Published: 15/01/2004, Volume II4, No. 5888 Page 6 7

A project slated for the end of the decade could see an increasing number of Europeans carrying smartcards to access state healthcare. Steve Mathieson reports

First currency, next health insurance cards.Hot on the heels of the euro, six EU countries will have issued around 167 million hi-tech smartcards by the end of the decade, making it easier to claim state healthcare across national boundaries.

The plans, announced in February last year, are seen by the European Commission as another part of integrating the continent. EU social affairs commissioner Anna Diamantopoulou said: 'The card will have a powerful symbolic value: after the euro, the European health card is another piece of Europe in your pocket.'

The UK is not one of the six, but like it or not it will be involved in this project. Between June this year and the end of 2005, the UK and other countries without health insurance cards will have to replace E111 forms and their equivalents with a card (E111 is the form holidaymakers carry so any treatment bills can be paid for by their government).

Initially, these cards will be plastic, with a magnetic stripe. But these should be replaced with cards which use an embedded chip, towards the end of the decade (see box, below). This, however, depends on the success of a project called Netc@rds - a network designed to pass health insurance data between countries.

Speaking at the ID Smart conference in London last autumn, Noèl Nader, an independent French IT consultant, said the EU plans to market the card, which could increase takeup in the UK and elsewhere.

'Less than 30 per cent of people travelling across Europe apply for the E111 form, ' he said. 'No-one can predict the effect of this widespread roll-out.'

As part of the Netc@rd project, countries with existing health entitlement cards will upgrade them on a model being developed by France's state healthcare system (health smartcards are a French technology: leading producer SchlumbergerSema and one of its main rivals, Oberthur, are both based there).

In this model, any health transaction, such as a doctor's appointment, will require the presence of two smartcards: the patient's and the doctor's. Both will be placed in a card reader, demonstrating consent, and only at this point will the doctor access the patient's records online.

France already has a two-card system - well-established patient card Vitale, dating from 1984, and healthcare professional card CPS (carte de professionnel de santé) - though not all of these are yet in smartcard form.

The two-card model is designed to cope with the health insurance schemes used across much of continental Europe, where costs need to be charged back to a patient's healthcare provider, even if most or all of those costs are met by the state.

There is already a fair amount of cross-charging between EU countries: France reimbursed 500m last year.However, Germany will be the country issuing the most cards.

Some 72 million existing health cards will be re-issued in smartcard form, after which they will also function as social security cards, identity cards for health professionals and will support electronic prescriptions.

'Germany is a nation where privacy rights are emphasised, ' says Dr Stephan Schug, Centre for Health Telematics project manager, in Krefeld, Germany.

'Patients are to decide what data will be stored, what will be deleted [and] to what data health professionals have access.'

Italy's Lombardy region, Finland and Slovenia, which is due to join the EU, will have issued new cards, or made their existing cards compatible with Netc@rd, by the end of the decade. Austria and Greece are also involved in the project - the scheme will be tested during the Athens Olympics next summer - as are two further countries that will be joining the EU: the Czech and Slovakian republics. The Quebec region of Canada is involved as an observer.

As with most European projects, the UK is following rather than leading.However, it is moving - slowly - towards the infrastructure that would be needed for a French-style system.

The national programme for NHS IT is creating online patient records, though plans to give patients smartcard 'keys' seem to have been shelved in favour of password-protected access through NHS Direct online.

Meanwhile, up to 55,000 PCs heading for the NHS must have card readers for 'security' and the health service is already introducing smartcards for health professionals.

The NHS occupational health smartcard was present in 120 trusts as of July. The scheme, which has its database in Wakefield, places the health professional's name, General Medical Council number, photo, occupational health and basic medical data onto smartcards (the medical and occupational health information is secured by a PIN). Cards are already being issued in postgraduate deaneries and have been piloted with final-year medical students in London.

In France, the Vitale card is often used as an ID card; and the German example also shows that, once introduced, cards tend to find other uses. In the UK, home secretary David Blunkett's identity card could easily become a patient card - except in Scotland, where Westminster has no power over Scottish health policy.

The other devolved assemblies may take a similar view, and there is a serious question over Irish citizens, who have free access to the UK but no identity card scheme.

Further information

European health insurance card announcement http: //europa. eu. int/comm/employment_social/news/2003/ feb/hicard_en. html lNHS occupational health smartcard www. doh. gov. uk/occupationalhealth

Chip dip: what is a smartcard?

Smartcard technology is fairly simple: it involves standardsized plastic cards, but with an embedded microchip rather than (or as well as) a magnetic stripe.

A metal contact plate is visible on the surface of the card, beneath which lies the microchip.

The chip's memory can hold basic identification data, allowing the card to function as a 'digital key'- the model for the Home Office's proposed national identity card.

However, chips can also be used to carry more substantial amounts of information.

Smartcards are much harder to tamper with or fake than their 'dumb'equivalent.However, each card costs more - very roughly, a few pounds each rather than under a pound for other kinds of plastic cards.

Stars and stripes: magnetic-stripe card technology dominates US market

While Europe imposes smartcards from the top down, in the US they are being introduced from the bottom up, because of the dominance of magnetic-stripe card technology.

The expense of changing all the readers in the world's largest economy means the US is the only credit and debit card accepting country with no plans to move to 'chip and PIN', the financial industry's replacement of signatures with smartcards and personal identification numbers.

However, the western US has a health passport smartcard, set up by the Western Governors'Association in 1999 covering three cities: Bismarck, North Dakota; Cheyenne, Wyoming; and Reno, Nevada.

These were chosen largely thanks to the enthusiasm of their state governors, rather than geographical coherence: WGA is based in Colorado, the software was written in California and the scheme's helpdesk is in Texas.

The health passport is aimed at the young children of lower-income parents and is designed to carry 450 data fields.

This is a substantial amount of data.

Many schemes use cards carrying only enough information to let them function as an electronic key, but this means readers need to be constantly connected to a central server.

The scheme works across government programmes.The cards carry vaccination records on 30 jabs, for example, which uses up most of their memory - but the information is essential for getting children into schools and daycare facilities.

The largely private status of US healthcare has caused problems, nurses often do not like the admin involved when recording vaccinations on smartcards.

However, the card saves time when several agencies want to do the same checks.

'Say a child starts at Head Start (a preschool programme) and has their eyesight tested, ' says WGA health passport project site manager Bertie Bishop.'The next programme they go to would not need to make a vision check.'

Further information www. westgov. org/wga/ initiatives/hpp