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NETC@RDS: towards the introduction of the eEHIC

The NETC@RDS Project aims to improve access to national healthcare systems for mobile European citizens by introducing advanced smartcard technology. In this article we learn how pilot workstations have been set up to test the technical interoperability of different national cards.

George Pangalos PhD

S Kortesis
Informatics Laboratory
Computers Division
Faculty of Technology

I Pagkalos
Department of Informatics
University of Thessaloniki

Since 2004, EU citizens have been provided with a uniform, single document, the European Health Insurance Card (EHIC), which provides all details of their health insurance entitlement when ­seeking healthcare assistance in another Member State. The card replaces the different ­paper forms previously used. So far, 15 Member States have implemented the card, and others plan to ­follow soon. By unifying required documents and procedures for patients, healthcare ­workers and ­insurance providers, the EHIC card is a major step forward in the European integration process, including the free movement of people and services. In view of the differences between Member States in national organisational and technological arrangements, the Administrative ­Commission for Social Security of Migrant Workers decided to start with a minimum common ­denominator, an eye-readable EHIC card, with the view of developing and adopting a resolution on future solutions in 2007/2008.
In the last decade, EU Member States have distributed several health insurance smartcards to the population (eg, microprocessor cards in France, memory cards in Germany) as evidence of entitlement for healthcare access and/or reimbursement at national level. More than 200 million cards have already been distributed and used for this purpose in Europe.1 However, a major problem for all these smartcard-based systems is that, because they were designed for national healthcare information systems, they can be used only in their country of origin. There is a lack of consistent computerised services among national information systems for health/sickness interstate insurance, and services provided by those systems for patients in the country are therefore not available abroad. As a result, European citizens travelling within the EU (eg, for tourism or ­studies) can only use the eye-readable-only EHIC.
Although EHIC is a major breakthrough in itself, its eye-readable nature presents some obvious disadvantages in terms of organisation, processing workloads, data accuracy and reliability, security and fraud control, as well as acceptability by professionals and the general public. By definition, the electronic EHIC (eEHIC) is a process of establishing a trustworthy health insurance dataset from the healthcare service providers.

The NETC@RDS Project
The NETC@RDS Project seeks to test and verify the concepts related to the coexistence of different smartcard-based platforms and the progressive migration of different countries towards advanced IT-supported arrangements at EU level, while maximising the involvement of the national systems already in place. The idea of the NETC@RDS Project originates from an international consortium of nonprofit institutions from 10 European countries.
Within the NETC@RDS Project, each country has implemented a pilot project in one or more of its regions. Pilot workstations have been set up to test technical interoperability of different national cards. The project aims to test, in practice, the arrangements for electronic acquisition of data on the validity of health insurance for foreign citizens. Anticipated results and benefits include:
•  Simplified access to healthcare services abroad (in pilot regions).
•  Reliable source of health insurance validity data.
•  Definition of the required dataset to facilitate administrative procedures involved in financial flows between healthcare service providers and health insurance providers.
•  Valuable experience for the future introduction of the eEHIC card.

The project in context
The NETC@RDS Project aims to improve the access of mobile European citizens to different national healthcare systems using advanced smartcard technology. It also aims to implement and evaluate technical solutions for the electronification of the EHIC card and to improve additional services such as the inter-European health costs clearing/billing process. The process of introducing the eEHIC is, however, hampered by difficulties related to the justification of its cost, the necessity to have an interoperable reading infrastructure available, and so on. Furthermore, in order to avoid parallel and redundant technical implementations, a fusion of the eEHIC with existing and planned national health card schemes is necessary.
However, since existing national implementation schemes are not homogeneous, no simple, ­convergent strategy seems applicable. The strategic view for the introduction of the eEHIC should therefore ­address a number of different options, for example:
•  An eEHIC stored on a national chip card with a common eEHIC dataset and interoperable
•  An eEHIC as an additional chip card.
•  An eEHIC as a functionality detached from a chip card as carrier medium.

Technical and organisational structure
From its early steps, the NETC@RDS Project has acknowledged the diversity of existing national and ­regional approaches to eEHIC introduction, and offered a wide range of options, for example:
•  To allow implementation at different speeds.
•  To use existing infrastructure.
•  To enable competitive testing of various techniques.
•  To increase the robustness of the service.
•  To ensure acceptance.
The target NETC@RDS infrastructure is an extranet system (Figure 1) made up of national portals ­necessary for dataset downloading from a foreign health insurance database. Each national portal is considered as a single exit point for each NETC@RDS pilot workstation and as a single entry point for each foreign portal to access foreign health insurance database (front-office server).

The health insurance data postprocessing environment
Regardless of the source of the eEHIC dataset (whether delivered from card or server), it is evident that a simple transfer of all data items from the eye-readable EHIC to constitute an electronic version is not sufficient. For example, the field selection and carrier reflect the requirements of manual and optical processing and effective industrial production of a plastic card. In addition, the integrity of the data and single existence of the object must be covered by other means. More specifically, in the case of the eEHIC dataset, it is necessary to:
•  Set up a file structure.
•  Define mandatory and optional content.
•  Define items for integrity, attributability and object identification.
Fostering electronic postprocessing is frequently declared as a main goal of the introduction of the eEHIC. It must, however, be appreciated that electronic reimbursement does exist today in many countries. With implementation of diagnosis-related groups (DRGs) and case tariffs in various European countries, a huge amount of structured data is to be transmitted between healthcare institutions. IT
systems are standard for handling these data within most hospitals and ambulatory units.
These datasets, both within the institutions and for national transmission, provide fields to tag foreign patients. An alteration to add additional fields (eg, for EHIC numbers) will be only a minor issue compared with the huge update rounds frequently taking place for medical and procedural coding reasons. Therefore the modernisation impact of the eEHIC will be limited in systems where electronic postprocessing is used. As a first step, however, it is useful to support the integration of patient-related data fields at present in the EHIC into subsequent systems. For users in the healthcare units, this could provide a very convenient and attractive simplification and help avoid transcription errors.

Challenges addressed
The introduction of a health and insurance card and the definition of the next stages through digitalisation will drive member countries to both technical and institutional changes. The NETC@RDS Project addresses a number of problems, which are directly related to the capacity of healthcare providers, public administration and health insurance bodies to cope with the complexity of such an introduction: on the one hand by ensuring the control of national and regional governmental bodies to act according their own scheme of competence (depending on the different local regulatory frameworks), and on the other hand by effectively proposing shared solutions acceptable for each of them. More specifically, public administrations and governmental bodies involved in this domain have to address:
•  The rising demand for health and social services.
•  The increasing expectations of citizens who want the best care available, and at the same time a reduction in inequalities in access to good healthcare.
•  The increasing mobility of patients and healthcare professionals within a better-functioning internal market.
•  The difficulties experienced by public authorities in matching investment in technology with
investment in the complex organisational changes needed to exploit its potential.
•  The management of huge amounts of health information that need to be available securely,
accessibly and in a timely manner at the point of need, processed efficiently for administrative purposes.
•  The need to provide the best possible healthcare under limited budgetary conditions.
•  The need to cover the development of standards addressing the interoperability of diverse
systems and services.

Challenges facing the project
The eEHIC implementation is an ambitious project that must be implemented in a complex environment and at the same time lacks a clear target definition and allocation of organisational responsibilities. Following the main lesson learnt during the project implementation phase, it is recommended not to waste effort and credibility in an all-embracing gigantic deployment scheme, but to focus on two elements:
•  The card-reading functionality, which encompasses basically the cards and associated reading
infrastructure. All efforts should be directed to guarantee interoperability of upcoming national
solutions to read administrative data, wherever card-reading infrastructure is deployed in Europe.
•  The network functionality, which includes server and network structures for remote access to
databases of health insurances. This functionality should be developed in migration steps, enabling low-cost routing of point-to-point connections integrating existing infrastructure elements such as the code-list database of DG Employment up to a full-scale European server network.

This twofold approach, being in line with the NETC@RDS scheme, is a realistic and practicable path for providing convergent solutions for eEHIC. Also, starting from this evidence, it is advisable to consider two further elements when introducing an eEHIC: the need to ensure a proper level of security in data exchange; and the possible additional services associated with the eEHIC such as interstate clearing/billing procedures.

In order to accelerate the rollout of eHealth services through advanced infrastructure and technologies, full use should be made of IT and eSolutions to support public administrations in delivering eHealth systems and services.
Public authorities can play a pivotal role in stimulating both supply and demand for eHealth services – particularly those provided through health and insurance cards.
The NETC@RDS Project aims to improve access of mobile European citizens to the national healthcare systems using advanced smart card technology. It also aims to implement and evaluate technical solutions for the EHIC electronification.
The NETC@RDS central and underlying principle is to accommodate different environments, technological and organisational setups, through a set of scenarios. In this way, the project and the resulting concept allow the joining up of a broad range of countries, from those with relatively obsolete technological solutions in place to those with state-of-the-art national solutions.
With options of entering at any appropriate stage and progressive transition to the higher stages, the project builds a bridge from the past to the future.

1. NETC@RDS Project
Technical Annex. 2004.
Available from European Union, TEN-TELECOM, Brussels.
e-Government & e-Health Conference, Desio, Italy, 9-10 July 2004. ­
3. NETC@RDS Project. Reporting pilot phase during Olympic Games. Press release.
presentation. e-Health
Ministerial Conference, Cork, Ireland,
5-6 May 2004.
5. The “SanitàFutura” Conference and
Exhibition, organised by the Italian Ministry for Health, Cernobbio, Italy, 5-8 April 2004.
6. NETC@RDS poster. “FORUM PA” Fair and Exhibition on ICT applications for Public Administration and
e-Government organised by the Italian
Government, 10-14 May 2004, Rome,
7. NETC@RDS Project website. Available at:
8. Suselj M, Zuffada R. NETC@RDS for e-EHIC – a step towards the
introduction of the
European Health
Insurance Card.
NETC@RDS Conference, Brussels, Oct 2006.