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A young woman is rushed unconscious into casualty after a road accident.
If an operation is not performed quickly, she may die. But what the duty
doctor does not know is that the patient has had a bad reaction to anaesthetic
in the past and been warned that another dose could be fatal.

This situation is extreme, but it illustrates the dangerous consequences
of a problem faced by doctors every day – making decisions about people’s
health without knowing all the facts. To compound the problem, the duty
doctor’s chances of finding out more about the patient quickly are virtually
non-existent, because communications within the health service are so primitive.

From this perspective was born the idea of the clinical memory card,
an optical or electronic store in the form of a credit card which carries
a person’s medical history. Where the patient goes the card goes too, giving
doctors a better chance to make better decisions, and ultimately saving
the country money.

Last month saw the start of Britain’s latest clinical card project.
Based at the West London Hospital, the study is small and has a low profile.
But things were not always so. In 1989, amid hints of a nationwide scheme
to come, a trial in Exmouth, Devon, was billed as a health care revolution.
It even attracted a ministerial visit. David Mellor, then a health minister,
pronounced that ‘for the first time patients will have control of their
medical records’.

Since then, the Department of Health has lowered its sights. Gone is
any notion of a grand, national scheme. In its place are ideas for a range
of ‘niche’ cards for groups such as pregnant women or diabetics. If the
department’s present plans come to fruition, the first memory card that
most Britons see will be an electronic prescription – a one-shot, disposable
card, similar to a London underground ticket.

The view that it is not yet time to introduce clinical cards nationally
is not unique to Britain. What does set Britain apart is that other countries,
such as Japan, France and Italy, are still pumping big money into developing
the concept. Japan has more than 10 trials of optical cards under way, France
is running numerous studies, and more than 60 000 Italians have been recruited
to trials of clinical cards since 1988.

As things now stand in Britain, doctors other than a person’s own GP
must rely on that person’s memory for details of past illnesses, test results
and treat-ments. Unfortunately, patients are bad at remembering such things.

The present system is also wasteful. Children, for example, can have
up to eight different sets of overlapping records, lodged with their GPs,
the schools health service, and local health authorities, among others.
But the waste does not stop there. ‘You spend 20 minutes filling in forms
and five minutes getting treated. And every time you interface with the
National Health Service you have to repeat the same information,’ says Bob
Stevens of the Welsh School of Pharmacy, who is one of the pioneers of patient
data cards.

The Exmouth trial was Britain’s big chance to prove the cost-effectiveness
of data cards. More than 8000 patients were given ‘smart’ cards which they
carried from family doctor to pharmacist and from hospital doctor to dentist.
The security system built into the chip allowed different people access
to different information. For example, while doctors could read the latest
medical records and update them, pharmacists could see only details of drugs,
allergies and other serious disorders such as angina that might influence
the drugs a person could safely take.

The trial took a year to complete and cost the Department of Health
nearly £400 000. But the government report of the trial makes depressing
reading. ‘It is clear,’ it says, ‘that no further trial should be contemplated
without first testing thoroughly the technology and software which is being
deployed . . . The budget for the Exmouth trial was clearly inadequate.’

It is not surprising that there were teething problems with the technology.
More worrying is the lack of thought that went into the design of the trial.
For example, not all doctors involved in the trial were asked what they
thought the scheme should provide, and as a result some were antagonistic
towards the cards. There was a lack of control patients against whom any
gains could be measured. And, crucially, the people who carried the cards
did not visit all of the doctors, pharmacists and dentists often enough
to give the study the statistical power necessary to confirm the perceived
gains.

Stevens says the department failed to find the cards’ full potential
because the trial was too short and too few cards involved.

‘The original proposal was for four years,’ says Robin Hopkins, a lecturer
in medical informatics at the University of Exeter who also works as a GP
in Exmouth. It was Hopkins who managed the day-to-day running of the trial.
‘It was curtailed before the trial went live,’ he says.

Unlike the published report, Hopkins sees the outcome of the trial as
positive and is optimistic about the prospects for clinical memory cards
in general. He says the Exmouth study clearly found that immediate access
to patients’ records led to savings. For example, there was a 6 per cent
decrease in the cost of prescribing among doctors who had access to the
cards. Also, they ordered fewer blood tests and other medical investigations
than doctors without card readers.

Hopkins argues that these savings arose because doctors made better
decisions in the light of information they would not have had were it not
for the cards. ‘These savings don’t take into account the days lost from
work or a reduction in dental anaesthetic disasters,’ he says.

Opinion at the Department of Health is less firm about the savings found
in Exmouth. One official says that while prescribing did fall among doctors
with card readers, ‘we couldn’t come up with a good reason why the card
was involved’. Similarly, on the fall in the number of medical investigations:
‘We couldn’t say with our hands on our hearts that this was due to the card.’

So was Exmouth a failure? ‘It was never capable of delivering what we
thought it might deliver. But it taught us a lot of lessons,’ says the official.

Last May a private firm, Pareto Consulting, was asked by the department
to come up with a development strategy, by gleaning what it could from the
Exmouth trial and studies carried out abroad. The report has not been published,
but according to department officials it examines a range of scenarios
with a variety of electronic cards, from identity cards that carry only
the patient’s name and NHS number to electronic presciption cards and smart
cards similar to those used in Exmouth.

Pareto came down firmly against issuing clinical cards nationally. ‘It
is impossible presently to define the cost savings,’ says one department
official. Without assurances of savings, national implementation and even
further large-scale trials of cards will not take place says David Markwell,
an independent clinical information consultant. At a time when there are
ward closures the Treasury does not understand expenditure on ‘bits of plastic’,
he says.

Instead of further large-scale research into clinical cards, the Pareto
report advocated research into a magnetic stripe card to replace prescriptions.
The department expects to start a trial soon.

More than 63 per cent of GPs now have a computer on which they can issue
prescriptions. A device attached to it could write the details, both physically
and magnetically, onto a card. Pharmacists, presently, transfer prescription
details onto labels and onto their own computers. This information is later
sent to the Prescription Pricing Authority. With a magnetic stripe card,
all the data transfer within the pharmacy could be done automatically and
without errors. Equally, GPs could issue repeat prescriptions on a single
card, saving patients the trouble of continually phoning up for repeats.

But economies from such improvements could be dwarfed by the money saved
by computerising the link between pharmacists and the PPA. At present, the
400 million prescriptions written every year in Britain are sent by mail
to the PPA, where the details are typed into computers. Removing the need
for this massive typing effort would save the country millions of pounds.

Other research being pursued by the department involves clinical cards
for small groups, such as the trial among pregnant women at the West London
Hospital. This trial will use optical memory cards . The women will carry
the cards between their doctors’ surgeries and the antenatal clinic. This
trial will avoid many of the problems encountered in Exmouth.

Hospital staff are already familiar with the technology and software
because a previous one-year study has already been carried out within the
hospital. This first phase was sponsored by BT, which holds a licence on
the technology. It also provided time to overcome teething problems.

The second phase will be carefully controlled with women being allocated
at random to carry a card, while the rest have paper files. Because women
are seen by a doctor or midwife about 20 times during pregnancy, the 240
women who will carry cards will generate data from about 4800 encounters.
These factors make pregnancy an ideal test-bed for evaluating the cards,
says Simon Jenkinson, the obstetrician who managed phase one.

During phase two, researchers will also be trying to measure the clinical
benefits of the cards, by homing in on high blood pressure. Prompt detection
is essential to reduce risks to mother and child. A program is being written
so that the hospital computer can spot and highlight trends such as rising
blood pressure very early on. ‘There’s a limit to what you can do with handwritten
notes – they can’t alert you to warning signs, but a computer can,’ Jenkinson
says.

Beyond the west London trial which will cost it £200 000, the
Department of Health is watching developments in clinical cards elsewhere.
It is, for example, giving moral and technical – but not financial – support
to doctors in Scotland who want to begin a trial. The size and nature of
the Scottish plan is still under wraps although it is widely thought to
involve optical cards. The study is awaiting approval by the Scottish Office.

The European Commission, through its Advanced Informatics in Medicine
programme, is funding research into a new smart card for people with diabeties,
developed by IBM and Siemens. A trial of this ‘Diabcard’ has just started
in Germany.

Markwell believes that it is not only Treasury pressure that is putting
the brake on clinical card development. The Department of Health may also
be considering alternatives for moving information around the country. The
NHS has been working hard to get its computer networks in place, and is
still toying with the idea of electronic identity cards for patients. Markwell
says that such a card could eventually be used simply to authorise a doctor
to retrieve a person’s records from elsewhere on the network, in much the
same way that cash cards allow people to draw money from cash points.

* * *

PICK A CARD . . . ANY CARD . . .

Of the three card technologies available to the Department of Health,
only two have enough capacity to store medical records. Optical memory cards,
developed by the Drexler Corporation in California, work like stationary
compact discs. To store data, a high-powered laser burns lines of 5-micrometre
pits into a thin metal coating. This data is read by a low-powered laser
which scans the surface, sensing changes in light reflected from the pits.

A precision mechanism moves the card in front of the laser optics in
12-micrometre steps. The 2500 parallel tracks can have a capacity of 2.6
megabytes, equivalent to about 2 million text characters or 1000 pages of
A4. Data cannot be altered or erased once they are stored.

The smart card, which has a built-in computer and memory chip, is the
main rival to the optical card. The French, who invented the idea, have
pushed both the technique and the technology. In France smart cards are
already used for telephone cards and as sophisticated credit cards.

The smart cards used in Exmouth had a capacity of around 2 kilobytes,
or 2000 text characters. The latest cards can handle 8 kilobytes. Information
on smart cards can be erased and altered.

Choosing between these rival technologies is a matter of need, says
Bob Stevens of the Welsh School of Pharmacy. In bulk, both cards cost in
the order of £1 each. But the greater memory capacity of optical
cards is offset by the higher price of the precision readers. Stevens says
one of the most exciting possibilities for clinical cards is their use in
emergencies. So far only smart card readers have been made portable. Smart
cards also have an advantage in that levels of security can be built into
them so that certain information can be restricted.

Both cards pose practical problems. If the surface of an optical card
is scuffed it can become unreadable. Equally, during the Exmouth trial there
were problems with smart cards. ‘Men put them in their back pockets and
ruined them, because when they sat down the chips fell out,’ says one department
official.

The third technology being considered by the department is the magnetic
stripe card. Like cash cards, these carry a strip which acts like magnetic
recording tape. They cost only a few pence each but have very limited capacity
– a few hundred characters or numbers.

Their main drawback is that the data are insecure. It can be erased
with a magnet or copied by a simple contact printing technique similar to
that used to reproduce digital audio and video tapes. This could be a serious
cause for concern if these cards are to replace prescriptions.