The Biggest Problem of Digital Solutions in Healthcare. Digital Health Interviews: Nick Guldemond

“Every startup has to solve a specific problem” — that’s what everyone, including investors, says. More and more digital health startups appear on the market every second. On the one hand, it gives more competition tint and more useful products; on the other — it’s getting harder and harder to integrate them into healthcare systems. We decided to speak on this topic with Healthcare & Public Health Professor Nick Guldemond.

Introduction:

Nick Guldemond: holds degrees in medicine and electric engineering and a Ph.D. from Maastricht University. CEO and Founder of the Medical Field Lab (early 2000): he performed work with the development of the first low-temperature 3D printing technology for bone structures, mobile monitoring systems for various diseases, early days smartTV (2007) based blended homecare, virtual surgical systems with augmented reality and haptic feedback as well as innovative care service concepts: diabetes, oncology and frail elderly. Professor of Integrated Care and Technology at Sechenov Medical University, Professor of Public Health and Healthcare. Holds a position as a Senior Researcher at Leiden University Medical Center in the Netherlands. During his career, he worked as a clinical researcher on numerous health innovation projects. As a key expert on Health and integrated care, he is an Expert Member of the WHO Working Group Digital Health, WHO Pan-European Commission on Health and Sustainable Development, and a consultant for Health programs and medical curriculum development in various countries on different continents, NGO's, multi-nationals and start-ups. Also served as the coordinator of EU EIP on Healthy and Active Ageing, an expert at the World’s Organisation of Family Doctors WONCA, and an expert implementation of human rights in biomedicine at the European Council.

Nick is well-known as an ex-mentor of Rockstart — an institution with a mission to empower founders to drive positive change on a global scale. Its specialists know from experience that most early-stage founders face challenges in several key areas when growing their startups. The team of commercially seasoned entrepreneurs guides startuppers on how to optimize their time and resources to achieve the highest possible output.

Nick Guldemond: “That was an interesting experience. I had an idea of how I could improve the healthcare sphere. At that time startups were quite booming, and I thought: maybe I would have a contribution also to learning how the healthcare system worked and what sorts of implications could be for startups. I saw a lot of startups who pitched their great ideas: social robotics, AI, language-based solutions, some support services, etc. Rockstart is a sort of institution for training. Startups are very opportunistic: you tell something, and they consider whether it is useful or not. Usually, the implications are more complex, so the startuppers easily move away to something else. I stopped to be a mentor not because it wasn’t interesting and inspiring, but at the phase of the training, it was not so effective for me. I stopped doing that collaboration, but I think initiatives like Rockstart are very useful to learn the basics of startups.”

Then our host Alex and the expert raised the subject of healthcare improvements around the world, especially — which system can be a role model for other countries. Nick proposed to consider this issue from several angles: a digital health perspective and a more general one.

Nick Guldemond: “Many countries, almost all of them, have some specific features that are really going well for people, but also a lot of challenges. The US, for example, has a healthcare system, which has very bad performance (the amount of money spent and the quality really differs). It’s good for business but bad for people. But the organizations like Kaiser Permanente are doing a very integrated people-oriented service. It’s a good collaboration between all the aspects of healthcare to make it work. Catalonia and Bask Country — the region in Spain — do really well in organizing the system. Singapore is also a very interesting country with pretty much-integrated usage of data. Cuba is an example of how very community-oriented care can be organized: there are a lot of social elements in approaches to how to help people, and how to invest in the quality of professionals. We can learn a lot of lessons and use them to improve. Collaboration is really important to make things more sustainable.

From the digital angle, Estonia is very integrated into this environment. They still have some challenges with digital services and the exchange of information between different organizations, but at a system level, it’s really good. If you’re looking at how to use data for segmentized patient groups and providing very dedicated services, there’s quite an old example, in the southwest of Germany. I was also very impressed by China, but they are lacking primary care. As an alternative, they build platforms for the first access to healthcare when you try to solve the problem in the simplest way. There are 300 million consultations online in a year, they are serving so many people!”

Nick also told his attitude toward European reimbursement programs: “I think it’s one piece of a puzzle. During proper reimbursement, people can find the right solutions, or these solutions can be prescribed. The complexity is with digital: if digital wants to be successful, you have to change many things, not only the sort of solutions; it’s not a matter only of having the right reimbursement or having the proper regulations. The challenges are more about how the system works in terms of service provision, and how people are provided with digital solutions. I think this development is good but it doesn’t gonna work in a successful way if you don’t do the other things.”

The next topic of the interview was the healthcare system in the Netherlands.

Nick Guldemond: “Netherlands’ healthcare system is primary care oriented, which is an asset in terms of the effectiveness of a system. Everybody should have insurance, you can choose it from different insurers. You can also select your healthcare professional, but you should keep to the sort of process first by going to the family doctor: he can solve the problem by himself at a primary care level. People can get reimbursed, usually automatically, through their insurance. Otherwise, they have an out-of-pocket payment which will be reimbursed. In terms of solutions, it’s a little bit complex, especially when looking at digital health, although there are some facilities and instruments to use digital solutions. Their usage is not so much as it could be. Healthcare professionals don’t have a good overview of what solutions might be available. The digital solutions are very fragmented, too. The way of reimbursement differs from insurer to insurer. There’s no alignment for people typically to understand, for example, “for my type of problem how solutions should work with an app”, it’s not very clear. It prevents the sort of proper uptake at the scale we basically use to improve our healthcare system.”

Better care at a lower cost. Can digital health help with that? If we look at the US healthcare system, digital technologies are already part of it. Still a long way to go but there is lots of innovation there. But it doesn’t look like the cost is going down though.

Nick Guldemond: “It’s a profit-driven system, and many actors in this system are focusing on making money. It doesn’t mean, of course, that they want to do harm to people: they will do more instead of doing what’s right. The profit-driven system tends to increase overdiagnosing and overtreatment. This is an important cost driver; cost efficiency is achieved by collaboration and integrated care, because you will have better outcomes rather than focusing on repairing one simple issue, and the other things still remain as a problem. Technology solutions help increase the sort of overdiagnosis and overtreatment — that’s one of the paradoxes in healthcare. If you provide all kinds of solutions, you get a cost rise. Together with the type of financial model they have, there’s a sort of increase of costs.”

As Nick said, he considered the way how to make a system integrated to be the main problem in digital health adoption nowadays: “If we want to be more preventive, to have better health outcomes from lower costs, we need integrated solutions for that. Most countries still have problems with the sort of changing from a fragmented to an integrated system. That applies to finances, services, and data. If you are a single startup and you deliver a good solution for the aspects of care, it is not well embedded into the service environment. People don’t tend to use it in a sort of integrated way, so it will not be so successful. For example, in the Netherlands, we have a sort of startup environment and organizations supporting it. Sadly, they don’t want to talk about the system change. A single startup cannot change the system. We need some changes in how we organize the adaptation of these solutions to the system. The implications for the system are quite huge, and it needs an overall strategy.”

The digital health revolution is underway, and in many aspects, we can see progress in how technical things are integrated: “I think that’s encouraging. The pandemic crisis also made a sort of awareness that digital could help as an alternative. The problems are not usually coming as a single thing: there are geopolitical troubles, staff shortages, economic crises, etc. In order to make effective changes it needs leadership and a comprehensive approach. When people are in crisis, they tend to focus and follow their own interests. I think we are at a critical phase. We kept the sort of vision of how we should collaborate in Europe and further how to work on typical system problems. We need alignment on different levels. I have a lot of inspiration from Central, Eastern, and Southern Europe. There are a lot of talents and opportunities for steps that can really improve the lives of many people.”

And traditionally, at the final of the episode, there are some invaluable pieces of advice for startup founders in digital health.

Nick Guldemond: “For the right solution, you need a context with how the system works from the different actors. Sometimes we have challenges concerning some kind of ecosystem. For a startup, finding a microenvironment by which you can develop and test products is vital. There is some tiredness from people who propose new solutions because optimistic behavior doesn’t work. Finding the right supporting environment is really critical. You should search for a balance, loyalty, and reliable long-lasting relations.”

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