Health information technology integrated with a strong healthcare infrastructure and advance planning can be a powerful tool for a nation’s epidemic control
Taiwan was the first nation to implement proactive measures against the novel coronavirus. On 31 December 2019, Taiwan was the first nation to inform the World Health Organization of the potential for human-to-human transmission of the novel coronavirus in Wuhan, China. As a precaution, the government of Taiwan started on-board health inspection of flight passengers from Wuhan to Taiwan. Numerous academic papers and international media sources have since reported on how effective Taiwan’s policy has been in controlling the covid-19 epidemic. Its low number of total cases (449) and deaths (7) from covid-19, and 86 consecutive days without any domestic cases (all data as of 7 July) attest to this success. One of the key factors in Taiwan’s success has been the use of innovative information technology, which works with the National Health Insurance (NHI) system and the national Central Epidemic Command Center (CECC). This system played a vital role in controlling the covid-19 pandemic in Taiwan.
Three measures have been identified by researchers as critical steps in controlling the spread of covid-19: contact-tracing, testing, and quarantine or isolation-treatment. Effective execution of these measures hinges on effective leadership and a strong public health infrastructure.
Taiwan established its National Health Insurance system in 1995, and uses a reimbursement system to guide and prioritize the nation’s healthcare organizations. This system was found to be effective in helping to combat the 2003’s SARS epidemic. Through the bitter experience of SARS, Taiwan determined never to be caught unprepared for another pandemic and dramatically strengthened its pandemic control measures. These include, developing hospital standard operating procedures to address highly contagious diseases. The National Health Insurance Administration (NHIA) developed two forms of information technology that are critical in its pandemic preparedness and control. The first is the NHI Smart Card that allows all providers real-time access to upload patient records and claims. The other is the MediCloud system, developed in 2018, that provides providers and patients real-time access to patient’s health records, including diagnostic imaging and prescriptions.
The Central Epidemic Command Center was established after SARS in 2003, and was activated on 20 January 2020, before Taiwan had its first case of covid-19. It incorporated the NHIA and MediCloud into the pandemic control system immediately and used MediCloud to develop a real-time alert system by linking it with immigration data. This allows providers to obtain patients’ travel history, occupation, contact history, and clustering at mass gatherings in real-time, enabling efficient triage and rapid and accurate diagnoses while keeping them safe. This information system is vital for Taiwan’s precision testing strategy that is efficient in testing a small but critical number of people, instead of mass-testing. MediCloud has also been instrumental in facilitating Taiwan’s universal access to rationed surgical masks.
Another vital part of technology for Taiwan’s contact-tracing and quarantine monitoring, is a GPS-based information system called Intelligent Electronic Fences System (IEFS). It is a collaboration between the Central Epidemic Command Center and mobile phone carriers that was developed in early February. Based on an individual’s mobile phone signals and nearby cell towers, it triangulates the location of quarantined individuals. It monitors the nation’s entire quarantined population and any potential people that they may come into contact with. It tracks them in real time and retrospectively for up to a month.
This technology was used to contain two major crises. The first one was after over 3,000 passengers from the Diamond Princess visited multiple places in northern Taiwan; the IEFS tracked 627,386 potential contacts, advised them to quarantine at home, and thereby helped prevent community outbreaks. The second crisis was in mid-April when a naval vessel returned from overseas, and 36 of its 377 crews were found to be infected with covid-19, after they already visited several cities over the course of three days. The IEFS identified all the public places they visited, informed potential contacts, and averted community outbreaks. One of the concerns about this system is the infringement of people’s privacy, however there have been minimal objections from the public. This could be due to high levels of trust between the government and the public during the pandemic, solidarity fostered by international political isolation, and memory of the SARS epidemic, as well as the mandate of Infectious Disease Control Act.
Taiwan’s pandemic control measures were complemented by effective social care. As well as free access to testing, the government also finances the cost of 14 day quarantine. Everyone under quarantine was compensated with USD $35 per day. Local government staff make daily phone calls to those under quarantine to offer assistance, and provide them with a care package that includes 14 surgical masks, detailed instructions on quarantine, free online access to exercise videos, and free online access to movies. Taiwan’s government recognizes that the general public are a crucial partner for the success of pandemic control.
Thanks to effective epidemic control measures, Taiwan is one of the few nations to maintain relative normalcy during the pandemic. Other nations could also learn from Taiwan’s success. Taiwan is planning ahead for a potential resurgence of covid-19 in the fall, by accelerating vaccine and drug research, expanding medical resources and capacity, while improving its border inspection and quarantine measures that can accommodate reopening borders for commerce and travel with a world that is not as safe as Taiwan.
Po-Chang Lee, Director General, National Health Insurance Administration, Ministry of Health and Welfare, Taiwan.
Shih-Chung Chen, Commander, Central Epidemic Command Center, and Minister of Health and Welfare, Taiwan.
Tai-Yuan Chiu, President, Taiwan Medical Association, Taiwan.
Chi-Mai Chen, Former Deputy Premier (left the post on 19 June of 2020), Executive Yuan, Taiwan.
Chunhuei Chi, Professor and Director, Center for Global Health, College of Public Health and Human Sciences, Oregon State University, USA.
Competing interests: There is no financial interest associated to all authors in writing this manuscript. Three co-authors (Drs. Po-Chang Lee, Shih-Chung Chen and Chi-Mai Chen) are key policy makers in all epidemic control policies and measures discussed in this article.