JMIR MEDICAL INFORMATICS

Julian et al

Viewpoint

Bridging Real-World Data Gaps: Connecting Dots Across 10 AsianCountries
Guilherme Silva Julian1, MSc; Wen-Yi Shau2, MD, PhD; Hsu-Wen Chou3, PhD; Sajita Setia4, MD
1

Pfizer Brazil, São Paulo, Brazil

2

Pfizer Corporation Hong Kong Limited, Hong Kong, China (Hong Kong)

3

Pfizer Ltd, Taipei, Taiwan

4

Executive Office, Transform Medical Communications Limited, Wanganui, New ZealandCorresponding Author:
Sajita Setia, MD
Executive Office, Transform Medical Communications Limited
184 Glasgow Street
Wanganui, 4500
New ZealandPhone: 64 276175433
Email: sajita.setia@transform-medcomms.com

Abstract
The economic trend and the health care landscape are rapidly evolving across Asia. Effective real-world data (RWD) for regulatory
and clinical decision-making is a crucial milestone associated with this evolution. This necessitates a critical evaluation of RWD
generation within distinct nations for the use of various RWD warehouses in the generation of real-world evidence (RWE). In
this article, we outline the RWD generation trends for 2 contrasting nation archetypes: “Solo Scholars”—nations with relatively
self-sufficient RWD research systems—and “Global Collaborators”—countries largely reliant on international infrastructures
for RWD generation. The key trends and patterns in RWD generation, country-specific insights into the predominant databases
used in each country to produce RWE, and insights into the broader landscape of RWD database use across these countries are
discussed. Conclusively, the data point out the heterogeneous nature of RWD generation practices across 10 different Asian
nations and advocate for strategic enhancements in data harmonization. The evidence highlights the imperative for improved
database integration and the establishment of standardized protocols and infrastructure for leveraging electronic medical records(EMR) in streamlining RWD acquisition. The clinical data analysis and reporting system of Hong Kong is an excellent example
of a successful EMR system that showcases the capacity of integrated robust EMR platforms to consolidate and produce diverse
RWE. This, in turn, can potentially reduce the necessity for reliance on numerous condition-specific local and global registries
or limited and largely unavailable medical insurance or claims databases in most Asian nations. Linking health technology
assessment processes with open data initiatives such as the Observational Medical Outcomes Partnership Common Data Modeland the Observational Health Data Sciences and Informatics could enable the leveraging of global data resources to inform local
decision-making. Advancing such initiatives is crucial for reinforcing health care frameworks in resource-limited settings andadvancing toward cohesive, evidence-driven health care policy and improved patient outcomes in the region.
(JMIR Med Inform 2024;12:e58548) doi: 10.2196/58548
KEYWORDS
Asia; electronic medical records; EMR; health care databases; health technology assessment; HTA; real-world data; real-world
evidence

Introduction
Real-world data (RWD) in medical and health research describes
data relating to patients’ health status or the delivery of healthcare in an environment outside of conventional clinical trials.
This includes data routinely collected for treatment and disease
registries, electronic medical records (EMRs), insurance claims,
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and other health databases that collect information reported bypatients or health care professionals [1,2]. Extending from thisconcept of RWD is real-world evidence (RWE), which is theanalyses produced from appropriate, well-designed studies using
RWD [3].
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participating due to potential risks or adverse events [2]. This
leads to a large number of underrepresented patients, reducing
the generalizability of interventions in the population,
particularly for those who may need it most. RWD can provide
the external validity needed when exploring different
interventions and treatment strategies across the health caresystem [2]. To provide external validity for different
interventions and disease management strategies, different study
styles are used for RWD generation. These can be broadly
categorized as comparative effectiveness research (CER) anddescriptive studies (non-CER) [4]. CER can be defined asstudies that primarily compare interventions and strategies,
while non-CER are observational studies that aim to provide a
descriptive overview of factors such as disease prevalence ortreatment patterns [4,5].
Two scoping reviews have been conducted to explore thespectrum of RWE from linked databases in Asia and their
possible impact on health care evolution, strategy, and policy[6,7]. The literature search for these reviews was conducted on
PubMed in September 2022 and May 2023, and analysis of
RWD publications across these countries assumed a linear
distribution of studies [6,7]. In the initial scoping review, thetrends and research warehouses for RWD-published studies
from 3 countries in Asia with varying health care systems,
Taiwan, India, and Thailand, were evaluated. The second
scoping review continued this explorative research in 7 otherdiverse Asian health care systems using the established protocol
from the prior review [4,7]. This study aimed to understand the
evolving landscape of RWD use and its implications acrossHong Kong, Indonesia, Malaysia, Pakistan, the Philippines,
Singapore, and Vietnam. The number of total publications andsingle-country studies (SCS) and cross-country collaboration

Julian et al
studies (CCCS) from all the countries in these scoping reviews
was used to archetype them as either “Solo Scholars” if they
published predominantly SCS with relatively higher number ofstudies published in last 5 years or “Global Collaborators” ifthey published less numbers and predominantly CCCS [7].
Hong Kong, India, Malaysia, Singapore, Taiwan, and Thailand
were categorized as Solo Scholars, and Indonesia, Pakistan, thePhilippines, and Vietnam were categorized as Global
Collaborators (Multimedia Appendix 1).
Using these archetypes generated from the 2 scoping reviews,
this viewpoint review intends to evaluate evolving trends andpatterns in the use of various RWD warehouses andcontextualize these findings within the broader health care andeconomic trends. Studying these evolving trends is crucial as
it helps understand how RWD warehouses are generating RWE,
which in turn informs health care policy and economic decisions[8]. Health technology assessment (HTA) organizations evaluate
the clinical and economic aspects of medicines and health caretechnologies and recommend reimbursement and other policy
criteria. Country HTAs are increasingly incorporating RWE for
crucialcomplementary
evidence,
particularlyincost-effectiveness analyses [8,9]. However, data accessibility
issues, lack of knowledge on robust methodologies, and ashortage of qualified researchers limit the generation of RWE
for regulatory and reimbursement decision-making [10]. Our
selection of countries for this scoping review was strategically
based on the contrasting spectrum of HTA expertise at different
timelines of development, from relatively mature systems in
Taiwan, Singapore, Hong Kong, Malaysia, and Thailand to
emerging frameworks in India, Indonesia, the Philippines, andVietnam, and nascent systems in Pakistan (Figure 1).

Figure 1. Timeline of HTA development across selected 10 countries in Asia. ACE: Agency for Care Effectiveness; CDE: Centre for Drug Evaluation;
DAC: Drug Advisory Committee; HA: Hospital Authority; HITAP: Health Intervention and Technology Assessment Program; HSPI: Health Strategy
and Planning Institute; HTA: health technology assessment; HTAIn: Health Technology India; InaHTAC: Indonesian Health Technology and Assessment
Committee; MaHTAS: Malaysian Health Technology Assessment; MOH: Ministry of Health; UHC: universal health coverage.

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Julian et al

Country Trends and Key Identified
Databases for 10 Asian Countries

Solo Scholars

Harnessing RWD is pivotal for improving health care outcomes,
and understanding country-specific trends and the databasesthat underpin this research is crucial [11,12]. The following
section provides a granular view of the health care and RWD
landscape across 10 Asian countries, dissecting the trends inresearch publications and the key linked databases that havebeen pivotal in generating RWE (Multimedia Appendix 2[13-20]). Countries are listed in order of highest to lowest countsof generated RWD publications in the last few years [6,7].

Taiwan is a thriving democracy with a population of 23.3 million
and a prosperous market economy. Taiwan’s gross domestic
product (GDP) grew by 2.45% in 2022 [21]. Development of
the digital infrastructure in health care is one of the Taiwan
government’s major goals in the next few years [22]. Although
there seems a lower overall usage of EMRs or electronic healthrecords (EHRs) in SCS for Taiwan (71/623, 11.4%) (Figure 2),
there was a noticeable increase in their usage from 2.8% (1/36)
to 19.4% (20/103) from 2017 to 2022 [6]. As shown in Figure
2, Taiwan has a high percentage of CER in their SCS (410/623,
65.8%). Inversely, the trend for higher CER is not seen in the
CCCS (14/51, 27.5%).

TaiwanFigure 2. Real-world data landscape for Taiwan (2017-2022). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

Taiwan has a robust health care system, which is reflected in
the percentages describing their RWD publications. Following
the creation of the National Health Insurance (NHI) in 1995,
Taiwan has set a benchmark in the region with a successful
universal health coverage (UHC) scheme in their health caresystem [23]. Enrollment in the NHI provides coverage for
essential medical care and pharmaceuticals for all residents [24].
The success of this system is exemplified in Taiwan’s favorable
result on the world’s health and health systems ranking in 2023[25], on which they were placed fourth (based on the Legatum
Prosperity Index that also accounts for economic and social
well-being). Furthermore, most health care facilities in Taiwan
upload the claims data of each visit to NHI, including patient
visits, drug prescriptions, surgeries, and examinations [23].
However, Taiwan’s NHI has changed since its creation in 1995
and continues to evolve [26]. In 2007, Taiwan implemented its
HTA within their Centre for Drug Evaluation to evaluate thefinancial suitability and clinical effectiveness of new drugs forreimbursement decisions [27]. This evolved into the formationof the Division of HTA in 2008 [28]. The high proportion of
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system, and there were general recommendations to have a
reduction in drug expenditure [29]. As such, with this goal of
reducing drug expenditures, some behind-the-counter products
were delisted from Taiwan’s national Drug Reimbursement
Scheme [23]. Along with this, coverage change was aimed at
reshaping patient expectations and attitudes toward health.
Taiwan’s vision for 2030 includes “precision health,” whichplaces an important focus on health promotion. This conceptof precision health involves using data to gather sufficient
information that can be used to predict health risks and prevent
diseases at the population level [30]. This vision relies on
adopting descriptive RWD to produce RWE that can aid in therefinement of specific health policies that contribute to precision
health and less comparative research. This also partially explains
why there was a decrease in the publication of CER studies
most notably from 75% in 2018 to 60% in 2022 [6]. It is worth
noting that the literature search on the publication of RWE fromlinked databases in Taiwan was conducted in September 2022
on PubMed, and the analysis assumed a linear distribution forstudies in 2017 and 2022.

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Taiwan stands out as a significant contributor to RWD studies
in Asia, predominantly through SCS, because it employs adiverse array of databases and holds a wealth of insurance claims
data.

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The key identified databases contributing to RWD publications
included the following [6]:
•

•

•

•
•

•

•

Chang Gung Research Database (CGRD): CGRD is amulti-institutional EMR database collected from the Chang
Gung Memorial Hospital system, which is the largest
medical system in Taiwan [31]. Except for 2 municipal
hospitals, all EMR data from Chang Gung Memorial
Hospital are included in the CGRD. The database includes
approximately 6%-20% outpatient and 10%-12% inpatient
claims records [32,33].
Taiwan Cancer Registry (TCR) Database: TCR wasdeveloped to monitor cancer incidence at the national level.
The TCR holds basic information on patients with newly
diagnosed cancer from hospitals with >50 beds throughout
the country [34].
Registry for Catastrophic Illness Patients: It is associatedwith the National Health Insurance Research Database(NHIRD) and is used to identify patients with catastrophic
illness in the Taiwan health insurance system [35].
Taiwan Death Registry: It contains information on accuratecauses of death and dates for all residents of Taiwan [36].
Taiwan Stroke Registry: This is a nationwide hospital-based
registry that enrolls patients with stroke from 19 academic
medical centers, 37 regional hospitals, and 8 district
hospitals. The data are collected prospectively by trained
neurologists and study nurses [37].
Taiwan Renal Registry Data System: It collects patients’clinical and laboratory information from all dialysis units
in Taiwan [38].
Taiwan Hepatitis C Virus Registry: This registry programis a nationwide hepatitis C virus platform implemented by
the Taiwan Association for the Study of the Liver [39].

•

•

•

•

•

Taipei Out-of-Hospital Cardiac Arrest Registry: It includes
prehospital and hospital information on patients with
out-of-hospital cardiac arrest in Taipei [40].
Taiwan Bone Marrow Transplant Registry: This registryholds clinical data from consecutive allogeneic
hematopoietic cell transplant recipients from 15 transplant
centers in Taiwan [41].
Acute Coronary Syndrome-Diabetes Mellitus Registry: It
is a nationwide registry of patients with acute coronary
syndrome in Taiwan that collects real-world clinicalpractices and outcomes data [42].
Taiwan Society of Cardiology Registry: This registrycollects data from patients at 21 medical centers or teaching
hospitals in Taiwan from patients who are hospitalized withacute new-onset heart failure or acute decompensatedchronic heart failure with a reduced ejection fraction [43].
NHIRD: It covers >99.6% of the Taiwanese population andcollects claims data from outpatient and inpatient hospitalcare settings [26].
Longitudinal Health Insurance Database: This database isderived from the NHI system and includes the registration
files and original reimbursement claims of a million
randomly selected beneficiaries, under the NHI program[44].
Longitudinal Cohort of Diabetes: This is a de-identified
subset of data from the NHIRD [45].

Singapore
Singapore is a prosperous nation with one of the highest GDP
per capita in Asia. In 2022, Singapore’s GDP grew by 3.6%
[46]. In 2023, the Singapore government announced the plan
to spend US $2.5 billion on info-communications technology
with the redevelopment of major hospitals [47]. Compared with
Taiwan, Singapore relies on higher use of EMRs or EHRs forreal-world SCS (43/80, 53.8%), which is balanced with theiruse of clinical registries (46/80, 57.5%) [7]. Although Singapore
SCS was predominantly in CER style (54/80, 67.5%), unlike
Taiwan, the percentage of CCCS publications remained
relatively high (57/77, 57.1%; Figure 3).

Figure 3. Real-world data landscape for Singapore (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies; TB: tuberculosis.

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In 2023, Singapore was regarded as top-ranking in the world’s
health and health systems, 3 places ahead of Taiwan [25].
Despite emerging issues surrounding health care services andthe affordability of health care, Singapore is able to achieve
good health outcomes with a health index score of 86.9 througha hybrid public and private health care model that is dominatedby public hospitals in the hospital sector and private clinics inthe outpatient sector [25,48]. Trusted Research and Real World
Data Utilization or TRUST platform stands as the cornerstone
for national data exchange in Singapore by facilitating the secureand anonymized sharing of health-related RWD between public
and private health care sectors [49]. The Ministry of Health(MOH) aimed to increase health care capacity to enhance healthcare affordability in the Healthcare 2020 Masterplan [50].
Within the MOH, the Agency for Care Effectiveness wasestablished in 2015 as the national HTA agency with the aimof evaluating drugs for subsidization and medical technologies[51,52]. This may partially explain Singapore’s relatively highpercentage of CER publications in both SCS and CCCS,
particularly as these types of studies enable a comparison ofdifferent medications and health management strategies. Thisis further magnified by the observation that the percentage of
SCS CER publications from Singapore increased from 2018 to2023 (analysis of these publications assumed a linear distribution
for studies in 2018 and 2023) [7].
The key identified databases contributing to RWD publications
from Singapore included the following [7]:
•

•

•

•

•

National Healthcare Group: This record links key
administrative and clinical information from a group of
National Healthcare Group health care institutions forpatients with chronic diseases such as diabetes mellitus,
hypertension, dyslipidemia, stroke, cardiovascular diseases,
and chronic renal disease [53].
Living Matters—Advance Care Planning (ACP): This
framework provides a comprehensive web-based resource
about ACP, including options for documenting patients’care preferences, particularly valuable in emergencies orwhen making critical care decisions. ACP details are also
integrated into EMR or EHR, and all health care providers
involved in patient care can easily access and understanda patient’s end-of-life care preferences [54].
Pan-Asian Resuscitation Outcomes Study Registry: The
Pan-Asian Resuscitation Outcomes Study registry contains
information from dispatch centers, ambulances, andhospitals from 7 countries in the Asia Pacific region (Japan,
South Korea, Taiwan, Thailand, United ArabEmirates-Dubai, Singapore, and Malaysia) [55].
Singapore Myocardial Infarction Registry: It is an
island-wide registry that is being managed by the National
Registry of Diseases Office that contains epidemiological
data on acute myocardial infarction cases diagnosed inpublic and private sector hospitals and some out-of-hospital
deaths certified by medical practitioners in Singapore [56].
National Immunization Registry of Singapore: This registrycollects and maintains accurate, complete, and current

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vaccination records of children and adults living in
Singapore [57].
National Human Immunodeficiency Virus Registry: This
registry is a name‐based system that holds identifiabledata for known human immunodeficiency virus cases in
Singapore, as well as contacts of cases that were reported[58].
Singapore National Tuberculosis Registry: This registry iselectronically linked to the 2 mycobacterial culture
laboratories in Singapore and captures all positive
Mycobacterium tuberculosis complex culture results in the
country [59].
Singapore Registry of Births and Deaths: This death registry
is maintained by the Ministry of Home Affairs Immigration
and Checkpoints Authority. It collects data on the cause
and date of death of all Singaporeans and permanent
residents in Singapore [60].
Singapore National Stroke Registry: This is a countrywide
registry of risk factors, stroke subtypes, management, andoutcomes of incident and recurrent stroke in Singapore [61].
National Trauma/Death Registry: This is a registry that
contains anatomical injury codes, indicators of physiologicalresponse to injury, and patient demographics [62].
MOH’s Central Claims Processing System: It is used in
Singapore to process the patient’s MediSave and
MediShield claims [63].

India
India is the largest lower-middle-income country in the world
and accounts for around 18% of the total population [64].
According to Nexdigm, the Indian health care industry is
expected to reach more than US $610 billion by 2026, as there
is a growing demand for specialized and higher-quality healthcare facilities [65]. Hospitals, clinical trials, telemedicine,
medical tourism, medical devices, medical and diagnostic
equipment, and health insurance are among the key products
and services that would drive this growth [66].
Compared with Taiwan and Singapore, India has a less extensive
health care system [25], which is also reflected in its
comparatively lower percentage of SCS (12/81, 14.8%) and
CCCS (10/52, 19.2%; Figure 4). India attracts a growing medical
tourism market with a growth of 22%-25% from 2014 andadvocacy for adoption of EMR across the country [67]. AmongRWD databases, the studies primarily use EHR or EMR (45/81,
55.6%), with an increasing trend from 20% in 2017 to 48% in
2022 [6]. Its usage is expected to continue to rise with the
National Digital Health Mission, since 2020 [68]. India has
made commitments toward achieving UHC and has been
producing policies and institutional changes that are directed
toward increasing health coverage and access to health services[69]. Government-funded health care sector is the provider ofhealth care to lower-income populations; however, the private
health care sector is the dominant health care provider [70]. In
2020, 70% of hospital market share was controlled by private
sector providers, and 63% of hospital beds were provided by
the hospital sector [71,72].

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Figure 4. Real-world data landscape for India (2017-2022). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

India launched Ayushman Bharat—one of the most ambitious
health missions ever to achieve UHC in 2018 [73]. Ayushman
Bharat encompasses 2 complementary schemes, Health andWellness Centres and the National Health Protection Scheme[69]. Along with this, there have been other initiatives to achieve
UHC [69]. The Pradhan Mantri Jan Arogya Yojana scheme
provides secondary and tertiary hospital care insurance to thebottom 40% of the population [68]. Previously called the“Medical Technology Assessment Board,” HTAIn, founded in2017, is the HTA agency within the Ministry of Health andFamily Welfare tasked with developing an HTA system to aid
in decision-making for resource allocation at the national andstate levels [74,75]. Reflecting these policy aims, the proportionof CER for SCS and CCCS was low in India but increased from2017 to 2022 (12/81, 14.8% and 10/52, 19.2%, respectively,
Figure 4), assuming a linear distribution for studies in 2017 and2022 [6].
The key identified databases contributing to RWD publications
from India included the following [6]:
•
•

•

•

•

HealthPlix EMR: This is an artificial intelligence–powered
electronic medical software system in India [76].
EyeSmart EMR: This is an EMR and Hospital Management
System in India that integrates the clinical, surgical,
financial, and operational functions of the LV Prasad Eye
Institute on a single platform [77].
Envision en-ABL-e Registry: This was a multicenter registrythat enrolled 2500 patients treated with 3286 Abluminus
DES (Envision Scientific, Surat, India) across 31 centers
across the country from June 2012 to December 2018 [78].
Nanoluté Registry: Nanoluté registry was used to observe
the clinical performance of a novel sirolimus-coated balloon(Concept Medical Research Private Limited, India) for
treating coronary de novo and restenotic lesions [79].
Primary Percutaneous Coronary Intervention Registry of
Kerala: This registry is a large multicenter primarypercutaneous coronary intervention registry from Kerala,

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India. It reports long‐term outcomes of patients presenting
with ST‐segment–elevation myocardial infarction to
percutaneous coronary intervention–capable hospitals or
facilities [80].
OncoCollect Lymphoma Registry: This registry was set up
in 2017 as a collaborative group effort to evaluate current
practices for managing diffuse large B-cell lymphoma in
middle-income countries [81].
Association of Surgical Gastroenterologists of Kerala
Colorectal Cancer Registry: This registry collects
demographics and perioperative outcomes of colorectal
cancer in Kerala from volunteer members of the Associationof Surgical Gastroenterologists of Kerala [82].
Towards Improved Trauma Care Outcomes in India: It isa multicenter trauma registry that contains data on trauma
patients admitted to 4 public university hospitals in Mumbai,
Delhi, and Kolkata from October 1, 2013, to September 30,
2015 [83].
The Indian Pediatric Continuous Renal Replacement
Therapy-International Collaboration of Nephrologists andIntensivists for Critical Care Children Neonatal Kidney
Educational Registry: This registry is a database of all
admitted neonates ≤28 days who received intravenous fluids
for at least 48 hours [84].
Aarogyasri Health Insurance Scheme: This is a social
insurance scheme with a private-public partnership model
to deal with the problems of medical expenditures for poor
households [85].

Hong Kong
Health care services in Hong Kong are provided by both private
and government-funded public sectors, with public medical
services provided by the Department of Health and the Hong
Kong Hospital Authority (HA) [86]. Hong Kong has awell-developed health care system that ranked 14th among thehealth and health systems ranking of countries worldwide in2023 [25]. Hong Kong’s system is a parallel, segmented public
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and private financed and provided health care, where the public
sector accounted for 51% of total health expenditure and theprivate sector accounted for 49% in 2017/18 [87]. With thegovernment’s commitment to provide UHC, the Drug Advisory
Committee is used to evaluate and advise on new drugs listedon the Hospital Authority Drug Formulary, which is the largest
public health care service provider in Hong Kong. One of themissions of the Drug Advisory Committee is to ensure equal
access of patients to cost-effective drugs with proven safety andefficacy [88].

Julian et al
As shown in Figure 5, CER publications made up 66.3% (57/86)
of SCS publications and 70.5% (31/44) of CCCS. To put thesehigh percentages into context, the drug appraisal and review
process involves an assessment of clinical evidence and healtheconomic evidence that is then used to make recommendations
on reimbursement of new drugs [89]. In Hong Kong, there has
been an increase in the requirement for a systematic HTA,
placing emphasis on the value and comparison of emerging andconventional drugs [88]. In line with this, there is an upward
trend in the percentage of SCS CER publications for Hong Kongfrom 2018 to 2023, assuming a linear distribution for studies
in 2018 and 2023 [7].

Figure 5. Real-world data landscape for Hong Kong (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

The key identified databases contributing to RWD publications
from Hong Kong included the following [7]:
•

•

•

•

Clinical Data Analysis and Reporting System (CDARS):CDARS is a centralized database developed for research
and audit purposes. It is managed by the HA. It collects
anonymized records of demographics, admission,prescription, diagnosis, procedure, laboratory test, and death
information [90].
Hong Kong Diabetes Registry: This is a diabetes registry
used for quality assurance and risk stratification to facilitate
subsequent triage of patients to different clinic settings [91].
Hong Kong Cancer Registry: This is a population-based
registry committed to collecting and conducting analyses
on data from all cancer cases in Hong Kong [92].
Hong Kong Biologics Registry: This is a registry that wasestablished in December 2005 by The Hong Kong Societyof Rheumatology to capture efficacy and safety data
regarding the use of biological agents for the treatment ofrheumatic disease [93].

Malaysia
Malaysia is an upper-middle-income country with a populationof about 34 million [94]. It is located at the heart of Southeast
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Asia and represents one of the regional hubs for informationand communication technology and medical travel [95].
Digitalization of information forms across major industrial
sectors will help secure Malaysia’s role in the future global
economy. As of 2023, Malaysia was ranked 42nd on the healthand health systems of countries worldwide [25]. Malaysia’s
health care system consists of tax-funded and highly subsidized
government-led services, with a fast-growing private sector[96]. Their dual-tier system consists of a government-led public
sector with an existing private sector, and in 2019, their publichealth expenditure amounted to 52% of their total healthexpenditure.
Malaysia’s 2023 Health White Paper outlines a transformative
masterplan for health management information and data system[97]. They aim to improve the health outcomes and well-beingof Malaysians and the use of the Malaysian Health Technology
Assessment, also termed as MaHTAS. HTA has been formalizedin Malaysia as a central structure within the MOH since 1995
and is a trusted medical evidence source [97]. Their generationof RWD publication used registries, with no, or low
contributions from other database types [7] (Figure 6). In linewith other countries that use HTA, 56% (28/50) of SCS were
CER, as were 54% (27/50) of the CCCS [7].
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Figure 6. Real-world data landscape for Malaysia (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

The key identified databases contributing to RWD publications
from Malaysia included the following [7]:••Malaysian National Cardiovascular Database Registry:
This is a service supported by the Malaysian MOH to collectinformation about cardiovascular diseases [98].
National Diabetes/Diabetic Registry: This is a registry used
to enable tracking of glycemic control and clinical outcomesof patients with diabetes managed at MOH health clinics[99].

ThailandThailand is also an upper-middle-income country but with thesecond largest economy (after Indonesia) in the Association ofSoutheast Asian Nations (ASEAN). Its GDP in 2022 was US$526 billion [100]. Thailand has the fourth greatest number of
Joint Commission International accreditation–certified hospitals
after Saudi Arabia, the United Arab Emirates, and Brazil. Yet
the medical expenses in Thailand are 50%-80% lower than thosein Europe, the United States, and Canada [101].

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On the health and health systems ranking of countries worldwide
in 2023, Thailand was ranked 13th [25]. In 2020, the private
health expenditure in Thailand accounted for about 71.2% of
the total health expenditure [102]. Furthermore, Thailand has
become internationally known for its success with UHC policy
since its development in 2002 [103]. The National List of
Essential Medicines is a drug reimbursement list for the publichealth insurance schemes in Thailand, and the HealthIntervention and Technology Assessment Program is a Thai
HTA agency established in 2007 that supports reimbursement
decisions [104]. Thailand used a relatively low percentage of
EHR or EMR warehouses in their RWD publications, with only
22% contribution in SCS publications and 16.1% in CCCS
publications (Figure 7). Surprisingly, they also had a relatively
low percentage of CER publications with 26.5% of their SCS
being CER publications and 29% of the CCCS being CER
publications [6].

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Figure 7. Real-world data landscape for Thailand (2017-2022). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
COOL-AF: Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation; EHR: electronic
health record; EMR: electronic medical record; SCS: single-country studies.

The key identified databases contributing to RWD publications
from Thailand included the following [6]:
•

•

•

•

•

•

COOL-AF Registry: The “Cohort of Antithrombotic Use
and Optimal International Normalized Ratio Levels in
Patients with Atrial Fibrillation (COOL-AF)” registry is adatabase of patients with atrial fibrillation in Thailand [105].
Type 1 Diabetes and Diabetes Diagnosed Before Age 30
Years Registry: This registry was established in 2014 andinvolves 31 hospitals to evaluate glycemic control andcomplications in patients with type 1 diabetes [106].
Cardiac Intervention Association of Thailand Registry:
This nationwide registry was an initiative of the Cardiac
Intervention Association of Thailand. All cardiac
catheterization laboratories in Thailand were invited toparticipate [107].
Khon Kaen Cancer Registry: This is a population-based
cancer registry of Khon Kaen that covers 26 districts inNortheastern Thailand [108].
Thai Lymphoma Study Group Registry: This is a web-based
nationwide lymphoma registry from the Thai Lymphoma
Study Group [109].
Rheumatic Disease Prior Authorization Registry: This is anational registry used for government reimbursement in the
Rheumatic Disease Prior Authorization system. This registrycontains data on patients’ demographic and clinicalcharacteristics at baseline, data-related disease activity, andtype of biologic medication prescribed [110].

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43-Files Database: These are administrative data collectedby the Thai Ministry of Public Health for the purpose ofreimbursement and health service use [111].
Universal Coverage Scheme: This health coverage scheme
consists of 3 main public insurance schemes that offer
full-service coverage. The 3 schemes are the Civil Servants
Medical Benefits Scheme for civil servants and theirdependents, Social Health Insurance for private sector
employees, and the Universal Coverage Scheme that covers
70% of the population in Thailand [112,113].

Global Collaborators
Indonesia
Indonesia is a country of 279.5 million people and is South East
Asia’s largest economy with a GDP of ~US $1.32 trillion in
2022. Ranked 97th in the 2023 health and systems ranking,Indonesia is progressing their UHC through the expansion of
NHI (Jaminan Kesehatan Nasional scheme) [25,114,115]. The
Indonesian government established the Indonesian HealthTechnology and Assessment Committee as an HTA committee
in 2014 to be the center of HTA activity, and as a starting point
for the development of HTA [116]. Similar to the other Solo
Scholars in this study, Indonesia was responsible for a relatively
low number of RWD publications [7]. Of their SCS, 28.6%(2/7) used EMR and 42.9% (3/7) were CER (Figure 8).

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Figure 8. Real-world data landscape for Indonesia (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

The key identified databases contributing to RWD publications
from Indonesia included the following [7]:•••Nationwide Percutaneous Coronary Intervention Registry:
This is a multicenter registry of interventional cardiology
projects involving 9 centers across Indonesia [117].
Jakarta Province COVID-19 Epidemiological Registry:
This is a database of patients with confirmed COVID-19
cases from Jakarta province [118].
Hasan Sadikin Lupus Registry: This is a registry created in
January 2016 that reports the medical records of patientswith systemic lupus erythematosus from the Dr Hasan
Sadikin General Hospital [119].

Pakistan
Health care has been identified as one of the best industry
prospects for Pakistan, a country with a population of more than

240 million and a GDP growth rate of 0.29% in 2023 [120].
Ranked 124th on the health and health systems ranking ofcountries in 2023, Pakistan’s health care comprises a 3-tiersystem of primary, secondary, and tertiary levels. The public
and private sectors work together to provide the best possiblecare, but there have been tremendous concerns about the failureof the delivery of quality care due to various factors, ranging
from inadequate infrastructure to inequitable distribution ofhealth care facilities [121]. Of note, to our knowledge, there are
currently no formal HTA programs in Pakistan [122].
These challenges are reflected in their low number ofpublications and, more specifically, their low number of SCS.
Among the SCS, only 7.7% (1/13) were CER studies.
Alternatively, due to their inadequate infrastructure, more CER
was conducted in CCCS (12/18, 66.7%) (Figure 9).

Figure 9. Real-world data landscape for Pakistan (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

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JMIR MEDICAL INFORMATICSThe key identified databases contributing to RWD publications
from Pakistan included the following [7]:•••Cardiac Registry of Pakistan: This is a cardiac registry that
includes 25 facilities from 3 provinces of Pakistan.
Standardized data are collected every 3 weeks for thisdatabase [123].
Punjab Cancer Registry: This registry collects
population-level cancer statistics in Pakistan [124].
Transfusion-Dependent Thalassemia Quality Improvement
Registry: It is a database comprising patients withtransfusion-dependent thalassemia from 4 centers in
Karachi, Pakistan [125].

Vietnam
In the 2022 ASEAN Business Outlook Survey, AmCham
Singapore members indicated Vietnam as the top Asia Pacificcountry (30%), where companies are considering expansion,
followed by Malaysia (25%), Thailand (24%), and Indonesia(23%) [126]. The per capita GDP for Vietnam was US $4086
in 2022 and is meant to increase to at least US $18,000 by 2035.
A large population of almost 100 million (half of which areyounger than 30 years), consistent strong economic growth, andongoing reform have created a dynamic and rapidly evolving
commercial environment in Vietnam [126].

Julian et al
Vietnam was ranked 44th on the health and health systems
ranking of countries in 2023 [25]. The Vietnamese MOH
manages 3 levels of health service delivery: primary level in
districts and communes, secondary level in provinces, andtertiary level in national institutions under central government
control. Working within this hierarchical system, Vietnam aims
to build a solid health care infrastructure from the grassroots[127]. Despite the significant progress, the health care systemstill faces challenges to keeping ahead of the country’s escalating
population [127]. Vietnam is making significant progress towardachieving UHC and is committed to delivering UHC [127]. In
2014, Vietnam introduced the HTA, working closely with the
Health Strategy and Planning Institute to facilitate its
institutionalization [128].
Similar to the other Global Collaborators, Vietnam generated
a low percentage of publications. However, 71.4% (5/7) of SCS
and 55% (11/20) of CCCS were CER (Figure 10). Based on theliterature search of RWE publications from linked databases inVietnam conducted in May 2023 on PubMed where the analysis
assumed a linear distribution for studies in 2019 and 2023,
Vietnam also exhibited the most significant increase with agrowth rate of 24.5% in RWD publications in the last 5 years[7].

Figure 10. Real-world data landscape for Vietnam (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

The key identified databases contributing to RWD publications
from Vietnam included the following [7]:••Ho Chi Minh City Cancer Registry: This registry documents
all diagnosed cancer cases in Ho Chi Minh City [129].
Vietnam Health Insurance Scheme Database: This claims
database is managed by the Vietnam Social Security Service
and it contains medical examinations and care, preventive
care, rehabilitation, maternity care, and prescribed
medications [130].

Philippines
The health care system is shared between the public and private
sectors in Philippines and was ranked 96th on the health andhttps://medinform.jmir.org/2024/1/e58548

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health systems ranking of countries worldwide in 2023 [25].
To respond to health financing gaps, the Philippines made major
reforms including the passage of the Universal Health Care Law
in 2019; however, there are ongoing issues with expenditure[131]. Following this passage, there were increased efforts toinstitutionalize HTA in the Philippines and as a result, a healthtechnology assessment unit was set up and is under development[52]. During the time period of 2018-2023, the majority of thePhilippines’ RWD publications were CCCS (19/22, 86.4%) andonly 33.3% (1/3) each of SCS were CER and used EMR (Figure11). Although the adoption of EMR for research is low and the
publication count has been scanty in the last 5 years [7], thePhilippines is estimated to spend approximately US $4.4 billion
on digital infrastructure over the next 6 years [132].
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Figure 11. Real-world data landscape for Philippines (2018-2023). CCCS: cross-country collaboration studies; CER: comparative effectiveness research;
EHR: electronic health record; EMR: electronic medical record; SCS: single-country studies.

The key identified databases contributing to RWD publications
from the Philippines included the following [7]:••Lysosomal Storage Disease Registry: It is a registry ofFilipinos diagnosed with any lysosomal storage disease[133].
Philippine Renal Disease Registry: This is a registry
consisting of 2 major components: The Chronic Renal
Disease Registry and the End Stage Renal Disease Registry.
The Chronic Renal Disease Registry is composed of the
Renal Biopsy Registry, and the End Stage Renal Disease
Registry is composed of Haemodialysis, Peritoneal Dialysis,
and Transplant Registries [134].

Discussion
RWD is used to inform policies in different capacities acrossthe countries. Focusing on the types and sources of RWD, wenoted key differences across the countries. For example, Taiwan
has a strong market economy [21], with a robust and successful
health care system [25]. It was noted that they had fewer
publications using EHR or EMR and more so used healthinsurance or administrative claims for their numerous
publications. They also had many identified databases and, assuch, were able to access several data sources to generate RWE(Figure 1). Taiwan exemplifies a country with the infrastructure
and resources to comfortably produce RWE. A trend in Solo
Scholar countries such as Taiwan was that they are prolific in
the publication of SCS, with a general decrease in CER studies
over time [6,7]. Typically, Global Collaborators have less robust
economies and health care systems. These were countries that
had less variety in data sources within their health system anda lack of standardized or integrated databases. These countries
published more CCCS with a general increasing trend in thepercentage of CER studies [7].
For Global Collaborators, CCCS are important for the generationof RWE. This highlights the necessity for data-sharing strategies
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and a need for the development of data-sharing frameworks,
particularly to aid countries that have weaker health care systems
and less established infrastructure for RWD [7]. It also
underscores the potential benefits of opening data initiatives,
where governments play a pivotal role [135]. Opening thesedata resources to a broader spectrum of stakeholders, including
academic institutions, can spur innovation, improve publichealth outcomes, and foster a more collaborative ecosystem[136]. Such initiatives not only democratize access to valuable
health data but also pave the way for a more inclusive approachto tackling global health challenges. This reflects a growing
recognition of the importance of transparency and collaboration
between the public sector and external entities in enhancing
health care delivery and research [137]. Indeed, many nations
such as Vietnam leverage regional and global studies conductedin a CER style to match their requirements for HTA. HTA
agencies across Asia could contribute to these types ofdevelopments as this may be beneficial to them. In 2011, theHTAsiaLink Network was set up as a collaborative network for
HTA agencies in Asia [138]. There is also the International
Network of Agencies for Health Technology Assessment, which
is an international HTA community, though to our knowledge,
Taiwan, Singapore, and Malaysia are the only countries
discussed that are part of this network [139]. Cross-sectoral
partnerships through HTAsiaLink Network and International
Network of Agencies for Health Technology Assessment could
help address challenges related to RWE generation, which aremuch more common in lesser developed countries, and support
country HTA and regulatory decision makers in decision-making[140,141]. However, there is also a need to improve database
identification and integration across countries as there is no
consistent naming of the databases, resulting in difficulty in
identifying and analyzing RWD publications across Asia.
Outside of reimbursement decisions, these improvements would
be helpful for a range of groups including health professionals
and researchers, health system managers, researchers, policy
makers, and investors. Along with these improvements, there
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JMIR MEDICAL INFORMATICS
is a need for focused use of EMR to streamline the process ofgenerating RWD for disease surveillance and management[142].
In recent years, an increasing number of Asian countries havebegun to recognize the importance of HTA in making informed
pricing and reimbursement decisions for health care technologies[143]. This shift toward evidence-based health care policy is
critical to ensure that decisions around health care technologies
are transparent and equitable [144]. To further enhance thetransparency and effectiveness of the HTA process, it is crucial
to involve all stakeholders at every step of the implementation.
In this context, global observational networks such as theObservational Health Data Sciences and Informatics (OHDSI)
program offer a promising avenue for enriching HTA processes
with robust RWE. Countries such as Taiwan, Singapore, andIndia already participate in OHDSI, although the global presence
remains limited [145]. By aligning governmental initiatives
with the Observational Medical Outcomes Partnership Common
Data Model used by OHDSI, there is a unique opportunity to
rapidly scale up the generation and use of RWE [146]. Suchcollaboration broadens the evidence base for HTA and facilitatesinternational cooperation and benchmarking in health caretechnology assessment. Moreover, linking HTA processes with
Observational and Medical Outcomes Partnerships or OHDSI
could serve as a catalyst for developing sophisticated andevidence-driven health care policies.
In the Hong Kong government’s 2021-2022 budget, an increaseof US $480 million was allotted to the HA to meet increasing
demand for health care services [86]. One such service is the
CDARS, which emerged as the key EMR database for Hong

Julian et al
Kong [7]. It is a database developed by HA, which is readily
used in Hong Kong for RWD [90]. Among all 10 countries,
Hong Kong leveraged EMR for most of its RWD SCS (80.2%)(Figure 4). Streamlined use of EMRs has the potential to collecta variety of RWD, which reduces the need to set up multiple
disease-specificclinicalregistries
forgenerating
non–cost-related RWE. The CDARS database is a good exampleof this as it has been established for research purposes andcontains necessary medical information, including patient
demographics, details on admission, diagnosis, and prescription
and laboratory tests [90].

Conclusions
RWD plays a significant role in informing policy decisions
across Asia. There are differing trends and patterns in the useof databases for published RWD across Asia and clear gaps inusage of warehouses across countries. However, based on theeconomic and health care development trends, there seems agreat potential in generating fit-for-purpose RWE across distinct
health care systems. Global Collaborators demonstrate a relianceon international partnerships for CCCS, due to a strategic driveto overcome infrastructural limitations. The review stresses thenecessity for enhanced data-sharing strategies and more robust
database integration, which are critical for countries with limited
health care system resources. Furthermore, the consistent naming
and use of databases, especially EMRs, are pivotal for advancing
disease surveillance and RWD generation across Asia. The
findings call for joint efforts by HTA agencies and stakeholders
to fortify RWD frameworks, which would not only aid
reimbursement decisions but also support the broader spectrumof health care stakeholders.

Acknowledgments
Desktop research and medical writing for this article were funded by Pfizer and were conducted by Transform Medical
Communications Limited (Transform Medcomms), New Zealand. The authors thank Ms Dansoa Tabi-Amponsah from Transform
Medcomms for editorial assistance.

Data Availability
Data generated or analyzed during this study are included in Multimedia Appendices 1 and 2.

Authors' Contributions
All the authors were involved in the idea’s conception, design, and interpretation of the facts and data. SS led the manuscript
writing, and all authors were engaged in revising it for scientific content and final approval before submission for publication.

Conflicts of Interest
GSJ, H-WC, and W-YS declare that while being employees of Pfizer, there is no conflict of interest in relation to the work
presented in this article. The views and opinions expressed herein are solely those of the author(s) and do not reflect the views
or positions of their employers.

Multimedia Appendix 1
Methodology for plotting Solo Scholars and Global Collaborators archetypes.
[PDF File (Adobe PDF File), 316 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Database types used in real-world studies across 10 target Asian countries.
[PDF File (Adobe PDF File), 138 KB-Multimedia Appendix 2]
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Abbreviations
ACP: advance care planning
ASEAN: Association of Southeast Asian Nations
CCCS: cross-country collaboration studies
CDARS: clinical data analysis and reporting system
CER: comparative effectiveness research
CGRD: Chang Gung Research Database
COOL-AF: Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with
Atrial Fibrillation
EHR: electronic health record
EMR: electronic medical record
GDP: gross domestic product
HA: Hospital Authority
HTA: health technology assessment
MOH: Ministry of Health
NHI: National Health Insurance
NHIRD: National Health Insurance Research Database
OHDSI: Observational Health Data Sciences and Informatics
RWD: real-world data
RWE: real-world evidence
SCS: single-country studies
TCR: Taiwan Cancer Registry
UHC: universal health coverage
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Julian et al

Edited by G Eysenbach, A Benis; submitted 18.03.24; peer-reviewed by C-Y Chen; comments to author 30.05.24; revised version
received 17.06.24; accepted 19.07.24; published 15.08.24
Please cite as:
Julian GS, Shau W-Y, Chou H-W, Setia S
Bridging Real-World Data Gaps: Connecting Dots Across 10 Asian Countries
JMIR Med Inform 2024;12:e58548
URL: https://medinform.jmir.org/2024/1/e58548
doi: 10.2196/58548
PMID: 39026427©Guilherme Silva Julian, Wen-Yi Shau, Hsu-Wen Chou, Sajita Setia. Originally published in JMIR Medical Informatics(https://medinform.jmir.org), 15.08.2024. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete
bibliographic information, a link to the original publication on https://medinform.jmir.org/, as well as this copyright and license
information must be included.

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