Clipping Board » Medical Affairs and Administration ─ Medical system, pharmaceuticals, and medical community-related reports
Text/Selected from the Medical Voice Forum
2008, Vol.51, No.10 Taiwan Medical Journal
Since the introduction of the NHI IC card, the Bureau of National Health Insurance (BNHI) has required all medical institutions to lease a VPN dedicated line from Chunghwa Telecom to connect with the BNHI, citing security concerns. All setup costs and monthly fees are borne by the medical institutions themselves. In the first two years, the BNHI provided a subsidy of a few hundred dollars, and Chunghwa Telecom also offered a partial discount on the monthly fee. Behind this seemingly benevolent policy of subsidies and discounts lies an entirely unnecessary and absurd practice. In other words, over the past five years, medical institutions across the country have needlessly paid billions of dollars that they shouldn’t have had to pay!
Current Internet Status of General Clinics
In the current medical environment, clinics must have two external internet connections to complete various online reporting tasks: one is the BNHI’s VPN dedicated line, and the other is a general internet connection (since most use ADSL, we’ll simply refer to it as ADSL). We’ve taken data from a typical clinic to create a comparison chart:
From the above chart, everyone can clearly see that the clinic maintains two internet connections, with costs that are not significantly different, but the traffic and functionality are worlds apart. ADSL not only helps us complete various online submissions outside the National Health Insurance Administration (NHIA) but also offers many other functions, such as accessing Medline, filing taxes, online banking, forums, etc. On the other hand, VPN is only used for very low-traffic tasks like updating patient IC cards and uploading daily patient visit data, with the transmitted files being extremely small—averaging less than 90K per day. A size of 90K is less than a quarter of this article. Spending money to maintain a VPN network that transmits such minimal data daily is not only a waste of network resources but also raises the question: "Is this worth it? Aren’t there more cost-effective and efficient alternatives?"
The NHIA must take on greater responsibility for network information security, and the costs should not be passed on to the medical community.
At the inception of the National Health Insurance (NHI) program, medical expense claims could be submitted via media, which involved printing summary sheets and copying the claim data onto floppy disks to be mailed to the NHIA. Later, the NHIA allowed online submissions via the internet, which operated smoothly for several years until the introduction of IC cards. At that point, the NHIA, citing security concerns, introduced Chunghwa Telecom's VPN medical network, abruptly discontinuing internet-based submissions. While we understand the internet is fraught with risks and agree that enhancing the security of data transmission is crucial, what constitutes secure network transmission? How secure is secure enough? Does Chunghwa Telecom's VPN equate to security? Are there no other sufficiently secure alternatives besides Chunghwa Telecom's VPN? These are critical considerations—did the NHIA thoroughly analyze and compare options during its decision-making process?
The NHIA has never publicly detailed why it discontinued internet-based submissions, only vaguely citing security reasons for switching to VPN, specifically Chunghwa Telecom's VPN. No one opposes a more secure information network, and we can accept the NHIA's adoption of VPN. However, the NHIA has its own equipment and professional IT staff—why couldn’t it set up its own VPN servers, allowing members to establish VPN tunnels via ADSL to transmit data? Is Chunghwa Telecom's VPN inherently more secure than a VPN server set up by the NHIA itself? Likely not. Instead, by outsourcing VPN services to Chunghwa Telecom, the NHIA has shifted the responsibility for information security while passing the costs onto medical institutions.
Medical information networks must be well-integrated.
Whether during the early days of internet-based medical expense submissions or the transition to VPN submissions, clinics rarely needed the internet for other tasks. For medical institutions not using the internet, whether VPN or ADSL, a single connection sufficed. However, with advancements in government network infrastructure, more online services have emerged, such as the Controlled Substances Management Information System, the Continuing Education Credit Management System for Medical Personnel, the Centers for Disease Control's Influenza Vaccine Information System, the NHIA's Multi-Certificate Online Underwriting System, the Labor Insurance Bureau's Online Submission and Inquiry System, and the Ministry of Health and Welfare's push for electronic medical records, including digital signatures and timestamps (which will only increase in the future). As society progresses, medical institutions are keeping pace with e-government initiatives, and their reliance on the internet will only grow.Watching the VPN crawl at a snail's pace trying to connect to the restricted internet, we can't help but recall the bold words of former Deputy General Manager Jiang of the Bureau of National Health Insurance when he vigorously promoted the VPN: "The total solution of VPN: In the future, using VPN ADSL, this line is multifunctional. It can access the internet, handle IC card operations, submit medical expense claims, and exchange medical information. You can cancel your single-function home ADSL and switch to the Bureau’s ADSL, with the monthly fee now reduced to 926 NT dollars. This multifunctional ADSL line is currently being planned. In the future, all doctors will enter the Bureau’s line and then go out from there, forming an intranet between medical institutions and the Bureau." What caused this supposedly total solution VPN to falter instead? The undeniable reality is: while the government’s internet-based medical applications are flourishing, the Bureau’s VPN not only fails to deliver on its promise of a total solution but clings stubbornly to the expensive and slow Chunghwa Telecom VPN network, keeping medical institutions bound to it.
Undeniably, the internet itself is an insecure environment, with frequent reports of hacking and viruses. However, antivirus and authentication technologies are also advancing rapidly. If critical matters like finance and tax payments—which directly impact public welfare—can be conducted over ADSL networks, there’s absolutely no excuse for the Bureau’s data to be an exception. Consider how crucial tax filing data is—it includes not only personal information but also private details like salary and income. If the National Taxation Bureau claimed that, to protect taxpayer data security, anyone filing taxes online must first apply for a dedicated VPN line, would that be reasonable? Could banks similarly demand that online banking users install a dedicated VPN line? Health insurance data is important, but isn’t the data transmitted over ADSL by other agencies equally important? Why can they do it, but the Bureau can’t? This can’t be brushed off with vague claims about security.
We hardly dare hope such a suggestion would be adopted. Without support from medical associations or louder protests, expecting the Bureau to take on the task of connectivity and free medical institutions from the endless nightmare of VPNs is unrealistic under the bureaucratic culture of avoiding extra work. Therefore, the physician team in the computer information department of the Medical Voices Forum has devised an alternative solution: setting up servers that allow medical institutions to connect to the Bureau’s VPN via their ADSL lines through program relays. In other words, medical institutions no longer need Chunghwa Telecom’s VPN line to connect with the Bureau. This method has already been successfully tested in practice, with participating members reporting performance identical to the existing VPN.
While the Medical Voices Forum successfully tested the relay servers, some members pointed out that a certain medical association had already implemented a similar system. Currently, it only serves locations without VPN access for house calls, allowing them to replace the VPN line with any available ADSL connection. This further proves the feasibility of our approach. However, our self-built servers can’t handle large-scale relay services due to limited personal resources. We recommend that medical associations take the initiative to establish such servers for members to connect to the Bureau’s VPN. This way, members could use just one ADSL line without paying extra monthly fees for VPN. We estimate that a few strategically placed servers would suffice for nationwide medical institutions, with setup costs amounting to just tens of thousands of NT dollars. The trade-off of a few thousand dollars to eliminate billions in waste is clearly worthwhile.Of course, we do not wish to resort to self-help, as this is a debatable issue and one that can be resolved with genuine effort. We sincerely urge the health authorities to address this problem and take further steps to resolve it:
1. **Expedite the integration of medical networks** so that all healthcare institutions can connect to all relevant government agencies through a single network. Stop tolerating the NHIA’s (National Health Insurance Administration) independent actions, which only perpetuate the absurdity of "one country, two systems."
2. **Under the framework of an integrated medical network**, the NHIA should establish its own cybersecurity mechanisms rather than isolating itself from the medical network system of the Ministry of Health and Welfare. Stop wasting money on Chunghwa Telecom’s VPN—the monthly expenditure of over NT$18 million on VPN services is still public funds, after all.
Doctor Voice Forum: [http://doctorvoice.org](http://doctorvoice.org)
We welcome you to contact us.
The Absurdity of the Health Insurance Agency's Hotline
2008, Vol.51, No.10 Taiwan Medical Journal
Since the introduction of the NHI IC card, the Bureau of National Health Insurance (BNHI) has required all medical institutions to lease a VPN dedicated line from Chunghwa Telecom to connect with the BNHI, citing security concerns. All setup costs and monthly fees are borne by the medical institutions themselves. In the first two years, the BNHI provided a subsidy of a few hundred dollars, and Chunghwa Telecom also offered a partial discount on the monthly fee. Behind this seemingly benevolent policy of subsidies and discounts lies an entirely unnecessary and absurd practice. In other words, over the past five years, medical institutions across the country have needlessly paid billions of dollars that they shouldn’t have had to pay!
Current Internet Status of General Clinics
In the current medical environment, clinics must have two external internet connections to complete various online reporting tasks: one is the BNHI’s VPN dedicated line, and the other is a general internet connection (since most use ADSL, we’ll simply refer to it as ADSL). We’ve taken data from a typical clinic to create a comparison chart:
| VPN | ADSL | Comparison Notes | |
|---|---|---|---|
| Specification | 1M/64K | 8M/640K | |
| Cost (NTD/month) | 684 | 930 | |
| Connected Websites | BNHI VPN (theoretically can also connect to the internet, but extremely slow) | General websites, Controlled Substances Management Information System, Continuing Education Credit Management System for Medical Personnel, CDC Influenza Vaccine Information System, BNHI Multi-Certificate Online Underwriting System, Labor Insurance Bureau Online Reporting and Inquiry System, and the electronic signature timestamp required for the electronic medical records heavily promoted by the Department of Health (and this list will only grow longer). | |
| Average Daily Traffic | 4,147,200 | 5,322,240,000 | VPN traffic is about 7.8% of ADSL traffic |
| Function | Main functions: daily IC card data upload, outpatient fee reporting, payment inquiry | Can connect to various websites except the BNHI VPN site |
From the above chart, everyone can clearly see that the clinic maintains two internet connections, with costs that are not significantly different, but the traffic and functionality are worlds apart. ADSL not only helps us complete various online submissions outside the National Health Insurance Administration (NHIA) but also offers many other functions, such as accessing Medline, filing taxes, online banking, forums, etc. On the other hand, VPN is only used for very low-traffic tasks like updating patient IC cards and uploading daily patient visit data, with the transmitted files being extremely small—averaging less than 90K per day. A size of 90K is less than a quarter of this article. Spending money to maintain a VPN network that transmits such minimal data daily is not only a waste of network resources but also raises the question: "Is this worth it? Aren’t there more cost-effective and efficient alternatives?"
The NHIA must take on greater responsibility for network information security, and the costs should not be passed on to the medical community.
At the inception of the National Health Insurance (NHI) program, medical expense claims could be submitted via media, which involved printing summary sheets and copying the claim data onto floppy disks to be mailed to the NHIA. Later, the NHIA allowed online submissions via the internet, which operated smoothly for several years until the introduction of IC cards. At that point, the NHIA, citing security concerns, introduced Chunghwa Telecom's VPN medical network, abruptly discontinuing internet-based submissions. While we understand the internet is fraught with risks and agree that enhancing the security of data transmission is crucial, what constitutes secure network transmission? How secure is secure enough? Does Chunghwa Telecom's VPN equate to security? Are there no other sufficiently secure alternatives besides Chunghwa Telecom's VPN? These are critical considerations—did the NHIA thoroughly analyze and compare options during its decision-making process?
The NHIA has never publicly detailed why it discontinued internet-based submissions, only vaguely citing security reasons for switching to VPN, specifically Chunghwa Telecom's VPN. No one opposes a more secure information network, and we can accept the NHIA's adoption of VPN. However, the NHIA has its own equipment and professional IT staff—why couldn’t it set up its own VPN servers, allowing members to establish VPN tunnels via ADSL to transmit data? Is Chunghwa Telecom's VPN inherently more secure than a VPN server set up by the NHIA itself? Likely not. Instead, by outsourcing VPN services to Chunghwa Telecom, the NHIA has shifted the responsibility for information security while passing the costs onto medical institutions.
Medical information networks must be well-integrated.
Whether during the early days of internet-based medical expense submissions or the transition to VPN submissions, clinics rarely needed the internet for other tasks. For medical institutions not using the internet, whether VPN or ADSL, a single connection sufficed. However, with advancements in government network infrastructure, more online services have emerged, such as the Controlled Substances Management Information System, the Continuing Education Credit Management System for Medical Personnel, the Centers for Disease Control's Influenza Vaccine Information System, the NHIA's Multi-Certificate Online Underwriting System, the Labor Insurance Bureau's Online Submission and Inquiry System, and the Ministry of Health and Welfare's push for electronic medical records, including digital signatures and timestamps (which will only increase in the future). As society progresses, medical institutions are keeping pace with e-government initiatives, and their reliance on the internet will only grow.Watching the VPN crawl at a snail's pace trying to connect to the restricted internet, we can't help but recall the bold words of former Deputy General Manager Jiang of the Bureau of National Health Insurance when he vigorously promoted the VPN: "The total solution of VPN: In the future, using VPN ADSL, this line is multifunctional. It can access the internet, handle IC card operations, submit medical expense claims, and exchange medical information. You can cancel your single-function home ADSL and switch to the Bureau’s ADSL, with the monthly fee now reduced to 926 NT dollars. This multifunctional ADSL line is currently being planned. In the future, all doctors will enter the Bureau’s line and then go out from there, forming an intranet between medical institutions and the Bureau." What caused this supposedly total solution VPN to falter instead? The undeniable reality is: while the government’s internet-based medical applications are flourishing, the Bureau’s VPN not only fails to deliver on its promise of a total solution but clings stubbornly to the expensive and slow Chunghwa Telecom VPN network, keeping medical institutions bound to it.
Undeniably, the internet itself is an insecure environment, with frequent reports of hacking and viruses. However, antivirus and authentication technologies are also advancing rapidly. If critical matters like finance and tax payments—which directly impact public welfare—can be conducted over ADSL networks, there’s absolutely no excuse for the Bureau’s data to be an exception. Consider how crucial tax filing data is—it includes not only personal information but also private details like salary and income. If the National Taxation Bureau claimed that, to protect taxpayer data security, anyone filing taxes online must first apply for a dedicated VPN line, would that be reasonable? Could banks similarly demand that online banking users install a dedicated VPN line? Health insurance data is important, but isn’t the data transmitted over ADSL by other agencies equally important? Why can they do it, but the Bureau can’t? This can’t be brushed off with vague claims about security.
We hardly dare hope such a suggestion would be adopted. Without support from medical associations or louder protests, expecting the Bureau to take on the task of connectivity and free medical institutions from the endless nightmare of VPNs is unrealistic under the bureaucratic culture of avoiding extra work. Therefore, the physician team in the computer information department of the Medical Voices Forum has devised an alternative solution: setting up servers that allow medical institutions to connect to the Bureau’s VPN via their ADSL lines through program relays. In other words, medical institutions no longer need Chunghwa Telecom’s VPN line to connect with the Bureau. This method has already been successfully tested in practice, with participating members reporting performance identical to the existing VPN.
While the Medical Voices Forum successfully tested the relay servers, some members pointed out that a certain medical association had already implemented a similar system. Currently, it only serves locations without VPN access for house calls, allowing them to replace the VPN line with any available ADSL connection. This further proves the feasibility of our approach. However, our self-built servers can’t handle large-scale relay services due to limited personal resources. We recommend that medical associations take the initiative to establish such servers for members to connect to the Bureau’s VPN. This way, members could use just one ADSL line without paying extra monthly fees for VPN. We estimate that a few strategically placed servers would suffice for nationwide medical institutions, with setup costs amounting to just tens of thousands of NT dollars. The trade-off of a few thousand dollars to eliminate billions in waste is clearly worthwhile.Of course, we do not wish to resort to self-help, as this is a debatable issue and one that can be resolved with genuine effort. We sincerely urge the health authorities to address this problem and take further steps to resolve it:
1. **Expedite the integration of medical networks** so that all healthcare institutions can connect to all relevant government agencies through a single network. Stop tolerating the NHIA’s (National Health Insurance Administration) independent actions, which only perpetuate the absurdity of "one country, two systems."
2. **Under the framework of an integrated medical network**, the NHIA should establish its own cybersecurity mechanisms rather than isolating itself from the medical network system of the Ministry of Health and Welfare. Stop wasting money on Chunghwa Telecom’s VPN—the monthly expenditure of over NT$18 million on VPN services is still public funds, after all.
Doctor Voice Forum: [http://doctorvoice.org](http://doctorvoice.org)
We welcome you to contact us.