The Business of eHealth
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Keynote given at the Nigerian National eHealth Summit, Dec 2015, on the conference theme of 'The Business of eHealth'. Dr Claudia Pagliari directs the Global eHealth masters programme at the University of Edinburgh, UK. www.health@ed.ac.uk
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The Business of eHealth
- 1. THE BUSINESS OF E-HEALTH GLOBAL & REGIONAL CONSIDERATIONS CLAUDIA PAGLIARI, PHD FRCPE DIRECTOR, GLOBAL EHEALTH PROGRAMME, UNIVERSITY OF EDINBURGH, UK 9th Nigerian Conference on Telemedicine & eHealth, Nov 2015
- 2. GLOBAL E-HEALTH ECONOMY Global E-Health market expected to reach USD 308.0 billion by 2022, according to recent reports (Grand View Research Inc.)
- 3. WESTERN PRIORITIES Disease • Chronic conditions & aging Business • Telehealth & supported self-care • Mobile web, wearables, insidables • Smart homes • Augmented and virtual reality • Assistive robots • Big Data analytics • Genomics & personalised medicine • Machine Learning & Artificial Intelligence • Open data Diagram: Paul Sonnier. LinkedIn Digital Health Group
- 4. NEW PLAYERS http://www.rolandberger.fr/media/pdf/Roland_Berger_EHealthAndNewCommercialModel_20140924.pdf Pharmaeutical industry investing in data analytics,direct-to-consumer compliance tech Global IT businesses investing in Smart Homes, Internet of Things etc http://www.slideshare.net/Tracxn/tracxn-smart-homes-startup-landscape-feb- 2015 ICTs investing in mobile trial recruitment & real time evaluation
- 5. AFRICAN PRIORITIES Health priorities • Maternal & child mortality • HIV/AIDS. Malaria • Malnutrition. Security. • Access to meds & immunisation Business opportunities • Mobile money & micro insurance • Data collection & analytics • Stock management • SMS/smartphone interventions • Crowdsourcing • Accountability interventions • Cloud solutions From: Techcabal.com From: phn.ng Whose job – Government, Global Donors, Non-Profits, Companies, Individuals?
- 6. UNDERSTANDING CONTEXT: NIGERIA • Informal economy (c. 75% small businesses) • ‘Islands’ of wealth (oil) & technology, but majority poor (90%) • State responsible for public health but invests little in it • c. 70% of health expenditure is private, more so amongst the poorest • Emerging eHeath strategy & innovation but systemic problems of governance • Business caught in the gap – Innovate without gov support or crawl with it? • Potential markets – • Citizens without adequate provision • Private health service providers • Government/Public Health agencies Where to target – Luxury market? Average citizen? Instutitions? Glocalisation or home-grown innovation?
- 7. “Healthcare has been all about government and treated like social welfare but the private sector needs to be involved” PHN Blog http://www.phn.ng http://nigeria.gsmamhealthfeasibility.com
- 8. Source: UN Foundation draft eHealth strategy 2015-20 “of 45 mHealth services in Nigeria 18 target maternal and child health and nutrition, 12 of which include demand generation, registration and data surveillance. Commercial aggregators and mobile operators have signed up to common short codes and discounted pricing as a means of improving access” http://nigeria.gsmamhealthfeasibility.com/GSMA_Country_Feasibility_Repo rt_Nigeria_2014.pdf
- 9. Source: www.slideshare.net/eddodds/e-health- strategiespdf National Information Technology Development Agency-NITDA 2011 Source: Personal communication Key themes: Capacity Building; Governance; Leadership; Strategy & Investment; Legisation & Policy Compliance; Architecture, Standards & Interoperability; Infrastructure, Solutions
- 11. GOVERNMENTS REACHING OUT • E-Government • “…can provide savings for governments and businesses, increased transparency, and greater participation of citizens in political life” https://ec.europa.eu/digital-agenda/en/public-services • “ …can be a tool for sustainable development and a lever for new employment, better health and education” http://nuviun.com/content/3-global-lessons-for- ehealth-providers
- 12. OPEN DATA 4 BUSINESS • “governments should focus more on starting, growing and sustaining open data initiatives” UN e-Government Survey 2014 http://unpan3.un.org/egovkb/en-us/Reports/UN-E-Government-Survey-2014 • “...Open data [can] enable public health services, private sector innovation, and prosperity in developing countries. The …annual potential economic value of open data may be as high as $3-5 trillion” http://www.acquia.com/gb/blog/government/open-data-global-health-data- imperative/22/06/2015/3285076
- 13. • Mobile apps • On-top data services • Visualisation platforms etc. • “companies are combining different open datasets, or public and private datasets to build new businesses. We're seeing companies starting to use sophisticated data analytics" http://www.informationweek.com/government/open- government/open-government-data-companies-cash- in/d/d-id/1113143
- 14. OPEN TECHNOLOGY • Massive infrastructural investments can be too costly with commercial tech • Open Source Software Platforms useful for scaling at low cost • Some issues with paid-for customisation when consultants leave • Organisations like OpenMRS are prioritising local health informatics capacity to fill the gap • Open APIs support the evolution of a local businesses around big tech
- 15. THE ‘BIG DATA’ BUSINESS • Data as a Commodity • Linked health records for pharma R&D • Social media and mobile device data for market segmentation research & public health surveillance • Analytics as a Service • Data-driven insights for business, government or citizens • Prediction of health risks & resources • Ethics as a Necessity • Risk of exploitation and privacy breaches. Need to ensure reciprocal benefit and government trustworthiness • Business opportunities in privacy-as a service, consent software etc. • Security as a Priority -> Privacy-as-a-service? • Hacking, Identity Theft • Market governance & enforced penalties
- 17. OPTIMISTIC BIAS • Companies want to sell • Politicians want to be elected • Governments want to ‘spend to save’ • Investors want the ‘next big thing’ • Consultants want to get paid • Lawyers and bankers want a slice in the middle …and so do some public servants -> Financial front-loading -> Failure to anticipate or budget for complexity -> High failure rate -> Lack of organisational learning -> Repetition & failure to penetrate/scale www.nao.org.uk http://www.slideshare.net/assocpm/where-did-it-go-wrong-handout -> HYPE
- 18. ETHICS & GOVERNANCE Holeman, Cookson & Pagliari. ICT for increasing transparency, accountability & public participation in lower income country health systems. MSH/USAID
- 20. Poor security is expensive for governments & businesses
- 21. FRUGAL & REVERSE INNOVATION “In low-income countries…the need for solutions is often felt more urgently, driving entrepreneurs to challenge assumptions on the ground and find new, immediate ways of delivering healthcare that connect vulnerable populations with the care they need” UK Health Foundation, 2011 http://www.health.org.uk/publications/what-can-the-uk-learn-from- healthcare-innovation-in-india/ www.who.int/goe/publications/baseline/en/
- 22. FOSTERING LOCAL INNOVATION http://ubi-global.com/wp-content/uploads/2015/07/UBI-Global-GBR1415-Preview.pdf Supporting Business Start-Ups & Technology Hubs: http://venturesafrica.com/five-innovative-startups-in- nigeria-for-2015/
- 23. WHY WE NEED ‘R’ AS WELL AS ‘D’ Ensure valid products Improve usability & ‘fit’ Unpick complexity to inform investment & implementation Evidence-based business case Avoid costly failures Promote sustainability Developers, designers (Suppliers) Researchers & evaluators (Scientists) Users, Purchasers, Commissioners (Payers) Integrated approaches work best http://www.jogh.org/pdfviewer.aspx?pdf=documents/f orthcoming/jogh-06-010401.pdf “Most studies are of poor quality and few have evaluated impacts. Ambiguous descriptions of interventions and their mechanisms of impact present difficulties for interpretation and replication” 20 reasons start-ups fail https://www.cbinsights.com/blog/startup-failure- reasons-top/
- 24. CAPACITY BUILDING Focus: Generic health system leadership Partnering with Univ LagosFocus – Overall Health Information Workforce (applied) Nigerian HIM representation Focus: Global e-Health Innovations, Research & Strategy (Leadership). Includes Nigerian students & tutors
- 25. INSIGHTS CAN BE EXPENSIVE!
- 26. Enrolling Now The Business of eHealth April-June 2016 Executive-level online study (credit is transferrable to the full MSc) GlobaleHealth@ed.ac.uk www.eHealth.ed.ac.uk @mscehealth @EeHRN
Notes de l'éditeur
- Hello and thank you to the conference organisers for inviting me to speak to you today, particularly Olajide Joseph Adebola, a colleague in our executive masters progrmme in Global eHealth
- The expansion of the eHealth business sector over the last few years has been quite remarkable. As some of these graphics illustrate, this spans a number of technology areas and global market places. With industry pundits forecasting huge revenues over the next two decades it's no surprise that innovators and investors are being drawn to the area in increasing numbers, as are governments and citizens in many cases. But how will the market shape up, what will be the key drivers and obstacles to success and do we really know what we are doing yet? These are some of the questions I'll talk about today.
- Much of the analysis in the tech blogs and market research reports comes from high income regions like the USA and Europe, where the dominant health concerns are 'diseases of plenty', such as over-eating, tobacco & alcohol consumption and lack of exercise, as well as increasing longevity, in both cases leading to a greater prevalence of chronic conditions. Businesses focused on home-based telemonitoring and mobile apps have emerged as a means of augmenting traditional healthcare services. Wellness and self-tracking, including wearables, are penetrating the direct to consumer market (insidables are coming). Medical sciences are beginning to shape new forms of treatment, based on big data derived from health records, and personalised genomic and microbiomic testing companies are springing up. Virtual reality is already being used in contexts such as surgical preparation and online psychological counselling, and assistive robots are on the edge of penetrating the home care market. As you can see this is quite high-end technology. I haven’t mentoned the IT infrastructure projects that characterise large scale healthcare enterprises, such as the UK NHS, as these are dominated by a small number of corporate vendors, although they do contribute vastly to overall global expenditure on health IT and are close-coupled with the Big Data business agenda.
- Some of the newer players in this area include the pharmaceutical industry, keen to harness big data for drug impact evaluation and, more recently, the capture and monitoring of patients for clinical trials using mobile phone platforms.
- African markets present quite a different proposition, for the reasons listed here. Many of the challenges shown here are public health priorities, which aren’t the natural home of the start-up and suggest government-level inte0rventions, which raises questions about who the payer is and what the lines of reciprocal benefit are. Nevertheless, with governments being slow to adopt, citizens and businesses are beginning to take these objectives into their own hands, providing supplementary services and direct-to-consumer applications. The growth of mobile payment methods is also putting more control in citizens’ hands.
- Marketing from international companies can be persuasive but technologies developed for high income country health systems may not suit the requirements of LMIC and models of adaptation, such as ‘glocalisation’, only work so far. Likewise, donor-sponsored solutions often rely on western technologists and implementers, creating challenges for sustainability. Some international social enterprises, such as MedicMobile and OpenMRS, have made a commitment to working within Africa and with local providers to develop context-sensitive solutions, and these should be prioritised, alongside home-grown innovations. Unfortunately in countries like Nigeria there are many systemic barriers to developing and sustaining local solutions, beyond health itself, and these need to be taken into account in order to plan investments and products appropriately. As already noted, one area of tension is the business proposition for eHealth investments where public health services are already, in theory, available to all. However the massive gap between state provision and consumer need calls for innovations to fill it and much of healthcare is already paid for out-of-pocket. For the wider eHealth ecosystem to function successfully in the long term there must be shared strategies that benefit all players equitably and transparently.
- In many countries the private sector has come to realise the importance of coordinating efforts and aligning with government in order to meet health targets. In Nigeria the ‘Private Sector Health Alliance’ has made a commitment to supporting the ‘One Milllion Lives’ scheme. Digital health is a natural area where alingment of business growth, public health requirements and efficient delivery of government objectives is potentially possible, although it remains to be seen how the value propositions stack up for the different players involved. The European Union is currently wrestling with similar tensions under its ‘Digital Agenda’, where an alignment is being assumed between economic growth through innovation, improvements in citizen health, and public sector efficiency, which may be unrealistic.
- I’ve enjoyed reading some of the recent scoping reports on eHealth in Nigeria, to understand how the ‘enabling environment’ is being characterised. The figure on the right is from the draft UN Foundation eHealth strategy and gives a good picture of the transition from experimentation to mainstream adoption, with your country somewhere around the middle of the pathway. The GMSA report on mHealth ‘feasibility’ in Nigeria also highights some positive developments, such as common agreements on data formats and pricing, which add to the enabling environment.
- Having coherent strategies and policies in place at the national level is a key part of the enabling environment for eHealth, and is essential for ensuring the growth of services and the sustainabile delivery of technology-enabled healthcare improvements. The report shown on the left is from NITDA 2011, part of Federal Ministry of Communication Technology. This helped to drive investments in infrastructure & telehealth pilots but may now have ended. The second report has been developed by the UN Foundation in consultation with the Federal Ministry of Health and multiple stakeholders. It is still in-draft form, for release at the end of 2015. Key themes are Capacity Building; Governance; Leadership; Strategy & Investment; Legisation & Policy Compliance; Architecture, Standards & Interoperability; Infrastructure, and Solutions, all of which will be required if the strategy is to be effectvely implemented.
- I’ve talked about aligning government public health agencies and businesses around eHealth, as well as the role of government in supporting eHealth. I wanted to turn now to trends in the alignment of e-government and e-health, which are creating other business opportunities.
- Around the world democraticaly-elected governments are beginning to open-up to their citizens, capitaising on the availabiity of the internet to make services and information available on the internet or via smartphones. The progress of countries is measured on the UN’s eGov index, here shown for Nigeria. While the philosophy underpinning e-Government is compelling and the economic benefits of digital services seem intuitive, countries vary widely in how successfully they are achieving this. For example, this in-progress review of the use of social media by government health providers suggests that there has been little thought about the reasons why it is worthwhile, and almost no evaluation of its benefits.
- From a business perspective, the most obvious way in which Open Government is influential is via the release of aggregated (not personally identifiable) public sector data. Some companies and ‘third sector’ organisations (e.g. NGOs) are also doing this. One objective is to increase public trust through greater transparency, but the other is to make datasets available upon which businesses may build innovative technologies.
- On-top services that use open government data to populate visualisation tools, such as Google Maps and OpenStreetMap, are one such solution. Some of these converge official data with crowdsoured data, such as Ushahidi which is useful in managing natural disasters. In the commercial space Facebook recently opened its ‘find my friends’ feature during the Paris bombings, and Nigerians have been asking for similar solutions when dealing with terrorist events. From a business perspective, the greatest potential lies in the development of sellable apps, visualisation tools and data aggregation and analytics services. The multi-channel ‘smart cities’ ecosystem is a prime example. The value of data for supporting businesses based overseas, which will never return tax revenues to the national treasury, has nevertheless been realised, and the Nigerian government will benefit from analysing the evolution of the open and commercially protected open data marts in certain high income countries.
- The concept of ‘open’ goes beyond the data to the ecosystem of devices and other technologies that surround it. Just as Apple has realised that their most profitable business model lies not in investing in app development, but in the protected platforms surrounding them, large healthcare providers and governments are beginning to loosen up their ties and allow small companies to innovate in ways that enable value to be added to the large scale infrastructures and databases that they have already invested in. In the UK this remains a key area of tension for the business-hungry digital health sector, since tight firewalls and governance regimes can prevent innovations from penetrating the NHS, which accounts for the vast majority of the national healthcare sector. Starting from a baseline of ‘Open’ may put some lower income countries at a relative advantage in years to come, in terms of being able to provide flexible public-private eHealth ecosystems mindful of the greater challenges of effective governance.
- While I am once again returning to ‘data’ in this slide, the reason for doing so is to emphasise how important the so-called ‘big data’ sector is becoming to the global health economy, particularly in high income countries with established electronic health record systems and research datasets. Countries like the UK, Australia and Canada are investing heavily in the development of infrastructures, tools and services for ‘data intensive healthcare’ in order to capitalise on the potential for data linkage to support epidemilogical research, pharmacosurvaillance and policy evaluation. This is aligns closely with innovations in ‘data science’, which are looking applying advanced statistical and informatics techniques to draw meaning from large distributed datasets. There are a number of business opportunities surrounding these sorts of data, mainly in the service area. Beyond that, big commercial data, and big social media data have also inspired new business models built on analytics services. How these fare in the future will partly depend on how sophisticated the algorithms become and how much emphasis governments and citizens place on privacy and control in different countries. The latter themselves give rise to new business opportunities that have not yet been fully explored.
- The phenomenon of ‘optimistic bias’ in technology projects – especially large ones - is a problem in all countries. It has been defined as “the measure of the extent to which actual project costs (capital and operating) and duration (time from business case to benefit delivery and time from contract award to benefit delivery) exceed those estimated (for a defined functional output)”. Some of the contributing factors are shown here. It is an entrenched problem for this sector, and can lead to a sort of mass delusion and collusion between vendors and purchasers who come to rely on the promise and fail to spot the danger signs. The graphic in the bottom right of this slide is taken from a presentation about what went wrong in a massive government railway procurement in the UK but similar patterns are found in public sector IT projects everywhere. The Gartner hype cycle is more about the psychology of investors, business media and markets in relation to new innovations; the famous ‘peak of inflated expectations’ has much in common with the concept of optimism bias.
- Ethics and Governance are high level concepts but are relevant for the Business of eHealth in several different ways. Combatting mismanagement and lack of oversight at the highlest levels of government and health organisations is vital for ensuring that eHealth projects are rationally and fairly planned, procured, delivered and audited. Better training, ICT leadership and auditability/accountability are all necessary. Realising the effective delivery and impact of eHealth is dependent upon ensuring the trustworthiness of organisations holding and using personal data. Protecting privacy through effective information policies and procedures, and avoiding unethical or illegal practices such as data selling for commercial gain, are vital. In the age of data as a commodity, this also requires training to avoid being wrong footed by commercial data brokers. ICT also offers opportunities to reduce corrupt and unethical practices. For example crowdsourcing platforms are being used to name and shame those taking bribes, open government data is helping to create a culture of transparency, and trusted medicines apps are helping professionals and patients to check the validity of the products they have purchased.
- Counterfeit or stolen medicines represent a significant source of risk to the lives of patients, as well as to the balance sheets of suppliers and purchasers. I was horrified to hear of the recent case of a fake teething medicine which caused the deaths of 84 children in Nigeria. A number of new business ventures have emerged to address these issues. For example, Sproxil is a Nigerian-US venture-backed, social enterprise aimed at providing ‘brand protection services’ in emerging markets. It uses Mobile Product Authentication™ (MPA) solution to enable customers to check the authenticity of the goods the have purchased. In a global internet-mediated market for medicines, this is a problem everywhere, irrespective of national protections, and eHealth innovations such as this offer potential solutions beyond lower income countries.
- Good security and effective governance (including penalties) will be essential if these new forms of innovation are to survive. The high value of patient records presents a significant source of temptation for those with access to data, therefore inculcating the moral values of good governance and ensuring trustworthy data guardianship will be essential. Methods such as de-identification of personal data, minimum data sampling and data provenance tracking will help, although human error is a significant cause of data breaches. Many countries are bringing in new laws to criminalise the misuse or unauthorised sharing of personal data, which will affect individuals as well as companies and national authorities. (I see that Nigeria has recently implemented the Cybercrime Prohibtion and Prevention act 2015). As already noted, the growth of consumers’ and organisations’ awareness of privacy risks, is also generating new opportunities for businesses to develop innovations to address this.
- “Successful frugal innovations are not only low cost but out-perform the alternative, and can be made available at large scale.… Low cost doesn’t necessarily mean low tech …but it’s also about remodeling services.” (Nesta, 2012) www.nesta.org.uk/sites/default/files/our_frugal_future.pd Nowadays we are also seeing many more examples of ‘reverse’ innovations, originating in lower income countries but offering excellent solutions for other regions. The BRCK mobile wifi unit is one such example, as is Sproxil for verifying drigs purchased over the counter, or via the internet. The Nigerian eHealth business sector needs to look to repurposable technologies for other nations, as well as at the specific needs of the Nigerian population. The key is to find low-cost solutions which truly make a difference.
- An enabling environment for new technology businesses is essential everywhere and specialist support networks and tech hubs are emerging in all parts of the world. The iHub in Keynya is perhaps the best known internationally, although I’ve been impressed at what I have seen of the Nigerian examples. This Global Benchmark report describes some of the university-led business incubators around the world and their characteristics, and also draws attention to some of the successful innovations that have emerged from them. In reading the section on Africa I was struck by how many of the products are donor-funded. Will this flip to local investor-led models in the future? This will partly depend on the success of the innovation hubs, as well as their ability to innovate beyond public health and development imperatives, but the signs are positive.
- And now, a brief call for more research to balance all the development that is going in on the eHealth sector right now. Amongst the most common reasons why technology start-ups often don’t succeed are the absence of a market need, a poor or badly timed product, lack of a coherent business model and failure to consult appropriate networks and advisors. This why we always recommend that new innovators (and old ones, where they are tackling a new product or market) engage with appropriate academics who can guide them in how best to evaluate and, if necessary modify, their concepts and products. Good market research, user centred design and robust pilots that provide some evidence of usability, usefulness and likely impacts, are also vital for supporting a good business case. With the right training, vendors can do this for themselves; indeed companies like IBM and Intel are already employing teams of social scientists. The secret is being as rigorous as the context and budget allows, and not forgetting that the effort and expense may pay off in the future. eHealth researchers also need to be more careful when describing the interventions they study. As we have found in this recent systematic review of mHealth, and elsewhere, published reports often give very little information about what was actually included in the intervention or how each component might influene the intended outcomes. More co-working between eHealth companies and universities should benefit both communities of practice and ultimately the consumer.
- Capacity building is vital at several levels – General workforce strenghening is needed, so that organisations and practitioners are better able to manage the requirements of digital health and businesses have the skills to innovate. Improving leadership capacity at government level is also critical, to enable better decisions to be made about strategic priorities, procurement and resource planning, and to realistically budget for and anticipate eHealth delivery projects. Avoiding the brain drain by retaining health workers, business innovators and policy experts while they learn is also vital, which is why we have developed the masters in Global eHealth in partnership with our international network of eHealth specialists from academia, industry and government.
- Finally, a brief word on trying to establish the market dynamics and value of eHealth. There is clearly a massive business in writing about business! Some of these market research reports cost thousands and it is impossible to judge their value until after purchasing them. Much the same is true of the consulting sector, and more robust methods of evaluting the costs and benefits of these services are needed to inform governments and businesses who may wish to obtain them.
- Thank you for your time. There are many issues for the Business of eHealth which I have not had time to cover in this conference presentation, but I hope this has whetted your appetite for further learning, or at least has offered one or two useful insights for your work as an eHealth investor, innovator, implementer or purchaser.