July 17, 2011

The Anatomy of E-Health Ecosystem: Creating E-Health Programmes in Order to Ensure Lasting Viability for Initiatives to Reflect Its Local Conditions

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 programme requires for long-term success.

Around the world, the healthcare industry is facing a number of challenges. Rising rates of chronic diseases require more-complex healthcare services, aging populations need longer periods of care, and the growing use of ever-more-sophisticated medical technologies generates increased operating costs. Worldwide, healthcare 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, 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 programmes requires for long-term success.

The concept of E-Health is the application of the latest information and communication technologies to care delivery. Over the past decade, there have been an increasing number of 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 programmes, 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 initiative lies in its potentially massive benefits for all parties in the health sector. Applying the latest technologies to care delivery frees doctors, nurses and other caregivers from administrative tasks, allowing them to devote more attention to patient care. They also have better access to patients’ information and a more holistic view of their medical history, with the potential to reduce human error.

Equally important, E-Health programmes reduce costs because of the efficiencies 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 quantified some of the projected benefits from a proposed E-Health initiative in Australia: “We found that by 2020, the programme could potentially eliminate as many as 10,000 deaths caused by medication mistakes, and avoid up to 310,000 unnecessary hospital admissions, two million unnecessary outpatient visits, and seven million lab tests. The patients who need these procedures would still get them, of course, but the proposed E-Health programmes would help avoid unnecessary or redundant procedures,” explains Booz & Company.

Yet most E-Health initiatives have yet to fully deliver on their promised 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 programmes have been implemented hastily, without long-term road maps for success, and as a result may have fizzled before attaining their full potential. At their core, e-health initiatives are a technology infrastructure comprising a secure network connection, a series of data centres, a call centre, 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.

“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 and stakeholders. Finally, customisation is crucial, as each E-Health initiative will reflect its local conditions,” said Dr. Walid Tohme, Principal at Booz & Company.

The Five Elements of an E-Health Ecosystem Involve:


National governments have found the greatest efficiencies when they have legislated policies and regulations to oversee, regulate, and manage E-Health programmes.


Those planning E-Health programmes must ensure that appropriate funding is in place for its design, development, implementation, and ongoing operation. Financing can come from different sources, such as governments or public–private partnerships (PPPs). This will require governments to consider what type of reimbursement 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 preventive medicine and wellness programmes, if this is a priority for proposed E-Health programmes.


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 programmes. 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. There is often a temptation to throw money at building a technology infrastructure for an e-health initiative and then rest on one’s laurels. This is short-sighted because getting the right technology infrastructure in place is only one dimension of a successful e-health programme.


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 patients on specific conditions such as diabetes monitoring or HIV prevention. Because stakeholders will likely be wary early on, it is crucial to establish some early “wins” by choosing 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 analyse information on chronic diseases such as diabetes

  • Ambient Assisted Living (AAL) services such as monitoring the vital signs of homebound elderly people, as well as communicating adverse events to care providers

  • Integrated disease surveillance platforms for public health agencies to detect unhealthy syndromes and coordinate responses

  • Solutions in self-care, health-risk prevention, and adherence to prescribed treatments, such as educational text messages for pregnancy and infant care

  • Products monitoring that monitor a patient’s medication regimen, such as pill containers with computer chips that automatically provide reminders to patients and inform physicians of results


It is critical to have a human-centric approach and to involve key stakeholders from both the public and private sectors when designing an E-Health programmes, as each stakeholder has different motivations for semi-private hospitals and clinics), payers (like insurance companies), and patient advocacy groups (including not-for-profit associations that help patients with research, education, and services. Each stakeholder has different objectives and motivations for participating in e-health programmes. Stakeholders include gov¬ernments, providers (both public and from governments and providers feeling the pressures of rising healthcare costs, while medical professionals try to cope with increasing patient demands and large volumes of health information. On the other hand payors want to reduce their financial burden and turnaround time for processing claims and medical information while at the same time 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 programme 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,” stated Jad Bitar, Principal, Booz & Company.

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 E-Health programmes, but want to expand it. 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.

“One theme binds all five elements of the e-health ecosystem framework is ‘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,” explained Shehadi.

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 customised solution for the envisaged e-health initiative.

The Five Key Areas to Be Investigated Include:

  • What is the current legislative support, if any, for an e-health programme? Do existing laws and regulations cover the necessary privacy concerns, financial requirements, and ethical and professional standards? What legal constraints need to be addressed?

  • What technology infrastructure already exists and how will it have to be upgraded to meet the requirements of the envisaged e-health programme?

  • What services do we intend to offer, and what services will the public expect to receive from the e-health programme?

  • 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 programme once it is up and running?

  • How will this programme 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 programme?

“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. However, local conditions, and the precise task at hand, whether it is starting an e-health programme from scratch or revising one already in place,” added Tohme.

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 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. Lombardy’s e-health programme was launched in phases starting in December 2001. “Lombardy’s e-health programme required electronic health records to provide a unified vision of patients’ medical history. 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,” commented Bitar.

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. By launching such initiatives, a multi-dimensional endeavour that requires careful examination of a broad panorama of inputs, goes far beyond the creation of an electronic platform for delivering healthcare services. Additionally, creating sustainable e-health programmes requires recognition that a ‘one-size-fits-all’ approach will not work…customisation is key.

“It is not an easy undertaking but the benefits of an intelligent e-health programme, implemented with a long-term strategy in mind, will justify the effort,” concluded Shehadi.