Pictures of the Future Fall 2005
Digital Health – Health Card
Nine Million Trump Cards
Nine million residents of Lombardy have received new electronic "citizen cards" that offer a range of benefits, especially for visits to the doctor. Now that there’s less administrative work to deal with, doctors have more time for healing. It’s virtually impossible to issue the wrong prescriptions, confidential patient data is more secure, and costs are decreasing.
The health card. For Angela Turcatti and her fellow citizens, it saves a lot of traveling back and forth—and it gives doctors like Claudio Negrini (left) more time for their patients
There’s no way Dr. Claudio Negrini can avoid having a quick espresso after he has left his office in Grosotto and started walking down the narrow streets of this mountain village. His patients call out greetings, and many consider it an honor to treat him to refreshments. The people of Grosotto trust their doctor—and one another. When Dr. Negrini makes a house call, he often doesn’t even lock the office door behind him. His patient files, in the form of huge stacks of paper, are stored in a cupboard that is secured by only a small padlock. His long-standing custom is to write out his prescriptions by hand. He hasn’t had any need for a computer so far.
But all that will change fairly soon. And there’s little, according to Negrini, to be sorry about. In fact, Negrini is looking forward to the new era that’s about to begin for him and his patients. In April 2005, all nine million inhabitants of the Lombardy region in northern Italy received their personal electronic "citizen cards." These cards will bring them benefits, especially when they visit their doctors. For example, the cards can be used to write digital prescriptions, which can be processed much faster than the ones scribbled on red paper that are currently used in Italy. What’s more, in the future it will be nearly impossible to forge a prescription. Pharmacists will be able to call up prescriptions directly from the server where they are stored, and nobody will have to despair over doctors’ illegible handwriting anymore.
In a few weeks, Dr. Negrini intends to buy a computer and invest in a high-speed DSL link to the health care server in Milan so that he and his patients can benefit as soon as possible from the "citizen card." One of these patients is former kiosk owner Angela Turcatti. Although it’s hard for her to get from place to place, in the past she has had to make some unavoidable trips, for example to make appointments in person for examinations by medical specialists. To do this, she has had to go to the local health service coordination center, the "Azienda Sanitaria Locale" (ASL) in the provincial capital, Sondrio. "I’m looking forward to the time when my doctor is hooked up to the network," she says. "Then I can use my citizen card in Dottore Negrini’s office to make an appointment for my next examination at the hospital, without running around and then having to wait."
Digital Prescriptions and Transfers. In Lecco, a province north of Milan, this convenience is already a reality. The card system that will soon be used throughout Lombardy has been tested here since 2003. Local doctors and patients have been benefiting from digital prescriptions and transfers to specialists, online transmission of medical data, and quick paper-free billing.
Dr. Maurizio Tedeschi explains the advantages of the health card—including how secure the data is on servers in Milan
Maurizio Tedeschi was one of the first doctors to use the new system. "The amount of time I need for paperwork has decreased significantly, and most procedures go faster now," he says. "I now have more time for my patients. Most of them have no idea how sophisticated the technology is that’s backing me up." Word of the system’s success is spreading, and other Italian regions such as Sicily are interested in the pilot project.
When patients visit Dr. Tedeschi’s office, the first thing they do is to hand over their new citizen cards so that he can slide them into a reading device. Using his own card—his health care professional’s ID—he then logs in via a second reading device. Programs on the cards’ chips identify the doctor and the patient and register both of them together at Lombardy’s health care servers. Within seconds, a secure data link is activated to transmit the patient’s medical data, including his or her age and address, previous illnesses, medications being taken, and the results of previous examinations.
If the patient then enters his or her PIN, Dr. Tedeschi can also access confidential data such as a current hepatitis infection. In Italy, a strict data protection law allows patients to withhold sensitive information of this type even from their doctors. That’s why the new citizen cards enable them to keep their health data to themselves if they wish. After all, an optometrist testing a patient’s vision doesn’t need to know whether he or she is HIV-positive. "So far, none of my patients have denied me access to their medical information," says Dr. Tedeschi. "That’s probably because our relationship is based on trust. It’s ultimately the patient who benefits the most from increased transparency."
As soon as Dr. Tedeschi enters his own PIN, he can order further examinations or write an electronic prescription. The system then automatically checks for possible negative interactions between the prescribed medicine and other medications the patient is taking. As a result, there is virtually no risk of doctors inadvertently prescribing medicines that could endanger their patients’ health. When the patient visits a nearby pharmacy, the prescription is once again checked online in real time. The pharmacist also has to identify himself or reherself with a health care professional’s ID and a PIN. Even prison chaplains in Lombardy have health care professionals’ IDs so that their services can be billed electronically.
"The important thing is that the access rights are clearly regulated," explains Carlo Leonardi, the project manager responsible for the card project at Lombardia Informatica, the company that coordinates the services of the various companies working on this complex IT project. Siemens Informatica, a joint venture between Siemens AG (51 %) and Telecom Italia (49 %), developed the Smart Cards, whose chips use an operating system that not only meets high security standards but also guarantees compatibility with all the interfaces involved. Siemens Informatica was also commissioned to produce and distribute the cards. Finally, the company ensures that the card management system runs smoothly, including the call centers that are available to all of Lombardy’s residents.
e-Health – a Range of Pilot Projects
An e-card solution is being develop in Austria (left). A similar system is being tested in Germany (right). In each case, systems are being tailored to national healthcare and insurance requirements
IT support can make healthcare more efficient—something that has been proven by success stories worldwide The Lombardy region in Italy is showing how health cards can improve medical treatment, while also reducing healthcare costs. There are similar projects around the world, in Spain, for example, and in Austria, Canada and Germany. Although national healthcare systems are very differently organized, many processes are similar, which means that the technologies required for the IT infrastructure are essentially the same. Confidential information must be exchanged at high speeds, and large volumes of data have to be securely managed. But patients see only a chip card in their wallets—the key to the entire system.
In nearly every case, the ultimate goal of these projects is an electronic patient file. The approaches to realizing this, however, are frequently different. Usually, the first step is to be able to check the patient’s insurance files online, often together with electronic prescriptions. In Valencia, Spain, for example, Siemens has helped to network ambulatory care centers. Doctors at the centers now have online access to some treatment records, and billing is conducted electronically—so it’s faster than ever before. Furthermore, the system allows physicians to sign prescriptions with a digital signature.
In Austria, social insurance providers are replacing health insurance certificates with e-cards this year—also with support from Siemens. During visits to the doctor’s office, this makes it possible to more quickly scan in the insured person’s administrative data and evaluate it more efficiently. Doctors treating patients can enter digital signatures by using their medical profession ID card, or "doctor’s card." And that’s just the beginning. The cards that have already been issued are sufficiently sophisticated to access electronic patient files. To accomplish this, however, it will be necessary to make additional infrastructure investments.
The electronic patient file is also the objective of the GO IN physicians’ network in Ingolstadt, Germany. GO IN was founded in 2000 by Siegfried Jedamzik, a general practitioner who wants to show in detail what can be done with health cards. Today, more than 250,000 GO IN patients are already enjoying the benefits of individual health files in paper form. The members of the physicians’ network (currently more than 500 family doctors and specialists in private practices and at hospitals) make their entries on the form after treating a patient. This helps to prevent unnecessary duplicate examinations. But the volume of patient data is continually increasing. "Modern, efficient and patient-oriented medical care can not function without IT support," says Jedamzik. In particular, the automatic monitoring of possible side-effects and contraindications is only possible if patient data—as is the case in Lombardy—is stored on a server and continually updated. That’s why plans call for the paper files in Ingolstadt to be replaced with digital files as quickly as possible. Siemens is helping to develop the IT infrastructure and the chip cards that will make it all possible. "We expect the cards to be issued in the Ingolstadt area by spring 2006," says Martin Praetorius of Siemens Communications, who is providing support for the project. Information gleaned from experience with the Ingolstadt project will be used for the introduction of a planned German national health card.
According to the latest plans for the German healthcare system, cards will initially be limited to electronic prescriptions. For GO IN doctors and their patients, however, the electronic patient file is the top priority. The Bavarian physicians’ network wants to introduce them as soon as possible. "In terms of technology, it can certainly be done," Praetorius says. "Things have already progressed further in other parts of the world."
Andreas Kleinschmidt
Data Bunkers. "Nine million people have already received their new citizen cards," says Leonardi. "An additional 145,000 personal IDs have been distributed to health care professionals. But not everyone who has such an ID has access to all of a patient’s data. For example, nurses will have access to only as much patient data as they need." He proudly gestures to one of the server rooms at Lombardia Informatica, which is located in an industrial park on the outskirts of Milan. Computer specialist Andrea Zino can open the door of this room, which he calls a "digital Fort Knox," only by using his chip card and an access code. Security guards protect the room from outside, and cameras record who goes in and out. To prevent the mammoth computers from overheating, gigantic air conditioners cool the air to exactly 21.3 °C. Some 220 servers already store the medical files of approximately one million citizens, and the data is continuously updated, whenever a doctor writes a prescription, a blood test is performed, or a patient picks up a medication at a pharmacy. By late this year, the system’s operators expect the number of citizens benefiting from the network to be double what it was back in April.
"Our top priority is security," says Zino as he clicks on a monitor. "Even I can’t call up patient files. Hackers who try to penetrate the system from outside won’t have a chance. We’ve built up a complete extranet that is practically invisible to the outside world." Not even an earthquake could disturb the system’s operation, according to Zino. "Even if the whole building that houses our servers collapsed, emergency systems located outside Milan would take over the core functions," he says. Updated copies of the database are stored in emergency systems and at another secure location.
Highly Transparent. Dr. Tedeschi has often had to convince his colleagues that the new system is secure. After all, even he was initially skeptical. "Every step I take is now being documented. At first, that makes you nervous. But it’s good for the patients and helps me manage my practice. I can now monitor my budget continually, and that’s important in view of the rising cost of health care," he explains.
The region’s economy is certainly benefiting from the citizen card, which is expected to reduce the cost of Lombardy’s health care system by 1 to 2 %. By lowering administrative costs, reducing the number of redundant examinations and speeding up processes, the system should save up to 240 million euros annually. What’s more, it will become more difficult to cheat the health care system.
And in the future, when not only lab results but also X-ray images and photos will be routinely transmitted online, costs are expected to decrease even further, while treatment becomes even more efficient. "Siemens could provide an even more comprehensive system, from the cards to the IT infrastructure," explains Maurizio Michi, a project manager manager at Siemens Informatica in Milan. The citizens of Lecco will eventually be able to use their cards not only to visit their doctors, but also to withdraw money from the bank or provide a digital signature. Today, they can already use the cards to borrow books from the local library.
But today the cards’ greatest benefits are still experienced at the doctor’s office. "Alqualitative enhancements and quantitative savings. However, economic advantages, especially cost benefits, are one of the hardest things to prove in terms of a better quality of life. This is why we are now supporting several cost-benefit assessments of eHealth. Which new technologies are most important in improving health care? Comyn: Lots of new possibilities are arising at the moment. Biomedical informatics, modeling and simulation of human physiology, knowledge extraction and management systems, molecular imaging, wearable monitoring systems, labs on a chip, broadband and mobile communications, intelligent sensors, decision support, as well as security systems, are some of today’s key technologies. The successful integration of many of these technologies will help us to achieve the vision of ubiquitous, personalized medical care. Will computer-assisted diagnosis and therapy, which help physicians to manage steadily increasing data volumes, be part of the game? Comyn: Undoubtedly. As stated in the international Open Clinical report (www.openclinical.org), recent growth in the scientific understanding of diseases and their managemost all of my patients think the card is a good thing," says Tedeschi. "It has increased their faith in the health care system."
The security of confidential data is also growing. Dr. Negrini in Grosotto will soon be able to throw away his padlocked cupboard, because his patients’ medical records will be safely stored in servers in Milan.
In some cases, though, even the citizen card is not the fastest way to transfer a patient to a specialist—and Maurizio Tedeschi is a case in point. If one of his patients needs to go to the dentist, he simply goes to the office next door, where Dr. Tedeschi’s twin brother Marziano has his dental practice. He too has been a member of the new cardbased health care system from the very start.
Andreas Kleinschmidt