Background: Medical referral is the transfer of a patient’s care from one physician to another upon request. This process involves multiple steps that require provider-to-provider and provider-to-patient communication. In Taiwan, the National Health Insurance Administration (NHIA) has implemented a national medical referral (NMR) system, which encourages physicians to refer their patients to different health care facilities to reduce unnecessary hospital visits and the financial stress on the national health insurance. However, the NHIA’s NMR system is a government-based electronic medical referral service, and its referral data access and exchange are limited to authorized clinical professionals using their national health smart cards over the NHIA virtual private network. Therefore, this system lacks scalability and flexibility and cannot establish trusting relationships among patients, family doctors, and specialists. Objective: To eliminate the existing restrictions of the NHIA’s NMR system, this study developed a scalable, flexible, and blockchain-enabled framework that leverages the NHIA’s NMR referral data to build an alliance-based medical referral service connecting health care facilities. Methods: We developed a blockchain-enabled framework that can integrate patient referral data from the NHIA’s NMR system with electronic medical record (EMR) and electronic health record (EHR) data of hospitals and community-based clinics to establish an alliance-based medical referral service serving patients, clinics, and hospitals and improve the trust in relationships and transaction security. We also developed a blockchain-enabled personal health record decentralized app (DApp) based on our blockchain-enabled framework for patients to acquire their EMR and EHR data; DApp access logs were collected to assess patients’ behavior and investigate the acceptance of our personal authorization-controlled framework. Results: The constructed iWellChain Framework was installed in an affiliated teaching hospital and four collaborative clinics. The framework renders all medical referral processes automatic and paperless and facilitates efficient NHIA reimbursements. In addition, the blockchain-enabled iWellChain DApp was distributed for patients to access and control their EMR and EHR data. Analysis of 3 months (September to December 2018) of access logs revealed that patients were highly interested in acquiring health data, especially those of laboratory test reports. Conclusions: This study is a pioneer of blockchain applications for medical referral services, and the constructed framework and DApp have been applied practically in clinical settings. The iWellChain Framework has the scalability to deploy a blockchain environment effectively for health care facilities; the iWellChain DApp has potential for use with more patient-centered applications to collaborate with the industry and facilitate its adoption.

Clinical informatics, decision support for health professionals, electronic health records, and ehealth infrastructures.

Background: The global nursing shortage, exacerbated by heavy workloads and high turnover rates associated with the COVID-19 pandemic, continues to undermine care quality and nurse well-being. Although digital health technologies have enhanced coordination, improved communication, and reduced clinical errors in nursing practice, they have also increased nurses’ documentation burden. Advances in large language models (LLMs) and other generative artificial intelligence (GenAI) tools facilitate the generation of accurate reports from electronic medical records (EMRs), thereby streamlining documentation workflows, saving time, and reducing nurses’ workloads. Accordingly, integrating LLMs into electronic nursing documentation systems warrants further exploration. Objective: This study examines the integration of an LLM into an in-house nursing information system (NIS) implemented across 3 hospitals in Taiwan to reduce the time and effort required for nursing handover documentation and to preliminarily assess the operational and economic implications of GenAI-assisted workflows. Methods: A multidisciplinary team of nursing specialists and information technology experts at Taipei Medical University (TMU) restructured the organization’s existing nursing handover documentation process to facilitate interaction with the LLM. The team also developed prompt-based interfaces to automatically generate section-specific content for the nursing handover document. The LLM-integrated NIS was subsequently deployed across 3 hospitals in Taiwan: Taipei Medical University Hospital (TMUH), Wan Fang Hospital (WFH), and Shuang Ho Hospital (SHH). We then extracted and analyzed NIS log data to compare documentation times before and after LLM implementation, thereby quantifying time savings. Results: Integration of the LLM into nursing handover documentation was associated with shorter per-patient documentation time in routine clinical use across TMUH, WFH, and SHH. Based on preintegration NIS logs (September 2024), the average handover document completion time per patient ranged from 3.45 (SD 3.82) to 4.32 (SD 4.48) minutes across hospitals and shifts, providing a preliminary baseline for subsequent comparisons. In postintegration NIS logs (October-December 2024), the overall handover document completion time per patient (mean) was substantially lower, ranging from 1.17 (SD 1.86) to 2.54 (SD 2.82) minutes across hospitals and shifts. Using monthly patient volume to estimate time savings, 113-273, 160-314, and 198-391 hours were saved per month at TMUH, WFH, and SHH, respectively, corresponding to aggregate savings of 474-981 hours per month across hospitals during the study period. Conclusions: We integrated an LLM into an NIS to generate nursing handover documents without altering existing workflows. Across 3 hospitals within TMU’s health system, GenAI assistance was associated with shorter documentation time and a positive net labor value from October to December 2024. Prompts were constrained, and nurse verification was required to mitigate hallucinations. Future work will enhance logging to capture reliability and editing metrics, compare LLM-generated drafts with nurse-finalized notes to inform prompt refinement, and assess generalizability to other documentation workflows.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Influenza is a leading global cause of death and contributes to heavy economic losses to individuals and communities. Early prediction of and interventions against influenza epidemics are essential to reduce mortality and morbidity. As in other countries, the Taiwan Centers for Disease Control and Prevention (TWCDC) has implemented influenza surveillance and reporting systems, which mainly rely on influenza-like illness (ILI) data reported by healthcare providers for early prediction of influenza epidemics. However, these surveillance and reporting systems have at least a 2-week delay, leaving room for improvement. Objective: We aimed to integrate the TWCDC’s ILI data with the electronic medical records (EMRs) of multiple Taiwan hospitals. Our overall goal in doing so was to develop a more accurate and efficient tool for national influenza trend prediction than that available currently. Methods: First, surveillance variables relevant to the prediction of influenza epidemics were identified by the influenza expertise team at the Taipei Medical University Healthcare System (TMUHcS). Second, we developed a framework for integrating hospital EMR data with the ILI data from the TWCDC website. Third, we used Pearson correlation coefficients to measure the strength of the linear relationship between the TMUHcS’s EMR data and TWCDC’s ILI data (including regional and national ILI data) for two weekly time series datasets. Lastly, we evaluated the predictive power of each surveillance variable for influenza epidemics using the Moving Epidemic Method (MEM) analyzes. Results: For the past three influenza seasons (October 2014 to September 2017), three surveillance variables (TMUHcS-ILI, TMUHcS-RITP, and TMUHcS-IMU, reflecting patients with ILI, those with positive results from rapid influenza diagnostic tests, and those treated with antiviral drugs, respectively) were identified from the EMRs of multiple hospitals and showed strong correlations with the TWCDC’s regional and national ILI data (r = 0.86–0.98). Two surveillance variables (TMUHcS-RITP and TMUHcS-IMU) showed predictive power for influenza epidemics 3–4 weeks prior to an increase in TWCDC ILI reports. Conclusions: This framework integrates surveillance data from multiple hospitals and the TWCDC website. It could be easily extended to other infectious diseases, mitigating the time and effort required for data collection and analysis. Furthermore, this approach could be developed as a cost-effective electronic surveillance tool for early and accurate prediction of epidemics of influenza as well as other infectious diseases in densely populated regions and nations.

The National Health Insurance Administration (NHIA) has adopted smart cards (or NHI-IC cards) as health cards to carry patients’ medication histories across hospitals in Taiwan. The aims of this study are to enhance a computerized physician order entry system to support drug-drug interaction (DDI) checking based on a patient’s medication history stored in his/her NHI-IC card. For performance evaluation, we developed a transaction tracking log to keep track of every operation on NHI-IC cards. Based on analysis of the transaction tracking log from 1 August to 31 October 2007, physicians read patients’ NHI-IC cards in 71.01% (8,246) of patient visits; 33.02% (2,723) of the card reads showed at least one medicine currently being taken by the patient, 82.94% of which were prescribed during the last visit. Among 10,036 issued prescriptions, seven prescriptions (0.09%) contained at least one drug item that might interact with the currently-taken medicines stored in NHI-IC cards and triggered pop-up alerts. This study showed that the capacity of an NHI-IC card is adequate to support DDI checking across hospitals. Thus, the enhanced computerized physician order entry (CPOE) system can support better DDI checking when physicians are making prescriptions and provide safer medication care, particularly for patients who receive medication care from different hospitals.

Background: During the COVID-19 pandemic, personal health records (PHRs) have enabled patients to monitor and manage their medical data without visiting hospitals and, consequently, minimize their infection risk. Taiwan’s National Health Insurance Administration (NHIA) launched the My Health Bank (MHB) service, a national PHR system through which insured individuals to access their cross-hospital medical data. Furthermore, in 2019, the NHIA released the MHB software development kit (SDK), which enables development of mobile apps with which insured individuals can retrieve their MHB data. However, the NHIA MHB service has its limitations, and the participation rate among insured individuals is low. Objective: We aimed to integrate the MHB SDK with our developed blockchain-enabled PHR mobile app, which enables patients to access, store, and manage their cross-hospital PHR data. We also collected and analyzed the app’s log data to examine patients’ MHB use during the COVID-19 pandemic. Methods: We integrated our existing blockchain-enabled mobile app with the MHB SDK to enable NHIA MHB data retrieval. The app utilizes blockchain technology to encrypt the downloaded NHIA MHB data. Existing and new indexes can be synchronized between the app and blockchain nodes, and high security can be achieved for PHR management. Finally, we analyzed the app’s access logs to compare patients’ activities during high and low COVID-19 infection periods. Results: We successfully integrated the MHB SDK into our mobile app, thereby enabling patients to retrieve their cross-hospital medical data, particularly those related to COVID-19 rapid and polymerase chain reaction testing and vaccination information and progress. We retrospectively collected the app’s log data for the period of July 2019 to June 2021. From January 2020, the preliminary results revealed a steady increase in the number of people who applied to create a blockchain account for access to their medical data and the number of app subscribers among patients who visited the outpatient department (OPD) and emergency department (ED). Notably, for patients who visited the OPD and ED, the peak proportions with respect to the use of the app for OPD and ED notes and laboratory test results also increased year by year. The highest proportions were 52.40% for ED notes in June 2021, 88.10% for ED laboratory test reports in May 2021, 34.61% for OPD notes in June 2021, and 41.87% for OPD laboratory test reports in June 2021. These peaks coincided with Taiwan’s local COVID-19 outbreak lasting from May to June 2021. Conclusions: This study developed a blockchain-enabled mobile app, which can periodically retrieve and integrate PHRs from the NHIA MHB's cross-hospital data and the investigated hospital's self-pay medical data. Analysis of users’ access logs revealed that the COVID-19 pandemic substantially increased individuals’ use of PHRs and their health awareness with respect to COVID-19 prevention.