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To achieve universal access to medical resources, China introduced its second health care reform in 2010, with health information technologies (HIT) as an important technical support point.
This study is the first attempt to explore the unique contributions and characteristics of HIT development in Chinese hospitals from the three major aspects of hospital HIT—human resources, funding, and materials—in an all-around, multi-angled, and time-longitudinal manner, so as to serve as a reference for decision makers in China and the rest of the world when formulating HIT development strategies.
A longitudinal research method is used to analyze the results of the CHIMA Annual Survey of Hospital Information System in China carried out by a Chinese national industrial association, CHIMA, from 2007 to 2018. The development characteristics of human resources, funding, and materials of HIT in China for the past 12 years are summarized. The Bass model is used to fit and predict the popularization trend of EMR in Chinese hospitals from 2007 to 2020.
From 2007 to 2018, the CHIMA Annual Survey interviewed 10,954 hospital CIOs across 32 administrative regions in Mainland China. Compared with 2007, as of 2018, in terms of human resources, the average full time equivalent (FTE) count in each hospital’s IT center is still lower than the average level of US counterparts in 2014 (9.66 FTEs vs. 34 FTEs). The proportion of CIOs with a master’s degree or above was 25.61%, showing an increase of 18.51%, among which those with computer-related backgrounds accounted for 64.75%, however, those with a medical informatics background only accounted for 3.67%. In terms of funding, the sampled hospitals’ annual HIT investment increased from ¥957,700 (US $136,874) to ¥6.376 million (US $911,261), and the average investment per bed increased from ¥4,600 (US $658) to ¥8,100 (US $1158). In terms of information system construction, as of 2018, the average EMR implementation rate of the sampled hospitals exceeded the average level of their US counterparts in 2015 and their German counterparts in 2017 (85.26% vs. 83.8% vs. 68.4%, respectively). The results of the Bass prediction model show that Chinese hospitals will likely reach an adoption rate of 91.4% by 2020 (
In more than 10 years, based on this top-down approach, China’s medical care industry has accepted government instructions and implemented the unified model planned by administrative intervention. With only about one-fifth of the required funding, and about one-fourth of the required human resources per hospital as compared to the US HITECH project, China’s EMR coverage in 2018 exceeded the average level of its US counterparts in 2015 and German counterparts in 2017. This experience deserves further study and analysis by other countries.
Health information technologies (HIT) can effectively improve the quality and efficiency of medical services, distribution of health care resources, safety in health care, and output of scientific research. Therefore, governments of various countries have set up ambitious plans to develop HIT and invested enormous amounts of money in this development, using HIT as an important starting point for the reformation of medical services and medical systems.
The US government invested $787 billion in the American Recovery and Reinvestment Act of 2009. In particular, $19 billion of this investment was used to promote nationalized and interoperable health information systems and implement them through the Health Information Technology for Economic and Clinical Health (HITECH) Act [
China has been no exception to this trend. As early as the beginning of the second health care reform in 2010, the government adopted HIT as one of the “four beams and eight pillars” supporting health care reform [
In order to build the HIT system, as detailed in the Healthy China 2020: Strategic Research Report released by the National Health Commission of the People’s Republic of China in 2012 [
Despite the formulation of very active macro policies and the investment of a large amount of funds, governments of various countries have always faced significant challenges in the technological research and development, project implementation, effect evaluation, and speed of advancement of HIT. Governments, academic circles, and industries have constantly presented the relevant experience and lessons. Kruse et al [
As the largest country in the world in terms of population and number of hospitals and the second largest in total economic volume, China currently lacks relevant research on the application status, characteristics, and challenges of HIT in its hospitals. In this study, we try to answer the following questions:
How can we describe, evaluate, and summarize the achievements and problems in China’s HIT development from 2007 to 2018?
During this period, compared with countries with advanced HIT such as the United States, what are China’s characteristics in terms of the number and quality of HIT employees, capital and resource investment, network support environment, and application of clinical information systems (CIS) such as EMR?
Our data are from the 2007-2018 China Hospital Information Management Association (CHIMA) annual survey hospital information systems, which is the only national HIT industry survey covering a period of more than 10 years in China. Over the last decade or so, CHIMA [
The CHIMA survey comprised 9 parts: respondents' basic information, IT application, infrastructure and hardware use, information system application, IT outsourcing, IT construction obstacles, information system construction investment, data standardization, and regional medical and health information system construction. We mainly used the data from the first to seventh of the 9 parts; in particular, the data from parts I-V and VII: respondents' basic information, IT application, infrastructure and hardware use, information system application, IT outsourcing, and information system construction investment. Each year’s survey report provides a summary of the current situation of hospital digitalization and the overall trend of HIT in China. The 2018 survey was completed between March 2019 and June 2019 and released on September 10, 2019.
In China, most hospitals purchase HIT software from the HIT market, which is outsourced by system suppliers. Therefore, the IT departments of hospitals are mainly responsible for the procurement, management, and subsequent maintenance of the system. The head of the IT department is the CIO of the hospital, and these CIOs are the main subjects of this research.
Bass diffusion modeling was employed as one method to predict the progress of EMR adoption and analyze its characteristics. Diffusion theory is an essential branch of communication theory that has long attracted the attention of scholars in management, marketing, and other disciplines [
There are two important measures for the implementation of the Bass model [
Mathematical expression of the Bass model.
We conducted statistical analyses and forecasts using linear optimization in Excel for Mac 2011 (Microsoft Corp). The parameters of the Bass model were trained and estimated using SPSS Statistics software version 20 (IBM Corp). We used the method of least squares to determine the optimal values of q and p.
The scale and regional coverage of the 2007-2018 CHIMA annual survey of hospital information systems are shown in
China Hospital Information Management Association survey on hospital digitalization in China by hospital level, 2007 to 2018.
From 2007 to 2018, the shortage of human resources in China’s hospital IT centers eased and the quality of personnel improved (
First, manpower allocation was 9.66 full-time equivalents (FTEs), on average, in 2018. At the same time, the average number of beds managed by each staff member in the hospital IT center decreased from 122 in 2007 to 93 in 2018, as shown in
Proportion of human resources in China’s hospital information technology centers from 2007 to 2018. FTE: full-time equivalent; IT: information technology.
Information technology centers with 10 or more staff members in China’s level III hospitals and hospitals below level III from 2007 to 2018. IT: information technology; FTE: full-time equivalent.
Second, the professional quality of CIOs in China’s hospital IT centers also improved significantly. The proportion of hospital CIOs with a master’s degree or above nearly tripled from 7.1% in 2007 to 25.61% in 2018. The proportion of CIOs with a master’s degree in level III hospitals increased from 14.56% in 2007 to 42.17%, and the proportion of CIOs with a master’s degree in level I and II hospitals increased from 2.08% to 6.31%, as shown in
Proportion of chief information officers with a master’s degree or above in China’s hospital information technology centers from 2007 to 2018. CIO: chief information officer.
Academic background and composition of chief information officers in China’s hospital information technology centers from 2007 to 2018. CIO: chief information officer.
Stimulated and driven by the state’s direct investment and relevant policies, the total direct investment by hospitals in HIT greatly increased.
First, the total investment in HIT rose from ¥957,700 (US $136,875) per year in 2007 to ¥6.376 million (US $0.91 million) per year in 2018, an increase of 5.66 times. The average annual HIT investment of level III hospitals increased from ¥1.689 million (US $0.24 million) per year to ¥10.192 million (US $1.46 million) per year, an increase of 5 times. The average annual HIT investment of hospitals below level III increased from ¥489,600 (US $69,974) to ¥2.401 million (US $0.34 million) per year, an increase of nearly 4 times, as shown in
Health information technologies investment in Chinese hospitals from 2007 to 2018. IT: information technology.
Second, relative to China’s fast-growing economy (per capita gross domestic product increased from ¥20,500 (US $2930) in 2007 to ¥64,600 (US $9233) in 2018, an increase of 2.15 times) and the rapid increase of medical expenses (per capita medical expenses increased from ¥900 (US $129) in 2007 to ¥3700 (US $528) in 2017, an increase of 4.28 times), the annual IT investment per bed increased insignificantly (only 76%) from ¥4600 (US $657) in 2007 to ¥8100 (US $1158) in 2018, as shown in
China’s per capita gross domestic product, medical expenditure per capita, and information technology investment per hospital bed from 2007 to 2018. IT: information technology; GDP: gross domestic product. (Note: As of the date of submission, the per capita health spending data for China in 2018 has not been announced.).
The overall network infrastructure construction and configuration of Chinese hospitals have also been continuously improving. On one hand, in terms of traditional wired Ethernet local area network (LAN) construction, in 2017 about 75.83% of the sampled hospitals had achieved the goal of one wired LAN interface supporting 5 beds or fewer, which was basically the same as in 2008. On the other hand, in terms of wireless network infrastructure, about 69.21% of the sampled hospitals had launched wireless networks, compared with 17.18% in 2007. In addition, about 30.79% of the sampled hospitals that had launched wireless networks had more than 100 wireless network access hotspots in 2017, as shown in
Wired local area network and wireless network facility construction in Chinese hospitals from 2007 to 2017. LAN: local area network. (Note: Wireless network-related indicators were not included in the 2007 CHIMA Annual Survey; relevant indicators on hospital networks were no longer included in the 2018 CHIMA Annual Survey.).
CIS has been implemented in Chinese hospitals to a considerable extent. After more than 10 years of development, medical digitalization has been adopted as one of the “four beams and eight pillars” supporting China’s health care reform, especially China’s second health care reform, which began in 2010; a large amount of funds and resources have been invested, and a large number of policies have been promulgated for support and guidance [
CIS has been applied to a considerable extent, and the popularization rate of EMR exceeded the average level of its US counterparts in 2015 [
Application and implementation of computerized prescriber order entry, electronic medical record, laboratory information system, and picture archiving and communication system in the sampled hospitals from 2007 to 2018. CPOE: computerized prescriber order entry; EMR: electronic medical record; LIS: laboratory information system; PACS: picture archiving and communication system. (Note: Due to a change in the leadership of CHIMA in 2016, the CHIMA Annual Survey was not launched, and survey data of 2016 and 2017 were not available for analysis.).
We estimated the p- and q-coefficients using the Bass model and linear optimization based on the CHIMA hospital adoption rate of EMR data from 2007-2018 (excluding 2016 and 2017; because of a leadership change in CHIMA in 2016, the 2016 annual survey was not launched).
The estimating parameters for Chinese hospitals’ adoption rate of electronic medical records.
Model parameter | Estimated result |
External motivation coefficient (p) | 0.102 |
Internal motivation coefficient (q) | 0.106 |
Motivation coefficient ratio (q/p) | 1.039 |
|
.951 |
Electronic medical record adoption among Chinese hospitals using the China Hospital Information Management Association Annual Survey (figures for 2016, 2017, and 2020 are forecasted using the Bass mode). CHIMA: China Hospital Information Management Association.
On one hand, the fitted external coefficient (p=0.102) of Chinese hospitals’ adoption rate of EMR is much larger than those of medical examination equipment popular in the United States, such as ultrasound images (p=0.000) and molybdenum target x-rays (p=0.000) [
On the other hand, compared with certain medical examination equipment, the internal motion coefficient (q) fitted in this study is relatively small, which indicates that the internal driving force of the hospitals themselves was relatively weak in this process. First, according to research by Sillup et al [
This study uses the data from the survey of medical digitalization construction conducted by CHIMA, a national industrial association in China, on 10,954 Chinese hospital CIOs from 2007 to 2018 to evaluate the progress of HIT in Chinese hospitals in terms of professional staffing, funding, infrastructure construction, and clinical system application. Here we discuss the US HIMSS annual survey exploring the difficulties and challenges encountered in the development of China’s HIT.
As of 2018, compared with their US counterparts, IT departments in Chinese hospitals were still short of IT human resources. The average allocation of human resources in the IT centers of the sampled Chinese hospitals was only 28% of that of their US counterparts in 2014 (9.66 FTEs vs 34 FTEs). We believe that this may further affect the development and deepening of subsequent HIT applications. In terms of the quantity of human resources, the survey results showed that hospital IT centers had an average of 9.66 FTEs in 2018, and the number of beds served by each IT staff member also dropped from 122 in 2007 to 93 in 2018. However, according to the annual survey of HIMSS in 2014, IT centers in the United States were equipped with an average of 34 FTEs, 3.5 times that of their Chinese counterparts [
Hospital information work such as system management; operation and maintenance; system and network security; content management; system integration and interface design; and hardware, network, and software maintenance is tedious and labor intensive, especially providing training for users of various levels and types of systems. Considering that many of the above services need to be provided on a 24/7 basis, it is an objective need and an inevitable trend for the development of hospital information systems to consume a large amount of human resources. We believe that, on one hand, the breadth and depth of HIT application in Chinese hospitals are still relatively low; on the other hand, policy makers and hospital managers do not fully understand that the safe and effective operation of information systems depends on the support of a large number of human resources.
The analysis of the highest degree of CIOs in hospitals indicates that the educational levels of information professionals working in hospitals in China had significantly improved; however, their distribution was not uniform. In 2018, 25.6% of CIOs had a master’s degree or above, an increase of 18.51% compared with 2007; however, there was a significant difference between level III hospitals and hospitals below level III. Taking 2018 as an example, the proportion in the former was 35.8% higher than that in the latter. We believe that IT faces the urgent matter of cultivating interdisciplinary senior management talent who understand both medical care and IT technology. According to the survey results in 2018, more than 60% of the CIOs in China’s hospital IT centers majored in computer information systems, while only 3.67% had a medical informatics background. Hospital CIOs demonstrated a relative lack of knowledge of hospital information management and medical informatics.
Unlike the cross-disciplinary definition of “using computer technology in the fields of health care and medical science” [
HIT investment in a large number of hospitals classified as level II and below in China may be mainly driven by state investment, but their own investment willingness is not strong. After the previous health care reform, hospitals could only receive limited government financial subsidies and had to be self-financing [
According to an analysis of national HIT investment directions from 2010 to 2015 (
The utilization rate of CIS represented by EMR in Chinese hospitals continued to increase. First, the EMR popularization rate of the sampled hospitals increased from 18.6% in 2007 to 85.3% in 2018, an increase of 3.6 times in 8 years, and the average EMR implementation rate of the sampled hospitals exceeded the average level of their US counterparts in 2015 [
On the other hand, as CIS, represented by EMR, has gradually been built and put into use, it faces the challenge of how to carry out the secondary application of massive precipitated data in China. In the survey samples in 2018, the implementation rates of CPOE, EMR, LIS, and PACS all exceeded 65%. However, real-world clinical data from EMR and other CIS have not been widely used for secondary data research in China. The second health care reform in China established medical digitalization as an essential strategic development direction [
In terms of interoperability, the various EMR systems used in different hospitals are incompatible with each other. There are currently more than 300 EMR software providers in China, all with their own proprietary technology structures and data standards. The hospitals have no initiative to exchange data despite the government establishment of some regional health information organizations (RHIOs). As of 2015, the proportion of hospitals participating in RHIOs in the sample had reached 50% [
Concerning the quality of information, EMR data in China is not informative. One study used Charmaz’s grounded theory approach to perform a difference analysis of the medical questions and number of examination and treatment terminologies in the EMR corpus samples among 3 US hospitals and a Chinese hospital [
Regarding ease of use, there are large discrepancies and gaps between EMR data in China and the United States. This indirectly leads to problems of integrity and accuracy in China’s EMR data. Previous research used the US Stage 2 Meaningful Use objectives to evaluate usability of EMR data from the two best Chinese teaching hospitals affiliated with Peking University Medical School (Peking University First Hospital and Beijing Cancer Hospital) [
This study is based on self-reported questionnaire survey results from 2007-2018 regarding investment in HIT funds, staffing and training, investment in funds, construction and implementation of applied technologies, and difficulties encountered in the processes of Chinese hospitals. The data have not been independently verified. Therefore, such an analysis is subject to the potential confounding factors of data bias. In addition, we did not use a multivariate model to evaluate the independence of different factors (such as hospital level, hospital type, and economic development level in the region of the hospital). Although we only limit the inference to our own samples, these analyses are still valuable because these data spanning 12 years are the only data on the development trend of HIT in China collected by China’s national industrial association that can be quantitatively analyzed.
In addition, the absence of feedback on data offset will affect the survey results. For example, hospitals with high HIT application levels are more likely to give feedback. However, the feedback providers of this survey should be representative of the true level of HIT application in Chinese hospitals to some extent, especially for the level III hospitals in China, which have an average coverage rate of 34.44% over 12 years.
China’s unique institutional model may have distinct advantages in achieving the goals of health care reform. In this case, the Chinese government used a top-down, top-level design mode and took HIT development as an important technical support and starting point to support health care reform through policies, systems, funds, and other comprehensive methods. According to the survey results of the CHIMA annual survey of hospital information systems, with about only one-fifth of the required funding and one-fourth of the required human resources funding per hospital IT FTE as compared with the US HITECH project, China’s EMR coverage in 2018 exceeded the average level of its US counterpart in 2015 and the average level of its German counterpart in 2017. Fitting results based on the Bass model suggest that it is expected that 91% of hospitals in China will use EMR by 2020. All signs show that the Chinese government is gradually approaching and realizing the phased goals set in the second health care reform launched in 2010: integrating medical resources, improving medical care popularization, reducing medical costs, and improving medical care quality.
National health information technologies investment directions from 2010 to 2015.
China Hospital Information Management Association
clinical information system
chief information officer
computerized prescriber order entry
electronic health record
electronic medical record
full-time equivalent
Healthcare Information and Management Systems Society
health information technologies
Health Information Technology for Economic and Clinical Health
information technology
local area network
laboratory information system
picture archiving and communication system
regional health information organization
We thank Elsevier language editing. This work was supported by the National Natural Science Foundation of China (grant numbers 81771937, 81871455).
None declared.