Open Source Software in Medicine and its

Cultivation in Japan

Shinji KOBAYASHI
Ehime University, Japan
 Agenda

 e-Health care
 Background, health care in Japan
 Many standards, few implementations
 Open Source Software in Medicine
 World wide trends
 Japan Medical Association IT Declaration
 ORCA Project
 Medical Open Source Software Council in Japan
 Discussion
 e-Health care in Japan and
My bibliography
Era E-Health in Japan My bibliography

1970 Start for research Born in Saga Japan at April

Happy Origin 19, 1970

1980 'Receipt computer' Manga, Anime, Computer

Hopeful Claiming system for Medical student/ Kyushu
development insurance University
1990 Clinical Physicians Order MD license, 1995
Painful / Entry system Resident, Clinical
growth hematology/oncology
2000 Electronic medical PhD. research and
record/Electronic health development on OSS in
record, full digital medical field
Japanese Medical Insurance System
 From a patient and a medical perspective
 All citizens are able to join one insurance system
 Free access to providers and specialists
 Fee-for-service payment
 Providers must submit claims for processing by the
10th of the month following the visit.
 Co-payments collected by providers each visit
 Each prefecture and county-level government, as
well as cities, towns and villages, has its own
individual system of additional subsidies for medical
care payments.
Average life span and infant mortality
rates are among the best in the world!
Health expenditure/GDP
'Receipt' claim form

 Demographics
 Insurance number
 Diagnosis
 Laboratory test/exam
 Procedure
 Prescription
 Many local rules
 'Receipt computer'

 Claiming/billing application
 Calculate medical claim under complex rule
 Print out 'Receipt'
 Database
 Patients' demographics
 Name, birthday, insurance
 Disease, drug, procedures
 Proprietary
 Data can be utilized for only 'Receipt' work
 Problems of e-Health (in Japan)

 High cost, Low investment

 Oligopoly market
 Suppression to raising cost for health care
 Many standards, few implementation
 'Paper' standard, restriction to use
 'Proprietary' standards
 'Lock in'
 Vendor lock in → Oligopoly
 Data lock in → absence of reusability
 How many patients? Disease outcome?
 AYDBTU?

VENDOR: ALL YOUR DATA ARE

BELONGS TO US!?
 OSS

 Open license, free distribution

 Share intellectual resources
 Avoid 'lock in'
 Health data has long life time as Human.
 Assurance for future availability
 Drives open standard
 Reference implementation accelerate standard
 Cost reduction
 Not aim, but result.
 ORCA Project

 JMA Standard Receipt Computer

 OSS, under GPL 2.0(translated into Japanese)
 Avoid 'lock-in'
 Standard
 Implementation based 'de facto'
 MML/CLAIM protocol ↔ EMR
 Collect data
 Health care policy based data against meaningless
government policy
 Converting Claims Processing Computers
to a Network Terminal
Offer of receipt software
Sleeping by OSS (Open source software)
Giant
standalones

High-cost, ・Setup
network center ・Maintenance
standalone receipt 　・ Masterupdate ・Option
computer now used 　・ Coding of data
Support
by 80% of medical business
facilities
ORCA
Research project of JMA which aimed at
upgrading receipt computers for future Multifunctional terminals
medical IT
 Componentry of JMA-Receipt System
Table & Screen &
Application Main body of JMA - receipt
documents definition
Utility CLAIM, shell, etc… Various scripts
monpe, gcc, OpenCOBOL,
Tools glade, Ruby, GNUpgp
OLTP MONTSUQI PANDA, glclient
GNOME GDM,libglade,Gtk
GUI widget (GtkPanda,etc…)
Xwindow
DB PostgreSQL pg_dump, tdump

Device driver XFree86 4.x , Printer driver GS driver, OCR fonts

OS Debian GNU/Linux woody, sarge
Hardware P4 2GHz, 512MB, 100GB.. GPU, Others device17/32
Adoption of ORCA（May 2002 ～April 2010）
日レセ稼動状況（2002年5月～2010年4月）
医療機関

10000
Working・・・8800

9000 稼動レベル1 レベル2 レベル3

　

8000
【specification】
　

　・OSS＋Billing
7000 software, morethan 1M steps
　・Process 1T JPY( 10B USD) claims/year
6000
　・Only 2 week for adjust new rules/2years
5000

4000

3000

2000
Preparing・・・1145
1000

0 Planning・・・ 498
14
14
2010
2002年 2003年 2004年 2005年 2006年 2007年 2008年 2009年 年
 Fixed Point Survey Study (2006.12～)
Personal information
deleted
JMA Improvement of
medical quality
Outcome
Proposal of a fair
medical policy
Medical
facilities
Feedback

Permit Patients / Members

• Voluntary participation by medical facilities

• No information collected that can specify an individual patient
• Secure security using electronic certification
• Privacy of individual medical facilities strictly maintained
 For Elderly
(Concerning of Long-term Care Insurance)

• IKENSHO Software (OSS)

– Medical certification documents required for
long-term care insurance (LTCI) for elderly and
handicapped persons
– Medical certification documents for
home-visit nursing
– Number of users
• 13,259（as of April, 2007）
• KYUKANCHO Software (OSS)
– Claims for service eligible for LTCI
– Number of users
・1,067（as of April, 2007）

27/32
 CLAIM standard

 Communication standard between EMR/CPOE

and 'Receipt computer'
 XML based standard
 Clinical information and Insurance data
 Arranged for Japan insurance system
 EMR development cost
 Remove the cost for 'Receipt computer' part
 > 20 EMRs implemented CLAIM to connect ORCA
 OSS Electronic medical record

 OpenDolphin
 Regional health care system supported by
government fund
 Java/JBoss
 Doctors are arranging for their use
 NOA
 Dr Ohashi (68yo)developed by 20 years experience
 PHP/Java Script
 Project Maintenance
(Authorization System)

• Quality Assurance
– The total resources of JMARI provide formal
support and certification for qualified persons (
business establishments)

JMARI

ORCA Support Center

JMARI-Authorized ORCA Support Business

（ 135 companies: 2007-04）

14/32
20
 Impacts of ORCA project

 Declined price of 'Receipt Computer'

 Before ORCA: 30,000USD - 50,000USD
 After ORCA: 10,000USD – 20,000USD
 Declined also EMR
 Market share
 'Receipt computer' usually replaces 5-8 years
period
 10%, 8800 installed.
 Derived works
 OpenCOBOL , CLAIM standard
 ORCA Ecosystem
Information

JMA/JMARI Hospital/Clinic
Membership fee

Au Support

Community
ee
th
f
n
t ioor fee Support service
Development fee ize
Source iz a
or
codes Au
th

Developer Support vendor

Bug report/request
 MOSS

 Medical Open Source Software Council

 Glue work with ORCA and other projects
 Introduction OSS seeds to medical developers
 Introduction Medical OSS to general developers
 1st seminar, April 2004
 8th seminar, Oct 2009
 Many Asian developers / students gathered
 Communication with developers, doctors, supports
MOSS1
 openEHR.jp

 The openEHR Project

 Implementation based standardization
 ISO/EN 13606
 Local activity of the openEHR project
 Translation
 Adjust clinical concept for Japanese situation
 Ruby implementation
 Conclusion

 OSS in medical field

 Avoid 'lock-in'
 Cost reduction
 Synergy effect with open standard
 All stake holders should work together
 Government, medical association, support
vendor, medical provider
 Prevent oligopoly
 More EMR vendors involved in medical field
 For future..

 More and more developers

 Internationalization
 Localization
 More standard
 More implementation for standard
 Reform of ORCA
 Reconstruct of legacy part(all?)