structuring wan and lan for epr use in community health care

International Journal of Medical Informatics 60 (2000) 219–226

Structuring WAN and LAN for EPR use in communityhealth care

Koji Yamamoto a,*, Takahiro Takada a, Keiji Nakai a, Hirotomo Nagaoka b

a Department of Medical Informatics, Mie Uni6ersity Hospital, School of Medicine, Edobashi 2-174 Tsu Mie 514-8507, Japanb Department of Computer Science and Systems Engineering, Miyazaki Uni6ersity, Tsu Mie, Japan

Abstract

After describing determinants for the creation of a successfully used community health care network, our newproject of making a mechanism fostering steady development of WAN and LAN among community is presented.Most of the difficulties that inhibit the sound development of community health care system are solved. © 2000Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Community health; EPR; Health care networking; Autonomous system

www.elsevier.com/locate/ijmedinf

1. Introduction

If we are to impro6e the health of the popu-lation and reduce the inequalities in healththat plague our communities and our planet,we will ha6e to gi6e greater attention to thedeterminants of health. The reform of thehealth care system, though necessary , willne6er be sufficient; we need to reform ourwhole society and in particular to focus onhuman rather than economic de6elopment.Tre6or Hancock [1]

On 1st April 2000 a new government-runnursing care insurance system began to sup-port the country’s rapidly aging populationin Japan. People 65- or older and theirfamilies have the freedom to choose whetherbeneficiaries will receive support at home orat a facility on a contractual basis. To miti-gate the staggering public costs and familyburdens of providing such care, the new pro-gram obliges people aged 40- and above topay a monthly premium to cover part of thecost. Municipal governments are chargedwith authorizing eligibility and specifying thelevels of support that beneficiaries need. Italso intends to upgrade the elderly supportby stimulating private nursing-care firms toparticipate in the system. This system was

* Corresponding author.E-mail address: [email protected] (K. Ya-

mamoto).

1386-5056/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.

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K. Yamamoto et al. / International Journal of Medical Informatics 60 (2000) 219–226220

devised in accordance with the plan ‘Ten-yearstrategy to promote health care and welfarefor the elderly by establishing a long-termcare service system’ proposed in 1989 [2].This is one of the reforms, the Japanesegovernment has made to deal with the grow-ing and diversifying needs for social securityin the society of aging population with fewerchildren in a depressed economy.

Reorganization of national hospitals andsanatoria by merging and transferring facili-ties on a national scale is also going on, inwhich the personnel, budgets and overallmanagement resources of the national hospi-tals and sanatoria is concentrated in the fieldsthat are ‘appropriate ’ for national institu-tions. The Japanese government has alsomade several structural reforms on medicalinsurance systems to enable the medicalproviders give high efficiency and make re-forms to meet their ‘theoretical ’ roles.

Although all of these reforms may be nec-essary to increase efficiency of medical caredelivery and to modify the visiting pattern ofpatients to bigger hospitals, the detailed plan-ning never works exactly under such complexcircumstances as health care [3]. Indeed, asthe in-home care is promoted, the number ofunexpected natural deaths of the aged livingalone has increased somewhat sharply [4].

It is time to think deeply and seriouslyabout community health care systems bywhich the integral care for each individualcould be offered with a quality as if he wereadmitted in a big hospital.

2. Two approaches, citizen-based andinstitution-based

There are a lot of subsidized projects tocreate community health care systems inJapan, where doctors are paid for active par-

ticipation. One of the most successfulprojects, in the sense that the system createdfrom the project was actively deployed atseveral other cities and towns, may be theone originally developed at Kamaishi city [5].In that project, a home monitoring devicewas developed, which was simple enough forthe senile persons to monitor their healthcondition by themselves and send it to thecare-center and receive professional evalua-tion. We call this type of system the ‘citizen-based’ system. Lovell reported the strength ofsuch ‘citizen-based’ system [6]. This type ofsystem, however, has a drawback that a greatdeal of workload is concentrated on thephysicians working on a voluntary basis atthe care-center. The high price of each moni-toring device hinders the distribution of theequipment to all the homes needed. Thisinequality of service is a problem.

Several university hospitals have systemsfor community health care, e.g. [7,8]. In thesecases, sharing of detailed electronic medicalrecords (EPR) of patients could be achievedbetween the central hospital and the memberhospitals and/or clinics, i.e., a tree structurerooted at the central hospital.We call thistype of system the ‘institution-based’ system.To share EPR, however, difficulties arise toget incentives of use. The following are themajor reasons for difficulty in the effectiveuse of a shared EPR.

2.1. Conflict of benefits among healthpro6iders, patients, and the society

Sharing EPR among medical institutionsand/or clinics is certainly beneficial to pa-tients, and it may reduce the total cost forhealth care delivery in a society, but it alsosometimes reduce the income of each institu-tion and/or clinic. This type of conflictamong the participating parties hinders theuse of a shared EPR. Some powerful incen-

K. Yamamoto et al. / International Journal of Medical Informatics 60 (2000) 219–226 221

tives from outside are necessary to promotethe sharing of EPR. The Japanese Govern-ment has gradually introduced DRG/PPS forseveral chronic diseases and the systems simi-lar to managed care, which might promotethe sharing of EPR. On 22nd April 1999, theJapanese Ministry of Health and Welfaremade an announcement ‘Notification on theElectronic Storage of Clinical Records’ [9].Asper this announcement, EPR becomes anofficial document if it satisfies the criteriagiven below (Table 1), which certainly sup-ports the development of EPR and its usage.

2.2. Low computer skills

Many doctors, especially those who areworking in rural areas, are old and not accus-tomed to using computers. In practical set-tings, this sometimes causes basic difficultywhen we want to expand the coverage of the‘institution-based’ system to a rural area.

When considering the community healthcare, the tree structure of the ‘institution-based’ system may not meet all the demands.As many organizations and individuals areparticipating in the health care of a patient, itis also necessary to have effective communi-cations among these groups of people. Forexample, as the ‘all-round’ general practi-tioners (GPs) are very rare in Japan, coopera-tion between GPs of different disciplines isvery important for better community healthcare. For this purpose, a net- rather than atree-structure is pursued as the health carenetworking system. However, this may resultin other intrinsic difficulties.

2.3. Lack of confidence

Itkonen pointed out one of the most im-portant issues, the confidence in each other[10]. All the participants in the system musttrust each other to do their jobs faithfully.They must trust that the EPR is always avail-able from the system when necessary, and itis correct, complete and sufficient to under-stand. Indeed, if a physician makes a mistakeby using the wrong data who takes the re-sponsibility? [11]

2.4. Increase of 6ulnerability in networking

Although the progress of computer tech-nologies for secure networking is remarkable,it is very difficult to use these technologiesthroughout the community-health-care net-work. This is partly because it is too expen-sive to deploy these technologies, but mainlybecause it is very difficult to regulate theactivities of participants who pay little atten-tion to security. Coping with the variety ofsettings of EPR use, such as the cases ofemergency, also makes the system securityvulnerable.

Table 1Criteria for EPR to become official documents

(a) The authenticity and accuracy of information mustbe ensured during the transfer process(i) False input, rewriting and deletion of

information, by intention or mistake, are strictlyprohibitedtient

(ii) The person or persons responsible forinformation transfer must be clearly stated

(b) The 6isual readability of the information must beensured

(i) If needed, the information should be able to beread easily

(ii) If needed, the contents of the information canbe presented on paper

(c)The storage obligation must be followed in aneffort to protect stored information

(i) The information is stored in a recoverable statewithin the timeframe provided by the law


2.5. Increase of miscellaneous problemsamong organizations

There is a saying in Japan that ‘‘Too manycaptains will dri6e a boat up a mountain’’. Themeaning is ‘‘too many cooks spoil the broth’’.As the number of participating organizationsincreases, it becomes more and more difficultto reach consensus among participants, whichrenders the objectives of the system vague andthe coordination difficult. Southon et al., re-ported in some detail about the failure ofintroducing information systems in an envi-ronment of complex organizations [12]. Theysuggested a need for independent institutionalmanagement. Similar notification could alsobe seen in several other articles [13].

To end this section, we want to add that the‘management ’ of information system may benecessary, however, ‘management ’ does notonly mean to make a system, to deliver it, andto control the use of it. In the article above [12],a somewhat miserable scene was described thatthe system was made and delivered to physi-cians irrespective of their wishes. The physi-cians stopped using the system whenever theyfound any uneasiness of use. If the physiciansknew the objectives of the system and if theyapproved these, then a somewhat differentattitude might occur. We think that ‘manage-ment’ of information system also means themanagement of system objectives and the waysto make them attractive and accepted. All ofthese difficulties determine the success of thecommunity health care system.

3. A new project of community health carenetworking — an alternative approach

3.1. The project set-up

It was gradually recognized that the organi-zational issues are the key to lead to the success

of a system [14]. It was also known that asubsidized system is very rare to become anindependently growing system after the sub-sidy is over. This is partly because, too muchof commitment is usually given about thesystem before its implementation, but mainlybecause, the workload of reaching consensusin the community is sometimes too muchunderestimated in considering the sublime ob-jectives of the system that project leaders mayhave. The community health care system mustbe able to grow by itself. No external supportlasts forever.

Since the beneficiaries of the communityhealth care are the people in the communityand some of them are also the providers of thesystem, the key issue will be to make anautonomous mechanism by which all the par-ticipants obtain benefits from each other, andhave an ability to develop systems appropriateto their purpose. If the mechanism is goodenough that all the participants, i.e. people,can understand its supreme objectives easily,then they will follow the mechanism and asystem will grow steadily.

With these considerations, we havelaunched a project to create a prefecture-widehealth care networking system at Mie prefec-ture in Japan, starting from Hisai districtsincluding Hisai city this year. The JapaneseGovernment, Mie prefectural agency, and Hi-sai municipal government backed this project.The project committee includes medical associ-ations of Hisai and Tsu branches, Fire Defensedepartment of Hisai branch, Mie pharmaceu-tical association, Mie dental association,Mie National hospital, Mie University hospi-tal, besides Mie prefectural and Hisai mun-icipal governments. Mie CATV Ltd., andseveral computer system providers are alsoparticipating in the system development team.The project was announced in the localpress on 23 March 2000, and the system


development has just started. Below is a briefdescription of the mechanism.

3.2. Mechanism

3.2.1. Systems for clinicsSuppose that at each clinic there is a com-

puter system of its own. Doctors and/ornurses in that clinic use this system for theirdaily patient care. The system is so designedthat it is actively used daily for most of thepatients and EPRs are accumulated. Such asituation can be obtained if the system aidsthe management of the clinic by offering thebilling and medical insurance functionalitybesides the patient care, and if the system iseasy to use with affordable price and withmany functions to support the care. Thereare already many commercially availableEPR systems satisfying most of these require-ments. In those systems, reference images canbe viewed as a standard utility.

Suppose in addition that the computer sys-tem at each clinic is connected via a virtualprivate network (VPN) or ISDN to a dedi-cated big server located at a computer center(C-center) in a community, where a backupof that system is taken daily in a standardizedformat. A large collection of backup data ofeach clinic is present at the C-center,but ‘nosharing ’ of detailed EPR is the policy, anddoctors working at a clinic do not need toworry about other clinics.

In principle records in the backup data-bases, are not the targets of alteration. Theycan be neither erased nor modified so theysatisfy the criteria of the official EPR. Whena patient returns to a clinic after a longabsence and the EPR for that patient is notfound at the clinic, at that time, doctorsand/or nurses can easily download the pa-tient’s earlier EPR from the backup databaseof that clinic.

At the C-center, a data manager makes a‘Common Patient-ID’ (CP-ID) databasefrom these backup data. It may be possible toidentify a person from his/her name, sex,birthday, present address, and birthplace.The CP-ID database consists of a commonID throughout the community, a list of clin-ics attended by the patient and IDs used atthese clinics, levels of assertion of these IDs,and notifications, if any, for emergency use.The level of assertion is very important infor-mation, which controls the share of EPR asdiscussed later. Some miscellaneous indexesfor the ease of running CP-ID system are alsopresent.

The CP-ID database is put on the WorldWide Web (WWW) in a secure way, i.e.,either using VPN, or ISDN, or the ‘Extranet’technology [15]. The Extranet technologyuses a card named ‘Secure-ID’ besides thesign-on ID of the user and the password. Onthe Secure-ID, a pseudo-random number isdisplayed which is progressed pseudo-ran-domly every minute. Though to get access tothe CP-ID database using Extranet, the num-ber on the Secure-ID, the sign-on ID, and thepassword are required, no special device isnecessary. Therefore, the authenticated userscan see the list of clinics attended by thepatient and notifications for emergency fromany place where Internet is available if theyknow the common ID of the patient or anyof the IDs of the patient at the clinics heattended. Though CP-ID information onlytells the notification at emergency and thenames of the clinics attended, this wouldgreatly reduce the risk in case of emergency,and also give a stimulus for better coopera-tion among clinics, i.e. the creation of anet-structure.

The system has a simple tool to create aletter of introduction of a patient by selectingitems from his EPR. This utility is used whena doctor wants to ask cooperation with other


specialists in another hospital or clinic, orwhen a doctor is requested to send EPR toother authenticated users. This is the onlyway that the transfer of EPR among authen-ticated users occurs. That is, the transfer ofEPR is done under the control of the personresponsible for that EPR. This transfer isdone in a secure way via the C-center.

3.2.2. Systems for big hospitals and theuni6ersity hospital

A different approach is taken for hospitalswhere hospital information systems (HIS) oftheir own are present. At the C-center, theCP-ID database is created similar to thecase of clinics, but the backup of the EPR isnot made. Each hospital is requested tomake an interface between the C-center andHIS. In case of Mie University hospital, wehave a server outside the firewall of the hos-pital, which is used only for this project, i.e.the server is connected to the C-center viaVPN. Letters of introduction of a patientfrom a clinic are first placed on this server,which are then transmitted to HIS when thepatient attends to the hospital or when re-quested. Any reports of a patient to therequesting clinic are also placed on thisserver. These reports contain texts, hand-written sketches, and copies of reference- im-ages. The doctors and/or nurses at therequesting clinic share these reports. Thoughthe real-time communication between clinicsand hospitals is not provided, this coversmost of the needs of telemedicine such astele-radiography, and tele-pathology, whichare currently done.

In the letter of introduction of a patient,the CP-ID of that patient is included, whichis used to make or to modify a reduced copydatabase of the CP-ID stored in HIS. Incase when the letter of introduction does notcontain the patient ID of Mie Universityhospital in its CP-ID information, the re-

duced copy of that patient is sent to theC-center as the latest information includinga patient ID of Mie University hospital.

When a new patient comes without a let-ter of introduction, this reduced copy data-base of the CP-ID is first checked whetherhe has a CP-ID or not. In case, his CP-ID isnot found in the database, a message includ-ing the patient ID of Mie University hospi-tal is sent to the C-center, where the CP-IDof that patient is either created or modified.

A similar set-up will be introduced at Na-tional Mie Hospital at Hisai city.

3.3. Le6el of assertion, a key to promote thesharing of EPR

The CP-ID database contains a list ofclinics attended and IDs of a patient asmentioned above. This list is made automat-ically by the system at first. Though this listis expected to be almost correct, it is notconfirmed except for the clinic for which theCP-ID is first made. So we put the level ofassertion of each attended clinic as zero. Inpractical settings, no serious trouble mayhappen even for zero assertion case, if thenotification for emergency in the CP-IDdatabase is taken from the EPR of the ‘top-of-the-list’ clinic. To make this more reli-able, it is necessary to have a mechanism ofconfirmation. One scenario to assure thismay be seen at the time when a new patientvisits a clinic. If his EPR is not present, thesystem at the clinic sends a message to theC-center to create the CP-ID. The createdCP-ID is then sent back to the clinic, andthere is plenty of time for that patient tocheck this information. To this affirmed in-formation, level 1 of assertion is given.

When a doctor wants to introduce his pa-tient to other specialists in another hospital,he writes a letter of introduction with de-


tailed information and sents it to the hospitalvia the C-center. In this case there is a closerelationship between these medical institu-tions. To this relationship, level 2 of assertionis given. At this level, sharing of the EPR isdone partly by transferring records. In theproject committee, level 3 or more of asser-tion is discussed, where some fact data suchas the clinical test result, the drug-dispensinghistory, and images is shared completelyamong medical institutions for such patientto whom the ‘letter of introduction’ basedrelationship is present. In this case, data isnot transferred but shared. The sharing of‘decision data’ such as diagnoses comes lastand this must be done very carefully.

3.4. Another functionality

In the C-center several functions are onschedule of development to support betterpatient care. A drug information database isone of these, which provides timely updatedinformation about drugs. Standardization isalso pursued, such as the codes for diagnosisand treatment. Other information, such asthe medical examination for the public is alsothe target of accumulation at the C-center.Creation of any statistical database for epi-demiological research becomes technicallypossible and an ethical committee necessarilychecks the research objectives in the future.

4. Discussion

In this paper we described three differentapproaches for structuring WAN and LANfor EPR use in community health care, i.e.‘citizen-based’ and ‘institution-based’ sys-tems, and our project. In the citizen-basedsystem, information is generated by the citi-zen, who is expected to participate actively,but this is very costly and labor intensive at

present. In the institution-based system, net-works between a big hospital and surround-ing hospitals and/or clinics are created andthe sharing of EPR between these medicalinstitutions is made possible. But, networkingamong member hospitals and/or clinics israther restricted in this case, which wouldlimit the autonomous growing. In our pro-ject, a mechanism is proposed to supportdeeper and easier coordination among mem-ber doctors for better health care. By thisstrategy sharing of EPR is done on requestwhere strong needs are present, which willprovide the ‘confidence’ among people partic-ipating. We hope that coordination betweenmember doctors will become so intensive thatthe mindful care to a patient is achieved [16].We hope that this will give us one of thesolutions to community health care network-ing, which should be growing steadily andsoundly by itself.

These approaches, except the citizen-basedone, result in the creation of systems forhealth care providers. To improve the com-munity health care, another approach mightbe necessary which supplements these, theso-called citizen-centered system.

In 1996, Kenneth Shine described perspec-tives about the future of medicine [17]. Inthat article he said that knowledgeable pa-tients by increased availability of informationwould improve the quality of patient-doctorinteractions. This is gradually going to be-come the reality. As the growth of healthinformation on the Internet and WWW con-tinues, people can get more knowledge aboutdiseases relating to their health, which wouldmake the patient–doctor relationship morecollaborative [18,19]. Though Bader stressedthe need of deeper participation of academichealth science committees in auditing thehealth information on WWW [20], the situa-tion will be far more difficult. To make cor-rect data recognizable correctly among


people is very difficult, which would open usa new research area, ‘keep integrity of infor-mation among people’. However, howdifficult it may be, improvement of the qual-ity, quantity and usability of health informa-tion on WWW will give us one of the clues tothe citizen-centered system. These two typesof systems, the systems for health careproviders and those for citizens, will play akey role in promoting community healthcare.

References

[1] T. Hancock, Health care reform and reform forhealth: Creating a health system for communitiesin the 21st century, Future 31 (1999) 417–436.

[2] http://www.mhw.go.jp/english/ssp – in – j/services/6th.html.

[3] I.M. Mur-Veeman, et al., Integrated care: theimpact of governmental behavior on collaborativenetworks, Health Policy 49 (1999) 149–159.

[4] N. Kuroki, et al., Increase of unexpected naturaldeaths of the aged in Osaka prefecture, Jpn. J.Leg. Med. 54 (2000) 63.

[5] Y. Saito, Y. Saito, Chiiki Shakai Jouho noShisutemuka (Systematization of social informa-tion at Local society), Ochanomizu Ltd., 1999.

[6] N.H. Lovell, B.G. Celler, Information technologyin primary health care, Int. J. Med. Inf. 55 (1999)9–22.

[7] K. Yamamoto et al., An integrated multimedia

medical information network system, MED-INFO’97, 1998.

[8] G.F. Egan, et al., Computers and networks inmedical and healthcare systems, Comput. Biol.Med. 25 (1995) 355–365.

[9] http://www.medis.or.jp/pdf/e

–notification990422.pdf.[10] P. Itkonen, Information technology as tool for

change, Int. J. Med. Inf. 56 (1999) 135–139.[11] E. LeBourdais, When medicine moves to the In-

ternet, its legal issues tag along, Can. Med. Assoc.J. 157 (1997) 1431–1433.

[12] G. Southon, et al., Lessons from a failed informa-tion systems initiative: issues from complex orga-nizations, Int. J. Med. Inf. 55 (1999) 33–46.

[13] B. Hardy, et al., Inter-agency services in UK andThe Netherlands. A comparative study of inte-grated care, Health Policy 48 (1999) 87–105.

[14] R. Boland, et al., Office Automation: A Social andOrganizational Perspective, Wiley, Chichester,1985.

[15] http://www.medis.or.jp/pdf/e – notification990422.pdf

[16] R.M. Epstein, Mindful practice, J. Am. Med.Assoc. 282 (1999) 833–839.

[17] K.I. Shine, Impact of information technology onmedicine, Technol. Soc. 18 (1996) 117–126.

[18] D.M. William, et al., Using the Internet to im-prove knowledge diffusion in medicine, Commun.ACM 40 (1997) 101–108.

[19] K.G. David, et al., International collaboratorybased on virtual patient records, Commun. ACM40 (1997) 110–117.

[20] S.A. Bader, et al., ‘Patient informatics’ creatingnew partnerships in medical decision making,Acad. Med. 73 (1998) 408–411.

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structuring wan and lan for epr use in community health care

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