The Netherlands are always referred to as one of the leading nations in Europe and even worldwide, when it comes to Digital Health. An attribute and quality that is not necessarily associated with the German healthcare system.
We wanted to know whether this is really true and what the reasons are for the country’s exceptional innovation climate, which turned it into a hub for digital health start-ups and international reference projects.
We interviewed Jan-Eric Slot, who is one of the most renowned European experts in digital health and has worked in both countries in healthcare management positions for a long time. He has been CIO of the Amsterdam University Medical Center, CEO of SNOMED International and serves currently on the Dutch national program on Outcome Measures for Shared Decision Making.
The interview was conducted by Rainer Herzog.
RH: Jan-Eric, you know both countries – The Netherlands and Germany – and have an in-depth insight into their digital health strategies and implementations. Are the Netherlands really so much ahead and if yes, what do you think are the reasons?
JES: Well, I think there is a difference. The Dutch have a much stronger focus on implementing and scaling digital health than their German neighbors. Let’s take the hospital sector as an example: the share of IT investments in Dutch hospitals is around 3.5% each year. With only 1.7%, German hospitals currently spend about half.
I see a major reason for the overall situation in a different attitude of the Dutch people: The Netherlands is a country which has been built from the beginning on cooperation and the necessity to achieve compromises in order to safeguard the country against the water and ensure progress and prosperity.
It seems fundamentally different in Germany, where individual stakeholder interests often prevail and block out innovation. The Digital Health Insurance Card (Elektronische Gesundheitskarte) is probably a good example. It started with a lot of good intentions from gematik (the German digital health infrastructure agency), but its features and functionalities have been constantly eroded over the years. All that is left now is a piece of plastic with a picture on it – currently probably the most expensive piece of plastic in the world.
RH: Is there one particular area in which the gap between the 2 countries is especially wide?
JES: This probably comes down to the role and position of the patient. In The Netherlands, there is the firm belief and commitment that all medical data has to be made accessible to the patient in a digital format. There has never been doubt that the patient should be in command of his or her medical data, so over time they can assume a more educated and active role in their own health.
The government has a strong willingness to drive the mandatory exchange of medical data between care providers and patients and has also set-up a framework to install so-called “Personal Health Environments”. Each of these environments is built on the basis of a personal health record structure and needs to be certified according to defined standards, including care processes and patient outcomes measurements (PROM’s).
RH: Talking about the governments in Germany and The Netherlands - how would you describe their different role and approach to digitalization?
JES: In the Netherlands, the Ministry of Health, Welfare and Sport has assumed the role of a moderator and facilitator at a very early stage – and it has been remarkably successful. All healthcare stakeholders (from patients to insurers and healthcare providers) meet at the ministry every 2 months to agree on digital topics to address and implement – and all stakeholders commit themselves to the taken decisions.
I think that the government has understood early that it needs to be in the driving seat for developing the digital health agenda. But unlike in Germany, it only provides the framework for digital health and leaves the implementation to the different stakeholders. I guess that Germans are much more inclined to develop a masterplan that is defined up to the last “bolt and screw”, which unfortunately proved to be rather ineffective in such a complex environment.
RH: Did the Dutch government limit itself only to facilitation, or did it also support digital implementation through funding or financing certain endeavors?
JES: Yes, indeed - the Dutch ministry has supported a number of initiatives in the past in their early stages to get them off the ground with “impulse financing”. This has for example been the case for the earlier mentioned Personal Health Environments (the providers of the Personal Health Environments are supported for each patient that subscribes) or for stimulating the interaction between patients and their care providers by having the data available. Here, the ministry applies a “carrot and stick” approach similar to the one used in the Meaningful Use Program in the US: a hospital can obtain up to 1 million Euros in financial support, however, it has to pay back the money if at audit time (June 2018 and December 2019) it fails to show successful implementation.
RH: In Germany, the current health minister is pushing much harder for digitalization than his predecessors. He has now launched a legal initiative which includes a number of items, amongst them being:
Medical apps shall become and reimbursable more easily;
Electronic patient records will need to be made available by health insurers latest in 2021;
Hospitals will need to be connected to the telematics infrastructure in the same year;
Office-based doctors will suffer from a reduction of their remuneration if they fail to connect to the IT infrastructure by 2020.
In addition to this, the minister has founded a “Health Innovation Hub”.
Is this enough for the country to catch up?
JES: Well, although many details on how to make the initiatives work are still missing, it looks like things are finally moving. If they can be really implemented, it should give a substantial boost to Germany’s digital health journey.
I truly hope that the minister is able to push this through parliament and that the different measurers will not again be minimalized by the different interest groups (as it was happening with the Digital Health Insurance Card).
What will certainly be important in this whole transition is to achieve a kind of common consensus and willingness to acknowledge and embrace the benefits of digital health and putting them above individual concerns. Otherwise, there is a risk that the initiatives currently launched remain a rag rug and fail to transform the system on a broader basis and within a reasonable time-span. It is certainly good to have a “Health Innovation Hub”, but this innovation effort needs to be matched by the system, its stakeholders and culture, to be successful.
RH: What should we focus on in Germany?
JES: For me, it always starts with patients. Providing clinical data to patients and granting them access to their personal health data is at the very core of any digital transformation. In Germany, this is less of a technical challenge than a cultural one.
In addition, authorities and stakeholders might initially focus more on services that have a short-term impact (within 6-12 months) and are able to show immediate benefits for patients and doctors. This greatly helps to gain buy-in and support and motivates stakeholders to continue along the digital path and initiate meaningful change. Once these priorities have been set and agreed, the government should support them with some initial funding to get them going.
Finally, we should move away from the monolithic and detailed masterplan approach to a framework-based one which grants the different parties more freedom to implement and execute digital strategies.
RH: If you compare the digital health innovation and start-up climate in Germany and The Netherlands, what would be your conclusions?
JES: Apart from available investment capital, there are really 2 factors that determine whether a particular location is attractive for start-ups: the first one comes down to the business potential that a start-up is able to access, the second one is about a reliable legal, technical and infrastructure environment (based on international standards), that a new digital service or solution needs to find and build upon in order to thrive in its home market and abroad.
As for the latter, the Netherlands have already created such an environment, e.g. through the implementation of the previously mentioned certified Personal Health Environments (common standards and formats).
Regarding the accessible business and market potential, it seems to me that the challenges are the same in most European countries: start-ups need to show that their solutions are able to improve outcomes and ideally reduce costs in order to get reimbursed. It looks like that in both countries, certain stakeholders, such as health insurers, have opened up to support and integrate digital services and solutions into their offering and think about how to find new ways to evaluate the effectiveness of digital solutions.
Moreover, the recent initiative by the ministry in Germany is able to strongly promote the country as an interesting innovation hub for start-ups and investors, as it will allow new digital services and solutions to access the market much more easily. It could actually become a winning combination for Germany: a large market combined with a favorable business environment.
RH: What would happen if Germany misses the digital health train?
JES: One does not need to be a prophet to conclude that healthcare costs would continue to rise whilst the quality of healthcare delivery would risk to fall at the same time. Emerging therapies based on genomics or artificial intelligence might not be readily available on a broader basis and this could potentially widen the gap between what privately insured patients are able to obtain and services available for patients in the public healthcare system.
But above all, healthcare is also an important national socio-economic parameter. If Germany falls behind here, it will ultimately weaken the entire national economy and business location.
RH: In the light of this, what would be your top 3 recommendations to the German health minister?
JES: Well, I guess the first one would be to change focus: away from cost reduction and efficiency gains to value creation and benefits for patients and doctors. This is important in order to obtain a broader consensus on the advantages and returns coming from digital health and also addresses its socio-economic component.
My second recommendation would be to prioritize easy-to-implement digital solutions. These can be rather “low-tech”, but need to show short-term impact and benefits for patients and doctors.
Lastly, I think that the government should continue its path and strongly support digital infrastructures that allow all citizens to gain access to their medical data in an easy, secure and understandable way and exchange health data between providers. These need of course to be based on common standards and rules, but their implementation and associated details are left to other healthcare stakeholders.
RH: What is your best guess - where is the German healthcare system in terms of digitalization in 10 years?
JES: I am an optimist. With the initiatives started by the ministry, Germany is on a good way. Moreover, as elsewhere in the world, consumerization and patient choices will change the way healthcare will be delivered in the future. And this will also be true for Germany. The next generation of citizens, patients and doctors will no longer accept to have no or only a limited say in their care process, or pushing heaps of papers through hospital corridors. Digitalization in healthcare will become much more of an everyday thing. In the end, even if healthcare stakeholders should be unable or unwilling to change, it will be the patients driving the system towards more personalized healthcare.
RH: Thanks Jan-Eric for this positive outlook and for sharing your thoughts and insights with us.
If you want to obtain more insights into the dynamic and evolving economic and innovation climate for digital health in Germany (and other regions) and how you best succeed with your digital health business strategies, please reach out to us.