Works with the networked data**
**As the Network improves, the location of the data can change**
**Network means Local and World Wide Network (Internet)**
**Continuum with Essential data on card**
**Many applications can be supported**
**What critical Business Problem do YOU need to solve?**

## Slide 7

## Roles for a Card

**Multiple roles including:**
**Visual Identification**
**Electronic identification (Keys and certificates)**
**Portable Data Carrier or Pointers to Data**
**Electronic Payment - insurance or e-cash**
**Two Card Present model - patient and doctor cards at the same time to access data located either on the card or on the network**

## <footer>

- <date/time>

## Pressures in Health Care

**Profitability of the healthcare organization**
**Insurance and government organizations are concentrating on cutting health care costs and fraud**
**Citizen Choice**
**Different Information Systems are often fragmented and do not communicate**
**The patient’s difficulty accessing their own record **
**The patient’s fear of uncontrolled access to their medical records**
** ****The provider’s inability to access accurate and appropriate /complete information about the patient’s treatment**

## Why Use Cards In Healthcare?

_**Cards are a part of local or networked system**_** **
**Deliver Better Service and Benefits Faster**
**Decrease Paper Work and Administrative Costs **
**Decrease Date Entry Error **
**Quicker and easier retrieval of Data (from a portable card or using card as key to data lookup)**
**Increased Patient Convenience**
**Decrease Fraud**
**Secure Access to On-line Data**
**Enable secure and private communications**
**Digital Signatures**
**Support Financial Transactions**

## Influencing Events

**Health Insurance Portability and Accountability Act of 1996 (PL 104-191)**
**HHS responsible for identifying or developing EDI, privacy and security standards**
**Original Feb 1998 report deadline, reports being written**
**Standards Groups have accelerated activities**
**National Research Council report “For the Record: Protecting Electronic Health Information” - March 5, 1997**
**“****password or PIN in conjunction with a token”**
**GSA Government wide procurement for Cards and for PKI Services in 1998**

## Applications on a Healthcare Data Card

**Patient Medical **_**Identifier**_**, visual ID**
**Insurance Identifier and Data**
**Administrative Data, Demographics for registration**
**Specialty Medical **_**Data Bases**_**, Medication, Dialysis,  Pregnancy History, Portions of Medical Record**
**Emergency Data, Immunization History, Allergies, Primary Physician, Locations of Treatment**
**Information carrier: Prescriptions**
**Preventative Health Care, i.e. WIC**
_**Electronic ID:**_** Keys to access data on the network, Secure Authentication / Digital Signature**
_**Financial Transactions:**_** Credit/debit Cards for Payments, EBT**

## Public Awareness

**Smart card articles are appearing in the popular press, not just professional journals**
**Many articles about electronic cash and smart cards**
**Articles about Internet and the need for  better electronic identification**
**Discussions about Public /Private Key Infrastructure in many different industries**
**People immediately understand the need for confidentiality in Healthcare**

## Card Technology    Unit Cost ($)     Major Benefits      Options 

**Paper, bar code option   ****	****.01-.04****	**** ****	****Inexpensive, bar code**
**Plastic, embossed   ****	****.10-.15 ****	****familiar, paper transfer**
**Serial Memory card  ****	****1.50-4.00 ****	****additional storage**
**Computer chip card  ****	****3.50-15.00 ****	****additional data security,**
**  ****	****	****	****	****	****	****	****difficult to copy**
**Optical card   ****	****	****6.00- 8.00 ****	****much more storage**
**IC Optical Card****	****          10.00-15.00****	****large storage and data ****	****	****	****	****	****	****security**
**PC Card****	****	****       60.00 - 100.00****	****more storage and ****	****	****	****	****	****	****	****computational capability**

## Card Technology    Unit Cost ($)     Major Benefits       Options 

**Plastic, embossed   ****	****.10-.15 ****	****familiar, paper transfer**
** ****add Magnetic stripe     ****	****.02-.10 ****	****electronic readable**
** ****add Bar Code  ****	****	****.00-.10 ****	****electronic readable**
** ****add signature panel     ****	****.02-.05 ****	****visual authentication**
** ****add photograph, B+W     .00-.15 ****	****visual authentication**
** ****add photograph, color   ****	****.20-.25 ****	****visual authentication**
** ****add hologram laminate   .06-.07 ****	****	****deter fraud**
** ****add hologram stamp ****	****.05-.06 ****	****deter fraud**

## Technology

**Cards with cryptographic capabilities**
**32 bit computer chips on cards**
**Decreasing costs of biometrics fingerprint readers**
**Combination cards with contact and contactless communications**
**Reader Inrastructure**
**Large software vendors like ****Microsoft**** are delivering software, API’s and now a card operating system to support smart cards**

## Interoperability

**Interoperability will make it easier to deliver smart card solutions**
**G-8 technical interoperability specification is being used in Healthcare (CardLink)**
**Application - EMV, GSM, SET**
**On the Workstation - PC/SC Specification and the OpenCard Framework**
**On card - Java Card, MULTOS and Microsoft Card Operating System (6/99)**
**Hardware level - ISO 7816**

## What is the VA doing?

## Department of Veterans Affairs - Patient Card Upgrade

**Rollout began in Dec 1996, finished in April 1997, Planning began in Dec 1993**
**Upgrade cards from simple plastic embossed card**
**New cards  have printed and  embossed information, magnetic stripe, bar code, black and white picture**
**Function as identifier and carrier of small amount of information**
**Speeds patient look-up on medical information system, allows mini registration**
**Personalized at facility, 2.5 million cards first year**
**magnetic stripe - date of birth, period of service and service related disabilities**
**Enhancements are planned**

## The Veteran ID Card

- Photo Image
- SC Indicator
- Barcode
- Embossed Info
- Name
- SSN, DOB
- MAG Stripe
- 1-800 Number

## VA Electronic Purse

**Department of Veterans Affairs,**
** ****U.S. Treasury, Nations Bank and Visa began an electronic purse pilot with smart cards**
**Announced Phase 1 on Oct 20, 1997 at the Bronx Veterans Affairs Medical Center located in New York City**
**Announced Phase 2 on Nov 24, 1997 at the Tampa Florida Veterans Affairs Medical Center**
**25,000 cards will be issued at Bronx and 23,000 in Tampa**
**Used by staff and patients**

## Visa Cash in the hands of patients, 
physicians, visitors, volunteers and employees 
test numerous applications including:
combining identification badge and electronic purse
vending machine acceptance; 
integrated cash registers and terminals; 
reloadable cards; and 
cashless ATMs that transfer cash value onto reloadable cards, rather than distribute currency

**physicians, visitors, volunteers and employees **
**test numerous applications including:**
**combining identification badge and electronic purse**
**vending machine acceptance; **
**integrated cash registers and terminals; **
**reloadable cards; and **
**cashless ATMs that transfer cash value onto reloadable cards, rather than distribute currency**

**VA Electronic Purse**

## At the Bronx site, 
up to 4,000 reloadable cards used as identification badges. 
Approximately 10,000 cards issued for meal tickets, and 
1,000 for personal patient checking accounts.   
The Tampa pilot also has a special purpose card to be distributed by Veterans’ organizations for special events hosted at the medical center throughout the year

**up to 4,000 reloadable cards used as identification badges. **
**Approximately 10,000 cards issued for meal tickets, and **
**1,000 for personal patient checking accounts.   **
**The Tampa pilot ****also**** has a special purpose card to be distributed by Veterans’ organizations for special events hosted at the medical center throughout the year**

**VA Electronic Purse**

## Department of Veterans Affairs - Pilot of Secure Access from Internet

**Strong Authentication with smart card to control access from Internet to selected VA networked Resources**
**Levels of Control ****by person, by target resource (system, directory, file or URL), and by protocol**
**Pilot began in May 1998**
**40 users for telnet and web access**
**FTP and Exchange delayed**
**Plans to migrate to system that uses PKI**
**Support and coordination problems**

## Department of Veterans Affairs - Home Health Care Initiative- Design Stage

**Store commonly needed data on card to improve communications between different home health care providers**
**Always available to home health care provider**
**Also to be used at Emergency rooms and health care providers offices**
**Use of portable devices to read and update patient card**
**Begin Summer of 1999**

## Department of Veterans Affairs - VA / DoD Initiative- Planning Stage

**Reviewing Technical Interoperability Standards**
**Reviewing Medical Emergency Data Standards**
**Campus style multi-application card**
**Healthcare Functions - Identification of patient, data sharing and possibly electronic cash**
**Select potential applications (registration, emergency, contract provider, access, finance)**
**Select data fields (ID, Administration, Emergency, provider, treatment locations, keys and cash)**
**Select Site**
**Initiate Pilot in Summer of 1999**

## Department of Veterans Affairs - Lab Test of New Technology

**Microsoft Windows Card Operating System (Beta now, projected release in June 1999)**
**Workstation Development Tools**
**ActiveX for Healthcare to transfer data bi-directionally between chip and VA VistA Medical Information System**
**Shown in DataCard booth at HIMSS in February 1999**

## Overview of Healthcare Card Projects

## Western Governors Association Health Passport Project

**Objectives: Improve Delivery of Benefits**
**Lower Administrative Barriers to Care, and **
**Improve Data sharing Between Programs**
**RFP for system with 30,000 cards awarded in June 97**
**Phased launch to begin in May 1999**
**Locations - Nevada, North Dakota, Wyoming**
**Preventative Health Care Programs**
**Women’s Infant and Children (WIC)**
**Medicaid Eligibility (EPSDT)**
**Immunizations**
**Head Start**
**Maternal and Child Health**

## Secure Collaborative Telemedicine Over Public Networks

**West Virginia University in Morgantown, West Virginia under NLM Grant **
**Secure and private Telemedicine involves policy, administration, regulation and technology systems**
**Building on standards**
**Health professional cards are required for use of secure Telemedicine applications**
**Includes role-based information access to data on patient cards **
**Emergency room physicians will have web based access to their patient’s electronic medical records**
**Authentication based on Digital Certificates (PKI)**

## Department of Defense MARC

**Multifunction and Multitechnology card**
**Testing in Hawaii and used for deployment**
**50,000 cards in use**
**Smart Card, bar code, magnetic stripe, picture, signature block and embossed characters**
**Non Medical Functions include manifesting and deployment, food services and security**
**Medical Information includes Identification, Emergency Data, Blood Type, Immunizations, Allergies and Registration**
**DoD defining applications and planning the next generation of MARC**
**Highly successful program**

## Southern Oklahoma Physician Hospital Organization (SOPHO)

**Share Patient Data throughout the healthcare community**
**Smart Card to be used as the first step to integrated health card delivery network**
**Includes pharmacists and ambulance workers**
**Begun in September 1997**
**Insurance, demographics, allergies, medications, treatment history, notes, emergency contact information**

## EUROCARDS Framework

**EUROCARDS is a European Union (EU) Advanced Informatics in Medicine (AIM) Concerted Action on Data Card Applications in the Healthcare system**
**Created in late 1993**
**Final reports delivered in 1995**
**Developed a technical, social and legal framework for data card applications**
**European Union (EU) -Austria, Belgium, Britain, Denmark, Finland, France, Germany (originally West Germany), Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, and Sweden**

## EUROCARDS

**Healthcare Professional Cards uses**
**Identification in machine readable form**
**Access control to information systems, local and remote**
**Keys for Electronic signatures of stored and transmitted electronic documents**
**Access control to patient data based on the possession of cryptographic class keys indicating certain professional status**

## EUROCARDS

**EUROCARDS priority 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**
**Patient Cards containing medical and pharmaceutical information, or pointers to the data**

## EUROCARDS - Outcomes

**Book - “Healthcare Card Systems, EUROCARDS Concerted Action Results and Recommendations”, A. Pernice, H. Doare and O. Rienhoff, IOS Press, 218 pages**
**Detailed material from EUROCARDS WG1-WG4 From DGXIII of EU**
**G7 Healthcare Data Cards - An initiative extended to US, Canada and Japan**

## TrustHealth Project Framework

**Demonstrate trustworthy telematic systems using modern security techniques in an open systems connectivity environment with trans-European interoperability**
**Using smart cards and RSA asymmetric encryption for health care information security**
**User authentication, digital signatures and exchange of session keys for confidentiality protection, proof of professional registration and as access control devices**
**European Commission sponsored and started in 1995 **
**National Trusted Third Parties to issue key cards and maintain link between the user and the public key**
**Spri in Sweden**

## G-8 Healthcare Data Card Project

**Members are Canada, France, Germany, Italy, Japan, United Kingdom, United States, Russia.**
**Two pilot areas were initially identified for a global project approach**
**an **_**international emergency card **_**with an international harmonized emergency and administrative data set (CardLink Project)**
**an **_**international professional card **_**that will allow the **_**secure identification **_**of healthcare professionals when accessing medical data and network services (NetLink Project,  PKI)**
**http://www.sesam-vitale.fr/Projects/Netlink-G7-En/**

## G-8 Healthcare Data Card Project

_**the card is a carrier of data**_**: where the telematic infrastructure is not available, the patient, moving from one point of care to the other, and carrying in a card his/her own data and **_**pointers to remote databases**_**, actually makes a sort of "virtual" flexible infrastructure that can substitute and complement a more “physical” infrastructure (cabled or wireless).**
_**the card is a key to access the network**_**: both the **_**patient's card**_**, containing the pointers to federate remote data bases, and the **_**doctor's professional card**_**, containing the profile of the user and the associated rights to access the system and its services, constitute essential elements for the overall networked system.**

## G-8 Healthcare Data Card Project

**Plans for **_**Technical Interoperability **_**- The functional goal is to allow data to be exchanged between different projects in multiple countries using equipment and cards from multiple vendors**
**Multiple **_**levels of standardization**__** **_**are required - Standard in areas of Nomenclature,  Data Sets for emergency data, data sets for administrative data, and Standards related to various aspects of security**
**More information and links at http://www.va.gov/card/ and http://www.sesam-vitale.fr/Projects/Netlink-G7-En/**

## CARDLINK Project

**Portable Administrative, Emergency, Medical and Prescription Data**
**User driven, supported by European Commission**
**Interoperable European data set with language translation**
**10 sites in 9 countries include France; Dublin, Ireland; Germany; Holland; Spain; Greece; Portugal; Italy; Finland**
**Demonstrate standards based card and reader interoperability with multiple manufacturers**
**Measure usefulness in emergency situations**
**Begun in 9/1994, pilot to be completed in 1999**
**Use of card is voluntary**

## NetLink Project

**The NETLINK project aims at establishing recommendations and technical specifications for :**
**Health Professionals to access to Patient Data Cards (free or controlled access to data stored in Patient cards)**
**Health Professionals to securely exchange documents (including digital signature and confidentiality services)**
**Health Professionals secure access to on-line servers****	**
**Involves smart cards (used by Health Professionals and Patients), computers (used by Health Professionals, Hospitals, Health Insurance Funds), large networks, and Security architectures including data encryption**
**France, Germany, Italy and the Province of Québec**

## Germany

**Germany has completed a project distributing 80 million cards to all citizens during 1994 and 1995, along with the reader/printer infrastructure**
**Memory chip cards used for insurance identification.**
**Printing of Health Insurance forms**
**Options for electronic submission to insurance fund, eliminating paper and reducing insurance processing costs**

## French Health Patient Card - Vitale

**4 Pilots for Administrative Data Card**
**Santal Card - Medical Card converging with Vitale**
**Vitale 1 - family insurance cards being distributed 1999**
**Vitale 2 - French patient data card**
**patient card with medical data pilots in 1998**
**plan for 50 million card distribution starting in 2000**
**Emergency Data Sets Compatible with G-8 framework**

## French Health Patient Card - Vitale (cont’d)

**Vitale 1 being distribute now**
**26 million patient cards  distributed as of 2/1999**
**ID and Administrative data**
**Smart card with M9 operating system similar to French Bank card**
**5 million cards distributed per month from 4 suppliers**
**target of 42 million cards by May 1999**

## The French Health Professional Card - Carte "CPS"

**2 Pilots for CPS Health Professional Card**
**CPS Health Professional Card with crypto chip to be distributed with a total of 300,000 cards**
**Goals similar to patient card (simplicity, reliable information Confidentiality, limitation of frauds)**
**Access key to the Healthcare Intranet**
**Access key to the medical data set on the patient card**

## The French Health Professional Card - Carte "CPS” (cont’d)

**35,000 Health professional cards distributed as of 2/1999**
**10,000 distributed each month**
**currently being distributed to physicians.  **
**identification of healthcare provider, RSA public /private keys, PIN protected**
**distribution to nurses, pharmacists, and hospitals next**
**negotiations ongoing with health professional organizations**

## The French Health Care Network

**Network for health communications**
**Available nation wide since November 1998**
**IP based**
**provides e-mail and directory services**
**access control by CPS - need CPS card to enter**
**2000 physicians connected**
**1000 physicians being added per month**
**traffic doubling each month**
**current use is secure administrative transactions**

## Quasi Niere Renal Dialysis 

**Quality Assurance and Renal Dialysis Treatment**
**Medical Association in Berlin, Ministry of Health in Germany**
**Operational with 35,000 cards as of March  1997**
**50,000 patients, 3,000 doctors**
**Secure collection of confidential medical information over the Internet**
**Includes TrustHealth concepts for authentication, digital signature and communication over Internet**
**providers and patients**

## Canada

**Rimouski Project 1993 to 1995**
**Québec is building on the experiences of European and Canadian projects  **
**Administrative and Clinical purposes (Identification, data transport, security and privacy)**
**Large Scale Smart Card Distribution for providers and patients - budget request**
**Patient and Professional Smart Card project at Unité de Médecine Familiale de l’Enfant-Jésus in Quebec starting in 1999 emphasizing patient access to their data**
**NetLink participant**

## Summary

**Opportunities in administrative simplification, data transfer, improved security/ privacy, decreased fraud**
**Widespread Implementations of non-chip cards**
**Many Health Cards are not electronically readable**
**Multiple Chip Cards pilots in US: HPP, Secure Telemedicine**
**National projects in Europe: Germany, France, Spain with plans in Italy and Quebec**
**The use of chip cards are gradually becoming more common in North America**
**Secure access to medical data on the network**
**Patient uses keys of smart card to control access to their record**

## Roles for a Card

**Multiple roles including:**
**Visual Identification**
**Electronic identification (Keys and certificates)**
**Portable Data Carrier or Pointers to Data**
**Electronic Payment - insurance or e-cash**
**Two Card Present model - patient and doctor cards at the same time to access data located either on the card or on the network**

## Major Concepts

**Card functions as part of the System**
**Works with the networked data**
**As the Network improves, the location of the data can change**
**Local network and world wide network (Internet)**
**Many applications can be supported**
**Will the future be gradual or explosive?**
**What critical Business Problem do YOU need to solve?**