Japan is currently the oldest society in the world, with 29.3% of its population over 65 years old, and the rate is estimated to be 36.3% in 2045 [1]. As the country's population continues to shrink and age, 10.7 million medical and welfare service workers will be needed in 2040, but only an estimated 9.74 million will be available [2].

The shortage of healthcare workers is already severe in local areas, and it is expected to worsen as the population over 65 years old could reach 50% in some locations, such as Akita Prefecture. While medical and care service supplies are abundant in larger cities like Tokyo, the demand has already overwhelmed the supply due to the large population. This situation is also expected to worsen as the aging population is projected to peak in the next 20 years [3].

The Japanese government's promotion of a 'Community-based Integrated Care System and its evolution into a Community Symbiotic Society' that emphasizes home care is a significant step towards addressing the healthcare worker shortage [4].

The aging population caused severe problems in rural Japan as early as the 1970s, which incited various responses. One of the notable initiatives was a collaborative project in Mitsugi, Hiroshima prefecture, aimed at uniting medical and care resources in the area. The goal was to ensure these services work together seamlessly to address the medical and care needs of the local population, with a strong focus on home care services [5]. The model had developed to be a nationwide installment of a "Community-based Integrated Care System" system that mainly focused on fulfilling the medical and care needs of the elderly population of the community, and the promotion is being made toward the world as the population aging is becoming the global challenge [6]. Domestically, the government is now trying to realize the "Community Symbiotic Society," where "children, the elderly, people with disabilities, and all individuals can come together to create, share, and mutually enhance their community, daily lives, and senses of purpose [7]." Home care medicine in Japan has been developed and implemented in these systems to collaborate with care service providers. The importance of multidisciplinary collaboration has been emphasized; multiple medical and care workers of independent facilities in the community cooperate while sharing information. The "interprofessional competency framework for collaborative practice in Japan" summarizes the principle of collaboration [8].

Information-sharing methods have evolved, and communication based on Information and Communication Technology (ICT) has become widespread. It is the backbone of the medical and care systems, with the most successful implementations being SNS-based. One of the most thoroughly analyzed systems is the "connect 8" in Hachinohe-City, Aomori prefecture [9,10], provided by NPO Reconnect, chaired by the author, with funding commissioned by the city. This SNS-based information-sharing network connects healthcare professionals in different community facilities who provide medical and care services to patients receiving home medical care. Similar information-sharing systems are utilized in many places across Japan, enabling multidisciplinary collaboration to support individuals who require care at home.

During the COVID-19 pandemic, effective coordination and response efforts were urgently needed. At the beginning of the crisis, information sharing and coordination between health centers and medical institutions in Japan needed improvement. Many individuals faced deteriorating conditions at home without any medical professionals available to evaluate their situation. In order to prevent similar situations at the regional level, the connect 8 system was used for information sharing and online medical consultations in Hachinohe.

From the opening of the lodging care facility, telemedicine based on information sharing with the connect 8 system has been deployed. This system was applied to people quarantined at home during Japan's fifth pandemic wave, from July 1 to September 31, 2021, specifically from August to September locally [11].

At that time, public health centers were responsible for managing information about patients who tested positive for COVID-19; however, this information was often stored on paper at those centers in many regions of Japan. When home visits by doctors or nurses were necessary, data was shared via fax, which limited effective communication. The information was shared in Hachinohe using the connect 8 system among medical institutions responsible for in-patient care, long-term care, and home care. This system enabled the immediate sharing of vital information and patient progress when hospitalization was required, particularly in cases of pneumonia for patients receiving care at home or in lodging facilities.

From the outset, a system was established at the lodging care facility to collaborate with on-site nurses and conduct online medical consultations when necessary. The system allowed us to quickly prescribe or modify medications according to the patient's symptoms. Using online auscultation and stress tests, with the help of the nurses in the lodging facility, we could quickly identify worsening conditions and coordinate with hospitals to ensure timely admission and treatment.

For individuals home-quarantining without a nurse present, telemedicine could be conducted via an app if necessary. Patients could request the session by chat, or the doctor could initiate it after reviewing the data online. For suspected pneumonia, a stress test-where the patient stands up and sits down for one minute to check for a drop in blood oxygen saturation-proved beneficial.

The telemedicine sessions for lodging and home care patients during the fifth wave in Hachinohe Family Clinic amounted to 549. There were 2,933 sessions until COVID-19 was downgraded to a common infectious disease in May 2023. Collaboration with on-site nurses and sharing information through ICT enabled service provision in the solo practice clinic.

Ironically, the pandemic allowed us to fully utilize the system we initially prepared to facilitate efficient and effective healthcare delivery during regular periods. It became clear that if we continue using these methods during normal circumstances, they will significantly improve healthcare delivery in areas with limited medical resources. This method will also enhance our readiness for emergencies, such as pandemics or natural disasters.

Among them was an AI-integrated translation system in telemedicine [12]. Given that even in Hachinohe, the majority of patients who needed telemedicine in the lodging facility were foreign residents who did not speak either Japanese or English during the last period of the pandemic, an AI-assisted translation integrated into the telemedicine system seems to be desirable in various locations and situations to guarantee the equitable provision of medical care.

Another inspiring trial was a symptom-based AI assistance for diagnosis with Chatbot [13]. Due to the limited supply of human resources and information about patients needing medical consultations, an AI-assisted chatbot can be a valuable tool for triaging and facilitating actual online consultations. If the information gathered by multidisciplinary professionals is available in EHR or an ICT information-sharing system, AI may also utilize it for triage and diagnosis assistance.

As Sharma et al. point out, "Collaboratively, telemedicine and AI have the potential to transform healthcare delivery by enhancing access to care, enhancing diagnostic accuracy, and optimizing treatment outcomes [14]," and that can be best achieved in home care settings.

Some argue that installing systems and regulations for providing appropriate telemedicine is not feasible, and the practical solution to the urgent shortage of medical resources is establishing an effective system to provide home care in Japan. The argument, however, needs to include critical points. Surveys show that most clinics that provide home care medicine also offer outpatient services [15]. This so-called "hybrid practice" leaves no room for doctors to allocate more time for home visits. The rate of such practice among Home Care Support Clinics is 48.1% in small towns and villages compared to 34.9% in Tokyo [15]. Additionally, the average commuting distance for home visits is nearly twice as long in rural areas compared to Tokyo, with the average being 9.8km and 5.6km, respectively [16].

The author has experience working at a clinic in a vast but sparsely populated village in Hokkaido. As the only doctor on weekends, I had to handle ambulance calls and make urgent home visits, sometimes requiring a 90-minute or more extended round trip. Even with the devoted help of staff, time management was highly challenging. If telemedicine had been available at the time, the health of the village residents would not have been endangered. Based on the data and daily experience as a physician, effective home care can only be achieved by using telemedicine as a complementary support to in-person visits, relying on sharing information through ICT, and collaborating with nurses and care workers.

The World Health Organization has been promoting telemedicine, especially since it presented the 2010 report [17]. Transitioning to a digital health system, including telemedicine, is crucial for ensuring equitable and sustainable healthcare. It emphasizes the need for a strategic and systematic approach to facilitate this process in each country [18,19].

At the Japan Association for Home Care Medicine's annual conference in Niigata in September 2023, the need for "hybrid care" was emphasized. This approach combines telemedicine with in-person home visits. The initiative was officially recognized as the Niigata Declaration, developed in collaboration with the Taiwan Association for Home Care Medicine and NPO National Network of Medical & Care Workers with Citizens Supporting Community Symbiotic Society [20].

The mission of the Network, co-chaired by the author, is "to contribute to the establishment, maintenance, and development of a 'community symbiotic society' where individuals can live and grow in the communities they are familiar with, supporting each other while raising children with peace of mind and continuing to live there until the end of their lives, even while facing various physical, mental, social, or economic challenges." We believe this can be achieved in a society where education, healthcare, and welfare services are provided integrally to support individuals living true to themselves.

Ikai claims that, unlike in the last century, when advanced health services were mainly provided in hospitals, activities that support health are being brought closer to daily living environments. As care is shifting from hospital-based to community-based, "the way caregiving roles are structured is transitioning from the traditional hierarchical system led by physicians at the top to a network encompassing diverse professions and local residents [21]" in the Community-based Integrated Care System. This transition can only be achieved through solid multidisciplinary and inter-facility collaboration, supported by adequate information sharing and communication through ICT.

As the world faces declining birthrates and aging populations, providing equitable and sustainable medical care and services with limited human resources will become increasingly difficult. Japanese economist Hirofumi Uzawa proposed the concept of "social common capital," which comprises "natural capital, social infrastructure, and institutional capital [22]" that allows all people to lead and maintain a humane society where they can thrive culturally and economically. An innovative healthcare system that provides home care utilizing ICT, telemedicine, and AI must be considered a social common capital that paves the way to a brighter future for us and future generations.

Conflict of interest

The author declares no conflict of interest.

Funding

No funding was received for this paper.

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