Germany
Electronic health cards - European perspectives
1st national eHealth conference
2006-02-01
Sofia, Bulgaria
Reinhold A. Mainz
Federal Ministry of Health (BMG), Germany
Group Telematics
Germany
Content


Electronic European Health Insurance Card
Overview: Some activities of Member States of the EU in
the field of electronic cards

The German example

The perspective

Collaboration in Europe
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
2
Germany
Electronic European Health Insurance Card
Germany
The eHealth Action Plan - Overview of actions with
responsibility by the Member States: 2008


Promote the use of cards in the health sector
Adopt implementation of a European electronic health insurance
card (EC)
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
4
Germany
(Electronic) „European“ (Health) (Insurance) Card eEHIC

Responsible: Administrative Commission to the basic Regulation
on Social Security Schemes and the Free Movement of Persons
(EEC No 1408/71)

Secretariat: EC DG EMPL

EC eHealth Action Plan (COM(2004)356): Introduction of an
eEHIC shall start in 2008


on-line verification of insurance data?
„Inclusion“ of medical data?

emergency data set

key to the electronic health record
Electronic health cards - European perspectives
Off-line use of chip
cards or need to setup secure and
interoperable
infrastructure
services
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
5
Germany
Overview: Some activities of Member States of the EU in the
field of electronic cards
Germany
Austria

1) until end 2005: e-card
Electronic social security card; usable as a tool for all
eGovernment processes
Only used for health insurance entitlement online checks (
connector concept)
Access together with health professional cards
Enables the citizen also to sign administrative documents
electronically

2) beginning in 2006: implementation of a first application using
medical data: ePrescribtion
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
7
Germany
Belgium

1) 1998: SIS card as social security card
Insurance data can be read by everybody, some
medical data can be read and stored by health
professionals using a health professional card

2) until 2009: electronic id card for all
eGovernment applications
Shall include the SIS card data
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
8
Germany
Estonia

1) since 2002: electronic national id cards for every citizen
eGovernment portal  can and shall provide health related
applications to the citizens
Central document index for patient related documents of the
health system
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
9
Germany
Finland


1) electronic national id cards for every citizen
2) beginning in 2007: Access to electronic health records
shall be given after authentication by the national id cards
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
10
Germany
France

1) until 2006: Sesam Vital II card
Electronic health cards for all insured persons
elder than 15 years
Includes biometric data for security measures
instead of a PIN

2) beginning in 2007: as a tool for access to
an electronic patient record
Access together with health professional cards or
special passwords
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
11
Germany
Italy


1) electronic health cards in the regions Veneto and
Lombardia
2) End 2005: Some other Italian regions begin to issue
electronic health cards
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
12
Germany
Slovenia

1) 2000 - 2004: electronic health card
Health insurance entitlement online checks
Access together with health professional cards
Public kiosks for the citizens, where they shall change some
personal data

2) modell regions: implementation of first applications using
medical data like allergies, immunization, …
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
13
Germany
Spain

1) Since 2004: Andalusia tests an electronic health card,
used as a tool for access to electronic patient records

2) Beginning in 2006: electronic national id cards for every
citizen
For eGovernment applications (including eHealth?)
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
14
Germany
Switzerland

1) Since 2004: Modell region Tessin for the carta sanitaria
no foto, biometric data (fingerprint) instead of a PIN
Card can be used for ePayment functions (coffee in a hospital,
…)
Software on the card for a reservation system
Mandatory (?): Insurance data, emergency data, eprescription
Not mandatory: electronic patient record on servers, some
copies on the card itself
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
15
Germany
The German example: Target, strategy, concept, costs
Germany
Target
Modernize the healthcare system by use of
ICT:
 establish
more citizen oriented services
 support patient-centred care
 improve quality and services
 reduce costs
 provide data for health systems management
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
17
Germany
Strategy (1)
Establish an ICT infrastructure financed by one / some
applications, so that other applications can build on
the infrastructure – without having those basic
costs
Choosen applications with priority (positive cost-benefit
analysis):
Mandatory

Online verification of insurance status

Transport of (drug) prescriptions
Voluntary for citizens

Drug interaction and contraindication checks
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
18
Germany
Strategy (2)
Stepwise implementation of applications (and
functions) of a private electronic patient record by
using the established infrastructure
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
19
Germany
Strategy (3)
Data provided electronically in principle can be better
used for different purposes
But: Statistical data can not be read from medical
application related storages (encryption!); at the
source of data separate purpose related data
streams have to be implemented using aggregation,
pseudonymisation and anonymisation techniques
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
20
Germany
Citizen managed personal electronic health record
 A citizen managed personal electronic
health record

is offered and operated by the healthcare system

is defined by law and contracts of the self-
governmental healthcare system on the federal
level

data is provided by healthcare professionals (in
form of copies from the original documentation) –
if the citizen gives his consent for an application
and to specific healthcare providers

data can be provided by the citizen

the citizen is the owner of the data (right to
delete!) ( „virtual record“, „view“)
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
21
Germany
Access to the personal electronic health record
 A special smart card („Gesundheitskarte“,
Health Card) is the citizens tool to manage
data in a trustworthy and secure way

access to the Electronic Health Card – and the
managed data - exclusively by authorized
healthcare professionals authenticated by using a
Health Professional Card (HPC) (in principle)

logging of access

management-rights (hide/unhide/delete!) - except
for administrative data

(in principle) electronic authorisation by the
insured person required (exception: emergency
data set)
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
22
Germany
The healthcare system in Germany:
A system with a pressing demand for communication
65 000 dentists
80 Mio. persons insured
2 200 hospitals
123 000 licensed
practical doctors
Patient centered communication:
The Electronic Health Card
is the main tool for linkage of data
21 000 pharmacies
Ca. 290 statutory health
insurance funds
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
23
Germany
Key elements of the security concept
The citizen`s tool
The professional`s tool
The combination of these smart
cards is the
base for a secure and trustworthy
Telematics Infrastructure
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
24
Germany
Infrastructure
 A special infrastructure is constructed

connecting „closed virtual private networks“ operated
by responsible healthcare organizations (sectors:
doctors, hospitals, pharmacies, dentists, …)

using special „connectors“ to connect local systems to
the network, to infrastructure services and to smart
card terminals

using cryptographic techniques between components
for authentication and encryption / decryption

using (qualified) digital signatures

storing and transporting data using cryptography, so
that data can only be used with a citizen`s consent
(the health card in principle must be used)
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
25
Germany
Overview about the planned infrastructure for the
Electronic Health Card - Solution Architecture –
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
26
Germany
Storage concept

data - resp. copies of the original data - (in principle)
is / are stored by each healthcare provider in a
distributed environment

some data is stored (also) on the „Gesundheitskarte“
itself


(European) Emergency data / basic clinical data set

identification data

insurance data

private cryptographic keys (on the card only)
citizens can use their own data after authorization by
a smart card with qualified digital signature (might be
the health card itself) and if the data has been copied to
a special storage space
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
27
Germany
Cost categories (2004 – 2006/2007)


Central infrastructure set-up

connected virtual private networks

infrastructure services
Local infrastructure set-up

modern hard-/software in doctors offices, hospitals,
pharmacies

connector

smart card terminals
Prognosis:
Infrastructure set-up costs about
1.000 – 1.500 Mill. EUR (?) [~20 € per citizen]
Return of investment
within max. 3
years
Development costs about
100 – 150 Mill. EUR (?) [~2 € per citizen]
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
28
Germany
The perspective
Germany
Perspectives



Services used at home
shall be available
while staying in other Member States
(or world-wide)
Smart cards are (at the moment) the security
tool to identify persons, authenticate them,
derive rights for access to data, applications,
services, infrastructure
Most services will be network based, smart
cards can store some synchronized data
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
30
Germany
Collaboration in Europe
Germany
eEurope
eHealth services in Europe:
Dynamic development driven by citizen
demand
Mobile self-aware citizens want to use the
eHealth services all other Europe

Cross-border health care / European-wide services

Services used at home shall be available while staying in
other Member States / countries

Demand of citizens is beyond
national borders (use of specialiced centres)

Generic concepts and (framework) architectures as well as the
use of standards can lead to a European (international)
market of eHealth products and services
Systems (in Europe) must be interoperable
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
32
Germany
eEurope
Co-operation in Europe on eHealth
 Transparency about national
strategies, roadmaps and
developments gives chances to
learn from others
 Finalized developments can be
used by others to avoid
reinventing the wheel
 Co-operation backed by
agreements on the policy level
is needed
 Bilateral – but co-ordinated –
pilot projects on different issues
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
33
Germany
Networking in Europe:
European Health Telematics Association
http://www.EHTEL.org
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
34
Germany
Many thanks for your attention!
Do you have questions?
Reinhold.A.Mainz@BMGS.Bund.DE
Tel. +49 228 941 3199
Electronic health cards - European perspectives
R. A. Mainz, 2006-02-01, Sofia, Bulgaria, 1st national eHealth conference
35