COVID-19, which presumably originated in bats and was transmitted to humans by means of unknown mechanisms in Wuhan, Hubei Province, China in December 2019, has affected more than 180 countries and territories around the world. On March 11, 2020, the World Health Organization (WHO) characterized the COVID-19 outbreak as a pandemic. This is the first pandemic known to be caused by a new virus. Although the complete clinical picture with regard to COVID-19 is not fully known, based on currently available information, older adults and people with serious underlying medical conditions might be at a higher risk for the severe illness caused by COVID-19.

Since a total of 41 cases with an unknown etiology of pneumonia were confirmed in Wuhan City, Hubei Province, China in December 2019 [1], COVID-19 has spread rapidly across that country and around the world [2-8]. Thus far, it has affected more than 12,723,798 people in 188 countries and regions (data obtained through July 12, 2020) [9]. COVID-19 is now the most serious infectious disease event after severe acute respiratory syndrome (SARS) in 2003, and no effective vaccine, drug, or treatment has been found.

Many different infectious diseases still exist in the world, such as the Ebola hemorrhagic fever, the highly pathogenic avian influenza, SARS, Middle East respiratory syndrome (MERS)–related coronavirus, and seasonal influenza. When an infectious disease event occurs suddenly, it is crucial to find a quick treatment and control method. Normal patient treatment needs to be based on the medical history and symptoms of the different cases.

The rise of COVID-19 was sudden and marked by the global information flow not being fast enough and the case reports being transmitted slowly, which has led to a sluggish treatment progress, patients not being cured in an efficient manner, and the infectious disease still not being effectively controlled. In today’s age of information, our global connectivity gives us a strong advantage in the fight against infectious diseases. We can analyze large amounts of data to identify outbreaks across different parts of the world, and we can use advanced machine learning models to predict their future movement across different geographical territories. The challenge is that collating relevant data and standardizing it on a global level is a complicated task. In many parts of the world, data does not flow easily from hospitals into the public realm or across borders. Global data standards have yet to be developed, and this creates gaps in the data sets and delays in how the data can be used to shape global health efforts. One way of improving the speed that data is standardized could be to encourage better interconnectivity across national data systems by using more homogenous data standards. This would require a great deal of collaboration between the various stakeholders, and it could be challenging to promote it across borders [10].

The challenge of a slow and insufficient global information flow could be tackled by a good framework such as the Asia eHealth Information Network’s Governance, Architecture, Program Management, Standards and Interoperability framework as well as a good collaboration model.

According to different research case reports in China [2,5,6], of the patients who are in the 18 years and older group, 61.9% (n=172) were male, and in another report, 2 of 13 patients with COVID-19 were children, who ranged between 2 and 15 years old [11]. Conclusions of the symptoms and disease history of patients with COVID-19 were found in these studies. Hypertension and cardiovascular disease were the two most common diseases in the adult patient group, followed by diabetes mellitus. With regard to the symptoms, fever was the most common (n=28, 92.8%), followed by a cough (n=194, 69.8%), dyspnea (n=96, 34.5%), myalgia (n=77, 27.7%), a headache (n=20, 7.2%), diarrhea (n=17, 6.1%), a sore throat (5.1% [6]), and pharyngeal (17.4% [2]). Wang et al [2] showed that the intensive care rate was significant in older patients. Other research noted that patients who needed intensive care had a greater percentage of dyspnea than those not needing intensive care [2,5]. From a report presented by a Beijing research team, among 13 patients with COVID-19, 12 (92.3%) had a fever, with a mean of 1.6 days before the patient went to a hospital, and they had a cough (46.3%), myalgia (23.1%), upper airway congestion (61.5%), and a headache (23.1%) [11].

Although there are many reports and studies on COVID-19, the details of disease control and treatment are still being broadcast slowly, which may cause the disease spread to be out of control and make it difficult to share the experiences of successful case treatments. According to the control status and experience of COVID-19, all cases should be uploaded to the WHO website by different governments, but the route of transmission is still difficult to track, and treatment experiences in different countries cannot be effectively shared. A literature review of infectious disease surveillance, presented by Jajosky and Groseclose [12], and an analysis of the timeliness of reporting by the National Notifiable Diseases Surveillance System showed that longer reporting lags and the variability among the states limit its usefulness. Some systems have the function of being a static continuous spatial map of infectious disease risk, while others have the function of continuously updating the reporting of infectious diseases, but there is still no system that combines these two functions [13].

After the rise of COVID-19, the problem has developed into the pathogenic spread across, and among, nations by means of international travel, which has unfortunately enabled the pathogens to invade new countries and adapt to new environments and hosts faster [14,15]. In many countries where the public health infrastructure is poor or where there is an insufficient budget to develop it, the ability of electronic disease surveillance, including data collection and an analysis capability, should be improved [16,17]. Furthermore, the data exchange of international infectious disease reports and information has certain constraints, not only out of fear for the repercussions on trade and tourism but also because of the delays in data transfer through the multiple levels of governments or organizations [18]. After experiencing epidemic infectious diseases caused by mutant viruses such as SARS and MERS, we have found that, when facing treatment for unknown diseases, related health organizations and authorities should conduct comprehensive tests, using different drugs and treatment methods, and they should then present the differences between each case and the analyzed treatment results to find the best treatment. However, this process is tedious and dangerous, and it creates uncertainties regarding patient treatment. In the face of new infectious diseases, the exchange of treatment results and case experiences is critical.

When facing a new type of infectious disease, it is important not only to treat the disease but also to prevent its contagion. For example, hundreds of COVID-19 cases in South Korea were found to have occurred at the same church. Hundreds of cases in Japan were found to have originated on a cruise ship. In Hong Kong, several cases were found to have been infected through a hot pot meal. Iran’s speedy and large-scale infection may be due to specific types of religious behavior. In Italy, the outbreak may have been caused by the Italian culture, where hugs and kisses are a common way of greeting someone. During the SARS outbreak in 2003, it was found that infections were caused by the drainage designs of high-rise buildings [19]. Information on the correlation between the context of the event, living, transportation or environmental design, religion, and cultural behavior is critical for studying COVID-19 transmission.

To understand the epidemiology and trends of COVID-19, the WHO has provided a template for a case-based reporting form and a data dictionary for that case-based reporting form, and it has requested member countries to report probable and confirmed cases of COVID-19 infection within 48 hours of their identification [20]. These reports are sent through the National Focal Point and the Regional Contact Point for International Health Regulations at the appropriate WHO regional office. The WHO has asked the countries to provide aggregated data for surveillance when it is not feasible to report case-based data.

However, to the best of our knowledge, there has thus far been no functional collaborative global case exchange model that can cocreate case data on COVID-19 and facilitate care coordination across countries. The aim of this study is to design an infectious disease surveillance module for the global exchange of infectious cases and the sharing of treatment experience. Information on the movement and path tracking of cases, including the linkage and correlation between each case, can also be included in infectious disease control in various countries. Therefore, when an infectious disease outbreak occurs, it can be quickly controlled.

In the initial stages of the COVID-19 outbreak, little research was available on the data format of the disease, and no one knew what the best data format was; there had only been some discussions on the importance of clinical data exchange regarding the disease.

Currently, several places have created a Fast Healthcare Interoperability Resources (FHIR)–based COVID-19 data structure. A good example is provided by the National Coordinator for Health Information Technology in its Interoperability Standards Advisory section of Interoperability for the COVID-19 Novel Coronavirus Pandemic [21,22], namely, the Logica COVID-19 (FHIR v4.0.1) Implementation Guide CI Build. The Logica used Health Level 7 (HL7) FHIR profiles for COVID-19 to create an implementation guide for a collection or library of data elements that relate to COVID-19. This can be used in many different situations where COVID-19 data are shared to support patient care, billing, research, or public reporting.

Another example can be found in the Dedalus COVID-19 Solution [23]. In their “COVID-19 Simplifier Project,” they used FHIR resources in the Dedalus COVID-19 Solution software. The data elements cover a patient self-assessment, a remote clinical assessment, and telemedicine and self-monitoring. They claimed that their first activations will be in Italy and France. Our study uses a similar method that started from COVID-19–related clinical data, and we used the International Patient Summary (IPS) as a basis for the data structure. The IPS document is an electronic health record (EHR) extract that contains essential health care information for the necessary care of patients. Due to the rapid outbreak of the disease in the early weeks, no format had been designed for the exchange of COVID-19 data. Therefore, we designed a version of the IPS that can be used for COVID-19.

An IPS document is an EHR extract that contains essential health care information about a patient [24]. It is designed to support the used case scenario for unplanned, cross-border care, but it is not limited to that. It is intended to be international (ie, to provide generic solutions for global application beyond a particular region or country), and the IPS data set is minimal and nonexhaustive, specialty agnostic, and condition independent yet still clinically relevant. The design, global scope, and utility of IPS toward unplanned cross-border care, and its potential for reuse, make it suitable for a situation like COVID-19. The FHIR confirmed that IPS, including the symptoms, therapies, medications, and laboratory data, can be efficiently transferred and exchanged on the system for easy access by physicians. Patient data are deidentified to protect their privacy. In addition, the blockchain-based architecture can be used to ensure the security and immutability of the case data.

Our goal is to provide an immediate reference for people to use in the current crisis, so the design is not focused on a single use case, and the IPS therefore has a more general data structure that focuses on the clinical data needed for COVID-19.

We understand that the data structure will not be perfect or comprehensive, but it can be modified in the future after more and more institutions use the data structure to exchange records. According to the research of Holmgren et al [25], the inability of hospitals to receive electronic data is an obstacle for the effective monitoring of patient symptoms. Therefore, the aim of our study is to create a COVID-19 data structure and a system that can share the data among health care institutions. It is expected that the proposed system can contribute to the control of the COVID-19 situation.

After the outbreak of infectious diseases such as SARS, MERS, and COVID-19, it is well-known that international cooperation for disease treatment is critical, especially due to the current high frequency of travel between countries around the world. Diseases such as SARS and MERS not only affect people’s health but also seriously affect the world economy [29]. Although the deterioration of a disease condition depends on many variables, when facing unknown diseases, experience sharing and the exchange of advice are still key points. The control and treatment of any disease needs to be found as soon as possible. To control and treat the disease, a global case study sharing system must be established, not only for clinical data sharing but also for the development of treatment methods.

Through the system designed by this study, minimal and useful patient summary data can be shared. Physicians only need to focus on essential clinical data that can be followed up on, and they can try a specific treatment or medicine when facing unknown diseases such as COVID-19. Data from other countries or other patients can be taken as a reference for patient care and treatment. According to published studies, having a fever and a cough are the dominant symptoms of COVID-19, while gastrointestinal symptoms are uncommon [5,30,31]. One report presents the first confirmed case of COVID-19 in the United States, including the process of identification, diagnosis, clinical course, management, and the patient’s symptoms [3]. Overall, there is an important need for coordination between clinicians and public health authorities, as well as for the rapid transfer of clinical information relating to the care of patients with COVID-19.

One case study of the first-known imported case of COVID-19 infection in Taiwan describes how the doctor gave the patient supporting treatment for all her symptoms. However, there is still a lack of details on the clinical information about the patient [28]. Another study of numerous cases was conducted by Chan et al [32] at Hong Kong University. They found that the outbreak of COVID-19 in Wuhan, China was similar to the 2003 SARS outbreak in Guangzhou, China. Both outbreaks initially happened in the animal-to-people transmission model and not by person-to-person transmission in the community. The case study exchange from the model and the subsequent knowledge exchange, analysis, conclusion, planning, and evaluation will provide a basis for understanding the experiences of previous epidemics, like SARS and MERS, and help to streamline the disease prevention and control measures (eg, regulations for animal and wet markets, patient isolation and tracking, contact quarantine, and public health and hygiene education) to prevent any rapid spread. As their system was helpless against SARS, Hong Kong later developed the Communicable Disease Information System to provide real-time and intelligent syndromic and communicable disease surveillance; to enable rapid intervention and quicker outbreak and emergency responses via field investigations, outbreak control, responsive risk communication, ongoing analysis, alert generation, predictive capability, and early outbreak detection; and to offer a framework for strategic planning and program evaluation. We can rapidly gather information for COVID-19 through international channels, but the information is still not clear enough to use as a reference for treating patients. Lipsitch et al [33] showed that viral testing should not be used just for clinical care, and public health efforts should use it to target the trajectory and severity of the disease. Guan et al [34], from the State Key Laboratory of Respiratory Diseases, noted the limitations of COVID-19 research due to the collection of data from different structures of electronic databases and the urgent timeline for data extraction. Some cases, therefore, have incomplete clinical data of the patients’ exposure history and laboratory testing [34].

The main challenge of COVID-19 is that we do not have enough knowledge of the therapy, control methods, and full spread route of the virus, which can only be obtained from the patient. Based on the experience of rapid virus transmission and the burden on the health care system, a global information system is essential. When analyzing the development of COVID-19, it seems that an effective global communicable disease surveillance system has not yet been developed. The disease data are not timely or effectively linked. Physicians and scientists around the world are unable to obtain sufficient disease information in a thorough and timely manner to control the epidemic. Currently, the exchange of case data for clinical research on COVID-19 is incomplete and not quick enough, which limits the development of a treatment design. Even if many case reports were to be submitted, the goals of real-time tracking, data exchange, and referencing could not be achieved. Therefore, to reduce the restrictions on COVID-19 research, an EHRs–based information communication system is necessary, as it can quickly achieve such goals for the public.

This study created the IPS of infectious diseases that physicians can access when treating patients with COVID-19. We have also established a secure blockchain architecture for the protection of the IPS, and we have completed the application of tracking patients’ moving path. The IPS case studies can be exchanged through our system and verified through the blockchain architecture. Over the past few years, blockchain has been used in many different fields, not only with regard to medical records (EHRs and personal health records) but also to medical data exchange issues. Benil and Jasper [35] introduced blockchain architecture for managing EHRs. In its design, the EHR is stored in the cloud, and its integrity in the cloud will be checked through the blockchain. This is a similar architecture to our study and proves that the blockchain can protect and verify EHRs. Fan et al [36] proposed a blockchain-based consensus mechanism for medical information data security and privacy in the medical system. Sun et al [37] presented a distributed signature scheme for medical systems with a record-sharing protocol that is based on blockchain. Yang and Li [38] designed an architecture for securing the EHR system, which is based on distributed ledger technology, to improve the interoperability of health record exchanges between different organizations. Chen et al [39] introduced a searchable encryption scheme for EHRs by using blockchain. Blockchain architecture can ensure data security and verify that the information is correct, and it is therefore a suitable architecture for global IPS file exchange.

The results of this study can help health authorities respond quickly to the transmission and spread of any unknown disease, and it can provide a good system for information retrieval on disease transmission. Another benefit of this system is that it can help public health researchers form study trials and analyze data from different countries. A trial on medication treatment in patients with COVID-19 found that the lopinavir–ritonavir treatment added to the standard supportive care, but it was not significant for clinical improvement or mortality in patients with COVID-19 [40]. Other research on the use of chloroquine and hydroxychloroquine in COVID-19 shows that the use of these drugs is premature and potentially harmful [41].

However, the clinical observation details of patients were not described by the authors. It is hard to identify which supportive care works best for patients in different situations. Another effective means for fighting an unknown virus could be using a common forum to facilitate the mutual sharing of experiences, best practices, therapies for patients, and the possible useful medications and outcomes from clinical interventions being trialed in various countries in a secure, trustworthy manner. The system designed by this study can become an effective tool for facilitating global collaboration and cooperation, and for promoting collective evidence-based efforts to address the unprecedented situation created by COVID-19. However, this study has some limitations. At present, there is no optimal treatment, and complete information about this disease has not yet been found. Governments, medical institutions, and physicians from all over the world should cooperate in the study of this virus. Without international cooperation, global interests will have significant losses. This study has completed the design and development of a global infectious disease surveillance and case tracking system for COVID-19, and found that it has a stable foundation and is a balanced system. However, there is still a need to test the effectiveness of a large number of users uploading and exchanging data simultaneously. In the future, our team will have discussions with governments, international medical service providers, and medical institutions to activate this system and to promote international cooperation and development during the COVID-19 outbreak.