Taiwan’s “smart card:” A functional Electronic Medical Record system

Virtually every health system on the planet dreams about the day when it is blessed with a fully functional electronic medical record system (EMR). EMRs are a digital version of the paper files containing your medical history, including examination notes from nurses and docs, and details about tests, treatments and hospital stays. EMRs allow these records to be shared by any clinician in any office or hospital across the land. The reality often falls short of this ideal, and we’ll visit some of the promises and pitfalls of EMRs in coming posts. But many systems seeking to implement EMRs could learn from the few places that have achieved some successes. Taiwan, for example.

Healthcare in Taiwan is a private sector driven, single payer system covering 99% of the island’s 23 million inhabitants. In 1995 the government coordinated an EMR effort to stitch together hospitals and clinics around the mountainous island into one electronic system. Digitizing paper records is an implementation hurdle faced by all such initiatives. An ongoing technological hurdle is how to get different computerized networks to talk to each other and function as one system.

Central to Taiwan’s EMR system is the “smart card,” carried by every insured Taiwanese. A swipe of the card (along with a doctor’s card and a hospital of clinic card) instantly reveals the patients complete medical record, ready for review or update. This system allows patients to carry their complete medical history with them in their wallet, where it is accessible by any health practitioner that is visited. The card also allows public health officials to notify you if, for example, you were sitting on a plane next to a passenger who has been diagnosed with a communicable disease such as SARS.

Five implementation challenges that the Taiwanese overcame are instructive to those studying, implementing or designing such a system:

1. Integration. Teaching different computer systems to speak the same language. In the city of Boston alone, over 30 different EMR systems are being used. To realize the potential of EMR they must share information among organizations, not just within them.

2. Process engineering. Introducing a new data management system requires adding new steps to old processes. To be effective and minimize growing pains, new steps and procedures must be well thought-out and purpose-designed.

3. Personnel issues. Attention must be paid to the attitudes, habits, cultures of the staff, and new systems integrated with them in mind, and their input.

4. Funding. EMR implementation is expensive. Upgrading a single doctors office can cost $30,000 to $70,000, and upgrading a hospital or health system many times that much.

5. Laws and regulations. Expanding immediate access to medical records is a good thing, as long as the information doesn’t fall into the wrong hands. Privacy concerns must be addressed, as well as procedures for cases where a patient may not be able to provide consent, such as when they are unconscious. And when is it OK for a government agency to open those records?