CHAPTER 5 - CASE ANALYSIS
5.2 Case Analysis
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most important factor, as well as proof of successful services. The customer value is made up of quality and satisfaction.
Quality refers to cases’ physical conditions, such as blood sugar, blood pressure, etc. Satisfaction refers to whether cases are satisfied with the e-health services, plat-forms and instruments. Additional details can be found in Appendix L - The decision area: Customer Value.
5.1.5.3. Operating Value
In addition to using financial value and customer value to assess whether e-health services are successful or not, the operating value should also be considered.
It can be discussed from the perspective of management and personnel.
In general, almost all hospitals only consider financial value and customer value, and in previous studies, the operating value rarely receives attention. From the per-spective of management, hospitals are only concerned with economies of scale, such as the number of enrollments, and do not consider stakeholder value from the person-nel side. Additional details can be found in Appendix M - The decision area: Operat-ing Value.
5.2 Case Analysis
The above section concludes the foundation level, and through interviews, ques-tionnaires and related data collection, we develop the proprietary and rules levels of the NTUH e-health business model. In this section, we attempt to determine the ad-vantages and differences of NTUH, propose some feasible ideas for e-health services that present a good fit for NTUH, and finally evaluate those ideas. After a series of decisions, the business model for NTUH e-health services will be outlined.
5.2.1. Organization
NTUH is a top teaching hospital in Taiwan focused on medicine, teaching, re-search, services, medical care policies and social reforms. It has an international rep-utation and a complete medical system offering patients integrated medical services and outstanding medical teams ensuring that patients obtain excellent quality of med-ical care. Its culture is not of taking patients’ money, but of making patients healthy;
thus, NTUH has a different mission from other hospitals to consider when developing e-health services.
The type of e-health mode NTUH develops is Home Care. Other hospitals may hope to attract a greater number of outpatient stays through e-health services. Howev-er, NTUH wishes to bring patients healthy lives and accordingly reduce the number of
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outpatient stays, hospitalizations, emergency department (ED) visits, etc. to improve bed turnover rates and provide more patients with medical services. In addition, through e-health, NTUH hopes to provide a contact channel for people in need, offer-ing continuous monitoroffer-ing and care and realizoffer-ing early intervention therapy. There-fore, NTUH’s objectives for Home care are to develop innovation in medicine, teach-ing, research or services, contribute to marginal benefits for NTUH, such as reducing the hospital length of stay and enhancing bed turnover rates, and eventually having the ability to independently balance revenues and costs. Hence, NTUH set three goals for Home care: the short-term goal is to incorporate Diabetes Telecare into the NTUH Telehealth Center; the medium-term goal is to become a routine, comprehensive and independent department; and the long-term goal is to become an important depart-ment to maintain people’s health.
There are some strengths to consider in developing NTUH’s e-health services.
First, its brand influence can influence many patients to take part in such services; in particular, NTUH can bear the losses and invest in e-health on the basis of a high number of patients and outpatient visits, which other hospitals may not be able to do.
In addition, NTUH can utilize resources from each department as well as link chan-nels of these departments to develop integrated e-health services in order to provide complete medical care services for patients. Another advantage is that NTUH actively researches and develops innovative service systems and products.
From these differentiators, advantages and strategies, we conclude that NTUH can develop a suitable e-health business model in the extreme disparity between the exclusive market of “crisis management” and the mass market of “health manage-ment” to balance its finances or sources of cases. NTUH can try to make this model feasible and successful, and in the future, copy and diffuse the business model to other hospitals to achieve a Transfer of Technology (TOT).
In addition, NTUH’s Jin-Shan Branch Hospital (JSH) is also actively engaged in the e-health model of Community Care. To develop this e-health model, JSH’s mis-sion is to build up a positive relationship with the community and provide patients with care for more diseases. Therefore, the goals for JSH are to extend the types of disease care, ranging from diabetes to heart diseases or hypertension (HTN), in the short term as well as to promote this model to the community in the medium term, using methods such as establishing Health Stations.
The strength of JSH is having medical back up from NTUH. Its strategies are to actively make home visits to maintain a positive relationship with patients and to set up Health Stations in the community to maintain a positive relationship with the
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community.
However, there are difficulties in the development of e-health for JSH. Because patients are almost exclusively elderly and their socioeconomic status is usually not high, the payment is difficult for patients and acceptance of e-health platforms or in-struments is also low in this group. Additional details can be found in Appendix C - The decision area: Organization.
5.2.2. Customer Segments
In response to the previously mentioned challenges, NTUH can develop a suita-ble e-health business model between the exclusive “crisis management” market and the “health management” mass market
First, NTUH should utilize its medical and care advantages to obtain an exclu-sive market, namely in crisis management, to establish high barriers against other competitors who want to enter this segment of the market. If NTUH has the intention to develop the exclusive market in “crisis management,” it can consider patients with Type 1 diabetes or severe cardiovascular disease, which are more difficult diseases to treat; additionally, other hospitals rarely run e-health platforms for these patients. Pa-tients who have related conditions, such as Chronic Obstructive Pulmonary Disease (COPD), mental illness, diet management, pulse diagnosis, cancer, are also a potential source. In addition, we advise that NTUH targets patients with complications or he-reditary, complex or long-term diseases to offer integrated and complete e-health ser-vices. However, although targeting these severe cases can be a good niche market for NTUH, there are some issues: How does the system provide so many functions for different patients? Is it relatively easy to reach commercial operations by targeting severe cases? How is it possible to integrate the departments of NTUH, the platform and shared data? Such problems should be figured out if NTUH wants to operate in crisis management.
There is another market in which to operate so that NTUH can expand its own business model and run independently: the mass market, namely health management.
NTUH should spread its services to health management to satisfy those mass-market customers, including people who feel healthy but hope to become healthier or those who feel unwell but hope to return to their original healthy states. The simplest way to operate health management in order to offer e-health services for the public is through building a cloud database, using the sorting ability of the database to reach optimiza-tion in machine learning, performing auto-detecoptimiza-tion through machine learning, and giving customers timely feedback with the help of artificial intelligence.
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In this study, we used a questionnaire to survey users’ gender, age, disease, and level of education to learn the basic distribution of the current customers so that in the future, the hospital can provide different e-health services for different customer groups. After the survey, we found that almost all users participating in the e-health services of the project had Type 1 diabetes, were young and middle-aged, and had a long-term history of disease (see Table 19). For this customer group, we advise that from composite and multiple aspects, NTUH can design service content focusing on satisfying the basic necessities of diabetes patients, such as food, clothing, housing, and transportation to combine life with e-health services. For example, this may in-clude providing patients with exercise and diet plans.
Table 19 Characteristics of the users in the project
Gender Number Percentage
Male 29 59%
Female 20 41%
Disease Number Percentage
Type 1 diabetes 31 63%
Type 2 diabetes 18 37%
Age Number Percentage
Under age 20 1 2%
Age 20-35 9 18%
Age 35-50 15 31%
Age 50-65 20 41%
Age 65 and over 4 8%
Education Number Percentage
Less than junior high school graduate 4 8%
High school graduate 10 20%
Bachelor’s degree 29 59%
Master’s degree or higher 6 12%
Because it focuses on Community Care, JSH targets patients with chronic dis-eases, such as diabetes or hypertension, the elderly, and community or neighborhood residents. As for service design, most patients in JSH are the elderly, and as a result, JSH can consider designing some life care services for these older patients.
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Currently, because of limited human resources and equipment, JSH would need to choose appropriate patients to take part in e-health services. Therefore, physicians or case managers would judge whether the patient has the ability to operate a machine or whether his/her disease control is sufficient to recommend participation in the ser-vices. Additionally, patients with the help of foreign caregivers are also potential cus-tomers because foreign caregivers can learn how to use the instruments to assist pa-tients. Additional details can be found in Appendix D - The decision area: Customer Segments.
5.2.3. Service Proposition
For e-health service propositions of NTUH Home Care, we propose two main services: integrated services and health management services.
First, the real intention of providing integrated services is to realize comprehen-sive care for patients by linking each department and their disease care. To have the ability to offer integrated e-health services, NTUH should integrate patients’ elec-tronic medical records, physiological measurements, medical information platforms, related services, resources of each department, etc. Currently, NTUH tries to construct a comprehensive platform, integrating the medical records of the hospital, personal-ized information of individual cases, and self-health management information of the e-health portal and the mobile platform in order to facilitate efficiency of care. In the future, e-health services will be integrated, and NTUH patients will receive more complete and comprehensive care. However, the realization of integrated services does not involve a single step but rather needs progressive development. As an e-health department gradually expands, it will also obtain more equipment, personnel, training, income and resources. Then, other departments and physicians will be more willing to introduce their patients to the services. Additionally, before the integrated service is ready, patients may need care or services from departments that have not been included in the e-health model, and case managers would then introduce the pa-tients to referred departments. In the future, cardiac, diabetes, postoperative papa-tients or rehabilitation departments will be successively contained in the integrated services, and finally, all departments will participate in e-health services, just like tele-NTUH.
Second, for public health and the mass market, NTUH can provide preven-tion-focused health management services aimed at connecting care services with as-pects of patients’ lives, such as exercise and diet. Offering health management ser-vices requires some professional abilities, but hospitals generally do not run these ar-eas. Therefore, NTUH can consider cooperating with affiliate institutions, such as fit-ness centers. After assessing a patient’s situation, for example, NTUH can
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mend a fitness center to a patient, where they can participate in a particular diet or ex-ercise plan.
For e-health service propositions of Community Care, JSH chose to set up Health Stations in the community and provide community residents with blood pres-sure, height and weight measuring services. In addition, because of these patient fea-tures, JSH offers Life Care Services for elders, such as accompaniment to medical visits.
Next, we discuss the ways in which services are packaged. As mentioned previ-ously in the service propositions on the foundation level, hospitals mainly provide pa-tients with several standard service options that are composed of different combina-tions, which are less flexible for some patient needs. Thus, we propose to distinguish services on several levels to form basic and value-added services and to make the op-tions more flexible. We think it is necessary to offer basic and value-added services.
For example, not every patient needs 24-hour care services. If the hospital offers the same service options to every patient with different needs, it will not only cause a waste of resources but it will also not cater to the real needs of patients.
How is it possible to set service options or basic and value-added services? We should classify services and distinguish some services on several levels. There are three ways of doing so: First, classifying services according to instruments, namely offering service options according different combinations of instruments, such as electrocardiography (EKG), blood pressure monitors, blood glucose meters and blood oxygen meters; second, classifying services according to diseases, namely offering service options depending upon the relevant types of diseases, for which there are basic and value-added services according to disease severity—for example, heart dis-ease has a service package, and minor cases may only need basic services, but severe cases may need value-added services; third, classifying services according to the ser-vice itself, namely the nature of the serser-vices. Some serser-vices fall under the serser-vice category instead of the disease category. For example, patients with heart disease cer-tainly need medical treatment and care, but there are other services that could improve health, such as aerobic exercise or flexibility training. Additional details can be found in Appendix E - The decision area: Service Proposition.
To know which e-health services can be developed in the future, we issued ques-tionnaires to cases in order to investigate patients’ demands for e-health services as well as interview-related service personnel to assess the feasibility of these services.
For these developing e-health services, we wanted to know their priority and feasibil-ity, and for each service, which service options users prefer. For future e-health
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vices, we wish to understand which services are potential and feasible. Table 20 shows the users’ preference for service options of each e-health service. Table 21 shows the priority of services in users’ minds compared to the feasibility of these ser-vices from the perspective of service personnel.
Table 20 The users’ need for e-health services
Exception alert services Number Percentage
No 16 33%
Case managers take care of patients after assessing their
sit-uation. 20 41%
In addition to assessment and treatment by case managers,
also send sync e-notification to patients’ relatives. 4 8%
In addition to assessment and treatment by case managers as well as sending sync e-notification to relatives, if patients are in an emergency situation, the system can automatically dispatch ambulances.
9 18%
Reminder services Number Percentage
No 5 10%
By phone 14 29%
By cell phone text messages 28 57%
By notifications on the platform 17 35%
By e-mail 9 18%
Inquiry services Number Percentage
24 hours a day and 7 days a week 23 47%
12 hours a day and 7 days a week, extra charge except
dur-ing business hours 6 12%
12 hours a day and 5 days a week (excluding holidays),
ex-tra charge except during business hours 20 41%
Regular health reports Number Percentage
No 4 9%
Send monthly reports by e-mail 38 78%
Send monthly reports by regular mail 6 13%
Sending sync e-notification to relatives Number Percentage
Yes 17 35%
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No 32 65%
Regular phone visiting Number Percentage
No 20 41%
Once a week 29 59%
Twice/thrice a week 0 0%
Once a day 0 0%
Home visiting Number Percentage
No 28 57%
Once a month 19 39%
Once a week 2 4%
Health education services Number Percentage
No 12 24%
Providing education videos in the platform 18 37%
Periodic health clinics 28 57%
Speeches on health 11 22%
Community health services 3 6%
Issuing propaganda 4 8%
Periodic newsletters 11 22%
Mobile care services (cell phone, PDA, etc.) Number Percentage
No 10 20%
Mobile e-health platform 27 55%
Uploading physiological measurements by using mobile
communications 18 37%
Sending care text messages 11 22%
Mobile positioning services 11 22%
Life care services Number Percentage
No 33 67%
Other relatives help patients receive medicine 6 12%
Pickup services 4 8%
Accompanied to medical visit 6 12%
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Care videos 5 10%
Logistics and distribution 4 8%
Helping with chores and housework 3 6%
Appliance repair 2 4%
Table 21 The priority and feasibility of e-health services Users
Service personnel E-health services Count Percentage
Developing e-health services
Exception alert
ser-vices 26 53%
Need to define what is “abnormal”
and identify anomalies through CDSS monitoring; The CDSS currently can only pick out cases that do not upload in the typical amount of time
The current approach: if the patients themselves or their families inform case managers, case managers may inform outpatient treatment immedi-ately
A formal e-health center around the clock will be more feasible in the fu-ture
Only patients have certainty in up-loaded data; case managers and CDSS can monitor their situation
Reminder services 25 51%
Case managers will present reminders flexibly according to the patient’s condition
Reminder services are more effective for aggressive patients
For those patients who are less ag-gressive, reminder service has little effect
Inquiry services 25 51%
Currently, in addition to office hours, case managers and physicians can be contacted by official telephone
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In the future, the official e-health center is available 24 hours a day and seven days a week, so the service will be more flexible
Regular health reports 23 47%
Now patients can login to use this feature
Additionally, when patients go back to the clinic once every three months, physicians will describe their situa-tion for them
Mobile care services 18 37%
Health education
ser-vices 17 35%
Provide some relevant and deeper knowledge of health education, diet, medicines and other functions, etc.
Regular phone calls 9 18%
Provide different options according to patients’ wishes
In the project, patients included few elderly and were almost all young adults; those young adults only need-ed reminders via mobile phones using text messaging
However, if telephone calls occur too many times, it could greatly increase case managers’ burden
May cause inefficiencies if some pa-tients gossip or harass case managers through this system
Home visits 8 16%
Okay for the elderly, but young peo-ple should have no need for it
Once a month is more appropriate, or it may cause a burden
Case manager as the service executor is ideal because case managers have increased likelihood of contacting pa-tients and knowing more patient in-formation
The services have much uncertainty, such as distance or the safety of case
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managers
There are rarely home visits; addi-tionally, even with home care, pa-tients still should go back to the clinic every three months
Life care services 8 16%
Users
Service personnel E-health services Count Percentage
The future e-health services
Priority registration 22 45%
Feasibility is not high
Physicians themselves are too busy, and for case managers, it is hard to add extra patients to the list of outpa-tient cases
Health management 21 43%
If these services are again handled by
If these services are again handled by