Research Directorate, Immigration and Refugee Board of Canada
1. Overview
Sources indicate that the Chinese Ministry of Health (MOH) adopted a Five-Year Plan which included the development of two electronic databases: electronic health records (EHRs) and electronic medical records (EMRs) (Lei, et al. 28 Mar. 2017, 2; Gao, et al. 2013, 127), in 2012 (Gao, et al. 2013, 129). According to a summary by Li et al. of a conference on EMRs in China, jointly hosted in October 2016 by representatives of the Massachusetts Institute of Technology (MIT) and the People's Liberation Army General Hospital (PLAGH), published in JMIR Medical Informatics, a peer-reviewed journal that focuses on topics including big data in health and healthcare (JMIR Medical Informatics n.d.), the strategy was revised to include the development of three databases: EMRs, EHRs and a national database recording healthcare information for the entire population (Li, et al. 14 Nov. 2017, 2). In correspondence with the Research Directorate, a lecturer at Southern Cross University in Australia, who has written about the EHR and EMR systems in China, stated that the Chinese MOH launched the national Resident EHR system in 2012 (Lecturer 23 Mar. 2020).
1.1 EHRs
Citing Chinese government information, sources report that as of 2012 or 2013, approximately 47 or 48 percent of hospitals in China had adopted EHRs (Lei, et al. 28 Aug. 2013, 2; Li, et al. 14 Nov. 2017, 2). The Lecturer, citing the MOH's Basic Structure and Data Standards for Health Records,explained that the MOH defines a health record as "personal information and the records of health services at health service institutions, including children's health, women's health, disease management, disease control and medical service" (Lecturer 23 Mar. 2020). In a peer-reviewed article published in the Journal of Global Health, authors Payne et al. state that the EHR system manages and shares "basic medical and health information among hospitals in the region and, most importantly, for public health information management" (Payne, et al. Dec. 2019, 4). The article by Li et al. states that the PLAGH invented a software framework for an EHR system, launched in 1997, which recorded "patient visits, medical history, treatments, and drug prescriptions" and which was subsequently built and refined, and adopted by "several hundred hospitals over the next decade" (Li, et al. 14 Nov. 2017, 2). The same source adds that current EHRs are designed for administrative and billing functions, and has poor usability, which prevents the system from capturing clinical information in a "structured manner" (Li, et al. 14 Nov. 2017, 2).
1.2 EMRs
Sources state that an EMR consists of patients' clinical information and is generated by hospitals (Wang 1 Apr. 2019, 5; Gao, et al. 2013, 127; Lei, et al. 28 Aug. 2013, 2, 3). According to a 2019 article written by Zhong Wang, an associate professor at the Beijing Academy of Social Sciences, EMR data includes "the records of outpatient and emergency visits, hospitalization, medical imaging and so on" (Wang 1 Apr. 2019, 5). Sources indicate that most hospitals in China [over 90 percent (Zhang, et al. 5 Feb. 2018, 2)] have adopted EMRs (Zhang, et al. 5 Feb. 2018, 2; Wang 1 Apr. 2019, 5). Sources further report that hospitals use different commercial providers to develop their own EMR system (Zhang, et al. 5 Feb. 2018, 5; Lecturer 23 Mar. 2020). According to Wang, EMR data is "normally" confined to individual hospitals without interaction with data from other hospitals (Wang 1 Apr. 2019, 5).
1.3 Information Sharing
Sources report that EMR and EHR systems are separate and that most systems lack the ability to share information (Payne, et al. Dec. 2019, 4; Gao, et al. 2013, 130, 131). According to a 2018 article published in the BMJ, a peer-reviewed medical journal (BMJ n.d.), some regions plan to establish regional EHRs, but most are in "preliminary stages" (Zhang, et al. 5 Feb. 2018, 2). According to the article by Payne et al., local governments in developed areas, including Beijing, Shanghai, Zhejiang, Guangdong, Shandong, Fujian and Henan, have started to build regional health information networks and have had some "preliminary success" in sharing health care information locally or regionally (Payne, et al. Dec. 2019, 3).
2. Printed Health Records
The Lecturer explained that medical booklets [1] have been replaced by EMR systems in large- and medium-sized cities, but are still used in "some counties or remote areas" (Lecturer 23 Mar. 2020). Article 10 of the Regulation on Medical Records Management in Medical Institutions provides the following:
In theory, outpatient (emergency) medical records should be kept by patients. Medical institutes that have established an outpatient (emergency) medical record room or electronic medical record can take care of medical records after getting approval of patients or their legal representatives. (China 2013)
According to Wang, "almost all" hospitals have not sought the consent of their patients in using EMRs through the signing of privacy agreements (Wang 1 Apr. 2019, 5). According to a profile of the Chinese health care system written by Hai Fang, a professor at the China Center for Health Development Studies at Peking University (Peking University 25 Dec. 2017), and published by the Commonwealth Fund [2],
EHR systems vary significantly by hospital and are usually not integrated or interoperable. Patients often must bring with them a printed health record if they want to see doctors in different hospitals. Even if hospitals are owned by the same local bureau of health or affiliated with the same universities, different EHR systems may be used. Patients generally do not use EHR systems for accessing information, scheduling appointments, sending secure messages, refilling prescriptions, or accessing doctors' notes. (The Commonwealth Fund May 2017, 37)
The article by Payne et al. similarly explains that if a patient goes to a new health care facility whose EHR system is not compatible with that of his previous health care provider, they will need to "bring all of [the] pertinent information printed on paper" from the first provider, for example, if a patient is referred to see a specialist in a "larger" hospital by the patient's primary doctor (Payne, et al. Dec. 2019, 4-5).
According to a doctor from a large hospital in Wuhan interviewed by the Lecturer, as part of research conducted "since 2012," patients can request printed copies for outpatient services, but not for inpatient services (Lecturer 23 Mar. 2020). Articles 17 to 19 of the Regulation on Medical Records Management in Medical Institutions provide the following:
17. Medical institutions should accept applications from the following personnel and organizations for copying or reading medical records, and offer medical record copying and reference services in accordance with relevant provisions:
- Patients or their legal representatives
- Dead patient's legal heir or agent
18. Medical institutions shall assign a specific department or personnel to deal with applications for medical record replication. They should ask applicants to provide required materials and review them when dealing with the application.
- If the applicant is a patient, valid proof of patient's identity is required.
- If applicant is a patient's agent, valid proof of patient and agent identities, as well as a legal proof on the relationship between the patient and agent and authorization letter, are required.
- If applicant is a dead patient's legal heir, a death certificate, valid proof of the heir's identity, as well as evidentiary materials proving the dead patient and their legal heir relationship are required.
4. [sic] If applicant is agent of a dead patient's legal heir, a death certificate, valid proof of the heir's and agent's identities, as well as evidentiary materials proving the relationship between dead patient and their legal heir and that between the legal heir and agent and authorization letter are required.
19. Medical institutes can replicate medical records for applicants, including temperature chart, doctor's advice note, resident admit note, operation agreement, anesthesia agreement and record, operation record, seriously ill (dying) patients' nursing records, discharge record, blood transfusion informed consent letter, special examination (special treatment) consent letter, pathological and test report, and medical imaging examination data. (China 2013)
3. Health Cards
The Lecturer explained the following:
A health card is a smart card, which was supposed to include individual life-long health information. Currently, however, it does not include health information because of the inconsistency between EMR systems and healthcare services. Currently it is used for reimbursement from insurances. (Lecturer 23 Mar. 2020)
The same source further stated that every resident who is covered by medical insurance has a health card (Lecturer 23 Mar. 2020). According to the profile of the Chinese health care system, hospitals' EHRs are connected to health insurance system for payment purposes and patients are assigned "identifiers" according to their insurance or citizenship identification (The Commonwealth Fund May 2017, 37). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.
Further information on health cards, including whether they can be used by individuals to access their own records, such as through an online portal, from within or outside of China, could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.
4. Shanghai
Sources indicate that the Minhang District in Shanghai established an EHR system (He, et al. 22 May 2019, 2; Wang, et al. 13 Aug. 2013, 2) in 2005 (He, et al. 22 May 2019, 2) or 2007 (Wang, et al. 13 Aug. 2013, 2). According to a 2013 article published in Plos One, a peer-reviewed scientific journal (Plos One n.d.), all town and district hospitals in the Minhang district were using the same EHR (Wang, et al. 13 Aug. 2013, 2). The same source states that each patient had a health card with a personal identification number, which allowed them to access their own EHR, including clinical and laboratory data (Wang, et al. 13 Aug. 2013, 2). A 2019 article published in Frontiers in Oncology,a peer-reviewed journal focusing on cancer research (Frontiers in Oncology n.d.),indicates that all residents in Minhang District have a medical care card with a microchip, which allows doctors in "all local health institutions" to access patients' medical records (He, et al. 22 May 2019, 3). The same source states that the Minhang EHR system is administrated by the Health Commission of Minhang District and implemented by the Minhang District Centre for Disease Control and Prevention (CDC), whose staff also have access to information in the system (He, et al. May 2019, 2-3).
Shen Xiaoming, Vice Mayor of Shanghai from 2008 to 2013, stated in a 2013 interview that all hospitals in Shanghai were interconnected as of June 2013 and that "[d]octors at any hospital, with patients' permission, can see their patients' medical records from any Shanghai hospital" (Cheng Dec. 2013, 2201). Further information on the coverage of the Shanghai EHR system could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.
This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim for refugee protection. Please find below the list of sources consulted in researching this Information Request.
Notes
[1] Paper-based outpatient medical records were given to and managed by individual patients in China (Chen and Pine 2014, 413).
[2] The Commonwealth Fund is a US-based private non-profit foundation which promotes "a high-performing health care system" by supporting independent research on health care issues (The Commonwealth Fund n.d.).
References
BMJ. N.d. "Our Expertise." [Accessed 1 Apr. 2020]
Chen, Yunan, and Kathleen Pine. 2014. "When Medical Expertise Meets Record Expertise: The Practices of Patient Accessible Medical Records in China." COOP 2014 - Proceedings of the 11th International Conference on the Design of Cooperative Systems, 27–30 May 2014, Nice (France). Edited by C. Rossitto, et al. [Accessed 24 Mar. 2020]
Cheng, Tsung-Mei. December 2013. "Explaining Shanghai's Health Care Reforms, Successes, and Challenges." Health Affairs. Vol. 32, No. 12. [Accessed 23 Mar. 2020]
China. 2013. Regulation on Medical Records Management in Medical Institutions. [Accessed 19 Mar. 2020]
The Commonwealth Fund. May 2017. "The Chinese Health Care System." By Hai Fang in International Profiles of Health Care Systems. Edited by Elias Mossialos, et al. [Accessed 20 Mar. 2020]
The Commonwealth Fund. N.d. "About Us." [Accessed 24 Mar. 2020]
Frontiers in Oncology. N.d. "Scope & Mission." [Accessed 1 Apr. 2020]
Gao, Xiangzhu, et al. 2013. "Implementation of E-Health Record Systems and E-Medical Record Systems in China." The International Technology Management Review. Vol. 3, No. 2. [Accessed 20 Mar. 2020]
He, Dandan, et al. 22 May 2019. "Electronic Health Record-Based Screening for Major Cancers: A 9-Year Experience in Minhang District of Shanghai, China." Frontiers in Oncology. Vol. 9, No. 375. [Accessed 20 Mar. 2020]
JMIR Medical Informatics. N.d. "Journal Description." [Accessed 1 Apr. 2020]
Lecturer, Southern Cross University, Australia. 23 March 2020. Correspondence with the Research Directorate.
Lei, Jianbo, et al. 28 March 2017. "Enabling Health Reform Through Regional Health Information Exchange: A Model Study from China." Journal of Healthcare Engineering. Vol. 2017. [Accessed 20 Mar. 2020]
Lei, Jianbo, et al. 28 August 2013. "A Comparison of Electronic Health Records at Two Major Peking University Hospitals in China to United States Meaningful Use Objectives." BMC Medical Informatics and Decision Making. Vol. 13, No. 96. [Accessed 23 Mar. 2020]
Li, Peiyao, et al. 14 November 2017. "Promoting Secondary Analysis of Electronic Medical Records in China: Summary of the PLAGH-MIT Critical Data Conference and Health Datathon." JMIR Medical Informatics. Vol. 5, No. 4. [Accessed 25 Mar. 2020]
Payne, Thomas H., et al. December 2019. "Status of Health Information Exchange: A Comparison of Six Countries." Journal of Global Health. Vol. 9, No. 2. [Accessed 19 Mar. 2020]
Peking University. 25 December 2017. China Center for Health Development Studies. "Prof. Fang Hai." [Accessed 23 Mar. 2020]
Plos One. N.d. "Journal Information." [Accessed 1 Apr. 2020]
Wang, Yan, et al. 13 August 2013. "Association of Body Mass Index with Cause Specific Deaths in Chinese Elderly Hypertensive Patients: Minhang Community Study." Plos One. Vol. 8, No. 8. [Accessed 24 Mar. 2020]
Wang, Zhong. 1 April 2019. "Data Integration of Electronic Medical Record Under Administrative Decentralization of Medical Insurance and Healthcare in China: A Case Study." Israel Journal of Health Policy Research. Vol. 8, No. 24. [Accessed 19 Mar. 2020]
Zhang, Luxia, et al. 5 February 2018. "Big Data and Medical Research in China." The BMJ. Vol. 360. [Accessed 19 Mar. 2020]
Additional Sources Consulted
Oral sources: associate professor of management information systems who has written about the health information exchange in Shanghai; associate professor of medicine who has written about EHR adoption in China.
Internet sites, including: BMC Public Health; China Daily; ecoi.net; Factiva; Healthcare IT News; The New York Times; Shanghai – Minhang District Government, Municipal People's Government; South China Morning Post; TechNode; UN – Refworld; US – Congressional-Executive Commission on China, National Library of Medicine; Xinhua News Agency.
