A different kind of Green Card

If you have lived in the US as an expat, like me, you know well that if there is one topic expats love to talk about more than anything else, it is Green Cards. The allure is unexplainable and yet very real. The wait time is like forever but you wait. You may or may not feel a sense of accomplishment after you get it, yet we talk about it every time we meet. The topic has made its way into popular culture, definitely professional culture, coffee conversations, and even dinner table conversations. That coveted little green card is life-changing for a lot of people, literally. So when I stumbled upon this Green Card while reading about French healthcare, all those memories came back rushing. My mind obviously went in the direction of employment authorization, permanent residency, citizenship, etc. I was curious if this was a similar Green Card. So I went down the rabbit hole. What I learned expanded my mind about how seemingly insignificant tech has the potential to change industries and the world. These fancy-looking French green cards are basically smart cards with programmable chips that open the doors to the world of French healthcare.?

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The Baker’s Dilemma

On a cold morning in March of 1892, a 37 yr old baker showed up in the halls of Saint-Louis hospital in Paris with an unusual infection. The infection was eating into his shoulder. He knocked on the doors of many clinics and hospitals to get help. Unfortunately for him, their decision was unanimous and not in his favour - amputate they said. The baker was not happy since amputation meant losing 50% of his dexterity which in turn meant a steep drop in his business and a potential loss of livelihood.?He said, “No”. The doctors were dumbfounded. "What do you mean No? This is the only option available". They said he either amputates or he dies. The baker thought long and hard and said “No thanks”.

The doctors were left utterly confused. Given a choice between amputating a limb and dying, who would want to die? What they did not realize at the time was how that stubbornness would soon be pivotal in France pushing the boundaries of surgery. Dr. Jules-émile Péan was sipping on his hot coffee and eating a freshly baked piece of bread when the complicated case reached him. Someone knocked at the door. Dr. Péan looked over his shoulder, said "Come in". The person explained the problem to him and left the room. Dr. Péan sipped on and thought long and hard about the problem. In a light bulb moment, he conceived a treatment that was not tried before. He proposed replacing the baker’s infected ball and socket joint with an artificial joint. This joint was made of metal and rubber. After a long and arduous surgery, the baker walked back into his bakery and, lo and behold, started baking again! This moment is pivotal in the history of surgical interventions all over the world. Alas, none of the specific details, outside of the knowledge that was verbally transferred, were recorded anywhere so there is very literature about the surgery. Even the outcomes could not be recorded given the times. Recording medical data is not a problem that the French would face today. There are building blocks that empower the French healthcare system to record rich longitudinal data. Wondering how did their healthtech story start?

It all started with money.?

‘Take the Money and Run’

The French were always ahead in the game when it comes to smart cards. Heck, they invented it. But the invention of the smart card was not a light bulb moment. There were several iterations before the smart card, as we know it today, came into being. First, there were cards with magnetic strips. This made financial transactions, especially shopping, very convenient. The idea behind was that the magnetic strip sent a query to the bank’s computer to confirm whether or not the buyer was authorized to use the card. But this query to the bank server was time and cost expensive. Plus there was a greater problem in that the magnetic strip could be easily cloned. Roland Moreno was not happy with it. A true dreamer, he literally dreamt of the smart card and manifested it in the real world. What you see below is an early prototype of what would later become a fashionable smart card. Moreno is a Woody Allen fan and the idea was being conceived within the financial realm, so Moreno named his research project at the time after Allen’s movie ‘Take the Money and Run’ code-named TMR.

Source: https://northeypoint.substack.com/p/the-historical-roots-of-electronic

This was a bold 0 to 1 move. It was tough. But once the tough part was sorted, there were conceptual improvisations from other inventors around the world in the subsequent years. Michel Ugon, another French engineer, thought even bigger and filed a patent to put an entire microprocessor inside the card where you could potentially run applications. But then he built the concept off of Moreno’s original patent. So while there were several inventors from various countries competing for the top spot, Moreno eventually won the ‘Smart Card inventor’ tag in popular culture.?

Source: Michel Ugon’s patent filing where he references Moreno's patent

It took about a decade after Moreno first filed his patent but once the benefits of smart cards were apparent, they started popping up everywhere in the world. Smart cards have entered all realms of our lives. From debit cards to credit cards to ID cards to SIM cards to prepaid cards for everything, there are billions of smart cards floating around the world and probably millions more on the way. ?

Source: https://histoire.bnpparibas/

What I find amusing is Roland Moreno conceived the idea of a smart card in his dream. I have to admit, my dreams are not as inventive as Moreno’s. In one of the interviews, Moreno mentions that he sees a couple of uses of Smart Cards, healthcare being one of them. The French took his word seriously and literally ran with the idea.?

This brings us to Carte Vitale.

Carte Vitale - Indeed the Vital Card

In his book The Healing of America, author T.R. Reid captures a rather futuristic snapshot of his experience with French health technology interestingly from over a decade ago. The author writes about his experience of seeing a spartan set up for a medical practice with no paper records stuffed in large cabinets but instead a small card reader sitting next to a computer. The card reader is basically used to read information from a golden chip embedded in the smart card otherwise known as Carte Vitale (The Vital Card). Carte Vitale was originally conceived with the philosophy of having a patient’s entire medical record embedded in the chip. A digital record for every doctor visit, referral, procedure, surgery, imaging data, and prescription in addition to the final bill that the doctor generates with a split of how much money will be paid by the insurance as compared to the patient. If you are under the age of 16, all of this information was expected to be on Carte Vitale of one of your guardians. Once the card is in the reader, which is connected to the internet, all claims are automatically transmitted to insurance upon close of the consultation. This takes care of billing.?

Source: Google?

The author states that he noticed something unusual in terms of reimbursements. There was no billing department wherever he went because the French didn’t need one. Since everything is predetermined and final, doctors get paid 3 days from the day the consultation ends - 3 days ! The impact of this staffing change is simple. There are more doctors and nurses in French hospitals than the administrative staff.?

Source: Google?

The idea of using smart cards for healthcare caught on so much that several countries across the globe experimented with their own versions of Carte Vitale and contextualized it.?

Source: https://139.91.210.27/CBML/PROCEEDINGS/2013_BIBE/papers/113.pdf

Source: Sample images picked up from Google?

Smart Card Alliance has published a detailed paper about smart cards can actually help attain meaningful use goals in the US. They have analyzed all core measures and posted specific guidance on how smart cards can help.?

The paper cites a case where a hospital discovered 200,000 duplicate records in its system. Fixing it at $60 - $100 per record set back $1.5 Million for the hospital to clean up the mess. And this was a recurring cost every 2 - 3 years. The paper makes a case for de-duping the records via smart cards and avoiding this multi-million dollar problem.?

Like all good ideas, Carte Vitale is evolving too. A couple of years into the national roll-out, the French administration hit upon a roadblock that is the arch nemesis of every healthtech professional - interoperability. The original idea behind Carte Vitale was that it contain longitudinal health information. When inserted into the smart card reader, all that health information be read into a computer application, get updated with notes from the current visit, and pushed back to Carte Vitale. The problem was that the software applications varied in terms of interoperability maturity. If you have worked in healthtech, you know well that a single application cannot suffice the needs of all specialties and functions. Doctors have different needs than radiologists, who have different needs than pharmacists. As such, the systems they were working on were different and this acted as a roadblock in freely moving data from Carte Vitale into the system and back to Carte Vitale. The French realized this and decoupled the health information from insurance information that resided on Carte Vitale. The health information found a new home in the form of Dossier Médical Partagé (DMP) - which in English means Medical File Sharing. This longitudinal record was maintained on the internet, accessible to the patient and his care team. This information was also accessible across the variety of software applications that were used all over France. This shared medical record stores a variety of your health information - treatments, test results, allergies, and any other medical data points relevant for continuity of care.?

Source: https://www.dmp.fr/

Physicians could access the information stored in DMP using a combination of their own professional health card (CPS) and the patient’s Carte Vitale. So Carte Vitale was now used more as a key to unlock the rich data that is stored in the DMP. The interoperability issue was solved because 80% of the software applications used by healthcare professionals were integrated with the DMP. That list of software applications is accessible here. But DMP unfortunately did not get a lot of traction. There were some lessons learned along the way. The French administration evolved it into yet another modern version of shared medical records titled Mon espace santé (My Health Space). Learning from their past mistakes, My Health Space is an opt-out mechanism in comparison to opt-in which DMP worked on. All patient data on DMP was automatically migrated to My Health Space. My health space has upgraded security, and data ownership and added feature functionality to make patients’ lives simpler and hopefully get more traction this time around. Again, all of this was possible because Moreno dreamt of that smart card. It might not be very apparent but it is all connected. And these are all separate and very interesting rabbit holes that are very tempting to explore. But all rabbit holes lead to one conclusion.?

French healthcare system was always punching above its weight. It is up there in terms of quality as well as ranking.?

Mirror, mirror on the wall, which is the best health system of them all?

It would be a mistake to read about Carte Vitale in isolation. Carte Vitale is just one dot of the several dots that need to be connected to see the high-resolution picture of French healthcare. It is one of the important dots though. It has tipped the healthcare quality scale in France’s favor on the back of a surprisingly simple idea. In his book 'Healing of America', T. R. Reid mentions how he was stumped when one of the doctors looked him in the eye and said this about billing -?

“Why would I pay somebody to do my billing?.”?

“C’est automatique.”?

Commonwealth fund ran a report across countries to assess their health systems on 5 parameters.?

• Access to care
• Care process
• Administrative efficiency?
• Equity?
• Healthcare outcomes?

France made it to the top 10.?

PCP visit costs you around 10 $ USD, and a specialist visit costs you around 25$ USD.?

Source: Commonwealth fund

The French health system has been ranked consistently among the top health systems in the world for the past several years. And it comes as no surprise since they provide Universal Health Coverage combined with a comprehensive health service framework. They got it covered.?

Life expectancy is among the highest in EU.?

Of course, there are opportunities to improve and jump higher in the ranking.?

But overall France is doing a fantastic job at managing the health of its population through a combination of policy, technology, funding, and infrastructure. These are the ingredients of their secret sauce IMO. ?

• Use of electronic medical records
• Use of electronic billing
• Allocating the healthcare workforce in problem areas that actually matter and using tech wherever human intervention is not required
• Focus on preventive
• Focus on prescription adherence for the elderly and sick and literally meet the patients wherever they are when needed
• Fail fast and correct faster

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I am a big fan of everything Michael Moore. Coincidentally, I was introduced to his work because of a documentary he produced on the state of healthcare around the world. In that documentary, he visits a couple of countries asking common people for feedback about their respective country’s healthcare systems. This clip is reflective of what the French think about their healthcare system. You realize that France indeed thinks about healthcare in a truly comprehensive manner. From pregnancy to child care to education and everything in between, they live, breathe and have a laser focus on what otherwise qualifies as social determinants of health. Because they know that these are the things that actually matter.?

Going back to that scene from the documentary, while the group excitedly paints an almost utopian picture about healthcare in France and talks about what the government does to ensure the physical and mental well-being of its citizens, Moore jokes

“And they (the French govt.) will come to your house and do laundry!”?

“It’s true” comes back the response.?

Michael Moore is stumped in disbelief and says a big “No wayyyyy!!!” as the scene cuts to him standing next to someone actually employed by the French government doing the laundry of a young mother.?

This person who helps with the laundry comes 2 days a week, 4 hours a day, and literally ensures that a young mother has any and all help - including cooking. Cooking!

And if you are thinking this sounds like life of the top 1%, it is not. This is what the life of a common citizen looks like under the French health system.?

Surprised?

Me too.?

Welcome to French Healthcare.?

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References?

1. What information does Carte Vitale carry: https://www.service-public.fr/particuliers/vosdroits/F21742
2. Commonwealth fund report: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
3. Smart cards and meaningful use: https://www.securetechalliance.org/publications-getting-to-meaningful-use-and-beyond/
4. Case study: https://universaldesign.ie/technology-ict/archive-irish-national-it-accessibility-guidelines/smart-cards/smart-card-applications-case-studies/french-health-card/
5. Meaningful Use: https://www.cdc.gov/cancer/npcr/meaningful_use.htm
6. Smart Cards Alliance paper: https://www.securetechalliance.org/publications-getting-to-meaningful-use-and-beyond/
7. Dossier Médical Partagé
8. Mon espace santé - Vous avez la main sur votre santé