An Ecosystem Approach for Healthcare Services Cloud Henry H. Chang, Paul B. Chou, Sreeram Ramakrishnan

IBM T.J. Watson Research Center, New York

hychang@us.ibm.com, pchou@us.ibm.com, sramakr@us.ibm.com

Abstract—Patient-centric healthcare and evidence-based medicine with the emphasis on prevention and wellness promise to deliver better and more affordable healthcare. At minimal, they require health related information to be shared among a community including patients, providers, payers, and regulators. It is important for IT systems to facilitate information sharing within such communities. Furthermore, we argue that it is highly valuable to develop IT technologies that can foster sustainable healthcare ecosystems for collaborative, coordinated healthcare delivery.

The emerging cloud computing appears well-suited to meet the demand of a broad set of health service scenarios. In particular, the concept of shared infrastructure and services provides the foundation for supporting healthcare service ecosystems. This paper proposes an ecosystem approach to identify high-level requirements for cloud computing technologies to provide hosting environments for sustainable healthcare ecosystems. We draw the lessons and principles from the sustainable ecological ecosystems, review some of the existing IT-enabled healthcare ecosystems, and provide our view on the imperatives for cloud computing research to support future healthcare IT needs.

Keywords-healthcare; cloud computing; ecosystems; patient-centric; evidence-based medicine

I. INTRODUCTION Healthcare costs have been increasing at an alarming rate and the quality of care remains poor or inconsistent in many countries. As a result, the public policy makers are exploring the various options of transforming healthcare in order to reduce the healthcare delivery cost with increased quality. A key element for a successful transformation is empowering individuals to assume greater financial oversight and responsibility for their health. This drives the individuals to seek better knowledge to make informed decisions regarding their healthcare needs with value-aligned quality [1]. The current widespread disregard of healthy lifestyle choices among people leads to the rising rates of obesity and chronic diseases. According to the US healthcare statistics [2], the medical cost incurred by 10% of the US population with chronic diseases accounts for 70% of the total national medical expenditure. Shifting from doctor’s care to information-enabled self-management may reduce the cost of caring for chronic patients. And it may deliver better results because it provides continuous care required by chronic diseases compared to the episode-based hospital treatment paradigm.

A key element in the transformation of healthcare is a fundamental shift in the emphasis of preventive care. The United States Congressional Budget Office has stated that one key focus for healthcare innovation is preventive care. Instead of caring for “sickness” using a reactive model, the society might be better off investing in disease prevention and wellness using a proactive model. The end goal is to lower the probability of disease onset in order to reduce the overall cost of care. Private employers such as Safeway have demonstrated successes of adopting wellness programs to help reduce healthcare costs [3]. It is anticipated that consumers will participate in preventive care activities such as blood pressure measurement and excises in retail stores, home, workplace, using web information managers to manage and connect with care channels such as a primary care physician with convenience. Although early results from wellness/prevention-centric initiatives are not yet conclusive, they are promising enough for many to see preventive care as transformative.

The prospect for continuous medical improvement via large scale clinical information analysis is very exciting. Innovations are becoming feasible such as continual updates of disease treatment guidelines based on evidence-based correlation and mining of longitudinal treatment and genome translational records. High impact comparative effectiveness studies can be successful if an integrated information repository of health medical records is available. Without a standards-based infrastructure, it will be challenging to enable information sources to become commonly accessible.

Another critical challenge today is “deficient care linkage” (DCL) [4] where the effective treatment of a patient of co-morbidity necessitates a better linkage of cares by multiple specialists than is commonly available. Due to the nature of compartmentalized care treatments in today’s medical environment, a patient is often left with one’s own device to address the deficiency of the linkage. For example, a patient may need to be sure to remind the diabetes doctor about his heart conditions for not all the patient’s information is available. Any automation of care linkage must be delivered within the context of a coordinated healthcare IT system, so that the insights generated by the comprehensive analysis can be made available to the medical decision makers at the right time in the right context.

The above transformative efforts all portrait the need of what amounts to a collaborative, coordinated ecosystem for supporting a patient-centric healthcare system

2009 IEEE International Conference on e-Business Engineering

978-0-7695-3842-6/09 $26.00 © 2009 IEEE

DOI 10.1109/ICEBE.2009.98

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2009 IEEE International Conference on e-Business Engineering

978-0-7695-3842-6/09 $26.00 © 2009 IEEE

DOI 10.1109/ICEBE.2009.98

608

2009 IEEE International Conference on e-Business Engineering

978-0-7695-3842-6/09 $26.00 © 2009 IEEE

DOI 10.1109/ICEBE.2009.98

608

2009 IEEE International Conference on e-Business Engineering

978-0-7695-3842-6/09 $26.00 © 2009 IEEE

DOI 10.1109/ICEBE.2009.98

608

of systems with the participation of multiple stakeholders including patients, family and community, doctors and nurses, care delivery organizations, insurance/payers, and government entities. Diagram 1 shows a holistic view of a patient-centric health system to illustrate the need for systematic thinking in delivering comprehensive and successful healthcare.

Information technologies must play an essential

role in the patient-centric healthcare transformation. It must address the need to access complete, verifiable and protected information from distributed sources. It must connect the information from myriads of care centers and institutions, and bridge the gap among isolated clinical delivery processes for the benefits of patients. It needs to support organic, evolving changes of the future healthcare such as preventive medicine, chronic disease management, acute disease treatment, wellness, and end-of-life care with more patient-care, home tele-healthcare, and evidence-based knowledge infusion.

Electronic Health Record (EHR) and the associated applications leveraging the common data have become a key part of the evolution of the healthcare IT systems. However, the adoption of EHR critically depends on the available financial and technical resources of the care delivery organizations. The rural and small clinics typically have very limited electronic health record system support, while the larger urban hospitals have better automation in transactional support in areas such as patient payment, insurance billing, pharmacy management, clinical ordering.

The emerging cloud computing technologies provide a promising approach to address the IT needs for the future collaborative and coordinated healthcare. We envision not only healthcare services will be shared, but the associated healthcare IT services will also be delivered to and consumed by the interconnected healthcare ecosystem participants. By introducing dynamic infrastructure-as-a-service to the players needing a digital presences on the network, a pay-by-usage model can be deployed to address the concerns of the cost of the IT services and overcome the entry-cost barriers, in particular for the small and rural parties. Moreover, the common infrastructure can simplify the sharing and governance of the healthcare information to

better facilitate the transformation to patient-centric healthcare and evidence-based medicine.

As cloud computing being exploited for various application domains, we propose to leverage it to create IT environments that could foster and support healthcare ecosystems. Section 2 draws from ecology the common characteristics of sustainable biological ecosystems. Section 3 describes some examples of the existing healthcare ecosystems. Section 4 provides our view of the imperatives for cloud computing to create and foster sustainable healthcare ecosystems to deliver better and more affordable care.

II. THE ECOSYSTEM APPROACH The essence of a business service ecosystem is that the

relationships among service providers need to be analyzed from a higher holistic level rather than from the viewpoint of individual services. A business service ecosystem’s scope is the set of symbiotic relationships among actors who work together around a core technology platform. James Moor [5] has identified the business ecosystem notion as an innovative strategic planning concept involving enterprises, supply chain, and network of trading systems. We apply this strategic thinking to the domain of incubating services on Cloud. The main difference between the ecosystem approach and the traditional enterprise architecture approach to managing inter-connected applications is that the former supports a large number of actors with a management style that calls for the lowest level of control. It is therefore worthwhile to investigate lessons from biological systems.

In ecology terms, an ecosystem is a unit of interdependent organisms which share the same habitat. For example, in an island environment which has a closed ecosystem, the living entities form a number of food webs which show the interdependence of the organisms within the ecosystem. The lessons from the spatial and temporal dynamics of the rich relationship in the ecosystem have been debated and adopted by the environmental groups which, we believe, can be helpful in guiding the development of a service ecosystem for healthcare where the interdependency of services must be fostered in a sustainable way. We shall first identify three styles of relationship in an ecosystem using the biology analogy. i. Symbiosis relationship – where species co-exists with

positive or no benefit to each other. An ecosystem example in the digital world is the currently available 65000 applications in the “Apple Store” for iPhone; all contribute to the viability of the market that has generated 1 billion downloads in the first year of existence. An important variation of the symbiosis relationship is the dominate-subjugate relationship where a keystone service such as the CRM services in the salesforce.com support the existence of related add-on services.

ii. Competitive (Predator/Prey) relationship – where the energy of a being is transferred through the

Individuals will be served by collaborative, coordinated health systems

Care Delivery Organizations

Doctors and care takers

Payers and Health Plans

Regulation and governing bodies

Pharmaceuticals and Device Manufacturers

Communities andFamily

IT solution providers

Diagram 1: Collaborative, coordinated health systems

Individuals will be served by collaborative, coordinated health systems

Care Delivery Organizations

Doctors and care takers

Payers and Health Plans

Regulation and governing bodies

Pharmaceuticals and Device Manufacturers

Communities andFamily

IT solution providers

Diagram 1: Collaborative, coordinated health systems

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provider/consumption food network. The digital world example is like “substitutable applications” where the commoditized functions can be sourced from multiple providers just like one “BMI body mass index” function may easily be replaced by another BMI calculation.

iii. Gated (Parasitic) relationship – one species’ existence at the expense of the host species. The digital world example is harder to find here, because each services need to be self-justified or bundled in the digital world. However, we envision virtual parasitic functions might exist for the reason of security control and privacy compliance where additional non-functional operations must be performed for legal assurance. Many sustainable ecosystem principles have been

established by ecologists [8]. The Convention of Biological Diversity (CBD) publishes 12 principles [7] which suggest that a well managed, sustainable environment of services should adopt a goal of creating service diversity that complements each other. It also point out that one should seek the appropriate balance between conserving existing services and encouraging competition through the usage of policies and regulations. It recognizes the fact that changes are inevitable and one should respond to the business, societal, and culture choices for services through constructing an integrated, interacting scope. Using these principles, we will examine some of the existing and potential ecosystems for healthcare services.

III. EMERGING HEALTHCARE SERVICE ECOSYSTEMS There are several IT-enabled healthcare service

ecosystems emerging. We examine some of those ecosystems in this section and summarize the analysis in a table I. • Radiology Image Data Network

The remote outsourcing of radiology image reading has enjoyed rising adoption in US and Europe over the last 10 years. The trend is the result of the general radiologist shortage as well as the successful business model based on using off-shore board-certified doctors who can do an effective job with lower cost. It is also supported by the fact that the network technology has become mature enough to transmit large volume of data with assured privacy protection. This ecosystem takes a broad remote sourcing approach to match right-skilled radiologists from a certified network with the tasks at hand. For example, an infant’s liver image reading may require a specialized radiologist. We expect the applications deployed on the network to be competitive and substitutable, because the functions are more mature.

• Electronic Medical/Health Record (EMR/EHR) Ecosystem It is now an accepted wisdom that rapid acceleration of EMR adoption is crucial for the improving the quality and reducing the cost of care. In US, the Government has reserved budget for incentives to

encourage clinics to implementing the EMR, and the department of Health and Human Services has appointed a national coordinator to help transform the healthcare IT system. The Connecting for Health [9] created a preliminary roadmap of common framework, which specifically points out the construction of “network of networks” with interoperable, standard-based, decentralized and federated information exchanges. The exchanges need a number of actors (e.g. hospitals, clinics, individual care providers) with a minimum set of standard-based capabilities to participate in the network. Once the network is operational, we foresee additional standard-based clinical applications such as electronic prescribing tools and medical alert programs be provided by IT vendors to operate on the interoperable systems. The standard-based applications must be certified first to avoid disruptions to the network. In addition, they should not be too complex to discourage new and continued innovations.

• Tele-Healthcare Services Network Tele-healthcare has been demonstrated to reduce cost and improve the quality of care for patients. According to a study done at Taiwan [6], following up chronic heart failure patients at home with specialist nurse-led telephone visiting regularly can decrease adverse outcomes, most notably hospitalization and length of stay. The study shows an over 40% reduction in total hospitalization fees. Tele-healthcare arrangement allows patient to stay at home, local community, and care centers. The key insight of the tele-healthcare’s success is the role of “case manager” who is responsible for coordinating an ecosystem of actors including the patient himself, the local nurses, and remote doctors, and the network operators. There will have many value-added services on such a network to fill the need of different cases such as diabetes, cardiology patients, or people with co-morbidity.

• Personal Healthcare Record (PHR) Ecosystem Both Microsoft and Google have started efforts on personal health record in 2007, with Google Health and Microsoft Health Vault respectively. Their goal is to provide the healthcare consumers with more control over their own health records so that they can be proactive in using expert-guided self-care for wellness. Google Health and Microsoft Health Vault respectively provide an environment that empowers a community of innovative service providers to attach value added services to PHR. We see different categories of players such as wellness program providers, drug consultants, and medical specialists. Clearly, some of the MD created services can continuously coach chronic-ill patients to enhance their personal confidence in making the right choices in the steps of taking care of oneself. Google Health

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gives a person the tool to enter, gather and share personal health information. Being the center point of the personal data, Google Health enables an early symbiosis ecosystem of “free services”. The free consultation includes drug prescription savings and usage, wellness program assistance, and connection to physicians. On the other hand, Microsoft Health Vault represents a more ambitious attempt. Not only does it allow for manual entry of personal healthcare information, but also support automated data collection from health measuring devices (6 in the category and counting) and provide connections to hospital IT systems. Both Google Heath and Microsoft Health Vault system have gathered a sizable number of third party services in its ecosystem, including cardiovascular wellness, health manager, community health portal and private network of physicians, healthy living coach, etc. Along the line of employer-sponsored PHR, Dossia

[8] is an employer coalition founded by several industry leaders including Wal-Mart. Dossia aims at providing secure, convenient access to lifelong health information widely available to employees and their doctors in the hope of promoting better living style, informed medical consumers, and lower risks and costs of healthcare.

The above examples show that IT technologies can improve the healthcare delivery and potentially lead to new business models and ecosystems built around a technology base. In reality, the speed of technology adoption is typically slow. The penetration of EMR is less than 15% in U.S. [10]. In Taiwan, the e-healthcare deployment of electronic insurance claim has reached almost 100% but has yet to benefit the individuals. In the next section, we discuss how the merging cloud computing can support sustainable healthcare ecosystems and where research is still needed.

IT-enabled Healthcare

Service Ecosystems

Service Consumers

Actors (Applications and Business Services)

Relationship Types Care Domains

Radiology Image data network

Medical specialist, physicians

Remote image reading applications

Competitive Lab testing

Electronic Medical Record Exchange

Hospitals, physicians, person

Hospitals and clinic applications

Symbiosis, gated Continuous care

Tele-healthcare services network

Family community

Nurses, physicians, life cycle of care applications

Symbiosis, Gated Home care, community care

Personal Health Record service network

End user person or family

Wellness advisers, health coach applications

Competitive and symbiosis

Wellness self-care

Table 1: Ecosystem Analysis of emerging healthcare services network

IV. ATTRIBUTES OF CLOUD-ENABLED SERVICES Cloud computing promises many benefits that are

essential for business service ecosystems. One immediate benefit is the reduced cost to the small and medium business participants, who may not have adequate in-house IT expertise and financial resources to embark on IT investments alone. While low entry and operation cost is a necessary condition for a sustainable ecosystem, we believe further research is needed on cloud computing to provide a nurturing and protective environment to facilitate an ecosystem to grow, and allow the organisms of the ecosystem to collaborate, compete, and evolve. For healthcare, this development would accelerate innovation and the adoption of new healthcare delivery models

supported by cloud-enabled ecosystems, leading to higher-quality, less-costly healthcare services. We enumerate below the key attributes that cloud computing must possess to provide such an environment for healthcare ecosystems.

Information sharing and privacy protection: A key to the success of patient-centric healthcare and evidence-base medicine is the ability to access information in the proper context. The information may involve a patent’s medical history, health conditions, and others’ medical records of similar cases. Cloud computing provides a number of advantages to facilitate information sharing. By sharing the same underlying infrastructure, finding and accessing to others’ data potentially can be simplified and performance optimized. In addition, the data involved may be private or proprietary in nature. Governing the use of sensitive data

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according to policies establishing by the ecosystem could be a capability provided by the enabling cloud, thus allowing the service providers to focus on the task rather than worrying about getting and protecting the data.

Service composition, coordination, and competition: To establish collaborative, coordinated healthcare services, it is useful to exploit service composition and orchestration techniques for cloud for the purpose of fostering symbiosis relationships among the services in the ecosystem. Take tobacco prevention as an example, there may be multiple services on a PHR network to be orchestrated together for the benefit of a person with smoking habits. Not only the care network could monitor the person’s behavior pattern using a wellness coach, but the measurement data maybe correlated with historical trends of such kind of smokers in order to generate early diagnosis alert. After an alert is generated, another hospital application may spring up to organize a ‘case treatment management” plan for early care intervention to reduce the disease onset risks. In an extended dynamic data flow scenario, we also envision the scenario in which a person’s deteriorating health situation is automatically brought to the attention of family members, connected providers (clinics, community care center) and payers through the available up-to-date real-time data links. To encourage similar services to compete in quality and cost, the cloud could provide mechanisms to support dynamic discovery and substituting services by service consumers. Another interesting possibility is the ecosystem level learning; the cloud environment could facilitate sharing the experiences by the crowd in what works, quality of particular services, etc.. This would encourage the providers to continuously improve to stay competitive.

Safety and security and scalability: Cloud computing must provide a safe and secure environment for the services to operate. It should protect the ecosystem from external attacks that may endanger the operation and sustainability of the ecosystem, and protect the individual organisms from unfair competitions and practices by the others. It should also have the ability to provide sufficient resources at a cost that the ecosystem can count on it to grow and sustain.

Self-governing and automated management: To conceal the complexity and reduce the operational cost of the IT systems, cloud computing must provide simplified mechanisms for governing and management of the ecosystem and its environment. Ideally, system and resource management should be automated, and the business service level management tasks could be carried out by the end users without requiring the involvement of a system administrator. In addition, cloud computing should enable the execution and enforcement of operational policies established by the ecosystem, allowing the ecosystem to operate without disruptions and interventions.

V. CONCLUSIONS In a fully digitized medicine world, clinical data and

applications are readily available to patients, care takers and

physicians through a network of information systems in a community of clouds. For example, at the point of care, according to the preference of a physician, relevant health data may be retrieved from multiple sources, enabling intelligent decision making of diagnosis and prognosis by invoking complementary services from the healthcare service network. Without a disciplined approach to foster these services, we will not be able to meet the challenges of coordinating and supporting the necessary rich relationships that are efficient, effective and smarter.

We advocate an ecosystem approach to analyze these relationships of healthcare services: competitive, symbiosis, and gated. We show the complementary and competitive relationships of future healthcare ecosystems. As a result, we offer a preliminary set of attributes of the healthcare services clouds to support the rich ecosystem requirements of healthcare ecosystems: Information sharing and privacy protection, Service composition, coordination, and competition, Safety and security and scalability, and self-governing and automated management. The consultation of the biology principles of an ecosystem helps us with new angles of openness and sharing.

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