Impulsvortrag von Professor Volker Amelung bei der informellen Tagung der EU-Gesundheitsminister
Impulsvortrag von Professor Dr. Volker Amelung am 11. September 2018 in Wien, Österreich
Dear Presidency, dear honoured Ministers of Health, dear ladies and gentlemen,
It is a great honour for me talking to you today!
This informal round has been summoned to discuss digitalisation in health care and certainly it will not be your first session on this topic. It has been more than 25 years since I listened to a presentation on the benefits of digitalisation in the health system for the first time. When you look at current conference and panel invitations, it sometimes seems difficult to find other topics than the buzz words digital transformation, health apps, big data, AI.
Technology, resources and attitude
Opposed to the overall focus on the technical conversion, the digital transformation is from my perspective especially a question of attitudes towards change and technology that will change the relationships and the self-perception of patients and citizens. Relevant questions therefore are changes in liability, the relevance of empathy in connection with technology use, processes for integrating new technologies in health care, the informing of patients and so forth. From a health system perspective, we should therefore discuss the structures of incentives – and probably even more importantly the disincentives – as well as possibilities for blockade and/or ignorance and the attitude towards digital change. We should not underestimate the resistance to change from many health systems.
The discussion on the digital transformation is to my belief mainly still too technical and fear-driven, whereas the attitude, individual incentives and individual effect mechanisms may play a much bigger role in reality. There are few areas where German Angst is as prominent and whenever countries lag behind, such as Germany, it is not a question of technology or resources.
Evidence – cost and quality in health care
The benefits of digitalisation in the health care system are obvious and manifold demonstrated. A study being published next week from McKinsey with support from the German managed care association predicts that digitalisation has the potential to save up to 34 billion euros – only in the German system – when rolled out fully. This corresponds to 8 to 12 percent of the overall health spending. Regardless of the exact figure, it’s enormous and the study is most probably reproduceable in most other countries. The largest share of these savings would come from paperless data and online interaction in the health system, followed by outcomes transparency and the automation of workflows. Before going into detail, let me briefly share some thoughts on the functioning of the health care system.
Increasing quality and decreasing costs
Doing research in health care for more than 25 years, my strongest belief is that health care functions completely different than other markets. Whereas in most markets the relationship between the price and what you get for it is linear, this is fundamentally different in health care. While decreasing costs in the long run, digitalised health care can increase quality of care through a higher transparency and better cooperation among and between care providers and further actors. In fact, health systems are in this regard quite unlike other economic sectors: If you buy a new car, we can generally say that you get a better car if you pay more; same with an expensive hotel: good hotel and expensive restaurant: good food.
Not in health care: From a health system perspective, nothing is more expensive than bad quality. A chronic diabetes patient will be cheaper for the system if the care is coordinated well and the therapy is adjusted to the patient’s medical needs.
Digital health is one of these characteristic fields, where lower costs and better quality are a logical consequence, not a contradiction. This is especially the case when digital is one instrument of the overall care process and is intertwined cleverly with classical offline support. We should therefore think about what is necessary in order to provide good health care. Technology is one piece of that. In consequence, the digital transformation has to lead to a strengthened and relieved work force, so that they can focus on the relevant parts of their work. We need better marketing for the topic towards health care professionals – we will not get their support only with “savings on the system level”.
The uneven distribution of benefits of digital transformation
This brings me to Topic 3: Despite the benefits for the system, the potentials are very heterogeneous and the benefits for many individual actors limited.
I often hear that it were irrational that the health system is lagging behind in the digital transformation. In my mind, it is quite rational that we are. We have to keep in mind that keeping the status quo is for many players attractive – and their experience with change is mainly negative. And implementing digitalisation goes along with increased expenses and time to implement new structures, with more bureaucracy and more transparency.
It may make sense for an office-based physician to digitalise the billing with insurances or the office schedule – the benefits are obvious and 1:1.
But why should the federal representation of health care providers put effort into more transparency and receiving more information through an electronic health record or in the data exchange with study registers? Many don’t oppose, this would not be opportune, but sit it out and they are very strong in finding other problems… We are therefore locked in a prisoner’s dilemma, where everyone acts rationally for him- or herself, but not rationally for the system.
Medicine: innovative / structures: uninnovative
What I just said is quite strange, as medicine continues to be highly innovative: we have tremendous innovations and they are largely technology driven. We observe the paradox that our medical care continues to be highly innovative, while the health structures are exactly the opposite. It is difficult to list all the changes that took place in medical care during the last 100 years – but what happened to the health structures in the same time? A lot of hospital buildings look mostly the same as 100 years ago and are just not prepared for modern delivery of health care.
Leadership – Incremental change or cold turkey?
Should we trust in health care reforms? From my perspective, I would at least be very careful. The German government decreed an electronic health card in the federal law in 2003 followed by the electronic patient record in 2008. It has been many years since and we just got the news this month that one of the 16 provinces is doing a pilot project on the electronic patient record and electronic prescriptions. Laws thus are not always enough to generate change. Also every single actor in the health system continually proclaims how important digitalisation is. But this rhetoric should not lull us.
Digital transformation is too obvious
Besides the opposing interests and attitude, digitalisation and especially the complexity of the digital transformation have been underestimated. Maybe this is also due to the fact that the topic is so obvious. The analogy to prevention or also integrated care makes my point obvious: Prevention, just like digitalisation, is self-evident – everyone supports it saying “Prevention is important.” – and at the same time it is very heterogeneous. Discussions are therefore either generic and superficial or extremely specific and highly technical. Prevention, just like digitalisation, has lagged far behind our expectations.
Low pressure / allocated pots of money / little transparency
But there are some further reasons: I think three reasons largely explain the lacking cultural attitude towards digitalisation in some health systems: Firstly, many health systems are isolated markets where market exits basically don’t happen, so that there is a low pressure to action. Secondly, the pots of money are strictly allocated, which fits most persons involved and thus should not be touched. Thirdly, there is very little transparency in non-digitalised systems. In consequence of these, it is largely a lip service when so many are calling the digital age in health care. Policy-making and change management are quite a challenge in environments with high entry barriers and quasi monopolies and low pressure to action. Under these circumstances, it is a pretty risky strategy to delegate it to self-governing structures and trust that they will be the driver for significant change.
First things first: administrative processes
Digitalisation has an incredible spectrum ranging from administrative process optimisation to artificial intelligence and genome computing. I agree that the latter sound sexier and have tremendous potential. However, we will only be able to exploit their full potential if we are successful in setting up a digital network and data exchange. We cannot start now backwards. We first need a functioning digital infrastructure followed by a widespread electronic patient record in order to then use all other new technologies effectively.
Leadership to implement: cold turkey strategy
In consequence to what I said before, digitalisation will not happen to my belief profoundly, except for it is pushed through. You will have to push it through. This requires a high level of leadership and governance. And if you want my recommendation: I guess it should be without any without 5-year plans, but a cold turkey: implement it quick, tough and as consistent as possible, even accepting not everything will work from the first moment. I am aware that this is probably easier in Beveridge health care systems than in Bismarck systems.
Kurt Lewin’s theory from the 1950s describes change management in three phases: unfreeze – implement – refreeze. It first requires an unfreeze phase where the structures and individuals are prepared for the upcoming changes. Once that the decision to implement is made all the required changes take place, which temporarily may be more inefficient than before. Most importantly, a refreeze phase should follow. Most businesses don’t put enough focus on this: We cannot always follow a change by a change by a change. We implement changes which should become the new routine. Routines are efficient. And physicians should be focused on their medical care, not getting used to a new information system every other year.
Some policy recommendations
Dear ladies and gentlemen, let me conclude with some policy thoughts on this.
- It goes without saying that if a health system wants a digital infrastructure it should pay for implementing it – and in some countries it will be expensive. We cannot expect from individuals to finance it against their own interests. And besides fostering innovations, we should focus on eliminating blockades and disincentives so that innovations can find their own path.
- As health economist, when money comes into the picture I immediately think of evaluation. Not in this case, however. The one thing we don’t need is another pilot to measure the benefits of a digital network. We need to do it. We have to keep in mind that we are not requesting anything unusual, but something that is the norm in most other economic fields.
- Several countries have implemented digital infrastructures and electronic patient records. I often refer to Kathleen Frisbee, Director at the US-American Veterans Affairs. For their innovative health concepts, they went shopping around the world – one idea coming from Australia, from Spain, the other one from Denmark and Romania. Let us look at functioning solutions and copy these instead of “newly developing” something that exists umpteen times.
- Up to now, no sensible business cases exist for health care. Digital solutions have almost zero incremental costs. There is no large difference if a digital app is used by 1.000 or 10.000 or 100.000 patients. Maybe the app provider needs a larger computer, but otherwise the costs are basically the same. A working business case also requires a fast, pragmatic and reliable access to coverage.
- Digital business cases can only work if they are scaled up. We therefore need international European markets where business cases can enter patient care easily.
- Having said all this, I’m convinced that it would be as effective as several health reforms to make the health systems more interchangeable for young and female leaders. Several studies reveal that countries with a more diverse leadership are also more successful with their digital transformation. In order to see digital innovations in health care fly, we need to loosen the powerful cartels of old men and let younger people and more women step in and make decisions in important positions of the health systems.
I want to conclude with one slide which gives a lot of hope! When you look into the past, it took very long times to get market penetration – this changed dramatically and I we can add digital health very soon to this slide.
Thank you very much for your attention.
Presseartikel: EU-Debatte über Digitalisierung des Gesundheitssystems
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