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2019 world

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ISSN 1897-5828, price 10 PLN (incl. 8% VAT)

o p e n

AI ELIMINATES MISDIAGNOSIS

1 in every 7 diagnoses is incorrect.

1.5 million people around the world die each year due to misdiagnoses.

HEALTHCARE

THE RISE OF

How to build a system for predicting the development of health, so that early prevention replaces treatment?

Medical professionals and policy-makers should always be one step ahead of technology.

& MATHEMATICS

DIGITAL HEALTH

Integrating healthcare Caring for Patients

KAMSOF T Next generation healthcare IT solutions

WWW.KAMSOFT.PL

EDITOR’S NOTE

Let’s trust digital health Virtual visits, digital doctors, automatic operating machines, implanted health monitoring sensors or robots as carers – many people are afraid of this vision of a future where the machine does away with man, while omnipresent sensors and systems optimise our life. Are these fears well-founded?

Artur Olesch Editor-in-Chief OSOZ Polska OSOZ World  contact@osoz.pl

Not everyone looks on healthcare technologies positively. What comes to our minds are robots incapable of empathy, a lack of personal contact with a doctor, and the reduction of the patient to a medical procedure and statistical disease number. Will we entrust our arm to a machine so that it can sample our blood as we do with an experienced nurse? Will we allow a robot to stitch up our wound without engaging medical staff throughout the procedure? Will we accept the doctor’s virtual presence at our bedside during their rounds? Will we have a sensor collecting data on our health parameters implanted without worrying about data transmission safety? Numerous technologies are so ground-breaking that it is difficult to understand their meaning and influence on our everyday life, which stirs up negative emotions and instils fear. The dynamics of change and progress is unprecedented in the history of mankind, and it is not only about single inventions but the holistic transformation of healthcare. Until now entirely based on the knowledge and experience of man, it now begins to rely on artificial intelligence to make decisions. Let us take the example of automatic machines sampling blood for lab tests. How will our attitude change if they become more precise than the human hand, therefore minimising potential complications, pain and guaranteeing 100% precision and safety? Will personal emotions still be more important than medical facts? Health is the most important value for each and every one of us, and this fact will lead even the staunchest of conservatives to embracing methods today viewed as controversial or dehumanising of healthcare. DNA information assigned to one’s health account? By all means, if it prevents the development of hereditary diseases. Medical consultations with a system available from an app instead of talking to one’s doctor? Of course, as it becomes a more convenient alternative quickly providing necessary assistance. Robots equipped with artificial intelligence to keep the elderly company? Yes, as even conversation with a machine is better than loneliness. And so on.

Everyone would like to live the longest life possible in the best health. This will be possible in the decades to come, first and foremost due to technologies, artificial intelligence and robotics. In the name of the highest values and priorities, even the most soulless of innovations will be welcomed with enthusiasm. What is at stake is also the quality of treatment and the minimising of the negative effects of staff shortages in healthcare.

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OSOZ WORLD 2019

INSIGHTS

interviews

6

How to strengthen digital health literacy?

38

Zygmunt Kamiński: Health in the language of numbers

11

Solutions hidden in numbers

42

John Nosta: Technology is destiny

14

Digital detox

45

Bertalan Meskó: Technologies will continue to advance

48

Jama Nateqi: Will AI eliminate misdiagnosis?

innovations

51

Nick Guldemond: From A to B: Integrated healthcare & data sharing

18

App therapy

54

20

Blockchain technology. Opportunities offered by cryptography

Artur Pruszko: Digital transformation in healthcare as a strategy

56

Discussion: Will AI replace doctors?

22

Computer based clinical trails

24

Digital philanthropy

26

Hospitals beyond and above

in practice

28

25 ways to strengthen IT competencies

32

CMIO. The bridge between IT and medicine

report

34

The bright and dark sides of Big Data One point for an 8-hour sleep, two points for a morning jog, one point for having a healthy meal – one of the ways to strengthen prevention for an individual is to reward good habits. Today this is possible thanks to technologies and omnipresent sensors. However, restrictive control of lifestyle may inhibit personal freedoms, privacy and solidarity in health insurance.

infographics

58

Virtual care

60

Digital health 2018

64

Digital health and care in the digital single market

new ideas

67

No more “hit-or-miss” prescription of antibiotics

71

Curing loneliness with robots

72

Human electronic record

73

Laboratory in a box

conferences

74

HIMSS Europe & Health 2.0 Conference Big dreams meet real challenges

WHAT’S YOUR OPINION?

79

Artificial, yet better?

80

Robot disguised as a doctor

81

Humans in gigabytes

MARKET ANALYSIS

» Healthcare suffers from the shortage of available resources.« Zygmunt Kamiński, PhD | CEO of KAMSOFT S.A. | page 38

OSOZ World 2019

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Pharma market in Poland

eHealth Trends & Talks

Polish healthcare Journal

online / offline

eHealth Trends & Talks

» Big data will help us save many lives.« John Nosta | Digital Health Futurist | page 42

Digital Health Literacy | Innovative Ecosystems | Mobile Health | Telemedicine | Gamification | Wearables | Health Apps | Data-Driven Healthcare | Startups | Big Data | Integrated Health | Cloud Technology | Digital Patient | Democratization Of Healthcare | Fitness Trackers | Electronic Health Records

Polish Healthcare Journal

» Technologies will continue to advance at an amazing rate, but we don’t.« Bertalan Meskó | Medical Futurist | page 45

eHealth Trends&Talks Special report by OSOZ World Your guide to digital health DOWNLOAD HERE WWW.OSOZ.PL/eHEALTH

SCIENTIFIC COUNCIL

» In the future, doctors will also have to be data managers.« Jama Nateqi | Symptoma | page 48

» Artificial intelligence may take over some of the more routine and time-consuming diagnostic tasks.« John Crawford | IBM | page 56

1. prof. dr hab. n. med. Ryszard Andrzejak, 2. prof. dr hab. Piotr Andziak, 3. dr hab. n. med. Małgorzata Baka-Ostrowska, 4. dr Marek Balicki, 5. dr hab. n. med. Rafał Białynicki-Birula, 6. prof. dr hab. n. med. Bożena Birkenfeld, 7. prof. dr hab. n. med. Andrzej Bohatyrewicz, 8. dr hab. med. prof. UJ Małgorzata Bulanda, 9. dr n. med. Małgorzata Czyżewska, 10. dr hab. n. med. (prof. PAN) Marek Durlik, 11. lek. med. Michał Ekkert, 12. dr n. med. Emilia Filipczyk-Cisarż, 13. lek. med. Halina Flisiak-Antonijczuk, 14. prof. dr hab. n. med. Ryszard Gellert, 15. prof. dr hab. med. Tomasz Grodzicki, 16. prof. dr hab. n. med. Tomasz Grodzki, 17. dr hab. inż. Antoni Grzanka, 18. prof. dr hab. Edmund Grześkowiak, 19. dr n. farm. Jerzy Hennig, 20. prof. zw. dr hab. n. med. Krzysztof Herman, 21. prof. dr hab. Tomasz Hermanowski, 22. dr med. Andrzej Horoch, 23. prof. dr hab. n. med. Jacek Imiela, 24. dr n. med. Maria Jagas, 25. prof. dr hab. Jerzy Janecki, 26. prof. dr hab. n. med. Marek Jarema, 27. prof. dr hab. n. med. Włodzimierz Jarmundowicz, 28. prof. dr hab. Mirosław Jarosz, 29. Urszula Jaworska, 30. mgr Renata Jażdż-Zaleska, 31. prof. dr hab. n. med. Sergiusz Jóźwiak, 32. prof. dr hab. n. med. Piotr Kaliciński, 33. prof. dr hab. Roman Kaliszan, 34. prof. dr hab. n. med. Danuta Karczewicz, 35. prof. dr hab. med. Przemysław Kardas, 36. prof. dr hab. n. med. Andrzej Kaszuba, 37. prof. dr hab. n. med. Wanda Kawalec, 38. prof. zw. dr hab. n. med. Jerzy E. Kiwerski, 39. prof. dr hab. n. med. Marian Klinger, 40. prof. zw. dr hab. n. med. Jerzy Kołodziej, 41. prof. dr hab. n. med.

Jerzy R. Kowalczyk, 42. dr n. med. Robert Kowalczyk, 43. dr n. med. Jacek Kozakiewicz, 44. lek. Ryszard Kozłowski, 45. prof. dr hab. n. med. Leszek Królicki, 46. prof. dr hab. Maciej Krzakowski, 47. prof. dr hab., dr h.c. mult. Andrzej Książek, 48. prof. dr hab. Teresa Kulik, 49. prof. dr hab. n. med.

Jan Kulpa, 50. prof. dr hab. n. med. Wojciech Kustrzycki, 51. dr hab. (prof. UMK) Krzysztof Kusza, 52. dr n. med. Krzysztof Kuszewski, 53. dr n. med. Aleksandra Lewandowicz-Uszyńska, 54. prof. dr hab. n. med. Andrzej Lewiński, 55. prof. dr hab. n. med. Witold Lukas, 56. prof. dr hab. n. med.

Romuald Maleszka, 57. prof. dr hab. n. med. Paweł Małdyk, 58. dr n. med. Beata Małecka-Libera, 59. prof. dr hab. Grażyna Mielnik-Niedzielska, 60. prof. dr hab. n. med. Marta Misiuk-Hojło, 61. prof. dr hab. n. med. Janusz Moryś, 62. prof. dr hab. n. med. Krzysztof Narkiewicz, 63. prof. dr hab. n. med. Wojciech Nowak, 64. prof. dr hab. n. med. Krystyna Olczyk, 65. prof. dr hab. n. med. Tadeusz Orłowski, 66. dr hab. n. med. Krystyna Pawlas, 67. prof. dr hab. inż. Grzegorz Pawlicki, 68. prof. dr hab. n. med. Irena Ponikowska, 69. prof. zw. dr hab. n. med. Stanisław Radowicki, 70. dr n. med. Andrzej Rakowski, 71. dr n. med. Grażyna Rogala-Pawelczyk, 72. prof. dr hab. med. Kazimierz Roszkowski-Śliż, 73. prof. dr hab. n. med. Grażyna Rydzewska, 74. dr hab. n. med. Leszek Sagan, 75. prof. dr hab. Bolesław Samoliński, 76. prof. dr hab. Maria Małgorzata Sąsiadek, 77. dr hab. med. (prof. UJ) Maciej Siedlar, 78. dr hab. n. med. Waldemar Skawiński, 79. lek. Maciej Sokołowski, 80. prof. dr hab. n. med. Jerzy Stelmachów, 81. prof. dr hab. n. med. Krzysztof Strojek, 82. prof. dr hab. n. med. Jerzy Strużyna, 83. prof. dr hab. n. med. Andrzej Szawłowski, 84. prof. dr hab. n. med. Cezary Szczylik, 85. dr hab. n. med. prof. nadzw. Zbigniew Śliwiński, 86. dr n. med. Jakub Śmiechowicz, 87. prof. dr hab. n. med. Barbara Świątek, 88. dr n. med. Jakub Trnka, 89. prof. dr hab. n. med. Tomasz Trojanowski, 90. prof. dr hab. n. med. Krystyna Walden-Gałuszko, 91. prof. dr hab. Andrzej Wall, 92. prof. dr hab. n. med. Anna Walecka, 93. prof. dr hab. Marek Wesołowski, 94. dr hab. n. med. Andrzej Wojnar (prof. nadzw. WSF), 95. dr n. med. Andrzej Wojtyła, 96. prof. dr hab. Jacek Wysocki, 97. prof. dr hab. n. med. Mirosław J. Wysocki, 98. dr hab. n. med. Stanisław Zajączek (prof. nadzw. PUM), 99. prof. dr hab. Marek Ziętek

OSOZ World 2019

INSIGHTS

How to strengthen digital health literacy?

Instead of frustration – understanding. Instead of confusion – successful use of IT tools by patients and physicians.

Instead of the unused potential of IT solutions – savings and more efficient healthcare. Is this possible?

Karolina Mackiewicz Baltic Region Healthy Cities Association

There is no doubt that the future of healthcare belongs to digital health. Already today, we can see the impact of digital health solutions on access to medical services. On the one hand, social media can provide information on diets, diseases or medications at any time of the day and night to people of any age and social group. On the other hand, every smartphone user can download thousands of mobile apps. As those innovations should make access to services and information simpler and fairer, they also pose new challenges for users. To be able to effectively navigate this reality, which is new for many people, we need a wide range of technological, cognitive and social skills, jointly referred to as ‘digital health literacy’ or ‘health literacy.’

OSOZ World 2019

Is it important?

Computer or tablet skills are obviously indispensable for those who want to use devices, services and software applications. But to do this in a manner that is skilful and beneficial to our health, we need to be able to distinguish between valuable and worthless information in all this information noise. Facebook is flooded with pseudo-articles such as: “Physicians are unable to explain: cook cinnamon with honey and get rid of arthritis, cancer, cholesterol, flu and other diseases!” or “Egg diet: how to lose ten pounds in one week”. And even though some find them unreliable, others believe and share them. Another example involves sensational reports of anti-vaccination movements. All these messages have some things in common: they are brief and concise, use simple language, contain a lot of photos or iconographies,

promise quick results and... are usually false and in no way confirmed by scientific research. However, they appeal to people much more than official healthrelated communications. In the limitless space of the Web, it is hard for dry scientific facts to get past all the false but well-packaged information.

According to the results of Flash Eurobarometer 2014 (TNS Political & social E-health literacy), 60% of European Union citizens use the Internet in search of information about health-related issues, and almost 60% rely on it to make their decisions, even if they allow themselves to question its quality and source.

In Poland, 73% of respondents considered online information useful, and 91% were fairly satisfied with the information they were able to find. What does all this mean? Should we be happy or worried about such high rates? On the one hand, it is wonderful that health information is commonly available and that many people increasingly often seek it on their own. On the other hand, we should consider two issues: reliability of the information and its interpretation by the patient. Urszula Jaworska, the Chair of a foundation named after her, believes that good information is only that which

INSIGHTS

comes from reliable sources, official bodies, and credible non-governmental organisations. Unfortunately, such information is sparse.

Much more than health literacy And this is where digital health literacy comes to play. The term is much broader than ‘health literacy,’ and includes digital, media, scientific and information competencies. In a nutshell – this is about the skills that people without medical education need to use electronic devices and services provided in a way that allows them to manage their health.

And this is not just about the specific needs of a group of patients. Considering how common digitalisation is, we all need these skills on a daily basis. Forums, dedicated websites, social media, software applications – this is no longer something new. They will be soon joined by electronic patient registers, clinic appointment booking sites, online consultations, electronic prescriptions and many other solutions. And just as the majority of European Union citizens currently have full access to smartphones and the Internet, the gap between those who can successfully use them and those who are lost in this world keeps getting wider.

The results of a European study on health literacy (HLS-EU, 2011) show that elderly people and those with lower education and earnings generally have more problems understanding and using health-related information. This division is also visible in e-health literacy. A uniform model for assessing such skills is yet to be developed but a number of studies and general observations of those who have trouble using digital devices confirm this hypothesis. The recent IC-Health project (Horizon 2020) brings new data about the digital gap in the European Union. There is one division running between the north of Europe – which is more developed in terms of digitalisation – and the southern countries that are trying to keep up. The other division pertains to age – older people find it much harder to navigate the new, digitalised world than young people, who use the Internet all the time.

How to make things better?

The purpose of IC-Health is to develop a series of Massive Open Online Courses to improve the digital health literacy of European citizens. The project is addressed to representatives of five specific social groups: children, adolescents, pregnant and breastfeeding women, sen-

Health Literacy The ability to navigate health-related topics We are currently experiencing an information overload. After entering ‘cancer’ in Google, 575 million results are presented. For ‘diabetes,’ it is 250 million pages.

8 out of 10 consultations regarding health take place through search engines.

1 out of 20 search phrases in Google pertains to health issues.

Digital health literacy (or eHealth literacy) is the ability to search for, find and understand information from electronic sources and to properly utilise this knowledge in the context of a specific health problem.

47% of the world’s population has a computer and Internet access at home.

According to a study by the World Health Organisation conducted in 64 countries, 78% of potential users do not have the skills required to use them, and 77% of the countries do not have the right infrastructure. Political involvement is inadequate and necessary business models are missing.

The main differentiators of the ability to use digital health solutions are: age, health status, education, financial status, and motivation.

OSOZ World 2019

INSIGHTS

iors and type 1 and 2 diabetics. As a result, the course should meet the needs of a wide range of recipients.

There is no doubt that such actions are necessary because we can only expect the demand for digital literacy to increase.

What is the best way to do this? According to Anna-Lena Pohl, who works on the e-health literacy issues at the Institute for eHealth and Management in Healthcare, Flensburg University of Applied Sciences, there is no single answer to this question. The reason is simple – people are different. “Various social groups, for instance children, seniors or people with a specific disease, need different support.

We obviously have some solutions. Computer courses, even the simplest ones, are necessary and useful. But when it comes to media literacy or scientific competencies, that is the ability to find, understand and use information, things become more complicated. Here we need intervention at a wider scale.”

Since e-health literacy is a complex issue, the works on its reinforcement re-

quire the involvement of various entities: insurers, schools, libraries, patient organisations, social welfare providers, IT companies, schools for adults, clinics, local information centres, and of course healthcare professionals. “Nurses rather than physicians,” Anna-Lena Pohl says, pointing out that they are often in better contact with patients and have a more profound understanding of their needs.

However, sometimes it seems that medical personnel also need support in the digital reality. More and more, though still too few, medical schools are starting to notice this need by offering e-health courses to allow the clinic and hospital staff to better advise the patients on the one hand, and on the other hand – to use modern solutions on their own to a greater extent.

A simple matter The final issue to be addressed is the usefulness of digital health solutions, whether they meet the individual expectations of consumers. Frequently, a device or

app is obsolete or poorly designed and thus only causes confusion and frustration rather than provide assistance. The available information is too complicated and too long, and can be tiring and discouraging. It would seem that innovation, in a broad sense of the term, does not make our life easier. Urszula Jaworska claims that according to the “Health Innovations – Patient’s Perspective” studies over 47% of respondents are not satisfied with the level of healthcare innovation in Poland, with 40% having no opinion. “Many respondents mentioned the low availability of innovative solutions, or even the reluctance of physicians and ignorance of the staff in this respect,” she adds.

Since the issue of digital health literacy is highly complex, it seems to be a good idea to take care of the quality of the provided solutions and communications so that they match the needs of a wide range of recipients. Along with the development of digital skills, this is the key to the quick growth of digital health. 

Ignorance costs us health and money We can estimate that the poor health literacy of a part of society leads to a loss of 8-10% of a country’s health budget – in an interview with OSOZ World, Kristine Sørensen, the founder of the Global Health Literacy Academy, the Chairwoman of the International Health Literacy Association, explains why digital health literacy is an important issue and discusses its significance for e-health development.

You and the Health Literacy Survey that you led (2008) brought the topic of health literacy to the discussion about health care system in Europe. Now, the issue of eHealth literacy or digital health literacy is becoming more popular. Is it a temporary hype or indeed something we should get interested about?

I think that digital health literacy is a very important matter. Mostly because of how we live today – we are more often online that offline, and electronic information is available 24/7. So-called health information is available all the time, out-

OSOZ World 2019

side of the working hours of clinics, and we should make use of this. And, importantly enough, those who are interested should be able to find the information they need and determine whether it is reliable or not. At the same time, public institutions should make sure that information is available where it is sought and that it is comprehensible to the average person.

You say that users should be able to determine if the information available online is reliable. From the findings on your studies, we know that the majority of people have problems understanding it.

Yes, we know that this is a half or a third of the population. Please note that Facebook posts or popular women’s magazines use simple language, have a lot of pictures, and often tell a relatable story of someone fighting cancer or giving up smoking. These pictures and this storytelling are simple tricks to catch the interest of the recipient, make them trust the author and motivate them to act. As far as social media are concerned – I believe that they have permitted the democratisation of health. People have gained a wide platform to talk and exchange their knowledge and experience.

INSIGHTS

This is very positive! On the other hand, there is a risk of disseminating inaccurate information, fake news or data from research of questionable quality. And people have trouble distinguishing what is correct and reliable from fiction. They may ask themselves: does this information come from health institutions, from the ministry of health, a scientific body?

I would ask reverse questions – are institutions, ministries and agencies good enough in communicating through Facebook? Do they even have Facebook profiles? Are they a part of the e-health world?

And why should they be?

Because the majority of people use Facebook. It’s a fact. So maybe instead of blaming patients for not taking information about their health from official, recognised sources, the official sources should be more visible in social media.

Do I understand correctly that you are suggesting that health experts draw from examples of commercial companies in their campaigns?

Yes. Because people find it hard to understand complex information. They cannot decide whether this information is right for them or not. And if we present the same content more simply and add a reference to an authentic situation, the information will become more digestible.

Of course, we shouldn’t forget about additional materials for those who want and are able to understand more. But the primary focus is to reach people with limited knowledge about health. If we fail to do so, they may come across unverified sources in their search.

You often participate in health economics conferences to discuss digital health literacy. How are these topics connected with the issues of economy and economic development?

We know, and this is confirmed in numerous studies, that people with poorer education face more limitations in terms of access to information, including electronic information. We also know that they more often use medical services, are more frequently ill or hospitalised. This costs us too much. We can estimate that we lose about 8-10% of the health budget because of the low health literacy of a part of the society.

This is a lot.

This is wasted money. It is a financial issue and we should discuss this in economic forums. The matter applies not only to doctors, nurses or clerks. Whenever we start talking about return on investment, the decision-makers understand the need to develop e-health and health literacy.

E-health solutions are seen as a medicine for a failing healthcare system, in particular in ageing societies. What should we keep in mind while introducing digital services for seniors, whose health literacy, as we know, is poor?

First of all, we should realize that seniors are just as diverse as any other social group. Some are very progressive, use various apps, gizmos, etc. The opposite pole is represented by those who have no idea about any of this – they are practically digital illiterates. Not so long ago I heard a conversation between two elderly ladies on a bus. One of them complained that a printed timetable was nowhere to be found. She said: “Can’t they afford it anymore? Why am I forced to buy a phone for 400 euros only to be able to check when the bus leaves? I already have a phone at home!” For me this means one thing – we have such seniors as well and we cannot forget about them. But how to make sure their needs are satisfied so that they do not become social outsiders? And even if I’m an optimist and I believe that people can quickly adapt to a new reality, I think that e-health providers must adjust their products to the needs and capabilities of their customers, starting with the basics, for instance larger fonts.

Do physicians and nurses keep up with those changes?

There’s still a lot to be done in that area.

I will use anorexia as an example – currently young girls have access to any types of sites where they can find advice how to quickly and extremely lose weight. Some of them end up in mental institutions to get treatment. We know that physicians in those hospitals haven’t got the faintest idea about the existence of those sites or Facebook groups! We also see that many professionals have problems with technology and this is unfortunately a huge barrier.

We must reduce it.

And what about the communication skills of medical staff?

The way the physicians and nurses, but also people in charge of awareness campaigns, communicate with a patient is immensely important. We need dedicated programmes that will become a part of the curriculum in medical schools.

What will be the role of healthcare digitalisation in the consolidation of knowledge about health?

We need e-health to reach people of low health literacy with our services and information. I have recently met with representatives of one of Denmark’s regions about a platform for people over the age of 55. The solution is based on short films telling the stories of patients and their families, presenting short medical advice. This is an approach that actually supports treatment or prophylaxis.

The platform was created by a team of specialists, with only one of them having a medical degree. The others were web designers as well as communication and service development experts. They knew what to do to achieve high-quality communication. If the same project were handled by health professionals no one would understand a thing!

Don’t you think that the current development of digital tools is largely limited to teams of engineers and IT specialists? Example: there are thousands of health apps on the market, but they are rarely created with the participation of people with medical expertise.

It is my impression that the companies that deliver e-health solutions, which are behind the apps or IT systems, are seriously interested in making a difference, addressing a specific problem. They need our money, so they must provide quality-based solutions. I can imagine that the first thing they do before launching their product is to test it with the users. Then the product is systematically improved.

This is how it works. People in charge of health should learn from companies – not only in terms of new technologies but also in terms of design thinking. I am in favour of healthcare professionals joining the teams that work on e-health solutions and learning how new products and services are developed but also how to work together in multidisciplinary teams. 

OSOZ World 2019

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INSIGHTS

Solutions hidden in numbers During the past few years hospitals have invested large sums into advanced IT systems. Not many of them, however, use the IT potential to increase the quality of treatments, coordinate care and manage organisational processes. How do we change that? Step 1: build a data management strategy.

Unallocated resources Since healthcare providers introduced IT systems the amount of data gathered and processed has been rapidly increasing from year to year. Thanks to electronic medical documentation and digitisation of organisational units we now know more about patients and how hospitals function. At least in theory, because having information in a database is one thing, but their proper use is another story altogether. Even though hospitals acquire resources to buy hardware and software, sometimes with great effort, they rarely try to maximise the return from their investment in IT in terms of finances and quality. According to research conducted last year by Dimen-

sional Insight, more than half of American hospitals lack a strategy for data management and analysis. There are many reasons for neglecting data analysis: limited staff dedicated to information processing, more important priorities, lack of time required to implement a strategy, additional costs, belief that the data is of low quality or lack of pertaining standards and knowledge. Even private healthcare providers, which are forced to maintain financial feasibility, do not know how to use IT resources to increase quality and optimise costs, instead focusing on predefined reporting.

Hospitals which based their operational strategy on data management enjoy many benefits of this approach. These in-

clude, among others: increase of trust in digitisation and data among employees, higher acceptance for using IT tools, increased standards of care and treatment, increase of treatment safety or lowered operational costs. These effects can be noticed even on the clinical layer of their functioning. When the Queen Alexandra Hospital in Portsmouth introduced a system for analysing data from health condition monitoring and for warning nurses about life-threatening events (which allows them to react faster) the death rate in the facility dropped from 7.75% do 6.42% (by 17.2%). A data management strategy is also the basis for other initiatives, such as population healthcare management. Here are some other

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INSIGHTS

benefits created by a well prepared information flow system: reduction of administrative costs (e.g. better resource allocation, work time management), more fluent patient admission, better medical staff working conditions, limitation of misuse, better coordination of patient treatment processes, clinical decision making assistance, lowering of medical intervention costs (e.g. repeating the same medical tests).

Internal organising Even the best strategy won’t help you, if you do not change your organisational attitude towards digitisation. Creating an innovative culture may prove to be the hardest step of this process. Enthusiasm for innovative approaches should trickle down from the hospital management and department directors. It should be based on the understanding of the need for information. An analysis of key organisational issues and using IT resources in solving them helps with this phase. For example, increasing healthcare quality is very often limited by a lack of quick, real-time access to data. If a doctor has to wait for test results and a nurse does not see the information recorded by the doctor moments ago, this can create data obstacles which lead to major healthcare flaws. The identification of issues and using IT to eliminate them increase the acceptance level for the digitisation process as well. This way the staff understands the aim of the digitisation. They will know that the purchase of computers and systems provided concrete benefits.

When trying to include the whole staff in the digitisation process, we should try to find leaders of change at each organisational level. There will surely be enthusiasts of new technologies, which can serve as a source of inspiration and motivation for others.

Data standardisation is yet another major challenge, especially when hospitals use different IT systems in each organisational units (electronic medical documentation, hospital pharmacy, laboratory, administrative departments, medical imaging, etc.). Ideally, a hospital should use a cohesive database, which can be used to perform comparative analyses. If this is not possible, the organisation should introduce interoperability for all systems as fast as possible. This is a tedious process that takes years, but from a long-term perspective it is the only way to get rid of an IT mess. BI (Business Intelligence) systems are espe-

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» Reporting belongs to the lowest data management level, but its potential is only barely used.« cially useful when conducting more advanced analyses, even in the case of different data sources.

A culture of transparency and engagement is the third foundation of an IT strategy. It is the medical staff that is often blamed for the low quality of treatments, long registration queues or medical errors. In most cases the blame lies elsewhere – that is with poorly organised processes. In a transparently managed hospital it is the role of ground level employees to identify and solve everyday obstacles and problems on the spot, without involving managers and directors. This strategy is used, for example, in the automotive or aeronautics industries, where it has proven to work well, especially from the perspective of proper staff motivation.

Strategy level You can extract data and reports from databases in order to inform better decision making processes, even in the case of hospitals with the lowest technological development levels. Simple analytical modules introduced into an integrated system enable hospitals to prepare multidimensional comparisons and monitor processes, becoming sources of knowledge about what is happening inside an organisation. Reporting, which is often undervalued and inappropriately used, belongs to the lowest level of data management systems. Many types of information require correlation and deep analysis. An increasing number of patients can be a result of a better hospital image among the population as well as of a changing epidemiological situation, or of both these factors. Instead of limiting oneself to standard comparisons, it is better to think through which data will help perfect the organisational and clinical processes as well as assist the achievement of goals. Creating a list of systematically generated reports with defined recipients, generating frequency, detail level and required actions is yet another interesting solution. Available knowledge should be used to draw actual conclusions.

In the case of a higher data management level we use real-time monitoring

– the available information gives a picture of the present, not past, situation.

These types of data inform, for example, clinical decisions. Checking interactions between the medicine that is being prescribed at the moment and the one the patient is taking or used to take is the best example of this process. This also includes data transferred from the medical archive to the laboratory or the data gathered with measuring devices (also in the case of telemedical solutions). The next step of the strategy should include evaluation processes. If an abnormality is identified, what was its cause and how to prevent it in the future? Heads of wards can analyse clinical processes or complications, doctors can browse patient data in order to assess their health condition (which happens, for example, during rounds) and identify epidemiological threats in the hospital, administrative employees are able to view financial balances in order to monitor budget performance. Quality control teams, which include doctors, nurses, quality department representatives and directors, can use the data to assess the present state of strategy and plan execution.

Yet even on the level of data evaluation we only react to what has already happened, trying to mitigate mistakes. This is why the prediction step is the highest layer of a data management strategy. Based on previous data, a hospital can perform a simulation of its functioning (cost and income development) and potential risks. On the clinical level this includes a prognosis of healthcare conditions on the basis of information gathered in an electronic archive. This way patients become parts of a preventive programme, which tries to proactively protect them from potential illnesses. With the development of artificial intelligence systems, which analyse large amounts of data, the point of focus of medicine will shift to prevention, so this level of information management will become crucial.

Required tasks Building an organisation focused on the use of data to systematically improve internal processes is not an easy task. It re-

INSIGHTS

» In most cases you should blame financial issues as well as patient and employee dissatisfaction on wrongly organised processes.« quires an innovative approach to patient care as well as an investment in both technologies and people. This task, however, is not impossible. Neither does it require exceptional competencies or time and resources. At the first step, healthcare providers should focus on several tasks: − broad adaptation of digital health solutions, including electronic medical records, motivating the staff to use the IT resources as tools for improving patient care; − development of a strategy to integrate data in the framework, including all the sources, e.g. other subsystems, medical devices; − elimination of obstacles in the access to information (including granting proper authorisations); − data use for operational, clinical and managing purposes as well as sharing the analyses with other entities, for example local authorities, in order to de-

velop joint population healthcare strategies; − creation of data protection strategies and their constant updating processes; − co-operation in interdisciplinary teams with the goal of solving issues, including IT department employees in clinicians’ meetings and quality strategy development; − defining the so-called golden data sources, i.e. those providing high quality clinical and organisational data with the highest precision and their use in analyses; − creation of data infrastructure for the hospital – defining the types of data gathered (which are gathered at the moment and which should be gathered) and their analytical potential; − development of interoperability strategies and integration of existing data; − creation of decision making teams in scope of quality, development, and

management (with the use of present staff). The aim is to analyse data and define requirements for IT resources (instead of imposing decisions); − creation of a “data-based approach” with a constant flow of competencies between IT and medical departments (avoiding separating IT and medicine); − development of strategies which place the patient at the centre of processes, e.g. healthcare co-ordination, increasing hospital stay satisfaction, remote care. Using IT systems to achieve those goals; − systematic audit of the use of IT resources, provided together with the representatives of the developer in order to identify new and unused features.

Data is a key resource for each healthcare facility. It provides information about internal issues, expands knowledge, allows us to identify new medical and organisational capabilities, reveals the weakest links in the work flow, but most importantly, it is indispensable for the development and improvement of processes. In order to use data properly we need to organise it and then build a work culture based on information. 

DATA ANALYSIS BASED HOSPITAL DEVELOPMENT STRATEGY

ASPIRATIONS

ASSESSMENT

TOOLS

What is the goal / mission of the hospital?

Providing measurable (e.g. profits, treatment results, patient satisfaction) and immeasurable (organisational culture, team spirit) elements.

Are we ready?

Identification of deficiencies, which are the basis of the present issues. Understanding necessary changes to the staff’s approach.

What do we need to implement?

Preparation of a list of initiatives and changes required to improve results. Designing a process to create an innovative organisational culture – modification of staff attitude.

ACTIONS

PROGRESS

How do we implement the process?

Designing the implementation of assumed initiatives.

Monitoring changes on the organisational culture / attitude to change levels. Personnel motivation.

How do we maintain the improvement process?

Introducing tools for constant improvement of internal processes. Identifying leaders of change, who will drive innovative working methods.

Source: The “big data” revolution in healthcare. Accelerating value and innovation, Center for US Health System Reform, Business Technology Office

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Digital detox The first smartphones appeared 10 years ago. Today, it seems impossible to live without them. They are a working tool, a device connecting us with friends, a source of news and entertainment, a window onto the world.

We reach for our phones every dozen minutes or so, 88 times a day.

We touch their screens 2,617 times. Numbers that give food for thought and ways how to deal with this modern addiction.

Fear of disconnection When was the last time you left the house without your phone? What do you feel when your battery dies and you can’t use the smartphone for a few hours? Nomophobia (No-Mobile-Phobia) – the fear of being out of mobile phone contact – is a term proposed by scientists and, unfor-

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tunately, it applies to a growing number of people. According to research carried out at the University of Maryland, between the years 2000 and 2011 (that is, still before the age of smartphonization) 11,000 road accidents were caused by people distracted by a phone. In October 2017, the authorities of Hawaii in-

troduced a fine of 99 USD for staring at your phone or texting while crossing the street. This is how Honolulu wants to fight against the growing number of road accidents involving the so-called smartphone zombies, that is, pedestrians who are so focused on the screens of their phones that they pay no attention to what is going on around them.

Today, there is no doubt about smartphones being a milestone for the digital revolution, an invention to which we owe, above all, our unlimited connectedness. We can pay, do shopping, communicate, take care of our health, plan our daily schedule and watch films with our phones. The broader the array of possibilities, the more time we spend with phones in our hands. According to the latest research, it already amounts to

INSIGHTS

2 hours and 51 minutes, which is twice as much as four years ago. The newest statistics on the American market speak of even 5 hours a day. Checking your phone 88 times a day is an average for all age groups. The so-called Millennials, people born between 1980 and 2000, do it even 150 times a day and 79% of them keep their phones near them even when they go to sleep. We stare at lighting screens day and night – 87% of people tested turn on their phones even between midnight and 5 a.m. The constant urge to press the start button is a result of the FOMO syndrome – fear of missing out. Perhaps a friend has messaged or shared some interesting news on Facebook, maybe something big has just happened in the world? Such thoughts are usually but an illusion.

stress, emotional exhaustion and a sense of disorganization. Our creativity suffers because of that. If we work in such an interrupted mode, we must invest more time compared to when we spend a few hours on just one task. A machine that is turned on and turned off every few minutes breaks down faster than one which works continuously. This is not all. Being exposed to the blue light given off by smartphones accelerates the ageing of the retina and may cause insomnia.

While using a smartphone, the head leans forward even by 60 degrees, which increases the pressure on cervical vertebrae by 5 times compared to a straight position. Consequences? The so-called “text neck” or “tech neck syndrome” – a technological neck which leads to headaches, as well as neck and shoulder pains.

Concentration suffers

Real vs virtual time

Is it wrong to use new technologies? Not if we know how to use them. We can understand the current enchantment with smartphones – we have been carrying these tiny computers in our pockets only for a few years. It is good to be aware of how they affect our lives and how much time they steal from us. Mobile phones distract us all the time, which is why we cannot focus on one activity for a longer period of time. It is not only about looking at the screen of a smartphone incessantly but also checking your work and private emails on your computer. According to neurobiologists, after reading a message, people need a few minutes to get their focus back and resume their previous activity. Human brain does not deal with multitasking too well, each distraction has a negative impact on the concentration necessary for doing your work and daily activities. This leads to

Our concentration, long-term memory and cervical vertebrae all suffer. The fact that a phone is always within our reach does not mean that the quality and frequency of social interactions have improved.

This seems odd, given that, according to the research carried out by eMarketer, we spend a good 65% of our time with a phone on communication (texts, phone calls, emails, social media) and only 22% on sheer entertainment. Neither Whatsapp nor Facebook, nor any other social media channel helped with that. Instead of facilitating communication, the new applications focused the users’ attention on themselves, in many cases becoming a substitute for real life and real friends. Instead of spending time with our children, we give them tablets full of games and a conversation over a family dinner is often interrupted by the sounds made by smartphones.

Taking into account only the current sta-

tistics, an average person spends 5 years and 4 months of the entire life on social media (source: Business Insider). Mostly on YouTube (1 year and 10 months), Facebook (1 year and 7 months) and Snapchat (1 year and 2 months). Compared to other daily activities, it is quite a lot.

Eating and drinking takes us less time – 3 years and 5 months in total, while doing laundry – 6 months. Only watching traditional television (7 years and 8 months) still comes before our online activity. Is more than 5 years of our entire lives little or a lot? It equals, for example, 93,000 walks with a dog or, to translate it into more abstract activities, 32 trips to the Moon and back or 3,500 strolls along the entire Great Wall of China. The latest report “Information Society In Poland in the years 2012–2016” published by GUS (Central Statistical Office) points to interesting conclusions. 73.6% of people between the age of 16 and 24 connect to the Internet via mobile phones. The higher the age group, the lower the percentage and for people at the age of 65 or above, it reaches merely 2.7%. When it comes to professional activity, the analyzed data shows that 80.8% of students at schools and universities use their smartphones.

Between the years 2013 and 2016, the number of households in which children use smartphones increased by over three times – from 13.1% to 44.1% At that time, the number of households in which children do not use either a mobile phone or a smartphone dropped down from 30.5% to 27.7%.

You control the phone, the phone does not control you Nowadays, a life without a smartphone is virtually impossible or, at least, much more difficult. Besides, there is no need

1 MINUTE OF THE YEAR 2017 ON THE INTERNET

3.5 million searches in the search engine

900,000 log-ins

16 million text messages

156 million e-mails sent

40,000 hours of listening to the music

751,522 USD spent online

452,000 tweets on Twitter

4.1 million films watched

46,200 photos published

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to get rid of a phone altogether. New technologies increase the quality of dayto-day life, they offer possibilities that have not been available to us before, they are the tool for communicating in modern societies. However, under the thick layer of benefits are negative aspects of smartphonization. If we are aware of that, we can apply a few rules which can free us from the tyranny of the phone and gain us more free time, increase the quality of our social interactions, optimize our working time, as well as reduce stress and the number of hours wasted on staring blankly at a screen. Every day is a good time for resolutions. Digital detox may be among the ones that will definitely change our lives of the better.

1. The first step: check how much time you spend on using your smartphone each day. In order to do that, install an app which monitors how many times you turn your phone on and how much time you spend on using certain apps. Apple offers for its devices so called “screen time control”.

2. If it is difficult for you to keep away from your phone, install an application which blocks access to chosen apps (such as Offtime, ClearLock, Quality Time, Menthal). If you want to focus on a task for 30 minutes straight, you should choose the Forest app. Once you turn it on, a tree starts growing and it continues for chosen period of time – but if within that time you start to use the smartphone again, the tree will die. Step by step, you can create an entire forest.

3. Limit the number of applications and instead, browse for information in a search engine.

4. Turn off the distracting app notifications and alerts. By popping up on the screen, they provoke you to, for example, reply to the message.

5. Create smartphone-free zones, starting with the bedroom. In your free time, like when you read a book, place your phone out of your sight.

6. Change the alarm in your smartphone into the most basic clock, whose only function is to show the time and wake you up. When we keep a smartphone near the beds, we spend extra minutes on fiddling around with it.

7. You should set time frames that are smartphone-free, for example, while eating a meal with your family and friends, during meetings, after 9 p.m. in the evenings etc. Think carefully about when you want to be completely offline and when you need to be online.

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8. Change your attitude. It will not be the end of the world if you do not check your phone every 10 minutes. All the messages and information will still be available even after a few hours and the world will still be turning. It is enough to check your email three times a day.

9. You are afraid that if you do not respond immediately to a message from a friend or a relative, they might get worried? Then let them know in advance that you will be out of reach all day.

10. Go on digital detox every day.

Start with devoting, for example, 60 minutes to real-life activities which have a beginning and an end, such as preparing a meal that requires more involvement, reading a book or sports.

11. While doing sports, switch into offline mode.

12. Gradually, extend this ritual to one day a week, a whole weekend, a holiday.

When you are on vacation, it is enough if you check your phone once a day (with-

out replying to any emails that can wait).

Replace a phone camera with a regular camera.

13. Rethink your attitude towards social interactions. A phone lying on the table next to you during a conversation is a signal that your interlocutor cannot count on getting exclusive attention.

14. Move social media to real life – instead of chatting on Whatsapp, meet up for a coffee, go to the cinema, an art gallery or a museum, go for a walk. Instead of reading the news online, take out a newspaper subscription.

Just like any other diet – whether you are cutting down on cigarettes, chocolate or alcohol – it leads not only to health benefits, but also to internal satisfaction, a sense of gaining back control over your life and a reduction of stressful rush. Even though the battle with a smartphone addiction will not be easy, it is worth to give it a try. 

» Using different applications consumes 90% of the time spent with a smartphone in hand.«

5 years and 4 months – this is how much time an average person spends on social media throughout their life.

150 times a day

– this is how often Millennials (a generation of people born between 1980 and 2000) check their social media.

65%

– this is the percentage of our time with a phone in hand spent on communicating (text messages, phone calls, emails, social media).

44.1%

– this is the percentage of households in which children use either a smartphone or a mobile phone. In 2013, it was only 13.1%.

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I nno v a tions

App therapy Do you have a chronic disease? Therapies will regularly feature mobile apps before long. Technology will help us to act on medical advice, and may form a source of knowledge and improve the patient’s mood.

The first physical activity trackers to hit the market as early as 8 years ago were available as wristbands. Their functionality boiled down to counting steps, but now, thanks to m-health technology, we can measure a whole range of parameters as well as monitor our mental state and mood. In 2016 the NHS (National Health Service) announced that it would soon provide its patients suffering from chronic diseases with apps and telecare devices for monitoring prevalent chronic ailments such as diabetes or heart disease.

With this end in mind, the NHS launched

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its first pilot programmes, including the NHS Connected Asthma Programme. It is high time that all ministries of health recognised these new technologies.

Many people, including doctors, are sceptical about the development of mhealth. So far m-health apps have been looked on as toys for hypochondriacs to feel better or gadgets for techies, without any particular relevance to medicine.

Will any cardiologist take us seriously when we show him pulse measurement results collected with a smartwatch? Will any psychologist base his diagnosis on

the results of a daily mood measurement from an app for people with depression?

Will any doctor acknowledge the results of a pressure self-measurement system and their monthly summary?

In the Wired magazine, Daniel Kraft describes another milestone in digital health. Data from the HealthKit app, such as information collected on physical activity, blood pressure, weight and sleep quality, has been integrated with the electronic medical register of Stanford Hospital (USA). Full medical records can be accessed by the author even today with the MyStanford app. After a week of using the new solution, Daniel was informed by his GP that his data “looked good.� When apps and technologies monitoring life functions become professional and certified medical devices, and prove their efficiency, the awareness

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of and approach to digital health will also change.

In the case of healthy people, the added value of these new e-tools is improved prevention, rather than being intuitive – resulting from the general knowledge of what a healthy diet and lifestyle should look like, or how many times a year one should undergo a preventive evaluation. What intangibles can be measured (the “quantified self” concept) today? Knowledge is the first step towards better planning and the management of one’s life and health, something that can be of considerable importance for the chronically ill. Aside from the disease itself, someone chronically ill has to bear the additional burden of their own awareness of the affliction and the feeling of uncertainty. When home alone, someone anxious and depressed, isolated from his or her doctor may have to struggle with a sense of hopelessness and fear. Someone with hypertension has no way of telling whether the sudden increase in their blood pressure is detrimental to their health or acceptable. There is no connection between them and their doctor, no opinion to soothe them nor form grounds for medical intervention. Digital health solutions transfer this supervision from the doctors’ surgery to the field of everyday life, therefore improving the one’s quality of life and allowing one to feel cared for on a regular basis.

A chronic disease requires discipline too, namely in taking drugs, measurements and steps towards changing one’s way of life. Not everybody is strongwilled enough to consistently follow the doctor’s guidelines. It is also difficult to remember which medicines to take at what time, and when to go for a medical examination. The same applies to checking whether we have done all our recommended exercises according to plan. This is where apps come in: they are becoming increasingly better suited to the needs of people with various chronic diseases, developed in cooperation with medical centres and discussed with physicians and patients alike. Gone are simple systems reminding us to take our medicine: modern-day apps are heuristic systems that help manage the disease like a complex project.

The widespread computerisation of healthcare leads to increased integration of information flows. Doctors gain better insight into their patients’ condition, whereas patients gain greater awareness

while making rational health-related decisions. Before the pieces of the technological puzzle come together, and mobile health apps are prescribed by doctors, we must take a few important steps: – implement the validation and certification system of health apps to provide doctors with arguments for their safe use; – encourage state institutions to develop their own health apps that, thanks to their reputation, will become the driving force of the entire m-health market;

– launch pilot programmes in patient groups with chronic diseases; – implement financial incentives for public healthcare facilities promoting the use of e-health solutions; – invest in e-health and computerisation of healthcare facilities; – develop solutions that are easy to use regardless of the age group; – promote technologies with emphasis on precise measurement, preliminary analysis of results and heuristic algorithms; – support digital education in schools. 

» A chronic disease requires rigorous discipline, whereas the patient needs to be certain that everything is all right.«

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Blockchain technology.

Opportunities offered by cryptography Blockchain technology and its application in the field of health protection is becoming an increasingly popular topic. In Estonia, electronic medical patient records and e-prescriptions are protected by a blockchain. Similar solutions are set to be implemented in Dubai. Turkey wants to use the method for trading in medications.

Experts see the blockchain as a hope for overcoming the problem of access to medical data gathered in various places and for reducing system costs. We explain what is blockchain.

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No one really knows who really created the blockchain. The basis for the technology is a concept developed in 2009 by an anonymous person (or group) known as Satoshi Nakamoto. Its further development led to the creation of the world’s first cryptocurrency – Bitcoin. Bitcoin is an electronic coin divisible into 100,000,000 smaller units and it can be stored on a PC as a wallet file or on an external website and sent online directly to another person with a Bitcoin address.

Blockchain technology is used to store and send information about online transactions, which is recorded in the form of consecutive data blocks. One block contains information about a specific number of transactions. Once it is filled up, another block is created, and so on and so forth, thus resulting in a chain being formed. The whole methodology is based on a peer-to-peer network rather than on a central server where every transaction would otherwise be carried

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out or recorded (central database or server). Every computer in the network may participate in any transactions that are public. However, a single user may only view their own transactions within specific access rights. With the current level of technological advancement, no one is able to falsify or modify the historical data, while complicated cryptographic tools protect the transmitted data blocks against unauthorized access.

Instead of analysing the complex blockchain technique in any more depth, let’s focus on the potential advantages.

The greatest one is that it enables secure data interchange between people or entities or devices that do not know each other and, as such, should not trust each other. Identification and authentication takes place based on a unique ID of strategic significance. What would such a data interchange transaction look like in the healthcare system? Every participant (e.g. a patient) would have an ID defining which data can be disclosed, to whom and on what terms. Access to information would be strictly rationed and individually controlled. This is the potential of blockchain technology in healthcare – an area involving a large number of entities and market participants which should communicate with one another efficiently (patient, physician, nurse, clinic, hospital, pharmacist, laboratory, public payer, private insurers, manufacturers of medical devices etc.). Without a centralized IT infrastructure, efficient communication is impossible; that said, blockchain technology guarantees safe communication without the need to build and maintain an additional system. Blockchain-based data interchange between the healthcare market participants would primarily reduce the costs of building an e-health infrastructure, which must additionally include continuously updated security mechanisms. Many people potentially see the new technology as a substitute to e-health projects but – as we will learn in a moment – this assumption is incorrect.

Blockchain technology may simplify the whole system of healthcare premiums by converting all of the settlements in the healthcare system into a cryptocurrency (MedCoin): every employer paying a healthcare premium would record the payment in a publicly accessible register, paying the required number of MedCoins to the employee’s individual account. This way, every insured person would be able to check if the pay-

ment was made on time and in the right amount.

Another advantage of the transaction blockchain is security. Traditional central systems are exposed to attacks by cyber criminals and the negative consequences of malware. These hazards can be minimized with multi-layer protections and security systems but this increases the operational costs of e-health systems. Blockchain operations may be visible to the public (this increases the possibility of identifying any irregularities), encrypted or accessible only to authorized users.

The most important element that is of interest to healthcare providers is the synchronization and transmission of medical documentation. Data chain technology could be used to exchange data recorded in various formats. For instance, a doctor authorized by the patient could gain access to information kept in another place. This also reveals a weakness of the solution, as it is not based on data standardization and interoperability but only on the facilitation of secure access within filing systems kept in various places, in various formats (any text records, photos, notes). After all, digital health is about something more – it is about introducing standardization to permit data analyses that would support the clinical decision-making process, treatment and prevention personalization, and health management at a population level. First and foremost – it is about organizing information filing systems. In the case of blockchain technology, data are still kept in information silos (the doctor’s computer, the hospital server), but with the possibility of rapid and properly authorized access. Such a model could only temporarily improve the level of communication in the system and help users to promptly obtain the required data in critical situations, even if we still have a long way to go before we achieve system interoperability, synchronization of information from various places of origin, and the necessary standardization that would permit mutu-

al communication between various systems and devices as well as data recording in the online account of the patient.

In the long run, this leads nowhere.

Blockchain technology is mostly tempting due to the security of transactions and access to information spread all over the system. All of this is achievable without the need to build a central mega system or IT infrastructure, which makes things much cheaper. Moreover, the solution can be introduced practically immediately since it has been developed according to the open source model (open source code which can be implemented by anyone) practically from the beginning. Nonetheless, it still does not answer certain healthcare problems, in contrast to centralized e-health systems.

Besides, the technology generates potential problems and it remains a great unknown. Temporary access to the data archived in various places and in various formats is not conducive to the process of standardizing healthcare information.

It is still difficult to estimate the cost of introducing such a solution. The openness and virtual nature of the technology does not foster trust in the use of blockchains, especially in the highly conservative environment of healthcare (in financial transactions, Bitcoins are only used by about 10 million users all over the world). It is hard to imagine that in the area of the highly sensitive issue of data archiving and security, local or state authorities would implement a solution that has not been fully explored and whose future development is hard to foresee.

While data transmission security is the greatest strength of the transaction blockchain, there are concerns connected with the risk of population data being associated with location data, which may result in the data of a single person being traced. Nonetheless, blockchains remain an alternative technology that may turn the way we perceive digital health upside down and become a source of new, innovative solutions. Whether or not it actually will, we shall see in the years to come. 

» Despite secure and rapid access to dispersed information without the need to build a centralized system, blockchain technology is not a substitute for other e-health systems.« OSOZ World 2019

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Computer-based clinical trials Before a drug becomes distributed on a large scale, it must succeed in following the long path of clinical trials, where the manufacturer has to prove the safety and efficiency of the new product. After the preliminary phase of laboratory tests, sometimes also conducted on animals, the biomedical product must be tested on people. Will it soon be possible to perform the whole analytic procedure with computer-based simulations, thus lowering the costs of the trials and increasing the safety of pharmacotherapy?

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According to the calculations of the Tufts Center for the Study of Drug Development, the average cost of marketing a new pharmaceutical product is estimated at USD 2.5 bln, with 75% of this sum being spent on clinical trials. Each time the drug fails to succeed at one of the trial stages, the pharmaceutical company faces gigantic financial losses. These losses are of course reflected in the prices of other pharmaceuticals. In the case of more advanced drugs, this USD 2.5 bln is increasing quickly, resulting in pro-

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portionally higher prices for innovative drugs, such as those used in therapies for cancerous diseases.

Although traditional clinical trials allow us to answer the question as to whether the product is safe and effective, they do show why this is so or how we can improve its imperfect formula. Essentially, when a drug fails at any stage of the trials, we do not learn why it happened. It is an “all or nothing” model – where the whole development process, knowledge and know-how related to a non-marketable drug practically ends up in the bin. This even happens when the drug is efficient to some extent and only requires some changes to improve its formula. This means that resources are wasted on an enormous scale, hence blocking innovation in the pharmaceutical industry and decreasing the number of marketable drugs. Moreover, the risk associated with research makes pharmaceutical companies unwilling to invest in studies on drugs for rare diseases, where the return on investment is unsure as the treatment price must remain at a level acceptable for the healthcare system. Additionally there are ethical tensions related to this, which greatly taint the image of the whole pharmaceutical industry.

This may change thanks to the use of computer models in clinical trials, called In Silico Clinical Trials (ISCT), as an analogy to “in vivo” and “in vitro” trials.

The field is not completely new, and has already found application in the development of biomedical products. Pharmaceutical companies use special software for the evaluation of pharmacokinetics (manner of distribution of the drug in the body) and pharmacodynamics (biochemical and physical impact of the drug on the body) of new compounds. However, its potential is much greater, and one of the possibilities is the individualisation of the whole process of conducting clinical trials. IT systems could check the body’s reactions and treatment effects for various types and intensities of the disease, depending on the age, weight and other personal traits of the patient. The new model would involve the administration of a “virtual drug” described by chemical formulas to a “virtual patient”.

A digital laboratory would enable the observation of all stages from drug administration (its metabolism in the body, distribution, and influence on non-target organs), therapeutic effects and results, to the process of excretion and any adverse effects.

» Computer-based clinical trials may potentially improve, reduce or even replace traditional testing procedures.« Clinical trials performed using suitable software could increase the efficiency of the tests and limit or even partially substitute currently used procedures.

This will happen partly thanks to the reduction in logistics and the scale of the undertaking, as well as its duration.

Some of the stages will be performed as simulations in advanced digital laboratories, with tests on humans being reduced to smaller populations. Often just the recruitment of volunteers itself is a process that lasts several months. The strength of digitalisation is already visible, such as in the case of clinical-trial support applications like Research Kit (available in mobile devices by Apple). Secondly, the simulations will enable the performance of trials in a more detailed way, using many different, freely-chosen scenarios. For example: “what will happen after the administration of drug X to a patient with disease Y if the patient is additionally burdened with disease Z?” Such deeper forms of analyses are currently very limited. Thirdly, if some tests give a negative result, then the whole research process may become the basis for new studies, limiting the repetition of the same errors and enabling the use of the gained knowledge. Fourthly, we will obtain more knowledge about the effect of the drug on the functions of the body, allowing us to better predict the long-term effects of its use. The same applies to medical devices, as the interactions between, for example, implants and living tissues, blood and other body fluids are all important factors.

In the long term view, we are talking here about developing technology towards full treatment personalisation, in which the dose or even composition of the drug is adjusted to suit each patient separately, depending on his or her genetic profile, body structure, concurrent diseases, etc. Apart from the so-called “virtual patient”, which must be created for the purpose of the clinical trials, a “virtual population” will also emerge. The virtual population model will be available for various pharmaceutical companies working on different pharmaceutical

products. An extensive database created from the results of partial tests, gathered in one large data collection, will enable mutual learning and systematic building of increasingly detailed simulation models. This is contrary to the current situation, where each of the competing companies keeps its know-how to itself, wasting the garnered scientific knowledge. Yet another positive effect would be the democratisation of research processes.

What if the efficiency of a drug is less than expected? How will the drug affect a person weighing twice as much as the average patient in the studied population? How will the interactions with other drugs influence its effects – now and in a year? We still do not know the answers to many questions that arise during traditional clinical trials, as they are performed in very limited conditions, both as to their time and population. Computer-based simulations in research into new drugs will contribute to a change, creating a completely new concept for medicine based on the early prediction of therapy results. This also gives hope for increased interest in research related to drugs for rare diseases and lowering of the prices, which will consequently lead to their greater availability and lesser cost burden on healthcare systems.  Based on “Clinical Trials: How Computer Simulation Will Transform the Biomedical Industry”, Avicenna Consortium

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Digital philanthropy Theoretically, we could effectively treat and prevent diseases if scientists had access to medical databases of big data, and more specifically to anonymous information in patients’ electronic files. In the era of privacy concerns, unclear regulations, lack of standards and dispersion of data, clinical studies can be supported by a new trend: data donation.

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It’s a project which could provide a breakthrough in the study of Parkinson’s disease. In the space of just three months, the company Sage Bionetworks recruited 11,360 volunteers (patients) for clinical trials – a record number in the history of scientific studies on this disease. None of the participants received

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a penny for their commitment and time spent, and the study was conducted with the use of ResearchKit – an app for Apple smartphones. This success would not have been possible without the engagement of individuals who – acting voluntarily for the common good – decided to share data for the purpose of scientific studies. The paradoxical data donation trend is a reaction to disappointment with digital reality, something which was supposed to ensure free access to information, thus accelerating progress in, among other things, medical science.

The current situation is completely different – dispersed information is less valuable, cybercrime leads to the tightening of regulations concerning personal data protection and the abused and misinterpreted notion of the “security of medical data” is something which hinders ambitious projects. Contrary to this, people are willing to share anonymous records collected in EDM systems, knowing that they will be used for a good purpose. As with blood donation, data donation provides hope for the faster development of medical science.

New technologies impress with the possibilities they offer, but the strategy and coordination of digital health projects are insufficient. Even the exchange of information between two health care centres with different IT systems is a challenge. For years, the digitization of health care was conducted at the level of service providers, ignoring the necessity to develop standards and interoperability mechanisms. The priority while building electronic medical records remains the fulfilment of legal requirements and financial settlement with the payer. In such a model, digitization does not go beyond supporting the internal organizational processes and does not contribute much to health care on a global scale. Additionally, one should take into account that a large number of doctors and hospitals still collect and process data in paper form (it is estimated that in the US 80% of doctors and hospitals already work using EDM, while in Europe the situation is different, depending on the country). Given the amount of money which has been funnelled into digitization, it is difficult to be euphoric about the effects.

It is highly likely that in a few decades healthcare will be entirely digital, connected to information networks. But before this happens, initiatives which enable science to use the potential of big data are necessary. We cannot wait any long-

» Modern philanthropists donate their personal medical data because of idealistic motives, in order to support research on diseases and medical science.« er. Aside from data donation, it is necessary to provide collaborative networks connecting the different participants in the healthcare market: hospitals, doctors, the pharmaceutical industry, insurers and digital service providers. There are plenty of examples of good practice. One of them is CancerLinq – a project initiated by the American Society of Clinical Oncology (ASCO) where the data stored in EDM systems helps to broaden knowledge on cancer and its treatment.

Numerous surveys have shown that patients would be happy to share their personal medical record details for medical purposes. Most of the respondents declare their willingness to participate in information philanthropy, albeit under several conditions. The most important one is intention. Precise scientific objectives and specific clinical research on a disease is much more convincing than general statements on the purpose.

Also important are the transparency of the whole process, anonymity and the open availability of results. Another motivating factor is compatibility with one’s own health interests, for example, the potential future danger of a disease, or episodes of a disease in the past, including among family members or friends. Many respondents simply want to do something good for society, without analysing the reasons. It is similar to the trend of public fundraising for small projects (so-called crowdfunding), which in the traditional economy and business model would have no chance of implementation. In the case of data donation, the currency is not money but information of considerable scientific value. It is even more valuable considering that it is not merely information collected by a doctor or in hospital, but data which can be generated by the patient themselves with the help of mobile technologies, something not available in EDM systems, and related for instance to lifestyle, social factors and behaviours. The more data there is, the better the chance of finding the link between the risk factors and the disease.

On the road to the broader use of personal data, there are a few more obstacles. Aside from the insufficient interoperability of systems, there are also legal problems. Without patients being firmly placed at the centre of the health care system, and appointed as the sole legal owners of medical data, using medical records for the purposes of clinical trials will be difficult. The patients must be able to manage their medical files freely, and the existing organizational solutions should encourage them down the route of digital philanthropy. In order not to lose the trust of modern philanthropists, it is necessary to systematically improve safety standards for collecting and exchanging medical data.

Transparency, fairness and openness of scientific research are a necessity. It is hard to imagine a situation where the results of clinical trials, based on data submitted voluntarily, serve the interests of only one group or are used commercially.

Finally, the so-called posthumous donation of data for scientific purposes should be mentioned. It is a field which needs to be regulated, respecting the will of each patient by introducing declarations similar to those relating to posthumous organ donation.

The phenomenon of voluntary data sharing is an opportunity for science.

Currently only a small part of the wealth of knowledge hidden in electronic medical files is being used. Drawing on it on a larger scale could accelerate disease research by decades. 

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Hospitals beyond and above Innovations such as telemedicine, virtual reality, big data and robotics are often talked about with confidence, but so far have rarely been experienced in day-to-day practice. However, hospitals will soon see a wave of change defined more by e-health solutions and less by treatment technology.

Today’s symbol of innovation in hospitals is the da Vinci Surgical System. Despite the cost of around $2 million (the “Si� version), 3100 systems were sold worldwide in 2014, while the year previously the figure was 1000 lower. With its ability to reduce the invasiveness of certain

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procedures and to improve patient safety, the system is slowly becoming standard equipment in the USA, with surgeons there now making good use of over 2100 da Vinci systems. It is estimated that the surgical robot market will grow to $6.4 billion by 2020, and these numbers are

attracting new players. Google has recently partnered with Johnson & Johnson, a pharmaceutical and medical device manufacturer, with the objective of developing a system competitive to the da Vinci.

The most innovative medical and research centres now use remote surgery techniques, virtual visits or clinical decision support systems every day. However, the barriers to accessing these technologies by other hospitals still remain insurmountable. These include limited funds and the deficiency in the knowhow and human resources required to use such systems. These are the two key

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factors behind the painfully slow technological evolution in healthcare. Nevertheless, various other drivers are providing a step-by-step change in the functioning of stationary healthcare centres.

One of the fastest developing areas that certainly has the potential of widespread application is telemedicine. There are three strong arguments for it: remote monitoring to reduce hospitalisation costs; increased patient safety and comfort; demographic changes and epidemiological trends (higher rates of seniors in the population and greater numbers of non-communicable chronic diseases).

When the first telemedicine centres began to appear next to hospitals in Europe they looked more like data or call centres rather than medical facilities. “Healthcare is shifting from hospitals to mobile phones,” said Lucien Engelen, Director at the ReShape Center for Healthcare Innovation (Radbound University Medical Center, the Netherlands). The information collected from the sensors is forwarded 24/7 to processing centres where artificial intelligence systems analyse them online and notify the personnel (nurses and/or doctors) of any alarming changes.

In 20 to 30 years, a hospital visit will only be required when a procedure or operation is necessary. Rehabilitation will be done for the most part at home with the assistance of robots. A good example of this is Riba, an amiable looking robot

» Healthcare is shifting from hospitals to mobile phones.« that can lift an adult with great precision and sensitivity. Designed by the RIKENTRI Collaborative Center for Human-Interactive Robot Research, the robot is an answer to a quickly-ageing population and shortages in care personnel. While lifting sick patients can often put the carers’ own health at risk, it is not a problem for Riba. Telemedicine solutions are further augmented with virtual visits that are made possible owing to new virtual reality (VR) technologies. Patients will not miss the bricks-and-mortar hospitals because they will be equally safe and comfortable at home. The data collected on individual patient accounts will be analysed day and night by artificial intelligence systems to ensure that health care is provided in a personalised and all-inclusive manner. According to the Global Industry Analysts 2015 report, the global market for virtual reality in healthcare is projected to reach $3.8 billion by 2020.

This technology is becoming increasingly popular, especially in learning, psychiatry and rehabilitation.

Many changes will take place in a less striking way than the introduction of robots to hospital wards. Laboratories as

we know them will disappear and they will be replaced by real-time diagnostics carried out by innovative sensors, without having to take blood samples for testing. This will unavoidably bring about transformations in a host of medical professions, and so the continuous development of professional qualifications will be required. Learning systems will assist doctors in taking decisions and in conducting procedures. Hospital corridors will become less populated as they will mostly be frequented by robots visiting patients. Virtual visits made with the aid of robots, such as the iRobot developed

by InTouch Health, are now conducted in 1500 hospitals worldwide. 3D printers will become standard equipment, making it possible to manufacture the personalised implants used in surgical operations.

However, there is still a long way to go before we are able to reproduce human organs applying similar principles.

There is one especially fascinating aspect to all these game-changing solutions – moving care towards the home for increased safety, precision and comfort of treatment. 

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25 ways to strengthen IT competencies The computerisation of a hospital or clinic is a multi-dimensional challenge. For the technology to pro-actively support the organisational procedures, streamline the information flows and help to arrange management and clinical processes, it is not enough to buy and implement a system. The successful implementation of an electronic medical record requires a completely new philosophy in terms of operation and innovative thinking. This is our list of 25 ideas to help integrate the medical facility IT system into the organisational structure, while generating added value for patients and personnel.

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Appoint a leading doctor and leading nurse to be responsible for IT Computerisation requires leaders that understand IT-related subjects and have an interest in innovative technologies, while also being active IT system users who are familiar with its strengths and weaknesses. For administering the software modules, a leading role can be played by a manager, while medical issues should be managed by people selected from the staff. The organisation of work processes differs between doctors and nurses. This means that involved and passionate lead-

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ers should be appointed from each group – a leading doctor for IT and a leading nurse for IT. They will be notified of the needs, problems and ideas to be discussed at the next stage during the regular meetings with the manager. New positions are a way of bringing medical personnel closer to digitalisation issues.

Define a vision, strategy and measurable targets A document that describes the vision and long-term objectives should form the basis for each decision to invest in IT systems. It should include information on the objectives of the facility (e.g. EMDimplementation, patient service quality and personnel satisfaction improvement, cost reductions) with a definition of the time horizon. The objectives should be defined as numbers and percentages, to enable ongoing verification of progress towards their achievement.

Plan the budget One of the greatest investment errors is the lack of pre-reserved funds for digitalisation. Purchasing a system is not a one-time cost – it requires that the strategic plans include the necessary system updates, upgrades, equipment maintenance, additional training, functional expansions and personnel hiring.

One way is to reserve a specific percentage of the budget for IT purposes, which helps to avoid regular conflicts of interest with other, more important investments (which are not uncommon). When the budget is limited, funds should be sought from external resources or a public-private partnership.

IT resources and integration audits This is important not just for those facilities implementing a complex system, but also for units already using an integrated solution. How can we convert the information we collect and exchange into an electronic form? Can we integrate information from various areas? What kind of information, apart from obligatory information, do we need to include in electronic patient records to achieve the objectives? What data do we need to make clinical decisions, for smooth management and for patient service? What information does the manager need for smooth facility management? Each medical facility should review its IT resources on a regular basis to sustain the development of the current system and to increase the digitalisation rate of the processes.

» Organisational efficiency is all about the people, meaning that personnel management must consider the IT department employees.« Strengthen the IT department Organisational efficiency is all about the people, meaning that personnel management must consider the IT department employees. Purchase press subscriptions (sometimes international) on digital health issues, attend specialist training, conferences and fairs, purchase books, and make reference visits to other facilities: the digitalisation of healthcare is so dynamic that we need to keep pace. New knowledge should inspire and initiate ideas for the IT development of the facility.

Monitor the registered data quality Even the most advanced system will fail to deliver material benefits if we fail to ensure the scope, accuracy and correctness of the data being entered. The informative value is significantly reduced by incomplete input, using custom descriptions instead of prepared dictionaries, spelling errors, limiting doctor’s appointment information to the minimum required (diagnosis, service), and other mistakes. The IT department personnel should systematically analyse information quality and initiate personnel training to resolve the issues. A good solution is to force systematic data input, preparing medical check-up templates and updating dictionaries regularly.

Maintain the partnership with the solution supplier One of the mistakes made during the software purchase process is to adopt a transactional approach instead of developing a partnership with a supplier.

IT is not a product, but primarily a service to be performed and developed constantly, both today and in 10 years’ time.

Having regular meetings with the supplier’s representative after they implement the system keeps us up to date with innovations and helps us to plan any expansion of resources. It is better if we communicate this in advance, at the purchasing stage. Sometimes it is enough to exchange emails, and check wheth-

er any new options could be useful for the facility.

Digital health benchmarking It is better, or at least cheaper, to learn from the mistakes of others rather than from our own. There are many of wellimplemented IT solutions in healthcare.

The IT solution supplier should have a list of reference implementations available. A visit and conversation will help to recognise any pitfalls and to learn how to build digital competencies. Going one step further, we could establish a knowhow partnership with the best-digitalised facilities in Poland and abroad. There is nothing wrong in looking for good practices, which is easier with an overview of market information concerning new implementations and projects, as well as reading professional reports on computerisation procedures.

Use innovative public procurement In innovative public procurement the priority is not the price, but the added value of the solution. This does not exclude the achieving of a good price, but it certainly increases the probability of obtaining the projected benefits. The procurement process should, for example, allow us to enter into dialogue with the suppliers, to define our needs and to find the optimum solution together. This also means that a medical facility with specific expectations does not have to purchase a finished, standard IT system.

Our approach to IT and operating philosophies A culture of innovation is always initiated by the manager. Unless phrases like “modernity”, “digital competencies”, “patient service quality”, “digital health” become priorities, the potential of the software will not be employed in practice. The potential functionality of the systems offered by the market leaders remain largely unused in most facilities, because using the potential of IT resources depends on the management and

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» With time, the IT system becomes a source of knowledge about the local epidemiological situation and health trends.«

having a modernity-oriented organisational culture. This is an approach worth passing on to the personnel.

Communicate the achievement of IT objectives The personnel should be part of the software implementation strategy for unit operations. Training is not everything. During the meetings with employees, it is necessary to communicate the achievement of the computerisation objectives as well as the further plans, along with analysing and discussing all difficulties and current successes. This helps to avoid the situation where the personnel consider the system to be a waste of money and a problem (e.g. lengthened data input) determines the general evaluation of the system. Communicating IT objectives is also about listening to the personnel and modifying the inconveniences related to the use of the software. Also at this point it is necessary to consider a strategic instead of a technical approach to computerisation.

Launch multi-disciplinary innovation teams How can we streamline the patient service procedures? How can we improve appointment planning or use of reasonably available technical resources? How can we improve communication with the patient? Organisational improvements can be implemented by launching system functions. Ideas coming from the lowest rank of employees often lead to multimillion savings, so they are worth noting during the meetings and in the surveys.

Giving managers the sole ability to make decisions is a detachment from the realities of facility operation.

Close the distance between patient and IT Patients often complain that doctors hide behind their computer displays, while

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doctors complain that they cannot talk to patients in any other way because they are obliged to enter the required information into the electronic records. Technology does not increase this distance, but poor working procedures do. According to communication experts, it is enough to set the computer display so that the patient can see the data being entered during the appointment. In turn, up to date patient notifications about the procedures in the system strengthens the feeling of professionalism. Such transparency also increases patient trust and understanding.

Co-ordinate patient care The patient journey (hospital, outpatient department, rehabilitation, catering etc.) should be integrated as part of a well-designed information exchange process in the IT system. The doctor will see the prescribed examination results, the procedures performed by the nurse and the medicines prescribed by other specialists, and thus be able to prescribe a suitable diet and provide key information to the specialist taking over the patient care.

A smooth information flow leads to improvements in the standards of care.

Offer IT benefits to the patient One of the most important objectives of the IT system implementation is to improve the patient service quality. We should not forget about this, while we focus on administration procedures, the development of electronic medical records or paying agent billings. A propatient operating strategy can strengthen selected system functions: medicine interaction control, dosing recommendation print-outs, registration via the Internet, appointment reminders, notifications on prevention and health promotion activities, periodic examinations, waiting room queue shortening system, etc.

Surprise through innovations Mobile applications for doctors to aid completing electronic medical records, applications for patients with e-registration and automatic notification of patient presence at the facility, an EHR with the option of information input (e.g. blood pressure measurements, etc.), a patient portal with signing-up to the EHR and prevention programmes, applications and tools for remote consultations, and clinical procedure paths for the personnel. These technologies offer a range of innovations that can be successfully (and inexpensively) offered to the patients and the personnel.

Develop co-operation with science and business New research operations, additional funds, and interesting initiatives – we need to do no more than look around to see opportunities for partnership and cooperation in the projects that the medical facility cannot complete on its own (due to limited funds, development base or know-how). Whether it is a health event organised with the local government and other stakeholders, an information campaign executed with a regional newspaper or television, or an application developed in co-operation with a start-up – each activity helps everyone to gain knowledge and strengthen competencies.

Share the knowledge With time, the IT system becomes a source of knowledge about the local epidemiological situation and health trends. Based on anonymous data, a facility can prepare cross-sectional analyses, using them to plan for the future, including prevention and health-promotion programmes. What is known as “small data” has significant information potential, which we can access through

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» One of the most important objectives of the IT system implementation is to improve the patient service quality.«

the analyses and statistics section available with every professional IT system.

Of course, this relates to data without patient information (anonymous).

Involve the patient One way to involve the patients in the health protection process is to give them an digital health account integrated into the IT system. The adding by the individual of medical data, such as blood pressure measurements or well-being notes, extends the electronic medical records, while strengthening the doctor-patient relationship. For example, an Individual Health Account gives the user access to the managing of interactions between medicines being taken concurrently, food interactions, allergy alerts, dosing messaging reminders, Internet registration, and prevention programmes.

Forecasting and planning The data on registration, admissions by particular doctors, appointment hours, services and issued prescription medicines help to define target groups for the medical facility and to manage them (e.g. suitable personnel numbers at rush hours, registration organisation). Every manager should define the type of necessary reports and how often they are prepared. With results and essential summaries being presented during the meetings attended by the personnel and management, the operation of the entity becomes more transparent and correspond more closely to the actual processes.

Implement procedure paths The necessity of moving between tabs and entering data without any chronological order makes the work of the medical personnel significantly more difficult.

The system should organise the work, arrange the order and force the data type for entry into the system. This is a way

to define the operating procedures that support information quality and facilitate daily, routine operations, especially for the medical personnel. Tip: before the system defines the operating mode, the sequence of activities should be thoroughly discussed with the personnel.

Once established, the order will determine the manner of fulfilling duties, efficiency and, finally, employee satisfaction and patient service quality.

Personalise the software Despite procedures and standardisation, most good IT systems allow a wide customisation margin. The visibility of tabs and particular data groups should depend on access rights, the availability of functions and even colours – since we work with the software every day the personal aspect is essential. More understanding of the IT department, even regarding impossible requests, is always welcome.

Prepare for remote healthcare The intrusion of technology into healthcare and remote healthcare has promising prospects. Although everyone is waiting for better e-consultation funding, it is high time to explore the subject and include it in a digitalisation strategies. Although this might not be a necessity now, it will be in a few years’ time, as will coordinated healthcare. To avoid surprises, the possibility of implementing remote healthcare modules or applications means it is necessary for the system to include technical requirement specification or, if an IT solution has already been implemented, to ask the manufacturer for an opinion and prepare for the project.

Concentrate on personalised healthcare

implementing the principles of personalised healthcare, in which detailed patient records are essential for the adjustment of the doctor’s and medical facility’s activities to suit the patient’s needs.

Personalised healthcare is not just about treatment, it also includes prevention.

A transparent overview of information from laboratory test results, illnesses, medicines taken, and lifestyle (based on interviews) can help us to select a suitable health promotion programme. Personalised healthcare also translates into medicine interaction control, determination of treatment path in accordance with the patient’s situation, preferences or age group.

Involve the IT department in clinical processes The IT personnel should achieve a detailed understanding of hospital operation, working procedures, daily patient service paths, and the organisational problems of doctors, nurses and administration personnel. The basic concept is to avoid the situation where the IT department is reduced to equipment maintenance, software configuration and troubleshooting. The purpose is to avoid misunderstandings between the IT personnel and medical personnel, hence bridging the communication and trust gap. The IT specialists are obliged to observe the daily work of the hospital, including attendance at meetings with doctors (understanding clinical processes), and nurses (exploring the patient service process).

The idea is to organise regular consultations between, for example, the leading doctor for IT, the leading nurse for IT, IT specialists and management, seeking ways to resolve organisational bottlenecks. 

The greater the use of electronic patient records, the wider the opportunities for

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CMIO. The bridge between IT and medicine For many years hospital IT departments have operated as isolated units, focusing all their attention on technology, IT infrastructure, IT networks, hardware repair and software problem solving. These days this is not enough, as the opportunities and pace of digitalisation require innovative strategies and new business models.

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The “we deal with the medical treatment, they are responsible for IT� approach, which may have been true 20 years ago when software functioned as a glorified health care reimbursement calculator, is today one of the major barriers to the smooth computerisation of health care, an archaism no longer fit for a modern environment. Why is this so?

Because information technology has become an integral part of any health care service development process, and technologies are a prerequisite for maintaining a high level of organisational processes and patient service, and an element in the creation of health care quality. As the digitalisation process has developed dynamically in our domestic health care

market, the IT department of every hospital has taken on a strategic role in the development of the organisation. Its competence goes far beyond purchasing hardware and providing software maintenance, moving on towards the level of organisational change and culture management, participating in the formulation of a digital development strategy (which is an integral part of the services offered to patients and strategies for improving treatment outcomes), motivating staff, monitoring data sets and managing the data itself. We are talking about the tasks of a leader in transformation, one which has become a continuous process in today’s world, intrinsic to the activity of nearly every hospital unit.

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» The role of the CMIO is crucial, especially in those places where it is not the technology itself, but the process of organisational change that plays the strategic role.«

Therefore, every hospital needs someone who can combine IT and medical issues, someone known as the CMIO, or Chief Medical Information Officer. Who is the CMIO? Generally this is a doctor with additional education in IT, but may be a graduate of studies in the field of medical information or simply a medical professional who is both greatly interested in new technologies and well-versed in digitalisation processes and new solutions. Thanks to their medical competences, they represent two perspectives: that of the user (doctor and nurse) and the IT specialist (systems and new tools).

Information technologies in health care are evolving rapidly, as are the tasks of the CMIO. In general, the CMIO per-

forms managerial functions, with the main aim of designing, implementing and developing new technologies within the organisational structure of the hospital. The list of difficult competences is long: implementing the system within the workflow of individual units, analysing the management of electronic medical records, defining standards and objectives related to IT development, and developing a long-term digitalisation strategy. The role of the CMIO can be crucial in many areas, such as in the process of implementing an electronic patient record system, where it is not the technology itself but the process of organisational change that is of a strategic importance.

While IT competences remain within the domain of the IT Manager, the CMIO should be characterised primarily by soft competences. They have to be a mentor, passionate about digital tools, a leader of change, and able to inspire all employees, especially doctors and nurses. It is not easy to translate the value of IT solutions into the language of benefits for the whole organisation, as this requires understanding the day-to-day work of the medical staff and the new technologies, as well as participating in digital health conferences. Strategic thinking must be accompanied by the ability to turn plans into practical actions, which is a highly difficult task. The CMIO should a good negotiator, seeking compromise between different groups as well as between technology and medicine. Good interpersonal skills enable the CMIO to build IT project teams, while thinking in terms of benefits and goals translates into real change that impacts everyone in a positive manner. As a visionary and a leader, the CMIO continues to implement new solutions, attempts to use the latest technologies, takes risks, and does not limit themselves to maintaining the already existing IT systems - not for the technological development itself, but to achieve specific organisational and qualitative objectives.

The CMIO is the bridge between the IT department, the doctors, the nurses and the facility manager. Their role in the structure of hospitals is the precondition for improving the processes related to medical treatment, patient service and quality of work. They are conductors, who know how to create a harmonious orchestra from the combination of simple instruments at their disposal. 

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Re p o r t

The bright and dark sides of Big Data One point for an 8-hour sleep, two points for a morning jog, one point for having a healthy meal – one of the ways to strengthen prevention for an individual is to reward good habits. Today this is possible thanks to technologies and omnipresent sensors. However, restrictive control of lifestyle may inhibit personal freedoms, privacy and solidarity in health insurance. This is exactly what has happened in China, where Big Data is slowly becoming a tool for the social control of its citizens.

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It needs to stop Well-developed hospitals, advanced medical technologies and state-of-theart pharmaceutics enable us to prolong and save lives; however, they are hopeless when it comes to people who ruin their health by smoking, avoiding exercise or consuming unhealthy food. Statistics clearly show that cardiovascular diseases have for years been the number one killer in modern societies. Accord-

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ing to the latest data from Statistics Poland (GUS), they account for 70% of all deaths in Poland. Diabetes and some types of tumours are also recognised as diseases closely linked to lifestyle. It is estimated that chronic diseases eat up to 80% of our healthcare budgets. Moreover, we need to consider the consequences of failing to follow doctor’s instructions, which, according to WHO estimates, annually leads to the deaths of 125 000 people around the world. Even the most advanced methods of treatment are not effective if the patient does not to do what is necessary. This is why it is becoming increasingly common to state that we should focus on prevention.

What in theory seems to be logical and simple, in real life is almost impossible to achieve. Despite new disease prevention programmes, national strategies, information and educational campaigns, so far we have not experienced any radical change in epidemiological trends and statistics. The problem has remained the same for years: people lack the motivation to lead a healthy lifestyle and it is hard for them to change their habits, even the most harmful ones. As a result, huge amounts of money in health care are spent on the treatment of people who only become ill because they did not take adequate care of themselves in the first place. However, now there is hope that we can stop this vicious circle – with new wearable technologies that enable the systematic measurement of health parameters, such as physical activity, the number of consumed calories, the length of sleep and blood pressure. The new generation of medicine includes sensors informing about their taking and action.

As a consequence, insurance undertakings are slowly but certainly introducing bonuses for their customers for leading a healthy lifestyle. Such an approach comes from a simple calculation: it pays to invest in prevention instead of spending huge amounts of money on ever more expensive drugs and medical technologies, to which we have been paying too much attention in recent years. Other initiatives are being developed as well that, with the help of Big Data, aim to motivate patients or control their lives. Two diametrically opposed solutions have recently been put into practice.

programme in New York, which aims to motivate people from high-risk groups to take medicine regularly. How? Patients receive remuneration for complying with the pharmacotherapy. It is a method that has been talked about for years, but until now no one wanted to try it and risk criticism. At least, not until the Wellth startup summoned the courage to put this idea into practice: for each pill taken, the patient “earns” 2 dollars. Good discipline is rewarded monthly with 50 dollars. The creators assume that the consequences of not taking the drugs are much more expensive than the bonus paid to the patient. It appears to be beneficial, especially in the case of heart and cardiovascular disease (benefit: reduction of hospitalisation), rehabilitation after heart attacks (reduction of readmission), type 2 diabetes (improvement of treatment results and prophylaxis of complications), and COPD and asthma (avoidance of urgent medical interventions). How does it work? The programme begins in the hospital at the point of patient discharge,

» USA: For good monthly discipline in taking medicine, the patient gets 50 dollars. The creators of the system assume that the consequences of not taking drugs are much more expensive than the bonus paid to patients.«

In the programme developed by the Wellth start-up, the patient receives a certain amount of money for strict adherence to the treatment schedule. Each failure to comply with the schedule for taking their medicine results in a deduction of, for example, 2 dollars from the sum assigned at the beginning. The awareness of losing money is much more motivating than the promise of receiving a bonus. Monthly therapies carried out in accordance with the doctor’s instructions may be rewarded with a bonus of up to 50 dollars.

Money for prevention Mount Sinai Health System (a science and medical centre focusing on integrated health care) has recently launched a pilot

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when they are given a special application that monitors the times of taking the drugs and reminds them of the next doses. To confirm the taking of a pill, the patient must take a picture of it at a specific time. It works like this: 150 dollars are assigned upfront to their account for 3 months. Each time they fail to take the medicine in accordance with the treatment or miss a dose, 2 dollars are deducted from their account. Only after at the end of the series does the patient receive the remaining sum.

Jill Carroll, IT project manager at Mount Sinai, is impressed with the results: “The first people selected for the pilot phase were very undisciplined.

However, after just a week or two, they started to follow the treatment schedule.” When developing the application, the start-up referred to behavioural psychology. This is why the patient sees their full account balance right at the beginning, and can see it dwindle every time they fail to comply with the schedule. It is avoiding the loss, rather than gaining money from a zero state that generates their motivation.

Paying the patient for compliance with medical instructions is an interesting approach, which although it cannot work for all diseases, it can prove helpful in cases where recovery requires the systematic taking of medicine. This is just one of the elements of a compre-

hensive prevention programme that can be put into effect with the use of digital health technologies. By adding health programmes composed for the needs of a specific person, individual guidelines based on measurements made by various types of health sensors or coupled with insurance plans, a new set of tools is created that could motivate the patient toward a positive change in their behaviour. Bearing in mind the rapidly growing nature of health budgets, it is certain that health care systems will have to resort to solutions where data supports prevention.

Control of citizens Strengthening the prevention processes requires much closer control. A worthy end, but does it justify the means? Let’s take another example: social commitment is important for the development of any country, but does strengthening it justify interference in the life of every citizen? Yes, at least that is the thinking in China, where by 2020 a national digital social rating system will have been created that will cover the entire population of 1.3 billion citizens. This is how the Chinese government wants to support the honesty of its citizens and transparency in social and economic coexistence. As the Chinese Ministry of Trade argues, the country’s economy is losing 600 billion pounds annually because

A comparison of the adherence factor (regular compliance with the doctor’s instructions) in programmes without motivational factors and in programmes that financially reward the patient. After 6 months, adherence is clearly higher (by 35%) in favour of programmes that reward compliant patients. In the case of patients with chronic diseases, the motivation to take medicine drops quickly with time. After half a year, only 27% of them regularly take their medicines. This is a huge problem in medicine.

Volpp et al. J Gen Intern Med. 2014 May; 29(5): 770–777

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» China: every citizen has an account on a social e-platform. Depending on the score, they are categorised on a scale from AAA to D. The rating is associated with a system of penalties and prizes.« there are no mechanisms to assess creditworthiness. Such a pilot programme has been launched in the city of Suining in the Jiangsu province. Every resident has an account on a special platform, which is a form of municipal account for each resident. Depending on the number of points, they are categorised on a scale from AAA to D. For paying off a loan or paying bills on time, the balance goes up. It can also fall for negative behaviour on social networks or fines for offences.

Some professions of public trust, such as teachers or officials, require a top AAA category. People who are entitled to this are those with a score above 1,300 points.

If it falls below 600 points, it is even possible that they may lose their job. The further education of children may also depend on whether a given person is regarded as a “model” citizen. The score can be checked with a dedicated application. It is deceptively similar to systems used by rating agencies that assess the investment attractiveness of a state.

China has no doubts that social evaluation with the use of Big Data systems will bring enormous benefits, enable the fair assessment of citizens in such a huge country and strengthen their honesty. Actually, the government has already started working with private companies on developing assessment algorithms. Critics compare the system to the Orwell’s vision of “Big Brother,” where nothing can be hidden and everyone is under full surveillance.

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It all began with an e-commerce platform, Alibaba, which introduced something called Sesame Credit. Making purchases with the platform is linked to social benefits. Spending money on valuable and useful products (books, local food, healthy food) is rewarded with additional points which later on can be exchanged for free services, such as internet access or a city bike system. According to Li Yingyun, the director of technology at Sesame Credit, these types of solutions can positively lead to the adoption of pro-health attitudes. If someone spends 10 consecutive hours playing games, it means that that they are damaging their own health.

The Chinese solution is a combination of “Big Brother” and “Big Data.”

It shows that central scoring systems, whether for social or health behaviour, should be built in such a way that they motivate rather than punish, and monitor the necessary parameters instead of tracking them in a manner devoid of transparency. Let’s imagine a similar health scoring system, where all the determinants of health are taken into account: physical activity, shopping, consuming meals, sleep, watching TV, alcohol consumption, etc. On this basis, everyone scores points that later on influence their lives: insurance premiums,

the ability to apply for a job, or extending a loan. However, ill-considered solutions of prevention programmes based on Big Data, artificial intelligence, sensors measuring health parameters, health accounts can quickly turn into a totalitarian health management system or a solution that people will not accept.

Social credits in a project implemented in Suining, China. Every citizen has an account with points that can be lost (unpaid receivables, fines, unhealthy purchases) or scored (social behaviour). By 2020, China wants to include 1.3 billion of its citizens within the scoring programme.

The Golden Mean Both extreme examples show that the implementation of prevention programmes in these times of universal digitisation is more complicated than one might think.

Apart from the technological solutions, what is also needed is cooperation in interdisciplinary teams, respect for human rights and free choice, considering the mechanisms of psychology and behavioural economics, and better understanding of prevention costs in terms of savings, so the development of disease and its treatment can be avoided. If it is possible to create such a socially and democratically acceptable system, then the vision for the future of health protection looks very promising. What is more, work on such a system should be a higher priority than investments in new technologies that only enable the treatment of already existing diseases. Intelligent prevention is the future. 

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XXIV International Congress of Open Health Care System DIGITAL HEALTH IN HOSPITALS 9 April 2019 | Katowice, Poland The International Conference Centre

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Health in the language of numbers He perceives human health in terms of numbers, using fields of science such as mathematics and biocybernetics. His aim is to build a system for predicting the development of health, so that early prevention replaces treatment. He is an innovator, reformer, inventor and visionary who has created the theoretical and practical foundations of an unprecedented concept that can revolutionise health care. We have talked to Zygmunt Kamiński, PhD, Eng., the inventor of the OSOZ concept and CEO of KAMSOFT S.A. How did you imagine the future of health care 30 years ago, when KAMSOFT started operating?

KAMSOFT was established in 1985 in Silesia, the heart of Poland’s largest heavy industrial region. Back then, communism (socialism) was the only legitimate political system in Poland, with the labourer considered to be of the utmost importance, but without any interest in the labourer’s health. The health care of that era was rather primitive and lacked access to new technologies. Modern health market management did not exist as chief focus of the socialist economy was on coal and steel production for the arms industry. To address the market demand, KAMSOFT started off by automating industrial facilities, mainly mines and steelworks. It developed and deployed IT systems based on PCs and industrial controllers.

The economy did not change until the breakthrough changes following the Round Table Talks, when transformation from socialism to capitalism began and the rapid process of ineffective industry elimination started. In the early 1990s,

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KAMSOFT had to choose a new direction of development and look for new areas of operation. After long and thorough analysis, we decided to focus on the informatisation and cybernetisation of the health market.

What motivated that choice? There were many reasons. The main reasons included the political change, the trust in young people, and the belief that we could build something new and unique.

Another reason was the multi-field technical educations of the KAMSOFT owners, which combined technology, cybernetics and mathematics. The third driver was our willingness to look for serious and long-term challenges, such as the ones found in the health care market. To stay healthy and live long are some of the main human aims, so this area gives hope for many years of interesting work.

The health market is a difficult one but at the same time it remains stable over time, and it will exist as long as humans exist. Given its difficulty, it should have limited appeal to companies uninterested in complex problems, resulting in less competition. Looking back, all these assumptions proved right, and KAMSOFT

is now the undisputed Polish leader in the area of health market informatisation, automation and cybernetisation.

In the early 1990s, the concept of health care market informatisation was too vague and abstract for the society of that time. Many creators of health market development were unable to imagine approaching a human like a machine and viewing a human as an impersonal object of control. It took years of painstaking grass-roots efforts and persuasion to show that this approach was possible. In

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Has the OSOZ concept changed along with the growth of technologies and the surrounding world?

The concept of health market informatisation based on the Open Health Care System turns out to be quite stable and has not changed much over the last 30 years. The principle of patient and patient environment digitisation uses the basic assumptions of cybernetics, and it was impossible for the principal concepts of control theory to change significantly. However, as the IT technologies have changed, so have the tools we use for realising the OSOZ idea. Back in the early days we used DOS and 2400 bps modems.

There is one serious social problem at the foundation of the OSOZ that will probably never be solved: the definition of the strategic objective of OSOZ development, which takes social objectives into account. In principle, the OSOZ system is intended to provide comprehensive and long-term support for the health of patients and the society, and these objectives are contradictory, indeed antagonistic, in many aspects.

This philosophical problem is mainly about the unlimited health care needs and the ever finite funds. You cannot execute an unlimited goal function via limited control power, just like you cannot cover an unlimited distance with a finite amount of fuel. Health definitely suffers from the shortage of available resources.

If the OSOZ system is to support and optimise human health by prioritising the good of individual beings, this objective will inevitably be pursued at the expense of the society. In this situation, the only rational approach to health care market management seems to be a compromise involving a complex goal function that

fact, the belief that health could be controlled was present from the beginning, but there were no high-performance IT technologies for big data collection and processing.

After KAMSOFT chose to work in the health market, another question was how to approach the problem. We faced the difficult task of specifying the longterm development programme for our business. Based on in-depth analysis, we made an important decision: to build a cybernetic system offering comprehen-

sive and long term support for the health of individuals, families and the society at large, under the general slogan “toward a healthier society”.

Based on general plans and assumptions, a specific, long-term programme was created in 1990: the “OSOZ National Health Care System”, now known as the “OSOZ Open Health Care System” to emphasise the transparency, interoperability and openness to cooperation with all willing health market creators in Poland, Europe and worldwide.

» Health definitely suffers from the shortage of available resources.«

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takes into account both the aims of individuals and the aims of the wider society. The combined individual and social aims must be scaled using appropriate weighting factors, of course. The problem lies in that there is no single and fair method to calculate the objective value of such factors. They will be adopted as a compromise, which means that no party will be fully satisfied with the health care system.

While many companies focus on the business development of single products, you have gone one step further with the Open Health Care System strategy. What motivated this approach?

The concept of building the OSOZ to provide comprehensive and long-term health support was largely motivated by the nature of health problems. In past centuries, treatment processes used to be rather simple and short in terms of time. A leg damaged in an accident was amputated.

A child with a heart defect most likely did not live long. With the development of health care technologies, the treatment processes have become increasingly long and complex. An rising number of health problems are treated based on historic information, which leads to health systems building their own memory.

As you can see, the OSOZ concept involves complex health control over long periods of time and is not just about using simple computer programs to informatise and automate selected health processes. This does not mean that individual programmes are not important, however.

On the contrary, the computer programs used in clinics and practices are the primary generators of health information for the OSOZ. For many years, KAMSOFT has developed and deployed specialised software for various health market areas as well.

It was a brave and revolutionary vision for that time. What drove your willingness to change the health care system for the better?

That decision was brave, in a sense, but most of all in was spontaneous. We wanted to build something new. We live to make a lasting and positive impact and the OSOZ can be just that, given enough perseverance and resources. The motivation to build the OSOZ system also resulted from the willingness to improve the health of society and reduce the costs

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» In the future a doctor will be an engineer of patient health and a designer of health processes.« of health care, as health is always underfunded and irrational spending hinders the growth of the health market.

What are the basic assumptions of the OSOZ, what is its current progress and what needs to be done to realise its vision?

To understand the idea and strategy of the OSOZ system, the underlying elements of mathematics and cybernetics must be discussed. Individual products, that is, computer programmes, are just tools to achieve a goal and are not overly important in themselves. Here are some of the essential points: 1. To support human health management or manage human health, you need to build a system that comprises more than single computer programmes: a system based on proved scientific foundations.

2. If you view a human as a control object, human health can be defined as the control object state in a certain mathematical space, known as the Health Space, which must be constructed at the very start of building the system.

3. Since human health over a period of 100 years depends on a great number of factors, the health space and its dimension must be specified in the first place.

4. The health space dimension largely depends on the number of factors that can actually affect health. The number of health-affecting variables keeps growing proportionally to the horizon of control and the excellence of technologies supporting health care. The health space dimension also depends on the society type, location, culture and development, and many other social and political conditions.

5. With the current condition of the development of Polish society, the health space dimension, defined as

the number of independent variables that actually affect health, exceeds 200,000. For years the health space dimension used to be a significant factor impeding the growth of the health care system, as defined by the OSOZ. It was not until the IT revolution that new possibilities opened up for the mass collection and processing of information to enable mathematical modelling of health processes. The problem is somewhat simpler with respect to single individuals, as in practice the dimension of the Personal Health Space does not exceed 10,000.

6. The health of an individual defines a unique path within the health space, described by the Patient Health Function. The Patient Health Function starts at the moment of conception and ends at the time of death.

7. At any one moment of a human’s life, the Patient Health Function divides their Personal Health Space into 3 separate areas: – History of health – described by the information collected in the Patient Health Account, which illustrates past health problems, diseases, medicines, test results, etc.; – Present health – describes the current state of the patient's health (health vector); – Future health – the patient's upcoming health space, where the future health trajectory will be plotted.

8. The history collected in the Health Account is the basic resource for building the Patient Health Model and finding the Health Function.

9. The Patient Health Model plays a fundamental role in health optimisation, as it enables us to predict the state of health in future periods.

10. Health prediction is the basic method of health control in the OSOZ system and provides doctors with brand new areas of health design. In the future, a doctor working with the OSOZ system will focus less on restoring health that has been damaged and more on designing the future health of patients and preventing damage.

Can mathematical methods describe human health if it is shaped by so many factors, such as the environment, genes, behaviours, etc.?

Of course they can. It is just a matter of technique and the performance of data processing equipment. In the current

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era of the information technology revolution, transmitting and processing information is no longer a technical challenge, and data processing can be carried out in real time. We have definitely overcome the barrier of costs, which used to be the primary factor impeding the development of cybernetics in health for years. The only challenge today is the dimension of the Health Space to be processed, as the processing costs increase non-linearly with the increase of this dimension.

Modelling human health resembles weather forecast modelling. We can predict weather many days in advance. The same can be true with health with one fundamental difference: any error leads to incomparably greater consequences and in extreme cases might result in the patient’s death. This is why unlike weather prediction, health prediction must ensure exceptional precision.

Technologies evolve much faster than habits and traditional views about medicine.

How can we reconcile the dissonance between digitisation, social awareness and slow-evolving methods of work?

This obstacle is impossible to defeat.

Science has always been ahead of practical social needs and technological capabilities. For instance, physicists invented the laser almost 100 years before the first prototype was constructed, and nowadays lasers are ubiquitous. The mental barrier seems to have disappeared by now, as people are quick to adopt anything new as long as they find it useful for their everyday lives, often without even realising how something works.

Few people understand cryptography and yet almost everyone uses information security keys, access passwords and so on. CD player users do not know how their equipment works, but this does not prevent them from enjoying music. The only barrier left standing is the technological one. With health, fortunately, society understands health process digitisation, which involves describing health as discrete functions.

How do you imagine the future of doctors’ work and health care? Will the vision of preventive medicine come true?

In the future, a doctor will be an engineer of patient health and a designer of health processes. Computers will carry out many of the processes that are cur-

» Science has always been ahead of practical social needs and technological capabilities.« rently assigned to doctors. There will be health programs and processes for automatic health supervision and adjustment resembling plane auto-pilots. The doctor’s responsibilities will still include processes that are unique and incidental or require heuresis, or ‘having a nose’, that unique quality of intelligent beings capable of creating new entities. Preventive medicine will be prevalent in the future, since the current model of repair medicine offers poor effectiveness while generating heavy costs. Consequently, the health care systems based on reactive medicine breaks down even in the wealthiest countries, including in America. Keeping a car engine lubricated is cheaper than replacing it, and the same applies to health: it is cheaper to protect the lungs than remove a tumour. Preventive medicine is unquestionably more effective and cheaper, and the only reason why it was at a standstill was the lack of technologies to build multi-dimensional health models that are the foundation of health prediction.

The e-health model developed by KAMSOFT also uses big data analysis, harnessing information from the medical and pharmaceutical market to manage the health market on a central level. What are the potential benefits of big data analytics?

The OSOZ system has collected tens of terabytes of data over the recent years. It can be turned into information with big data technologies, as well as other methods. The practical objective of the OSOZ, however, is not to output analytical tables and plot charts, but to parametrise patient health. During a visit, the doctor needs quick access to unambiguous indicators describing the patient’s health and does not have enough time to study the health history recorded in the Health Account. The baseline health indicator

in the OSOZ is the Patient Health Indicator, which is a number between 0 and 1, with 1 meaning that the patient is perfectly healthy and 0 meaning that the patient is dead. It starts off near 1 and keeps decreasing towards 0 over the course of life. The OSOZ system aims to support health in such a way that this indicator always has the highest value possible under given boundary conditions.

Over the years, a number of IT tools for hospitals, pharmacists, doctors, patients and health market organisations have been created in the course of OSOZ development. Also, the name of the system was changed from “National” to Open Health Care System. What does “Open” imply in this case?

The OSOZ system keeps growing and is slowly starting to cross Polish borders. Implementing the OSOZ in other countries, communities and legal environments requires working together with companies operating in those countries.

Besides that, many companies have interesting solutions that can be integrated on the OSOZ platform. The open nature of the OSOZ system means it is open to solutions from other companies, open to interoperability, and open to wide-ranging cooperation in order to improve the health of today’s generation and ones to come.

What should the digital health care model look like in the next several years or decades?

It seems that the digital world will win the confrontation with the analogue one because the former has its memory and the latter gets dispersed. The medicine of the future will be preventive medicine, based on health modelling and prediction. Protecting health against illnesses will become a common practice. However, reactive medicine will also be around because random incidents, such as injuries and accidents, will still require repair treatment and the replacement of damaged organs.

In the not-so-distant future the moral problem of “who is who?” will arise. We will face the difficult and morally complex question of whether a brain transplant patient is person A or person B. As we learn to replace more organs, the problem of identity is bound to come up at some point. 

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Technology is destiny An interview with John Nosta, an innovator, leader of the digital revolution, digital futurist, thought leader.

Why is healthcare so resistant to the omnipresent technological progress, and why are the changes introduced much slower than in other industries?

There is no single or simple answer to this question. Technological progress proceeds unevenly in healthcare and in

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medicine, and innovations have to be adapted to the outdated reality. Let’s take medical imaging techniques as an example. Medical imaging technologies have to meet requirements with respect to storing data, which, in turn, must be harmonised with data transmission technologies. Data transmission must be con-

sistent with the interpretation capabilities at respective healthcare facilities, and so on. The chain of subsequent relations is long. Especially with respect to radiology, we can speak of tremendous progress throughout the past ten years. An image taken at one facility can be sent to another country for interpretation, which al-

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ing regulative procedures in healthcare, which are totally incompatible with the life of technological innovations. Another aspect is society adapting to the changes and accepting them. Medicine deals with the life and health of a human being, so the risks posed by the changes are larger. It’s not a surprise that many doctors are afraid of the innovations because they want to be sure their patients get the best and safest care. So, on the one hand we have the legal regulations and rules of adapting technologies, and, on the other hand, we have human nature and the unique nature of the sector.

When we talk of digital health, we imagine specific changes: digital doctors and nurses, virtual visits, and robots. Do people want such sort of healthcare in the future?

I think a large part of our society doesn’t understand ongoing technological progress and isn’t fully aware of its influence. That’s why they remain so sceptical. When we ask them whether they’d like a doctor in the flesh or a robotdoctor, most would opt for the former.

There’s a simple reason for this – we’re used to such care. We value personal contact with a true doctor first and foremost. On the other hand, we have cold and unknown technologies which seem alien to us.

» Big data will help us save many lives.« lows us to optimally manage our resources and save significantly. Soon, advanced analytical technologies based on artificial intelligence and machine learning will once more change the models of the present. Once new and successful technologies are introduced, other aspects of healthcare also change.

Nowadays, progress is so rapid that technologies become outdated even before they become widespread and widely available. The nature of healthcare is quite unique. Whereas introducing a given product on the market is a relatively fast process in other industries, it is burdened with complex and time-consum-

Despite this, there’s no stopping progress. It will come gradually. I’ll give you one more example. Only a few years ago you had to go to a mechanic to discover what was wrong with your car. Today, you simply need the right device attached to a computer, and the problem is diagnosed in a matter of a few seconds.

The human body can be diagnosed in the same way, provided there is some access to data. Doctors and healthcare providers will benefit from computer-assisted analysis, and patients will be able to get a second opinion thanks to artificial intelligence. This is about expanding the traditional role of doctors, not replacing

it with something new. Obviously, with time, these two aspects of healthcare will get closer and become more similar to each other, more related to each other.

I am sure that doctors will soon no longer be at the forefront of healthcare; instead we’ll have computers, algorithms, and artificial intelligence. Today, we think that doctors have greater competence in assessing one’s health. They see the patient, they can observe their behaviour, listen to their speech. This isn’t entirely true. We have to be aware that machines remember things much more accurately, and detect significant nuances.

Artificial intelligence can notice subtle changes in one’s voice, and observe that a few months ago I had used the word “pain” only a few times during my visit to the doctor, whereas today I used it over a dozen times. It’s a significant improvement in analysing all aspects of our health. Doctors have to serve large numbers of patients, and simply won’t remember or detect such nuances, not to mention how much we can learn about an individual’s health with devices placed in or on their body, which continuously measure and analyse relevant parameters.

There are more and more of these innovations: the Internet of Things, health applications, big data, 3D printing, and augmented reality. Can any of these be the driving force for changes in healthcare?

The fact that there are numerous and diverse technologies is something good. It’s the free market that drives and accelerates their development. Innovation, progress, and inventiveness are not things of the health sector – they come from the outside. Will one or more of the present innovations be leading in the future? It’s hard to say. Technologies change rapidly. What is brand new today, might be obsolete in a few years. New inventions appearing on the market can change the rules of the game and totally turn the tables. At the same time, I’m convinced that big data will be one of the most important trends shaping healthcare in the future, allowing us to better understand the governing mechanisms of health and medicine.

We currently have too much data and too little knowledge. Interoperability and data interpretation mechanisms are lacking, which often makes the data useless...

I wouldn’t worry about interoperability. It’s a small slip-up in the techno-

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logical evolution which has no strategic effect on the industry. Such functional problems can be solved. Indeed, we have more and more data from different sources, but this is a result of natural developments, given today’s information technologies and the nature of innovation. Innovation is never linear. I’d say the surplus of data is more of a luxury than an obstacle. We must also take into account that interoperability is still being developed, and it’s not standing still.

All processes need time. You can’t solve some inconveniences just like that.

What, then, can be a danger for the digital evolution of health?

Paradoxically, I think the danger might not lie in data security, but in some sort of ignorance, a lack of understanding for the innovations. Medicine is a conservative domain, which now faces aggressive changes driven by technological innovations. That’s what fascinates me about digital health: the fact that we’re in a whole new stage and we have to keep our minds more open. We’re facing significant challenges in healthcare, outbreaks of diabetes, Alzheimer’s disease, and mental disorders. Innovations have the potential to cope with these problems in a totally different way, and there are so many urgent problems that putting the significance of technologies in doubt would be simply illogical.

Let’s come back to the first question. When we speak of democratising healthcare, we often mention examples from other industries. Uber, Amazon, and Airbnb brought a revolution into their relevant sectors. But what if healthcare is so unique that it has no chance for democratisation?

The concept of democratisation cannot be reduced to one entity suddenly overthrowing the whole market and gaining full control over it. To make a political analogy, democracy is the best regime because decisions made by political parties have some support of the voters. Similarly, as a result of democratising healthcare, the patient becomes the partner of their doctor and their caregiver, and gains equal rights; thus becoming involved in decision processes. The patient gains freedom in managing their health. The focus of healthcare shifts onto cooperation. People want to have control over their own health but have to know they won’t have full con-

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» Artificial intelligence will allow us to detect diseases at such early stages of development that the lines between diagnostics and prevention will become blurred.«

trol over it. The responsibility will be divided between the patient, the doctor, the payer, and the state. True democratisation doesn’t have to result from strengthening the role of an individual but… can result from strengthening the role of computers. Technologies will serve as interfaces thanks to which the patient will gain insight to previously inaccessible and unknown processes.

There’s still one more fundamental question: how do we organise innovative healthcare? What do we need to be efficient in healthcare?

The answer to this question is multifaceted and depends on many factors. One element of reducing healthcare costs lies in early diagnoses and preventive measures.

We’ve been talking a lot about prevention, healthy lifestyles, and nutrition but without much result. Technologies might be the missing link to our progress. It will be an amazing achievement if we’ll be able to detect diseases earlier and earlier, not allowing them to develop. For this, we need accurate monitoring of multiple parameters and systems based on artificial intelligence which will be able to analyse large data sets. Today’s system is in a large part reactive. We react to the diseases and treat them, which is very

expensive. It may become proactive in the future though, acting at the very first stages of development, blurring the lines between prevention and treatment.

In many interviews, you’ve mentioned that data “will help save our lives.” What do you mean by that?

The ability to analyse different sorts of information and make relevant connections will be crucial. Here’s an extreme example, albeit a bit unrealistic. Let’s assume we can measure how many steps we take every day, and how many times we open the fridge. Then we put these data together with ECG results obtained during sleep. From these three elements, it very well might be possible to calculate the chances of obesity at a given age, as well as other diseases. In other words, we can find unique relations between certain types of data and draw meaningful conclusions from them, which would be impossible without access to data.

That’s why I think big data will save our lives. It will help detect health problems well in advance and test the relations between individual elements. It will help us make more accurate prognoses and learn more about the things we cannot predict today. I often point out that big data will be our third window to mankind and the world, the first being the telescope, and the second being the microscope. These data are of wide diversity, and they concern not only medical matters but also sociological and societal issues, and so on.

Which of the issues in healthcare fascinates you the most?

One of the issues is big data, which I’ve mentioned before. It’s a way in which we can gain a unique insight into various questions of humanity. Another issue is the nature of innovation. It’s not medical or clinical. From what I’ve seen, many pharmaceutical companies approach digital health innovations in a way which doesn’t necessarily lead to optimising healthcare processes. When we analyse the nature of innovation, we have to ask ourselves some questions: Why isn’t innovation linear? Why is it a curve? Why do we see further unexpected changes in a field where innovation is a bit overrated and where innovations seem more like well-balanced changes? This very unique nature of innovation is indeed fascinating. 

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Technologies in healthcare will continue to advance An interview with Dr. Bertalan Meskó, director at The Medical Futurist Institute.

From a medical doctor to a medical futurist – could you please explain how you became an expert in digital health technologies and why you became interested in this topic?

Even though I always wanted to become a researcher focusing on genetics, I remain a geek. In order to combine my doctor and geek selves in one profession, I had to create one. This is how I became The Medical Futurist. Fortunately, now I can work with a team of researchers and digital experts, helping patients, physicians, organizations and governments to prepare for technological changes.

There are many different trends in digital health. If you could choose the three that will have the greatest impact on the future of healthcare, what would they be?

Clearly, artificial intelligence will have the largest impact on anything we do in healthcare. Besides that, patient design is key, which essentially means that we do not develop, create and design anything in care without involving the patient. The third would be health sensors to make the patient the point-of-care.

On your blog you have written that „digital health is the cultural transformation of traditional healthcare through disruptive technologies”. What do you mean by that?

In a recent paper we described that the use of technology only leads to better health outcomes if the related cultural challenges are acknowledged and the new needs of patients are met. That’s why we also needed to define digital health, which we did as: „the cultural transformation

of how the disruptive technologies that provide digital and objective data accessible to both the caregivers and the patients leads to an equal level in the doctor-patient relationship, with shared decision-making and the democratization of care.”

There are significant changes happening right now in healthcare: AI, Big Data, VR, health apps, robotics etc. What do we need to do to get all of these innovations implemented successfully? To move from “disruptive technologies” to “supportive technologies”?

Technologies will continue to advance at an amazing rate, but we don’t. We don’t like to change, and we are generally slow at adopting new things. People are the bottleneck of innovation; there-

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fore what we can do is to actively trade with the future today. By this I mean that it’s worth thinking about the „what if” question every day. What if this technology goes berserk or becomes the greatest development of all time? What if it leads to ethical issues? What if it creates equality? By doing so, we gradually prepare for whatever is coming next.

You have personally tested many new innovations. What is your personal experience with health trackers (wearables)?

Let me answer that through a story.

My childhood dream was to become an astronaut. There are many others who also have space travel as their life goal, but I actually started to exercise six days a week just to achieve this purpose – and I still do. However, on 27 March 2016 I suffered a heavy muscle inflammation due to over-straining. I felt crushed. I had to stop exercising for more than two months. This period had a serious negative effect on my emotional as well as my cognitive health. I knew I had to somehow solve how to do some sport every day, otherwise my brain could not focus hard enough – therefore preventing me from working as effectively.

My most useful aid was DATA. I chose Fitbit mainly due to the GPSfactor, the design and the widely known brand – it was the first watch to include all-day fitness tracking. So I started using it every day.

Until my muscle inflammation, I worked out every day for 30 minutes on average. After 27 March 2016, my daily average dropped to 10.9 minutes, and this lasted for the more than two-month long rest period. Once I could start my recovery, and I bought my Fitbit, I was able to increase my average workout to 41.2 minutes per day (!). My performance skyrocketed due to Fitbit. I had the motivation, of course, but I have to admit I could not reach this level of activity without the data. I realized that I was running, playing football or doing more TRX workout because I wanted my results to look better on my Fitbit-screen. It might sound silly, but it does work.

Do you think patients will accept them?

How should they be “improved” to make them more “usable”?

Patients don’t need to accept anything.

They are motivated because they want to get better. Once they realize that tech-

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» Artificial intelligence will have the largest impact on anything we do in healthcare.«

nologies can help, it gives them even more motivation. However, I firmly believe that no technology can change lifestyle; only we can change that, but with the help of good technologies.

How about robots? Are patients ready for support from machines?

Looking at the practical side and the harsh facts, it seems the ability of digital technologies to reach out to patients through empathy and compassion should have a place in healthcare. Although from the perspective of the human-technology relationship, as well as the interactions between humans themselves, it’s more problematic. Is it a coincidence that research and development into empathic and emotionally charged robots are the most advanced in Japan, where over 60% of unmarried people aged between 18 and 34 have no relationship with a member of the opposite sex?

There are so many ethical and moral questions and possible outcomes regarding empowering technology with humanoid features. However, time is pressing for figuring out what our responses should be and our attitudes towards emotionally intelligent machines, because experiments in modelling human emotions with the help of machines are on-going and there are already amazing results!

Healthcare is a very conservative sector, and our health systems – as well the doctors and patients – do not adopt changes as quickly as industry can generate them.

What is needed to change this?

The only great examples of digital health adoption I have seen were those that in-

volved people dedicated enough to push this through their over-regulated, conservative system. Either this happens, or patients have to find their own way.

Policy-makers, medical professionals and basically every responsible person should contemplate the possible responses to pressing ethical questions and the challenges that digital health presents. As the waves of different technologies are already flooding patients, the faster the appropriate answers come from the regulatory side then the better it will be for the whole of society. The reluctance and lack of incentives for physicians as well as policy-makers in this cultural transformation make patients the leading driving forces in initiating change. Although there are positive examples, such as the story of the FDA approving an artificial pancreas as the result of the #WeAreNotWaiting movement, individual entrepreneurship skills should not define patients’ health outcomes in the long run.

You are a digital health speaker presenting new trends around the world. You’ve made over 500 presentations so far. Is there a single common message or thought that you always want to leave in the audiences’ minds? What would this be?

Patients need to be the point-of-care. This is the best way I can summarize the content of all my talks and keynotes, which while they are customized to each audience they always bear this major message.

Early and precise diagnosis, personalized medicine, preventing instead of curing illnesses – digital health promises us a lot.

What steps need to be taken before we can profit from digitalization?

No matter how difficult it is, medical professionals and policy-makers should always be one step ahead of technology.

They must take the role of guiding patients through the myriad of digital health technologies – but this is only possible if they are up-to-date and open-minded.

On the one hand, they must ensure patients don’t turn to non-proven services or technological solutions, while on the other they must involve patients as partners in designing care and in the decision making.

Patients need to step up and be curious about their health. Today, with all the available digital health technologies, they can finally be curious. 

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Will artificial intelligence eliminate misdiagnoses?

Diagnosing a patient requires encyclopedic knowledge, an objective analysis of symptoms and the ability to see the connection between different factors. Can the reasoning process be represented through mathematical formulas? Is artificial intelligence, based on vast collections of data and recently discovered scientific facts, able to match symptoms to a disease more accurately and faster than an actual doctor?

We are discussing these issues with Dr Jama Nateqi from the startup Symptoma.

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How does Symptoma work and what are the arguments for using artificial intelligence as a diagnostic tool?

Symptoma is a system based on artificial intelligence solutions. The patient enters his symptoms into the search engine and receives a list of their potential causes, each result accompanied by its degree of probability. In that way, patients can self-diagnose even the rarest diseases of which they have never heard before.

However, the system’s main task is not to diagnose diseases based on the symptoms entered into the search engine, but rather to reduce the scale of misdiagnoses.

This has been a major challenge in medicine for centuries. One in every seven diagnoses is incorrect, which amounts to 1.5 million deaths across the world every year. The main reason for incorrect diagnoses is lack of access to information. It is virtually impossible for one doctor to have detailed knowledge of 20,000 different diseases listed in a contemporary medical encyclopedia. In their first year of medical practice, doctors diagnose on average 500 diseases. The greater the experience and the higher level of seniority, the lower the number of diagnoses, with

the number of diagnosed diseases dropping down to ca. 200 after 10–15 years of work. It is a peculiar paradox. One could think that knowledge increases with seniority and that with time doctors should be able to associate symptoms with diseases more accurately. In reality, as time goes by, doctors go through the process of specialization, mastering a narrow field of expertise at the cost of their general medical knowledge.

Let us take a look at how medicine has evolved over the last few thousand years. In the beginning, a doctor assessed a patient’s health on the basis of highly limited knowledge – he did not have the tools to tell the exact body temperature in case of fever. As a result, his knowledge was strictly limited. Today, it is the opposite – we do have access to vast collections of data, but, in fact, they are used only to a small extent. Isn’t it odd that with such a high level of scientific knowledge, a patient consulting three different doctors may still hear three different diagnoses? The accuracy of a diagnosis depends on whether a given specialist has all the crucial information and experience in a given field. As a society, we still tend to believe that doctors

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are like an encyclopedia of knowledge.

Such cultural, paternalistic conditioning pushed them to act the part expected by the patients. Only in that way are they perceived as “good” doctors. Another undesirable consequence of that is the fear of speaking about mistakes and limited possibilities or skepticism towards patients trying to find out information about their health on their own.

This is why we are in desperate need of a new generation of doctors and supporting tools, so that reaching a diagnosis is based on objective data rather than subjective impressions. In the future, doctors will also have to be data managers.

You have mentioned that doctors do not have comprehensive knowledge, which often leads to incorrect diagnoses. It is considered taboo in the healthcare environment. But is artificial intelligence really a guarantee of a better, more accurate diagnosis?

Definitely, which our example proves.

The main argument is standardization. With access to the entirety of a patient’s medical information, it is possible to reach a conclusion based on complete medical knowledge contained in algorithms. There is no room for making

judgments on the basis of one symptom only or having to make assumptions due to lack of information. It must be stated confidently and openly: in the future, artificial intelligence will be able to diagnose more accurately than a doctor. Today, such statements arouse great controversy and concerns are being raised that doctors might be replaced by AI solutions. They will not, as there will always be a need for an emotional interaction between a doctor and a patient, as well as for the ability to acknowledge the context of the patient’s expectations, needs and worries. But a change of roles is inevitable and the hard analysis of data for the purposes of establishing a diagnosis will become fully automated.

AI is taking over a chunk of doctors’ competences and breaks their monopoly on understanding the ins and outs of medicine.

Devising the technology itself might prove much easier than changing the habits and the roles of doctors.

Symptoma seriously divides the medical community. There are some who explicitly say that a diagnosis based on experience cannot be replaced by a machine.

They claim that it is too complicated a process, that many details have to be

taken into account, whereas AI simplifies it all way too much. However, many counter-arguments can be presented. For example, in the 60s and 70s, doctors noted a surge of infant mortality. The problem was lying in a subjective choice of interventions regarding intubation and assisted breathing in children. Doctors made decisions based only on their experience and intuition, which led to inconsistent practices and many incorrect steps. That was until a procedure was established based on five simple indicators, a procedure used until today. It allowed doctors to save probably hundreds of thousands of children. No doctor questions the principles of medicine based on facts, but, as we often see, these principles are not often followed in practice. I often notice how the first impression clouds objective premises and determines the overall assessment of a patient’s health. This is because doctors do not have access to full medical history, they cannot possibly be up to date with advancements in all branches of medicine, know all the newest medication or treatment methods. And yet, this is what most patients think.

Patients have already been trying to diagnose themselves, even by typing their

» One in every seven diagnoses is incorrect.

1.5 million people around the world die each year due to misdiagnoses.«

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» After over a dozen years of practice, a doctor diagnoses only 200 different diseases per year – out of 20,000 listed diseases.« Photo: designed by freepik.com

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symptoms into a search engine. Is it a good or a bad thing?

tient’s quality of life for years or even determine if they live or die.

On one hand, doctors complain that patients acquire information on-line on their own. We claim that this is exactly how they should be taking over the initiative and the responsibility. But I do understand the doctors’ standpoint, as patients usually use either search engines not suited for those purposes, such as Google or WebMD, which contains information about 600–700 diseases. In the case of Dr Google, search results are based on the criterion of popularity. In short, patients do not have access to a reliable tool. This is why a solution like Symptoma may prove groundbreaking.

We rely on scientific collections of data, where the process of drawing a conclusion takes into account a series of different factors, such as geographical location, age or gender. However, we must also take into account that a long time will pass before patients change their habits. At the moment, we already have half a million individual users, a rapidly growing number of inquiries and positive reviews from many people, including those who were finally diagnosed correctly thanks to Symptoma after years and years of doctor’s appointments. Such stories are upsetting - one overlooked piece of information can determine a pa-

Another problem in developing artificial intelligence for medical diagnosis may potentially stem from the way the healthcare industry and the system of refunds are organized.

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That is a major issue. Currently, it is impossible to establish even which procedures towards patients are correct and which are not. This means that we cannot say: patient X was taken care of properly in keeping with the regulations and patient Y was not. As a result, the refund for the services provided to patient X will be bigger. The system of financing healthcare services is based on procedures that are beneficial for the service providers, not on the results of treatment. A market organized in such a way breeds dysfunctions. You can already see the first signs of changes for the better and I am convinced that with the popularization of the technology, new solutions will be taken into account by people involved in devising healthcare policies.

What time frame should we prepare for?

At first, the innovations will reshape the private healthcare market. I do not expect politicians to introduce the chang-

es into the public sector. However, I do hope it happens eventually as a result of pressure from patients who expect positive reforms. In my opinion, the commercial sector of healthcare services will change drastically under the influence of the technology within the next 5 years and the adaptation of the innovation into the public healthcare system will begin in the next 10 years.

And what if artificial intelligence also proves to be imperfect and leads to incorrect diagnoses?

It is not a competition between AI and humans, it is about how machines can assist doctors in making the right decisions.

It is a method of broadening doctors’ current knowledge, a method of increasing the quality of the diagnostic process, an additional tool for improving the doctors’ level of competence.

So how will AI affect the medical profession in the future?

A new specialization will appear, that is, medical data management. Artificial intelligence will not replace us in all activities, but surely diagnoses will be reached much sooner than they are now. The role of a doctor will focus more on preventive measures and treatment. 

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From A to B: Integrated healthcare & data sharing – Because the alignment and operability is lacking, the real benefit of what digital health potentially could offer for the integration of care, cannot be realised – says Dr. Nick Guldemond, Associate Professor Integrated Care & Technology at Erasmus School of Health Policy the alignment of all activities is crucial & Management (Rotterdam).

How would you describe the concept of integrated health?

There are various definitions for the integration of care, but they all refer to the integration and joint coordination of the activities in health and social care that anticipates the needs of the patient/citizen. From the patient’s perspective, we often require much more support and care than a single hospital intervention or service can provide. For example, surgery includes many activities before and after the actual surgical intervention to achieve the optimal outcomes: things like optimising health status before surgery (‘fitter in’ is ‘better out’) and adequate rehabilitation and social care. Therefore,

for better outcomes rather than focussing primarily on the performance in the operation theatre. Another example is appropriate care for patients with multiple chronic conditions, who need a range of services from different disciplines across a range of organisations, such as hospital, primary and social care as well a combination of formal and informal care. With an ageing population and the related increases in the number of chronic conditions, the demand for integrated services to anticipate these complex needs is rising sharply. If we do not get better at meeting the needs of these patients, they will suffer more complications, which means they will require more specialist and hospital care resources. From an economic perspective, higher costs are not really affordable, both at the individual

and the national levels, and we simply do not have the human resources to manage this demand. Consequently, we have to improve the health outcomes at lower costs, and succeed better in prevention.

What are the pillars in the integration of care services?

The key elements the success of integrated care are: 1) alignment and joint coordination of activities/services across organisations in the health and care sectors (dynamic team work), 2) seamless flow of information for planning and organising activities among professional and informal carers as well as for engaging and supporting patients and measuring outcomes, 3) shared decision making on the basis of values, best evidence and transdisciplinary guidelines and protocols,

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4) self-management, patient empowerment and education, 5) creation of a relevant support environment, such as taking the different personal life spheres of people into account to leverage support in: work, private, leisure and school settings, or a combination of the same, 6) more attention on public health and individualised prevention, and 7) community involvement at the citizen-to-citizen, neighbourhood level.

There are a few concepts that, from time to time, draw more attention: integrated health, personalised healthcare, coordinated healthcare etc. What are the most important principles related to how healthcare should be organised to be effective?

We have been discussing these integrated health concepts for almost 30 years, and they are not so different from the current very popular principles of value-based healthcare (VBHC). The integrated health and care concepts place more attention on the process of integrating the activities into personalised services and interactions between the different stakeholders, including the patient and their carers.

Value-based healthcare is more oriented on outcomes, and the use of supply chain principles to optimise the processes in order to reduce costs and increase service efficiency. There is much specific jargon, hype and cult-type discussions within the groups of followers and believers. In reality, we need very different principles to achieve better health and social care work at lower cost. We need to discuss together how services could be redesigned through better alignment, integration, personalisation, communication and coordination, the integrated care approach, while currently as soon as a service is established we start work on its optimisation and measurement (VBHC). Service redesign typically happens in the workplace, at the local or micro level. However, the requirements and conditions for healthcare redesign at a local level are often also arranged at the regional or meso level, involving the relevant stakeholders, and sometimes we even need to facilitate measures such as rules and regulations at the national or macro level. However, the community and local stakeholders are key to making the healthcare transformation successful.

Do digital health technologies help in implementing the theory of integrated health in daily practice? In what way?

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» With this lack of alignment and operability, the real benefits of what digital health could potentially offer cannot be achieved.« As already mentioned, the free flow of correct and up to date information, accessible everywhere and at any time for all the relevant carers and the patient, is essential in organising integrated health. This is a fundamental requirement: information flow from A to B. However, while this may seem a simple requirement, it is often not possible in many countries, including the Netherlands and the USA. Accordingly, many digital health technologies cannot work across the health continuum and the organisations involved, resulting in separate stand-alone solutions that are not integrated into a coherent services structure. This means that interoperability and data sharing should have high priority in order to make digital health work. Currently, the digital health industry is too much absorbed by their individual interests, which applies to multinationals with their locked-in business strategies as well as to startups with their opportunistic and short-term focuses. I would say we need to place more attention on the social factors and the ‘why’ aspects first, because only then can we talk about the ‘how’.

We need to create a shared understanding, rather than continuing to live in different stakeholder bubbles.

Some people see in digital health a Holy Grail for all the problems. Is this good thinking?

As mentioned previously, with this lack of alignment and operability, the real benefits of what digital health could potentially offer cannot be achieved. The real benefit of digital health for societies, economies and individual people is in improving effectiveness, in the planning and organising of care, rather than in popular VR applications, 3D printing or AI diagnoses.

Healthcare is full of paradoxes, and one reality is that technology often makes healthcare more expensive while not nec-

essarily improving the health of people.

So we need to think carefully about the technology we should invest in.

Digital transformation in healthcare leads to easier the communication between patients and GPs, but will it reduce the inequalities, one of the biggest challenge of public health?

Considering we have yet to overcome the most fundamental requirements for sharing health and care information, reaching out to minorities or vulnerable groups of people with digital health solutions is still far ahead. Navigating our way through the health and care system is still quite a challenge, even for well educated people. Personal attention is often what is needed most, but this may be compromised for what is known as a ‘difficult population’. If we could use technology to create more time for professionals to give attention to these people, and to support them in collaboration with their colleagues and informal carers, we would be working smart. There are some examples where tailored software applications do help specific groups to maintain their health and social networks as well as managing their problems. But we could do better in integrating and up-scaling these applications.

Is integrated care a matter for healthcare policy solutions, or can healthcare providers and local communities take steps to strengthen the coordination of care for patients?

I should say that it is the responsibility of all of us. It is about the transformation of society at all levels. At every level we should do what is required, using both top-down and bottom-up approaches. Clearly, we need a strong shared vision, a shared roadmap and suitable leadership to do this.

What topic in digital health is too often ignored and needs more attention?

Palliative care….end of life care is often very complex and there are many professionals involved. In general people want to die peacefully at home, with their family and loved ones, rather than in a hospital, in a sterile ICU department. So how can we help these people to spend the last phase of their lives in the most optimised environment of home?

That would be wonderful. 

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Digital transformation in healthcare as a strategy The added value of digitalization in the hospital results not only from the knowledge and competences of IT managers, but also from the concept of hospital operation. A concept in which IT can be treated as a way to create values in the form of patient experience or operational excellence – says Dr. Artur Pruszko from the Centre of Integrated Care and Telemedicine of the Medical University of Gdansk.

What is the essence of digitization? How can we build an ecosystem that fosters innovation in healthcare facilities?

At the beginning, a seemingly simple question – can digital health improve the efficiency of health care?

Digital health solutions, including telemedicine, can improve the effectiveness

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of health protection in both the area of therapy and the management of the health system. Specific examples include telemonitoring in chronic diseases or issuing e-prescriptions during remote consultations and delivery of medicines to the pa-

tient’s home. The improvement of efficiency is also associated with the significant and radical change brought about by the digital revolution, including, in particular, the creation of new business models, new areas of creating value for users and the system of care.

It must be kept in mind, however, that in the sphere of digital health, there is no simple automatism. New technologies can be introduced which – incorrectly applied or introduced in an unprepared environment – will not bring the expected results and may even cause difficulties. As an example, you can refer to providing doctors with excess information about a patient, which they are not able to analyse during a visit lasting a few minutes. In this case, it is crucial to provide appropriate analytical tools that will indicate the essence of information

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and support doctors in designing appropriate treatment.

Managers of medical centres often lack knowledge on how to run computerization projects to bring added value to hospital work and not only to swap paper for a computer. Where should they seek knowledge regarding this subject?

Knowledge and competences of IT managers in medical entities are growing steadily, also due to numerous training courses and conferences or contacts with leading technology companies. In today’s global world, knowledge is relatively easy to access, while competences are developed through practice, executing good and challenging projects, also in other industries, especially in those where the key to success is to focus on customer (patient) experience and operational excellence. Are there many such IT leaders in our hospitals?

The added value of digitalization in the hospital results not only from the knowledge and competences of IT managers, but also from the concept of hospital operation. The concept in which IT could be treated as a way to create values, like the aforementioned patient’s experience or operational excellence. When looking for an answer, let us consider how many hospitals have a CIO function in their management, how many hospitals have an IT manager as a partner in the implementation of the facility’s mission, and in how many IT is perceived only as a cost and a nuisance.

The added value you are asking for is inextricably linked to the digital maturity of the entity and its environment – the digital health ecosystem, which consists not only of technological aspects but also management and organizational aspects and the model of the entity’s operation, including the “digitalisation” of clinical (care) processes.

Computerization of medical entities and the use of IT systems must be supported by an appropriate system of incentives for doctors and managers. An example is the United States, where financial benefits have led to the situation in which, today, almost every doctor and institution keeps medical records in electronic form. What pillars should such a motivational system be based on?

In fact, the digitization of a medical entity cannot be decreed, although it is pos-

achieve set goals and how many unexpected side effects may occur, such as the increase in bureaucratic burdens indicated by many doctors.

» In the sphere of digital health, there is no simple automatism.

Incorrectly applied or introduced technologies will not bring the expected results and may even cause difficulties.« sible to enforce certain means and forms of communication regarding reporting or documentation, but this is not the essence of the value of digitization that can remodel operational processes and interaction with patients. In order to achieve the benefits indicated here, and these are real and important benefits, a significant reconfiguration of a medical entity should be made. This reconfiguration is a complex process, requiring a vision of change as well as management and technological competence. The system of financial incentives facilitates this process, covering part of its costs/expenditures, but for the sake of success the availability of financial incentives is insufficient. To carry out this difficult process, the first one attempted on such a scale, a medical entity will need competent support and assistance.

The example of the American Meaningful Use Program recalled in the question confirms that such programs significantly stimulate the introduction and adequate application of IT solutions in medical entities, but it also shows how difficult and complex this project is. It was implemented in stages (2010–2013; 2014–2015, since 2016), which had appropriately selected goals and intervention/incentive mechanisms, for which over USD 30 billion was allocated. It is also an example of how difficult it is to

Looking at various national digital health strategies, what good practices should be followed?

Digital health strategies, both national and regional, have been created for several decades by leaders managing the health area in order to use the potential of information and communication technology (ICT) development and its impact on particular areas of our lives. These strategies were created in appropriate technological contexts. The possibilities of their use in the area of health initially referred to the implementation of ICT in diagnostic and therapeutic (telemedicine) and management (EMR) processes.

In the next phase, they focused on the comprehensive development of digital health, including the cooperation of stakeholders – interoperability, development of digital competences. Currently, digital health strategies regard the inclusion and coherence of the health area with digital experience that a patient/citizen, medical professional or manager bring in from other, much more digitalized areas. E-health is, therefore, an element of e-public and e-reality.

To sum up, digital health strategies, or digital health as we would call them today, with a consistent view to using the potential associated with the development and widespread use of the digital world, now focus on the experience of users immersed in the information continuum, on ensuring privacy and (cyber)security.

They formulate an approach that enables effective use of extensive data resources, automation, artificial intelligence (AI), or robotics in healthcare processes. Good practices suggest that the digital health strategy should constitute a broad consensus of health system stakeholders for an effective, fast and agile use of the potential of the digital revolution that we experience in many areas of life, and which in the area of health – due to its nature – should take the form of a digital transformation.  Dr Artur Pruszko is the Director of the Centre of Integrated Care and Telemedicine of the Medical University of Gdansk, Ph.D. in mathematics (IM PAN), manager (MBA, University of Minnesota), an expert with many years of experience in strategy, business development, investment project management and restructuring.

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Will AI replace doctors?

What will be the role of Artificial Intelligence (AI) in healthcare? An interview with three experts: Daniel Nathrath (Co-Founder and CEO, Ada Health), John Crawford (European Healthcare Industry Leader, IBM), Jama Nateqi (Co-Founder, Symptoma).

What AI can offer in healthcare? In which areas will it substitute or supplement doctor’s work?

Daniel Nathrath, Ada Health: On a daily basis, healthcare professionals make tough decisions that affect the wellbeing of their patients. Yet, with increasing demand for services and a global shortage of healthcare workers, there’s less time for physicians to gather a comprehensive picture of each patient’s case. AIpowered health tools can empower patients with the information they need to better understand their condition. These personalized records can also be used to give doctors a more timely, holistic picture of the patient’s health, helping them to make more informed decisions and allowing them to spend more time on patient care and prevention.

AI-powered scanners and symptom assessments can also make a big difference when it comes to understand-

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Daniel Nathrath Ada Health

John Crawford IBM

ing and identifying rare diseases. These ‘orphan’ illnesses affect less than 5 in 10,000 people, which makes them very difficult for doctors to identify and diagnose, and patients may sometimes spend years visiting multiple specialists and undergoing tests before they can be treated. Advanced AI has the potential to cut those years down to seconds by suggesting possible rare conditions to doctors who may not otherwise think to consider them. There are many areas where AI can have a meaningful effect on healthcare and medicine by facilitating more realtime sharing of resources and knowledge, and by supporting doctors in analysing new patterns of disease and health issues on a whole new level.

Jama Nateqi Symptoma

Dr Jama Nateqi, Symptoma: In my humble opinion, in the next five years, AI will first supplement and then probably even start substituting tasks demanding the interpretation of large amount of data within the next 10 years. This comes in handy for diagnostic decision making especially.

John Crawford, IBM: The use of AI in healthcare is not new. For example, the 2006-8 EuResist project that IBM was involved in, to develop decision support for HIV treatment, using large databases of previous case histories and viral genome data. Predictive algorithms were developed and refined, leading to antiretroviral treatment plans as good as

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expert doctors could produce (HIV Medicine 12(4) pp. 211–218). Since then, AI (and in particular Machine Learning) has found its way into many areas of medicine, particularly those involving image analysis such as radiology and dermatology. It also shows potential in cardiology, using ECG and other data to predict heart problems. We also see the emergence of AI in the form of ‘chatbots’, allowing people to have conversational interactions about their symptoms or treatment options. A recent example is the virtual assistant IBM developed for Arthritis Research UK. So far, AI has been limited to relatively narrow problem domains, where it has allowed doctors to make better decisions, or helped citizens to understand health issues. There is much more scope for AI to be used as a form of triage, so that less urgent medical needs can be handled more quickly and effectively. AI may also take over some of the more routine and time-consuming diagnostic tasks, allowing doctors more time to focus on the human aspects of working with patients. It seems unlikely that AI will completely replace doctors, at least in the short term, although it will change some medical specialisms.

What are the biggest challenges, chances and threats of AI in healthcare?

Daniel Nathrath, Ada Health: Simply put, the biggest challenge is that healthcare is extremely complex and, of course, there may be very serious consequences if anything goes wrong. Unlike other areas of tech, you cannot launch a minimally viable product in healthcare - you have to be sure that your technology is safe and accurate.

This is why we rigorously test our technology to make sure that it is as accurate and as easy to understand as possible. We also make sure that we are very clear about how Ada should be used. For instance, Ada does not offer a diagnosis.

It offers a health assessment which aims to provide the patient and their doctor with information about the possible underlying causes for their symptoms.

Of course, the potential benefits once you get this right are vast. The biggest opportunity lies in empowering people to play a much more active role in managing their own health. We need solutions that shift care to more appropriate, effe­ ctive and convenient patient-centered approaches that support people through every stage of their healthcare journey.

» The biggest opportunity lies in empowering people to play a much more active role in managing their own health.«

Dr Jama Nateqi, Symptoma: A major technological challenge to overcome are the ambiguities, lack of available information and the structure of data for any kind of interpretation. However, the biggest challenge is not technological, but philosophical. Are we, as a society ready to allow a machine to tell us, what condition we might have?

Once these challenges have been overcome, we might be able to provide everyone in the world access to free healthcare at the highest levels. This will disrupt healthcare as we know it. Increasing costs, the diverse quality of healthcare given, the lack of doctors and specialists… these will all become problems of the past (our present).

The biggest threat we are facing has probably already become a reality. We have willingly and unwillingly allowed companies and governments to collect our data. As always, this may be used for good or bad. Advancing AI into healthcare is only adding another layer to the existing situation.

John Crawford, IBM: The biggest challenge remains the availability of a sufficient quantity and quality of data, to train AI systems, and to allow them to continuously improve. There is also insufficient independent evidence of the effectiveness and safety of AI solutions, but this will surely develop faster over the next few years. To gain the support of the medical profession, transparency is also important. It must be possible to understand why AI systems have produced their recommendations, and to look at the evidence behind them, as we have done with the IBM Watson for Oncology solution. Finally, it is vital that AI is deployed

in such a way that it does not replace human contact and judgement, especially where complex needs have to be assessed, or decisions made about treatment plans.

When and under what conditions will the use of AI in healthcare become common?

Daniel Nathrath, Ada Health: The desire from patients has been there for years now, with people commonly Googling their symptoms to get more information about their health. New AI-powered technologies have the potential to give users much more accurate, personalized information and to truly change the way people engage with and manage their own health. They are already doing so, in fact: Ada’s mobile app has completed more than 5 million assessments since it was launched, with over 22,000 now completed every day.

It will take several years before AI becomes fully integrated into healthcare systems but the move towards a more patient-centric, digitally enabled, proactive approach to health management has begun and it is really building momentum.

In order for the full potential of AI to be realized and become commonly used within the healthcare ecosystem, it will be critical for emerging players, traditional healthcare companies, providers, insurers and regulators, to work together to establish clear policies that encourage patient-centric innovation and safety.

Dr Jama Nateqi, Symptoma: It is apparent that a lack of doctors within an aging population will at some point threaten the collapse of the various healthcare systems worldwide. At the very least, this breaking point will provide advanced AIs an opportunity to demonstrate their value at scale.

John Crawford, IBM: AI is already being used in healthcare, and its use is likely to accelerate fastest in areas where the AI solutions are at least as good as the alternatives, but provide faster access and more convenience. Certainly in areas such as improving health literacy, symptom checking, and the rapid analysis of medical images, it will become common in the next few years. It will take longer to find its way into clinical pathways, but when it does, it will transform the ability of doctors to speedily make the most accurate diagnosis and best treatment decisions – precision medicine will become a reality. 

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Virtual CARE Consumer interest in virtual care outpaces physician adoption consumers

physicians

Have had a virtual visit with a doctor or nurse

Have implemented the technology for virtual visits

Of those who have not used virtual visits are willing to try it

Of those without a virtual visit capability plan to add it within the next two years

Top reasons consumers did not opt for a virtual visit:

Top physician concerns about virtual care technologies:

Loss of personal connection with their doctor

Medical errors

Concerns regarding quality of care

Access to technology

Issues with access

Data security

Top three benefits of virtual care relate to patient experience What are some of the benefits of virtual care technologies?

Improved patient access to care

Improved patient satisfaction

Staying connected with patiets and their caregivers

Other benefits: Improved care coordination, outcomes and quality of care

Potential to improve workflow

Potential to improve cost effectiveness of care

Staying connected with my peers and other clinicians

Increased flexibility to clinician’s schedule

I don’t see any benefits

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What can health systems do to encourage physicians to embrace virtual care?

With changing health care reimbursement models, growing consumer demand, and advances in digital technologies, virtual care is a must-have for health systems. But how can hospitals and health systems gain physician buy-in? It might be easier than you think.

The 2018 Deloitte Survey of US Physicians is a national survey of 624 US primary care and specialty physicians.

Concerns about potential medical errors, patient privacy and access to technology are main barriers to adopting virtual care technologies Assuming satisfactory reimbursement and no regulatory and licensing barriers for telemedicine and virtual care, what are some of the reasons you would not use these technologies?

Potential medical errors Workplace doesn’t offer these technologies Security and privacy of patient information Patients aren’t interested / don’t have technology to support virtual care Won’t work with current practice workflow Increased practice cost Aren’t interested Don’t see a need to add to practice None of these

Email / patient portals are most frequently used technologies, foloved by electronic physician-to-physician consultations For the telemedicine and virtual care technologies available at your organization, how frequently do you use them?

Every day Every week

Email / patient portal consultations with patients

Physician-to-physician consultations

Want technologies to be more interoperable

Virtual / video visits Want training on the technologies OSOZ World 2019

Source: Deloitte Insights “What can health systems do to encourage physicians to embrace virtual care?”

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Digital Advance: Importance of Technology to Managing Health How important is the use of technology when it comes to managing your health?

GLOBAL 2018 TECHNOLOGY IS VERY/SOMEWHAT IMPORTANT

TECHNOLOGY IS VERY IMPORTANT

NORWAY

FINLAND

SPAIN

ENGLAND

60%

b.d.

b.d.

52%

NORWAY

FINLAND

SPAIN

ENGLAND

23%

b.d.

b.d.

15%

GLOBAL 2016

digital health 2018 Accenture’s Digital Health Survey

Which of the following technologies have you used to manage your health in the past year?

GLOBAL 2018 NORWAY

FINLAND

SPAIN

ENGLAND

WEBSITES

MOBILE PHONE / TABLET

websites

mobile phone / tablet

social media

electronic health records

mobile phone / tablet

ELECTRONIC HEALTH RECORDS websites

mobile phone / tablet

smart scales

websites

mobile phone / tablet

websites

wearables

Most Helpful Information Residing in EHR Which of the following types of information in your EHR most helps you manage your health?

lab work & blood test results

physician notes from medical visits / about medical condition in general

prescription medication history

x-rays or nuclear imaging results

immunization status

personal profile information, such as demographics

billing information

Consumers are Willing to Share Data from Wearables and Health Apps How willing would you be to share information from your wearable technology or mobile app with each of the following? global average Europe average

Your doctor

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Your nurse / healthcare professional

friend or family member

Your health insurance plan

a government department / agency

online community / other app users

Your employer

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Consumers are Getting Comfortable with Healthcare Provided by Man and Machines Imagine you require surgery on your spine to fix chronic, debilitating back pain from degenerative disc disease.

Which type of surgery planning and method would you prefer? You then learn that clinical studies show robotassisted surgery requires a smaller incision, has lower complication rates and a faster, less-painful recovery. Which method would you now prefer?

AI-assisted surgery method after learning about benefits

AI-assisted surgery method

AI-assisted surgery planning

Few Patients Have Received Virtual Healthcare Have you personally received any kind of healthcare virtually?

2018 NIE

TAK GLOBAL

NORWAY

FINLAND

SPAIN

ENGLAND

Top Potential Uses of Virtual Care Which of the following, if any, would you do virtually if given the choice?

GLOBAL 2018 get remainders to do things that help me stay healthy

have a follow-up appointment (after seeingthe doctor etc.)

get remainders to take my medications

participate in a support group

get daily support to manage an ongoing health issue

get follow-up care services in my home after being visited

an after hours appointment (e.g. at night‌)

health status (blood pressure, blood glucose, pulse rate)

attend a class about a specific condition you have

discuss a specific health concern with a doctor

Consumers Want Intelligent Technology for Healthcare Convenience How likely would you be to use the following services?

2018 virtual nurse to monitor conditions / meds / vital signs at ome

Source: Accenture, 2018 Consumer Survey on Digital Health.

GLOBAL

NORWAY

device to test blood at home for variety of indicators

virtual coach to manage health / wellbeing

FINLAND

SPAIN

ENGLAND

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Rising acceptance for artificial intelligence in healthcare Key Findings From Accenture’s Digital Health Survey.

Kaveh Safavi, Head of Accenture’s Global Health Practice

Patients + machines to have a greater role in medical care Health consumers increasingly expect to use digital technologies to control when,

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where and how they receive care services.

And with that, they are more open to using intelligent technologies, sharing data and allowing a combination of man and machine to power a new model of care.

According to our seven-country survey of 7,905 consumers, we are increas-

ingly comfortable with the idea that technology – including artificial intelligence (AI), virtual clinicians and home-based diagnostics – will play a significantly greater role in overall medical care.

For example, while only one in ten respondents have used AI-powered health-

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care services, most said they are likely to try AI-enabled clinical services, such as home-based diagnostics, virtual health assistants and virtual nurses that monitor health conditions, medications and vital signs at home.

In part, the acceptance of digital care delivery stems from consumers’ familiarity with technology outside of healthcare. The use of wearable devices has nearly quadrupled in the past four years, from just 7 percent in 2014 to 29 percent today. Three-quarters of the survey respondents see wearables – such as those that monitor glucose, heart rate, physical activity and sleep – as beneficial to understanding their health condition, engaging with their health and monitoring the health of a loved one.

» The use of wearable devices has nearly quadrupled in the past four years, from just 7 percent in 2014 to 29 percent today.«

Care on their own terms Done right, digital tools could have three big positive effects: putting more control in the hands of consumers, freeing up clinicians’ time, and personalizing care services. Consumers are already taking a lead on the first point. One in three survey respondents said they had accessed their electronic health records in the previous year, mostly to get information on lab and blood test results, view physician notes regarding medical visits, and view their prescription history.

The survey shows that consumers are overwhelmingly willing to share personal data with their doctor, and to a lesser degree with a nurse or other healthcare professional. Additionally, 58 percent of respondents expressed willingness to share data collected from their wearable devices with their insurance company

(although they are less willing to share with their employer or a government agency). But as digital health becomes the norm, it will be vital for technology providers to make sure that their customers’ privacy is protected – one major data breach could put a dent in progress.

Another heartening signal from the survey – especially for stretched health service providers – is that consumers are increasingly willing to take advantage of virtual services when they are available. One fifth of respondents said they had received virtual care services in the previous year. What’s more, nearly half of those respondents said that, given a choice, they would prefer a virtual medical appointment over an in-person appointment if it meant that they had more immediate access to care.

Consumers are likely to support virtual care across a range of activities, including after-hours appointments, group therapy, education on their condition, and follow-up appointments. From a consumer’s point of view, the biggest benefits of virtual care are that they will reduce their medical bills and free up their valuable time.

As digital applications proliferate throughout the health care economy, the many benefits they offer will continually improve the industry’s performance, efficiency and outcomes, moving it onto a more sustainable path – one that could better withstand a labor shortage and an aging population while tailoring biology and service experience to markets of one. 

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Digital Health TRANSFORMATION OF HEALTH AND CARE IN THE DIGITAL SINGLE MARKET

European health challenges geing population and chronic diseases putting A pressure on health budgets Unequal quality and access to healthcare services Storage of health professionals

Potential of digital applications and data to improve health Efficient and integrated healthcare systems Personalised health research, diagnosis and treatment Prevention and citizen-centered health services

What EU citizens expect‌ 90% agree

To access their own health data

TWOJA KARTOTEKA ZDROWIA

(requiring interoperable and quality health data)

80% agree

To share their health data (if privacy and security are ensured)

80% agree

To provide feedback on quality of treatments

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#DigitalHealth

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and Care Harnessing the potential of data to empower citizens and build a healthier society

Support European Commission: 1

Secure access and exchange of health data ambition:

actions:

Citizens securely access their health data. and health providers (doctors, pharmacies…) can exchange them across EU.

– eHealth Digital Service Infrastructure will deliver initial cross-border services (patient summaries and ePrescriptions) and cooperation between participating countries will be strengthened.

–P roposals to extend scope of eHealth cross-border services to additional cases, e.g. full electronic health records.

–R ecommended exchange format for interoperability of existing electronic health records in Europe.

2

Health data pooled for research and personalised medicine ambition:

actions:

Shared health resources (data, infrastructure, expertise…) allowing targeted and faster research, diagnosis and treatment.

–V oluntary collaboration mechanisms for health research and clinical practice (starting with ”one million genomes by 2022” target).

3

@eHealth_EU

– S pecifications for secure access and exchange of health data.

–P ilot actions an rare diseases, infectious diseases and impact data.

Digital tools and data for citizen empowerment and person-centered healthcare ambition:

actions:

Citizens can monitor their health, adapt their lifestyle and interact with their doctors and carers (receiving and providing feedback).

– F acilitate supply of innovative digital-based solutions for health, also by SMEs, with common principles and certification.

@EU_Health

– S upport demand uptake of innovative digital-based solutions for health, notably by healthcare authorities and providers, with exchange of practices and technical assistance.

–M obilise more efficiently public funding for innovative digital-based solutions for health, including EU funding.

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No more “hit-or-miss” prescription of antibiotics Inaccurate antibiotic therapy is one of the key challenges of modern medicine. It leads the patient to experience side effects, prolongs the treatment process, generates additional costs and increases global antimicrobial resistance. However, there is hope for change. Young scientists from Poland have been working on a technology to be used by GPs to select an antibiotic within a few hours without sending any samples to the lab. The participants in the international start-up accelerator programme Startupbootcamp have been developing the final version of their device.

OSOZ World interviewed Olga Grudniak, CIO of biolumo.

The issue of the quick selection of antibiotics matching the type of bacteria has been known for some time now. Why is there still no cheap and widely available solution on the market? What do you think?

The issue was raised by Alexander Fleming, the discoverer of penicillin. He said that there would probably come a time when everybody was able to buy penicillin in the shops. Then, as a result of the abuse of antibiotics owing to our ignorance, we would cause bacteria to develop resistance. Sadly, in the light of his words, we come across as very ignorant, since it has not even been a hundred years since his groundbreaking discovery and it is already happening.

The precise selection of antibiotics was not a burning issue until recently. In severe cases of hospitalisation, we can use the traditional antibiogram or specialist equipment. Unfortunately, the traditional antibiogram takes a lot of time to test the patient with. In the best case scenario, 24 hours. Besides, it requires the services of a microbiology lab. On

the other hand, the specialist equipment costs a great deal of money. In the north of Poland, for instance, only the University Clinical Centre in Gdańsk can afford to buy such equipment.

The issue arises when we take these two factors into account: increased antimicrobial resistance and the lack of a method for GPs to choose antibiotics for their patients. Twenty years ago, the doctor’s knowledge and experience were quite sufficient to prescribe an effective antibiotic. Nowadays, it is different due to the fact that drug resistance has been increasing.

How did you think up the idea and manage to develop the basics of the proper technology?

We were inspired by our business mentor Kamil Borowski. Knowing that we had been working on the issue of bacterial drug resistance, he asked about a quick and cheap method for checking the efficiency of an antibiotic administered to the patient. His then one-year old

son was sick and from his experience Kamil knew that antibiotics do not always work.

The sole commonly available solution is the antibiogram, which takes 2-3 days for Polish hospitals to examine and issue a diagnosis. No parent will wait as long as that before treating his or her child.

The situation inspired Marcin Pitka, our chief scientist, to begin the work aimed at developing a solution which would be both quick and cheap. This is how the Aurora Project was born, which is now our company, biolumo.

The first prototype was created as a result of the simplification of the existing lab technology. At the moment, we are developing a more complex solution which allows us to determine your antimicrobial resistance with greater precision; in future, it will also be used to specify strains. As we learned from our partner in the private health care sector, it is an unwritten rule for putting a medical device on the market.

Our solution combines knowledge of biotechnology, engineering and program-

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ming. It consists of: a diagnostic device, by means of which all measurements are performed for analysis; a test algorithm developed by Marcin; cartridges, which contain a mixture of media and antibiotics developed by us. All of the above tailored to speed up the analysis.

Certainly, we would not have made it without proper support. When it comes to substantive aspects of our work, we are aided by Dr Dawid Nidzworski, the founder of SensDX. On the technical side of things, it is Dawid Masłowski from Intema that helps us; he designs and manufactures medical devices, including our prototypes.

When examining the efficiency of an antibiotic, time and costs play a strategic role.

How do these two factors present themselves in your case?

At the moment, time is the most important. We are optimising our method to speed up the process of evaluating the efficiency of antibiotics. With our first prototype, we managed to limit the time span to 12 hours. Recently, we have been testing the second prototype and the results

» The sole widely available solution is the antibiogram. No parent will wait as long as that before treating his or her child.« are very promising so far. The span of six hours is definitely within our reach.

Our first environmental test on a human sample yielded results after eight hours. We are also launching tests of many bacterial strains with various levels of antimicrobial resistance.

Costs are important when it comes to the widespread implementation in the health care system. The closer to the end, the more important the optimisation of production costs will become to us. For the moment, what counts is keeping the costs below those of the classic antibio-

Biolumo and other finalists of the start-up accelerator programme Startupbootcamp.

Here, young companies gain access to knowledge, support of experts and opportunity to develop their businesses.

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gram. An ideal solution would be 8 PLZ (2 euros) per test, which amount is the refund threshold for a patient’s visit at the GP’s in a public health clinic.

Will this selection method, which takes six hours, have a chance to compete against current solutions, some of which are quicker to use?

As far as the classic antibiogram is concerned, the difference is incomparable.

Under ideal conditions, it takes 24 hours; however, if we take into account the workload of any lab and its employees, the “realistic” test duration is 48 hours.

Add the time required for a sample to be transported, and queues into the bargain, and it takes 72 hours already.

A good alternative are tests and equipment based on other technologies, such as the analysis of bacterial DNA fragments. These are the quickest solutions available on the market right now, which can provide test results in just one hour.

Unfortunately, they cost more than six thousand euros; in addition, they require a specialist lab and do not adapt to new types of resistance. The solution based on mass spectrometry provides results after roughly six hours; however it costs over 40 thousand euros.

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Needless to say, we also monitor all the solutions that are currently being tested; however, they all share the same problem: they have been developed by scientists and engineers for lab work and they are technologically advanced, but this inherently increases the costs. From the very outset, we have been trying to think of a solution for GPs. You have the concept and technology.

What do you need now to make your specific product available on the market?

Time and money, plus the support from key decision-makers responsible for implementing medical devices. We have no shortage of the latter and our solution has generated a lot of interest ever since its first public presentation at the International Bioinnovation Summit 2016.

As for time, access to subsidies considerably affects the pace of our work.

Until recently we financed the project with our own means. But we have already attracted our first investors: the accelerator programme Startupbootcamp Digital Health Berlin, and Dr Dawid Nidzworski’s, engaged in the project as our mentor and business “angel”. This enables us to work at full speed for at least half a year.

»O ur first environmental test yielded results after eight hours. We are launching tests of many bacterial strains with various levels of antimicrobial resistance.« We are also seeking funds to subsidise our further work, which in the startup environment is referred to as the seed round. We are counting on investors from the private health care and medical equipment sectors, which do not need to have the issue and potential explained, but also funds such as Venture Capital, which openly declare their support for research projects in the field of health care and quality of life.

What amount of funds are we referring to and what do you need this money for?

For the seed round, we need up to 800 thousand euros. This will allow us to perform clinical research and to certify the device. As a result, we will have a product ready to be put on the market.

How much time do you need to market the device, assuming that you find companies willing to invest in the idea?

The estimated time from the seed investment to the product’s entering the market is 24 months. During this time not only do we want to carry out the optimisation research, clinical tests and certification, but also take care of the business aspect of the project. To prepare the device for mass production, get suppliers, handle logistics and collect the first orders.

These days, scientists are more eager to get into the market with their ideas, and the start-up environment is a good way. Not only is it open to innovative ideas, but it also is abundant with people willing to help scientists in the commercialisation of their knowledge and inventions.

“At the moment, time is the most important. We are optimising our method to speed up the process of evaluating the efficiency of antibiotics” – says Olga Grudnik, CIO of the polish start-up biolumo.

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This was the case with our project.

I met Marcin while working on a nextgen medicine alternative to antibiotics.

In the beginning, Wojciech Giżowski and Jakub Wysocki provided us with advice about financing the research; together, we raised first money to fund that project.

They persuaded us to perceive our job as business, not science only.

Your idea gained recognition, for instance at the start-up competition infoShare 2017, Gdańsk. You were also participating in the Startupbootcamp accelerator programme.

What does it mean to you?

These are all very important achievements for us. We have resolved to work on our own; therefore, instead of applying for grants, we have to attract investors. There is no better opportunity for presentation than such events, maybe not to mention the meeting with the Investment Committee of the fund. infoShare 2017 has opened many windows of opportunity for us. It certainly helped us get to the Startupbootcamp

» We believe that with our project we will be able to improve health care and, in effect, quality of an average person’s life.« accelerator. Yes, we did enjoy success at several conferences, as the Bioinnovation International Summit I mentioned earlier, but never on such a scale. This is the best reflected in the fact that we were the only start-up at the final R&D stage, that is to say we did not have a ready product yet.

Personally, as the team leader, I also think that each small success is key for projects such as ours. At this stage, high salaries are not an option; there-

Wojciech Giżowski, Olga Grudnia and Jakub Wysocki – the young team of the start-up biolumo. The goal of the scientists from Gdańsk (Poland) is ambitious: selection of antibiotics directly at the GP’s, cheaply, within a few hours.

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fore such feats are our key motivators.

Thanks to them, we see that our actions and progress with the project serve a purpose.

You are very young scientists. What motivates you the most to work on innovations for health care?

True, the mean age in our team is 24. It may sound pompous or idealistic, but from day one we have believed that with our project we will be able to improve healthcare and quality of an average person’s life.

At the very outset, even before our first prototype was created, we had thought about Third World countries as our target market. Only later did it emerge that, regardless of the latitude, there was no effective method for selecting antibiotics.

We do want our device to keep at bay the disturbing vision of humanity decimated by tonsillitis again, which the discoverer of the first antibiotic warned us about. 

Photo: “Changing Batteries,” Sunny Side Up Productions

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Curing loneliness with robots For many people old age means a lack of physical independence, limited mobility and, most of all, social isolation. Can robots, apart from assisting us in everyday physical activities, help fulfil our emotional needs by becoming trusted friends and everyday companions?

In the film “Her” the writer Theodore Twombly undergoes a crisis following the end of a long relationship. However, everything starts changing for the better when he discovers a new, intelligent, intuitive and individualised operating system. Theodore finds himself increasingly bonding with the voice of “Samantha,” a digital personification of an application. Is this pure fiction or a look into a foreseeable future? Another emotional film, “Changing Batteries,” accurately presents the topic of robot-assisted life for elderly people. An elderly woman, the protagonist of the film, receives a robot to help her in her everyday activities.

With time, by helping the woman with real commitment a standard machine becomes something more than a mechanical assistant. A real attachment emerges be-

tween the two, an attachment that lonely people often dream about. The tragic ending in the film gives food for thought.

For some people it’s just a touching story, for others, though, that relationship is dysfunctional and hard to imagine at the same time. Could a robot replace a human being on such an emotional level? Do we have the right to judge older and other lonely people who may create a friendly relationship with a robot? These robots could become closer than a family that lacks the time to care for their elderly and who would rather place them in a home.

Healthcare is not only about healing, it is also about helping a person in need to

feel that someone cares about them. Trips to the doctor’s office or home visits from a nurse are only a small fraction of a patient’s life: during the remaining hours, days, months, and years the patient or older person remains completely alone, without the mental care, support, and conversation they need, or even the simplest thought of someone sitting nearby. Would it be a tragedy if a robot could play such a role? Soon, machines using artificial intelligence systems will be able to do more than help us get out of bed, bring meals or give medicines. They will be able to start a fluent conversation, give advice about suitable lifestyle choices, provide entertainment, react to an emotion with empathy and fill time with their presence. Although they will never be able to replace human beings completely in that respect, they will become a means of psychological support, a substitute for the emotions and relations which are especially needed by ill, older or other lonely people. 

» Healthcare is not only about healing.« OSOZ World 2019

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Photo: designed by freepik.com

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Human electronic record Artificial intelligence systems being used to determine the best possible therapy based on an analysis of the medical data filing systems and the patient’s individual profile offer a chance of more effective treatment and better disease prevention. However, the personalization of healthcare also means taking into account the wishes of the patient, which may not necessarily be aligned with the procedure determined technologically.

Health digitalization gives us hope that the patient’s central role in the system will be restored. The information gathered in the patient’s electronic record, available to every physician tending to the patient, precisely presents the medical history, test results, treatment to date and currently administered medications.

The information follows the patient, it is objective and it does not have to be repeated (retold) during every visit. This is already happening. In a few years, the process of diagnosing and of determining the optimal treatment or prophylaxis scenario will be assisted by artificial intelligence and clinical decision support systems. After all, computers are able to analyse an unimaginable quantity of data over a short period and make the best possible decisions based on the knowledge thus gained. Technology op-

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timizes medical decisions and puts evidence-based medicine into practice. But there is one more element that can complement treatment and prophylaxis personalization in the era of digital health – the patient’s individual point of view and wishes. These issues are barely taken into consideration in the bureaucratic system, where the treatment applied is the outcome of the available procedures, their price, and a short period of face to face contact which prevents the formation of any meaningful relationship between doctor and patient. In the absence of such a relationship, the patient remains merely an element of the health industry. In electronic patient documentation, the patient’s wishes and expectations can be included in the decision-making process relatively easily – with a questionnaire where the patient defines their needs and expectations in the event of extreme conditions, e.g. in terms of life support in critical states or pharmacotherapy with uncertain effects that place a burden on the body. The patient’s point of view should also be included in the approach

to prophylaxis (the freedom to make certain lifestyle choices notwithstanding the health recommendations determined by the system), their preferences with respect to access to information by specific healthcare professionals or e.g. the maximum monthly budget that the patient can spend on medications. Today, nobody asks such questions, which means that the needs, milieu and social determinants of the patient are excluded from treatment and prophylaxis. These factors can have a tremendous impact on how the patient behaves after leaving the doctor’s office.

At present, an electronic record of the patient’s wishes is only an emerging philosophy, which is being introduced by the digitalization leaders, but it should soon attract the interest of healthcare providers implementing electronic medical documentation. After all, such an approach may change the image of digital health by strengthening the trust in technology.

The problem of how to prepare the questionnaire template to mirror the patient’s (always current) point of view is yet another challenge. 

» In healthcare digitalization, an electronic record of expectations gives us the hope that the patient’s needs will be placed above technology and procedures.«

Photo: VITALITI – the Cloud DX entry in the Qualcomm Tricorder XPRIZE

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Laboratory in a box

Many conditions and only one diagnostic device – this is the vision we can see in “Star Trek” science-fiction films. You simply scan the patient with a handy gadget and all the vital parameters will appear on the screen. It has not taken long for this fiction, as it was seen at first, to become real. The work aiming to develop universal health decoders is now in progress and the first prototypes are raising expectations.

Today, nobody goes to the doctor to check their temperature or blood pressure but several decades ago only a specialist could do it. Thermometers and blood pressure monitors are commonly available at pharmacies. In several years, it will be enough to buy one little device to diagnose most, or even all, conditions. Or just to make examinations which now require the visit at a laboratory or at a hospital (imaging diagnostics). Further interpretation of the outcomes will be done by artificial intelligence systems.

Medicine has always dreamt of a quick and precise diagnosis – the basis of effective treatment and prophylaxis. But the main technological obstacles came on the way. To test basic blood parameters, one had to use very complicated analytical devices, and to obtain the image of internal organs it required the use of huge and very expensive magnetic

resonance devices. Over the years, however, technologies improved, miniaturised, thus increasing the capabilities of the available computer processors. As a result, the works on universal diagnostic devices are currently entering an advanced stage. Around 230 teams from all over the world joined the competition in 2012 organised by Qualcomm Tricorder X Prize. After five years, the winner was chosen – DrextER – it was composed of several sensors and could detect 13 diseases. The next laureate – Dynamical Biomarkers Group – intended to detect 50 diseases. With new companies promising even better solutions, a real race of in-

novation is taking place. Today the market is flooded by new devices which can measure the parameters of physical activity, sleep or lifestyle and they are integrated with smartphones. They are expected to grow.

A cold or a flu? A common headache or the symptom of a serious disease?

A cough or a severe infection of the upper or the lower respiratory tract? A stomachache or a stomach cancer? These questions only a doctor can answer today, also by referring to make additional laboratory tests. Before the patient learns the diagnosis, they often have to go through a lot of tests and examinations in different places, impatiently waiting for the outcomes. Unfortunately, time is against the patient. Universal diagnostic devices would bring a revolution which is hardly to predict. Will the laboratory visit or a doctor’s appointment be necessary only in the case of very complicated conditions or diagnoses? Will patients examine themselves on their own? Will we take on such a big responsibility for our health? And will it bring a very conservative healthcare market? 

WHAT’S YOUR OPINION? Is the introduction of the home diagnostic devices a step in the right direction?

We’re looking forward to your comments: contact@osoz.pl

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HIMSS Europe & Health 2.0 conference: Big dreams meet real challenges Several hundred reports, thousands of studies, and positive results from pilot projects – almost everything has been already said about the potential and the advantages of digital healthcare. It’s been said but not yet done.

Health IT is not a wizard’s wand, it’s not an answer to the biggest healthcare challenges. However, it can help to transform healthcare, to create an open and transparent system oriented to the needs of patients. This is why the oft stated necessity for democratisation in healthcare still sounds convincing to me. Several conclusions from the HIMSS Europe & Health 2.0 Conference.

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» Old processes + new technology = very expensive old processes.« When I think about how healthcare is organised in most countries, the first words that come to my mind are “regulation”, “central control”, “providers” and “payers”. And the next one is not “patient”, but rather “beneficiary”. I am perfectly aware that health is a different sector from power engineering or industry. Everyone must have access to care, regardless of their wealth or social position.

However, in recent years we have been idly watching the exact opposite: healthcare, by means of subsequent regulations, shuts itself off from the patients. In times when digitisation facilitates dealing with everyday matters – paying bills, shopping, communication with friends – healthcare has reached a stalemate. Hermetic political solutions solidify the conservative way in which health services are provided. And so in 2018 patients still have to take leave from work and spend hours in waiting rooms just to get a prescription. The chronically ill wander around in a sea of information found on Google, as they do not even have access to the basic information on their own health collected in their medical records.

Owing to digitisation such absurd solutions will become a thing of the past. At least that’s what I’m hoping for.

It’s not that digital healthcare will be perfect. As is normally the case in nature, the old problems will be replaced by new ones. But healthcare will be more friendly to the patient – open, transparent, safer, more accessible, cheaper, flexible and sustainable. In the process of transformation the technology will build the very much needed communication bridges between doctors and patients, supply information to politicians, advance understanding about factors in the development of diseases. New healthcare will be based on data and proofs instead of speculation and wandering in informational chaos. It will be available 24/7 on a smartphone, not where a hospital is built. Provision of health services and the

paternalistic system will be replaced by shared decision-making and engagement of the patient in the process of prevention, therapy and rehabilitation. Nowadays, a patient is just a unit of account in the reimbursement for health services and diagnosis – a beneficiary.

- The world, society and technology – they all change. Healthcare also changes. And it is happening at a rate we have never experienced before. However, the real tsunami of change is still ahead of us – Lucien Engelen, the Director of the REshape Center Radboud University Medical Center, apart from stating great visions, also reminds us about the barriers blocking the road to positive changes: work procedures, politics, reimbursement of medical services, culture, and knowledge. We have to change the way we educate and train healthcare

professionals, reform the way we pay for health services, prepare patients for being engaged “health consumers” instead of passive recipients of external orders who have to adapt to the framework of the system.

HIMSS conferences are a place where great visions are meant to aid the consequential pursuit of change, regardless of great difficulties. For there is no better motivation and inspiration for action than great goals that may sometimes be very distant in terms of their time horizons. This is where difficult questions are posed, which sometimes lack an answer. For example, when we watch a video with an elderly, lonely person in the lead role, who is only accompanied by a robot. Technology makes us face difficult ethical dilemmas and requires us as humans to redefine our needs and expec-

Patient in the healthcare system. Anne-Miek Vroom (IKONE Foundation) illustrated a complex ecosystem navigated by the patient. All the elements are spread and uncoordinated.

Although the patient should be in the centre of this map, this is far from reality.

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tations. Any time now we will be confronted with artificial intelligence systems that will not only have impressive medical knowledge, but also emotions that have previously only been expressed by humans. Are we able to trust such systems as much as we do a real doctor? Is a patient with depression less opposed to seeking help in a mobile application than from a doctor not a sufficient reason for us to pursue popularisation of such solutions? Do patients in the world of new communication technologies still have to travel several and in some cases several dozen kilometres to get advice related to trivial health issues? If we really want to place the patient in the centre of healthcare, should the patient not have the right to a consult at any time, whenever a need arises, without making appointments and waiting in queues, which sometimes reach months in length?

In 2018, the HIMSS Europe & Health 2.0 conference for the first time united with the events organised under the Health 2.0 brand, primarily oriented at

start-ups operating in healthcare. One has to admit that a mix of the knowledge of different stakeholders / experts and the enthusiasm of young innovators generated some totally new energy. Real digital health solutions, already available on the market or at the development stage, presented at the exhibition, did well to complement the theoretical lectures and declarations on the role of digital health in the process of systemic transformation or the stories on the fourth technological revolution. Start-ups may prove to be the decisive force in the revolution, in which the aim is to regain democracy in health. Their purpose is clear – they want to solve a specific problem faced by the patients (and often their founders).

They are determined, and although they are very often defeated by market reality or rigorous law, sometimes they are the ones to break through the previous barriers and established rules. Rome was not built in a day.

Start-ups remind us how a patient should be placed in the centre of health-

The starting point. Robert Wachter presents a seven-year-old girl’s picture illustrating a visit at a doctor’s office. What is wrong with it? The doctor working on a computer has his back turned to the patient and the family. We are still at a basic level of health IT. There is a lot we need to do to reap the rewards from digital healthcare.

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care. In recent years a lot has been said about technologies, IT solutions and technical aspects of digital transformation. These discussions manifest new trends: mobile applications, artificial intelligence, augmented reality, blockchain, patient portals and robotics. And it’s a good thing, as this way we are focusing our attention on the challenges and solutions that are still being developed or the ones that should be developed. However, this fascination with technology way too often caused the patient to be forgotten. The forgotten issues included the patient’s needs, issues, obstacles in access to care, expectations and their daily struggle. This should be the starting point for all the discussions on what healthcare – with the aid of new technologies – we wish to create and what we want to change and how. In the traditional model of the health systems the patient was always on the side, reduced to a medical diagnosis and ICD10 number.

Health digitisation is supposed to introduce an entirely new value and approach.

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» We are only at the first of four stages of health IT.« This is why it was a good thing that during the HIMSS Europe and Health 2.0 conference there was no shortage of patients themselves on the stage – their personal stories and the talks on their struggles with access to information, in communication with their doctors, and their battle against unfavourable administrative solutions. This, for example, was the case presented by Anne-Miek Vroom, the founder of the IKONE Foundation. On one of the slides she presented the complex ecosystem navigated by each patient. Several dozen people and institutions can be distinguished within it,

from the closest family to medical specialists to health market organisations.

In the puzzle of a system that is meant to guarantee proper care to a patient there is a lack of any coordination or communication. This is why Anne-Miek Vroom, together with sixty other patients, by means of the foundation, wants to change the system so as to put the patient in the centre of all the activities. Information technologies are necessary for this.

Access to information itself results in a change in the patient’s role. The rule is simple: if someone is hungry you can give that person ready-made food or teach that person how to fish. Instead of giving the patients medicines and medical services let’s teach them how to navigate the issues related to prevention and health. Let’s reinforce their role, give them a chance to make decisions on the issues on which they have the best knowledge after all – on the issues of their own health.

However, the way to better healthcare, apart from words, requires actions

and real initiatives. There are great challenges and work at the grassroots ahead of us. Robert Wachter, the author of the book “The Digital Doctor” leaves no doubts: we are only at the first of four stages in the digitisation of health. This level is the digitisation of the patient’s data. Ahead of us there is still the connection of all the elements of the health system, gaining knowledge from the collected information, and ultimately – utilisation of this knowledge for improvement in the quality of patient care. We’ll have to wait until the fourth stage to reap the rewards of digitisation. There will be years of hard work at the grass roots before we get there.

The coordination of patient care is still in its infancy. IT is an important tool binding the particular elements of a patient’s path in the system, but it is not a solution itself. It is not enough to computerise all the health market participants, the doctors and healthcare institutions, therefore improving communication between them. Politicians also

Coordination vs. dispersed information. There are a lot of discussions about new solutions, such as artificial intelligence and robotics. But first we need to handle the interoperability of systems and data integration. This is arduous, but necessary work.

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have to be convinced by the new, patient-focused model of care. It will not happen without drastic changes in the way in which medical services are reimbursed. Doctors will also have to learn the new model of care based on knowledge-sharing, cooperation in interdisciplinary teams instead of the one based on individually made decisions. If we digitalize the current processes, we will only strengthen the inefficient procedures without any added value for the patient.

This stems from a simple formula: old processes + new technology = very expensive old processes.

Once again: conversations and discussions are not enough. Cooperation and implementation of great visions in specific activities are much more important. It’s not easy, which became evident from the questions of participants in the workshops organised as a part of the conference. They were related to the basics: What should we start with to improve coordination of health serv-

» The way to better healthcare, apart from words, requires actions and real initiatives.« ices? How to integrate different sources of information? What is most important in the process of digitization of a hospital? What mistakes should be avoided? How to ensure the interoperability of different IT systems? How to implement telemedicine solutions successfully? For global visions to be reflected in local solutions we need education on

Smart home. This is how we will live and care for health in the future. Omnipresent sensors measure health parameters on a current basis, robots aid in making decisions about health, regular contact with the doctor is ensured by telemedicine solutions. Dutch Ministry of Health presents its vision of digital health.

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digital health, especially for those who are responsible for designing new solutions and their users.

The HIMSS Europe & Health 2.0 conference invokes dreams about the potential of digital health and motivates action.

Here is an analogy from a video presented by Lucien Engelen during the opening session: an ostrich searching for food accidentally stuck its head in VR goggles.

A simulated flight in the skies motivates the flightless bird to rise into the air. It keeps trying all the time, trains, and at the same time all the other ostriches keep on laughing – after all, the birds of this species cannot fly. There is no lack of falls and resignation. However, the determination and the goal in front of the eyes ultimately lead to success. Likewise, all the people in the health sector should dream about better healthcare and implement the solutions – including the digital ones – that will make this goal come true. Let’s keep our eyes set on it, so as not to fall into despair. It is about health and life, after all. 

DISCUSS

Artificial, yet better?

Photo: designed by freepik.com

New technologies change the world and the people in it. The digital revolution is disrupting the established order, provoking discussion, giving rise to concerns and hopes, and dividing society into enthusiasts and sceptics. Today we will discuss artificial intelligence, health chatbots and electronic health records..

Pro AI

Contra AI

It is already present in our daily life. It suggests books that we may enjoy, controls production processes and autonomous cars, writes newspaper articles, and composes music. It wins chess tournaments, but it can also diagnose patients and select individual therapies. The best known example is the IBM Watson supercomputer, used in over 150 hospitals around the world. This is merely the beginning of a vast change that healthcare has to face. The list of potential AI applications in medicine continues to expand. Chatbots serve as virtual physicians, diagnosing illnesses based on a series of questions (and lab test results, if necessary). All it takes us is to launch an app – and this new generation of robot doctors is available 24/7, anywhere in the world with access to the Internet. AI systems absorb huge amounts of information from worldwide literature resources, far beyond anything that a human is able to memorise, improving themselves with every diagnosis. AI experts have no doubt that, in the near future, machines will exceed humans in their ability to think and solve complex problems. Even now, their processing power and memorisation abilities are overwhelmingly in their favour. Medicine is a highly complex science. Uncomplicated illnesses, such as sore throats or flu, can be detected by asking the patient a few simple questions. Rare diseases require the analysis of hundreds of parameters, not just health-related, and a thorough familiarity with the patient’s medical record, not infrequently covering their entire life. What takes doctors several days, weeks or years, an artificial intelligence system can do in a few seconds or minutes. Another reason that mankind needs AI in medicine is the insufficient number of doctors, difficulties in accessing healthcare services for some groups of patients, the rapidly growing amount of data that must be analysed, and increasing expectations from patients used to digitalisation in other sectors. 

The level of “intelligence” in artificial intelligence systems depends on the level of algorithm refinement, as constructed by humans. And these may be flawed, so that an erroneous diagnosis process could be repeated thousands or millions of times by the system. This is not the limit of the reasons for scepticism towards AI. The patient is more than a mere set of data to be analysed like a mathematical formula, but is above all a human being in need of empathy, psychological support, and conversation with the doctor. A diagnosis requires a comprehensive analysis of the patient’s condition, and in addition to access to laboratory test results, the physician observes the patient, their behaviour, movements, and appearance. In this way they can tell a lot about the patient’s emotional and mental condition.

Such a holistic attitude is likely to remain beyond the grasp of AI for a long time, creating the risk of the approach to the patient becoming mechanical. Another matter is the certification of such decision-making systems, which may decide the course of a person’s life or their death. We need to answer difficult ethical questions related to liability in the event of medical errors.

One can also imagine the threats posed by cyberattacks on AI systems, with algorithm tinkering set to become a new field of cybercrime. What will be the role of medical workers in the future if everyone has their own all-knowing doctor of every possible speciality in their cellphone? Will human doctors be reduced to validating the decisions of machines? Is artificial intelligence an adequate response to medical personnel understaffing? Would it not be better to seek solutions in the healthcare system, instead of technology? While for minor illnesses, AI can take the burden off the doctors’ shoulders, communicating such grievous diagnoses as cancer or mental illness requires compassion and emotions that remain in the exclusive domain of humanity. These cannot be programmed even in the smartest of systems, as they are characteristic only of members of the same species – humans. 

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Photo: designed by freepik.com

Robot disguised as a doctor

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Contra chatbots

Medical chatbots – artificial intelligence systems which can communicate orally or in writing – have increasing knowledge and learn at a rapid pace. In order to check the symptoms of a disease or ask how to take care of our health, all we need is a special application. The Ada system was created by doctors, scientists and engineers, and we can chat with it as smoothly as with a friend. When we feel unwell, Ada is able to make an initial diagnosis anywhere and at any time. For those who prefer conversation to typing, there is a version available for voice devices. The AI systems can imitate human speech with such precision that it is sometimes difficult to recognise them as robots.

This is why when beginning a chat with a Woebot chatbot, we are informed that it is an artificial intelligence system and not a doctor. Woebot cares for our mental health based on the basics of cognitive-behavioural therapy. It can amuse us, it can express its emotions, and it has impressive knowledge. It is not able to answer all questions yet, however, considering the current pace of technological development, it will be impossible to distinguish a chat with an artificial intelligence system from a conversation with a real-life doctor in a few years. Health care will get a new type of assistance – a simple tool for medical consultation in every person’s pocket. Instead of going to the doctor with the most trivial problems, all we have to do is launch an application. As a result, queues will diminish, and doctors will have time for patients who truly need help. It will be possible to make a diagnosis much quicker, which may be imperative for our health and even our lives, in case of some diseases. Rather than looking for advice using Google, we will obtain professional help at the touch of a button. We will be able to get psychological assistance at home, and patients will not have to be afraid of being stigmatised. Medical help will be available at any time and for everyone. 

In a few years’ time, we will be unable to distinguish a doctor from a robot during a conversation. The AI systems will reach perfection not only in terms of messages conveyed, but they will also become similar to humans in order to express emotions that are so important in doctor-patient communication (the human face in the above photograph was computer-generated).

This is where a series of ethical questions begins. Should humans be only treated by humans? Who will be held responsible for the information provided by artificial intelligence systems which result in the patient making wrong decisions or not seeking treatment of a serious disease? Doctor’s appointments are a multi-layered form of communication where making diagnoses and dispensing medication is only a part of the whole process. Other equally important elements are understanding, providing psychological support, motivating patients to change their habits or to fight a disease, as well as talking with the family. For some people, a medical appointment has a soothing effect and is a form therapy in its own right. What is important is the psychological aspect, and doctors seen as authority figures.

Chatbots cannot see people, they are not able to observe their reactions, facial expressions, their general physical condition or behaviours. Based on these factors, doctors are able to gain a great deal of valuable information, apart from those provided by the patients. Due to malaise, stress or ambiguous symptoms, patients are not always able to describe their health status objectively or explain their symptoms accurately. Chatbots work on a Boolean basis and may overlook such nuances. It may also turn out that such solutions will only be available for those wellversed in the world of new technologies. Health care is under threat of becoming overly technologised and depersonalised.

Chatbots will not hold a patient’s hand or hear their other worries. In the name of economies, they will reduce them to data sets to be processed in diagnoses, a mathematical formula. 

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Humans in gigabytes

Pro EHR

Contra EHR

All information accessible in one place – without the need for time-consuming searches of different sources, and no information gaps leading to incorrect diagnoses. All of it neatly arranged, and easy to view and sort as required. Most importantly, though, all standardised and saved in the same format. Health accounts are the best example of the practical benefits promised with the switch to digital healthcare, and a natural consequence of the shift from analogue to digital information storage. They not only enable the quickly expanding sea of information to be arranged, they also change the rules governing medical practice.

Previously, the only wielder of the information was the doctor or the healthcare centre, but now it can also be in the hands of the patient. Access to information is intended to make healthcare more transparent, as well as to facilitate navigating the maze of information and decision taking. The patient also becomes an equal partner with the doctor, co-deciding on their own health, being better informed and gaining greater health competences.

The accumulation of information on an EHR enables patient care to be better coordinated at every level of the system, regardless of where or when they have an appointment with a doctor. A family doctor, specialist or nurse can all, within their licences, verify the patient’s information to avoid redundant medical tests or the prescribing of conflicting medicines. The entire path the patient follows from one healthcare centre to another, regardless of whether it is a doctor’s appointment, laboratory test, or a purchase of medicines in a pharmacy, is recorded on their account. When the data are gathered in a single location they are easier to secure. A doctor does not need to record again the same data that another specialist entered. The patient can even add some information themselves, such as blood pressure or blood sugar level measurements. Monitoring of patients with chronic illnesses improves, while preventive actions or health promotion programmes can be run more accurately. Information gaps that lead to the leaking of huge amounts of money can now be plugged. 

The centralisation of data is a serious logistical, technological and organisational challenge that many countries to date have failed to overcome, regardless of the budgets allocated to such projects. The primary issue is data interoperability and the merging of the information generated from different sources.

Today we face a chaos of standards and methods of generating information. Sorting all this out will take many years, and only then will building health accounts become feasible. The issue of security raises many concerns, because how do we guarantee data protection in such a large, centralised system? Especially considering the numbers of cyber attacks on healthcare centres. We are talking 38 million EHRs in Poland alone, if they were to be set up on one’s birth. Another matter is utilisation of the patients’ Big Data for other purposes than treatment and preventive healthcare. Such information will clearly be of interest, such as to health insurance companies. There is a risk that national health insurance premiums will depend on the patient’s medical record or their genetic risks. This will be the death knell of the solitary healthcare system that we know, and will bring about many ethical challenges we are not prepared to face. Patients do not have to know all the information about their health, and they are unable to interpret or understand them correctly. Furthermore, patients are not interested in taking the initiative in health-related matters. They are not prepared for this as they were raised in a completely different environment. Younger generations will quicker accept such changes. Independently entered data are liable to a high risk of errors and cannot be relied on when taking decisions crucial from the perspective of human health. Another potential risk is the exclusion of people without the necessary digital skills or access to computer equipment or the Internet. For these reasons, it is too early to introduce such revolutionary changes on such a large scale, regardless of whether the ultimate vision is laudable. 

FOR OR AGAINST? We look forward to receiving your comments: contact@osoz.pl

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Surgery robots of tomorrow

Amin Akhshi, designer of industrial products, has presented his vision of da Vinci robots of the future.

However, this is only a vision inspired by surgery robots. Is this how we are going to be operated on in a few decades?

Source: amin.artstation.com

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Photo: designed by freepik.com

m a r k et a n a l y sis

The pharmaceutical market in Poland in a time of change The Polish pharmaceutical market is – in terms of its value – the 6th market in the European Union. However, other indicators depicting not only the pharmaceutical market, but also, from a broader perspective, the healthcare market, diverge from the EU averages.

Jarek Frąckowiak PhD Vice-president of PEX PharmaSequence

This mainly applies to the level of public financing of healthcare expenditure.

While spending for this purpose – from public and private sources – slightly over

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6% of GDP, Poland has been continuously facing the problem of the underfunding of the healthcare system, which is in large part financed by private expenditure (estimated PLN 34 billion annually) instead of public sources (PLN 80 billion annually). Public healthcare expenditure per capita ranks Poland at the bottom of European Union rankings (24th place: on the basis of the PEX PharmaSequence (PEX) estimations and the Eurostat data).

Demographic changes and the growing pressure on increasing healthcare spending are the reasons for the constant changes in law and regulations as well as new amendments, which are to improve the citizens’ access to health services, reduce queues, rationalise expenditure and handle the shortage of medical professionals.

The facts and projections are implacable. During a period of ten years (2018– 2028), the number of people aged over 65 in the population will increase by 1.8 million, whereas the number of people younger than 65 will decrease by 1.9 million. Moreover, this decrease of 1.9 million may – according to projections – apply exclusively to people aged 19–34, i.e. those of working age. Within a decade, this demographic change will result in an increase in the number of sold prescription medicines by 110 million (plus 25% between 2028 and 2018). As a consequence of the rise in the number of sold prescription drugs, there will be a rise in both public and private expenditures. The PEX analysis shows that the share of NFZ spending (National Health Found) on drugs in the group of people aged over 65 will increase from 40% in the year 2018 to 54% in 2028. And such

increases may not be compensated even by the planned increase in public healthcare spending to 6% GDP until 2025.

Obviously, financial shortfalls and resource shortages in the healthcare market are not specific to Poland; almost every market faces such difficulties, and not only in Europe.

The rationalisation of healthcare expenditure is supposed to be fostered by the networking of hospitals, which is already taking place. Opinions are divided on its efficiency. The deterioration of the profitability of the medical facilities outside the network is an unquestionable result of the new regulation. Being a part of the network ensures public funding.

The computerisation project is also being implemented, and has been for many years. The e-prescribing pilot program is still in progress. This project raises major concerns amongst medical practitioners, particularly the more experienced ones, who are used to paper prescriptions. However, unless the e-prescription succeeds, another project is doomed to fail – Patient’s Online Accounts (Internetowe Konta Pacjenta, IKP), where every citizen’s data regarding health is supposed to be collected.

These accounts are to gather information on prescriptions and medical services, but are also intended to monitor costs and prevent polypharmacy.

The implementation of the Integrated System for Monitoring of Trade in Medicinal Products (Zintegrowany System Monitorowania Obrotu Produktów Leczniczych, ZSMOPL) has also been delayed. The ZSMOPL is intended not only as a tool for monitoring the trade of medicines, but also as a remedy for the export of medicines from Poland. It is one of the

major problems of the market; since the exported medicines are those which are needed in the local market, and currently – due to such practices – it is difficult for a Polish patient to access these medicines. The export of drugs is caused by remarkable differences in prices of medicines in Poland and in the Western Europe. The Polish market – due to the negotiation mechanisms introduced by the Reimbursement Act – is one of the most affordable markets in Europe. In 2019, the Polish market will also see the implementation of The Falsified Medicines Directive. This directive, introduced by the European Union, obligates the EU members to monitor the trade of drugs in order to detect falsified medicines. Poland chose the supplier of the IT system only several months ago, and there is very little time for its implementation… Not implementing the system on time may result in the disruption to the trade of almost all prescription drugs.

The access to medicines is not only linked to the ability of purchasing a drug when the need arises, but also a matter of the access to new treatments. Despite undeniable progress and the growing number of new molecules introduced to the reimbursement system, there are still many treatments that are commonly available in the Western Europe and not reimbursed in Poland. Cancer treatment is an example of this. 46% of drugs included in ESMO standards (European Society for Medical Oncology) are unavailable in Poland.

The shortage of medical professionals is a growing problem. In Poland, there are about 1,100 hospitals (including about 700 private facilities) and around 20,000 clinics of various types. PEX es-

» The Polish distribution market consists of hundreds of superbly organised wholesalers, top 10 of which are responsible for over 90% of turnover, and almost 15,000 pharmacies, many of which have been facing economic problems.«

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timates that about 100,000 doctors and 250,000 nurses work in these establishments. Despite a high number of facilities and professionals in Poland, Poland has the least number of working doctors per 1,000 inhabitants (only 2.31) when compared to other countries of the UE; the average age of a doctor is 52.6. Similarly, in the case of nurses, Poland also ranks at the bottom with the number of 5.24 nurses per 1,000 inhabitants and the average age of a nurse being 50.8. The migration of doctors from abroad (mainly Ukraine and Belarus) as well as the measures undertaken by the government, such as increasing the number of places in medical faculties, may bring positive results; however, not immediately.

Moreover, the salaries of medical professionals in Poland are significantly lower than those in Western Europe, which, for years, has been resulting in the emigration of young doctors and nurses and thus increasing the shortage in the local market.

The Polish distribution market consists of hundreds of superbly organised wholesalers, top 10 of which are responsible for over 90% of turnover, and almost 15,000 pharmacies, many of which have been facing economic problems.

A new legal regulation, introduced last year, called “A Pharmacy for a Pharmacist” (AdA – Apteka dla Aptekarza) restricts the possibility to create new pharmacies and pharmacy networks. Only pharmacists can own newly established pharmacies, they cannot be in possession of more than four facilities and pharmacies can be created on the condition that a specified distance from the already existing pharmacies is kept. At the same time, the number of inhabitants per pharmacy in a given commune is no higher than 3000. The new law has changed the market. The numbers of pharmacies are decreasing, pharmacy networks are developing franchise programmes, and independent pharmacies, as well as micronetworks, are organising themselves into purchasing groups or virtual networks arranged by wholesalers. Almost 400 pharmacy networks in Poland incorporate over 40% of pharmacies, and they represent almost 60% of the turnover. AdA has accelerated the consolidation processes; before its entering into force many transactions took place, big networks bought the smaller ones. Currently, it is possible to take over commercial law companies, but it is not possible to take over any other type of business. There is also a pro-

hibition against the advertising of pharmacies.

Pharmacy margins deteriorate further, which also boosts the closing of pharmacies. The situation is remedied by different types of pharmacy affiliations (franchise, purchasing groups, virtual networks) – a bigger player in the market can acquire products at better prices, ergo, improve the profitability of the business.

In the reimbursement act, many provisions foster lowering of the prices. This includes the price negotiations with the Ministry of Health, dividing the medicines in the reimbursement list into limit groups, in which the limit of reimbursement is defined by the state with a mathematical algorithm (this causes some of the medicines on the list to entail a significant surcharge on the part of a patient, which translates to lower chances of purchase), encouraging the drug substitution mechanism as well as the payback mechanism. The latter consists in pharmaceutical companies reimbursing a specifically calculated half of the bud­ get overrun for a given drug. Currently, a project has been under discussion aiming at pharmaceutical companies reimbursing 100% of the overrun. Pharmaceutical companies object to this idea; medicine prices are low and – especially Polish companies – point out the fact that any new budgetary burden will result in a decline in investment. To some degree, this can be addressed by Development Mode Reimbursement (Refundacyjny Tryb Rozwojowy, RTR), which is a system supporting the companies investing in Poland in R&D, production or clinical studies. However, RTR is still only a project. This and other issues will be regulated by, among others, a government document currently being developed – the National Drug Policy (Polityka Lekowa Państwa).

It is impossible to discuss all the introduced and planned changes in a brief text; the author chose to evaluate those which he judged most relevant – not all of them have an immediate and direct influence on the dynamics of the development of the pharmaceutical market. And the market has been developing dynamically, despite the slowdown in growth.

In 2017, the pharmaceutical market was worth almost PLN 40 billion (EUR 9.5 billion). 85% of the turnover comes from retail pharmacies (retail prices), and 15% comes from hospitals (wholesale prices). In 2017, the pharmaceutical

» PEX estimated that the value of the pharmacy market would grow in the year 2018, in comparison with the precedent year’s 2–3%.«

market has grown compared to the precedent year by 4.9%, including the retail market by 4%, and the hospital market by 10.4%.

In the retail market, over-the-counter drugs (also: Non-Rx) are the most valuable segment, according to the PEX MAT (moving annual total) data, they have represented 42% by June 2018. Other segments: reimbursed prescription drugs constitute 35%, non-reimbursed prescription drugs represent 22%, and other – 1%. The Non-Rx segment is characterised by the greatest dynamics.

The ranking according to sold medications looks the same, but there are significant differences in shares (MAT 06 2018). Out of 1.6 billion medications sold in pharmacies during the analysed period, 58% represented over-the-counter products, 24% reimbursed prescrip-

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tion drugs, 17% - non-reimbursed prescription drugs and 1% - other products. In the recent period, the number of medicines sold has been decreasing. The growth of the market value described above is caused by the increase in prices and new product introductions.

In Poland, reimbursed drugs are sold with different levels of patients’ co-payment. The surcharge can be insignificant, PLN 3.2 for drugs available at a flat fee (in each case for a specific DDD value and depending on the reimbursement limit in the given reimbursement group), 50%, 70% and free of charge to eligible patients. Since 2016, this group includes seniors, i.e. persons aged over 75. The regulator defines the molecules and indications for which reimbursed drugs are dispensed free of charge. The list, called the S List (Lista S) is gradually extended. At the moment, the S List contains molecules representing 32% of the pre-

scriptions of the entire Rx market. The prescriptions of the patients aged over 75 for the S List drugs (regardless of the cost-sharing level) represent 9% of packages.

The Polish pharmacy market differs from other markets in terms of the value ranking and the sales volume with regard to active substances (details on a YTD basis 06 2018 in figures; YTD = year to date). In terms of value, anticoagulants, ibuprofen and diclofenac prevail, whereas ibuprofen, acetylsalicylic acid and bisoprolol are in the lead regarding quantity.

Non-prescription products represent – in both value and quantity terms – over 55% of the market (all data comes from MAT 06 2018). The greatest Non-Rx segment with regard to value are overthe-counter drugs – during the analysed period, they were sold (at retail prices) for over PLN 7.3 billion. For that money, the patients bought almost 520 million packages. Food supplements are the second largest segment: their sales value is PLN 2,8 billion, and the number of packages purchased by patients reached 171 million. The last of the three greatest segments are cosmetics – almost 75 million packages cost the clients almost PLN 1.5 billion.

For a long time, Non-Rx products have been the driving force for the market; however, recently, there has been a slowdown in growth and lower numbers of sold packages.

Having examined the first half of 2018, one can see that the Non-Rx market was dominated by the following categories (the analysis was conducted according to the original PEX categorisation of the Non-Rx market): in terms

of value and quantity – Cold, Digestive Tract and metabolism as well as Vitamins/Minerals/Tonics.

Both Polish and foreign pharmaceutical companies are successful in the Polish market. In the first half of 2018, the companies with the highest turnover in the pharmacy market (in retail prices) were (top 10): Polpharma, Sanofi, Teva, GSK, Aflofarm, Adamed, Bayer, Sandoz, KRKA and USP Zdrowie.

PEX estimated that the value of the pharmacy market would grow in the year 2018, in comparison with the precedent year’s 2-3%.  Sources: the following sources were used in the article: in the case of the pharmacy market – the PEX PharmaSequence data (on the basis of the representative national panel of pharmacies), Eurostat statistics, OECD, GUS (Statistics Poland), Alivia Report, publications by RynekAptek.pl (including those referring to IQVIA data) as well as PEX’s own estimations.

About the company: PEX PharmaSequence - a consulting and market research company with a nearly 20-year focus on the pharmaceutical market and the healthcare sector. PEX PharmaSequence combines the knowledge of close to 60 teams of experts in various fields with vast data resources (data from more than 6,000 pharmacies as well as data and information from syndicated market research studies conducted with the participation of physicians, pharmacists, nurses and other healthcare professionals).

About the author: Jarek Frąckowiak, PhD, vice-president of PEX PharmaSequence – pharmaceutical market expert, who for 20 years has been holding key management positions in both local and international companies offering expert services in such fields as research, database management and services supporting marketing and sales activities in the pharmaceutical market (Medical Data Management, e-zdrowie.com, Dendrite, Cegedim, PharmaExpert).

Copyright © 2018 by K AMSOFT S.A.

Publisher: OSOZ World K AMSOFT S.A. 1 Maja 133 40-235 Katowice | Poland Internet: www.osoz.pl E-mail: contact@osoz.pl Tel.: +48 32 209 07 05

Editor-in-chief: Artur Olesch Design: Piotr Chamera Print: INFOMAX, Katowice Graphics: freepik.com Published: November 2018 ISBN: 978-83-940479-1-7

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