Section 3. Medical Services of the New Age

While environment surrounding medical care is changing with rapid progress of aging society with fewer children and with the changes in disease patterns to the orientation of chronic diseases, it is important to deliver high quality and adequate medical care efficiently. To ensure high quality medical care, medical institutions are increasingly required to enhance their efforts for active information offering from patient's point of view.

Considering the circumstance, the "Discussion Group for In-Hospital Medical Care in the 21st Century", the "Discussion Group on the Required Number of Hospital Beds, etc.", and the "Discussion Group on the Utilization of Medical Information such as Medical Records, etc." held discussions and each compiled reports in summer of 1998. Since the end of September 1998, the Council on Medical Service Facilities is carrying on discussions based on these report on: 1 development of a system to deliver in-hospital medical care, 2 promotion of offering information on medical care and services, etc.

Overview of each report is as indicated below:

1 Overview of the report from the "Discussion Group for In-Hospital Medical Care in the 21st Century" (July 1998) As hospitals need management and operation to efficiently deliver adequate medical care for each patient conditions while accurately responding to patients' requirements, proper manpower allocation standard, and structure and facility standard should be set for general hospital beds by clarifying their functions. Categorize general hospital beds into "acute stage beds" and "chronic stage beds" Acute stage beds: Mainly for patients requiring medical care for acute stage (Patients who became ill recently including acute aggravation) and for patients requiring medical care for subacute stage (Patients in an unstable condition during their recovery period) , and providing intensive medical care for a certain time period to improve patients' condition. Chronic stage beds: Mainly for patients requiring medical care for chronic stage (Patients in stable condition, but have diseases and/or disabilities), and to offer long-term medical care. Manpower allocation standard for acute stage beds shall be determined by referencing the standard for current general hospital beds, and for chronic stage beds it is necessary to maintain the consistency with the standard for sanatorium-type wards. Structure and facility standard needs fundamental review with the view of deregulation. Based on the review, the structure and facility standard for acute stage beds and for chronic stage beds should be set to keep consistency with the standard for general hospital beds and for sanatorium-type wards respectively. 2 Overview of the report from the "Discussion Group on the Required Number of Hospital Beds, etc." (July 1998) With the Third Amendment to the Medical Service Law the contents of the Medical Care Plan was revised, and the characteristics of necessary hospital beds need to be reexamined. For acute stage hospital beds the current average length of stay shall be further reduced, and for chronic stage beds the improvement shall be made to long-term hospitalization through the advancement of therapeutic effect and medical treatment environment. For the correction of the difference in the number of necessary hospital beds within regions, it is appropriate to change the concept of the block-unit system and to aim the nationwide integration as the ultimate goal. For the calculation method of the number of necessary hospital beds, the number of inpatients and the average length of stay shall be used for acute stage beds. For the number of necessary chronic stage beds, it is adequate to calculate by subtracting the number of necessary acute stage beds from the total number of required hospital beds. 3 Overview of the report from the "Discussion Group on the Utilization of Medical Information such as Medical Records, etc." (June 1998) Possible reasons for the needs of offering medical information would be first to enhance the feeling of trust between medical professionals and patients and to improve the quality of medical care through the sharing of information. The second reason would be for self-control of one's own private information. Medical information should be provided to patients as part of the routine for explaining patients about their conditions and treatments regardless of having patients' request, and when patients request the disclosure of their medical records in addition to ordinary explanation, medical professionals should respond to the request as basic practice. Medical record is private information, and disclosure of the information to other people than the patient must be deliberated carefully. When the disclosure of information may affect the therapeutic result negatively, it might be necessary to stop providing medical information to the patient. To realize the practice of offering medical information to serve its purpose, medical activities must be recorded in a way that patients can understand easily, and the record must be managed properly. Computerization of medical information such as electronic medical records will contribute to high quality medical service for patients. It should be further promoted. To actively propel medical information offering, it is significantly meaningful to stipulate the obligation to disclose medical information by law.

2. Improving the Quality of Life of Patients under Terminal Medical Care

In order to understand the changes in people's opinions towards terminal care as well as the current status of the difference in such opinions between general citizens and medical professionals, and also to investigate terminal medical care that is appropriate for Japan, the "Study Group for the Survey on the Opinions of Terminal Medical Care, etc." conducted a survey (questionnaire format) during January to March 1998 to general citizens and to medical professionals. This survey had been conducted in 1993 to general citizens only.

The outcome of this survey was similar to the result of the survey conducted previously, and it confirmed that people's opinions on terminal medical care have not changed very much between 1993 and 1998. The confirmed opinions are as follows: People have high interest in the issue of terminal medical care; Many people wish to stop treatment for simply prolonging life, and wish to have treatment to reduce pains and other symptoms; Not many people want to establish laws on living will (Presenting one's own will in a written document while alive.); and Not many people accept euthanasia.

Based on the survey result, the Study Group compiled a report in the meeting in June 1998, and the group indicates in the report that for the future actions for terminal medical care it is necessary to develop human resources and environment for terminal medical care and treatment including in-hospital medical care such as palliative care ward and improved terminal medical care for the elderly living at home

3. Securing Medical Service Personnel and Improving Their Quality

In order to deliver adequate and high quality medical services, it is important to secure medical professionals and improve their quality, and for this purpose consistent education and training are necessary starting from in-school education to national examinations and lifelong education.

For the adjustment of the number of physicians and dentists, the "Study Group on the Supply and Demand of Physicians" and the "Study Group on the Supply and Demand of Dentists" compiled reports in May 1998, and pointed out the need for balancing the supply-demand relation because the population of both physicians and dentists are projected to be excessive in the future. Considering the demand for further improvement of post-graduate clinical training for physicians and dentists, the Clinical Training Committee for Physicians and the Clinical Training Committee for Dentists in the Council for Medical Professions are examining the possibility for requiring compulsory clinical training for physicians and dentists as such training is currently included in the obligations to make efforts. Also, the Ministry of Education, the Ministry of Health and Welfare, and other relevant people are discussing on the improvement of post-graduate clinical training for physicians, and the "Council on the Post-graduate Clinical Training for Physicians" is discussing the possibility for making such training a requirement.

In case of pharmacists, the revision has been made recently to secure adequate number of people in hospitals with consideration of the progress with pharmacy technology, increased task in patient care units including drug administration guidance and patient medication profile, etc. In addition, to respond to the final report of the "Committee to Study Problems in Pharmacist Training" in June 1994, which strongly recommends the policy on the eligibility for taking the State Examinations for Pharmacists as six years of education including a minimum of six months of practical training, the Ministry of Education, Ministry of Health and Welfare and relevant organizations are discussing in the "Committee to Study Problem in Pharmacist Training" on measures to develop a system to facilitate practical training and to improve the development of pharmacists.

In case of nursing staffs, a comprehensive measure is in place based on the "Law to Promote the Securing of Nursing Personnel" for preventing resignation, promoting re-employment, enhancing manpower development capability, improving quality, etc., and projects for securing and developing nursing staffs have been making steady progress. Regarding the issue on assistant nurses, in March 1998 the "Study Group on Quality Improvement of Assistant Nurses" started discussions on the improvement of the quality of assistant nurse education, and the "Study Group on the Education for Assistant Nurses to Become a Registered Nurse" started discussions on education for assistant nurses to become a registered nurse. Then, in April 1999 the "Study Group on the Education for Assistant Nurses to Become a Registered Nurse" compiled a report. In the report, the group recommends to implement a temporal measure with five year limit to offer assistant nurses with a minimum of 10 years of work experience an education program to become a registered nurse.

4. Emergency Medical Care Measures

Directions for the emergency medical service system have presented in the "Report of Council on Basic Problems in Emergency Medical Service System" compiled in December 1997 to consolidate the emergency medical service system which consists of emergency medical care institutions including primary medical care institutions for emergency patients in local area (rotation on-call system among practitioners, holiday and night emergency patient center, etc.), secondary medical care institutions (a group of hospitals on rotational duty, joint-use hospital) and tertiary medical care institutions (emergency medical service centers), and the emergency reporting system in which some medical institutions are certified for accepting emergency patients and ambulance crews deliver wounded and sick people to those certified institutions. The report also indicated to re-evaluate emergency medical service centers and to enhance their functions. Based on the recommendations, various measures have been taken including the revision made to the "Ordinance to Determine Emergency Hospitals, etc." in March 1998 to further improve the quality of emergency medical service system and to reduce the gaps between regions.

5. Health and Medical Care Measures for Remote Areas

In terms of health and medical care measures for remote areas, the new Eighth Health and Medical Care Plan for Remote Areas was formulated in 1996. This plan includes a strategy to further improve medical care in remote areas by positioning hospitals to supply substitute doctors when doctors at remote area clinics take leaves, or are absent, as "support hospitals for medical care in remote areas" which will augment the existing system of core hospitals and clinics in remote areas that currently provide medical care there. Other measures in health care will be taken for qualitative improvements such as increasing clinical specialties, using information and communications technology, and promoting coordination among health, medical and welfare services according to a situation in remote areas.

6. Evaluating the Quality of Medical Care

Along with the advancement and diversification of people's requirement to medical care and with the improving awareness for the importance of guaranteeing the quality of medical care, the interest in the evaluation of medical activities by a third party is rising.

Considering the circumstance, the Japan Medical Function Evaluation Organization has been formally implementing the "Hospital Function Evaluation Service by Third Party" starting in 1997 to evaluate hospital functions. In this evaluation, the conditions of medical examinations, nursing system, operation and management, etc. are examined as a third party's point of view. As a result of this evaluation, 175 hospitals (as of February 15, 1999) have received a certificate of the evaluation, and names of those hospitals are listed in the homepage of the Ministry of Health and Welfare.

Regarding the evaluation of medical practice, the "Medical Technology Assessment (MTA)" has been introduced to the U.S. and Europe as a method for improving the quality of medical care and patient services through efficient utilization of medical resources, and a certain result has been recognized. Therefore, the "Study Group on the Positioning of Medical Technology Assessment" investigated the potential for using this method in Japan, and compiled a report in June 1997 with the direction to recommend the promotion of MTA.

To promote MTA, it is also necessary to verify that the outcome can be effectively utilized in the actual field of medical practice. The "Study Group on the Promotion of the Medical Technology Assessment" investigated specific promotion and utilization measures for MTA, and formulated a report in March 1999. This report indicates that 1 MTA will lead to the improvement of the quality of medical care through the utilization of its outcome, and 2 as a way of utilizing the outcome, it is important that physicians select and decide diagnosis and therapeutic approaches based on scientific reasons. This is a way of medical practice in which when a physician treating a patient has clinical questions, he/she retrieves relevant literatures and carefully studies them with critical views, then evaluates the appropriateness of applying a certain diagnosis or treatment method to the patient, and after this process the doctor considers the patient's common sense of value and preferences, and then makes decision on the treatment method. Once the decision is made the doctor performs the method using his/her own professional skills. This practice is called "Evidence Based Medicine (EBM)". Based on the recommendations of this report, active efforts will be made for the development of specific environment including the further investigation for the creation of medical treatment guidelines which can be a sound support measure for adopting MTA and EBM.