Digital transformation, Uberization: threats or opportunities for the healthcare sector?
While it has become commonplace to talk about the digital revolution, it is clear that the development of connected and communicating objects, as well as the rise of new Internet services, are giving rise to radical innovations that are shaking up the economy.
Roxana Ologeanu-Taddei, University of Montpellier and David Morquin, University of Montpellier
While it has become commonplace to talk about the digital revolution, it is clear that the development of connected and communicating objects, as well as the rise of new Internet services, are giving rise to radical innovations that are shaking up the economy.
The example of the self-driving car is undoubtedly one of the most prominent in people's minds, presenting new challenges: technical reliability and safety, and above all the sharing of responsibility among industry players due to the integration of new entrants (companies entering a new market), namely the Internet giants such as Google, Apple, Microsoft, AmazonNew services are being tested, such as communication between connected or autonomous cars and home appliances, and remote control of certain devices.
Regarding new Internet services in France, the platform economy, in sectors as varied as passenger transport (BlaBlaCar, Uber), accommodation (AirBnB), the crowdfunding (Kisskissbankbank), or parking (Mr. Parking), renders existing models obsolete, particularly in sectors where exclusive practice was guaranteed by professional licensing.
Rapid changes in the environment affecting health
Although more protected than other economic sectors by strong barriers to entry linked to strict public and professional regulation (Conseil de l’Ordre national des médecins), the healthcare sector is also affected by this dual transformation: the emergence of new connected products and new services via specific networking platforms.
Already, in both private practices and hospitals, information technologies have been integrated into the daily work of doctors: prescription assistance software, clinical decision support systems, secure professional messaging, appointment and home visit management software, and above all clinical software, including electronic medical records, which enable the organization and storage of the patient's medical information needed for diagnosis and care.
Far from being limited to the storage of information, the digitization of medical information is transforming professions by changing the way healthcare professionals communicate and coordinate with each other, enabling the emergence of new telemedicine practices and creating a need for specific technological skills to implement them.
Health apps for patients: are doctors losing control?
On the patient side, new medical information websites offer free, more personalized advice services, such as Mesvaccins.net, aimed at travelers and published by an association of travel medicine experts including several medical professors. Using a series of questionnaires based on the destination country and the traveler's history, it offers targeted vaccination advice as well as an electronic vaccination record, which can be validated by a healthcare professional (such as a general practitioner), medical information for healthcare professionals, and a software solution for managing vaccination centers.
In addition, there are currently more than 750 French-language health apps, ranging from diabetes monitoring to the monitoring of various health parameters and therapeutic education, such as Mission Phosphore, developed by Sanofi and intended for patients with chronic kidney failure to teach them how to take their treatment more effectively and make the best dietary choices.
Doctors need to take an interest in these apps in order to advise their patients, but there is currently no regulatory framework for evaluating the medical benefits of these apps, unlike the existing processes for drugs and medical devices.
Two responses can therefore be considered: doctors can prescribe these apps based on advertising and industry lobbying, following models familiar inthe pharmaceutical industry, or they can ignore them completely, leaving patients to choose based on more or less opaque criteria from rankings published by consumer magazines and websites, as Doctissimo does for diabetes management apps.
Or they may use an additional app to search for the best health apps based on user feedback.
In both cases, the attending physician may lose control of a significant amount of personalized information and medical advice that could influence the quality of patient care. Could this phenomenon go so far as to call into question the role of the physician in terms of diagnostic skills and therapeutic choices, as suggested by current discourse on the role of big data?
From connected patients to autonomous patients?
For the time being, big data projects using medical data (electronic health records, telemedicine software, and connected biomedical devices) are still in their infancy due to difficulties in sharing data, linked in particular to the lack of interoperability between existing software and harmonization of the terminology used, in a context where the sector is fragmented and compartmentalized.
Furthermore, the processing of computer data, including big data, requires a redefinition of responsibilities and roles. Medical information is regulated by law due to medical confidentiality. In France, doctors in the Medical Informatics Departments (DIM) are responsible for processing this personal information within each institution, which is necessary for analyzing activity and reimbursing costs related to patient care by the Health Insurance system. What about anonymized medical information? Who owns this data, and who can be responsible for processing it, programming this processing, and using the results of automatic processing?
For now, Apple and IBM are sketching out a new model in which big data from Apple's smartwatch would feed into IBM's artificial intelligence program, called Watson. The major Internet companies have the financial capacity, technological expertise, agility required for innovation, and a global customer base to experiment with new expert system models that could herald the advent of "automatic" doctors or "autonomous" patients, as announced in the prospective report published by the University of Oxford. However, while big data analysis can be used to establish a diagnosis and therapeutic proposal for a given individual, the question of how to share medical responsibility with software publishers remains to be defined.
New health services, a Trojan horse for the commodification of health
Software publishers and pure Internet players are not the only drivers of change. Healthcare professionals themselves are using technology to create new services. For example, the iDoc24 and Epiderm apps offer remote dermatological consultations for a fee, based on photos and information about symptoms provided by patients. Other examples include the Expenli website, which allows users to ask doctors questions online 24 hours a day, and DirectoDoc, which allows patients to use their smartphones to request a callback from their primary care physician, who will call them back for a telephone consultation when available. Another website published by a medical association, Deuxièmeavis.fr, offers patients expert advice on specific medical situations outside the pricing framework set by the CNAM. Does this type of website herald the rise of paid services, as initiated by numerous telemedicine apps on smartphones in the United States?
Paradoxically, the restrictive regulatory framework forthe practice of telemedicine is encouraging the emergence of paid medical services outside the reimbursement system, allowing the potential of the Internet to be exploited and meeting the demand for ease and accessibility of standard medical services. Recently, the French Medical Council highlighted this contradiction, calling for regulation of the sector while ensuring flexibility for telemedicine, which, through the digitization of patient records, has been integrated into the daily practice of physicians.
Uber in healthcare?
Alongside medical services and medical information, new networking platforms are targeting specific markets, such as online medical appointment booking and patient transport.
Several players are competing for the online medical appointment booking market: Doctolib, KelDoc, Dokiliko, and Allodocteurs. Among them, MonDocteur.fr, which was acquired by Doctissimo, the Lagardère group's health brand, stands out by offering an additional service: it has just partnered with Uber to allow its users to book a driver to take them to their doctor's appointment.
However, the platform's business model can only remain on the fringes of the healthcare sector, as it requires the existence of a competitive market with numerous service providers (taxi drivers for Uber) and the definition of a standard service (transportation of people for Uber). These conditions are not met by medical services, as France is affected by a shortage of doctors and medical services cannot be defined in a standardized way on a large scale. Unless certain doctors abandon their practices in favor of online expertise, or app and online service publishers outsource medical expertise to doctors located abroad, which is unlikely due to labor market legislation. Furthermore, medical prescriptions, which engage the legal responsibility of the prescriber, are not offered by existing applications and services outside the framework of telemedicine.
However, Uber offers an innovative service (accessibility and flexibility of ordering), which differs from the existing service, perceived as inadequate (expensive, restrictive, inconvenient—since orders often have to be placed in advance), provided by players in a monopoly situation. The goal of digital transformation in the healthcare sector must remain the provision of innovative services.
On the healthcare system side, we can imagine accessibility and ease of use at the heart of innovation for patients, such as e-prescriptions, implemented nationally in several countries such as the United Kingdom, Finland, and Sweden, to facilitate the transfer of prescriptions between doctors and pharmacists and allow patients to view prescribed and dispensed prescriptions.
From the doctor's point of view, whether it is remote medical applications and services or the use of predictive algorithms that analyze big data to propose diagnoses and treatments, the question arises of redefining their profession: what part of the job cannot be automated? What part of the job can only be done face-to-face? In what situations are the doctor-patient relationship (listening, psychological support) and clinical examination particularly essential compared to other digitized information?
Avoiding the Kodak syndrome
Digital technology is driving change in the healthcare sector, which may lead to resistance from stakeholders in the system (healthcare professionals, regulatory bodies, public and private institutions), who are keen to avoid challenging the rules of the game and redefining them to take account of new entrants. However, the besieged citadel syndrome risks leading toKodak effect : the continuation of a proven business model (selling silver halide photographic film) while ignoring changes in the environment and the impact of technology, which led to Kodak's bankruptcy.
The question facing healthcare stakeholders is not whether to move toward regulation and/or deregulation, paid or free services, or the use or rejection of information technology, but rather how to use digital technology as an opportunity to provide better patient care by offering new services, rather than simply accepting the technology and models proposed by software publishers. The digital transformation of the sector must involve an analysis of the risks and challenges associated with the various technologies used, as is done for autonomous cars.
Roxana Ologeanu-Taddei, Senior Lecturer, HDR, Information Systems Management and Health, University of Montpellier and David Morquin, Doctor of Medicine, Montpellier University Hospital, University of Montpellier
The original version of this article was published on The Conversation.