Ebook: Health Cards ’95

HEALTH CARDS ’95 from October 24-26 in Frankfurt/Main was the third international congress on patient cards in health care in Europe in a row. Previous congresses took place in Barcelona (1991) and Marseille (1993). Again, this congress was organised in close cooperation with the national health administrations and the European Union. It took place in Germany for the first time and was held at the facilities of the Frankfurt Messe.

The congress consisted of a conference and an industrial exhibition both of which were well attended by international experts. After the successful nationwide introduction of the Health Insurance Card in Germany, HEALTH CARDS ’95 aimed at providing an international synopsis of the present state of affairs:

Which patient card applications are promising in the health sector?

Which other European countries will follow in introducing national insurance cards?

Why are professional card systems so important?

What is the present state of the European emergency pass?

Which legal conditions have to be created for a safe use of card systems?

During the congress, current applications in Europe, the USA, Canada, and Japan were presented and demonstrated. In addition to this, members of the European Concerted Action on patient and professional cards presented results of the investigation: A detailed framework on how to install card systems in national health care systems. Also, the state of affairs of the G-7 action on patient data cards was reported.

HEALTH CARDS ’95 was organised by the Coordination Office of the German Association of Public Sickness Funds (Spitzenverb‰nde der Krankenkassen), the Federal Association of Sickness Fund Physicians (Kassenärztliche Bundesvereinigung), the National Medical Council (Bundes‰rztekammer), and the German Society for Medical Informatics, Biometrics, and Epidemiology (GMDS) under the patronage of

Horst Seehofer, Federal Minister for Health,

Dr. Martin Bangemann, European Commissioner,

Barbara Stolterfoht, Minister for Women, Labor and Social Affairs of Hesse.

More than 90 papers were received and edited in this proceedings volume. Many papers did not arrive in the requested format and were reedited by Michael Haegele and Ursula Piccolo, who performed a tremendous job to have everything ready in time. The proceedings volume will be the second edition on health care card systems within the series “Studies on Health Technology and Informatics” by IOS. It certainly will contribute to the advancement in this specific field of telematics for health.

C.O. Köhler, O. Rienhoff, O.P.Schaefer

Frankfurt, September 1995

To investigate the current status of health care card projects, a questionnaire survey was conducted for major organizational bodies in Europe, North America and Japan. The questionnaire majorly consists of the environment, resources, operation and evaluation. And replies were collected and analysed. According to the result of analysis, an analytical model to evaluate a health care card system will be proposed.

Actually, the Belgian Health card projects are rare and are “private” initiatives until a few months ago politics seemed not to be very concerned with these projects (no interest? not enough information?) but this is changing slowly. The media coverage of the different Belgiam projects, the German model made them wake up.

What is hidden under the concept of “Health Card”, in Belgium? It means every card used in the Health care system. Two experiences obviously refer to the notion of “Health Card”: the Hemacard experience, a specialized clinical record on a smart card which, in keeping with the Constructive Technology Assessment method is conducted in Haematology department of the Mont-Godinne Hospital, and the experience of the CPAS of the city of Charleroi, an administrative Health “card” for people who are in a precarious situation¹. There are other administrative cards used in the Belgiam Health care system but they are not called “Health cards”: the Health insurance cards given by the Mutual insurance companies to their affiliated members, the internal cards used in some hospitals.

France has based its health care expenses containment on the maîtrise médicalisée des dépenses de santé (medical containment of health care expenses). For that purpose, an electronic data interchange system, based on the use of smart cards, will play an important part. Through SESAM-Vitale, France experiments the diffusion of patient and health professional cards and the use of electronic messages between professionals and the social security organisms.

In recent years, German health authorities and legislature have concentrated on the introduction of a standardized nation-wide insurance card. By selecting ISO-compatible chip cards they provided a perspective for more sophisticated applications like emergency or diabetes cards based on processor chip technology. In this field emphasis is concentrated on an active role in the Eurocards concerted action aiming at interoperability of card functions and harmonisation of data structures.

In this paper we describe the Italian reality of the use and diffusion of Health Cards or Patient Data Cards (PDC). The computerisation of Medical Record is becoming now a necessity, and the role of a portable medical record by means of Patient Card is very important and useful to integrate the Health Information Systems. We will briefly illustrate the history and the present Italian situation on the cards applications in health care. Experiences, projects and pilot experiments will be listed. A lot of these initiatives present a lack of harmonisation and coordination aspects. The proposal is to create national and regional plans in order to increase the diffusion of the electronic data cards applications in social and health care, and, in this context, to involve the Public Administration offices, (at national, regional and local levels), the health services operators and also the companies of medical informatics sector.

The article gives an overview of chip card developments in the Netherlands. Figures on operational chip card schemes are broken down for different fields of application, including health care. In its turn the health care applications are divided into ‘administration & registration’, ‘service’ and ‘security’. Coordination activities on a national level are carried out by the National Chip card Forum (NCP). The NCP is active in creating the conditions for an open infrastructure for multiapplication chip cards.

At the beginning of 1995, the introduction of the statutory Health Insurance Card in Germany has been successfully completed. Its electronic memory chip permits the storage of the personal identification data of the about 73 Mio insured persons in Germany. Personal identification data are name, address, date of birth, health insurance number and insurance status. The offices of the about 110.000 German ambulatory physicians have at the same time been equipped with card reading devices and printers that permit the reading and processing of administrative data. In the meantime, the presentation of the health insurance card at each consultation has become mandatory and thus replaced the obligatory submission of claims forms. The health insurance card entitles the patient to receive medical services. The identification data stored on the memory chip are transferred to all forms used in practices (such as reimbursement forms, prescriptions, disability forms and referrals to hospitals).

The French Government has committed itself in favor of a card system, which should be generalized after January 1997. This paper presents the reasons having led to this commitment. They are administrative, medical and economic. Then, in relation to the specific situation of France and the field of healthcards, the Government exercises its classical functions as guardian of general interest, regulator of the health care system, and maker of the legal frame.

The Spanish social Security Card Project consists of issuing a smart card for the entire Spanish population (approx. 37,000,000 inhabitants) along a five year period. The objectives of the card are:

- Identify citizens vis-a-vis Social Security.

- Provide access to information.

- Reduce irregular situations and ease the supervision of the services (Ministry of Labour and Social Security transacts services for over $60 billion)

The card selected for the field trial contains a microprocessor and a multiplication operating system with 3 KBytes of EEPROM which allows the storage of personal data required by the Social Security and Health System. The Social Security Card Project integrates numerous Spanish public administration bodies belonging not only to the Ministry of Labour and social Security, but also to health administration. Its budget is of over $300 million. In addition, project will include the installation of terminal for information, self-service mode, throughout the offices network (over 3.000 Points of Information) and LAN PCs for health care management in the health care centers (over 20.000 PCs). Citizen’s identification will be made by mean of fingerprint biometric recognition. The pilot phase, already completed, has consisted of issuing 5000,000 cards do the population in Cordoba and of installing the terminals and PoI’s needed in that city. It has already showed the significant advantages and benefits that will be obtained. Among them we should point out a very fast payback thanks to the fraud reduction that will be achieved. Massive issue of cards will start by the end of this year.

New technologies may contribute to innovation and improvement of quality of healthcare. A necessary condition to achieve this objective is good relationships between all parties involved: health care providers, health care institutions and health care insurance companies. Public Health Care Insurance Company DSW, a regionally based healthcare insurer, was the first insurer to provide their insured with a smart card for health care in the Netherlands. The Delft project proves that a smart card facilitates the linking up of activities of the various participants. As a result the quality of care improves, while at the same time administrative procedures and the financial settlement of transactions are simplified. The presentation will give a historic overview and the present status of the project. Also, plans for the near future will be mentioned. The motives and objectives of the different participants will be summarized. Finally, a list of data on the smart card is given.

This report explains first the difference between medical confidentiality and data protection. It comments the legal aspects of introducing the Health Insurance Card, specially on medical confidentiality. It shows last the requirements a patient card with medical data has to comply to realise that the patient is master of his data.

Interoperability remains the key factor for a widespread acceptance of health cards and for further investment in technical infrastructure. To achieve interoperability, it is inevitable to find a consensus on certain technical, structural, ethical, and legal standards. European and G7 efforts on global harmonisation of card systems give an example for the ultimate goal, which should be taken into account right from the outset.

Owing to the incentives provided by the nation-wide introduction of the Health Insurance Card various card projects with different targets have been launched since the second half of 1994. As the projects may differ considerably as far as motives, card contents and technical aspects are concerned, the harmonization of these aspects is an urgent need. Thus, it can be prevented that the failure of projects would suppress the budding acceptance of medical patient cards by the population. Since the Joint Panel on Health Cards has been founded in 1995, project partners and other responsible persons try to agree upon the introduction of medical patient cards. Special emphasis is put on the aspect of interoperability.

Two points should be raised concerning the activity for the introduction of medical cards in Italy. The first one is related to standardisation of the information to be stored on medical cards. The Italian body in charge of the standardisation in all the fields, has a Commission on Medical Informatics that has created a working group, parallel to the corresponding CEN European group. The working group is coordinated by the author of the present abstract. The group has reached a first conclusion that the medical card should be composed of three parts: personal identification parameters, emergency-urgency personal data, oriented clinical data. These three parts will be discussed in some detail. The second part will be the illustration of field activity in Italy, essentially centred around the use of optical cards. It will be shown that this activity goes far beyond the experimental phase, being already an operative tool that includes the building of specialistic medical data bases and the use of telecommunications.