Dr. Guy Harris
President, Digital Medical Communications Corp.
Tokyo, Japan
harris@dmed.com

In the November 1996 issue of Telemedicine Today I wrote, "Japan is at the edge of a major push into telemedicine." Since that time, however, progress has slowed considerably. While the number of active programs jumped from 49 in 1995, to 98 in 1996 and to 148 in 1997, only 7 new programs have been identified this year, indicating that the expected boom has failed to materialized.

While Table 1 suggests that Japan is perhaps second only to the United States in overall telemedicine activity, the lack of reimbursement under the national health insurance scheme has dampened enthusiasm and little telemedicine service has developed.

Reasons are not hard to find. Dr. Yoshiyuki Matsumoto, Director of the Medical Technology Information Promotion Division at the Ministry of Health and Welfare (Koseisho) and the man directly responsible for telemedicine policy, states that current cost-effectiveness data are insufficient to justify reimbursement. Other interviewees report that this problem is exacerbated by Japan’s relatively under-developed health economics field and a lack of technical evaluative expertise within the ministry.

A second barrier is cultural. Dr. Kiyonari Inamura and Prof. Takashi Sawai, leaders in teleradiology and telepathology, respectively, both acknowledge informal enthusiasm for telemedicine within the ministry. However, they and others cite a generation gap here and in the medical profession at large, with younger participants unable to overcome the resistance of older entrenched interests. Unlike the USA’s National Library of Medicine, for example, which recently provided significant funding to 21 telemedicine projects, Koseisho’s financial support is largely limited to incidental funding of expert advisory groups. It is currently funding 5 telecare projects, but these are uncoordinated and the ministry has no clear idea of the results it seeks to obtain.

Overall development is also hindered by a lack of hospital information systems infrastructure. Dr. Hiroshi Mizushima, Head of Bioinformatics at the National Cancer Center (Koseisho’s lead institute for telemedicine) reports that unlike the Ministry of Agriculture, Fisheries and Forestry, for example, which is installing an extensive intranet planned eventually to link with its confreres in other Asian countries, Koseisho does not consider network development within its jurisdiction. Prof. Patrick Barron of Tokyo Medical College notes that this absence of government support means that Japan is missing an important opportunity to provide leadership in Asia-Pacific countries. Dr. Mizushima currently obtains much of his support from other ministries, such as those of Posts and Telecommunications and International Trade and Industry. He states that while most hospitals will be linked to networks within the next several years, senior physicians show little interest in telemedicine and that widespread implementation must await generational change.

The above notwithstanding, a number of innovative programs and studies may be identified. A 1997 study funded by Koseisho identified the first telemedicine study in Japan to be conducted in Wakayama Prefecture in 1971, involving closed circuit television and facsimile transmission of sound and images. As occurred elsewhere, none of the various programs started in the 70’s survived the decade. But at last May’s 3^rd International Conference on the Medical Aspects of Telemedicine in Kobe, Japanese authors presented a total of 101 papers. Highlights included the work of Dr. Katsuyuki Miyasaka and colleagues at the National Children’s Hospital. In a group of children requiring long-term respiratory care, an ISDN-mediated videophone link with the hospital reduced the number of unscheduled emergency room visits by close to 80%, and also the number of calls to the hospital as families gained greater confidence in the operation of ventilation equipment.

In other recent work, Dr. Isao Nakajima of Tokai Medical School has partnered with Hitachi to develop a satellite-mediated ambulance data transmission system. Due to the particular orbit of the satellite used and an innovative dish tracking system developed by Dr. Nakajima, data transmission from a moving ambulance remains largely uninterrupted, even in highly built-up areas.

Dr. Keiko Nakamura of Tokyo Medical and Dental University has also described the second and third phases of her widely reported home telecare study. The second phase was designed to investigate provider acceptance of telecare: 13 medical and ancillary staff at a local municipality center used ISDN videoconferencing equipment from Fujitsu to care for a total of 45 homebound patients. The staff were aware of the good results of the first phase (described in Telemedicine Today Vol. 3, #3) but showed strong resistance to participation, considering the system suitable only for professional community rehabilitation experts and requiring technological expertise beyond their ability. However, their attitude markedly changed as they observed the satisfaction shown by the patients.

Two cases were of particular note. The first was an 85-year-old woman bedridden for one year following abdominal surgery, whose continual demands had exhausted her family. With videoconference access to the providers, however, her mental condition rapidly improved. Her complaints largely ceased, she took an interest in her appearance (e.g., she began wearing of make-up), and she was eventually able to leave her bed with assistance and venture into the garden.

The second was a severely demented 73-year-old woman living with her son and receiving frequent home nursing visits. Although she was unable to communicate with providers, she showed sufficient understanding of the presence of the monitor. Both her son and nurses reported a marked change in her emotional status. In one 2-day period during which she refused food, the need for urgent hospitalization, which would otherwise have been missed, was identified by videophone and hospitalization was averted.

Phase 3 was an intervention study in which two groups each of 16 age-, sex- and condition-matched patients were treated by conventional home nursing or with telecare. Although total contact time per patient was the same, the telecare group showed significantly better improvements in activities of daily living (ADL), communication independence and social cognition independence scores as a result of the greater frequency of contact (mean 15 minutes per contact) and the ability to see the patient’s home environment. The study will soon be reported in Medical Care, the journal of the American Public Health Association. A Phase 4 cost-effectiveness study is now in preparation.

Finally, Secom’s world-leading Hospi-net teleradiology service shows continued growth. In the absence of reimbursement, the service now provides 6,000 CT and MR readings per month from 125 spokes. General Manager Mr. Takashi Kobayashi expects to reach financial break-even at 150 spokes.

Commercial interest in telemedicine is high, particularly for telecare. Note that Koseisho predicts Japan’s over-65 ratio will reach 25.7% of total population by 2020, well above that of Germany, the next highest at 20.9%). Prof. Inamura recruited a "who’s who" of Japanese electronics companies to exhibit at the Kobe conference, a total of 42 in all. A recent issue of the Nikkei, Japan’s Wall Street Journal, contained back-to-back full-page ads announcing telecare services. The vendors evidently considered profile-building in these early days worth the approx. US$150,000 price tag for each ad. Hitachi recently ran a humorous national TV campaign describing its telemedicine plans, surely a world first. Others have followed. But in the absence of reimbursement, no one yet seems to have figured out how services can be provided profitably.

Overall, telemedicine in Japan can be described as progressive but lacking integration or any cohesive planning. Many projects are conducted on an ad hoc basis, relying less on needs analysis than on relationships among medical school alumni. Prof. Inamura, a medical engineer, notes that Japanese technology in the field is world-best, but with insufficient engineering expertise within institutions, it is prone to misapplication through single-source vendor push of non-standards-based equipment. A group such as the Association of Telemedicine Service Providers would find few members here, and a telemedicine business newsletter recently ceased publication after only 8 issues. And yet, all interviewees for this report expressed optimism for the future, and expect considerable progress over the coming two to three years.

Finally, the language barrier means that many researchers in Japan remain unaware of what is happening overseas. While domestic publication is highly developed, with over 100,000 biomedical papers appearing annually, few Japanese telemedicine reports make it into the English literature. Nevertheless, the field remains filled with enthusiasts and some exciting programs and technology. Researchers in other countries would do well to seek out contacts with their counterparts in Japan.

Telemedicine Installations in Japan (Feb. 1998)

Source: Prof. Kiyonari Inamura, Osaka University
Originally published in Gekkan Shin Iriyo