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Patient health record on a smart card
International Journal of Medical Informatics 48 (1998) 191 – 194
Patient health record on a smart card Attila Naszlady a,*, Ja´nos Naszlady b a
National Institute of Pulmonology, 1529 Budapest 124, Hungary Ga´bor De´nes High School for Informatics, Budapest, Hungary
b
Abstract A validated health questionnaire has been used for the documentation of a patient’s history (826 items) and of the findings from physical examination (591 items) in our clinical ward for 25 years. This computerized patient record has been completed in EUCLIDES code (CEN TC/251) for laboratory tests and an ATC and EAN code listing for the names of the drugs permanently required by the patient. In addition, emergency data were also included on an EEPROM chipcard with a 24 kb capacity. The program is written in FOX-PRO language. A group of 5000 chronically ill in-patients received these cards which contain their health data. For security reasons the contents of the smart card is only accessible by a doctor’s PIN coded key card. The personalization of each card was carried out in our health center and the depersonalized alphanumeric data were collected for further statistical evaluation. This information served as a basis for a real need assessment of health care and for the calculation of its cost. Code-combined with an optical card, a completely paperless electronic patient record system has been developed containing all three information carriers in medicine: Texts, Curves and Pictures. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Smartcard; Electronic patient record; Patient’s need assessment; Health data storage
Systematic structuralization of the anamnestic patient history began 25 years ago. We compiled our health questionnaire for general clinical practice in 1972 [1]. Due to the western embargo on high technology in Hungary at that time modern electronic information technology (IT) only became available in Hungary in the late 1970’s. * Corresponding author.
We were able to introduce medical data storage on passive read-only memory chips (ROM) from the middle of the 1980’s and chipcard technology in the 1990’s [2]. A pilot study was carried out with 5000 chipcards in 1995–1996. The scope of our work in this field was to achieve more complete patient documentation and to support the growing and much needed shared care with it. The aim is to
1386-5056/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 1 3 8 6 - 5 0 5 6 ( 9 7 ) 0 0 1 2 5 - 1
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A. Naszlady, J. Naszlady / International Journal of Medical Informatics 48 (1998) 191–194
produce a completely paperless electronic health care record (EHCR), which can also be used for recording the individual’s medication consumption combined with a check on insurance eligibility. The methodology for these complex goals involves a system which has been worked out using an EHCR on an active memory chipcard (this smart card was named the ESzEM card, which translates as: personal health electronic memory, and as abbreviated means: my brain). For alphanumeric textual data, it is portable for both the patient and for pictures (curves, diagrams, images) of the patient, a laser card forms a ‘portable archive’ at the doctor’s office. The main requirements for this health card system are the following: (1) it should be well structured; (2) sufficiently (not minimally or maximally) detailed; (3) medical information content should be selected and validated for 1000 in-patients first and then applied to 5000 outpatients; (4) it should reduce specific administrative work for health care professionals; (5) it should be legally (e.g. related to privacy protection) acceptable; (6) portable for shared care, e.g. usable in general practice also; (7) economically optimal, i.e. it should support resource management and cost effectiveness. The information technology we have applied consists of: (1) a PC terminal (a work station, more or less complete, depending on the position and role it plays within the health care system); (2) a card read/write interface (IF); (3) an EEPROM chip-card with a 24 kbit memory capacity (IOS 7816 standard); (4) a small sized CD with 128 Mb storage capacity with a CD-terminal (R/W IF); and (5) software written in FOX PRO, suitable for this complex system. Authorized accessibility is secured by so called professional cards (authentication card, i.e. a doctor’s card) with a key function
for the patient’s card. This professional card is different from a patient’s card and it functions on the doctor’s PIN code. The picturescontaining CD-card can be identified only by the insurance number of the patient and pictures on it by the date written on them. Data input is keyed onto the chip card using arrow keys only, according to yes/no answers to 826 anamnestic and 591 status items in a dichotomized way on a hierarchically structured pathway. If the answer is ‘no’ to the main question, then one can skip over a lot of detailed questions. Diagnoses, (2000 ICD standard codes), prostheses (50 standard codes), medication (2000 ATC and 7000 EAN codes), 117 lab. tests (from the entire CEN TC/251 standard EUCLIDES codes) can be selected from background menues. Remarks (on anything) and laboratory test results (until online data transferbecomes available) can be keyed in and stored. The structure of the sections on our ESzEM. card system is as follows: 1. Administrative 2. Emergency 3. Confidential 3.1. Anamnesis 3.2. Status 3.3. Path. lab. 4. Pharmaceuticals Different accessibility rights are shown in Table 1. A pilot study was carried out to verify this health card system in a geographically well defined region of South West Hungary. It is one of the most underdeveloped counties in Hungary with regard to computerization and the health personnel are not very familiar with informatics and IT. Five medical outpatient departments and dispensaries were involved in to this project, where 5000 patients with long-term chronic illnesses were selected. The local operations were: (a) a invitation letter sent to the patients; (b) informed con-
A. Naszlady, J. Naszlady / International Journal of Medical Informatics 48 (1998) 191–194
193
Table 1 Accessibilities to different sectors of ESzEM card Who
Which
How
By
Administrative clerk Ambulance Doctors
1 1,2 1,2,3
Password Professional card A Professional card B
Pharmacy
1
R/W R R/W R R R/W
4 4
Password Billing
Accessibilities to different sectors of ESzEM. card. The numerals in the 2nd column represent the various sectors on the smart card as described in the text. R/W means read/write type of accessibilities. Authentication card A is for doctors, B is for ambulance personnel.
sent obtained; © Polaroid photographs; (d) completed health cards (e) cards and photos sent to our centre where personalization of the cards was performed. In our centre, the data was copied onto an object oriented database and the depersonalized data was processed statistically (Fig. 1). After evaluation of the results, the ESzEM. cards were sent back to the centres for distribution. Evaluation included frequency distributions of different signs and symptoms, administration of medication and the comparison of the five subregions within the county, to assess possible differences with regard to real needs.It is reasonable to state that: 1. The quality of patient documentation improved. 2. Standardized sentences of the questionnaire are coded, making it more efficient for compression and linguistic translation in a possible interoperability procedure. 3. The administrative workload of health professional personnel has been markedly reduced. 4. The needs of patients can be assessed much better by being based on signs and
symptoms rather than on diagnosis. 5. EHCR is a much more manageable process than paper based documentation. 6. Currently it is fully adequate for shared health care. 7. A step-by-step extension of the ESzEM card system to the whole population is recommended. Healthcare information systems are being computerized world-wide. The electronic patient record (EPR) is a sine qua non for shared care which is necessary in the European Union due to at least 10% of the population leaving their home country as migrant workers. This may be the reason for an increased interest in smartcard systems as indicated the litrature [3–8] on healthcard systems and their uses. Referring to the political and legal framework, it is worth citing the European Council conclusions of 29 September 1998 [8]: ‘‘…requested the European Commission, with the long-term aim of establishing a European card for provision of immediate care. To conduct a survey initially of procedures whereby member states could recognise national social insurance cards issued by other member states.
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A. Naszlady, J. Naszlady / International Journal of Medical Informatics 48 (1998) 191–194
Fig. 1. The main interactive menu window. The toolbar on the top serves for menu selection. The icons mean the same as usual. On the right hand side, there is a place for a picture of the patient.
This should enable cardholders staying temporarily in a member state other than the competent member state to have access on the terms laid down by Article 22 (1) (a) of Regulation (EEC) No 1408/71. to urgently needed treatment, on presentation of their national insurance card or form E111. As of now, the Council is in favour of any experiments in mutual recognition of national social insurance cards that member states may engage in. ‘‘A pilot project (‘Cardlink’), supported by the EU 4th Framework Programme for research and development is already in operation in the health sector in Ireland, Italy, France and Spain. This project is to be extended to five more countries by the end of 1996 — The Netherlands, Finland, Greece and Portugal. Some non-EU countries have also shown an interest in participation’’.
References [1] Simon, P., Naszlady, A., Memory card in primary health care, Medinfo, ‘86, pp. 1015 – 1018. [2] Naszlady, A., ESzEM. card — implementation possibilities, AIM Europe ETK VTK SCAN, Hungary, 1992, pp. 37 – 40 (in hungarian). [3] Dick, R.S., Steen, E.B.,The Computer Based Patient Record, National Academy Press, Washington D.C., 1991. [4] Pernice, A., Doare, H., Rienhoff, O, Healthcare Card Systems, IOS Press, Amsterdam, 1995. [5] Rankl, W., Effing, W., Handbuch der Chipkarten CarlHauser, Mu¨nchen, 1995. [6] Engelbrecht, R., Hildebrand, C., Jung, E., The smart card: an ideal tool for a computer-based patient record, Medinfo 8, 1995, pp. 344 – 348. [7] Markwell, D., Healthcard Interoperability, EU and G7 Activities Health Cards Conference, Cartes, 1996. [8] O’ Reilly, P., Strategy for European Social Security Card TESS Pre-Build 7, Discussion Paper, Dept. Social Welfare, Ireland, 1996.
Patient health record on a smart card Attila Naszlady a,*, Ja´nos Naszlady b a
National Institute of Pulmonology, 1529 Budapest 124, Hungary Ga´bor De´nes High School for Informatics, Budapest, Hungary
b
Abstract A validated health questionnaire has been used for the documentation of a patient’s history (826 items) and of the findings from physical examination (591 items) in our clinical ward for 25 years. This computerized patient record has been completed in EUCLIDES code (CEN TC/251) for laboratory tests and an ATC and EAN code listing for the names of the drugs permanently required by the patient. In addition, emergency data were also included on an EEPROM chipcard with a 24 kb capacity. The program is written in FOX-PRO language. A group of 5000 chronically ill in-patients received these cards which contain their health data. For security reasons the contents of the smart card is only accessible by a doctor’s PIN coded key card. The personalization of each card was carried out in our health center and the depersonalized alphanumeric data were collected for further statistical evaluation. This information served as a basis for a real need assessment of health care and for the calculation of its cost. Code-combined with an optical card, a completely paperless electronic patient record system has been developed containing all three information carriers in medicine: Texts, Curves and Pictures. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Smartcard; Electronic patient record; Patient’s need assessment; Health data storage
Systematic structuralization of the anamnestic patient history began 25 years ago. We compiled our health questionnaire for general clinical practice in 1972 [1]. Due to the western embargo on high technology in Hungary at that time modern electronic information technology (IT) only became available in Hungary in the late 1970’s. * Corresponding author.
We were able to introduce medical data storage on passive read-only memory chips (ROM) from the middle of the 1980’s and chipcard technology in the 1990’s [2]. A pilot study was carried out with 5000 chipcards in 1995–1996. The scope of our work in this field was to achieve more complete patient documentation and to support the growing and much needed shared care with it. The aim is to
1386-5056/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 1 3 8 6 - 5 0 5 6 ( 9 7 ) 0 0 1 2 5 - 1
192
A. Naszlady, J. Naszlady / International Journal of Medical Informatics 48 (1998) 191–194
produce a completely paperless electronic health care record (EHCR), which can also be used for recording the individual’s medication consumption combined with a check on insurance eligibility. The methodology for these complex goals involves a system which has been worked out using an EHCR on an active memory chipcard (this smart card was named the ESzEM card, which translates as: personal health electronic memory, and as abbreviated means: my brain). For alphanumeric textual data, it is portable for both the patient and for pictures (curves, diagrams, images) of the patient, a laser card forms a ‘portable archive’ at the doctor’s office. The main requirements for this health card system are the following: (1) it should be well structured; (2) sufficiently (not minimally or maximally) detailed; (3) medical information content should be selected and validated for 1000 in-patients first and then applied to 5000 outpatients; (4) it should reduce specific administrative work for health care professionals; (5) it should be legally (e.g. related to privacy protection) acceptable; (6) portable for shared care, e.g. usable in general practice also; (7) economically optimal, i.e. it should support resource management and cost effectiveness. The information technology we have applied consists of: (1) a PC terminal (a work station, more or less complete, depending on the position and role it plays within the health care system); (2) a card read/write interface (IF); (3) an EEPROM chip-card with a 24 kbit memory capacity (IOS 7816 standard); (4) a small sized CD with 128 Mb storage capacity with a CD-terminal (R/W IF); and (5) software written in FOX PRO, suitable for this complex system. Authorized accessibility is secured by so called professional cards (authentication card, i.e. a doctor’s card) with a key function
for the patient’s card. This professional card is different from a patient’s card and it functions on the doctor’s PIN code. The picturescontaining CD-card can be identified only by the insurance number of the patient and pictures on it by the date written on them. Data input is keyed onto the chip card using arrow keys only, according to yes/no answers to 826 anamnestic and 591 status items in a dichotomized way on a hierarchically structured pathway. If the answer is ‘no’ to the main question, then one can skip over a lot of detailed questions. Diagnoses, (2000 ICD standard codes), prostheses (50 standard codes), medication (2000 ATC and 7000 EAN codes), 117 lab. tests (from the entire CEN TC/251 standard EUCLIDES codes) can be selected from background menues. Remarks (on anything) and laboratory test results (until online data transferbecomes available) can be keyed in and stored. The structure of the sections on our ESzEM. card system is as follows: 1. Administrative 2. Emergency 3. Confidential 3.1. Anamnesis 3.2. Status 3.3. Path. lab. 4. Pharmaceuticals Different accessibility rights are shown in Table 1. A pilot study was carried out to verify this health card system in a geographically well defined region of South West Hungary. It is one of the most underdeveloped counties in Hungary with regard to computerization and the health personnel are not very familiar with informatics and IT. Five medical outpatient departments and dispensaries were involved in to this project, where 5000 patients with long-term chronic illnesses were selected. The local operations were: (a) a invitation letter sent to the patients; (b) informed con-
A. Naszlady, J. Naszlady / International Journal of Medical Informatics 48 (1998) 191–194
193
Table 1 Accessibilities to different sectors of ESzEM card Who
Which
How
By
Administrative clerk Ambulance Doctors
1 1,2 1,2,3
Password Professional card A Professional card B
Pharmacy
1
R/W R R/W R R R/W
4 4
Password Billing
Accessibilities to different sectors of ESzEM. card. The numerals in the 2nd column represent the various sectors on the smart card as described in the text. R/W means read/write type of accessibilities. Authentication card A is for doctors, B is for ambulance personnel.
sent obtained; © Polaroid photographs; (d) completed health cards (e) cards and photos sent to our centre where personalization of the cards was performed. In our centre, the data was copied onto an object oriented database and the depersonalized data was processed statistically (Fig. 1). After evaluation of the results, the ESzEM. cards were sent back to the centres for distribution. Evaluation included frequency distributions of different signs and symptoms, administration of medication and the comparison of the five subregions within the county, to assess possible differences with regard to real needs.It is reasonable to state that: 1. The quality of patient documentation improved. 2. Standardized sentences of the questionnaire are coded, making it more efficient for compression and linguistic translation in a possible interoperability procedure. 3. The administrative workload of health professional personnel has been markedly reduced. 4. The needs of patients can be assessed much better by being based on signs and
symptoms rather than on diagnosis. 5. EHCR is a much more manageable process than paper based documentation. 6. Currently it is fully adequate for shared health care. 7. A step-by-step extension of the ESzEM card system to the whole population is recommended. Healthcare information systems are being computerized world-wide. The electronic patient record (EPR) is a sine qua non for shared care which is necessary in the European Union due to at least 10% of the population leaving their home country as migrant workers. This may be the reason for an increased interest in smartcard systems as indicated the litrature [3–8] on healthcard systems and their uses. Referring to the political and legal framework, it is worth citing the European Council conclusions of 29 September 1998 [8]: ‘‘…requested the European Commission, with the long-term aim of establishing a European card for provision of immediate care. To conduct a survey initially of procedures whereby member states could recognise national social insurance cards issued by other member states.
194
A. Naszlady, J. Naszlady / International Journal of Medical Informatics 48 (1998) 191–194
Fig. 1. The main interactive menu window. The toolbar on the top serves for menu selection. The icons mean the same as usual. On the right hand side, there is a place for a picture of the patient.
This should enable cardholders staying temporarily in a member state other than the competent member state to have access on the terms laid down by Article 22 (1) (a) of Regulation (EEC) No 1408/71. to urgently needed treatment, on presentation of their national insurance card or form E111. As of now, the Council is in favour of any experiments in mutual recognition of national social insurance cards that member states may engage in. ‘‘A pilot project (‘Cardlink’), supported by the EU 4th Framework Programme for research and development is already in operation in the health sector in Ireland, Italy, France and Spain. This project is to be extended to five more countries by the end of 1996 — The Netherlands, Finland, Greece and Portugal. Some non-EU countries have also shown an interest in participation’’.
References [1] Simon, P., Naszlady, A., Memory card in primary health care, Medinfo, ‘86, pp. 1015 – 1018. [2] Naszlady, A., ESzEM. card — implementation possibilities, AIM Europe ETK VTK SCAN, Hungary, 1992, pp. 37 – 40 (in hungarian). [3] Dick, R.S., Steen, E.B.,The Computer Based Patient Record, National Academy Press, Washington D.C., 1991. [4] Pernice, A., Doare, H., Rienhoff, O, Healthcare Card Systems, IOS Press, Amsterdam, 1995. [5] Rankl, W., Effing, W., Handbuch der Chipkarten CarlHauser, Mu¨nchen, 1995. [6] Engelbrecht, R., Hildebrand, C., Jung, E., The smart card: an ideal tool for a computer-based patient record, Medinfo 8, 1995, pp. 344 – 348. [7] Markwell, D., Healthcard Interoperability, EU and G7 Activities Health Cards Conference, Cartes, 1996. [8] O’ Reilly, P., Strategy for European Social Security Card TESS Pre-Build 7, Discussion Paper, Dept. Social Welfare, Ireland, 1996.