Challenges and Opportunities in Scaling up Digital Health

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1 Challenges and Opportunities in Scaling up Digital Health Ericsson, in partnership with the Digital Health Initiative

2 Mobile and fixed broadband communications are changing the world. They bring distinct benefits wherever they are installed, whether improving efficiencies and conveniences in more developed markets, they also have the potential to transform lives in less developed and more remote communities. Effectively tackling extreme poverty demands a multi-pronged and multi stakeholder approach to development, and in recent years, rather than relying solely on governmental aid commitments to scale the MDGs, public-private partnerships have demonstrated significant benefit and impact. The United Nations Millennium Development Goals (MDGs) represent an unprecedented opportunity to usher in this new era of collaboration is a critical year, as it marks the 10 year anniversary of the MDGs, and the target date of 2015 only 5 years away. The evidence so far suggests that while there has been some progress, many countries - particularly the poorest - are falling behind in many of the targets and particularly on health (MDG 4, 5 and 6). Access to information and communication technology (ICT) has become a basic need as basic as access to clean water, roads and electricity. In developing regions particularly, an uptake in broadband access has driven advances in GDP growth, as well as health care, commerce, education and social inclusion. Literally billions of people, some two-thirds of the population globally now have access to (and in many cases take for granted) a reliable means of voice and data communication. That adds up to 5 billion mobile subscriptions representing about 4 billion people worldwide. The Report by the Broadband Commission on Digital Development, delivered to the United Nations Secretary General on September , highlights the absolutely critical role that broadband can play in helping to achieve the MDGs. The Millennium Goals Bridging the Gaps Of the more than 11 million deaths each year among children under five, over half are due to preventable and treatable diseases, while more than 300,000 women die each year due to complications during pregnancy. Additionally, the HIV/AIDS pandemic continues to be by far the leading cause of premature mortality in sub- Saharan Africa. Healthcare systems are facing tremendous pressure to improve health quality, accessibility and outcomes and to do so in a cost-effective manner. The deployment of broadband networks around the world is accelerating ICT deployment in health, and offering an unprecedented opportunity to address these challenges. New smarter and infinitely more efficient tools for decision support, data collection, remote diagnostics, collaboration and m-learning can together with electronic medical records and public communication networks completely revolutionize the way healthcare is delivered in many regions. This is referred to as digital health. A number of digital health pilot projects exist worldwide, and the potential benefit been identified. By using broadband solutions based on standardized, mainstream technology, the health sector can greatly benefit in terms of technical innovation, economies of scale and ultimately help to achieve the MDGs. While enabling a faster adoption of digital health. With economies of scale, the benefits from digital health pilot initiatives can be then scaled and provide an increased access to health services and information, more efficient and cost-effective processes, and engaging citizens as active participants in their own healthcare. These initiatives also create a cadre of well trained and accountable health workers and reduce the sense of isolation for many of those who work in rural areas. Benefits to patients: improves quality of life for patients by enabling timely and precise diagnosing medical conditions and, consequently, treatments. Benefits to healthcare professionals: enables effective patient management, increased efficiency through remote diagnosis and reductions in treatment and management costs. Benefits to operators: supports the launch of new business initiatives in the healthcare domain that can be used to retain customers and attain new ones. Benefits to healthcare insurers: provides healthcare cost savings and improved quality of the healthcare services through optimized patient monitoring. Benefits to governments: delivers healthcare more cost effectively and efficiently to citizens. CHALLENGES AND OPPORTUNITIES IN SCALING UP DIGITAL HEALTH 2

3 Beyond the pilot project: the search for scale To be sustainable, projects that have passed the pilot stage must still usually undergo a process of commercialization and digital health projects are no exception. This process can be painful since most pilot projects start on a small scale, typically fully subsidized by a donor, with innovative ideas, system designs and a full focus on the use case. This focus initially makes sense, but does not always go hand in hand with scalable, robust and interoperable systems that will be commercially sustainable over time. It is therefore of great importance to find ways to bridge the gap between innovation projects and the large-scale rollout of digital health services. Technical considerations to achieve scale There are many design options and technical elements to consider during the process of scaling pilot projects, the ICT industry can help meet the challenges in a variety of areas: Security, privacy and integrity Digital health systems containing sensitive patient data have to be treated with the highest level of security, privacy and patient integrity protection. If the potential liability challenge is resolved among the stakeholders in a digital health ecosystem, the data can be a valuable source for public health statistics and research. Mobile and fixed networks can help as they are designed to support business critical processes if the applications are designed in the right way. Architecture and quality of service In order for a system to be truly scalable, a well-designed architecture is crucial. This makes choosing the right solution even more critical, for system architecture, topology and technology choices define to a large extent quality and availability of the service that can be expected. Digital health solutions should utilize ICT technologies and standards that are well proven in terms of openness, coverage, accessibility and reliability. As with any industry digital health should be driven by standards to ensure compatibility interoperability between systems. It is therefore vital to have a good mix of proprietary and open technology to ensure maximized re-use and uptake. This model is especially effective when existing 3GPP 2 technology and mobile standards are used to complement legacy and public mobile networks. Interoperability and standardization Since most developing countries have fewer legacy systems than developed countries, they have an excellent opportunity to leapfrog years of technological development and build interoperable systems to existing international standards, particularly those related to the healthcare domain such as the Health Layer 7. Total cost of ownership (TCO) Both TCO and return of investment depend to a large extent on whether a project is sustainable. All factors, such as development costs, software licenses, system upgrades, support, maintenance, hardware (capital and operational expenditure) and system integration, should be included when calculating the return of investment. A key consideration in TCO is the right partners. By partnering with private operators, governments can leverage on the massive mobile telecommunications infrastructure currently being rolled out privately. This will lead to increased affordability through economies of scale, as the network can be used by all types of users across all industries and verticals. The advantage of the health sector is that everyone needs access to it; hence economies of scale are fairly easy to achieve provided a solution is designed to be easily scalable to cope with mass uptake and demand. 2 The 3rd Generation Partnership Project (3GPP) is a family of technologies such as GSM, EDGE,WCDMA, HSPA and LTE. CHALLENGES AND OPPORTUNITIES IN SCALING UP DIGITAL HEALTH BEYOND THE PILOT PROJECT: THE SEARCH FOR SCALE 3

4 Economies of scale The tremendous success of the global system for mobile communication (GSM) which manifests itself through 5 billion users worldwide was established through the unification of multiple network operators and equipment vendors around a set of common open standards and practices. This allowed the industry to reach critical scale of economy, both on the network and the terminal side, with low prices and high diversity and choice as result. Thus, GSM was the technology which prevailed in the 2G (second generation) domain. That scale has now moved on to make technologies such as WCDMA/HSPA the dominating 3G technology, and is currently evolving to establish LTE as the standard of choice for 4G. Economies of scale also apply to development. Opening up parts of a telecommunications network can allow communities of developers to create solutions of their own, but using commercial telecom grade scalable solutions already used by many other developer communities, industry sectors and companies. This should be done with finance and security controls in mind, in order to avoid misuse of an operator s infrastructure. Yet true scalability will only be reached when developer communities are consolidated and large enough to be supported on a global scale. This is something usually only achieved by private companies working with these communities to reuse open resources and applications in proprietary offerings. Synergistic development of this kind can ensure the longevity of digital health initiatives, as individuals and companies with vested interests (financial and technical) will try to ensure the continuous support and evolution of the various core and secondary platforms, services and applications. FOSTERING INNOVATION: Many examples of mobile broadband innovations have emerged. The mobile survey tool is an example of that. The tool has been developed to deliver a custom designed survey to any mobile device. This particular survey was designed to collect and submit data to a physician prior to a teleconsultation. The physician would receive an SMS and an to review the case and call back to the nurse requesting the teleconsultation. Business models As the digital health sector is a fairly new arena for most telecom vendors and suppliers, effort needs to be put into building business models that benefit all stakeholders and here cross sector partnerships are of outmost importance. In order to survive in the long run, all stakeholders need to have a positive business case, and should expect to have a positive return on investment for what they deliver (such as healthcare, software, telecom services, or know-how). Pilot projects which are financed by charitable donations or sponsorships will simply not be sustainable in the long term and will not scale. Ultimately different models will probably be required for different services. For instance a medical service that allows us to visit the doctor without having to physically travel to the doctor (especially for routine visits or for common ailments such as the common cold) would probably be best charged for using a standard consultation approach with the revenue being split between the doctor and service provider. On the other hand the medical practice could keep the full amount of the consultation but instead pay the service provider a monthly fee for the enablement of this service and the patient could pay a flat call fee. Requests for telecom vendors to charitably provide free services and access will quickly put a halt to the long term success and scale of any digital health initiative. Eventually an effective solution must cater to the needs of an entire population whether of individuals, a village, city or country. Asking an operator to handle the sheer volume of ensuing traffic is not plausible unless there is a sound business case supporting the solution. Large-scale implementation of digital health services does have an impact on the healthcare system in an entire country. Understanding of benefits and support of all key government and non-government stakeholders must be assured in order to ensure project acceptance and success. CHALLENGES AND OPPORTUNITIES IN SCALING UP DIGITAL HEALTH BEYOND THE PILOT PROJECT: THE SEARCH FOR SCALE 4

5 Go-to-market strategy and partnerships New partnerships are necessary in order to develop scalable, interoperable and sustainable solutions in digital health. To accomplish this, the health sector should be viewed as an organic whole, and the needs and benefits of a complex web of stakeholders and beneficiaries, from telecom vendors to healthcare workers to the patients themselves, should be taken into account. The scale and type of project will determine which stakeholders will be involved. A mix of healthcare providers, municipalities, system integrators, communication providers, universities and other institutions are also normally involved in such projects. Ideally, business leaders can see that they can profit from such partnerships, making them more open to cooperating with non-profit stakeholders such as governments and universities. The facilitating and harmonizing role of standardization, in particular standardization between sectors, should not be underestimated. Standardization in both health as well as telcom is fairly established. Nevertheless, the coming together of these sectors is not. The role of governments Governments play a pivotal role in forming successful collaborations in the area of digital health, and in some cases could have the most to gain from them. The top concerns for governments (as well as for the health industry as a whole) include cost, secure and reliable infrastructure, legislation, safety regulations, harmonization of technologies and investments. The more industries that make use of broadband the more cost effective broadband can become and the quicker the rollout and uptake will be. Many developing countries need guidance and advice of how broadband can be used across industries like health, agriculture and education. This in turn will help them to mandate the rollout of broadband and its use. The more countries that adopt broadband to be used in these industries the quicker industry solutions and applications will evolve. This means that economies of scale are reached more quickly ensuring end to end sustainable solutions with quick turn around and maximized return of investment. Without this there is the danger that mobile broadband becomes a service relegated to the affluent minority that merely uses it to download movies and music. The broadband content most useful in developing countries is municipal and government information governments at all levels should endeavor to make their info readily available not only via own applications/content services but also to make their info available to private actors who can use it for their applications As the digital health industry matures, we will see more and more players coming on board. It is therefore essential that each player from health industry conglomerates, individual entrepreneurs and large city hospitals to small rural clinics, pharmaceutical companies, governments and telecommunications specialists works with common standards. This will ensure a more efficient and ultimately cost-effective solution. Each piece of the puzzle must be considered in order to build a complete big picture. For example, if we look at one aspect of this chain that of medicine, we realize that the pharmaceutical companies are of paramount importance, for their medicines will be used to treat the patients of the digital health environment. When focusing on this piece of the puzzle we see some key areas that need to be addressed. Some examples include: How can patients, hospital staff, doctors and rural healthcare workers all access and benefit from the vast pool of existing pharmaceutical information pool? What is the best way of providing different types of information to these stakeholders, and how can information then be efficiently passed back to the pharmaceutical companies? How can pharmacies be linked to both patients and doctors in order, for example, to track the efficiency and compliance of medicines, or stock levels? When considering such questions across all the players in the health arena and not just the pharmaceuticals, it quickly becomes apparent that a great deal of financial investment will be required in order to achieve, develop and roll out an end-to-end digital health initiative. This requires a sound business model that not only ensures a return on investment but also produces ongoing revenues to allow for further development, support and maintenance. It is imperative therefore that the various partners and stakeholders work closely together. This very collaboration combined with the reutilization of technologies across multiple sectors will lead to an open and interoperable competitor environment and ensure that digital health is affordable for all. CHALLENGES AND OPPORTUNITIES IN SCALING UP DIGITAL HEALTH BEYOND THE PILOT PROJECT: THE SEARCH FOR SCALE 5

6 Many opportunities Recommendations from organizations such as the Broadband Commission for Digital Development and direction from government and industry will go a long way in stimulating the creation of digital health content. The more industries such as health care that adopt broadband the greater the demand for content will be. Convenience is vital. In this case convenience has two facets. The first is ensuring that content developers have access to the tools and guidance they need and the second is ensuring that there are clear and convenient ways to generate income off the content they create. As broadband becomes more readily available in more countries, the translation or evolution of content into multi-lingual content will become a natural next step. Medical content in one part of the world is just as useful in another part, provided that it can be understood and naturally the more countries that content is available in the more revenue it will generate. The success of a digital health initiative must be built on multidisciplinary approach from the healthcare, business and technology domains. Particular digital health initiatives have to address the main challenges in the healthcare system so the benefits can be clearly spoken and understood by all key stakeholders. Furthermore, implementation of digital health initiatives could lead towards introduction of new or reengineering of the existing healthcare processes which have to be built on the efficient change management process. If necessary, a new way of working, based on digital health, needs to be supported by appropriate legislative and regulatory frameworks. The business model for digital health should be based on the net-economy principles where scale effects are of tremendous importance. This leads towards the requirements for technology platform that has to be built on the proven, scalable and open technologies. In that sense existing public mobile networks based on 3GPP standards play a vital role and represents a solid basis for the development and rapid deployment of the digital health applications. CHALLENGES AND OPPORTUNITIES IN SCALING UP DIGITAL HEALTH MANY OPPORTUNITIES 6

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