18/06/2020

E-Health: Turning a Trial into a Triumph

Author

Fellow - Healthcare

Institut Montaigne has just published an important report on e-health: "E-santé: augmentons la dose" (E-health: increasing the dosage). Led by a working group chaired by Thomas Buberl, CEO of AXA, Bernard Charlès, CEO of Dassault Systèmes, and Thomas London, a Partner at McKinsey's French office, and based on more than a hundred hearings with stakeholders in the French healthcare ecosystem (patient associations, healthcare professionals, businesses, etc.), this report puts forward 12 proposals to accelerate the roll-out of e-health in France.

Making Europe an e-health leader

While digital technology is not the only answer to all the ills of our healthcare system, a massive deployment of e-health could help respond to many of the challenges it faces. These include the ageing of the population, changes in medical demographics, territorial inequalities in access to care, the explosion of chronic diseases, the fight against epidemics, and budgetary constraints.

Health data represents a major competitive advantage in the global competition for AI and predictive medicine. It will also contribute to building a more effective, qualitative and efficient healthcare system by transforming the way the French system is managed and regulated through an approved, data-driven logic. In addition, the use of health data has proven to be a considerable asset in preventing and dealing with the Covid-19 health crisis.

In Germany, in January 2020, the Minister of Health, Jens Spahn, declared that he wanted to escape from "police or capitalist surveillance models that are not ours" by developing a 100% European e-health system. The German Health Minister's clearly stated aim is to create a European model that is different from the one built in China or the United States. E-health has already reached the general public, "the question is whether this offer should come only from American or Chinese companies or whether we can develop it at home, based on European data protection regulations".With this in mind, we recommend that Europe and France rapidly adopt a sovereign strategy for managing and exchanging health data around a strict "third way" based on the security of health data and ethical sharing with prior patient consent. The trust French and European citizens have in how their health data is used, depends as much on the technology itself as on the ethics surrounding it.

Health data represents a major competitive advantage in the global competition for AI and predictive medicine.

At the same time, a data-driven health system holds immense potential. Better data feedback and a data-driven steering strategy can enable an assessment of the quality of both care and care pathways, and a stratification of needs and supply according to patients' requirements It would also allow for better prevention through early detection, better coordinated pathways thanks to information exchange and continuous monitoring, or new financing methods that incentivize stakeholders according to the results obtained rather than by simply relying on the volume-based payment model that is still largely predominant (fee-for-service).

In light of this, we recommend basing the management and regulation of our system on a "culture of data" and facilitating access to health data for all stakeholders, both public and private. This would be accompanied by a strict method of anonymizing sensitive personal data through the French "Health Data Hub".

E-health in France: where things stand

The report by Institut Montaigne reviews the deployment of e-health in France, through international comparisons, and across five areas of transformation.

Patients become more autonomous through digital solutions that allow them to monitor their disease and interact with the healthcare system. E-health thereby enables patients to be more involved and become actors of their own health.
The circulation of medical information between professionals is made more fluid via the digitalization of exchanges, to the benefit of patients. These digital tools allow better monitoring, better access, better coordination of care and optimization of management costs.
Telehealth allows a patient to remotely consult a healthcare professional. It is a key tool in the fight against medical deserts and in providing patients with access to quality care throughout the country.
Digitization and automation make care structures much more efficient and improve the patient experience. These digital solutions enable healthcare institutions to improve the performance and availability of teams, medical equipment, and operating theatres in particular.
Medical and paramedical decision making is made more reliable and secure with the help of artificial intelligence (AI). These AI software programs support healthcare professionals by allowing them to reduce the risk of error or delays in diagnosis.

Despite e-health’s potential, the digital revolution taking over all sectors of the economy is slow to penetrate the healthcare industry. The lack of a visible and united health sector in France is one of the major obstacles to a full-scale digitalization. This fledgling sector faces a high level of conservatism and numerous silos, and is too often hampered by regulations, cultural barriers and financial constraints. How, then, can we enable a genuine transformation of the health system through digitalization and the use of data?

The lack of a visible and united health sector in France is one of the major obstacles to a full-scale digitalization.

Relying on the mobilization of stakeholders to create a strong health sector in France

A powerful and internationally-visible ecosystem of alliances is an essential prerequisite to meeting the challenges of deploying e-health in France. The health sector consists of companies of all sizes, with different levels of maturity. It combines players from the “traditional” health sector and the ICT sector. This complicates the creation of a single industry, which would represent all the sector’s stakeholders in conversations with public authorities. All players in the healthcare world are now impacted by the digital revolution and face common challenges. As demonstrated by the coalition of public and private health stakeholders which came together to face Covid-19 in France, and the many solutions provided by e-health companies, cooperation and alliances foster innovation. They constitute an important response mechanism to health crises,and an economic opportunity to export French excellence abroad.

The aeronautics industry provides an interesting example when it comes to devising ways to structure the health sector for increased consistency, efficiency and international visibility. The Groupement des Industries Françaises Aéronautiques et Spatiales (GIFAS) represents all stakeholders in the aeronautics sector before national, European or international, public or private bodies. It thereby contributes to the structuring, coherence and solidarity of the French aerospace industry.

We therefore recommend including quantified targets in the industrial policy objectives for the e-health sector in order to achieve a strong and clearly established level of ambition, capable of uniting all stakeholders. This policy will enable the structures and the environment to be driven towards projects that are feasible, visible, with a high-priority level and short-term showcasing potential, thereby fostering the creation of exportable solutions and, as a consequence, a real industrial sector.

Building a regulatory and technical environment conducive to the development of innovative solutions

One of the main challenges related to the development of e-health in France remains the definition of an appropriate legal and regulatory framework. Indeed, France has an innovative ecosystem thanks to a dynamic pool of start-ups and excellence in healthcare training and education. However, the implementation and development level of e-health in the healthcare system remains unsatisfactory.

France has an innovative ecosystem. However, the implementation and development level of e-health in the healthcare system remains unsatisfactory.

French regulations are too oriented towards experimentation, pilot projects or derogatory frameworks that hinder the scaling up of innovative solutions. In the US, the FDA has recently published a discussion paper to propose a regulatory framework on how to evaluate Artificial Intelligence / Machine Learning-based software as a medical device: “Our vision is that with appropriately tailored regulatory oversight, AI/ML-based SaMD will deliver safe and effective software functionality that improves the quality of care that patients receive”.

Inflexibility of regulatory frameworks can be an obstacle to the deployment of e-health tools. That is precisely the case in France with telehealth, which is struggling to developunder the current conventional amendments. These constraints were lifted in a few days to respond to the Covid-19 health emergency, which will certainly lead to a change of behavior of both doctors and patients. Telehealth has advantages beyond the current crisis. It is therefore crucial to make it a sustainable solution and to make access to it more flexible by building on the framework implemented during the Covid-19 epidemic.

However, the absence of regulations can also turn out to be a stumbling block for digital tools. E-health and artificial intelligence solutions are complicated to assess. These solutions are sometimes halfway between a drug and a medical device, and as such, they do not fit in the traditional assessment channels (and therefore make access to reimbursement all the more difficult). These specificities make the assessment of these technologies more complex and justify the adaptation of traditional clinical assessment methods – based on randomized controlled trials – while ensuring the reliability, validity and quality of the results taken into account for the reimbursement decision.

In line with Institut Montaigne’s previous work, we recommend that patients be more systematically involved in the assessment of digital technologies. To this end, new result-based indicators relevant to our health system must be created.

Building a culture of trust among stakeholders

Lack of trust is currently one of the main obstacles to the use of digital solutions by healthcare stakeholders (primarily professionals and patients). In order to develop trust, we need to develop usage, and this requires a stronger involvement of patients in the monitoring of their own diseases and a more advanced training of health professionals.

The use of digital consultations during the Covid-19 epidemic illustrates how mentalities can change very quickly in response to emergencies. As indicated by the French health insurance authority (CNAM) in a press release on March 31, 2020, remote consultation “has become established among private physicians as a relevant patient management method, whether for the orientation and follow-up of patients concerned by a non-severe form of Covid-19 or for the follow-up of patients suffering from other pathologies". In fact, for the week of March 23, 2020, 44% of general practitioners had given remote consultations thanks to regulatory constraints being lifted.

Beyond highlighting the benefit of remote care practices, the Covid-19 epidemic also exposed the importance of having reliable data to monitor the spread of the virus throughout the country. In an unprecedented decision, health authorities chose transparency by publishing daily reports on the spread of the virus in France, raising citizens’ awareness of the value of this epidemiological data in anticipating and improving public action.

In order to consolidate citizens' trust in the advantages of digitalization, measures are urgently needed to boost public opinion regarding the benefits of sharing health data. We therefore recommend the creation of an observatory on the use of health data managed by members of civil society (patient associations, doctor federations, etc.) to regularly publicize how data is used for research, patient monitoring, the improvement of care, etc.

The issue of trust with regard to digital tools and the use of health data also concerns healthcare professionals and therefore implies the acquisition of the necessary skills to use digital tools, to successfully achieve this digital transformation. In the United Kingdom, the NHS set up an independent interdisciplinary expert consultation group between 2017 and 2019 to determine the new needs in terms of skills, the roles and tasks of healthcare professionals in the context of a swift digitalization, as well as the implications on the training (initial and continued) of healthcare professionals. Such an approach could be implemented in France to identify the training needs of students and professionals.

Mass adoption of digital tools, the creation of a culture of trust, and specific training on the use of AI and data are all equally important, and as such should be included in all healthcare management training courses.