Open Source Software in Medicine and its Cultivation in Japan Shinji KOBAYASHI Ehime University, Japan


e-Health care
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Background, health care in Japan Many standards, few implementations World wide trends Japan Medical Association IT Declaration ORCA Project Medical Open Source Software Council in Japan

Open Source Software in Medicine
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e-Health care in Japan and My bibliography
Era 1970 Happy Origin 1980 Hopeful development 1990 Painful growth 2000 E-Health in Japan Start for research 'Receipt computer' Claiming system for insurance My bibliography Born in Saga Japan at April 19, 1970 Manga, Anime, Computer Medical student/ Kyushu University

Clinical Physicians Order MD license, 1995 / Entry system Resident, Clinical hematology/oncology Electronic medical PhD. research and record/Electronic health development on OSS in record, full digital medical field

Japanese Medical Insurance System

From a patient and a medical perspective
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All citizens are able to join one insurance system Free access to providers and specialists Fee-for-service payment Providers must submit claims for processing by the 10th of the month following the visit. Co-payments collected by providers each visit Each prefecture and county-level government, as well as cities, towns and villages, has its own individual system of additional subsidies for medical care payments. Average life span and infant mortality rates are among the best in the world!

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Health expenditure/GDP

'Receipt' claim form
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Demographics Insurance number Diagnosis Laboratory test/exam Procedure Prescription Many local rules

'Receipt computer'

Claiming/billing application
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Calculate medical claim under complex rule Print out 'Receipt' Patients' demographics


Name, birthday, insurance

Disease, drug, procedures Data can be utilized for only 'Receipt' work


Problems of e-Health (in Japan)

High cost, Low investment
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Oligopoly market Suppression to raising cost for health care 'Paper' standard, restriction to use 'Proprietary' standards Vendor lock in → Oligopoly Data lock in → absence of reusability

Many standards, few implementation
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'Lock in'
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How many patients? Disease outcome?




Open license, free distribution

Share intellectual resources Health data has long life time as Human. Assurance for future availability Reference implementation accelerate standard Not aim, but result.

Avoid 'lock in'
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Drives open standard

Cost reduction

ORCA Project

JMA Standard Receipt Computer
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OSS, under GPL 2.0(translated into Japanese) Avoid 'lock-in' Implementation based 'de facto' MML/CLAIM protocol ↔ EMR Health care policy based data against meaningless government policy

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Collect data

Converting Claims Processing Computers to a Network Terminal
Sleeping Giant standalones
Offer of receipt software by OSS (Open source software)

High-cost, standalone receipt computer now used by 80% of medical facilities

network center
 ・ Master

update  ・ Coding of data

・Setup ・Maintenance ・Option
Support business

ORCA Research project of JMA which aimed at upgrading receipt computers for future medical IT

Multifunctional terminals

Componentry of JMA-Receipt System
Application Utility Tools OLTP GUI DB OS Hardware
Main body of JMA - receipt CLAIM, shell, etc… monpe, gcc, OpenCOBOL, glade, Ruby, GNUpgp MONTSUQI GNOME Xwindow PostgreSQL PANDA, glclient GDM,libglade,Gtk widget (GtkPanda,etc…) pg_dump, tdump Table & Screen & documents definition Various scripts

Device driver XFree86 4.x , Printer driver GS driver, OCR fonts
Debian GNU/Linux P4 2GHz, 512MB, 100GB.. woody, sarge GPU, Others device 17/32

Adoption of ORCA(May 2002 ~April 2010)
医療機関 10000

稼動レベル1 レベル2 レベル3


8000 【specification】

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





0 2002年 2003年 2004年 2005年 2006年 2007年 2008年 2009年
2010 年

Planning・・・ 498
14 14

Fixed Point Survey Study (2006.12~)
Personal information deleted

Improvement of medical quality Outcome Proposal of a fair medical policy Feedback

Medical facilities


Patients / Members

• Voluntary participation by medical facilities • No information collected that can specify an individual patient • Secure security using electronic certification • Privacy of individual medical facilities strictly maintained

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

For Elderly


CLAIM standard

Communication standard between EMR/CPOE and 'Receipt computer'
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XML based standard Clinical information and Insurance data

Arranged for Japan insurance system

EMR development cost
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Remove the cost for 'Receipt computer' part > 20 EMRs implemented CLAIM to connect ORCA

OSS Electronic medical record


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

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Project Maintenance
(Authorization System)

• Quality Assurance

– The total resources of JMARI provide formal support and certification for qualified persons ( business establishments) JMARI ORCA Support Center JMARI-Authorized ORCA Support Business
( 135 companies: 2007-04)


Impacts of ORCA project

Declined price of 'Receipt Computer'
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Before ORCA: 30,000USD - 50,000USD After ORCA: 10,000USD – 20,000USD Declined also EMR 'Receipt computer' usually replaces 5-8 years period 10%, 8800 installed. OpenCOBOL , CLAIM standard

Market share

Derived works

ORCA Ecosystem

Membership fee
Au th or ize
n f ee

Support fee

Development fee

Bug report/request
Au t ho r

Support service

Source codes


iz ati o

Support vendor


Medical Open Source Software Council
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Glue work with ORCA and other projects Introduction OSS seeds to medical developers Introduction Medical OSS to general developers 1st seminar, April 2004 8th seminar, Oct 2009

Many Asian developers / students gathered

Communication with developers, doctors, supports


The openEHR Project
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Implementation based standardization ISO/EN 13606 Translation Adjust clinical concept for Japanese situation Ruby implementation

Local activity of the openEHR project
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OSS in medical field
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Avoid 'lock-in' Cost reduction Synergy effect with open standard All stake holders should work together

Government, medical association, support vendor, medical provider More EMR vendors involved in medical field

Prevent oligopoly

For future..

More and more developers
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Internationalization Localization More implementation for standard Reconstruct of legacy part(all?)

More standard

Reform of ORCA

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