Appendix I - The decision area: Key Activities
Foundation level Proprietary level Rules level
Production, operating systems：
Platform, network：
Build and maintain e-health and mobile platform
Technology, R&D, creative or innovative capa-bility, intellectual：
Develop instruments
Problem solving, Offering service：
Offer e-health service
First generation: Asynchronously
Second generation: Synchronously/Medical staff can analyze the data immediately only during office hours
Third generation: synchronously/Medical staff analyze the data around the clock/Only inform the patients that the abnormal
physiological data
Fourth generation: Synchronously/Medical staff analyze the data around the
Production, operating systems：
Platform, network：
Develop Continuous, Personalized Healthcare Integrated Platform
Develop CDSS to assist service personnel Technology, R&D, creative or innovative capa-bility, intellectual：
Problem solving, Offering service：
NTUH: Offer e-health service for Home Care by using synchronous/around the clock/back up.
JSH: Set up Health Station to offer services for Community Care
Integrate resources and services of each
Production, operating systems：
Platform, network：
Building Continuous, Personalized Healthcare Integrated Platform
Consolidate functions of each care diseases
Consolidate case information
Allow cases to get comprehensive care Developing CDSS
CDSS: In order to reduce the workload of physicians and case managers, hope to have a fixed medical model, namely use CDSS to solve the patients’ problems
Personalized Medicine: However, the pa-tient’s’ condition keeps changing and each patient is individual so they need Personal-ized Medicine. It is not easy to handle. A variety of different issues and a lot of indi-vidual judgments are involved in Personal-ized Medicine. Therefore, it needs to rely
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clock/Provide patient management and contact with medical team
Selling, marketing, packaging：
Information management, mining：
Financial transactions, arbitrage：
Balance the gap between profit and cost Supply chain management：
Networking, resource leveraging：
Cooperation with instrument
manufacturers, platform developer, etc.
Recruitment, training：
E-health service personnel recruitment
E-health service personnel training
department
Via remote consulting, link NTUH and JSH
Recruitment, training：
on physicians and case managers to sup-port, but accordingly costs will inevitably increase.
The balance: From a different perspective, if setting conditions are very simple varia-bles, then it can be systematic and auto-mated more easily. In many situations, CDSS is able to solve problems, and it is not necessary to use too much Personalized Medicine. Therefore, timely CDSS should still be able to give timely supports.
Technology, R&D, creative or innovative capa-bility, intellectual：
Problem solving, Offering service：
Design an architecture that can be scaled up
The architecture: When the front-end filter discovers a problem, directly pass it to the back-end service group to handle with it.
For example, NTUH Telehealth Center is able to handle 200 cases now, after scaling up 200 times, and that is, the center can accommodate 20,000 people in the e-health services.
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The front-end filter: The auto filter has to be very powerful, be able to accurately screen patients in need, and maintain accessible all the time
The back-end service group: It means the capacity for the number of patients which the service group can handle. Only the center has the ability to operate the back-end, it could run the front-end.
The percentage (%):What percentage of patients to pass the front-end filter to the back-end service group
JSH sets up Health Station
Look for instruments of Community Care with the feature of personal identification
Find a suitable region, such as temples or village offices
Organize local volunteer teams
Give patients feedback and maintain a positive relationship with the community Selling, marketing, packaging：
Information management, mining：
Financial transactions, arbitrage：
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Supply chain management：
Networking, resource leveraging：
The problems of integrating each department
Technically feasible, but there are issues about regulations, such as Physicians Act and Personal Information Protection Act
How to share the charges and profits among each department
From Cloud Ward to Cloud Hospital
First do a successful model, and then spread out it. For example, if NTUH wants to increase the types of diseases, of course, needs to take a successful disease to be the core, and then gradually run other related diseases. For NTUH, currently, the heart disease is the most successful case.
Accordingly, first include heart-related diseases into e-health services, and finally progressively develop all disease cares into an integrated service.
Development direction should be from bottom to top, like a unit slowly pushed to stack up. If the development direction is
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from top to bottom, it would lead to scale-up problems; moreover, it is hard to see an outcome.
Cloud Hospital is NTUH’s ultimate goal to offer e-health services of a combination of multi-disciplinary and multiple diseases. In the future, e-health services will be
provided gradually from Cloud Ward level to Cloud Hospital level.
Recruitment, training：
The abilities of case managers
Instant judgment and treatment
Basic knowledge of health education
The ability to adjust medication Case managers recruitment
The role of case managers can also be served by nurses or health educators.
Two case managers are employed in this project. One has health education
certification and the other one recently graduated.
Case managers training
Case managers: Of course, they hope
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NTUH can provide related training, such as exclusive care skills or knowledge.
Administrators: When the number of cases reaches a critical mass, there will be relevant education and training to enable case managers care patients.
The professional e-health team
The shift system: The number of online patients in NTUH Telehealth Center is 200 cases every day. Namely, one shift for case managers is 200 cases. The shift system needs a very complex management and control, and it basically constitutes barriers to e-health for other service providers.
Education and Management: The center needs to educate its personnel and improve management
Exchanges and competitions: Participate in various exchanges, certification and
competitions to get patients’ trust
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Appendix J - The decision area: Key Partners
Foundation level Proprietary level Rules level
Medical equipment: Medical equipment and supply manufacturer
Client hardware: Client equipment manufacturer
Program software: Program development/integration
Service operations: E-health services center
Medical care: Primary care facilities, mountain area and off-coast health centers, cooperative medical units
Daily care: Chronic care centers, social welfare service units, Personnel allocation
Local security service: Security service provider
Government: Department of Health, Bureau of National Health Insurance, Bureau of Health Promotion, Centers for Disease Control, The Development Plan of Telecare Service of Department of Health of
NTUH Telehealth Center: Mainly offering heart disease care
Other departments offering care service:
Such as Diabetes, COPD, Mentally ill, Diet, Chinese medicine and Hospice, these departments have taken part in e-health.
Besides, Shaping and Nutrition departments also have the intention.
Family Medicine: As the first line of primary health care, Family Medicine can provide patients with a more integrated, comprehensive and holistic care
Diabetes Education Team: Offering diabetes care training
National Taiwan University (NTU): help to build the e-health platform and research innovative technology
Instrument manufacturers
Introduction but not intervene: Patients are free to choose any brand of instruments.
NTUH probably introduce some brands of instruments to patients if patients have questions, but NTUH won’t intervene in patients’ purchasing instruments. However, maybe NTUH can discuss with instrument manufacturers to offer a collective budget if NTUH help them promote their product.
Transmission cost: In fact, transmission costs are tied to the measuring instruments because the manufacturer has signed with Chunghwa Telecom. Therefore, once patients purchase instruments, they have paid for transmission costs. In other words, when patients receive e-health services, they won’t need to pay for the costs again.
Partners: The project is currently planning
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Executive Yuan, Island Health Centre, Health Centre in remote areas
Other: Insurance provider,
Telecommunication service provider
to work with domestic instrument
manufacturers to spur industry cooperation and the domestic economy
The platform developer, NTU
NTU helps NTUH build the customized e-health platform, and the partnerships are relatively flexible
In the future, technology will gradually be transferred to NTUH Information
Management Office
On the basis of medical and research cooperation, actually NTH charges no fees to save the money for patients
JSH for Community Care
The first-line emergency treatment: The community hospital, such as JSH, is responsible for the first line of treatment.
By using the e-health system to screen relatively stable patients, they only needs to receive local control; besides, severe
patients will be passed to NTUH to accept treatment.
The tele-consultation: There are sets of
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42-inch monitors, with a camera and connecting to NTUH by the information system. Once personnel in JSH upload data, the medical team in NTUH immediately sees it. Therefore, when personnel in JSH need to consult physicians in NTUH, they can use the equipment. However, because of the limit of regulations, the operating method is restricted to seeking NTUH’s advice, and judgments must be offered by JSH. It is not considered a formal
consultation. The usage is to seek other specialists’ advice or allow patients in JSH seeing their surgery or attending physicians in NTUH
A large nursing facility for Institutional care
Potentiality: The large nursing facility is very potential. First, it has 1000-2000 patients to reach economies of scale.
Second, it is fit for e-health services because of some characteristics it has; for example, these large nursing facilities is almost located in remote regions and for
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patients here, seeing a doctor is relatively difficult. Third, these large nursing facilities have nurses to support care services.
Gap: There are some nurses but no e-health systems, good medical equipment, and medical support from hospitals
Way: The nursing facility can cooperate with hospitals through the e-health system.
Hospital can offer some medical guidelines and consultation for the nursing facility, and the nursing facility can provide better care to patients and improve the quality of care.
Institutions and communities
Cooperate with institutions and communities to expand the scope of enrollment. However, for NTUH, the burden will be heavier.
The NTUH system has a high-level architecture. NTUH is on the top level of management, and its level and professional degree is relatively high. In the middle there are community hospitals, such as
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JSH, responsible for the first-line emergency treatment.
If the community hospitals, institutions and branches also join e-health services in the future, it can be done to use the cloud directly to filter patients to the center, so it will not have the needs to add more manpower.
Government: policies & regulations
From the perspective of legislation or health care, require patients to upload data to the platform; with a sound legislative system and the environment, the hospital is able to have a better and more long-term care planning. With these measurement data, the hospital can research the quality of care, the death rate, the complication rates of chronic, etc. These research results can help hospitals to improve patients’ health.
Government: The rights and obligations of patients with Type 1 diabetes
Patients’ rights: The government grants them almost all medical expenses or
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inspection fees.
Patient’s obligations: They should have the obligation to participate in e-health services to help hospitals to verify that offering e-health service is indeed useful.
The hospital’s obligations: Hospitals are also obliged to give patients proper care.
Hospital right: However, hospitals in fact do not get anything useful from the e-health service.
Governments: The tripartite relationship is difficult to balance, and the government needs to think about how to balance the relationship and make this model work.
Government: Fee-for-service and Case payment
Fee-for-service (FFS): On the basis of FFS mode, for example, NHI can set if patients’
HbA1c value is higher than 8%, the hospital can open medical orders to allow patients to use the instruments. Moreover, the instruments can be provided here by the NHI Bureau. The concept is like the
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prescription. NHI Bureau should have such measures so that the hospital is able to offer billing services. As for performance, NHI and hospitals also should consider how to assign it.
Case payment: Case payment is a virtual budget. If the hospital can make patients healthier to lead that patients actually spent less than the virtual budget, then the
hospital can get the share savings.
Therefore, On the basis of Case payment mode in the future, the hospital should research and verify e-health indeed improve patients’ healthy. Besides, if the hospital finds that e-health may decrease medical expenses, it will have more intention to offer e-health service for free. After all, at this stage, demanding patients to pay for the service is still hard.
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Appendix K - The decision area: Financial Value
Foundation level Proprietary level Rules level
Cost：
Self-financing
Salaries: Physicians, case managers, health educators, health managers, dieticians, pharmacists, social workers, information technologists, administrative staff, etc.
Equipment costs (including transfer fee):
Medical equipment, measuring instruments, etc.
Platform costs
Materials and supplies
Rental fee
Other Revenue：
National Health Insurance
Private insurance
Grants from the government
Self-paid premium services
Other
Cost：
Investment from NTUH Revenue：
Technology Transfer Fee: $2,000,000 NTD
Basic and value-added services charges
Cost：
In the present, NTUH Telehealth center still needs support from other plans or NTUH’s investment. Relying only on the incomes to pay salaries for case managers is still difficult; physicians are supportive in the e-health project and hired by other department.
From the long-term perspective, the Telehealth center is potential. While it is still not self-financing but certainly needs support until the independent and
sustainable business in the future.
Revenue：
The charge: It refers to the range prices patients willing to pay. It depends on current patients’ state of the economy and the severity of the disease. For example, chronic diseases fees should be lower and
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heart disease fees will be a little higher.
The prices patients expect: There is usually a gap between the prices patients expect and the real charge prices. How to adjust the gap is an issue.
According to survey results, it show users’ atti-tude toward e-health service fees in the future.
61% users still want to join if services fee is reasonable, and 39% don’t want to join if they need to pay for service fee. Besides, users hope the service fees can be controlled at less than
$500 NTD per month.
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Appendix L - The decision area: Customer Value
Foundation level Proprietary level Rules level
Quality：
Establish indicators to assess cases’
physical conditions, such as blood sugar, blood pressure changes, etc.
Satisfaction：
Cases’ satisfaction at the e-health services, platform, instruments, etc.
Quality of life
Quality：
Satisfaction：
Questionnaire of investigating customers’
needs
Quality：
Outcome indicators: For example, the death rate is lower before participating in the e-health service. However, there is not enough information to finish the final result.
Short-term effects: Blood glucose, blood pressure, blood fats, etc.
Intermediate indicators: Some early indicators complications, such as microalbuminuria
Satisfaction：
We put the questionnaires on the e-health platform to investigate patients’ satisfaction and demands for services
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Appendix M - The decision area: Operating Value
Foundation level Proprietary level Rules level
Management：
Economies of scale: Such as the number of enrollments
Personnel：
Management：
Marginal benefit or other contributions:
Bed turnover rate, the hospital management on length of stay, outpatient,
hospitalizations, ED visits, etc.
Personnel：
To enhance physicians and case managers’
willingness to participate
Management：
Economies of scale
Data: With no enough users, it is hard to measure data, such as the medical outcome.
Price: It is possible to get the cheapest and the best test paper and instrument with enough users
Basic User: When there are no basic users, the system and the business model are difficult to survive
Marginal benefit
E-health service can contribute to NTUH’s marginal benefit, for example, e-health would improve bed turnover rate, so patients in the same time are able to increase
Personnel：
Encourage physicians and case managers to participate in e-health
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Provide reasonable pay