CHAPTER 5 - CASE ANALYSIS
5.1 Industry Analysis
國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
CHAPTER 5 - CASE ANALYSIS
5.1 Industry Analysis
Past and current cases in developing e-health services can be classified according to the leading industries, including medical units, security companies, telecommuni-cation companies, medical equipment manufacturers, system or platform developers, construction companies, etc. The leaders in different industries will develop distinct e-health services and business models due to different positioning, resources and strengths. For example, medical units focus on disease treatment and medical re-sources; security companies concentrate on security services by using the existing structure composed of the reporting center and security personnel; telecommunication companies develop mobile care services through cooperation with hospitals. Table 16 presents an overview of past and current e-health cases in different industries.
From Table 16, we can observe that the business models led by medical units tend to operate successfully. The possible reason for this success is that disease treat-ment or health managetreat-ment hospitals indeed satisfy some people’s demands, such as those of severe cardiovascular disease patients or solitary elders. Additionally, the e-health business model of the project is also led by NTUH. Therefore, we will focus on cases that are hospitals and have the same medical basis to execute industry analy-sis in the hope of developing an innovative e-health model. The cases include the Na-tional Taiwan University Hospital (NTUH) Telehealth Center, Changhua Christian Hospital (CCH) Long Distance Health Management Center, Far Eastern Memorial Hospital (FEMH) and Far Eastone Telecommunications (FET) 880 Mobile Care Ser-vice, Cheng Hsin General Hospital (CHGH) Telecare Services Center and Min-Sheng Healthcare. The comparison of these cases is seen in Table 17.
From Table 17, we find that each hospital has different service positions and ac-cordingly develops a distinct service offering by getting support from the front-end and the back-end, and finally generates diverse value. By analyzing these cases and collecting related research and information, we generalize basic e-health service deci-sion making, which happens at the foundation level. In the next section, we will detail this analysis.
Table 16 Overview of the e-health industry
Organization The leading industry Services & Products Formal Operation NTUH Telehealth Center Medical unit Telehealth Center Yes
‧
Personalized telehealth platform
Heart care service, health management, etc.
CCH Long Distance
Health Management Center
Medical unit Long Distance Health Management Center
Telecare information platform
Diabetes care service health management, etc.
880 Mobile Care Services
Yes
CHGH Telecare Services Center
Medical unit Telecare Services Center
Card Guard
Heart care service, chronic care service, etc.
Yes
Min-Sheng Healthcare Medical unit Call center
Project smart care system
Postoperative Care
Yes
Taiwan SECOM Security company Security Call Center
MyCASA
Yes
Lifecare Personal emergency or
tele-homecare
PERS Call Center
Lifeline Service
Yes Netown Corporation Systems/platform
vendor
Telecare System, Wisdom Healthcare Platform, etc.
Yes Century Digital Science &
Technology Co.
Construction Company Smart House No
Farglory Land Construction Company Farglory Future City No DailyCare BioMedical Inc Medical equipment
manufacturer
Remote monitoring and management system for heart disease
No
Taiwan Pujidi Corporation Personal emergency or tele-homecare
Portable guide care system No
Chunghwa Telecom and Chang Gung Medical
Tele-health Center
Tele-health Service
End
‧
Table 17 A comparison of e-health business models Service position Service offering Front-end
Delivery process
Back-end
Supporting process Value Successful factors NTUH
Cardiovascular dis-ease patients
Patients with chronic diseases
Postoperative patients
The elderly
People who feel healthy but hope to become healthier may also participate
People who feel un-well but hope to re-turn to their original healthy states may minor daily fee of a few dozen NTD
Professional medical team
Heart disease care
Health management service
‧
Discharged patients
Outpatients
Institutional care per-sonnel
Institutional residents
Home/Community care:
Physiological measurements
Client health management
Video counseling service
Health education, medication safety service
Resource referral
Emergency notification service
Institutional care:
Video tele-consultation
Physiological
Measurements
Video visitation
Health education
Medication safety service
Develop specialized medicine and help disadvantaged groups
Professional medical team
Diabetes care
Health management and weight loss
Support from CCH healthcare system
Home, Community, and Institutional care
‧
Mobile tracking service
Registration
Customer service
Query prescription
Reserve prescription
Medicine consultation
Reserve special clinic
Reserve Health Center
Reserve Beauty Center
Care center
Professional medical team
Patients with chronic diseases, such as dia-betes or hypertension
Patients who need 24 hr home care
Institutional residents
Home blood
Tracking services
Emergency notification
Telecare
Aescu Technology
TaiDoc
Blood pressure ser-vice fee (per month):
$500 NTD
Blood glucose ser-vice fee (monthly) (excluding paper):
$500 NTD
EKG service fee (10
Professional medical team
Heart disease care
Synchronous data transfer
Medical staff analyze the data around the clock
‧
Physiological value analysis
Regular health report
Sync notify
Postoperative patients Physiological measurements
Reminder services:
measurements/medicines /outpatient
Regular phone calls
Health consultation
Call center
Professional medical team
Postoperative care
The support from Min-Sheng healthcare system
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
5.1.1. Service Position
For the development of e-health services, the first step is to start at the service position to decide its overall future direction by finding the organization’s advanta-geous and differential strengths compared with other competitors in the e-health in-dustry and by choosing its customer segments.
5.1.1.1. Organization
To capture organizational characteristics, we need to know the organizations’
structure, systems, environment, culture, missions, objectives, differentiation, ad-vantages, challenges and problems as they develop e-health services.
First, the organizations participating in e-health are almost all hospitals that have performed a number of pilot projects in the field of e-health services. Each hospital has a different culture and will set different missions, objectives and goals according-ly. In accordance with The Development Plan of Telecare Service of the Department of Health of Executive Yuan, there are three care models of e-health, including Home Care, Community Care and Institutional Care. These three models have diverse mis-sions. For example, the mission of Home Care is to establish a people-centered and integrated care model for the general public; that of Community Care is to implement community-based long-term care services policy; and that of Institutional Care is to develop and promote an e-health business model for hospitals and long-term care in-stitutions. An organization’s culture and mission are important in order to decide its future direction.
In addition, after a number of case analyses, we found that utilizing the differen-tiating qualities and advantages of the hospital leads to greater success. In general, these differentiations and advantages may involve cooperating with other medical units, obtaining strategic alliances with different business fields, and providing other related or innovative e-health services.
Last but not least, there are some challenges to developing e-health services in Taiwan. If a hospital wants to employ e-health, it should consider these problems.
First and the most important are regulatory restrictions, such as the Physicians Act and Personal Information Protection Act; second, the fact that e-health services have still not been included in National Health Insurance (NHI); third, that Taiwan has a good healthcare environment, which makes it easy for patients to see a doctor -- only if their diseases are urgent, such as heart disease, would they be willing to take part in e-health services and pay for them; finally, it is difficult to control the balance be-tween automation systems and personalized medicine. For these reasons, most
hospi-‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
tals fail to operate e-health services independently and sustainably. Additional details can be found in Appendix C - The decision area: Organization.
5.1.1.2. Customer Segments
The organization needs to identify its target customers and then design different service propositions to satisfy each customer group.
Overall, customer groups that most hospitals choose include patients with chron-ic diseases, such as diabetes or hypertension, cardiovascular disease patients, postop-erative patients, the elderly, and people who want to lose weight or manage health; in addition to individual customers, hospitals also target community residents, institu-tional residents and enterprise employees.
The three care models will have their own target customers, and these customers are all a bit different. For Home Care, hospitals place an emphasis on patients with diabetes, hypertension, mild or moderate disability or mild dementia, elderly people living alone, chronic patients’ primary caregivers, and needy people whom the case managers consider appropriate; for Community Care, their customers are similar to Home Care and also include local cases; for Institutional Care, they concentrate on offering services to institutional residents, their relatives or care personnel. Additional details can be found in Appendix D - The decision area: Customer Segments.
5.1.2. Service Offering
According to the hospital’s strategies and target customers, it designs e-health services to meet users’ needs and expectations. Service offerings are based on the front-end delivery process and the back-end supporting process to construct the ser-vices as a whole.
5.1.2.1. Service Proposition
After reviewing related cases, reports and secondary data, e-health services can be divided into several categories, including remote services, front-end services, mo-bile services, other related services, innovative services and group services. In remote services, users receive services at home or in other places, such as remote physiologi-cal measurements and monitoring; as for front-end services, service personnel would actually be in contact with customers to offer services, such as visiting services. Addi-tionally, mobile services enable users get services anywhere and anytime, such as us-ing mobile phones to make an appointment. Related and innovative services also can be linked to e-health services, such as weight and health management, social net-working websites for patients or 24-hour convenience store blood pressure and blood
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
sugar measurement stations; in addition, some hospitals develop services for group customers, such as population health analysis and proposals of employee health checks.
Because the three care modes target different customer features, their e-health services also differ accordingly.
After understanding e-health service content, we also need to know the way in which services are packaged. Hospitals mostly provide patients with several standard service options that are composed of different combinations. For example, service op-tion A has blood pressure monitors and blood glucose meters, and service opop-tion B has electrocardiography (EKG). Such standard service options seems less flexible to some patients to satisfy their needs. Additional details can be found in Appendix E - The decision area: Service Proposition.
5.1.3. Front End- Delivery Process
After defining the service offerings, a hospital needs to consider how to deliver services to customers at the front end, namely the delivery process. The delivery pro-cess includes how to interact with customers and how to execute each propro-cess.
5.1.3.1. Service Encounter
In the service encounter, there are three important roles that involve a hospital, its service personnel and customers, and each role has duties to complete.
The hospital needs to establish e-health centers or 24-hour call centers to provide patients with a contact channel, as well as an e-health platform, mobile platform and measuring instruments to create a continuous link with patients, such as keeping track of their physical condition. In addition, the hospital should develop a mature envi-ronment to enable contact personnel to offer services for patients, such as building up a clinical decision support system (CDSS) to automatically diagnose patients’ situa-tions to reduce the burden on service personnel.
Service personnel include physicians, case managers, health educators, health managers and dieticians, among others. Physicians bring value to e-health services and attract their patients to these services. As for case managers, health educators, etc., their roles are similar. They hold important roles in e-health services in the front-end contact with patients, as a communicative bridge between patients and physicians.
They are responsible for assessing the status of cases and giving personalized health management.
Patients, as customers, also have some essential responsibilities. They should
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
upload blood glucose, blood pressure, medication, diet, exercise and other records to the e-platform. With the connection of the platform or instruments, the system would remotely monitor their health situation so that case managers are able to provide per-sonalized health services. In addition, patients’ relatives can also take part in the e-health service to care for patients. For example, through video surveillance, obser-vation of patient medical information, and syncing e-mail, they can understand pa-tients’ physical condition. Additional details can be found in Appendix F - The deci-sion area: Service Encounter.
5.1.3.2. Service Delivery
Service delivery is how and where services are delivered and affects stakeholders.
In e-health services, there are three processes, including enrollment, care and case closure.
First, we discuss enrollment. The awareness channels whereby cases know about e-health services may be through an introduction by physicians, relatives, patients’
associations, websites, newspapers or magazines. As for the contact channel, inter-ested people can go to e-health centers, use online registration or call services to apply for registration. The general application process is shown in Figure 10.
Figure 10 The general application process
Second is the care process. Cases should upload physiological measurements, and in this way, the platform receives data. After assessing the data, case managers will give personalized care or health management and physicians give recommenda-tions and judgments in a timely fashion. The center will offer emergency treatment in critical conditions or introduce cases to referral departments if necessary. Additionally, cases need to regularly come back to the clinic for professional examinations and to make adjustments. In the care process, there are other services for cases, such as phone visits, medical and health consultation, reminders for measurements, etc.
If participants have no intention to continue or are short-term participants, such as postoperative patients that have completed their treatment, then cases are closed.
More details can be found in Appendix G - The decision area: Service Delivery.
Registration Health consultation and filling out basic
infor-mation
Consult physicians
Assessment by Case managers/Health
educa-tors/Health Managers/
Dieticians Customize personalized
care / health management programs
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
5.1.4. Back end - Supporting Process
The e-health services offered depend on the aid of the back-end supporting pro-cesses, containing key resources to use, key activities to perform, and key partners to work with.
5.1.4.1. Key Resources
This part concerns what resources a hospital needs. There are four types of key resources: physical, intellectual, human or financial resources.
Physical resources refer to the e-health center, e-health platform, mobile platform, instruments and other medical partners. Intellectual resources include hospital brand reputation, innovative technology and unique patents. Human resources are the most important resources in e-health services, including physicians, case managers, health educators, health managers and dieticians. Finally, financial resources describe gov-ernment grants or National Health Insurance (NHI). Additional details can be found in Appendix H - The decision area: Key Resources.
5.1.4.2. Key Activities
A hospital should use resources to execute a series of activities to enable the of-fering of e-health services.
To offer e-health services, the hospital may first have an e-health platform, a mobile platform or instruments. They can build and maintain e-health and mobile platforms as well as develop instruments on their own, or cooperate with platform developers and instrument manufacturers. Then, the hospital needs to decide the way to offer e-health services. There are four types of telemedical data transfer and analy-sis (see Table 18). The hospital should choose the best way for its e-health model. The hospital is also supposed to balance the gap between profit and cost. Additionally, because developing e-health services involves many industries, the hospital should leverage its network and resources, such as cooperation with instrument manufactur-ers, platform developmanufactur-ers, etc. Another important activity involves e-health service personnel recruitment and training. The hospital must enable these service personnel, such as case managers, to offer services to patients. Additional details can be found in Appendix I - The decision area: Key Activities.
Table 18 Four types of telemedical data transfer and analysis Data transfer Data analysis
Provide patient management and contact with medical
Case
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
team 1st generation
Asynchronous Medical staff cannot analyze the data imme-diately
No CCH
2nd generation
Synchronous Medical staff can ana-lyze the data immedi-ately only during office hours
No Taipei City
Hospital
3rd generation
Synchronous Medical staff analyze the data around the clock
Only inform the pa-tients of abnormal physiological data
Taiwan SECOM MyCASA 4th generation
Synchronous Medical staff analyze the data around the clock
Provide patient man-agement and contact with medical team
NTUH Tele-health Center
5.1.4.3. Key Partners
As previously mentioned, offering e-health services involves so many industries, such as instrument manufacturers or platform developers, that the hospital cannot ex-ecute the whole model on its own. Therefore, it is necessary to cooperate with other partners.
Figure 11 The framework of partnership in e-health
‧ 國
立 政 治 大 學
‧
N a tio na
l C h engchi U ni ve rs it y
For example, for medical equipment, cooperation is necessary with medical equipment and supply manufacturers; for client hardware, hospitals must seek client equipment manufacturers; for the platforms or systems, hospitals must outsource their development to platform developers; for medical care, they may collaborate with pri-mary care facilities, mountain area and off-coast health centers or cooperative medical units; for daily care, chronic care centers, social welfare service units, or personnel allocation are possible options for collaboration; additionally, hospitals may also con-sider whether to cooperate with security service providers, insurance providers and telecommunication service providers.
A hospital’s most important partner is the government, including the Department of Health, Bureau of National Health Insurance (NHI), Bureau of Health Promotion, etc. They play critical roles in e-health service delivery because they manage the di-rection of policy, such as fee-for-service or case payment, or the limits of the Physi-cians Act and Personal Information Protection Act. Additionally, the grants from governments are necessary for some hospitals that barely maintain e-health services because of imbalanced finances. The whole framework of the partnership in e-health is shown in Figure 11.Additional details can be found in Appendix J - The decision area: Key Partners.
5.1.5. Value
What value e-health service will eventually be able to generate is critical to sup-port the sustainable operation of e-health services. This pillar includes financial value, customer value and operating value.
5.1.5.1. Financial Value
Financial value is composed of costs and revenues, and it determines whether the hospital could maintain operation of the e-health business model. Even if the hospital has been able to obtain profits from e-health services and even balance the costs and revenues of them, it is still possible for these services to eventually fail.
Costs include self-financing, salaries, equipment costs (including transfer fees), platform costs, materials and costs of supplies, rental fees, etc. Revenues can be gen-erated from National Health Insurance, private insurance, grants from the government, customers’ self-paid premium services, etc. Additional details can be found in Ap-pendix K - The decision area: Financial Value.
5.1.5.2. Customer Value
For e-health services, the customer value is the customers’ direct feedback, the