Ann Aerts emphasized that there is a unique opportunity for public–private sector collaboration for digital health. Stakeholders in the private sector are developing strategies to advance the concepts of connected living and digital lifestyles. Health has been recognized as a critical element in this space with significant potential for new investments. As noted by several
workshop speakers within the private sector, both technology and health care companies are well positioned to bring their core competencies to bear in the development of digital health initiatives and broad strategies to apply digital technology to health. In the public sector, governments have a clear interest in improving population health and well-being. Despite the incentives for investments in digital health within the private and public sectors, a number of workshop speakers acknowledged that barriers to collaboration exist. Some of the barriers raised by workshop speakers include a lack of support and infrastructure that allows access and affordability to digital health technologies, as well as a lack of interoperability across systems to increase ease in usage and minimize inefficiency.
The workshop’s second session, moderated by Aerts, focused on established multidisciplinary business models for digital health employed by technology and health care companies. The two panelists—Jennifer Esposito from Intel Corporation and Darrell Johnson from Medtronic—discussed multidisciplinary business models for digital health. This session also featured a World Café in which the workshop participants addressed a number of questions related to how digital technology can enable a multidisciplinary approach to health.
Intel’s processors power many types of medical imaging equipment as well as the networks and clouds that process, transmit, and store electronic health data. Jennifer Esposito explained that this application of its technology drives the company’s interest in health. The Health and Life Sciences group she leads at Intel works to apply lessons from other industries to solutions for health care and to inform Intel’s future product development road map.
Darrell Johnson explained that Medtronic’s interest in digital technology has been driven by the company’s shift to value-based health care, which focuses on selling outcomes rather than products. Selling outcomes requires data, and the company’s 70 years of experience in the health care arena has produced a trove of data on patient care. “We spend a lot of money generating this evidence, and we have great relationships with regulatory bodies and payers with regard to this evidence,” said Johnson. “This is in our wheel house to be able to use these data scientifically to figure out what an outcome should be.” His group’s work focuses on tapping into real-world databases to solve three problems:
- How to embed clinical research into clinical practice as a means of changing how Medtronic brings products to the market;
- How to use data to understand the performance of the company’s products in the clinic at any time; and
- How to use data to create products with the largest possible effect on value-based health care.
Aerts asked Esposito and Johnson for examples of where a multidisciplinary business model has worked to develop and deploy a digital health solution. Esposito replied that her group’s work in low- and middle-income countries (LMICs) starts with assessing a country’s underlying digital technology infrastructure. Sufficient infrastructure, she said, is a key to the ultimate adoption and scalability of a specific solution. Johnson agreed that there needs to be a technology platform on which to build a digital health solution. In the case of data, that platform comprises the multiple databases that are likely to be present in a country, and solutions must be able to extract data from those multiple sources in a way that empowers quality decision making. One type of solution that will not work well, he noted, is one that generates more data for physicians. Physicians, he suggested, do not need more data, but rather they need data they can trust and act on as part of their normal workflow; they need data that provides feedback to let them know the outcomes from acting on the data. Aerts agreed that actionability and feedback are two essential features of data that will be useful to the clinician.
Regarding how Intel decides to engage in a public–private partnership (PPP), Esposito said that a prime consideration is whether such a partnership might provide an opportunity to understand the unique challenges for a specific issue and how its technology can solve those problems, saying, “We are doing it from the perspective of learning more about how we can take those unique challenges in a specific industry and drive solutions across the ecosystem with a variety of different types of partners.”
The other reason to get involved in such partnerships, she added, is when there are opportunities to harness untapped data in a way that brings new insights to health care and that can ultimately change the way health care practitioners do their jobs. Johnson said that Medtronic is involved in many PPPs and embraces them as a tool for transforming health care and facilitating the exchange of data between patients and providers.
One of Medtronic’s priorities in digital health is figuring out how to standardize data formats so patients can access their clinical data and share them with other providers or entities of their choice. Esposito noted there are other sources of health-relevant data beyond clinical data, such as education level, wealth, and social services, that would be useful and shareable with policy makers. In particular, she noted the ease
with which the current generation of young adults operates in a mobile, data-generating environment. “They are used to the idea of continuously collecting data about themselves on the devices they carry with them,” said Esposito. “How that data can contribute to an overall improvement in public health is interesting to think about in terms of government involvement for broader societal gain.” She noted that there has been more interest in LMICs about developing a universal data platform that would cut across all social programs, in part because there is often no legacy infrastructure that can get in the way of data sharing.
In response to a question about how to use big data to help reduce waste in health care systems, Johnson said one key will be to use data to make costs and outcomes transparent, enabling policy makers to address problems in ways that are specific to the location and circumstances. It will also be important, though, to convince providers and patients to make better use of the data that are already available. As an example, Medtronic makes a remote monitoring system for implanted cardiovascular devices that has proven to produce better clinical and cost outcomes by means of getting data to physicians quickly. Nonetheless, utilization is less than 50 percent because there is no consequence for reimbursement for not using it.
Esposito agreed with the idea that it is important to encourage data use to create incentives for change, and she added that the ability to access multiple forms of data and use them to address specific problems has the potential to change how care is delivered. “If you are able to have real-time clinical information and all of this other information that surrounds the patient, I think you may be delivering health care differently,” said Esposito. “Instead of a disease-based approach, you are tailoring your actions around everything that is going on with that patient.”
Richard Guerrant from the University of Virginia said that one obstacle to using data to improve care is the need to conduct research to generate the guidelines that physicians would then use. Johnson agreed and credited a partnership with the U.S. Food and Drug Administration that provides access to real-time data networks and large data sets on outcomes to conduct the research needed to generate evidence-based guidelines at a small fraction of the cost of current clinical studies. Jessica Herzstein, a specialist in preventive medicine, commented that even when good guidelines are available, the medical community is often slow to follow them, and Johnson added that the comment he hears repeatedly from physicians is that they do not trust the data that goes into the guidelines. Alain Labrique added that the World Health Organization (WHO) has
embarked on a digital health guidelines development process,1 a formal mechanism to develop guidelines for digital interventions, such as text message reminders for drug adherence.
Florence Gaudry-Perkins asked the two panelists if they could provide some examples of business models with payers that take advantage of digital health technologies. Esposito said Intel has a partner in Latin America for which it built a device that patients take home with them from the hospital. This device has multiple sensors that patients can use to capture important physiological data that are then transmitted to the provider. The device also provides educational materials and allows patients to connect to a nurse call center if they need immediate help when a reading from one of the sensors is over a certain threshold. The payer provides the device as a means of controlling the ongoing cost of care, and the business model is that the service provider does not get paid unless there are cost savings. Initial results have shown there is a positive return on investment associated with this device, and Esposito’s hope is that the provider will deploy the device more broadly in multiple countries.
George Alleyne asked if there are any private companies that would devote the resources needed to solving the data compatibility issue and if such an effort would be the focus of a PPP. Johnson replied that there are large companies working on this issue using blockchain technology to create an open market to exchange private health care information, something that he predicts will revolutionize the medical information industry.
With regard to data transparency, Labrique asked the panelists what they see as the path of “fighting back against decades of dysfunction and the status quo of hiding things in the obscurity of having no data?” Esposito replied that in her experience, visibility quickly causes the status quo to change. “We have seen that in many different projects where as soon as you make data visible to a decision maker, everybody suddenly mobilizes around it and changes their behavior much more quickly,” she said.
As a final note, Esposito said that collecting electronic data does not have to be expensive and is not necessarily the province of the developed world, a statement with which Johnson agreed. “The technologies that work in today’s world are designed with simplicity, elegance, and simple usability,” said Johnson. As an example, Medtronic has a project in Ghana where mobile phones are used to monitor blood pressure and make payments to physicians.
1 For more information on the WHO Guidelines for Digital Health Interventions, see http://www.who.int/reproductivehealth/topics/mhealth/digital-health-interventions/en (accessed November 7, 2017).
While the incentives for the technology and health sectors to invest in digital health were clearly defined by Esposito and Johnson, Aerts noted that the current health realities require broad-based approaches inclusive of additional sectors to address the underlying determinants. The health systems in LMICs in particular are not prepared to face the challenges arising with rapid urbanization, the increase in health inequalities that comes with urbanization, the continuing threat of existing infectious diseases and from emerging diseases, and the rising burden of chronic disease. Noncommunicable diseases such as hypertension, the number one killer in the world, are ubiquitous, but they affect LMICs disproportionately, with four out of five deaths from noncommunicable diseases occurring in those countries. The loss in economic development in LMICs from noncommunicable diseases is estimated at $47 trillion over the next 15 years.
This situation, said Aerts, calls for innovation in the way health care and prevention are delivered and for bringing together multiple disciplines to address the enormity of the challenges in global health. As an example, the underlying causes of cardiovascular disease include exercise level, smoking, food habits, alcohol consumption, and exposure to air pollution. These determinants, she said, cannot be addressed by the health system alone. “We have to work together with partners from other sectors,” said Aerts. “Only then can we think about how to improve health care.” Toward that end, she noted that among the workshop participants were public- and private-sector experts in information technologies, transportation, food production, consumer goods, finance and insurance, and energy, and she encouraged the participants to have robust discussions during the World Café2 segment of the workshop while discussing these two questions:
- Digital health is a tool that could enable intersectoral collaboration for better health. In which of three of these sectors—government, food and beverage and consumer goods, research and education, financial and insurance, infrastructure and transport, and energy—should digital technology be leveraged to address the underlying determinants of health? For each of these three sectors, define the three most important lines of action.
2 During the World Café, workshop participants broke into small groups and were led through a collaborative dialogue process to share knowledge and ideas for action.
- When considering translation into action, what can the health care sector drive and what can the digital sector drive for other sectors to adopt digital technology as a common platform?
Reporting back from the World Café discussions, Gillian Christie from The Vitality Institute shared that several participants at her table described three groups that were important to using digital technologies to enable a multidisciplinary approach to health: finance and insurance, consumer goods not including food and beverage, and research and education. The first group is needed to address the behavioral determinants of using this technology, the second group would be instrumental in deploying new technologies, and the third group would generate a better understanding of how technology and the data from technology could be used to change behaviors. Several participants at this table agreed that there is good alignment between finance and insurance and consumer goods, given the role of the private sector in each of those sectors, and that health care costs and outcomes were the primary drivers for these sectors to engage in partnerships. The research and education sector would focus on translation and commercialization and how to tap into social networks and cultural empowerment to produce change.
Herzstein, reporting from her table, said that several participants singled out the food and beverage sector and said that its role was to inform and communicate about nutrition and its link to noncommunicable diseases and to address myths and develop trust around new technologies and foods. The information technology (IT) sector would focus on understanding nutritional content, developing a system for food labels, and helping the public understand what good science is and how to judge nutritional information. Another line of action this group decided on was how to involve the transport sector in helping rural and underserved areas access health care by developing mobile health units for delivering emergent and nonemergent care. The IT sector would play a role with technologies for matching health needs with available transportation options. The transport sector could also work on developing a centralized and integrated control function that would improve the efficiency of responding to disasters or a developing disruptive situation such as the emergence of disease. The IT sector would contribute by digitizing cities and translating complex data to simple data that could be used quickly for an urgent response to a disaster or developing disruptive situation. The transport and IT sectors could also work together to develop geographical information systems to match needs with resources and transport options to deliver those resources to where they are needed.
A participant from an additional table shared that her group selected three important sectors: government, research and education, and insur-
ance and financial. This group decided that government’s most important actions were related to leadership, developing an effective governance mechanism, and creating a national information and communiation technology network to eliminate fragmentation and silos. The research and education sector should explore approaches for increasing the usefulness of collected data for providers and should focus on digital literacy and best practices in digital health. For the financial and insurance sector, this group suggested that it needs to use big data to identify the risk factors linked to the social determinants of health. This sector should also adopt a different perspective on return on investments and explore ways of using mobile money as an incentive for adopting and scaling digital health initiatives.
With regard to how to translate these suggestions into action, this group decided that the health care sector should prioritize the key issues that it needs to address and work to harness big data to reduce inefficiencies in care while the digital sector should work to standardize data collection systems and use those data to model health outcomes. For its proposal to develop a different perspective about return on investment, this group proposed that the health care and financial and insurance sectors should adopt a transparent outcome-based purchasing and reimbursement mechanism that could be informed by the digital sector’s work on modeling health outcomes using big data. At the same time, the digital sector should improve the security of financial transactions in a way that would enable mobile money. The digital and financial sectors should also work toward standardizing regulations for mobile money among countries.