Building a e-Hospital

Lessons from Taiwan

Min-Huei Hsu

Min-Huei Hsu

Chief Information Officer and Consultant Neurosurgeon Wan Fang Hospital Taipei Medical University Taiwan.

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The application of information technology has improved the quality and lowered the cost of medical services in Taiwan.

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Before computers became popular, calculating rulers used by engineers and abacuses invented by Chinese have both been used as calculating tools. In 1943, John Mauchly led the development of ENIAC (Electronic Numerical Integrator and Calculator). ENIAC was the first programmable electronic calculator in the world, and it replaced the original mechanical components with vacuum tubes. In February 1946, the public saw the ENIAC for the first time in Philadelphia, and a new era of electronic computing began.

In the last 60 years, computers have changed drastically. The changes were in the form of smaller sizes, larger storage, higher speed, higher accuracy, more functions and cheaper prices. With the advent of Internet, people were brought into the information era.

In the last 20 years, the development and application of information technology has deeply affected the world economy and various industries, and the healthcare sector is no exception to this.

As a result, hospitals have implemented various computer systems, such as medical record management systems, insurance claim systems, patient billing systems and computerised physician order entry (CPOE) systems. At the Wan Fang Hospital we divided hospital information systems (HIS) into 4 categories according to their functions. The 4 letters in the word “CARE” could stand for these 4 categories: C for clinical care, A for administration, R for research and E for education.

Clinical care

In recent years, there has been a growth of computer-based tools to improve physician decision-making and clinical effectiveness. There are several islands of progress, particularly in applications designed to reduce medical errors, improve access to knowledge and telemedicine. Our hospital has instituted a variety of such technologies, and they are already producing a substantial reduction in the incidence of dangerous errors.

In 1999, we began to replace paper-based physician ordering (including orders for drugs, diagnostic tests, and the setting of ventilators and other devices) with computer-based order entry. Among other functions, this system automatically suggests appropriate dosages to physicians and checks for drug allergies and drug-to-drug interactions.

We instituted an alert system whereby a computer constantly scans new data, including patient laboratory results, as they are generated. If it encounters a critical value—for example, a dangerous potassium level in a medication—the computer will automatically send a short message to the mobile phone of the patient’s attending physician.

In 2004, we implemented a Surgical Patient Safety System (SPSS) in our hospital to prevent three important surgery-related problems: wrong site, wrong procedure and wrong patient surgery. Although only 17% of adverse surgical events are judged to be preventable, wrong site, wrong procedure, wrong person surgery are totally preventable. Using computers in the operative room, surgeons access this system to key in patient’s data before operation. It takes about two minutes to complete this procedure. The system checks this data with the database of operating theatre schedule. If there are any mismatches, an alert is displayed on the screen. The transactions log is stored in the server. The patient safety committee of the hospital reviews the records with mismatches on a weekly basis. Mismatches have been detected in about 5% of all operations. A final verification of the correct site, procedure and person by this system helps in preventing complications.

Telemedicine can involve technologies as simple as a radio, or as advanced as a digital video and data transmission, but the key aspect is that it allows physicians to practice medicine from a distance. The potential benefit for isolated areas—where the much needed physicians, particularly specialists, are unavailable—is believed to be substantial. Taiwan is a heavily populated country, with small land area and many mountains and isolated islands. Unequal distribution of medical resources has made high-quality accessible medical care for all a major problem in rural areas. Medical personnel are unwilling to practice in rural areas because of fear of isolation from peers and lack of continuing medical education in those areas. Telemedicine provides a timeless and spaceless measure for teleconsultation and education. We have established computer networks between our hospital and 10 rural primary care centers through high-speed networks and high power computer processing to electronically exchange medical information and to conduct clinical examination and consultation. Our system provides teleconsultation of good quality and is cost-effective.

Administration

In Taiwan, computers were first introduced into hospitals for managing administrative activities. Earlier systems focused on admissions / discharge / transfer (ADT), patient billing, claims processing and materials management.

In 1995 the government of Taiwan introduced universal health insurance to cover all citizens. The policy of Bureau of National Health Insurance (BNHI) has become the biggest influence in the development of Taiwan’s healthcare industry since then. BNHI has launched a nationwide project for replacement of its paper-based health insurance cards by smart cards (or NHI-IC cards) since November 1999. These cards have been used since July 1, 2003, and they fully replaced paper-based cards after January 1, 2004. Hospitals must support the cards in order to provide medical services for insured patients. Health smart card system has to be linked into the hospital information system for patient registration, billing, examination and prescriptions. Because of frequent changes to the claim rules, hospitals have to invest large resource to maintain their information systems.

Quality has become an important issue to the healthcare sector. Information systems are increasingly important for measuring and improving quality. The Taiwanese government also recognises the need to implement a nationwide healthcare quality indicator system to strengthen quality surveillance. In 1999, the Department of Health funded a 2-year project led by the Taiwan Healthcare Executive College to develop a comprehensive performance assessment system, later named Taiwan Healthcare Indicator Series (THIS). It includes four categories of indicators, namely, outpatient, inpatient, emergency care and intensive care, and has 139 items in total. The system was officially launched in 2001. In light of the success of the indicator series, BNHI of Taiwan has proposed participation in the series as being one of the criteria to be reimbursed for quality.

Research

Information technology is responsible for data management and providing critical statistical support to research studies. We have developed the “Clinical Research Information Management System” to facilitate the data management of studies in our hospital. Using this system, investigators can integrate clinical, molecular, genetic and other translational and clinical research data. This system supports collaborations among clinicians and statisticians from the design stage through analysis and final report stage.

Education

We opened the clinical skill center 2 years ago. The center’s mission is to promote and provide high-quality clinical education and reliable assessment of skills and procedures, with the ultimate intent being to advance patient care. This center provides simulation-based medical education. Through new approaches to healthcare training and practice, the clinical skill center strives to improve patient-safety and the clinical skills of healthcare providers. By proactively exposing trainees to challenging clinical and humanistic encounters, this center aims to reduce errors and improve teamwork and uality of care. This center serves the needs of all sectors of healthcare providers in our hospital and is involved in the development of simulation-based medical curriculum to produce courses to answer the needs of these sectors.

An IT-driven future

In 2003, health expenditure as a percentage of gross domestic product (GDP) was 6.8% in Taiwan, which is lower than 14.6% in America, 9.6% in Canada, 7.7% in UK and 7.8% in Japan, but medical care of high quality was provided to all nationals.

One important factor was the good information management in the healthcare industry in our country. Medical care, hospital management, health insurance, public health and health promotion are now digitised to a certain extent in Taiwan. In fact, information technology not only raises the efficiency but also improves medical quality to a great extent. Hospitals with excellent information technology service can have innovative processes to break through the limit of traditional service, and thereby save the time wasted and raise the low efficiency to effectively improve the quality of medical service.

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