F101 A collection of global digital health thoughts

Episode 101 highlights some of the thoughts about digital health development and factors impacting innovation and solutions design across the world.

The aim of the Faces of digital health podcast is to explore how healthcare systems around the world adopt technologies. This is why the editorial policy is to move away from American-centricity in reporting and offer the audience a global picture of the digital health development, with speakers from across the world. This, of course, does not mean we don’t host speakers from the US on the show.

The state of digital health in 2020

In episode 81 dr. Daniel Kraft, one of the top opinion leaders in digital health, nicely summarized the current state of digital health:

“It was only 2009, 11 years ago that the first Fitbit came out. That was one of the earliest connected devices which collected very basic things - step count, and sleep. Now we have thousands of different connected wearables, insideables, and breatheables, voice can give away our digital exhaust. All that digital exhaust is now being integrated. The health kit application on my iPhone can integrate data from my scale, my blood pressure cuff, my heart rate data over time.

We're starting to move from quantified self to quantified health, where all that data flows to your medical record. What happens when it gets your medical records is a second question, but all that potential is really here now. We can now use the data much smarter and be much more proactive - real-time continuous measurements can optimize prevention and healthspan. There's a lot of work now in the era of COVID, such as using a Fitbit or Apple Watch to pick up the signs of someone two or three days before they become symptomatic with COVID. Some great solutions are out there.

The next step is to connect the dots, align incentives, and get these things utilized, particularly mindful of the workflow of the clinician who does not want to see every piece of data. They want the meaning of that.

My view of the future of healthcare is that if you're a primary care doctor of 2000 patients, you don't want to wait for them to show up with a problem in the ER. Instead, you want to have a dashboard of your 2000 patients with those who are in the green, those are in the yellow that might have their blood pressures out of range or haven't been taking their medication or are showing signs of relapsing in some form. Those in the red you really want to act upon, keeping them out of the hospital and giving better outcomes.”

Asia: racing to become the leading digital health market

Many hospitals, especially in the US, are very progressive in terms of making the most of the available innovations on the market and are doing a lot for improved patient experience and process optimization. After all, the US presents the leading digital health market in the world. However, Asia is getting stronger and stronger in second place. The continent is diverse and as Julien de Salaberry, the CEO of Galen Growth Asia emphasized in episode 41, diversity is important to keep in mind when thinking about expanding in this area of the world.

“One of the golden rules for anyone looking at Asia Pacific is that you should not treat it as one block. You should certainly not think that the fact that you're being successful in one particular country means you'll be successful in the neighboring country.

In the past, a lot of investors have regarded Europe and the US as stable. You could more or less predict the way the economy was going to grow, and therefore, you could make decisions accordingly. That was always in contrast with a lot of the Asian markets. However, we are now seeing a paradigm shift where those assumptions have been more or less turned on the head, which means that in fact, we're looking at certain markets in Asia with potentially greater degrees of stability going forward.”

Language as the biggest barrier to scaling

Guillem Serra, the CEO of the Spanish based telemedicine company Mediquo, guest in episode 84, says that in internationalization and looking at new potential markets, language is the most important factor to consider.

“The most important limiting factor for internationalization is language. Translating the app is very easy. It's not costly. But if we wish to open in Portuguese, or in English, we need to have this 24/7 basic, immediate medical service. This means that we need to have a doctor available at five o'clock in the morning, which is fairly costly. This the most limiting factor for us. This is why it was much much easier for us to go to Latin America, than for example opening in France.”

Beyond communication: how platform shape societies (India and China)

Different countries differ in their culture and how technologies are used. In China, society “runs” on WeChat. In India, the key communication platform in Whatsapp. Abhishek Shah, CEO of Wellthy digital therapeutics company from India, who was the guest of episode 78, explained how the use of Whatsapp in India differs from the West. It is gaining a similar significance as WeChat has in China. Which is why Wellthy conducted some of their clinical studies through Whatsapp.

“When looking at India, you're looking at an environment where hundreds of millions of individuals are coming online, but have never seen a laptop or a desktop computer. Their first device that they're ever going to get access to internet is the mobile phone. This is an environment where landlines and broadband is not really seen at scale. Internet is wireless and driven by 3G, 4G and soon 5G is going to be dominating consumption. This is an environment where today the number of digital wallets is about 10 times the number of credit and debit cards in this country. And in this kind of environment, you see adoption of communication platforms at an unprecedented scale today. In China, WeChat I think contributes to one third of all time spent online. In India, even commerce is happening on WhatsApp, payments will happen on WhatsApp. And this is a fraction of the kind of environment WeChat has created in China. You can buy movie tickets, your grocery shopping or your payments, your taxi booking on WeChat. The sheer amount of use cases that have been built on top of WeChat is astounding. So while WhatsApp is used broadly in India, I think it's just scraping the tip of the iceberg right now. There's a lot a lot left underneath.

The first study we ever did was on WhatsApp, where we actually worked with patients and we delivered the entire therapy through WhatsApp to see whether or not this could actually improve outcomes. And that was amazing because it allowed us to test the core principles.”

Africa: digital health on cellular phones

Africa is a good reminder that digital health apps span beyond smartphones. Since cellular phones are still prevailing, many digital health solutions are based on the USSD protocol - a communications protocol used by GSM cellular telephones to communicate with the mobile network operator's computers. USSD can be used for WAP browsing, prepaid callback service, mobile-money services, location-based content services, menu-based information services, and as part of configuring the phone on the network.

Among the speakers on the show coming from Africa, was the founder of Mobile Afya - Mariatheresa Samson Kadushi. She is a Tanzanian innovator passionate about disrupting the public health sector, which is in Africa marked by traditional beliefs. In episode 056 she among other things explained how in Africa, worries about privacy in the digital age are not worries about how are global corporations are exploiting our data:

““Privacy in Europe is more about who has personal data and how are they going to use it. But back in Africa, privacy is: how can I keep whatever I'm doing to myself and not people around me. This is why we offer interactive sessions, where you're getting the message right after you finished selecting what you want to learn about. You can read the message right at that instant and delete that message without a trace.”

Europe: universal healthcare with inequalities to healthcare access

Moving from Asia to Africa, European healthcare systems are often praised for universal access to care. However, as mentioned by the patient advocate Bettina Ryll in episode 68, in Europe where you live significantly impacts your access to healthcare. Especially in rare diseases chances of survival of a patient can depend on where the patient resides and are there any clinical trials near her. People move to get a chance at survival. This very much reminds of the often-mentioned fact by US experts, that the ZIP code the biggest determinant of health:

“If you look at rare melanomas, there are just a handful of trials in Europe that are interesting right now. If you're not living in the country where the trials take place, the only chance to have access to an experimental drug is to move to where the trial is. Sometimes you can travel back and forth. Some people live close to the trial site for a couple of months. That is already our reality and I don't think it's going to get any better.

I do believe that rare exemplifies that problem. If a condition is very, very rare, and especially when you live in a small country, you cannot expect to have access to a specialist for every rare condition. So I believe in international collaboration, especially for rare conditions, because that's the only way how we can accumulate sufficient knowledge on one side. But this also means that we have to get the patients there. So either the patients have to travel or we have to set up systems in order to take care of these patients so that they can travel only occasionally, and then you have some type of telemedicine or some collaboration between your local partner and to partner abroad. We are going to have to change our system.”

“In Germany trust is earned rather than assumed”

From a business perspective, Europe is a complicated market. You need to tackle language barriers, the diversity of healthcare systems and policies. Kaia Health is a digital therapeutics startup that was founded in Germany and is now operating broader, especially in the US market as well. In episode 77 Mark Liber, the VP of business development at Kaia Health, talked about the differences they are noticing between the German and the US.

“The healthcare systems are different with a lot of similarities. For example, both systems have private and public sectors even though Germany has a larger public health sector than perhaps the US does, as a percentage of the population. But what I was struck by at first is the differences between the consumer habits. What we hear about quite often is that in Germany, consumers value medical advice and medical recommendations very highly. Data privacy is very, very important for this consumer group. And trust is earned rather than assumed. So this group of consumers can be quite skeptical of companies that enter the market if they're not familiar with them. And a lot of that has to do privacy, as well as.

What I noticed is that there's also a lower willingness to pay for services by patients or by insurance. So indeed, convincing German insurances to pay for Kaia for their members was very difficult at the start. And we actually began as a direct to consumer product. Once we had a lot of users and the direct to consumer side to building that trust, we were able to appeal more to the insurances, because they saw that a lot of their members were already using the product and feeling better.”

Venezuela: Digitalization is not a one-way street - devolution can happen

While we mostly perceive the future of healthcare digitization as a one-way progression street, Luis Santigo, the CEO of a Venezuelan healthcare IT company PEGASI explained how progress can get crushed when the economic situation of a country changes. In the last few years, in Venezuela, many hospitals had to switch from IT back to paper, because IT companies went bankrupt and ceased existing.

“In the past the Venezuelan market grew fast. The peak time was around 2014 and 2015. There were a lot of competitors in the market, there were at least eight other companies who are providing similar to our services. But then the crisis hit, and the lowest moment in crisis in acquisition power. In 2016, a lot of our competitors left the country. We then saw customers who had part of our solution implemented, and they did the rest with their software but said the vendors are not taking their calls anymore. Consequently the service that you provide to patients declines. There were a lot of processes that our customers used to do on computers that they had to resort to doing by hand. Which means they are again exposed to the error on transcription, multiplying that information, etc. Venezuela has faced a devolution, as you might say, in that sense. Currently, a lot of areas operate like they did in the 80s perhaps even earlier, because the technology adoption is not possible.”

These are just a few insights into the global aspect of digital health. If you’d like to explore more, go to www.facesofdigitalhealth.com/archive to search through other episodes as well. And if you’d like to continue the exploration journey in the future, do subscribe to the show to be notified about new episodes automatically.

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F101 A collection of thoughts about digital health from around the world