| 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%.
-Medical Institutions : 24,556 accesses/year
-Fire Service : 10,701 accesses/year
-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.