Blue Skies Ahead?

Forty-eight of Taiwan’s townships and municipal districts are located in mountainous areas or on outlying islands, and each has its own public health center (PHC). According to the Department of Health (DOH), these PHCs collectively provide services to some 370,000 people, many of whom are elderly Aborigines in great need of healthcare.

However, such centers have only limited staff (they average only two doctors each), which prevents them from offering the kind of comprehensive specialist care available on Taiwan’s plains. In an effort to provide more comprehensive service to township residents, PHCs utilize a system that sends medical personnel on rounds of the villages under their care.

The transmission of medical data over the Internet and the sharing of that data via the cloud are turning out to be crucial to providing better care in remote areas. The DOH chose Fu­xing Township, which accounts for one-third of Tao­yuan’s geographic area, as a pilot location for its cloud-medicine program in part on the principle that it should begin the rollout where problems are the most pressing.

Patients in Fuxing Township are largely Aborigines and predominantly elderly, with many suffering from chronic illnesses. By making the rounds of villages, township medical staff make healthcare more readily available to their patients. In the photo, residents of Kuihui Village await treatment.

It is a chilly 9° Celsius on Fu­xing’s Mt. Lala in the early morning of New Year’s Eve. Mrs. Yang, an Atayal woman, awakens her son in their Hua­ling Village home, and reminds him he needs to see the doctor at school today. It’s important that he remember because today is the day the doctor from the PHC halfway down the mountain will be at the school.

For roughly 15,000 Fu­xing resi­dents, nearly 70% of whom are Atayal, the PHC is the most convenient place to see a doctor, pick up medications, have their infants inoculated, and get flu vaccines for the elderly. A trip down to the plains for care means a drive of at least two hours. To make it a bit easier for township residents to receive care, one of the PHC’s doctors makes rounds of its 10 villages while the other holds down the fort at the PHC itself.

At just past 8 a.m., the PHC is already busy. Employees are loading the supplies they’ll need for their “rounds” into the center’s service vehicle. These include several boxes of pharmaceuticals and examination equipment, and three notebook computers, one each for registrations, examinations, and prescriptions. All of this gear enables examinations to be carried out just as they would be at a major hospital.

Today, Dr. Lin De­wen, an internist and the director of the Fu­xing PHC, will be making the rounds. On the road by 8:30 with two nurses and a pharmacist, the team will be visiting Ye­heng, a hamlet under the jurisdiction of San­guang Village, and Guang­hua, a hamlet administered by Hu­ling Village, the two most remote sites on the Fu­xing Township medical circuit.

Once they enter a hamlet and get connected to the network, the remoteness and 600 or 700-meter difference in altitude cease to be hindrances to care. Instead, the network provides the doctor with instant access to patient records on the center’s servers, and the ability to update them with any diagnoses and prescriptions made today.

“This is our ‘little cloud,’” says Dr. Lin, himself an Atayal from Li­shan, Tai­chung. His “little cloud” is a system that enables the laptops making the rounds to share medical records with the center’s servers.

Lin and his colleagues continue their rounds of Fu­xing’s mountain hamlets after the New Year’s holidays are over, again making use of their “little cloud.”

In the examining room in Kui­hui Village, a Ms. Lin makes an appointment for her four-year-old son to get a vaccination, while Li A-mei, a 77-year-old diabetic, drops in to have her blood tested and pick up her medications.

The medical team’s next stop is Gao­rao, a Chang­xing Village hamlet that’s about 50 minutes by car from the PHC. Here they see the 80-year-old Grandma Ceng, who has come in for the results of a blood test, and a Mrs. ­Huang, who moved back to the hamlet seven years ago and has come to have her grandson, who has a runny nose, looked at. Since she’s already here, Mrs. ­Huang also plans to have her blood pressure checked. With the help of a 3G network card and the “little cloud,” Dr. Lin enters all of his notes directly into his patients’ records.

Dr. Lin’s “little cloud” has now been in operation for about four years.

One doctor, two nurses and three laptop computers… The Fuxing Township Public Health Center medical team utilizes cloud technology to access the medical resources of the plains while making the rounds of remote villages.

Aiming to improve the quality of care in remote areas, in 2006 the DOH began promoting the construction of Hospital Information Systems (HIS) and Picture Archiving and Communication Systems (PACS) in the 48 townships and districts in Taiwan’s mountainous areas and on its outlying islands. These systems are helping to raise the quality of care in these localities towards those of hospitals in Taiwan’s more developed areas.

The Fu­xing PHC completed its HIS/PACS in 2009, and has achieved especially good results with its PACS. Dr. Lin explains that the system allows you to send digital X-ray images straight to the Image Reading Center at Tao­yuan General Hospital with a request to have a radiologist there examine them and send back a report immediately. The frontline doctor can then use this report in conjunction with the patient’s current condition to determine whether the patient needs to travel to the plains for further treatment.

In other words, the PACS has enabled more accurate interpretation of X-rays, allowing patients whose condition is serious to seek treatment in the plains within the so-called “golden hour,” patients whose condition is less severe to save themselves a long and unnecessary trip, and the system to avoid redundant care.

Given that residents of Taiwan’s mountain areas and outlying islands receive free medical care at their local PHCs, the Fu­xing PHC estimates that from 2009 to 2012, its HIS/PACS program saved its patients nearly NT$4 million in expenditures on registration fees, National Health Insurance co-pays, and transportation to and treatment outside the township, not to mention nearly 3,000 days of sick leave that would otherwise have been used seeking care at more distant locations.

Lin stresses that medical information systems bring convenience, as well as savings in time and money, to Taiwan’s remote areas. The key, he says, is communication.

“We already have a good superstructure [the HIS], but we could still use some help with broadband infrastructure.” He adds: “The quality of our connection determines the quality of our service.”

Before making their rounds of mountain villages, township medical personnel have to pack up the gear and supplies they’ll need, including pharmaceuticals, testing equipment, and three laptop computers with wireless Internet access.

But even a perfect Internet connection doesn’t eliminate every problem. For example, when mountain residents have to seek treatment down on the plains, how do they get the reports on their condition and medications back to their local PHC to facilitate follow-on care and health management? Is there no alternative to requesting the hospital that treated them to make physical copies for them to hand carry back to the PHC?

In March 2012, the Department of Health established an inter-hospital electronic medical records exchange mechanism that operates via a government-created medical cloud. With a patient’s consent, the system enables hospitals and clinics to exchange the patient’s discharge summary, blood-test and medical-imaging reports, and treatment and pharmaceutical-use records. Given that the United States was able to reduce its medical costs by 10% through the use of electronic medical records, the DOH estimates that its medical cloud will save Taiwan some NT$50 billion per year in healthcare expenditures.

One of the reasons that the DOH chose Fu­xing for the pilot study of its cloud-based electronic medical records exchange system was Fu­xing’s success with HIS/PACS. Fu­xing began its rollout of the new cloud system, the first by a township PHC, in December 2012.

Lin says that prior to the system’s introduction, PHC doctors had a hard time providing medications to patients who had received treatment for a chronic condition in the plains. Patients often weren’t familiar with their medications, requiring PHC doctors to guess at their pharmaceutical use based on either what was printed on the bag in which medicines had previously been dispensed (if the patient had happened to bring it in) or on the patient’s descriptions of the medication’s appearance. Patient care suffered as a result.

Fortunately, the DOH says that 142 hospitals across Taiwan are currently connected to the records system, including 19 major medical centers. Now, when a patient presents an NHI card and signs a consent form, care providers can use the system to review the patient’s medical records from other hospitals. This ensures continuity of care for patients receiving treatment at more than one facility.

However, Lin observes that with cloud-based exchanges of medical records just entering the pilot stage and without a legal basis for compelling compliance, large hospitals that participate can choose to exchange only very limited information. That is, they can use their possession of patients’ medical records to hold patients hostage.

After 10 years laying the groundwork for electronic medical records, the government has now rolled out phase one of the medical cloud. But we still have a long way to go before we discover how much sharing of medical records and resources will actually occur and whether this sharing will ultimately improve patient care.