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.