The bank card/financial card industry has a demonstrated success with its plastic card identification systems. It can be utilized to design and manage the healthcare ID system. The experience, know-how and capability to implement such a system is in the private industry and not in the government. Therefore, the capabilities of the industry must be exploited to develop, implement and manage the operation after transition. The necessary technology such as inexpensive card readers that respond to keystrokes or magnetic-stripe, printers etc. has already been developed. The industry has considerable experience in issuing and replacing (lost) cards. In 1994, Dr. Willis Ware from RAND, the proponent of this method recommended that a comprehensive set of requirements be developed by a team of payers, medical practitioners, hospital administrators, clinical managers, etc., and that competitive RFP sent to the card industry to assume charge of developing, implementing and managing this process during and after transition.
The initial design recommendation of Dr. Willis Ware consisted of a 13 to 15 digit identifier with a set of digits to identify the practitioner or the medical group, another set of digits to identify payers, a third set of digits to identify the individual and finally check digits to control errors. The use of separate additional digits to identify conditions such as allergies, disease, etc. was also suggested. The proposal included a credit card-type plastic card as the identification medium with an authenticator such as mother's maiden name or date of birth "woven" into the card along with the individual's name as a easily read identifier for convenience. Dr. Ware ruled out the use of magnetic stripe due to frequent accidental erasure by refrigerator magnets or large electrical equipment.
Conversation with Dr. Willis Ware during this study, however, indicated significant changes to his original thinking. He preferred the smart card in place of Bank Card as the medium and recommended against the inclusion of any patient care information in the card or the identifier.
The proponent of this method, Dr. Willis Ware, has recommended the following steps for the design and implementation of the Bank Card Method:
Dr. Ware indicated that his current interests and involvement with patient identifier were limited and these steps have not occurred. The current procedure to obtain a Bank Card requires the submission of an application to the financial institution. An individual can have multiple Bank Cards each with a different identification number. Dr. Ware's concept needs to be developed further to fully understand his method, design, characteristics, functions and processes.
Accessible: Dr. Ware recommends a Central Trusted Authority or a tightly controlled regional or state authority for the issue and maintenance of the method.
Assignable: The Bank Card Method requires a Central Trusted Authority or a tightly controlled regional or state authority to assign and maintain the identifier.
Identifiable: The issue of identifiers will be based on personal identification information. However, the necessary specifications, design and development are yet to be planned.
Verifiable: Check-digit verification is included in the proposal.
Mergeable: This can be accomplished at the regional or at the Central Trusted Authority level. However, this capability will be subject to policies, procedures, specifications, design and development that are yet to be planned.
Splittable: This can be addressed with appropriate procedures at the regional or at the Central Trusted Authority level.
Linkable: The Unique Patient Identifier based on Bank Card Method can be used to link patient records from multiple sources.
Mappable: Bidirectional linkage is possible between the Unique Patient Identifier based on Bank Card Method and the existing Identifiers.
Content Free: Dr. Ware's current thinking has changed his original proposal with regard to this characteristic. The Bank Card Method is content-free. However, this capability will be subject to the final specifications, design and development that are yet to be planned.
Controllable: The proposal does not include encryption. However, this number can be encrypted and encryption schemes administered by a Central Trusted Authority, or regional/state authority.
Healthcare Focused: Dr. Ware's proposal is specific to healthcare.
Secure: The Unique Patient Identifier based on the Bank Card Method can be encrypted and the security administered by the Central Trusted Authority. However, the proposal does not include encryption.
Disidentifiable: The Unique Patient Identifier based on Bank Card Method can be encrypted to protect the identifier.
Public: Public disclosure of the Unique Patient Identifier without risks to privacy and confidentiality of patient information is not discussed. It will depend on appropriate access security and privacy legislation. The patient ID is not intended to be a public information.
Based on Industry Standards: Bank cards that are currently in use are based on industry standard. However, the compatibility with the industry standard for healthcare purpose will depend on the appropriate specification, design and development that are yet to be organized.
Deployable: The Bank Cards are in extensive use. The necessary technology, such as inexpensive card readers that respond to keystrokes or magnetic-stripe, printers etc. has already been developed.
Usable: Bank Card is used in both manual and automated modes.
Bank Cards are issued by individual banks. The issuing organizations follow common standards with regard to its content and processes. Dr. Willis Ware recommends that the method can be administered either by a Central Trusted Authority or by establishing a tightly controlled regional/state authority.
Unique: The information contained in the magnetic stripe is standardized across the industry. However, the account numbers issued and maintained by individual banks are not unique. An individual can have multiple ID numbers. Therefore, this capability is subject to the development of appropriate specification and design that are yet to be done.
Repository-based: Banks maintain a data base of identifying information for each individual. They also use authentication processes with data elements such as mother's maiden name, data of birth, etc. Therefore, it is possible to meet this requirement subject to appropriate specifications, design and development that are yet to be done.
Atomic: Although the number includes groups of numbers, it can function as a single data element.
Concise: Bank Card Method Numbers are moderately concise.
Unambiguous: Bank Card Method does not include alphanumeric characters. Therefore, it is unambiguous.
Permanent: The Unique Patient Identifier based on Bank Card Method is a permanent identifier.
Centrally governed: Dr. Willis Ware proposes that this method be administered either by a Central Trusted Authority or by establishing a tightly controlled regional/state authority.
Networked: Telephone, telecommunication (modem) and online links are currently utilized for inquiry with regard to approval and transmission of credit and debit transactions. It can be operated on a network.
Longevity: This option can support patient identification for a foreseeable future.
Retroactive: Bank Card method can be used for retroactive assignment of identifiers.
Universal: This method can support universal use. However, this capability will be subject to specifications, design and development that are yet to be planned.
Incremental Implementation: Can be implemented incrementally.
Cost-effectiveness: This capability is subject to specifications, design and development that are yet to be planned.
Currently operational: The Bank Card Method is not currently operational as a Unique Patient Identifier.
Existing infrastructure: Does not have existing administrative and technical infrastructures
Readiness of the required technology: Telephone, online links, modem, card readers, point of sale terminals etc. are currently available and utilized by financial institutions.
Timeliness: The Bank Card Method is not a fully developed concept. It needs to be developed further to address healthcare applications. It is not ready for implementation and requires significant amount of additional time for implementation.
Adequacy of information to support identification functions: The Patient identification data base and its contents have not yet been addressed.
Dr. Willis Ware's proposal for the Unique Patient Identifier based on Bank Card Method consists of 13 to 15 digits. The Bank Card Method remains as a concept. The identifier format has not been finalized.
The Patient identification data base and its contents have not yet been addressed. The Bank Card Method remains as a concept. It is not ready for implementation.
The index that would link the identifier and the patient's identification information has not been addressed. The Bank Card Method needs to be developed further.
Encryption is not part of the proposal.
Dr. Ware's proposal requires the use of the card industry to serve as the technology infrastructure. He recommends issuing a competitive RFP to the card industry for the design and implementation of the method, which remains as a concept now.
The proposal recommends either a Central Trusted Authority or a tightly controlled regional/state authority which is not in existence at this time.
Compliance with the basic functions criteria depends on the identifier's compliance with operational characteristics and the required identifier components. The Bank Card Method proposal is at a preliminary stage. Dr. Willis Ware's steps relating to organizing a team of experts, developing specifications and issuing an RFP to the card industry have not taken place. The proposal needs further development before its capabilities can be compared with other options. Currently the method does not meet all of the operational characteristics and component requirements. Therefore, the Bank Card Method's ability to perform all of the basic functions discussed below is unknown. It will depend on the development of a complete proposal and inclusion of missing components and operational requirements.
Delivery of care functions: The ability to support the manual and automated identification of an individual will depend on the final format and content of the identifier, implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements.
Administrative functions: The ability to support the identification required by practitioners, provider organizations and secondary users for administrative functions will depend on the final format and content of the identifier, implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements.
Coordination of multi-disciplinary care processes: The ability to support multi- disciplinary functions and coordination of care processes including ordering of procedures, medications and tests, communication of results and consultations will depend on the implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements.
Organization of patient information and medical record keeping: The ability to support manual medical record keeping and automated collection, storage and retrieval of information will depend on the implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements.
Manual and automated linkage of lifelong health records: The ability to identify, organize and link information and records across multiple episodes of care and multiple sites of care will depend on the implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements.
Aggregation of health information for analysis and research: The ability to support the aggregation of health information on the basis of groups of patients, regions, diseases, treatments, outcomes, etc. for research, planning and preventive measures will depend on the implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements.
Support the protection of privacy, confidentiality & security
Access Security: Access Security procedures are not part of the proposal.
Content-free Identifier: Dr. Ware has revised his original position to keep the identifier content-free.
Mask/Hide/Encrypt/Protect/Disidentify: The proposal does not include encryption to protect the Identifier.
The Unique Patient Identifier based on Bank Card Method has the potential to support the functions of a Unique Patient Identifier. However, its success depends on the implementation of the remaining Unique Patient Identifier components and the capability to address all of the operational requirements. The nation-wide implementation of a new system will require a huge investment of resource, time and effort.
1. Meets almost all of the ASTM conceptual characteristics (of the 30 requirements, fully meets 27)
1. The Bank Card Method is a new choice and can be designed to exclude known defects or limitations.
2. It provides an opportunity to develop the required specifications and design precisely for the system to efficiently meet the industry's need.
3. It avoids crossover problems from an existing system that need to be remedied or those that cannot be corrected retrospectively.
4. The financial industry has a demonstrated success with the plastic card identification systems.
5. The experience, know-how and the capability to implement such a system is already in the private sector.
6. The necessary technology such as inexpensive card readers that respond to keystrokes or magnetic-stripe, printers etc. has already been developed.
9. Overcoming/solving the above weaknesses will require a substantial investment of money, huge effort and a longer time frame than enhancing an existing identification system.
4. Timeliness of the solution.
1) Inclusion of the missing identifier components and operational characteristics.
2) Establishment of a team of experts, recommended by Dr. Ware to develop this concept and help in:
a) the development of identifier specifications, design, etc.
b) the development and issue of the RFP recommended by Dr. Ware.
c ) the establishment of a Central Trusted Authority
d) the technology infrastructure including software, hardware and communication issues
e) the implementation methodologies and policies and procedures
f) investment and implementation schedule.