ITUのe-health 関係のStudy Groupの報告書出版され、弊社代表尾形が総務省や経済産業省の事業として実施された岩手県、ラオスでの周産期遠隔医療の取り組みについて発表した内容が掲載されました。





3.5 Perinatal telemedicine in remote areas: ready to implement Japanese solution
3.5.1 Background and issues
In Japan, there is trend to reuse data which is gathered in hospitals and clinics to make use of patient diagnoses by using accumulation case data.50 The history of medical ICT has begun from electronic health records in hospitals, and then it has expanded to various types of regional medical alliances since 2000. The hospital is able to manage and obtain patients’ test results, diagnoses, images and prescriptions by using electronic medical record system.
The regional medical alliances, and the networked hospitals make it possible to share patients’ data and able to reduce medicine duplication or duplicate examination of patient who has visited from different hospitals. According to the common data, high-risk patient can be transferred to a higher‑level hospital immediately. The higher-level hospital is able to prepare to accept the high-risk patient, examining the data of previous hospital.
The important role of telemedicine is sharing the medical information between doctor and patient, and utilizing health data of patients effectively. If patients want to improve their own condition, they recognize what is required for them to get better themselves by selecting telemedicine system. MITLA (Medical Information Technology Laboratory), which is specialized in Medical IT, is providing services in this domain and this contribution describes the experiences for introducing telemedicine technology in the field of perinatal medicine in rural and remote areas.
3.5.2 Perinatal telemedicine system
The perinatal electronic record is the key technology of this telemedicine system. It is quite different from the general Electronic Medical Record (EMR) or other departments EMR, because the perinatal
50 Isao Nakajima, Tokai University, School of Medicine, Japan, Rapporteur Q2/2.
Question 2/2: Information and telecommunications/ICTs for e-health
EMR has to accumulate the data of two lives, mother and fetus. The related laws and regulations of obstetrics and gynecology department are also different from others. Considering those differences, the perinatal EMR is worthwhile and perinatal care technologies would have valuable implications to medical ICT as a whole.
There are three types of specialized perinatal EMR; for hospitals, clinics and perinatal telemedicine. For hospitals, it has an excellent high-risk management function for the Perinatal Maternal and Child Medical Center, the tertiary hospital. Secondly for clinics, it can manage every system of the hospital as an EMR. It is also easy to find any risks of pregnancy. All of the specialized perinatal EMR has a list of prenatal checkup screen. Maternal basic information and the prenatal checkup data for each pregnancy can be observed. It comes with screens exclusively for obstetrics and gynecology which can register medical information of prenatal checkups and health guidance. Clinical information which cannot be found on general EMRs can easily be recorded. It also has computerized formats, which is specific to obstetrics and gynecology including the pregnogram and partogram. The specialized perinatal EMR is possessed with authenticity, visual readability, and storability.
Figure 23: Total number of obstetricians
Figure 24: Perinatal Telemedicine System
Question 2/2: Information and telecommunications/ICTs for e-health
The number of obstetricians and gynecologists has decreased dramatically from 1984 to 2006 compared to other departments of doctors (Figure 23). This caused due to the large number of obstetric litigations sued by patients and the increasing number of women doctors who discontinue work after marriage.
In remote areas such as islands and mountainous areas, social issues are arising as no obstetricians work in hospitals. Such social phenomenon is noticeable from 2004 to 2006 and this is continuing. The perinatal telemedicine system (Figure 24) was developed in 2006 and connected the core hospital to the maternity center where there are no medical specialists. The distant medical doctor is able to examine the information entered by the midwife at the maternity branch. The perinatal telemedicine system is composed from the data center server system, ASP perinatal electronic medical record and mobile CTG, the medical equipment that measures the mother’s contraction and the baby’s heart rate. It can also connect diagnostic imaging system as needed. ASP perinatal electronic medical record and mobile CTG are placed together in the core hospital, clinics and the maternity center respectively, and all data can be shared mutually. Medical specialists, general physicians and midwives share the real-time medical information, depending on the risk of the patients and able to examine their condition together. The patient can receive the appropriate advice from a medical specialist utilizing telemedicine.
Initially this perinatal telemedicine system was introduced to Tono city, Iwate prefecture, where there were no obstetricians. Pregnant women were in need of a perinatal checkup once a month or more frequently, however, for women living in Tono, this meant a long 50 km drive to the main hospital on mountainous roads. Facing this problem, a medical center called Net Yurikago (cradle) was built in Tono city in 2007. At this maternity center, pregnant women in Tono city are able to have regular checkups provided by midwives. If the pregnant woman has any worries or concerns, she can speak to a doctor via the Internet.
After introducing the perinatal telemedicine system in Tono city, it has also been implemented in Hokkaido, Okinawa, and on Amami-Oshima Island. After the International Conference held in 2011, it was introduced in Phitsanulok region in Thailand. At this time, it used a server which was located in Japan, however, medical specialists in Phitsanulok wanted to locate the servers in their own country, in order to store the medical information collected. Following the case of Phitsanulok, the server was introduced in Chiang Mai, Thailand for JICA grassroots project of Kagawa Prefecture. In the same year, this system was introduced in Lao People’s Democratic Republic, including the server. In that same period, an advisory committee was set up in Iwate Prefecture in Japan. They discussed a regional alliances system that covered not only telemedicine, but also perinatal emergency and personal healthcare. This meeting comprised of eminent panelists from industry, government and academia.
3.5.3 Application to the perinatal regional alliances “Ihatov (Utopia)”
“Ihatov51” is a perinatal medicine information network system for pregnant women, which allows hospitals and municipalities to build a good relationship during the pregnancy period. Pregnant women can maintain the relationship even after delivery and if the pregnant woman decides to return to her hometown to give birth at the parents’ home, her nearest clinic can check her medical information in advance (Figure 25).
51 Toshihiro Ogasawara. Kazuhiro Hara. A challenge for producing Data cooperation system of medicine information network construction “Ihatov” and electronic medical recording system for perinatal medicine. Japanese Journal of Telemedicine and Telecare. 9(2):2013.10. 203-206 ISSN 1880-800X.
Question 2/2: Information and telecommunications/ICTs for e-health
Figure 25: “Ihatov” network
The Great East Japan Earthquake caused devastating damage on the coastal area of the northeastern
region of Honshu of Japan, and much medical information flowed out from tsunami. Since the information of the perinatal care of the Iwate Prefecture, where the tsunami hits, was recorded by the
data center server of “Ihatov”. Therefore, “Ihatov” has been recognized as a very effective system.
The Japanese Government has decided to introduce a social security ID number in the near future;
however Iwate prefecture has already introduced ID number for newborn baby in advance. This number is one of the keys for sharing information between medical institutions and municipalities
utilizing “Ihatov”. The pregnant woman can decide whether she will agree to share her information
or not when she receives the maternity passbook with the number. If she agrees, the information can
be shared with all hospitals and municipalities, and the data is carefully kept for the future. Medical
institutions can find all patients’ data from various places easier utilizing “Ihatov”.
In Japan, hospitals are classified under three categories according to the risk of the patient; primary,
secondary and specialized hospital. The specialized hospital is able to accept patients with higher
risks. If the patient’s condition takes a sudden turn, the patient might be transferred to a specialized
hospital at a higher stage. If the accepted hospital already has the patient’s data, using “Ihatov” they
can prepare and manage the patient transfer faster and more efficiently, and are also able to manage
transfer of the high risk pregnant woman to the hospitals selected from primary to specialized hospital in its region. The core hospitals joined the network and the clinics may also follow. This perinatal
regional liaison has been bringing satisfactory results. Other prefectures will follow this model in the
near future.
“Ihatov” regional alliances represent a significant effect in the following three points. “Ihatov” is a
system to take advantage of a medical health information database. By registering using “Ihatov”,
the pregnant women and babies’ emergency transfer to the hospital is implemented smoothly, and
prenatal care is carried out under fully prepared circumstances. Furthermore, registration is carried
out based on a personal agreement, and the individual’s privacy is strictly managed.
3.5.4 Accelerate overseas operations and domestic operation
Accelerate overseas operations
Question 2/2: Information and telecommunications/ICTs for e-health
In Japan, due to the decrease of obstetricians and gynecologists, some areas have to rely on a telemedicine system. In overseas, especially some developing countries, the situation is similar to Japan. There are not enough medical specialists for the increasing number of pregnant women. There are three risk categories; high, medium and low. Most hospitals overseas, especially those located in rural areas, treat medium and low risk patients due to the lack of medical specialists and medical surgery equipment.
Introducing a perinatal telemedicine system is meaningful to developing countries and rural areas. The perinatal telemedicine system is relatively simple and easy to operate. Hospitals are only to prepare PC and mobile CTG. The benefit of using mobile CTG and PC telemedicine system will efficiently improve perinatal care even with the decreasing number of healthcare specialist. For example: the possibility to diagnose pregnant woman in remote location from the hospital with only a few specialist.
Accelerate domestic operation
Declining birthrate and the increasing of aged population in Japan are progressing more rapidly compared to countries in Europe. The population of 65 and above years of age is 25 per cent of the total current population. It has been estimated that the rate of aging will be 30 per cent in 10 years, and a nearly 40 per cent in 30 years. It means that the number of young people who takes care of the elderly will reduce. There are not enough young people to adequately take care of the elderly. To ensure better health for the elderly, there is necessity to manage their own health by using smartphone and check the health data for themselves.
The maternity passbook is the starting point of the Personal Healthcare, PHR. Relatively young women began to use the maternity passbook at first, which is written in the paper; however, they have already gotten used to using mobile technology such as: tablets and smartphones as necessary in their daily life. We emphasize Electronic Maternity Passbook. The Electronic Maternity Passbook is connected and it can share information to hospitals and municipalities. The concept of the Electronic Maternity Passbook enables the user to be able to confirm the information, which is automatically inputted by municipalities and her primary care hospitals. For example: to take the necessary measures immediately from the system. The Electronic Maternity Passbook has the advantage not only childcare generation and pregnant woman, but also it bring benefits to the local hospitals, municipalities where she lives, and shops or companies that she is interested in.
It is desirable to generate PHR data from the system like “Ihatov”, which is a data interface with municipalities and the hospital. The PHR mechanism should be developed for many companies or shops that provide detailed information to the people as needed. In the future, we need a more realistic data integration technology and data mining technology. Data mining technology differentiates into environmental statistical processing and personal health history management. These technologies are also related to each other. It is convenient for individuals to find out their information instantly, based on their own health data. Currently, various institutions are carrying out R&D for creating mechanism to deliver more useful information to individuals.
The contribution below is an illustration of the application of the above perinatal telemedicine system.
3.6 Introducing perinatal telemedicine in Laos
3.6.1 Introduction
The Lao People’s Democratic Republic (hereinafter Laos) is a landlocked country, and its population is 6,510,00052 inhabitants. Laos is bordered by China, Vietnam, Cambodia, Thailand and Myanmar. Its area is same as Honshu, Japan. Laos is located important positions geopolitically in Mekong area and Indochina. Laos is a developing country in the ASEAN area, so there is big economic difference
52 Yhuko Ogata, Japan,
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between Laos and other ASEAN countries. However, Laos is doing steady economic development by growth in the field of mineral resources and hydraulic power generation. Population growth is necessary for economic development, and Lao government’s targets are achievement of Millennium Development Goals (MDGs) and breakaway from the developing country by 2020.
For perinatal care, target 4 of MDGs is reducing infant and toddler mortality, and target 5 is improvement of pregnant women health. The under 5 year-old child death decreased to 79 in 2011 from 131 people in 2003 per 1,000. Even though it achieved 80 people aimed for until 2015, it is still a low level. Therefore, the Lao government modified their target to 70 people per 1,000 until 2015. In addition, Laos has the second highest rate for the under 5 year-old child death next to Myanmar among Mekong area. The infant mortality was improved to 68 in 2011 from 104 in 2003 per 1,000 people, but it is far from new target value of 45.
3.6.2 Background and issues
On average a woman from Laos gives birth to 3.108108 children, and approximately 100,000 children are born every year in the whole country. This number is however not completely accurate as there is no family registry system in Laos. There is a health checklist for pregnant women decided by the Lao government. Based on WHO guidelines, examination items and contents are decided on depending on the week of pregnancy. Even though WHO recommends four check-ups during a pregnancy, some mothers never have a medical examination. The average medical examination rate in whole country is less than 80 per cent.
The medical facilities compose of the central hospital, prefectural hospital, county hospital and health center. There is no doctor present at the health center, which is the primary medical facility, and usually there are only one to three nurses. The second medical facility is a county hospital where only 27 of 130 facilities can perform an operation. For referral system from health center to county hospital is judged appropriately by patient diagnosis.
The number of the cell-phone subscribers is approximately 6,700,000 in Laos, and the population diffusion rate is around 104 per cent. Not all people have an own cell phone, and one has several prepaid SIM cards because of overflow SIM card. As a result, cell phone diffusion rate is very high.
Most of the subscribers of the cell-phone is 2G, and they use mainly telephone (voice call) and SMS (text). New smartphones are getting available, but there are still few people using it by 3G networks. LTC started providing 4G (LTE) at Vientiane on January in 2013, and will provide 4G (LTE) for major cities. So communications infrastructure is developing rapidly.
In addition, comparing to the landline is 150,000 (14 per cent of household diffusion rate) and broadband is 110,000 (10 per cent of household diffusion rate); we can see how cell phone subscriber rate is high.
3.6.3 System integration
Two proposals are presented: 1) Web type of Perinatal Medical Record System and 2) Mobile fetal heart rates monitor “Mobile CTG”.
Doctors and hospitals can use them by Internet and through server. Core hospital can see the data which rural hospital input, and also rural hospital can see the core hospital data in same way. Mobile CTG equipment set up at rural hospital and measure. They send data to core hospital doctors or specialist doctors, so doctors can diagnose from remote areas. It enables to share medical information of pregnant women with remote medical facilities in a real time. The primary hospital with no specialist can perform an appropriate and safe medical care by the instruction of the specialist in remote area hospitals by using this telemedicine system. It brings good result for primary hospitals to improve their skills and to care patient properly.
Question 2/2: Information and telecommunications/ICTs for e-health
Using communication line (2G, 3G, 4G), Mobile CTG can measure fetal heart rate, fetal movement and contraction. It enables to share those data to the medical specialists in rural areas. Medical specialist can confirm the data of high-risk pregnant women, and they can refer immediate and appropriate examination by using perinatal telemedicine system. The perinatal telemedicine system has been introduced in Laos in 2013. Two to three clinics that match the following characteristics were selected: (1) Rural area; (2) Only has midwives or nurses; (3) Does not have a specialized doctor.
The timeliness of the mobile CTG Monitor
During pregnancy, most likely, the condition of the patient will not take a sudden turn. Doctors can examine the results from a 20-40 minutes measurement, and see the fetus’ heart rate to check the wellbeing of the fetus. This is the most seen case for telemedicine.
During delivery, there is a possibility that the condition of the patient changes all of a sudden. The monitor has an automatic diagnosis function which prompts you to send the measurement results immediately. You can change the length of time of measurement deepening on the situation.
Two Mobile CTG Monitors were let to each two clinics to examine. The perinatal medical record system was ready for trial use, and the aim was to improve the system to suit the needs in Laos. For tele-consulting, TV meeting system by a Japanese company was used. The PCs were also supplied by the same company. The government-affiliated local network was used. During this trial at Mittaphab Hospital in Vientiane, a pregnant woman who measured the graph mentioned above in the morning (labor pains are strong, short interval). It was decided to keep her in the hospital. She gave a birth in the afternoon safely.
3.6.4 Discussion and conclusion
One of the most important matters for perinatal care is data management. Data management has evolved beyond paper medical records, into the paperless digital world. Therefore, we have to establish the check-up for mother and baby with further improvement of medical technologies. The following recording format is required for perinatal electronic medical records:
– The data of perinatal information is recorded in time series.
– Easy to detect the slight changes in pregnant woman.
– Enables doctors to know good conditions for pregnant woman and if there any complications.
– Viewing the data provides critical information for the doctors to make confident decisions.
– Sharing perinatal information makes hospital to be patient ready before the ambulance arrives. Also, doctors and specialist enable checking for high risk patients remotely.
In Japan, clinics, primary hospitals, and core hospitals accept patients depend on patient risks and condition. This system has been advanced especially in the fields of obstetrician due to the decrease in obstetricians and gynecologists. Regional alliances, open and semi-open systems, have proceedings with the primary, secondary and core hospitals. Overseas, especially in developing countries as is the case in Japan, there is a shortage of doctors. However, what is different between developing countries and Japan, is that in Japan medical education level, and mother and child medical examination system, are available. Solution to these problems: specialist in developed countries takes the second opinion in remotely. In addition, the usage of a maternity record book in developing countries is encouraged.
In order to introduce Japanese perinatal care model in developing countries, especially in Southeast Asia, and in particular in Laos, this takes time and needs some efforts. Once the systems are introduced and being used, the value and usefulness of them will surely be noticed. Currently, doctors in core hospitals have the technical ability to read mobile CTG monitor graphs. The mobile CTG system is a medical measuring instrument which transmits medical data of fetal heart rate, fetal movement and contraction through internet connection. High risk patients in primary hospitals or secondary
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hospitals can be helped through the specialist’s early diagnosis. When the Japanese perinatal care model was introduced in Laos, doctors and midwives were also dispatched to educate local staff and to introduce the system efficiency.
The “Research project for introduction of ICT system for basic health and medical care (remote consultation for perinatal healthcare in rural areas) in Laos” was funded by the Ministry of Internal Affairs and Communications, Japan. Working models of eHealth services already developed and implemented in developing countries or in process of implementation, i.e. the so called start-ups are summarized as tables in Annex 7. Information about the benefits of IMT2020 for eHealth implementation in developing countries and examples of women’s health wearable for the developing world are also included as annexes (Annex 8 and Annex 9).