1Telemedicine is the use of information and communication technologies to transfer medical information to aid in the delivery of clinical and educational services (Norris, 2002). It appears likely that telemedicine contributes to avoiding the costs and dangers of transporting patients to external medical institutions, known as the “tyranny of distance,” and to improving the equitable geographic distribution of health care resources (Shannon, 1997). Telemedicine is regarded as a blueprint for futuristic medical innovation that can greatly improve accessibility to and utilization of medical institutions and the transfer of medical information (Cutchin, 2002). However, telemedicine’s efficacy requires further research on the dearth of empirical verifications and the potential limitation of related technologies, which is open to dispute from a practical perspective. It is treated as a complementary medical innovation (Reid, 1996), and patients who make use of telemedicine are required to see a medical specialist in person at least once to avoid an incorrect diagnosis in many countries, including Korea and Japan. General health care concerns that relate to accessing and utilizing medical institutions are also present with telemedicine. Also, the current research in geography and related fields has suggested alternative theories and introduced regionalization as one of the practical measures (i.e., management, regulation, and investment) in the existing spatial theories of health care (Cutchin, 2002; Shannon et al., 2002).
- 1 According to the legislation of the health care system in Korea and Japan, the diagnostic area is d (...)
2The introduction of advanced information technologies and the increase in availability of health care in the mid-1990s led to the practice of telemedicine in Korea and Japan within the potential geographical boundary known as the tertiary care level1 with regard to regionalization. Particularly, the on-line referral system in Korea is the focus of this research as it shares the patients’ medical records between medical institutions, with general hospitals being the central unit within one diagnostic area. In Japan, each prefecture, which is the geographical boundary of one diagnostic area, services the telemedicine system according to the residences or local doctors’ needs or demands. Although there are some differences in utilization, the original purpose of telemedicine operations in Korea and Japan is the promotion of regional health care at the tertiary care level, according to the medical laws and regulations.
3Curiously, despite the significance of telemedicine with regard to a geographical or spatial discipline, few studies have attempted to address the geographical characteristics as to whether telemedicine networks correspond with the medical laws and regulations regarding regionalization in Korea and Japan, namely, the virtual relationship between medical institutions receiving telemedicine (clinical sites mostly) and medical institutions providing telemedicine (general hospitals or tertiary care centers) via the telemedicine system. Therefore, the aim of this paper is to investigate the geographical characteristics of telemedicine, in particular the telemedicine networks related to regionalization in Korea and Japan, by considering Choongbook in Korea and Kagawa in Japan. To ascertain the distinctive geographical characteristics of telemedicine networks with regard to regionalization in Korea and Japan, two questions are investigated: 1) how medical institutions receiving telemedicine are associated with medical institutions providing telemedicine, in other words, telemedicine networks within one diagnostic area or between diagnostic areas; and 2) what determinants influence the propensities of telemedicine users toward those telemedicine networks.
- 2 In terms of health care, regionalization can be substituted for decentralization, although decentra (...)
4Telemedicine has frequently been noted in geography and related fields but has rarely been studied in depth. The dearth of research on this subject is likely a result of the considerable complexities involved with telemedicine, such as considering the relationship of health care with welfare or other public interests, technology, and even economic implications; the system is continually advancing. Therefore, it is not easy to obtain a clear geographical consensus with regard to telemedicine (Abou-Shaaba and Naizy, 1991; Reid, 1996; Capalbo and Heggem, 1999; Cutchin, 2002; Glasgow, 2002; Shannon et al., 2002; Mihara, 2004; Gilbert, et al., 2008). However, a few studies have reported that regionalization is viable and preferable (Cutchin, 2002; Shannon et al., 2002; Nguyen, et al., 2010). Regionalization2 in health care refers to the purveying of medical services being delegated to a specialized local office and to local organizations within well-defined geographical boundaries (Mills, 1990). The same terms apply to telemedicine. Telemedicine is associated with cyberspace or placelessness (Dyb and Halford, 2009) and is, therefore, not beholden to physical restrictions or geographical considerations. Thus, regionalization might seem irrelevant in a discussion about telemedicine. However, the following three reasons show why regionalization is a key geographic factor in telemedicine.
5First, though a complete shift from offline to online care seems plausible and attractive, telemedicine requires further study regarding its related technologies and potential limitations. These limitations include language barriers, time limitations, infrastructure-related geographical restrictions and the limited availability of telemedicine from a practical standpoint (Cutchin, 2002; Norris, 2002; Shannon, 1997; Tanriverdi and Iacono, 1999; World Health Organization, n.d.). For example, telemedicine is most widely used for medical examinations through interviews, a practice that is associated with the danger of indirect medical interactions, such as time delays or language barriers. Moreover, healthcare itself is strongly associated with face-to-face interactions between medical specialists and their patients rather than interactions with a coded online system (Andrews and Kitchin, 2005). Furthermore, many countries require patients to see medical specialists in person at least once to avoid an incorrect diagnosis through such a system. It is commonly accepted that telemedicine is an auxiliary medical practice instead of a replacement for in-person examinations (Reid, 1996). Accordingly, one of the existing optimal spatial theories in healthcare delivery (regionalization) plays an important role in telemedicine.
6Second, through the development of telemedical technologies, telemedicine has connected multifariously to other information-sharing domains in the healthcare industry, including the control, management, and analysis of medical records for the provision of clinical, administrative, and educational services (Braa and Hedberg, 2002; Grimson, 2001; Mäenpää et al., 2009; Norris, 2002; Lucas, 2008; Solomon, 2007). The collection of medical records via telemedicine is routine on both national and global scales, but information systems are caught in a complex web of social and technical interactions. These social and technical interactions include racial segregation, social strata, and conflict among regions (Braa and Hedberg, 2002). Regionally based telemedical systems, which encompass an optimal geographic area for control, have been developed from the bottom-up. For example, medical records contained within the telemedical system can aid in emergency situations because paramedics refer to these records when administering first aid to their patients (Wang et al., 2009). These records can also be used in the analysis of epidemics or chronic diseases in a certain region and can aid in both disease prevention and the provision of better public healthcare. Moreover, medical records are not only used in medical institutions but also in pharmacies, gyms, schools, companies, and other institutions to improve healthcare in residents’ home areas.
7Third, as with general healthcare, profits derived from telemedicine are not confined to fixed diagnostic areas. Healthcare, including telemedicine, has two opposing characteristics: effectiveness, which is an economic factor, and equity, which is a public interest factor (Smith, 1977; DeVerteuil, 2000). The most important problem in delivering public healthcare is how to successfully balance the competing needs for equity and efficiency. Generally, this issue can be simplified into a question about the diagnostic boundary as it relates to regionalization. The diagnostic boundary encompasses those living within a certain radius of a facility, and many countries have incorporated these boundaries into laws related to their healthcare delivery system (Mills, 1990). Because telemedicine is generally centered in existing medical institutions, rather than new facilities, and is conducted under established healthcare delivery systems, it is necessary to maintain the diagnostic area of each medical institution and to ensure offline delivery of services from existing hospitals and clinics. Online capabilities should only be used to extend services to distant areas (Norris, 2002). Confining medical incomes to only one diagnostic area might lead to a broad-scale breakdown of alternative diagnostic areas, which, in turn, may threaten the effectiveness and equity of healthcare because profits are directly associated with the offline healthcare system upon which telemedical healthcare is dependent.
8Regionalization is not a new idea (Shannon et al, 2002) in medical geography. In the 1970s, there was much vigorous discussion on how to promote accessibility to and utilization of medical institutions, including public facilities (Smith, 1977; DeVerteuil, 2000), and how to cope with the conflict between equity (welfare) and efficiency (economic) through geographical ideas. Regionalization was suggested as the answer and many countries have incorporated this concept into their healthcare delivery policies (Mills, 1990). Such a concept is also applied in telemedicine because of its character and methods of practice, as mentioned earlier.
9“Region,” however, is a flexible idea and changes according to social and medical circumstances. Regionalization is also a slippery concept that varies from writer to writer (Cutchin, 2002). Therefore, it is reasonable to situate this ambiguous definition in a regional scale before contending with other criteria. In Korea and Japan, telemedical operations are monitored by the medical laws and regulations and are dispersed on the basis of one diagnostic area (generally, based on one province in Korea or one prefecture in Japan), i.e., medical institutions as telemedical service sites (mostly, tertiary care centers) assume the responsibility for regional health care. The availability of telemedicine corresponds with promoting regional health care within a potential geographical boundary at the tertiary care level. The focus of this research is to examine whether the relationship between medical institutions providing telemedicine and those receiving telemedicine via the telemedicine system functions within the medical laws and regulations with regard to regionalization.
10My examination of “online referrals” in Korea is a major objective in this research. The study focused on the relationship between the first or secondary medical institutions and tertiary care centers and the relationship of the online referral system was structured with the public interest in mind by allowing hospitals and clinics to share medical records in terms of regional health care. Initially, the referral system was based on a traditional “hands-on” or “paper-based” health care practice, but there have been several changes to the practice since the mid-1990s, such as the advent of the online-referral system. The online-referral system promoted the transmission of health care delivery via online communication systems within one diagnostic area based on tertiary medical care level and was composed of all eight diagnostic areas in Korea originally.
11The transmission of health care delivery in online referrals is conducted by in-person and virtual interactions among patients, physicians, and medical specialists. In other words, physicians provide the medical records of the patients who require special treatment at tertiary care sites to the medical specialists using this system. Patients visit the tertiary medical institutions without any of their medical records on hand, and medical specialists can diagnose their condition by referring to the patients’ Web-based medical records. This protocol can prevent duplicated medical treatment and allow medical specialists to provide only essential medical treatments to patients. Likewise, medical specialists can refer those patients back to their primary care physicians with their updated Web-based medical records, and the patients can receive continuing care from their physicians without the excessive burden of having to keep track of their medical records. Online referrals can prevent overflow of patients in tertiary medical institutions and promote accessibility to and use of other medical institutions, despite the requirement that patients visit in person with a health care provider at least once.
12The telemedicine system was instituted to cope with local residents’ demand or need in one diagnostic area (one prefecture) independently. Kagawa, a main geographic area included in this study, also suggested the telemedicine system for local residents and medical participants. The initial telemedicine system in Kagawa originated with the online transmission of information for pregnant women and has continued to expand with the support from the central governments’ strategies, such as the telecommunications revival and rural health care measures, so that Kagawa has the present telemedicine system, that is known as “K-MIX (Kagawa Medical Internet eXchange, http://www.m-ix.jp/)”. Initially, only 35 medical institutions were involved in the K-Mix system, but now 78 medical institutions, including medical institutions in other prefectures (however, their utilization is limited by data control and storage), utilize telemedicine services and transfer interactive communication data among medical institutions. This system provides the function of online referrals, the transmission of medical images, such as teleradiology or telepathology, the management of data control and storage, and the additional health care information according to the kind of various diseases. Although there are differences between the online referral system and K-MIX, they both use telecommunications to transmit data and images between two or more sites remotely located from each other and to share medical records among doctors (American Telemedicine Association, 2010).
Figure 1. Location of Choongbook in Korea
13To verify geographical phenomena in detail, I examined two local areas: Choongbook in Korea (Figure 1) and Kagawa in Japan (Figure 2). According to a socially and geographically accepted idea, it is easy to have telemedicine networks that are generated in or that connect to the metropolitan areas according to the distribution of potential customers or the population. Identifying the telemedicine networks in the metropolitan areas does not sufficiently explain whether telemedicine networks in each country correspond with the medical laws and regulations. By investigating local areas, the geographical characteristics of telemedicine networks appear more clearly, namely, whether telemedicine networks are associated with the original purpose of telemedicine with regard to the potential boundary of the tertiary care level or whether a telemedicine network exceeds one diagnostic area or not. Therefore, two representative areas are valuable to investigate this geographical issue.
Figure 2. Location of Kagawa in Japan
Both local areas border major urban areas: Kyunggi, including the capital of Korea, Seoul, in Korea and Okayama, Osaka and Kyoto in Japan.
14I focus on two major factors in this analysis: comprehensive characteristics of telemedicine networks from two research areas, Choongbook in Korea and Kagawa in Japan; doctors and patients as telemedicine users’ propensities and determinants.
15The first method examined the comprehensive characteristics of telemedicine networks using data from 243 medical institutions receiving telemedicine in Choongbook and 63 medical institutions receiving telemedicine in Kagawa. In Korea, the online referral system operates in 62 medical institutions spread across the country, with 51 of these institutions posting their data on the web for other medical institutions providing telemedicine (Park, 2010). Out of 17,783 nationwide medical institutions receiving telemedicine, data from the 51 Korean medical institutions providing telemedicine and from 243 medical institutions in Choongbook were used in the analysis. The number of medical institutions receiving telemedicine represents 30.8% of the total medical institutions (790 medical institutions including general hospitals, middle size hospitals and clinics) throughout Choongbook in 2007. For Japan, the number of medical institutions providing or receiving telemedicine was not very large, mainly due to the telemedicine council’s control over the telemedicine applications in Kagawa. Each telemedicine network is released onto the K-MIX website. Using homepages that provide information on the telemedicine practices of Kagawa, this study obtained data regarding 8 medical institutions providing telemedicine and the 63 medical institutions receiving telemedicine in 2008. In addition, the data center provided the data on telemedicine flow between health care sites providing telemedicine and health care sites receiving telemedicine. The first method examined how medical institutions receiving telemedicine are associated with medical institutions providing telemedicine comprehensively with regard to regionalization. In other words, an exploration of telemedicine network patterns contributes to the discussion on whether telemedicine in Korea and Japan is operated faithfully within a regional-based diagnostic system at a tertiary-care level.
16The second method explored the notion that doctors and patients (telemedicine users) are crucial decision-makers for telemedicine networks’ propensities and determinants. In Korea, I conducted interviews at 4 medical institutions receiving telemedicine and with 28 patients who were referred by these medical institutions in 2009. In Japan, I investigated 3 medical institutions receiving telemedicine and 25 patients who were referred by these medical institutions in 2010. The criteria to be interviewed were that for doctors or medical staff included: (1) understanding of online referrals, K-MIX, and the process between the first and secondary medical institutions and tertiary care centers (medical institutions providing online referrals or K-MIX) individually; (2) having referred their patients to medical institutions providing online referrals or K-MIX. In addition, the selection criteria for patients was based on: (1) residential area and medical insurance address in Choongbook and Kagawa; (2) referrals via the online referral system and via K-MIX by doctors of the first and secondary medical institutions in Choongbook and Kagawa; and (3) understanding of online referrals or K-MIX and the process between the first and secondary medical institutions and tertiary care centers. Before conducting the interviews, I asked the collaboration of this interview for permission to conduct these interviews from 17 pharmacists that were registered as members of the pharmaceutical association in each area of Choongbook. Moreover, the telemedicine council in Kagawa, which controls and participates in the all aspects of telemedicine, collaborated with this research very aggressively, including suggesting the medical institutions utilizing K-MIX that are relevant with the top three users of K-MIX.
17To ascertain the propensities of telemedicine users, I asked telemedicine users (patients and physicians) 1) what the choice of medical institutions was that provided online referrals and K-MIX that they had been referred 2) the frequency of using telemedicine monthly.
18In contrast, it is not currently feasible to make valid generalizations about the effectiveness of telemedicine, including online referrals and K-MIX, across disparate health services, technological configurations, and settings (Grigsby et al., 2005). However, the determinants of telemedicine users were guided by the evaluations from past research on criteria in telemedicine, in particular, from clients’ and patients’ perspectives (Coughlan et al., 2006; Dávalos et al., 2009; Hicks et al., n.d.; Garshnek and Hassell, 2000; Mair and Whitten, 2000; Whitten and Love, 2005).
19With regard to private dimensions, patients or doctors make the final decisions and must be included in this discussion. Therefore, it is a key to examine what patients and doctors think of online referrals and K-MIX, including relative disease seriousness and satisfaction. In addition, the Korean and Japanese societies are focused on strong human relationships; private relationships are also evaluated in determinants. The following parameters focus on social and medical aspects in Choongbook and Kagawa or other diagnostic areas and are applicable to the external influences of online referrals and K-MIX: the images that patients or doctors have and their level of awareness of tertiary medical institutions, the use of tertiary medical institutions as medical institutions providing telemedicine services, the medical services of tertiary medical institutions and the advantages of online referrals and K-MIX. The final criteria are based on geographical dimensions, such as the decrease in accessibility via online referrals and K-MIX (proximity), the transportation system, and the distribution of medical institutions providing telemedicine (Table 1).
Table 1. Determinants of the decisions for online referrals and K-MIX from telemedicine users in Choongbook and Kagawa
Provision 1. Relative seriousness of disease
Provision 2. Satisfaction with medical services
Provision 3. Private preference regarding medical institutions providing telemedicine without considering the seriousness of the disease
Provision 4. Private relationships with medical specialists or staff (acquaintances) of medical institutions providing telemedicine and, accordingly, various advantages
Social and medical dimensions
Provision 5. Image or awareness associated with the appraisal of medical institutions providing telemedicine in Choongbook and Kagawa or in other diagnostic areas
Provision 6. Utilization of medical institutions providing telemedicine (time or cost)
Provision 7. Good medical services or the strong attraction of good medical institutions providing telemedicine
Provision 8. Advantage of the telemedicine system
Provision 9. Proximity of medical institutions providing telemedicine
Provision 10. Development of the transportation system (improved accessibility)
Provision 11. Poor distribution of medical institutions providing telemedicine
20Although there are similar points in the medial laws and circumstances in Korea and Japan, the key decision-makers present different views: online referrals in Korea are conducted by patients dominantly, with K-MIX mostly being utilized for telemedicine networks between physicians and medical specialists. This research referred to two telemedicine users’ opinions often, but online referrals in Korea were surveyed centering on patients and the major interviewees with regard to K-MIX were physicians.
Figure 3. Sites of medical institutions providing telemedicine where clinical sites refer their patients across all diagnostic areas (n=243)
21Locations with clinical sites receiving telemedicine via telemedicine networks in Choongbook include 158 clinical sites (65.0%) that had established telemedicine, in Choongbook itself (41, 16.9%), in Choongnam (21, 8.6%) and in Kangwon (6, 2.5%) (Figure 3). Some clinical sites in Choongbook have telemedicine networks with medical institutions that provide telemedicine with several telemedicine networks, e.g., Kyunggi and Choongbook (8, 3.3%), Kyunggi and Chungnam (3, 1.2%), Kyunggi and Kangwon (5, 2.1%), even Kyunggi, Choongbook and Kangwon at once (1, 0.4%). Remarkably, it appears that many of the clinical sites as medical institutions receiving telemedicine in Choongbook are utilize medical institutions providing telemedicine in Kyunggi, irrespective of both online referrals and the health care delivery system with regard to regionalization. Therefore, telemedicine networks connecting with the external diagnostic areas are general phenomena in Choongbook.
22A closer inspection of each area in Choongbook may explain the geographical characteristics of the telemedicine networks more fully. For this question, the investigation takes note of where and how much telemedicine networks in Choongbook occur and in what direction telemedicine networks connect (Figure 4). Medical institutions receiving telemedicine throughout Choongbook are responsible for the proliferation of telemedicine networks toward Kyunggi. Most of the telemedicine networks served by Kyunggi are associated with Cheongju as a major city in Choongbook and Chungju and Jincheon as the second major cities, but many of the networks originate from the peripheries of Choongbook. The telemedicine networks in Choongbook serve medical institutions receiving telemedicine from all areas of Choongbook, except for Danyang, Jechoen, Okcheon, and Yeongdong, which are far away from the central urban area (Cheongju). In addition, some clinical sites as medical institutions receiving online referrals in Okcheon and Yeongdong deal with tertiary care centers as medical institutions providing online referrals in Choongnam. The telemedicine networks servicing Kangwon are used by medical institutions receiving online referrals from Chungju, Jecheon (10, 3.2%), and Danyang (2, 0.6%). Hence, telemedicine networks services are centralized to Kyunggi, whereas outputs to outlying areas can be observed all over Choongbook.
Given the results, the comprehensive geographical characteristics of telemedicine networks can be defined as many clinical sites in Choongbook that are associated with outside medical institutions providing online referrals. In addition, the online referrals’ networks show a peculiar result in Choongbook in that geographical characteristics of telemedicine networks depend on which specific areas in Choongbook telemedicine networks occur and where those telemedicine networks are directed: from the southern part of Choongbook, from the eastern part of Choongbook and the central part of Choongbook centering around Cheongju as the seat of a Choongbook provincial government. The following investigation explores core telemedicine users’ propensities and determinants with regard to these geographical results through three typical areas.
Figure 4. Telemedicine networks connect Choongbook to Kyunggi, to Choongbook itself, to Choongnam and to Kangwon
n=158, including 17 plural telemedicine networks, n=50, 9 plural telemedicine networks, n=21, 3 plural telemedicine networks, n=12, 6 plural telemedicine networks
23Through the examination of four medical institutions receiving online referrals according to the connection of online referrals in three typical areas, one can conclude that the propensities among those areas are clearly different. In particular, the C health care site providing online referrals plays a role as a provider of online-referrals service within Choongbook and its patients were referred by local clinical sites. The C health care site providing online referrals could not solve the patients’ medical problems; therefore, the patients were referred from this health care site to other medical institutions providing online referrals. The case of the C clinical site shows the propensities or the determinants of telemedicine users, in particular, the difference between the patients’ choice of the internal medical institution providing online referrals and the external one (Table 2).
24Te decisions to use online referrals depends on patients, who generally show strong private preferences toward medical institutions providing online referrals in Kyunggi, in spite of travel time and burdens to medical institutions providing online referrals (provision 3). Although the online referral system is a medical innovation, the fact that medical institutions providing online referrals can guarantee healthcare services to patients is the most important consideration among patients (provision 7). Some physicians utilize the positive image of online referrals to promote clinical sites’ images and to attract many patients to their own clinical sites in the competitive health care market in Korea (provision 5). Finally, online referrals’ technology or related convenience and utility were not observed as important factors in the results of the interview.
25As discussed previously, patients have a strong tendency to prefer medical institutions providing online referrals outside Choongbook, in particular, to Kyunggi. Given the results of their determinants, it is clear the reasons why many patients want to be referred to the outside health care sites providing online referrals. Personal motives that inform their health care decisions include the relative severity of their disease (serious symptom) and their personal satisfaction with the healthcare sites among other preferences (provision 1, provision 2, and provision 3). In this context, images or awareness of medical institutions providing telemedicine in other diagnostic areas (provision 5) and good medical services (provision 7) are also major considerations as part of the social and medical elements of this study, possibly due to the high rate of medical accidents in medical institutions in Choongbook. Although there is no direct reference in the results, geographic characteristics, such as the poor distribution of tertiary medical institutions as online-referrals service sites (the centralized distribution of medical institutions providing online referrals centering around Kyunggi), and the lack of strong restrictions in the accessibility to online-referral service sites because of the development of the transportation system also stimulate the patients’ preference to visit online-referral service sites outside of Choongbook. Though the online-referral system associated with regional health care in Korea is regarded as an innovative device for the delivery of medical care via telecommunications technology, patients don’t prefer online referrals for their technological value, convenience, and original purpose.
26Some patients, who were referred by the C health care sites provided online referrals within Choongbook and visited medical institutions providing online referrals outside of Choongbook once more due to their disease, dissatisfaction or other reasons. This suggests that the relative seriousness of disease (slight symptom) and good medical services were considerations when patients chose a medical institution providing online referrals within Choongbook as the secondary medical institutions (provision 1 and provision 6). Similar reasons are observed in the selection of medical institutions providing online referrals in Choongnam and Kangwon. Although those areas are not included in the same diagnostic area (Choongbook), the accessibility to and utilization (time and cost) of medical institutions providing online referrals in Choongnam and Kangwon is good and medical institutions providing online referrals in Choongnam and Kangwon can guarantee high-level health care. Therefore, many residents who live in the southern or eastern parts of Choongbook regarded those medical institutions as the appropriate tertiary care centers for them instead of the internal ones. The favor of the medical institutions providing online referrals in Choongnam and Kangwon is higher than the medical institutions providing online referrals in Choongbook because of the high reputation and good medical services of those medical institutions.
Table 2. The summary of the propensities and determinants in terms of medical staff (physicians) and patients in Choongbook
27Finally, without the provision of good medical services, patients cannot choose medical institutions providing online referrals regardless of the location of medical institutions. The existing health care system is the most important consideration currently. In addition, many patients don’t come back to the clinical sites of the first medical institutions; rather, they continue or finish their medical treatment in outlying medical institutions providing online referrals. Therefore, online referrals degenerated into one-way transmission via the Web contrary to the original purpose of the online referral system.
28Telemedicine networks in Kagawa do not operate outside of the potential boundary for diagnosis at the tertiary care level. There are some outlying medical institutions receiving telemedicine that are associated with Kagawa; these medical institutions are not interested in diagnosis through telemedicine, only in data control. The data center in Kagawa is managed by a telecommunications company as well as the management committee of the telemedicine system in Kagawa, which consists of representatives from the Kagawa prefecture government, the Kagawa medical association, and STNet (company for data control). Due to this management, telemedicine’s focus in Kagawa is on stable regional health care. Its high reputation for information security is acknowledged by many diagnostic areas in Japan and some medical institutions ask Kagawa for assistance with their data control although Kagawa is not directly associated with diagnosis through telemedicine. There have been some experiments in sharing telemedicine services between Kagawa and other diagnostic areas (including the University of Tokyo, Hokkaido University, and other Shikoku area), but these have not gone beyond the experimental stage. Because telemedicine technologies were sometimes incompatible, the trial of joint telemedicine services between Kagawa and other diagnostic areas did not attract sufficient medical institutions, due to time delays and a lack of profitability.
29By taking a closer look at the connections between telemedicine networks among the regions in Kagawa, I can identify the geographical characteristics of telemedicine with respect to the outward flow and the inward flow of telemedicine networks (Figure 5). The outflow of telemedicine networks occurs in Marugume, Miyoto, Miki and Kotohira, whereas the inflow occurs in Zentsuji. In other words, judging from the outflow of telemedicine networks in Kagawa, it appears likely that most of the telemedicine networks there serve Marugume (1,938, 66.0%), Miki (340, 11.6%), Mitoyo (290, 9.9%) and Kotohira (237, 8.1%), in that order. Many medical institutions receiving telemedicine in Kagawa are centralized in Takamatsu (21, 28.4%), Sakaide (8, 10.8%) and Miki and Kanonji (5, 6.8%, respectively), but the outflow of telemedicine networks in Takamatsu, Sakaide, and Kanonji are minimal, except for that of Miki. With regard to the inward flow of telemedicine networks, the majority of medical institutions providing telemedicine are located in Takamatsu (3, 37.5%), Kanonji (2, 25.0%), Sakaide and Miki and Zentsuji (1, 12.5%, individually), which are located in major urban areas in Kagawa, but only the telemedicine supplier in Zentsuji, which doesn’t hold a major position among eight telemedicine suppliers relatively, operates in Kagawa. Therefore, one can safely state that there is no direct relation between the number of medical institutions receiving telemedicine and the outflow of telemedicine networks. With this in mind, geographical characteristics of telemedicine networks in Kagawa are defined by decentralized telemedicine networks with regard to regionalization. However, geographical characteristics, for example, an inadequate number of medical institutions in relation to the inflow or outflow of telemedicine networks, do not determine the flow of telemedicine networks.
Figure 5. Inflow and outflow of telemedicine for each region in Kagawa
Note. « The arrow » means that the inflow of telemedicine corresponds with the outflow of telemedicine
( , ) means (the number of medical institutions providing K-MIX, the number of medical institutions receiving K-MIX)
30According to the interview with the telemedicine council, it is likely that the geographical characteristics of telemedicine networks in Kagawa are associated with the utilization of medical institutions receiving telemedicine. The operation of telemedicine networks is observed within Kagawa according to the residents or medical staff’s request and the geographical characteristics of telemedicine networks have no regular patterns outwardly; control and storage of medical care information, vertical telemedicine networks, horizontal telemedicine networks, and telemedicine networks with an offline meeting.
31The accumulated data is used to exchange medical information among medical institutions or doctors and to have the ability to refer to each patient’s medical history when diagnosing. But this utilization is not associated with delivering of medical records directly; therefore, this research investigates this factor. Secondly, telemedicine networks consist of vertical telemedicine relationships between medical institutions providing telemedicine and those receiving telemedicine. In other words, telemedicine networks mean that medical institutions centering around clinics, which don’t possess special medical departments in general, refer patients to receive professional advice from larger medical institutions, i.e., general hospitals or university hospitals as telemedicine service providers. By referring specialized medical opinion about patients to larger medical institutions via the telemedicine system, those medical institutions and patients can solve medical problems without accessibility to or utilization of medical institutions as telemedicine service providers. The third utilization of telemedicine is observed in the horizontal telemedicine networks among medical institutions. General hospitals have medical specialists for specific medical departments; however, their diagnosis may be difficult to complete with actual medical treatments. These general hospitals can seek expert advice through this system. The last utilization of the telemedicine system in Kagawa is closely allied with the health of a target population. For example, there is one telemedicine group targeting stroke with a core medical institution providing telemedicine services and associated facilities (clinics, rehabilitation centers, care houses, etc.) receiving telemedicine services use the telemedicine system to interchange patients’ data smoothly with each other. To promote the mutual understanding of whether patients are covered in each facility and what medical treatment patients need, the telemedicine group targeting stroke has a regular meeting to discuss patients’ needs or conveniences (Hujimoto, 2009; Hayashi, 2010). In the mainland of Kagawa, vertical telemedicine networks and telemedicine networks with an offline meeting occupy an important position; moreover, medical institutions receiving telemedicine in an island of Kagawa are using the telemedicine system for horizontal telemedicine networks. The original purpose of telemedicine networks was to support isolated areas; therefore, it is clear why medical institutions receiving telemedicine are located on islands. Given these factors, the following section provides specific determinants concretely.
32With regard to human networks and mutual agreement, K-MIX is utilized in response to the local demand. In other words, each participant of K-MIX, such as medical institutions providing or receiving K-MIX, and business sectors are connected to the telemedicine council that consists of the local government, an innovator group, and the medical association within Kagawa. Specifically, the innovator group suggests the use of delivering medical information via K-MIX to local doctors and the telemedicine council provides proper telemedicine technologies to medical institutions providing or receiving K-MIX according to the demand or need of local doctors or patients. Doctors utilize this system to promote patients’ condition and protect patients’ accessibility to and utilization of medical institutions. Before operating K-MIX, the help of the telemedicine council and medical institutions providing K-MIX is required. With their consensus, this system can operate. Moreover, owing to mutual trust between physicians and patients as inpatients or outpatients of the medical institutions receiving K-MIX for a long period of time, patients accept the operation of K-MIX, namely, delivering their medical records online, without any resistance. Physicians prepare various countermeasures in case K-MIX has medical problems or cannot solve patients’ medical problems clearly (provision 4 and provision 8) (Tab. 3).
33The most important consideration for using this system was whether this system or the medical institutions providing telemedicine could guarantee high-level medical treatment or diagnosis. In most cases, physicians or doctors in the medical institutions receiving telemedicine have referred their patients to the medical institutions providing telemedicine through the traditional health care delivery methods, such as handwriting referrals, and already knew whether medical institutions providing telemedicine could support physicians or doctors in the medical institutions receiving telemedicine via the online system. The existing health care services are associated with the crucial determinants of physicians and doctors in operating this telemedicine system (provision 7).
34There is a multitude of alternative ways to refer patients to other medical institutions or to deliver (share) medical records. Telemedicine users have acknowledged the utility or convenience of this system, but this system is not regarded as an indispensable method. In addition, the telemedicine networks via K-MIX are not connected with big general hospitals as telemedicine serving sites because of their outpatients and inpatients and the difficulty predicting profitability. Telemedicine users pointed out this aspect as an improvement. According to regional differences, such as telemedicine networks on the mainland and on islands, the crucial determinants of telemedicine networks don’t show indisputable differences. As an example of horizontal telemedicine networks, only just recently did the U general hospital indicate the advantage of the telemedicine system and various experiments and applications via the telemedicine system. It may be due to the presence of other alternative supportive health care systems, such as visiting nurse system or the system in which doctors visit the medical institutions receiving telemedicine networks regularly.
Table 3. Summary of the determinants in terms of medical staff (physicians) in Kagawa
35The results of the present research can be summarized as follows: the analysis scrutinized the decision-making characteristics of the patients toward online referrals in Choongbook: the patients did not enjoy their experience at the local tertiary medical institutions. Most patients showed a strong inclination to visit the tertiary medical institutions outside of Choongbook. Psychological considerations regarding quality and level of health care services, personal stakes in online-referral service sites, acceptability and credibility of good tertiary care centers and easy access to and use of medical institutions were associated with their deliberate propensities. Patients’ desire to experience good medical services while taking into consideration existing healthcare’s level of service and quality, influences the current state of online referrals, which reflects their decision-making.
In contrast, the decentralized telemedicine networks are outstanding in Kagawa. The interviews with doctors and their patients provided further insight into Kagawa. Both the existing health care system and the telemedicine system support the maintenance of stable regional healthcare in each diagnostic area. Moreover, the convenient reduction in patients’ travel time and burdens, as well as the transmission of medical records for good and proper medical treatment in terms of social and medical dimensions are considerable. The most important consideration is private relationships between either the telemedicine council or physicians in medical institutions receiving telemedicine or between physicians and their patients. These determinants were associated with the original purpose of telemedicine, which was to promote regional health care in Kagawa as well as the original purpose of telemedicine (K-MIX) regarding regionalization. The technological value, convenience and utility were considered important at this stage of telemedicine in Japan.
36Although telemedicine operations in Korea and Japan are accord with the medical laws and regulations with regard to promoting regional health care at the tertiary care level, the sharp geographical differences in the application of telemedicine between Choongbook and Kagawa are enhanced by centralization (inter-regional telemedicine networks at the national level) and decentralization (regional-based telemedicine networks). In other words, medical institutions associated with telemedicine operations in Choongbook are concentrated in one specific diagnostic area (Kyunggi). Additionally, it is easier to identify the telemedicine networks at the inter-regional level in Choongbook as they are involved with Kyunggi (at the national level) in most cases, than at the regional level. Medical institutions that participate in telemedicine operations are associated with telemedicine suppliers in each diagnostic area in Kagawa. Moreover, the major geographical patterns of telemedicine networks are observed at the regional level in Kagawa (Figure 6).
Figure 6. Telemedicine networks for local areas in Korea (up) and Japan (down)
37The difference between telemedicine networks for local areas in Korea and Japan is associated with the following hidden aspects. In Korea, the imbalance of healthcare services encourages patient preference for outside medical institutions compared to inside ones. Tertiary medical centers center around Kyunggi, particularly, Seoul, in proportion to the population (22.5%). More than one-half of all online-referral service sites (54.9%), which are acknowledged as high-level tertiary care centers, are located in Kyunggi. Moreover, these medical institutions are included in private sectors, managed by big companies and universities instead of public ones, and have a profit-oriented bias relatively. Although they suggested this system themselves for regional health care, these online-referral service sites accepted patients willing to accept high travel time and burdens for high-level health care without considering the original purpose of online-referrals. Additionally, extrinsic factors, excepting for unfair health care services themselves, such as a greater desire to diagnose in good medical institutions among patients, enhanced life’s quality, the development of transportation and communication and many propagators, who have ever experienced good care services, or various medical stimulate patients, in particular, in local areas.
38As previously mentioned, telemedicine networks have been strongly based on human networks in Japan from the beginning start of its operation. More specifically, if the telemedicine council, which consists of general telemedicine participants in Japan, cannot play an original role for making stable regional health care services, it is very difficult to maintain the system because of steady investment in telemedicine and technological innovation. In contrast to highly motivated attention in the early stage, some prefectures remain undeveloped due to a lack of innovators and varying gaps in telemedicine usage among prefectures. In Kagawa, the telemedicine council’s activities are very progressive and have support from various sources, including from the local government, from huge investments, and from the development of related businesses, that have uplifted and maintained that system. Given this system, the K-MIX system is developing in various directions. For example, the accumulated medical records compiled from operating telemedicine play an important role in health care, e.g., in emergency situations, the analysis of epidemics or chronic diseases for the residents. Moreover, medical records are not only used in medical institutions but also in pharmacies, gyms, schools, companies, and other institutions for improving health care services within Kagawa (Hara, 2009).
39The major reason why telemedicine networks have unique geographical characteristics in Korea and Japan in spite of common medical laws and regulations regarding regionalization is that the operation of telemedicine in Choongbook and Kagawa is influenced by social and medical circumstances. In Choongbook and Kagawa, the telemedicine system provides for nothing or offers a cheap price and is affiliated at the beginning stage. There are various alternative methods to transmit medical records or to help patients directly, such as community medicine or domiciliary health care services without operating telemedicine. This research suggests that online referrals in Choongbook have many improvements offline, in particular, healthcare services on a nationwide scale without discrimination, rather than online aspects related to technological dimensions regarding regionalization. Likewise, the Kagawa telemedicine system urges the participation of major tertiary care centers that can play a role as high-level medical institutions.
40This research focused on telemedicine networks for local areas in Korea and Japan, including an examination of the perspectives of telemedicine users (patients and physicians). To understand telemedicine networks regarding regionalization more comprehensively, future studies should address nationwide telemedicine networks according to regional differences, such as local, urban fringe, and metropolitan areas. It is necessary to examine the decisions of various telemedicine participants, e.g., telemedicine service providers, and administrators.