The use of electronic medical record (EMR) systems equipped with critical pathway function have increased in hospitals, but outcome hasn't necessarily achieved what it aimed for.
Many hospitals which initially had introduced EMR, returned to a paper-based clinical pathway. It must be understood that there are plural patterns in the critical pathway format, the usage, the analysis methods, and the way of quality improvement of a medical plan set in clinical pathway. Developing EMRs without thoroughly understanding critical pathway fundamentals definitely may result in a useless system.
A function of critical pathway depends on the structural situation of the EMR. It is important how the record system is implemented at each section, and how the system acts regarding correct time scheduling, enforcement and recording.
Low speed performance and frequent click operation disturb the correct use and collection of data, which normally would contribute to medical quality improvement. Therefore caution and care is required when developing and introducing a new electronic critical pathway.

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The preparation of an electronic critical pathway requires entry of all medical care data, and an overall view of the records. A computerized critical pathway permits medical staff to refer to it at anytime and anywhere. An electronic critical pathway enables the sharing of medical information, which is one of its advantages over the paper critical pathway. However, electronic medical records have the disadvantage that they do not provide an overall view. Overall view with reduced display (showing the first line only) can be achieved at the same level as that with a paper critical pathway. Variance becomes available for assessment at all levels between a single outcome and the entire outcome of the critical pathway.
At Kumamoto Medical Center, 379 electronic critical pathways were created and used in 43%-49% of hospital inpatients. There was no true improvement in places without standardization. It is important to provide attractive functions of critical pathways in order to promote their use. There is little use of an electronic pathway though, however excellent, at places that lack a critical pathway culture. It is absolutely essential to foster the critical pathway culture in order to provide efficient healthcare.

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This research on measuring medical quality objectively, was conducted by establishing a standard for the evaluation index of the critical pathway. This index was divided into three parts, which form the quality of medical care: structure, process and outcome. By using these indicators, we evaluated the critical paths of many medical institutes in Japan. Evaluating them by the index of structure and process recognized problem atic issues using the critical pathway. As for evaluating them by the index of outcome, further research is needed for a proven result. This evaluation index is considered to be useful as a common indicator for a selfanalysis on the quality of the critical pathway and for the improvement of medical quality.

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The first issue for success of a Critical Pathway Conference is in defining a goal for the conference. Frequency, time and form of a Critical Pathway Conference depend on this goal and the conditions of hospitals. A conference will consist of a combination of announcements, lectures, reports and special lectures. A theme should be decided upon with relation to the goal. This theme may or may not be Critical Pathway. The second issue is to make thorough preparations. The conference program and agenda must be prepared with the goal, form and theme in mind.

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The financial burden of healthcare expenditures has been increasing and it is becoming more and more important for local governments and insurers to conduct health expenditure analyses.
We conducted an ecological study to define factors, which are associated with specific disease medical costs per insured person for inpatients and outpatients using claim data of the national health insurance of 53 municipalities in Tokyo from May 2006.
A model was developed using the proportion of elderly seniors over 75years, gender, supply of medical service, income and educational level as possible factors for predicting healthcare costs. The targeted diseases were 4 lifestyle related diseases (diabetes, hypertension, ischemic heart disease, cerebrovascular disease), 5 cancers (stomach, colon, rectum, liver, lung) and 2 mental disorders (dementia, mood disorder). We selected one principal diagnosis for each claim.
Our analyses suggest that the factors related to medical costs of specific disease are different by disease. The proportion of patients over 75 years was most often related to medical costs for inpatients and outpatients. Furthermore gender or educational levels were seldom related to medical costs. Disease specific medical costs for outpatients were related significantly to the proportion of patients over 75 years, male gender and the high school entrance rate. Multiple regression analyses suggest that the proportion of patients over 75 years was related to 5 diseases for inpatients and 8 diseases for outpatients. Coefficients of determination after adjustment of the degree of freedom were 0.165-0.326 for inpatients and 0.141-0.434 for outpatients.
The results of this study suggest that predicting factors for medical costs are different for every disease and clinical setting and this should be taken into account when developing models for economic analyses.

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The Markov model regarding the prognosis of a 60-year-old male hypercholesterolemia (HL) patient was established and the cost-effectiveness of several HMG-CoA Reductase Inhibitors (statins) therapies for two kinds of patients: general HL patients and severe HL patients, was evaluated. As statins for general HL patients, rosuvastatin 2.5mg/day, atorvastatin 10mg/day, pitavastatin 2mg/day and pravastatin 10mg/day were analyzed. For severe HL patients, rosuvastatin 5mg/day, atorvastatin 20mg/day, and pitavastatin 4mg/day were analyzed. The analysis was conducted based on the payer's perspective. Medical costs and qualityadjusted life years (QALYs) were calculated. QALYs in the case of general HL patients were the largest with atorvastatin, but incremental cost-effectiveness ratio of atorvastatin against rosuvastatin amounted very high to 1.1 billion yen. In the case of severe HL patients, rosuvastatin had smaller cost and larger QALYs than the other two drugs. As a result of this study, in both, general and severe HL patients, rosuvastatin was evaluated as the most favorable pharmacotherapy from the viewpoint of cost-effectiveness.

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Patient participation is regarded as necessary to establish high quality care in various fields of clinical practice including medical safety. Hitherto, there are only empirical studies and few studies with quantitative data available. The purpose of this study is to clarify patients' role in medical safety; whether patients can be witness to unsafe events, and if so, under which circumstances they can function well complimenting an in-house incident reporting system.
A questionnaire survey was conducted at three hospitals in Japan: a university teaching hospital with about 1, 000 beds, a general acute care hospital with about 180 beds and a caremix hospital with about 160 acute care beds and chronic care beds each.
As the result, 85.4%(1, 506/1, 764) of the outpatients and 47.9%(516/1, 078) of the inpatients responded. 8.7% of the outpatients and 11.0% of the inpatients experienced unsafe or uneasydissatisfying events. Inpatients who stayed at the hospital for 1 to 7 days, 7.1% answered that they experienced possible unsafe events. The proportion increased to 10.6% for those who stayed 8 to 14 days, and to 10.8% for those who stayed 15 days or longer. Only 30.4% of the outpatients and 23.6% of the inpatients reported their experience to medical staff. Medical Staff reported 14.3% of the incidents/accidents to the in-house incident reporting system. Error modes, which patients could identify with ease, included “medication to a wrong patient”, “inappropriate infusion speed”, “use of contradicting medication”, “appearance of side-effect” and “leak of intravenous infusion”.
Our study suggests that medical staff finds or reports only part of the unsafe or uneasydissatisfying events experienced by patients. If utilized properly patients' witnessed adverse events information can improve hospital medical safety.

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The aims of this study were to examine the relationship between living with family and discharging to home and the relationship between living with family and length of hospital stay for Japanese patients after hip fracture surgery who were 65 years old and older.
This is a correlational analysis of data retrospectively collected from medical charts of patients hospitalized for hip fracture surgery in two hospitals in Japan between 2000 and 2002. After bivariate analyses, possible confounders were included in logistic regression for the outcome variable of discharging to home.
As a result of logistic regression, living with family independently predicted discharging to home after adjusting for dementia, place of residence just before fracture, ambulatory ability at discharge, and hospital. When change in ambulatory ability from before fracture to at discharge was adjusted, however, living with family was no longer an independent predictor of going home. Living with family was not related to shorter length of hospital stay. Patients who went home had longer lengths of hospital stay with higher ambulatory ability at discharge than patients who went to nursing homes. In this study generally, living with family predicted discharging to home but on the contrary, length of stay terded to be increased. Daughter might be able to take care of patients and they could be discharged earlier; however, most patients did not live with daughter. Therefore, living with daughter unlikely practically reduces LOS. Patients could go home if family members lived with them and when patients recovered ambulatory ability.

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Since July 1999 140 paper base critical pathways were developed and used at the Kagawa Rosai hospital, which totaled 25% of the discharged patients. When the Order Entry System (OES) was introduced in 2004, the critical pathway was treated as one of the orders. In 2007, when electronic medical records were introduced, the critical pathway was regarded as a keystone of the system, and it was further used in daily medical examinations and at present about 450 critical pathways are in use, a total of about 70% of the discharged patients.
The critical pathway software was improved as follows:
1) The information of each medical section is reflected in a critical path screen so that information sharing was achieved.
2) The software and information is accessible from all medical sections by the critical pathway screen.
3) Access to individual characteristics of patients is possible.
4) Efficiency is increased by the reduction of repetitive statements.
5) Outcome evaluation using a clinical index can be performed.
6) Cost accounting corresponding to Diagnosis Procedure Combination is possible.
The above-mentioned software improvements were actually reported at the Kagawa Rosai hospital.

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In cases of strokes rehabilitation at an early stage is important to a functional convalescence. To achieve an early rehabilitation, smooth cooperation between the acute care hospital and the maintenance facilities is required. It is equally necessary for the patient and the family to understand the importance of this cooperation. Especially good cooperation between the convalescence hospital and the acute care hospital is necessary. But currently there is no attempt of an introduction of a liaison critical path of stroke in the Tokyo Metropolitan area. Our institute, which is a convalescent hospital, initiated the compilation of a liaison critical path, and started its use. In this critical path, patient information should be sufficient and concise. We found that combining the liaison critical path with the in-hospital critical path shortened the length of hospital stay. For the future, through the accumulation and analysis of variances, we like to further improve the liaison critical path.

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Health care does not always result in an outcome that patients expected. Furthermore, physicians are sometimes obligatory to make decisions without enough clinical evidence. In these situations, medical dispute may occur, and judgment about malpractice may sometimes be difficult to make by the hospital staff alone. Since the fiscal year 2004 the National Hospital Organization (NHO) Headquarters Kyushu Office has introduced expanded review boards regarding serious medical accidents, including professional specialists from outside the hospital investigating the cases. Professional specialists include physicians of the NHO Kyushu area hospitals who graduated from other medical schools than the one of the disputed physician, as well as co-medical staff such as nurses, pharmacists, physical therapists and medical engineers. In cases where no specialist from inside the NHO could be provided, professionals from outside the NHO hospitals were invited. Before getting the board started all participants review medical and nursing charts as well as imaging diagnostics, specify the problems and prepare up-to-date resources regarding the case. The issues are strictly discussed in the light of both medical and legal aspects. Many disputed cases could be resolved after honestly informing the parties involved about the conclusions of the board. In addition background, cause and prevention strategy of an accident are afterwards disclosed by the board to representatives of the NHO Kyushu area hospitals in a series of education programs. Such efforts have actually reduced the number of disputed cases.

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