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Session 2: The Next Revolution: The Role of Informatics in Improving Healthcare (continued)
Cindy Dibiasi: I know you have piloted Health-e-App in one county and done an evaluation of that demonstration. What did you find?
Sandra Shewry: Well, we did test the program. The whole Health-e-App has been developed really in a partnership with the California HealthCare Foundation. They approached us about Health-e-App. It was very consistent with our State's interest in e-government. They basically have spent two years working with us, have contributed a million dollars to the development effort. We did test the program in San Diego, one of the counties with a lot of children eligible for Healthy Families and MediCal. The HealthCare Foundation contracted with the Lewin Group to do a business case analysis.
So, what we found is that application errors went down by almost 40 percent. The time that it took to submit an application decreased by 21 percent. Where Health-e-App scored off the charts was in satisfaction. This gets back to your digital divide concern. Applicants loved it. Part of it is that community workers that were working with the applicants were very enthusiastic about it. People had sort of a face, but the technology was getting it right. That automated error checking really increases satisfaction. People liked knowing that their application was on file with the official government agency and the community workers, the folks we call CAAs [Certified Application Assistants], really picked it up quickly. There wasn't a long learning curve for them.
Now, of course, in any sort of roll out, there are challenges. These are the things we found were hard. Getting an electronic signature approved. Concern about fraud. How will you be able to authenticate the signature and have all the documents go together? That was a challenge for our State. Getting the first month's premium payment. Our SCHIP [State Child Health Insurance Program] program, like many other States' SCHIP programs, charge families to participate. So in addition to getting all those paycheck stubs and birth certificates, how are we going to get that premium payment in-house? As we are rolling out Health-e-App, we are basically setting up the ability for families to let us tap into their checking accounts using the Web again. Matching up documentation that gets faxed after the point. If somebody has got their birth certificate with them when they are filling out the application, it can be faxed right in and goes right into the database. We needed to develop a way for a family to go home, find that birth certificate, and then get it linked up in the system in the right file. So, again, our goal here is never to have paper, but just have things come in as image files. And then the technology sounds simple, but there are actually a lot of behind-the-scenes technology challenges to this. So having a business partner in this, in our case the Foundation, that could bring in resources from the private sector, was really a helpful relationship.
Cindy Dibiasi: Now I understand that you are planning to implement the Web site statewide, is that right?
Sandra Shewry: We are. We are very excited about this. The pilot was such a success that even with those challenges, we feel that we can address those and we are planning to move forward with our Web-based training. That is a key part. We do need to automate the premium payments so that the funding is there and we can approve an application as soon as we have all the data. The Web-based training needs to roll out to all those community members that I talked about so they are trained. One of the security features of Health-e-App is you don't get access to it until you have had the training and we are comfortable that you know how to use it.
This fall, we are going to go live with the community workers and the statewide training and then over the next year, roll it out to our 58 counties.
Cindy Dibiasi: Sandra, people are having trouble reading the Web site address. Can you give us the address for the Health-e-Apps Web site?
Sandra Shewry: Sure. http://www.dhs.ca.gov/health-e-app/
Cindy Dibiasi: That is "app"?
Sandra Shewry: That's right.
Cindy Dibiasi: If other States are interested in developing their own Web sites to enroll children in SCHIP, who can I contact for more information about Health-e-App?
Sandra Shewry: Well, I would be happy to be the contact point and my E-mail address is right there on the slide: Sshewry@mr.mib.ca.gov and if I can't find the answer, I will get someone who can.
Cindy Dibiasi: Terrific. Thanks and we will be back with some questions because in a moment we are going to open the discussion up to the audience's questions. Remember, you can communicate your questions to us in the following ways: If you would like to call us on the phone, we would love to hear from you and talk to you. You could dial "14." You can fax your question to us at (301) 594-0380 or you may E-mail us your question at email@example.com. You may also directly type your question in the messaging field and hit "enter" and remember that your sent message will not appear in the chat box.
Before going to the questions, however, I would like to say a few words about AHRQ [Agency for Healthcare Research and Quality] and the User Liaison Program [ULP]. The mission of AHRQ is to develop and disseminate research-based information that will help clinicians and other healthcare stakeholders make decisions to improve healthcare quality and promote efficiency in the way that healthcare is delivered. The User Liaison Program serves as a bridge between researchers and State and local policymakers. We not only take research information to policymakers so they are better informed, we take the policymakers' questions back to researches so they are aware of the priorities. Hundreds of State and local officials participate in ULP workshops every year. As a relatively new addition to the ULP portfolio of products, we hope that today's Web-assisted teleconference and the two other events in this Web-assisted teleconference series will provide a forum for discussion between our audience of policymakers and researchers like those joining me for our discussion today.
We'd appreciate any feedback you have on these teleconferences so please E-mail your comments to the AHRQ User Liaison Program and that URL is firstname.lastname@example.org. And now let's go to your questions.
This one is for Molly from Bob in Oklahoma. Does the main assessment system address mental health issues?
Molly Baldwin: There are questions on there about mood and behavior and depression, but it does not do a full-scale mental health assessment.
Cindy Dibiasi: And for Sandra, this is from Sandra, not the same one, obviously. Should the map also include bus routes?
Sandra Shewry: Great idea. At this point, we contract with a vendor for that mapping service. That is a great idea, bus routes, yeah.
Cindy Dibiasi: OK. Good. One of the beauties of the call is you get half the brainpower of the entire audience.
This one is for Terry. Tony Hausner has some questions on the Smart Card. He wants to know, does the card handle all health information or just a portion of the information? How is that information entered and does a parent get the report? Or how does the parent get the report?
Terry Williams: OK. Thanks, Cindy. The data that is on the card are limited to the shared information, the common information across the various maternal and child health programs. Such as, everybody needs, for example, to know what is the immunization status. WIC [Women, Infants, and Children] needs information relative to heights and weights and hematocrits and hemoglobins, that type of thing. So, it doesn't contain everything. It basically is a way of hopefully removing some of the smokestacks by the client being able to take the health information from (end of tape) the data is being added to the card simultaneously so that the health provider doesn't have to do a two-step strategy here. It is just one. They write in their own software and at the same time, the data is being written to the card. Does the client have access to the information? Most definitely. Across the three participating communities, we have kiosks located in high-traffic areas such as the community college, some of the major retail stores. The grocers, that is. The emergency room at the hospital, the public health nursing office. At those locations, a client can simply go in and take the card for their child, put in their PIN number into the kiosk and they can get any of the data that is currently written on the card is available in terms of getting a printout.
Cindy Dibiasi: Tony Hausner from CNS, who has asked these questions, is now on the phone because he has more questions. Why don't you let me put him through and he can ask you some of these things directly.
Terry Wiliams: Sure.
Cindy Dibiasi: Tony, are you there? Hello? We seem to have lost him. You can continue and if I get him back, I will put him right through to you.
Terry Williams: Well, thank you. I think I have pretty much answered the question and that is that the client has full access to all of the information. Consequently, in the case of, we have had some experiences Cindy, where, not a lot of them, but clients are moving from Bismarck to Cheyenne or from Cheyenne to Reno and they can actually have their card read in the new community that they are going to or if they are going out of the system, they can go up to a kiosk and get a hard copy record of all of the data that is on the card.
Cindy Dibiasi: Terry, you had better take a drink of water because I have a lot of questions for you on the Smart Card. I am just going to give them to you one after the other so we will have to click through them a little bit.
The first one is from Jim in New York and he wants to know what measures are in place to ensure that the card belonging to the person using it, for instance, if the card is lost or stolen, how do we know it is that person's card who is actually using it?
Terry Williams: Well, if it is lost or stolen, as soon as we are advised of the fact that the card had been misplaced, we hot list it. We put an automatic lock on the card so that the next time the card is entered into the system it is automatically locked up.
Cindy Dibiasi: Much like a bankcard, I would imagine.
Terry Williams: Same idea.
Cindy Dibiasi: Are you integrating your Smart Card with your State's immunization registry and if so, are you partnering with scientific technologies on this?
Terry Williams: Yes we are. We are integrating with the State immunization registries. In the case of, as you might expect, it's a different strategy in each of the three States. In North Dakota, Blue Cross/Blue Shield handles the State immunization registry online. We are linked into that system with the Smart Card so that as data, as services are provided to the child, it is written into Blue Cross/Blue Shield's database and simultaneously onto the card. Here in Wyoming, the immunization registry is just in the process of being developed. They have been using a system called Healthmaster and we are integrated into that system. In the case of the Reno application, Cindy, that is a State-sponsored initiative out there and we are integrated with that application as well.
Cindy Dibiasi: OK. From Marty in Minnesota, he wants to know, what happens if a family goes to a clinic without a card reader? How do they get the information and can families get readers for their cards and edit their own information?
Terry Williams: Last question first. I am sure in time we will probably be able to furnish the card reader equipment. Some of the, for example, the new Compaq Presario line is incorporating a Smart Card reader into their PC operations and some of the Hewlett Packard more advanced applications have Smart Card readers built into them as well.
I'm sorry, what was the first part of the question?
Cindy Dibiasi: The first part of the question was, I am just collecting it again. The first part of the question is, "What happens if a family goes to a clinic without a card reader?"
Terry Williams: OK. That is a limitation. That is why we are just doing a demonstration to check out the proof of principle and its application in these three communities. Ultimately you need a PC that has got a card reader built into it or a card reader that has been provided for the application.
Cindy Dibiasi: We are going to come back to you with more questions but I'd like to go to Molly for a bit. Molly, there are some questions about the cost of your assessment program. What are the ongoing maintenance costs and where has the funding for the project come from?
Molly Baldwin: The funding has come from a mix of State and Federal funds using Medicaid dollars, using our State funds as a match for those Medicaid dollars. The ongoing costs, we have about 50 assessors across the State and we try to cycle about 15 new laptops and printers on an annual basis. So it is built into their assessment rate, what we pay them to do the assessment.
Cindy Dibiasi: Here is a question from Cathy on the HIPAA [The Health Insurance Portability and Accountability Act] regulations and she wants to know, will HIPAA have any impact upon the electronic data sharing of these programs?
Molly Baldwin: We are doing an in-depth review and analysis of what the impact of HIPAA will be and what system changes will result from the HIPAA regulations.
Cindy Dibiasi: OK. Now here's a question for all of the presenters, each of the presenters regarding their programs. I'll start with Sandra. What are the cost benefits and cost savings of your technology of your program?
Sandra Shewry: I think over time we are going to see savings in our administrative costs. We currently contract with a vendor to run our single point of entry and to process applications for our SCHIP program and then our counties do all our processing of our Medicaid applications. We think over time that this will have cost savings both in terms of storage, how much square feet you would need in a building, and staff time. In the early years, it is an investment that we are making. That's why it was very important to do the pilot test to see if it was worth it. Because most of these technology projects are short-term; you put the money in and then you wait and get the service improvements and the efficiencies of operations.
Cindy Dibiasi: Molly?
Molly Baldwin: Well, what we have demonstrated is that we are serving more individuals by having this assessment process. People tend not to want to approach their long-term care needs until they are in crisis. By having the availability of this assessment, we are getting people into the system where we have the opportunity to get them services which maintains them in the community for a longer period of time. Fifty-two percent of consumers are receiving home care in fiscal year 2000 compared to 32,000 in 1995 and our spending for home and community-based care has gone up from 16 percent to 35 percent. But our spending for institutional care, which is very costly, has gone from 84 percent down to 65 percent. So we have shifted where we are actually spending our resources.
Cindy Dibiasi: And Terry?
Terry Williams: I think one of the potentially significant things that we have identified by the providers is that we are eliminating the redundant testing that frequently goes on because the protocol calls for it within each of these particular programs. Also, we have got the documentation that the providers are actually, particularly in the public health arena, spending more quality time in terms of working with a client, in terms of the whole education process. Of course, the dividend here for us in terms of focusing on parents and helping them become, giving them the skill set and the information to be able to be full partners in this is that as they are more informed and better trained parents, they are better parents and more knowledgeable and better able to handle them, as an active participant in the care of their children.
Cindy Dibiasi: Terry, we talked about HIPAA regulations yesterday, as well. How would you address the HIPAA issues concerning privacy and proposed security?
Terry Williams: OK. Thank you, Cindy. HIPAA was just kind of on the horizon. It is out there and it is something that we are all concerned with. We have a strategy in place and we are exploring basically, Cindy, in terms of a phase two in terms of how do we proceed to bring additional security to the sharing of just that health information that is essential or is being requested by these various providers? First off, in terms of what we do today, the card requires the patient or the parent to enter their own personal identification number in order to be able to open up the card. Then each of the providers, whether it be a secretary or a nurse nutritionist or the physician, they have to have their own card and the ability to access the information and write information onto the card is based upon basically the area they are working in. So that the WIC nurse or excuse me, the WIC clerk is simply looking at administrative and demographic data and making any changes in phone numbers or whatever and that of course gets populated and shared across the entire system. So, people are basically working within their practice. We do recognize in terms of the Internet and Web-based services are a component that we need to be addressing in concert with the use of the Smart Card. So we are looking at the issue of addressing, using the card because it has got a significant memory base. The newer cards that are available today, 32K cards basically are costing the same price as the 8K card that we started with several years ago. So we are looking at the issue of public key infrastructure and having basically a digitized signature on the card for a provider so that the provider then can go out and make a request for the information and then it would come back securely to him over the Internet protecting the transfer of the information via this technology that is called PKI.
Cindy Dibiasi: Sandra, let's talk a little bit more about Health-e-App. Once you have gone statewide, then what's next?
Sandra Shewry: Well, the "what's next" is identifying those other State and Federally funded public programs that we can partner with. An obvious
"what's next" might be the Food Stamp Program. We could add that. It's basically going through and looking for partners in other State agencies that would be interested in either using the technology as a platform or to actually combine it into one, more comprehensive entry system into our State and Federally funded programs.
Terry Williams: Cindy, if you don't mind, I can complement what she is saying here. We look at this platform as a vehicle not only to manage timely and relevant health care, but the Women, Infants, and Children program food prescription is on our card together with food stamps. The idea, as Sandra is saying, is to use the technology broadly and bring as much efficiency and convenience to the citizen user as is possible.
Cindy Dibiasi: We have a question for Molly from Barb. She says that you mentioned that nurse assessors download the assessments before they go out. Is this just a form or is this the customer record with all the data that is updated by the assessor?
Molly Baldwin: It has got all the demographic and prior medical eligibility and current financial eligibility. The assessor verifies all the data that are already there and she, at the time of the assessment, enters the new data regarding their clinical needs, environmental assessments, all those kinds of things. She does get a copy of the prior assessment downloaded at the same time so she can look and see how things have changed since the last assessment, what is currently being provided in the care plan and then authorizing a new care plan.
Cindy Dibiasi: Sandra, from Neal in New York. He would like to know, can you clarify how the worker who is at a client's home or at a community event transmits documentation and how does the client get a printout of their approval?
Sandra Shewry: In order to get a printout, you need a printer, of course. To get the documents into the system, you need a fax machine. So, you can fax right into our single point of entry and that can either happen at some of our community events. Our larger CBOs are bringing out all the technology they need. Today, in our mail-in process, where they are helping families fax and Xerox their documents, and so you do need both a fax machine, some kind of a modem hooking into the Web. The way the client gets it back is at the end of Health-e-App; there is that summary that prints out the application and that can be handed right to the family.
Cindy Dibiasi: Terry, we have a question on fraud. The caller wants to know what is the potential for fraud with the Smart Card?
Terry Williams: Thank you, Cindy. The potential for fraud with a Smart Card. Well, the reason why the banking systems, such as American Express Blue Card and Visa now is now in the process of distributing seven million cards in the States this year. They are wanting to step ahead of magnetic stripe, get ahead of the increasing fraud problems that relate to magnetic stripe technology. A microchip is extremely secure. When we started, we asked a group of engineers, "Here's a thousand dollars if any of you can correct this." Chips are extremely secure and we think that by bringing the additional features such as the digitized signature and public key infrastructure into this, we will be able to address HIPAA and facilitate an extremely secure delivery system.
Cindy Dibiasi: Molly, a question from Tanya from the Utah Department of Health. She wants to know if your assessment tool is being utilized and/or drafted by the State of Maine or is it a standard assessment tool from a vendor?
Molly Baldwin: No, it is Maine's assessment tool. It does incorporate some of the definitions and timeframes from the MDS or Minimum Data Set, but if you are familiar at all with the Minimum Data Set, you know most of the items on that tool do not lend themselves to community settings. We had to design and implement areas of questioning and assessment items that address living in the community, like, how do you do meal preparation? How do you get your laundry done? How do you get to the bank? Those kinds of items.
Cindy Dibiasi: Sandra, are there ways in which you could use the information that you are collecting from Health-e-App to evaluate the program or for program evaluation purposes?
Sandra Shewry: At this point, well, it would have definite use for evaluating the responsiveness of the program to clients' needs. One of the things that clients want is an easy application. We can see the reduction in processing time, the reduction in errors so we don't have to go back to the family to ask them again about their child's birth date.
The incremental increase in the database from Health-e-App, since we already have an automated single point of entry that captures all that demographic information. Probably the evaluation is going to be on customer service and being responsive to families.
Cindy Dibiasi: Terry, a few more questions for you. How are the Health Passport demonstration sites, how are they being funded? Robert Burns would like to know that. He is with the National Governor's Association Center for Best Practices.
Terry Williams: Thank you. Cindy, how are they being funded? Western Governor's Association approached, basically at a Federal level, the sponsors basically of many of these maternal and child health programs. So we approached the public health service, Maternal and Child Health, CDC [Centers for Disease Control and Prevention], Medicaid, the USDA [U.S. Department of Agriculture] who sponsors the WIC and Food Stamp Program, the National Head Start Office. On the informatics side, we approached the National Library of Medicine, some of the pharmacy companies, and we were able to put together basically about $3.5 million dollars in terms of the demonstration funding from various and sundry sources that I have just identified here in order to be able to hire a contractor. We hired Siemens Business Communications and they had a host of subcontractors that worked with us as well. Basically, their portion of it was like $2.5 million and then there was about a million dollars in terms of the management, the site managers, the equipment that we had to secure, Smart Cards, that type of thing. So, it was demonstration funding from these various sources that we were able to approach and make the business case that the application would have value and potential to bringing, ultimately, efficiencies to each of their programs.
Cindy Dibiasi: OK. A question from Ronald Beatty from Care Oregon. He wants to know if you had success in getting migrant populations to use the card, and if so, what has the success rate been?
Terry Williams: Migrant populations. I sure wish we would have been able to include a migrant population in this, because my earlier career in public health was several years with migrant health services and I can see the absolutely direct and wonderful application. The closest I guess that we came to migrant populations was half of our caseload, half of the 9,000 or so participants who are in Reno, Nevada, are Hispanic, and English is their second language. While they are not migrating, the technology was completely new to them and we worked extensively with the Hispanic community in Reno and church leaders and civic leaders to present the technology and provide the leaders and the families the assurance that what this was all about and it was simply a vehicle that was family-based in order to facilitate a better service delivery of health and benefit programs for their families.
Cindy Dibiasi: Molly, what other enhancements that build off your long-term care approach do you have in mind?
Molly Baldwin: Well, when the person I think from Oklahoma did ask about mental health, that probably is an additional module or piece that could be added on at some future time. As well as we see by identifying these quality indicators, having a mechanism where at the time of the assessment, the assessor is covering based on a pop-up screen, or whatever, actually doing some additional education and making sure that the consumer is referred or given ideas about how they can improve things that are preventative in nature.
Cindy Dibiasi: There is a question from Sam. He wants to know what challenges you had in selling the idea of Health Passport to the participating communities, how much the pilot cost, and what does it cost to add help indicators, for example, CD4 counts and other HIV indicators?
Terry Williams: Challenges. (laughs) They were significant. In terms of very few people as we completed the feasibility study initial design in '97, had much in the way of familiarity with Smart Cards. It was a question of basically taking our business case to the State level and the community team that we were hoping to work with in each environment and to ask for their participation. Busy people asking them for participation and making a significant voluntary investment in terms of working with us and in terms of conducting the demonstration over an 18-month period. I would note that we ended up doing a tiered launch and that probably was our saving grace. We started in Bismarck in June of 1999 and several weeks later we took the lessons learned from the half a dozen or so partners up there and applied them as we were bringing up the application in Cheyenne. Considerably later because the WIC piece was a centerpiece for the application over in Reno, we took the application and brought it up in Reno beginning in June of 2000. That tiered launch ended up being a really important feature in terms of bringing up several programs concurrently and then adding as we went along.
In terms of the cost, I indicated earlier, Cindy, that the investment so far in terms of the contracted work and the design development, what have you. That whole piece cost approximately $2.5 million dollars. Because we have done it using basically Federal funding that was donated to us by foundations, what have you; the whole application is in the public domain. That is available really to any State or entity that would want to consider using this maybe as a hospital-based service delivery system or another sister State would want to pick up on it.
In terms of adding data, I think before we would add any new data, Cindy, to the system, we are first looking at wanting to do a critical evaluation of the 500 data elements that are currently on the card. I certainly recognize that probably 10 percent or 15 percent of them have relatively little value and so we can simply delete those and add additional information that providers and the clients want added to the card.
Cindy Dibiasi: Let me pose this same question to Sandra in terms of any challenges that you faced in bringing this into your pilot project.
Sandra Shewry: Well, in our State one of the challenges was getting policymaker acceptance about the use of an electronic signature and documentation. That really involved making the business case and providing the information, that information would be secure, and that the program would not be subjected to fraud. That probably took the longest amount of time to raise all of our understanding about exactly what were we talking about when we talk about capturing signatures electronically. What kind of security would the system contain? It's a very kind of key issue for policymakers in California.
Beyond that, I think the pilot was really an essential step. I imagine Terry would echo those comments mightily in that we learned things we just didn't envision at all. The whole need for matching of documents was challenging in our paper process. That exact same challenge came up in the pilot and we probably could have seen it, but we didn't. Now as we go to statewide roll out, we are building that into the system. Another thing, the pilot helped us add things that we should have added to our paper process. Now we are going to add them as we roll out Health-e-App and by that I mean the premium payment. Making it easier. We have a lot of different methods people can use to pay their premiums today, but allowing people to get on a Web site and give us the information for their checking account or their Visa card, that is going to be a good innovation.
I think that the challenges were both first just policymaker acceptance of the concept. There is a lot of enthusiasm about these projects when you are talking casually, and then when you say, well, governor, well legislator, well policymaker, now we need to commit. Then people think, "Hmm, better raise my understanding of what technology we are using, what safeguards are in place." So that took us quite a while. Beyond that, the challenges have all sort of been technologically fun. OK, gee it's not working as well as we'd like. What's the fix? So, there has been the sort of challenges that create a lot of staff enthusiasm.
Cindy Dibiasi: Molly, I'd like to ask you, we have a question for you from Cathy. Her question is, "Do you aggregate data and if so, do you utilize the data to support policy decisions or decisions regarding funding or growth of programs?"
Molly Baldwin: Absolutely. Our ability to aggregate our data from our State-funded program was able to allow us to develop four levels of acuity and there are reimbursement rates attached to those levels of acuity. They are actually based on the service utilization from the prior year. We could predict how many hours of PTA service a consumer with this need was getting and we could develop a reimbursement rate that was sure to cover those hours and allowed us to project forward what we needed to consider as we looked at these levels.
Cindy Dibiasi: I have a question for, same question for all of the panelists. Again, this comes from Robert Burns who is a policy analyst at the Health Policy Studies Division of the National Governors' Association Center for Best Practices in Washington. He wants to know, "Are providers adopting the necessary tools such as hardware, software, and training to advance your efforts? Are they being cooperative?" Molly, why don't we start with you.
Molly Baldwin: Yes. I think that what really happened is initially when we became online with real-time information, it forced the issues for other people to get on with the program. Additionally, I think it increased their accountability. They no longer can use an excuse. "Oh, the fax? I faxed it out or I put it in the mail." All those things because things are transmitted electronically and we have had minimal to no failures with the electronic transmission.
Cindy Dibiasi: Terry?
Terry Williams: Cindy, I guess I would say it is too soon to know. What we are counting on as we go forward in terms of looking at a broader, more robust application and not only using the card, but the Internet. We probably have a time in which I think we are anticipating that the technology and its universality is going to be catching up with us in terms of as people buy new computers. As I said, the Compaq Presario, for example, are committed to putting the Smart Card reader into them. The technology, thank goodness, has come down significantly in the cost of the technology. So that is not merely as much of a limitation as it was certainly when we started several years ago. You can buy Smart Card readers for $19.95 and hook them into your PC.
Cindy Dibiasi: Plus I am sure that once it gets institutionalized, it will just be one more feature on all PCs, right?
Terry Williams: Right. The thing, too, Cindy, is that the technology is going to be driven by significant other applications or components. You have to look at the Smart Card basically as an electronic service platform in which you can deliver or provide many customer conveniences. As Visa rolls out their Smart Card in terms of credit and debit work, as the telecommunication companies make stored value Smart Cards available, that all is going forward in terms of just going to make for the universality as the nation's electronic benefit transfer systems look at migrating from magnetic stripe to Smart Card applications. Such as the State of Ohio has done. They then will, those cards are going to be in the hands of much of the same population that we are working with. Consequently, they will be more universally available.
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