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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.
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.
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.
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.
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.
Electronic medical records (EMRs) have enabled the digital transformation of health facilities worldwide [
In 2014, Taiwan’s National Health Insurance Administration (NHIA) launched the My Health Bank (MHB) 1.0 service [
The MHB SDK can attract more health care providers and startups to create innovative mobile apps in the health industry and encourage them to invest their resources into realizing market opportunities. It can also drive more users to engage in the control and management of their health data. However, the MHB SDK has several limitations that must be addressed. First, only the 3 most recent years of an individual’s data are stored in the MHB. Therefore, a person cannot retrieve older medical data [
Because of the weak gatekeeper role of Taiwan’s NHI system, patients can freely seek clinical services without referral whenever they feel uncomfortable [
In our previous study, we adopted the Go Ethereum version 1.7.3-stable to construct the iWellChain Framework, which is a permissioned consortium blockchain network with trusted parties to ensure consensus by proof of authority. Thus, the framework can limit participants who transact on the blockchain and define users who can serve the network by writing new blocks into the chain. In this way, the iWellChain Framework can assist the cooperative health care parties to establish their blockchain environment efficiently and further acquire the patient's EMRs and EHRs in accordance with the patient’s signed Ethereum-based smart contracts. Accordingly, the framework could help health care parties to reduce their implementation costs and difficulties associated with the hospital’s legacy information technology systems and security features surrounding data access. Moreover, the iWellChain Framework provides a better secure data protection because there is no centralized structure for a malicious user to target, as the patients’ EMRs and EHRs are stored in numerous copies on different blockchain nodes. With the iWellChain Framework, we also developed a blockchain-enabled mobile app, the iWellChain app, as a PHR tool for patients to acquire their EMRs and EHRs from the investigated hospital and cooperative clinics [
In this study, 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. This study involved the launch of an updated version of the iWellChain app in July 2019. The updated version incorporates the MHB SDK. Therefore, patients can regularly use it to retrieve, store, and track cross-hospital MHB data. Consequently, the iWellChain app addresses time restrictions related to the MHB data retention period. Additionally, the iWellChain app incorporates blockchain technology. Hence, a user can employ a public key to encrypt downloaded MHB data and ensure that their personal health data are secure. Furthermore, to encourage more individuals to use the iWellChain app, the investigated hospital released patients’ self-pay medical data and health checkup reports, which are not available in the MHB database. Finally, to enhance our understanding of patients’ PHR use during the COVID-19 pandemic, we analyzed the access logs of iWellChain app users to examine patients’ activities during a 24-month study period.
This study was conducted at the Taipei Medical University Hospital (TMUH)—a teaching hospital with almost 800 beds and a good information infrastructure. In 2018, this hospital released five types of EMR and EHR that patients can access through the iWellChain app: outpatient department (OPD) notes, OPD laboratory test reports, discharge notes, pathology reports, and health check reports. An updated version of the iWellChain app was integrated with the MHB SDK and released in July 2019. This version enables patient access to emergency department (ED) notes and ED laboratory test reports.
The MHB SDK was used to develop a mobile app that enables users to access their NHIA MHB data by completing an identity verification process.
Integration workflow of the My Health Bank software development kit and mobile app. MHB: My Health Bank, NHIA: National Health Insurance Administration, SDK: software development kit.
Identity verification process of the My Health Bank software development kit for accessing My Health Bank services (left panel); third-party statements relating to use of My Health Bank data (right panel).
The content of the downloaded NHIA MHB data is presented in a tagged format, such as XML or JASON format. Each tag contains a name, value, and the corresponding medical data.
Tag codes and values of National Health Insurance Administration My Health Bank data.
Name | Value |
bdata | Patient information |
r1 | Outpatient clinic data |
r2 | Admission data |
r3 | Dental clinic data |
r4 | Allergy data |
r5 | Organ donation or palliative medicine |
r6 | Vaccination data |
r7 | Laboratory data |
r8 | Imaging or pathological examination reports |
r9 | Chinese medicine data |
r10 | Health and preventive care |
Downloaded My Health Bank data in XML format.
In our previous study, we constructed the iWellChain Framework—a permissioned consortium blockchain that utilizes trusted parties to ensure consensus by proof of authority [
Interactions with the iWellChain app and My Health Bank data through the iWellChain Framework.
After a patient has created his/her blockchain account, he/she can use his/her national ID and application password and the password for the private key to sign into the iWellChain app.
Next, the iWellChain app synchronizes his/her Ethereum blockchain ledger through the iWellChain Framework. Thus, the patient can quickly obtain EMR and EHR indexes and further acquire the physical EMR and EHR files of these indexes using the iWellChain app.
After a patient has successfully signed into the NHIA MHB, his/her NHIA MHB data are downloaded. Once the NHIA MHB data are fully downloaded, the iWellChain app decrypts these data and stores them in the mobile app sandbox.
The iWellChain app then analyzes each of the patient’s NHIA MHB data records to verify that these records were not previously acquired or did not originate from other health facilities.
For each record that has been verified as a new record, the iWellChain app synchronizes with the iWellChain Framework to request the patient’s public key, which is then used to encrypt the record’s path. Finally, the iWellChain app registers the record's information and its encrypted path in the iWellChain Framework.
According to Taiwan’s Central Epidemic Command Center (CECC) reports, confirmed COVID-19 cases can be classified as locally acquired cases (LACs) and imported cases (ICs).
Taiwan’s locally acquired and imported case trends.
Because of the COVID-19 pandemic, the investigated hospital had to adhere to CECC guidelines regarding the reservation of general wards for the influx of patients with COVID-19. Accordingly, in this study, we only included patients attending the OPD and ED of TMUH and used the iWellChain app. We retrospectively collected patients’ iWellChain app access logs over a 24-month period (before and during the COVID-19 pandemic) from July 2019 to June 2021. Accordingly, an access log database was created, and information on the actions that the patients performed through the iWellChain app was collected. We integrated Google Analytics for Firebase into the iWellChain app to capture patients’ click data. Once the data had been captured and stored, the access log could be linked to the Google Colaboratory [
When a patient signs into his/her blockchain account, the iWellChain app displays his/her subscribed PHR services per the signed Ethereum-based smart contracts.
Patient's subscribed personal health record services in the iWellChain app (left panel) and medical data sorted by visit date from latest to oldest.
Patient’s outpatient department notes and corresponding prescription information.
We collected 24 months of data (July 1, 2019, to June 30, 2021) from the investigated hospital. During this 2-year period, the total number of patients who visited the OPD and ED was 1,405,316, and 92,184, respectively. From July 1, 2019, to December 30, 2019, the proportion of patients who visited the ED and OPD who subscribed to the iWellChain app ranged from 0.29% to 1.67% and from 3.09% to 5.36%, respectively. In 2020, the proportion of patients who visited the ED and OPD who subscribed to the iWellChain app ranged from 1.41% to 2.54% and from 5.29% to 6.25%, respectively. Finally, from January 1, 2021, to June 30, 2021, the proportion of patients who visited the ED and OPD who subscribed to the iWellChain app ranged from 1.95% to 8.20% and from 5.58% to 7.49%, respectively. Therefore, the iWellChain subscription trend for patients who visited the OPD or ED was a steady increase during the investigated period. The descriptive statistics for the study population are presented in
Proportion of patients who visited the outpatient department and emergency department and who subscribed to the mobile app between July 2019 and June 2021.
Month# |
EDa patients, n | ED patients subscribed to the app, n (%) | OPDb patients, n | OPD patient subscribed to the app, n (%) | |
|
|||||
|
7 | 4199 | 12 (0.29) | 65,152 | 2011 (3.09) |
|
8 | 4194 | 22 (0.52) | 62,841 | 2178 (3.47) |
|
9 | 4266 | 27 (0.63) | 61,108 | 2354 (3.85) |
|
10 | 4250 | 17 (0.4) | 64,454 | 2544 (3.95) |
|
11 | 3877 | 32 (0.83) | 64,080 | 2676 (4.18) |
|
12 | 4187 | 70 (1.67) | 63,709 | 3413 (5.36) |
|
|||||
|
1 | 4980 | 89 (1.79) | 59,506 | 3150 (5.29) |
|
2 | 3421 | 71 (2.08) | 53,918 | 2919 (5.41) |
|
3 | 3226 | 68 (2.11) | 48,970 | 3052 (6.23) |
|
4 | 2842 | 51 (1.79) | 47,116 | 2833 (6.01) |
|
5 | 3186 | 45 (1.41) | 54,119 | 3185 (5.89) |
|
6 | 3427 | 76 (2.22) | 54,100 | 3308 (6.11) |
|
7 | 3549 | 90 (2.54) | 63,144 | 3829 (6.06) |
|
8 | 3577 | 81 (2.26) | 61,902 | 3607 (5.83) |
|
9 | 3647 | 72 (1.97) | 63,712 | 3680 (5.78) |
|
10 | 4040 | 71 (1.76) | 65,443 | 3667 (5.6) |
|
11 | 3788 | 74 (1.95) | 61,820 | 3707 (6) |
|
12 | 3546 | 74 (2.09) | 63,752 | 3986 (6.25) |
|
|||||
|
1 | 3835 | 79 (2.06) | 59,872 | 3530 (5.9) |
|
2 | 3602 | 89 (2.47) | 52,761 | 2942 (5.58) |
|
3 | 3995 | 78 (1.95) | 65,574 | 4083 (6.23) |
|
4 | 3829 | 82 (2.14) | 64,043 | 3812 (5.95) |
|
5 | 5025 | 412 (8.2) | 46,908 | 3394 (7.24) |
|
6 | 3696 | 208 (5.63) | 37,312 | 2794 (7.49) |
aED: emergency department.
bOPD: outpatient department.
The iWellChain app has several basic functions (ie, an appointment service, inquiring for a doctor’s information, and a payment service); however, patients have to apply for and register web-based blockchain accounts to acquire their medical data.
Numbers of new applicants of the blockchain accounts.
Through the access log data, we further examined the investigated hospital’s data set of patients who visited the OPD and ED, with data including OPD notes, OPD laboratory test results, ED notes, and ED laboratory test reports. The content of the OPD and ED notes include OPD or ED visit dates, chief complaints, diagnosis codes and descriptions, and prescription information.
In
Analysis of patients’ access log data with respect to acquisition of outpatient department (OPD) notes, OPD laboratory test results, emergency department (ED) notes, and ED laboratory test reports through the iWellChain app.
During the 2-year study period, subscribers who retrieved OPD or ED notes and laboratory test reports accounted for the highest proportion of patients who visited the OPD or ED in May and June 2021. These peak proportions were 52.40%, 88.10%, 70.30%, 34.61%, 41.87%, and 59.85% for OPD notes (June 2021), OPD laboratory test results (June 2021), ED notes (June 2021), and ED laboratory test reports (May 2021), respectively.
From July 2019 to December 2019, only a few patients visiting the OPD or ED subscribed to the iWellChain app and used it to acquire their OPD or ED notes and laboratory test reports (
In 2019, for each type of medical data, the peak proportions were thus 8.33% for ED notes (July 2019), 29.73% for ED laboratory test reports (December 2019), 3.57% for OPD notes (December 2019), and 15.68% for OPD laboratory test reports (December 2019). In 2020, the peak proportions for each type of medical data were all higher than those observed in 2019. Moreover, from January to June 2021, the peak proportions for each type of medical data and report were all higher than those observed in 2019 and 2020.
Taiwan’s NHI system is a single-payer system that was introduced in 1995; by 2010, it was already providing universal and mandatory insurance coverage for almost all of Taiwan’s population (99.5%) [
In this study, we successfully integrated the MHB SDK into our blockchain-enabled mobile app to enable use by patients. The iWellChain app’s implementation has three advantages. First, iWellChain app can help patients periodically acquire their own cross-hospital EMRs and avoid the time restrictions relating to the NHIA MHB data retention period. Second, to protect patients’ privacy and data security, the downloaded NHIA MHB data are stored on the patients’ mobile devices without moving these data to or depositing them in other storage or cloud-based spaces. With our method, patients feel more secure in using the iWellChain app for PHR data management. Third, the investigated hospital also released self-pay patients’ EMRs and EHRs (eg, health checkup reports) to complement the deficiencies of NHIA MHB data. However, under the Taiwan NHI system, people could easily obtain in-person clinic/hospital medical consultations with relatively low costs. Consequently, people would rather go to the hospital or clinic than use such the PHR mobile app to acquire their medical or health information. A previous study indicated the NHI-insured individuals’ participation rate in the NHIA MHB service was low [
Before May 2021, Taiwan only had a few LACs (
Under Taiwan’s NHI system, insured individuals’ medical data are routinely collected through a network with well-developed infrastructure. Although Taiwan has been affected by the COVID-19 outbreak, the CECC could effectively coordinate with all levels of health care facilities to control and manage epidemic information in response to the disease’s spread (eg, establishment of a rapid testing station in a hotspot or contact tracing) by implementing the existing infectious disease notification method. Taiwan lifted the Level 3 alert on July 27, 2021, and only a few LACs were reported in August 2021 [
In a patient-centered model, EMRs and EHRs belong to the individual patient. Furthermore, Taiwan’s NHIA MHB database offers a robust foundation for PHR development. This study provides a blockchain-enabled mobile app that can periodically retrieve and integrate cross-hospital PHRs from the NHIA MHB database and the investigated hospital’s self-pay medical data and provide secure data protection through blockchain technology. The user access log analysis indicates that the COVID-19 pandemic has had a substantial effect on the app’s use, increasing individuals’ PHR use and health awareness regarding COVID-19 prevention. However, compared with the investigated hospital’s total number of patients who visited the OPD and ED, the number of app users remains low. Therefore, use of the iWellChain app for PHR acquisition can be further improved.
Centers for Disease Control
Central Epidemic Command Center
emergency department
electronic health record
electronic medical record
imported case
locally acquired case
My Health Bank
National Health Insurance
National Health Insurance Administration
outpatient department
polymerase chain reaction
personal health record
software development kit
Taipei Medical University Hospital
We would like to thank all information team members and the Preventive and Community Medicine Department of TMUH for their support. We would also like to thank and recognize the Radica Health startup for their technical contributions. This study was supported in part by the Ministry of Science and Technology of Taiwan (grant MOST 107-2823-8-038-001, 109-2221-E-305-006, 110-2221-E-305-002, 110-2218-E-305-001-MBK) and University System of Taipei Joint Research Program (grant TMU 104-AE1-B31, USTP-NTPU-TMU-109-02).
None declared.