Journal:Implement an international interoperable PHR by FHIR: A Taiwan innovative application

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Full article title Implement an international interoperable PHR by FHIR: A Taiwan innovative application
Journal Sustainability
Author(s) Lee, Yen-Liang; Lee, Hsiu-An; Hsu, Chien-Yeh; Kung, Hsin-Yeh; Chiu, Hung-Wen
Author affiliation(s) Taipei Medical University, Chunghwa Telecom Laboratories, Tamkang University,
Smart Healthcare Center of Excellence, National Taipei University of Nursing and Health Sciences
Primary contact hwchiu at tmu dot edu dot tw
Year published 2020
Volume and issue 13(1)
Article # 198
DOI 10.3390/su13010198
ISSN 2071-1050
Distribution license Creative Commons Attribution 4.0 International
Website https://www.mdpi.com/2071-1050/13/1/198/htm
Download https://www.mdpi.com/2071-1050/13/1/198/pdf (PDF)
Emblem-important-yellow.svg This article should be considered a work in progress and incomplete. Consider this article incomplete until this notice is removed.

Abstract

Personal health records (PHRs) have many benefits for things such as health surveillance, epidemiological surveillance, self-control, links to various services, public health and health management, and international surveillance. The implementation of an international standard for interoperability is essential to accessing PHRs. In Taiwan, the nationwide exchange platform for electronic medical records (EMRs) has been in use for many years. The Health Level Seven International (HL7) Clinical Document Architecture (CDA) was used as the standard for those EMRs. However, the complication of implementing CDA became a barrier for many hospitals to realizing standard EMRs.

In this study, we implemented a Fast Healthcare Interoperability Resources (FHIR)-based PHR transformation process, including a user interface module to review the contents of PHRs. We used “My Health Bank” (MHB), a PHR data book developed and issued to all people by the Taiwan National Health Insurance, as the PHRs' contents in this study. Network Time Protocol (NTP)/Simple Network Time Protocol (SNTP) was used in the security and user authentication mechanism when processing and applying personal health information. Transport Layer Security (TLS) 1.2 (such as HyperText Transfer Protocol Secure or HTTPS) was used for protection in data communication. User authentication is important in the platform. OAuth (OAuth 2.0) was used as a user authentication mechanism to confirm legitimate user access to ensure data security. The contents of MHB were analyzed and mapped to FHIR, and then converted to FHIR format according to the mapping logic template. The function of format conversion was carried out by using ASP.NET. XPath and JSPath technologies filtered out specific information tags. The converted data structure was verified through an HL7 application programming interface (HAPI) server, and a new JSON file was finally created.

This platform can not only capture any PHR based on the FHIR format but also publish FHIR-based MHB records to any other platform to bridge the interoperability gap between different PHR systems. Therefore, our implementation/application with the automatic transformation from MHB to FHIR format provides an innovative method for people to access their own PHRs through MHB. No one has published a similar application like us using a nationwide PHR standard, MHB, in Taiwan. The application we developed will be very useful for a single person to use or for other system developers to implement their own standard PHR software.

Keywords: FHIR, interoperability, PHR, data management, precision health management

Introduction

Personal health records (PHRs) are personalized records that include data related to health.[1] The Markle Foundation’s "Connecting for Health" collaborative defines a PHR as “an electronic application through which individuals can access, manage, and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.”[2] This differs from the more widely used electronic medical record (EMR), which focuses on clinical data and is operated by the medical service provider (such as clinics and hospitals). PHRs have great benefits for health monitoring, epidemiological surveillance, self-control, linkages with different services, and public health management in areas such as international health care.[3][4]

Recently, medical services have placed more focus on precision medicine, which refers to specific medical treatments based on the individual characteristics of each patient.[5] PHRs are a crucial component of precision medicine. The information in PHRs can provide more details for clinical decision support. Based on a foundation of an electronic hospital information system, we can get plentiful personal health data to create PHRs. Taiwan has implemented national centralized health insurance information systems since the establishment of the Taiwan National Health Insurance Administration (NHIA) in 1995. According to CEOWORLD magazine’s 2019 “Health Care Index” statistics, Taiwan has the best medical system in the world[6], while the National Health Insurance (NHI) has a coverage rate of more than 99%.[7] The NHIA pays for most of the medical service expenses of all Taiwanese citizens to the hospitals and clinics that provide services. For the reimbursement procedure, hospitals and clinics need to upload patient care data related to the payment, including the diagnosis, prescriptions, treatment information, images, testing data, etc. to NHIA information systems. By doing so, the NHIA has collected almost all individual medical care data in Taiwan and stores it at the NHIA’s data center. To promote personal health management, the NHIA launched the "My Health Bank" (MHB) system in September 2014. The MHB system is a personalized cloud-based service that aims to return personal medical data back to the citizens. Individuals can use their citizen digital certificate or password-registered NHI card as identity verification to download their medical data that have been collected by health insurance.

The NHIA aims to let citizens more directly control and manage their health data. Based on a cloud-based system, people can access their personal health insurance records in the past three years via the NHIA’s MHB portal, and the data can be printed out or downloaded. The NHIA hopes that citizens will have access to MHB when they go to a clinic or hospital as a reference for the physician. This service promotes people to have their health information and know their own health status.

However, despite the rich content of MHB and the data quality of the information confirmed in diagnosis, medicine, and other items, the information continues to use the original insurance declaration form and does not follow the relevant medical information standards. This makes it difficult to integrate and apply information. In addition, the official MHB system is mainly used as a data provider. The content is mainly based on the qualified medical insurance service records of various contracted hospitals, clinics, or institutions. Individuals are not allowed to add other personalized information themselves. Additionally, cloud-based systems can make it hard to share data with the doctor. When people see a doctor for an urgent reason, there may not be enough time to log into the MHB system and search for data. Although individuals can download data from the website, the data will be in the XML or JSON format, which most individuals cannot read. In addition, the content of PHRs does not follow any international format, making it quite difficult to exchange data or interoperate with other health information systems. The application and sharing of PHRs are very important. In order to achieve precision medicine, PHRs need to comply with international standards before they can be accepted, integrated, and applied by different systems.

Jung et al.[8] agree that an integrated personal health record is more valuable than a single record. The impact of interoperability on PHRs has been the focus of interdisciplinary researchers in recent years. A survey article by Alyami and Song[9] emphasized the vital role of interoperability in the implementation and adoption of PHRs. Plastiras and O'Sullivan[10] developed an ontology-driven intermediary layer to achieve interoperability between PHRs and electronic health records (EHRs) of various standards. Li[11] developed a service-oriented interoperable integrated PHR system and explained that it can be used to overcome interoperability problems between medical systems. Urbauer et al.[12] compared the interoperability procedures for the communication of medical systems and personal health devices to analyze the advantages and gaps, including presenting a total solution for interoperability. And Roehrs et al.[13] presented the crucial concept of interoperability for developing and using PHRs.



References

  1. ↑ Tang, P.C.; Ash, J.S.; Bates, D.W. et al. (2006). "Personal health records: definitions, benefits, and strategies for overcoming barriers to adoption". JAMIA 13 (2): 121–6. doi:10.1197/jamia.M2025. PMC PMC1447551. PMID 16357345. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447551. 
  2. ↑ Markle Foundation (1 July 2003). "Connecting for Health: A Public-Private Collaborative" (PDF). Markle Foundation. https://www.markle.org/sites/default/files/final_phwg_report1.pdf. Retrieved 10 March 2021. 
  3. ↑ Bower, J.K.; Bollinger, C.E.; Foraker, R.E. et al. (2017). "Active Use of Electronic Health Records (EHRs) and Personal Health Records (PHRs) for Epidemiologic Research: Sample Representativeness and Nonresponse Bias in a Study of Women During Pregnancy". EGEMS 5 (1): 1263. doi:10.13063/2327-9214.1263. PMC PMC5340503. PMID 28303255. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340503. 
  4. ↑ Bonanader, J.; Gates, S. (2010). "Public health in an era of personal health records: Opportunities for innovation and new partnerships". Journal of Medical Internet Research 12 (3): e33. doi:10.2196/jmir.1346. PMC PMC2956336. PMID 20699216. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2956336. 
  5. ↑ Timmerman, L. (4 February 2013). "What’s in a Name? A Lot, When It Comes to ‘Precision Medicine’". Xconomy. https://xconomy.com/national/2013/02/04/whats-in-a-name-a-lot-when-it-comes-to-precision-medicine/. 
  6. ↑ Ireland, S. (5 August 2019). "Revealed: Countries With The Best Health Care Systems, 2019". CEOWORLD magazine. https://ceoworld.biz/2019/08/05/revealed-countries-with-the-best-health-care-systems-2019/. 
  7. ↑ Iqbal, U.; Nguyen, P.-A.; Syed-Abdul, S. et al.. Is long-term use of benzodiazepine a risk for cancer?. 94. e483. doi:10.1097/MD.0000000000000483. PMC PMC4602739. PMID 25674736. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4602739. 
  8. ↑ Jung, S.Y.; Lee, K.; Hwang, H. et al. (2017). "Support for Sustainable Use of Personal Health Records: Understanding the Needs of Users as a First Step Towards Patient-Driven Mobile Health". JMIR mHealth and uHealth 5 (2): e19. doi:10.2196/mhealth.6021. PMC PMC5344982. PMID 28232300. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5344982. 
  9. ↑ Alyami, M.A.; Song, Y.-T. (2016). "Removing barriers in using personal health record systems". Proceedings of the 2016 IEEE/ACIS 15th International Conference on Computer and Information Science: 1–8. doi:10.1109/ICIS.2016.7550810. 
  10. ↑ Plastiras, P.; O'Sullivan, D.M. (2017). "Combining Ontologies and Open Standards to Derive a Middle Layer Information Model for Interoperability of Personal and Electronic Health Records". Journal of Medical Systems 41 (12): 195. doi:10.1007/s10916-017-0838-9. PMID 29081012. 
  11. ↑ Li, J. (2017). "A Service-Oriented Approach to Interoperable and Secure Personal Health Record Systems". Proceedings of the 2017 IEEE Symposium on Service-Oriented System Engineering. doi:10.1109/SOSE.2017.20. 
  12. ↑ Urbauer, P.; Sauermann, S.; Frohner, M. et al. (2015). "Applicability of IHE/Continua components for PHR systems: Learning from experiences". Computers in Biology and Medicine 59: 186–93. doi:10.1016/j.compbiomed.2013.12.003. PMID 24374230. 
  13. ↑ Roehrs, A.; da Costa, C.A.; da Rosa Righi, R. et al. (2017). "Personal Health Records: A Systematic Literature Review". Journal of Medical Internet Research 19 (1): e13. doi:10.2196/jmir.5876. PMC PMC5251169. PMID 28062391. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5251169. 

Notes

This presentation is faithful to the original, with only a few minor changes to presentation. In some cases important information was missing from the references, and that information was added. The original reference 12 (Crabtree et al.) seems to have no bearing on the text and appears to have been accidentally included; it was omitted for this version.

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