The use of telemedicine for delivering healthcare in Japan: Systematic review of literature published in Japanese and English languages

Abstract

Background

In common with other countries, Japan has an ageing population and geographical impediments to healthcare access. The role of telemedicine within the Japanese health system may be of wide interest, yet it has not been comprehensively explored and documented. Thus, the aim of this study was to systematically review the Japanese and English language literature relating to the clinical use of telemedicine in Japan.

Methods

For studies published in Japanese, we searched Ichushi and CiNii. For English language publications, we searched Cochrane Library, PubMed, Embase, and Web of Science. All peer-reviewed articles describing the clinical use of telemedicine and published between 2007 and 2016 were included. Data on clinical area, study type, technology used, and type of communication were extracted. Studies were categorised by prevention, screening, diagnosis, surveillance, and treatment.

Results

The search yielded 1476 records; 26 Japanese language and 15 English language articles were selected for review. A wide range of clinical areas were represented; however, home care and life-style related studies were dominant. More than 50% of studies were related to prevention and early diagnosis. The majority of Japanese studies involved doctor-to-doctor consultation. Smartphones and remote monitoring systems were the main types of technology used.

Conclusions

Most studies of telemedicine in Japan are published in the Japanese language and are thus relatively inaccessible to the rest of the world; for the first time, this study has provided an overview of the clinical use of telemedicine in Japan. The clinically related papers reflect the Japanese cultural focus on disease prevention.

Keywords

Japan telemedicine review clinical use

Introduction

Anecdotally, Japan is known as a technologically advanced nation with innovations that have global influence. Compared with western countries, Japan has a strong cultural and health-system focus on prevention. In common with other countries, Japan has an ageing population and geographical impediments to healthcare access; given this, it seems logical that telemedicine would have some kind of role.

The role of telemedicine within the Japanese health system may be of wide interest, yet little is known because it has not been comprehensively explored and documented, in part because of the language barrier.

Thus, the aim of this review was to understand the available evidence relating to the clinical use of telemedicine in Japan over the last 10 years. We reviewed literature published in both the Japanese and English languages to answer our question.

Methods

Two teams (Japanese language JI, TA; English language SE, NRA) independently undertook searches and data extraction in their respective languages. Identical processes were conducted in each language.

Search strategy

One member of each of the Japanese (JI) and English language teams (SE) independently undertook searches.

Search terms relevant to the use of telemedicine for clinical service delivery were determined by group discussion (English versions shown in Table 1). Equivalent search terms were used in Japanese.

For studies published in Japanese, we searched Ichushi and CiNii (the largest Japanese language health and academic databases, respectively). For English language publications, we searched Cochrane Library, PubMed, Embase, and Web of Science. We included all peer-reviewed articles that described the clinical use of telemedicine, published between January 2007 and December 2016. Details of the inclusion and exclusion criteria are presented in Table 2.

Table 1.

Search terms.

Step in search strategy	Search term
1	TELEMEDICINE. MESH Terms: Telemedicine; Remote consultation; videoconferencing Keywords: Telemedicine , OR Remote consultation OR Videoconferencing OR video conference* OR Mobile Health OR online health OR on-line health OR telehealth OR tele-health OR tele-home OR e-health OR ehealth OR tele-care OR telecare OR tele-consult* OR teleconsult* OR tele-conference* OR teleconference*
2	Country Japan
3	Limit to English and Japanese, abstract available; 2007–2016
4	1 and 2 and 3

Table 2.

Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Telemedicine: Provision of a clinical service (screening, diagnosis, treatment, surveillance prevention/lifestyle modification) All modes of communication (store and forward, real-time) All formats of telemedicine delivery (videoconferencing, mobile devises, monitoring, clinical decision support)	Technical Educational studies Review Standardised Assessment Tools Economics Legal, ethical aspects Japanese studies reporting results of overseas context Policy reports, reports from commercial organisations

Review process

Based on the inclusion and exclusion criteria, candidate articles were identified by examining titles and abstracts by one of the authors for each language team (Japanese language JI; English language SE).

Relevant full-text articles were then obtained and carefully read, and data extracted by both authors within each language team. Any disagreements were discussed and resolved by discussion. PRISMA Flow charts show the steps followed in the review (Figures 1 and 2).

Figure 1.

PRISMA flow diagram for studies published in English language.

Figure 2.

PRISMA flow diagram for studies published in Japanese language.

Analysis

Reviewed studies were grouped according to their primary purpose into the following categories: screening, diagnosis, treatment, surveillance, and prevention.

Within these categories, we tabulated and described studies by health area (e.g. dermatology, emergency medicine), study aim, study design (e.g. randomised controlled trials (RCT), observational), outcome measures, study population, length of study, results, type of telemedicine, and the type of technology (e.g. real time (RT), store and forward (S&F), or combination). We also tabulated the place of study and the journal.

Results

The searches identified 1476 papers (n = 1293 Japanese, n = 183 English), of which 26 Japanese papers and 15 English papers were included in the final review (Figures 1 and 2). The earliest paper was published (Japanese language) in 2007;¹ 73% (n = 11/15) of English language papers were published between 2013 and 2016,^2–12 while 38% (n = 10/26) of Japanese language papers were published in the same period.^13–22 The majority of studies were conducted in Tohoku^{16,18,22–24} and Chubu^{15,21,25–27)} (n = 5 each). Four studies involved multiple areas.^13,28–30 The Kanto,^31–33 Hokkaido,^17,20,34 and Kyushu^19,35,36 areas were involved in three studies each. There were two studies in Chugoku^1,37 and one in Shikoku.¹⁴ Nine English language studies were conducted in the Kanto area;^{2–5,7,11,12,38,39} Kansai^9,40 and Tohoku^6,10 were involved in two studies each, while Kyushu⁴¹ and Shikoku⁸ were involved in one study each.

Of the 26 Japanese language papers, 14 were published in Japanese Journal of Telemedicine and Telecare.^{1,13,14,16,17,20,22,26,27,29–31,34,37} Others were published in various clinically focused journals. Of the English language studies, 73% (n = 11/15) have been published in clinical journals.^{2–5,7,9,11,12,38,40,41} The remainder have been published in telemedicine-specific journals,^6,8,10,39 namely Journal of Telemedicine and Telecare and Telemedicine and e-Health. No studies in both languages were found. Full details of the included studies appear in supplementary table 1 and 2.

Health area

In the English language studies, only cardiology and hypertension had more than one study (four (Takeuchi²/Kabe³/Hishitani⁴/Ando⁴¹) and three (Kaihara⁷/Okura⁸/Kaihara¹²), respectively). The areas of occupational health,⁵ mental health,⁹ stroke,³⁸ geriatrics,⁶ diabetes,¹¹ and weight problems⁴⁰ were each represented by a single study. However, in the Japanese language, neurosurgery (four) (Narisawa¹⁸/Honda¹⁹/Kawahara³⁵/Hori²³), ophthalmology (three) (Hanada¹⁷/Hanada²⁰/Takahashi³⁷), cardiology (two) (Obata¹⁴/Hagiwara²⁶), neurology (two) (Sawada³⁴/Iguchi²⁸), pathology (two) (Shimizu²⁴/Yanai¹), and home health (two) (Morita²⁹/Hasegawa³⁰) were represented by multiple studies, while the areas of dermatology (Takemura¹³), obstetrics (Ogasawara¹⁶), general internal medicine (Ohta³¹), radiology (Yamaguchi²¹), geriatrics (Homma²²), respiratory (Ohbayashi²⁵), nursing (Kamei³²), and diabetes (Morita²⁷) were each represented by a single study.

Mode of telemedicine

Ten studies published in the English language involved the S&F modality,^{2,3,5,7–9,12,38,40,41} while only two studies used only RT methods.^6,39 The remaining two studies used mixed methods of RT and S&F.^4,10 Nineteen studies published in the Japanese language used RT telemedicine methods,^{1,14–19,21–24,26,28–32,34,35} while six studies used S&F.^{13,25,27,33,36,37} One study used a mixture of RT and S&F.²⁰

Types of communication

Fourteen studies published in the Japanese language involved doctor-to-doctor communication,^{1,13–15,17,19,20,23,24,28,31,34,35,37} while seven studies involved communication between doctor and patient.^{21,22,25,27,29,30,36} Telemedicine communication between doctor and midwife,¹⁶ nurse and patient,³² nutritionist and patient,³³ and physiotherapist and patient²⁶ was presented in single studies.

Studies published in the English language presented diverse types of communication by participants. In the majority of studies (n = 6), telemedicine was used by doctors to communicate health related data remotely.^{3,4,7,8,38,41} In four studies, patients used online methods to access information and help.^5,9,12,40 In two cases, nurses communicated with patients using telemedicine methods. Doctor-to doctor² and doctor-to-patient communication¹⁰ were represented in single studies.

Technology

In terms of technology used for telemedicine communication, the majority of studies published in English studies have used specialised devices for remote monitoring and information (data) delivery. In 80% of cases (12/15), these were purpose built systems for delivering data and remote monitoring. One study used videophones³⁹ and one used mobile phones⁹ for telemedicine communication. Studies published in the Japanese language reported the use of a range of technologies. Mobile phones were used for both RT and S&F communication (n = 6/26);^{13,14,19,27–29} seven studies used remote monitoring technologies,^{16,22,25,26,32,33,36} while videoconferencing was used by six studies^{17,18,22,30,31,34} and electronic health records by four studies.^1,23,24,35

Setting

The dominant type of setting for Japanese language studies was the hospital setting (15).^{1,13,14,17–21,23,24,28,31,34,35,37} Next was the home setting (eight).^{25–27,29,30,32,33,36} Ambulance,¹⁵ maternity home,¹⁶ and nursing home²² were each represented by a single study. Ten English studies were conducted in the home environment, of which one study involved overseas based Japanese people.³ Two studies were in a hospital setting.^4,38 One study was conducted in the workplace,⁵ one in a nursing home,³⁹and one in the ambulance setting.²

Study type

Seven studies in the English language were RCTs,^{5,7,10–12,39,40} while others represented observational, method comparison,⁴ and case control studies² in single studies. In Japanese language publications, only one study was an RCT.³² Others were observational studies, except one qualitative study.¹³

Discussion

This study is the first to compare and contrast the existing evidence published in the Japanese and English languages relating to telemedicine use for clinical purposes in Japan. The study found that there is an active research community undertaking research in telemedicine and publishing in both English and Japanese. Researchers tend to publish findings in clinically focused English language journals. Researchers publish findings from their studies in dedicated telemedicine journals in the Japanese language. Overall, the majority of studies involved rural and remote locations of Japan, indicating that there is a significant emphasis on investigating the potential of telemedicine for providing healthcare to remote communities using telemedicine.

As this study found, there is a strong emphasis on prevention and lifestyle modification in research. From the health area perspective, research in telemedicine covers a large number of health disciplines. However, areas such as cardiology and hypertension show prevalence.

The technology used in telemedicine for clinical purposes varies. There is a trend towards using purpose-built telemedicine systems such as remote monitoring systems and electronic medical record systems. Smartphones are also used for both RT and S&F communication.

In the past, some studies have reviewed the status of telemedicine in Japan.^42–45 But no study has examined the recent evidence, except for one that reviewed the economics of telemedicine in Japan.⁴⁶

As this study revealed, Japan is actively seeking opportunities to use telemedicine in addressing the healthcare needs of the population. Key areas of focus seem to be 1) access to healthcare for rural and remote communities, 2) home telemedicine, and 3) prevention and lifestyle modification.

The results of this study show that while some research in the field is taking place, the number of studies published in telemedicine is not very high. This may be due to some cultural attitudes towards medical services in Japanese people. One such specific aspect may be the high sensitivity of Japanese people regarding privacy and security. There may be some reluctance towards wider use of technology for healthcare delivery services.

One of the key strengths of this study is that it has reviewed evidence comprehensively in both the Japanese and English languages. Japanese and English speakers who could reliably extract and interpret the evidence were involved in the review. We should also acknowledge a weakness of this study. The study does not evaluate the quality of evidence. However, the main purpose of this study was to understand the key trends in telemedicine in Japan, and the evaluation of quality of evidence was not an intended goal.

While interest in telemedicine in Japan is growing, aspects of the health insurance system and remuneration have been limiting factors. However, areas such as tele-radiology and tele-pathology have overcome these barriers to make successful cases. The Japanese Government has enacted some important policies to encourage telemedicine. In August 2015, the Ministry of Health, Labour, and Welfare permitted the use of telemedicine in areas other than rural and remote areas. Since November 2016, the Japanese Government has declared telemedicine to be considered as an equivalent clinical intervention similar to face-to-face medical treatment. Thus, the fee structure will be changed accordingly.

Conclusions

Most studies of telemedicine in Japan are published in the Japanese language and thus relatively inaccessible to the rest of the world; for the first time, this study has provided an overview of the clinical use of telemedicine in Japan. As this study revealed, Japan is actively seeking opportunities to use telemedicine in addressing the healthcare needs of the population. Key focus areas are 1) access to healthcare for rural and remote communities and 2) home telemedicine. Also, the clinically related studies reflect the Japanese cultural focus on disease prevention and surveillance.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplementary material

Supplementary materials may be accessed online alongside full text articles, or obtained through correspondence with the authors.

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Supplementary Material

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The use of telemedicine for delivering healthcare in Japan: Systematic review of literature published in Japanese and English languages

Abstract

Background

Methods

Results

Conclusions

Keywords

Introduction

Methods

Search strategy

Review process

Analysis

Results

Category

Health area

Mode of telemedicine

Types of communication

Technology

Setting

Study type

Discussion

Conclusions

Footnotes

Declaration of conflicting interests

Funding

Supplementary material

References

Supplementary Material