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IntroductionDiffusion means the spread of a phenomenon (including ideas, objects and living beings) over space and through time (Gregory, 2009). The specific contribution of geography was to reconstruct diffusion pathways and to evaluate the influence of physical barriers (Sauer, 1952 ; Wagner and Mikesell, 1962). Two tasks appeared in the much more formal study of innovation diffusion inaugurated by Hägerstrand (1967).Most immediate discussion focused on the operationalization of Hägerstrand model – on the use of simulation methods, the comparison of ‘observed’ and ‘predicted’ patterns of adoption of innovation, and the detection of a localized neighborhood effect. Within this modelling tradition, the most important developments included the following : a formalization of the mathematical relationships between the structure of the mean information field and the form and velocity of diffusion waves, revealing the connections between different distance-decay curves and the classic neighborhood effect. A demonstration that the Hägerstrand model is only a special instance of the simple epidemic model, and subsequent derivation of more complex epidemic models, which recognized hierarchical diffusion.However, the Hägerstrand model begins with a pool of ‘potential adopters’ and does not explain the selective process through which they are constituted in the first place. The Hägerstrand model also assumes a ‘uniform cognitive region’ and does not explain the selective process through which information flows are interpreted (Gregory, 2009).Related to technology, a core interest of interpretivist health geographers is to explore how technology, particularly information and communication technology (ICT), influences interactions between people and places (Graham, 1998 ; Parr, 2002 ; Andrews and Kitchen, 2005 ; Andrews and Evans, 2008). At the present time, ICT is regarded in the general population as computers, Internet, interactive web applications, GPS, ‘smart’ phones and other wireless devices. Technologies through constantly evolve and new applications and devices emerge. For interpretivist health geographers, advancements made in technology are viewed as an ongoing, fluid progression of innovation and not a static process (Graham, 1998 ; Parr, 2002 ; Andrews and Kitchen, 2005 ; Andrews and Evans, 2008).In technology discourse before the mid-late 1990s, many of geographical studies are dependent on technical determinism and have verified the effectiveness of ICT as a means of solving various regional issues (Graham and Marvin, 1996). However, cyberspace constructed through information systems that multiple actors can communally utilize is affected by the physical nature of the infrastructure or the varied resources and different social relations, including cooperative behaviors, with others. This complexity renders it difficult to interpret cyberspace using technical determinism (Graham, 1998).Most interpretivist geographers now widely accept that humans are responsible for the invention of technology and the adaptation of it to fit their needs and suit their environment. Rather than viewing technological progress as something that happens to humans, technologies are recognized as the creation and innovation by people, for people. This theoretical framework largely informs health geographers’ work on the application of ICT to health care delivery (Rosenberg and Waldbrook, 2017).The concept of social capital is an accounting of relationships of reciprocity or social ties among different actors. Putnam (1993) defines social capital as “features of social organization, such as trust, norms, and networks that can improve the efficiency of society by facilitating coordinated actions.” It was found that the use of social capital can lead to effective and responsive governance in Italy (Putnam, 1993) or at a state level in the US (Putnam, 2000).With Japanese local governments, however, it is not social capital but the power of the civic elites, who support, criticize, demand benefits from, and monitor political elites, that ensures that administrative reforms, disclosure of information, industrial policies, reforms of bidding systems, NPO reform, and other issues are properly taken care of. The resulting performance is thus partly determined by other factors beyond social capital, such as historical, political, structural, institutional, and socio-economic factors (Sakamoto, 2010). On the other hand, the effects of improved fiscal management and better welfare policies on the power of the civic elites has not been confirmed. Policy-specific differences in the effectiveness of the power of citizens must be theoretically developed.This paper examines a medical information system as an example of an information system that is intimately related to social relations. A system-promoting agency was established to support the construction and diffusion of a medical information system, working in coordination with multiple medical institutions and regional medical associations. The civic elites were healthcare professionals with specialized knowledge and free time. Cooperative behavior among professional organizations or with local governments are considered to affect how systems are diffused. The behavior of professional organizations must be understood to support further discussion of the function of medical information systems as a common basis for supporting a community-based integrated care system.This paper illustrates the diffusion of ICT in a case study of a medical information system, namely, Ajisai Net, based in Nagasaki Prefecture, Japan. Regional differences in system-diffusion patterns and their factors are exhibited through a focus on the decision-making of primary actors, including system-promoting agencies. This study also indicates the status of system utilization and the effects of and issues with the system. An interview survey was conducted in the healthcare policy division of the government of Nagasaki Prefecture, National Hospital Nagasaki Medical Center, the Omura Tohi Pharmaceutical Association, and participating facilities in the Goto area, an archipelago of relatively isolated islands that appertains to Nagasaki Prefecture. A questionnaire survey of members of the Omura Tohi Pharmaceutical Association was also conducted.This paper first outlines ICT-based healthcare policy in the study area. After which, we provide a case study of the construction and diffusion process of the medical information system in Nagasaki Prefecture in chronological order. Then, the factors leading to widespread adoption of the medical information system are considered in two relations. Finally, I conclude with geographical implications about diffusion process of medical information system.Outline of study areaThe first characteristic of the medical care provision system in Japan is that it adopts a system of social insurance so-called the Bismarck model : only medical fees, which are prices to be paid by the insurer, are controlled uniformly throughout the country. By adjusting medical fee points and the calculation requirements, the content and volume of medical care to be provided are controlled (Morita 2016). The second is that all residents participate in public medical care insurance programs through the universal medical care insurance system. The third is that it is based on a free medical practitioner system in which doctors can start their practice freely anywhere they like, if facility standards are satisfied. For those reasons, only Japan combines public and private components in terms of medical care supply and medical care finance. Although this environment has played an important role in the quantitative development of medical institutions (medical care providing facilities), it has led to a condition in which most medical institutions have been established by private entities. According to the 2014 Static Survey of Medical Institutions, private medical institutions in Japan account for 80.9 % of hospitals and for 97.1 % of clinics, including dental clinics (Nakamura et al., 2020, forthcoming).We specifically examined the number of medical institutions per 100,000 population. Both hospitals and medical clinics exhibit a trend by which the number is high in western Japan and low in eastern Japan (Figures. 1A and 1B). Regarding hospitals, many secondary medical areas show high values in Hokkaido and in the Shikoku, Kyushu, and Chugoku regions, although the number of hospitals per 100,000 population is low from the Tohoku region throughout the Kinki region (Figure 1A). The number of medical clinics per 100,000 population is high in the west of Kinki region (Figure 1B).The free medical practitioner system led by the private sector greatly contributed to the quantitative expansion of medical institutions. Nevertheless, it fostered a strikingly uneven regional distribution because of the concentration of medical institutions in urban areas. In actuality, this trend is more readily apparent for medical clinics and dental clinics (Figures. 1B and 1C). Particularly, the number of dental clinics, most of which are established by private practitioners, per capita is remarkably high in large cities, such as Tokyo’s 23 wards and Osaka City. Regional disparities in access to dental consultation are very high, which suggests a rather excessive supply of dental clinics in urban areas. By contrast, the component ratio of public medical institutions is high mainly in town and village areas where, although the population is scattered, traffic conditions are not satisfactory and private hospitals and clinics are not readily accessible. Public medical institutions support medical care in those areas.However, the number of hospitals per 100,000 population is low in many medical areas, including prefectural capital cities (Figure. 1A). Such regions are regarded as having experienced population increase above the growth rate of the number of medical institutions throughout the high economic growth period. Among mountainous areas and isolated islands that have experienced a population decrease, the number of hospitals and that of medical clinics per population tend to be high in the regions where medical services in remote areas including Nagasaki Prefecture have been secured mainly by public medical institutions (Nakamura et al., 2020, forthcoming).Figure 1. Number of medical institutions per 100,000 population (by secondary medical area in 2014)Sources : Survey of Medical Institutions by the Ministry of Health, Labour and Welfare and a “Basic Resident Register in Japan” by Welfare the Ministry of Internal Affairs and Communications 2016. Reprinted from Nakamura et al. (2020, forthcoming).Nagasaki Prefecture includes about 600 islands, most of which are uninhabited. About 140,000 people live on 51 remote islands, each of which is officially designated a region and where development measures are implemented (Nagasaki Prefecture, 2013). Nagasaki Prefecture is rich in healthcare resources, such as healthcare facilities, hospital beds, and healthcare professionals per capita. The density of healthcare resources on the mainland differs greatly from that found on the islands (Figure 2). Inpatients flow from the remote islands, where healthcare resources are relatively scarce, to the mainland, where resources are abundant. Additionally, ICT-based telemedicine is used to supplement the shortage of resources on some islands.Figure 2. Number of doctors per 100 thousand populations by municipality and behavior of inpatients by Secondary Medical AreaSources : Medical statistics of Nagasaki Prefecture of 2010 and patient survey by the Ministry of Health, Labour and Welfare.The attempt to supply ICT-based healthcare resources to Nagasaki Prefecture was begun at an early period. In 1973, Nagasaki Prefecture was designated a model district for the development of a healthcare system for remote islands, developed by the Ministry of Health and Welfare. An electrocardiographic telephone transmission system was created in 1974 through experimental work and instituted. The Nagasaki prefectural government set up its Investigative Committee on the Informational Network System for the Remote Islands of Nagasaki in 1984, and it implemented a transmission experiment using INS for healthcare in remote islands. In 1991, an island medical information system (with a remote image diagnostic system) was introduced, commissioned by Nagasaki Prefecture. The Telecommunications Advancement Organization (now the National Institute of Information and Communications Technology) organized and implemented the Project for Nagasaki Multimedia Model Medical Development, in collaboration with Nagasaki Prefecture, from 2000 to 2002 (Nagasaki Prefecture, 2010). This project allowed 12 hospitals or clinics on remote islands to benefit from diagnostic support from Nagasaki University Hospital or the National Hospital Nagasaki Medical Center. Currently, about 500 cases of intercommunication occur per year are performed and are utilized for specialized diagnosis, medical treatment, and helicopter transport.Medical support entails collaboration with medical institutions in remote areas and system-promoting agencies. Thus, the results of past support could be used to help lower psychological barriers to collaboration with other institutions.National Hospital Nagasaki Medical Center has become a pillar of diffusion for medical information in the network of Nagasaki Prefecture. The center develops healthcare policy for the central government, as well as conducting medical research, activities but has many clinical cases like local hospitals. It could be advantageous for the center to develop a medical information network to share information with other healthcare facilities, but it was relatively rare for the private facilities to participate in the ICT program.Government policy emphasis is on community-based health information exchange, which the government strongly supports in rhetoric and funding as a concerted effort between all medical factions in the community, but is coordinated in reality by the main hospital with the largest service capacity and resources within the respective community, operated mainly by public entity (Abraham et al., 2011).Diffusion process of a medical information system in Nagasaki PrefectureThe ICT system discussed in this paper has two forms of participation, information disclosure and information browsing. The former is performed by hospitals that disclose clinical information from their own electronic medical charts through Ajisai Net. The latter is done by healthcare-related facilities that require clinical information from hospitals.The diffusion process can be divided into three phases (Figure 3). The first (from May 2003 to March 2009) was the infrastructure-building phase in Omura City and neighboring areas, performed with the cooperation of National Hospital Nagasaki Medical Center, Omura Municipal Hospital, and the Omura Medical Association. The second was the phase of spatial expansion (from April 2009 to June 2011), in which the participating facilities were able to access the system in the city of Nagasaki and in Kamigoto. The third was when widespread dissemination was begun to the entire prefecture (from July 2011 to October 2014).The diffusion process did not follow S shaped curve along logistic function in the Hägerstrand model but inverted-L shaped. System utilization spread through system-promoting agencies in the form of increases in information-disclosure facilities. The diffusion process of this case differed from the hierarchical effect. Based on the ICT’s utilization, the results demonstrate that the diffusion of medical information system was determined by existing social relations ; however, the degree of social relations was not always proportional to the size of the urban area. System-diffusion patterns were also found to be a different form than the neighborhood effect on a municipal scale. The infrastructure building and spatial expansion are described in their turns below.Infrastructure-building phaseCollaboration was required among medical institutions based on a pre-existing human social network that was found in Omura before the infrastructure-building phase. A home-care seminar has been held here annually since, 1991 and it provided opportunities for medical, dental, and pharmaceutical professionals and their associations to have social interactions. Additionally, healthcare professionals have promoted sharing of notes with patients to create memos. However, inputting health conditions and service contents requires time, and patients often forget to bring their notes.The Omura Medical Association took the opportunity offered by the Y2K crisis (computer glitch) to form an information-sharing system, which could send messages to lists of members of an executive board (Kimura, 2011). About 60 % of the members of the association used e-mail, and many of these expressed a positive intention to take the advantage of new systems.National Hospital Nagasaki Medical Center ordered an electronic ordering system from Fujitsu in 2001, and then it switched to Fujitsu’s electronic medical records system in 2004. Because the center received approval to act as a Regional Medical Care Support Hospital in 2003, it acquired the need to share clinical information with Omura Medical Association. However, the association considered information sharing with specific medical institutions as going against patients needs and established a committee to investigate community healthcare using IT with an eye to developing a system that would enable users in the entire area to participate by May 2003. Omura Municipal Hospital was afraid of being left behind and joined the committee.Finally, representatives of each member institution were holding a meeting once or twice a month. Causes of failure were explored in the committee using examples of past cases. In December 2003, a needs survey was conducted on the browsing of clinical information with ICT.Ajisai Net began as a system in which 31 medical institutions located in Omura and Isahaya City were able to browse electronic clinical information from the National Hospital Nagasaki Medical Center in November 2004 through the efforts described above. Nagasaki Community Medicine Coalition Network Systems Council officially launched as an unincorporated association in July 2004. The council was established as the organizational structure to oversee autonomous activities, not by specific medical institutions but by local medical institutions (Kimura, 2011). Omura Municipal Hospital added its own clinical information in May 2005. The organization was incorporated in October 2005 with non-profit status.During its first days of operations, an internet virtual private network (VPN) was adopted due to its high cost-effectiveness and reliability, and this made it possible to browse clinical information from the information-disclosing hospitals. Association members were able to browse clinical information on hospitals, including the process from examination to diagnosis. The participating facilities for the first phase are distributed close to National Hospital Nagasaki Medical Center and Omura Municipal Hospital, as well as in the heart of the cities of Omura and Isahaya and widely along the JR Omura Line (Figure 3). At the same time, many pharmacies in Omura or Higashisonogi County (including the towns of Higashisonogi, Kawatana, and Hasami) joined the system. It can be concluded that many of these functioned as healthcare facilities for outpatients who had received medical examination at the information-disclosure hospitals.Spatial expansion to Nagasaki CityThe following paragraphs discuss diffusion process in the city of Nagasaki through the cooperation of the Nagasaki City Medical Association. It was expected that Nagasaki would be one of the most difficult sites to expand the system. The Nagasaki City Medical Association has about 510 general practitioners and 450 hospital doctors as members. It took three and a half years to obtain consensus among the members because multiple public and private hospitals were in competition with each other (NEC, 2013). Further, it was important for the diffusion of the system that collaboration with Nagasaki Home Care Doctor Net, the relevant division of the Nagasaki City Medical Association, be achieved.Nagasaki Home Care Doctor Net allows the secretariat to find and introduce to home treatment patients attending doctors and sub-attending doctors among general practitioners in the membership. Previously, home-care-related information had been shared via mailing list after individuals left hospitals, communicating among such parties as hospital staff, attending and sub-attending home care doctors, visiting nurses, long-term care support specialists, and nursing-care helpers.Nagasaki City Medical Association joined Ajisai Net in February 2009 after a discussion among its membership. Ajisai Net began operating in Nagasaki after three information-disclosure hospitals joined Ajisai Net in April 2009, followed by the added participation of two other hospitals in November 2009, then four hospitals in 2010, and one each in 2013 and 2014. In all, 3,037 hospital beds (29.7 % of all hospital beds in Nagasaki) of eleven hospitals (22.4 % of all hospitals in Nagasaki) were included in Ajisai Net. The participating facilities were distributed from the heart of Nagasaki City to the urban areas along the JR Nagasaki Main Line (Figure 3).Widespread dissemination to the entire prefectureThe financial support of the Nagasaki prefectural government brought about the dissemination of the system to the entire prefecture. Local governments had never previously been involved in the system diffusion, as documented above. However, a temporary special community healthcare revitalization grants and budgetary allowance by Ministry of Health, Labour and Welfare (MHLW) were utilized to bring the system to the entire prefecture. A grant was allocated to each prefecture to resolve issues of community healthcare. Nagasaki Prefecture provided the funds to defray the initial costs of the expansion of Ajisai Net to Sasebo and Kenhoku. In all, 320 million yen of the proffered 5 billion yen was allocated to ensure interoperability among vendors in January 2010. Half of the costs of the gateway servers were subsidized.Four hospitals in Sasebo joined the system and began operation in March 2012, followed by the Sasebo City Medical Association in April 2012 and then 32 health-related facilities in Sasebo, 2 facilities in Hirado, and 1 facility passing information through the system as of October 2014.Moreover, a temporary special grant for community healthcare revitalization was enhanced under the fiscal 2010 supplementary budget. Specifically, 1.5 billion yen was allocated to each of 52 tertiary medical areas (each equivalent to a prefectural area, except for Hokkaido, which was divided into several areas) for the solution of problems of healthcare provision over a wide area. The community healthcare revitalization plan in Nagasaki Prefecture was intended to reduce cancer-related mortality and medical care cooperation system for stroke. As for the latter, about 140 million yen was allocated to the expansion of Ajisai Net to the Isahaya and Shimabara areas (refer to a map). The former was intended to develop image transmission and image-reading systems, as well as to improve the quality of cancer examinations at medical institutions nearby (Nagasaki Prefecture, 2013). A series of subsidies by the fund met the costs of a cloud-storage service until 2014.Isahaya Medical Association joined the system in October 2012, followed by another one hospital in August 2013 and three more in July 2014. In all, 20 facilities in Isahaya and one clinic each from in Shimabara and Unzen began to pass information on Ajisai Net in October 2014 (Figure 3). Kamigoto Hospital also joined the system as an information-browsing facility in November 2004. Kamigoto Hospital had the benefit of checking medical practices before introducing patients to National Hospital Nagasaki Medical Center. Kamigoto Hospital began to disclose its own clinical information for smooth discharge of patients in July 2011. Two affiliated clinics, three pharmacies, and a long-term care health facility took this opportunity to use clinical information from the hospital. The long-term care health facility experienced positive exchanges of information with the hospital after patient discharge. The participating pharmacies generally fill prescriptions written at the hospital, due to their close proximity to it (refer to a map systematically).Figure 3. Distribution of facilities participating to Ajisai NetSource : Website of Ajisai Net and interviews.As noted above, taking into account the transition of a number of facilities in their participation in Ajisai Net, only two hospitals disclosed their own information on the one hand, while many other facilities made use of their information immediately after acceding to operations (Figure 4). After the first phase, the number of facilities increased, and the number of participating hospitals and facilities grew rapidly ; it expanded at an even faster pace in the third phase. The monthly increase of information-disclosing hospitals grew from 0.04 in the first phase to 0.40 in the second phase. The monthly increase of the information-browsing facilities also grew, from 1.26 to 2.78 during the same period. Information-browsing facilities spread widely, coming to include establishments in Hirado, Matsuura, Hasami, and Nagayo, where there are no information-disclosure hospitals (Figure 3).Figure 4. Changes in the number of facilities participating to Ajisai NetSource : Website of Ajisai Net.Ajisai Net now features 437 members, 27 information-disclosure hospitals, 240 information-browsing facilities, and 40,115 registrations as of December 2014. The correlation coefficient between the numbers of information-disclosure hospitals and of information-browsing facilities for each municipality was 0.965, implying high correlation. Further, the correlation coefficient between the number of information-browsing facilities and population by municipalities was 0.923 ; this means that the two are in close relation. Although there are 46 information-browsing facilities in Omura, which has a population of 90,000 and a total of 1,003 hospital beds in information-disclosure hospitals, Sasebo has only 32 facilities for a population of 261,000and 1,669 hospital beds. In some municipalities, the population or number of information-disclosure hospitals does not correlate well with the number of information-browsing facilities (Figure 5). This suggests that organizations in Omura, where the system was developed, have a deeper understanding of the usefulness of the system than is prevalent in Sasebo City, which began to appear later in system diffusion.The absolute number of information-browsing facilities is small outside the cities or on the isolated islands, but the proportion of health-related facilities, especially pharmacies, is high (Figure 5). Such facilities are dependent on a few information-disclosure hospitals and function as local core hospitals for their sales or benefits. This would suggest that the system is relatively cost-effective for facilities.Figure 5. Distribution of information-browsing facilitiesNote : The values given in parentheses are the number of information-disclosure hospitals.Source : Website of Ajisai Net.Factors for widespread adoption of the medical information systemThe factors leading to widespread adoption of the medical information system are considered in two relations in this section : in relation to the prefecture and in relation to the municipality. The former relates to the development of confidential relationships within the system-promoting agency and cooperative behavior among other organizations and groups. The latter relates to confidential relationships among members of the Nagasaki City Medical Association and the Omura Tohi Pharmaceutical Association, and it will be illustrated in how the behaviors of professional organizations affect the diffusion of the system.PrefectureThe Nagasaki Community Medicine Coalition Network Systems Council officially began operations as a system-promoting agency in the first phase (Figure 6). This council was established in collaboration with the national hospital, the municipal hospital, and the regional medical association for the single purpose of developing a medical information network to share information with healthcare providers with varied, other interests.National Hospital Nagasaki Medical Center was the first to introduce the given ICT in Nagasaki Prefecture. This center was initially called Omura Naval Hospital and aided survivors of the atom bombing. After World War II, the center became a national hospital organization and developed healthcare policies promoted by the MHLW. Due to this historical background, the center is not only a core hospital in the Chuo Medical Area but also has a support function for isolated islands. Its importance as a hub allowed the introduction of ICT as a means of cooperation with the other healthcare facilities.The establishment of the council was expected to help bring users within certain specific medical institutions and to reduce the psychological barriers that occur when medical subjects participate in the medical system. The council may become the basis for borrowing funds and clarifying accountability in the operations of Ajisai Net (Fujitsu, 2011). The system was also designed to minimize the service-use burden on users. The general rule followed is that only a subscription policy can allow operating cost to be met and ensure that public funds are not depended on excessively.Multiple hospitals with one and the same medical function are located in Nagasaki, which has a large population, and they compete with each other. Each hospital collaborates with nearby clinics and long-term care facilities, but there was originally no incentive to introduce a system for all to use in common. This bottleneck was canceled through cooperation with the Nagasaki City Medical Association, which is led by the members of the Nagasaki Home Care Doctor Net (Figure 6).An enrollment fee was levied on groups, to request cooperation from medical associations. Individuals were required to pay 50,000 yen for the entry fee, but there would be no need to pay if the medical association that the individual belonged to would pay 2,000,000 yen (Fujitsu, 2011). This solution enhanced the effect of reducing the individual entry fee, as in this way, the ultimate number of members is greater. It is possible to see that the fact that the Nagasaki City Medical Association decided to pay the enrollment fee for groups led to the reinforcement of organizational strength through a joint avoidance of cost burdens on individual members.Finally, the financial support of Nagasaki prefectural government contributed to the spread of the system throughout Nagasaki Prefecture. In particular, it was impossible to allow subsidies for half of the initial cost that the participating hospitals pay in Sasebo-Kenhoku, Isahaya, and Shimabara area without the temporary budgetary support of MHLW. It should be stated that the fact that the existing ICT used positive medical support for the entire prefecture was the underlying cause for the support of the system by healthcare suppliers, including Nagasaki Prefecture (Figure 6).As shown above, the widespread dissemination of Ajisai Net over the prefectural area was made possible by the harmonization of interests by establishing a system-promoting agency, coordination of the system-promoting agency and the regional medical association and increases in the number of participating facilities through reduction in the costs borne by users.MunicipalitiesThe behaviors of the Nagasaki City Medical Association and Omura Tohi Pharmaceutical Association on a municipal scale are worthy of attention.First, the cooperative behavior by the members of the Nagasaki Home Care Doctor Net led to enrollment in a group unit by the Nagasaki City Medical Association. The establishment of the Nagasaki Home Care Doctor Net was triggered by the organization of the Nagasaki Home Care Conference by the Nagasaki City Medical Association in 2002. This conference opened study sessions by special teams and gave lectures for doctors, healthcare providers, and the general public. Requests for cooperation among doctors were brought forward in discussions in study sessions. This led to the organization of the Nagasaki Home Care Doctor Net, mainly by group of 13 people, including conference members and their old classmates (Shirahige et al., 2012). After a revision of medical fees in FY 2006 and later, in-home treatment-support clinics were built, and the number of the members of the Nagasaki Home Care Doctor Net increased. Immediately following the accession of a representative of the Nagasaki Home Care Doctor Net to directorship of the Nagasaki City Medical Association, the Nagasaki Home Care Doctor Net was recognized as a task force of the Nagasaki City Medical Association and began to receive tens of thousands of yen in annual subsidies from 2007 on.Most members served as members of the information-processing committee of the Nagasaki City Medical Association. Ajisai Net was adopted because it was an inexpensive system that association members could participate in through a common standard (Fujitsu, 2011). Ajisai Net is in compliance with security-management guidelines that MHLW requires. Because the shared information is well encrypted, a security problems are eliminated. Moreover, the users can grasp what types of treatment patients can receive more easily than through the old mailing list (Shirahige et al., 2012).In this way, a well-founded relationship of trust among the members of the Nagasaki City Medical Association enticed the association and information-disclosure hospitals to participate in the system (Figure 6). Because the Nagasaki City Medical Association enjoys a large membership that centers on general practitioners, the system utilization behavior of the association may reduce the cost burden on individual members and promote information disclosure by larger hospitals.Figure 6. Main participating institutions by diffusion phase of Ajisai NetSources : Interviews.Second, the type of information-browsing facilities diversified into pharmacies in Omura and Higashisonogi County. National Hospital Nagasaki Medical Center, which disclosed only clinical information on inpatients in 2006, called for the participation of the Omura Tohi Pharmaceutical Association (there were 59 pharmacists in the association) on the assumption that it would disclose clinical information on outpatients. In response to this, Nagasaki Chuo Pharmacy became the first pharmacy to participate in Ajisai Net in 2007. The accession of the pharmacy was regarded as an experiment to allow member policy to take on concrete shape. After the disclosure of outpatient information was begun and the trial period was complete, five pharmacies joined Ajisai Net in 2008.In response to the questionnaire survey, representatives of eight participating pharmacies indicated that there was an effect of appropriate patient compliance instruction and drug history management through the inspection of information or prescription intentions. The non-participating pharmacies also recognized the effectiveness of the system, but they withheld participation in the system due to the small number of prescriptions they filled for patients of information-disclosure hospitals (five respondents) and the lower cost-reduction effects (five respondents) joining could be expected to have under the circumstances. On the other hand, the participating pharmacies adjoining the information-disclosure hospitals accepted prescriptions from the hospitals and are used to improving compliance instructions through clinical information provided through Ajisai Net. However, there are multiple participating pharmacies that do not adjoin hospitals. The pharmacists in these pharmacies included at that time the president and directors of a pharmaceutical association. These individuals had a virtual window to negotiate with these organizations and had a chance to exchange information with people related to system-promoting agencies on a day-to-day basis. For this reason, it should be noted that one factor of system diffusion is the pharmacists’ high evaluation of the usefulness of the system, at least among those who have held managerial posts.Thus, some pharmacies have participated in the system because of the trusting relationship existing among the members in the system (Figure 7). It is clear that the expansion of the medical information network to the entire prefecture is affected not only by system-promoting agencies but also by the size of the professional organizations or the trust relationship among members in related bodies, which differ from region to region.Figure 7. Distribution of pharmacy respondentsSources : questionnaire survey.ConclusionThis paper illustrates the process of the diffusion of a medical information network along relationships among healthcare providers in Nagasaki Prefecture. Examining the diffusion on a prefectural scale, the cooperative behavior fostered by system-promoting agencies could function as a common system joining variously related actors. In addition, the system ultimately diffused beyond the jurisdiction of any local government. System-promoting agencies were combined with professional organizations, which increased the number of participating facilities by means of cost reductions. The power of the civic elites through healthcare providers mobilized financial support from Nagasaki Prefecture through the diffusion of the system. This implies that political power contributed to the establishment of effective and responsive local government.However, the relationship of trust with regional medical associations and regional pharmaceutical associations played several important roles on the municipal scale. This study found that system diffusion encounters not only technical issues but also issues of the characteristics of the professional organizations at play, and these vary among regions.Thus, the ICT diffusion process did not follow S shaped curve along logistic function in the Hägerstrand model but inverted-L shaped with three stage of adoption : first slowly, second increases rapidly and then speeded up (Table 1). Barrier effects were identified as intensely competitive relationships among medical institutions and low cost-effectiveness albeit establishing a system-promoting agency as a promotion effect in the first stage. On the other hand, coordination of the system-promoting agency and a regional medical association, reduction in the costs borne by users worked as promotion effects in the second stage, as well as financial support worked as a promotion effect in the third stage.Table 1. Speed of ICT diffusion and promotion and/or barrier effectsThe classical modelThe case studySpeed of ICT diffusionPromotion effectsBarrier effectsThe first stageVery slowSlowEstablishing a system-promoting agencyIntensely competitive relationshipsLow cost-effectivenessThe second stageFastFastCoordination of the system-promoting agency and a regional medical associationReduction in the costs borne by usersIntensely competitive relationshipsThe third stageVery slowVery fastFinancial support-Sources : questionnaire survey.These geographical factors formed non-hierarchical diffusion pattern. Based on the ICT’s utilization, the results demonstrate that the diffusion of medical information system was determined by existing social relations ; however, the degree of social relations was not always proportional to the size of the urban area. System-diffusion patterns were also found to be a random different form than the neighborhood effect on a municipal scale.The study area of Nagasaki Prefecture includes many isolated islands and exhibits large regional differences in medical resources. Against this geographical background, cooperative relationships among healthcare providers were developed before any ICT system was introduced, and its spread is consequent on this pre-existing network. This study suggests that adequate consolidation of the geographical conditions for ICT diffusion and its effects on a variety of spatial scales show how ICT functions as social infrastructure. It might be a future research issue that the framework for the explanation above is refined to explain non-hierarchical diffusion of innovation or diffusion at random.