Current status electronic medical recording in Japan and issues involved

摘要

For team care to function smoothly, it is necessary for healthcare providers to have unified management and convenient sharing of medical care information and to promptly implement such information in the planning of examinations, diagnosis, and treatment. In addition, to provide patients with appropriate medical care information on the basis of informed consent, healthcare providers need to prepare medical records that are worthy of disclosure. Electronic medical recording systems can serve as a good tool to this end. In Japan, the storage of medical records in electronic media was permitted in 1999, and 2 years later, the Grand Design toward Computerization in the Medical Field implemented by the Ministry of Health, Labor and Welfare targeted the dissemination of electronic medical records in at least 60% of clinics and at least 60% of hospitals with 400 or more beds throughout the country during the five years prior to 2006. The form of medical records and their method of storage have been left up to each medical institution provided that three criteria, namely, authenticity, visual readability, and storage property, are ensured. However, as of April 2004, electronic medical recording systems had been introduced in only 11.7% of medical institutions with 400 or more beds. The reasons for the delay in the spread of electronic recording are its high introductory costs and unknown cost-effectiveness. A governmental subsidy for the introduction of electronic medical recording that was provided during the initial two years has been abolished owing to financial constraints. Moreover, the introduction of such a recording system may impose an increased burden on doctors and other staff members in terms of data input, and consequently may adversely affect the quality of patient services by, for example, increasing waiting time. To further disseminate electronic medical recording systems, it is desirable for each medical institution to review its current daily clinical practices and for the Government to providesome form of official support to institutions in which an electronic medical recording system has been adopted.