Wednesday, 24 December, 2008

SIX Sigma in Healthcare

Improve Process:

1. Define the problem - that is wait time and the high number of non-emergency patients
2. Develop a solution - in an emergency room situation, this can include adding beds by expanding the department or decreasing the size of current rooms; outsourcing certain testing and radiology services; and/or adding an ‘express care’ program to deal with non-emergency patients
3. Form a plan for improving the process, measuring improvements to the process, and reducing deviations from the goal - many hospitals have found that Lean Six Sigma practices are a particularly effective way of identifying and dealing with the challenges and problems inherent to health care .
How Six Sigma help reduce Medical Errors:
Six Sigma is a process improvement method that focuses on eliminating defects by reducing variation. It relies heavily on statistical analysis of data and strong problem-solving techniques. For more than a decade, companies such as GE, Motorola and Toshiba have used Six Sigma to foster excellence by virtually eliminating errors. Only recently have health care organizations begun applying Six Sigma methods into their operations.
Areas of Benefit:I personally deployed Six Sigma in the following fields and have seen success.
Drug Infusions:
1. concentrations prepared by the pharmacy
2. how physician orders were formatted
3. how nurses calculated drip rates
Improvements were initiated, including standardizing of drug concentrations, development of tables to improve the accuracy of drip calculations. Error rates and clinical discrepancies improved significantly.
Pain Medications:
1. the pharmacy reviewed orders earlier in the process and intervened when non-standard medications were ordered
2. medications that were kept in patient areas were standardized and limited colored labels were utilized to indicate non-standardized concentrations nurses were retrained in the more problematic steps of programming the pump
3. After these improvements were there were significantly fewer errors, and if errors did occur, they were less severe and were discovered more quickly.
Diagnostic Centres:

1. Patient falls in the rehabilitation unit
2. Reducing the time a physician orders an antibiotic and the patient’s receiving it
3. Elapsed time from when a patient diagnosed with a heart attack arrives at the hospital to treatment in the catheterization lab
4. Frequency and severity of low glucose readings in insulin recipients
5. Post-operative narcotic sedation
Main Areas of Deployment Could be:
1. pacemaker billing and reimbursement
2. length of stay for percutaneous coronary intervention (PCI)
3. use of Omnicell non-narcotic
4. medical record retrieval
5. room availability cycle time,
6. lab supply management.

Sunday, 21 December, 2008

Smart Cards and Usability

What is a smart card and how is it used?

A smart card is a card similar in size to today's plastic payment card that has a chip embedded in it. By adding a chip to the card, it becomes a smart card with the power to serve many different uses.

As an access-control device, smart cards make personal and business data available only to the appropriate users. Another application provides users with the ability to make a purchase or exchange value. Smart cards provide data portability, security and convenience. Smart cards help businesses evolve and expand their products and services in a changing global marketplace. Banks, telecommunications, computer software and hardware companies, and airlines all have the opportunity to tailor their card products and services to better differentiate their offerings and brands. The combination of applications available on smart cards also may help them to develop closer relationships with their customers.

What is the potential for the smart card business?

Today, there are fewer than one billion smart cards in use. Market researcher Dataquest forecasts that by the year 2001, 3.4 billion smart cards will be used worldwide. Smart card activities are growing at 30 percent a year, predominately outside the U.S. Over the next five years, the industry will experience steady growth, particularly in cards and devices to conduct electronic commerce and to enable secure access to computer networks. Within the same time frame, smart cards are expected to be used in 95 percent of the digital wireless phone services offered worldwide. Asia, Latin America and North America are areas believed to be of greatest potential in the next three years. Globally, the uses that have emerged so far are for payphones, wireless telephony, Internet access, banking, healthcare and pay TV.

Why is interoperability crucial to widespread adoption of smart card use?

Even though there are hundreds of smart card pilots in existence around the world, users may not take a card from one country or scheme and use it in another. In order to accelerate the widespread acceptance of multiple-application smart card technology , interoperability - compatibility between cards, card-reading devices, and applications -must be achieved. To do this, the industry must examine the business and technical issues surrounding the need for standardized interfaces between cards, terminals and slots, which is the key to securing dramatic growth for the industry.

What role does "standards" play in smart card use?

Standards are required to ensure that cards and card-accepting devices are built to uniform specifications. This ensures that cards manufactured and issued by one industry sector in one part of the world can be accepted by a device in another part of the world. These cards and devices may support many different types of industries so that, for example, payment cards may be accepted in card-accepting devices at gas stations. This is possible because there are international standards in place.The International Organization for Standardization (ISO) has developed standards for smart cards. These standards were developed for use by multiple industries.

Individual industries are now developing proprietary versions of these ISO standards to support their own specific smart card applications. These are designed to conform with the standards issued by ISO. The goal is to ensure uniform standards for smart cards that will allow interoperability of cards among a wide array of industries.
What are the major benefits that smart cards offer consumers?

The benefits depend on the application. In general, applications supported by smart cards benefit consumers where their lifestyles intersect with information access and payment-related processing technologies. Some of these benefits include: the ability to manage or control expenditures more effectively, fraud reduction, reduced paperwork and elimination of the need to complete redundant, time-consuming forms, the potential of having one card with the ability to access multiple services, networks and the Internet.

You will hear the terms "chip card," Integrated circuit card," and "smart card" used to refer to a plastic card with a chip. Are these different types of technology?
There are three types of integrated circuit cards: simple memory card, hardwired logic card and microprocessor card. The term smart card is used in different ways by different organizations, but the Forum defines a smart card as a card with a chip.

What is a multiple application card?

The smart card has the capability of carrying multiple applications. A multiple application card can support different types of applications (e.g., healthcare, financial services, travel, and loyalty programs) on the card itself thereby reducing the number of cards in the wallet.For example, Visa's multiple application card plans call for a card to include a combination of Visa-developed credit, debit and stored-value functions along with member-developed Java cardlets such as loyalty programs, local transit applications or drivers license programs. This open architecture will allow Visa issuers to add applications to existing cards after they have been issued while maintaining security "firewalls" between applications.A hybrid chip and magnetic stripe card is in use with nearly 60,000 students, faculty and staff at the University of Michigan and Western Michigan. The multi-application card features personal identification and dormitory security, banking, and a wide range of stored value functions for the purchase of food, books, photocopying and vending services.

What is a contact less card?

There are two types of contactless cards. The first is a contactless proximity card in which the card is read by inserting it in a special reader. The second is a remote contactless card in which the card can be read from a distance, such as at a toll booth.

How is a chip card different from the magnetic stripe card that I carry in my wallet?

Existing magnetic stripe cards have limited capacities to carry information. A smart card carries more information than can be accommodated on a magnetic stripe card. It can make a decision, as it has relatively powerful processing capabilities that allow it to do more than a magnetic stripe card (e.g., data encryption).
How many chip cards* have been issued worldwide?

According to the consulting firm Frost & Sullivan, more than 676 million chip cards were issued in 1996. The approximate breakdown is as follows: 575 million phone; 15 million GSM; 36 million financial; 30 million dataq & ID cards, 17 million pay TV, and 3.8 million other cards.*includes memory and microprocessor cards
What is the cost of an average chip card?

Trying to respond to this question is like asking the cost of a car without defining whether it is a used VW or a new Rolls Royce. Chip cards range from $.80 to $15 depending upon their capacity and quantities.

Why is reloadability important to the development of the smart card vis-a-vis disposable cards?

There are markets for both disposable and reloadable cards. Disposable cards work well for an event and as a collectible card. Disposable is also desirable when people are traveling or visiting a location and may only want to purchase a stored value card for a specific amount of time. If the card is a multiple application card supporting for example debit and/or credit and stored value, the customer would not want to throw this type of card away. It would be more appropriate that the stored value application be reloadable.A standalone reloadable card (as opposed to a standalone disposable card) is very attractive to some customers. This customer would tend to be someone who uses their stored value on a frequent basis perhaps for public transportation, corporate cafeteria etc. and wants to be able to reload the card on a periodic basis rather than have to buy a new card each time.

How secure and confidential are smart cards?

Smart cards actually offer more security and confidentiality than other financial information or transaction storage vehicles. A smart card is a safe place to store valuable information such as private keys, account numbers, passwords, or valuable personal information. It's also a secure place to perform processes that one doesn't want exposed to the world, for example, performing a public key or private key encryption. Chip cards have computational power to provide greater security, allowing verification of the cardholder. Entering a PIN is one method of verification. The benefit of the smart card is that you can verify the PIN securely, off-line.

Wednesday, 17 December, 2008

Health Cards called "Smart Cards"

Recently received a mail from one of my Friends Senthil asking more about smart cards and their implementation in Indian Health care Scenario. Here I am describing the use of smart cards with the technology that is usually deployed for the same.

Components of Smart card System









What all these components do?

SMART CARDS - Securely hold patient information.

CARD READERS- Work with any PC and are branded with your logo.

CLIENT SOFTWARE -Upgrades the web browser on the PC so it works with smart cards and card readers

SERVERS WITH HARDWARE SECURITY- Host and protect private information.

ADMINISTRATOR PORTAL WEBSITE- A web application that lets administrators issue and manage cards.

PATIENT PORTAL WEBSITE- A web application where patients view and update their information.

CAREGIVER PORTAL WEBSITE- A web application that lets caregivers work with information on the smart cards.

PDA & LAPTOP SOFTWARE -For working with cards in mobile and off-line environments

VISUAL BASIC & .NET TOOLS -For customizing and extending the system.

HL7 MESSAGING SERVER -For integrating with other systems.

What are the possible benefits you are passing on to your customers in case you deploy a smart card facility?

  • Enhance patient loyalty and improve patient relationships.

  • Speed up registration with less paperwork.

  • Improve communication and information sharing between points of care.

  • Let patients view and update their medical information online.

  • Convert paper records to digital format.
  • Reduce erroneous and fraudulent registration information.

  • Track and log with all changes to the patient’s information.

  • Comply with rules about information portability and privacy.

  • Maintain patient confidentiality using the best information security technologies on the market.

Benefits to the patients:

  1. Patients can access their health care information online and are better informed.
  2. Gives patients control of their medical information.
  3. Patients have added assurance that their personal information is released on a “need-to-know” basis.
  4. Reduced waiting and duplicate paperwork during registration.
What a Smart Card ought to provide?

Provide secure, re-writeable storage with more space than a magnetic stripe

• Storage is protected with multiple access levels

• On-card software can be updated “post-issuance” with new features as often as necessary

• Optional magnetic stripe for backwards compatibility with existing systems

• Manufacturing services to support mass mailings, telephone user activation and bulk-personalization

• Military grade security and cryptography.

What all You should/can store in a smart card?

Demographic information

• Employer information

• Emergency contacts

• Medicines/Prescription information

• Allergies

• Medical History

• Primary & Referring physician information

• Insurers/Payors

• Guarantor information

• Advanced Directives

• Special requests/ pastoral care requests

• Organ donor information

• Caregiver notes

• Audit trail information tracking all changes

• Custom fields

What is the best technology to deploy them in the healthcare field?

• Multi-tier server architecture based on Microsoft .NET and SQL Server

• Server applications can customized with C#, VB.NET or ASP.NET)

• Server side scripts control interactions with the smart card so no specialized smart card programming is required

• The client software is an ActiveX control that uses the PC/SC standard to communicate with smart cards.

• Dedicated security hardware on the server protects private information.

What are the Security Features while passing on critical health Info?

The cards should store certificates and keys for PKI interoperability and include hardware based cryptography features.

• The card should store a complete audit trail.

• The storage on the cards should be tamper resistant.

• The cards should support multiple PINs for patients and caregivers, with lockout features that prevent PIN/password guessing.

• Smart cards should also provide multi-factor authentication when users log-in to the portal applications.

• In addition to the smart card security features, network traffic should be encrypted using SSL.

Friday, 5 December, 2008

Ehealth- The Competitive Advantage

Defining e-health - where are we?

E-health is health's version of e-commerce: that is, conducting health business electronically. E-health is the combined use of electronic communication and IT in the health sector, both at the local site and at a distance for clinical, educational and administrative purposes (Unstoppable rise of e-health, 1999).
E-health is a broad, encompassing term that envelops information technologies and telecommunication technologies. Telehealth, the provision of health at a distance using telecommunications, is subsumed by e-health.
Unfortunately there is a lot of confusion about this new field and some vendors are getting onto the hype bandwagon by adding "e-" to old solutions. Many new initiatives remain unproven, and, like modern art, time will tell which shall endure.
Users' strategic goals and end users' needs should drive solutions and not the vendors or suppliers’ business models. However, sometimes the users' needs are latent and thus it may be very difficult for us to identify sustainable competitive advantage in e-health. We will present some ideas on an approach that we hope will help you create sustainable competitive advantage.
There is much activity in Australia in the e-health area, and we have had some success, in areas such as call centres, radiology, pathology, psychiatry, pharmaceuticals, smart cards and staff development, in particular. We are now moving beyond the stage of telemedicine trials and telehealth networks. There's a new commercial focus on electronic health records and supply chain management.
The increasing Commonwealth activity with initiatives such as HealthConnect and similar State/Territory initiatives are creating the environment for e-health to develop. Steadily business and political imperatives are emerging .

Information Exchange Standards
Telecom infrastructure supplies the medium for information exchange. We also require standards for information exchange. These are beginning to emerge, but there still remains much work to be done.
There is much talk about XML (eXtensible Markup Language) as standard for exchanging data elements, yet this requires defining the medical meta-data set so everyone can agree how to label health care data entities. Certainly there is considerable consciousness about XML in South Africa. HL7 is also being used. I am aware of its use by two large healthcare informediaries (claims handing agents), both of whom claim that HL7 still required some "customisation" for their purposes.
Other important information exchange standards include e-mail protocols, and the older electronic data interchange standards such as EDIFACT. We require standard ways of accessing databases such as SQL and MIQUEST, a healthcare data query language being used in the UK to access clinical data from practice management systems. The Electronic Health Record too, may be viewed at this level as a "standard" for storing and retrieving clinical episode and encounter data, as distinct from a particular software application or database server infrastructure.
On the whole the progress in this vital area is good and is improving all the time.

Some general thoughts are:
Buyers: e-health has the potential to improve the value proposition for healthcare consumers. This means affecting one or more of the criteria of Time, Quality, and Cost. Healthcare is a very high involvement product. Customers are very concerned about their own health. E-health is an ideal medium for shifting from a transaction-based to relationship-based product. I will shortly describe a patient intervention product where we did just this.
Rivals: Differentiate yourself from the competition by emphasising your brand or reputation. As a communication medium e-health creates opportunity to do this. E-Health is also an ideal medium to reduce inefficiencies and reduce costs enabling you to achieve competitive advantage through cost reduction.
New Entrants and Substitutes: Your power against substitutes and new entrants may come from adopting a pioneering and innovative culture, retaining the best staff, and emphasising your reputation.
Suppliers: E-health can give competitive advantage through supplier integration, with resulting cost efficiencies.
In My Next post we will examine a few examples...within these networks......
Patient-> Provider->Funder->Broker->Referrel->Medical School->

Monday, 1 December, 2008

E-Health India - Case Study

To understand the Barriers Better, Am sharing with you various Case Studies for the Same.

The first case study involved a company that was primarily in the business of selling prescription drugs online. This was a pure Internet startup, rather than an existing pharmacy that added an online channel.

ePharmacy focuses exclusively on the sale of

(1) prescription pharmaceuticals,

(2) over-the-counter (OTC) pharmaceuticals,

(3) vitamins, minerals, supplements (VMS) and herbal products and

(4) related healthcare products.

The Company has invested over $10 million in state-of-the-art technology and facilities including fully automated pharmaceutical dispensing equipment that enables the company to fulfil customer orders rapidly upon receipt of the order via the Internet.

ePharmacy began selling OTC pharmaceuticals and other healthcare products through its website in May 1999 and began sales of prescription drugs and providing healthcare information in late October 1999.

With respect to prescription pharmaceuticals, the company had the ability to service over 75 million insured lives as well as the entire cash-pay market which accounts for over 20% of the prescription market.

Now Lets See the stats in the US market

ePharmacy's target markets include the estimated $120 billion U.S. prescription pharmaceutical market, the estimated $22 billion U.S. OTC pharmaceutical market and the $11 billion U.S. vitamin market. Currently, most of these products are sold through bricks-and-mortar retail pharmacies and a smaller percentage, particularly prescription pharmaceuticals for chronic conditions, are purchased by mail.

The company's long-term goal involves development of a comprehensive pharmacy services vertical portal-delivering all aspects of pharmacy services to consumers as well as business constituencies within the healthcare industry. The online pharmacy allows customers, via the Internet, to receive comprehensive drug and healthcare information, and correspond privately with pharmacists.

ePharmacy's genesis began in the middle portion of 1998, with three co-founders who believed the Internet could offer a new value and dimension to healthcare. The hiring and operations began in the early part of 1999, and then focused on creating an infrastructure (business and technical) from which to begin.

At the time of data collection, ePharmacy employed 150 workers in such departments as marketing, financing, and most importantly, operations. ePharmacy has the facilities to fill between 20,000 to 21,000 prescriptions per day, or about ten thousand in a seven and a half-hour shift. In order to operate at an efficient level, ePharmacy has a fifty-thousand square foot physical location, which houses the automated dispenser that is connected to high levels of interfacing and interconnectivity between the automated dispensing equipment and the rest of the company.

ePharmacy employs the services of United States Postal service, which disseminates their prescriptions as well as any other items such as OTC's and related healthcare products. Shipping is free for prescription orders; however, for all non-prescription items, the cost of shipping is assumed by the consumer. ePharmacy actually subsidizes a portion of the shipping in order to ameliorate the process of doing business on the web, as well as sustaining customer loyalty. Moreover, ePharmacy also provides prescription reminders through the use of email.

For example, if an individual has a prescription for a chronic drug, and the prescription is for more than a single dispense, ePharmacy advises the customer when the refill is coming to an end. In effect, the company is attempting to turn each chronic drug customer into a loyal customer by providing a service that is not readily available from traditional, physical pharmacies.

In order to fully receive service from ePharmacy, customers must provide information such as name, address, and billing information. Payment for all healthcare items usually involves credit cards, but the company also accepts check and money orders when applicable. In addition to traditional e-commerce payment, ePharmacy also accepts third party payers, such insurance companies. Insurance companies normally cover the cost of the prescription.

In that case, the customers must provide payment information for their co-pay, and also provide information concerning their insurance company, as well as their coverage plan. Naturally, the company confirms the insurance coverage and the authenticity of the prescription. ePharmacy checks the accuracy of the prescription against the patient's medical history, as well as unearthing and verifying any possible interactions with other drugs.

ePharmacy's Web site offers a reference desk to potential and current customers, which is a database of information relating to drug interaction, vitamin information, and other pharmacy-related information that the customers can access.

Further, in-house publications are also available to consumers. The company offers this service to the consumers in order to allay any questions or concerns pertaining to the online, or traditional, pharmaceutical field. ePharmacy feels this combination of products and information affords them an edge in terms of competing for consumers. The site becomes a "one-stop-shop" Web site that offers a vast array of medical and pharmaceutical information.

All information disseminated and originating from the site is fully encrypted, and where there are areas on the site where information is traveling back and forth-it is strictly one-way communication. In addition, the company utilizes secure Web pages to take all orders and to display prescription information. No personal information can be accessed by or released to any third-party, doctor, etc. without consent.

All information is stored in a secure database behind a firewall. Customer accounts are accessible over the Internet only by entering a user name and password. Presently, ePharmacy uses Secure Socket Layer (SSL) software, a security standard supported by common Web browser software, including Microsoft Internet Explorer (3.0 and higher) and Netscape Navigator (2.0 and higher).

Sensitive information such as passwords, address, and credit card information is encrypted using 56-bit encryption for transit over the Internet. ePharmacy argues that encryption makes business transactions over the Internet even more secure than purchasing by telephone. While select departments at ePharmacy have access to contact information and aggregate demographic information, only departments with necessary access can view health and insurance information. This site has additional security measures in place to prevent the loss, misuse and alteration of the information under the company's control

Moral of the Story i.e. Lessons Learnt

The business model for the online pharmacy is mainly a virtual merchant model, whereby revenues are derived directly from the sales of prescription drugs. Their hope was that due to their lower operating costs, they could offer prescription drugs at prices that were competitive with those of brick and mortar pharmacies. Hence their dominant competitive strategy was to seek a cost leadership position in the pharmacy retail sector.

However, the online pharmacy clearly sought to differentiate itself from brick and mortar-based competitors in a number of ways. Four specific sources of differentiation discussed in the interviews were:

Convenience. Consumers no longer need to leave home to fill prescriptions, since they could be ordered online and delivered to them at home. This was particularly important for homebound consumers.

Anonymity and private transactions: For many buyers of prescription drugs, the ability to ask sensitive questions in private, rather than in front of other customers or a pharmacist that they may know outside of the pharmacy, is an advantage.

Rich information: The ability to complement the provision of drugs with additional content is a distinct advantage. The online pharmacy provided detailed information about the drugs, including potential interactions and side effects.

After-sales service: The online pharmacy offered a number of after-sales services to prescription drug buyers that would be hard for traditional pharmacies to replicate. This included allowing customers to email any questions they had about taking prescription drugs, and sending automatic reminders when prescriptions should be refilled. Like many other e-businesses, the online pharmacy took advantage of the ease with which complementary products could be sold on their site. These other products added to the potential sources of revenue.

However, the online pharmacy faced many challenges. The cost of delivery had to be absorbed or added to every sale, and since quantities of prescription drugs are usually not large, little efficiency was possible for home deliveries. In addition, many people obtain prescription drugs only when they become ill, and need medication right away. For these customers, even overnight delivery represents an intolerable delay.

Several challenges result directly from the complex structure of the healthcare industry. The online pharmacy was fighting to be listed as an approved supplier of prescription drugs by the major health insurance companies. Without this, customers would not be reimbursed for their medication expenditures, making it unlikely that they would substitute the online service for a traditional one recognized by their insurance provider.

And, even if they could be reimbursed for online prescription drug purchases, the current model requiring customers to pay upfront via credit card is far less attractive for those with prescription drug coverage who only have to make small co-payments or do not have to pay at all at their local traditional pharmacy.

Many of these challenges would not apply to a traditional pharmacy that provided an integrated e-commerce offering to its customers. Indeed, the online pharmacy faced stiff competition from click and mortar pharmacies that offered immediate pick-up of prescription drugs ordered online as well as the advantages of approved coverage by insurance providers.

Indeed, as a postscript on this interview, by June of 2001, the online pharmacy has ceased independent operation, and now directed online inquiries for prescription drugs to an established click and mortar pharmacy.

How To Jazz the Party?

An Online Physician's Consultation Service

The second case study was an online physician consultation service. Founded in July 1999 by three emergency room doctors, eDoctor has a proven business model and the only Internet malpractice insurance policy ever written.

A full 60% of the company's demand for consultations comes from abroad. The substantial traffic to the company's site has been generated without advertising or registering with a search engine. eDoctor estimates that by 2005, 10% of the 1.1 billion annual emergency room and doctor office consultations in the United States will be conducted online.

eDoctor enjoys a "first to market" advantage in this rapidly growing field. Specifically, the company provides one-on-one consultations between physicians and patients. The doctors who started the company noticed many people were coming into the emergency room because they had forgotten their prescription somewhere, and to get the prescription, they would need to see a local doctor. This niche need is the primary impetus for eDoctor, but other ancillary factors also played a role in its creation. For example, the founders believed a platform existed for a Web site that dispenses medical information and services for emergency room situations.

Further, this company would offer this service to executives or other people traveling abroad who do not have access to their regular medical outlets, or who have just forgotten a prescription. eDoctor is a liaison between the patient, local doctors, and medical services.

eDoctor's target market includes American executives traveling abroad, specifically customers who need medical advice or attention, but cannot locate or reach their primary care physician. The Web site allows consumers to contact and communicate with U.S. trained and certified doctors, and when necessary, these doctors can prescribe medication to the consumer and then overnight the product to the patient.

eDoctor has emergency room physicians that are on call, 24 hours a day, seven days a week for those customers requiring immediate attention. Conversely, the company can also set up an appointment and meet with that physician immediately (non-emergency), or if it is a specialist they are interested in, the doctors can arrange that appointment as well.

In order to receive services from the company, patients must log onto the network with a credit cared, as well as divulge medical information, personal information and other ancillary items germane to the specific visit. Since emergency consultations are the major impetus for the company, medical records are not necessary required for all patients due to the uniqueness of the situation. However, the standard medical information is required of the patients (e.g., current medication, past surgeries or ailment, and allergies to medicine).

In addition to medical information, the patient must also provide information on their primary care physician in order to relay the information and mediation to the proper outlets, as well as verify the veracity of information supplied to the company by the patient. When a non-emergency situation arises, such as a routine appointment with the company, the patient must provide the primary care information up-front before visiting the doctor-this reduces any liability indemnity as well as increases the potential for assistance.

Interestingly, if a patient is seeking an immediate medical consultation from one of the emergency medicine physicians, he or she will first complete payment for the physician's service through the secure CyberCash credit card processing system. Then, the patient will complete the registration form, which includes personal information, past medical history, and review of systems, as well as some specific questions relating to the immediate medical concern.

If a patient is seeking an appointment with one of the other physicians in another specialty, the patient will first go through the secure CyberCash credit card processing system for a credit card authorization, which will not result in a charge to the card; it will verify the validity of the credit card. The patient will then provide preliminary information (personal, past medical history, and nature of the medical problem or question).

Next the patient will be brought to the eDoctor's Appointment Center, where she will be able to set up an appointment with the chosen physician. The patient will be given an appointment ID, which will allow reentry to the site for the actual consultation with the doctor. When the patient returns for the appointment, he or she will fill out the review of systems form and then proceed with the actual consultation. The patient is not charged for the appointment-based consultation until it has concluded.

All patient information on eDoctor is fully encrypted, which means personal medical information and online consultation is secured through SSL encryption, and will not be accessible to anyone other than the company's physician. After the patient has completed the registration process (either for an immediate consultation with one of the Emergency Physicians, or when they return to the company's Web site for an appointment with a non-Emergency physician), she will be brought to the eDoctor's "Doctor's Office," where the physician, after briefly reviewing the supplied patient information, will join the patient in a secure, encrypted, "one-on-one," virtual conference room environment.

The physician will then provide the type of service requested during the registration for that visit. There is no "pre-set" format for the dialogue with the physician; the doctor may ask additional questions, depending on the nature of the medical problem, and will help guide the patient through the consultation.

If initiation of medical treatment is deemed warranted by the doctor at the time of consultation, prescription medication can be provided by "pharmacy call-in" by the physician. If the patient is traveling or away from home, the eDoctor physician can arrange delivery of U.S.-formulated prescription medication to almost anywhere in the world.

If the patient is seeking an appointment with one of the non-emergency medicine specialists, and needs to submit electronic data such as ultrasounds or x-rays, specific instructions from the physician will be provided at the time of the consultation. At the conclusion of the online consultation, the company's doctor will provide the patient with detailed discharge instructions. Patients may print these by clicking with the mouse on the browser's print button, or else "copy and paste."

Moral of the Case Study on E-Doctor

This e-health firm relies primarily on a brokerage model, serving as an intermediary service that connects patients with physicians for secure e-mail or Internet-based video consultations. Patients can either choose their preferred physician, if their doctor has registered with the service, or allow the service to select a physician for them. Physicians are paid by the e-health service, which retains some portion of the fees paid by patients.

Their primary competitive strategy is a differentiation-focus strategy, allowing them to offer a premium service mainly directed at a particular segment of the market, the international business traveler. As a broker, they must have a strategy to bring both "buyers" (patients) and "sellers" (doctors) into their business.

They promote their services to physicians, and also use patients to "pull" their preferred doctors into the service. Given their need to create a critical mass of physicians and patients registered with the service, this service benefits from their "first mover" advantage, since it is unlikely that doctors will want to sign up with more than one such intermediary.

Particularly for international business travelers, their service is differentiated from the alternative source of medical consultation by their ability to offer:

English-language physician consultations in countries where English is not the native language
Access to a US trained physician while traveling abroad, including secure email to a patient's regular doctor if enrolled in the service

Access to prescriptions for familiar drugs which can be delivered almost anywhere in the world
Immediate access to a physician when needed. The physician consultation service also faces a number of challenges. Like the online pharmacy, lack of physical presence is a problem when patients need immediate in-person attention or immediate medication. Even with prescription drug delivery, the delays may not be tolerable.

In addition, as with the previous case, the reimbursement issues raised by lack of recognition by health insurance companies makes it difficult for patients to choose in preference to a traditional in-person physician consultation. Even though many travelers need to pay in advance of services anyway when obtaining medical treatment abroad, they still are able to obtain reimbursement from their insurance companies. This is not necessarily the case for online consultations. Hence the target market is limited to those who can afford to pay outright for their healthcare, or receive this as an executive perquisite from their companies.

State licensure requirements are another barrier being addressed by this firm. In this case, the strategy to have consumers recruit their own physicians is a smart way to try to pull in doctors already licensed in the states from which patients seek services.

Other challenges faced by this firm follow from their focus on travelers and from their reliance on Internet-based communications only. Internet access may not be available in all locations, or may be so poor that services such as Web-based video do not work.

Moreover, there is little possibility to use many of the available phone-based remote diagnostic instruments now becoming more common in telemedicine. Even if Web-based interfaces were developed for these instruments, it is not clear that travelers would always have them on hand.
Despite these problems, the online physicians service has not yet succumbed to the bust afflicting so many other Internet start-ups.

Its first mover advantage, ability to offer some service immediately without the need for physical delivery, focus on linking patients to their own regular and trusted physicians where possible, and clear focus on an unmet need of business travelers are all possible explanations.

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