The introduction of patient cards has recently progressed into sensors containing all of the information, and the possibilities are endless …
Peter Pharow, eHealth Competence Center, University of Regensburg Medical Centre, Germany, Paul Cheshire
Atos Origin UK, London
Cards have widely been used in healthcare for more than 40 years. Many countries are still scheduling the introduction of patient cards on a national level. The European Health Insurance Card (EHIC) is being introduced in almost all EU countries and its electronic successor, the eEHIC, is being addressed in standardisation and the EU’s political decision-making. But these tokens are just pieces of the infrastructure.[1] They need readers, networks and information processing systems for exchanging information.
It has been quite a long way from the card patent back in 1967 to 1980s plastic cards to 1990s chip cards and smart cards to 21st century networks of smart tags on medical items and personalised portable devices that are being introduced in hospital care provision.[2] And whilst applying very tiny sensors to humans – allowing the observation of blood vessels by searching for bottlenecks – may sound like science fiction, industrial domains like the oil industry use slightly larger versions of such detectors to do exactly the same in their pipelines.
Current status
Specific processing capabilities in sensors and mobile devices are well known and well applied for different healthcare purposes. They record and store person-related medical data; they help in managing lifestyle; they support availability and accessibility; and they allow location in emergency situations.
Personalised portable devices are going to play an important role in the context of modern healthcare information systems and healthcare service provision. The ways to make use of them is manifold. Contact and contactless cards and devices are considered to be secure tokens storing keys and pointers to access information archived in networks. They are able to bear a certain amount of administrative (eg, keys, access rights, attributes) and medical information (eg, a set of emergency data, immunisation and vaccination records, disease records, medication records).
Devices are becoming smaller as nanotechnology allows development of tiny technical pieces (sensors, detectors) to be applied to the human body.
The focus area for the future shall be defined as the next step (see Figure 1).
Future research and development objectives
It is the next generation of portable medical devices that enable greater service personalisation. Medical devices in this respect are not, per se, just a new kind of information technology device, even though these devices will probably be built on computer technologies. While often currently being restricted to simply collecting data, the addressed devices will, over time, evolve to support further medical functions allowing personalisation of healthcare service delivery, with a patient becoming a “networked node”, whether they are in a traditional hospital or at home.[3]
Personalised health (pHealth) focuses on personal healthcare service provision and therefore sees the patient at the centre of all care delivery processes.[4] Related portable devices (eg, cards, chips, tokens, mobile phones, smart devices, sensors, actuators, detectors) are considered first-line communication tools, offering interfaces allowing an easy-to-use communication for proper identity management for purposes such as insurance, access control, reimbursement and entitlement. They improve the accessibility to healthcare service data and personalised healthcare data, enabling better healthcare service provision.
[[HHE.IT3]]
Such devices allow access to a set of vital signs in routine (and intensive) care observation situations, and they can improve the quality of care provision by providing health professionals with up-to-date portable devices, allowing access to patient healthcare data from anywhere, anytime.
Besides different views on the topic (mobile devices, security, privacy, EHR interaction, interfaces, personalisation, ID management, sensors, networks), current research includes the development of micro- and nanotechnology to be applied to human bodies. Questions to be answered may be:
- Can such a medical device be used for seamlessly providing identity management, healthcare data, healthcare information and access to healthcare services?
- Can the rules and policies related to security, safety, ethics and privacy be guaranteed while wirelessly applying such a personalised portable device?
- How can hospital management scenarios benefit from the new generation of personalised portable medical devices?
All these questions need to be addressed always having in mind what the new key elements in science and technology in the new framework of personalised healthcare provision are.
The future paradigm shift and intermediate steps
This is not a one-step approach. Many steps are needed to go from simple cards to advanced medical devices. An intermediate step could be the application of intelligent chips to patients inside and outside hospitals as a kind of personal health and wellness adviser.
The technology could be based on RFID.[5] Existing solutions include an RFID-based drug sensor device, implanted smart sensors and a socalled personal smart PC applied to the human body. Such chip-based solutions enable proactive care, and they build a component of what might be called cyberhealth.
New-generation personal electronic identity gadgets allow the concept of universal liberal personal electronic access control tools for healthcare services. There is a guideline to apply RFID technology, issued by the International Society of Blood Transfusion (ISBT), the body for standardising blood donation, product development and transfusion.[7]
Different categories shall be taken into account in comparing cards and devices. In terms of portability, personalised devices are typically not as small as cards. The readers are wholly integrated; the related security management can be integrated. Card specifications currently allow space for a limited set of emergency data.[1,2] Newer devices allow increasing the amount of such data to include even image data.
Standards are either already in place or emerging. The authentication is stronger with biometrics – the application of biometric authentication may be an opportunity for acceptance of the new-generation devices.
Last but not least, combining devices with personal electronic healthcare record systems and graphical interactive user interfaces allows for storing and processing device data in patient records.
Purpose and form
Portable personalised devices in hospital and healthcare settings do not have one single purpose only. The range of purposes is as broad as the set of processes involved in the delivery and administration of care services.
Whenever personal medical devices are used in the delivery of care they are being used in situations where the patient’s life may depend upon availability, integrity and accuracy of information stored in the device. Often situations occur where the person needing care is not able to personally participate in the identity management process (eg, permanent or temporary physical or mental incapacity), or where their portable personalised token is not usable (eg, the token is missing or destroyed, or remote computers are not available).
Comprehensive usage of intelligent portable personalised tokens for medical and management purposes requires a high level of awareness, confidence and acceptance among all empowered stakeholders involved (healthcare professionals and patients). There are many options for the form-factor of a portable personalised token device for use in health-related applications, such as mobile phone, smartcard, USB stick, RFID tag embedded in a personal item, NFC technology, and more.
All these options need to be supported by political and standardisation initiatives.[8,9]
Outlook
The paradigm shift as such is not a single trivial step. It requires many steps in between to manage the challenge of next-generation medical devices that are portable, wireless and can be applied to persons.
The steps address technology, policy, management, application, standardisation and other business areas. In five years from now, technology will be able to provide the hospital sector with devices small enough to be implanted into, or temporarily attached to, the human body.
The new paradigm of applying personalised portable devices for the provision of wireless and seamless care is linked to Ubiquitous Computing, which is the combination of Pervasive Computing (location-independent service provision for healthcare telematics and telemedicine), Autonomic Computing (self-organisation of healthcare information systems) and Mobile Computing (accessibility to services such as teleconsultation).
References
1. Pharow P, Blobel B. Benefits and weaknesses of health cards used in health information systems. Proceedings of MIE 2006, Maastricht, 27–30 Aug 2006.
2. Cheshire P. Ambient technology in care services – the role of PPDs. World eID 2006, Sophia Antipolis, Sept 2006.
3. Cheshire P. Data sharing sans frontières – the role of technologies for patient confidentiality. Proceedings of Global Forum 2006, Paris, Nov 2006.
4. Blobel B, Pharow P, Norgall T. How to enhance integrated care towards the personal health paradigm? In: Kuhn KA, Warren JR, Leong T-Z, editors. MEDINFO 2007. IOS Press; 2007.p.172-6.
5. US National Institute for Standards and Technology (NIST). NIST Special Publication 800-98: Guidelines for securing radio frequency identification (RFID) systems. http://csrc.nist.gov/
publications/nistpubs/800-98/SP800- 98_RFID-2007.pdf (last accessed 20 Oct 2008).
6. Hildebrand C, Demski H. BioHealth – the need for security and identity management standards in eHealth. In: Bos L, Roa L, Yogesan K, et al, editors. Medical and care compunetics 3.
Series Studies in Health Technology and Informatics, Vol 121. IOS Press, Amsterdam, 2006. p.327-36.
7. International Society of Blood Transfusion. http://www.isbt-web.org (last accessed 20 Oct 2008)
8. Berlin eHealth Week Conference Declaration (19/04/2007) – Better health care in Europe – renewed commitment for co-operation on cross-border electronic health services. http://
ec.europa.eu/information_society/ newsroom/cf/itemlongdetail.cfm?item_
id=3370 (last accessed 20 Oct 2008)
9. European Commission Mandate M/403 on the development of co-ordinated work programme on standardisation. www.vidavo.gr/en/ Mandate.html (last accessed 20 Oct
2008)
Resources
• EU – European Commission; http://
ec.europa.eu/index_en.htm
• EFMI – European Federation for Medical Informatics (currently 30 countries and 17 active working groups) http://www.efmi.org
• CEN – European Committee for Standardization; http://www.cen.eu/cenorm/homepage.htm
• ISO – International Standardization Organization; http://www.iso.org/iso/home.htm
• IEEE – Institute of Electrical and Electronic Engineering, Inc; http://www.ieee.org/portal/site
• IEEE SA – IEEE Standards Association;
http://standards.ieee.org
• CHA – Continua Health Alliance; http://www.continuaalliance.org
• WHO – World Health Organization; http://www.who.int/en
