Assistant Professor of Law, National Central University, Taiwan
J.S.D. The University of Chicago Law Schooltgcn143@ibm.net
Director, Bureau of health planning Department of Health, Taiwan
M.D., Ph.D., Yale Univiersity
Assistant Research Fellow, Institute of Information Science, Academia Sinica, Taiwan
Ph.D., Yale University
As it has become one of the most important strategies to integrate medical and pharmaceutical services and develop health information networks for many countries' national information policies[1,2,3], Taiwan also initiated its health information network (HIN) project in 1987. With the deployment of national information infrastructure (NII) , HIN  has been put under remodeling for better performance. This paper will examine the HIN 2.0 proposed and promoted by the government in Taiwan both from technological and regulatory perspectives. Given its experiences in overcoming bandwidth, application and regulatory problems, an overall and detailed review on HIN 2.0 should be interesting to the world audience.
To further enhance the capacity of HIN and develop more applications on it, HIN2.0 has been proposed. The authors have been heavily involved with the advisory work of the HIN 2.0 project and therefore the paper would be a first-hand observation and commentary. As an interdisciplinary paper, it first reviews extensively the particular environment of creating a national health information network in Taiwan, the history of Taiwan's HIN, as well as the reasons why the HIN 2.0 has been proposed and constructed. It is followed by a detailed analysis on its potential applications, its impacts on the quality of medical services, as well as the regulatory issues that might become critical for its eventual success. Furthermore, this paper assesses the potential advantages and disadvantages of the HIN 2.0 based upon the above analysis. It is concluded by suggesting the major obstacles in the process of proposing and implementing health information network in countries like Taiwan and their feasible solutions. Given Taiwan's experiences in overcoming bandwidth, application and regulatory problems, this paper would be useful in helping people understand the most important issues for the creation of a national health information network. It would be particularly useful for us to understand what kind of special problems would emerge in the process of creating health information networks for countries similar to the situation of Taiwan.
NOW: HIN 1.0
In order to collect timely and accurate information from health agencies at all levels and numerous health and medical care institutions, the Government in Taiwan initiate a plan for the Establishment of National Health Information System in 1989. It is hoped that this will help improve the service quality of health and medical care. A pilot project was tested out in the Hsinchu medical care region in 1991-93. In 1994-96, the plan was extended to other regions in Taiwan. Currently, a follow-up implementation plan is under its way. Since then, an information network has built, which consists of three regional centers and a backbone with TCP/IP over frame-relay. Although it is supported successfully for public health administration ranging from hospital regulation to cancer registry, but as launched by the Health Ministry to reconstruct the infrastructure. Over the past two years of planning stage, MIEC was one of the major pilot projects.
It is worthwhile to mention that to improve the exchange and sharing of information, four regional information centers were created. The regional information centers construct a national health information network to serve as the information interchange stations of the HIN.
On this network, health and medical care institutions are able to transfer and exchange information directly with regional information centers. Health agencies are directly connected to each regional information centers. In addition, telemedical care systems for transmission of images have been set up, with the assistance of several university hospitals. In other words, the functions of the regional information centers at least include: transmission and searching of health and medical care information, online consultation and inquiries, as well as online training and promotion.
TCP/IP over frame relay is used to connect DOH, regional centers and National Health Insurance Bureau, serving as the backbone of HIN. Other institutes are connected to HIN with X.25 virtual private network, local dedicate phone lines or dial-in ports as shown in Fig 1. The users for HIN
are shown in Fig2.
There are several purposes for the establishment of HIN 1.0: to collect accurate and useful administrative information, to improve the timely handling and quality of public requests, to provide information for the formulation of health policies. However, although the government in Taiwan had spent two billion NT dollars (about 67 millions US dollars) in the past 12 years to build the health information network (HIN). Despite the considerable efforts, is seems that the HIN did not reach its goal to facilitate exchange of health information over the network. As a matter of fact, three problems are penetrate not enough bandwidth for multimedia application, obsolete application systems, and few medical applications.
First of all, insufficient bandwidth has deterred the full realization of HIN functions. As the network was designed for transferring text data, for today's purpose of the multimedia applications, higher bandwidth is needed. Second, low interoperatablity has become one of the major problems for the HIN. As most of the application programs and systems in use were developed before WWW era, the degree of interoperability is very low. We even found cases that one machine was dedicated for only one purpose. Therefore, future applications should be designed as web-based. Third, very few medical applications have been developed and used. Although it is called health information network, there are very few medical applications on it. Given its current applications, “health administration network” might be more appropriate. However, it is reasonable to say that more medical related applications could be expected once the bandwidth problem is solved and the common interface and platform are established.
With a total of $NT 2 billion spent, the NIH is however a partial success. It supported successfully for public health administration raging from hospital regulation to cancer registry, but only 13% of all health insurance claim was done online through the HIN and almost no function for patient referrals. Therefore a new 6-year project, HIN 2.0 was recently launched by the Health Ministry to reconstruct the infrastructure and enhance function originally proposed. New focuses includes VPN with an emphasis on security and privacy protection, life-long electronic health records, 24hrs access to records, health insurance smartcard, establishment of CA for all health professionals, public access to online information and a national virtual library for health.
To solve the three problems mentioned above, the department of health has proposed a two-stage, six-year project, Health Information Network 2.0 last year. As far as its purposes are concerned, HIN 2.0 will first try to solve its bandwidth and VPN problems, as well as revamp network resources of local health administration agencies. It also aims at the development of web-based models and more applications. Finally, HIN 2.0 will endeavor to undertake regulatory reforms in terms of legal standards and technological standards.
Until recently, HIN 2.0 has financed local health administration agencies to revamp and upgrade their network resources. In addition to the establishment of network management center, this project also complete the design of the HIN 2.0 technological architecture and fundamental applications. The HIN 2.0 has connected to the Internet and government service network (GSN). It also created a PharmaNet  as a testbed and a pilot project on electronic medical record.
There are three goals in HIN2.0, the first one is to build the health information administration network, the second is to establish the HIN network management center and to extend the health database, and the third is to establish the standards for health information to facilitate health data exchange and other applicaitons.
To build the health information administration network, the bandwidth and the quality of the communication network has to be upgraded and improved; the computing facility of local health centers has to be upgraded; and a new disease control information system will be developed. We have to establish HIN network management center and extend the health database so that the utilization rate of HIN can be increased and various public available health database can be integrated.
After one year of effort, we have subsided local health centers to upgrade their computing facilities, connect them to the Internet and GSN. We established the HIN network management center, integrated the disease control information system, and studied the mechanism to insure the integrity of electronic patient record. A pilot study to connect pharmacies has connected 33 pharmacies in Taipei area. To study the feasibility of interchange patient medical record over the computer network, MIEC (medical information exchange center) project has been funded and connected several hospitals for pilot study. The system architecture of MIEC is shown in Fig 3.
Lesson Learned from HIN of Taiwan
In addition to the bandwidth problem mentioned in the above, we have witnessed how the HIN operates in the past few years. Also, some problems of the HIN have been detected and identified. Whether good or bad, these lessons learned from the past are significant for the future of HIN and therefore it is worthwhile to examine their implications.
First of all, the applications of the HIN include three major parts: public health service, national health insurance, as well as private health service. Under the HIN 2.0, how to make the best use of information technology in the above three fields to enhance the quality of medical service will be determinative for its success.
Second, one of the most fundamental problems arising for the past experiences of the HIN is its lack of universality. In particular, the use of HIN in public health service and private health service has not been sufficiently popular. To find solutions in this respect, user education has become one of the primary missions before the full potential of the HIN could be realized. More specifically, personnel of local health agencies and institutions need more education and training in their mastering of information technology. In addition, telemedical services should be more decentralized so that more people could benefit from the HIN 2.0.
Third, the development of HIN 2.0 has also aimed at the control of medical costs and the improvement of medical quality both in rural, suburban and remote areas. To obtain this goal, economic incentives should be created for users to replace or upgrade their systems to accommodate the performance requirement of the HIN 2.0. How this goal could be reached is another significant task for the department in charge of the HIN 2.0.
Fifth, it has been expected that the HIN 2.0 will have positive impacts upon the information technology in medical care uses and consequently the development of local industry in health and medical care applications or technical standards. However, given that Taiwan has very limited experiences in this regard, it seems whether this will become true in the near future is at best in doubt.
As one of the most fundamental infrastructures for Taiwan's information policy, whether the HIN 2.0 will become successful is crucial for the future of health and medical qualities in Taiwan. As this paper has analyzed, the HIN 2.0 is not only a government-oriented project, it is never an overstatement to say that more participation and cooperation are necessary for it to succeed. Moreover, the HIN 2.0 has presented significant implications not only in terms of a technical network, but also in the sense of a legal network. In other words, regulatory issues such as information security and privacy should be clarified so that the balance of medical service quality and individual autonomy of patients could be struck delicately. Finally, Taiwan is an island country whose development of information technology and growth of information technology industry both have proved to be impressive. At the same time, its experience in the use of information technology in health and medical care is not as mature as those of western countries such as U.S.A. and Canada. Taiwan's experiences in its HIN has, we believe, set up an example for any country who is at the similar status of Taiwan's health care system and plans to develop or improve its own health care network. This sharing of information and experience on establishing national health information networks will therefore enhance the use of information technology in health care and the medical care quality in the global sense.
 Australia : http://www.telehealth.org.au/
 Canada : http://www.hinetbc.org/telehealth/telehealth.html
 Britain : http://www.nhsia.nhs.uk/
 Yu-Chuan Li Hsu-Sung Kuo , Wen-Shan Jian, Dah-Dian Tang, Chien-Tsai Liu, Li Liu, Chien-Yeh Hsu, Yong-Kok Tan “Building a Generic Architecture for Medical Information Exchange among Healthcare Providers” To appear in International Journal of Medical Informatics.