Open Innovation in Healthcare Ecosystem – a systematic review

Background: Several countries are facing significant troubles of health services, particularly rising prices. Innovative technologies and services are expected to help boost medical quality and cut costs. In this sense, there is a lack of innovative work in spite of a growing interest in open innovation and approaches that advocate for expanded cooperation among various actors in healthcare. Objective: This paper describes the findings of a study concerning the commitment of the healthcare sector to open innovation. Materials and methods: The search for literature focused on English-language papers to 12 January 2020. Based on the indicated criteria for inclusion, 29 articles were included. Results: Results show that most experiments concentrate on the areas of pharmaceutical research (drug discovery) and health informatics (health information systems and infrastructures) that were brought out as concepts or applied as pilot and prototype. Conclusions: The participation of the healthcare sector limited in open innovation, and more work is required with an emphasis how to get open innovation.


Introduction
Nowadays, healthcare institutions in developed countries face numerous and dynamic environmental and financial problems, such as the lack of trained workers, and the need for openness (Bullinger et al., 2012a). This involves the problem of raising the wellbeing and life expectancy requires of the aging population, the growth of chronic illnesses, and growing customer expectations (Dandonoli, 2013). Around the same time, more pressure is placed on healthcare budgets and it has been suggested that more innovation is needed to provide effective and high-quality healthcare services (Keller et al., 2013). In healthcare systems, innovation is a new collection of practices, habits and operating strategies aimed at enhancing patient quality, institutional performance, expense, or customer experience, and enforced by organized and orchestrated activities (Omachonu & Einspruch, 2010). With respect to innovations, it is claimed that the innovation needs to be new or significantly changed. The different types of innovation apply to production or result, but it is important to note that innovation is not simply an act but a mechanism. Four innovation types are distinguished: organizational, process, products (including services) and marketing. Innovation has become a vital power within healthcare institutions as a means to close the gap between what is feasible, and what is not being done in the current provision of healthcare (Thakur et al., 2012). However, companies have historically focused on internal expertise and competencies in the quest for innovation (Bullinger et al., 2012b).
To maintain existing market positions and ensure success in a competitive market, relying on internal expertise is no longer adequate as information is spread through companies and individuals, and increasingly more qualified people are available, so organizations have difficulty in recruit all the requisite skills (Andersson et al., 2011). As the technology environment has shifted dramatically, so has the view of innovation and organizations gone from innovating within divisions of research and development (R&D) and relying on internal capability to becoming more transparent and inclusive through the participation of a number of stakeholders (Dal Molin, 2011). The company's boundaries with the world became blurred, and companies looked to outside players to discover new ways of seeking creative solutions (Huizingh, 2011). A new approach, called open innovation, has gained attention for its goal of decreasing internal production costs while still rising revenue (Davey et al., 2010). Recently open innovation was identified as a centralized method of innovation focused on intentionally controlled information flows across organizational borders, using pecuniary and non-pecuniary processes in line with the business model of the organization (Chesbrough, 2012). In open innovation the emphasis is on collaboration between different players during the production and promotion of an innovation. That concept of innovation emphasizes the importance of extending the organization's scope, and recognizes that not all innovative innovations can originate from within the enterprise and not all good ideas generated within the company will be effectively internally sold. This helps projects to be introduced in various forms and at different times (Chesbrough & Bogers, 2014).
Because of the increasing need for patient participation, cooperation with other actors is a major task for healthcare organizations to develop and enable expertise and innovations to spill into and out of the innovation process (Lundberg et al., 2013). Innovation seeking to include internal and external information, in diverse industries such as healthcare, is represented by the idea of open innovation, relating to the need to reach through the organization's conventional borders to develop to make the organization's borders more permeable (Lindgren & Rasmussen, 2013). Application of open innovation in the healthcare has a wide variety of meanings. Health open innovation includes health care innovations, as well as innovations in disease prevention and health promotion. It could come in the new form of services, products, processes, organizations, or policies. In fact, some of these are often involved at the same time. For example, the successful introduction of new technological innovations could require the development of new roles for patients, complementary technologies, new processes, new business models, and policy changes (Keller et al., 2013).
Given increasing academic interest in open innovation, the approach to the healthcare context is constrained and less discussed as a way to study transparency and collaboration in healthcare, and open innovation analysis in healthcare contexts is currently gaping (Wass & Vimarlund, 2016). To the best of our information, there was no systematic presentation of the Implementing open innovation in the health care industry. Therefore, in the context of healthcare, more emphasis is needed on open innovation. The purpose of this review is to summarize current work and present it on the commitment to open innovation in the healthcare ecosystem.

Methods
A systematic review was performed of the literature to fulfill this study's research objective. This review followed the authors reporting a systematic review of the PRISMA guidelines.

Information Source
Studies were identified to 12 January 2020. They were selected by searching the online databases PubMed, Web of science, Scopus, and Embase, and Search Google Scholar. Searches included online books, published papers, conference abstracts and seminar and reference publications to avoid bias in publishing and to ensure that as many articles as possible were included. Additionally, the selected articles reference lists were searched for other relevant studies. In addition, the bibliographies of articles and reviews published were searched by hand for potentially relevant articles. An online archive email warning feature was developed to keep track of any newly released publications that meet the selection criteria based on the saved search history by 12 January 2020.

Eligibility Criteria
Reviewers separately appraised the titles of the papers. The publications were classified into a category "definitely remove" and a category "probably include;" the abstract of any of the papers likely included was assessed. Studies that contained abstracts that did not meet the criteria for inclusion were ruled out. The entire text of the remaining articles was assessed and duplicate articles were deleted. Articles were eligible when they reported instrument development, validation or translation studies of open innovation in health area. In addition, only articles written in English were included, and from which full text access was available. Letters to the editor, commentary, review and opinion papers were also excluded. There was no limit on publishing year.

Search
The search terms were derived from the concepts in the research objective: open innovation, medicine, medical, care, health, healthcare and health care. This resulted in the following syntax.
("open innovation" AND (health OR medicine OR medical OR care OR healthcare OR "health care")) Potentially relevant papers were selected first based on title and imported into the Endnote. Further selection was performed on the basis of the papers' abstract and full text.

Article Selection
An overview of the selection process for the entire article is shown in Figure 1 of the PRISMA flow chart. Two hundred and two articles based on title were selected. They analyzed the abstracts and excluded 133 articles as they did not meet the eligibility criteria. By reading the full text, the remaining 69 articles were further assessed as eligibility. 40 were excluded from this Finally, 29 articles were included in the analysis.

Data Collection Process
The type of study had been determined for each article. It was followed by extracting information according to various templates appropriate for these types of research studies, discussed in the next section.

Data Items
The full text of the chosen articles was then independently reviewed by the reviewer. The standardized data extraction form was used to extract the data from the selected articles. The data extraction sheet for each study included the authors and year, country, research type, aim of research, stakeholders, key findings, open innovation context, open innovation outcome and stage in the open innovation process. All results were collated from the selected studies. Another independent investigator reviewed and verified for completeness and consistency of all data entries.

Quality Assessment
The consistency of the initially chosen research was assessed and analyzed to support the inclusion / exclusion process. The essential testing method used was a fairly modern checklist intended to evaluate mixed tests of reliability and validity, or to measure validity and reliability as independent elements. There are 13 points on the checklist. This tool was developed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and the Quality Appraisal of Reliability Studies (QAREL) tool. Two researchers have analyzed all of the identified research for threat of bias. Researchers were judged to be of good standard because they earned 60%. All differences were overcome by agreement. Figure 1 presents a flow diagram based on the PRISMA guidelines, which details the movement of articles through the review process. In total, 5295 titles were retrieved from the databases and 1859 titles remained after duplicated articles were removed. Two reviewers screened the titles and abstracts for relevance, and 1657 articles were deemed irrelevant to the review topic and were excluded. Two hundred two articles were selected based on title. The abstracts were analyzed and 133 articles were excluded as they did not meet the eligibility criteria. In total, 69 full-text articles were retrieved and assessed according to the eligibility criteria. After the assessment, 40 articles were excluded (refer to Figure 1) and 29 articles were included in the review.  (Figure 2, 3), but nevertheless the results of the study show that this topic has been raised in the field of health from 2010; and now it is one of the topics of interest to researchers ( Figure 4). As can be seen in Figure 6, most of the studies are in the fields of pharmaceutical sciences (drug discovery) and health informatics (health information systems and infrastructures) that have been put forward as ideas or implemented as pilot and prototypes as well as most of these studies had product and service outcome. Consequently, words such as drug, platform development, model, and framework were used more in the studies. Also, all citizens, patients, and health care providers and managers have also been identified as stakeholders in most studies. Further studies were of the conceptual and Practical type that belonged to European countries such as Germany and Sweden. Among other countries, the United States has done well in this area ( Figure 5).

Discussion
In recent years the demands for managing innovation have changed dramatically. In the conventional understanding the in-house R&D department is the most significant source of creativity. Opening up to the outside world to better meet the growing demands changes this traditional understanding (Kratzer et al., 2017). The distinction between open innovation and closed innovation lies in how innovation is created. While in a self-contained enterprise environment a closed innovation is created, Open Innovation integrates external information into innovation management. A closed innovation is based on assuming that innovations are produced by the companies themselves. The innovation process is carried out exclusively within the company, from idea generation to development and marketing. Thus, it is impossible to open to the outside. Innovation is developed within the framework of the firm's clearly defined limits. Company know-how, technology, processes, and intellectual property remain under innovative control. Certain factors must be taken into account in order to implement a closed innovation successfully within the company. Closed Innovation, for example, sets very high employee demands so the company should always aim to recruit highly qualified employees. Protection of one's own intellectual property is also important (Alawamleh et al., 2018).
Open innovation involves opening up the innovation cycle outside client limits to maximize one's own creativity capacity through the successful strategic usage of the environment. While innovation emerges from the combination between internal and external concepts, techniques, procedures and networks between distribution with the company's goal of developing promising, innovative products, services or businesses models. It is possible to integrate own employees, customers, suppliers, LEAD users, universities, competitors or firms of other industries. However, sharing information and networking know-how that is characteristic of open innovation does not mean free access to a company's expertise and technologies. The word pertains only to social networking. Hence, open innovation will entail high license and other intellectual property costs (Comai, 2019).
The closed form of innovation has become increasingly less important in recent years as well as the importance of open innovation is steadily increasing. According to the studies the following variables are responsible for this growth: Highly trained professionals are becoming increasingly accessible and more interactive. Invest capital supply is on the rise. An innovative environment for a company offers opportunities outside of potentially unused innovations. As collaboration partners the increasing number of professional consumers and specialist suppliers available. A company's creative ecosystem is therefore progressively relevant, and the standard and quantity of external know-how is continuously rising (Svirina et al., 2016).
Although the value of open innovation is increasing, proceeding pursuing a closed approach to innovation or a combination of open and closed innovation can make sense for a company. In turn, whether an organization chooses open or closed experimentation as part of its product policy has three factors to depend on: a) Complex innovation: transparent innovation will bear some hazards because innovations are strongly linked; it may contain improper elements that impair the innovation mechanism itself, or even adversely affect the whole product line. b) Unique innovation: Closed innovation is generally favored when an innovation makes profound technical advances that offer the business an unassailable edge over its rivals. Open innovation thus works better where creativity is a continuous process where gains can be produced by collaboration. c) High competition: Closed innovation is usually better suited in industries with intensive competition to exploit the benefits for the company itself (Felin & Zenger, 2014;Marques, 2014).
Open innovation literature stresses the need for companies to collaborate with other players in order to identify new innovations and tools to remain successful, which can be represented by three separate key processes or practices. The first method, called inbound process, enhances the organization's creative ability by incorporating information from outside players into the internal knowledge base. The emphasis is on providing quality facilities leveraging business, academics, vendors and client's expertise. The second form is the inside out process, also referred to as outbound process, which focuses on income generation by moving internal, creative ideas to outside actors. The coupling process which focuses on combining the processes outside and inside by establishing alliances with complementary external actors is third type of process. Recognizing that an innovation cycle is not necessarily opened or closed, is critical. Therefore, open creativity is something like a continuum of increasing degrees of openness (Gassmann et al., 2010).
Generally, open innovation provides opportunities for creativity, as it leads to developing one's own entrepreneurship awareness. Open creativity, however, is not only a "replacement" for closed innovation but can be treated as complimentary. However, stable internal innovation structures and processes are the requirement for an opening up to the outside world to successfully integrate and utilize external knowledge (Lopez-Vega & Vanhaverbeke, 2009).
The consequence of most open innovation projects in healthcare, as can be seen in most studies, is service. Overall, however, the study of innovation often relates primarily to the notion of service, which is considered the key element of the modern service economy and the so-called innovation in services. Service innovation is a kind of open innovation which has recently gained popularity (Berry, 2019). Given the increasing economic importance of the service sector, service innovation plays a vital role to accelerate development in a knowledge-intensive economy today (Ciasullo et al., 2017). Such form of innovation is sensitive to enhanced consumer feedback, interactivity and specialization; is multidimensional in nature; and incorporates economic, efficiency, and production dimensions. Increased consumer interactivity services provide expanded incentives for innovation by experiences requiring enhanced information exchange and learning activities and these higher-order skills lead to service innovation (Bitner et al., 2008).
As the details in this essay demonstrate, service innovation is not only feasible but also necessary in healthcare. Traditionally, the healthcare industry has not encountered significant external competition to be successful in-service delivery, but it does so now (Barrett et al., 2015). Wasteful expenditure is widespread and there is an immense demand to control costs. Business conditions are increasingly evolving, and economic stability for a healthcare institution is no longer a guarantee. Non-traditional competition and non-traditional technologies, among other market factors, need a broad-based effort to increase performance and clinical and service quality, in order to meet the demands that most consumers today have when they view healthcare progressively through a customer lens (Lusch & Nambisan, 2015). The complexity of healthcare as a company raises difficulties in introducing service innovation. However, local hospital services have simply, operationally and effectively, taken on the role of the innovation service. That remains for this necessity is to propagate more broadly and more consistently, including experts in the area of communications, such that attending to the "customer experience" is one of the key priorities on how healthcare is provided worldwide (Joiner & Lusch, 2016).
Examination of the present study shows that drug discovery is the one of the most important needs of the healthcare sector, which led to the creation of open innovation. Open innovation has not come to the pharmaceutical industry of course. While in the early 2000's the consumer goods and manufacturing industries rapidly embraced open innovation, the pharmaceutical industry needed an extra push. This extra push came in the form of patent expirations (Munos, 2009). In the past years the pharmaceutical industries to develop new drugs is slow and have not productivity. The reality is that costs have escalated, and hence investment in R&D, with no concomitant increase in return on that investment (Coopers, 2007). The current success rates of the pharmaceutical industry are still not enough to sustain large internal R&D organizations, making the current operating model of the industry financially non-viable. Therefore, companies are seeking new avenues to either increase their level of innovation, cut costs or reduce risk. This situation pushed them towards embracing open innovation. Not for wanting to, simply because they had to. Faced with the highest failure rates in any industry, unprecedented discovery and development costs, heightened competition, the patent cliff and the increasing complexity of therapeutic intervention methods, biopharmaceutical companies had virtually no choice but to adopt open innovation in some way (Hunter & Stephens, 2010). It is very early, but there are signs that large pharmaceutical companies are prepared to move towards a more flexible and open way of working. But there are also barriers to the industry fully embracing this new way of working and adding it to other models for externalization. Perhaps the greatest obstacles to the full open pharmaceutical innovation implementation are cultural, and strong senior internal leadership in companies will be needed to ensure the necessary changes in mentality and behavior are encouraged (Munos, 2010).
A second reason for creating open innovation in this field is the need to create connected health in the health care sector. In recent years the connected health concept is gaining traction as a new technology has enabled and networked the delivery model of health care. It is also used as a generic word for eHealth, digital health, medical informatics, telemedicine, mHealth and includes building up and maintaining a network of partners with a view to enhancing the standard and results of medical care (Priyadarshini et al., 2017). However, the absence of open exchanges and information networks and the lack of integration with the broader population with interdisciplinary expertise hinder the implementation of the model and restrict the ability to establish programs and strategies using common health-related evidence across the needs of patients. Communication by stakeholders in an open innovative format in the health care ecosystem removes constraints and maximizes the concept of connected health (Kemppainen et al., 2019).
Another concept that was mostly observed in studies was the living lab. Living Labs become networks of innovation focused on the open innovation paradigm under which consumers are equal to all participants (Almirall & Wareham, 2008). Living labs can be classified in three major types: Living labs to learn and play with omnipresent computation, Living Labs as open platforms for innovation and Living Labs to expose testbed applications to users (Santoro & Conte, 2009). This awareness will allow them to recognize which actor drives creativity, to predict probable outcomes, and to determine what kind of role they should play when "living lab". Living labs are networks that can help them to create innovations that match the needs of the user and can be upgraded to the global market promptly. By living labs, we mean the space of interaction being reconstructed. It can be any place, wherever, appropriate for the use of innovation for collaborative design, the application of knowledge for empowerment, enhancement and growth of citizens and communities ( Leminen & Westerlund, 2012).
In scientific there are four specific forms of living labs that can be classified by the person guiding the activity and creativity activities of the network. These types are: user-driven, enabler-driven, supplier-driven, and user-driven living labs. The intent, the logic of value-creation and the results differ among the types. Participation in living labs can further assist companies in creating innovations that meet the needs of users and can be upgraded to a global market in a short time (Schuurman et al., 2016).

Conclusion
We discuss and address the usage of open innovation to healthcare environments in this report. The research indicates that open innovation is the main result, with innovative health information systems and products. At its initial level, the innovation process was researched, though also in innovation networks. Several scholars advocate for a step toward open healthcare innovation as a way to promote the possibilities of healthcare information systems. Even this review reveals that in changing conventional organizational boundaries and the role of supplier and customer the healthcare sector has been slow. The move from closed to open innovation has been described as a paradigm change in which it is important to turn from control to openness and evaluate processes in order to grab interest and produce value. A general conclusion from the report is that it suggests that open innovation research is at a premature stage in the healthcare sector. Even though the research concentrates on the promising results and challenges that impede open healthcare progress, they did not examine in detail and empirically whether open innovation has been placed into practice or what benefits and prerequisites there are for stakeholders. Consequently, more work is needed with an emphasis on how to handle open innovation in healthcare. Development of efficient accounting and information system able to process, store and share data.