1. Perspective Ramez Shehadi
Dr. Walid Tohme
Jad Bitar
Sindhu Kutty
Anatomy of an
E-Health Ecosystem

2. Contact Information
Beirut Delhi London São Paulo
Ramez Shehadi Suvojoy Sengupta Hugo Trépant Ivan De Souza
Partner Partner Partner Senior Partner
+961-1-985-655 +44-20-7393-3314 +44-20-7393-3230 +55-11-5501-6368
ramez.shehadi@booz.com suvojoy.sengupta@booz.com hugo.trepant@booz.com ivan.desouza@booz.com
Jad Bitar Dubai Milan Sydney
Principal Sindhu Kutty Pietro Candela Vanessa Wallace
+961-1-985-655 Associate Partner Senior Partner
jad.bitar@booz.com +971-4-390-0260 +390 2-72-50-91 +61-2-9321-1906
sindhu.kutty@booz.com pietro.candela@booz.com vanessa.wallace@booz.com
Walid Tohme
Principal Düsseldorf New York Chris Bartlett
+961-1-985-655 Michael Ruhl Gil Irwin Senior Associate
walid.tohme@booz.com Partner Senior Partner +61-2-9321-2839
+49-211-3890-183 +1-212-551-6548 chris.bartlett@booz.com
Canberra michael.ruhl@booz.com gil.irwin@booz.com
Andrew Robson Tokyo
Principal Frankfurt Jack Topdjian Paul Duerloo
+61-2-6279-1241 Dr. Rainer Bernnat Partner Partner
andrew.robson@booz.com Partner +1-212-551-6601 +81-3-6757-8615
+49-69-97167-0 jack.topdjian@booz.com paul.duerloo@booz.com
Chicago rainer.bernnat@booz.com
Mike Connolly San Francisco
Partner Hong Kong Dr. Sanjay Saxena
+1-312-578-4580 Ting Zhao Principal
mike.connolly@booz.com Principal +1-415-263-3729
+86-21-2327-9800 sanjay.saxena@booz.com
ting.zhao@booz.com
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3. EXECUTIVE Faced with new challenges such as rising costs, more-complex
services, and growing populations, the healthcare industry
SUMMARY
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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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 view
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5. of their medical history. Human save it S$190 million (US$150.6 mil- regional HIEs created in the United
errors are reduced. Preventative lion) a year associated with the after- States in the 1990s (primarily to
health programs, disease outbreak effects of adverse drug reactions just exchange clinical and administrative
surveillance, and other public health by making more information easily information) grew rapidly as long
programs can be planned and accessible to caregivers. as their initial funding lasted. But
executed more effectively. they became increasingly difficult to
Yet for all their promise, most sustain when key stakeholders were
Equally important, e-health programs e-health initiatives have yet to fully not given clear incentives to continue
reduce 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 have
Duplication of lab tests and x-rays, reached their projected goal of highly The choice, deployment, and
for example, can be avoided, thus efficient, fully accessible, high-quality integration of technology can also
saving 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 healthcare
from a proposed e-health initiative long-term road maps for success, and vendors, the more numerous the
in Australia: By 2020, the program as a result many have fizzled before systems with which an application
could 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 also
mistakes, and avoid up to 310,000 Most e-health programs are massive, increases, especially in the absence of
unnecessary 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 problem
who need these procedures would still government agencies—that often lies in an ill-defined conception of
get 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 structured
unnecessary or redundant procedures. participating in a proposed e-health approach for developing a long-term
Similarly, Singapore has found that program if it is to be viable in strategy to ensure the program’s
its 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.
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6. THE FIVE At their core, e-health initiatives are a
technology infrastructure comprising
Governance
National governments have found the
ELEMENTS 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.
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7. Financing Technology have succeeded by implementing
Those planning an e-health program The selection, deployment, and systems across their entire e-initiatives
must ensure that appropriate funding integration of technology is another for shared infrastructure that helps
is in place for its design, develop- important element that, if not existing technology platforms talk to
ment, implementation, and ongoing carefully calibrated, can quickly each other.
operation. Financing can come from become an impediment to the success
different sources, such as govern- of e-health programs. The choice There is often a temptation to throw
ments 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 initiative
to consider what type of reimburse- it determines the applications, data, and then rest on one’s laurels. This is
ment model they want to follow, and infrastructure needed to support shortsighted because getting the right
as well what incentives to provide specific services and reap the full technology infrastructure in place is
stakeholders in exchange for their benefits of an e-health initiative. More only one dimension of a successful
participation. For example, a pay- important, defining shared standards e-health program. And although there
per-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 infrastructure
tive medicine and wellness programs, Some programs, such as Canada in the early stages, it is vital to make
if this is a priority for a proposed Health Infoway and Denmark’s all stakeholders aware that its benefits
e-health program. national e-health portal sundhed.dk, will be realized in the long term.
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8. Services • National electronic health records • Solutions in self-care, health-risk
E-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 pregnancy
technology infrastructure in order to and infant care
ensure they meet customers’ needs. • Disease management systems that
Services may be as sophisticated as gather, store, transmit, and analyze • Products that monitor a patient’s
national electronic health records, information on chronic diseases medication regimen, such as pill
or as simple as text-message alerts such as diabetes containers with computer chips
from 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 results
tes monitoring or HIV prevention. signs of homebound elderly people
Because stakeholders will likely be and communicating adverse events Stakeholders
wary early on, it is crucial to estab- to care providers It is critical to have a human-centric
lish 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 private
to implement and endorsed by all forms for public health agencies to sectors when designing an e-health
parties. Some recent examples of detect unhealthy syndromes and program. Stakeholders include gov-
e-health services are: coordinate responses ernments, providers (both public and
It is crucial to estab­ish some early
l
“wins” by choos­ ng services that are
i
relatively easy to implement.
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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 alignment
advocacy groups (including not-for- e-health programs. For example: of their needs and objectives, any
profit associations that help patients program is likely to flounder.
with research, education, and services, • Governments and providers feel the Incentives for each group of
such as the American Cancer Society, pressures of rising healthcare costs stakeholders will have to be
the American Diabetes Association, considered. For example, what
and the American Health Information • Medical professionals try to cope incentive—other than the intangible
Management Association). Other with increasing patient demands and one of saving time—might convince
stakeholders would include medical large volumes of health information a physician to communicate with his
professionals associations (such as the patients by e-mail, which he would
American Medical Association or the • Payors want to reduce their do for free, rather than through a
International Council of Nurses) and financial burden and turnaround visit to his office, for which he can
medical industry associations (such time for processing claims and charge a fee?
as the Radiological Society of North medical information
America or the Healthcare Information
and Management Systems Society). • Patients seek accessible, more
informed, high-quality healthcare
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10. CUSTOMIZING The e-health ecosystem discussed here
is an adaptable, flexible framework
emerge only over a period of several
years. Governments in particular
THE 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 usually
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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, reining
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
Governance Governance
5 5
4 4
3 3
2 2
Services Finance Services Finance
1 1
0 0
Stakeholders Technology Stakeholders Technology
Focus areas
Note: 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 & Company
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12. This island state’s 5 million citizens had a state-of-the-art technology to quantify the NEHR program’s
enjoy 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 was
the World Health Organization of the framework did not need developed in order to successfully
as a leader in its field. It achieves immediate attention. implement, operate, and sustain the
excellent health outcomes with high NEHR. This strategy allowed the
cost-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 is
upwards 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 benefits
nized that it had a problem: Its health were quantified, it was necessary Singapore’s methodical, thorough
expenditures had begun rising at the to engage stakeholders—senior approach to launching this e-health
rate of over 8 percent annually, which officials from Singapore’s Ministry venture is a prime example of how
was 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 from
To deal with this, the government’s hospitals, clinics, and long-term a different starting point and thus
10-year master plan in 2005 included care facilities—to obtain their input face different challenges, requiring
the goal of accelerating its healthcare on a proposed financial model. different approaches.
transformation by establishing a For instance, because it would be
National 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 residents
quality 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, hospital
sophisticated legislative regime with departments, and community
well-defined guidelines for ensuring With the information collected clinics. Like Singapore, Lombardy’s
efficient rollout and implementation from stakeholders, it was possible healthcare system faced the challenge
of e-health initiatives. It also to develop a cost-benefit model of rising costs. But it also had
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13. another pressing problem: Citizen The region would obtain annual fees stakeholders, including citizens
dissatisfaction with long wait times from citizens for identification cards and healthcare operators. Citizens
for 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 to
In 1999, Lombardy’s regional join, and offered training and support.
government decided to investigate Next, it was necessary to decide
the benefits of setting up an e-health what services were to be provided by Lombardy’s e-health program
services management system. Because the regional e-health system. It was was launched in phases starting
the region had an established determined that Lombardy’s e-health in December 2001. It is now fully
company in place to plan and manage program would require electronic operational and has resulted in an
regional governance, as well as health records (EHRs) to provide a estimated annual savings of €1 billion
create technology infrastructure for unified vision of patients’ medical thanks to streamlined procedures, less
information exchanges and access to history across the 200,000 healthcare bureaucracy, and reduced fraud.
government services, these two areas players. Other services to be provided
were not top priorities. Financing, included electronic medical IDs, The PPP financing approach has
services, and stakeholders were online appointment booking and enjoyed tremendous success, resulting
the initial elements of focus of the selection of general practitioners in a 10-year relationship between the
e-health program. by consumers, e-prescriptions regional government, private service
by providers, digitization of providers, and an IT vendor.
Financing required immediate administrative functions for
attention. Lombardy developed a provider administrators, and disease Furthermore, 9.5 million patients
state-of-the-art cost-benefit model management programs for the now have smart card IDs, and over
to quantify the impacts and assess region’s public health officials. 90 percent of general practitioners,
the viability of PPPs. This approach pharmacies, public hospitals, and
involved getting private partners to The government used a variety of clinics have joined the integrated
provide the initial investment in an measures, accounting for one-third network. The program is considered
e-health services company owned and of the overall budget, to market the an example of best practices in the
operated 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.
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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.
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15. Resources
Daniel Castro, “Explaining International IT Application Leadership: Infocomm Development Authority of Singapore, “Realising the
Health IT,” The Information Technology and Innovation Founda- iN2015 Vision—Singapore: An Intelligent Nation, a Global City,
tion, September 2009 Powered by Infocomm,” 2010 (http://www.ida.gov.sg/images/
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-
,
(http://ec.europa.eu/information_society/activities/health/docs/ lenges and Opportunities,” 2007 (http://www.unescap.org/esid/
publications/201002ehrimpact_study-final.pdf) hds/lastestadd/eHealthReport.pdf)
About the Authors
Ramez Shehadi is a partner Dr. Walid Tohme is a principal
with Booz & Company in with Booz & Company in Beirut.
Beirut. He leads the informa- He specializes in helping
tion technology practice in the healthcare organizations in the
Middle East. He specializes in management and strategic
e-government, e-business, and use of technology to enable
IT-enabled transformation, help- transformation via IT as well as
ing corporations and govern- e-health strategies, organiza-
ment organizations maximize tional restructuring, outsourc-
leverage of IT, achieve opera- ing solutions, and operational
tional efficiencies, and improve improvements.
governance of IT services.
Sindhu Kutty is an associate
Jad Bitar is a principal with with Booz & Company in Dubai.
Booz & Company in Beirut. She focuses on the strategic
He focuses on healthcare use of technology and technol-
providers and public health ogy-enabled transformations
organization, specializing in for healthcare providers and
strategic planning, transforma- regulators.
tion, operational excellence,
and e-business.
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