Stop the Collapse of Emergency Medical Care with the Use of iPads!
Saga Prefectural Government

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
In August 2006, a woman fell unconscious in critical condition while giving birth. After being denied admission by 19 medical institutions, the woman was taken to a hospital 60 km away, where she eventually died after the delivery. This incident was featured in the Japanese media with headlines such as “Pregnant Woman Kept Getting the Runaround” and “Admission Denied”. People all over the country shed tears in response to this tragic event. Subsequently, the inefficiencies in emergency medical care came to be widely recognized as a problem. Yet, fatal “runaround” cases have continued to occur. Medical institutions in Japan have a serious problem in “giving critical-care patients the runaround”. Even when an ambulance arrives in response to an emergency 1-1-9 call from a citizen, the ambulance attendants often have difficulty finding a medical institution that will accept the patient. When people with serious injuries or illnesses lose their lives just because no medical institution can be found to promptly accept them, the predicament rightly become a serious social issue. One of the causes of this problem is that, although the number of people who are taken by ambulance continues to increase year after year,*1 the number of medical institutions and emergency medical doctors who can accept critical-care patients remains insufficient. Along with this unfavorable supply-demand balance, some ambulances in Japan are equipped with just a single mobile phone as a means of communication to find a suitable medical institution. In Saga Prefecture, this created a situation where an ambulance attendant was forced to make one phone call after another in order to find a medical institution to accept their patient. Even when ambulance attendants call a medical institution and explain the condition of their patient and ask for admission, the medical institution often declines, saying “We’re terribly sorry, but we have no doctors with expertise for that condition,” or “As we have just accepted another critical-care patient, we can’t accept yours.” Even so, ambulance attendants cannot just give up; they have no choice but to keep on calling no matter how many times they are refused. As a result, the record for “the longest time from a 1-1-9 call to the patient being admitted to a medical institution” has increased with each year.*2 The situation has created a negative cycle in which, as more patients are concentrated in the larger medical institutions and other institutions that actively accept critical-care patients, the more likely patients are also denied admission from those institutions. *1 The number of people carried by ambulance in Japan: 3.761 million people (in 1999) → 5.182 million people (in 2011) *2 The average time from a 1-1-9 call to the patient arriving at a hospital: 27.1 minutes (in 1999) → 38.1 minutes (in 2011)

B. Strategic Approach

 2. What was the solution?
In 2010, a Saga Prefectural Office employee assigned to related duties—Mr. Yusuke Enjyouji—was dismayed at the critical situation of emergency medical care, and began considering possible solutions. He worried that Japan’s emergency medical system might otherwise collapse. Although he had no knowledge, experience or authority related to medical care, he embodied Saga Prefecture’s spirit of the “on-site principle.” This policy encourages staff of the Saga Prefectural Office to perform their duties without losing the sense of being an ordinary citizen, keeping in mind the real needs of citizens, rather than just performing their duties from an administrative perspective. Yasushi Furukawa, who has been the governor since 2003, implemented this “on-site principle” as a basic policy, reforming the prefecture’s administrative organs and the mindset of the staff. Enjyouji realized that he could not contribute to the drafting of effective policies without seeing the state of emergency care “on-site” with his own eyes and gaining some understanding from his own experience. He rushed to a nearby fire station and asked, “Please let me ride in an ambulance with you!” The person in charge at the fire station responded, “I can’t let you do that! There is no precedent of allowing an unauthorized person to ride on an ambulance. We couldn’t even guarantee your safety at a dangerous emergency site.” Still, in order to find a solution, it was important to learn what the actual site was. Even after being refused many times, he didn’t give up. As a result of continuous requests made for nearly a month, he was permitted as a very exceptional case to ride with the ambulance attendants for one night when the ambulance was mobilized for a 1-1-9 call. Similarly, he asked a medical institution which accepted emergency-care patients to allow him to study the situation there by closely observing the activities of the doctors. While Enjyoji was making regular visits to the medical institution, he came to think that if the information at the respective emergency medical care sites could be shared, the amount of wasted time could be reduced. He came up with the idea of using ICT as a solution. He worked to resolve inefficiencies in the emergency care system by proposing the unprecedented use of iPads in ambulances, and by drawing in the support of people from various organizations involved in emergency medical care including the fire service, medical institutions, and even the medical association. He brought in an IT company to build the system and to procure the iPads, actively advancing his plan while maintaining open communications with the people on-site to discuss their challenges and needs. After establishing collaboration among the fire service, medical institutions, and the medical association, he pushed forward by “visualizing” emergency medical care situations and considering improvements from the perspective of respective staff. As such, he laid the foundations to build an independent system in which Saga Prefecture could cooperate with respective communities to solve problems by deepening mutual understanding between people in different positions through effective communication.

 3. How did the initiative solve the problem and improve people’s lives?
In order to solve this problem, Saga Prefecture has taken an innovative initiative utilizing information and communication technology (ICT) to share the actual situations at each medical emergency site. This is an effort to save as many lives as possible by delivering critical-care patients to the appropriate medical institutions as quickly as possible. In other words, the prefecture established a mechanism whereby ambulance attendants can instantly share with medical institutions such medical emergency information as “Which medical institution has a doctor with expertise to treat this condition?”, “Which hospitals currently have high concentrations of patients transported by ambulance?” and “Which hospitals have a system to accept critical-care patients?” The key ICT for this mechanism is a tablet-style PC—the “iPad.” The advantage of “iPad” is that it uses inexpensive technology, which anyone can use and buy, in addition, unlike with the prior system; the information in the database can be updated by both the medical institutions and the ambulance attendants. With this new approach, ambulance attendants have become able to access relevant data on hospital openings in a timely manner as they transport the patient.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
April 2002 : Saga Prefecture’s Emergency Medical Care Information System (old system) began operation. August 2006: A pregnant woman refused by 19 medical institutions died after giving birth. This incident was featured by the mass media as a serious social issue. October 2008: The national trend of the underutilization of the Emergency Medical Care Information System was featured on the news and presented as a problem. April 2010: Mr. Yusuke Enjyouji at the Saga Prefectural Office was assigned to the Medical Division. His request for a field study aboard an ambulance was rejected by the fire station. May 2010: He received permission to ride in an ambulance with ambulance attendants, and to study the emergency medical situation at a medical institution. He suggested the idea of utilizing ICT. His action to bring a mobile PC and a smartphone into an ambulance was fiercely opposed by ambulance attendants. In Japan, iPads were put on the market. He proposed the use of iPads in ambulances to ambulance attendants, and obtained their permission. June 2010: The 1st Investigative Commission on the New Saga Prefectural Emergency Medical Care Information System was held. July 2010: Meetings for an exchange of views with all fire defense organizations and with emergency medical institutions in Saga Prefecture were held. August 2010: The 2nd Investigative Commission on the New Saga Prefectural Emergency Medical Care Information System was held and it decided to adopt the initiative proposed by Mr. Enjyouji. September 2010: Bidding by companies started. November 2010: Entered into a contract with a company to build the relevant system. February 2011: The 3rd Investigative Commission on the New Saga Prefectural Emergency Medical Care Information System was held and it discussed how a test information-sharing system can be improved and decided to take a revised system design based on the discussion. March 2011: Training for on-site workers was provided by visiting various sites in the prefecture (Total number of participants: 250) April 2011: The New Saga Prefectural Emergency Medical Care Information System began operations. September 2011: Yahoo! News introduced Saga Prefecture’s initiative as its top news. April 2012: Similar initiatives began to be taken in three other prefectures. July 2012: In the Japanese government’s Investigative Commission to Consider an Optimum Ambulance Service, Saga Prefecture’s initiative was introduced. The Japanese government set forth its policy to utilize ICT. September 2012: Mr. Yusuke Enjyouji at the Saga Prefectural Office was commissioned as an ICT regional manager under a national program to support the spread of ICT use across the rest of the country. December 2012: Similar initiatives began to be adopted in six prefectures including Saga Prefecture. January 2013: After being denied admission by 25 neighboring hospitals a total of 36 times, a 75-year-old man lost his life. The dysfunction of the Japanese emergency medical care system was featured once again by the mass media as a serious social issue. March 2013: In response to the January 2013 incident, the national government issued an emergency notice urging fire services nationwide to improve their correspondence with medical institutions. The government referred to the example of Saga Prefecture as a successful model for reducing the time taken from an emergency call to a patient being admitted to a hospital. November 2013: The prefecture where the January 2013 incident occurred adopted a similar initiative. The number of prefectures using this system increased to eight and continues to rise today.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Yusuke Enjyouji, a staff member of the Saga Prefectural Office contributed significantly to this initiative. He led the initiative from beginning to end to tackle the emergency medical care problem that was constantly on his mind as he carried out his daily duties. The ambulance attendants directly engaged in emergency medical care were the first to offer him support. To create an information system that identifies hospital availability for critical-care patients, it is necessary to input relevant data into the system. Ambulance attendants on the scene are best suited for this task. Enjyouji thought ambulance attendants might easily enter information in their free time after they finish transporting a patient to a hospital. Taking into account suggestions from on-site ambulance attendants he conducted some experiments and finally came up with the idea of using iPads. To introduce iPads into all of the prefecture’s ambulances, cooperation from the prefecture’s fire service was essential. In addition to the medical institutions to which patients are taken, all sectors in the prefecture needed to be on board for the initiative to work. The different parties engaged in emergency medical care such as the medical association came together to exchange opinions in order to make this initiative successful. IT companies also played a significant role in establishing the system and procuring iPads. As a member, a representative of the emergency and critical care center and Person in charge of our each fire department participated in many discussions with concerning system design and screen layouts. After establishing a collaborative relationship with the administration, the fire service, the medical institutions, and the medical association, he pushed forward the “visualization” of emergency medical care sites by ensuring that each sector thinks about what they can do and how they can contribute in their positions.
 6. How was the strategy implemented and what resources were mobilized?
• Financial resources We needed approximately 1 million US dollars for the development cost of the main system. The initial installation cost of 80 iPads, including 49 iPads for ambulances, was approximately 60,000 US dollars. Our initial development estimate of nearly 2 million US dollars was reduced roughly in half to 1 million US dollars through the adoption of a cloud system. The annual running costs total approximately 210,000 US dollars, which comprises around 270,000 US dollars for the main system, and 60,000 US dollars for communication fees and maintenance service for the iPads. The annual running cost for the old system, which had rarely been used, was surprisingly high at about 670,000 US dollars. So, despite the system’s substantial improvement, we have achieved a reduction in related costs of approximately 400,000 US dollars annually. Considering the useful five-year life of the new system, we can expect a cost reduction effect of approximately 2 million US dollars over the next five years. Even if the development cost of 1 million US dollars is subtracted, we will still have reduced the cost by approximately 1 million US dollars. • Technological resources The iPads in the ambulances needed to be immediately recognizable as a special device relevant to emergency care by the people around the ambulance attendants, including the family members of patients being taken to a hospital. Therefore, we put an orange cover on each iPad as a standardized measure across the prefecture. • Human resources We launched this initiative in the hope of solving a problem in emergency medical care through cooperation between the administration and related organizations. To resolve the problem, we paid attention to the maximum use of information provided by the respective groups.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Now that information on emergency medical care sites is shared between all ambulances and all medical institutions in the prefecture, the following results have been achieved. First, the transportation of critical-care patients has been decentralized among medical institutions. Since ambulance attendants are now able to obtain information on congestion at medical institutions, concentration at specific medical institutions has been relieved. Compared to the national average, Saga Prefecture previously had a higher rate at 32.7% of critical-care patients being transported to specific medical institutions, such as large hospitals. This concentration placed a heavy burden on doctors at the hospitals. After introducing the system, however, the rate of critical-care patients transported to these large hospitals fell to 29.6%. Because decentralization among medical institutions mitigated the burden on doctors and eliminated congestion at institutions receiving many patients, ambulances transporting critical-care patients were more smoothly accepted. Subsequently, the time taken from an emergency call to the patient being admitted to a hospital has shortened. Since ambulance attendants can now smoothly search while in transit for medical institutions with suitable available doctors, the average transportation time of patients—which continues to grow longer in other prefectures of Japan—has miraculously shortened in Saga Prefecture in the six months since the introduction of the system, down by nearly 1 minute, from 34.3 minutes the previous year to 33.3 minutes. If you are experiencing heavy bleeding, the probability of your survival decreases by 10% every minute after 30 minutes from the start of blood loss. There are many people who have been saved by this single minute. Finally, the operation cost has dropped by up to 400,000 US dollars per year. - Results achieved after introduction of the system 1) High Utilization Rate by Medical Personnel (Number of Accesses to the System) (Fire Service) 10,701 accesses → 109,794 accesses (11-fold) (Medical Institutions) 24,566 accesses → 199,321 accesses (8-fold) (Other Sectors) 145,946 accesses → 1,413,435 accesses (10-fold) 2) Reduction in the Transportation Time of Patients Reduction by One Minute 34.3 minutes → 33.3 minutes (*Average of the first half fiscal year after introduction of the system) 3) Decentralization of Patient Transportation (Percentage of Transportation to Emergency and Critical Care Centers) 32.7% → 29.6% 4) Operation Costs Approx. 670,000 US dollars per year → Approx. 270,000 US dollars per year (including costs for a cloud system + iPads)

 8. What were the most successful outputs and why was the initiative effective?
With this new approach, ambulance attendants have become able to access relevant data on hospital openings in a timely manner as they transport the patient. The patient transportation information input rate is now 100%. Previous System -Medical Institutions : 24,556 accesses/year -Fire Service : 10,701 accesses/year New System -Medical Institutions : 199,321 accesses/year -Fire Service : 109,794 accesses/year On-site ambulance attendants have responded to the initiative with the following comments: “The system is easy to use; it enables ambulance attendants to search for available hospitals while in their ambulances.”; “The system is helpful; using the iPads, we can search for available medical institutions even if they are located outside our designated areas.”; and “Since we can share the up-to-date information on which hospitals can accept critical-care patients, it has become easier to select the best hospital to transport the patient to.” Emergency medical care doctors are also praising the system, saying that the system has enabled them for the first time to identify the availability of other hospitals and note what is actually happening in their local communities. Also, it is very good to be able to find out the status of an emergency medical care case in real-time. Moreover, the introduction of a cloud system has reduced operation costs by up to approximately 400,000 US dollars per year compared with the previous system. Furthermore, analysis of the transportation data reveals not only that the transportation of critical-care patients has been decentralized among medical institutions, but also that the average transportation time of patients, which continues to grow longer in other prefectures, has shortened in Saga Prefecture in the six months (April to October 2011) since the introduction of the new system. This reduction is the first ever in the history of Japan.

 9. What were the main obstacles encountered and how were they overcome?
We faced three major obstacles. The first obstacle was the budget deficit. Facing financial difficulties, Saga Prefecture had no budget to purchase iPads in the middle of a fiscal year. Therefore, Enjyouji worked on the following three efforts: (1) Make use of a cloud system (2) Stream-line the old system by venturing to eliminate low-priority functions (3) Be thorough with competitive bidding by increasing the number of entrants As a result, we were able to resolve the budget deficit problem through “overall cost reductions” in which the installation cost of the equipment (initial cost) was offset by reducing each year’s operational costs (running cost). The second obstacle was establishing a relationship of mutual trust. Our creative initiative was a plan for ambulance attendants to use iPads in all ambulances. Voices of opposition grew from workers at emergency medical care sites due to the “sense of burden”. Therefore, Saga Prefecture provided practical training for on-site workers, where they could try operating the iPads themselves. Moreover, in cooperation with a key person who was trusted on-site by ambulance attendants, Enjyouji set up an investigative commission to jointly consider the system design and the design of the iPad’s operational screens. They then became cooperative. The third obstacle was awareness of protecting personal information. Since people in Japan are highly conscious and aware of the protection of personal information, how to handle critical-care patients’ personal information presented the greatest obstacle. As such, we decided to do what we could because “done is better than perfect” for a first trial. In other words, we decided for the time being to make the patient’s personal information confidential by using numbers such as “12-1 (the first patient of ambulance No. 12)”, which were understood only by the ambulance attendants and medical personnel using the system.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
First, we can now save many more lives than before. In addition, the initiative has realized the reduction of operation costs by up to 400,000 US dollars per year compared with the previous system. After the initiative achieved a certain level of results in Saga Prefecture, we began to hope that the use of ICT at emergency medical care sites would spread across the rest of the country. To this end, we have been positive about accepting visits from other local governments for study tours, meeting requests from companies to deliver lectures, and giving interviews to the media. Furthermore, our initiative has gained praise and recognition by the residents of Saga Prefecture on social networking sites; there are many comments placed on such services suggesting that similar initiatives should be adopted in other prefectures. This has further increased the number of requests from other local governments, local assemblies, and medical associations to visit Saga for study tours; so far more than 50 organizations have visited Saga to learn about our initiative. Consequently, the use of tablet terminals in ambulances is spreading across the country. The initiative is currently being implemented in eight prefectures. Our initiative started from the awareness of only one prefectural employee, spread to other prefectures, and is now expanding into a national trend. This phenomenon was covered by the media in Japan, which serves as one example of how the initiative has been gaining attention.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Commencing in April 2011 in Saga Prefecture, this initiative was applied to systems across six prefectures by November 2012. Altogether 23 other prefectures in Japan are currently considering its application. This initiative is now becoming the standard for Japan’s emergency medical care. Saga Prefecture has made the expertise in this initiative completely open to everyone. We hope this initiative becomes not only a national trend but also a global trend. We believe that there are two major reasons why this initiative has been widely accepted: (1) Saga Prefecture’s innovative initiative was highly valued by the mass media. For example, it received recognition at the 2012 Mobile Computing Promotion Consortium held in April, winning 1st place as well as the “MCPC Minister’s Award.” Additionally, in May of 2012 it won the “MCF (Mobile Contents Forum) Contribution to Society Award” at the Mobile Project Awards. It received high marks for the wide applicability of the system and the successful utilization of mobile technology to save lives. Having outstanding creativity and innovation, this initiative gained numerous opportunities for expansion, receiving constant requests for interviews, study tours and lectures, despite being just an effort by a small local government. (2) One of the pillars of Saga Prefecture’s measures is the spirit of openness. In the hope of improving Japan’s emergency medical care, Saga Prefecture has made its expertise in this initiative completely open to everyone. As we originally aimed at simplicity, this initiative can easily be replicated. The prefectures that have replicated our initiative have now operated improved versions by incorporating their own initiatives into our original system. We believe our next step should be to establish a positive cycle by replicating the new versions created by each prefecture in Saga Prefecture. The aspect of “visualization” in Saga Prefecture’s initiative can be applied to various types of industries. For example, taking a hint from the utilization of iPads in ambulances, a medical institution in Saga Prefecture has improved the efficiency of its operations by achieving paperless meetings with iPads loaded with meeting materials. In the future, we would like to make use of this system not only for doctors’ treatment but also for ensuring a safer and more comfortable society for citizens. For this reason, we will take such measures as (1) sending photos and moving images of the wounded or sick person on an ambulance on the spot to the medical institution that agrees to accept the person, as well as (2) further improving this system so as to function as a mechanism where such medical information on the injured or sick person such as medication they are currently on, allergies, and medical history, can be utilized for treating the patient during emergency medical transportation.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Our initiative started from the awareness of only one prefectural employee, spread into other prefectures, and is now expanding into a national trend. Every time our initiative has been shown in the news, we have heard many voices in favor of our initiative on Twitter and Facebook—“Great!!” “I wouldn’t complain about our taxes being used for an initiative like this!” and “This idea should be spread throughout Japan!” We have also heard the voices of on-site emergency medical doctors and ambulance attendants with comments such as, “I’m pleased that the emergency medical care system of Saga, which has rarely been featured, has attracted attention nation-wide.” While it is important to make changes in the situation of emergency medical care, we believe that raising the morale of on-site workers is one of the national government’s most important roles. We would like to describe three lessons we learned from Saga Prefecture’s initiative. (1) “Innovation does not happen unless you take action yourself.” This phrase means that you should first do what you can, rather than lament about an unchanged situation or what you cannot do. Before blaming the national government, think about what your local government can do first, and about what you can do as an individual. As a result, one or more active policies for the betterment of society may be developed. And those policies may be able to change the whole country for the better. (2) “Innovation does not spread unless it is shared.” It is important to simplify the purpose and the initiative as much as possible. Issues and problems, no matter how large or serious they are, will not attract any attention or be featured in the media without being recognized by everyone. In the same vein, no matter how good your initiative is, it will turn out to be meaningless unless it is disseminated. Simplifying the method facilitates the replication process, allowing the initiative to be widely disseminated, which in turn may lead to changing the world. (3) “If it cannot impress, the innovation will not be sustainable.” The third lesson is that no matter how high your motive is or how firm your sense of mission is, that alone cannot sustain your initiative. Without an exciting element of fun or an aspect that can move people emotionally, any initiative will never be sustainable, and will likely end up being merely a temporary measure. It’s been more than 18 months since Saga Prefecture’s initiative was implemented. We believe that what has made the initiative sustainable is the utilization of an exciting tool—the iPad—and the sense of joy users feel in helping someone through the information they have entered into the device.

Contact Information

Institution Name:   Saga Prefectural Government
Institution Type:   Government Agency  
Contact Person:   Yuusuke Enjyouji
Title:   Project Chief  
Telephone/ Fax:   +81-952-25-7072 / 81-952-25-7267
Institution's / Project's Website:  
Address:   1-1-59 Jonai
Postal Code:   840-8570
City:   Saga-shi
State/Province:   Saga

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