Innovation is a wonderful phenomenon. It leads to all sorts of astonishing products and services like the internet and the tablet PC. As big an impact these innovations have on our lives, it is in health care that innovation is of existential importance. To be blunt, innovation in health care matters because most of us will have to face a miserable disease at some point in our lives; and all of us will have to face death. If we continue to innovate, then one day in the future people may not need to undergo the distress of cancer, heart disease or Alzheimer’s. Perhaps we even await a future where we transcend the limitations of our physical bodies—as imagined by science fiction authors like Peter F Hamilton and predicted by futurists such as Ray Kurzweil. Today, however, we have to make do with our present health care system—and its challenges and limitations.
The challenges are diverse. The most fundamental limitation is the fact that most of us continue to suffer from a number of persistently incurable diseases. Even in the European region, where life expectancy is relatively high, the healthy life expectancy is only 67 years (1). That is just too short given the number of things that most of us would like to do in our lives.
Perhaps most deplorable, however, is the gaping inequality in the world when it comes to health and health care. According to the 2010 statistics of the World Health Organisation, life expectancy in the European region averages 75 years; in the African region it is 53 years (and healthy life expectancy is only 45). In Africa the probability that a child will die under the age of 5 is 142 per 1000 live births; in Europe that number is 14 per 1000 live births. In Africa there are 2 doctors per 10,000 population; in Europe that figure is 33. Notwithstanding the wonders of the digital era, when it comes to health and health care much of the world lives in medieval circumstances.
In much of the developed world we tend to celebrate the excellence of our health care systems. Given the progress in recent years (life expectancy in EU countries has increased by six years since 1980) and the inequality in the world there is some justification for such celebration, but more likely it has to do with our psychology (don’t bite the hand that feeds you). The facts are that health care in the developed world can be managed better. The OECD has calculated, for example, that life expectancy could be raised by more than two years in the OECD area if all countries were to become as efficient as the best performers (2). The OECD is specifically talking about ‘efficiency’ here; according to the same OECD study, simply throwing more money at health care is unlikely to have much impact on health outcomes in the OECD area.
Efficiency will also be important to deal with the looming budgeting and staffing crisis in most OECD countries. Health care costs are increasing rapidly, mainly due to the rising costs of drug development and medical technology. And in Europe the situation is exacerbated by the ageing population and increasing prevalence of chronic illness. In 2008, EU countries spent, on average, 8.3% of their GDP on health, compared to 7.3% in 1998 (3). Budgets often have been rising faster than GDP. Clearly this is an unsustainable situation for most EU countries, especially given the need to reduce budget deficits following the financial crisis. Not only is the ageing population driving demand for health care, it is also leading to shortages of nurses and other health care workers in many European countries. And this while nurses are set to play an increasingly important role in a health care system that will be overwhelmed by the elderly and chronically ill.
What can be done to address the above outlined challenges? Fortunately, there are at least three broad innovation trends that could ensure continued progress in the state of our health.
Firstly, medical science appears to be standing at the cusp of what some call a post-genome paradigm shift. Recent advances in genetics and genomics are ushering in the personalization of medicine where treatments are customized to the genetic profile of each individual. It is also enabling us, as patients, to gain insight into our individual risk factors for certain types of diseases—via DNA genotyping services like 23andme—and make appropriate lifestyle changes to minimize risk. Other exciting developments are the recent inductions of pluripotent stem cells (transforming mature body cells into stem cells that, in theory, are able to produce any body part) (4) and the ‘programming’ of cell DNA by researchers at the J Craig Venter Institute. It is these types of developments and what in effect is the increasing digitization of biology that suggests that one day we may be able to program life (“wetware”) much akin to the way we program software today. In a parallel to what has happened in the software development business, the biotech sector is now also seeing an increasing number of open source initiatives such as the Pink Army Cooperative (focused on breast cancer treatments using synthetic biology) and Bio Bricks (a registry of standardized DNA sequences for use in synthetic biology).
A second major trend is the economic rise of India and the way it is spurring innovation in low-cost health care services and medical technology. Emerging regions with a strong entrepreneurial drive have one great advantage over developed regions when it comes to innovation: they’re less encumbered by legacy infrastructure and vested interests. It is probable, therefore, that much of the innovation in telemedicine, medical technology and new health care models will come from countries like India. Entrepreneurs are able to experiment with new models in part because there is unmet demand for health care services and partly because they’re less likely to provoke the types of interests groups (hospital groupings, doctor associations, etc) that control health care in Europe.
Examples abound of entrepreneurs experimenting with new business models for the delivery of health care. LifeSpring Hospital is an Indian network of small (20-25 bed) maternity hospitals that is able to deliver world-class maternity care at remarkably low cost. Mothers pay 4000 rupees (€65) for a normal delivery. LifeSpring’s business model works because its operation is highly standardized and process-driven. This increases efficiency but also makes the model easy to replicate across India and possibly worldwide. At the total other end of the scale, Dr. Devi Shetty is trying to build huge “health cities” across India that are specialized in complex disciplines such as cardiology, oncology and organ transplant. Again, it is via process innovation, not product innovation, that health care is becoming more accessible to India’s population. Dr. Shetty’s 1000-bed cardiology hospital in Bangalore, for example, is able to price cardiac surgeries at less than $3,000 and his goal is to reduce it further. The Narayana Hrudayalaya group is also making active use of telemedicine to extend its reach. For example, it has treated nearly 70,000 heart patients via its Tele-Cardiology program (using satellite technology).
This level of ambition and total willingness to do things differently if it saves costs and improves accessibility is difficult to imagine in the European context. These are just two examples but there are numerous cases of innovation in telemedicine (e.g. ReMeDi remote diagnostics kits by Neurosynaptic), low-cost medical devices (e.g. Forus Health) and low-cost health care delivery (e.g. Aravind Eye Hospitals).
The third key trend that is making a difference in health care is the use of IT and the impact of the internet more generally, especially in the developed world (and the US more specifically). Over the last two decades IT has gradually been making a bigger impact on the way health care is organized. In Europe the first wave of automation was focused mainly on administrative and logistical processes at hospitals, although even today there is still opportunity for greater efficiencies. As it stands, the market for hospital IT systems is still relatively immature and fragmented, mainly because the regulatory environments and financing models differ substantially from country to country. As a result, many hospitals have developed their own systems or the market is dominated by local IT providers.
In a second wave, IT entered the clinical domain via the introduction of digital imaging technology and electronic medical records. Simultaneously, national governments started developing eHealth strategies to improve coordination across the entire health care system. A recent study by the European Commission (5) concludes that substantial progress has been made in that regard, with most EU member states having in place policy initiatives for Electronic Health Records (a summary health record that would make basic patient health data available to any health care professional whenever and wherever as needed), Electronic Prescriptions (to reduce the paper trail and improve safety by, for example, relying on systems that alert doctors and pharmacists about potential contra-indications or fraud), and Telemedicine (to connect rural patients to health care professionals and to facilitate home-based care for patients with chronic conditions). However, the same report concludes that most member states radically underestimated the implementation challenges inherent to eHealth strategies.
It has turned out to be tremendously time-consuming to reach agreement on eHealth strategies among the core stakeholders within the health care system. This delays implementation and creates problems during implementation if some stakeholders actively resist new methods. As a result, the actual implementation of eHealth strategies has, to date, been less successful in Europe. For example, while every EU member state has an EHR policy initiative, only 7 EU member states are routinely using EHRs. Some member states have also changed tactics, replacing top-down centralist approaches (imposing new standards and tools on health care providers) with a more decentralist, bottoms-up approach (creating incentives and setting standards but letting the market take the lead in implementing systems).
IT is also gradually being used by health care providers in Europe to improve clinical processes and support clinical decisions. As illustrated by the Indian cases studies, this could have a tremendous impact on efficiency. Moreover, it could also significantly improve the quality and outcomes of health care. One of the key benefits of eHealth will be the tremendous amount of data that is gathered automatically via Electronic Records and Decision Support Tools. The countries that have made most progress implementing eHealth technologies (such as Israel and the Scandinavian countries) are now beginning to put their data to use to improve health care.
While eHealth may be suffering somewhat from the trough of disillusionment, a new trend is emerging that is rapidly climbing the first ascent of the hype cycle: Health 2.0. In the period that health care providers and policy makers argued about how to manage the patient data they controlled, patients have been discovering the liberating effects of the internet and social networks. Over the last two decades patients have gained, via the internet, near unlimited access to the world’s stock of medical information. A motivated ePatient (using ePatient Dave deBronkart’s terminology, referring to engaged, empowered, equipped and enabled patients) can, with some effort, become a better expert on his or her disease than the attending physician. And in recent years, patients have begun forming social networks for sharing medical information. Via online platforms like CureTogether and PatientsLikeMe, people are able to compare their symptoms with each other and share advice about treatments and medical providers. Much of this information sharing is happening in a structured way enabling data mining and research. CureTogether, for example, recently reported a link between infertility and asthma (members with infertility are 40% more likely to report asthma). Patients are being empowered with highly focused, relevant information and medical science gains too because so much additional data is becoming available. All this is placing significant pressure on health care providers to adapt to these new realities by improving patient communication and moving to a more participatory style of health care provision. While many health care providers are still arguing about eHealth strategies and implementing heavy-duty IT systems, the institutions that ‘get it’, such as Radboud University Nijmegen Medical Centre in the Netherlands (see our interview with Lucien Engelen), are taking a closer look at consumer technologies and open internet platforms that lower the threshold for patient participation.
So what does all this mean for innovative entrepreneurs? Where are the opportunities? Based on this summary of the key innovation trends in health care, the main opportunities are in more process-driven health care delivery business models, as is experimented with in India; in telemedicine and low cost medical devices (especially diagnostic devices), to extend the reach and accessibility of health care; in data analytics tools and services (e.g. see interview with Candace Toner of Biomatters), to tackle the flood of data coming from biotech on the one hand, and eHealth and Health 2.0 platforms on the other hand.