Reflections on My Trip to Asia

For 12 days, I served as guest professor in China, Japan and Taiwan, giving lectures, running meetings, and joining my colleagues for ceremonial meals.    In many ways, all three countries are trying to solve the same basic technology and policy challenges, but there are subtle differences.

China - China has a single payer system with universal, nationally funded healthcare in state operated hospitals and clinics.  Privately funded, entrepreneurial ventures  including high-end hospitals and clinics are emerging for those who want to purchase concierge care.   This article nicely summarizes the economic issues.

During this visit I had the opportunity to meet with Vice Minister of Health for China, as well as several hospital leaders, and informatics professionals.   Here's what I learned, although I will qualify my impressions with the fact that China is a large and diverse country and my visit was limited to Beijing, Hangzhou, and Shanghai.

There are over 500 vendors of EHR products and no market leader.   Many applications are home built or created by small, local companies which address the specific workflow needs of a single healthcare facility.    There is not a specific national healthcare IT policy, but there is recognition of the need for national interoperability standards and an incentive to use them.    Something like a certification program and meaningful use program may evolve.    There are many proprietary approaches to interoperability currently in use, and HL7 CDA is seen as a possible candidate for summary exchange.   Vocabularies such as SNOMED-CT, ICD9 or 10, and LOINC are not yet deployed but there is an understanding of the need for terminology services and an eagerness to work with US companies proving such services.  There are  pilots of healthcare information exchange, generally using a central repository model.   I asked an audience of 1000 people if they had ever used a PHR, and not a single hand was raised.   There is a desire to engage patients and families but no products in the marketplace yet.

The challenges faced by China include a population of 1.35 billion people, environmental concerns (air/water/land), an aging population, a significant migration of citizens from rural to city life,  and an increase in cancer/birth defects/respiratory diseases as a side of effect of rapid industrialization.

I look forward to next steps, which I hope include interoperability policy planning at the national level.  I've forwarded several US policy documents to the Chinese government and remain eager to work on Meaningful Use for 1.3 billion people and 20,000 hospitals.

Japan - Japan has broad healthcare coverage with a mixture of universal insurance and self pay.  This article nicely summarizes the economic issues.

There are a few large companies providing EHRs in China - Fujitsu, Mitsubishi, and NEC.  Hospital IT is frequently outsourced to such companies.   EHRs are typically client server architectures.   The web has not been widely embraced for EHRs, PHRs, or HIEs because of privacy concerns, but a few cloud computing pilots have been successful including an EHR for first responders in Fukushima.    There have been pilots of data sharing such as the Dolphin project in Kyoto and planning for PHR implementation.  

The challenges faced by Japan are an aging society, declining birth rate (1.4), lack of coordination of care because patients have access to any hospital/urgent care/clinician office on demand, creating a fractured record, and privacy policy that makes interoperability difficult.   Standards are emerging and there is an understanding of the need to use summary formats like CDA and controlled vocabularies.     A national policy requiring interoperability standards and encouraging data sharing with patient consent would significantly enhance quality, safety, and efficiency in Japan.

The government of Japan has recently changed and I'm told Mr. Abe will embrace innovation in healthcare IT as part of his economic recovery package.   Just as with China, I'm eager to help with a certification and meaningful use program, serving the 126 million citizens of Japan.

Taiwan - Taiwan has universal healthcare coverage with a mixture of universal insurance and self pay.  This article nicely summarizes the economic issues.

As with China, there are many small companies selling EHRs to local hospitals and clinician offices.  There's a long tradition of self-built systems as well.

Also, like China and Japan, most EHRs are client server, with little use of the web.

Privacy concerns restrict remote access, but I found the Taiwanese much more willing to embrace the internet and offer support for mobile devices, restricting information flows only to international locations because of privacy laws.

The hospitals I visited in Taiwan were high volume - 10,000 outpatients a day.  They implemented industrial process automation to help manage patient flow, laboratory specimen labeling, and medication dispensing.   I was impressed by their degree of EHR and ancillary system support.    Health Information Exchange and Personal Health Records are not widely used but there is a recognition of their importance for care coordination,

The challenges faced by Taiwan are an aging society, declining birth rate (.9), and ‘doctor shopping’ – patients visiting numerous practitioners simultaneously because of easy access to care at any facility without a primary care gatekeeper, creating a fractured medical record.

I look forward to further collaboration with my colleagues in Taiwan, helping create interoperability policy and technology to serve 23 million people.

In 12 days, I took 15 flights and worked long days to spend nearly 200 hours with government, academic and industry leaders.   I learned more than I taught.   Each country has its own unique history, culture and people.   However, the challenges of healthcare IT are very similar all over the world and the evolution that is taking place in our lifetime will ensure that Asia moves closer to the goal of  electronic health records for every citizen.