States find cards a smart solution for health care

The Western Governors' Association has gotten "smart." The association

is leading a $3.5 million initiative that allows residents and social

service providers in three states to use smart cards, which WGA says will

allow for more efficient and secure delivery of services.

Health Passport, a pilot program, has been launched in Bismarck, N.D.;

Cheyenne, Wyo.; and Reno, Nev. It is the largest use of smart-card technology

in the United States. Some 30,000 residents are participating in the project,

which encompasses more than a dozen programs including the Women, Infants

and Children program (WIC) and Head Start.

Although Health Passport works in conjunction with the delivery of a

number of services, its primary focus is health care. Smart cards, credit

card-sized devices with silicon memory chips, can carry an person's entire

medical history for use by physicians or social workers.

"I think that all of us feel that when we go into health care, things get

done to us," said Terry Williams, a Health Passport manager. "You kind of

go into this black box and get a prescription for medication and...10 days

later, hopefully you feel better. If you don't, you go in for surgery. The

Health Passport card allows families to become fully engaged in terms of

medical care because they're the ones carrying the relevant and timely information

among providers, and I think that's the way it should be."

Williams says WGA recognized the technology's potential for administering

social services and medical care nearly a decade ago. After examining a

series of initiatives involving information technology and government services,

WGA embarked on Health Passport in 1997.

The association began by posing a series of questions: What's the best

way to facilitate communication across programs? What should be the vehicle?

Should it be online or offline? Should it be a mag stripe? Should it be

an optical laser card? The driver, Williams says, was determining the common

information that patients and health care providers needed to share data

across different programs.

For the standard card, WGA selected a hybrid 8K plate that can hold

about eight pages of single-spaced information and has the ability to read

and write 30,000 times over the life of the chip.

One of the most important benefits of the smart card, Williams said,

is that its microchip makes it very secure. But WGA also developed a "security

hierarchy" with partners, which enables each program manager to determine

who can access the information on the card by using personal identification

numbers. Clients also have their own PINs to make them feel secure.

A secretary in a doctor's office, for instance, can't read the medical

or clinical data but can only view administrative, demographic and eligibility

information. On the other hand, nurses, nutritionists, social workers and

mid-level professionals can view clinical data. Other than the card owner,

only physicians or other primary-care providers have access to all of the

information on the card.

An attractive feature of the cards is their ability to be constantly

updated. "In our case, because we are rural states, frequently those laboratory

results aren't back for a week or so because they are sent to Denver or

Salt Lake or San Francisco or some place for analysis," Williams said. "If

you run into a situation like that, there is a flag that is built into the

design of the card that says not all of the information is available. [The

provider] can go out on the Internet and go to a secured host and pick

up that information and add it to the card before the next service is rendered."

Smart-card technology has proven especially useful with patients who

see several doctors, such as cancer patients. In those cases, the card is

updated with each doctor visit, and physicians can have immediate access

to those records. Information can be stored on the cards that patients might

forget, such as the types of medication they are taking.

This helps doctors prescribe new medications and diagnose conditions.

If a physician knows a patient is taking a certain medication, he or she

might realize that a symptom points to a possible drug reaction rather than

an illness.

An important benefit for patients is that they can take their cards

to kiosks at libraries or community colleges and read the data on them.

Also, each time a patient uses his or her card to receive services, a receipt

is printed that shows pending appointments at other participating programs.

And even more features are possible. David Armour, manager of Siemens

Health Services, the largest systems integrator of smart-card technology,

sees great potential for smart cards. In Germany, which has a national health

care system, 80 million citizens carry the cards.

"It's on the very early growth curve in this country, but ultimately

everyone will carry one," Armour predicted. He said the card has "limitless

potential" because it can be used in so many ways. Williams said it is likely

that the technology will eventually be applied in all 17 states under WGA's

umbrella.

At the Mayo Clinic in Jacksonville, Fla., which serves a large senior

population, smart cards have eliminated the need for patients to wait in

line at the outpatient laboratory to announce their arrival for an appointment.

Patients now insert their smart cards into a card reader to alert the staff

that they have arrived.

"The system eliminates the No. 1 complaint of patients: clipboards,"

said Chris Lotz, a business solutions manager at Siemens.

Meanwhile, WGA is seeking to enhance its smart-card use. While some

European programs have incorporated biometrics, including the use of fingerprints,

into their smart-card systems, Williams said digitized signatures will likely

fit better into the United States' use of the technology.

"We feel that the digitized signature is, from the perspective of health

information, probably the most valuable additional tool that we could add

to our application," he said. "The digitized signature is unique. It can

be handled within the parameters of the microchip itself so that when your

health information goes out to a secure Web site or another provider, it's

unique to you. The probability is one in 10 billion...that you would be

able to crack a digitized signature."

Williams said that in the future, all information, including health

data, will be managed using both online and offline solutions. "If I am

unconscious, it's going to be real important in terms of blood types and

what medicine I'm on and what my chronic disease history is," he said.

The WGA's pilot program will end in 2001. Next summer, the Urban Institute

will present its evaluation of the project at the WGA's annual meeting.

—Kelly is a freelance writer based in Chicago.