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

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation

Background

A computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients’ integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients’ medication records prescribed by different health care facilities across Taiwan.

Objective

This study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters.

Methods

A CDS engine was developed that can download patients’ up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians’ responses to handling the alerts for each encounter.

Results

The CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians’ responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled.

Conclusions

The CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient’s medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required.

Identifying and Prioritizing of Data Elements for the Ophthalmology Health Smart Card

Background:

Recently, with the development of information and communication technology in the healthcare industry, the tools of this technology have different applications such as Health Smart Card in this area. The main application of health smart card in the field of ophthalmology is providing demographic and clinical information for different people. Therefore, this study was done to identify and prioritize the data elements of the ophthalmology health smart card.

Methods:

This study was a descriptive-development one that was done in 2017. A review was conducted in relevant databases including PubMed, Web of knowledge, Science direct, and Web of Science to identify appropriate related sources. In the second phase, the ophthalmology specialists and health information managers (20) in RassolAkram, Farabi and Noor Eye Hospital consulted by a questionnaire for health smart card requirements. This study carried out in Iran. Collected data were analyzed by descriptive methods in SPSS software version 19.

Results:

Two categories of demographic and clinical data requirements for health smart card were determined. Patient ID, Occupation, and National Code were the most important demographic requirements of ophthalmology health card. Furthermore, clinical data elements of the ophthalmology health smart card were identified in three categories: Corneal Tests, Retinal Tests, Glaucoma Tests, and Associated Conditions.

Conclusion:

Using the identified data elements, it is possible to design and implement an ophthalmology health smart card. Developing an ophthalmology health smart card is expected to progress of information retrieve, facilitate communication of healthcare organizations and improve healthcare quality.

Identification of key factors in consumers' adoption behavior of intelligent medical terminals based on a hybrid modified MADM model for product improvement

BACKGROUND

As a new application technology of the Internet of Things (IoT), intelligent medical treatment has attracted the attention of both nations and industries through its promotion of medical informatisation, modernisation, and intelligentisation. Faced with a wide variety of intelligent medical terminals, consumers may be affected by various factors when making purchase decisions.

PURPOSE

To examine and evaluate the key influential factors (and their interrelationships) of consumer adoption behavior for improving and promoting intelligent medical terminals toward achieving set aspiration level in each dimension and criterion.

METHOD

A hybrid modified Multiple Attribute Decision-Making (MADM) model was used for this study, based on three components: (1) the Decision-Making Trial and Evaluation Laboratory (DEMATEL) technique, to build an influential network relationship map (INRM) at both 'dimensions' and 'criteria' levels; (2) the DEMATEL-based analytic network process (DANP) method, to determine the interrelationships and influential weights among the criteria and identify the source-influential factors; and (3) the modified Vlse Kriterijumska Optimizacija I Kompromisno Resenje (VIKOR) method, to evaluate and improve for reducing the performance gaps to meet the consumers' needs for continuous improvement and sustainable products-development. First, a consensus on the influential factors affecting consumers' adoption of intelligent medical terminals was collected from experts' opinion in practical experience. Next, the interrelationships and influential weights of DANP among dimensions/criteria based on the DEMATEL technique were determined. Finally, two intelligent medicine bottles (AdhereTech, A₁ alternative; and Audio/Visual Alerting Pillbox, A₂ alternative) were reviewed as the terminal devices to verify the accuracy of the MADM model and evaluate its performance on each criterion for improving the total certification gaps by systematics according to the modified VIKOR method based on an INRM.

RESULTS

In this paper, the criteria and dimensions used to improve the evaluation framework are validated. The systematic evaluation in index system is constructed on the basis of five dimensions and corresponding ten criteria. Influential weights of all criteria ranges from 0.037 to 0.152, which shows the rank of criteria importance. The evaluative framework were validated synthetically and scientifically. INRM (influential network relation map) was obtained from experts' opinion through DEMATEL technique shows complex interrelationship among factors. At the dimension level, the environmental dimension influences other dimensions the most, whereas the security dimension is most influenced by others. So the improvement order of environmental dimension is prior to security dimension. The newly constructed approach was still further validated by the results of the empirical case, where performance gap improvement strategies were analyzed for decision-makers. The modified VIKOR method was especially validated for solving real-world problems in intelligent medical terminal improvement processes. For this paper, A₁ performs better than A₂, however, promotion mix, brand factor, and market environment are shortcomings faced by both A₁ and A₂. In addition, A₂ should be improved in the wireless network technology, and the objective contact with a high degree of gaps.

CONCLUSIONS

Based on the evaluation index system and the integrated model proposed here, decision-makers in enterprises can identify gaps when promoting intelligent medical terminals, from which they can get valuable advice to improve consumer adoption. Additionally, an INRM and the influential weights of DANP can be combined using the modified VIKOR method as integrated weightings to determine how to reduce gaps and provide the best improvement strategies for reaching set aspiration levels.

Organizational decision to adopt hospital information system: an empirical investigation in the case of Malaysian public hospitals

OBJECTIVES

This study mainly integrates the mature Technology-Organization-Environment (TOE) framework and recently developed Human-Organization-Technology (HOT) fit model to identify factors that affect the hospital decision in adopting Hospital Information System (HIS).

METHODS

Accordingly, a hybrid Multi-Criteria-Decision-Making (MCDM) model is used to address the dependence relationships of factors with the aid of Analytic Network Processes (ANP) and Decision Making Trial and Evaluation Laboratory (DEMATEL) approaches. The initial model of the study is designed by considering four main dimensions with 13 variables as organizational innovation adoption factors with respect to HIS. By using DEMATEL, the interdependencies strength among the dimensions and variables are tested. The ANP method is then adopted in order to determine the relative importance of the adoption factors, and is used to identify how these factors are weighted and prioritized by the public hospital professionals, who are wholly familiar with the HIS and have years of experience in decision making in hospitals' Information System (IS) department.

RESULTS

The results of this study indicate that from the experts' viewpoint "Perceived Technical Competence" is the most important factor in the Human dimension. In the Technology dimension, the experts agree that the "Relative Advantage" is more important in relation to the other factors. In the Organization dimension, "Hospital Size" is considered more important rather than others. And, in the Environment dimension, according to the experts judgment, "Government Policy" is the most important factor. The results of ANP survey from experts also reveal that the experts in the HIS field believed that these factors should not be overlooked by managers of hospitals and the adoption of HIS is more related to more consideration of these factors. In addition, from the results, it is found that the experts are more concerned about Environment and Technology for the adoption HIS.

CONCLUSIONS

The findings of this study make a novel contribution in the context of healthcare industry that is to improve the decision process of innovation in adoption stage and to help enhance more the diffusion of IS in the hospital setting, which by doing so, can provide plenty of profits to the patient community and the hospitals.

Dilemma of prescribing aripiprazole under the Taiwan health insurance program: a descriptive study

OBJECTIVES

Refractory major depressive disorder (MDD) is a serious problem leading to a heavy economic burden. Antipsychotic augmentation treatment with aripiprazole and quetiapine is approved for MDD patients and can achieve a high remission rate. This study aimed to examine how psychiatrists in Taiwan choose medications and how that choice is influenced by health insurance payments and administrative policy.

DESIGN

Descriptive study.

OUTCOME MEASURES

Eight questions about the choice of treatment strategy and atypical antipsychotics, and the reason to choose aripiprazole.

INTERVENTION

We designed an augmentation strategy questionnaire for psychiatrists whose patients had a poor response to antidepressants, and handed it out during the annual meeting of the Taiwanese Society of Psychiatry in October 2012. It included eight questions addressing the choice of treatment strategy and atypical antipsychotics, and the reason whether or not to choose aripiprazole as the augmentation antipsychotic.

RESULTS

Choosing antipsychotic augmentation therapy or switching to other antidepressant strategies for MDD patients with an inadequate response to antidepressants was common with a similar probability (76.1% vs 76.4%). The most frequently used antipsychotics were aripiprazole and quetiapine, however a substantial number of psychiatrists chose olanzapine, risperidone, and sulpiride. The major reason for not choosing aripiprazole was cost (52.1%), followed by insurance official policy audit and deletion in the claims review system (30.1%).

CONCLUSION

The prescribing behavior of Taiwanese psychiatrists for augmentation antipsy-chotics is affected by health insurance policy.

A HIPAA-compliant key management scheme with revocation of authorization

Patient control over electronic protected health information (ePHI) is one of the major concerns in the Health Insurance and Accountability Act (HIPAA). In this paper, a new key management scheme is proposed to facilitate control by providing two functionalities. First, a patient can authorize more than one healthcare institute within a designated time period to access his or her ePHIs. Second, a patient can revoke authorization and add new authorized institutes at any time as necessary. In the design, it is not required to re-encrypt ePHIs for adding and revoking authorizations, and the implementation is time- and cost-efficient. Consent exception is also considered by the proposed scheme.

Detection of potential drug-drug interactions for outpatients across hospitals

The National Health Insurance Administration (NHIA) has adopted smart cards (or NHI-IC cards) as health cards to carry patients' medication histories across hospitals in Taiwan. The aims of this study are to enhance a computerized physician order entry system to support drug-drug interaction (DDI) checking based on a patient's medication history stored in his/her NHI-IC card. For performance evaluation, we developed a transaction tracking log to keep track of every operation on NHI-IC cards. Based on analysis of the transaction tracking log from 1 August to 31 October 2007, physicians read patients' NHI-IC cards in 71.01% (8,246) of patient visits; 33.02% (2,723) of the card reads showed at least one medicine currently being taken by the patient, 82.94% of which were prescribed during the last visit. Among 10,036 issued prescriptions, seven prescriptions (0.09%) contained at least one drug item that might interact with the currently-taken medicines stored in NHI-IC cards and triggered pop-up alerts. This study showed that the capacity of an NHI-IC card is adequate to support DDI checking across hospitals. Thus, the enhanced computerized physician order entry (CPOE) system can support better DDI checking when physicians are making prescriptions and provide safer medication care, particularly for patients who receive medication care from different hospitals.

Factors Influencing the Success of National Healthcare Services Information Systems

By extending the updated D&M IS success model, this study examines the multi-dimensional aspects to identify influential factors and construct a suitable model for explaining NHSS success in Taiwan. Through the empirical results from the perspective of 1215 public healthcare workers, this study has arrived at several findings. First, eight salient factors were found which influenced NHSS success from the dimensions of user characteristics, organizational context, and system characteristics. Second, the factors of user experience, user training, information quality, service quality, and user satisfaction have a strong positive effect on system use, whereas user attitude and facilitating conditions have a significant and negative effect. Further, user attitude, user training, top management support, system quality, information quality, and service quality are also significantly correlated to user satisfaction. The results of this study can assist governments in other countries in developing more effective NHSS and better e-Government practices.

Online detection of potential duplicate medications and changes of physician behavior for outpatients visiting multiple hospitals using national health insurance smart cards in Taiwan

OBJECTIVES

Doctor shopping (or hospital shopping), which means changing doctors (or hospitals) without professional referral for the same or similar illness conditions, is common in Hong Kong, Taiwan and Japan. Due to the lack of infrastructure for sharing health information and medication history among hospitals, doctor-shopping patients are more likely to receive duplicate medications and suffer adverse drug reactions. The Bureau of National Health Insurance (BNHI) adopted smart cards (or NHI-IC cards) as health cards in Taiwan. With their NHI-IC cards, patients can freely access different medical institutions. Because an NHI-IC card carries information about a patient's prescribed medications received from different hospitals nationwide, we used this system to address the problem of duplicate medications for outpatients visiting multiple hospitals.

METHODS

A computerized physician order entry (CPOE) system was enhanced with the capability of accessing NHI-IC cards and providing alerts to physicians when the system detects potential duplicate medications at the time of prescribing. Physician responses to the alerts were also collected to analyze changes in physicians' behavior. Chi-square tests and two-sided z-tests with Bonferroni adjustments for multiple comparisons were used to assess statistical significance of differences in actions taken by physicians over the three months.

RESULTS

The enhanced CPOE system for outpatient services was implemented and installed at the Pediatric and Urology Departments of Taipei Medical University Wan-Fang Hospital in March 2007. The "Change Log" that recorded physician behavior was activated during a 3-month study period from April to June 2007. In 67.93% of patient visits, the physicians read patient NHI-IC cards, and in 16.76% of the reads, the NHI-IC card contained at least one prescribed medication that was taken by the patient. Among the prescriptions issued by physicians, on average, there were 2.36% prescriptions containing at least one medication that might be duplicative to the prior prescriptions stored in NHI-IC cards. The rate of potential duplicate medication alerts for the Pediatric Department was higher than that for the Urology Department (2.78% versus 1.67%). However, the rate of revisions to prescriptions was higher in the Urology Department than the Pediatric Department. Overall, the rate of physicians reviewing and revising their prescriptions was 29.25%; the rate of physicians reviewing without revising their prescriptions was 43.62%; the rate of physicians turning off the alert screens right after the screens popped up (overridden) was 27.13%. Thus, physicians accepted alerts to review their prescriptions with patients in most situations (72.87%). Moreover, over the study period, the rate of total revisions made to prescriptions increased and the "overridden" rate decreased.

CONCLUSIONS

Our approach enhances the capability of CPOE systems using NHI-IC cards as a nationwide infrastructure to provide more complete patient health information and medication history sharing among hospitals in Taiwan. Thus, our system can provide a better prescribing tool to help physicians detect potential duplicate medications for frequent doctor-shopping patients and hence enhance patient safety across hospital boundaries. However, the effectiveness of detecting duplicate medications with our approach is very much dependent on the completeness of NHI-IC cards, which in turn primarily depends on physician use of the cards when prescribing.

Using health smart cards to check drug allergy history: the perspective from Taiwan's experiences

In Taiwan, national health insurance coverage began in 1994, and the Bureau of National Health Insurance has issued health smart cards since 2004. In addition to tracking medical reimbursements, these smart cards store healthcare information, including electronic prescriptions, medical procedure and vaccination records, drug allergy histories, and information about a patient's willingness to be an organ donor. We conducted this study 4 years after the smart cards had been introduced in order to review how drug allergy history is recorded using this system. Our results reveal that the drug allergy histories are incomplete in many cases, and the format used to record a patient's drug allergy history is not consistent. We offer suggestions to promote the standardization of drug allergy history records.

Primary care physician's attitude towards the German e-health card project--determinants and implications

In Germany e-health cards will be distributed nationwide to over 80 million patients. Given the impending mandatory introduction of the e-health technology, the objective of this study was to examine the determinants of primary care physicians' acceptance of the technological innovation. The study was conducted prior to the introduction of the e-health cards. A questionnaire survey was carried out addressing primary care physicians from different fields. The reduction of medication error rates and the improvement of communication between medical caregivers are central aspects of the perceived usefulness. Primary care physicians rate their involvement in the process of the development of the technology and their own IT expertise concerning the technological innovation as rather low. User involvement and IT expertise can explain 46 % of the variance of perceived usefulness of the e-health card. User involvement plays a crucial role in the adoption of the German e-health card. Primary care physician's perspective should be represented in the process of developing and designing the technology.

Electronic health records approaches and challenges: a comparison between Malaysia and four East Asian countries

An integrated Lifetime Health Record (LHR) is fundamental for achieving seamless and continuous access to patient medical information and for the continuum of care. However, the aim has not yet been fully realised. The efforts are actively progressing around the globe. Every stage of the development of the LHR initiatives had presented peculiar challenges. The best lessons in life are those of someone else's experiences. This paper presents an overview of the development approaches undertaken by four East Asian countries in implementing a national Electronic Health Record (EHR) in the public health system. The major challenges elicited from the review including integration efforts, process reengineering, funding, people, and law and regulation will be presented, compared, discussed and used as lessons learned for the further development of the Malaysian integrated LHR.

Design and prototype of a mechanism for active on-line emerging/notifiable infectious diseases control, tracking and surveillance, based on a national healthcare card system

Timeliness is a critical issue in preventing the spread of emerging/notifiable infectious diseases, such as severe acute respiratory syndrome (SARS) or avian influenza (bird flu). Current computerized surveillance systems in many countries have demonstrated their usefulness in detecting specified communicable-diseases. However, the off-line, daily or weekly data reporting mode induces a time lag in data collection, transmission, processing, and responses. This paper proposes an on-line real-time mechanism, named EDICTS, for emerging/notifiable infectious diseases control, tracking and surveillance. It is based on the on-line health IC card system and works at the registration process of primary care practices and emergency departments. Hence, should a disease defined by CDC (Center for disease control) be detected at the registration station, EDICTS responds in real time. Note that EDICTS is a mechanism; it is CDC that determines the policy and activates it. A prototype is designed and implemented on a simulated environment of the Taiwan's national health insurance IC card system. The proposed policy and rules are defined according to the CDC regulations. Timely, sensitive and cost-effective, EDICTS complements the existing successive level of CDC reporting system as a fast-response control channel.

Providing longitudinal health care information with the new German Health Card--a pilot system to track patient pathways

The paper describes an application system that employs the new German Health Card to provide a technical solution for tracking patient pathways. The aim is to improve the flow and availability of health care information. We used standard software components and technologies in order to facilitate interoperability with multiple system platforms and allow for customizing as the specification process for the German Health Card is not yet completed. Every health care provider contact is recorded on the card and associated medical documents are stored in a central database and can be retrieved via Web Services running on a central application server. The patient pathway can thus be chronologically tracked by the clinician and relevant longitudinal information is made accessible quickly. Our system for tracking patient pathways with the new German Health Card can be regarded as a first example of its great future potential.