outlier — and not in a good way — with more than 2.5 million cases and 125,000 deaths, or about 36 deaths per 100,000 people. One of the strongest performers is Taiwan, with 446 confirmed cases and just seven deaths for nearly 24 million citizens, or 0.03 deaths per 100,000. On a per capita basis, the U.S. has 1,200 times as many Covid-19 deaths as Taiwan.
Lost in the fractious and frankly broken conversation about reopening the economy is a simple truism: containing the virus is the best fiscal stimulus. The U.S. Congressional Budget Office is projecting double-digit contractions in the gross domestic product for 2020 and unemployment rates going up to 16% this year — the highest they have been since the Great Depression. By comparison, Taiwan’s central bank expects growth to slow to about 1.5% for the year, and unemployment has “surged” to 4.1%.
To get the economy moving again, we need a functioning health care system.
A lot can be learned about handling a pandemic — and its aftermath — by looking at the health care systems in other countries. Over the past few years, we have been studying 11 countries to write a book titled, “Which Country has the World’s Best Health Care?” Taiwan was one of the countries we studied, and its successful response to Covid-19 was not a matter of luck. It was the result of careful planning and digital innovation, which the U.S. must learn from.
Taiwan could easily have had a Covid-19 disaster. It is situated less than 100 miles from China, and more than 1 million Taiwanese work in China. There is frequent travel between the two countries. As a result, Taiwan is at high risk of exposure to any novel infection that arises in China. So why didn’t it get slammed by SARS-Cov-2?
Some of the success is due to accidents of history, including the outbreak of severe acute respiratory syndrome (SARS) that began in February 2003. It generated a culture of taking infections from China seriously — unlike what happened in the U.S. The island also has a strong “face mask” culture, which the U.S. should be emulating, but isn’t.
Perhaps the most important element is Taiwan’s deliberate, systematic use of its digital health infrastructure.
The key to avoiding massive, economically ruinous lockdowns is effective testing, isolation, and contact tracing to control viral spread. Taiwan’s innovative electronic health records system made possible the country’s swift, targeted response to Covid-19. Although the system was not designed to stop a pandemic, it was nimble enough to be reoriented toward one.
Every person in Taiwan has a health card with a unique ID that all doctors and hospitals use to access online medical records. Providers use the card to document care episodes for reimbursement from the Ministry of Health. As a result, the card gives the ministry regular, nearly real-time data on physician and hospital visits and use of specific services.
With that data, the ministry can modify payments to reflect utilization. If physicians collectively have more office visits than anticipated or are ordering more MRI scans than budgeted, payments per service are reduced quarterly to reflect the overuse. This payment-adjustment mechanism allows the country to adhere to its annual health care budget and return information to physicians on aggregate and individual resource utilization.
When Covid-19 hit, the health card and electronic health records system were repurposed to fight the spread of the virus.
The government merged the health card database with information from immigration and customs to send physicians alerts about patients at higher risk for having Covid-19 based on their travel history. Utilization data was also employed to identify candidates for Covid-19 testing when supplies were limited. As researchers reported in the Journal of the American Medical Association, “Taiwan enhanced Covid-19 case finding by proactively seeking out patients with severe respiratory symptoms (based on information from the National Health Insurance [NHI] database) who had tested negative for influenza and retested them for Covid-19.” The availability of almost immediate data on patient visits allowed the country to efficiently identify, test, trace, and isolate cases. This has dramatically reduced Covid-19 spread without the need for extensive lockdowns.
No other country we studied had a comparably effective real-time electronic health record system, including the U.S. The U.S. has come a long with its use of electronic records, thanks in part to the financial incentives built into the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. The percentage of office-based physicians who use these systems has grown from 48% in 2009 to 86% today. They are nearly universal in hospitals as well, with utilization now at 96%.
But sharing the data — so-called interoperability between different electronic health record vendors — has lagged. Only now are we beginning to see real-time data monitoring to permit proactive interventions to improve quality of care, not only in a pandemic but also in routine care. Only recently has the data been used to give physicians timely feedback on their quality of care and resource use. It will be years before these features become integral to routine health system operations across the entire country. As Taiwan shows, however, this is a challenge of policy, not technology.
Even in the midst of the ongoing pandemic, we can learn from Taiwan. Americans share every movement and sentiment with Facebook and Google, yet we seem reluctant to allow the Department of Health and Human Services to monitor patient encounters, as Taiwan does, to track disease and determine what medical tests and treatments to order.
Medicare and Medicaid could adopt something similar to the Taiwanese health card and allow an independent third party to monitor the data. The third party could proactively identify infectious outbreaks, deficiencies in the quality of care, and other important health issues. The contract would have to strictly forbid sharing the underlying data or commercializing them in any way.
Insurers already get data based on hospital and physician claims, but only weeks or months after encounters, making the information less useful for tracking infectious outbreaks. They could use Taiwan as a model to upgrade their data systems and share the insights with public health authorities.
Such an upgrade is tremendously expensive, prohibitively so without inducement. Fortunately, the HITECH Act showed that the federal government can spur investment in electronic health records. Nearly a decade since HITECH, we have the benefit of hindsight for what went well and what went wrong. Another round of investment in electronic health record upgrades — specifically targeted to generating interoperable data that can be shared in real time with public health officials — should be part of any new stimulus bill.
Taiwan’s amazing success in responding to Covid-19 highlights ways the U.S. can improve its pandemic response. By now it is evident that we need a faster, more serious response to public health emergencies, and Taiwan’s health card offers a basis for executing such a response.
Shoring up the U.S.’s digital health infrastructure will help improve routine care in the long run while empowering us to better respond to future infectious disease outbreaks.
Ezekiel J. Emanuel is a physician, vice provost of global initiatives, professor of medical ethics and health policy at the University of Pennsylvania. He is also the author of “Which Country Has the World’s Best Health Care?” (Public Affairs, June 2020), co-host of the “Making the Call” podcast, and a member of the Biden for President public health advisory committee. Cathy Zhang is a senior research fellow at the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Aaron Glickman is a project manager in the Department of Medical Ethics and Health Policy at the University of Pennsylvania.