Digital transformation, uberization: threats or opportunities for the healthcare sector?

While it's become commonplace to speak of the digital revolution, it's clear that the development of connected and communicating objects, and the rise of new services on the Internet, 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's become commonplace to speak of the digital revolution, it's clear that the development of connected and communicating objects, and the rise of new services on the Internet, are giving rise to radical innovations that are shaking up the economy.
The example of autonomous car is undoubtedly one of the most present in people's minds, with new issues at stake: technical reliability and safetyand, above all, the sharing of responsibility between industry players due to the integration of new entrants (companies entering a new market) such as the Internet majors Google, Apple and Microsoft, Amazon. New services are being tested, such as the dialogue between the connected or autonomous car and domestic equipment, and the remote control of certain appliances.
With regard to new Internet services in France, theplatform economyin sectors as varied as passenger transport (BlaBlaCar, Uber), accommodation (AirBnB), the crowdfunding (Kisskissbank), or parking (MrParking), renders existing models obsolete, particularly in sectors where exclusivity of practice was guaranteed by the professional license.

Rapid environmental change affecting health

Although more protected than other economic sectors by strong barriers to entry, linked to public regulation and strong 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 practices and hospitals alike, information technologies have been integrated into doctors' day-to-day practice: prescription support software, clinical decision support systems, professional secure messaging systems, appointment and home visit management software and, above all, clinical software such as the computerized medical record, which organizes and stores the patient's medical information required for diagnosis and treatment.
The dematerialization of medical information, far from being limited to the medium on which it is stored, is leading to a transformation of professions by modifying the methods of exchange and coordination between healthcare professionals, enabling the emergence of new telemedicine practices and justifying the need for specific technological skills for their implementation.

Health applications for patients: are GPs losing control?

On the patient side, new medical information sites are offering free, more personalized advice services, such as Mesvaccins.net, a site for travelers edited by an association of travel medicine experts including several professors of medicine. Using a cascading algorithm of questionnaires based on the traveler's country of destination and medical history, it offers targeted vaccination advice, as well as an electronic vaccination record that can be validated by a healthcare professional (such as the attending physician), medical information for healthcare professionals and a software solution for managing vaccination centers.
In addition, there are currently more than 750 French-language health applications, ranging from diabetes monitoring to the surveillance of various health parameters, or therapeutic education, such as Mission Phosphore, developed by Sanofi and aimed at chronic kidney failure patients to teach them how to take their treatment more effectively and make the best dietary choices.
At present, however, there is no regulatory framework for evaluating the medical benefits rendered by these applications, unlike existing processes for drugs or medical devices.
There are two possible solutions to this problem: either the doctor becomes a prescriber of these applications, relying on the advertising and lobbying efforts of manufacturers, as is the case in thepharmaceutical industry, or he or she loses interest in them altogether, even if it means letting the patient choose according to the more or less opaque criteria of the rankings drawn up by mainstream magazines and websites, as Doctissimo does for diabetes management applications.
or by using an additional application to search for the best health applications, 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 follow-up. Could this phenomenon go so far as to call into question the doctor's role in terms of diagnostic skills and therapeutic choices, as current discourse on the role of Big Data suggests?

From connected patient to autonomous patient?

For the time being, big data projects using medical data (Electronic Patient Record, telemedicine software and connected biomedical devices) are still in their infancy, due to the difficulties of sharing data, linked in particular to the lack of interoperability of existing software and harmonization of reference systems for the terminologies used, in a context where the sector's organization is fragmented and compartmentalized.
In addition, the processing of computerized data, including Big Data, calls for a redefinition of responsibilities and professions. In fact, medical information is governed by the law, due to medical confidentiality. In France, it is the doctors in the Medical Data Processing Departments (Départements d'Informatique Médicale - DIM) who are responsible for processing this nominal information within each establishment, necessary for analyzing activity and reimbursing expenses linked to patient care by the Assurance Maladie. What about anonymized medical information? Who owns this data, then, and who can be responsible for processing it, programming it and using the results of automatic processing?
For the time being, Apple and IBM are sketching out a new model whereby Big Data from Apple's connected watch would feed IBM's artificial intelligence program, called Watson. The Internet majors have the financial capacity, the technological skills, the agility required for innovation and the global customer portfolio to experiment with new expert system models that could prefigure the advent of "automatic" doctors or "autonomous" patients, as predicted by the foresight report published by Oxford University. However, if Big Data analysis can be used to establish a diagnosis and a therapeutic proposal for a given individual, it remains to be defined how medical responsibility will be shared with software publishers.

New healthcare services, the Trojan horse of the commodification of healthcare

Software publishers and Internet pure players are not the only vectors of change. Healthcare professionals themselves are using technology to create new services. For example, the iDoc24 and Epiderm applications offer a paid dermatologist's opinion remotely, based on photos and symptom information provided by patients. There's also the Expenli site, which lets you ask doctors questions online 24 hours a day, and DirectoDoc, which lets patients use their smartphone to activate a call-back request from their GP, who will call them back for a telephone consultation when he or she is available. Another site published by a medical association, Deuxièmeavis.fr, offers patients expert advice on a given medical situation, outside the tariff framework set by the CNAM. Does this type of site herald the rise of a pay-as-you-go offering, as initiated by numerous telemedicine applications on smartphones in the United States?
Paradoxically, the restrictive regulatory framework fortelemedicine encourages the emergence of paid medical services on the bangs of the reimbursement system, making it possible to exploit the potential of the Internet and meet a demand for ease and accessibility of a standard medical service. Recently, the French Medical Council (Conseil de l'Ordre des Médecins) pointed out this contradiction, calling for regulation of the sector while guaranteeing flexibility for telemedicine which, through the digitization of patient records, has been integrated into doctors' daily practice.

Uber in healthcare?

Alongside medical services and medical information, new contact platforms are targeting specific markets, such as online medical appointment booking or patient transport.
When it comes to booking medical appointments online, several players are vying for a share of the market: Doctolib, KelDoc, Dokiliko and Allodocteurs. Among them, MonDocteur.fr, which has been acquired by Doctissimo, the Lagardère Group's health brand, is differentiating itself by providing a complementary service: it has just partnered with Uber to enable its users to book a driver to visit their doctor.
However, the platform's business model can only remain on the bangs of the healthcare sector, since this model requires the existence of a competitive market, in which numerous service providers are present (cab drivers for Uber) and the definition of a standard service (transporting people for Uber). These conditions are not met by the medical service, since France is affected by a shortage of doctors, and the medical service cannot be defined on a large-scale standard basis. Unless some doctors abandon the practice for online expertise, or publishers of online applications and services outsource medical expertise to doctors located abroad - an unlikely phenomenon due to labor market legislation. What's more, medical prescriptions, which engage the prescriber's legal liability, are not offered by existing apps and services outside the telemedicine framework.
But Uber offers an innovative service (accessibility and flexibility of ordering), which stands out from the existing service perceived as insufficient (expensive, restrictive, impractical - since you often have to place an order in advance), provided by players in a monopoly situation. The goal of digital transformation in the healthcare sector must continue to be the provision of innovative services.
On the healthcare system side, we can imagine accessibility and ease of use at the heart of innovation for the patient, such as e-prescription, implemented at national level in several countries such as the UK, Finland and Sweden, to facilitate the transfer of prescriptions between doctors and pharmacists and enable patients to consult prescriptions prescribed and dispensed.
On the doctor's side, whether we're talking about remote medical applications and services, or the use of predictive algorithms to analyze Big Data and propose diagnoses and therapies, the question arises of redefining his or her profession: how much of the job cannot be automated? how much of the job can only be done face-to-face? In which situations are the relationship between doctor and patient (listening, psychological support) and the clinical examination particularly essential, compared with other digitized information?

Avoid the Kodak syndrome

Digital technology is driving change in the healthcare sector, and this can lead to resistance on the part of the players in the system (healthcare professionals, regulatory bodies, public and private establishments), who are anxious not to call the rules of the game into question, but to redefine them by taking new entrants into account. However, the "besieged citadel" syndrome is likely to result in theKodak effect Kodak's strategy: the continuity of a proven business model (the sale of silver photographic film), while neglecting changes in the environment and the impact of technology, which led to Kodak's bankruptcy.
For the question facing players in the healthcare system is not whether to regulate and/or deregulate, whether to charge for services or not, or whether to use information technologies or not, but how to use digital technology as an opportunity to provide better care for patients, by offering them new services, rather than being subjected to the technology and models proposed by publishers. The sector's digital transformation must include an analysis of the risks and challenges associated with the various technologies used, as is being done for the autonomous car.
Roxana Ologeanu-TaddeiMaitre de conférence, HDR, Management des sytèmes d'information et santé, University of Montpellier and David MorquinDoctor of Medicine, CHU Montpellier, University of Montpellier
Visit original version of this article was published on The Conversation.