Changes to the healthcare market

Questions for Stephan Rietiker, digital health expert, Switzerland/U.S.

How will the healthcare market change in the coming years?

It will be far more strongly defined on the basis of quality than is the case today. Physicians will have to position themselves in the market as regards their availability, specialization or their efficiency and hospitals will have to do the same as regards hygiene, the number of reoperations or the need for hospital readmissions  and additional exams or procedures.

Diagnostics in digital health is now shifting from the physician to the patient. To what extent does the latter need to be protected from himself, I’m thinking of potential propensity to self-treatment here?

Prescription drug laws govern what drugs you can buy and which ones you can’t. And it’s already the case that you can get certain drugs at pharmacies without a prescription. I’m against the gradual paternalism of patients we’re unfortunately seeing in this country. It’s important that the quality of the drugs is high so that patients feel safe  when  taking them. But the technological development in diagnostics doesn’t change anything about this.

What are the origins of digital health?

Questions for Dr. Stephan Rietiker, digital health expert and entrepreneur

It’s already possible today to measure our heart rate using mobile electronic devices. In the future, we will be able to monitor far more health-relevant data on our smartphones. What is driving this development?

It all began in the early 1990s as so-called “patient monitoring,” in particular with diabetes patients. Although patients were able to check their urine glucose levels themselves back then, they still had to see a physician for blood glucose testing. By rolling out technically more advanced monitoring devices, it became significantly easier to check blood glucose levels. Patients could prick themselves and analyze the drop of blood on the spot by inserting a test strip in a monitoring device. This was called “point-of-care testing,” a precursor to today’s digital healthcare world.

What characterized this innovation?

It was not only a highly profitable business, the technology was also highly accepted among patients because it made their lives easier and reduced their number of medical consultations. At that time neither a widely usable Internet nor any other interaction platforms existed. It was Bill Gates, the visionary, who predicted the next quantum leap in medicine: the merger of IT, user-friendly devices, science and medicine.

How did the healthcare industry respond to this?

Bizarrely, up until about 2005 the industry praised its reluctance to make any significant investment in IT – not even amounting to 1% of overall revenues on average. In other words, we were working with completely outdated systems. Upgrades did not come until a very late stage, and they focused strictly on placing IT behind massive firewalls to prevent competitors from getting any access to research data.

What is the situation today?

The customization and mobilization of digitized platforms turned this concept upside down in just a few years. Today, the focus is on patients or customers who are fully interconnected digitally. It’s no longer a question of whether a company approves of this or not. Individuals today have the possibility to view and exchange data. This new trend and the increased willingness to share data is forcing pharmaceutical and med-tech companies to rethink their position and to instead be willing to share data with third parties, e.g. competitors. However, this trend is still in its infancy.

Physician and patient, and the future

Will the patient-physician relationship change profoundly in the near future?
Dr. Stephan Rietiker, MD, graduated in medicine from the University of Zurich

In the future, we will increasingly be able to determine for ourselves whether we are sick or healthy.

This technology allows us, so far to a limited degree, albeit ever increasingly and comprehensively, to determine symptoms of a sickness at any time and individually and make an initial basic diagnosis.

Imagine a transatlantic flight during which a passenger suddenly complains of pain in his chest. A portable device, perhaps a smartphone in the future, could be used to obtain a quick ECG reading and analyze the results using algorithms so that the curves no longer need to be read and interpreted by us. Early signs of a heart attack would be identified and the pilot could turn around immediately and land if necessary. Technically, this will be possible very soon.

Now, does this mean that we won’t be needing physicians anymore in the near future? Obviously not. The digital system cannot replace physicians. But it can make their work more efficient and help you as a patient – or as a healthy bystander – to identify symptoms. A physician will always need to be involved when it comes to deciding on or administering treatment. What we offer is diagnostics in a technologically integrated system. However, this is merely a first step toward deciding on and administering treatment, which can only be done by a physician. This also sets us apart from manufacturers of lifestyle gadgets such as Google or Apple.

The shifting understanding of the physician’s role toward a medical services provider

In the future, physicians will be part of an information and data collection system; something that is already a reality in the U.S. The change from formerly eminence- to now evidence-based healthcare will further accelerate considerably. Physicians will no longer be diagnostic gatekeepers , but rather be in charge of verifying diagnoses and ultimately treating their patients. Let’s assume you are suffering from persistent tonsillitis. The app on your smartphone can tell you not only who specializes in this disease, but also who is actually available to see you, whether this physician is accepted by your health insurance and with what hospital he collaborates if surgery is necessary. This means that in such an environment we are no longer speaking merely of diagnosis, but of a global coverage of all the patient’s needs.

The transformation illustrated here cannot be reversed, and it has already progressed considerably in the U.S. But the good old family doctor model should nevertheless not be abolished. I would consider such a development to be disastrous. After all, it’s the physician who continues to have an in-depth idea of his patients’ health, because he has been providing them with care which may even span many years.

Interestingly, we are also seeing a backlash against highly specialized medicine in the U.S. Physicians are again being trained for some hospital positions to play a supervisory role with an overall picture of the patients. However, I fear that the trend points toward the other direction, also because it’s becoming increasingly difficult for general practitioners to find adequate training residency training positions.

The digital revolution in healthcare will change our lives profoundly

Thesis of Stephan Rietiker, CEO of a stock exchange-listed digital health business (lifewatch.com)

Is this digital revolution being incorporated into medical training yet?

I am often asked by journalists and entrepreneurs whether the digital revolution is reflected in today’s training of young physicians at universities yet. I’m afraid that universities and medical training facilities are still entirely out of their depth in this area, even in the U.S. The example of interventional cardiology shows what influence technology is having. As a result the number of trained heart surgeons is gradually decreasing.

You’re a physician yourself: doesn’t such a development affect the sense of self-esteem of the entire medical profession?

For an “old-school” physician, which I consider myself to be, this development marks a profound break with the past. I was trained in the 1980s to learn the “clinical views.” In other words, to observe how a patient enters the physician’s office, to systematically take the patient history and to perform a thorough physical exam. Moreover, I became a physician during a generation when specialization was rather frowned upon. Younger physicians will have to adjust; for the physicians of the future, it will be normal that patients come to consultations with a basic diagnosis.

Is it conceivable that we’ll be able to comprehensively monitor our vital signs consistently and in real time ourselves in the future?

That will happen, yes. Whether we like it or not. The real challenge is not in the technology, but in how we handle it. The fact that one can also know too much poses a problem in its own right. If you’re not aware today that you may become severely ill in five years’ time, you’ll likely feel better today than if you did know. In turn, if health insurers know about how prone you are to sickness, they may cut your coverage or introduce  provisos in their liability. These are the major challenges we must address.

What does that mean specifically?

In the U.S. reference market,  we can see on a case-by-case basis that health insurers are having to toe the line when it comes to drafting provisos.  Insurers’ business models will have to change fundamentally over the longer term.

And what does that mean  for us? Eternal life?

No, our bodies reach their limit at some stage around the statistical mean. Nothing will change in this regard. But what may change, and this is relevant, is that we have the highest possible quality of life for as long as possible. This also means reducing the time when we are no longer healthy. This will certainly be possible with digital technologies and individualized diagnoses and treatment, which will also have a positive effect on costs. Just remember that about one third of all drugs prescribed end up in the trash can.

Digital health is more than a fad. It’s part of contemporary entrepreneurship.

Questions for Stephan Rietiker, digital health expert and physician, on opportunities, risks, markets and companies

What does a company need to succeed in this market?

We need to distinguish between the regulated and unregulated markets. The latter primarily involves technically rather simple lifestyle gadgets, such as pulse, pace or heart-rate meters, as provided in wristbands, smartwatches or smartphones. In the regulated market, where medical diagnosis is conducted to devise a subsequent course of treatment and where we at LifeWatch (lifewatch.com) are active, measurement systems are far more complex. It takes reliable algorithms, the ability to interconnect them with software applications and to then integrate such apps in a robust and routine manner in a system that comes with a very high degree of safety and a sufficiently long service life. This requires the highest level of testing and production quality.

You outline a fine world because it will be safer. What are the downsides?

They certainly exist. First, if we all start running around with these devices we could see a glut of diagnoses. Second, diagnostic errors may occur. And, third, there is a risk of wrong or self-applied treatment with accordingly negative consequences. However, these downsides always need to be weighed up against the benefits that come with this change. We expect to see efficiency gains with corresponding cost reductions, more safety, greater responsibility of patients, targeted diagnoses and therefore more successful treatment. In short: better healthcare thanks to individualization. Ultimately, as with all things in life, it boils down to two things: a certain degree of personal responsibility and a careful application of technology.

Are people today actually capable of coping with the new variety of diagnostic options?

We’re all able to fill out our own tax return. The pure administration of data is something we already do on a daily basis, in many areas of our lives. I don’t consider this to be an issue. But the matter you rightly raise, and which is also prompting warnings from Swiss physicians, is the question of what you do with the data. If your statistical risk of developing cancer is 1%, it’s difficult for you and your physician to apply these biostatistics to you as an individual. This requires in-depth knowledge. What we are seeing in the U.S. is that such data, in the wrong hands, predominantly results in more work for psychiatrists. This so-called Angelina Jolie effect isn’t always the original intention. Even I learned back in my days at medical school that one in 13 laboratory tests will be statistically pathological. However, this doesn’t mean that this test result, assuming it’s even correct, actually constitutes a health risk.

The development of the digital healthcare market and the role of Switzerland

There is a risk of the digital development passing by Europe due to regulation.
Dr. Stephan Rietiker, CEO LifeWatch AG and digital health expert

As in many areas, the U.S. also has a significant lead in digital health thanks to Silicon Valley. Switzerland is lagging along with many major European countries, in terms of technology, by about 8 to 10 years. Markets such as China, India or Turkey, in contrast, are further developed. These are countries that don’t have a well-developed healthcare system in the traditional sense and now need to make some headway for economic or political reasons in order to provide their citizens efficient and good healthcare services as soon as possible. It’s much like the telecom sector, where the step of laying landlines was simply skipped thanks to digitalization.

“The current regulatory efforts in Europe and Switzerland are not seen to boost innovation.”

The regulatory environment is always a drag as a rule, even in the U.S. However, in the States, the FDA (Food and Drug Administration) has proven to be relatively open-minded and has indicated that it will permit as broad a range as possible. But where the health of patients is affected, they rightly take a very close look. This discussion hasn’t even started in Switzerland. Data protection still dominates the debate, for instance when considering  electronic medical records. Some CEOs of health insurers know the system and would welcome a switch. But the political machine moves slowly.

“The willingness to share data is far greater in the U.S. than in Europe.”

It’s clear that pressure from businesses in Switzerland is still not sufficient to permit innovative new solutions as a way of addressing the ballooning healthcare costs. Physicians fear the loss of their diagnostic authority, and the same goes for many insurers. Other markets are simply already under greater pressure of having to become more efficient. Things are a bit different in the U.S.: there, the willingness to share data is a lot higher, and the ownership of the data is shifting toward the patients. This is not yet the case here. The authorities are still trusted. But this will change. Technology will overwhelm us and create facts.

Switzerland would actually be predestined for playing a leading role in Europe at least in this development: we have a globally unique cluster of companies in the pharmaceuticals, life sciences and med-tech sectors, we have outstanding basic research and a high-quality healthcare system. The question arises as to why we haven’t been making use of this opportunity so far.

We’re stagnating a bit, although we would have the best preconditions in Switzerland. There’s still a lack of insight and understanding for the technological disruption currently taking place in the medical sector. We talk about gadgets such as pedometers, argue about data privacy and patients’ rights and moan about the strong Swiss franc. But we don’t talk about the unique opportunities we as a country have in this area, at least not to date. And, yet, we already have three small Silicon Valleys of our own: in Basel, in Zug and Zurich, and in the Arc Lémanique.