Chapter 39
Disaster and Medical Information (Medical Records)
Field of expertise: Disaster Medical Informatics Lab

Susumu Fujii & Masaharu Nakayama
Summary
The development of medical information technology has contributed not only to the efficiency of
medical treatment but also to medical safety. The Great East Japan Earthquake reaffirmed thesignificance of remote backup of data and medical information sharing among regions. It is
important for disaster countermeasures to seamlessly link medical care during normal times andduring disasters. It is necessary to establish an information system that can be effectively used ineveryday medical practice and to create an environment in which it can be used in the event of adisaster.
Keywords: medical information, personal health records, medical information and communication
technology, regional cooperation systems, remote backup

Introduction
Information Technology (IT) plays an important role in the efficiency and safety of medicaltreatment. In the aftermath of the Great East Japan Earthquake, many hospitals were able tomaintain their hospital information systems, but immediately after the disaster, unstable power
supply made it difficult to operate them. In addition, medical records were lost in hospitals thatwere damaged by the tsunami, and the need for measures to prevent the loss of medical
information was recognized more than ever.

1: Problems Revealed by the Great East Japan Earthquake
What happened?
The evolution of information technology has become indispensable for improving the qualityof medical care by addressing the high level of specialization, complexity, safety, and speed
required in medicine. Without a hospital information system, it would be impossible to check tests,prescriptions, and names of diseases, and it would take a long time to get a correct understandingof patients' conditions. For example, the system contributes to safety by checking contraindications
and erroneous medications, such as medication combinations, dosages, and allergies, but these
become difficult.
1With this shift to IT in medical services, medical records have shifted from paper records
to electronic records, and are now stored on hospital information system servers as electronic
medical record information (medical information). Since a system shutdown would have asignificant impact on medical operations, measures have been taken to ensure stable operations,such as duplicating servers and installing emergency power supplies. In addition, backups are
made in case medical information is lost due to hardware failure, so that system failures can becomprehensively predicted and dealt with. Our response to the earthquake was also prepared as
an extension of this system.
The reality of the damage
In the Great East Japan Earthquake, according to the survey report by the Ministry ofHealth, Labor and Welfare (2011), the damage to medical institutions in the three prefectures ofIwate, Miyagi, and Fukushima is shown in Table 39-1. According to the survey report by theMinistry of Internal Affairs and Communications (Ministry of Internal Affairs and Communications,2012), 27.3% (n=11) of hospitals had data loss, and 60% (n=15) of hospitals had businesssystems that could not be used. In addition, 78.9% (n=19) of the hospitals had conducted disaster
drills and prepared response manuals before the disaster, but the situation exceeded theirexpectations due to the tsunami. According to the data of Japan Association for Medical
Informatics (Kondo, 2013), about 60% (n=55) of hospital information systems were difficult tooperate in the early stage of the disaster. In the case of systems that were not damaged by thetsunami, most of them were back to normal operation in three days. One of the reported reasonsfor the early operation difficulties was the unstable power supply immediately after the disaster. It isalso reported that the loss of paper medical records and backup data due to the tsunami made itdifficult to restore medical records (medical information).
Table 39-1. Damage to hospitals and clinics in the affected areas
Complete
Partially
Numb Complet Partiall Number of!
clinics
destruction
damageder ofeyhospit destructi damag MedicMedicDentalsoned!
alDental al
Dental Medical al
Iwate
Prefectu
re94359927
613
38
4676
79
MiyagiPrefectu
re
147
5123
1,623 1,065 43
32581
367
FukushimaPrefectu
re
139
2108
1,483 919
25516
374
Total
380
10290
4,033 2,597 83
83
1,173
820
Ministry of Health, Labor and Welfare, Health Policy Bureau. Summary as of July 11, 2011

2: Paradigms Destroyed by the Earthquake
Conventional wisdom and necessary responses
2In order to avoid system downtime, hospital information systems have generally employedsystem failure countermeasures based on so-called redundancy, in which servers and power
supply units are duplicated to improve the operating rate. In addition, to protect the data fromphysical failure of the server, the data was backed up periodically and stored in a state removed
from the server. If the backup data was stored in the same location as the server, it could bedestroyed along with the server in a fire, etc. Therefore, it was common practice to store thebackup data in a different location within the same hospital.
In the Great East Japan Earthquake, hospitals that were spared or suffered only minor
damage due to their earthquake-resistant structures and other preparations had difficulty operating
their hospital information systems immediately after the disaster, but were able to start operations
as soon as the electricity supply was restored. On the other hand, hospitals that were severely
damaged by the tsunami lost not only their paper medical records but also the medical informationin their hospital information systems, including backups.
If it were your family hospital, it would be difficult, even temporarily, to receive proper
treatment despite the high demand for medical care that comes with the disaster. Some people
with chronic diseases such as hypertension and diabetes had medicines that they had to takeregularly, but could not take them with them during the evacuation. In a disaster situation, it would
be difficult to obtain and safely take medicines if they do not remember their regular medications
and their hospital records are missing.
Through these experiences, it became clear that conventional system failurecountermeasures were inadequate for the disaster. We recognized the necessity of storing backup
data in remote areas that would not be affected by the disaster, and the need for a system thatwould allow other hospitals to access medical information even if some hospitals were severely
damaged, or in other words, we needed a system that would allow each hospital to share its
medical information within the region. In addition, in order to respond quickly and correctly atevacuation centers, it is now considered necessary to have a system that allows patientsthemselves to own and provide their medical information so that correct medical information isavailable at any time.

3: A New Approach
The Gemini ProjectIn the wake of the Great East Japan Earthquake, it became clear that conventional
disaster preparedness measures for hospital information systems were not sufficient. In the 2012fiscal year, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) launched
The Gemini Project, in which backup data of the hospital information systems of 42 national
universities and 46 university hospitals across Japan are stored in data centers located in eastern
and western Japan. If the server is repaired after the disaster, the system can be restored from thestored data. Unless the earthquake strikes at the same time in areas more than 1,000 kilometers
away, it is highly unlikely that medical information will be lost. In addition, the system has a medical
information reference function, which makes it possible to refer to pre-earthquake information suchas test values, names of diseases, and prescriptions when it is difficult to operate the system earlyin the disaster.

3MMWIN
Due to the disaster, some hospitals will not be able to provide medical functions, and the
supply-demand balance of regional healthcare will be disrupted. In order to cope with this situation,a system that can share medical information in the region was expected. In Miyagi Prefecture, theMiyagi Medical and Welfare Information Network (MMWIN) was established to share information
among hospitals, clinics, pharmacies, and nursing care facilities in the prefecture. Like The Gemini
Project, it has a backup storage function and a medical information reference function. The system
was expanded to include the Ishinomaki and Kesennuma medical areas in 2012, the Sendai areain 2013, and the Kenhoku and Kennan medical areas in 2014. At the end of March 2020, thenumber of registered consenting patients exceeded 100,000 and the total number of backuppatients exceeded 14 million. In addition, clinics in Fukushima Prefecture, which is adjacent to theMiyagi-Kennan medical area, have also joined, steadily expanding the scope of the program. It isimportant that such earthquake preparedness and patient information sharing be useful in the dayto-day provision of medical care. If it cannot be used in normal times, it is unlikely to function
effectively in times of disaster. Currently, the Ministry of Health, Labor and Welfare is promoting thedivision of roles among medical institutions, such as hospitals that perform surgeries and highly
specialized treatments, and clinics that manage day-to-day symptoms. Sharing medical information
among hospitals is also useful in terms of medical efficiency and safety, as it means that accurate
information can be grasped among medical personnel instead of relying on vague memories ofpatients' disease names and prescribed medications. The disaster response of medical information
contributes to the quality of medical care among hospitals and in the community.

Figure 39-1. The MMWIN schematic diagram4

4: Achievements and the Future
A new approach to disaster scienceAccording to a July 2020 tally by the Reconstruction Agency, the number of evacuees
outside their own prefectures due to the Great East Japan Earthquake was 29,706 fromFukushima Prefecture, 3,841 from Miyagi Prefecture, and 944 from Iwate Prefecture. Theseevacuees are unlikely to benefit even if the hospital information system is restored with backups
and even if information is shared in the community. Hospitals in the evacuation areas do not havethe medical information they had before, and in effect, it is almost as if they have lost it.
The Ministry of Health, Labor and Welfare has been promoting data health reform and is
working to make it possible for people to use their own medical information at any time. This iscalled a Personal Health Record (PHR) and includes a system that allows people to access andcarry their own medical information on their smartphones. If you carry your own medical
information as a PHR before the disaster, you may be able to provide medical information tohospitals in the evacuation area. Also, if you evacuate with only the clothes on your back and you
cannot bring your regular medication with you, having the correct medical information will allow you
to receive and take your medication with peace of mind during the evacuation.

Conclusion - from the authors
A system that realizes seamless community-based medical care not only improves thequality of community-based medical care, but is actually a system that is resistant to disaster.
Hospitals and communities are preparing for disasters by using this system in normal times.
However, the benefits of this system are limited to those who live in the area. If they move out of
the area, they will effectively lose their medical information. In order to solve these problems, aPHR system that is centered on individuals, who carry their own medical information and use it attheir own will, is needed to deal with the disaster.

References
Kondo, T., Hasegawa, A. (2013). The Aftermath of the Tohoku Region Pacific Coast Earthquake
Relating to the Medical Information System in the Disaster Area. Medical Information Science,33(5), 279-291. https://doi.org/10.14948/jami.33.279 (In Japanese)
Ministry of Health, Labor and Welfare. (2011). Damage to Base Hospitals for Disaster MedicalServices in the Great East Japan Earthquake. Government of Japan.
https://www.mhlw.go.jp/stf/shingi/2r9852000001uo3f-att/2r9852000001uo7y.pdf (In Japanese)
Ministry of Internal Affairs and Communications. (2012). The Great East Japan Earthquake andBusiness Continuity [White paper]. Government of Japan.
https://www.soumu.go.jp/johotsusintokei/whitepaper/ja/h24/pdf/n3020000.pdf (In Japanese)5