eHealth-Experte: Von Tech-Giganten aus China und USA “abhängiger als wir denken”

 

Heal Capital was made possible by private health insurance companies (PKV), with which the company works closely. While the PKVs are the financiers, Heal Capital evaluates the start-ups and works out the advantages and disadvantages for patients. Among other things, they invest in digitally integrated medical practices, the development of robot-assisted surgery and instant messaging services for physicians and are rooted in the entire German healthcare ecosystem.

voonze online: How do you see the current influence of large tech companies in healthcare, for example the takeover of One Medical by Amazon?

Eckhardt Weber: The takeover of One Medical is very interesting, we have been following what Amazon is planning in the healthcare sector for some time. The big question is always what Big Tech is doing in this space. We see this as a development in which health will at some point also be dominated by the big players – most of whom are not just from Europe. Be it from the West or, more recently, from the East.

What dependencies do we already have on big tech companies in Germany and Europe?

Weber: We already have a wide variety of dependencies, for example with Amazon Web Services (AWS) or with the Microsoft Cloud – with cloud solutions on which providers run.

Which services are not allowed to run with AWS?

Weber: Digital health applications (DiGAs), for example, are not allowed to run on these cloud solutions, but this does not apply to all healthcare companies. The Open Telekom Cloud, operated by Telekom, which meets all German standards, also works with Huawei’s infrastructure solutions. And Huawei is China and also the reason why Mr. Trump wanted to ban Huawei’s entire smartphone business in the USA at some point. I think that in some cases we no longer even know where dependencies are already emerging or have arisen. Such players should be regulated.

We would have to do an accounting on the questions “Where are we already dependent, where are we almost naïve?” The digital world is very interconnected – so we are probably already more dependent than we think. Therefore, it makes perfect sense that we rethink this holistically and with political will and create the conditions for innovation. So that we can have purely European cloud solutions based on purely European infrastructure with purely European software.

Can you estimate how big our digitization gap is in the area of ​​eHealth?

Eckhardt Weber: The digitization gap is definitely still quite large. But it is also large in many countries, including the USA. When I look at healthcare now, I just see that the demand is increasing every year. We have an aging society, we have potential solutions, but we have less and less supply. Doctors and nurses are missing, but also money to pay for the services.

There is a lack of efficiency in the system – we have to get to it. Nobody wants to say “ok, then there’s less for everyone now and we still pay higher health insurance fees every year”, but we have to become more efficient. The only solution I see there lies in digitization. Fortunately, a lot has happened, thanks in particular to former Health Minister Jens Spahn, who set a lot in motion. The government of Lauterbach is still lagging behind, but now wants to push various digitization projects. When that happens, we’ll take a big step forward.

We are still not far enough with projects such as the electronic patient file, the electronic prescription and the communication and infrastructure solutions from Gematik. Some of these are projects that started 10 to 15 years ago.

The gap is quite big, but still it’s not like it’s necessarily better in the US or England. They still work a lot with paper there and carry a CD from A to B. We’re still a long way from other industries, let alone programs that run purely on machine learning. We don’t need to think that far, it will come. In the next couple of years it would be good if we can handle basic, administrative data usability and linkage across the healthcare market.

But do we even have the capacity to implement this because we somehow have a lack of developers on every corner?

Weber: That’s up to us again. We are investors in the market and we have to raise capital to put it in good developer hands. In every market there are developers who develop fast and well and there are those who are slower. We have to see that the financial resources come to the right people. We have to support the good developers and we have to show that the European market is big enough. The best entrepreneurs in Europe will at some point say “I get thrown in the foot five every month, so I’d rather go to the USA, the market is even bigger and there I’m courted to offer my solution on the market”. That’s partly down to the investors in the space, but we’re working to make that work.

How do you decide which healthcare companies or ventures to invest in?

Weber: We are looking for companies that can become the health platforms of the future and help a very large number of patients to improve their health. It is very much about what vision the founding team has for the future and how they want to achieve it. Economically, they must be large markets and have the potential for a billion-dollar company.

In Austria, the ELGA (electronic health record) has existed for years, and in France the “Dossier Médical Partagé” (DMP). Things are also said to be going better in the Scandinavian countries. Did it work faster there – as is often suggested – because the ePA was implemented there with an opt-out, or are there other factors there as well?

Weber: I think it’s multifactorial and not just due to the opt-out procedure. In France, I don’t know if they really do it any better. However, in the Scandinavian countries and the Baltic States, there seems to be a greater openness to the digitization of the relationship between citizen and state and citizen and health. Overall, this is due to a higher level of trust between citizens and the state. Citizens trust that the data will be handled with care. It starts with the digital identity. That’s also something that hasn’t really worked in Germany so far.

But it is also a cultural issue and nevertheless we have to learn things from these countries. On the one hand, we have to show politically that the ePA has more advantages than disadvantages and is an added value for everyone involved. On the other hand, we have to be more open to the fact that our data is also common property and can provide added value for everyone. We should not resist every new change, but show acceptance. However, I am well aware that this is a complex subject.

What is going wrong with Gematik’s implementation of digitization in healthcare?

Weber: The way I see it from the private capital market, the more digital a product is, the more iteratively it has to be built. The more difficult it is to implement top-down politically. There are very many particular interests and the incentives are not such that you just build up there. In case of doubt, I think that Apple does something better. This is a business driven company. That understands “if we make a big mistake with data protection, then we lose the trust of the customers and with it our sales”. These companies then have to be much more careful not to make any mistakes when it comes to data protection. Where implementation takes place politically from the top down, it is relatively slow and qualitatively lower than it would be in the private sector.

At Gematik, no one gets “trouble”, no one resigns, there are no “negative incentives”. If a mistake is made there, we get upset about it for a moment and then we still don’t have the implementation next year. In a privately run company, there would be no more sales in such a case, or people would be laid off. If we aren’t a little more open to the consequences – if things don’t go well – then we don’t have the prerequisites to build the best products. If other countries do it better and I later have a perfect maternity card in my Apple Health file, why shouldn’t I use it? The brand finally gave me confidence.

However, many companies do not want to give out the interfaces without further ado. In your opinion, should there be stricter regulations regarding interoperability?

Weber: There are already some regulations, but they seem to be toothless tigers. Nobody really opens up their interfaces. In the future, however, interfaces must become more open. At some point, the pressure from customers will be so high that we need more open interfaces. Practice owners and clinics then want to integrate various solutions into their purchased products, for example. In my opinion, there shouldn’t be any practice management system that doesn’t have open interfaces. This is pure market prevention. You would also have to consider this in terms of antitrust law. There are also players who have quite a large share of the market. In my view, this is something that needs to be tackled more vigorously. In case of doubt, the market will regulate this in the medium term.

But not if things are going the way they have been?

Weber: At some point the customer will want so many additional software solutions for a product that they will change their provider as soon as they charge for each connection to the interfaces. For example, if Apple says “if you want to use Spotify, you first have to pay Apple 200 euros to open the Spotify API”, then I would scratch my head. It’s also going to come at some point for healthcare, where every doctor will say “hey, you’re my core system, but you have to open everything now because I have so many different solutions that I want to connect”. At some point, customers will no longer accept that. There is hope that the market will regulate this if it cannot be implemented quickly enough politically – but that also takes some time.

Do you also have an idea for the telematics infrastructure?

Weber: It’s more difficult for the telematics infrastructure. This is the most complex challenge we currently have in the healthcare sector. When I look at the use cases, for example e-prescriptions or the news service or data exchange, I actually think to myself: young companies that address the individual use cases could also build them. On the other hand, if I say, “ok, this is the intranet for medicine in Germany, then you can say, “yes, it makes sense if it is implemented in a high-quality manner”.

When it comes to the implementation of the connectors for connecting to the telematics infrastructure, many consultants were commissioned for many IT projects. A lot of money went to people who build it in such a way that only they can solve it themselves. It’s difficult in the long run. Here we are again with the same problem. Solving things top-down is very challenging. I wish it would just start and work now. But to turn around and go another way might be wrong.

Software, in particular, requires many iterations. The product has to be adjusted again and again. It is very difficult to plan something like this on a state level. The market is moving way too fast for that. We have an iOS update every twelve months. Everything I associate with Apple has to be adjusted every 12 months or more. If that goes through a cascade of specifications, it’s very difficult. Then there is a mismatch between software in the consumer area and the enterprise and healthcare area. So it makes more sense to leave that to the private sector, which can keep up with the pace.

Is it also up to the doctors and customers to change something?

Weber: Yes, if customers and doctors simply say “We want what is best for us in terms of quality”, there are ways around it that the system prefers, i.e. Gematik, i.e. telemedicine, e-prescriptions, then the doctors decide that. That will come. If one day a health app from Apple is better than anything my insurance company can offer me, then I will use it. The electronic patient file that I have, or this data file, has not yet convinced me and has not yet added any value for me.

What has to happen in order to advance digitization in the German healthcare system?

Weber: We already have a lot and we have a very good healthcare system in Germany, but I think we and other European countries simply have to manage to get digitalization going ourselves. Therefore we need to find out what is there for existing blockers and what we need to create for enablers. We can create this if we promote entrepreneurship and innovation – be it in new entrepreneurs, start-ups or in existing companies. On the regulatory side, we have to see that we have standardization and not a fragmented European market. With the existing blockers, data protection is also an issue. It is absolutely important and makes sense, but we also have to see when the hurdle is too high and when we are restricting innovation.

We need more digitization in healthcare, otherwise at some point we will no longer be able to process the demand. At some point, consumers will also want to know the advantages (convenience) of shopping at Amazon, or with music on Spotify or with banking on their smartphone. We also need the same quality of service in the healthcare sector. If Apple delivers that, it’s likely that many individuals will say “yeah, then privacy isn’t that important to me,” as we’ve been doing at Facebook for years. The course must be set.

Could standardizing data protection help?

Weber: There are tendencies towards standardization. The basis for data protection is the General Data Protection Regulation (GDPR). There are two extremes, on the one hand we can standardize something across Europe and on the other hand each federal state in Germany has its own data protection officer, who in turn uses his own sometimes very individual interpretation of the standards and rules. We look at many companies that deal intensively with the topic of data protection. There are countries that are a lot more open to a more innovative interpretation. Other countries are relatively strict. On the other side is Europe. From a cultural perspective, we should be able to achieve common data protection. The basis for this should be the GDPR.

Besides, it’s probably better if the data isn’t with corporations like Facebook, but in Germany?

Weber: Yes, one thing is: is it Facebook or Tiktok? Because if we’re being completely honest, these days it’s intensely Tiktok and Tiktok is China. The other is: Where is data hosted? What is the cloud infrastructure? Is this one that is on European soil and also owned by European providers or is it non-European providers or maybe even data structures that are stored outside of Europe? Then the access is not really secured.
You also have to weigh up what the lesser evil is. I think we will have to die one death. We will not be able to successfully digitize our system and ensure that all desired data protection requirements are met. Somewhere you have to be willing to compromise. It is extremely difficult when there are too many players who are allowed to have a say. A uniform solution requires political will from higher up. It will also mean that we do not have the highest standard of data protection that the strictest privacy advocate would wish for.

Do you think it would be feasible for data sharing to remain voluntary?

Weber: That’s a complex topic. I believe that we need more enablers and fewer blockers to promote innovation. But we don’t want to promote any scum with data either. We need a good set of rules. There is more and more digital health data and it is certainly more susceptible to mass hacks and the like. They have to be protected. Security must be very high, but the use of data – either with anonymization, pseudonymization or with consent – must be encouraged.

It is therefore difficult to give a general answer to the question, but that is exactly where you have to go and in case of doubt there must be political will – for example when it comes to the question of whether to opt-in or opt-out. One could perhaps say “if it is anonymous and no tracking is possible, then in areas such as science you do not need the consent of the potential data donors”. That could be achieved with political will. A Europe-wide standardization would be desirable. However, I am aware that the political landscape is complex.