Cool Technology of the Week

I'm in Japan this week and have had the opportunity to review the clinical applications and infrastructure of information systems in Tokyo hospitals (St. Luke's, Japan Federation for Cancer Research, and Tokyo Medical University), Nagoya hospitals (Nagoya University Hospital, Higashi Nagoya National Hospital) and Kyoto Hospitals (Kyoto University Hospital).

A few observations about clinical applications in Japan, which are my cool technology of the week.

*The majority are client server, except Tokyo Medical University which is web based using a Java client. Nagoya University uses a Visual Basic client with a Cache database server, similar to the Brigham and Women's design. The reason for the client-server preference in Japan is strict privacy and security regulation. There is great concern that the web/HTTPS is not secure enough because of the possibility of IP spoofing, man in the middle attacks and attacks from the public internet. In the pilot HIE efforts, SSLVPN is used in addition to HTTPS to minimize these risks. I received several email from Japanese colleagues asking me to clarify the notion that EHRs and PHRs in the US use HTTPS with firewalls/intrusion detection and prevention, requiring no additional client-side software or certifications. I was told that no clinical information systems in the country are connected to the public internet except at Tokyo Medical University. In all the spots I visited, I could not reach the public internet with my laptop via a wired or wireless connection - I had to configure a secure proxy server in my network settings and Firefox before the internet was accessible.

*While most EHRs in the US focus on clinical data - problem lists, medication lists, allergy lists, notes, and result reporting - I found that most clinical applications in Japan focus on workflow. How is the work done and how do we ensure processes are optimized via IT. I found the use of bar codes for positive patient identification, medication identification, and electronic medical administration records to be more widely adopted than the US. I found integration of supply chain/just in time inventory with clinical applications. This focus on workflow is consistent with the country that invented the Toyota Production System and a focus on the work which happens on the "factory floor".

*While most EHRs in the US are very spreadsheet like, using screen position and columns/rows to represent data, Japanese systems are very visual - using colors, different font sizes and graphical icons to provide dashboards of information such as the process of drug ordering and administration. They also use colors to indicate the kind of data available about the patient on a given date in the historical medical record.

The Japanese have not yet implemented e-Prescribing, largely due to policy restrictions and regulation. Health Information Exchange is implemented in Kyoto in the very forward thinking Dolphin project, which obtains patient consent to transfer data from a hospital to a citywide repository and then enables the patient to make this data available to other hospitals by enabling the patient to grant access at the institutional level.

Because of concerns about privacy and the complex regulations surrounding healthcare information exchange in Japan, it's likely that the PHR will be their most successful short term approach to sharing electronic records. I've encouraged Google Health to consider Japan their first international pilot site. My friends in the Japanese informatics community - Dr. Tanaka, Dr. Akiyama, Drs. Yoshida (Shigetsu and Jun), and Dr. Yoshihara - are very enthusiastic to accelerate PHR use in Japan.

The focus on workflow, the graphic user interfaces and the early focus on patient controlled data exchange make Japanese EHRs my cool technology of the week.