Digitalization of Medicine: We Have the Technologies, We Need Systemic Changes

Interview with Marek Kubicki, Member of the Board of Directors of Damian Medical Center

Digital innovations have allowed improvements in the availability of services, while optimizing costs. So far, however, both in Poland and globally, this transformation has not been transferred to the level of the entire healthcare system, says Marek Kubicki, member of the board of directors of the Damian Medical Center.

IDC: Digital health transformation is a very broad term. What does it mean for managers and medical professionals?

Marek Kubicki: This term refers to many different aspects of our operation — from customer service to the channel of access to medical services to the treatment process itself. Digital transformation touches every aspect of our lives, including health care. We can also talk about peri-medical technologies, such as VR, 3D imaging, artificial intelligence that analyzes images, and robotics. Many of these technologies were present before, but it took a pandemic for the digital transformation of health to finally take off.

Changes in this area in Poland were made possible by two seemingly insignificant developments: e-prescriptions and e-referral. Many people forget that these things appeared even before the pandemic. Without these elements, the digitization of health in Poland could not have taken place. They opened the way for telemedicine.

But when it comes to other technologies, medicine is conservative by design. Doctors need to see clinical trials, experience, verification of effectiveness — and only then can they recommend something for use. And it's the same with digital solutions: There must be a certain continuum of experience. To give an example: We have electronic stethoscopes which allow to you to hear better than the conventional ones, and they are supported with artificial intelligence to analyze the sound. But these devices are entering clinical practice very slowly. This is because doctors' ears were used to the sound of the old stethoscopes. It's a kind of human barrier, but young doctors are coming in and they have no problem with it.

IDC: Many studies show that doctors, even in middle age, do not want to use these modern solutions at all.

This is the conservative aspect of medicine. A doctor is most willing to use those solutions that he is familiar with, that he has studied in college and knows that they work. But if circumstances force him, he will use new solutions. And so it was, for example, with virtual visits.

IDC: One of the biggest problems facing digital transformation, in any field, not just health, is the reluctance to change. How did your Medical Center encourage doctors and non-medical staff to use new technologies?

It wasn't encouragement. It was a collision with a wall. During the pandemic, a lockdown was put in place, which meant that people seeking medical advice couldn't get to the doctor. Patients, moreover, didn't want to wait outside offices either, for fear of getting infected. At the time, little was known about the disease, so doctors also didn't want to see patients because they were afraid of COVID-19. This fear led both sides to start using telemedicine. But surveys showed that neither doctors nor patients were entirely satisfied with this form of contact.

IDC: Today, online consultation is a basic service. What other technologies are you using? Which are the most promising, and which have already brought significant changes? Have their implementations had a financial effect?

We have introduced, admittedly belatedly, appointment scheduling applications. Considered from a certain perspective, we introduced it too late. The app has some features that are quite popular, such as a waiting list — that is, waiting for a spot that suddenly becomes vacant because someone else has cancelled an appointment. It also has something that seems obvious today, which is viewing the results of your tests. Instead of going to get the result, you simply glance at the mobile app.

IDC: What about other, more sophisticated technologies?

The more technologically advanced the device, the more often we hear from doctors "Very cool, extremely interesting; it seems like we're going to use this." But as a rule, they never get beyond the testing phase. Only the most digitally advanced doctors and patients will use it. Among other things, we use remote diagnostic devices from Higo or StethoMe, as well as from other companies, that allow remote auscultation of the lungs and bronchi, temperature measurement, or visual examination of the throat and ear. We know that it works, and doctors who are accustomed to it are eager to use these technologies. However, the answer to the question of whether they have gained in popularity is no. Why? Because again, it's the issue of a mental barrier in both patients and in doctors.

IDC: And which of these solutions have had a financial effect?

The simpler the solution, the greater the financial effect. For example, a self-service application transfers the task of registering an appointment from a receptionist to the patient. This results in measurable savings on personnel costs.

If we are talking about high-end solutions, I have to say that, so far, they have not brought any notable cost effects. However, we believe that they will in the future. When? When the normal solutions won't work — specifically, during the infectious season. In autumn, when the waiting time for an appointment increases from one to three days, telediagnostic devices will bring tangible benefits. These kinds of solutions must wait for their moment, as was the case with COVID-19. In turn, costs will fall, as doctors' salaries are the most significant part of our costs. These solutions will make it possible for us to transfer patient care to cheaper doctors from another locality. That is, we immediately solve the problem in two areas: availability of care and cost.

IDC: Many e-health experts say that the process of technological transformation of health has already taken place, and now we need to think about how to use these solutions to create an entirely new system of care.

This is what we are aiming for, but we don't all agree on how quickly this will happen. Generally, in Poland and around the world, we start treatment too late. That is, we take care of a patient who has already become seriously ill, and the process of treatment and rehabilitation is then very expensive. Digital-enabled treatment will rely on the fact that algorithms for analyzing behavior, measuring vital signs, population prediction, neighborhood morbidity will make it possible to treat patients at an earlier stage of medical need. For example, we can already use a system that predicts the peak incidence of infectious diseases based on pharmacy purchasing data, which allows us to respond early.

It can be said that instead of going to specialized care, the patient will go to a primary care physician sooner. And instead of going to a general practitioner, they can go to a nurse practitioner who will order simple laboratory tests. This will dramatically reduce public health care costs. If we don't do this, then there simply won't be enough money for treatment. Let's remember that Western societies are aging, and multi-disease is emerging, which significantly increases the cost of care. That's why we need to take advantage of real-time diagnostics, artificial intelligence, and continuous monitoring devices. These could be wristbands or toilets that automatically perform urine tests, for example. Modern medicine will also involve having a digital advisor to manage the whole process. In fact, this is the direction in which the changes in Poland's primary health care centers are going.

But for this to happen, to put it bluntly, someone has to make money on it, or someone has to lose less on it. That is, either healthcare facilities will have such solutions centrally imposed and reasonably refunded by payers, or the patient will pay less for it. People expect to pay less for telemedicine because, after all, they didn't meet the doctor in the office. But the doctor wants to earn the same amount, and so they need to provide more telemedicine services. This, by the way, is the reason why those doctors stopped using telemedicine, and that's why today in telemedicine we have doctors who are young or remote — working from locations where the cost of living is lower.

IDC: At one point, the Polish Ministry of Health even said that there were signs of telehealth abuse and started to limit it.

Yes, and a good thing too! It may sound strange, but today the biggest innovator is the conservative Ministry of Health, which is concerned about lowering the cost of treatment. They want to introduce as many predictive and preventive mechanisms as possible, because they are the ones who will save the most. It's a bit counterintuitive, but it's the state that is pushing certain innovative solutions — e-prescriptions and e-referrals, the P1 data exchange platform, COVID-19 passports, and the Individual Patient Account portal, which will soon include medical data from private providers as well. Only data collected in this way and big data analysis will make it possible to create predictive models for seasonal diseases and diseases of modern civilization. The question is whether the state will know how to use this data meaningfully.

However, it seems to me that medicine has not yet been reformed. It is not at all the case that a coup has taken place. The technologies are there, the equipment is there, but the systemic transformation is not yet there. I would compare it to banking: in Poland, online banking is extremely popular and we don't actually need physical branches. In other countries, like the U.K., you can still use checks. And so it is with medicine in Poland — we still like using checks.

IDC: What, then, will this revolution look like?

In a while, it won't call the doctor; rather the doctor or the medical company will call and tell me, "Dear Mark, it's time for a preventive check-up," or "We noticed that you didn't use your prescription," or "The tests show that you may be developing some kind of disease, and so you should get further diagnostics."

And that's what the system solution will be: a standard, the same way that every bank today has its own app. Banks may also offer concierge services for select customers, but the average John Smith won't have access to such facilities. It will be the same in medicine — an in-person visit will be a premium service, for which you will have to pay extra. Most services will be provided at the level of the application or artificial intelligence algorithm. Only a few will involve an actual doctor.

IDC: Well, there is no shortage of voices warning against the excessive dehumanization of care caused by technological advances — such as remote care or the implementation of AI to work with patients. There are patients who expect not only advice, but also empathy.

I have a doctoral thesis showing that a patient who is convinced that he is being treated well has a 19% faster rate of bone growth after fractures. That is, we have proof of the effect of medical hand stroking — and not in aspects that are difficult to measure, but in physical bone mass growth. Personal contact is something we underestimate. But unfortunately, demographics mean that this contact will be a rare benefit.

In our clinic, the average age of nurses is 55. The average age of doctors in some specialties is 60. We have a generation gap. When these seniors retire, we will have a collapse of the system. In Europe it looks the same, or at least not much better. This means that dehumanization will continue… and in my opinion, this is a bad thing, because physicality is needed.

IDC: Digitization was supposed to bring about the fulfillment of the so-called Triple Aim — that is, to increase the quality and accessibility of health care while reducing costs. Has it been successful?

If we ask whether innovative technical solutions bring improvements in these three areas, the answer is undoubtedly yes. This is already happening. But if you ask whether it has succeeded systemically, then no, it hasn't yet. The challenge is to apply digital technologies on a wider scale, comprehensively. Meanwhile, for the time being, it succeeds only in certain areas — like self-service at registration, automation of documentation creation, and robotization of medicine (e.g., surgery assistance). But here, too, we are reducing costs and improving quality as we avoid errors and increase accessibility. Speech recognition systems are a good example. If a doctor who types on a keyboard with one finger can say what she wants to note down and it only takes 30 seconds, it means she will have more time for the patient. And, after all, that's what we're all about.