Preliminary Study on Wellbeing and Healthcare Services Needs in Japan and Finland for Telehealth Solutions Based on Dwelling

“Leave no one behind” is the core principle of the UN Agenda 2030 [1] as it is crucial for institutions to possess the capability to guide and harness digital technologies inclusively and equitably. The digital divide is most pronounced in rural and remote areas due to the inequality in connectivity [2]. Additionally, the capacity to collaborate effectively with the private sector and other entities to promote the public interest is equally important [1].

While technology is advancing towards more capable and complex solutions to ease every day lives, digital health services in the EU, and specifically in Finland and Japan face similar growing issues; How to get the relevant services equally to everyone regardless of dwelling? An issue for people living in rural areas is not only poor connectivity, but also that they do not have access to the same services offered in larger, concentrated cities [3]. This is not limited to regular citizens but also for people with disabilities [4] and presents an equality problem where your location affects your health outcome. These services which often require physical mobility, such as emergency services, or a health assessment, are needed especially for the older population. This is due to the tendency of the younger generations to move away from rural areas. This phenomenon skews the age demographics even more towards older population in rural areas and it has already been an economic and sustainability concern in Japan [5], and there is a need for more eHealth services due to the increased amount of age related diseases [6]. We focus on Japan and Finland due to the existing research collaboration between the countries and having experience in their healthcare systems and assistance efforts for the elderly, including creating mobile services [7], safety guidance [8] and telecommunication [9] and medication guidance [10]. The still existing problems need further collaboration, focus outside of single solutions and on the broader problems in healthcare. The researchers have access to institutions, researchers and materials from both countries to ease this process. It is worthy of note, that some of the examples mentioned in this study are derived from these real-world experiences of the researchers in both countries, having access to local news sources, and from interactions with researchers and doctors, also during Covid-19. They act as illustrations on how e.g. the Japanese healthcare system works in a daily life albeit from somewhat subjective point of view. As a smaller population country, Finland can implement healthcare solutions faster, which can also be later implemented on a smaller scale in Japan. This ongoing exchange of efforts has so far been shown beneficial, but in the future the scope should be extended as several European countries have shown to have good eHealth structures. As an example, 27 EU countries have 100% electronic medical records (eMR) structures compared to Japan’s 45% [11]. As such, we want to see why the Japanese healthcare progress is slower compared to Finland and if we can have answers for them through this study.

The general problem is however how to deliver services for the rural elderly populations. In Japan some prefectures have attracted families and younger generations to move to the rural areas as they seek a more quiet life and a better place to raise their kids [12]. This is indicative of the stress people experience in larger cities. Supporting this notion is the evidence of people having greater likelihood of mental illnesses in larger cities even with better access to healthcare services [13] to rural. Looking at the mental well-being of individuals, there is evidence that having access to greener environments positively affects mental health [14]. Regarding physical health, the positive benefits of green environments also exists for children’s respiratory resilience [16]. For this to happen studies are needed on how healthcare services are currently provided, and how they differ between various dwelling areas. In addition, how to offer better access to digitally enhanced future healthcare for mental and physical well-being.

As an example, a recent 6G-project in Finland, aims to reach UN’s sustainable goals by using future technology to create new services for smart cities and is also doing these in collaboration with Japan [17]. These UN sustainable goals aim to offer healthcare for all parties regardless of age and economic status [18] and can be seen as a future problem alleviating effort. In this conceptual paper we first look into two relatively similar countries in terms of their social structures and the distribution of population in rural and urban areas, but also the differences the implementation of their digital health structures. We look into how the two countries could benefit from sharing solutions and data in an efficient way. We begin by discussing the challenges in telehealth to point out the problems and what basic needs for example administrative or educational should be done when offering them. Then we delve into wearable sensors for vital health tracking and why they should be used. Finally we discuss a singular example technologies could address, stress and mental health issues among citizens and healthcare staff especially in Japan. Lastly we propose future work in regards to a broader study on existing solutions and new technologies.

Creation of digital systems has been a target for both countries for a long time. The Finnish Society for Telemedicine and eHealth was already founded in 1995 and has produced the first electronic tools, like the e-prescription, e-referrals and e-consultation over the years [31]. As such the Finland’s societal goal has been to promote health through telecommunications and to share knowledge within the health care communities. With this the country already has a solid basis on some existing telehealth adaptations. Finland has also invested in the Healthcare Information Technology education for healthcare professional to better understand the role of technology needed in the healthcare sector. As of 1998, there has already been video consultation for psychiatry available for patients [32] and a study made in 2006 showed that 3 out of 4 patients in general practice could be diagnosed reliably via remote work [33], which clearly reduces the load on caretakers and also removes the need for patients to travel to get diagnosed.

Japan has studied telemedicine solutions also for more than 20 years, and the research community has seen the discrepancy in delivering health to rural areas as an important factor. However, the bulk of these studies are written in Japanese and there is a lack of systematic reviews on the Japanese telemedicine studies as pointed out in [34], so these findings, which the international community might find important, do not easily reach that audience. While an extensive review is needed, Japanese journals has already looked into doctor-patient diagnosis using digital tools, studied effectiveness of telemedicine, management of diseases like diabetes or heart failure and studied elderly care, but a more comprehensive approach is needed. Japan and Finland have both also started to focus on one of the more important factors related to the economy, the implementation of telemedicine that will help save huge costs in healthcare. But, there is a need to do a literature review on the existing studies to understand the extent, so we can start creating more precise solutions to the problems. While at a basic level telehealth can help with the diagnosis and communication issues quite readily, there are still procedures which so far can not be easily done remotely, such as, radiology for example. It requires the x-rays done with a professional healthcare staff and to have some larger equipment, or to have an on-location hospital required for other treatments. A study [35] addressing telehealth challenges highlights the following common problems, primarily related to human factors:

These are points which are also reflected in [38] and [36] as various layers of the digital divide. They are also common in areas outside of this divide, as for example the introduction of new methods into a work environment is often met with resistance from the older workforce accustomed to the existing, learned ways. What we can speculate is that there are similarities to other existing worries present in a working environment, e.g. the fear of new technologies. The oft result in a refusal to learn, to use or to be exposed to anything new which would require re-learning [37]. As such effective implementation requires a solid plan from the implementing agency from the ground level (patients, nurses, doctors) to the higher level (administrators, engineers) to cover all of the stages of uncertainty. A steady construction of layers to support the low, middle and high level activities is needed. As an example, the training, comprehension and sharing of the tasks, pre-planning, having adequate funding and following through on a plan. Additionally it is important to make sure that all parties, especially the local authorities who need to actually use the system for a long period, to understand the overarching goal cohesively.

The rise of wearable body sensors, such as the Apple Watch [39], Oura Ring [40], and Dexcom sensor [41], has introduced a wealth of health data that can significantly benefit telehealth. These technologies can now monitor a user’s heart rate variability (HRV), sleep quality, various exercise types, and even glucose levels. The introduction of these sensor technologies opens up possibilities for preventative healthcare. Instead of periodic check-ups, healthcare staff can now access relevant health data directly from wearable devices. Predictive assessments based on continuous user data or aggregated data from multiple individuals can influence health outcomes by identifying potential issues early on. While this do not replace the need for comprehensive check-ups, it aids in lifestyle advice and timely interventions, particularly for sedentary lifestyle problems.

For the elderly, wearable sensors, like smart sensors, can detect events such as sudden falls and prompt assistance, enhancing safety [42]. The use of wearable sensors can contribute to reducing inequality in healthcare access by reaching a broader audience, offering predictive and preventative medical services regardless of location. It enables healthcare institutions to allocate resources efficiently, predicting when and where they are needed for individuals, based on sensor data. However, the challenge lies in effectively reaching users in rural areas, even though the use of sensors can potentially reduce the need for frequent doctor visits. While developing better telehealth treatment methods from tracking data is crucial, the primary goal of sensor data remains the prevention of medical issues. We propose an extensive look into what exact existing equipment could be used for vital data tracking, which commercial sensor data is reliable enough for medical use or are they interpretive data for estimations only. Or is there need to create totally new sensors for each situation. As there are a variety of existing sensors available, it would be logical to start first with the existing solutions as a basis. Also, for any medical implementation due to strict device guidelines e.g. regarding health and radio frequency interference, the use of any existing solution would reduce the costs of implementations as it is one of the burdens for societies and even more in the future. If we look at even Wifi implementations in hospitals, we can already use the pre-existing network to track equipment, people and even respiratory rates without changes into the structure [43], so we hope to discover the same for existing wearable sensors effective use in healthcare.

Notably, while wearable sensors offer real-time advantages, consideration should also be given to the use of external digital sensors integrated into the environment. For instance, an implanted sensor in a commonly used location like a toilet could provide processed health data from multiple users without requiring individual effort or changes in routines. Wearable sensors are just one aspect of the broader picture, and this study initially focuses on them due to their flexibility in data collection.

Over the years and across various projects, visits to nursing homes in Finland and Japan, both in urban and rural areas, aimed to comprehend the caregiving processes, the elderly’s daily lives, and their physical or mental challenges. Observations revealed that many solutions did not utilize technological aids, relying instead on paper and pen guides or calendars for reminders, especially in cases of dementia. While these manual methods were effective, they required physical presence for updates. Teleassistance could potentially replace certain tasks or personnel, allowing digital solutions to streamline updates and reduce the time spent on routine tasks. This becomes particularly crucial in addressing the shortage of nursing staff, a prevalent issue in the current aging population, as highlighted in various studies.

As stated earlier in [14], mental health is affected by the dwelling area of individuals as there are more prevalence of mental issues in the urban areas. Additionally, sedentary lifestyles are often related to office work and present themselves as various diseases; obesity, decreases cardiac output and systemic blood flow, and elevated chronic inflammation caused by this sedentary behaviour and are risk factors for cancer [44]. As these basic physical and mental declines happen, we can argue that moving from an urban area to a rural location would increase the overall health outcomes of people. This is not only a positive for adults getting these diseases, but other positive effects are for children with respiratory issues as improvements happen if they interact more with nature. General studies have shown that air quality, increase in exercise, stress reduction and social cohesion increase from contact with nature. These also affect general well-being of individuals [45] and provide better future health prognosis. It is suggests that moving to a rural area should be considered for individuals with a high stress work or sedentary lifestyle diseases, if possible. The positives of rural areas is due to Covid-19 presenting new and interesting developments regarding remote work in companies. Due to the isolation periods, employees had to stay at home and perform duties remotely. This meant companies had to adjust from on-location to a hybrid or fully remote and it helped create a more telework style living. Because of it, employees are now facing a new reality where they can choose where to work from and are not tied to commuting depending on the work. This makes rural areas more attractive due to the space they can offer [46] and because of the aforementioned positive effect on the mental and physical health compared to an urban environment. This would suggest that in the future there might be a bigger influx of people choosing rural living instead of urban centers. It also insinuates that telehealth plays an important role as the services are needed for people of all ages and the current centralisation of services to cities need to be reconsidered.

During Covid-19, the hospitals suffered from overworking problems, such as stress, as the staff needed to respond to the pandemic wave of new patients. While severe patients needed to be taken care of at hospitals, the less severe were isolating at home. In Japan these were followed up by daily phone and/or video calls to inquire the symptoms and the general health of a covid patient. The pandemic created a sudden need to deal with an influx of telehealth diagnosis but soon new applications need to replace the video and phone calls. This was to reduce the workload for the nurses by having patients create self reporting through teleservices, instead of one-to-one nurse calls. Both patients and citizens suffered from the effect of stress, while the former was due to the amount of work, the latter were due to isolation issues. Stress is a significant factor in overall well-being, and there’s a growing feasibility in using smart devices to measure stress levels. Heart rate variability (HVR) has been identified as a reliable predictor for stress based on data obtained from the Apple Watch [47]. Moreover, smartwatches have proven to be effective tools in predicting COVID-19 infections, especially when combined with self-reported symptoms [48]. This underscores the potential utility of sensor devices in rural areas, as the data they provide can contribute to the early detection of both mental and physical health deterioration.

To identify current challenges perceived by medical professionals and the preferences of healthcare recipients regarding improvements in healthcare services. The following efforts needed to be made. To gain a comprehensive understanding of how telehealth can be improved in Finland and Japan, and how new technology can be designed, an examination on the current technological landscape in both countries for both urban and rural areas is essential. This involves conducting a systematic review of existing literature, particularly focusing on Japanese publications not available in other languages. Additionally, surveys targeting medical institutions and citizens in urban and rural settings should be conducted.

The comprehensive research approach includes literature reviews, qualitative and quantitative interviews, observations, and questionnaire surveys. The objective is to gather a dataset from both countries that can uncover unique, shared, or unidentified problems in telehealth.

To establish a solid foundation, the proposed steps include: 1) detailed comparison of Finnish and Japanese services, 2) identification of existing telehealth services, and 3) exploration of ways to create new or enhance existing eHealth systems. With a focus on improving individual well-being, additional steps involve: 4) enhancing physical and mental well-being for all individuals through these systems, and 5) increasing inclusivity, social connectivity, and reducing the digital divide. Based on the data results, there is an opportunity to formulate a broader system’s design guideline for developing eHealth services. This guideline, depicted in Fig. 1, could serve as a basis for government policymakers. A less-explored avenue involves conducting a comparative study on how urban and rural living impacts mental and physical health. This includes investigating if there are optimal dwelling locations near urban areas and this kind of study could facilitate better access to urban medical care while benefiting from the natural advantages of rural living.

The core principle of the UN Agenda 2030, “Leave no one behind,” underscores the importance of guiding and harnessing digital technologies inclusively. The digital divide, most pronounced in rural areas, raises challenges in providing equitable access to healthcare services. This paper explored the shared issues faced by the EU, Finland, and Japan, focusing on delivering relevant services to all, irrespective of dwelling. Examination of the demographic structures of Japan and Finland reveals distinctive challenges posed by an aging population and increasing healthcare demands. Disparities in population density contribute to heightened burdens on healthcare systems, necessitating innovative approaches to address the rising needs of the elderly in rural areas. Comparing healthcare data structures in Japan and Finland, the study highlights the differences in data accessibility and privacy concerns. While Finland boasts a unified database system (MyKanta), Japan faces challenges in implementing Electronic Medical Records (EMRs) due to concerns about data theft and slow digital service adoption. However, there are privacy related issues in collecting healthcare data, so consideration on how legislation and privacy for one’s own health data is maintained is needed when dealing with sensitive data. Finland is already fairly advanced in this area from the use of e.g. MyData [49, 50], which is a non-profit solution on maintaining data privacy and ownership of it by the citizens. Both countries have a history of studying telehealth solutions, stressing the importance of leveraging technology for healthcare improvements. Challenges identified include staff training, project management, patient and staff support, technology compatibility, local partnerships, funding, and strategic planning. The COVID-19 pandemic and the rise of remote work present opportunities for the increased adoption of telehealth services. Wearable devices and sensor technologies offer potential solutions for monitoring health metrics and providing real-time data. The study underscores the significance of sensor technologies in predicting and preventing health issues, especially for the elderly population. The paper proposes a comprehensive research plan, including a systematic literature review, surveys for medical institutions and residents, and the creation of design guidelines for eHealth services. The aim is to gather data on existing technologies, identify unique problems, and develop solutions to increase inclusivity and well-being. Collaboration, knowledge sharing, and a holistic approach are highlighted as essential for addressing multifaceted challenges and opportunities in the implementation of digital health services. The importance of international collaboration in developing and testing telehealth services is also highlighted. In conclusion, this research contributes to the understanding of telehealth challenges and solutions in Finland and Japan, offering insights for future improvements in healthcare systems, with a focus on inclusivity and well-being in times of the digital divide.