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From Our Dialogue with Disaster-affected Areas Comes Support for Community Medical Care

Highlights 1 Advancing Hand in Hand with the Local Community

As Japan becomes a super-aging society at an unprecedented rate, the question of how best to support medical and welfare services in the community is a growing concern. The support of Fuji Xerox for the areas hit by the March 2011 earthquake and tsunami led to a series of dialogues with physicians and other home-care providers in the affected areas of Iwate Prefecture, and these in turn led us to develop an "integrated patient information system." This system is indispensable for the coordination of home-care provision by a team of specialists. It ensures that all the records they need are at their fingertips, even during emergency house calls, thus easing the doctors' task and giving the patient a sense of security. This year, we began expanding the system throughout the three prefectures most affected by the disaster. Its advantages are appreciated by the local medical associations, and we have also been hearing from doctors outside the affected areas who would like to use the system outside the home-care setting. Thus, The innovative solution of Fuji Xerox is taking on an important role in realizing the integrated community care that the Japanese government recommends as the new model for community health and welfare services.

Japan's elderly population(age 65 and over), 2015 estimated number and percentage
(National Institute of Population and Social Security Research, Population Projections for Japan)
33.95 million, 26.8 percent
Number of patients per day receiving home medical care
(Ministry of Health, Labour and Welfare, Patient Survey, 2008)
98,700
Number and percentage of medical institutions that provide home visits
(Ministry of Health, Labour and Welfare, Static Survey of Medical Institutions, 2011)
Hospitals 2,407, 28.0 percent
Clinics 19,950, 20.0 percent
Number of daily home visits per doctor at Kamaishi Family Clinic 25

The Realities of Frontline Community Care

Dr. Naohiro Terada
Director, Kamaishi Family Clinic

In October 2013, the integrated patient information system became fully operative at Kamaishi Family Clinic (KFC), the main provider of home care in Kamaishi City and Otsuchi Town, Iwate Prefecture. When the Director, Dr. Naohiro Terada, makes a house call, he can use a tablet device to access not only KFC's records for the patient but also test results, home nursing care records, pharmacy data, and so on, all displayed chronologically. Thus, no matter how late at night or how urgent the call, every bit of relevant information is at the doctor's fingertips. There is never a need for a detour to the clinic to pick up paper records.
Even before the March 2011 earthquake and tsunami, Kamaishi City was facing a rapidly dwindling and aging population and a falling birthrate as its key industries declined. The city suffered a blow in 2007 when one of its main hospitals providing emergency services closed. Since the 2011 disaster, a host of factors have aggravated Kamaishi's health care situation: seniors make up over 35 percent of the population, many of them living alone; an increasing number of caregivers are themselves elderly, and households where the only caregiver for a person with dementia suffers from the same condition are on the rise; and to these problems must be added the dislocation of the community by the disaster.
Says Dr. Terada: "The demand for home care will go on rising. But medical care alone is no longer enough to solve the district's health problems. When a community is fragmented, it becomes vulnerable physically, mentally, and socially. We needed to gain an overview of community care and home care from the perspective of how to restore the community to health in all of those areas."

Dialogue Sheds Light on the Type of Support Needed

Toshiya Yamada
Manager of Innovative
Revitalization Group, Fuji Xerox

For Fuji Xerox, this initiative is an integral part of the support we have provided in the areas affected by the disaster. Immediately after the earthquake, we decided to make multifunction devices available on loan, for free, in the affected areas. We went to work installing them in August 2011, in liaison with the medical associations of Iwate and Miyagi Prefectures, and after we formed the Innovative Revitalization Group in October 2011, Group staff members began to call on all the clinics that had reopened in temporary facilities in Kamaishi and Otsuchi, two of the areas hardest hit by the tsunami.
As a result of these visits, we installed multifunction devices in 24 medical facilities in the two prefectures, and members of our Innovative Revitalization Group continued to respond attentively to requests from both medical providers and local residents, helping them with everything from operating the multifunction devices to using their personal computers.
"You could say the multifunction devices were the hubs around which small communities formed," says Toshiya Yamada of the Innovative Revitalization Group. Thanks to the loan program, bonds of trust developed in each locality, and over the course of the next six months we gained insights, little by little, into the problems facing frontline care providers. This period also saw a dialogue begin between the Group and care providers including doctors, nurses, and longterm care support specialists. With the cooperation of KFC and other facilities in the affected areas, such as Hamato Neurological Clinic, we began studying how Fuji Xerox could best provide assistance in the medical and related fields.
Doctors called out late at night carrying thick paper files, night-duty staff back at the clinic urgently locating further records needed by a doctor on the phone: these images left a deep impression on the Group members. And so Office Manager Kunishi Higuchi, Toshiya Yamada, and their colleagues changed course as they explored the form that our assistance should take. "We started out picturing a system on a large scale," says Higuchi, "but then came to see that what was something entirely different. We needed to create a system, that would truly meet the local residents' real needs.

The Value Generated by the Integrated Patient Information System

To find out what was really needed, Toshiya Yamada, Takefumi Miyata and others from the Innovative Revitalization Group visited KFC every Wednesday night. "I wouldn't have expected a private-sector company to go that far," comments Dr. Terada, who was himself hoping to take an innovative step toward reconstruction.
Hundreds of hours of intense discussion followed. "Can we avoid carrying around thick paper files?" "The system constraints won't allow data entry from tablets!" "If that's the case, can we create a system where we can handwrite notes on paper and access data by tablets during house calls? It will be a big job, though, to scan notes back at the clinic." "Well, let's give it a try and find out where the problems lie!"
When both partners set aside their preconceptions and took a fresh look at clerical support operations and the potential role of documents in medical practice, a new procedure emerged that was in no sense a compromise. It consists of the doctor on house call making handwritten entries on a specially designed form (generally one sheet per consultation), to which a nurse or other staffer back at the clinic adds meta data such as dates, and then scans with a multifunction device. Thus all of the patient's information, regardless of whether it is paper or digital data, is organized in sequence. Test results and other data that, on paper, would be held in separate files by category can all be inserted sequentially into the record.
"There was no precedent for creating a separate sheet for each consultation," says Dr. Terada. "But on a tablet, this format is very easy to take in, and it enhances our understanding of the patient information. And the combination of hand writing notes and accessing data by tablets has proved easy to use." The necessary and sufficient information is thus shared via a simple operation, and the resulting system places no burden on frontline care providers.

Conceptual Diagram of the Integrated Patient Information SystemConceptual Diagram of the Integrated Patient Information System

Dr. Terada stresses that providers no longer risk missing relevant information and that it has become easier to gain a holistic view of the patient. The nurses, too, are unanimous: "We couldn't go back to the days of paper records only," says one. Adds another, "When we receive an urgent call, we are now able to judge whether a doctor's visit is really needed immediately, while checking the patient's medical contraindications." The fine-tuned response that this allows is a step toward cutting waste in home care while ensuring that patients have more peace of mind than ever before.

Care Truly Acceptable to the Community Takes Shape

Anticipating the advent of the aged society, Japan's national government currently recommends that local governments take the lead in adopting an integrated community care system which seamlessly meets the special needs of the elderly for housing, assistance in daily life, health and nursing care, and preventive medicine. Dr. Terada says, "If we are to marshal local resources effectively on this comprehensive basis, we must gain an overview of the challenges and needs that communities and individuals face. This means we need to integrate the information held by different professionals. Medical institutions play a major role as repositories of information supplied by a number of professions, and integrating patient information within a clinic, as we have done, is an important step toward grasping the big picture." As Dr. Terada points out, the system developed by Fuji Xerox has much to offer in the area of integrated community care.

Diagram of Integrated Community Care
(Source: Report of the Community-based Integrated Care Research Committee, March 2013)Diagram of Integrated Community Care
(Source: Report of the Community-based Integrated Care Research Committee, March 2013)

We owe our success in creating a realistic, forward-looking, and substantive support model to the candid discussions we were able to hold with local care providers and residents, starting with the issues involved in doctors' home visits. The system's performance is rated highly by the local medical association, local governments, and residents of the communities and their surrounding areas, and its adopters in Iwate Prefecture are beginning to extend beyond homecare facilities to encompass dental clinics, visiting nurse stations, and the like. In Kamaishi City, meanwhile, KFC is working with the Goyoryo nursing home to utilize the system fully in health management for the home's elderly residents. In addition to expanding the modes of use in this way, in April 2014 we began providing the standard system in two other disaster-affected prefectures, Miyagi and Fukushima, as well as Iwate. The problems facing each district may differ, but the importance of teamwork remains the same as the various core facilities that support the community collaborate with medical providers, pharmacists, nursing care specialists, and other care professionals. The large-scale systems that such collaboration requires exist in each district. But integrating information in the truest sense calls for a systematic approach to managing patient data, including the important data stored on paper, in a way that makes it easy for care providers to see the overall picture of each of their patients and, by extension, the community as a whole.
The integrated patient information system has been improved through ongoing dialogue and is gradually entering new areas of use, even as it helps build communities. Going forward, it is also beginning to demonstrate its value in contributing to an integrated community care system that will be truly accepted by the community.

Dr. Yoshiaki Koizumi
President, Kamaishi Medical
Association

"The community is crucial to care at the local level. Yet communities today are breaking down, even in the smaller cities and towns. I see the Kamaishi district's information network as a community-building tool, with various local functions backing one another up and sharing necessary information. Paper continues to be an essential medium in the management and utilization of information, and I expect much of the integrated patient information system as a vital component of community care."

Yoshimasa Kubo
Facility Director, the Goyoryo,
Nursing home for the aged

"The primary responsibility of a welfare facility like the Goyoryo home for the elderly is caring for our residents' health. After the tsunami, we worked closely with those around us. In terms of what we can do for our residents now, I regard the ability to convert handwritten records into a digital format so that we can read them chronologically and share them among doctors, nurses, nutritionists, and others, as a significant advance toward providing more efficient and better services. I look forward to pursuing this further, step by step."

Kunishi Higuchi
Office Manager of Innovative
Revitalization Group, Fuji Xerox

"We arrived at a system to resolve local residents' problems through ongoing dialogue with them, by steadily applying Human Centered Design (HCD), which identifies the issues to address by understanding how the residents see them. This approach also changes the quality of the relationship between local communities and Fuji Xerox, as it means that we become a member of the community building effort rather than a mere supplier of goods and services, and this experience has taught us that our corporate value to society is enhanced accordingly."

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