Perspective   Ramez Shehadi              Dr. Walid Tohme              Jad Bitar              Sindhu KuttyAnatomy of anE-He...
Contact InformationBeirut                   Delhi                       London                    São PauloRamez Shehadi  ...
EXECUTIVE        Faced with new challenges such as rising costs, more-complex                 services, and growing popula...
Key HIGHLIGHTS                                        THE PROMISE OF                              The concept of e-health—...
of their medical history. Human           save it S$190 million (US$150.6 mil-        regional HIEs created in the Unitede...
THE FIVE      At their core, e-health initiatives are a              technology infrastructure comprising                 ...
Financing                               Technology                                 have succeeded by implementingThose pla...
Services                                 •	 National electronic health records      •	 Solutions in self-care, health-risk...
private hospitals and clinics), payors    Each stakeholder has different objectives   Without the early support of all(lik...
CUSTOMIZING    The e-health ecosystem discussed here               is an adaptable, flexible framework                    ...
•	 What technology infrastructure                             term? What type of payment                              in c...
This island state’s 5 million citizens    had a state-of-the-art technology          to quantify the NEHR program’senjoy o...
another pressing problem: Citizen        The region would obtain annual fees      stakeholders, including citizensdissatis...
Conclusion   In this digital age, e-health initiatives             that hold out the promise of quality                   ...
ResourcesDaniel Castro, “Explaining International IT Application Leadership:   Infocomm Development Authority of Singapore...
The most recent             Worldwide Officeslist of our officesand affiliates, with        Asia                          ...
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Anatomy of an eheatlh ecosystem


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Anatomy of an eheatlh ecosystem

  1. 1. Perspective Ramez Shehadi Dr. Walid Tohme Jad Bitar Sindhu KuttyAnatomy of anE-Health Ecosystem
  2. 2. Contact InformationBeirut Delhi London São PauloRamez Shehadi Suvojoy Sengupta Hugo Trépant Ivan De SouzaPartner Partner Partner Senior Partner+961-1-985-655 +44-20-7393-3314 +44-20-7393-3230 ivan.desouza@booz.comJad Bitar Dubai Milan SydneyPrincipal Sindhu Kutty Pietro Candela Vanessa Wallace+961-1-985-655 Associate Partner Senior +971-4-390-0260 +390 2-72-50-91 +61-2-9321-1906 vanessa.wallace@booz.comWalid TohmePrincipal Düsseldorf New York Chris Bartlett+961-1-985-655 Michael Ruhl Gil Irwin Senior Partner Senior Partner +61-2-9321-2839 +49-211-3890-183 +1-212-551-6548 chris.bartlett@booz.comCanberra gil.irwin@booz.comAndrew Robson TokyoPrincipal Frankfurt Jack Topdjian Paul Duerloo+61-2-6279-1241 Dr. Rainer Bernnat Partner Partner +1-212-551-6601 +81-3-6757-8615 +49-69-97167-0 paul.duerloo@booz.comChicago rainer.bernnat@booz.comMike Connolly San FranciscoPartner Hong Kong Dr. Sanjay Saxena+1-312-578-4580 Ting Zhao Principal +1-415-263-3729 +86-21-2327-9800 Booz & Company
  3. 3. EXECUTIVE Faced with new challenges such as rising costs, more-complex services, and growing populations, the healthcare industrySUMMARY 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.Booz & Company 1
  4. 4. Key HIGHLIGHTS THE PROMISE OF The concept of e-health—i.e., the application of the latest information• E-health can improve patient care E-HEALTH and communication technologies to care delivery—has been around by simplifying access to patient for about 20 years. As early as the information and reduce costs by 1990s, there were regional efforts in introducing efficiencies. the United States to create “health• To succeed, e-health initiatives information exchanges” (HIEs) must be considered as Around the world, the healthcare that allowed electronic sharing of ecosystems with many industry is facing a number of chal- health information across disparate interconnected parts, rather than lenges. Rising rates of chronic diseases systems. Today, there is a wide just technology infrastructures. require more-complex healthcare ser- range of e-health programs, from vices. Aging populations need longer the simple use of mobile phone text• The best e-health ecosystems periods of care. And the growing use alerts to scattered populations about are based on an adaptable, of ever-more-sophisticated medi- potential health threats, to the very flexible framework that is equally cal technologies generates increased sophisticated, all-encompassing applicable to countries just operating costs. Worldwide, health- national health systems in places like launching initiatives and those care systems must offer more-complex Denmark and Singapore. that are expanding existing care to more-demanding and better- programs. informed patients at ever-increasing The attraction of any e-health initia- quality levels while also trying to tive lies in its potentially massive ben- control costs. efits for all parties in the health sector. Applying the latest technologies to To manage these challenges, many care delivery frees doctors, nurses, countries are turning to e-health and other caregivers from administra- initiatives, as both public officials and tive tasks, allowing them to devote healthcare industry leaders seek to more attention to patient care. They improve the delivery of health services also have better access to patients’ and contain rising costs. information and a more holistic view2 Booz & Company
  5. 5. of their medical history. Human save it S$190 million (US$150.6 mil- regional HIEs created in the Unitederrors are reduced. Preventative lion) a year associated with the after- States in the 1990s (primarily tohealth programs, disease outbreak effects of adverse drug reactions just exchange clinical and administrativesurveillance, and other public health by making more information easily information) grew rapidly as longprograms can be planned and accessible to caregivers. as their initial funding lasted. Butexecuted more effectively. they became increasingly difficult to Yet for all their promise, most sustain when key stakeholders wereEqually important, e-health programs e-health initiatives have yet to fully not given clear incentives to continuereduce costs because of the efficien- deliver on their potential benefits. The cooperating with the programs.cies they create in healthcare systems. reality is that few can claim to haveDuplication of lab tests and x-rays, reached their projected goal of highly The choice, deployment, andfor example, can be avoided, thus efficient, fully accessible, high-quality integration of technology can alsosaving millions of dollars. A Booz healthcare at reasonable costs. All quickly become an impediment to& Company study recently quanti- too often, e-health programs have the success of e-health programs.fied some of the projected benefits been implemented hastily, without The larger the number of healthcarefrom a proposed e-health initiative long-term road maps for success, and vendors, the more numerous thein Australia: By 2020, the program as a result many have fizzled before systems with which an applicationcould potentially eliminate as many as attaining their full potential. needs to exchange data. As a result,10,000 deaths caused by medication the integration complexity alsomistakes, and avoid up to 310,000 Most e-health programs are massive, increases, especially in the absence ofunnecessary hospital admissions, 2 encompassing a number of interested national standards.million unnecessary outpatient visits, parties—patients, hospitals, doctors,and 7 million lab tests. The patients pharmaceutical companies, insurers, However, the fundamental problemwho need these procedures would still government agencies—that often lies in an ill-defined conception ofget them, of course, but the proposed have competing demands and must what constitutes an e-health program,e-health program would help avoid see for themselves the benefits of along with the absence of a structuredunnecessary or redundant procedures. participating in a proposed e-health approach for developing a long-termSimilarly, Singapore has found that program if it is to be viable in strategy to ensure the program’sits e-health program could potentially the long term. For example, the lasting success. All too often, e-health programs have been implemented hastily, without long-term road maps for success.Booz & Company 3
  6. 6. THE FIVE At their core, e-health initiatives are a technology infrastructure comprising Governance National governments have found theELEMENTS OF a secure network connection, a series greatest efficiencies when they have legis-AN E-HEALTH of data centers, a call center, and a variety of service applications that lated policies and regulations to oversee, regulate, and manage e-health programs.ECOSYSTEM might include e-medical identification This legislation must address strong cards, e-claims, e-prescriptions, concerns over privacy, and any oversight e-health portals, national electronic regime should include security and confi- health records, national quality dentiality measures that assure all stake- databases, telemedicine, and disease holders that personal information will be outbreak surveillance. protected and shared judiciously—and that they will have legal recourse in cases However, it is a mistake to conceive where it is not. of an e-health initiative as merely a technology infrastructure. Instead, In creating a supportive legal environ- it is more properly envisioned as an ment for their e-health programs, ecosystem with a variety of essential, governments should have an eye on the interlinked elements: governance four “A’s” of sustainability: authority policies and regulations, financing (the power to effect change), ambi- model, technology infrastructure, tion (the desire for or intent to create services, and stakeholders. An improvement), ability (the financial and implementation strategy that takes human capital required for long-term into account these five aspects of a success), and agility (the willingness to successful e-health ecosystem will lead obtain feedback, observe opportunities, to not only improved quality of care, and adapt). but also financial savings.4 Booz & Company
  7. 7. Financing Technology have succeeded by implementingThose planning an e-health program The selection, deployment, and systems across their entire e-initiativesmust ensure that appropriate funding integration of technology is another for shared infrastructure that helpsis in place for its design, develop- important element that, if not existing technology platforms talk toment, implementation, and ongoing carefully calibrated, can quickly each other.operation. Financing can come from become an impediment to the successdifferent sources, such as govern- of e-health programs. The choice There is often a temptation to throwments or public–private partnerships of a specific technological platform money at building a technology infra-(PPPs). This will require governments has wide-ranging ramifications, as structure for an e-health initiativeto consider what type of reimburse- it determines the applications, data, and then rest on one’s laurels. This isment model they want to follow, and infrastructure needed to support shortsighted because getting the rightas well what incentives to provide specific services and reap the full technology infrastructure in place isstakeholders in exchange for their benefits of an e-health initiative. More only one dimension of a successfulparticipation. For example, a pay- important, defining shared standards e-health program. And although thereper-service reimbursement model can (e.g., technology and data) is crucial may be resistance to spending so pro-be a serious impediment to preven- to making this platform ubiquitous. digiously on technology infrastructuretive medicine and wellness programs, Some programs, such as Canada in the early stages, it is vital to makeif this is a priority for a proposed Health Infoway and Denmark’s all stakeholders aware that its benefitse-health program. national e-health portal, will be realized in the long term.Booz & Company 5
  8. 8. Services • National electronic health records • Solutions in self-care, health-riskE-health services, which vary widely, that can manage patient data prevention, and adherence to pre-should be tailored to local demands records and offer alerts on personal scribed treatments, such as educa-and to the available or planned drug allergies and drug side effects tional text messages for pregnancytechnology infrastructure in order to and infant careensure they meet customers’ needs. • Disease management systems thatServices may be as sophisticated as gather, store, transmit, and analyze • Products that monitor a patient’snational electronic health records, information on chronic diseases medication regimen, such as pillor as simple as text-message alerts such as diabetes containers with computer chipsfrom public health entities and NGOs that automatically provide remind-to educate and inform patients on • Ambient Assisted Living (AAL) ser- ers to patients and inform physi-specific conditions such as diabe- vices, such as monitoring the vital cians of resultstes monitoring or HIV prevention. signs of homebound elderly peopleBecause stakeholders will likely be and communicating adverse events Stakeholderswary early on, it is crucial to estab- to care providers It is critical to have a human-centriclish some early “wins” by choos- approach and to involve key stakehold-ing services that are relatively easy • Integrated disease surveillance plat- ers from both the public and privateto implement and endorsed by all forms for public health agencies to sectors when designing an e-healthparties. Some recent examples of detect unhealthy syndromes and program. Stakeholders include gov-e-health services are: coordinate responses ernments, providers (both public andIt is crucial to estab­ish some early l“wins” by choos­ ng services that are irelatively easy to implement.6 Booz & Company
  9. 9. private hospitals and clinics), payors Each stakeholder has different objectives Without the early support of all(like insurance companies), and patient and motivations for participating in of these players and an alignmentadvocacy groups (including not-for- e-health programs. For example: of their needs and objectives, anyprofit associations that help patients program is likely to flounder.with research, education, and services, • Governments and providers feel the Incentives for each group ofsuch as the American Cancer Society, pressures of rising healthcare costs stakeholders will have to bethe American Diabetes Association, considered. For example, whatand the American Health Information • Medical professionals try to cope incentive—other than the intangibleManagement Association). Other with increasing patient demands and one of saving time—might convincestakeholders would include medical large volumes of health information a physician to communicate with hisprofessionals associations (such as the patients by e-mail, which he wouldAmerican Medical Association or the • Payors want to reduce their do for free, rather than through aInternational Council of Nurses) and financial burden and turnaround visit to his office, for which he canmedical industry associations (such time for processing claims and charge a fee?as the Radiological Society of North medical informationAmerica or the Healthcare Informationand Management Systems Society). • Patients seek accessible, more informed, high-quality healthcareBooz & Company 7
  10. 10. CUSTOMIZING The e-health ecosystem discussed here is an adaptable, flexible framework emerge only over a period of several years. Governments in particularTHE SOLUTION that can be used no matter where must be attuned to the long-term sus- a country or private entity is on tainability of their e-health initiatives its e-health journey. It is equally because this improves their ability applicable to those that are just to meet the needs of the stakehold- starting down this road and those ers as well as attain the efficiencies that may have taken the first steps that were the reasons for creating the towards an e-health program but e-health programs in the first place. want to expand it. Governments and private entities The framework is also useful in contemplating the introduction of different settings. Because of the e-health initiatives are at different variety of ways that healthcare is stages of development in their delivered in different countries, healthcare sectors and will therefore e-health initiatives vary widely. face different challenges. While Gulf For instance, the United States has Cooperation Council countries are a fragmented system, whereas the just beginning to investigate the Scandinavian and Gulf countries, concept of e-health, for example, where governments have long been other nations have already developed the prime deliverer of health care, full-blown e-health ecosystems. have more unified systems. At every stage of development, The key is to approach any new it is essential to keep in mind the e-health initiative in a systematic critical necessity of first assessing manner using all five dimensions local conditions in order to design of the framework. Some of the five a customized solution for the dimensions will take precedence over envisaged e-health initiative. Copy others depending on where a country and paste is not an option in these or private entity is in its e-health multidimensional undertakings. journey. In other words, planners can The five key areas to be investigated are: customize their e-health programs to their unique needs and circumstances. • What is the current legislative support, if any, for an e-health One theme binds all five elements of program? Do existing laws and the e-health ecosystem framework: regulations cover the necessary sustainability. This is important not privacy concerns, financial require- only because the start-up costs of any ments, and ethical and professional e-health system are significant, but standards? What legal constraints also because the promised benefits need to be addressed? of most e-health initiatives usually8 Booz & Company
  11. 11. • What technology infrastructure term? What type of payment in costs, or selling a program to already exists and how will it have system will be used and what are stakeholders—will determine which to be upgraded to meet the require- the possible investment options of the five elements need the full and ments of the envisaged e-health that need to be considered in order immediate attention of policymakers program? to sustain the e-health program? and planners. The other elements will remain in the background,• What services do we intend to Once governments and other not forgotten but on hold, while offer, and what services will the stakeholders begin to address attention is focused on the most public expect to receive from the these questions, it becomes evident pressing element or elements. The e-health program? that they are intimately entwined. emphasis on different elements is Technology assets need to be in place illustrated in Exhibit 1.• Who are the stakeholders in our before services can be offered, for planned e-health initiative, when example, and sustainable financing For example, countries with a well- do we start engaging them, and is not possible without appropriate developed legislative environment how do we secure their committed regulatory practices. and technology infrastructure might involvement in the e-health pro- focus on the elements of financing for gram once it is up and running? But local conditions, and the precise long-term sustainability and selecting task at hand—whether it is starting which services should be provided. A• How will this program be financed, an e-health program from scratch, recent case in point is Singapore. both initially and over the long revising one already in place, reiningExhibit 1Countries at Various Stages in the E-Health Journey Will Have Different PrioritiesE-MATURE COUNTRIES COUNTRIES AT THE BEGINNING OF THE E-JOURNEY Governance Governance 5 5 4 4 3 3 2 2Services Finance Services Finance 1 1 0 0 Stakeholders Technology Stakeholders Technology Focus areasNote: The five stages of an e-health ecosystem element are: 5 = very advanced; 4 = advanced; 3 = basic; 2 = some progress to date; 1 = significant progress needed;0 = no progress.Source: Booz & CompanyBooz & Company 9
  12. 12. This island state’s 5 million citizens had a state-of-the-art technology to quantify the NEHR program’senjoy one of world’s best healthcare infrastructure and acceptable roster of projected benefits. From this model,systems, which is recognized by health services. Clearly, these elements a 10-year investment strategy wasthe World Health Organization of the framework did not need developed in order to successfullyas a leader in its field. It achieves immediate attention. implement, operate, and sustain theexcellent health outcomes with high NEHR. This strategy allowed thecost-efficiency, spending only 3 to Instead, the task at hand was to MOHH to secure the necessary long-4 percent of its GDP on healthcare proceed directly to developing a term funding for the NEHR program.while comparable countries spend financial model that would give a Implementation of that program isupwards of 9 percent. clear picture of the potential benefits now well under way and on track to and costs of the NEHR program. be fully operational by 2015.Nevertheless, in 2005 Singapore recog- Once preliminary costs and benefitsnized that it had a problem: Its health were quantified, it was necessary Singapore’s methodical, thoroughexpenditures had begun rising at the to engage stakeholders—senior approach to launching this e-healthrate of over 8 percent annually, which officials from Singapore’s Ministry venture is a prime example of howwas faster than its GDP growth. of Health Holdings (MOHH), as to do it right. Other countries are well as CEOs of public and private beginning their e-health journeys fromTo deal with this, the government’s hospitals, clinics, and long-term a different starting point and thus10-year master plan in 2005 included care facilities—to obtain their input face different challenges, requiringthe goal of accelerating its healthcare on a proposed financial model. different approaches.transformation by establishing a For instance, because it would beNational Electronic Health Record expensive for general practitioners to In Italy’s Lombardy region, for(NEHR) in order to achieve higher acquire the technology necessary for a instance, the 9.5 million residentsquality of care and reduced costs. NEHR, the MOHH realized it would have access to 200,000 healthcare need an incentive plan to help these operators, including pharmacies,Singapore already had in place a physicians defray costs. general practitioners, hospitalsophisticated legislative regime with departments, and communitywell-defined guidelines for ensuring With the information collected clinics. Like Singapore, Lombardy’sefficient rollout and implementation from stakeholders, it was possible healthcare system faced the challengeof e-health initiatives. It also to develop a cost-benefit model of rising costs. But it also had10 Booz & Company
  13. 13. another pressing problem: Citizen The region would obtain annual fees stakeholders, including citizensdissatisfaction with long wait times from citizens for identification cards and healthcare operators. Citizensfor procedures because of inefficient, and buy back the private partners’ were reached through doctors’paper-based administrative processes. stake in the company at a nominal offices, pharmacies, and the Internet. value after seven years. Operators were given incentives toIn 1999, Lombardy’s regional join, and offered training and support.government decided to investigate Next, it was necessary to decidethe benefits of setting up an e-health what services were to be provided by Lombardy’s e-health programservices management system. Because the regional e-health system. It was was launched in phases startingthe region had an established determined that Lombardy’s e-health in December 2001. It is now fullycompany in place to plan and manage program would require electronic operational and has resulted in anregional governance, as well as health records (EHRs) to provide a estimated annual savings of €1 billioncreate technology infrastructure for unified vision of patients’ medical thanks to streamlined procedures, lessinformation exchanges and access to history across the 200,000 healthcare bureaucracy, and reduced fraud.government services, these two areas players. Other services to be providedwere not top priorities. Financing, included electronic medical IDs, The PPP financing approach hasservices, and stakeholders were online appointment booking and enjoyed tremendous success, resultingthe initial elements of focus of the selection of general practitioners in a 10-year relationship between thee-health program. by consumers, e-prescriptions regional government, private service by providers, digitization of providers, and an IT vendor.Financing required immediate administrative functions forattention. Lombardy developed a provider administrators, and disease Furthermore, 9.5 million patientsstate-of-the-art cost-benefit model management programs for the now have smart card IDs, and overto quantify the impacts and assess region’s public health officials. 90 percent of general practitioners,the viability of PPPs. This approach pharmacies, public hospitals, andinvolved getting private partners to The government used a variety of clinics have joined the integratedprovide the initial investment in an measures, accounting for one-third network. The program is considerede-health services company owned and of the overall budget, to market the an example of best practices in theoperated by the regional government. e-health program to its proposed e-health sector. Lombardy’s e-health program required electronic health records to provide a unified vision of patients’ medical history.Booz & Company 11
  14. 14. Conclusion In this digital age, e-health initiatives that hold out the promise of quality Additionally, creating sustainable e-health programs requires a care at reasonable costs are becoming recognition that a one-size-fits- increasingly attractive to governments all approach will not work. and health-sector policymakers. Customization is key. But launching such initiatives is a It is not an easy undertaking but the multidimensional endeavor that benefits of an intelligent e-health requires careful examination of program, implemented with a long- a broad panorama of inputs that term strategy in mind, will justify goes far beyond the creation of an the effort. electronic platform for delivering healthcare services.12 Booz & Company
  15. 15. ResourcesDaniel Castro, “Explaining International IT Application Leadership: Infocomm Development Authority of Singapore, “Realising theHealth IT,” The Information Technology and Innovation Founda- iN2015 Vision—Singapore: An Intelligent Nation, a Global City,tion, September 2009 Powered by Infocomm,” 2010 ( content/About%20us/About_Us_level1/_iN2015/pdf/realisingthevi-European Commission Information Society and Media, “In- sionin2015.pdf)teroperable eHealth Is Worth It: Securing Benefits from Elec-tronic Health Records and ePrescribing,” Study Report 2010 United Nations ESCAP “e-Health in Asia and the Pacific: Chal- ,( lenges and Opportunities,” 2007 ( hds/lastestadd/eHealthReport.pdf)About the AuthorsRamez Shehadi is a partner Dr. Walid Tohme is a principalwith Booz & Company in with Booz & Company in Beirut.Beirut. He leads the informa- He specializes in helpingtion technology practice in the healthcare organizations in theMiddle East. He specializes in management and strategice-government, e-business, and use of technology to enableIT-enabled transformation, help- transformation via IT as well asing corporations and govern- e-health strategies, organiza-ment organizations maximize tional restructuring, outsourc-leverage of IT, achieve opera- ing solutions, and operationaltional efficiencies, and improve improvements.governance of IT services. Sindhu Kutty is an associateJad Bitar is a principal with with Booz & Company in Dubai.Booz & Company in Beirut. She focuses on the strategicHe focuses on healthcare use of technology and technol-providers and public health ogy-enabled transformationsorganization, specializing in for healthcare providers andstrategic planning, transforma- regulators.tion, operational excellence,and e-business.Booz & Company 13
  16. 16. The most recent Worldwide Officeslist of our officesand affiliates, with Asia Middle Eastaddresses and Beijing Brisbane Helsinki Abu Dhabi Detroittelephone numbers, Delhi Canberra Istanbul Beirut Florham Parkcan be found on Hong Kong Jakarta London Cairo Houstonour website, Mumbai Kuala Lumpur Madrid Doha Los Seoul Melbourne Milan Dubai Mexico City Shanghai Sydney Moscow Riyadh New York City Taipei Munich Parsippany Tokyo Europe Paris North America San Francisco Amsterdam Rome Atlanta Australia, Berlin Stockholm Boston South America New Zealand & Copenhagen Stuttgart Chicago Buenos Aires Southeast Asia Dublin Vienna Cleveland Rio de Janeiro Auckland Düsseldorf Warsaw Dallas Santiago Bangkok Frankfurt Zurich DC São PauloBooz & Company is a leading global managementconsulting firm, helping the world’s top businesses,governments, and organizations. Our founder,Edwin Booz, defined the profession when he estab-lished the first management consulting firm in 1914.Today, with more than 3,300 people in 60 officesaround the world, we bring foresight and knowledge,deep functional expertise, and a practical approachto building capabilities and delivering real impact.We work closely with our clients to create and deliveressential advantage. The independent White Spacereport ranked Booz & Company #1 among consultingfirms for “the best thought leadership” in 2011.For our management magazine strategy+business,visit and to learn more aboutBooz & Company.©2011 Booz & Company Inc.