Variance determination, which is similar to outcome determination, allows automatic determination if the outcome determination criteria have been specified and registered in the master file. In all variance methods, the patient's abnormal condition or changes in the interventions provided should be regarded as variances. An electronic pathway, however, cannot regard all such items as variances, and can only regard the changes of orders as variances. A variance can be registered when it is identified as a variance. In many institutes, the system is set to automatically display a prompt for registration. Registration items are generally descriptions of variances and occurrence factor codes. Since the changed orders cannot be used in all variance methods for tabulation if they are registered without description, the descriptions need to be registered separately. The registered variances are tabulated automatically by each variance. Some electronic pathways can tabulate the number of occurrences of variance for each outcome by code. This enables prioritization of examinations considering their importance using codes. Electronic pathway greatly reduces tabulation tasks. Determination of improved measures is solely dependent on medical providers, and electronic pathway cannot perform this task. The individual performing variance analysis and the time at which it is performed are important even after adoption of electronic pathway. Each institute should allow continuous variance analysis.

Chronic kidney diseases (CKD) are commonly found within large population around the world. To treat CKD patients adequately, the establishment of CKD management system is one of the most relevant issues in Japan. Since December 2008, we have continued an interactive referral system with a critical pathway to manage CKD patients between general practitioner (GP) and nephrologist in Kitano hospital. This program consists of medical examination by a nephrologist, educational counseling of food by a nutrition manager and coaching by a certified nurse. In this study, we examined variances in our system for two years to clarify the actual co-operations and its limitations. 211 CKD patients and 148 GPs were enrolled to this system. The outcome was determined as the inhibition of functional decline of the kidney and the prevention of cardio-vascular disease. The variances were defined as disease specific exacerbation, including worsening of urinalysis, edema, hypertension, electrolyte disorder, and progressive renal failure. The patients were distributed as 17.1%, 20.4%, 33.6%, 24.2%, and 4.7% belonging to CKD stage 1, 2, 3, 4, and 5, respectively. Males in their sixties and females in their seventies were the most common population. Not only general physicians but also surgeons were approved to participate in this system. Twenty-two patients did not become adherent due to personal reasons. We found both CKD specific variances and practical difficulties to manage this system in the study period. Our experiences were not sufficient to analyze the comparability, however, this system might have a favorable potential to treat a large number of CKD patients with considerable outcome. Further study would be necessary to clarify the burden reduction, cost effectiveness, and satisfaction of CKD patients.

Osaka University Hospital with 1,076 beds has developed a hospital-wide patient engagement program called “Iroha-Uta”. It has worked to develop an original tool, the “Iroha-Uta” file, and an accompanying operational framework between patient, families and health care professionals.

To develop the tool, seven key points relating to patient safety and engagement were identified from incident reports and other literature, namely：1) patient identity；2) fall prevention；3) prevention of personal property loss；4) asking questions to clinicians；5) seeking advice from clinicians, family or friends；6) understanding drug medication；7) self-management of illness and care.

Poems and illustrations were developed for each point, and cards were created based on the style of a traditional Japanese card game. These cards are presented in a paper file and given to all inpatients.

To construct the tool's operational framework, explanatory scenarios were developed to ensure that patients receive standardized instructions about this program, and a two-week trial was run in the general ward. From the questionnaires, over ninety percent of the patients liked the tool, found nurse's explanation to be clear, and patients could speak up to clinicians more. Iroha-Uta badges to be worn by all staff in our hospital were produced, and Iroha-Uta posters were displayed on hospital notice boards. Preparation to full implementation took 9 months.

The efforts of the hospital in developing a tool for the purpose of promoting patient engagement in healthcare and safety can be characterized by the following two points: the decision to pursue a method that enables communication with patients via a practical tool that emphasizes cultural context and is introduced using standardized instruction; and the establishment of an operational framework in conjunction with hospital-wide promotion. This program started in June 2010 and continues to present.

To integrate and make full use of medical data effectively, we constructed the computerized pressure-ulcers management system using retrieved data from the data warehouse in which all patients' data has been stored. The physical screening items were standardized among the medical collaboration teams and enrolled in the basic patient profiles in the electrical medical records. The management system of pressure-ulcers was composed of the risk screening, the risk evaluations, and the therapy for pressure-ulcers. The risk screening was obtained from the data warehouse, which resulted in the preventive plans for pressure-ulcers. The risk management of pressure ulcers was composed of the pressure-ulcer risk factors, the disease information, and the physical status of patients. The therapeutic management recorded the local photos and the evaluation of pressure-ulcers using the DESIGN methods standardized in the Japanese Society of Pressure Ulcers. At half-year after the system was introduced, we conducted 242 user surveys using nurses with more than five years working experience. The user nurses evaluated the system to be easy to use/relatively easy to use (80%), and to improve the interest to pressure-ulcers (95%).

The pressure-ulcers management system using the data warehouse seemed to improve usability and to enhance interest in pressure-ulcers of user nurses.

At Kagoshima University Hospital, the Medical Information Department manages and provides education to “doctor's office work assistant” (herein referred to as medical clerk). When medical clerks were first introduced, they were placed in each ward and department；however differences in the amount of work in each ward and department have led to the fluid operation of medical clerks including the provision of assistance to other departments at the discretion of the Medical Information Department. Analysis using Hospital Information System (HIS) log data revealed that it is possible for medical clerks to support other departments without leaving their own department and that it is possible to further strengthen the assistance system if a clear distinction is made between operations for which assistance is possible and operations that require assistance. The education of medical clerks is shifting from operational procedure-based guidance provided by the Medical Information Department to guidance in study meetings planned and managed by the medical clerks themselves and guidance from other professions. Study meetings conscious of standardization are held with the purpose of improving operations and strengthening the assistance system. The ease at which medical clerks can now provide assistance to other departments thanks to the standardization of operations has led to medical clerk's higher acquisition rate of paid holidays and lower turnover.

To clarify whether there is, and if so what kind of, difference in the consciousness of the healthcare worker by the penetrance such as the philosophy of the hospital, an attitude survey on 480 workers who worked in Miyazaki Medical Association Hospital was carried out. As a result of having analyzed the answer of 224 workers targeted for analysis, meaningful differences by the penetrance such as the philosophy of the hospital were recognized between the standards of each factor such as an age hierarchy, a post hierarchy, and the duty number of years. In addition, it was suggested that a feeling of conformity of ability and work and the sense of belonging to the hospital were high in the staff who understood the philosophy of the hospital, motivation for work such as a feeling of worth and the continuous willingness to service was high in the staff who not only understood the philosophy of the hospital, but also practiced activity on the basis of it.

In order to improve the morale and sense of unity to the organization, it is thought that it is essential to promote the penetration of shared vision to the hospital personnel such as the philosophy of the hospital by not only the philosophy of the hospital being simply shown, but also by being set along with the management policies and goals.

We conducted a retrospective observational study of current smokers and former smokers who came for their physical checkup at Ningen Dock of Showa University Northern Yokohama Hospital from January 2009 to December 2009. Total number of participants was 1,535 persons (947 males, 588 females) including non-smokers. Current smokers were 273 persons (231 males, 42 females), and former smokers were 513 persons (443 males, 70 females). The ratios of smokers both past and present were 24.4% in males and 7.1% in females, respectively. Both ratios were lower than national average of Japan in 2009. As for smoking period, males were significantly longer than females (male 29.2 years, female 24.3 years) and as for numbers of cigarettes, males smoke significantly more than females (male 19.8 cigarettes/day, female 15.0 cigarettes/day). The reasons of smoking cessation of former smokers were classified into 5 categories. There was no difference between males and females among those categories. Moreover, in the investigation of factors to continue smoking cessation, age, numbers of cigarettes smoked per day and beginning age of smoking were selected as important factors by multivariate statistics.

Our findings suggest that we have to strengthen the motivation for smoking cessation in persons with higher age, lower numbers of cigarettes smoked and lower beginning age of smoking.

Off-hospital-site electronic medical recoding system with all function was introduced in our hospital from July 2011. The current situation and problems were investigated. This system is considered to be the first trial in Japan. This off-site system is designed exactly as, and as securely as, the on-site terminal of the usual electronic medical recoding system, however, users found many steps of starting up and slow data transport to be slightly problematic.

We developed Android smartphones system for personal terminal unit interlocked into electronic medical records. This system launched in May, 2011, is designed to input clinical routine practice by healthcare professionals. We investigated change of data input hours using motion and time study between the conventional system and the new system during the period of time when both systems were used simultaneously. We also carried out a questionnaire survey of operability, portability, and visibility at the same time. From the motion and time study, as compared with the conventional system, the smartphones system indicated that clinical routine data input hours contracted. In the questionnaire survey, operability, portability, and visibility obtained good evaluation from healthcare professionals. In this research, Android smartphones system for personal terminal unit has suggested that it was effective to reduce data input hours for electronic medical records.

The present inadequate supply of obstetric services, owing mainly to man-power shortages, is a serious social problem. Regarding social reconstruction, some companies have improved after reducing costs and labor, using social net communication technology. Appling this system to the obstetrics problem, we introduced an e-mail newsletter system called Mama Care Mail in June 2012. To estimate satisfaction, we sent a questionnaire to mothers at full-term from June 2012 to June 2013. We found that 95.2% were satisfied with the system. Furthermore, the results suggest that our trial met the demands of pregnant women because 80.9% used it to learn about daily habits during each period of their pregnancy.