Digitisation can make medicine more humane
Does artificial intelligence improve medical treatments? Will robots take over the tasks of physiotherapists? Are exoskeletons set to make walkers redundant? Three experts from the ZHAW talk about the secrets to successful digitisation in the healthcare sector and why we shouldn't be afraid of it.
Eveline Graf: I would, but only in interaction with people. After all, a robot can’t know how I am feeling at any one moment in time. A person can pick up on this very quickly, allowing them to put the robot to appropriate use. This means that I receive my therapy when I actually need it and not when the therapist has time.
Sven Hirsch: In the field of microsurgery, in particular, robot assistants offer great advantages: robotic software can, for example, eliminate the effects of a surgeon's hand tremors on instrument movements. This means they can then perform their work with millimetre-precision. I would certainly welcome this if I ever found myself on the operating table..
“If the digitisation of healthcare is implemented correctly, it will provide an opportunity to improve quality at a low cost.” Alfred Angerer, this quote is taken from the fourth edition of the Swiss Digital Health Report, which is set to appear this autumn. Are these simply nice words? Or is there real substance to this statement?
Alfred Angerer: There absolutely is. In terms of quality, you can cite any number of studies that show that digitisation leads to improved healthcare and better process quality. Artificial intelligence will, for example, achieve better results than a doctor with average skills. All of this is beyond dispute.
Angerer: When it comes to costs, the picture isn't quite as clear. While it is true that the same service can be provided at a lower cost, premiums will not go down from one day to the next. These savings will be offset by volume growth.
Angerer: I like to use straightforward definitions and this is reflected in our own definition. For us, digital health can be defined as the use of modern information and communication technology in the healthcare sector with the aim of achieving higher quality at lower costs and with a greater focus on patients.
Hirsch: What I like about the term digital health is that it makes a nod to the digital transformation, which is a social project in which both people and technology play a role.
Graf: The digitisation of the healthcare sector isn't simply an IT project. However, not everyone understands this yet.
Angerer: One of the core elements in getting this process right will be gaining an in-depth understanding of users and their needs – you have to get the people who can benefit from the new solutions on board with you. Data and knowledge about the respective health sector as well as robust and secure disruptive technologies will also be key. The organisations need to be prepared, while processes and procedures will have to be adapted. And, last but not least, good framework conditions will be essential to ensuring an ecosystem with sustainable business models. These are the secrets to successful digitisation.
Angerer: In a project conducted with family doctor practices, we investigated how it might be possible to integrate so-called patient-reported outcome measures, or PROMs for short, in a useful way. PROMs are questionnaires that patients complete in order to provide a picture of their symptoms, quality of life and other aspects of their health and well-being. This is important information for the provision of treatment. In our case, they were digital questionnaires. It was not the technology that was the problem here: upon arriving at the practice, the first thing that patients were given was a tablet on which they had to answer a series of questions – you can put together something like this with a simple design. The information was then transferred to the respective doctor's computer. In itself, this is a simple process. However, somebody needs to take responsibility for answering the questions of how this process will fit into the already stressful routine of everyday practice life, how the questionnaire and user interface need to be designed, how much time the whole thing is going to take and which individuals will be involved. If this doesn’t happen, such an innovation will never get off the ground, as nobody will use it. Complicated processes are not a welcome addition to busy practice life.
Hirsch: And this is precisely where the ZHAW comes in. In performing our applied research, we bring together the various perspectives. This is also the case in the Innosuisse-funded SHIFT project, which Alfred Angerer and I are leading. My sub-project is specifically looking at the use of wearables, in other words mini-computers that measure vital data such as blood pressure and blood oxygen saturation levels. This work is throwing up many questions: Where should these devices be put on? Which specialist should assume responsibility for doing so? Which devices are suitable for different demographic groups? There are many small details that have to be considered and that will be vital if this solution is to work for everyone. We are looking at the same topic in our Digital Health Zurich project, a practice lab for patient-centred clinical innovation. As a core project, we are developing a PROM platform. Here, too, the question arises as to where the needs of patients will actually be ascertained and which specialist will assume responsibility for this task? Will this be taken care of as part of a consultation? You always have to take account of the users’ perspective. This will be crucial for the success of digitisation. The technology simply provides the foundation on which to build.
Angerer: In our Digital Health Report, we have identified five potentially disruptive technologies: artificial intelligence, the Internet of Medical Things, robotics, virtual, augmented and mixed reality, and blockchains. Artificial intelligence solutions, in particular, represent a significant growth market with great promise. The revenue generated from these solutions in 2022 has been estimated at USD 7 billion, with this figure expected to rise to approximately USD 67 billion by 2027. As AI offers a wide variety of different methods and, as a general purpose technology, can be combined very easily with other technology groups, the potential is enormous.
“You always have to take account of the users’ perspective. This will be crucial for the success of digitisation. The technology simply provides the foundation on which to build.”
Hirsch: What is needed are explanatory artificial intelligence methods that allow people to understand the data and criteria on the basis of which a diagnosis or treatment recommendation has been made. At present, AI is still a black box, meaning we don’t know how the result of machine learning comes about.
Angerer: We are now one and a half years into the project. From a technical standpoint, a great deal has already been tried out and we are well on track. The next major challenge that we are facing right now is how we are going to bring all of the results together and create something like a master plan. Such a transformation blueprint should help hospital directors in understanding how their facilities can be made “smart” and “liquid.” Together with the hospitals, we are currently developing a roadmap for this purpose. Here, we are performing real pioneering work in collaboration with our research and industry partners. You have to remember that there had previously been no data or concepts on how to transform a hospital.
Hirsch: A further example is the OR-X surgical research and teaching centre – an operating room of the future for orthopaedics at Balgrist University Hospital. Here, we are a welcome partner who can help to develop solutions that an OR team needs to train for reality. We are developing teaching tools, demonstrators, databases and machine learning algorithms. This is applied research, and we at the ZHAW are at the very pinnacle of this field.
Graf: At the “GEKONT” competence centre, we held a workshop in the summer together with elderly and even very elderly people and their relatives that looked at technologies for living in old age. The focus was placed on technologies designed to make life easier at home. They included electronic tablet boxes, electric aids to help people stand up when using the toilet, automatic jar openers and intelligent emergency buttons. We wanted to hear their opinion on these technologies and get to know the problems faced by the participants in their everyday lives so that we could understand what else they might need to enable them to lead a longer autonomous life at home. It is also important, however, that such individuals can voice their fears with regard to new technologies. As things stand, there is almost no data available on this aspect. Social discourse on this matter must ultimately be initiated.
Angerer: We can be quite relaxed about this: firstly, if we take a look back at history, we can see that the population is really quite adept at adapting to new developments. E-banking is a prime example of this. Depending on the country, between 70% and 80% of the population now use e-banking as a matter of course. I can give you another example from one of our projects, where we offer support to practices in Germany with digitisation and optimisation measures. To begin with, there was a great fear that making appointments online would prove to be absurd for many people, especially for the elderly. However, this didn’t turn out to be the case. Older people who couldn't do this themselves got help from their grandchildren.
“Developers often have little-to-no understanding of what the situation is like at a practice. They assume that all the practices now have to do is learn how to use these devices.”
Graf: Saying that older people are less tech-savvy is a bit of a myth. Of course, there are some who don’t want to use new technologies, but this also applies to a number of young people. Nevertheless, it is important to support people who don't have much direct access to such solutions. At present, however, it is not only unclear who is responsible here, but also who has the necessary skills to teach something like this. In many cases, it is grandchildren or relatives who lend a helping hand. Or organisations like Pro Senectute, which offer training courses. When implementing such solutions, it is important to consider how to make sure that everyone who wants to use these services actually can – even if they perhaps don’t have the ideal conditions for doing so.
Hirsch: There is also an enormous need for further training here. At medical practices, there is almost a complete lack of expertise when it comes to how a digitisation process needs to be implemented. As practices are economic units in their own right, it would make sense for standards to be introduced in these areas so that they can draw on tried-and-tested practices.
“We could bring about the democratisation of medicine with digitisation.”
Graf: I believe that one reason for this gap is the fact that all of these technological and digital solutions have emerged from the development departments of technology firms. These experts often have little-to-no understanding of what the situation is like at a practice. There is an assumption that all the practices now have to do is learn how to use these devices and then everything will run like clockwork. However, it might perhaps be a good idea for developers to also have a better understanding of what the everyday life of users looks like. Interdisciplinary training opportunities and degree programmes can help here. And there are ever more of them on offer, including at the ZHAW. These train people to work at the interface between different areas, helping to satisfy the urgent need for such individuals.
Angerer: The situation really is shameful. In a 2018 study conducted by the Bertelsmann Stiftung, Switzerland was ranked 14th out of 17. If you look at the reasons why an innovation succeeds or fails, there are three main components, which I describe as what is “possible, wanted and allowed.” With digital health, it is not a question of what is “possible.” When it comes to technology, we’re in a really strong position. Half the blame can be laid at the door of what is “allowed,” in other words the legislation in place. While you are allowed to do a great deal, there are few incentives to actually do so. The biggest hurdle to overcome is that the transformation isn’t sufficiently “wanted.” People have not yet come to the realisation that digitisation represents an enormous opportunity for the healthcare sector. There is not enough drive behind the whole thing – not only among Switzerland’s citizens, but also among service providers and politicians. Yet we could bring about the democratisation of medicine with digitisation.
Angerer: We like to look at the issue from our Western and privileged standpoint. I would like people to look at the big picture: for African countries, this would facilitate access to healthcare services. In our report, we write that 47 African countries need three times as many doctors as they currently have today. With digitised healthcare services, we could help to close this gap.
Hirsch: We are working on a project in Zimbabwe with pregnant women. Their blood pressure, for example, is not monitored at regular intervals, meaning that complications are not seen. For us, this is something we take for granted. However, if you have to cover 100 kilometres just to get to the nearest hospital, the situation is different. Nobody is going to head there one day and back again the next simply for a preventive appointment. Digital health would represent a major opportunity here. We are currently conducting testing there so as to identify what a good solution might look like.
“If the spread of this new solution were to continue in a linear fashion, it would be another 6,500 years before everyone in Switzerland has an EPR.”
Angerer: In Switzerland, we have been waiting for the electronic patient record, also referred to as the EPR, for 13 years now. Just 0.2% of people in this country have such an EPR. If the spread of this new solution were to continue in a linear fashion, it would be another 6,500 years before everyone has an EPR. In contrast, I can go to my Amazon account and see which book I purchased back in 2001, some 22 years ago when I finished my studies. However, I have no idea anymore what the doctor told me when I had an allergy test at around the same time. In other words, we are at least 20 years behind.
Graf: The coronavirus pandemic demonstrated that things can move much faster when the pressure is on. Unfortunately, this didn't apply to the healthcare sector, where there is still too little pressure. We still make do with this outdated system.
Angerer: I don’t have one, because at the time I would have had to travel from Winterthur to Aarau to apply for it in person. That was too much effort for me. Things have become easier in the meantime.
Graf: I don't have one either. I did hear from a colleague, however, that her doctor refused to fill out a form when she wanted to open an EPR. This doesn't make any sense either.
Hirsch: I live in both Germany and Switzerland and it doesn't work across borders. I would be happy, however, if I no longer had to take CDs to the doctors with me.
“I feel that to some extent the issue of data protection is just a pretext. From a technological standpoint, it is possible to design secure systems.”
Hirsch: I feel that to some extent the issue of data protection is just a pretext. From a technological standpoint, it is possible to create secure systems by design. And in studies that use digital health data, the issue of ethics is observed. Nothing gets stolen here. The problem is more that data protection in Switzerland is a cantonal matter, which means that there is a myriad of different regulations. The best thing you can do, however, it to offer good and simple security standards for the organisations. If I as the state provide good support to the various players and say that these are the tools you have and these are the rules you have to follow, then data protection is not the problem.
Angerer: If things continue to move at such a snail’s pace in terms of digitisation, then current providers in this area will vanish from the market, and in the end we will be left with the Googles and Facebooks of this world. I don't want to entrust them with my data either.
Graf: I think that people are quite willing to share their data via Facebook and similar platforms and are perhaps not aware that they may possibly already be disclosing health information today. I am convinced that when people see the actual benefits of digital health, the data protection debate will quickly be put to one side.
Angerer: That’s not how health insurance companies work at the moment. And we as a society have said that we want basic insurance and a system in which everyone is covered by mandatory insurance and receives good care. Those are the rules of the game today.
Hirsch: It isn't a question of digitisation. The question is do we as a society as a whole want to be jointly and severally liable – yes or no?
Graf: My experience with health insurance companies to date is that they are interested in ensuring that their policyholders receive good and efficient treatment. However, the healthcare sector as it stands isn't efficient: people with more complex health problems, for example individuals who have suffered a stroke, need to go to physiotherapy, complete occupational therapy and perhaps also have to undergo neurological treatment as well as further treatment with their family doctor. In each instance, they find themselves having to endure the same questions. This alone costs time and money. This information could be recorded centrally and shared with everyone, saving costs in the process.
“Repetitive tasks can be performed by machines, leaving more time for human exchanges.”
Graf: Technology and digitisation will ensure that healthcare professionals can relinquish repetitive tasks. The distribution of medicines could also be performed by a machine. Staff may also be relieved of the burden of having to make decisions based on the analysis of large volumes of data. The time saved could be used for human exchanges that may perhaps yield further information that is important for the treatment to be provided. For this reason, I don't believe there is any danger that fewer nurses will be needed. Human expertise is essential.
Angerer: Nursing staff at hospitals spend only 30 percent of their time with patients. You wouldn't believe how much administration we expect of these skilled professionals, and digitisation can help here.
Graf: Healthcare professionals will not be completely replaced by robots. I see no risk in that regard. One-to-one exchanges between people are highly relevant. Technologies that can fully grasp a person and their circumstances so quickly will never exit – and if they were to, we certainly won't see them in the next 20 years.
Hirsch: I like the idea of a “liquid” system, something that we also address very strongly in the SHIFT project. In this scenario, the physical boundaries between different institutions become more permeable. This means that patients are already known to the healthcare professionals working at hospitals before being admitted, as they can also communicate directly with the hospital physicians from home. The patient will then be optimally prepared for their stay, while any aftercare will also be made easier. This would represent the successful provision of integrated care or a hospital at home programme, and this will be a reality in 20 years’ time.
Angerer: My vision is very concrete: if I were to go to the doctor today complaining of a migraine, they would perhaps do an MRI and not see anything. They thus wouldn't know what the cause was. It is my hope that in 20 years the doctor will know what is going on with me, as they will be able to draw on a combination of so many different data sources. They will know, for example, that I have slept badly, that I am under stress, that my diet is not good or that I am getting too little exercise. And they will be able to tell me the reason why I am not feeling so good. Or, even more ideally, they will be able to tell me what I have to do to get better. This is the kind of healthcare system I would like to see.
The Winterthur Institute of Health Economics (WIG) is a competence centre for economic and business administration issues in the field of healthcare. It places a focus on health technology assessments (HTAs), health economic evaluations, health service research, patient classification systems, health policy, strategy and process optimisation, market analyses and integrated care.
The ZHAW Digital Health Lab and GEKONT competence centres are interdisciplinary networks of expertise based at the ZHAW. They create practical, people-centred innovations for the healthcare sector with the aim of improving healthcare provision and promoting the transfer of technology between the realms of science, business and society.
SHIFT is a flagship project of Innosuisse, the federal government’s Swiss Innovation Agency. SHIFT stands for Smart Hospital: Integrated Framework, Tools and Solutions. The research project is set to run until June 2025 and has a total budget of CHF 5.7 million. Over three and a half years, a consortium headed up by the ZHAW will investigate how hospitals can be transformed to be fit for the future – together with four other research partners (UBS, UZH, FNHW and UNIBAS), around 20 hospitals and 24 industry partners. The focus of this work will be on creating the smart hospital of the future.
PROMs are questionnaires that patients complete in order to provide a picture of their symptoms, quality of life and other aspects of their health and well-being. They systematically measure treatment success from a patient perspective. PROMS can also promote personalised medicine.
A podcast on the topic of management and leadership in the healthcare sector. Alfred Angerer is a Professor for Healthcare Management at the ZHAW and founder of the "Marktplatz Gesundheitswesen" ["Healthcare Marketplace"] podcast. In the podcast, he interviews interesting people with whom he discusses current trends. In doing so, he adopts a forward-looking perspective and gives ample attention to the topics of digitisation and process optimisation.