Health Smart Cards and NHIP A Taiwan Perspective

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1 Health Smart Cards and NHIP A Taiwan Perspective Yu-Chuan (Jack) Li, M.D., Ph.D. Vice President, Asia Pacific Assoc. for Medical Informatics (APAMI) President Emeritus, Taiwan Assoc. for Medical Informatics (TAMI) Professor and Chair, Graduate Institute of of Medical Informatics, Taipei Medical University, Taipei, Taiwan Graduate Institute of Medical Informatics, Taipei Medical University

2 Health Smart Card

3 Scale of Healthcare in Taiwan Population: 23 million Insurance: Health for All universal coverage, by National Health Insurance Outpatient visits: 360 million/year Inpatient stays: 28 million man-day/year Budget: Public: 13 billion USD/year Private: 8 billion USD/year

4 Scale of Healthcare in Taiwan 34,000 physicians ~600 hospitals 70% computerized, 50% with some kind of clinical information system, 20% with PACS 17,000 primary care clinics (including dental and Chinese medicine clinics) 60% computerized with CPOE

5 Current Infrastructure Health Insurance Information Infrastructure 23 Million Health Smart Cards A network that every hospitals/clinics connect to NHI VPN, 100% e-claims Health Certificate Authority (HCA) Issue Digital Signature on a RSA card for all 100,000+ healthcare professionals

6 Current Infrastructure (cont.) National Image Repository Now with NHI-required submission of EMR Health Information Network A network for most of the pubic hospitals and PHIS (Public Health Information System)

7 Health Smart Card Optical Variable Ink IC chip 陳 建 仁 A /12/31 Serial No Birth Date Personal ID Name

8 總 T e l e p h o n e 23 Million HSC 300,000 SAM Card 100,000 HPC 50,000 Health Care Card 50,000 card readers Health Professional Card 150 seats Call Center PetaByte IDC (Internet Data Center) Services Cards Operation Component 分 局 衛 生 署 A D S L D S - 3 A T M D S - 3 E 1 E 1 局 Readers 分 局 Software Networking 5 kinds of API (DOS,WINDOWS,UNIX, LINUX,OS2) 連 絡 辦 公 室 地 區 團 保 行 政 支 援 處 R A D I U S / L D A P T e r m i n a l S e r v e r I D C Virtual private network

9 The NHI VPN CDC DOH HIN Admin BOH HCA SC IDC NHI headquarter NHI VPN 100 HIS 600 Hospitals NHI local offices 17,000 Clinics 5,000 Pharmacy IDC Internet Data Center SC Service Center HIN Health Information Network NHI VPN Virtual Private Network

10 Visits Patient Visits using HSC visits( 人 次 ) / / / / / / / /02 Up to Mar.5,2004 Time

11 HCA Card RSA Card issues from HCA to health professionals non-rsa Card for all citizens

12 Dual-card System

13 Content of the Smart Card Column Basic Data Section Contents Card serial number, name, ID number or ID document number, date of birth, gender, issuing date and card cancel note. Healthcare data section (2nd phase) Major illness/injury, infant note, prenatal exam for pregnant women, vaccination, organ donation flag, insured person code, insured person identity note, period of card validity, available frequency of medical treatment, accumulated expense of medical treatment, accumulated expense, co-payment, personal insurance premium. Medical data section (3rd phase) Medications, diagnosis codes, allergies, major and important order items, etc.

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17 Lesson Learned A cost-effective replacement of the old multiple paper cards system (310 millions in in 6 years) Much less fraud in care access A nice token for patient-initiated health information exchange Can be a key for PHR and EHR

18 National Health Informatics Project - NHIP

19 NHIP Goals Population Health Personal Health Patient Safety and Quality of Care Health Informatics Technology and Industry Graduate Institute of Medical Informatics, Taipei Medical University

20 NHIP Goals (cont.) Population Health Surveillance/Containment Response/Prevention (SARS experience, Bioterrorists, etc.) Disease management resource planning Consumer health informatics Biotech development (new drugs, vaccines etc.) Graduate Institute of Medical Informatics, Taipei Medical University

21 NHIP Goals (cont.) Personal Health Information back to the hands of people Properly informed about own health Portable/exchangeable Personal Health Record TMT (Taiwan electronic Medical record Template) Project Graduate Institute of Medical Informatics, Taipei Medical University

22 NHIP Goals (cont.) Personal Health Information back to the hands of people Properly informed about own health Portable/exchangeable Personal Health Record Patient Safety and Quality of Care Reduce medical errors (45 million questionable orders/year) Continuity of care - JCAHO 2005 Graduate Institute of Medical Informatics, Taipei Medical University

23 NHIP 1. EBM and decision support systems 2. Personal Health Record and Management System 3. Integrated Public Health Information System 4.Public Consumer Health Information (Knowledgebase) I. Core Infrastructure 1. Medical Information Standards 2. ELSI infrastructure 3. Standard Platforms/Mechanism 4. Incentives for the industry 5. Training/education for informaticians 1. Telemedicine and chronic disease management systems 2. Value-added health information database II. Key Applications III. Value Applications Graduate Institute of Medical Informatics, Taipei Medical University

24 NHII 計 畫 主 軸 架 構 ( 續 ) 加 值 應 用 遠 距 醫 療 與 急 慢 性 照 護 系 統 建 立 醫 療 資 訊 加 值 資 料 庫 計 畫 追 蹤 評 估 關 鍵 應 用 建 立 實 證 醫 學 暨 醫 學 決 策 支 援 系 統 衛 生 行 政 資 訊 整 合 應 用 建 立 公 共 健 康 知 識 系 統 個 人 健 康 資 料 自 我 應 用 管 理 系 統 建 立 醫 療 照 護 急 慢 性 公 用 系 統 基 礎 架 構 推 動 健 康 資 訊 隱 產 業 推 動 及 創 私 保 護 認 證 標 章 新 技 術 發 展 國 家 健 康 資 料 交 換 平 台 與 機 制 建 立 健 康 資 訊 標 準 Graduate Institute of Medical Informatics, Taipei Medical University 健 康 醫 療 人 員 教 育 訓 練 推 動 國 家 健 康 資 訊 基 礎 架 構 之 基 礎 法 制

25 NHIP Key Issues Interoperability Standards Incentives Ethics, Legal and Social Issues (ELSI) Graduate Institute of Medical Informatics, Taipei Medical University

26 Pillars for the Health Information Highway DOH Hospitals Clinics Public Industry Vendors ELSI Incentives Interoperability Standards From: National Health Insurance Bureau

27 Interoperability Level Description Examples 1 Non-electronic data Mail, No phone PC/information technology Machine-transportable data Machine-organizable data Machine-interpretable data PC-based and manual fax, secure Fax/ of scanned documents Secure of free text or Structured messages, incompatible/proprietary file non-standard content/data formats, HL-7 message Automated entry of LOINC results from an Structured external messages, lab into a primary standardized care provider s content/data electronic health record From: Center for Information Technology Leadership

28 TMT (Taiwan electronic Medical record Template) Approach 600 hospitals 500 health information Different sub-systems and inconsistent database schema within one hospital TMT aims to provide a CDA R2- compliant XML template for all the hospitals Interoperability level 3~4 Graduate Institute of Medical Informatics, Taipei Medical University

29 TMT Graduate Institute of Medical Informatics, Taipei Medical University

30 Graduate Institute of Medical Informatics, Taipei Medical University

31 Graduate Institute of Medical Informatics, Taipei Medical University

32 Graduate Institute of Medical Informatics, Taipei Medical University

33 Graduate Institute of Medical Informatics, Taipei Medical University

34 Graduate Institute of Medical Informatics, Taipei Medical University

35 Graduate Institute of Medical Informatics, Taipei Medical University

36 Graduate Institute of Medical Informatics, Taipei Medical University

37 Graduate Institute of Medical Informatics, Taipei Medical University

38 Graduate Institute of Medical Informatics, Taipei Medical University

39 Standards (NHII) Vocabulary/Coding NHI codes (medications, procedures, diagnoses,...etc.) Medical terms: LOINC, SNOMED Message/Exchange HL7 and/or XML (e.g. referral note and immunization record) Content/Data structure Taiwan electronic Medical record Template (TMT) Information Systems Guideline THIS-RG (Taiwan Health Information System Reference Guideline) 2.0 in in progress Graduate Institute of Medical Informatics, Taipei Medical University

40 SDOs in Taiwan HL7 Taiwan since 2000 DICOM Taiwan since 2001 IHE Taiwan since 2002 TAMI (Taiwan Association for Medical Informatics) - since 1991 Vocabulary and Content standard THIS-RG, TMT Not yet an ISO member Graduate Institute of Medical Informatics, Taipei Medical University

41 NHII Key Issues (cont.) Incentives Subsidy/loans from the government Health insurance bonus Hospital accreditation Public awareness/pressure/needs Patient pay for health service, but not health information? Graduate Institute of Medical Informatics, Taipei Medical University

42 NHII Key Issues (cont.) ELSI Ethics, legal and social issues Very strict laws for medical record preservation Very strict regulation for paperless medical record Public doubt on network security Privacy protection vs continuity of care Health Insurance Portability and Accountability Act (HIPAA) US Health Information Privacy and Security Guideline -Taiwan Graduate Institute of Medical Informatics, Taipei Medical University

43 Plans for NHIP in Taiwan Graduate Institute of Medical Informatics, Taipei Medical University

44 Tried and Failed Health Information Network V One system for all hospitals limited IT National EMR Index Server 1998 Index of where the data reside provider resisted EMR on a CD-ROM for patients 2001 Demo from few hospitals, not financially sustainable Medical Information Exchange Center (MIEC) Graduate Institute of Medical Informatics, Taipei Medical University

45 Strategies Set up a Project Management Office for NHII ( ) Build upon the current NHI-VPN and smart card infrastructure (card as a token) Adopt/reconcile current local/international standards Solid business case for providers More patient-centric approach Safe Effective Patient centered Timely Efficient Equitable Graduate Institute of Medical Informatics, Taipei Medical University

46 NHIP Strategy Healthcare service for All Insurance Information Infrastructure Health Information for All Health Information Infrastructure Health for All Graduate Institute of Medical Informatics, Taipei Medical University

47 Graduate Institute of Medical Informatics, Taipei Medical University

48 Graduate Institute of Medical Informatics, Taipei Medical University

49 Graduate Institute of Medical Informatics, Taipei Medical University

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