Power to the Patient: Mount Sinai Puts Medical Records Snapshot on Smart Cards

Several years ago, Paul Contino and the IT team at New York’s Mount Sinai Medical Center spent about $1.5 million on a project to clean up duplicate medical records. Duplicate records can lead to problems with quality and continuity of patient care, plus billing snafus. For a major hospital like Mount Sinai, delayed or lost billing revenue resulting from claims denials can add up to $1 million per week. And patient registration errors, leading to inaccurate records, account for 70% of those claims denials, says Contino, a VP of IT at Mount Sinai.

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The records clean-up went well, Contino says. But three years later, the problem was back. The IT team became convinced of the need for a better system to register patients, and began exploring an idea that has now turned into a pioneering smart card system.

Today, Mount Sinai patients participating in the pilot test can choose to carry a “personal health card.” This encrypted smart card with 64K of memory holds not only the patient’s name, photo, and insurance information, but also a medical history snapshot, including notes on allergies, medications, recent treatment data, and even in some cases, a compressed EKG test result. The goal is to distribute 100,000 cards in the initial pilot project, Contino says.

Mount Sinai’s registration staffers can use the cards to check in patients quickly and accurately; emergency room triage nurses can use the cards for quick access to relevant patient data.

Mount Sinai, one of the oldest, largest and most prestigious teaching hospitals in the U.S., with 1,171 beds and some 1,800 medical staff, has ambitious goals for the smart card system: It aims toreduce fraud, improve revenue cycles through the reduction of registration errors, and boost quality of patient care.

A smart card bearing a medical snapshot is portable, encrypted for privacy and security, and requires little IT infrastructure to connect facilities ranging from mega-hospitals like Mt. Sinai to community clinics. This is not a replacement system: Today, these hospitals have no efficient way of sharing registration data or urgent care clinical data. For patients, the card has the ability to speed check-in and supply some peace of mind. After all, what patient, arriving at an emergency room such as Mount Sinai’s, doesn’t want hospital staff to have immediate access to the correct, key medical facts – even if the patient is not able to speak, or speaking a foreign language, or presenting an ID with a name that hundreds of other New Yorkers share.

Giving patients more control over their own medical records is a complicated problem that various companies and governmental groups have been trying to crack for years. President Bush backs the idea of a Nationwide Health Information Network to reduce costs and improve care, through making records electronic and more easily shared among institutions. As part of that NHIN effort, various RHIOs (regional health information organizations) are working on ways to connect records and make systems interoperable between institutions.

Private industry sees big dollars to be made in organizing medical records: Google’s expressed interest and Microsoft made news last week with its HealthVault service, an advertising-supported Web portal where consumers can collate their medical records. Contino believes Microsoft’s model asks a bit too much work of consumers.

“The card is portable,” he adds. “A Web site doesn’t have a security token that you can carry with you as you travel through institutions.”

Contino advocates an arrangement where consumers use a smart card with a medical history snapshot, combined with a personal health portal run by a trusted third-party like a hospital or medical practice. The portal becomes important since the Web has unlimited space, whereas a 64K smart card doesn’t, says Contino, who also serves as co-chair of the Smart Card Alliance‘s healthcare council, helping the non-profit industry group share expertise and best practices.

The key for patients is control, Contino says. “The patient can see everything on the card,” Contino says. “This gets rid of the fear factor that a lot of patients have.” Today Mount Sinai patients can view card data using a kiosk at the hospital; in the future, Contino envisions consumer kits including card readers for home use. Mount Sinai has already learned some interesting technology and organizational lessons since rolling out the first 2000 or so health cards since February, and since forming a network of 10 New York area medical institutions to use the system.

Paper Problem, Portable Answer

Most people know all too well the reality of medical records today: The first thing you do upon arrival at a medical facility is present your driver’s license and insurance card. Then you fill out an average of about 4 forms per visit. If you’re visiting different departments within a hospital in one day, you may fill out a form-filled clipboard with the same information repeatedly. That information will not necessarily follow you to your primary care doctor or offsite specialists.

As Frank Avignone, VP of medical data firm Cocentrx, noted at the Smart Card Alliance’s annual conference in Boston last week: “When was the last time you looked at anything other than a piece of paper for your healthcare information? The healthcare industry needs to catch up.” Everyone has their own paperwork-related snafu story. It’s not surprising that patients, Contino says, want more control.

Mount Sinai’s project doesn’t try to solve every piece of that puzzle at once. This project, for which development began about 2.5 years ago, focuses on data that’s critical to urgent care, Contino says. Also, Mount Sinai’s personal health cards don’t hold a complete medical history, just a medical snapshot that fits in 64K of memory. Over time, older data has to be rolled off the card to accommodate newer data.

What about privacy? Because the cards have tough triple DES-level encryption, plus require a PIN code, they’re “useless” if lost, Contino says. While Mount Sinai’s privacy officer was initially concerned about the smart card project, that changed when everyone involved agreed that a patient entering a PIN code while using the smart card met HIPAA requirements quite well, Contino says.

Mount Sinai offers patients the cards upon registration at the hospital, and at check-in time for follow-up visits.

For the hospital, the card system has the ability to reduce fraud, improve revenue cycles through the reduction of registration errors, and boost quality of patient care. For patients, the card has the ability to speed check-in and supply some peace of mind.

Why is positive identification so key for a hospital like Mount Sinai? One example: In densely-populated New York, where some names are very common, the hospital could have dozens of patients with the same name. When a patient named Maria Gonzales comes into the ER, they’d like to match her to the right history and paperwork. In other cases, patients may try to defraud the system by presenting someone else’s insurance card.

Process-wise, Mount Sinai has some 40 systems into which medical records flow; getting those records right upon registration saves work later.

Adding to the potential for errors, registration staffers face a high workload, for one of the hospital’s lower-paying jobs. The positions have high turnover rates.

The hospital has tried to improve the registration process by improving training, Contino says, but this didn’t pan out. “Training was a continuous burden,” he says. “Doing more wasn’t benefiting us.” The smart cards, he says, made sense to these staffers. “Immediately, people saw the tremendous advantage,” Contino says, both for saving time and preventing mistakes during patient check-in.

Connecting Hospitals Affordably

This pilot project isn’t just about Mount Sinai: From the start, the hospital saw benefit in sharing data with its local peers, Contino says. To date, Mount Sinai has signed up 10 tri-state area hospitals in an open network, called the HealthSmart Network, to use the cards to share patient data. One benefit of that network arrangement: If you are taken to Elmhurst Hospital in Elmhurst, Queens, suffering chest pains, and you had a heart attack at Mount Sinai’s ER in Manhattan a month ago, the Elmhurst staff can know immediately, from reading the history on your card, Contino says.

Interestingly, this network of hospitals takes a few lessons from the old idea of sneakernet. The network avoids expensive new infrastructure or systems investments for the hospital IT groups. The cards themselves are the network link, Contino says. The network is open to all providers as long as they maintain interoperability of the cards. (For instance, all the cards in this project must use the same operating system.)

If Mount Sinai’s biggest competitor wanted to use the cards, the hospital would agree, Contino says: “There’s no competitive advantage to closing down the channel of information.”

To use the cards, hospitals need only the readers ($20 gadgets) and freely downloadable viewer software. To add information to a patient’s card, they buy editing software.

Another key point about the HealthSmart network approach: It doesn’t matter if all the institutions use differing systems and software. This decision was born of practicality: “The 10 institutions had very few of the same anything,” Contino says.

The institutions range from Mount Sinai (which has 280 people in IT and a $47 million IT budget) to smaller hospitals and a community clinic. Some of these hospitals use fully electronic medical records, some don’t. Mount Sinai’s ER is paperless, others aren’t. The smart card system doesn’t depend on any of these factors.

Plans call for the smart card system to be running at production level by the end of this year in most of the network hospitals, Contino says.

Making the Business Case for Smart Cards

What have the challenges been on the IT side so far? One of the biggest challenges for IT was making the initial business case to the CEO, CFO and board, says Contino (who reports to the CIO). “We had to prove out the argument of duplicate medical records.”

Everyone felt there were valuable clinical benefits to exchanging patient data with other hospitals, but these benefits take time to prove out, Contino says. “We had to prove local value.” The cost figures around duplicate records and claims denials were provable, and a key part of IT’s pitch, he says.

A hospital can measure how much it’s saving on prevention of medical records mistakes. It can measure how billing revenue measures up after registration errors are reduced. (And these are metrics Mount Sinai is certainly watching, though it’s too early in their project to have ROI figures yet, Contino says.) It can be trickier to show financial payback for a hospital from the data-sharing from a RHIO (Regional Health Information Organization) network arrangement, Contino says. “RHIOs are typically sharing clinical data, not registration data,” Contino says.

Contino’s vision of the future for personal health records, using smart cards and a consumer health portal, also varies from the original RHIO vision in several ways. To date, RHIOs haven’t offered a sustainable business model for medical institutions, because they depend on grant money that can disappear. A RHIO also involves added infrastructure and operating costs, Contino says. Among the various RHIO arrangements being tried, there’s no common technical framework, so scalability is a question. Finally, RHIOs don’t actively engage patients with regard to records, Contino says.

For reasons including these, some early RHIOs, such as the Santa Barbara County Care Data Exchange in California, have already thrown in the towel, as Computerworld reported recently.

A smart card solution along the lines of what Mount Sinai is using could let hospitals in a RHIO or in an informal network get more payback from data sharing, Contino believes. “Smart cards [with registration data] allow the institution to gain some value and ROI from the data exchange,” he says.

What’s Next for Mount Sinai’s Smart Card Program

Ultimately, one of the biggest issues around Mount Sinai’s vision may be who issues the smart cards to consumers, and who bears the costs. The card issuer could be a hospital, an insurer, and employer, or a related entity. Mount Sinai’s pilot is being funded by smart card vendor Siemens, as it prepares to develop future products, and the first 100,000 cards have been paid for by Siemens. The hospital will bear the cost of the cards after that. Contino believes that in the long term, the entity that consumers will trust the most is a hospital or medical group.

On the technology side, Contino notes one potentially significant hurdle looms. “One thing we have to overcome is incompatibility,” he says. Given the way data is encoded on the chip on any smart card, the OS acts as a wrapper around that data. Different smart card vendors favor different operating systems. “There will continue to be several OSes,” in the world at large, being used on smart card applications as varied as security and public transit, Contino says. “Ultimately, we’ll need an interoperability layer.” This would let developers use API-like functionality to access data on the card no matter the OS, he notes.

As far as advice to other IT leaders working on smart card rollouts, Contino says the Mount Sinai team followed classic IT strategy in one key regard. “Think focused, on an area where you can get immediate improvement, then think about aggregating services on the card.”