In the early afternoon (14:46 JST; 05:46 GMT) on March 11, 2011, a 9.0 magnitude earthquake, now called the Great East Japan Earthquake, along with subsequent tsunamis, hit the northeast coast of Honshu. The earthquake's magnitude was the fourth largest in the world since 1900, and the largest in Japan since modern instrumental recordings began 130 years ago.Reference Benz and Ransom1 Based on official Japanese government figures (from June 16, 2011), 15 534 people were confirmed dead, 5364 were injured, and 7092 were missing. In addition, a total of 112 405 persons have remained displaced.2 After this earthquake, tens of thousands of evacuees required urgent medical care, and the damaged and affected areas were so extensive that clusters of local governments for cities and prefectures were paralyzed.
The medical facilities located in the damaged area lost not only their capacity to function but also the patients’ medical information. Many households were temporarily displaced; and in the rush to evacuate, many residents left home without documents, medications, and other essentials. Similarly, many people who were displaced by Hurricane Katrina in the United States had a number of chronic medical conditions. The most common chronic conditions of persons in shelters who were displaced by Katrina were hypertension, hypercholesterolemia, diabetes, pulmonary disease, and psychiatric illness. Also, 48.4% of those with a chronic disease who arrived at shelters lacked medication.Reference Greenough, Lappi and Hsu3 In such situations, health risks may emerge as the result of inadequate access to prescription medications.Reference Motoki, Mori and Kaji4 Discontinuation of medical care for chronic diseases, such as hypertension or diabetes mellitus, results in loss of quality medical careReference Tomio, Sato and Mizumura5, Reference Currier, King and Wofford6 and causes severe complications for evacuees.Reference Suzuki, Sakamoto and Koide7
It has been reported that sharing computerized patient information through a network system improved the quality of medical care support from the first-aid station for evacuees of Hurricane Katrina.Reference Arrieta, Foreman and Crook8 Accessibility to patient information was closely related to the quality of medical care given to evacuees. Similarly, the loss of patient information in a disaster has been one of the bottlenecks in reconstructing medical facilities in damaged areas. However, to our knowledge, little research has examined the relationship between the loss and restoration of patient information from destroyed medical facilities.
One of the characteristics of the Japanese universal health insurance system is that it provides all Japanese citizens with public medical insurance. Japan has 3 major public health insurance systems: the medical system for the elderly aged 75 years and older, the National Health Insurance, and employees’ insurance. In general, salaried workers, civil officers, and seamen (and their dependents) are covered by their employees’ insurance; individual proprietors, pensioners, farmers, and unemployed people (and their dependents) are covered by National Health Insurance.
To claim reimbursement for the costs of health care services in a given calendar month, excluding copayments, health care providers submit health insurance claims (HICs) to Health Insurance Claims Review and Reimbursement Services (HICRRS) or to the National Health Insurance Organization (NHIO), which is located in the same prefecture as the medical facilities that patients use, according to the patients’ health insurance. If patients are covered by National Health Insurance or the medical system for the elderly, health care providers submit HICs to NHIO. If patients are covered by employees’ insurance, health care providers submit HICs to the HICRRS.
Next, the HICRRS or NHIO investigates the HICs to determine (1) the patients’ qualification status and (2) if the health care services provided meet the regulations of the reimbursement rules. After investigating the HICs, the HICRRS or NHIO sends the HICs to the insurers. Because health insurance coverage is universal in Japan, all HICs are recorded in a uniform format, which is used by all of the insurers. In sum, information about the health care services provided is shared by the medical facilities, HICRRS or NHIO, and the insurers using a uniform format.
In Japan, handling personal information without obtaining previous consent of the person is restricted by the Act on the Protection of Personal Information (Act No. 57 of May 30, 2003). The provisions of the act do not apply to situations in which the handling of personal information is necessary for the protection of the life, body, or property of an individual and in which it is difficult to obtain the consent of the person; however, the information described in the HICs has never been used for medical care support to evacuees of natural disasters.
On March 19, 2011, Iwate Medical Association asked the Miyagi NHIO office to provide its HIC information to aid in the medical care of evacuees of the earthquake and tsunami, and Miyagi NHIO agreed to it that same day. On March 25, the Ministry of Health, Labour and Welfare (MHLW) noted that the provisions of the act did not include using HIC information for medical care support for evacuees of the incident, and notified all the NHIO offices in Japan about this. This situation might have caused somewhat of a delay in using the information. If the ministry had declared it possible to use HIC information for the medical care of evacuees of natural disasters before the disaster occurred, the system might have been more promptly accessible after the disaster. In this report, we describe how medical facilities used HICs after this major disaster, including medical care for evacuees and the lessons learned.
Methods
According to the process described, whereby medical facilities submit HICs to HICRRS or NHIO, claims are examined for legitimacy and then sent to insurers for payment. Also, patient records are maintained in 3 places: the medical facilities, either the HICRRS or NHIO, and the insurers. In the 3 prefectures affected by the earthquake and tsunami (Iwate, Miyagi, Fukushima), the NHIO offices were located inland and, hence, were not damaged by the tsunami. Therefore, even if the medical facilities close to the coast were damaged and patient information and HICs were lost, the NHIOs retained intact HICs. Subsequently, some of the patient information could be restored from the information described in the HICs.
In this study, the use of information on HICs after the major disaster was examined in the 3 affected prefectures (Fukushima, Miyagi, and Iwate). We conducted comprehensive interviews with officers in charge of the NHIO in each of these prefectures to obtain information about the use and provision of HIC data 3 to 4 months after the event. We then analyzed the official data concerning HIC use in chronological order. This study was based on the statistics from the operations of the 3 NHIOs after the disaster; names of patients and medical facilities were excluded before they were provided to the researchers, eliminating any ethical issues. No inferential statistical analyses were performed.
Fukushima
From March 15, 2011, to June 30, 2011, the NHIO in Fukushima Prefecture provided information from 2863 health insurance claims information to the 150 facilities that had requested it. Of the 150 facilities, 95 (63%) were located in Fukushima, and 55 (37%) were located in other prefectures. The number of facilities requesting information from health insurance claims peaked in early April 2011 and decreased gradually after late April. The NHIO in Fukushima provided information from HICs for more than 3 months after the earthquake.
Miyagi
From March 22, 2011, to June 30, 2011, the NHIO in Miyagi Prefecture provided information on the status of patient health insurance to 44 facilities that had requested it. The NHIO records mentioned previously yielded information about medical procedures, such as the names and amounts of the prescribed drugs for 34 patients of 52 health insurance claims, that were provided to medical facilities.
Iwate
The NHIO in Iwate Prefecture provided information from 363 health insurance claims to 196 facilities that had requested it. From March 18, 2011, to June 13, 2011, the Iwate NHIO distributed information to the facilities via fax (157, 80%), landline telephone (22, 11%), cell phone (14, 7%), mail (2, 1%), and satellite phone (1, 1%). Most of the information provided consisted of patients’ names and amounts of prescribed drugs. However, some of the information included the status of the patients’ health insurance.
Results
Fukushima
From NHIO records of how health care facilities intended to use the HIC information, we were able to derive the following data. Of the 2863 health insurance claims provided, 2767 (97%) were used by municipalities, hospitals, clinics, pharmacies, and HICRRS or NHIO to reconstruct paperwork for the health insurance system, such as the status of the patients’ health insurance. In addition, 96 (3%) health insurance claims were used to obtain information about medical procedures, such as the names and amounts of the drugs prescribed for each patient. Most of the patients had noncommunicable chronic diseases, such as diabetes, hypertension, epilepsy, and asthma.
Miyagi
Of the 44 facilities, 27 were in Miyagi Prefecture, and 17 were outside of it. Of the 24 hospitals or clinics with physicians, 13 were outside Miyagi Prefecture, as were 4 of the 6 pharmacies. All of the dentists’ offices and other types of institutions were in Miyagi Prefecture.
Iwate
The Figure shows the number of medical institutions for which the NHIO in Iwate Prefecture provided patient information from HICs according to the number of weeks from the onset of the earthquake. During the first week, the NHIO in Iwate Prefecture provided no information from HICs. Almost one quarter of the institutions (49) received information from HICs during the second week, and about one quarter (50) received information during the third week. After the fourth week, the number of institutions receiving information from HICs decreased gradually, and after the 14th week, no institution obtained information from HICs.
Figure The Number of Medical Institutions That Received Health Insurance Claim Information in Iwate Prefecture 1–16 Weeks After the Earthquake.
Hospitals located in inland municipalities received the highest percentage (n = 89, 45.4%) of patient information, followed by clinics in inland municipalities (n = 72, 36.7%), hospitals or clinics located in seaside municipalities (n = 16, 8.2%), and temporary medical-aid stations adjacent to shelters (n = 15, 7.7%).
Sixteen medical facilities requested the NHIO in Iwate Prefecture send back the HICs that were submitted before the earthquake. All 16 facilities were in seaside municipalities, and the information was used to rebuild their patient records that were damaged in the disaster. The NHIO in Iwate Prefecture provided information from the HICs through paper media (11 institutions), digital media (4 institutions), and a combination of paper and digital media (1 institution). The numbers of health insurance claims submitted by a medical institution before the earthquake ranged from fewer than 100 to about 3500.
Discussion
This study investigated the use of HIC information from the NHIO offices in 3 prefectures affected by the Great East Japan Earthquake. Two major findings emerged. First, patient information before the earthquake was obtained from the HICs and applied to the medical care of the evacuees. Second, medical institutions that lost their patient information in the disaster were able to restore it by using the information from HICs.
It has been reported that a disconnection with patient information obtained before a disaster has been a major problem in providing medical support to evacuees.Reference Tomio, Sato and Mizumura9 Patients with chronic diseases have been encouraged to keep information about their diseases and medication themselves.Reference Motoki, Mori and Kaji4 Most of the evacuees in this disaster, however, lost their medical records because the earthquake and tsunami damaged both residents’ homes and medical facilities. The quality of medical support activity for evacuees was improved through use of the electronically stored information in the network system among medical institutions.Reference Arrieta, Foreman and Crook8 The possibility of losing patient information can be minimized if facilities that share information are located at some distance from each other.
The information from HICs may be used effectively in similar situations because the medical facilities, the HICRRS or NHIO, and all insurers maintain HICs in a uniform format. Many medical facilities located in the coastal areas were damaged severely by the disaster, but the buildings and equipment could be rebuilt properly with sufficient resources. However, no amount of resources would be available to restore lost patient information without proper backup.
Although, we found that the use of information from HICs about medical procedures or drugs for each individual was rather less than expected. We thought this was because most patients with chronic conditions could remember what kinds of drugs that they were prescribed, although not necessarily the exact names. Having this information was essential on several occasions, for example when antiepileptic drugs were needed for the continued treatment for a child with epilepsy. Moreover, the information from HICs was crucial to rebuild patient records of those medical institutions damaged by the disaster.
Most of the previous studies on medical care for evacuees from large disasters have assessed action plans during the acute phases of emergencies, such as treatment of multiple injuriesReference Kuwagata, Oda and Tanaka10 or long-term results, such as suicide.Reference Chou, Huang and Lee11 In this study, the focus was on the transition stage between the acute and long-term phases to examine the continuity of medical care for evacuees whose previous medical information was lost in the disaster. In Japan's universal health insurance system, the possibility of losing all information from HICs, even from a huge disaster, is very low because of the uniform format of the HICs and because the information recorded is computerized and stored in multiple facilities. This inherent redundancy of multiple backup systems of the HICs is one of the key components of the disaster resilience.Reference Norris, Stevens and Pfefferbaum12 Thus, HICs can be an ideal resource for future disaster preparedness in the health care setting.
Limitations
This study has 2 major limitations. First, it does not directly investigate a specific hypothesis but only describes the use of information from HICs. Therefore, the information that was actually required for the medical care of the evacuees of the disaster is not revealed in this study. The information on HICs is limited to diagnoses and medical procedures provided, including names of prescribed drugs. Because no diagnostic test results are given in the HICs, the information is not as complete as it is in medical records.
However, most medical records in Japanese medical institutions are not computerized. A survey of medical institutions in 2008 showed that 10.8% of hospitals and 13.1% of medical clinics had introduced computerized medical records.13 After August 2010, however, all hospitals and medical clinics were mandated to submit electronic HICs to the HICRRS or NHIO to claim reimbursement for the costs of health care services. Thus, 93.1% of HICs had been computerized by March 2011.14 It has been possible to restore some of the information on medical records from HICs because the format of HICs is uniform, the information is already computerized, and facilities located at some distance from one another share the information. The HICs represent a suitable data source, for example, to evaluate measles surveillanceReference Tanihara, Okamoto and Imatoh15 and to provide quality care for patients with diabetes.Reference Tomio, Toyokawa and Tanihara16 A proper knowledge of the characteristics of the information obtained from HICs is required for improving the medical care system for evacuees after a disaster.
Second, the subjects of this study were limited to patients with National Health Insurance only. These patients included mainly individual proprietors, pensioners, farmers, and unemployed persons (and their dependents). Therefore, the data from the HICs analyzed in this study were not necessarily representative of the total population. However, we could assume that the current results were broadly applicable, because health insurance coverage in Japan is universal; it has a uniform claims format and fee schedule.
In conclusion, our investigation has shown that patient information obtained from the HICs was used to improve the quality of medical care for the evacuees and to reconstruct the medical records of those medical institutions damaged by the earthquake and tsunami. These findings indicated that use of information from HICs makes it possible to improve the health care provided after a large-scale disaster.
Funding and Support
This study was supported in part by a Grant-in-Aid for Scientific Research (21119006) and a Grant-in-Aid for Young Scientists (B) (22790504).
