Will the UK follow France and Germany in giving every citizen a health smartcard, asks Michael Cross
You survived the ski slope, but slipped on black ice on the way back from the bar. Now you're lying on a stretcher with a compound fracture of the femur, waiting for a helicopter ambulance. This is not a good moment for working out how to say, 'I am allergic to penicillin' in French.
The last part of the trauma, at least, is unnecessary. It is already possible to store your essential medical details in a microchip embedded in a 'smartcard' the size of a credit card in a form that computers can translate into any European language. Unfortunately for accident-prone travellers, the pan-European portable electronic medical record is many years away. But 1998 will be the year in which its central component, the health smartcard, reaches critical mass.
This year sees the national roll-out of a scheme that will eventually issue health smartcards to virtually every French citizen. (Germany has already issued smartcards to more than 70 million citizens, but these contain only administrative information.)
The French government will issue 8 million health smartcards in a scheme called SESAM-Vitale. (SESAM stands for Systeme Electronique de Saisie de l'Assurance Maladie; Vitale is the name given to the card itself.) By the end of 1999, individual members of compulsory health insurance schemes will have cards.
Every time a patient goes to a doctor, they will swipe their card through a computer device which will read information to compile into an electronic care sheet, which is transmitted to a clearing house for insurance agencies, the Caisse Nationale d'Assurance Medical (CNAM). Issuing around 67 million Vitale cards will cost Fr4bn (about pounds400m).
The government justifies the expenditure on the grounds that the scheme's main purpose is to cut the costs of handling the 1 billion paper reimbursement forms that are in circulation at any one time, a number that was expected to double by 2000. The health ministry estimates it will save up to Fr10bn (pounds1bn) in administrative costs over 10 years.
'SESAM-Vitale will have a fundamental effect on the internal organisation of healthcare institutions,' says Robert Grandi, CNAM's information systems director.
The government also maintains that SESAM-Vitale will lead to improvements in information on public health. The smartcard will enable the creation of electronic medical records, containing accurate and accessible information on the health of the nation. This is badly needed, according to Denis Bard of the Institut de Protection et de Surete Nucleaire, the body responsible for monitoring nuclear safety.
France's cancer registers, for example, cover only 14 per cent of the French population, and their scope and quality of information differ widely between local authorities (departements). The computerisation of doctors - with the right measures to protect confidentiality - will provide a 'bonanza of public health data', says Dr Bard.
The government's third justification - and the controversial one - is that the card gives the government more control over the supply of medical services. The health ministry hopes that recording details of doctors' activity electronically will curb misuse of medical services and outright fraud. The main target is patients who consult many different doctors in turn, with the government reimbursing their fees each time. Independent doctors have an incentive to collude with the practice.
To curb abuse, the Vitale card acts as a replacement for the existing paper health card (actually a 52-page document resembling a cheque book) which patients are supposed to produce whenever they consult a doctor. That document was introduced as a way of curbing over-use of medical services: it contains a brief medical history so that doctors can avoid duplicating tests and prescriptions. But because there are no sanctions for failing to produce the card, or failing to keep it up to date, it has had little effect. (It was part of a package of reforms which provoked widespread fury among French health professionals.1)
The smartcard means that, if doctors want to be reimbursed through CNAM, they must record their patient's details in their practice computer.
Many professionals are worried about threats to confidentiality between doctor and patient: like the NHS's electronic clearing service, SESAM- Vitale is creating a repository of information of huge value to drug firms and other commercial interests.
The Confederation des Syndicats Medicaux Francais (CSMF), France's largest doctors' organisation, whose 10,000 members include about 5,000 GPs, has said that any health information system must assist doctors in their daily work and should not be driven by administrative concerns. The confederation has also criticised what it sees as the system's inadequate storage capacity for medical information.
Mr Grandi admits that health professionals still need to be convinced: 'There will be a wide-ranging debate on the question of the use of medical data.'
According to the health ministry, the public do not share these worries. Smartcards are a familiar technology in France. They were a French invention, and have been driven by government and industry for everything from banking to paying public transport fares.
France's largest computer company, Groupe Bull, developed the basic technology in the SESAM-Vitale chips, which it is trying to establish as an international standard. This is an operating system called TB, which Bull supplies to other smartcard makers.
TB allows one smartcard to handle data issued by several different organisations, securely separated. This means that different organisations responsible for an individual's care, for example a GP and a social services department, can share data. The computer industry's dream is for every individual to carry a 'multifunction card', which acts as everything from a bank card to a national identity card - and medical record.
The SESAM-Vitale project was launched in 1980, with the first smartcards tested in six towns in 1986. The first mass-distribution trials began in 1995. There are three generations of Vitale cards. The professional health card (CPS), already issued to 300,000 independent practitioners (including dentists, nurses and physiotherapists as well as GPs), allows access to the network. It contains an encrypted digital signature which, together with a password, identifies the holder as an authorised health professional.
Vitale 1, the family card being issued in 1998, carries basic administrative data: name, address, social security number and insurance details. CSMF has expressed total opposition to this version, claiming that the card is already obsolete, with its use restricted to electronic processing of item-of-service claims. But the confederation says it will support a regional pilot of the card in the hope of establishing its shortcomings.
Vitale 2, the personal card, has a separate section for basic medical information and can store the equivalent of 32 A4 pages. No decision has yet been made on what information will be included. But the government is developing an integrated information network for health and social security departments that will be able to share the card.
Of course the cards will not work unless doctors have computers that can read them. As in the UK, central government subsidised computers for GP practices and persuaded IT firms to offer programs which handle data from smartcards. All doctors must equip themselves with computers capable of exchanging information with the CNAM by the end of 1998. Portable terminals are also available for doctors making house calls.
The French government is lobbying for a standard European emergency health card, based on the same technology. In 1996, the European Parliament backed the idea. The European Commission is sceptical, however, citing different systems of reimbursement as well as technical obstacles. One technological barrier to a standard European electronic card has recently fallen. An international research effort called the Good European Health Record (GEHR) has developed a standard structure for a patient-centred electronic record capable of being shared across all sectors of healthcare and of evolving through a patient's lifetime.
At least one computer-maker, the Belgian firm Health Data Management Partners, has demonstrated a commercial system that can read information from a GEHR-structured record and display it in any European language.
Chair Alain Maskens says the technology is only waiting for doctors to put it to use. 'All we are producing is a musical instrument. But you have no music without musicians.'
With both Germany and France committed to smartcards, Europe's sceptic is Britain. Smartcards play no part in the current NHS IT strategy. Ironically, the technology was tested in the NHS as long ago as 1989. The Care Card trial in Exeter gave cards to 8,500 patients in a 20-month project. It showed that the technology worked, but it was too brief and involved too few patients. (Another project in the Exmouth area, part-funded with Department of Trade and Industry and EC grants, is testing the technology further.)
Partly, there is a feeling that the NHS does not have much to learn from expensive and inefficient foreign health services. This is not just prejudice: the NHS has its own solution to the main problem SESAM-Vitale exists to tackle. Britain's GPs were well ahead of the rest of Europe in adopting personal computers and virtually all practices are now linked to health authorities' computers for exchanging administrative data electronically.
One form of NHS smartcard will almost certainly appear in the next few years - but for healthcare professionals only. Smartcards, acting as electronic keys, are one of the 'privacy enhancing technologies' envisaged as a way of protecting data on the NHS-wide computer network. Putting such a system into practice, however, raises many difficult questions - not least, who will issue and authorise the cards? Some details may emerge in the new NHS IM&T strategy due to be published next month.
Meanwhile, proposals for a multi-purpose national smartcard in Britain emerge regularly from think-tanks, especially those linked to the computer industry. In late 1996, the Cabinet Office floated plans for a card that would double as a driving licence and voluntary identity card. But the government had to abandon the idea when Conservative MPs learned that, to comply with European standards, the card would have to carry a European flag. Labour has revived the idea of a multi-purpose card, to speed up the paperwork surrounding taxes and benefits. But there are no plans for the card to contain any medical data or even the NHS number - the nearest thing in Britain to a national identity number.
Most recent studies of healthcare technology predict that the portable, electronic medical record will eventually be with us. Peter Cochrane, head of applied research and technologies at BT, says that in the near future people will be wearing their medical records as personal jewellery.
The objection to patients holding their own records is that they will lose them. But evidence suggests this fear is exaggerated. One 1991 study showed that even mentally ill homeless people are capable of looking after their own medical records - or at least that they lose fewer of them than hospitals do.2