SMART does it again with Health Cards and Links

This is article one of a series of three. Two is here; three is here!

A few weeks ago I helped out with a demo at UCSD that showed patients checking into the doctor using a QR code. It was pretty cool and worked well, excepting some glare issues on the kiosk camera. But why, you might ask, did this retired old guy choose to spend time writing code to support, of all things, workflow automation between providers and insurance companies? Well since you clearly did ask, I will be happy to explain!

I spent a lot of my career trying to make it easier for individuals to get the informed care they need to be healthy and safe. And while I’ll always be proud of those efforts, the reality is that we just weren’t able to change things very much. Especially here in the US, where the system is driven far more by dollars than by need. But I’m still a believer — longitudinal care that travels with the individual is the only way to fix all of this — and despite my exit from the daily commute, I’m always on the lookout for ideas that will push that ball forward.

COVID and the birth of SMART Health Cards

Flash back to COVID year two (bear with me here). We had vaccines and they worked really well, and folks were chomping at the bit to DO STUFF again. One way we tried to open the world back up was by requiring proof of vaccination for entry to movies and bars and such. And because healthcare still thinks it’s 1950, this “proof” was typically a piece of paper. Seriously. Anyways, a few folks who live in the current millenium came up with a better idea they called SMART Health Cards — a fancy way of using QR codes and phones to share information (like vaccine status) that can be digitally verified. It was a lot better than paper — The Commons Project even made a free mobile app that venues could use to quickly and easily scan cards. More than thirty states adopted the standard within months — a track record that will make any health tech wonk stand up and take notice.

Of course the problem with any new technology is that adoption takes time — most folks still just showed up at the bar with a piece of paper. But with SMART Health Cards, that’s fine! Paper records could easily include a SHC QR code and the system still worked great. I found this bridge between the paper and digital worlds super-compelling … it just smelled like maybe there was something going on here that was really different. Hmm.

As it turns out, the pandemic began to largely burn itself out just as all of this was building up steam. That’s a good thing of course, but it kind of put the brakes on SHC adoption for a bit.

Enter SMART Health Insurance Cards

One reason the states were so quick to adopt SHCs is because it was fundamentally simple:

  • Host a certificate (ok, a “signing key”).
  • Sign and Print a QR code on your existing paper records.

That’s the whole thing. Everything that worked before keeps working. All you need to do to get the digital benefits is to put a QR code on whatever document or card or app you already have. This is pretty neat. Of course, other pieces of the ecosystem like the verifier and “trust network” of issuers took a bit more work, but for the folks in the business of issuing proof, it’s really easy.

It’s pretty clear that this technology could be used in other ways as well. Extending vaccine cards to include more history for camps and schools is an obvious one. Folks are working on an “International Patient Summary” to help people move more seamlessly between health systems. And, finally getting back to the point of this post, it seems like there is a real opportunity to improve the experience of patient check-in for care — we all have insurance cards in our wallet, why not make them digital and use QR codes to simplify the process?

This idea gets me excited because, if you play it out, there appears to be a chance to move that “individual health record” ball forward. First, there is real business momentum behind the idea of improving check-in. 22% of claim denials are due to typos and other errors entering registration information. We’ve learned it takes six weeks to train front desk staff to interpret the thousands of different insurance card formats — and it’s a high-turnover job, so folks are running that training again and again. And even when the data makes it to the right place in the end, it’s only after a super-annoying process of form-filling and xeroxing that nobody feels positive about.

All of this together means there are a lot of people who are honestly psyched about the potential financial / experience benefits of digital check-in. Especially when the lift is simply “put a QR code on your existing cards.” It’s kind of a no-brainer and I think that’s why more than 70 different organizations were represented at the UCSD demonstration. It was pretty neat.

More than insurance

Cool, so there’s motivation to actually deploy these things and begin to transition check-in to the modern world. (I should acknowledge that this is not the first or only initiative in this space; for example Phreesia has been working the problem for years and does a fantastic job. SMART Health Cards are additive to these workflow solutions and will just make them all get traction quicker.)

But the other thing that gets me excited here is that the “payload” in a SMART Health Card can carry way more than just insurance data. That same card — especially since it’s coming from an insurance company that knows a lot about your health — could include information on your allergies, medications, recent procedures, and much more. All of the stuff that you have to fill out on forms every time you show up anyways, and that can make or break the quality of care you receive. You can even imagine using this connection to set up authorization for the provider to update your personal record after the visit.

Woo hoo! At the end of the day, I see this initiative as one that has the potential to improve coordination of care through individuals in a way that will actually be deployed and sustained, because it has immediate and obvious business benefit too. And with the ability of SHCs to bridge paper to digital, we may be looking at a real winner. Still a ton of work to do on the provider integration side, but that just makes it interesting.

Oops one problem (and a solution)

It turns out that there is one big technical issue with SHC QR codes that make a lot of what I’ve been gushing about kind of, well, impossible. The numbers bounce around depending on the physical size of the QR image, but basically you can only cram about 1,200 bytes of data into the QR itself. That’s enough for a really terse list of vaccines, but it just doesn’t work for larger payloads. Insurance data alone using the proposed CARIN FHIR format seems to average about 15k. Hmm.

No problem — Josh and his merry band of collaborators come to the rescue again with the concept of SMART Health Links. A SHL creates an indirection between the QR Code and a package of data of basically unlimited size that can contain multiple SMART Health Cards, other collections of health data, and even those authorization links I mentioned earlier. The data in the QR code is just a pointer to that package, encrypted at a URL somewhere. The standard defines how that encryption works, defines ways to add additional security, and so on. It’s great stuff.

The workflow we demonstrated at UCSD uses payor-issued SMART Health Cards wrapped up inside SMART Health Links. If a person has multiple insurance cards (or even potentially drivers licenses and other good stuff) they could combine them all into a “Super-Link” while still maintaining intact the ability to verify each back to the company or state or whatever that issued it. Ka-ching!

If you’re interested in all of this, I’d invite you to join/follow the “SMART Health Insurance Card Initiative” on LinkedIn so you can watch it evolve and, hopefully, scale up.

And if you’re a nerd like me, over the next week or so I’m going to write two techy posts about the details — one for SMART Health Cards and one for SMART Health Links. Hopefully they will serve to get folks more comfortable with what it will take for issuers and consumers to get moving with real, production deployments quickly. If you’d like to get notified when those go up, just follow me on LinkedIn or Twitter or whatever.

It’s a good fight and hopefully this one will get us closer to great care. Just Keep Swimming!