Taiwan's National Health Insurance Research Database (NHIRD): in the Era of Artificial Intelligence, Causal Inference, and Data Security.

Background: Taiwan's National Health Insurance Research Database (NHIRD) has evolved into a cornerstone of real-world evidence generation. As Taiwan's National Health Insurance program reaches its 30th anniversary, a comprehensive reassessment of the NHIRD's development, challenges and future directions is warranted. Objective: To provide an updated review of the NHIRD. Methods: We conducted a narrative review of Taiwan's NHIRD, synthesizing published studies, government reports, and policy documents from 2019 through 2024. We summarized developments related to database infrastructure, data collection, validation studies, linkage strategies, governance reforms and interoperability initiatives, with a particular focus on their implications for real-world evidence generation and AI-driven research. Results: The NHIRD has additionally incorporated structured laboratory results and medical imaging data, significantly broadening its research capabilities. Validation studies have demonstrated the reliability of International Classification of Diseases, 10th Revision, Clinical Modification codes across various conditions, reinforcing the database's applicability for epidemiological research. Integration efforts with national registries, surveys and electronic medical records have further enhanced the depth and accuracy of clinical outcome measurements. Nonetheless, critical challenges persist, including data standardization inconsistencies, cybersecurity vulnerabilities, and heightened scrutiny following constitutional court rulings on data governance and privacy rights. In response, Taiwan's Ministry of Health and Welfare has launched initiatives to address these concerns, notably through the development of a Fast Healthcare Interoperability Resources (FHIR)-based data infrastructure aimed at improving interoperability, data security, and artificial intelligence (AI)-readiness to balance ethical governance with scientific innovation. Conclusion: The NHIRD's transformation over three decades underscores the importance of continuous investment in data quality, privacy protection, and interoperability. With sustained reforms, the NHIRD will be poised to remain a leading resource for real-world evidence generation and to contribute meaningfully to global health and digital medicine.