A COMPARATIVE STUDY OF CANADIAN AND TAIWANESE STRATEGIES OF NATIONAL HEALTH INFORMATION EXCHANGE USING ELECTRONIC HEALTH RECORDS

Transcription

1 Image from A COMPARATIVE STUDY OF CANADIAN AND TAIWANESE STRATEGIES OF NATIONAL HEALTH INFORMATION EXCHANGE USING ELECTRONIC HEALTH RECORDS ABSTRACT An Electronic Health Record (EHR) is a digital patient record stored in a Health Information System (HIS). While efforts to digitize health information are increasing, it is important to consider the promised benefits of EHRs to enhance the quality and delivery of patient care compared to their non-electronic counterpart (i.e. paperbased patient records) namely, in the facilitation of health information exchange. Sharing health information is crucial to support communication among health care providers. Canada and Taiwan are two countries that use EHRs in their health care systems. This paper explores and compares strategies made towards a national system of interoperable EHRs in Canada and Taiwan to identify successful approaches to facilitate national health information exchange. Upon studying the strategies in these two countries, a national approach identified to be successful was one that focuses on local projects while developing innovative nation-wide infrastructures. Ga Eun Lee May 2014 CHSP Taiwan Program Participant Comparative Research Paper Motivated by Experiences from the 2014 CHSP Taiwan Program

2 National Health Information Exchange Using Electronic Health Records 1 INTRODUCTION Information processing and storage systems in health care organizations are known as Health Information Systems (HIS) (Winter et al., 2011). HIS are composed of application components, either computer-based or non-computer-based, which are tools to assist health care professionals when processing various types of data and information. Application components supporting patient care such as diagnostic and therapeutic measures contain at least a partial patient health record, or in the case of computer-based application components, an Electronic Health Record (EHR) (Winter et al., 2011). EHRs are partial or complete digital patient records stored in a HIS under the custodianship of health care provider(s) over the patient s lifetime (Winter et al., 2011; Hodge & Giokas, 2011). The content of EHRs varies depending on the application components used by each health care provider, but mainly includes medical and drug histories, allergies, vaccinations, and diagnostic information such as laboratory results and diagnostic imaging findings (PwC, 2013a; Paré et al., 2013). Used in community-based care, hospitals, and specialist facilities, EHRs primarily support health care professionals to enhance the quality and delivery of patient care (Häyrinen, Saranto & Nykänen, 2008). EHRs are found to be provider-centric in many health care institutions, meaning health information for a patient can be physically distributed across repositories of multiple health care providers (Winter et al., 2011). Provider-centric EHRs only contain medical data recorded in one institution (e.g. a hospital) and as a result, patient health information is often left fragmented and incomplete. This leads to efficiency problems such as repeated explanations of medical histories, duplicate tests, and adverse drug events (PwC, 2013b; Canada Health Infoway [CHI], 2009a). Although EHRs have the capacity to integrate health information in order to coordinate patient care, this potential has yet to be fully realized. The integration of health information becomes especially essential when patient information needs to be accessed quickly from locations beyond the institution holding that information. Communication among various health care providers is a constant challenge to the continuity of care; accordingly, EHRs must be shared (CHI, 2009a; Winter et al., 2011). Hence,

3 National Health Information Exchange Using Electronic Health Records 2 efforts are being made to facilitate health information exchange across health institutions using EHRs. Health information exchange is defined as the electronic mobilization of healthcare information among organizations within a jurisdiction (Accenture, 2013). The aim of various approaches is to organize patient-centric EHRs by sharing and linking a patient s health information with the HIS of multiple health care providers in communities, regions, and ultimately, the country (Winter et al., 2011; Hodge & Giokas, 2011). However, while the concept of longitudinal patient health records is ideal, the sharing of EHRs across multiple HIS is fraught with challenges. A major obstacle in the way of health information exchange is the necessity to integrate HIS of health institutions. Integration within a HIS involves data sharing among application components and the unification of data presentation while preserving data integrity (Figure A1). Moreover, to achieve integration within a HIS, application components need to be interoperable (Winter et al., 2011). Generally, interoperability is the ability of two or more systems to exchange information and use the information that has been exchanged (Jian et al., 2007). It can be further described in two ways: functional interoperability and semantic interoperability. Functional interoperability ensures the functionalities and data structures of different HIS enable humans to read information on the receiving end. In contrast, semantic interoperability is concerned with the use of the same system of defined concepts by different HIS to facilitate the processing of data by computers on the receiving end (Jian et al., 2007; Winter et al., 2011). Although the challenges of integration have been reduced with integration technologies and interoperable application components, the trials of integrating a network of HIS are intensified from integrating the several application components that compose a single HIS (Figure A2) (Winter et al., 2011). Novel strategies must be developed in order to connect health information among health care providers in a nation. An important problem to be solved is the method of sharing EHR information across various HIS.

4 National Health Information Exchange Using Electronic Health Records 3 TWO COUNTRIES STRATEGIES TOWARDS NATIONAL EHR INFORMATION EXCHANGE Like many countries in the world, Canada and Taiwan have integrated HIS/EHRs into their health care systems. Since both Canada and Taiwan operate under similar single-payer universal health care insurance programs, a basis of comparison can be used to examine each country s strategy and progress towards national health information exchange using EHRs. However, Canada and Taiwan are countries on different continents with different circumstances regarding healthcare organization, health info-structure, and rates of EHR adoption, all of which have influenced the implementation and progress of national strategies (Kuo, Kushniruk, Borycki, Hsu & Lai, 2011). Although issues such as privacy, security, and funding are also important in the development of national strategies, they will not be discussed in the scope of this paper. CANADA The Canadian national health care insurance program is called Medicare. Instead of a single plan, the national program is made up of ten provincial and three territorial universal health plans that are administered by provincial and territorial governments (Health Canada, 2010). All provincial and territorial health plans follow common criteria and conditions set by the federal government. Publically funded by provincial and territorial taxation, each health insurance plan covers medically necessary hospital and doctor services. These services are provided on a pre-paid basis by the government and are thus fundamentally free at the point of service (Health Canada, 2011). Health care in Canada is delivered by nearly 400,000 primary health care providers, more than 700 hospitals, and 1,600 long-term care facilities across 13 jurisdictions (CHI, 2009b). In a large, complex health care system involving numerous people, the coordination and management of health information is necessary to ensure the quality of health care delivery. Health care providers and stakeholders in Canada have recognized the value of EHRs as enablers of health information organization to improve the quality and efficiency of healthcare (PwC, 2013a). In 2001, Canada s First Ministers developed Canada Health Infoway (Infoway), an independent not-for-profit corporation that invests with public sectors to accelerate the modern systems of health information and to define and promote standards governing the health info-structure to ensure interoperability (CHI, 2009a).

5 National Health Information Exchange Using Electronic Health Records 4 THE ELECTRONIC HEALTH RECORD SOLUTION (EHRS) BLUEPRINT. To accomplish the core mission of Infoway, the Electronic Health Record Solution (EHRS) Blueprint was developed in 2003 (CHI, 2009a). The Blueprint serves as a business and technology framework to guide the development of pan-canadian network of EHRs that facilitates coast-to-coast communication between health care professionals (CHI, 2009c). Infoway-sponsored interoperability projects across Canada must adhere to the EHRS Blueprint (CHI, 2009c). The Blueprint describes a set of common information systems and design patterns in order to build a technological architecture enabling interoperability among different HIS used in health care (CHI, 2009c). On the local, provincial, or national level, each jurisdiction will have a customized EHRS shaped according to its needs but will operate through the same technological architecture as described in the Blueprint (CHI, 2006b). One standard-based set of interfaces will be used by HIS at many points of service in order to exchange information through a shared EHR Infostructure (EHRi). An EHRi is a collection of common and reusuable components in the support of a diverse set of health information management applications (CHI, 2006b). An EHRi within one EHRS will store and maintain shared EHR data. Key elements of the EHRi include HIS in healthcare settings called Point of Service (PoS) applications, EHR repositories, registry services, longitudinal record services, Health Information Access Layer (HIAL), and the EHR Viewer (Figure A3) (CHI, 2006b). THE CONCEPTUAL TECHNOLOGICAL ARCHITECTURE FOR THE EHRS BLUEPRINT (HOW IT WORKS) The basis of the EHRS is a series of hub-and-spoke repository systems (CHI, 2009a). At PoS such as a physician s office or the local pharmacy, PoS applications collect clinical data that forms a part of the patient s EHR (CHI, 2006b). Then, PoS applications are responsible for duplicating and publishing this health information to an EHR data repository, a shared information reference source in the EHRi. There are four EHR data repositories in the EHRi containing information that will assist in clinical decision making: Shared Health Record (clinically-relevant patient data), Drug Information, Diagnostic Imaging, and Laboratory Events and Results (CHI, 2006b). While each PoS application stores data locally, they do not communicate with each other directly (CHI, 2006b). PoS applications within or across jurisdictions communicate via the

6 National Health Information Exchange Using Electronic Health Records 5 Health Information Access Layer (HIAL) interface, the centralized point of access to the EHRi for PoS applications of different information languages (Figure A4). In order to share information between EHRi and PoS applications using the HIAL interface, PoS applications must use communication standards in compliance with pan-canadian EHR standards such as Health Level 7 (HL7) for communication of clinical information, and Digital Imaging and Communications in Medicine (DICOM) for image streaming (CHI, 2006a; Winter et al., 2011). Data retrieved from the EHRi is read and used by PoS applications or the EHR Viewer. Unlike PoS applications which store data locally, the EHR Viewer obtains all its information from the EHRi (CHI, 2006b). While data is stored in multiple repositories and shared via HIAL, long-term and complete health records are maintained with the assistance of Longitudinal Record Services (LRS) (CHI, 2006b). LRS in the EHRi organize stored health information and manage it for PoS systems, increasing the efficiency of retrieving EHR data in the EHRi. Additionally, registry services in the EHRi ensure that the health information exchanged is accurate and reliable by correctly identifying patients/clients, service providers, and service locations (CHI, 2006b). CANADA S PROGRESS TO DATE As of March 31, 2014, the pan-canadian average for data availability in six core EHR systems was at 89% (CHI, 2014a). These six systems that compose the core elements of an EHR include client registry, provider registry, diagnostic imaging, drug information systems, laboratory information systems, and clinical reports. By March 2015, EHR information is forecasted to be 100% available in Canada, with the exception of laboratory and drug domains (CHI, 2014b). Despite the availability of EHR data, infrastructures must be in place to use this information. Once all the core components of the EHR infrastructure have been set and EHR data is 100% available, a provider should be able to access unique patient health records within its jurisdiction (CHI, 2009a). Although the implementation of EHRs across Canada is not uniform, EHR users have increased by more than 700% from 2006 to 2014 and the rise seems to be a trend. Moreover, a 2013 National Physician Survey found that the primary care use of EHRs in Canada has risen from 24% in 2007, to 64% in 2013 (CHI, 2014a). The heterogeneity of EHR adoption in Canada reflects different provincial and territorial strategies and priorities.

7 National Health Information Exchange Using Electronic Health Records 6 Projects are taking place across all thirteen jurisdictions to develop and maintain pan- Canadian EHR standards for the six EHR systems in each province and territory (CHI, 2014a). Infoway offers a certification program for vendors and purchasers to promote the use of trusted, interopable health information technology solutions using pan-canadian standards (CHI, 2011). However, the use of pan-canadian standards varies from jurisdiction to jurisdiction: the implementation of standards may predate Infoway or other standards may have been deemed more appropriate under the judgement of each jurisdiction (CHI, 2014a). As of March 2014, most provinces seem to be conforming to or are in the process of implementing standards, while the three territories have indicated a commitment to standards but are lagging in progress (CHI, 2014a). In addition to general progress, Infoway targets priorities specific to each jurisdiction. In , 35 out of 38 jurisdiction-specific project objectives were completely or partially achieved across all 13 jurisdictions (CHI, 2014a). Key achievements made in parts of Canada include 91% of EHR adoption for family practices and specialists in British Columbia, more than 80% adoption of EHRs in physician s offices in Alberta, completion and rollout of the EHR Viewer to access drug data in Newfoundland, and advancements towards the automatic delivery of lab results from Whitehorse General Hospital to physician offices in Yukon (CHI, 2014a). In Quebec, the Quebec Health Record (QHR) began to rollout starting the summer of 2013 for all people included in the Quebec Health Insurance Plan (Santé et Services sociaux Québec, 2013). The QHR collects essential health information including prescribed medications, lab results, medical imaging results, vaccinations, hospital summaries, and allergies. This information is then made available to pharmacies, clinics, and health care facilities as they become connected to the QHR (Sante et Services sociaux Québec, 2013; Paré et al., 2013). Now, more than 60% of lab results are now included in the provincial lab solution. More than 60% of community pharmacies interact with the provincial drug system and more than 1,500 clinicians are enrolled in the EMR program. In primary care and emergency settings of all 18 regions, the EHR Viewer has been made available to view diagnostic imaging and drug and lab data. With these achievements, Quebec became the first jurisdiction to accomplish all key milestones of the EHR program (CHI, 2014a).

8 National Health Information Exchange Using Electronic Health Records 7 TAIWAN Taiwan s health care system covers nearly all of its population by enrolling its citizens in the compulsory National Health Insurance (NHI) program (National Health Insurance [NHI], 2014). The NHI program is managed by the Department of Health of Taiwan government (DOH) under the Bureau of National Health Insurance (BNHI). The NHI program is supported by premiums shared by the government, employers, and insured. These funds received by the NHI administration are then used to offset medical and medication costs at NHI-contracted facilities so that patients pay little or nothing for medical services. The comprehensive benefits package covers a broader range of medical services such as medications, dental services, and Chinese medicine (NHI, 2014). Similar to Canada s diffuse operation of health care delivery, at the end of 2010, the NHI-contracted facilities included more than 900 hospitals, 9000 clinics, and nearly 4,500 pharmacies (Misjan et al., 2013). Moreover, due to the absence of a gatekeeper system in Taiwan, patient health information is more likely to be scattered across many repositories (Wu & Kuo, 2010). To manage such a complex ecosystem of health information, currently there are several national health information infrastructures in place (Figure A5). NATIONAL HEALTH INFORMATION NETWORK (NHIN) Taiwan began implementing health information technology in the 1980s (Sinha, Sunder, Bendale, Mantri & Dande, 2012). In 1989, Taiwan initiated a project to develop a National Health Information Network (NHIN) to facilitate health information exchange (Li, 2010). A pilot project began in a region of Taiwan in and in , the project expanded to other areas in Taiwan (Liu, Kuo & Wang, 2000). The NHIN consists of four regional centres that are connected by a TCP/IP frame-relay communication architecture (Li, 2010). TCP/IP framerelay network is a communication protocol that aims to physically interconnect networks to enable communication between hosts on different networks (Winter et al., 2007; Parziale et al., 2006). With this architecture, the NHIN connects the DOI, regional information centres, and BNHI (Li, 2010). Despite supporting public health administration, hospital regulation, and cancer registries, the NHIN did not succeed as a system for health information exchange (Liu et al., 2000). First, the NHIN did not support the increasing use of multimedia data in applications (e.g. diagnostic

9 National Health Information Exchange Using Electronic Health Records 8 images) due to insufficient bandwidth (Sinha et al., 2012). Additionally, the level of interoperability was low in systems and very few medical applications were used. It was more appropriate to call the NHIN as a health administration network (Liu et al., 2000). To address these issues, HIN 2.0, the second phase of the NHIN plan was launched by the DOH in 1999 and several other phases (up to phase V) have been executed to date (Misjan, 2013). Currently, the NHIN includes NHI application systems such as public health systems (e.g. infectious disease reporting), health care administrative systems, and local systems to health care facilities. The bandwidth was upgraded and a Virtual Private Network (VPN) was introduced for healthcare services (Li, 2010). The VPN allows health institutions to communicate to the BNHI in order to verify and update smart health care cards, file medical claims using standard codes for diagnoses and procedures, and report plans for clinical trials. Nearly all health care providers are now connected to the VPN systems (Misjan, 2013). NATIONAL HEALTH INSURANCE SYSTEM (NHIS) The National Health Insurance System (NHIS) was developed to support three main players: the BNHI, the providers, and the insured (Misjan, 2013). It was designed to support enrollment, management of smart health care cards, and payment of medical services. All BNHI processes are done via a VPN. Currently, the information in the NHIS is distributed regionally in Taiwan while two major data centres are in Taipei (northern Taiwan) and Kaohsiung (southern Taiwan) (Misjan, 2013). TAIWAN SMART HEALTH CARE CARD A novel achievement in Taiwan s HIE was the introduction of IC (integrated circuit) smart health care cards that use Java Card technology. The NHI smart card has 32 kilobytes of memory which stores four types of information: personal information, NHI-related information (e.g. number of visits), medical service information (e.g. prescriptions), and public health administration information (e.g. immunization charts) (Smart Card Alliance Secure Personal Identification Task Force, 2005). Six medical visits are allotted on the NHI card and one visit is deducted each time the NHI Card is used. When the allotted visits run out, the information on the card needs to be updated to be able to continue receiving care (NHI, 2014).

10 National Health Information Exchange Using Electronic Health Records 9 The data in the smart card can be retrieved by a card reader at medical institutions, allowing a patient s medical history to be accessed by health care professionals (Hsu, Yeh, Chen, Liu, C. H., & Liu, C. T., 2011). A card reader has two slots, one for a patient s health card and the other for a health professional card (Li, 2006). Patient information can only be accessed by authorized health care providers (Misjan, 2013). Health care institutions upload information daily to the BNHI using smart cards and this health information is analyzed, audited, and authenticated (Smart Card Alliance Secure Personal Identification Task Force, 2005). Changing to the smart card system has improved communication between the BNHI and medical institutions. Inappropriate prescriptions have been prevented using the smart card (Long & Chang, 2012; Wolfstadt et al., 2008). Moreover, the smart card is proving to be a helpful tool used in monitoring and responding to emerging infectious diseases (e.g. SARS) (Huang & Hou., 2007). INTEGRATED HOSPITAL INFORMATION SYSTEMS All NHI-contracted hospitals in Taiwan use a HIS mandated by the DOH even though there is no mandate for a single HIS in Taiwan (Misjan, 2013). The use of a common HIS already provides an accelerated structure to facilitate the exchange of health information. Smart health care card and electronic medical claim capabilities are integrated into the HIS. The application components of the HIS include a clinical documentation system, laboratory information system, radiology information system, computerized order entry, and inpatient management (Misjan, 2013). TAIWAN MEDICAL TEMPLATE (TMT) In 2004, efforts were made to develop a local set of standard EHR templates to achieve functional and semantic interoperability in Taiwan (Sinha et al., 2012). What emerged was the Taiwan Electronic Medical Template (TMT), a Taiwanese EHR format compatible with international information standards (Jian et al., 2007). The TMT can be transformed to HL7 CDA, a well-known international EHR exchange standard. In 2007, the TMT was updated to version 2.0 (Rau, Hsu, Lee, Chen & Jian, 2010). The TMT was developed as a schema from the real world. More than 20,000 paper-based forms from over 200 hospitals were reviewed by nine technical committees and categorized into

11 National Health Information Exchange Using Electronic Health Records categories based on similarities (Jian et al., 2007). The current TMT includes 70 core forms such as lab reports, prescriptions, and outpatient visits that build the EHR. A patient s EHR is composed of instances or sheets of a TMT form. Each form has a unique XML schema that defines its content and structure. All medical information generated during a medical visit or consultation can be collected into what is referred to as a submission set (Jian et al., 2007). TMT forms are made up of four elements: header, body, user-defined section, and signature (Figure A6) (Jian et al., 2007). The header contains basic information about the patient, the document, and the healthcare organization. The main information is stored in the body which is structured differently in different forms but all forms follow the basic section-component layout. The section is a data structure that includes section information, narrative block (humanreadable text), entries (computer-readable data), and components which are references to reusable sections (Figure A7). Moreover, the user-defined section allows the customization of a data layout. Lastly, the signature allows health organizations to apply digital signatures (Jian et al., 2007). In the TMT File Exchange Pathway, EHRs of TMT format can be exchanged in three ways (Rau et al., 2010; Sinha, 2012). First, patients can use portable storage devices such as a USB, CD-ROM, or mobile device to transfer TMT-based EHRs to another medical institution. To encourage the use of portable EHRs, the DOH provided 2,200 free USB disks to patients (Chang, 2010). Additionally, EHRs can be exchanged between providers over the Internet with the patient s permission. Lastly, a patient s EHR can be saved to an online EHR data bank located in the NHIN. A patient s EHR can be transformed to a TMT XML file using a TMT gateway in hospitals (Rau et al., 2010). THE CURRENT STATE In 2009, the DOH set up the National EMR Development Committee to plan, coordinate, and audit EHR project at a national level (Ni, Hsu, Yang, Yeh & Liu, 2013; Liu, 2011b). A project called Accelerating Adoption of Electronic Health Records (AAEHR) was launched in In five years, the project hopes to achieve complete EHR adoption in 80% of all hospitals and medical institutions and facilitate the exchange of health information across hospital boundaries. By 2012, the EMR adoption rate was 100% for medical centres, 67.5% for regional

12 National Health Information Exchange Using Electronic Health Records 11 hospitals, and 29.9% for district hospitals (Liu, 2011a). In addition, at least 75 hospitals could exchange EHRs in three out of four clinical domains (medical images, radiology reports, lab tests & reports, discharge summaries or outpatient medication records) and 26% of total hospitals adopted EMR systems (Ni et al., 2013). Currently, four EHR templates have been standardized (CDA R2) for EHR exchange, including medical image and reports; discharge summary; laboratory blood test reports; and outpatient medications (Liu, 2011a). Additionally, a National Image Exchange Centre has been established to store all radiological images (Misjan, 2013). However, delays in EHR exchange among hospitals has been caused by the due to the development of the national EHR exchange infrastructure (Liu, 2011a). The technological architecture currently in place for the national exchange of EHRs among hospitals consists of a National EHR Exchange Centre (NEEC), a high speed VPN, and EHR gateway servers (EGS) (Figure A8) (Liu, 2011b). The NEEC provides a repository of patient indexes and information for patients who had visited Taiwanese hospitals in the last six months. This information is provided by the BNHI using the data received from electronic medical claims. Clients of hospitals are usually a part of hospital information systems or other clinical support systems such as computerized physician order entry systems. One EGS is located in each hospital and allows the exchange of patients stored EHRs. The hospital may also have an EHR depository (Liu, 2011b). The system for EHR exchange can be operated in two ways: provision mode and retrieval mode (Liu, 2011b). In provision mode, an EHR must be created using CDA R2 standardized templates. The EHR receives a digital signature and is uploaded to its EGS. The EGS then validates the EHR and generates an index if validation is correct. The index is then sent to the NEEC. In contrast, in retrieval mode, a smart card reader is used to log-in to the NEEC system. A patient index appropriate for the medical visit is selected and the NEEC locates the EGS of the hospital where the EHR is stored. The EHR is retrieved and sent to the EGS of the hospital where the request originated. This requested EHR can then be viewed with a NEEC viewer or downloaded for additional use (Figure A9). At the end of the retrieval, the EHR in the EGS is deleted (Liu, 2011b).

13 National Health Information Exchange Using Electronic Health Records 12 A COMPARISON OF CANADIAN AND TAIWANESE NATIONAL STRATEGIES FOR DATA INTEROPERABILITY A SINGLE VERSUS MULTIPLE INTERLOCKING NATIONAL HEALTH INSURANCE PLAN Although both Canada and Taiwan have similar single-payer universal health care policies, the countries differ in the organization of their health care systems. While Taiwan s NHI program is a single national health insurance program, Canada s national health insurance program is made up of thirteen interlocking provincial or territorial health care plans. Thus, health care policies (i.e. interoperable EHRs) are mandated and implemented by different levels of government. NHI-CREATED INCENTIVES FOR NATIONAL LEVEL ELECTRONIC HEALTH INFORMATION INFRASTRUCTURES In Taiwan, policies can be mandated at the national level since health care is managed by the DOH. The unique environment of Taiwan s NHI program has shaped the deployment of health information technology in Taiwan (Rau et al., 2010). Since the government manages the health insurance program, service providers are required to submit medical claims to the BNHI in order to be reimbursed for medical services (Smart Card Alliance Secure Personal Identification Task Force, 2005). In the early implementation of the NHI program, incentives were provided to computerize medical institutions. Later, service providers shifted to electronic medical claims. Today, almost 100% of medical claims are submitted electronically (Misjan, 2013). The NHI provided the necessity to implement national level electronic health infostructures including the NHIN, NHIS, and Integrated Hospital Information Systems. Unlike the Canadian system, the Taiwanese system gives the patient the choice to see any health care provider (Wu & Kuo, 2010). This ability often leads to doctor-shopping, and thus, patient health information may become scattered in various repositories. Here, the novel smart health care cards implemented in Taiwan help to organize distributed health information for the BNHI. The health cards facilitate a small instance of HIE through a common infrastructure.

14 National Health Information Exchange Using Electronic Health Records 13 CUSTOMIZED JURISDICTION-SPECIFIC INTEROPERABILITY SOLUTIONS IN CANADA On the other hand, in Canada, the federal government primarily provides financial incentives for health care and provinces and territories are responsible for implementing national policies within their own jurisdiction. Accordingly, interoperability strategies promoted in Canada by Infoway must fit with the strategies and priorities of each province or territory (Kuo et al, 2011). These strategies are observed in the implementation of different projects across Canada through Infoway, which translate to heterogeneous advances made in provinces and territories towards interoperable EHRs. THE DEPTH OF EHR IMPLEMENTATION AND FLEXIBILITY OF HIS In Taiwan, EHR adoption is high and a few national level electronic health infostructures are in place (Kuo et al, 2011). These HIS, such as Taiwan s smart health care cards, required significant investments, meaning major changes are not foreseen. As a result, these HIS may be more rigid to allow system growth and change. However, since Canada has a low rate of EHR adoption, it is likely that the HIS that are implemented will have greater facility to use EHR data and evolve to change in structure over time (Kuo et al, 2011). LESSONS LEARNED FOR A SUCCESSFUL NATIONAL INTEROPERABILITY STRATEGY While Canada is working on a health information exchange strategy that involves various jurisdictional projects that fit a national mission, Taiwan is developing solutions using the NHI framework of national health information infrastructures. The countries seem to be representations of strategies that are the responsibilities of different levels of government. Canada s strategy focuses on regional projects towards a national project while Taiwan s project involves the entire nation as a whole. NECESSITY FOR FEDERAL PRESSURE In Canada, provincial and territorial governments must first prioritize and establish healthcare projects within their own jurisdictions. Thus, national incentives such as national interoperable EHRs come second and accordingly, the goals for all of Canada are not uniform. Since provincial and territorial projects must be completed first, national projects achieve

15 National Health Information Exchange Using Electronic Health Records 14 progress slowly. To unite jurisdictions and encourage progress towards national healthcare projects, federal governments should mandate innovative national projects such as smart health cards like those used in Taiwan that are separate from jurisdictional projects and common for the whole nation. National pressure has worked to an extent in Taiwan where the Taiwanese national government is directly involved in healthcare. Due to the NHI program, implementation of health information technology has progressed significantly, providing an already advanced foundation for EHR interoperability projects. Moreover, since policies and programs regarding healthcare are mandated nationally, in the case of EHR interoperability programs, all districts in Taiwan would be affected uniformly and would strive towards one common national goal of interoperability. LOCAL NEEDS FIRST However, jurisdictional health care delivery in Canada is a good example that demonstrates how local healthcare needs must come first. While focussing on national interoperability strategies, local healthcare projects may not become prioritized even though the local primary care providers such as clinics and health agencies are citizens first contacts to the health care system. Different jurisdictions have different population demographics, geography, and priorities. Accordingly, a single national interoperability may not fit appropriately for each jurisdiction and a local customized approach may work better for health care delivery. National interoperability projects should be implemented after first establishing local interoperability. CONCLUSION Lessons learned from two countries national strategies can be used to understand how national EHR interoperability strategies should be developed. In this paper, Canada and Taiwan provide case studies which demonstrate strategies that put the onus on different levels of government. A balance should be found between Canada s jurisdiction-forward projects and Taiwan s national structured strategy to achieve success in a national EHR interoperability project.

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18 National Health Information Exchange Using Electronic Health Records 17 Liu, C.-Y., Kuo, H. S., & Wang, D.-W. (2000). Health Information Network in Taiwan--Now and Future. Retrieved from Long, A.-J., & Chang, P. (2012). The effect of using the health smart card vs. CPOE reminder system on the prescribing practices of non-obstetric physicians during outpatient visits for pregnant women in Taiwan. International Journal of Medical Informatics, 81(9), doi: Misjan, N., Yakub, K., Salleh, A. R., Hussein, R. H. T., Johnraj, D., Bakar, A. A.,... Hamid, L. A. (2013). Malaysia Taiwan Study Visit. Retrieved from wan_study_visit.pdf National Health Insurance. (2014). Handbook of Taiwan's National Health Insurance. Retrieved from Ni, C.-C., Hsu, M.-H., Yang, P.-T., Yeh, Y.-T., & Liu, C.-T. (2013). The strategies and approaches to develop electronic health records in Taiwan. Retrieved from Paré, G., Ortiz de Guinea, A., Raymond, L., Poba-Nzaou, P., Trudel, M.-C., Marsan, J., & Micheneau, T. (2013). Computerization of primary care medical clinics in Quebec: Results from a survey on EMR adoption, use and impacts. Retrieved from Parziale, L., Liu, W., Matthews, C., Rosselot, N., Davis, C., Forrester, J., & Britt, D. T. (2006). TCP/IP tutorial and technical overview. IBM Redbooks. PwC. (2013a). The emerging benefits of electronic medical record use in community-based care: Executive Summary. Retrieved from PwC. (2013b). The emerging benefits of electronic medical record use in community-based care: Full Report. Retrieved from Rau, H.-H., Hsu, C.-Y., Lee, Y.-L., Chen, W. & Jian, W.-S. (2010). Developing Electronic Health Records in Taiwan. IT Professional, 12(2),

19 National Health Information Exchange Using Electronic Health Records 18 Santé et Services sociaux Québec. (2013). Québec Health Record facts sheet. Retrieved from Sinha, P. K. (2012). Electronic health records standards, coding systems, frameworks, and infrastructures. Hoboken, N.J.: John Wiley & Sons. Smart Card Alliance Secure Personal Identification Task Force. (2005). The Taiwan Health Care Smart Card Project. Retrieved from Winter, A., & Haux, R. (2011). Health information systems architectures and strategies. London, England: Springer. Wolfstadt, J., Gurwitz, J., Field, T., Lee, M., Kalkar, S., Wu, W., & Rochon, P. (2008). The Effect of Computerized Physician Order Entry with Clinical Decision Support on the Rates of Adverse Drug Events: A Systematic Review. Journal of General Internal Medicine, 23(4), doi: /s Wu, T.-Y., & Kuo, K. N. (2010). An overview of the healthcare system in Taiwan. London Journal of Primary Care, 3,

20 National Health Information Exchange Using Electronic Health Records 19 Appendix A Figure A1. Integration within a single Health Information System (HIS). A HIS is composed of application components such as those described in the blocks surrounding the center cloud. A HIS must integrate its application components in order to function effectively. The cloud in the center represents a yet unknown method of integrating and linking the application components. Integration efforts have been reduced with the use of integration technologies and interoperable application components. Adapted from Health information systems architectures and strategies (p. 140), by A. Winter & R. Haux, 2011, London, England: Springer.

21 National Health Information Exchange Using Electronic Health Records 20 Figure A2. Integration within a network of HIS. Small blocks represent application components and each organized group of blocks represents a single HIS. Integration across multiple HIS is more complex than integration within a single HIS. As shown in Figure A2, to integrate a network of HIS, application components within a single HIS must be integrated as well application components across multiple HIS must be integrated and connected. Adapted from Health information systems architectures and strategies (p. 143), by A. Winter & R. Haux, 2011, London, England: Springer.

22 National Health Information Exchange Using Electronic Health Records 21 Figure A3. EHR as a network of EHR Info-structures. From EHRS Blueprint Version 2 (Summary) (p.12), by Canada Health Infoway Inc, 2006, retrieved from Figure A4. Point of Service (PoS) systems sharing EHR data from the Electronic Health Record Info-structure (EHRi) data repositories via the Health Information Access Layer (HIAL) (in red). From EHRS Blueprint Version 2 (Summary) (p.16), by Canada Health Infoway Inc, 2006, retrieved from

23 National Health Information Exchange Using Electronic Health Records 22 Figure A5. Diagrammatic view of national health information infrastructures in Taiwan. From Malaysia Taiwan Study Visit (p. 198), by Misjan et al., 2013, retrieved from udy_visit.pdf.

24 National Health Information Exchange Using Electronic Health Records 23 Figure A6. Taiwan Electronic Medical Record Template (TMT) form structure. From Building a portable data and information interoperability infrastructure-framework for a standard Taiwan Electronic Medical Record Template by Jian et al., 2007, Comput Methods Programs Biomed, 88, p.106. Figure A7. The framework of TMT component section. From Building a portable data and information interoperability infrastructure-framework for a standard Taiwan Electronic Medical Record Template by Jian et al., 2007, Comput Methods Programs Biomed, 88, p.106.

25 National Health Information Exchange Using Electronic Health Records 24 Figure A8. The framework of EHR exchange architecture. From Development of an interoperability infrastructure for exchange of electronic health records among hospitals in Taiwan by C.-T. Liu, 2011, retrieved from tructure.pdf

26 National Health Information Exchange Using Electronic Health Records 25 Figure A9. The National EHR Exchange Centre (NEEC) viewer. From Development of an interoperability infrastructure for exchange of electronic health records among hospitals in Taiwan by C.-T. Liu, 2011, retrieved from tructure.pdf