Difference between revisions of "Health Information Exchange Within Taiwan's National Health System"

Revision as of 03:31, 5 May 2024

Background

Taiwan’s National Health Insurance Act (NHIA) was implemented in 1995. This act mandates all citizens and foreign nationals living in Taiwan for great than six months to buy into a national health insurance. Premiums are income-based[1]. Prior to implementation, there were over ten public insurance policies[2]. After implementation of NHIA percent of citizens with health insurance has increased from 59% prior to implementation to 99.6%[1]. Information Technology forms the backbone of Taiwan’s National Health Insurance (NHI). Early on during the implementation of the NHIA, Taiwan invested in building a robust health information technology structure and have continued to develop it over the past 30 years[1]. In 2004, the national health informatics project developed Taiwan’s EHR system and transitioned from paper-based chart to electronic medical records in 3 stages.

- Stage 1 (2008 – 2011): Promoting EHR adoption strategies.

- Stage 2 (2010-2012): Widespread implementation.

- Stage 3 (2013 – 2015) Subsidizing EHR interoperability.

Presently, 80% of hospital EHRs and 54% of outpatient clinic EHRs are certified as being interoperable[3].

Three types of health information exchange systems are responsible for centralizing health data and promoting interoperability between health facilities: The NHI-IC Card network, NHI MediCloud, and the Electronic Medical Record Exchange (EEC)[3].

NHI-IC (integrated circuit) card network

To access any medical services, patients must bring their NHI-IC (integrated circuit) Card. The NHI-IC card contains a chip with a CPU and 32KB of memory which is used to store important health data about the patient[4]. Information saved on the card includes patient identification information, health insurance information, medical information from the past six visits, public health data such as vaccine records and organ donor status, as well as other crucial information such as do not resuscitate (DNR) status[1,4]. The NHI-IC card requires a special NHI-IC card reader that can both read and write data from the card. The hospital information system including card-readers and hospital data servers are connected to the NHI IC Card Data Center (IDC) through a health insurance service network VPN[4].

The overall process is as follows: a patient brings their NHI IC card to the hospital (or outpatient clinic), the medical center will then scan the card to obtain patient information for registration. After the doctors visit, the medical center will scan the card again, transmitting medical data from the visit back to the card. The data that is updated on the card will eventually be transmitted to the IDC by the hospital or clinic. Uploads to IDC take place daily. Claims data is transmitted monthly[1,4].

MediCloud

With the transition to a national health system, patients were able to visit any physician or specialist without a referral. This increased the need for a centralized medical record system. To meet this need, the NHI developed the NHI MediCloud System. MediCloud (Previously PharmaCloud), is a cloud-based system that allows the physician to see drugs or exams prescribed by other providers to avoid adverse reactions and duplications of tests or medications[5]. The system was initially developed in 2013 and supported query of medications and prescriptions only. In 2016 it was renamed MediCloud and expanded to include eleven more categories of information including Chinese medicine records, coagulation studies, controlled substances, dental care records, discharge summaries, drug allergy records, examination records, medication records, rehabilitation services records, specific medication records, surgery records, and vaccine records[6]. In 2018 they added the capability for medical institutions to upload radiology images and reports[6]. This reduces duplicate tests, radiation exposure, and the time and costs of requesting image disks needed to seek care at a different hospital. This reportedly saves about 5.98 million NTD (185 thousand USD) per month[5].

Additionally, the MediCloud system supports a number of “Active Reminders.” These reminders notify a physician about duplicate orders, potential drug-drug interactions, potential Chinese medicine-western medicine interactions, drug allergies, and renal dysfunction reminders. When a provider enters in an order, information about the order will be sent to the NHIA via API and then provides the relevant active reminder to the physician. This process takes between 1-3 seconds [5] The MediCloud system is built in a closed VPN which can only be accessed with three cards are present: The medical institution secure access module card, physician or pharmacist NHI IC-card, and the patients’ NHI IC card. Query history is documented. Hospitals can download patients’ data to integrate with their hospital information system if the patient consents. Additionally, patients are able to restrict physicians and pharmacists from querying their records by setting a password[5].

Electronic Medical Record Exchange Center (EEC)

In 2011, the Electronic Medical Record Exchange Center (EEC) was built to allow for sharing of EMRs between hospitals and clinics[3]. To facilitate the exchange of medical records, the hospital information system connects to the EEC through an “EMR gateway.” The hospital uploads standardized files from the past six months onto its EMR Gateway. The EEC does not store the information but rather generates an index of all the files uploaded to each hospital’s EMR gateway which allows for search and retrieval of records[7]. Clinical documents uploaded to the EMR gateway must meet HL7 CDA R2 standards. As of 2015, there were only four standard EMR Exchange formats: medical imaging reports, laboratory test reports, discharge summaries, and outpatient records. As such, these are the only types of medical records that can be exchanged through the EEC[7].

Conclusion

Since the passing of the National Health Insurance Act in 1995, Taiwan has invested in developing health information systems to facilitate provision of care. These advancements in health information technology have enabled them to decrease health care costs, reduce waste, increase access to care, monitor health outcomes, and quickly identify and address emergent public health emergencies.

References

1. Wen HC, Lee LH, Valvi N, Dixon BE. Chapter 30 - Health information exchange in Taiwan: multiple layers to facilitate broad access and use of data for clinical and population health. In: Dixon BE, ed. Health Information Exchange (Second Edition). Academic Press; 2023:621-645. doi:10.1016/B978-0-323-90802-3.00027-7

2. Cheng TM. International Health Care System Profiles: Taiwan. Published June 5, 2020. Accessed May 4, 2024. https://www.commonwealthfund.org/international-health-policy-center/countries/taiwan

3. Wen HC, Chang WP, Hsu MH, Ho CH, Chu CM. An Assessment of the Interoperability of Electronic Health Record Exchanges Among Hospitals and Clinics in Taiwan. JMIR Med Inform. 2019;7(1):e12630. doi:10.2196/12630

4. Liu CT, Yang PT, Yeh YT, Wang BL. The impacts of smart cards on hospital information systems—An investigation of the first phase of the national health insurance smart card project in Taiwan. Int J Med Inf. 2006;75(2):173-181. doi:10.1016/j.ijmedinf.2005.07.022

5. (Mary) Tai HY, Wu SH. Infrastructure of the Medical Information System. In: Lee PC, Wang JTH, Chen TY, Peng C hui, eds. Digital Health Care in Taiwan: Innovations of National Health Insurance. Springer International Publishing; 2022:111-128. doi:10.1007/978-3-031-05160-9_6

6. Welfare NHIAM of H and. Taiwan’s NHI MediCloud. National Health Insurance Administration Ministry of Health and Welfare. Published June 8, 2022. Accessed May 4, 2024. https://www.nhi.gov.tw/en/cp-415-ba452-57-2.html

7. Li YC (Jack), Yen JC, Chiu WT, Jian WS, Syed-Abdul S, Hsu MH. Building a National Electronic Medical Record Exchange System – Experiences in Taiwan. Comput Methods Programs Biomed. 2015;121(1):14-20. doi:10.1016/j.cmpb.2015.04.013

Submitted by (Michaela Go)