Metadata Correction: Importance-Performance Analysis of Personal Health Records in Taiwan: A Web-Based Survey.

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Importance-Performance Analysis of Personal Health Records in Taiwan: A Web-Based Survey.

BACKGROUND: Empowering personal health records (PHRs) provides basic human right, awareness, and intention for health promotion. As health care delivery changes toward patient-centered services, PHRs become an indispensable platform for consumers and providers. Recently, the government introduced "My health bank," a Web-based electronic medical records (EMRs) repository for consumers. However, it is not yet a PHR. To date, we do not have a platform that can let patients manage their own PHR. OBJECTIVE: This study creates a vision of a value-added platform for personal health data analysis and manages their health record based on the contents of the "My health bank." This study aimed to examine consumer expectation regarding PHR, using the importance-performance analysis. The purpose of this study was to explore consumer perception regarding this type of a platform: it would try to identify the key success factors and important aspects by using the importance-performance analysis, and give some suggestions for future development based on it. METHODS: This is a cross-sectional study conducted in Taiwan. Web-based invitation to participate in this study was distributed through Facebook. Respondents were asked to watch an introductory movie regarding PHR before filling in the questionnaire. The questionnaire was focused on 2 aspects, including (1) system functions, and (2) system design and security and privacy. The questionnaire would employ 12 and 7 questions respectively. The questionnaire was designed following 5-points Likert scale ranging from 1 ("disagree strongly") to 5 ("Agree strongly"). Afterwards, the questionnaire data was sorted using IBM SPSS Statistics 21 for descriptive statistics and the importance-performance analysis. RESULTS: This research received 350 valid questionnaires. Most respondents were female (219 of 350 participants, 62.6%), 21-30 years old (238 of 350 participants, 68.0%), with a university degree (228 of 350 participants, 65.1%). They were still students (195 out of 350 participants, 56.6%), with a monthly income of less than NT $30,000 (230 of 350 participants, 65.7%), and living in the North Taiwan (236 of 350 participants, 67.4%), with a good self-identified health status (171 of 350 participants, 48.9%). After performing the importance-performance analysis, we found the following: (1) instead of complex functions, people just want to have a platform that can let them integrate and manage their medical visit, health examination, and life behavior records; (2) they do not care whether their PHR is shared with others; and (3) most of the participants think the system security design is not important, but they also do not feel satisfied with the current security design. CONCLUSIONS: Overall, the issues receiving the most user attention were the system functions, circulation, integrity, ease of use, and continuity of the PHRs, data security, and privacy protection.

Factors influencing consumer adoption of USB-based Personal Health Records in Taiwan.

BACKGROUND: Usually patients receive healthcare services from multiple hospitals, and consequently their healthcare data are dispersed over many facilities' paper and electronic-based record systems. Therefore, many countries have encouraged the research on data interoperability, access, and patient authorization. This study is an important part of a national project to build an information exchange environment for cross-hospital digital medical records carried out by the Department of Health (DOH) of Taiwan in May 2008. The key objective of the core project is to set up a portable data exchange environment in order to enable people to maintain and own their essential health information.This study is aimed at exploring the factors influencing behavior and adoption of USB-based Personal Health Records (PHR) in Taiwan. METHODS: Quota sampling was used, and structured questionnaires were distributed to the outpatient department at ten medical centers which participated in the DOH project to establish the information exchange environment across hospitals. A total of 3000 questionnaires were distributed and 1549 responses were collected, out of those 1465 were valid, accumulating the response rate to 48.83%. RESULTS: 1025 out of 1465 respondents had expressed their willingness to apply for the USB-PHR. Detailed analysis of the data reflected that there was a remarkable difference in the "usage intention" between the PHR adopters and non-adopters (χ2 =182.4, p < 0.001). From the result of multivariate logistic regression analyses, we found the key factors affecting patients' adoption pattern were Usage Intention (OR, 9.43, 95%C.I., 5.87-15.16), Perceived Usefulness (OR, 1.60; 95%C.I., 1.11-2.29) and Subjective Norm (OR, 1.47; 95%C.I., 1.21-1.78). CONCLUSIONS: Higher Usage Intentions, Perceived Usefulness and Subjective Norm of patients were found to be the key factors influencing PHR adoption. Thus, we suggest that government and hospitals should promote the potential usefulness of PHR, and physicians should encourage patients' to adopt the PHR.

The Taiwanese method for providing patients data from multiple hospital EHR systems.

Personal Health Record (PHR) systems are growing in popularity and are receiving increased attention from the Biomedical Informatics research community. Information Collection is one PHR research topic and includes system functionality that helps patients retrieve their data from external sources. One of the most potentially useful external sources of information is the data stored in patients' EHRs at medical institutions. PHR systems that support Information Collection from EHR systems are thus interesting to investigate. In this paper we present PHR system that allows patients to receive data from 10 participating hospitals in Taiwan via a USB flash memory device. The overall design goals and architecture for the system are presented. Based on our experiences in designing and implementing the system we propose a three step method for accomplishing Information Collection from EHR systems at medical institutions for similar PHR systems in the future.

An Assessment of the Interoperability of Electronic Health Record Exchanges Among Hospitals and Clinics in Taiwan.

BACKGROUND: The rapid aging of the Taiwanese population in recent years has led to high medical needs for the elderly and increasing medical costs. Integrating patient information through electronic health records (EHRs) to reduce unnecessary medications and tests and enhance the quality of care has currently become an important issue. Although electronic data interchanges among hospitals and clinics have been implemented for many years in Taiwan, the interoperability of EHRs has not adequately been assessed. OBJECTIVE: The study aimed to analyze the efficiency of data exchanges and provide suggestions for future improvements. METHODS: We obtained 30 months of uploaded and downloaded data of EHRs among hospitals and clinics. The research objects of this study comprised 19 medical centers, 57 regional hospitals, 95 district hospitals, and 5520 clinics. We examined 4 exchange EHR forms: laboratory test reports, medical images, discharge summaries, and outpatient medical records. We used MySQL (Oracle Corporation) software (to save our data) and phpMyAdmin, which is a Personal Home Page program, to manage the database and then analyzed the data using SPSS 19.0 statistical software. RESULTS: The quarterly mean uploaded volume of EHRs among hospitals was 52,790,721 (SD 580,643). The quarterly mean downloaded volume of EHRs among hospitals and clinics was 650,323 (SD 215,099). The ratio of uploaded to downloaded EHRs was about 81:1. The total volume of EHRs was mainly downloaded by medical centers and clinics, which accounted for 53.82% (mean 318,717.80) and 45.41% (mean 269,082.10), respectively, and the statistical test was significant among different hospital accreditation levels (F2=7.63; P<.001). A comparison of EHR download volumes among the 6 National Health Insurance (NHI) branches showed that the central NHI branch downloaded 11,366,431 records (21.53%), which was the highest, and the eastern branch downloaded 1,615,391 records (3.06%), which was the lowest. The statistical test among the 6 NHI branches was significant (F5=8.82; P<.001). The download volumes of laboratory tests reports and outpatient medical records were 26,980,425 (50.3%) and 21,747,588 records (40.9%), respectively, and were much higher than medical images and discharge summaries. The statistical test was also significant (F=17.72; P<.001). Finally, the download time showed that the average for x-rays was 32.05 seconds, which was the longest, and was 9.92 seconds for electrocardiogram, which was the shortest, but there was no statistically significant difference among download times for various medical images. CONCLUSIONS: After years of operation, the Electronic Medical Record Exchange Center has achieved the initial goal of EHR interoperability, and data exchanges are running quite stably in Taiwan. However, the meaningful use of EHRs among hospitals and clinics still needs further encouragement and promotion. We suggest that the government's leading role and collective collaboration with health care organizations are important for providing effective health information exchanges.

Increased risk of cholesteatoma among patients with allergic rhinitis: A nationwide investigation.

OBJECTIVES: No large population-based studies have reported on the risk of cholesteatoma developing after allergic rhinitis (AR). This study used a nationwide population-based claims database to investigate the hypothesis that AR may increase the risk of cholesteatoma. STUDY DESIGN: Retrospective cohort study. METHODS: Data from Taiwan's Longitudinal Health Insurance Database were analyzed to compile the following: 1) 15,953 patients newly diagnosed with AR between 1997 and 2000, and 2) a comparison cohort of 63,812 matched non-AR enrollees (with a ratio of 1 to 4). Each patient was followed for 10 years to identify cases in which cholesteatoma subsequently developed. The Kaplan-Meier method was used to determine the cholesteatoma-free survival rate, and the log-rank test was used to compare survival curves. Cox proportional hazard regressions were performed to compute adjusted hazard ratios (HRs). RESULTS: Among the 79,765 patients enrolled in this study, 45 (159,364 person-years) from the AR cohort and 88 (638,130 person-years) from the comparison cohort were diagnosed with cholesteatoma during the follow-up period (incidence rates 0.28 and 0.14 of 1,000 person-years, respectively). Patients with AR were more likely to develop cholesteatoma compared to those without AR (adjusted HR 1.57, 95% confidence interval = 1.05-2.34, P < 0.05). Patients with AR presented a significantly lower 10-year cholesteatoma-free survival rate than did those in the comparison group (log-rank, P < 0.001). CONCLUSION: This is the first study to demonstrate a link between AR and the development of cholesteatoma. We suggest that clinicians keep this association in mind and carefully investigate the possibility of development of cholesteatoma among patients with AR. LEVEL OF EVIDENCE: 3b. Laryngoscope, 128:547-553, 2018.

Scientific production of electronic health record research, 1991-2005.

PURPOSE: The increasing numbers of publications on electronic health record (EHR) indicate its increasing importance in the world. This study attempted to quantify the scientific production of EHR research articles, and how they have changed over time, in an effort to investigate changes in the trends cited in these critical evaluations. METHOD: The articles were based on the science citation index (SCI) from 1991 to 2005. A descriptive study was performed using the 1803 documents published in the SCI from 39 countries in America, Europe, Africa, Asia, and Oceania. The evaluation was based on parameters including document type, language, first author's country of origin, number of citations and citations per publication. RESULTS: Of all publications, 1455 (80.7%) were articles, followed by meeting abstracts which represented about one-tenth of all types of EHR publications. Numbers of published articles have significantly increased when compared by each 5-year period. Most articles were published in English (98%) and were from the region of America (57%). The top 10 of the 374 journals accounted for 41% of the number of published articles. The US dominates publication production (57%) with a cumulative impact factor (IF) of 2227 and followed by the UK (8.5%, with a cumulative IF of 257.0) and the Netherlands (7.8%, with a cumulative IF of 211.1). An analysis of the number of articles related to population revealed a high publication output for relative small countries like Switzerland, the Netherlands, and Norway. CONCLUSIONS: Research production in EHR showed a considerable increase during 1991-2005. The production was dominated by articles, those from the US, and those published in English. The production came from many countries, denoting the devotion to this field in different areas around the world.

Building a portable data and information interoperability infrastructure-framework for a standard Taiwan Electronic Medical Record Template.

Traditional electronic health record (EHR) data are produced from various hospital information systems. They could not have existed independently without an information system until the incarnation of XML technology. The interoperability of a healthcare system can be divided into two dimensions: functional interoperability and semantic interoperability. Currently, no single EHR standard exists that provides complete EHR interoperability. In order to establish a national EHR standard, we developed a set of local EHR templates. The Taiwan Electronic Medical Record Template (TMT) is a standard that aims to achieve semantic interoperability in EHR exchanges nationally. The TMT architecture is basically composed of forms, components, sections, and elements. Data stored in the elements which can be referenced by the code set, data type, and narrative block. The TMT was established with the following requirements in mind: (1) transformable to international standards; (2) having a minimal impact on the existing healthcare system; (3) easy to implement and deploy, and (4) compliant with Taiwan's current laws and regulations. The TMT provides a basis for building a portable, interoperable information infrastructure for EHR exchange in Taiwan.

Predicting intentions of nurses to adopt patient personal health records: A structural equation modeling approach.

OBJECTIVE: The American Nurses Association endorsed the use of online patient personal health records (PHRs) and challenged all nurses to obtain the health records of patients. However, few studies have explored the factors associated with the intentions of nurses to use patient PHRs. Our study used an extended technology acceptance model, with the theory of planned behavior and perceived credibility, to explore factors associated with the intentions of nurses to use patient PHRs. METHODS: This cross-sectional quantitative study comprised a sample of 635 nurses who had worked full time for at least 3 months, and they were recruited from three hospitals affiliated with a university in northern Taiwan. We used a questionnaire to obtain information on perceived usefulness, perceived ease of use, perceived credibility, subjective norms, computer self-efficacy, attitudes, and intentions to use patient PHRs. RESULTS: This study indicated that perceived usefulness, computer self-efficacy, and subjective norms significantly and positively affected intentions to use patient PHRs. The attitudes of nurses toward PHR adoption directly influenced their intentions to use patient PHRs. Moreover, subjective norms indirectly affected intentions to use patient PHRs through the factor of attitudes. The proposed model explained 82.1% of the variance in the intentions of nurses to use patient PHRs. CONCLUSIONS: Subjective norms had stronger total effects on the attitudes and intentions of nurses to use patient PHRs than perceived usefulness, perceived ease of use, or perceived credibility did. The results may help practitioners further understand that the attitudes of nurses toward using patient PHRs are influenced by peer groups and administrators. The current study provides evidence that peer groups influence the attitudes of nurses to use patient PHRs, which in turn influence their intentions toward PHR adoption.

Costs of staged versus simultaneous bilateral total knee arthroplasty: a population-based study of the Taiwanese National Health Insurance Database.

BACKGROUND: Bilateral total knee arthroplasty (TKA) is required for many patients. There are few studies comparing the overall costs of staged and simultaneous bilateral TKA. METHODS: The Taiwan National Health Insurance Research Database (NHIRD) was searched, and the total medical costs of 452 patients who received simultaneous bilateral TKAs were compared with those of 690 who received staged bilateral TKAs. RESULTS: All categories of medical costs were lower in the simultaneous TKA group, with the exception of therapeutic procedure fees which were higher in the simultaneous bilateral TKA group. The 10-year prosthesis survival rates for simultaneous and staged bilateral TKA were 90.9% and 87.5% (p > 0.05), respectively. CONCLUSIONS: These results indicate that simultaneous bilateral TKA is more cost effective than staged bilateral TKA. Prosthesis survival is not affected by the choice for staged or simultaneous bilateral TKA.

The relationship between usage intention and adoption of electronic health records at primary care clinics.

OBJECTIVE: Despite of emerging evidence that electronic health records (EHRs) can improve the clinical quality, enhances patient safety and efficiency. Most physicians in primary health care clinics in the Taiwan do not currently adopt EHR at their clinic practices. We aim to measure the relationship between usage intention and adoption behavior. STUDY DESIGN AND METHODS: We used structured questionnaires distributed both EHRs adopter and non-adopter group to the primary health care physicians which participated in the DOH project to establish the information exchange environment across Taiwan. The response rate of adopter and non-adopter is 54.7% and 55.0% respectively. MEASUREMENTS: EHRs adoption behavior. RESULTS: The EHRs adopter group has higher intention than non-adopter (p=0.003). From the result of logistic regression analyses, we found the key factors affecting physicians' adoption pattern were intention to use (OR: 2.85; 95% CI: 2.30-3.54). In addition, higher perceived usefulness (OR: 1.29; 95% CI: 1.06-1.56) and perceived ease to use (OR: 1.48; 95% CI: 1.22-1.79) increase adoption of EHR found. CONCLUSION: The intention to use EHR, perceived usefulness and ease to use of primary care physicians were found as key factors influencing EHRs adoption. Thus, we suggest that government should promote the potential benefits of EHR and enhance physicians' willingness to adopt the EHRs at their clinic practices.

Association between surgeon and hospital volume in coronary artery bypass graft surgery outcomes: a population-based study.

BACKGROUND: We have found no study conducted outside of the United States on the association between physician volume and patient outcomes after coronary artery bypass graft surgery. The aim of this study is to examine the association between surgeon-hospital coronary artery bypass graft volume and patient outcomes using three-year population-based data on Taiwan. METHODS: This study uses the Taiwan National Health Insurance Research Database covering the period 2000 to 2002, with the study sample comprising 9,895 first-time coronary artery bypass graft admissions, treated by 316 surgeons in 46 hospitals. RESULTS: Of the sampled patients, 356 (3.6%) were discharged after death. Those patients treated by low-volume (1-50 cases) surgeons had significantly higher mortality rates than those treated by medium-volume (51-100 cases) surgeons (7.0% vs 3.8%), high-volume (101-150 cases) surgeons (7.0% vs 2.7%), or very-high-volume (> or = 151 cases) surgeons (7.0% vs 3.2%). However, hospital coronary artery bypass graft volume alone is an insufficient predictor of hospital in-patient deaths (p = 0.078). The adjusted odds ratio of hospital in-patient deaths declined with increasing surgeon volume, with the odds of in-patient death for those patients treated by low-volume surgeons being 1.52 times those of medium-volume surgeons, 1.89 times those of high-volume surgeons, and 2.04 times those of very-high-volume surgeons. CONCLUSIONS: We conclude that for all coronary artery bypass graft surgeries taking place in Taiwan, the skill and experience of individual surgeons is a more critical factor for patient outcome than either hospital equipment or surgical teams.

WHOQOL-BREF as predictors of mortality: a two-year follow-up study at veteran homes.

The main purpose of this study was to evaluate the effectiveness of the brief version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire as a predictor of mortality amongst the elderly. A total of 689 male residents of veteran homes, all above the age of 65 years, were randomly selected in 2001. The Taiwan version of the WHOQOL-BREF was administered as the baseline, with each of these subjects being interviewed and subsequently followed up for mortality until the end of 2003. Data on self-reported global health, life satisfaction, medical status, physical performance and health behavior was also collected. Following the death of 105 of the 689 subjects during the 2-year follow-up period, the relative risk (RR) of death was subsequently assessed using Cox's proportional hazard regression analyses. After adjusting for other predictors (age group, chronic diseases, emergency visits, hospitalization, physical performance, regular exercise, self-reported global health and life satisfaction), almost all of the WHOQOL-BREF items and domains failed to predict mortality; the one exception was working capacity levels (score 1-2 vs. score 4-5) which, after adjusting for other predictors, did demonstrate the ability to predict mortality (RR = 1.96, p < 0.05).

Length of stay and costs for asthma patients by hospital characteristics--a five-year population-based analysis.

This study sets out to explore the relationship between hospital characteristics, asthma length of stay (LOS), and costs per discharge. The study adopts hospitalization data from the Taiwan National Health Insurance Research Database covering the period from 1997 to 2001. Study subjects were identified from the database by principal diagnosis of asthma or asthmatic bronchitis, with a total of 139,630 cases being included in the study. Multiple-regression analyses were performed to explore the relationship between LOS, costs per discharge and hospital characteristics, adjusting for age, gender, and discharge status of patients, as well as complications or comorbidities. The regression analyses showed that, compared with district hospitals, medical centers and regional hospitals have longer and more statistically significant LOS, as well as higher costs. Hospitals operating on a for-profit basis have shorter LOS and lower costs than public and not-for-profit hospitals. This study shows the existence of wide variations in LOS and costs per discharge for asthma hospitalizations, between the various types of hospitals in Taiwan.