E-Health Card: The Three Hurdles on Its Path to Mainstream Adoption

Prior to the introduction of the Electronic Health Card, the Resident Health Card played a central role within the National Health Commission’s “3521 Project” framework. The purpose of issuing this card was to achieve comprehensive health management for residents and to enhance the uniformity of health service delivery.

However, as a unified standard for coordinated planning and implementation, the “Medical Visit Card,” or Resident Health Card, has long been constrained by multiple factors, making it difficult to achieve genuine adoption in hospitals across China. This issue primarily manifests in the following three aspects:

1. The issuance and consumption costs of resident health cards are relatively high, making it difficult to ensure cost-effectiveness even with a large population base.

2. Lack of a mandatory usage mechanism akin to that of the social security card. As it cannot be linked to patients’ medical insurance payments, it is perceived by patients as optional rather than essential.

3. Insufficiently diverse application scenarios. The Resident Health Card primarily centers on diagnostic and treatment services, with limited coverage of planned immunization, vaccination, and health check-ups. Furthermore, its limited cross-regional interoperability hinders residents from achieving a satisfactory user experience.

As smart card applications accelerate their transition from “offline physical” to “online virtual” formats, advancing the development of secure and trusted virtualized resident health card applications to achieve integrated online-offline identity authentication services is of great significance for optimizing service processes, ensuring the security of online applications, reducing card issuance and usage costs, and achieving widespread adoption of resident health card applications.

In December 2017, the Statistical Information Center of the National Health and Family Planning Commission and the Jiangsu Provincial Health and Family Planning Commission jointly held the inaugural launch ceremony for the national Electronic Health Card. Amid widespread public attention, the Electronic Health Card made its historic debut.

One year later, in December 2018, the General Office of the National Health Commission officially issued the “Opinions on Accelerating the Promotion and Application of Electronic Health Cards,” elevating the mission entrusted to electronic health cards to a new height…

In this article, VCBeat will delve into the three current models of electronic health cards and the three major obstacles encountered during their implementation.

What Is an Electronic Health Card? According to the official definition, it is a standardized, nationwide medical service card issued by health authorities to urban and rural residents based on their resident identity cards and other legal documents. The card aims to eliminate the bottleneck of “one hospital, one card, with no interoperability,” facilitating residents’ access to continuous medical care and free basic public health services, enabling dynamic management of personal electronic health records across the entire lifecycle, and making it more convenient for the public to seek medical treatment and manage their health. Residents can apply for and use the card at hospital service counters, self-service kiosks, or through various internet-based medical and health service applications at any time.

By using the Electronic Health Card as an access point, residents can seamlessly connect to various medical and health services, including family doctor contract services, appointment scheduling with time-slot-based consultations, authorized access to electronic health records, and internet-based diagnosis and treatment. Furthermore, the Electronic Health Card fully supports financial industry payment QR code standards. Leveraging the innovative “multi-code aggregation” mechanism, it integrates multiple codes—such as the health QR code, medical insurance settlement code, and payment QR code—into a unified application. This facilitates a “one-stop” convenient healthcare experience for residents, covering hospital visits, medical insurance settlements, and mobile payments.

According to data from the National Public Service Platform for Resident Health Cards, as of May 2018, electronic health cards had been initially issued in 22 provinces and municipalities across China, including Jiangsu, Sichuan, Qinghai, Fujian, Wuhan, Jiangxi, Anhui, and Hebei.

In terms of specific functionalities, the electronic health card can serve the following four categories of medical services:

Provide applications such as regional appointment registration, payment for medical services, waiting status inquiry, record inquiry, service navigation, and service evaluation based on the Electronic Health Card. This enables residents to use the Electronic Health Card to access end-to-end diagnostic and treatment services at any hospital within the region, facilitating convenient healthcare and achieving a "one-card" solution for medical visits. Simultaneously, it allows patients to review all electronic medical records (EMRs) generated during their care, realizing a "unified record" service for cross-institutional EMR sharing.

After receiving medical services at any healthcare institution within the region, users of the Electronic Health Card will have their information—including registration details, payment records, laboratory and imaging test results, prescription data, patient demographic information, medical examination reports, alerts for duplicate testing, outpatient diagnoses, and discharge diagnoses—pushed to them in real time. Residents can query these reports online and may freely choose any healthcare institution within the region to inquire about and print their reports, thereby achieving “universal report accessibility” across all medical institutions in the city.

Electronic Health Cards store residents' medical records and allergy history. By scanning the QR code on a patient's Electronic Health Card, healthcare providers can access the cardholder's disease history and allergy information, enabling targeted pre-hospital emergency care. During transit, ambulances promptly transmit the cardholder's relevant information and clinical condition to the hospital, allowing the hospital to formulate an accurate treatment plan and save the patient's life.

Provide internet-based public health services, such as free first-visit notifications, follow-up appointment scheduling, vaccination appointment booking, access to health records, file creation reminders, and targeted delivery of health education information. These services leverage digital tools to enhance citizens’ awareness of public health offerings, guide them conveniently to designated institutions for free basic public health services, and simultaneously promote the standardization of primary-level public health services, thereby improving the quality and completeness of public health data.

From the perspective of the system architecture, the Electronic Health Card primarily comprises the following components: a cross-domain master patient index system, a registration management system, reading terminals, and a key management system.

Master Index ID is the information that identifies the uniqueness of a resident health card user and is one of the most core systems. Through the Master Index ID, different types of accounts such as the physical resident health card, electronic health card, and hospital visit card can be associated with the user.

The Electronic Health Card Management System is used to identify information that ensures the uniqueness of an electronic health card account. The ID consists of the ciphertext of the user's ID type and ID number. Additionally, the electronic health card QR code is displayed in the form of a QR code and is interactively used through "face-to-face" methods.

QR codes are categorized into static and dynamic types. Static QR codes can be displayed via mobile apps or printed/affixed onto media such as patient cards, making them suitable for non-core scenarios like appointment registration and consultations. Dynamic QR codes are generated by the app before each use, with their validity period limited based on application security requirements; they are applicable to core scenarios such as medical record inquiries and settlement transactions.

On the terminal side, devices involved in electronic health cards mainly include three categories:

At present, there are three primary models for electronic health card management systems: province-centric, city-centric, and hospital- or medical consortium-centric. These three models correspond to different traffic entry points:

1. Establish a provincial-level health app platform as the entry point for electronic health cards.

2. Establish a health app as the entry point for electronic health cards on a city-by-city basis.

3. Establish WeChat Official Accounts, Lifestyle Accounts, or hospital-specific apps, with hospitals and medical consortia as the organizational units, and use remote connections to an independent card management center as the entry point for electronic health cards.

These entry points have emerged due to disparities in funding, technology, and timing of implementation across different provinces. While some provinces find it challenging to implement initiatives at the provincial level, certain cities or medical consortia already possess the necessary capabilities. Therefore, pilot programs can be launched first, with the construction of provincial-level platforms considered at a later stage. Below are practical cases illustrating three such models:

On November 8, 2018, the Statistical Information Center of the National Health and Family Planning Commission convened in Beijing an expert review meeting on the technical standards for the integration of three medical codes and the project construction plan. The meeting heard reports from the Fujian Provincial Health Commission and the Fujian Provincial Medical Insurance Center on the innovative application technical standards for the “integration of three codes,” the pilot project construction plan, and progress in implementation. Attendees also viewed a demonstration showcasing the end-to-end application of this system across the entire patient care process at the Second People’s Hospital of Fujian Province.

In accordance with the design plan, residents of Fujian Province can complete a one-time identity registration and authentication through channels such as hospital WeChat Official Accounts, WeChat Life Accounts, and the Rongyitong App (Fuzhou Medical Convenience Service Platform). Upon verification, they will receive a QR code featuring “three-code integration,” which facilitates seamless end-to-end processes, including appointment scheduling, online health record creation, scan-based medical consultations, laboratory and diagnostic tests, medication pickup, report retrieval, as well as online medical insurance settlement and digital financial payments.

Patients can seek medical care without the need to obtain a hospital visit card or carry a social security card, nor do they need to pay deposits at payment windows. This enables a convenient, card-free experience for medical consultation and settlement through a “One-Code Pass” system that implements “treatment first, payment later.” By achieving bidirectional integration of medical and health insurance data at the provincial platform level, the system facilitates traceable supervision of the entire healthcare process. It also helps reduce issues such as fraudulent use of social security cards under false identities and insurance fraud, thereby effectively promoting collaborative supervision among healthcare providers, health insurance agencies, and pharmaceutical regulators.

Leveraging platforms such as the “Healthy Shenzhen” app and the Shenzhen Health Network, the electronic health card serves as a key to unlocking a wide range of health-related functionalities. Citizens can not only authorize physicians at pilot hospitals to access their health records but also look forward to enjoying more convenient medical services in the future, including appointment reminders, chronic disease management, linking social security cards for online payments, inquiry of consumption bills, hospitalization prepayments, physical examination appointments, smart cloud pharmacies, online consultations or diagnoses, health science popularization, and health assessments.

It is reported that the Electronic Health Card, as an open platform, welcomes access by third-party payment channels to serve citizens at any time. In the future, the Electronic Health Card will function like a digital wallet, allowing citizens to top up online via bank cards or third-party payment methods, as well as offline using cash or bank cards. This means that, going forward, citizens can directly make payments within any third-party payment app that has integrated with the Electronic Health Card platform.

Next, Shenzhen will comprehensively promote the issuance and application of electronic health cards, gradually integrating medical visit cards and health and family planning service-related cards into the electronic health card system to truly achieve “one-card access.” It is planned that by 2020, electronic health cards will cover 90% of hospitals.

Lin Denan, Director of the Shenzhen Medical Information Center, pointed out, “The design and implementation of the Shenzhen Electronic Health Card feature distinct characteristics, including an open platform, rapid card issuance, broad population coverage, and diverse application scenarios. It not only delivers a comfortable and convenient medical experience but also provides residents with a one-stop health management platform.”

As the first large tertiary hospital in Beijing to pilot the issuance of electronic health cards via the WeChat platform, Peking University First Hospital aims to leverage these cards to facilitate the interconnectivity of patients’ health and clinical information. This initiative enables healthcare professionals to access more comprehensive and continuous clinical data, thereby providing patients with more convenient and practical medical and health services.

The WeChat-based electronic health card will serve as a “digital key” in residents’ hands, providing full-cycle, comprehensive medical and healthcare services, and enabling more convenient, efficient, and secure connections between residents, physicians, healthcare institutions, and administrative bodies.

From the hospital’s perspective, the introduction of electronic health cards enables patients to access comprehensive, full-cycle health and medical information, thereby ensuring a more continuous care experience. Meanwhile, the WeChat platform serves as a convenient internet-based tool for cross-institutional information services, two-way referrals within tiered diagnosis and treatment systems, and telemedicine, facilitating resource openness and sharing among hospitals.

Based on the three implementation models of the card management system, Huang Jiangping, Deputy Director of the Computer and Microelectronics Development Research Center under the Ministry of Industry and Information Technology (MIIT) and head of an electronic health card system evaluation agency, has identified three key challenges in the rollout of electronic health cards. According to his understanding, the successful implementation of electronic health cards requires at least the following conditions to be met:

In brief, the integration of three codes, mobile access points, and application scenarios are currently the key drivers in the promotion of electronic health cards. Due to the semi-mandatory nature of social security payments for the general public, the most critical aspect is the integration of electronic health card functions with those of the social security card. The National Health Commission’s “Opinions on Accelerating the Popularization and Application of Electronic Health Cards” also emphasizes:

Actively promote the integrated application of “multi-card/code convergence” by combining the electronic health card (code), electronic medical insurance card (code), and electronic bank card (payment QR code). In conjunction with exploring the construction of regional shared network payment platforms, support one-stop settlement of medical expenses covering basic medical insurance, commercial health insurance, and financial payments, thereby facilitating healthcare access for the public.

However, it is well known that the social security card is administered by the Ministry of Human Resources and Social Security, while the health card is led by the National Health Commission. Whether these two systems can truly achieve integration involves profoundly complex underlying issues.

In response, Cao Tong, Deputy Director of the Information Department at the General Hospital of the Lanzhou Military Region, stated, “From a purely technical and procedural standpoint, patients can complete the entire process of diagnosis, treatment, and payment using just one card, whether it is an electronic health card, an electronic social security card, or a similar card. However, at present, the electronic health card and the social security card remain largely unintegrated in most regions across China. If these two systems were to be integrated in the future, it would significantly advance the adoption of electronic health cards. For now, however, the two must coexist in parallel.”

According to VCBeat, like the health card, the social security card is also undergoing virtualization.

In April 2018, at the inaugural Digital China Construction Achievements Exhibition, the Ministry of Human Resources and Social Security issued the nation’s first electronic social security card.

Like the physical social security card, the electronic social security card is standardized and accepted nationwide. It serves multiple functions, including identity verification, information recording, self-service inquiries, medical insurance settlement, payment of contributions and receipt of benefits, and financial payments. As a valid electronic credential for online applications of the social security card, the nationally standardized electronic social security card has a one-to-one, unique correspondence with the physical card. It is uniformly issued by the National Social Security Card Platform and centrally administered by the Ministry of Human Resources and Social Security.

In fact, as early as June 2016, the social security card began its exploration of online services. At that time, the Shenzhen Human Resources and Social Security Bureau partnered with Alipay to pioneer the binding of social security cards to the Alipay platform, making Shenzhen the first city in China to implement mobile payment for medical insurance.

Subsequently, local social security bureaus and Alipay explored the feasibility of electronic social security cards. Over the course of more than a year, 14 cities, including Hangzhou, Wuhan, and Shenzhen, enabled residents to “store” their social security cards in Alipay. More than 40 cities, such as Nanjing and Changsha, supported social security premium payments via Alipay, while over 90 cities, including Shanghai and Tianjin, offered human resources and social security services, such as social security inquiries, through the platform.

According to Director Huang Jiangping, “Although there is some overlap between the electronic social security card and the electronic health card, most of their backend operations differ. The electronic health card primarily supports medical services, such as hospital diagnoses and laboratory test results, whereas the electronic social security card mainly stores social security records, including contribution histories. Precisely because the electronic health card lacks the strong application scenarios inherent to the electronic social security card, the future integration of the two will be key to the successful implementation of the electronic health card.”

The full integration of electronic health cards and electronic social security cards may still be a long way off, but with pilot initiatives in regions such as Fujian Province, the prospect of citizens using a single card for all healthcare and social security needs is truly promising.