A mamagazinegazine bbyy ERNI. Innovation 22/2019/2019 in Healthcare

Focus topic Digital Hospitals

3

Digitalisation takes time, courage and caution

Everything is moving forward. So monitoring their bodily functions and is healthcare. The digitalisation of searching for healthcare providers this field is rapidly progressing, and that suit their needs. With such active although it may be a bit more difficult clients, healthcare providers need to and sensitive than in many other take a closer look not only at quality industries, it is just as – if not even of services but also at the image they more – important. portray. It is not enough to rely on just “being there” anymore if they wish Switzerland is considered to be one of to attract new patients and clients. the most innovative countries in the Taking a closer look at the brand and world, and its healthcare system cannot its positioning on the market and be an exception. From April 2020, all taking the necessary steps to ensure hospitals, rehabilitation clinics and the best possible position among psychiatrists will have to offer digital the competition is the best thing any documentation of medical history to institution in healthcare can do to Bruno Wassmer their patients – an electronic medical improve its business. Managing Director report. The process of implementing ERNI Switzerland such a huge change is challenging. In this issue, we will dive deeper into From the human aspect and a certain the topic of digital healthcare, its hesitance in the face of adopting new possibilities as well as pitfalls and we technologies, and through data safety will take a good look at some of the and resources, digitalisation is an hottest topics in this field from both ongoing pursuit that takes a lot of time, points of view, inside and outside caution and courage. of ERNI.

With new technologies, platforms So, let’s use technology to change and accessibility of information, the healthcare around the world and keep whole healthcare chain is changing. people as well as businesses healthy. Patients are becoming ever more active in their own health management, researching medical information,

Innovation in Healthcare | 4 About ERNI / Imprint

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| Innovation in Healthcare Topic of the issue: Innovation in Healthcare HOSPITALS IN THE DIGITAL WORLD New technologies change the way healthcare providers work. BUILDING A SUCCESSFUL HOSPITAL BRAND STRATEGY Branding and positioning are essential in health business. – Maneka Fahrer Bruno NEW DIRECTION OF HEALTHCARE Where is the whole system heading? NEARSHORING PROJECT IN DIGITAL HEALTH The way of empowering companies.

Innovation in Healthcare | 6 Hospitals in the digital world

Hospitals in the digital world

Electronic records, faster and more precise diagnostics, new technologies helping people get better. There is no doubt that the future of hospitals is digital. Digitalisation is fuelled by rapid technological progress and almost everyone with a smartphone is already able to consult their health condition with a “pocket” doctor. However, every change is difficult, especially when large amounts of people, sensitive data and challenges are involved. Digitalisation of healthcare is one of the biggest challenges of the 21st century. Thus, successful encompassment of this shift requires an open mind, well-considered regulation and cooperation between the private and public sector.

Reto Zumbühl [email protected] Senior Principal Consultant at ERNI, overseeing its entire service portfolio across several industries

| Innovation in Healthcare 7

Hospitals create the backbone of document and choose between the initiatives are creating new platforms the healthcare system. It is a place three confidentiality levels "normal for interconnection among patients, where healthcare professionals access", "restricted access" and "secret". health professionals and institutions, manage complex processes in order including hospitals. to help patients to stay healthy and Although in 2017, U.S. News and Mr Toomas Hendrik Ilves, former enjoy life. Patients expect to get World Report ranked Switzerland’s President of Estonia, was in the lead the best service there as hospitals public health system as the ‘World’s in implementing the digitalisation possess the personal and material Best’ with an overall score of 9.3 out of project in the country back in 2008. capacities needed, but in order to 10, Switzerland is still at the midway The reasons why he supported receive the best care possible, there towards digitalised healthcare. There this process remain relevant today is a vast amount of data that needs are countries that invest heavily in as well: “A more extensive and to be handled. An important step this field and with great benefits. The systematic implementation of towards better and more connected frontrunner – Denmark – has invested e-Health solutions will allow us to healthcare is therefore creating in this particular effort for two make the service more flexible, electronic patient records (EPR). In decades now. The result? According improve the health of people by Switzerland, this application is to be to a study by the Danish Ministry of exercising more efficient preventive introduced nationwide from 2020 Health, today 99% of all prescriptions measures, increase the awareness and is regarded as the key to the are sent electronically to pharmacies, of patients and also save billions of digital transformation of hospitals, and 98% of general practitioners euros,“ stated Ilves. doctors' surgeries, retirement and exchange diagnostic data digitally or nursing homes, Spitex organisa- receive laboratory data from hospitals Digitalisation and connecting data tions, pharmacies and therapists. this way. Likewise, 97% of all hospital in healthcare is big topic in Germany So far, Basel has been the pioneer referrals and referrals to specialists or too. Although the country is still of these developments in which the psychologists are made electronically. gaining momentum, new laws and entire university hospital intends regulations are gradually being to introduce the EPR in the course implemented to speed up the of the year. Electronic records will process. The government is putting bring efficiency, both in time and significant emphasis on digital health resources, and create a connected and implementing electronic patient system that all doctors and records to as wide a population as healthcare professionals will be able possible is a crucial part of it. Also, to access to ensure personalised and the effort towards digitalisation best possible care for every patient is creating new opportunities for treated. medtech startups.

For example, IT penetration in Thun When we talk about good examples Hospital has already progressed so far of the e-Health approach, there are that doctors can access the electronic some cities that stand out. One of patient record anytime and from them is Barcelona, Spain. The city anywhere - even in the operating is well known for its lively startup room. There, the surgeon can display environment and new medtech important data, such as product companies are popping up on every information on implants. There is corner. In a study done by The also software already supported by Examples from Healthcare Access and Quality Index, artificial intelligence that provides Spain ranked as having the 8th lowest surgeons with important information interesting mortality rates by non-fatal causes out step by step during operations, thus of 195 countries, which emphasises reducing the risk. Automated drug markets the standard of care available in dispensing can also prevent human this country. Digitalisation is also error and increase patient safety. Some good experience exists in helping. Thanks to new technologies, countries like Denmark, Estonia, a vast amount of people use smart When talking about digitalisation, Finland and Australia. All are based technologies to monitor their health data security is always an important on projects transforming existing standard and a majority of them are topic. That is why accessibility of EPR healthcare structure via digitalisa- open to even more new technologies will be up to patients. Patients can tion. In other words, data-driven in healthcare in the future. define the access to each individual

Innovation in Healthcare | 8 Hospitals in the digital world

New technologies are Biggest eHealth priorities for healthcare here to help providers in Europe (includes health As mentioned, data is the most facilities, IT Software vendors and important asset, even in medicine. The rapid rise of technologies is governmental health authorities) changing all the aspects of working with data from collecting through assessing to diagnostics and Total  n = 548 storage. Technologies like AI, IoT, EMR implementation 23% wearable devices, cloud or complex algorithms are making it easier for Data exchange with external partners 17% healthcare providers to properly diagnose, assess, store and share Patient access to information 10% data about patients and by that, help Cybersecurity 9% more people and save more lives. New technologies like virtual and Data exchange within the organisation 9% augmented reality, all kinds of apps Clinician access to information 7% as well as remote and online classes are helping medical students and Telemedicine 6% professionals get better training and polish their skills, while robotics Use of mobile devices 5% and technologies like 3D printing Medication safety 4% are making it easier for surgeons to execute precise and minimally Updating hardware and/or network resources 3% invasive operations. Archiving and documentation 2% What is even more exciting about this shift in hospital business is that

Source: HIMSS Analytics, Annual European eHealth Survey, eHealth TRENDBAROMETER patients themselves are becoming an Q3/2017 *EMR stands for Electronic Medical Record (equivalent to EPR) active part of the health system. Even though a lot of medical professionals would agree that there is nothing worse than a “googling patient”, an eHealth revenue in selected European interest in one’s own health can be Countries in 2018 (in CHF million) crucial for healthcare providers. Germany 652 There are apps ranging from fitness, calorie intake, relaxation to prenatal GermanFrancey 471 652 care; there are also platforms and Germany Germany 652 656402 online forums for direct commu- FrancUKe 430 471 France France 471 462,8471 nication with health professionals. ItalyUK 328 430 There are not only wearable devices UK UK 430 43422,50 that monitor your basic life functions SpainItaly 222 328 but also those that are able to alarm Italy Italy328 32322,38 NetherlandsSpain 133 222 doctors if there is a problem with Spain 222Spain 222218 a patient’s new transplant. These NetherlandsSwitzerland 10132 3 devices are able to collect an unbe- Netherlands 13130,73 Netherlands 133 lievable amount of data which, apart SwitzerlandSweden 82102 Switzerland 102Switzerland 100,2102 from medical benefits, brings huge BelgiumSweden 7282 value in statistics on the overall Sweden 82 Sweden 80,682 health of the population. Belgium 0272 00 400600 800 Belgium 72 Belgium 70,772 0200 400600 800 0200 40020600 408000600 800

Source: Statista.com

| Innovation in Healthcare 9

ity data managed and stored in Switzerland KanTa - the National Archive of to implement Health Information. Decisive factors of successful implementa- progressive tion are legal framework, opening up the public healthcare system system to private-sector activities and cultural context; the culture is very The storing, sharing and interop- tech-savvy and prone to adopt new erability of data is a big topic in technologies. Having the National Switzerland. Data forms the basis Data Exchange Layer allows people for the electronic patient record, to renew electronic prescriptions, which is the primary electronic view records related to treatment, document that circulates within store their living wills and organ a digitised healthcare system. donation testament, etc. Switzerland has started to implement this personalised record, known as EPR, in mid - 2018 and the application is to be introduced nationwide in 2020. How to Thus, this project of digital trans- formation of hospitals, clinics and overcome other stakeholders will classify Switzerland as one of the most doctors’ progressive countries transforming its healthcare system following the resistance latest trends worldwide. Basel hospitals on the move The selected hospitals in canton Digitalisation is driven by fast their resistance is the first step to Basel will start creating digital technological progress and the desire spreading good experience through dossiers with doctor's reports, for increased comfort in doing any information sharing. analyses, patient histories or X-rays, activity in both professional and which can be accessed by other private life. It is enabled by data flow – A survey from the Association of treating persons such as health data that is accessible and processed Swiss Specialist Hospitals for Medical professionals or family doctors, and transmitted in the desired Informatics (VSFM) shows that more regardless of time and place. structure in a matter of millisec- than 30% of doctors’ practices still onds. Data that are understandable keep their patients' medical records Using this kind of new networking to patients and doctors – with use in paper form. Changing their platform will offer a lot of the regulated by principles agreed by all approach requires time, experience experience needed to tune it up. The stakeholders upfront – help to achieve and training. Hospitals that strive goal to have a safe, seamless and further efficiency gains and cost to become fully digitised must not secure healthcare structure requires savings. forget that even though technology overcoming various challenges. brings a lot of advantages, the human Data stored in Finnish archives Data already available on paper can factor should never be forgotten in Another example is Finland, be digitised and transmitted where this sensitive environment. And where the ongoing digitalisation needed in order to quickly define that means taking care of doctors of healthcare is leading to patient a diagnosis and apply the most and other healthcare personnel too. empowerment. After years of effective medication. Doctors – of Proper training, ongoing education precise collection of healthcare and first contact – are the first movers in and feedback from professionals social data, the Finnish Healthcare this change. After good experience can bring much more benefit for System has the fundamental with sharing best practices with their patient and hospital alike than any material to digitise the whole colleagues-doctors, they save a lot technology can. sector, providing healthcare profes- of time when considering patient sionals and patients with high-qual- status and thus settle on medication more precisely. Overcoming

Innovation in Healthcare | 10 Hospitals in the digital world

Characters rebooting medicine and health

Accelerating Digital Technology Super-Convergence Reboot

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echnology e Social an G Hum ced Networking quen r of se Numbe Genomics Digital T Internet

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Source: Based on: Wikimedia, CC BY 1.0, Digital Health Infographic. Based on the work of Dr Eric Topol, author of “The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care”

Digital skills needed

With digitalisation running across How to use current assets interoperable structures (partly industries, healthcare is not exempt in hospitals supported by AI too). Managers, from improving its current level of • Exploratory activities: activities roles change from distribution of service quality at lower cost. Thus, that explore new and better alterna- tasks, control and evaluation towards the hospital is subject to economic tives to deliver healthcare services engaging themselves into teamwork logic as well; just like any company, a - regarding both the administrative within Kanban and Agile methods hospital must cover its cost especially and clinical domains - in order to based internal programmes. when comes to using public funds in change existing routines; an efficient way. Digitalisation will mean changes in • Exploitatory activities: activities the roles of established professions, In Switzerland, not all healthcare players that refine and extend existing and hence a need to clarify ownership are fully digitalised; therefore, doctors healthcare competences, and responsibility for the services and hospitals that already use isolated simplifying the use of existing and care provided through new, electronic solutions often have problems routines in both the administrative innovative systems. According to networking with each other. The system and clinical domains. WHO, issues of resistance and trust landscape is usually more heterogeneous will undoubtedly arise, and will than commonly assumed, and missing (Source: WHO, 2018) have to be openly and transparently standards and interfaces slow down addressed for groups of health profes- unhindered data exchange. Healthcare professionals and sionals and the public. especially managers in the health The trend of increasing outpatient industry need to accept the challenge It is also important to remain cost triggers ideas of how to manage for further education - not just in sensitive to the degree to which health hospital performance – both in terms the case of new technologies and professionals invest in their personal of quality improvement and cost approaches (digital skills), but in identities as health workers, which rationalisation - by ambidextrous- understanding the workflow driven they may have taken decades to build. ly combining the exploration and by data – and take decisions within These identities can be threatened by exploitation of hospital assets. the new online interconnected and new technologies and changes to the

| Innovation in Healthcare 11

face-to-face, interpersonal aspect of Healthcare Educating the healthcare. It is crucial that relation- issues in ships are not destroyed in the process public of digitalisation. What planners and Switzerland policy makers perceive as small shifts may not be small to health workers. Two simultaneous trends are Development processes for digital visible in Switzerland. A shortage of health must closely involve both healthcare personnel and a growing health professionals and patient rep- proportion of older people. While Achieving steady progress in resentative organisations. lack of personnel might be solved digitalisation of a healthcare system by migration as in the past – today depends on the ability of patients The digital hospital of the future can more than one in four people are of to play an active role in this process leverage technologies that transform foreign origin and more and more and use digital devices in the proper care delivery, patient experience, staff of them have university education - manner. Therefore, programmes for management, operations management the ageing reflects increased health literacy for the public and and hospital design. life expectancy. According to health professionals are essential, Swissinfo.ch, global average life and so are platforms for patients and A good example is the clinical expectancy rose by over 35% or 18 health professionals that connect and command centre at Cleveland Clinic, years between 1960 and 2012. On unite different sources of data and which can help manage patient average, the Swiss live to be among information. capacity and other operational the oldest people in the world, with processes. For example, using data a projected lifespan of 82+ years in It will also be necessary to address on admissions, inter-facility transfers upcoming years. the implications for patients of having and predictive analytics on possible responsibility for their own data Digitalisation of the healthcare days for discharge, command centre and their own engagement with the sector might bring partial analysts can help staff manage patient system. This knowledge and interest resolution of both of these flow and improve care delivery, better in one’s own health is a crucial part of trends by applying labour-saving manage lengths of stay and enhance the switch from reactive to predictive technical innovations like robotic the discharge process. medicine. assistance, monitoring sensors, ambient assisted living, telemedi- cine or artificial intelligence.

Benefits of digitalisation

– Leaner and more efficient processes increase the quality of the overall system and ensure more transparency.

– The safety of patients is significantly improved by digitalisation. For example, the availability of electronic patient records around the clock can help doctors make decisions even in operating rooms.

– Digitalisation in the healthcare sector can also compensate for the growing shortage of skilled workers.

Innovation in Healthcare | 12 Hospitals in the digital world

across healthcare will increase Digital power eightfold by 2022;

Predictions for the next decade's – Artificial Intelligence (AI) will development show that digitalisa- directly impact 25% of business tion will become a leading driver processes by 2020. in changing healthcare systems worldwide. Let’s look at some global health IT predictions based on research by IDC International Data Corporation showing where and Important steps to how fast these changes are going to impact healthcare enterprises, an e-Health future companies and departments in the patients to ensure smooth commu- upcoming years. ❶ The digital hospital engages with patients in new ways using remote nication and quick response times in – Optimising the digital patient monitoring tools (wearables), telecon- the decision-making process. experience will become one of the sultancy, patient flow management, ❺ Secure data - as medical top 3 strategic priorities by 2020 etc., called digital care delivery and information is of the utmost for 60% of healthcare providers; digital patient experience. sensitivity, the digital hospital must possess solid anti-cyber breach – Personal data exchange in ❷ Internal processes digitised solutions, and their steady upgrade healthcare will triple by 2023; with help of robotics, sensors, portals, communication systems must be an integral part. – By 2022, 50% of clinical apps will and automation, which drive cost include ambient interfaces and efficiency up. Sources: 20-30% of acute care providers will ❸ Data is key – collecting, storing, Association of Swiss Specialist Hospitals for deploy smart watch-based apps - securing and analysing data in robust Medical Informatics; Cleveland Clinic; Danish both ensuring higher data quality IT infrastructure is a fundamental Ministry of Health; Kanta – National Archive and improving productivity; investment in order to run the digital of Health Information; KPMG; The Healthcare – Blockchain use for securing hospital. Access and Quality Index; Thun Hospital; multiparty information sharing ❹ Digital skills are required from U.S. News and World Report; WHO; IDC hospital personnel as well as from

TRENDS IN HOSPITAL CARE

Technological trends Digital transformation Use of new information and communication technologies, such as the electronic patient through e-Health dossier, to help implement e-Health

Personnel and Human Resources (HR) Shortage of skilled The most important innovations in the field are in human resources structures professionals (for example, expansion of the skill-grade mix)

Hospital services and competition Falling prices per case Includes topics such as compensation, optimisation of financial leadership, increased force higher number of cooperation (integrated care), investment needs and the construction boom in the cases healthcare industry.

Social developments The future of hospitals is Demographic change, changes in patient behaviour, individualisation, health literacy, all about sophisticated increased comfort and service demands patients

Source: ZHAW School of Management and Law - Das Schweizer Spitalwesen Eine Managementperspektive, authors: Alfred Angerer, Eva Hollenstein, Florian Liberatore, 2016

| Innovation in Healthcare 13

Digital hospital stages and criteria

Stage 0 • No part of the institution is included in the digital environment, including clinical support units (pharmacy, lab, radiology).

Stage 1 • Clinical support units (pharmacy, lab, radiology) are included in the digital environment.

Stage 2 • Digital environment includes a clinical data repository (CDR), physicians can view medical information and results internally.

• The CDR can receive medical image documents. If applicable, information exchange is enabled between hospitals.

Stage 3 • Clinical documents, electronic medication management records, order entry, and tracking systems are integrated with the CDS.

• Physicians located outside the radiology department can access medical images and image archive.

Stage 4 • Any licensed clinician can add a nurse to a computerised physician order entry (CPOE) system.

Stage 5 • Physicians outside the institution can access medical images via a secure, intra-institutional system.

Stage 6 • At least one in-patient has an integrated documentation system.

• A closed-loop system manages medications; the hospital uses a coded drug system.

• Automated ID and delivery technologies comply with the "5 Rights":

– Right patient;

– Right drug;

– Right dose;

– Right route;

– Right time.

Stage 7 • Total digitalisation: no use of paper documents.

• The institution stores and analyses data to increase healthcare quality and ensure patient safety.

• All data is standardised and accessible to all hospital personnel.

• A closed-loop system manages all healthcare materials.

Source: International Journal of Health Science Research and Policy Volume 1 Issue 2 2016

Innovation in Healthcare | 14 Branding and positioning

Creating stronger brand Building a successful hospital brand strategy

Maneka Fahrer Bruno Managing Director Bloom Identity

The healthcare sector has undergone a drastic evolution in the last few decades. Previously centred on the management of disease and symptoms in a fee-for-service approach, the healthcare industry is currently focused on providing patient-oriented services with the aim of reducing costs and ensuring a better overall health outcome.

This new value-based healthcare receives a massive amount of searches physicians and employees alike - model has been supported by every day, but did you know that healthcare organisations can remain the rapid progress of science and 5% of all Google searches are health profitable while providing higher - information technology. Indeed, related? This means that every day quality clinical services. patients have gained an increased millions of people see healthcare access to scientific and medical branding. We support our clients during the information. They are now part of the whole process of branding and decision-making process concerning In the present era of patient prioriti- positioning. Our clients can rely on the choice of their healthcare provider sation, competition between different our skills, expertise and in-depth and the medical treatment they healthcare providers is at its highest. knowledge of this industry and its receive. Hospitals, walk-in clinics and private needs. physicians’ practices are in the dire Healthcare has changed over the past need of promoting their services and few years. Like other industries, it’s engaging with their consumers in become consumer-driven. Patients, order to remain successful. providers and anyone else who purchases healthcare or devices By developing and maintaining a have developed a superpower. The brand that reaches in a meaningful superpower of knowledge. Google way to their audience - patients

| Innovation in Healthcare 15

What is branding and why do hospitals need it?

Branding is the art of creating a brand which A huge shift in healthcare (hand-in-hand with defines the company's goals and services, the importance of branding for health providers) embodies the consumer's emotional connection Branding came with generation Y, better known as to the product, and ultimately highlights its represents the millennials. Young adults born between the uniqueness in the market. Successful branding personality and '80s and '00s are the first to have grown up with doesn't only affect consumers; it can also have an promise of your access to the Internet and technology, which important impact on employees, investors and services - the created so many new opportunities for them stakeholders. way you look, to be interested in research and take care of feel, act and their health that their predecessors didn’t even In the healthcare sector, branding can play a deliver. think possible. Thanks to all these possibili- crucial role in building patients, and employees' ties, millennials are becoming more and more trust and can significantly reduce the usually interested in their health and are changing the perceived risks related to hospitals, disease and role of patient in healthcare from passive to treatment. active. They are actively seeking healthy lifestyle choices, turning to eco-friendly products, It can enhance service quality by attracting researching health-related information and competent medical specialists and by engaging turning to technology to monitor their own the views and needs of patients. health status. And although millennials are the first to power digitalisation of the healthcare More importantly, a strong healthcare brand can business, this is just the beginning. withstand financial uncertainties by boosting patients' loyalty and by increasing the value of the healthcare facility.

Innovation in Healthcare | 16 Branding and positioning

Firstly, millennials want to play a relevant part medicine and targeted treatment are just a few in their healthcare, which means they expect trends that will be considered normal for this to be equal partners with doctors, nurses and generation. healthcare providers and to be involved in deci- sionmaking. They also expect medical treatment So, when thinking about branding and to be tailor-made for their personal needs and positioning of healthcare providers, let’s not they are ready to take some responsibility for forget that the patients are drastically changing their health into their own hands, whether that with every new generation and what was once means gadgets and wearables that monitor their considered new, futuristic and innovative bio-functions, seeking information on various may be a standard norm just a few years later. medical platforms or trying telemedicine or Healthcare providers and hospitals must adapt online consultations. as quickly as companies in other industries that wish to stay on top of the game. Secondly, there is an even bigger shift coming with Generation Z. Although still very young – mostly in their teenage years – Generation Z is so accustomed to technology that digitalisation in healthcare is not a question of improvement, but a standard. Robotics, virtual reality in operating rooms, highly functional and detailed wearables, predictive

| Innovation in Healthcare 17

Why is effective Risks of not having branding needed in strong branding healthcare?

 It differentiates your facility from the  Weak branding makes it hard for competition in the market; customers to recognise you or become repeat customers;  A strong brand sharpens your competitive edge;  You can get lost in the sea of competitors;  A strong brand builds trust;  It will be more difficult to get support,  It provides a unique positive identity funding or partners; and increases the value of your company;  It’s nearly impossible for people to emotionally cement a positive  It engages an emotional connection connection in their brain if you don’t with patients, physicians, employees have a consistent way of presenting and stakeholders; your brand at all touch points.  It elicits the quality of your services by attracting and retaining highly talented experts;

 It builds trust in your healthcare service;

 It reduces financial risks by ensuring patients' loyalty and increases profit;

 It set guardrails for your marketing team.

In the current shifting attitudes of the healthcare market, building and maintaining a strong, reliable, and competitive Hospital brand is becoming critical for the survival of an organi- zation. A brand founded on consumers' expec- tations and needs while being consistent with its core values in delivering its promise, ensures a better navigation of the market and financial storms. Putting patient engagement at the core of your brand and ensuring excellency in service delivery creates trust, loyalty, and a long-lasting emotional connection between the patient and your facility. It increases your competitiveness and differentiates your company in the market. Moreover, solid and patient-oriented Hospital brands help bringing the healthcare industry to the modern standards of healthcare delivery.

Innovation in Healthcare | 18 Interview

Anne-Geneviève Bütikofer Managing Director H+ Hospitals in Switzerland

"Digitalisation is important, but relationships still remain crucial"

| Innovation in Healthcare 19

Anne-Geneviève Bütikofer, director of the organisation "H+ Die Spitäler der Schweiz" (H+ Hospitals in Switzerland), explains in an interview her view on the subject of digitalisation in the healthcare sector and why strong brands are necessary there today as a differentiating feature.

Ms Bütikofer, according to the latest hospital and How can you measure the quality of treatment? clinic barometer from H+, the number of patients Which criteria should be taken into account? who research the Internet before visiting a doctor According to the Health Insurance Act, hospitals and or hospital is growing. Does this really lead to the clinics, whether in the fields of acute somatics, psychiatry desired outcome according to your survey? or rehabilitation, must measure their quality and publicly Our survey clearly shows that there is a great need for report it. The hospitals meet these requirements with information. This is attempted primarily through the the nationally uniform quality measurements of the official websites of hospitals and clinics. It also became ANQ (National Association for Quality Development in clear, however, that patients almost everywhere trust that Hospitals and Clinics) and thus contribute to transparen- their doctors will refer them to a suitable health facility. cy. The measurements and their results also promote the hospital's own quality efforts. The criteria and require- In your opinion, how should hospitals respond to ments vary depending on the measurement and are this changed consumer behaviour? What do they developed by technical experts. have to offer the seekers? With Spitalinfo.ch, H+ operates its own It is important that users can easily find out about the information platform. How do they differ from range of services offered by a hospital. Furthermore, other offers? certain administrative steps, such as the possibility of online patient admission, should also be offered. The topic Spitalinfo.ch is aimed not only at patients and their of "quality" is also becoming increasingly important. Here, relatives but also at health professionals and other however, we are faced with the challenge that the quality interested parties. We want to support users in their search data are complex and difficult for laypersons to interpret. for the right hospital by highlighting the services provided Therefore, we must try to break them down as easily as by the individual facilities. But also quality data are not possible, without losing valuable information or leading to neglected. In comparison to other platforms, we deliber- misinterpretations. ately avoid rankings, as quality data are only suitable for comparisons to a limited extent. Spitalinfo.ch builds on transparency so that the user can form his own opinion and thus find the suitable hospital tailored to his needs.

"We want to support users in their search for the right hospital by highlighting the services provided by the individual facilities."

Innovation in Healthcare | 20 Interview

You know the importance of strong hospital How does digitalisation change communication brands from your work as a member of the board with patients and the role of hospital brands? of directors of Insel Gruppe AG. What role does Despite increasing digitalisation, direct communication brand building play in healthcare today in order between healthcare professionals, whether nurses or to survive in competition? doctors, remains one of the most important means in the While the brand has not been so important in the health doctor-patient relationship, or in the relationship between care sector for a number of years, especially in hospitals, nurse and patient. Because communication, especially the situation has intensified with increasing competitive in one's own language – as has also been shown in past pressure. A strong and trustworthy brand has a positive surveys of hospital and clinic barometers – is an important influence on the patients' greater room for manoeuvre good for patients. when choosing a service provider. Therefore, all areas that contribute to the building of trust and thus to a positive However, digitalisation in communications is increasingly image transfer must be recorded. This ranges from a simplifying the corresponding processes. For example, uniform, differentiated language and appearance in the guests in the new bed house at Triemli City Hospital can corporate identity and design, to measures across the entire use a multifunctional screen on the bed to directly place keyboard of communication and marketing, including orders for their food and this information is then sent corporate social responsibility issues. Equally important directly to the kitchen. At the Inselspital, for example, for a brand are personnel issues such as employer patients can already register online for admission to the branding, diversity and equal opportunity hospital. issues, and the opportunities that a company's employees What should good patient relationship have to reconcile their professional and private lives. management look like today? It should focus primarily on the patient. This means that all actions in a hospital must be directed towards the sick. The Lean concept, which is used by more and more hospitals and clinics in Switzerland, follows exactly this approach, with the extremely positive effect that both patients and employees are more satisfied.

| Innovation in Healthcare 21

According to various studies, Switzerland ranks After all, technology is only one aspect of rather in the midfield in terms of digitalisation in digitalisation; the attitude of employees and the the healthcare sector. Will the introduction of the processes are another. What role do you attribute electronic patient record change this? to change management in the context of digital It will certainly contribute to the fact that something is change? moving in the area of digitalisation in Switzerland as well. In addition to optimising work processes, digitalisation But whether it will be the big driver for digitalisation is also improves the quality of care and increases patient rather questionable in my eyes. Its goal is the exchange safety. But the step there should be accompanied by a of important medical data between patients and service change management system in addition to the moderni- providers. But to achieve this, the electronic patient record sation of the infrastructure. Attitudes must change, fear would also have to be mandatory for all parties involved. of new technologies must be overcome, working methods should be reviewed and processes dematerialised. Digi- talisation in the healthcare sector is an opportunity for hospitals, which opens up new opportunities overall. This process will affect all healthcare professions, for example through the use of robots or the strengthening of quality and patient safety through intelligent programmes and the optimisation of medical data flows. But without the support of employees at all levels, this is difficult to achieve.

Anne-Geneviève Bütikofer was elected as the new Director of "Swiss Hospitals" on 7 June 2018. She was also appointed to the OdASanté Board of Directors on 13 June 2018 and is its Chairwoman. The 45-year-old lawyer is very familiar with the Swiss healthcare system and has an excellent network. Since 2011, Anne-Gen- eviève Bütikofer has been Secretary General for the Swiss Medical Association (FMH).

From 2008 to 2011, she was Director General of Health in the Department of Economic Affairs and Health of the canton of Geneva and, before that, Head of the Cross-Border Cooperation Service for the Federal Department of Foreign Affairs (2005-2008) and Legal Compliance Manager for the toy manufacturer Hasbro (2001-2004). She has also worked as a lawyer in the Federal Department of Justice and Police and the Department of Justice, Health and Security of the canton of Neuchâtel.

Innovation in Healthcare | 22 Reactive vs. preventive medicine

Shifting from reactive to preventive medical care

TREATING SYMPTOMS

Reactive medicine involves a healthcare delivery According to Centers for Disease Control, system based on diagnosing an existing disease chronic diseases, while largely preventable, and finding a treatment for it. It is an acute care directly affect the quality of life and are model that doesn't focus on preventing an illness associated with significant economic costs, from happening but reacts to the consequences accounting for almost 75% of healthcare after the onset of a disorder. spending in the US alone.

It is a perfectly effective system for the In an effort to counteract the rising costs and management of acute short illnesses which limit the burden of today's chronic conditions, require a simple diagnosis and a fast treatment. the industry has been shifting to a modern approach for care delivery, one that is focused Reactive healthcare has been expensive and on preventive and proactive measures with the inadequate in the management of the highly patient's well-being and health as the ultimate prevalent chronic diseases, to which no ready objective. cure is available. According to the World Health Organization (WHO), chronic or non-com- municable diseases, such as diabetes mellitus, cancer or cardiovascular disease, currently constitute a major public health burden and are the leading cause of death worldwide.

Reactive medicine Effective only in the management of acute short illnesses with a clear treatment.

Does not prevent the onset of a disease.

Ineffective in the management of chronic diseases.

High costs due to the high prevalence and the necessary long-term care of chronic diseases.

Fee for service approach prioritising the volume of patients.

| Innovation in Healthcare 23

For decades, the healthcare industry has Medicine has been steadily moving from depended on delivering clinical care as a reactive to preventive, replacing a traditional reaction to an existing disease and detectable fee-for-service and volume-oriented care symptoms. However, with increasing healthcare system with a new and modern model that is costs and with the rise in patients' expectations, value-based and patient-oriented. a shift in the approach to medical care delivery has been developing.

EVALUATING RISK FACTORS

Preventive medicine is a healthcare system based From a consumer's perspective, this implies on a model that identifies the risk factors and the being active in managing one's own health by: early signs of a disease, thus preventing its onset • Increasing physical activity. rather than later addressing its symptoms. • Following a healthy diet. Recent technological advances and the evolution • Doing regular medical exams and vaccina- of science research have permitted an accurate tions. understanding of diseases and their risk factors, giving consumers and health providers the On the other side, the healthcare industry means not only to monitor a patient's health bears the responsibility of effectively managing status but also to actively prevent the onset of patients' health by: diseases in healthy individuals. This is partic- • Improving the availability of medical ularly of significance for the current aging and information. medically demanding population, burdened by the important increase of chronic diseases. • Encouraging research and investments in new technologies for early disease detection and Consequently, it is perfectly possible today to prevention. prevent or delay the onset of many illnesses • Enhancing consumers' health outcomes and such as diabetes or cardiovascular disease, by overall well-being. simply adopting a proactive health approach which equally engages patients and healthcare providers.

Preventive medicine Value-based and personalised model with a focus on consumers' interests.

Increase in life quality and expectancy.

Reduction in healthcare costs through disease prevention.

Emergence of new industries and improvement of workforce engagement.

Increase in patient retention rate and productivity.

Requires patient’s interest in own healthcare and availability of medical information.

Can hugely benefit from new technologies.

Innovation in Healthcare | 24 Guest essay

Digital hospitals

Klavs Renerts, MD Assistant Medical Doctor in Neurology at the University Eye-to-eye contact between the EHRs came with a promise of a single Hospital of Zurich doctor and the patient is a precious digital environment for stream- commodity. It is continuously being lining the management of patients bombarded by phone calls, direct and making the documentation messages and e-mails with inquiries easier. It would also be a tool to ranging from simply prolonging a order new examinations, prescribe prescription to handling an urgent drugs and reach other colleagues. medical problem elsewhere. Such an Most importantly, it would give an environment is not always optimal for oversight of medical practice at large, delivering sensitive news to a patient within and between different medical or contemplating a complex medical institutions. problem. However, it appears that EHRs have The good old saying "pics or it didn't not made the doctor's life easier. Now, happen" rings especially true for most of the doctor's time is spent medicine, where each task, conver- in front of a computer and not in The iconic doctor with a leather sation, correspondence and medical direct patient care, increasing work suitcase, illegible handwriting decision needs to be documented. dissatisfaction.❶,❹-❼ Some well-off and conservative views is being This is done to ensure continuity, as hospitals even employ medical substituted by the first internet one patient may be treated by several scribes – persons to handle the work generation: the handwriting is still different medical professionals. with EHR so that doctors are free illegible, but it does not matter, as to communicate with the patients.❽ the tech-savvy millennials typewrite The medical guidelines need to be This seems peculiar, as digitalisation everything. The hospitals are in a constantly adapted, as a blossoming should make the hospitals more transition period from a paper-based scientific scene is bringing out close efficient. It appears to me that EHRs era to an electronic one. The ship to a million medical papers yearly.❸ are the first place to search for of digitalisation has set sail, but it Doctors are expected to be up-to-date. potential improvement. risks steering in to deep waters as Because their patients sure are. medical professionals worldwide Until today, I have worked with three report of electronic health record different EHRs and read about several systems (EHRs) eating away their others. Mostly it is a "one-size-fits-all" most valuable resource – time.❶,❷ software. Hence, a function one clinic We should rethink the role of requires all the time might be hidden digital machinery in hospitals, to under ten layers of drop-down lists, increase their efficiency and, most just because other clinics need it less importantly, to advance the field of often. As medical data are sensitive medicine. Being a medical resident at and the security of the system is a university hospital, I humbly offer paramount, EHRs often offer little my personal point of view. flexibility.

| Innovation in Healthcare 25

An alternative approach would be to Healthcare is already extending create a modular EHR environment, outside the hospital. As people where a single clinic in a hospital become more accustomed to could mix and match from a range monitoring their health (smart of professional "apps" and extensions watches, smart scales, smart to the base EHR. To this end, the everything), a vast amount of data is software company running the EHR generated. Patients sometimes offer would have to provide an application me read- outs from their smart- programming interface (API) and watches, but the data are too "noisy" open the environment for third-party for human interpretation. Properly developers. This requires a change of interested. I sometimes dream of a analysed, however, such data could mindset, as software providers might system handing me a "weather report" illustrate health trends (high blood be reluctant to let smaller players for a ward I oversee, highlighting pressures, sleep and movement enter the field. Some EHRs, however, suspicious changes and reminding patterns) and indicate problems even are already experimenting with about burning priorities. before they arise. specialised marketplaces containing apps from third-party developers. Furthermore, the medical expertise In a truly digital hospital, every Such an environment increases (e.g. for recognising a rare medical employee is equipped with a software flexibility and allows for user-driven condition) tends to concentrate in environment, complementing evolution of the EHR. large hospitals, not always accessible each other like Batman and Robin. to all the patients. With digital aid, The system has many players and EHRs could bring medicine into a knowledge, informed by the latest undergoes continuous evolution, whole new era by providing data for science, could be delivered even in incorporating state-of-the-art medical continuous self-improvement of the remote areas. Although deep learn- knowledge. The patients, on the other hospital. For example, in the old days, ing-powered systems for medical hand, can participate in their health if a hospital wanted to battle the rate purposes (e.g. IBM Watson) are often management, their smart devices of infections acquired in the hospital, talked about, their wide application providing useful information and a labour- and time-consuming study has remained for years "just beyond being more than expensive toys. The needed to be carried out to assess the the horizon". digital system serves the humans, data. With an elegant EHR solution, a and not the other way around, and hospital would have a comprehensive Some might fear "doctors being the doctors can provide the one view of all the applied treatments at replaced by the machine", but instead thing a patient needs most – human its fingertips and could attempt to of pushing doctors aside, such a connection. Creating such an weed out any factors contributing system could be the best imaginable environment involves medical, legal to hospital-acquired ailments, thus assistant as well as teacher, tending and digital communities working side reducing the costs and improving the to the specific educational path of the by side. healthcare. doctor. It could even provide insights that had slipped human knowledge Some of the mentioned digital I argue that EHRs could be capable of before. If this sounds like science solutions might seem utopian now, far more than they are today – with fiction, let me bring up the study but so was Jules Verne's "From the some creativity and imagination where a deep-learning algorithm, Earth to the Moon" back in 1865, applied. An advanced system could trained on retinal images of 280,000 written just 102 years before the first take notes as the doctor communi- people, could predict their age, human landed on the Moon. The first cated with the patient, saving hours gender, blood pressure and smoking step is having a good imagination. of manual typing labour. It might status. Previously, nobody knew that not be a function all the clinics such information could be extracted require, but some would surely be from the back of a human eye.❾

❶ Ehrenfeld, J. M. & Wanderer, J. P. Technology as friend or foe? Do electronic health records increase burnout? Curr. Opin. Anaesthesiol. 31, 357–360 (2018). ❷ Poissant, L., Pereira, J., Tamblyn, R. & Kawasumi, Y. The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review. J. Am. Med. Inform. Assoc. JAMIA 12, 505–516 (2005). ❸ Citations Added to MEDLINE® by Fiscal Year. Available at: https://www.nlm.nih.gov/bsd/stats/cit_added.html. (Accessed: 5th December 2018). ❹ Tai-Seale, M. et al. The Practice of Medicine. Health Aff. Proj. Hope 36, 655–662 (2017).❺ Christino, M. A. et al. Paperwork Versus Patient Care: A Nationwide Survey of Residents’ Perceptions of Clinical Documentation Requirements and Patient Care. J. Grad. Med. Educ. 5, 600–604 (2013). ❻ Sinsky, C. et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann. Intern. Med. 165, 753–760 (2016). ❼ Shanafelt, T. D. et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin. Proc. 91, 836–848 (2016). ❽ Mishra, P., Kiang, J. C. & Grant, R. W. Association of Medical Scribes in Primary Care With Physician Workflow and Patient Experience. JAMA Intern. Med. 178, 1467–1472 (2018). ❾ Poplin, R. et al. Prediction of cardiovascular risk factors from retinal fundus photographs via deep learning. Nat. Biomed. Eng. 2, 158–164 (2018).

Innovation in Healthcare | 26 Facts and figures

Healthcare in numbers TOP 5 EUROPEAN TECH HUBS According to Biocat, Barcelona is among the top five European tech CHF 160.9bn hubs:

1. London – Scientific & Economic Capital 2. Munich – Big Innovative Companies 3. Barcelona – Biomedical & TIC 4. Berlin – attractive for entrepreneurs 5. Stockholm – allied health technologies

Source: Biocat

According to a PwC report, healthcare will be more patient-ori- ented, team-based and cross-sectored. Digitalisation and automation are expected to alter the roles and careers Global e-Health is projected to gross of employees, due to which hospitals over CHF 160.9bn in 2024. face a challenge of conducting

Source: maximizemarketresearch.com, 2017 continuous employee training to retain and attract employees.

Source: PwC

Unified electronic health The cost of healthcare in Switzerland record/exchange in is projected to rise annually by 3% Germany can generate an by 2040, while healthcare spending estimated potential will be below 15% of the national value of CHF 7.14 billion. economic output as compared to 11%

Source: McKinsey & Company in 2011. Source: Credit Suisse, 2017

| Innovation in Healthcare 27

75% of under 40-year-old physicians are in favour of the integration of technology into e-Health. This includes electronic Health Records, e-consultation and remote admin- According to WHO, 70% of member 42 out of 45 of the WHO European istration of services through video states in the WHO European Region Region member states surveyed have conferences, among others. have a national policy or strategy for public funding available for eHealth

Source: Study by KPMG and FMH in 2018. e-Health. programmes. The Study sampled 30,000 physicians. Source: WHO, 2017 Source: WHO, 2017

Use of social media by healthcare organisations.

Source: WHO, 2017

Innovation in Healthcare | 28 Facts and figures

CHF 279.5

CHF 650.7mil

Telemedicine market revenue is projected to grow at 12.4% to reach CHF 500 million in 2022. The tele- Estimated revenue generated by The health technology sector is medicine services are set to involve eHealth business in Germany was expected to reach CHF 279.5 billion the digitalisation of healthcare expected to amount to 650.7 million by 2021. systems and processes. Swiss Francs in 2018. Source: Deloitte, 2019 Global Health Source: KenResearch, 2018 Source: Statista.com, 2018 Care Outlook

Global healthcare spending is projected to reach 9.867 trillion CHF by 2022.

Source: Deloitte, 2019 Global Health Care Outlook

| Innovation in Healthcare 29

The U.S. healthcare The healthcare system in Europe Growth of Swiss telemedicine is is moving towards shorter Average analytics market is typically driven by the increasing Length of Stay (AVLOS) and a shift growing rapidly and is prevalence of chronic diseases, from inpatient treatment to outpatient forecasted to grow at public & private investments, treatment, driven by the development the aging population and digital of new treatment methods, protocols a 12.5% CAGR over the transformation. and equipment. period 2019-2025.

Source: Ken Research, 2018 Source: Capio, 2018 Source: MarketWatch.com, 2019

China's healthcare analytics market is 64% of consumers point to estimated to reach convenience and access as important benefits of virtual health. CHF 276.7 million

Source: Deloitte 2018 Surveys of US Health by 2025. Care Consumers and Physicians Source: MarketWatch.com, 2019

According to CB Insights, “Across digital health, biotechnology, and the medical device sector, startups are finally bringing medicine into the 21st century.” The trends to watch include intelligent drug design, skin-as-a-platform, blockchain-enabled hospitals, CAR-T, RNA and anti-ageing therapies, bioprinting and hand-held diagnostics.

Source: CB Insights, 2017

Innovation in Healthcare | 30 Health conferences 2019 HEALTH AUGUST SEPTEMBER CONFERENCES 12–13 13–14 7th International Conference on Medical Telemedicine, eHealth & Health Informatics & Telemedicine Informatics 2019 Rome, IT Singapore The 7th International Conference on The 2019 Telemedicine, e-Health & Health Medical Informatics &; Telemedicine will Informatics conference will be held at take place in on 12–13 August in Rome, Italy. Holiday Inn Atrium, Singapore.

The various topics to be canvassed are This conference is set to discuss the nature HEALTH toxicity informatics, clinical informatics, of healthcare informatics and its potential pharmacist evaluation, drug informatics to improve the quality and efficiency and patient assessments among other of healthcare and technology to assist telemedicine invention technologies. in remote monitoring and support for EVENTS NO patients. There will also be a topic about current and future utilisation of health data and how to make it efficient and the current and modern tools for effective healthcare. ONE IN THE 19–23 This 8th Telemedicine conference will bring together medical informatics 3rd China-Europe Innovation Forum on researchers and practitioners from over Smart Health and Privacy Protection 40 countries. INDUSTRY (Smart Health 2019) Leicester, UK

The Forum will offer talks, visions and per- spectives from industry and policy-making SHOULD organisations that will focus on Smart 14–18 Health. Digital revolution, implanted AHIMA19: Health Data and innovative devices, personalised medicine, Information Conference new technologies as well as the potential MISS of smart health business for patients – Chicago, IL these are the key topics of this conference. Discussions will also include much-needed This year’s AHIMA19 Health Data & talks about privacy protection and data Information Conference will be held in security in medicine. Chicago, Illinois. The conference will start on 14 September and end on 18 September.

Building from last year’s health conference that took place in Miami, Florida, this year seeks to bring together more speakers, investors, researchers and industry players.

These experts will talk about the importance of health data and how practitioners can take advantage of the milestones brought about by technology. 16–17 3rd International Conference on Lasers, Optics & Photonics Amsterdam, NL

The third International Conference on Optics-Photonics will take place on 16-17 September 2019 in Amsterdam, Netherlands.

The conference will bring together a mix of industry players and staff in academia to discuss the emerging issues around optics-photonics. Students and junior scientists will also have the opportunity to interact and network with established industry players and senior researchers.

| Innovation in Healthcare 31

OCTOBER NOVEMBER 27–30 11–13 HLTH: The Future of Healthcare - The EHiN, E-Health in Norway World's Largest Conference for Health Oslo, NOR Innovation Las Vegas, NV The biggest health conference in Norway is focusing on the digitalisation of the whole Las Vegas will host one of the largest med sector. EHiN was founded by the health conferences on 27–30 October 2019 Ministry of Health and Care Services and at the MGM Grand, Las Vegas. While the ICT Norway to put together experts across 2018 HLTH conference brought together the field. The goal is simple: to create a 3,500 attendees from over 30 countries, platform of cooperation between the IT the 2019 conference promises even more. industry and the health sector. EHiN is a place where companies, organisations and Some 5,000+ attendees will converge state departments share their experience in Las Vegas. Over 325 speakers are and knowledge. Main topics include already lined up for the HLTH conference, innovation, data security, research, health including Adam Boehler (senior advisor to design and more. the secretary, CMS), Lloyd Dean (President &; CEO of Dignity Health) and Meghan Callahan (VP, Healthcare Lyft Business).

The conference will discuss the future of healthcare even as WHO statistics show that over 45% of its member states have less than one doctor per 1,000 people.

Let’s look at some of the most interesting events and conferences in the field in the upcoming months.

Innovation in Healthcare | 32 IoT in healthcare The Internet of Medical Things

Why it matters What to do about it

The Internet of Things is gaining momentum in medtech. What kind of new challenges could this area pose for established hardware 8 billion companies? Medtech companies traditionally manufacture highly technolog- loMT ical, autonomous devices. The IoT enables those instruments to be connected together, and connected to instruments from other devices companies or even different industries. Predictions say that there will be 8 billion IoMT devices Integration will be one of the most challenging aspects. Proper and worldwide by the end of this easy integration of the vast numbers of devices is a market demand year and up to 21 billion and necessary to keep key advantages. by 2020.

| Innovation in Healthcare 33

30% How can the industry profit from the IoT and Time-effectiveness during connecting medtech devices to other industries? treatment. Healthcare plans First of all, the IoT means better, fact-based diagnosis. Data science of the future place a key allows us to analyse numerous sources regarding a patient's condition responsibility on clinical IoT of illness or disease and recommend treatments or preventive action devices. Those wearables’ to a doctor. Thus, the doctor does not need to rely solely on his data will speed up a clinician’s experience, but can assess and complement the outcome from assessment significantly a sophisticated computer-assisted analysis. by 2019. We’re talking a time savings of up to 30%. There are also other uses such as personalisation or remote healthcare. Hospitals will start to rely For example, the data from your smartwatch can improve diagnostics on robots for the delivery of and help you receive more personalised treatment. Also, various medication and supplies and sensors, cameras and devices can help with monitoring patients who as IoT-enabled biosensors. are treated at home, allowing them to function more independently. There is a lot of space for new ideas and innovation. Source: IDC Future Scape: Worldwide Healthcare IT 2017 Predictions Another IoT potential lies in much simpler visualisation of the health conditions of individuals, which can lead to greater motivation to live a healthy lifestyle and to better prevention of illnesses. CHF 166.1 billion Remote Healthcare A revenue of CHF 166,1 billion is expected in the global smart healthcare market by 2020. Remote monitoring will play a prominent role in the future.

Source: Technavio 3.2 billion downloads Health apps are in high demand now, as the download numbers show.

Source: mHealth App Economics 2017 report

Innovation in Healthcare | 34 Innovation in medtech The entry points What are the questions and situations that start the innovation process in medtech companies?

Digitalisation, the Internet of Things, smart data and cognitive services are changing the medtech industry. Error reduction Let’s have a look at some of the situations, opportunities and questions. A decrease in human error can be achieved by auto- mation of devices and therapy records. This is relevant especially for hospitals and subacute care facilities.

Your hardware has become a commodity Downtime of instruments and their predictive maintenance

Hardware is losing its importance in the medtech Another problem that our medtech customers face environment. It often slowly turns into a commodity is instrument downtimes. There are multitudes of and customers cannot distinguish market participants complex instruments on the market and each of them just by looking at hardware. On the other hands, the needs a lot of maintenance. software, cognitive services and data used along with As of now, predictive maintenance is getting more the hardware are becoming the important players. important in the area of medtech and in the industry They can enhance your hardware solution and help in general. What you can do is to analyse the health distinguish your business from the competition. status of an instrument (for example, by creating a digital twin), predict its potential future failures and fix situations even before they happen.

You are unsure what data to collect and analyse Regulations as an In medtech, there are three types of data worth innovation starter collecting: medical data (substances that your device measures in blood and urine), user data (either how One challenge that many of our customers face is the people use your device, or in the case of personal need to make huge efforts to submit a new drug – from healthcare, what they do in their everyday lives that the regulatory point of view. An innovative approach influences their medical results) and technical data they can take is to substitute some of the studies they (the status of the device itself). Based on our have to carry out with data analytics. Besides running predictions, major innovations will happen at the their own studies, medtech companies can use data intersection of these three areas. available on the market or in academia to prove that a certain drug or medicine is effective for a particular disease.

| Innovation in Healthcare 35

Wearables By 2021, the yearly revenue of the health-relat- ed wearables market will be worth $17.8 billion (Source: Tractica report, ‘Wearable Devices for Healthcare Markets’). Manufacturers are A new business model has entered the field – planning to include the next generation of and the expectations of customers or patients specialised wearables such as hearing aids, have changed with it skin patches, smart contact lenses or implant- High customer value can be created through data – if a com- able wearables in the existing markets of heart petitor manages to introduce a new business model based on monitors, sleep or step trackers and smart data science, other companies will need to follow. glucometers.

Connectivity Personal data The trend of connectivity will bring more and more From the end-user or patient perspective, devices and data sources connectivity and data management will play together and create pressure a big role too. The more data sources I can to innovate. In the past, all combine in my medical profile as a patient, the medical devices were standalone more interesting it gets. Combining different – as opposed to most of the data sources and creating new information will future medical devices, which give patients broader perspectives, open new will be interconnected. treatment options and spur innovation.

Reimbursement and personalised healthcare

Another example that leads to innovation in medtech is the pressure of reimbursement. Medtech companies don’t get reimbursed for medicine and Monitoring patients drugs that don’t have any effects on individual patients. This creates a new remotely trend and strategy for many companies to offer personalised healthcare. Through this, they can make sure that if a patient takes their medicine, it Remote patient monitoring really fits their personal genomic type. (RPM) is already helping to monitor vital statistics and in- crease prevention in senior living healthcare, where it has proven Saving costs through the Objective reports to be highly effective. RPM is Internet of Things about collecting and transmit- Access to precise, recorded ting patients’ real-time data to Real-time data transmission will reports on nervous system levels their caregivers, or to doctors or allow patients to be discharged means that healthcare providers nurses who are monitoring these from hospitals and be transferred don’t have to rely on subjective patients from a different location. to less expensive long-term facili- patient reports. Instead, they can ty care faster and more efficiently. objectively evaluate device data Shifting the healthcare industry and prescribe a patient’s therapy from reactive to preventive will more efficiently. provide substantial cuts to medi- cal fees as well.

Innovation in Healthcare | 36 New direction of healthcare

New direction of healthcare | Innovation in Healthcare 37

Connectivity A tale of modern medicine

Angus Long Senior Consultant in software project management, specialising in medtech

Imagine this. The year is 1982. John, a patient with chronic heart disease, walks into a GP office. Because he is taking the drug warfarin to thin his blood, he needs monthly blood tests. John sees his doctor, they chat about the weather and their families while the doctor takes a blood sample and checks up on John’s overall well-being.

“The results will be back from the lab in 10 days.” - the doctor says - “We will call you if there is anything. See you in a month!” Let’s jump to the present time...

Innovation in Healthcare | 38 New direction of healthcare

Agnes, another patient taking warfarin, is at Technology is at the forefront of home. An alert on her smartphone tells her development today is her monthly test. She is, however, in no There are a few tipping points that have formed hurry to get to the doctor. healthcare into what it is today.

Instead, she pulls out a device that is no bigger Ignaz Semmelweis linked cleanliness to disease than a typical smartphone. She pricks her finger, reduction; Wilhelm Conrad Roentgen acciden- dabs a bit of blood on a strip and feeds it in to tally discovering X-rays; and now we can also the machine. The results pop up on the device add digitalisation to the ranks of important monitor after only a few moments. Shortly tipping points in the history of the healthcare afterwards, she receives a call from her GP. industry.

In the most recent decade especially, the healthcare industry has seen many technolog- ical advancements. Some of the most notable advancements have been:

“I saw that your latest reading Electronic patient records (EPR). Although EPR are not a staple in every is a bit out of the normal range. hospital yet, more and more hospitals Come in tomorrow and we will across the world are digitising their see if you need to adjust your patients' records for easier access and better traceability. In Norway, paper pre- medication.” scriptions were abolished in 2013, thereby - says the doctor, who has already received the connecting all the GP offices with every result from Agnes’ device via a secured internet pharmacy in the country. This eliminated connection. medication abuse and also paper waste.

Although these two people are fictional, the way Mobile devices and connectivity. the healthcare industry has changed is not. Wireless devices are making the jobs of health practitioners and patients easier. The way healthcare is provided nowadays has With smartphones, tablets and medical completely changed with new approaches, new devices all connected to the central technologies, new mindsets. A big part of this system of a hospital or a doctor’s office, change are medtech companies that develop and it becomes easier to check on healthcare deliver healthcare devices that connect patients, processes on the go and access and send doctors’ offices and hospitals seamlessly. information more freely.

How are they doing it and what are the Remote monitoring tools. Monitoring challenges they have to address along the way? patients' health at home can reduce costs and unnecessary visits to the physician's office. Many remote monitoring devices have the ability to send data to the doctor, thereby providing them with a better overview of their patients’ health. The rise in popularity of such devices has not only been driven by convenience; patients have also been demanding a more active role in their own healthcare.

| Innovation in Healthcare 39

Challenges of the industry

❶ A lot of regulatory demands

Regulations are often a driving factor the project management perspective. in the medtech industry. Additional to the resources needed to carry out the project, extra resources Typically, before a project even are needed to document it. begins, there needs to be a plan in place that clearly demonstrates how A few past projects in which we a device or piece of software will used the agile methodology have be developed. Once the product been about point-of-care IT, where development is underway, any we worked on developing software changes from the original design need that connects medical devices to to be carefully documented and every the medical record systems. From change to the way the product works experience, ensuring good documen- has to be traceable. tation of an agile project is possible as long as we as the executing organi- However, all this documentation has a sation have the right expertise, in the purpose. In case of an audit, it should form of the ISO 13485 certification be easy to trace back every step of and adherence to other standards the project to show that the finished such as IEC 62304, together with the product is indeed as it’s supposed to right experience, in terms of be and that it is safe to use. skilled employees.

As much as this ensures the compliance and safety of the project, it also creates some challenges from

❷ Resistance to change within the organisation

Some medtech companies are experi- and quality departments work in a encing varying degrees of resistance solution-oriented way can realise the to change, especially when an agile benefits of agile and still comply with methodology is introduced. There is the regulations. often fear of increased risk in a project. Together with the previous point, this brings us to the final, and perhaps the The main detractors of the agile biggest, challenge faced by medtech methodology tend to be the regulatory companies. and the quality departments of the company. However, agile development of medical devices is possible – in fact, some regulations encourage iterative development. Medtech companies where the regulatory

Innovation in Healthcare | 40 New direction of healthcare

3. Reproductive health/ There are devices on market that, for 5 LIFE - fertility trackers example, increase blood circulation to In recent years, many companies reduce muscle soreness with the help CHANGING have worked on apps that use the of electrostimulation, which a study Fertility Awareness-based method from the Queen Mary University of TECHNOLOGIES IN (FABM) to plan or avoid a pregnancy. London found to be more effective In addition to general knowledge than acupuncture or regular rest. PERSONAL HEALTH about the female menstrual cycle, some solutions base their calcu- These are just a few examples of People want to have more control lations on body temperature or personal health technologies, but over their health – both to prevent hormone concentration in urine, the trend they help to highlight is it from deteriorating and manage while others collect several data clear: people are taking a bigger part it when it does. Fitness tracking points during sleep. in managing their own health, and technology has made people more it’s becoming easier and easier. aware and more interested in their 4. Implanted electrical health, which now has inspired a new stimulators The global digital health market wave of health-related technology The most known electrical is growing fast and the number of that range from simple preventive stimulator is perhaps the pacemaker, companies entering the health and gadget to equipment that can save which helps millions of people medical wearables space will only the lives of those who live with with bradycardia and heart block. continue to grow. This part of the chronic illnesses. However, there are other important health industry does not only enable electrical stimulators on the market. self-management of health and 1. Activity monitoring well-being, it also has cost-saving Wearable sensors and mobile apps Because the vagus nerve acts as potential by minimising unnecessary have taken a step further from merely a direct connection between the services, improving medical tracking your activity. Nowadays you brain and most of the critical organs, diagnosis, and increasing patient time can monitor your sleeping habits, stimulating it has been a recognised with those who genuinely need it. heartbeat, blood flow and get rec- way to treat drug-resistant epilepsy, ommendations for how long to wait depression and even obesity. before exercising again for optimal Boom of startups recovery, all by wearing a simple 5. Injury prevention and Ava Women watch-like device. recovery The startup Ava, based in Zurich, is A number of technologies are one of those companies that took the Most of such devices connect to a tackling the problems of injuries potential of technology in healthcare smartphone and the cloud, where in professional sports. One of the seriously with their fertility tracking the data is processed by an algorithm most significant issues professional device. The company melded to present you with a holistic athletes face is lengthy pauses or together hardware development picture of your health. The growing even premature end of their career with advanced analytical software to accuracy and the availability of such due to injuries. diagnose various measurements in measurements is enabling more and women’s bodies to help them keep more accurate predictions of future To prevent injuries and better track of their fertility cycles. The diseases. plan for rest periods, wearable company uses big data and artificial technologies are used to capture intelligence. 2. Smart pillbox biomechanical data about the strain A study done by Frank Roger Defanti put on joints and body parts when a Limmex e Souza and Carla da Silva Santana particular movement is performed. Another Swiss company that has from the University of São Paulo The wearable technologies can taken wearables by storm is Limmex. looked at how older adults, especially often connect to a smartphone The startup created an emergency those with cognitive and age-related where insights are displayed. This smart watch that enables you to send challenges are managing their data can further be used to better an instant message in case of need medication regimes. They found that plan training and optimise game to your contact persons. No need over time and with more than three performance for each player. for apps or a smartphone – the alarm medications involved, it gets harder message is triggered by pushing to stick to a routine, and adherence Proper recovery is said to be almost a button. rates can be as low as 27.8%. as important as the workout itself.

| | Innovation Innovation in in Healthcare Healthcare 41

❸ Getting products to the market fast enough This is still, however, more part of the future than the present. Medtech companies are not only problems with getting products competing with each other. They also fast enough to market. Solving this AI and machine learning are often are indirectly compared to consumer challenge is not easy. talked about in the media for the electronics companies. obvious reason of being an attractive On one hand, the medtech companies topic. These technologies do hold a It all starts with expectations. are feeling the pressure of delivering great potential, both for medicine and on the expectations, but on the other, for other industries; however, more Updates to consumer electronics are they have to make sure that the research and investments are needed being pushed to market quicker and products are safe and compliant with before AI autonomously makes quicker, which raises the expectations the regulations. diagnose and proposes treatments. consumers have of all electronics. In the end, medtech companies have What we are seeing today, however, is AI and doctors working together, where the doctor makes the final decision with the help of AI.

Another challenge that needs to be addressed for the AI to reach its full potential is access to the data. Opportunities for the future With the privacy regulations ramping up, getting good data is likely to be Technology has helped healthcare to get where it is today, and it a big issue. There is still little clarity can continue to do so in the future. about how and how much data companies are allowed to collect We see two technological areas that can bring more connectivity and use. The scepticism people have and efficiency to the healthcare industry: cloud services and AI. towards handing over their data also needs to be addressed, especially in Cloud computing has the potential to There are many projects around the light of multiple scandals surrounding deliver cost efficient and secure access world where AI and machine learning the misuse and sale of data. to information. are applied to data analysis of patient data. But think about this: if your medical Most cloud services, such as Microsoft data could be used to eventually find a Azure, Amazon or IBM, offer For example, there is an AI tool on cure for many types of cancer, would platforms that enable: the market that can scan patient’s you be willing to share it and maybe medical record together with relevant help thousands of people? Security: maintaining the confi- guidelines, best practices, and dentiality of patient information medical journals and textbooks in is important. a matter of minutes, and evaluates medical evidence, and displays Scalability: as the information potential treatment options ranked by bank grows, all of it can be level of confidence, always providing stored in the cloud. supporting evidence.

Connectivity: patient As an example of potential of such information can be shared easily, diagnostic tool, there is a case from and different medical devices Japan. A woman suffering from can be connected to the cloud leukemia was not responding to in order to upload the results treatment. The doctors turned to this directly. tool, and after just 10 minutes, the AI identified the correct type of leukemia Accessibility of the patient data can that the woman was suffering also help a lot in using AI to make from and suggested the necessary diagnostics easier. treatment.

Innovation in Healthcare | 42 Innovation in medtech

Data security, regulations and medtech

Software development cost reduction – even under regulatory compliance

Medical device and diagnostic laboratory equipment manufac- turers now face stricter regulatory compliance requirements. The increase in costs jeopardises market success. To achieve a more competitive cost structure, companies are relocating software development and/or software maintenance and using low-cost country sourcing.

In a recent case, our customer allocated software development locally and in a high-wage country in The final stage is to roll out the order to keep it close to the marketing Approaches full-scale solution. and sales departments. Their teams were hard to scale as a result of a to data projects local war for talent and restrictive 1 costs. Our goal was to lower the costs What data is worth collecting and of software engineering and enable from what type of source? Not Define the vision and achievable goals scalability while keeping the processes every data point is beneficial in in full compliance with regulations. achieving the goal of a project. By limiting the amount of collected 2 We relocated all development data, our customers are able to and maintenance work to shoring Identify data sources and reduce storage costs and keep select relevant inputs countries using the ERNI infrastruc- high-quality data only. It’s much ture, processes and know-how, while easier to integrate additional managing to maintain a high-quality sources when you have a good 3 interface with the local customer data structure. through on-site ERNI staff. Perform an offline analysis and prove feasibility In the next step, an offline analysis to prove the feasibility of the proposed concept can be 4 performed. Does it work in real Results: life? Does it fit into a customer's Rapidly implement a small-scale solution and – Cost decrease of up to 30% processes? After feasibility is prove the benefit – Team scaled up – up to proven, we promptly implement 5 software engineers per a small-scale solution. Our month/per team consultants collect feedback to see 5

– Quality of delivered software the first benefits of the approach Integrate the solution is stable/not affected and to prove them to the customer. in its full context

| Innovation in Healthcare 43

It is not just securing the transmission and storage of data against hacks that is important. Here are some easily missed security pitfalls:

Hoarding data Data integrity The amount of data produced and There is a need to collect and store acquired is often greater than what accurate and consistent data: in other is actually needed for the analysis. words, data integrity. A compelling Therefore, it’s important to decide amount of data can still be corrupt which data is relevant to keep and and useless for users, or dangerous how long to store it. for patients. This possibility cannot be neglected. For example, many users of With an infinite hoard of data, it’s fitness monitoring bracelets complain much more difficult and less efficient about inaccurate data output such as to identify the useful part. Added their heart rate measurement being security and regulatory measures off by tens of beats. for redundant data make efficient filtering even more crucial.

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www.iwantexperience.erni Principles of nearshoring 45

Human meets tech Nearshoring project in

Eva Molčanová Service Unit Leader digital health ERNI Slovakia

The healthcare business poses several so because of the benefits it brings. One must challenges. Some of them are unique for keep in mind that the sophistication of the this specific field. Others apply for every technology alone does not guarantee success. growing innovative company. Acquiring enough workforce and skilled employees in The solutions for the healthcare industry are this regulated and data-sensitive field can be not pieces of advanced tech. They serve real especially challenging. people who have real problems. These solutions have the potential to save lives. Developing You can solve this by assigning the workforce stronger health systems requires good human via an external partner. Still, establishing such connections and trust between solution a partnership can be demanding as well. providers and their partners.

Digital automation and transformation in Nearshoring offers the cultural and geographic the healthcare industry is in the scope of proximity that fosters those strong relation- many software development projects. This is ships and thus efficient outcomes.

Nearshoring is a way of outsourcing work to an external partner. This partner company is close in terms of geography and culture and has no big differences in time zone. Nearshoring enlarges the area for finding specific technical knowledge, skillsets or increased efficiency.

Innovation in Healthcare | 46 Principles of nearshoring

Nearshoring offers new possibilities for companies.

Within outsourcing, distributed teams deliver – Good collaboration. With modern the tasks. Agile software development can technology, distributed teams are no longer bring such teams closer together. Iterative an issue. Online meetings, video conference development and improvements are key for calls and chat tools are easy to schedule with high product quality, transparency and good teams in a similar time zone. Due to close collaboration. travel distances, you can even hold important workshops or meetings face to face, on site. When you decide on nearshoring, the major benefits you can get are: – Higher responsiveness and quicker turnaround time. Being close enables in-time – Hiring flexibility. You can sign a contract for communication. You can resolve issues and a specific task or a project. If you are unhappy answer questions faster. with the partner you’ve chosen, changing is easier than with an in-house team. – Cost savings. In general, nearshoring is costlier than offshoring. Yet nearshoring – Access to talent. Easier access to specialised saves the costs and hassles of hiring in-house trained and certified professionals – even professionals, which can turn out to be an to those who may not be available in your expensive thing to do. country. Nearshoring minimises cultural, social and – Diversity in the team: Diversity is good for linguistic issues. But it does not take them away covering all required skills. It brings different completely. For example, within Europe, one approaches and points of view. The variety of can still find significantly different cultures just personalities (education, age, cultures) fosters within a few time zones of each other. Thus, creativity and brings more ideas. some cultural nuances still need to be overcome. During the setup phase, face-to-face meetings – Act quickly on market opportunities. Some and team building activities can help to build trends or market opportunities cannot wait. good relationships in the team. In such cases, hiring an in-house team is not an option. It can be more time-consuming A nearshore team also still needs more agile and riskier than nearshoring. planning than an in-house team. You also need to make sure the communication is flowing well. – Increased focus on the core of your business. Nearshoring can give you the necessary time to improve the core of your business. Your partner supplies the supporting parts.

| Innovation in Healthcare 47

4 steps to start a nearshoring project There are a few things your company needs to consider before the project with your nearshore partner starts.

– Make sure you have stakeholders on board. Ensure that the key players working with your nearshore partner side by side are on board. Otherwise, getting anything done will be difficult.

– Assign a Scrum Master. Each project needs an individual as the focal point throughout the entire project lifecycle. It should be clear whom to talk to when day-to-day operational issues arise.

– Define the scope of the project. Explain the A lot of questions about the project desired outcome and double-check with your need to be answered upfront. partner that you are on the same page. Using the Scrum framework can help with this. We will talk about this later in the article. It can also be smart to have support during the start-up phase on both sides. This makes it much – Build trust with your nearshore partner. easier to set up everything needed for smooth In the introduction, we emphasised the collaboration and reach out for help. importance of trust in a nearshoring project. This is important throughout the whole And of course, honour deals and hold people project lifecycle. Yet it begins in the starting accountable both in your organisation and at the phase. nearshore location.

Spend a lot of time together during the start-up Be agile to succeed with nearshoring phase. Do team building activities, pair The advice to “build trust with your nearshore programming or some work on site together. partner” might sound intuitive. However, when Continue to meet often afterwards. Remove it comes to implementation, many questions barriers for easy online communication. Try arise. using online messaging tools like Slack, Skype, Appear.in, etc. How often should you meet in person? How frequent should the meetings happen? What should be on the agenda? Who should be Online tools enable communication with coworkers. Thanks to nearshoring, present? How should we organise the work? time-zone and cultural differences don’t have to be a challenge anymore. We tackle these and many other questions by following Agile. Our projects use different agile frameworks based on their needs and setup, like Scrum.

Innovation in Healthcare | 48 Principles of nearshoring

The timeline of a Scrum iteration The Scrum framework suggests that you execute projects in a series Inputs from Executives, Team, of iterations, called Sprints. Each Stakeholders, Inputs from Customers, Users Sprint lasts between one and fourExecutives,Inputs from Team, weeks. During this time you createExecutives,Stakeholders, a Team, Customers,Stakeholders, Users releasable product Increment.Customers, Users Daily Scrum Meeting Scrum The Team Daily Master Step 1: Plan your Sprint. Each Sprint ScrumDaily 3 - Week starts with a planning meeting. The Product PO Proxy 3 –Meeting ScrumWeek Scrum The Team Owner SpringSMeetingprint ScrumMaster The Team plan for the next Sprint is a result Master Product PO Proxy 3 – Week 3 – Week of the Scrum team collaboration ProductOwner PO Proxy Spring (Product Owner, Development teamOwner Spring and Scrum Master). Together they decide what they will do during the next iteration and how they will do it Product Sprint Sprint Sprint Product Sprint to achieve the Sprint goal. Backlog Planning Backlog Review Improvement Retrospective Meeting Meeting Meeting Product Sprint Sprint Sprint Product Sprint Step 2: Synchronise. During the Sprint,ProductBacklog PlanningSprint BacklogSprint ReviewSprint ImprovementProduct RetrospectiveSprint Backlog PlanningMeeting Backlog MeetingReview Improvement RetrospectiveMeeting the team meets each day. this is called WorkingMeeting in a Scrum enables you to be flexible.Meeting When it comes to changes,Meeting you learn throughout the daily Scrum meeting (max. 15 the process and incorporate the knowledge into future efforts. It also creates closer relationships within the team. minutes), where we synchronise about progress and plan for the day. We also discuss possible impediments which A few specific tips for working with emotions will show better than we need to remove to achieve the the Scrum methodology: through voice or text. Sprint goal. This frequent alignment optimises team collaboration and – Give the team the possibility to give – If possible, organise face-to-face eliminates the need for additional feedback about both bad and good meetings. Encourage team building meetings. It also promotes quick things. The daily Scrum meetings activities and unofficial events. decision making and improves the and Retrospectives are suitable for People can get to know each other shared level of knowledge. them. This is how you discover early better. It’s easier to work with warning signs of potential issues. people to whom you have a personal Step 3: Review. At the end of each – Cultivate communication. Provide connection. Sprint, we hold a Review meeting. the teams with webcams, dedicated – Acknowledge the performance of Their team presents the Product rooms for video conferences and both parts of the team (internal team Increment, the result of the Sprint other tools that make talking members and also team members work, to stakeholders. Feedback from to each other easier. Enforce from nearshore). This combats the the audience is the key element of visual communication as a lot of “us” and “them” attitude. the review. It helps the Scrum team to recognise if the development is going in the right direction.

Step 4: Adapt. The Retrospective meeting is an opportunity for the team to think about the last Sprint. It helps also to discover elements which helped or blocked them with regard to work, process, tools and rela- tionships. It is also a place to share feedback about themselves. We keep the good things and identify improve- ments to put in place in the following Sprint. This is what helps the team to Scrum praises self-organizing teams. get better with each Sprint. The opinion of each team member is important and the team chooses how to do their work best.

| Innovation in Healthcare