E-health Japan Enterprise-wide Use License - TABLE OF CONTENTS How to use this document 6 Japan E-health Trends 1. Key findings 7 2. Introduction 10 Background 10 Influence of Internet amongst the 4Ps of Healthcare 14 Figure 1. Pre-Internet healthcare 14 Figure 2. Post-Internet healthcare 15 E-Health Japan Activity Profile 16 Figure 3. Cumulative Number of Milestone e-Health Events in Japan (2000-2002) 18 Questionnaire Sampling and Data Management 19 Table 1: Response rate, age, gender and occupation stratification for each of the three stakeholder groups 20 3. Results and Analysis 21 Healthcare Related Internet Behavior in Japan - General Issues 21 Chart 1: Japanese Daily Healthcare Related Usage of Internet 21 Chart 2: E-mail Security & Privacy Attitudes Amongst e-Health Stakeholders 22 Healthcare Related Internet Behavior in Japan - The Pharma Group 23 Chart 3: Pharma's Work Related Search on the Internet 24 Chart 4: Number of Internet Related Projects in the Workplace 25 Chart 5: Where Pharma & Patient Stand on Factors Affecting Internet's Ability to Influence Healthcare Delivery & Management 26 Chart 6: Does Pharma Deliver the Strongest Element of their Portal to the Consumer? 27 Chart 7: Where Pharma & Patient Stand with Regard to Healthcare Portal Communication Focus 28 Chart 8: Pharma's Most Common Use of the Organization's Portal Site 30 Chart 9: Common Therapeutic Areas which Pharma Uses the Corporate Portal For 31 Chart 10: Pharma Corporate Portal Impact on the Work Situation 33 Chart 11: Pharma Corporate Portal's Most Important Component 34 Chart 12: Pharma Corporate Portal's Most Important Information Feature 35 Chart 13: Pharma Corporate Portal's Most Critical Design Factor 36 Chart 14: How Does Information Sharing on the Corporate Portal Help Healthcare Professionals 37 Healthcare Related Internet Behavior in Japan 　　　- The Patient Group 38 Chart 15: How Japanese Patients are Connected to the Internet 38 Chart 16: Type of Information Japanese Patients Most Often Seek on the Internet 39 Chart 17: How the Patient Uses the Internet for Health Related Issues 41 Chart 18: Key Patient Search Area for Health Related Issues on the Internet 42 Chart 19: Patient Attitude to e-Medical Record Storage 43 Healthcare Related Internet Behavior in Japan - The Provider Group 44 Chart 20: In What Capacity are Japanese Doctors Online 44 Chart 21: Employee Category Working Online with Japanese Doctors 45 Chart 22: Who do Japanese Doctors Mostly Use E-mail to Communicate With? 46 The Provider Group - Repository Grid Focus 47 Chart 23: Doctor's Attitude to Internet Clinical Applications 48 Chart 24: Doctor's Attitude to Internet Administrative Applications 49 4. Conclusions Conclusions on Questionnaire Cross Group Analysis 50 Table 2: Paired Comparison Significance Testing for Pharma, Patient and Provider Respondents 53 5. Appendix Conclusions on the U.S.-Japan Doctor Comparative Analysis 57 Questionnaire Respondent Age Related Variation 58 Table 3: Age Stratification of Stakeholder Groups 58 Statistically Significant Sample Sizes 59 Table 4: Statistically Significant Sample Sizes of Stakeholder Groups 59 Future Developments for Japanese e-Health 60 Disclaimer & Publisher information 62 How to use this document This JKS document contains the results from the most comprehensive study undertaken in the period of 2001-2003 to evaluate the status and prospects of the e-health in Japan, and trends on healthcare related Internet issues based on a 4P component view of the Japan market - Pharma, Provider, Patient and Payer. The report draws on survey results of Internet user behavior for three of the four stakeholder groups where change has been more significant in the Japanese healthcare industry - Pharma, Provider and Patient, culminating in 24 charts, 3 figures and 4 tables identifying the opportunity gaps and current trends of this fast growing industry. The report provides understanding of the key drivers and barriers to e-health development in Japan drawing from a Pharma pool of 578 recipients, 46 face-to-face Patient and 36 face-to-face hospital based Provider questionnaire samples using clear chart displays, repository grids and statistical analyses. Any further enquiries regarding the document, its contents and or related documents should be addressed to the ? Analytical to ehealth-japan@ehealth-japan.com ? General to ehealth-japan@ehealth-japan.com ? Sales inquires to orders@jouhoukoukai.com ? Licensing to licensing@jouhoukoukai.com ? Technical and Help to tech-support@jouhoukoukai.com ? Partnership by sending email E-health Group of Jouhou Koukai Services at ehealth-japan@jouhoukoukai.com 1. Key Findings This report, surveying three of the "4Ps" of e-health in Japan - Pharma (middle to upper management level in the Japanese pharmaceutical and related healthcare industry), Provider (Japanese hospital doctors) and Patient (Japanese volunteers; blinded health status) - found: * Contrary to popular belief Japanese doctors have a low Internet technology affinity amongst the 4P e-health groups while the Pharma group have a greater level of activity and risk taking in terms of e-health improvisation and online cross consortia communication - as reflected in Provider security and privacy concerns and a marked drop in healthcare related Internet usage relative to Pharma * Japanese vertical Net type ventures if they are to adopt appropriate strategies for medical communications should focus on doctor content enrichment for healthcare portals. This is evident from our findings that the Patient group is more convinced of the doctor being the communication focus for the healthcare portal than Pharma upholding this view. While for e-health delivery and management in Japan, consumer decision is key and this is the common stance taken by both Pharma and Patient against the background of these stakeholders being similar in their extent of daily healthcare related usage of the Internet. * A clear driver in healthcare development for Pharma end users is implementation of a suitable Internet platform that will provide an organized information function and/or organized navigational features on their corporate portal as delineated in the issue of corporate portal's most critical design factor. Also added value would come from an updated information facility with a focus in the regulatory area if included in this delivery suite and all executed within the objective of luring Pharma end users into being more active in their weekly utilization of their corporate portal. * It is success critical that e-health portals for patients are given an adequate balance of current general news and topical events against the core information of patient health and care. This is supported by a 3.25 times more significant popularity response in news & media for the type of information patients most often seek on the Internet compared with the second most popular category finance & business. Health/medical received only a lowly 8.3% response in this survey. * The doctor-patient relationship traditionally a revered one in Japan may be braced for a different communication function - Patients in our study are markedly 7.3 times more likely to use the Internet for a health related information search as opposed to undergoing a physician consultation online. * As hospital managements nationwide begin to embrace e-medical record implementation, unless public education programs are phased in, the final stumbling block could be acceptance by the patients themselves. As far as e- medical record storage was concerned Patient respondents were overwhelmingly 5.6 times in greater disapproval than they were in approval of this issue. There is a potential e-commerce opportunity for those who can harness the doctor's e- mailing time more effectively towards his colleagues and professional associates alike. Presently, Japanese doctors have a markedly 3.5 times greater tendency to use e-mail to communicate with non-professional recipients as opposed to e-mailing their professional colleagues. Meanwhile the opportunities for provider focused Internet clinical applications are clear: * Applications for advancing conferencing, consultation, results reporting, and decision making functions beyond their current performance limits were all viewed favorably by the Japanese doctors surveyed. As far as administrative applications are concerned, Japanese doctors are strongly positive and therefore represent viable e-business opportunities in the following areas: * Transcription, marketing/advertising and continuous medical education. WAP developers along with the local variant i-mode , are poised for further growth of the doctor PDA market - similar to the US Harris Interactive survey findings, a disproportionately high PDA/Mobile access to the Internet was also found amongst the Japanese doctors studied and a positive growth rate is supported by secondary findings. 2. Introduction Background As more and more Japanese seek access to the Internet, there is a notable movement towards the use of this new information communication medium in healthcare. Concomitantly initiatives formalized in the five year IT development policy set up by the former Japanese prime minister Yoshiro Mori are beginning to take root in several industrial sectors including healthcare and furthermore, e- commerce models historically mere imports from the US, have emerged in abundance and are now unique to Japan. One of the main influences to Japan's e-health infrastructure is the health insurance system and the physicians' and patients' attitude toward medical treatment affected by such a system. Under the post-war Japanese system, all citizens can receive basically equal medical treatment and the medical care needs of the population are served by institutions that provide medical treatment, from regional medical clinics that provide primary care to highly specialized hospitals providing comprehensive care. In the near future, however, there will be changes in the way people think about medical care of which the Internet is expected to play a vital role. Yet within the present Japanese e-health legal framework, this role is expected to be a somewhat lose arrangement. Japanese Medical Law No. 69 is a provision for when medical institutions offer information about the content of treatment administered and their services to an unspecified mass of people, it is considered advertising, and restrictions have been established for what information can be released. Japanese medical laws have been relaxed of advertising restrictions, but many restrictions are likely to remain. The Internet, however, is exempt from these restrictions. At this time of writing, information available over a Web site is not considered advertising and is allowed. This circumstance is one reason for the rapid establishment of Web sites by medical institutions over the last five years. With the objective of promoting safe and effective use of the Internet in the medical field, medical specialists, attorneys, and patient stakeholders in Japan assembled in 1998 to form a non-profit citizen's organization, the Japan Internet Medical Association (JIMA). JIMA first proposed the "Information Source Guideline," which ratified the following terms as minimal conditions for information providers: (a) The party offering the information should be identifiable. (b) Contact points or a communication interface should be made available for questions, such as telephone or e-mail. (c) A disclaimer to the effect that the user takes personal responsibility for his or her use of the information, with the premise that the information provided is not always correct or valid. However, new problems were foreseen in areas where such provisions could not be applied, and it would have been difficult to adopt an all-inclusive ethical standard. The e-Health Code of Ethics was similar to ethical standards being considered by JIMA, and the spirit of the code was in agreement with JIMA's basic ideas. Despite there being differences in language, law, and social environment, the problems encountered in the medical use of a worldwide information network were broadly common, and problems in the same arena were shared. Hence, participation in discussions seeking solutions to such issues was considered necessary. In December 2000, JIMA created the Japanese version of the e-Health Code of Ethics . This ethical code, which deals with the assured safety and benefit of users when medical and health-related information and services are provided by companies or individuals, is a guideline for taking ethical and legal actions. It is hoped that information and service providers will adhere to this guideline and, by achieving required conduct goals, will maintain a high-quality standard for activities within e-health. This compliance will, in turn, deliver reliability to users. It could be argued that the recent spate of events surrounding the quality of Japanese healthcare have impacted strongly on the public's perception of medical care. For example litigation actions brought on by AIDS infested blood samples in hemophiliacs receiving blood transfusions and problems of recently increasing medical malpractice. In response to such incidents, Japanese patients and the population in general are looking at medical care with a critical eye. Another recent contentious issue in the public eye is the increased use of the term "informed consent," which represents the emphasis placed on patients' rights and trends in the release of information, as seen in the trend toward disclosing of patient medical records. These changes may still be in their infancy, but as patients become aware of their rights, it is expected that these trends will become stronger and are expected to impact on health related information on the Internet. A further social driver for Japanese e-health development is the rapid aging of the population. The increase of the older population will increase the nation's financial burden of medical expenses. As a result, the foundations of the insurance system, which has provided low-cost medical care to Japanese citizens, both public and private sector alike will look more and more to the Internet to provide cost effective solutions. As we have identified in several aspects above, it appears that there are several influences taking shape in the Japanese healthcare industry that are working to change current medical practice with knock on effects in utilization and implementation of Internet related technologies. While the e-health gap between the US-Europe and Japan may be narrowing, no doubt there are still certain logistical factors to be overcome. These are likely to arise from the underdeveloped communication infrastructures, delays in standardization of terminology and codes for digitalizing medical information. In the legacy of Japan's burst e-commerce bubble, major challenges to promote the nation's e- health industry include measures to protect patients' privacy, protection and clarification of responsibility for leakage of information and more critically personal and health related damages suffered by patients following the advice and suggestions given by doctors over the Internet. This study will seek to identify key drivers and barriers to the development of e- health in Japan through a set of questionnaires targeted to Pharma, Patient and Provider stakeholder groups in the Japanese healthcare industry. Influence of Internet amongst the 4Ps of Healthcare Prior to the introduction of Internet in the healthcare sector, the market forces in most major global markets were considered simple and relatively few in number with the size of the sales force and prescriber relationships being by far the most powerful (Figure 1). Figure 1: Pre-Internet healthcare There have been several models proposed but common to all, the Internet and the subsequent e-detailing developments has drastically impacted on the healthcare industry with the Patients group playing a more central role. It has also introduced a new set of marketing interactions at prescription and service delivery points of the industry with both direct and indirect influences stemming from the web-based health information pool generated by the Pharma group (Figure 2, next page). Key 　　　 Direct Interactions Indirect Interactions Pharma: Personnel employed in a pharmaceutical company or healthcare related or service supporting organization. They are engaged in advancing and improving the production and delivery of healthcare products and services. Provider: Certified personnel professionally licensed to administer medical treatment and/or advice for a disease or condition. We assume here that they consolidate and reengineer their care delivery and information processes to provide cost-effective integrated services across the continuum of care. Payer: Health Insurance and managed care organizations focused on managing the quality and cost of healthcare delivery. Also they may provide financial incentives for medical providers to provide high-quality, cost effective care. Patient: Effectively consumers who take informed control of their health and work in partnership with physicians and payers to receive high-quality medical outcomes in the most appropriate clinical setting. Figure 2: Post-Internet healthcare E-Health Japan Activity Profile Surprisingly the September 11th derived global economic turndown has had minimal impact on the e-health activity in Japan to date. Generally e-commerce is thriving in Japan despite a decade long post bubble recession in the economy as a whole. At the time of the e-commerce collapse in the U.S., the Japanese e- commerce market had grown by 58.4 percent based on previous year's estimates to JPY35.51 trillion (USD264.52 billion), according to the Ministry of Industry, Trade and Industry (MITI) . In the business e-commerce market, transactions have soared in the IT and automotive sectors in particular, while services grew strongly in the consumer market. It is pertinent in this study to single out which sector of the healthcare industry (e-health stakeholder) the impact of Japan's e-commerce growth was felt more strongly. From the period January to September 2000, all sectors experienced negligible rates of growth with leveling off in the three latter months (Phase I, Figure 3), this was followed by significantly higher and equivalent growth rates for Patient, Provider and Pharma sectors during the months October 2000 to February 2001 with the Payer sector virtually unchanged (Phase II). Several factors would appear to contribute to the high growth rate period for Phase III: the e-commerce time gap between the US and Japan (see introduction) means the Internet bubble could take anything up to two years to take effect post the US led peak in the first quarter of 2000 ; the 5 year IT Japan initiative set out by the Mori cabinet in 2001 could well have knock on effects in accelerating business plans for Pharma and Provider sectors; and the Health Reform passed by the Diet similarly act as a stimulus for growth for Provider, Pharma and Payer sectors. In the latter four months of the two-year study period, Provider growth has remained in step with that of the Pharma sector with these two sectors showing a significant gap in expansion compared to that of Patient and Payer sectors (Phase IV). However the Patient stakeholder group is a key target group for e-health development since the ultimate delivery of healthcare services ends with this group, while Pharma and Provider groups are providing the greatest impetus for change, the e-health development amongst the Payer group has been minimal. It is for these reasons that the three stakeholders Pharma, Providers and Patients with the exclusion of the Payer group have become the foci for the empirical work described herein. Questionnaire Sampling and Data Management Questionnaires for three stakeholder groups were conducted over a 13-week period commencing March 6 and ending June 5 2002. Wherever possible the face-to-face interview was chosen as the most appropriate method for collecting questionnaire responses since it was considered likely to yield the most robust feedback and provide each respondent with a private environment in which to discuss the subject matter and examine aspects of the material that they may not understand. Despite a resume aided self-introduction, overwhelming reluctance to participate in face-to-face interviews was encountered in the Pharma group, commonly owing to conflict of scheduling and/or sensitivity to being interviewed under a corporate setting. Thus all Pharma stakeholder questionnaire sampling was conducted through a data pool of e-mail recipients, who represented personnel working within the Japanese healthcare industry. Respondent e-mail contacts acquired through attendance at exhibitions, trade fairs and seminars throughout the Tokyo central and greater metropolitan area made up 38%, another 51% were available from personal mailing lists and the remaining 11% were collected from direct company correspondence. The Pharma respondent pool included employees from middle management and upwards from the following commercial sectors: Japan and foreign-based healthcare companies, IT and Internet ASP entities managing healthcare projects, consultancy and financial corporate bodies having ongoing concerns with the Japanese healthcare sector. Replies were received from healthcare, healthcare related IT and healthcare related consultancy companies for the Pharma questionnaire and was sent to 215 recipients. All e-mail recipients were given a one-week period to return the questionnaire. In an effort to maximize questionnaire response rate, a combination of a report sample offer and e-mail &/or facsimile follow up reminders were sent out to all recipients who failed to respond within the initial one week submission timeline. The e-mail response rate for the Pharma group was 27 replies from a pool of 578 recipients (4.7%). All Patient stakeholder questionnaire sampling was done face-to-face and yielded a 100% response rate for the 46 recipients. The Provider stakeholder questionnaire was conducted on a sample of 36 HP personnel employed in a local Japanese hospital with all participants responding (100% response rate) to the questionnaire face-to-face. Questionnaire response rate, age, gender and occupation stratification for each of the three stakeholder groups are summarized in Table 1. Table 1: Response rate, age, gender and occupation stratification for each of the three stakeholder groups Stakeholder Group Overall Response Rate (Sample Size n) Age Range (Mean) Gender Ratio (M:F) Occupation Stratification* Pharma 12.6% (215) 25 - 66 yrs (45.1) 9:1 EM (5) MM (7) LM/SP (1) NC (7) NA (7) Provider 100% (36) 22 - 49 yrs (32.2) 3:1 NA Patient 100% (46) 22 - 49 yrs (33.2) 22:17 NA Note: *EM = Executive Management; MM = Middle Management; LM/SP = Lower Management/Subordinate Personnel; NC = Non-classifiable; NA = Non-Applicable 3. Results and Analysis Healthcare Related Internet Behavior in Japan - General Issues The Internet has become an integral communication medium for both consumers and healthcare professionals alike. Knowledge of healthcare related Internet usage and attitudes towards security concerns across key stakeholder groups is crucial for understanding the critical mass of e-commerce opportunities within Japanese healthcare. Pharma, Provider and Patient groups surveyed were mostly found to make light usage of the Internet within less than 2 hours a day. Providers take up the narrowest spread of Internet usage with all respondents falling within the <8 hour timeframe, while 2.8 and 3.7 times greater medium daily usage of the Internet (2-8hrs/day) was found for the Patient and Pharmaceutical stakeholder groups respectively (Chart 1). Pharma has been relatively uninhibited in sending e-mails and exchanging information over the Internet and are less concerned about security and privacy than their Provider counterparts. In fact almost half of the Provider respondents (45.2%), revealed that they don't e-mail work related information or exchange information over the Internet, but would do so if security and privacy could be guaranteed (Chart 2). Healthcare Related Internet Behavior in Japan - The Pharma Group Today's Japan based healthcare professionals are increasingly harnessing the power of the Internet to assist their day-to-day work activities and here we shall identify the key growth opportunity areas for the Pharma group. Drug regulatory information was the most frequently searched category on the Internet at 28.6% amongst the healthcare and healthcare related employees who responded. This was followed by drug information from manufacturers at 17.1% as the second most frequently searched category. Medical, pharmaceutical and other professional healthcare associations are searched twice as much as scientific societies at 11.4% and 5.7% respectively (Chart 3). Concerning Internet related projects in the Japanese healthcare workplace, most pharma respondents are involved in at least one Internet related project (52%). However the threshold on Internet related project management number appears to be ten or below since there is a significant reduction in respondent numbers (4%) or a 92.3% drop in response rate in exceeding this level (Chart 4). What is Japan Pharma's attitude towards the Internet's ability to influence healthcare delivery and management and how does this differ with that of the Patient group? There is considerable overlap between pharma and patient stakeholders on what factors these groups believe to be shaping the Internet's ability to influence healthcare delivery and management. 49.5% of Pharma favors Consumer Decision and Behavioral Changes in Patient &/or Doctor while 66.8% of the Patient group hold the same sentiment. The Patient group with an obvious bias, favor the Consumer Decision (42.4%) and marginally Behavioral Changes in Patient &/or Doctor (39.4%) as the two most important factors affecting Internet's ability to influence healthcare delivery and related management issues of the service delivered. The Pharma group however are more divided on the various factors overall, with significant favor towards Physician Utility (18.4%), Clinical Trials and related R&D Factors (15.8%), and Government Legislation (13.2%). Both stakeholder groups consider Public Healthcare Values (e.g. universal access to quality healthcare) to be minimal in shaping the influence of the Internet towards healthcare delivery and management (Chart 5). Does Pharma Deliver the Strongest Element of their Portal to the Consumer? Overwhelmingly most Pharma respondents believe Content & Information to be the strongest element of their corporate portal (81.8%), while 60.0% of Patient respondents share this opinion when they view a healthcare web site (Chart 6). Therefore, based on the e-Health 5C criteria , of the Content & Information element that Patients are anticipating to be delivered on the Pharma portal, 73.3% of this is potentially being met by the Pharma stakeholders themselves. Computer Applications are considered of minor but significant importance in the Pharma portal amongst both stakeholder groups (12.1% - Pharma and 12.3% - Patient), while only the Pharma group gives importance to Care (e.g. patient education and counseling) at 13.3%. The other 5C elements - Connectivity, e-Commerce, and Others were regarded as relatively unimportant amongst both groups of stakeholders. There is a disparity between Pharma and Patient stakeholders regarding what the key communication focus of a healthcare portal should be (Chart 7). When asked what was the key communication focus of their corporate portal, only a quarter of Pharma respondents (25%) believed healthcare Providers/Doctors to be the key focus whereas overwhelmingly as many as 70% of the Patient stakeholder group believe Doctors and other healthcare Providers to be the most important communication focus of a healthcare Web site. The attrition of communication focus away from Doctors is primarily due to the internal focus of the pharma portal as confirmed by the response rate of 29.2% amongst the Pharma stakeholder group. Interestingly a small but significant portion (11.8%) of the Patient stakeholder group perceives the strongest communication focus of the Pharma portal to be a Regulatory concern despite a non-response from Pharma for this particular communication focus. Is there categorically a common usage of the Pharma portal site? Pharma were very much divided on the issue of how they commonly use their organization's portal site, with Knowledge Management being responded marginally as the most common usage at a mere 15.6% response rate, this was closely followed by Customer Product Information, Internal Communication, and Internal Reports/Circulations all receiving response rates of 13.3%. At the other end of the scale, Clinical Trial Network/Patient Recruitment, Human Resource Management (HRM) and Clinical Trial Support Systems, were all found to rate as low as 2.2% (Chart 8). The Most Common Therapeutic Area of Pharma Portal Use is Vascular Diseases at a response rate of 21%, at half this response rate in second place is Diagnostics, although this is masked by the same level of response for Several simultaneous categories as well as Other(s) categories not listed in Chart 9. In third place came the Nervous System diseases (7.9%) followed by several fourth place contenders all at 5.6%: Musculoskeletal, Endocrine, Rheumatological and Allergies/Pain Control (Chart 9). Corporate Portal Impact on Pharma's Work Situation (Chart 10): Work Productivity and Business Partnering rank on par with each other at 19.4% as the work factors where the Pharma corporate portal has the biggest impact, this was closely followed by Customer Service with a 16.1% response rate. Pharma Portal's Most Important Component (Chart 11): Project/Process Information is the most important component at a response level of 17.6%, this was followed by Calendar/Events Planner and Marketing/Product Literature in an equal second place of 11.8%. Pharma Portal's Most Important Information Feature (Chart 12): Medical or Healthcare Professional Information received a 25% preference as the most important information feature for a Pharma corporate portal. In second place were the three information features Disease, Lifestyle and Company/Organization Background/Products/Service Profile information provisions all at 16.7%. Connectivity/Linkage with Other Sites and Interactivity/Consumer or Patient Information Capture were ranked as least important at 4.2%. Pharma Portal's Most Critical Design Factor (Chart 13): Information that is Easy to Find or Well Organized is considered three times more critical (38.7%) a design factor for the Pharma portal than design factors such as provision of Integrated Features (e.g. key word search, downloadable reports) and Updated Information both with response rates of 12.9%. Information Sharing on the Corporate Portal is a Time Saver for Healthcare Professionals (Chart 14): Most healthcare professionals found that information sharing on the corporate portal Saves Time (42.1%). At half this response rate (21.0%), the same information sharing on a corporate portal enables healthcare professionals to provide a Better Service. Healthcare Related Internet Behavior in Japan - The Patient Group Patient Internet Connection (Chart 15): The electronic patient connection is indeed a challenging frontier whereby the technical barriers are exacerbated by political, legal, and socio-economic ones. Among the difficulties faced by Japanese providers is choosing among various models of connectivity and component function. With the rapid emergence of physician-patient cyber models in Japan spurred on by the development of Web streaming and multi- media technologies, it is important in the planning and development stages to have a breakdown of the patient Internet connectivity to ensure that a suitable media delivery can be chosen for the appropriate technology platform in place. Currently the dial up connection is by far the most common means of patient connection to the Internet at 44.1%. At almost half the popularity level of the latter, ADSL trails in second place at 26.5%, only to be immediately followed by 20.6% for ISDN. PDAs and mobiles have been responded to poorly at a mere 2.9%. The Type of Information Japanese Patients Most Often Seek on the Internet (Chart 16): As expected for such a general topic, News & Media is the type of information most frequently sought after on the Internet by the patient group investigated (36.1% of respondents). While contrary to Harris Interactive survey findings in the US , Health/Medical only stands at 8.3% in terms of Internet information popularity for the Japanese patient group studied. Other Key Internet Findings Amongst the Patient Study Group: When asked how they use the Internet for health related issues (Chart 17), the overwhelming response amongst the patient group studied, was Searching for Health Related Information (73.3%) as opposed to Physician Consultation and Clinical Trial Participation at 10.0% and 6.7% respectively. As for the type of healthcare related information which the patient study group search for (Chart 18), Diseases and Conditions is the most common (21%) however the spread of information type preferences is wide and diverse covering 11 different categories with Others accounting for 20% of all responses. The "free floating" medical record, a model emerging from the U.S. is largely independent of the office-based physician, relying on compatible and intertwined physician and consumer relationships using an application services provider office practice system. Here in Japan as far as the patient attitude to the storage of e-Medical records was concerned (Chart 19), a majority 77.8% of the patients studied felt they were not in favor of having medical records stored electronically, however disapproval would not predominate if security and privacy could be fully guaranteed (Attitude B, 77.8% respondents). It is interesting to note that in Japan only for the public sector there is an Act for Protection of Computer Processed Personal Data held by the relevant administrative organs however this not a private sector law, only serves as a "Guideline". So it is reasonable to expect that Japanese approval ratings for storage of medical records would be boosted if greater legal transparency were in place. Healthcare Related Internet Behavior in Japan - The Provider Group In Japan as well as elsewhere there has been a growing demand for better quality healthcare, low-cost medical treatments and this combined with the popularization of the Internet has made the Internet an increasingly indispensable tool for Japanese doctors in their daily clinical practice. With the popularity of PDAs and mobile phones in today's marketplace and the convenience that they provide in business communications, it comes as no surprise that Mobile Phones/PDAs represent one of the most popular ways for Japanese doctors to work online (31.4%), while the multitasking involved in the clinical profession may justify why as much as 34.3% of respondent doctors use All/Several means of working online (Chart 20). Employee Category Working Online with Japanese Doctors (Chart 21): Once again multitasking factors and the propensity of doctors to network actively within their professional community lends support for why as much as 52.3% of respondent doctors are working online with Other Clinical Staff (other than Other non-professional Employees (11.2% of respondents) and Administrative Staff (36.4% of respondents)). This result is somewhat in contrast to the Harris Interactive findings on US Physician Use of Internet 2001 where Other Clinical Staff and Administrative Staff account for 46% and 62% of Physicians' staff currently online respectively. Japanese Doctors Using Email to Communicate (Chart 22): The breakdown of e- mail usage by Japanese doctors is in stark contrast to the Harris Interactive findings5: Only 20.6% of respondent Japanese doctors use the e-mail to communicate with Professional Colleagues, followed by 5.9% respondents typically e-mailing Support Staff, while the remainder are non-categorical Other recipients at 73.5% (compare with the Harris Interactive findings of 34%, 13%, 9%, 55% and 36% respectively for Support Staff, Patients, Health Insurance Groups, Professional Colleagues and Other non-categorical recipients.). The Provider Group - Repository Grid Focus Some of the primary objectives of e-health implementations are to improve clinical decision-making, reduce administrative costs, and improve competitive position by focusing on convenient access to care. The objective of the Repository Grid study was to gauge Japanese doctor's opinion on the extent of how much the Internet will play a role in integrating information across the numerous sources in Japan, making it meaningful for the Patient, Provider, Pharma and Payer. By monitoring Japanese doctors attitudes to cost-benefit issues on a grid interview scale we begin to address the issue of whether technology itself can effect e-health changes in Japan, or does the process of care delivery need to change as well? Japanese Doctor's Attitude's to Clinical Applications Using the Internet (Chart 23): By far Conferencing is perceived as the most beneficial Internet clinical application (70% perceived it as High Benefit) and has the minimal concern associated with it amongst the hospital practitioner (HP) respondent pool. Consultation is perceived as the second most potentially beneficial application however clinical consultation via e-mail remains largely un-initiated amongst doctors in Japan as reflected in the Serious Concern rating of 16.7%. Overall Japanese doctors have a positive attitude about the benefits derived from the clinical applications on the Internet as reflected in the majority responding to High Benefit for Telemedicine, Results Reporting, and Decision Making applications. Japanese Doctor's Attitude's to Administrative Applications Using the Internet (Chart 24): Clearly Payment/Billing is perceived as the most beneficial Internet administrative application (63.3% perceived it as High Benefit) amongst the HP respondent pool. Virtually on equal footing (60%) is Continuous Medical Education (CME) perceived as Highly Beneficial amongst 60% HP respondents. Marketing/Advertisement is the third most potentially beneficial application at 56.7% however there is considerable Serious Concern on this issue at the 26.7% respondent level. Respondent HPs had mixed feelings about using the Internet as a Messaging and Scheduling administrative application as revealed in Chart 24. 4. Conclusions Conclusions on Questionnaire Cross Group Analysis Interestingly a marked level of Pharma respondents are less concerned about security and privacy over the Internet and are spending significantly longer times on the Internet relative to their Provider counterparts. These findings are interpreted as Pharma group having a greater propensity for e-health project consortia initiation across the three stakeholder groups investigated. The present end-user gap in Japanese e-health is with the Patient group being convinced of a greater need for a doctor communication focus for the healthcare portal than Pharma upholding this view. While Pharma and Patient tend to take a common stance regarding the Consumer Decision as an influence to e-health delivery and management with both stakeholders similar in their extent of Daily Healthcare Related Usage of the Internet. The Pharma Group Pharma respondents were markedly 11.04 times more of a "light" user (<2 hours/day) of healthcare related Internet browsing than a "medium" user (2-8 hours/day). Thus a critical mass of Pharma e-health end users are needed to further accelerate e-health development in Japan. Probably owing to the small sample size (n =27) and thus the low statistical power, the following issues: Work Related Search on the Internet - Drug Regulatory vs. Drug Manufacturing; Number of Internet Related Projects in the Workplace - 1 to 10 Projects vs. Zero (0); Healthcare Portal Communication Focus - Pharma/Internal vs. Patient; Most Common Use of the Organization's Portal Site - Knowledge Management vs. Customer Product Information; Common Therapeutic Areas which Pharma Uses the Corporate Portal For - Vascular Disease vs. Diagnostics; Corporate Portal's Most Important Component - Project/Process Information vs. Calendar/Events Planner; Corporate Portal's Most Important Information Feature - Healthcare Professional vs. Disease Information; and How Does Information Sharing on the Corporate Portal Help Healthcare Professionals - Saves Time vs. Better Service Provision - all these issues were found to be non-significant responses for this stakeholder group. Organized Information was considered marginally significant as Corporate Portal's Most Critical Design Factor as opposed to Updated Information (p = 0.0561). Thus a critical success factor for the Pharma end user development is a technology platform that will provide effective organization of healthcare information with the additional importance of frequent updates. The Patient Group News & Media was 3.25 times more significantly the Type of Information Patients Most Often Seek on the Internet compared with the second most popular category Finance & Business. Health/Medical received only a lowly 8.3% response in this survey. This result is in stark contrast to the Harris Interactive findings cited earlier where up to 75% of adult respondents online in the U.S. choose Health/Medical as a top category of information searched on- line. Patients in this study were markedly 7.3 times more likely to use the Internet for a Health Related Information Search as opposed to undergoing a Physician Consultation online. This stands to reason as Internet based Physician Consultation is still in its early stages of acceptance in the Japanese professional medical arena. Also there was an expressed resistance to e-Medical Record Storage amongst the Patient respondents, with overwhelmingly a 5.6 times greater disapproval than there is approval on this issue. Hence greater public awareness may be needed before e-business development gains a critical mass in this area. The Provider Group The Provider survey findings indicate that Japanese doctors have a significant 3.5 times greater tendency to use E-mail to communicate with Non-categorical recipients as opposed to e-mailing their Professional Colleagues. Hence clear opportunities for e-health development exist in the area of peripheral applications for doctors. Some interesting attitude observations could be made concerning the findings of the Repertory Grid conducted on the Provider sample: Clinical Applications using the Internet were strongly perceived as deriving benefit in terms of Conferencing (p << 0.05), Consultation (p = 0.0032), Results Reporting (p = 0.0004), and Decision Making (p = 0.0009). As far as Administrative Applications using the Internet were concerned, Payment/Billing (p << 0.05), Transcription (p = 0.0003), Marketing/Advertising (p = 0.0443) and Continuous Medical Education (p << 0.05) were all perceived as being markedly beneficial rather than being a cause for any concern amongst the doctors surveyed. These all translate favorably as opportunities for market segmentation in Provider e-health development. Table 2: Paired Comparison Significance Testing for Pharma, Patient and Provider Respondents 3P Group; Internet Issue % Ratio of First to Second Choice Probability that Two Choices are Different (%) Degrees of Freedom (df) t-Value 2-Tailed Probability (p) Significant /Non- significant Pharma Work Related Search on the Internet - Drug Regulatory vs. Drug Manufacturing 28.6:17.1 62.33 26 0.897 0.3779 Non-significant Number of Internet Related Projects in the Workplace - 1 to 10 vs. Zero (0) 52.0:36.0 62.45 26 0.899 0.3767 Non-significant Healthcare Portal Communication Focus - Pharma/Internal vs. Patient 29.2:20.8 99.92 26 0.622 0.5396 Non-significant Daily Healthcare Related Usage of Internet - Light (<2 Hrs) vs. Medium (2-8 Hrs) 91.7:8.3 99.99 26 7.854 0.0000 Significant Most Common Use of the Organization's Portal Site - Knowledge Management vs. Customer Product Information 15.6:13.3 17.59 26 0.223 0.8257 Non-significant Common Therapeutic Areas which Pharma Uses the Corporate Portal For - Vascular Disease vs. Diagnostics 21.0:10.5 66.90 26 0.990 0.3315 Non-significant Corporate Portal Impact on the Work Situation - Work Productivity vs. Business Partnering 19.4:19.4 0.00 26 - - - Corporate Portal's Most Important Component - Project/Process Information vs. Calendar/Events Planner 17.6:11.8 42.17 26 0.559 0.5809 Non-significant Corporate Portal's Most Important Information Feature - Healthcare Professional vs. Disease Information 25.0:16.7 49.58 26 0.673 0.5066 Non-significant Corporate Portal's Most Critical Design Factor - Organized vs. Updated Information 38.7:12.9 93.80 26 2.000 0.0561 Non-significant How Does Information Sharing on the Corporate Portal Help Healthcare Professionals - Saves Time vs. Better Service Provision 42.1:21.0 83.25 26 1.432 0.1642 Non-significant Patients How Patients are Connected to the Internet - Dial Up vs. ADSL 44.1:26.5 84.46 45 1.453 0.1532 Non-significant Type of Information Patients Most Often Seek on the Internet - News & Media vs. Finance & Business 36.1:11.1 98.64 45 2.650 0.0111 Significant How the Patient Uses the Internet for Health Related Issues - Health Related Information Search vs. Physician Consultation 73.3:10.0 99.99 45 6.530 0.0000 Significant Key Patient Search Area for Health Related Issues on the Internet - Diseases & Conditions vs. Children's Health 21.0:11.0 76.95 45 1.218 0.2295 Non-significant Patient Attitude to e-Medical Record Storage - Not in favor vs. In favor 77.8:13 99.99 45 6.077 0.0000 Significant Provider In What Capacity are Japanese Doctors Online - Mobile/PDA vs. Home Access 31.4:22.8 51.66 35 0.706 0.4850 Non-significant Employee Category Working Online with Japanese Doctors - Clinical vs. Administrative Staff 52.3:36.4 68.89 35 1.028 0.3111 Non-significant Who do Japanese Doctors Mostly Use E- mail to Communicate With? Non-categorical vs. Professional Colleagues 73.5:20.6 99.89 35 3.903 0.0004 Significant Provider Repository Grid Analysis Japanese Doctor's Attitude's to Clinical Applications Using the Internet - Perceived Benefit vs. Concern * Conferencing * Telemedicine * Consultation * Results Reporting * Decision Making 70.0:8.3 40.0:20.0 56.7:16.7 46.7:6.7 50.0:10.0 99.99 87.87 99.49 99.90 99.81 35 35 35 35 35 5.837 1.604 3.168 3.924 3.618 0.0000 0.1178 0.0032 0.0004 0.0009 Significant Non-significant Significant Significant Significant Doctor's Attitude to Internet Administrative Applications - Perceived Benefit vs. Concern * Payment/Billing * Transcription * Messaging * Marketing/Advertisement * Scheduling * CME 63.3:10.0 40.0:3.3 26.7:16.7 56.7:26.7 23.3:16.7 60.0:3.3 99.98 99.92 63.76 95.13 46.88 99.99 35 35 35 35 35 35 4.773 4.032 0.921 2.087 0.630 6.095 0.0000 0.0003 0.3631 0.0443 0.5331 0.0000 Significant Significant Non-significant Significant Non-significant Significant Note: Worked Example t-value = 2.000 Degrees of freedom = 26 Two-tailed probability = 0.0561 A one-sample t-test between proportions was performed to determine whether there was a significant difference between the percent choosing corporate portal's most critical design factor - organized vs. updated Information. The t-statistic was not significant at the .05 critical alpha level, t (26)=2.000, p=0.0561. Therefore, we fail to reject the null hypothesis and conclude that the difference was not significant. 5. Appendix Conclusions on the U.S.-Japan Doctor Comparative Analysis Similar to the US Harris Interactive survey findings, a disproportionately high incidence of PDA/Mobile access to the Internet was also found amongst the Japanese doctors studied. Thus WAP development consortia may play increasingly an active role in future e-health developments. However differences in market segmentation and end user needs will be need to be addressed for the Japan market since significant differences were found both in the spread of U.S. Physician Staff Currently Online and the recipient category to which these physicians send their e-mails to, compared to the Japanese doctors surveyed in this study. Overwhelmingly 74% of the Japanese doctors studied tended to communicate with non-professional recipient groups. Questionnaire Respondent Age Related Variation From the 255,792 medical doctors in Japan, those who can utilize the Internet are reported to account for approximately 70%, 60% and 40%, corresponding to those aged less than 39 years of age, those in their 40's, and those in their 50's respectively. No doubt the attitudes towards utilization of the Internet and Internet related application in healthcare is age dependent so we should be wary of interpretation of results particularly in questionnaire responses where there is a large statistical spread in respondent ages. Table 3 gives a breakdown of the mean age, minimum and maximum ages, age range and standard deviation for each of the stakeholder groups investigated in this study. Table 3: Age Stratification of Stakeholder Groups Stakeholder Min. Age Max. Age Mean Age Range Standard Deviation Pharma 25 66 45.1 41 11.7 Provider 22 49 32.3 27 7.2 Patient 12 60 39.1 48 10.9 Obviously the smaller range and standard deviation for the Provider/Doctor age bracket studied would suggest more meaningful results than in the case of the other two stakeholder groups. Statistically Significant Sample Sizes The suggested sample sizes in Table 4 tell us whether we have obtained sufficient respondent numbers to be representative of the 3P stakeholder population. A common rule of thumb is 95% confidence so that the results are accurate to within +/- 5%. The results in Table 16 also tell us how many completed surveys that were needed for each population. A note of caution; although sample sizes actually obtained are well below the threshold for the 95% confidence interval, this is not the same as statistical power, which indicates if we have obtained a large enough sample to determine differences between groups or have identified relationships through correlations. A two tailed probability value of p < 0.05, is of sufficient statistical power to reveal differences between groups and also to reveal differences in the 1st or 2nd choice within a group. Table 4: Statistically Significant Sample Sizes of Stakeholder Groups Population; Size Sample Size Sample Needed2 Confidence Interval3 Pharma1; 142,577 27 383 18.9% Provider; 255,792 36 384 16.3% Patient; 125,600,000 46 384 14.4% Note: 1 Employees working in pharmaceutical divisions of JMPA (Japan Manufacturers Association) member companies (Membership number: 83 (1998)). 2 Sample size required if desired confidence interval and population size are known (p=0.5) 3 Confidence interval if population and sample size are known (p=0.5) The Table 4 18.9% confidence at 95% confidence level (p=0.5) for the Pharma stakeholder group, can be interpreted as if conducting the same survey 100 times, 95 out of the 100 administrations, should yield results within +/- 18.9% of the result found for this particular questionnaire. Future Developments for Japanese e-Health The classical system for health information in Japan was a pyramid structure with the physician at the pinnacle, the pharma industry and paramedics supporting at the periphery, and the patient embedded within the pyramid hierarchy. What the research here on the Patient stakeholder group shows is a desire for the patient to move to the centre, while the Provider and Pharma will surround the patient at the periphery, making up a network to jointly support the Patients quality of life. Japanese doctors traditionally revered as authority figures, may be in need of doing a reality check, if they are to take full advantage of the e-health opportunities that abound them today - as this study has revealed, both the pharmaceutical industry and Japanese consumers at large have come to the realization that the consumer decision is the prime concern in delivering healthcare solutions over the Internet. However the positive attitudes revealed in Provider repository grid analysis has the potential to change the state of medical treatment and to dramatically heighten the quality of medicine, which for number of years has fallen into a state of rigidity owing to the various restrictions and lack of communication. Japanese e-health is also expected to support patients and families who have been hitherto vulnerable to lack of health information and to convey power never before enjoyed on the receiving side of medical treatment. The empowerment of patients will, at the same time, be linked to the empowerment of those providing medical care and will result in progress in medicine as a whole. This is the very direction of Japan's e-health development. However Japan's e-health development cannot be effectively deployed without implementing security technologies. Security technologies such as firewalls, token-based authentication, encryption, digital signatures and Secure Socket Layer (SSL) are key technologies that enable the safe access and transfer of health data. Now with pharma stakeholders in Japan confidently exchanging data over the conventional Internet, extranets and corporate intranets with B2B and B2C partnering, this may free up the security concerns which other e-health stakeholders are having, and pave the way for a greater level of involvement in e-health development projects from all 4P players - Pharma, Patient, Provider and even Payer. This study has shown that Japan based e-commerce entities in their design phase of a pharmaceutical web site project would be wise to incorporate organized information features with a focus on drug regulatory updates if they are to maximize their chances of successful product delivery. U.S. and European ASPs seeking to break into the Japanese e-health market would be wise to identify how they can bring about a "win-win" solution for both themselves and the end users they are targeting. The end-user is almost invariably the patient but the more sobering finding from this study is that the Health/Medical information category has only 8.3% search preference rate in Japan as opposed to as high as 75% in the U.S. This translated into one person browsing all possible categories in Japan during their weekly 2 hour Internet session, just under 10 minutes of this (9.96 minutes) browsing time would be of Health/Medical related. The window of opportunity therefore is how to use a technology platform appropriate to Pharma and Provider yet is also able to engage the patient end user who has an inherently low attention span for online health information. The study findings showing a greater embracing of Internet technologies of both clinical and administrative applications by Japanese doctors than what the media suggests, so it may be just a matter of time before we will have a stream-less flow of medical storage information in Japan being shuttled between doctor, patient and insurer. For the time being the patients surveyed remain sceptical about the electronic security and privacy of their own records. Disclaimer This publication is based on information obtained through in-house research and from sources available to public and it is not a complete analysis of every material fact. Statements of fact have been obtained from sources considered reliable but no representation is made as to their completeness or accuracy. 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Jouhou Koukai Services LLC and its business Jouhou Koukai Publishing provide information and intelligence on the Japanese pharmaceutical market in the fields of medicine, pharmaceuticals, patents, licensing, copyrights and data protection, business and corporate development, information technology, including e-health, and medical communication, however, this information does not constitute for nor can it be used as such for a substitute of medical, legal or investment advice. Worldwide Copyright (c) 2001-2004 by JKS LLC Reproduction in whole or part without permission is forbidden. www.jouhoukoukai.com Vertical Net are e-commerce Web sites targeting a specific industry, profession, or special interest and aggregate content, services, communities, applications, and commerce relevant to that industry or profession. WAP stands for Wireless Application Protocol, a secure and low memory XML based specification allowing users to access information instantly via handheld wireless devices such as mobile phones, pagers, two-way radios, smart phones and communicators. In February, 2000 NTT DoCoMo launched its i-mode service, becoming the only network in the world at the time allowing subscribers continuous access to the Internet via mobile telephone. The service lets users send and receive e-mail, exchange photographs, do online shopping and banking, download personalized ringing melodies for their phones, and navigate among more than 7,000 specially formatted Web sites. PDA stands for personal digital assistant, a handheld device that combines computing, telephone/fax, Internet and networking features. Harris Interactive is a worldwide market research company which conducts scientific Internet and non-Internet based polls (Harris Poll) on popular or contentious issues. Rippen H, Risk A, for the e-Health Ethics Initiative. e-Health Code of Ethics. J Med Internet Res 2000; 2(2):e9. http://www.jima.or.jp/trust/eHealthEthics_jp1.pdf (in Japanese, December 12, 2003). A Japanese ministry formed in 1949 from the union of the Trade Agency and the Ministry of Commerce and Industry in an effort to curb post-war inflation and provide government leadership. Nowadays MITI responsibilities extend not only to areas of exports and imports but also for all domestic industries. This span has allowed MITI to integrate conflicting policies, such as export competitiveness to minimize damage to export industries. Although many regard extrapolation of US and European e-commerce developments into the Japanese market as an oversimplification, the flattening of activity curves for all stakeholder groups in the June - September 2000 period (Phase I) could be interpreted as an immediate impact of the U.S. led dot.com crash. The 5Cs of e-Health refers to Content, Commerce, Computer (Applications), Connectivity and Care. Based on the results of The Harris Poll (www.harrisinteractive.com/harris_poll/index.asp?PID=299 (March 29, 2004), a U.S. nationwide survey of 707 adults (18+) who are online from home, office, school, library or some other location, found that 75% of all adults who are online (i.e., 47% of all adults) use the Internet to look for health care information. This telephone survey was conducted between March 13 and 19, 2002. Harris Interactive 1(8), February 26, 2001; available online at http://www.harrisinteractive.com/news/newsletters/healthnews/HI_HealthCareNews2001Vol1_iss8.pdf (March 29, 2004) Confirmed from two independent sources: Nikkei BP (1998) and Juntendo Hospital's Library - National Physician Registry, Urayasu, Chiba-ken December 2000. 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