Japan's medical revolutionary: John Wocher shows the nation's hospitals just how good health care can get at Kameda Medical Center.

HERE'S HOW TO GET smack into the middle of Japan's health-care debate: Ride an express train from Tokyo Station two hours to the southern end of Chiba's Boso Peninsula, get off at the sleepy little station of Awa-Kamogawa, hop in one of the taxis waiting for tourists, ride down a long winding road, past the 'viking' buffet at the Sea World Hotel, past the Sea World park itself and finally to a heliport next to a rocky beach; turn left at the heliport and you've arrived at Kameda Medical Center.

One of the most provocative arguments for more competition in Japan's health-care system sits a stone's throw away from the craggy coast of Chiba prefecture. Kameda has been a family-run hospital for more than 350 years, but lately the complex of 11 buildings has started to turn heads around the world for its cutting-edge approach to hospital care. Its electronic medical records system has turned Kameda into a paperless hospital (see Cradle to Grave--Your Life on a Chip, page 21), its telemedicine services are the digital age's version of a house call (elderly people can be diagnosed from home by specialists even if those doctors aren't at Kameda) and its sun-splashed lobby, staff trained by Japan Airlines and frequently changing art displays are everything that socialized medicine is not.

Movie stars, political figures and other 'VIPs' can check into the hospital via a private entrance off the parking lot, then be whisked up to the sixth floor where private rooms with no names on the door, splendid ocean views and minibars full of fresh juice await. There are steam baths, a Jacuzzi, a fully equipped gym and private restaurants. "It feels like we're in Waikiki," says one young man strolling through the gym.

But Kameda is no elitist hideaway. The hospital treats about 2,500 outpatients a day. On one sultry summer morning, the lobby was packed with patients, family members and friends. By 1:10 pm the cashier's computer terminal showed that 2,137 patients had shown up that day and 1,268 had already been treated and released. Kameda may be tucked into a remote corner of the Kanto region, but it is a leader in promoting the idea that you should consider crossing prefectural lines to get the best medical care.

"I wish we were in Tokyo," says John Wocher, executive vice president of administration at Kameda. Why? Because then more people would know what is possible and begin to demand more out of their hospitals, he says. "Where would you go if cost wasn't a factor? Patients for some reason tend to think that bigger is better or they pick the hospital closest to their home."

World-class care

Wocher is the man behind much of the change at Kameda. He is also the author of the book Nippon no Byoin: Naze Nihon no Byoin wa Dame Nanoka (Japan's Hospitals: Why They Are Bad), published by Nikkei BP in October 2000. Wocher is introducing Japan to a different approach to health care, something more akin to the Mayo Clinic in the US or the Cleveland Clinic, near his hometown of Avon Lake, Ohio. At the Cleveland Clinic, for example, rich patients regularly fly in from the Middle East for treatment. Clevelanders talk of glimpsing harems at the local shopping mall or the hotel connected to the clinic. But in Japan, crossing prefectural lines to get medical care is rare, and while some cross national lines for transplant surgery and other operations that are taboo in Japan, there is little pull to make Japan a place with hospitals that draw patients from overseas.

Wocher is looking to open that market and make Kameda a hospital that draws people from all over the world. Today Kameda is considered one of Japan's best hospitals; it was ranked No. 4 in the nation by Nikkei Business in an August 2001 poll and No. 3 in terms of information disclosure. Wocher boasts that "my friends who are CEOs in the States come out here for their physicals" although he refused to divulge any names.

Wocher is a military man with a long career in Japan. He first came to Japan in the year Tokyo hosted the Olympics. "It was 1964 and I was a wide-eyed 20 year old. I climbed Mount Fuji," Wocher recalls. (For another take on climbing Fujisan and traditional Japanese hospitals, see The Other Side of the Coin below). He retired from the navy as a lieutenant commander in the medical service corps, but he is not a medical doctor--he's a trained health care administrator, a title that is all but unknown in Japan, where medical doctors run the hospitals.

Wocher met the Kameda family through his work at the US naval base in Yokosuka in the early 1980s. The family was looking to tie up with a hospital with a heliport to refer patients and they visited Yokosuka several times. The Kamedas and Wocher struck up a relationship and in 1991 they decided to join forces. "They were looking to take on the necessary evils--quality improvement, risk management--and they didn't want to do it in 100 years, they wanted to do it in three or four," Wocher says of the family. Today Dr. Toshitada Kameda is the center's chairman of the board.

New approach

In April 1995, the new Kameda hospital opened and it was immediately apparent that the Kamedas had struck on something new. Patients walk into a sunlit atrium when they enter the hospital; they are greeted by hostesses trained by

Japan Airlines. Even Wocher underwent the 16-hour training: "Feet at a 45-degree angle, bow 45 degrees. Smile, say 'whiskey'."

But there was more than just flash and good design behind the new and improved Kameda hospital. "We were trying to say to people that a hospital doesn't have to be institutional," Wocher says. "We want to be world class--not just the best Japanese hospital."

So what sets Kameda apart? "There are things here that could be used as benchmarks in the States," says Eric Bloom, an intern at Kameda from the University of Iowa. "The EMR system, for example, could be used as a benchmark."

Kameda also has a nursing school attached to it, guaranteeing a fresh supply of nurses familiar with the Kameda approach. Wocher himself takes 80 of these nurses abroad every year to visit some of the best hospitals in the world.

And there are quirky little things throughout the hospital that give it its personality. The center uses a pneumatic tube system to send messages and samples throughout its buildings. "It can shoot the tubes up to 5km, so we were thinking we could send it to local pharmacies," Wocher says. Also, tucked away on the sixth floor is a saddle and mount for injured jockeys to practice on. "They come up here in full uniform, with their riding crops," he says.

But perhaps most importantly, there is a markedly different approach toward patients here. For example, when patients are admitted to Kameda, they are given a package of information that recommends they get a second opinion, something that is not common practice in Japan.

Also, if an individual wants to know about his or her condition, but the family wants to shield the patient from that knowledge, Kameda will "always side with the individual patient," Wocher says. In a hospital system where "don't ask, don't tell" prevails, this is a marked difference.

Surprisingly, Wocher says he faced little resistance instituting all these changes. "Instead of improving two things 50 percent, we improve 50 things 2 percent," says Wocher, who has a penchant for slogans -- "We can't just satisfy the patients, we have to delight them" is one of his favorites, as is this critique of the Japanese medical system: "If you're wrong the first time and right the second, you get reimbursed twice."

Competitive medical care

But is a more competitive, free market approach to health care really what the Japanese want? Do they really want to go down the road of the US, where the rich get the best care and the rest get by? Isn't a private hospital like Kameda more for the rich, who can afford private rooms with no names?

Wocher takes issue with the idea that Japan's system is inexpensive and thus more egalitarian. "You think it's cheap, but what do you get for that premium? You have no choice in coverage because it's a monopoly provider, it doesn't include daily food charges, new technology is often not approved, you have to rent the TV and there's no same-day surgery," he says.

Wocher points to Kameda's physicals as a case in point. The half-day physical costs [yen]30,000, which is on par with fees at other Japanese hospitals. Kameda's [yen]30,000 physical is more specialized, however, concentrating on the brain.

Perhaps Kameda will end up serving as an example of what's possible while not really affecting the national scene. Its easy access to Narita airport on the other side of the prefecture means patients could fly in from anywhere and head to Kameda without even going through Tokyo. But is the Kameda experiment destined to remain a diamond among the rough? Or is Wocher going to put Kameda in the national spotlight to force debate about Japan's medical system?

Wocher is ready for the debate--he's no shrinking violet. He's appeared on TV with Beat Takeshi discussing second opinions, and when Nikkei BP published his book in the fail of 2000, he typed up a letter to health minister Yuji Tsushima and taped it into the book. The letter offered 10 suggestions on how to make an impact on health care "with the stroke of a pen." The suggestions include:

* Making a law that bans smoking in health-care facilities

* Making smokers pay higher premiums than nonsmokers

* Giving patients unrestricted access to their personal files

* Stopping the practice of licensing physicians for life

* Promoting continuing education for doctors

How many of his ideas were adopted? "None," Wocher says, but he doesn't seem all that dismayed as he says it. He's too busy to mope. He has blocked off two-and-a-half hours to show off the Kameda facilities to a couple of reporters. Little by little, he's getting the word out that down in southern Chiba there's a medical revolution going on. And, heck, even if the folks in Kasumigaseki don't listen to his ideas, he's having a lot of fun in sleepy Awa-Kamogawa. "If I could move the building just 25 yards, I could fish from the office," he says.

RELATED ARTICLE: THE OTHER SIDE OF THE COIN

Some hospitals are more equal than others. Craig Mod shares his adventures in primary care.

IT WAS 11PM WHEN Satoko dragged me to the hospital. We entered through the special 'emergencies' entrance in the back--it opened directly into the patient waiting area. The floor was hard and the air was stale and cold. The lights were dim, the room almost black, and for a minute, in my state of shock, I thought maybe the whole thing was closed and that maybe they figured emergencies could wait until tomorrow, But then I noticed a few people sitting on plastic benches that looked as if they had been transplanted from the nose-bleed section of Tokyo Dome.

Satoko tugged at my arm to get me to hurry as we passed along solid concrete walls with brown water stains running down cracks and under faulty flickering flourescent lighting. The receptionist was a cowering little man in a cramped box at the end of the hall. He quickly handed us the necessary paperwork with a grunt and I went to sit in the stadium seating while Satoko filled it all in for me.

A little background--the day before I had climbed Mount Fuji with a friend. To cut a long story short, we climbed to the top; there was a lot of snow; the glare from the snow and direct rays of the sun charred my face. I woke up the next morning to a stream of yellow goo oozing from the huge swollen blister which had replaced my face. When my friend saw this she screamed and immediately decided I needed to be taken to a hospital.

After waiting what felt like four years, someone finally called out Kureigu-sama and I was ushered out of the dark and evil depths of the waiting area into the brightest room I've ever seen. Someone (my pupils had gone into shock from the light) pulled me over to a cold metal stool. "What's wrong?" he asked. I pointed to my face and they commenced a series of motions which resulted in the most intense and horrible stabbing pains throughout my skull. "I'm sorry," he said, "but I have to poke your face for a bit."

That person, whom I assume was a doctor, then called another person, whom I also hope was a doctor, and they proceeded to poke in tandem, one attacking my left side and the other my right. This continued for about six hours' worth of pain, and they then had me lie down on a paper-covered cot. More people had come over and were looking at me (by this point I could see vague outlines). Someone smeared me with jelly, and another started taping ice packs to my face. The tape was mainly affixed to my hair, however, and when I sat up everything fell off, taking with it bits of my blistered head. This hurt.

The doctor, however, was a very compassionate man, and the first thing he said to me was, "You have horrible burns which may never heal." The impact of this statement was apparently supposed to be anesthetic because after hearing that I quickly forgot the stabbing, pounding that had just before been crashing into my skull. He said they would "let me stay one night." I was too tired, shocked, blinded and exhausted to argue about the semantics of "let" and "one night," even though I was ready to pack up and move in.

The room they brought me to was a standard hospital room. Everything metallic and cold, and air as stale as that on an airplane. The sheets in the bed felt like a rough equivalent of sandpaper. The last thing I wondered before passing out was if the pillow under my head was a brick wrapped in linen or not.

I woke up the next morning to a doctor shaking me and telling me to leave. "You have to go home." I noticed my leaking face had turned most of my bed yellow and told this to the doctor, asking if it wouldn't make more sense for me to stay a bit longer--you know, to avoid infection of the wildly gaping gash that was my face. He grunted, made a noise like he was going to spit, and then said, "Fine, stay until tomorrow. But it's expensive." Apparently he had never heard of insurance.

While hospitals are notorious for inedible mush in the form of food, this one must have won some awards. A sweet little nurse with the smile of a rabid wolf came in with a tray containing a soggy dinner roll and some lettuce with tuna on it. I asked if they had chopsticks and they said no. I then spent 20 minutes trying to convince myself that eating it wouldn't be counterproductive to my well being.

The other patients in the hospital weren't any better off. If you wanted to watch TV you had to go out into the common room (not an easy task for some of these people) and purchase a card to plug into the TV set. The common room offered to these people with crumbling old bodies a wonderfully appropriate view of a crumbling concrete tower.

It's not as if I am totally dissatisfied with the whole experience--contrary to the doctor's spot-on diagnosis (I must have been the first white guy with a sunburn he had ever seen), I was fine and completely healed within a week. Oh, and my mountaineering friend? He was fine as well. He's black.

CRADLE TO GRAVE -- YOUR LIFE ON A CHIP

Kameda leads the way with KAI, its electronic medical records system.

By Jasmine Pui

DESPITE ITS HIGH-TECH IMAGE, Japan is a nation where most things official are done the hard way -- in printed form and written out in triplicate. To date, hospitals and clinics have been thinking of adopting electronic medical records (EMR) -- in keeping with tradition, most have not.

Kameda's decision to voluntarily develop its own EMR raised eyebrows when it took the plunge in 1991. Most hospitals find the cost -- financial and in terms of staff training time and maintenance of technology -- of EMR to be excessive, but no doubt physicians welcome the chance to trade in their illegible penmanship for the clarity of onscreen records.

One concern is over patients' reactions to their caregivers typing away on keyboards while they discuss symptoms or progress. John Wocher, executive vice president at Kameda, believes patients are comfortable and feel well taken care of in these circumstances, "The physician can swivel the screen around and show patients exactly what their tests results were, what their x-rays and their other diagnostic tests look like. There are no lost lab results or films, and the patient record is structured and chronological. Patients can see everything at the point of care."

Now that Kameda's EMR (it's called KAI) is running in 20 other Japanese hospitals, clinics and private practices and Kameda has consistently ranked among Japan's top 10 medical institutions, hospital administrators can't put off thinking about taking similar measures any longer.

Traditionally, when the effects of a new technology specific to a department are measured, the finding is that staff performance either stays the same or is marginally better. The common problem with EMR is that hospital staff often simply opt not to use most of the technology's capabilities, or they have great difficulty in adjusting to the system's constraints, codes for tests or codes for pulling up results. Even if a department's efficiency or patient satisfaction ratings do get better, the hospital's performance as an organization tends to stay the same -the only difference is that the cost of running the hospital goes up a few million yen.

Wocher believes the to Kameda's success in key adopting KAI is threefold. Firstly, competing hospitals had previously never tried developing their own system, choosing instead to tinker indefinitely with software developed and serviced elsewhere. Kameda saw the need to ensure that its unique hospital patterns, work flow and health trends would be met. Its technology development branch, Health Informatics institute in Kamiyacho, Tokyo, works with the staff from Apius.com, a Kameda company, to keep KAI secure and running smoothly. Together they tailored the learning curve to be just three hours of structured orientation and one week or less of guided EMR use in each department. Kame also took into account the unique Japanese vocabulary of medical conditions such as Takotsubo's cardiomyopathy -- a heart condition that has only ever been observed in Japan.

KAI was developed so that doctors and nurses would have few adjustments in the way they work. Patient confidentiality is considered too. Receptionists and clerks have access only to the scheduling parts of patient records, while nurses, physicians and specialists have unlimited access. The sequence of ordering lab or test results is the same as on paper, except that the test results will already be filed according to the patient identification number when the physician goes to look at them. The physician can choose to have an automated prompt sent when the results are ready, or he can login in to any one of over 300 wireless laptops in every ward, floor and patient room to check if they are ready. "Our staff never feel helpless or out-of-date because they haven't had to learn codes and procedures which are completely unfamiliar to them," says Wocher.

The second way that Kameda stands out is that it doesn't allow staff to opt out of using the EMR. Kenji Kira, vice president of marketing at Kameda, believes this puts KAI ahead of others. "This is not a trial system and having it run 24 hours a day with every staff member required to understand and use the technology in real time and real clinical situations is the best way to test the system." Even with a minimum downtime for upgrades or repairs, a unique feature of KAI is that it does not require physicians to memorize alphanumerical codes for entering patient information, reviewing notes or any other of its functions. Drop-down menus give ready access to archived patient notes, trends and medication records. Kameda wants its patients to feel that KAI is an integral part of the consultation with a doctor, so it has to be completely legible when the computer monitor is pointed their way.

Thirdly, as a teaching hospital, each department and perhaps each individual, would have a slightly different way of doing things and KAT could nor be developed to favor one section over another. The Health informatics Institute developed a system that could be customized using templates from a standardized database of elements, graphic displays, visual cues and prompts, among other features. This means that both a specialized institution and a general one, such as Kameda, have the same benefits from using KAI as doctors in private practice and small clinics. KAI is unique in that, not only can it be scaled up or down for use, but it also does not lose any of its functionality or efficiency with scaling.

While Kameda's staff seem convinced of the long-term benefits of KAI, many remain unconvinced that labor costs can be lowered and greater reliability and better consistency in staff performance can be brought about by eliminating paper for good. Japan is the world's second highest spender on health care, yet its doctor-patient ratio is 1 to 600. This means that patients get very little attention from physicians. The bulk of health-care spending goes into technology and that's not even taking into account private companies like Kameda, where technology is the cornerstone of its survival. With healthcare expenses on the rise, its citizens living longer and a large aging population, Japan's universal medical health insurance will be put to the test by expensive technologies like KAI.

Kira believes the traditional doctor-patient relationship has been supplemented by a necessary technology.. "And we're doing it with the intangible benefits which come out of developing KAI, such as the reputation as a leader of consistent and quality patient care," he says.

Among the tangible benefits are the patents from the European Union and the US, in addition to those Kameda already has in Japan. There is still the risk that KM will become out of date, but at the moment, 2,500 outpatients and nearly 800 inpatients a day get the paperless treatment. In terms of improving the process, KM is one of Kameda's and Japan's greatest medical triumphs. Nursing observations of patients are recorded every hour directly onto the system. Patients get printouts explaining their prescriptions in detail. Medical records and nursing notes work together in KAI in much the same way that physicians and nurses do.

"Like online banking, medical records will be Web based in the not too distant future," Wocher says. "The patient in the future, with password and privacy protections, will be able to have his or her medical record downloaded to a health-care provider of his or her choice."

* JASMINE PUI (Cradle to Grave--Your Life on a Chip, page 21) writes on medical technology, drug and research discoveries and patents for Chinese Review Weekly, which is published in Japan, China Health, Parade and various academic journals. She stayed in Kyoto for one week for a conference on carbon polymers for medical and seafaring applications. She holds a joint appointment for researching cognitive processes and minimizing iatrogenic (physician caused) errors in medical technology implementation and use at Vanderbilt University in Nashville, Tennessee and the University of Alberta in Canada.