# ^Progress\ of\ Card\ Technologies\ in\ Health\ Care^

^Daniel\ L.\ Maloney^

^Director\ of\ Emerging\ Technologies^

^Department\ of\ Veterans\ Affairs,\ VHA^

^8403\ Colesville\ Road,\ Suite\ 200^

^Silver\ Spring,\ MD\ 20910^

# ^CardTech/SecurTech\ 98^

^April\ 29,\ 1998^

# ^Progress\ of\ Card\ Technologies\ in\ Health\ Care^

# ^Daniel\ L.\ Maloney^

^Director\ of\ Emerging\ Technologies^

^Department\ of\ Veterans\ Affairs,\ VHA^

^8403\ Colesville\ Road,\ Suite\ 200^

^Silver\ Spring,\ MD\ 20910^

^phone:\ 301-427-3707,\ fax\ 3711^

^email:\ daniel.maloney@med.va.gov^

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

**^1.\ Overview^**

There have been many new developments in smart card technology this
year. While these changes are not yet reflected in medical applications,
it will not be long before their impact is felt. This year the PC/SC
Workgroup specifications have been released, followed by the release by
Microsoft of code to support this specification. This will allow all
systems running Win95 and WinNT to easily support many different card
readers and cards. In the past, articles about smart card applications
were often found in professional journals. This year popular newspapers
and magazines seemed discover smart card technology with many more
articles about electronic cash and Internet security. Perhaps this was
because of the electronic cash pilots in New York City, or because of
the growth of the use of Internet. As more people use the Internet, an
expanding number of people would like to have better electronic
identification, authentication, privacy and confidentiality. The new
cards with cryptographic capabilities can perform encryption
calculations while protecting private keys. The costs of biometrics
fingerprint readers are decreasing leading more opportunities for
systems control access by means of fingerprint parameters and cards. In
other developments, the Java card was announced although the role it
will play is not well understood. In the next year, cards with new, more
powerful 32 bit computer chips are scheduled for release. All of these
improvements will make it easier to create and support a variety of
applications in medical and non medical areas.

^The\ largest\ implementation\ in\ the\ medical\ field\ will\ be\ in\ France\ where\ the\ distribution\ of\ the\ smart\ cards\ to\ all\ of\ the\ Healthcare\ Professionals\ will\ begin\ in\ mid\ 1998.\ This\ will\ be\ followed\ by\ the\ expanded\ pilots\ of\ the\ French\ patient\ card\ (Carte\ Vitale)\ during\ 1998,\ which\ will\ lead\ to\ the\ distribution\ of\ the\ Carte\ Vitale\ to\ each\ French\ citizen\ beginning\ in\ 1999.\ ^

**2. Pressures on Healthcare**

Healthcare is not immune to the downsizing pressures that are pervasive
in our world wide economy. Efficiency and profitability are under
increasingly important in all types of healthcare organizations.
Insurance and government organizations are concentrating on cutting
health care 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. When the
patient's information is captured in an automated healthcare system, it
is often not accessible because different information systems are often
fragmented and do not communicate with each other. At the same time, a
demand for citizen choice is being heard as patients pursue a more
active role in their healthcare treatment. Many patients would like to
have more 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

**3. Cards as part of the solution**

** **Cards can play an important role in delivering healthcare solutions
to the patients. These cards can meet business needs with either low
technology or high technology solutions. Most importantly, both patient
cards and healthcare provider cards need to be considered as a part of
the system. Both the network and the card are more effective if they are
combined to work together. Cards need to be considered as a part of
local or networked system. A card can carry a visually readable or a
electronically readable identifier to speed patient information lookup
in an automated system. This can lead to Decreased Paper Work and
Administrative Costs, Decreased Date Entry Error, and Better, Faster
Delivery of Services and Benefits. Information can be retrieved more
easier and more quickly when the card is used as the key for data
lookup, or when the card is used to store the data. This improvement in
service leads to Increased Patient Convenience. When the card is used as
a factor in establishing patient identity, fraud can be decreased. Using
cards containing more advanced technology, keys and certificates can be
used as part of the system for Secure Access to On-line 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\ Health\ Care\ 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\ health\ care,\ etc.\ ^

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

^Some\ evolving\ functions\ include:^

·
^Authentication\ -\ Cards\ can\ carry\ certificates\ and\ keys\ used\ for\ encryption\ and\ digital\ signatures.\ 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\ -\ 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.\ Health\ Care\ Use\ of\ Card\ Technology^

# ^5.1\ Projects\ in\ the\ United\ States^

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

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

^\ The\ VA\ has\ two\ smart\ card\ pilots.\ The\ first\ is\ an\ Electronic\ Purse\ pilot\ at\ the\ Tampa,\ Florida\ and\ Bronx,\ NY\ facilities\ which\ was\ begun\ in\ October\ 1997.\ The\ pilot\ is\ a\ joint\ project\ involving\ the\ VA,\ U.S.\ Treasury,\ Nations\ Bank\ and\ Visa.\ Approximately\ 50,000\ cards\ will\ be\ used\ by\ staff,\ patients\ and\ visitors.\ Applications\ to\ be\ tested\ include\ volunteer\ meal\ tickets,\ 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.\ ^

^The\ purpose\ of\ the\ second\ VA\ pilot\ is\ to\ allow\ selected\ users\ to\ have\ limited\ access\ to\ corporate\ resources\ from\ the\ Internet.\ The\ pilot\ will\ encrypt\ all\ traffic\ across\ the\ Internet\ and\ allow\ restriction\ of\ access\ 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\ and\ something\ you\ have\ (a\ key\ protected\ in\ a\ smart\ cards).\ Initially,\ 100\ users\ will\ be\ involved\ with\ the\ test.^

^West\ Virginia\ University\ in\ Morgantown,\ West\ Virginia\ has\ an\ pilot\ underway\ focusing\ on\ Secure\ Collaborative\ Telemedicine\ Over\ Public\ Networks.\ A\ National\ Library\ of\ Medicine\ Grant\ is\ supporting\ this\ effort\ in\ order\ to\ better\ understand\ secure\ and\ private\ Telemedicine\ systems\ and\ the\ associated\ policy,\ administration,\ regulation\ and\ technology\ issues.\ The\ system\ is\ building\ upon\ existing\ standards\ whenever\ possible.\ Smart\ Cards\ are\ used\ for\ identification,\ authentication\ and\ data\ storage.\ The\ project\ builds\ upon\ lessons\ from\ other\ Healthcare\ card\ initiatives\ including\ concepts\ of\ EUROCARDS\ and\ TrustHealth\ as\ well\ as\ the\ G-7\ Healthcard\ Interoperability\ Specifications\ and\ CARDLINK\ data\ sets.\ Initially,\ five\ sites\ will\ be\ involved\ in\ the\ test.\ The\ cards\ are\ used\ to\ authenticate\ users\ over\ the\ network\ .\ They\ also\ carry\ data\ such\ as\ the\ emergency\ data\ set\ which\ is\ compatible\ with\ CARDLINK.^

^\ The\ Western\ Governors\ Association\ is\ sponsoring\ the\ Health\ Passport\ Project\ with\ a\ focus\ on\ Preventative\ Health.\ The\ cards\ function\ as\ an\ identifier\ and\ as\ a\ data\ carrier.\ 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\ improving\ data\ sharing\ between\ programs.\ An\ award\ was\ made\ in\ 1997\ for\ the\ system\ with\ 30,000\ cards.\ The\ project\ is\ in\ the\ development\ phase\ with\ deployment\ expected\ to\ begin\ during\ 1998.\ The\ project\ includes\ smart\ cards,\ terminals,\ readers,\ software\ and\ Kiosks.\ The\ project\ will\ be\ implemented\ the\ 3\ states\ of\ Nevada,\ North\ Dakota,\ Wyoming.\ There\ are\ 7\ Preventative\ Health\ Care\ Programs\ including\ Women's\ Infant\ and\ Children\ (WIC),\ Immunizations,\ Medicaid\ (EPSDT),\ Immunizations,\ Head\ Start,\ Maternal\ and\ Child\ Health.^

^\ There\ are\ two\ emergency\ smart\ card\ projects\ in\ the\ state\ of\ Oklahoma.\ ^

^Southern\ Oklahoma\ Physician\ Hospital\ Organization\ (SOPHO)\ project\ focuses\ on\ sharing\ patient\ data\ throughout\ the\ healthcare\ community.\ The\ smart\ card\ is\ used\ as\ the\ first\ step\ to\ integrated\ health\ card\ delivery\ network.\ The\ project\ was\ begun\ in\ 1997\ and\ includes\ equipment\ for\ Pharmacists\ and\ ambulance\ workers.\ The\ patient\ card\ contains\ information\ on\ Insurance,\ demographics,\ allergies,\ medications,\ treatment\ history,\ notes,\ emergency\ contact\ information^

^The\ Oklahoma\ MediCard\ Project\ is\ an\ emergency\ smart\ card\ application\ developed\ and\ operated\ by\ Precis\ Smart\ Card\ Systems.\ The\ cards\ function\ as\ an\ identifier\ and\ as\ a\ data\ carrier.\ There\ are\ 8000\ cards\ in\ use\ in\ the\ Oklahoma\ City\ Area\ with\ readers\ many\ locations\ including\ medical\ centers\ and\ ambulances.\ The\ cards\ contain\ identification\ information\ as\ well\ as\ medical\ information\ such\ as\ emergency\ data,\ allergies,\ diagnoses,\ medical\ procedures,\ medications,\ primary\ physicians,\ and\ insurance\ information.^

^Department\ of\ Defense\ 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.\ DoD\ is\ currently\ identifying\ additional\ functionality\ and\ evaluating\ options\ for\ a\ Person\ Identification\ Carrier\ (PIC).^

# ^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 activities of
particular interest:

^The\ French\ government\ has\ begun\ an\ aggressive\ implementation\ plan.\ Smart\ cards\ will\ be\ distributed\ to\ all\ healthcare\ providers\ and\ to\ all\ patients.\ In\ addition,\ a\ communications\ system\ will\ be\ made\ available\ to\ healthcare\ providers.\ The\ original\ Sesam\ Vitale\ 1\ project\ began\ in\ 1985and\ included\ a\ family\ card\ for\ insurance\ entitlement.\ Beginning\ in\ mid\ 1998,\ the\ Healthcare\ Provider\ Card\ will\ be\ distributed\ to\ every\ provider.\ This\ card\ will\ contain\ keys\ for\ access\ to\ healthcare\ data\ on\ the\ network,\ for\ access\ to\ data\ contained\ on\ patient\ cards,\ and\ keys\ for\ digital\ signatures.\ This\ will\ be\ followed\ by\ the\ expanded\ pilots\ of\ the\ individual\ French\ patient\ card\ (Carte\ Vitale)\ during\ 1998\ which\ will\ include\ some\ medical\ data.\ Beginning\ in\ mid\ 1999,\ the\ Carte\ Vitale\ will\ be\ distributed\ to\ 50\ million\ French\ citizens.^

^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/printers\ system\ allows\ patient\ data\ contained\ on\ the\ card\ to\ be\ automatically\ printed\ as\ a\ completed\ the\ insurance\ form.\ 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.^

^CARDLINK\ project\ is\ a\ multi\ country\ Portable\ Emergency\ Record\ project\ implemented\ with\ smart\ cards.\ The\ cards\ function\ as\ an\ identifier\ and\ as\ a\ data\ carrier.\ The\ data\ includes\ emergency\ data\ as\ well\ as\ pointers\ to\ locations\ where\ additional\ patient\ medical\ data\ can\ be\ obtained.\ The\ project\ is\ user\ driven\ and\ supported\ by\ European\ Commission.\ It\ uses\ a\ interoperable\ European\ emergency\ data\ set.\ The\ project\ was\ begun\ in\ September,\ 1994.\ The\ initial\ 5\ pilot\ sites\ were\ Saint-Nazaire,\ France;\ Dublin,\ Ireland;\ Milan,\ Italy;\ Rome,\ Italy;\ and\ Valencia,\ Spain.\ Currently\ there\ are\ 10\ pilot\ locations\ in\ 9\ countries.\ One\ technical\ goal\ is\ to\ demonstrate\ standards\ based\ card\ and\ reader\ interoperability\ across\ multiple\ manufacturers.\ Evaluations\ will\ include\ a\ measure\ of\ usefulness\ in\ emergency\ situations.^

^NetLink\ is\ a\ coordinated\ action\ to\ ensure\ implementation\ of\ interoperable\ data\ cards\ systems\ and\ intranet\ solutions.\ NetLink\ is\ a\ new\ EU\ funded\ Project\ 1998-1999.\ It\ is\ a\ multi-country\ pilot\ of\ an\ interoperable\ Patient\ and\ Healthcare\ Provider\ Cards.\ There\ will\ be\ pilot\ sites\ in\ France,\ Germany,\ Italy\ and\ Canada.\ Benefits\ will\ include\ secure\ and\ easy\ communication\ of\ sensitive\ data\ across\ borders.\ ^

^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\ that\ their\ smart\ card\ will\ be\ compatible\ with\ the\ card\ in\ Europe,\ and\ that\ they\ will\ also\ begin\ a\ project\ to\ distribute\ 7\ million\ cards\ beginning\ in\ 1998.^

^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\ Ministry\ of\ Health\ in\ Germany.\ The\ project\ is\ operational\ with\ over\ 35,000\ cards\ in\ use\ as\ of\ March\ 1997.\ The\ project\ will\ involve\ 50,000\ patients\ and\ 3,000\ doctors.\ The\ project\ includes\ the\ authentication,\ digital\ signature\ and\ privacy\ of\ communication\ over\ Internet\ as\ outline\ in\ the\ TrustHealth\ framework.\ The\ project\ includes\ authentication\ cards\ for\ both\ providers\ and\ patients.^

# ^5.3\ Framework\ Projects^

In addition to these projects, there are several framework projects
which describe a structure to development

^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\ uses\ include\ electronic\ identification,\ 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\ 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,\ or\ pointers\ to\ the\ 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\ Project\ 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\ health\ care\ 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\ necessary\ component\ to\ issue\ key\ cards\ and\ maintain\ the\ link\ between\ the\ user\ and\ the\ public\ key.\ The\ project\ involves\ 9\ countries\ and\ multiple\ suppliers.\ Spri\ in\ Sweden\ played\ a\ major\ part\ in\ TrustHealth\ development.^

^The\ G-7\ Healthcare\ Data\ Card\ Project\ is\ 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\ and\ the\ European\ Commission\ established\ a\ number\ of\ projects\ where\ international\ cooperation\ could\ be\ an\ asset.\ This\ project's\ goals\ are\ to\ demonstrate:^

·
^an\ International\ Emergency\ Card\ with\ an\ international\ harmonized\ emergency\ and\ administrative\ data\ set,\ ^

·
^an\ International\ Professional\ Card\ that\ will\ allow\ the\ secure\ identification\ of\ healthcare\ professionals\ when\ accessing\ medical\ data\ and\ network\ services,\ and\ ^

·
^Technical\ Interoperability\ with\ the\ functional\ goal\ to\ allow\ data\ to\ be\ exchanged\ between\ different\ projects\ in\ multiple\ countries\ using\ equipment\ and\ cards\ from\ multiple\ vendors^

**^6.\ Card\ Technologies^**

Various types of cards technologies are available for use in the Health
Care environment. Cards are often made of paper or a variety of
plastics. They can contain printed human readable information . Cards
can carry information in machine readable format in a magnetic stripe, a
bar code, an optical memory strip, an electronic serial memory chip or a
computer chip. They can be embossed, carry graphics, identification
photographs, signature panels, holograms to discourage fraud, or
combinations of these. For any card technologies, select standards based
systems. Standards based systems can be read by equipment from more
manufacturers at more locations with fewer systems integration problems.
Standards based systems expand the market and lower prices for all. The
following are some of the technologies available.

  ---------------------------------- --------------------- ------------------------------------------------- ---------------------- ----------- ------------------------------ ------------------------ ------------- ----------------------- ------------------------ -------------- ---------------------------------------------------- ----------------- --------------- -----------------------
  ^Card\ Technologies^               ^Unit\ Cost\ (\$)^    ^Major\ Benefits^                                                                                                                                                                                                                                                                                                 
  ^Paper\ with\ 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\ Cards^                        ^50.00\ to\ 100.00^   ^more\ storage\ and\ computational\ capability^                                                                                                                                                                                                                                                                   
  ---------------------------------- --------------------- ------------------------------------------------- ---------------------- ----------- ------------------------------ ------------------------ ------------- ----------------------- ------------------------ -------------- ---------------------------------------------------- ----------------- --------------- -----------------------

# ^Table\ 1:\ Major\ Card\ Technologies^

  ----------------------------- -------------------- ------------------------ -------------------- ----------- ------------------------ --------------------------- ----------- -------------------------- --------------------------- ----------- -------------------------- ----------------------------- ----------- -------------------------- ----------------------------- ----------- ----------------
  ^Card\ Technology\ Options^   ^Unit\ Cost\ (\$)^   ^Major\ Benefits^                                                                                                                                                                                                                                                                                                                       
  ^\ 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^                                                                                                                                                                                                                                                                                                                          
  ----------------------------- -------------------- ------------------------ -------------------- ----------- ------------------------ --------------------------- ----------- -------------------------- --------------------------- ----------- -------------------------- ----------------------------- ----------- -------------------------- ----------------------------- ----------- ----------------

# ^Table\ 2:\ Major\ Card\ Technology\ Options^

# ^6.1\ Paper\ card\ with\ a\ bar\ code\ printed\ on\ a\ laser\ printer.^

^The\ advantages\ of\ a\ paper\ card\ is\ that\ it\ would\ be\ easy\ to\ produce\ on\ a\ wide\ variety\ of\ equipment\ and\ would\ be\ very\ inexpensive.\ The\ disadvantages\ include\ that\ it\ would\ wear\ out\ quickly\ unless\ it\ were\ protected\ by\ a\ plastic\ cover.\ A\ paper\ card\ could\ easily\ be\ printed\ with\ a\ machine\ readable\ bar\ code\ using\ a\ laser\ printer.\ A\ paper\ card\ could\ not\ be\ embossed.\ It\ could\ be\ easily\ copied.\ Estimated\ costs\ vary\ from\ fractions\ of\ a\ cent\ to\ a\ few\ cents\ per\ card.^

# ^6.2\ Plastic\ Embossed\ Card^

Plastic, wallet-sized card can be embossed allowing the mechanical
transfer of information to paper records currently used in many medical
facilities. Plastic cards can be printed with human readable and bar
code machine readable characteristics. A plastic card can be easily
copied, but it would be more difficult to copy than the paper card.
Estimated costs are approximately 10 to 15 cents per card.

# ^6.3\ Swipe\ Card\ -\ Plastic\ Embossed\ Magnetic\ Stripe\ Card.^

^The\ common\ swipe\ card\ is\ a\ plastic\ card\ with\ embossed\ characters\ and\ a\ machine\ readable\ magnetic\ stripe\ (credit\ card\ or\ ATM\ model).\ A\ maximum\ of\ 226\ characters\ can\ be\ stored\ on\ a\ low-density\ magnetic\ stripe\ on\ the\ card.\ Time\ can\ be\ saved\ by\ swiping\ the\ card\ through\ a\ device\ instead\ of\ requiring\ keyboard\ entry\ of\ the\ information.\ A\ bar\ code\ stripe\ can\ also\ be\ added\ as\ an\ alternate\ input\ device\ but\ it\ stores\ less\ information\ and\ is\ not\ changeable.\ A\ major\ advantage\ is\ that\ the\ card\ would\ be\ fairly\ easy\ to\ produce\ on\ a\ wide\ variety\ of\ equipment\ and\ would\ be\ moderately\ inexpensive.\ There\ are\ billions\ of\ magnetic\ stripe\ cards\ in\ use\ in\ the\ United\ States\ today.\ There\ are\ many\ vendors\ who\ manufacture\ the\ equipment.\ The\ disadvantages\ are\ that\ it\ can\ be\ easily\ copied\ and\ it\ carries\ a\ small\ amount\ of\ data.\ Estimated\ costs\ are\ approximately\ from\ 12\ to\ 25\ cents\ per\ card.^

# ^6.4\ Serial\ Memory\ Card:^

^Serial\ memory\ card\ is\ a\ plastic,\ machine\ readable,\ wallet-sized\ card.\ It\ contains\ memory\ chips\ that\ would\ allow\ more\ information\ to\ be\ stored\ on\ the\ card.\ It\ does\ not\ contain\ a\ computer\ to\ provide\ the\ additional\ security\ to\ protect\ the\ data.\ Without\ data\ protection,\ this\ card\ would\ not\ be\ used\ to\ store\ private\ information.\ It\ is\ well\ suited\ to\ store\ non\ medical,\ non\ sensitive\ information\ such\ as\ name,\ address,\ insurance\ company\ and\ other\ information\ commonly\ needed\ at\ the\ provider\'s\ office\ for\ administrative\ or\ payment\ purposes.\ The\ storage\ capacity\ can\ vary\ with\ this\ type\ of\ card.\ A\ version\ with\ 256\ characters\ capacity\ (256\ bytes\ or\ 2048\ bits)\ is\ being\ used\ by\ 80\ million\ German\ citizens\ today\ as\ a\ national\ medical\ insurance\ card.\ The\ major\ goal\ of\ the\ project\ is\ administrative\ simplification\ for\ identification\ and\ claim\ submission.\ Cost\ is\ about\ \$2.50\ per\ card\ for\ the\ German\ project\ including\ the\ card,\ the\ personalization\ of\ the\ card\ and\ delivery\ to\ the\ mail\ box\ of\ the\ citizen.\ A\ 2000\ character\ serial\ card\ would\ cost\ about\ \$4.00.^

# ^6.5\ Computer\ Chip\ (Smart)\ Card:^

^Computer\ Chip\ Cards\ is\ a\ plastic,\ machine\ readable,\ wallet-sized\ card.\ In\ addition\ to\ memory,\ it\ contains\ a\ programmable\ computer.\ A\ computer\ chip\ card\ supports\ additional\ functionality\ including\ data\ segregation\ and\ several\ levels\ of\ security\ to\ protect\ the\ data\ on\ the\ card.\ Computer\ Chip\ Card\ are\ used\ extensively\ in\ Europe.\ Smart\ cards\ are\ used\ to\ transport\ information,\ in\ isolated\ environments\ or\ in\ situations\ requiring\ enhanced\ card\ or\ network\ security\ and\ authentication.\ The\ storage\ capacity\ varies\ with\ the\ type\ of\ card.\ 3000\ characters\ and\ 8000\ character\ cards\ are\ common\ today\ and\ cost\ between\ \$3.50\ and\ \$15.00.\ Larger\ capacity\ cards\ are\ being\ introduced\ at\ a\ higher\ cost.\ Computer\ Chip\ Cards\ are\ extremely\ difficult\ to\ copy.^

# ^6.6\ Optical\ or\ Laser\ Card^

The optical card has a much larger storage capacity. One card available
for the past few years has a formatted storage of around 1600 pages of
text (4 Mega Bytes). This is a Write Once (WO) technology, meaning that
an area cannot be reused once data has been written in that area. Since
the data is not erasable, there will always be an audit trail and
tampering with the data is very difficult. Disadvantages include a more
expensive cost for the cards, the readers and writers. Costs are
approximately \$6.00 to \$8.00 per card.

# ^6.7\ Combination\ Optical\ and\ Integrated\ Chip\ Card^

Optical cards may be purchased with a chip card included into the card.
This combination card has the advantage of large storage capacity with
an associated smaller memory area in the computer chip that can be
secured. The data stored on the optical card can be protected by
encrypting it with a key that is then securely stored and carried in the
chip portion of the card. Costs are approximately \$10.00 to \$15.00 per
card

# ^6.8\ PC\ Cards^

PC Card are thicker than the traditional credit card sized card. They
are made to fit into the PC Card or PCMCIA card slot like those found on
many portable computers. Since these devices are thicker and are made
not to flex, they can carry many computer and memory chips. These
devices can have a much larger memory capacity and faster computer
chips. The costs of these devices vary depending on their
characteristics but may fall in the range of \$50.00 to \$100.

# ^6.9\ Biometrics^

Other personal identifiers include finger prints, voice prints,
signature dynamics, retina patterns, hand geometry or your DNA sequence.
Costs for manipulating many of these identifiers is decreasing to the
point that some of them are becoming more practical. For example, for
around \$300, equipment can be purchased that will capture the image of
a finger print in order for a personal computer to compare it to an
image of the finger print electronically stored in a card. As prices of
these recognition technologies fall, it will become more practical to
create a business case to use biometrics to meet an established need.

# ^6.10\ Additions^

Options can be added to almost all of the cards for additional costs.
Bar codes can be added to nearly all cards allowing the data in the bar
code to be read electronically by a scanner. The Bar Code capacity on
all cards is limited by the size of the card. 2D Bar codes are much
denser and can therefore contain many more characters. Magnetic stripes
can be added to nearly all cards. Fraud can be reduced by including an
identification photographs on the card. Black and White pictures can be
added for less than 15 cents per card. Color photographs can be added
for 20 to 25 cents per card. Adding holograms can make it harder to copy
the card. A hologram laminate can be added like some States are adding
to their drivers licenses for 6 to 7 cents. Postage stamp holograms
could be added for about 5-7 cents per card. Signature panels can be
added for 2 to 5 cents.

**7. **^\ Conclusion^

^Card\ technologies\ of\ all\ types\ are\ being\ used\ in\ the\ health\ care\ 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\ continues\ to\ rely\ on\ traditional\ card\ technologies,\ some\ are\ investigating\ the\ suitability\ of\ the\ newer\ technologies.\ 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.\ Outside\ of\ the\ US,\ there\ has\ been\ a\ high\ level\ of\ interest\ in\ techniques\ to\ increase\ health\ care\ system\ privacy,\ confidentiality\ and\ security.\ These\ areas\ are\ rapidly\ gathering\ interest\ in\ the\ US\ as\ more\ medical\ information\ is\ electronically\ stored\ and\ capable\ of\ being\ accessed\ from\ widely\ available\ networks.\ If\ we\ observe\ the\ activities\ and\ experiences\ in\ Europe,\ we\ have\ to\ wonder\ when\ these\ new\ technologies\ will\ begin\ to\ playing\ a\ larger\ part\ in\ the\ US\ health\ care\ environment.^

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. Large and
small companies are focusing their resources on solving the problems
associated with easy-to-use and affordable authentication and encrypted
private communication channels over the Internet. Because of the
importance of privacy and security in all aspects of health care data,
these developments will be of great interest to individuals and health
care providers. This past year we have seen the beginning of the
refinement of the next wave of integrated technical solutions which can
be applied to many business and health care needs.