The development of medical networks through ICT in Japan

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1 Netcom Réseaux, communication et territoires 21-3/ Le géocyberespace : usages et perspectives The development of medical networks through ICT in Japan Tsutomu Nakamura Publisher Netcom Association Electronic version URL: ISSN: X Printed version Date of publication: 16 décembre 2007 Number of pages: ISSN: Electronic reference Tsutomu Nakamura, «The development of medical networks through ICT in Japan», Netcom [Online], 21-3/4 2007, Online since 15 September 2016, connection on 14 December URL : netcom.revues.org/2256 ; DOI : /netcom.2256 The text is a facsimile of the print edition. Netcom Réseaux, communication et territoires est mis à disposition selon les termes de la licence Creative Commons Attribution - Pas d'utilisation Commerciale - Pas de Modification 4.0 International.

2 Networks and Communication Studies, NETCOM, vol. 21 (2007), n 3-4, pp THE DEVELOPMENT OF MEDICAL NETWORKS THROUGH ICT IN JAPAN TSUTOMU NAKAMURA 1 Abstract This paper examines how medical networks using Information and Communications Technology (ICT) have been constructed, and what kind of spatial impact they have on the existing medical care provision system. The results are reported below. In Japan, each prefecture implements its own regional health care program for the appropriate allocation of medical resources. However, regional disparities in such allocation have not yet been resolved. ICT applied to two cases (the Wakashio Medical Network in Chiba Prefecture and the Haniwa Health and Welfare Network in Miyazaki Prefecture) has promoted functional division and cooperation among medical institutions as well as the efficient use of resources on medical networks. Factors contributing to the construction of these networks and their continued utilization include strong leadership of central hospitals in the regions, and the fact that they have managed to solve problems related to system development and operation costs. However, differences in medical network awareness between doctors and patients, as well as the constraints of network maintenance costs, force participating doctors in ICT field. In this way, medical networks become a way to complement existing medical delivery systems. Key words ICT, medical care, medical network, Chiba Prefecture, Miyazaki Prefecture Résumé L article explore la façon dont les réseaux médicaux se sont construits au travers des Technologies de l Information et de la Communication (TIC), et quels sont leurs impacts sur le système de soins au Japon. Chaque préfecture a réalisé son propre programme de santé publique mais il reste tout de même de vraies disparités régionales dans la façon d envisager le système de soins. Deux cas particuliers sont étudiés, Wakashio Medical Network à Chiba et Haniwa Health and Welfare Network à Miyazaki. Chacun d eux promeut un système de coopération grâce aux TIC entre les différents établissements de santé en région afin d optimiser leurs performances. Le succès de leur création repose sur un fort investissement des hôpitaux les plus importants au sein des régions respectives même si le recours aux TIC dans le système de santé est différemment intégré selon que l on se situe dans la position du patient ou celle du médecin. Dans tous les cas, les TIC apparaissent aujourd hui au Japon comme un moyen complémentaire dans la fourniture de services médicaux. Mots clés TIC, santé, réseaux de santé, Préfecture de Chiba, Préfecture de Miyazaki 1 Graduate student. Department of Human Geography, the University of Tokyo at Komaba, 3-8-1, Komaba, Meguro-ku, Tokyo, , Japan.

3 364 NETCOM, vol. 21, n 3-4, 2007 I. Introduction 1. Background It is an important geographical theme to clarify the socio-economic impact that Information and Communications Technology (ICT) has had in industrial and public fields since the 1990s. However, geographical research has shown only a partial impact from ICT in public services such as education, medical care (Hayashi and Niimi, 1998), transport (Okamoto, 2000), firefighting and police work. This is because information systems as a social infrastructure (such as the Internet) were undeveloped, and had only a limited impact on the delivery of these public services. This research has estimated the role of information systems as a means of providing public services. As such services involve public funding; accessibility as well as cost-efficient use should be taken into account in their provision. In contrast to other services in Japan, medical care relates directly to life and health, and medical services must therefore be provided equally to each local resident. The first characteristic of current medical services is the hierarchical provision of care. This is determined according to the severity of a patient s symptoms and the division of medical institution functions according to symptoms (e.g. acute or chronic). An aging population and the declining birthrate as well as advances in medical technology and changes in public awareness of medical matters demonstrate how the environment surrounding medical care is changing tremendously. Such an environment requires medical services to meet the demand for a range of medical care functions including emergency medicine, medical services in remote areas and vocational rehabilitation in the places where patients live. However, the process of constructing medical networks involves different parties such as local governments, hospitals, clinics and pharmacies. In terms of the spatial definition of ICT development, therefore, the important issue is how cooperation among the parties involved influences the spatiality of the medical network. In the USA, medical information networks have been emerging since the 1990s, and the influence of these networks on the existing medical delivery system has been pointed out. Nonetheless, with only a few recent exceptions (Shannon, 1997, 2000; Mayer, 2000; Löytönen, 2000; Strömgren, 2000), geographers have paid little attention to the implications for medical care, both positive and negative, arising from telemedicine. Moreover, telemedicine research in general has all but ignored the character of virtual medical care regions and their integration with traditional care regions (Bashshur et al., 2000). Cutchin argued for the use of regional economic geography and territoriality as a context for understanding the continued growth and development of telemedicine networks. At least in the USA, ICT infrastructures are valuable and their development is based on the purpose of controlling space and gaining social power. For this reason, there is a need for geographical analysis on the territoriality of new technological networks of medical care (Cutchin, 2002). In Japan, each prefecture has implemented its own regional health care program to achieve appropriate allocation of medical resources, and has set secondary medical areas (SMAs) as regional units of hospital treatment since around This program was established by Medical Law, and is designed to be investigated and modified as necessary at least every five years. However, Japanese primary care policies have taken inadequate measures to correct regional disparities in medical resource distribution. Urban areas show an overabundance of doctors and beds, while rural areas demonstrate a chronic lack of doctors and beds and an imbalance in supply and demand. The regional disparity of medical resources in terms of the

4 NETCOM, vol. 21, n 3-4, number of doctors and beds has not yet been resolved. The second characteristic is a lack of firm definitions in terms of the functions of hospitals and clinics. The responsibilities of these two types of institutions in Japan (such as hospitals for hospital treatment and clinics for outpatient care) are not clear. Making hospitals specialize in hospitalization is expected to lead to the practical reduction of medical costs by reducing social hospitalization. Japanese medical institutions are classified according to the number of beds they contain; clinics have fewer than 20, while hospitals have 20 or more (Fig. 1). The Japanese government considers that the function of each medical institution should be defined, medical networks suitable for each type of disease should be constructed to make good use of human resources such as medical professionals and medical equipment, and that medical services should be decided according to the health condition of patients. For this purpose, the development of ICT as an information infrastructure is a matter of great urgency. 2. Purpose and method The present study focuses on medical providers efforts to alleviate the structural problems of the existing medical supply system, such as the uneven distribution of doctors and undifferentiated functions of medical institutions. It also examines how medical networks using ICT have been constructed, and what kind of spatial impact it has on the existing medical delivery system. Japanese information policy on health care is at the stage where the effectiveness of information systems through national funding is still under examination. Fiscally in 2000, the Ministry of International Trade and Industry (now the Ministry of Economy, Trade and Industry: METI) allotted about 5.6 billion yen to system development and operation for medical cooperation through the sharing of electronic charts. At the end of 2001, the Ministry of Health, Labor and Welfare (MHLW) also introduced a grand design by which electronic charts were to be introduced into more than 60% of medical institutions of 400 beds or over by However, 10 out of 26 projects adopted by METI were completely stopped in 2004 due to (1) high operational costs; (2) a lack of compatibility with other systems; and (3) a lack

5 366 NETCOM, vol. 21, n 3-4, 2007 of doctors appreciation of cost effectiveness. Thus, the effectiveness of electronic charts was recognized by demonstration, but technical, financial and awareness problems made the continuation of the operation difficult. We can demonstrate though how pioneering cases under continuous operation have overcome these difficulties. The objects of this study are the Wakashio Medical Network (Wakashio Net) in the Sambu Medical Area of Chiba Prefecture and the Miyazaki Health and Welfare Network (Haniwa Net) in Miyazaki Prefecture (Fig. 2). These two cases were selected for their status as medical networks adopted by METI and the MHLW. Both cases have a lot in common, in that they are aimed at the functional division and cooperation of multiple health-related institutions through the sharing of electronic charts, and substantial national funding was committed to their system development. However, their vision and the way they have developed differ. We can therefore clarify the similarities and differences in the impact on medical delivery systems through ICT. The survey was based on interviews with hospital officials and medical associations involved in the construction of these two medical networks. Its contents covered the process of construction for the medical networks and cooperation performance. II. Outline of cases 1. Outline of Wakashio Net in Sambu Medical Area, Chiba Prefecture First Wakashio Net is outlined in terms of the present status of demographic trends and the provision of medical resources in Chiba Prefecture by the SMA. Population growth data ( ) show that the highest growth rate of all areas is found in the Imba-sambu Medical Area (5.7%), while the second highest is found in the Chiba Medical Area (3.5%) (Fig.

6 NETCOM, vol. 21, n 3-4, a). It is likely that these areas have seen sudden increases in population due to their status as commuting areas to Chiba City and the Tokyo Metropolitan Area. Fig. 3-b lists the number of patient beds per 100,000 people, and shows that the ratio in Chiba Prefecture is far lower than the national average of In particular, the figures for the Tokatsu-hokubu Medical Area (642.5), the Tokatsu-nambu Medical Area (604.5) and the Imba-sambu Medical Area (654.1) are just 60% of the national average. The medical delivery system in the Imba-sambu Medical Area should be improved with great urgency due to the region s population explosion and the related increase in demand for health care. Note: The beds include long-term care beds, general beds and other beds. Sources: Ministry of Public Management, Census, Ministry of Health, Labor and Welfare, Survey of Medical Institutions. Wakashio Net was developed in the Sambu Medical Area, which is under the jurisdiction of one of the health centers in the Imba-sambu Medical Area. The Sambu Medical Area comprises one city and eight towns and villages, and has 200,000 people, 90 clinics and 7 hospitals (Fig. 4).

7 368 NETCOM, vol. 21, n 3-4, 2007 Note: As of December, Source: The data from Togane Hospital. Wakashio Net was planned and prepared to enhance the medical system for lifestyle-related diseases. An electronic chart server was installed at Togane Hospital, the region s central hospital, and the data management was centralized. Electronic chart systems were introduced into clinics, and the shared data was digitalized and sent to the regional shared electronic chart server with the aim of sharing information (Fig. 5).

8 NETCOM, vol. 21, n 3-4, Source: The data from Togane Hospital The advantage of the electronic chart system is that whole practice data can be overviewed as a time series. If a doctor at Togane Hospital refers a patient to a doctor in a clinic, the doctor in the clinic can view detailed information about the patient s consultation history or the previous doctor s opinions and future treatment policies before the referral. This enables the doctor in the clinic to treat the patient smoothly without confirming the process of the treatment with the patient himself (Hirai 2004: 44-45). This project was adopted as an information networking-related project by METI, and has been formally operated since April The participating institutions were selected through recommendations by the Medical Association and the Pharmaceutical Association, which resulted in the participation of 15 clinics and 16 pharmacies. The project was also adopted by the MHLW in 2002 to promote medical cooperation. The number and sectors of participating institutions was expanded, and new operation started fiscally in Outline of Haniwa Net in Miyazaki Prefecture Haniwa Net. Miyazaki Prefecture is the eleventh most densely populated region in Japan, and has many remote areas in the Kyusyu mountain range. The ratio of households where the head of the family is over 65 years old stands at 22.0%, a relatively high figure for Japan (2004) (MHLW, Comprehensive Survey of Living Conditions of the People on Health and Welfare ). Since it is difficult for patients to move in terms of logistics, they need a way to simply inform medical institutions of their everyday health records without traveling.

9 370 NETCOM, vol. 21, n 3-4, 2007 Population growth data ( ) shows that the population of Miyazaki Prefecture declined during the period other than in the Miyazaki-higashimorokata area (Fig. 6-a). However, the number of beds per 100,000 people by SMA exceeds the national average in most SMAs (Fig. 6-b). The demand for medical services is expected to increase here in the near future due to the many households with aged residents. It is thus necessary to use medical professionals and facilities effectively in this regard. Note: The beds include long-term care beds, general beds and other beds. Sources: Ministry of Public Management, Census, Ministry of Health, Labor and Welfare, Survey of Medical Institutions. Haniwa Net is an information network constructed to maintain medical care levels and to provide the most appropriate medical care for residents of Miyazaki Prefecture. The fiber optical cable (Miyazaki Information Highway 21: MIH21) constructed by Miyazaki Prefecture is used as the information infrastructure of Haniwa Net. MIH21 has eight access points, and interconnects Miyazaki Prefecture and 44 municipalities within the area (Fig. 7).

10 NETCOM, vol. 21, n 3-4, Source: The data from Univ. of Miyazaki Hospital. Participating hospitals and clinics can record and convey medical treatment data, while patients can refer to their own electronic charts and inform the medical institutions of their everyday condition by inputting the information themselves (Fig. 8).

11 372 NETCOM, vol. 21, n 3-4, 2007 Source: The data from Univ. of Miyazaki Hospital Participating pharmacies can also refer to the electronic charts of patients who bring their own prescriptions, and can input their conditions of compliance. The operation of the network has allowed participating institutions to move patients from one medical institution to another, prescribe smoothly and confirm whether people have chronic diseases or not. As the operation allows medical institutions to confirm patients medical histories, suitable medical treatment can be offered. This project was adopted as an information networking-related project by METI, and nine hospitals and ten clinics have so far been involved. The network is intended for the benefit of health and welfare in Miyazaki Prefecture. Consequently, it is assumed that the people of Miyazaki Prefecture are connected to health and welfare-related facilities such as local governments, hospitals, clinics, testing centers, pharmacies and welfare facilities. Indeed, in addition to medical institutions, eight pharmacies and one testing center participated during the demonstration phase (Fig. 9).

12 NETCOM, vol. 21, n 3-4, Note: As of Oct. 1, Source: Website of Miyazaki Health and Welfare Network. Haniwa Net was adopted by the MHLW fiscally in 2002 as a project to promote medical cooperation. At the same time, the number of participating institutions was expanded and the function of electronic charts was improved. Haniwa Network Association, founded by Miyazaki Medical Association and the University of Miyazaki s Faculty of Medicine, has developed into a full-fledged operation since April 2003 and performs maintenance on the network center as well as setting rules on operation. III. Construction process of medical networks and their cooperation performance 1. Construction process of medical networks and their cooperation performance First, we introduce the process by which Wakashio Net was constructed. There was a serious shortage of doctors in the Sambu Medical Area with less than half the national average (89/189) per 100,000 inhabitants, which was the lowest number in Chiba Prefecture. In particular, only one outpatient facility in the area dealt with lifestyle diseases such as diabetes; the medical delivery system for adult diseases was inadequate. A hospital director who arrived at Chiba Prefecture s Togane Hospital in 1998 initiated the construction of hospital LANs and prepared to hospitalize patients in internal medicine in all wards. At the same time, he held meetings to report analyses of the status quo in Togane

13 374 NETCOM, vol. 21, n 3-4, 2007 Hospital, research papers and case studies in order to assist training and promote interaction between hospital staff and members of the Medical Association and the Pharmaceutical Association in the area. Such exchanges allowed doctors and pharmacists to share the details of medical treatments and patient compliance instructions, and resulted in building trust between them (Hirai, 2004: 20). While the maintenance of the information infrastructure and the training of medical staff were in progress patients with lifestyle diseases accounted for no less than 40% of outpatients in the hospital. The hospital director planned to introduce the information network as a basis for the prevention of lifestyle diseases in tandem with health-related institutions. In particular, treatment for patients with diabetes needs cooperation between various health-related institutions, as care was required not only for prevention but also for prognosis. A system was established whereby clinics too could adopt insulin therapy and allow patients to self-inject through the promotion of insulin therapy (Hirai 2004: ). Wakashio Net has become the information infrastructure of the system, which was constructed together with the Medical Association and the Pharmaceutical Association. On introducing Wakashio Net most of the grant money from METI and the MHLW was allotted to the development costs of the system. Hospital LANs were prepared before application as a project of METI and the MHLW, resulting in the allocation of all the grant money for networking of the medical institutions. About 40 million yen was budgeted for annual personnel costs for two system engineers, who have been stationed for regular checks and system maintenance since the operation phase began in April The method for subscription involves the Sambu Medical Association and the Sambu Pharmaceutical Association inviting each member to participate with their own personal computers. Secondly, we introduce the process of Haniwa Net s construction. A professor at Miyazaki Medical College (now the Faculty of Medicine at the University of Miyazaki) promoted the cooperation of regional health care. Miyazaki Prefectural Medical Association applied for a METI project grant to examine the effectiveness of a standard code for the exchange and preservation of medical records. Miyazaki Prefecture had promoted MIH21 as the information infrastructure within the prefecture six months before the METI project was started, and the University of Miyazaki Hospital then proposed also using it as the information infrastructure of Haniwa Net. Miyazaki Prefecture judged that the proposal was suitable for the purpose of MIH21 and accepted it. In this way, the University of Miyazaki Hospital, the Prefectural Medical Association and Miyazaki Prefecture have carried out triangular cooperation with each other since There are no information infrastructure construction costs, as the existing MIH21 information network is already in place. The grant money from METI and the MHLW was used to develop hardware and software for Haniwa Net, and a system development company provides operation and maintenance for free. However, the open question remains: who should bear the operation costs, and in what way? The current membership of Miyazaki Prefectural Association is about 800, and the group invites doctors who are good at using their own personal computers to participate. 2. Characteristics of participating institutions Next the characteristics of the medical institutions participating in Wakashio Net are considered. Table 1 lists the participants by medical department, showing that the top three clinical departments are internal medicine (22), pediatrics (15) and surgery (6). This means that

14 NETCOM, vol. 21, n 3-4, the effect of cooperation differs among medical departments and doctors of internal medicine, pediatricians and surgeons who actively participate in the network. Pediatric surgery (100.0%), proctology (75.0%) and pulmonology (40.0%) occupy a high proportion of participation. Although the number of institutions in the Sambu Medical Area is not large, most of them participate in the network. On the other hand 50 facilities participate in Haniwa Net, which accounts for only 6% of the medical institutions in Miyazaki Prefecture, and 40,000 medical records have been computerized. As Table 2 shows, internal medicine (33), dermatology (20) and surgery (19) represent a large number of participants in Haniwa Net. It is suggested that medical institutions with these departments tend to actively cooperate with each other. Cardiovascular surgery (33.3%), respiratory surgery (16.7%) and dentistry (15.4%) also have a high proportion of participation despite the small absolute number of medical departments. As such these departments are expected to provide these special medical treatments in cooperation with clinics. However, the frequency of system utilization differs among participating medical institutions. According to the author s interview with Togane Hospital, some institutions provide information or refer patients to other institutions 100 times a month, while other institutions do so only several times a month.

15 376 NETCOM, vol. 21, n 3-4, Patients response What advantages and disadvantages do patients experience in using these networks? 1,473 patients had signed consent forms to share their medical records as of the end of December 2004 (Hirai 2004: 145). According to the results of a Togane Hospital questionnaire survey of 102 patients with lifestyle-related diseases, 77.4% replied that medical cooperation through electronic charts was beneficial to them. The advantages cited by patients participating in the demonstration of Haniwa Net included not having to provide letters of introduction (30 patients), the elimination of medicine duplication (28 patients), the ability to be promptly examined by doctors in other medical institutions (15 patients), and shorter waiting times (11 patients). Many patients, however, still prefer large hospitals even if they use Wakashio Net (Hirai, 2004: 51). Additionally, only 500 people agreed to the exchange of their information on Haniwa Net. One reason for this is that patients cannot experience the effectiveness of the network until they actually use it, and it is impossible to appreciate this effectiveness without using it. Another reason is that information security is hard to grasp for patients, and concerns about information leakage remain. Furthermore, Haniwa Net users appreciate the system not for the performance improvements achieved by medical cooperation but for the ability to confirm their own electronic charts at home. This explains the gap between the merit that has been assumed and the merit that patients actually feel.

16 NETCOM, vol. 21, n 3-4, IV. Issues of medical networks and impacts on the existing medical delivery systems Finally, we consider the issues of medical networks and their impact on existing medical delivery systems by examining the geographical scope of these two medical networks. As seen in the examples of Section III, the construction of the networks and their continuing utilization was brought about by the strong leadership of the central hospitals in the region and the fact that they have solved the problems of system development and operation costs. The result is that these central hospitals have realized a medical network on a regional scale as intended. Wakashio Net for example, has been developed in the Sambu Medical Area, which is half the size of the Imba-sambu Medical Area. This has reflected a number of background points: (1) the Sambu Medical Area was in serious need of medical resources, while the Imba Medical Area had many large hospitals, (2) there are financial problems as the maintenance costs rise with an increasing number of participating institutions, and (3) the medical specialists who constructed the network have identified the Sambu Medical Area as having the best geographical scope as a residential area for patients with diabetes. Taking these factors into consideration, Wakashio Net has estimated that the area can ideally cover 200,000 patients. On the other hand, the information infrastructure of Haniwa Net covers the whole prefecture. The geographical scope can correspond flexibly to the expansion of the active patient area in Miyazaki Prefecture, and the network can also be utilized in case of disaster or emergency. Cooperation with Miyazaki Prefecture, which has a stable foundation of information infrastructure, allows Haniwa Net to develop over the entire prefecture. Members of the medical institutions that were called to participate in Haniwa Net have become members of Miyazaki Prefectural Medical Association. The regional scale of the medical networks is decided by the central hospitals based on anticipated efficacy. These hospitals can set different regional scales for different purposes if they are able to solve maintenance cost problems. However, the participating health-related institutions stay within the confines applicable as members of the Medical Associations and Pharmaceutical Associations. The doctors involved tend to be young adults who have a sense of cost effectiveness before adopting the networks, and are familiar with how to use their own personal computers. Health-related institutions located near the residence of patients who have had medical examinations, and which have medical departments suited to the patients symptoms, tend to promote medical cooperation through electronic charts. Fig. 4 shows that the medical institutions participating in Wakashio Net are concentrated especially in central Togane City. There are few participating pharmacies located in the northern part of the Sambu Medical Area while most are concentrated in Togane City. This shows that the participating institutions are unevenly distributed throughout Togane City where Togane Hospital is located. The University of Miyazaki Hospital in fact plays a vital role in promoting the use of the Network, meaning that the network users have contact with the University of Miyazaki Hospital. Since clinics to which the hospital introduces patients are designated to be close to their residential distribution, clinics with good connections are unevenly distributed around Miyazaki City. Fig. 10 reveals that 28 of 46 participating medical institutions are located within Miyazaki City, and that there are few institutions outside Miyazaki city. Consequently, cooperation with medical institutions outside the city still needs conventional letters of

17 378 NETCOM, vol. 21, n 3-4, 2007 introduction. At present, only residents around Miyazaki City can enjoy the advantages of cooperation from the sharing of information on their welfare and health. Even though Haniwa Net has developed beyond the scope of the SMA, there are still cases where suitable cooperation is not available through the network for patients symptoms. Note: As of Oct. 1, Sources: The data from Univ. of Miyazaki Hospital, and Website of Miyazaki Pref. Medical Association. Fundamentally, medical networks act as a means to complement the existing medical delivery system rather than as a means to restructure it, regardless of their regional scale. This is because many doctors and patients do not participate in such networks, and even those who do may not be able to use the networks sufficiently. The differences in medical network awareness between doctors and patients, as well as the constraints of network maintenance costs, are forcing participating doctors to use the most expected case. V. Conclusions ICT has helped to alleviate the problem of a lack of doctors. In particular, it has promoted functional division and cooperation among medical institutions as well as the effective use of medical resources through the use of medical networks. Unless regional disparities are corrected in terms of the allocation of medical institutions and the number of doctors in them, the lack of medical resources may not be solved fundamentally. However, it has become clear that ICT is effective as the second-best policy to ease a range of problems resulting from a lack of doctors.

18 NETCOM, vol. 21, n 3-4, Nonetheless, cooperation with medical institutions, taking the residential areas of patients into consideration, is necessary in order to take full advantage of the electronic data sharing of medical records. The distribution of health-related institutions utilizing medical networks depends on the decisions made by medical professionals, but doctors are currently reluctant to adopt ICT in terms of cost effectiveness and personal information protection despite realizing its advantages. Although medical networks constructed on the basis of convenience for doctors may be inaccessible to some users, such networks are expected to become more important as a way of complementing existing medical delivery systems. For this purpose, it is necessary to share the idea of medical networks with the community as a whole, including local government, medical professionals and local residents. The idea is to provide medical services that synthesize health care, medical care and welfare through ICT aimed at receiving introductions to appropriate medical institutions if necessary. To put this idea into practice, local government should introduce legislation toward making good use of medical networks, along with continuous financial support during the operation phase. Medical institutions participating in such networks must promote the effectiveness and performance of cooperation to health-related institutions and local residents who show less interest in participation. We must strive for a definition of geographical scale among all parties concerned to examine the region-specific spatiality of medical networks. References Bashshur, R. L., Reardon, T. G. and Shannon, G.W. (2000). Telemedicine: a new health care delivery system. Annual Review of Public Health, vol. 21, p Cutchin, M. (2002). Virtual medical geographies: conceptualizing telemedicine and regionalization. Progress in Human Geography, vol. 26, p Hayashi, N. and Niimi, Y. (1998). Spatial supply system of emergency medical service in Aichi Prefecture. Annals of the Japan Association of Economic Geographers, vol. 44, p Hirai, A. (2004). Reliable cooperation of regional health care. Igaku-Geijutsusya. Löytönen, M. (2000). Telemedicine and the geography of health. Paper presented at the 9 th International Symposium in Medical Geography, Montreal, 3 July. Mayer, J. (2000). Place, telemedicine, and the doctor-patient relationship. Paper presented at the 9 th International Symposium in Medical Geography, Montreal, 3 July. Okamoto, K. (2000). Urban space and urban life in the information age. Annals of the Japan Association of Economic Geographers, vol. 46, p Shannon, G. W. (1997). Telemedicine: restructuring rural medical care in space and time. in Bashshur, R. L., Sanders, J. H. and Shannon, G. W. (eds), Telemedicine: theory and practice, Springfield, IL; Charles C. Thomas, p Shannon, G. W. (2000). Telemedicine: does distance matter? Paper presented at the 9 th International Symposium in Medical Geography, Montreal, 3 July. Strömgren, M. (2000). Health care provision in marginal areas by means of telemedicine. GERUM kulturgeografisk arbetsrapport Umeå: Kulturgeografiska institutionen, Umeå universitet.

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