Medical Imaging System Division,
Taiwan Visit Report 2010
1. Introduction
The Diagnostic Report Committee so far has surveyed the structure and interoperability of diagnostic reports. Diagnostic reports are less interoperable than standardized images and examination results. On the other hand, the infrastructure of interoperability has been standardized these days, with DICOM, HL7 Messaging V2/V3, ebXML (Electronic Business using eXtensible Markup Language), mobile media, etc. Depending upon the needs, we can select a suitable infrastructure. However, DICOM SR (Structured Report) and HL7 CDA R2 (HL7 Clinical Document Architecture Release 2) only offer structure. For the essential contents, we need domain specific templates that determine the details for interoperable information exchange. Accordingly, as a part of standardization of the contents of diagnostic reports, we began to write the guidelines of templates for image-interpretation reports. Taiwan is one of the global leaders in the development of report templates, implementing them in 108 domains. We thought that Taiwan was a good model and decided to survey the situation in Taiwan.
2. The advanced example of report standardization in Taiwan
Last year, the IHIC2009 (10th International HL7 Interoperability Conference 2009) was held in Kyoto. In that conference, the National Yang Ming University introduced an advanced example, where templates (Taiwan Medical Template) *1 were made and implemented in the 108 domains based on HL7 CDA R2. We contacted, at IHE-J Connectathon 2009, Mr. Tien Wei Liu of The Taiwan Electronic Data Processing Corp. (TEDPC) and Mr. Chung-Yueh Lien of the National Yang Ming University, and began to collect information on the templates of Taiwan. On that occasion, we told them JIRA's intention to visit Taiwan and exchange information about diagnostic reports between Japan and Taiwan. That contact resulted in our visit to Kaohsiung Veterans General Hospital and an information exchange meeting at Tzu Chi University.
3. Schedule and purpose of visit to Taiwan
Mr. Lien introduced us to Professor Chia-Hung Hsiao of Tzu Chi University, who arranged our visit from July 1 through 5. The sites and purposes of our visit are as follows.
(1) Kaohsiung Veterans General Hospital*2 : The purpose was to survey structured documents sharing and the remote diagnostic imaging system.
This is a veterans general hospital located in Kaohsiung in the southern part of Taiwan. Dr. Tsung Lung Yang of this hospital and TEDPC developed HIS (Hospital Information System). Group hospitals and the part-time radiologists began to share images and reports in April 2010.
(2) Tzu Chi University*3 : The purpose was to have an information exchange meeting between Japan and Taiwan.
This is a general hospital mainly of the medicine/medical care located in Hualien County in the eastern part of Taiwan. Professor Hsiao of this university, who arranged our visit, belongs to the Department of Medical Informatics. He is a member of TAMI (Taiwan Association for Medical Informatics) and MISAT (Medical Image Standards Association of Taiwan). We had a two-day meeting to exchange information with the key persons of the hospital and the local vendors (Carestream-Taiwan, GE-Taiwan, INFINIT-Taiwan). We collected information of the next-stage project of Tzu Chi University and the national project of Taiwan. JIRA explained the present market situation of Japanese medical information system, the report system, the remote image-interpreting system, the endoscopy report system, and the pathology ordering system.
(3) Taiwan Association for Medical Informatics*4 : A meeting to exchange information between Japan and Taiwan.
We had a meeting in Yilan County in the northeastern part of Taiwan. We were joined by Professor Hsiao and Professor Chien-Yeh Hsu (President of TAMI). We discussed the cost effectiveness of past business plans, furthering of technical standards and other issues related to wider use of medical information equipment. The exchange of information was significant.
4. Public health insurance and ID card of Taiwan
The people of Taiwan (23 million people) have an ID card with a unique number on it, and are managed together with the medical examination ID (patient ID) for every medical institution. Therefore, it is theoretically possible to centralize the medical-examination information of each medical institution. Moreover, medical professionals must have additionally a "medical-professionals certification IC card." This card must be used whenever medical professionals are engaged in their work. This is similar to Japanese HPKI (Healthcare Public Key Infrastructure). This card is indispensable in the electronic signature of diagnostic documents and medical reimbursement.
Moreover, the health insurance system in Taiwan covers all the people registered as Taiwanese. They referred to the Japanese health insurance system as a model. Since the insurance is compulsory, systems for reimbursement through dedicated telephone lines become in widespread use with clinics.
5. Electronic medical record system at Kaohsiung Veterans General Hospital
Veterans hospital group began to process diagnostic information electronically in 2006. They developed themselves the system to integrate electronic medical records, the ordering system, and PACS. Four hospitals are operated with the same system. Entering the diagnostic ID enables users to refer to diagnostic information stored in several hospitals. Information exchange with external medical institutions requires data exchange by IHE XDS. Therefore, the main medical documents are controlled by HL7 CDA R2.
Within this hospital, image-interpretation reports are stored in DICOM SR. When the reports are transmitted outside the hospital, they are converted into HL7 CDA R2. In order to make medical documents within Taiwan more exchangeable, the Department of Health plans to create templates (for 10 major diseases as priority) by Level 3 by 2011.
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| Fig. 1. Document sharing in Veterans hospital group |
6. Next PACS project of Tzu Chi General Hospital
The six hospitals of Tzu Chi General Hospital Group are connected via network to install Carestream's system at each hospital. Without upgrading the systems in the hospitals, collaboration is possible among hospitals. The data is controlled by the cloud system outside hospitals. Hospitals do not worry about the upper limit of capacity in order to operate the system. Registration/retrieval of contents with the cloud system is performed automatically and transparently to users. While medical staffs stay at home, they are able to use this system to access the diagnostic information. It is possible to handle "DICOM Object", "HL7 CDA R2", "WORD", "PDF", and various animations.
7. National project to EMR (Electronic Medical Record)
They began to develop EMR templates in 2006. At present, they have developed 108 kinds of templates, such as "hospital records", " summary hospital discharge ", "emergency visit hospitalization", and "prescriptions". These are in the form of XML(s) (Extensible Markup Language) and have information that is equivalent to Level 2 of HL7 CDA R2. They provided the means of information exchange, such as the security USB memory and the Web page for individuals. It was the experimental forerunner of PHR (Personal Health Records). But, it did not result in real operation at that time. In 2009, they began the succeeding project, that is, "EMR (Electronic Medical Record)/Image Exchange Center*5." PACS venders were selected for each of the five projects. Each project was joined by 20 hospitals, resulting in participation of 100 hospitals in total. Those 100 hospitals amount to about 20% of total target hospitals to be connected. The coverage percentage is expected to increase to 70% by 2012. It is a gigantic project.
Bibliography
- Template : Taiwan Medical Template
http://emrstd.doh.gov.tw/emr/documents/CDA%20R2/Forms/AllItems.aspx
- Kaohsiung Veterans General Hospital : http://www.vghks.gov.tw
- Tzu Chi University : http://www.tcu.edu.tw
- Taiwan Association for Medical Informatics : http://www.medinfo.org.tw
- EMR/Image Exchange Center : http://image.doh.gov.tw/rule.html
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