In today's hospitals, everything from reception to consultation, testing, prescribing, and billing runs on information systems. This did not happen overnight. Hospital information systems (HIS) evolved over roughly sixty years, from computerized billing in the 1960s through departmental systems, order entry, electronic health records, and now medical DX.
This series covers that journey in three parts. This first article addresses the 1960s through the 1990s, before EHRs appeared, when billing and order entry systems took root in hospitals. Knowing the history is the foundation for understanding why hospital systems are structured as they are today and what is about to change next.
The starting point was claims: universal insurance and computerized billing
The history of Japanese hospital information systems began not with clinical records but with calculating money. When universal health insurance was achieved in 1961, every medical institution had to convert care into points under the fee schedule and submit monthly claims (receipts) to review and payment agencies. In busy hospitals the volume of calculation and transcription was enormous and a heavy burden on administrative departments.
From the late 1960s, large hospitals began processing billing on mainframe computers. Initially this centered on outsourcing to computing centers and batch processing: care was written on paper slips, entered via punch cards, and calculated in bulk at month end. Even so, it was a dramatic improvement over manual calculation, and billing systems became established as hospitals' first substantial information systems.
The reasons billing was computerized first are clear: a nationwide fee schedule provided codified calculation logic, and the work was routine and recurred monthly. This idea of putting rule-based calculations defined by the system onto machines strongly shaped the character of Japanese medical information systems thereafter. The structure in which every fee revision requires system modification was also born at this point.
- 1961 universal insurance → claims preparation becomes routine for all institutions
- Late 1960s: batch billing on mainframes begins at large hospitals
- Codified calculation rules made computerization possible
- The pattern of system updates with each fee revision originates here
1970s: departmental computerization and the birth of medical informatics
In the 1970s, computerization spread from billing to the departments supporting care. Clinical laboratories moved fastest: as automated analyzers spread, laboratory systems emerged that captured large volumes of results directly from instruments and printed reports. Handling structured data such as test results propelled computerization in this department.
Pharmacies adopted systems that entered prescriptions and printed medication bags and dispensing labels; radiology adopted appointment and exposure record management; food service adopted meal ordering and menu management. Such departmental systems, specialized for each department's work, were developed and introduced individually. They ran independently, however, and information between departments still moved on paper slips.
During this period, the concept of handling hospital information in an integrated way began to be voiced, mainly at university hospitals, and medical informatics took shape academically. In Japan, the Japan Association for Medical Informatics was founded in 1980, and the first Joint Conference on Medical Informatics was held in 1981. The seeds of studying medical information systematically and viewing the whole hospital as one system grew in this era.
- Laboratory systems: the first department to computerize via analyzer connections
- Pharmacy, radiology, food service, and other departmental systems adopted separately
- Inter-departmental information still moved on paper
- 1980: Japan Association for Medical Informatics founded; medical informatics established as a discipline
1980s: the arrival of order entry and "point-of-origin entry"
The 1980s brought the first major turning point in hospital information systems: order entry systems. In order entry, physicians enter orders for tests, prescriptions, injections, and imaging directly at a terminal, and the information is transmitted electronically to the laboratory, pharmacy, radiology, and billing.
Until then, physicians wrote orders on paper slips, nurses or clerks carried them to each department, each department transcribed and processed them, and the billing office re-entered them for accounting. Multiple transcription was the norm. Order entry realized "point-of-origin entry" — the originator enters information once, where it arises — dramatically reducing transcription errors and waiting time. In having physicians operate terminals themselves, it fundamentally changed how clinical work was done.
In Japan, some university and large hospitals adopted order entry in the 1980s as pioneers, and it spread among large hospitals through the 1990s. Adoption always raised issues: physician resistance to entry work, terminal usability, connections with departmental systems, and heavy investment. The design philosophy established in this period — departments and billing connected around the order — became the skeleton of later EHRs and lives on in today's hospital systems.
- Order entry: physician orders entered at terminals and transmitted electronically to departments and billing
- Point-of-origin entry eliminated multiple transcription, cutting errors and waits
- Pioneered at university hospitals in the 1980s, spread to large hospitals in the 1990s
- The order-centered design became the skeleton of EHRs
1990s: client/server and the maturing of departmental systems
The 1990s was a decade in which changes in computing itself transformed hospital systems. Architectures shifted from centralized mainframes and office computers with dedicated terminals to client/server designs networking UNIX servers and PCs; terminal costs fell, allowing placement throughout wards and outpatient areas. Graphical interfaces became possible, improving usability for physicians and nurses.
Digitization of radiology images also advanced. With the spread of digital modalities such as CT and MRI, PACS (picture archiving and communication systems) began to be introduced to store and distribute images as data rather than film. The DICOM standard for image data was established in 1993, laying the groundwork for connecting equipment and systems from different manufacturers. Laboratory, pharmacy, imaging, nursing, and other departmental systems matured in function, and the HIS grew into an aggregate of multiple systems.
This aggregate character, however, also created long-lasting problems. Systems from different vendors were adopted per department, and interfaces connecting them were built individually for each hospital, making overall configurations complex and raising the cost of updates and migration. In Japan, this accumulation of local optimization is a distant cause of the "vendor lock-in" and "system update burden" that led 2020s medical DX policy to demand standardization.
- From centralized to client/server; terminals spread to wards and clinics
- PACS introduction and DICOM (1993) as the basis for image interoperability
- Departmental systems matured; HIS became an aggregate of many systems
- Accumulated bespoke connections became a distant cause of lock-in and update burden
Comparison abroad: what characterizes Japanese hospital systems
Japan's development path has distinctive features compared with other countries. In the United States, research and development of clinical information systems advanced from the 1960s at university and veterans' hospitals, and in the 1990s computerized physician order entry (CPOE) was promoted from the standpoint of quality and safety. With diverse insurance and payer-specific billing rules, however, billing computerization took complex, hospital- and payer-specific forms.
In Japan, by contrast, a nationwide uniform fee schedule allowed billing computerization to proceed early and at national scale. Order entry, too, was adopted in part from the standpoint of accurately transmitting data to billing rather than clinical quality alone. As a result, Japanese hospital systems came to be strong in billing and operational efficiency while relatively slow in clinical decision support and secondary data use.
This character persists to the present, for better and worse. Rapid response to fee revisions and high billing accuracy are strengths of Japanese systems, while mechanisms to feed accumulated data back into care quality and research have long been weaknesses. Understanding this history clarifies why current medical DX policy emphasizes standardization and secondary use of data.
- US: clinical information systems research led; CPOE promoted for quality and safety
- Japan: a uniform national fee schedule enabled early billing computerization
- Strong in billing and efficiency; relatively slow in decision support and secondary use
Why the chart itself stayed on paper the longest
While billing, departmental systems, and order entry were computerized, the clinical record itself — the chart — remained on paper through the 1990s. Even in hospitals with order entry, physicians typically entered orders at terminals and then handwrote findings and progress in paper charts, a dual operation. Why was the chart alone left behind?
The biggest reason was legal status. The Medical Practitioners Act and Medical Care Act mandated creating and retaining records, but whether storage on non-paper media was permitted remained unclear until the late 1990s. In addition, charts contain much unstructured free text such as findings and progress, and input technology of the time could not match the speed and flexibility of handwriting; physicians also strongly resisted operating terminals during consultations.
What changed this was a 1999 Ministry of Health and Welfare notice. By formally permitting electronic storage of medical records, it became the turning point called "year one of the electronic chart," after which hospital information systems were reorganized around the EHR. The story continues in Part 2, "The Birth and Spread of the Electronic Health Record."
- Charts stayed on paper through the 1990s; dual operation was common even with order entry
- Unclear legal status of electronic storage was the biggest barrier
- Free-text volume, input technology limits, and physician resistance also contributed
- The 1999 ministry notice became the turning point of "year one of the EHR"
Summary of Part 1
Pre-EHR hospital information systems began with billing systems that computerized claims work, passed through departmental computerization, and developed into point-of-origin entry via order entry. Two ideas established along the way — putting rule-based calculations into systems and connecting departments and billing around the order — remain deep within today's hospital systems.
At the same time, the structure of per-department optimization and vendor-specific connections also took shape in this period. Understanding how this led to later difficulties in standardization and data exchange makes the intent of current medical DX policy easier to see. Part 2 traces the birth and spread of the EHR from 1999 through the 2010s.
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