boozco anatomy of e heatlh ecosystem
TRANSCRIPT
Anatomy of anE-Health Ecosystem
Ramez ShehadiDr. Walid TohmeJad BitarSindhu Kutty
Perspective
Contact Information
BeirutRamez ShehadiPartner+961-1-985-655 [email protected]
Jad BitarPrincipal+961-1-985-655 [email protected]
Walid TohmePrincipal+961-1-985-655 [email protected]
CanberraAndrew [email protected]
ChicagoMike [email protected]
DelhiSuvojoy [email protected]
DubaiSindhu [email protected]
DüsseldorfMichael [email protected]
FrankfurtDr. Rainer [email protected]
Hong KongTing [email protected]
LondonHugo Tré[email protected]
MilanPietro CandelaPartner+390 [email protected]
New YorkGil IrwinSenior [email protected]
Jack [email protected]
San FranciscoDr. Sanjay [email protected]
São PauloIvan De SouzaSenior [email protected]
SydneyVanessa WallaceSenior [email protected]
Chris BartlettSenior [email protected]
TokyoPaul [email protected]
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EXECUTIVE SUMMARY
Faced with new challenges such as rising costs, more-complex services, and growing populations, the healthcare industry is increasingly turning to e-health initiatives to create efficiencies and share information more effectively. To date, however, many of those initiatives have failed to deliver their expected benefits.
A key reason for these failures is a widespread misconception about what an e-health program requires for long-term success: All too often, e-health systems are launched without a thorough approach that takes into account all the essential elements for a viable program. It is important to envision e-health initiatives as the outcome of a multifaceted e-health ecosystem that considers five key elements:
• Governance policies and regulations• Financing model• Technology infrastructure• Services• Stakeholders
Creating e-health programs in the context of their larger e-health ecosystem will ensure lasting viability for these initiatives. Finally, customization is crucial: Each e-health initiative will reflect its local conditions.
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Key HIGHLIGHTS
E-health can improve patient care •by simplifying access to patient information and reduce costs by introducingefficiencies.
To succeed, e-health initiatives •must be considered as ecosystems with many interconnected parts, rather than just technology infrastructures.
The best e-health ecosystems •are based on an adaptable, flexibleframeworkthatisequallyapplicable to countries just launching initiatives and those that are expanding existing programs.
THE PROMISE OF E-HEALTH
The concept of e-health—i.e., the application of the latest information and communication technologies to care delivery—has been around for about 20 years. As early as the 1990s, there were regional efforts in the United States to create “health information exchanges” (HIEs) that allowed electronic sharing of health information across disparate systems. Today, there is a wide range of e-health programs, from the simple use of mobile phone text alerts to scattered populations about potential health threats, to the very sophisticated, all-encompassing national health systems in places like Denmark and Singapore.
The attraction of any e-health initia-tive lies in its potentially massive ben-efits for all parties in the health sector. Applying the latest technologies to care delivery frees doctors, nurses, and other caregivers from administra-tive tasks, allowing them to devote more attention to patient care. They also have better access to patients’ information and a more holistic view
Around the world, the healthcare industry is facing a number of chal-lenges. Rising rates of chronic diseases require more-complex healthcare ser-vices. Aging populations need longer periods of care. And the growing use of ever-more-sophisticated medi-cal technologies generates increased operating costs. Worldwide, health-care systems must offer more-complex care to more-demanding and better-informed patients at ever-increasing quality levels while also trying to control costs.
To manage these challenges, many countries are turning to e-health initiatives, as both public officials and healthcare industry leaders seek to improve the delivery of health services and contain rising costs.
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of their medical history. Human errors are reduced. Preventative health programs, disease outbreak surveillance, and other public health programs can be planned and executed more effectively.
Equally important, e-health programs reduce costs because of the efficien-cies they create in healthcare systems. Duplication of lab tests and x-rays, for example, can be avoided, thus saving millions of dollars. A Booz & Company study recently quanti-fied some of the projected benefits from a proposed e-health initiative in Australia: By 2020, the program could potentially eliminate as many as 10,000 deaths caused by medication mistakes, and avoid up to 310,000 unnecessary hospital admissions, 2 million unnecessary outpatient visits, and 7 million lab tests. The patients who need these procedures would still get them, of course, but the proposed e-health program would help avoid unnecessary or redundant procedures. Similarly, Singapore has found that its e-health program could potentially
save it S$190 million (US$150.6 mil-lion) a year associated with the after-effects of adverse drug reactions just by making more information easily accessible to caregivers.
Yet for all their promise, most e-health initiatives have yet to fully deliver on their potential benefits. The reality is that few can claim to have reached their projected goal of highly efficient, fully accessible, high-quality healthcare at reasonable costs. All too often, e-health programs have been implemented hastily, without long-term road maps for success, and as a result many have fizzled before attaining their full potential.
Most e-health programs are massive, encompassing a number of interested parties—patients, hospitals, doctors, pharmaceutical companies, insurers, government agencies—that often have competing demands and must see for themselves the benefits of participating in a proposed e-health program if it is to be viable in the long term. For example, the
regional HIEs created in the United States in the 1990s (primarily to exchange clinical and administrative information) grew rapidly as long as their initial funding lasted. But they became increasingly difficult to sustain when key stakeholders were not given clear incentives to continue cooperating with the programs.
The choice, deployment, and integration of technology can also quickly become an impediment to the success of e-health programs. The larger the number of healthcare vendors, the more numerous the systems with which an application needs to exchange data. As a result, the integration complexity also increases, especially in the absence of national standards.
However, the fundamental problem lies in an ill-defined conception of what constitutes an e-health program, along with the absence of a structured approach for developing a long-term strategy to ensure the program’s lasting success.
All too often, e-health programs have been implemented hastily, without long-term road maps for success.
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At their core, e-health initiatives are a technology infrastructure comprising a secure network connection, a series of data centers, a call center, and a variety of service applications that might include e-medical identification cards, e-claims, e-prescriptions, e-health portals, national electronic health records, national quality databases, telemedicine, and disease outbreak surveillance.
However, it is a mistake to conceive of an e-health initiative as merely a technology infrastructure. Instead, it is more properly envisioned as an ecosystem with a variety of essential, interlinked elements: governance policies and regulations, financing model, technology infrastructure, services, and stakeholders. An implementation strategy that takes into account these five aspects of a successful e-health ecosystem will lead to not only improved quality of care, but also financial savings.
Governance National governments have found the greatest efficiencies when they have legis-lated policies and regulations to oversee, regulate, and manage e-health programs. This legislation must address strong concerns over privacy, and any oversight regime should include security and confi-dentiality measures that assure all stake-holders that personal information will be protected and shared judiciously—and that they will have legal recourse in cases where it is not.
In creating a supportive legal environ-ment for their e-health programs, governments should have an eye on the four “A’s” of sustainability: authority (the power to effect change), ambi-tion (the desire for or intent to create improvement), ability (the financial and human capital required for long-term success), and agility (the willingness to obtain feedback, observe opportunities, and adapt).
THE FIVE ELEMENTS OF AN E-HEALTH ECOSYSTEM
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Financing Those planning an e-health program must ensure that appropriate funding is in place for its design, develop-ment, implementation, and ongoing operation. Financing can come from different sources, such as govern-ments or public–private partnerships (PPPs). This will require governments to consider what type of reimburse-ment model they want to follow, as well what incentives to provide stakeholders in exchange for their participation. For example, a pay-per-service reimbursement model can be a serious impediment to preven-tive medicine and wellness programs, if this is a priority for a proposed e-health program.
Technology The selection, deployment, and integration of technology is another important element that, if not carefully calibrated, can quickly become an impediment to the success of e-health programs. The choice of a specific technological platform has wide-ranging ramifications, as it determines the applications, data, and infrastructure needed to support specific services and reap the full benefits of an e-health initiative. More important, defining shared standards (e.g., technology and data) is crucial to making this platform ubiquitous. Some programs, such as Canada Health Infoway and Denmark’s national e-health portal sundhed.dk,
have succeeded by implementing systems across their entire e-initiatives for shared infrastructure that helps existing technology platforms talk to each other.
There is often a temptation to throw money at building a technology infra-structure for an e-health initiative and then rest on one’s laurels. This is shortsighted because getting the right technology infrastructure in place is only one dimension of a successful e-health program. And although there may be resistance to spending so pro-digiously on technology infrastructure in the early stages, it is vital to make all stakeholders aware that its benefits will be realized in the long term.
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Services E-health services, which vary widely, should be tailored to local demands and to the available or planned technology infrastructure in order to ensure they meet customers’ needs. Services may be as sophisticated as national electronic health records, or as simple as text-message alerts from public health entities and NGOs to educate and inform patients on specific conditions such as diabe-tes monitoring or HIV prevention. Because stakeholders will likely be wary early on, it is crucial to estab-lish some early “wins” by choos-ing services that are relatively easy to implement and endorsed by all parties. Some recent examples of e-health services are:
National electronic health records • that can manage patient data records and offer alerts on personal drug allergies and drug side effects
Disease management systems that • gather, store, transmit, and analyze information on chronic diseases such as diabetes
Ambient Assisted Living (AAL) ser-• vices, such as monitoring the vital signs of homebound elderly people and communicating adverse events to care providers
Integrated disease surveillance plat-• forms for public health agencies to detect unhealthy syndromes and coordinate responses
Solutions in self-care, health-risk • prevention, and adherence to pre-scribed treatments, such as educa-tional text messages for pregnancy and infant care
Products that monitor a patient’s • medication regimen, such as pill containers with computer chips that automatically provide remind-ers to patients and inform physi-cians of results
Stakeholders It is critical to have a human-centric approach and to involve key stakehold-ers from both the public and private sectors when designing an e-health program. Stakeholders include gov-ernments, providers (both public and
It is crucial to estab lish some early “wins” by choos ing services that are relatively easy to implement.
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private hospitals and clinics), payors (like insurance companies), and patient advocacy groups (including not-for-profit associations that help patients with research, education, and services, such as the American Cancer Society, the American Diabetes Association, and the American Health Information Management Association). Other stakeholders would include medical professionals associations (such as the American Medical Association or the International Council of Nurses) and medical industry associations (such as the Radiological Society of North America or the Healthcare Information and Management Systems Society).
Each stakeholder has different objectives and motivations for participating in e-health programs. For example:
Governments and providers feel the • pressures of rising healthcare costs
Medical professionals try to cope • with increasing patient demands and large volumes of health information
Payors want to reduce their • financial burden and turnaround time for processing claims and medical information
Patients seek accessible, more • informed, high-quality healthcare
Without the early support of all of these players and an alignment of their needs and objectives, any program is likely to flounder. Incentives for each group of stakeholders will have to be considered. For example, what incentive—other than the intangible one of saving time—might convince a physician to communicate with his patients by e-mail, which he would do for free, rather than through a visit to his office, for which he can charge a fee?
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The e-health ecosystem discussed here is an adaptable, flexible framework that can be used no matter where a country or private entity is on its e-health journey. It is equally applicable to those that are just starting down this road and those that may have taken the first steps towards an e-health program but want to expand it.
The framework is also useful in different settings. Because of the variety of ways that healthcare is delivered in different countries, e-health initiatives vary widely. For instance, the United States has a fragmented system, whereas the Scandinavian and Gulf countries, where governments have long been the prime deliverer of health care, have more unified systems.
The key is to approach any new e-health initiative in a systematic manner using all five dimensions of the framework. Some of the five dimensions will take precedence over others depending on where a country or private entity is in its e-health journey. In other words, planners can customize their e-health programs to their unique needs and circumstances.
One theme binds all five elements of the e-health ecosystem framework: sustainability. This is important not only because the start-up costs of any e-health system are significant, but also because the promised benefits of most e-health initiatives usually
emerge only over a period of several years. Governments in particular must be attuned to the long-term sus-tainability of their e-health initiatives because this improves their ability to meet the needs of the stakehold-ers as well as attain the efficiencies that were the reasons for creating the e-health programs in the first place.
Governments and private entities contemplating the introduction of e-health initiatives are at different stages of development in their healthcare sectors and will therefore face different challenges. While Gulf Cooperation Council countries are just beginning to investigate the concept of e-health, for example, other nations have already developed full-blown e-health ecosystems.
At every stage of development, it is essential to keep in mind the critical necessity of first assessing local conditions in order to design a customized solution for the envisaged e-health initiative. Copy and paste is not an option in these multidimensional undertakings. The five key areas to be investigated are:
What is the current legislative • support, if any, for an e-health program? Do existing laws and regulations cover the necessary privacy concerns, financial require-ments, and ethical and professional standards? What legal constraints need to be addressed?
CUSTOMIZING THE SOLUTION
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What technology infrastructure • already exists and how will it have to be upgraded to meet the require-ments of the envisaged e-health program?
What services do we intend to • offer, and what services will the public expect to receive from the e-health program?
Who are the stakeholders in our • planned e-health initiative, when do we start engaging them, and how do we secure their committed involvement in the e-health pro-gram once it is up and running?
How will this program be financed, • both initially and over the long
term? What type of payment system will be used and what are the possible investment options that need to be considered in order to sustain the e-health program?
Once governments and other stakeholders begin to address these questions, it becomes evident that they are intimately entwined. Technology assets need to be in place before services can be offered, for example, and sustainable financing is not possible without appropriate regulatory practices.
But local conditions, and the precise task at hand—whether it is starting an e-health program from scratch, revising one already in place, reining
in costs, or selling a program to stakeholders—will determine which of the five elements need the full and immediate attention of policymakers and planners. The other elements will remain in the background, not forgotten but on hold, while attention is focused on the most pressing element or elements. The emphasis on different elements is illustrated in Exhibit 1.
For example, countries with a well-developed legislative environment and technology infrastructure might focus on the elements of financing for long-term sustainability and selecting which services should be provided. A recent case in point is Singapore.
Note:Thefivestagesofane-healthecosystemelementare:5=veryadvanced;4=advanced;3=basic;2=someprogresstodate;1=significantprogressneeded; 0=noprogress. Source: Booz & Company
Exhibit 1 Countries at Various Stages in the E-Health Journey Will Have Different Priorities
e-MATURe COUNTRIeS COUNTRIeS AT THe BeGINNING OF THe e-JOURNey
0
1
2
3
4
5
Governance
Finance
TechnologyStakeholders
Services
0
1
2
3
4
5
Governance
Finance
TechnologyStakeholders
Services
Focus areas
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This island state’s 5 million citizens enjoy one of world’s best healthcare systems, which is recognized by the World Health Organization as a leader in its field. It achieves excellent health outcomes with high cost-efficiency, spending only 3 to 4 percent of its GDP on healthcare while comparable countries spend upwards of 9 percent.
Nevertheless, in 2005 Singapore recog-nized that it had a problem: Its health expenditures had begun rising at the rate of over 8 percent annually, which was faster than its GDP growth.
To deal with this, the government’s 10-year master plan in 2005 included the goal of accelerating its healthcare transformation by establishing a National Electronic Health Record (NEHR) in order to achieve higher quality of care and reduced costs.
Singapore already had in place a sophisticated legislative regime with well-defined guidelines for ensuring efficient rollout and implementation of e-health initiatives. It also
had a state-of-the-art technology infrastructure and acceptable roster of health services. Clearly, these elements of the framework did not need immediate attention.
Instead, the task at hand was to proceed directly to developing a financial model that would give a clear picture of the potential benefits and costs of the NEHR program. Once preliminary costs and benefits were quantified, it was necessary to engage stakeholders—senior officials from Singapore’s Ministry of Health Holdings (MOHH), as well as CEOs of public and private hospitals, clinics, and long-term care facilities—to obtain their input on a proposed financial model. For instance, because it would be expensive for general practitioners to acquire the technology necessary for a NEHR, the MOHH realized it would need an incentive plan to help these physicians defray costs.
With the information collected from stakeholders, it was possible to develop a cost-benefit model
to quantify the NEHR program’s projected benefits. From this model, a 10-year investment strategy was developed in order to successfully implement, operate, and sustain the NEHR. This strategy allowed the MOHH to secure the necessary long-term funding for the NEHR program. Implementation of that program is now well under way and on track to be fully operational by 2015.
Singapore’s methodical, thorough approach to launching this e-health venture is a prime example of how to do it right. Other countries are beginning their e-health journeys from a different starting point and thus face different challenges, requiring different approaches.
In Italy’s Lombardy region, for instance, the 9.5 million residents have access to 200,000 healthcare operators, including pharmacies, general practitioners, hospital departments, and community clinics. Like Singapore, Lombardy’s healthcare system faced the challenge of rising costs. But it also had
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another pressing problem: Citizen dissatisfaction with long wait times for procedures because of inefficient, paper-based administrative processes.
In 1999, Lombardy’s regional government decided to investigate the benefits of setting up an e-health services management system. Because the region had an established company in place to plan and manage regional governance, as well as create technology infrastructure for information exchanges and access to government services, these two areas were not top priorities. Financing, services, and stakeholders were the initial elements of focus of the e-health program.
Financing required immediate attention. Lombardy developed a state-of-the-art cost-benefit model to quantify the impacts and assess the viability of PPPs. This approach involved getting private partners to provide the initial investment in an e-health services company owned and operated by the regional government.
The region would obtain annual fees from citizens for identification cards and buy back the private partners’ stake in the company at a nominal value after seven years.
Next, it was necessary to decide what services were to be provided by the regional e-health system. It was determined that Lombardy’s e-health program would require electronic health records (EHRs) to provide a unified vision of patients’ medical history across the 200,000 healthcare players. Other services to be provided included electronic medical IDs, online appointment booking and selection of general practitioners by consumers, e-prescriptions by providers, digitization of administrative functions for provider administrators, and disease management programs for the region’s public health officials.
The government used a variety of measures, accounting for one-third of the overall budget, to market the e-health program to its proposed
stakeholders, including citizens and healthcare operators. Citizens were reached through doctors’ offices, pharmacies, and the Internet. Operators were given incentives to join, and offered training and support.
Lombardy’s e-health program was launched in phases starting in December 2001. It is now fully operational and has resulted in an estimated annual savings of €1 billion thanks to streamlined procedures, less bureaucracy, and reduced fraud.
The PPP financing approach has enjoyed tremendous success, resulting in a 10-year relationship between the regional government, private service providers, and an IT vendor.
Furthermore, 9.5 million patients now have smart card IDs, and over 90 percent of general practitioners, pharmacies, public hospitals, and clinics have joined the integrated network. The program is considered an example of best practices in the e-health sector.
Lombardy’s e-health program required electronic health records to provide a unified vision of patients’ medical history.
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In this digital age, e-health initiatives that hold out the promise of quality care at reasonable costs are becoming increasingly attractive to governments and health-sector policymakers.
But launching such initiatives is a multidimensional endeavor that requires careful examination of a broad panorama of inputs that goes far beyond the creation of an electronic platform for delivering healthcare services.
Additionally, creating sustainable e-health programs requires a recognition that a one-size-fits-all approach will not work. Customization is key.
It is not an easy undertaking but the benefits of an intelligent e-health program, implemented with a long-term strategy in mind, will justifythe effort.
CONCLUSION
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About the Authors
Ramez Shehadi is a partner with Booz & Company in Beirut. He leads the informa-tion technology practice in the Middle East. He specializes in e-government, e-business, and IT-enabled transformation, help-ing corporations and govern-ment organizations maximize leverage of IT, achieve opera-tionalefficiencies,andimprovegovernance of IT services.
Jad Bitar is a principal with Booz & Company in Beirut. He focuses on healthcare providers and public health organization, specializing in strategic planning, transforma-tion, operational excellence, and e-business.
Dr. Walid Tohme is a principal with Booz & Company in Beirut. He specializes in helping healthcare organizations in the management and strategic use of technology to enable transformation via IT as well as e-health strategies, organiza-tional restructuring, outsourc-ing solutions, and operational improvements.
Sindhu Kutty is an associate with Booz & Company in Dubai. She focuses on the strategic use of technology and technol-ogy-enabled transformations for healthcare providers and regulators.
Resources
Daniel Castro, “Explaining International IT Application Leadership: Health IT,” The Information Technology and Innovation Founda-tion, September 2009
European Commission Information Society and Media, “In-teroperableeHealthIsWorthIt:SecuringBenefitsfromElec-tronic Health Records and ePrescribing,” Study Report 2010 (http://ec.europa.eu/information_society/activities/health/docs/publications/201002ehrimpact_study-final.pdf)
Infocomm Development Authority of Singapore, “Realising the iN2015 Vision—Singapore: An Intelligent Nation, a Global City, Powered by Infocomm,” 2010 (http://www.ida.gov.sg/images/content/About%20us/About_Us_level1/_iN2015/pdf/realisingthevi-sionin2015.pdf)
UnitedNationsESCAP,“e-HealthinAsiaandthePacific:Chal-lenges and Opportunities,” 2007 (http://www.unescap.org/esid/hds/lastestadd/eHealthReport.pdf)
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