"Digital solutions could reduce health expenditure for the chronically ill by at least 30 billion euros per year".

In Germany, we have a very differentiated health care system in which many actors work together in the care of patients. Digitalisation represents a great opportunity to improve the interaction of these actors. Jeremy Dähn, Chief Digital Officer and Head of Digital Business Models at Johanniter, and Amir Humanfar, Co-Founder of the Berlin-based start-up HUM Systems, explain how this can happen.

Mr Dähn, you work at Johanniter GmbH as a "driver of digital transformation", as can be read in your Xing profile. What exactly do you mean by this, and where do you focus in the multifaceted Johanniter world, which includes a wealth of hospitals, specialist and rehabilitation clinics, medical care and therapy centres, senior citizens' homes, hospices and care facilities?

Jeremy Dähn: You have to know that I have been with Johanniter for one year now and that my cross-sectoral leadership position for digitalisation and innovation did not exist before. The topic area was partly the responsibility of the individual hospitals and facilities and there with the respective management or with the Johanniter Competence Centre in Berlin, our in-house IT service manager. I link these individual strands, examine new options and give impulses in all directions.


What is important in this process?

Dähn: I work hand in hand with the Chief Information Officer of Johanniter, with a particular focus on the role of patients in the digital transformation. This means that the Johanniter Competence Centre is the heart of everything digital. This is where everything comes together. And the additional services and innovations that I am now developing with the clinics and facilities - from the outpatient to the inpatient sector, from the clinical to the nursing sector - will only work if I can base them on the IT infrastructure and apply them. This must be examined in each case. In addition, as many sectors as possible should benefit from the proposed changes. That is why my focus is primarily on chronically ill patients.


Why on this group?

Dähn: A chronically ill person is one who has a long-lasting, perhaps lifelong and usually incurable illness and is increasingly dependent on the care and attention of others. The range of chronic diseases extends from the joints, for example arthrosis, the heart and the lungs, such as asthma, to various cancers and the different so-called rare diseases, such as cystic fibrosis. Metabolic disorders such as diabetes or mental disorders and dementia are also of a chronic nature. Frequently, other diseases are added in the course of life, which can exist simultaneously, i.e. side by side, so that one speaks of multimorbidity. As a result, these patients are in continuous contact with Johanniter - for example, they are first treated in the outpatient area of the MVZs, then possibly have a stay in hospital for further therapy or surgery, and later possibly also visit one of our care facilities.

Chronically ill patients are therefore of central importance for various sectors of Johanniter. This is an important reason to take a closer look at this group. In addition, there is the large number of people affected: More than half of all Germans suffer from a chronic illness.


How can you make life easier for the chronically ill with your work?

Dähn: There are a number of chronic diseases that are not curable, but can nevertheless be treated well today through medical and nursing measures. It is important that those affected always receive the treatment that is suitable for them in every phase of their illness. We want to promote this with our work. A continuous exchange between the practitioner and the person being treated is also crucial.


So you want to accompany the individual phases of illness more intensively than before and, if possible, without interruption, in order to optimise care? And "digital" helps with that?

Dähn: Yes. Because in the traditional world of the hospital cosmos, we are unfortunately still in an incidence-driven exchange. That means that the hospital usually only gets to know something about a chronically ill person when he or she is admitted because of an event, for example an accident. What happened to them before, what they have in addition and what happens to them after their stay in hospital often remains largely unknown to the doctors treating them. But especially in the case of multimorbidity, it is advantageous to have an overall medical picture that takes into account previous illnesses, medication, etc., in order to be able to tailor therapy, rehabilitation and aftercare to the individual and thus improve the success of treatment. This is what we strive for.


Why is the holistic view rather rare?

Dähn: Up to now, personal patient data are usually available in a confusing way in different places - often without the person concerned having an easy access to this data. Some information is held by the family doctor, some by specialists and others may be incomplete due to a change of doctor. This means that examinations that have already been carried out may have to be repeated, and avoidable costs are incurred. 


How high do you estimate the avoidable costs?

Dähn: As the Federal Statistical Office averaged in April this year, health expenditure has risen to more than 400 billion euros in 2019. The increase in chronically ill people is one of the most serious challenges for our health care system: in the meantime, about 70 percent of all health care expenditure is spent on the care of patients with one or more chronic diseases. That is 280 billion euros per year. In my opinion, at least 10 per cent, or about 30 billion euros a year, could be saved if treatment could be more individualised and holistic than it is now with the help of digital tools.


What exactly are you planning to do to relieve the system and support those affected?

Dähn: We want to provide those affected with a digital navigation system that offers them orientation across all sectors in every phase of the disease, including rehabilitation and aftercare. The first step is to establish a digital patient portal. Patients can access this portal at any time, even from home, to obtain information or seek advice. A monitoring system can be integrated that automatically monitors the patient's state of health and supports recovery. That is why it is important for us to exchange ideas with experts such as the IoT start-up HUM Systems in order to jointly develop appropriate digital solutions. 


Mr Humanfar, where do you see the role of HUM Systems in the care of the chronically ill?

Amir Humanfar: Our technological solutions such as the Livy product family offer a range of applications that can be useful for chronically ill people, but also for their caregivers and supervising doctors and nurses. The Livy all-in-one security system, for example, combines fire protection, motion detectors and room climate monitoring in one device. It also includes an app with a community function. This means that in an emergency, for example, if the sick person does not get out of bed for some reason or does not take his medication, so Livy does not register any corresponding movement, or if someone falls, smoke development goes unnoticed or the air quality has deteriorated, then not only the patients themselves are alerted, but also relatives, friends and neighbours or the nursing staff.


So in this respect, your technological solutions are not a substitute for human interaction, but actually reinforce it to a certain extent?

Humanfar: Exactly. Thanks to smart homes or IoT, people who are close to each other and no longer live in close proximity to each other - as used to be the case - can reconnect with each other, creating a new sense of community, which in turn brings security. This can give chronically ill people, who do not need permanent support but only occasional assistance, longer autonomy in their own homes and at the same time relieve the burden on the healthcare system. Livy can also be controlled via voice commands and connected to other smart home devices, which is an additional relief. We are also continuously developing our products to better meet the needs of the market and all stakeholders. That is why the know-how of professionals like Johanniter is so valuable to us. Their practical experience flows into our product development.


Are those affected generally open to digital innovations?

Humanfar: Acceptance is an essential aspect. In this context, it is an advantage that our products actually come from the lifestyle or smart home segment. The users, by the way, increasingly also older people, install them at home because they are interested in them themselves. In other words, they make a conscious decision to do so because they want to make their everyday lives easier. They appreciate, for example, the comfort functions such as automatic light control, switching on the radio by voice, etc. So we introduce people to sensor technology with a positive association, completely without the context of needing help. This increases the general acceptance of such assistance systems. Because if the technology is brought to sick people from outside and they have not yet come to know and appreciate the system, many people tend to see its installation as paternalism or as a sign of their frailty and do not automatically see it as a plus in quality of life, which it is.


What role does acceptance play for you, Mr Dähn?

Dähn: Acceptance is crucial if we really want to make a difference. That's why I find the approach of HUM Systems very charming, that the need for assistance, i.e. the illness, runs along in the background, i.e. it's not at the forefront. But when it becomes important, the assistance system immediately makes itself felt, not by pointing out the illness, but by giving clear instructions for action that are very simple and understandable, so that you can incorporate them into your everyday life without much effort.


What does that mean for your projects?

Dähn: For example, it is important that the information that chronically ill people can access on the planned patient portal not only suits them, but that they also understand it. Medical knowledge alone, which is conveyed by the doctor, does not necessarily mean that they also understand or internalise what is said in the sense of: "I understand that the recommendation is really the best thing for me and that I should definitely stick to it. That's what I want to do." Depending on the chronic illness, the adherence rate, i.e. the willingness to actually follow the doctor's instructions, is just 40 percent. Therefore, understandable language is an important point. But it is also important to make therapy as easy as possible for patients.


Can digital aids support this?

Dähn: Absolutely. Let's assume a cancer patient regularly receives chemo treatment and has to travel a long way to the cancer centre each time. But it can happen that he has to wait there for hours and finally the preliminary examination shows that his values are not so optimal right now and he cannot have chemo that day because of his current condition, so the treatment has to be postponed. Then he goes home again, which puts additional stress on him, although he should actually be resting. The patient can be spared this trip if values such as blood pressure, temperature, heart rhythm, weight etc. can be transmitted digitally. In addition, the trained doctor can talk to the patient in advance via video to see how he or she reacts, whether he or she is stressed, what the colour of his or her face is like, etc. This way, the probability that the patient is actually resting can be reduced. In this way, the probability of the patient going to the clinic for nothing can be significantly reduced by means of digital possibilities.

Humanfar: This is a good example of how processes can be streamlined through the use of digital technologies, which both benefits patients and increases the efficiency of care. And that is exactly what we see as our core tasks. With our solutions, we want to help, together with our partners, to bring people closer together again and to form communities that support each other. And we want this to reduce expenditure in order to create and exploit economic potential, for example through healthcare on demand.

Dähn: We are completely on the same page here. HUM Systems' approach of networking different groups of people with each other, i.e. patients on the one hand and relatives or other caregivers on the other, is particularly exciting for us and fits our claim. Ultimately, the patient portal is also about networking. We want to create an ecosystem in the sense of patients and in the sense of health care. Our goal is to provide chronically ill patients with comprehensive care - from monitoring at home to diagnostics, sensor technology and digital therapy to our outpatient services and inpatient facilities.


Screening new business models, market trends and developments in the health care market is also one of your tasks. Where is the "music" playing at present and in the future, where are revolutions emerging in the health system?

Dähn: One point that sounds banal but is actually revolutionary is innovations in regulation. Unique in the world in this context is what Germany is now venturing with the Digital Health Care Act, or DVG for short, which has just come into force. With it, the federal government wants to enable access for digital therapeutics and digital health applications. In the course of this, further services such as the electronic patient file and the e-prescription will also be rolled out and the telematics infrastructure established. Importantly, all of these digital health applications are also to be reimbursed.


Germany as a pioneer. That's something new, because otherwise the USA tends to set the pace. What trends can be seen here that will soon come to us in Germany?

Dähn: What is becoming apparent abroad is, for example, the long-term care of patients. This is also partly related to regulation. In the USA, for example, hospitals can be fined if patients have to go back to hospital for the same thing within 90 days of their hospital stay, perhaps because the operation didn't go as well as expected. For this reason, the hospitals are very interested in staying in constant contact with the patients even after their stay in hospital, in order to refine the therapy promptly as needed and thus to prevent a new operation or a serious secondary illness. Home monitoring plays an important role here. This will also become more important in Germany, especially in the field of cardiology.

It also fits in with the fact that in the USA, patients are increasingly being cared for by health coaches who specialise in nutrition, relaxation, exercise therapy, long-term behavioural changes, reduction or abandonment of stimulant consumption, etc. This means that patients will be able to take care of themselves at home. This means that patients continuously interact with health counsellors who help them achieve their health goals. And not only in relation to a specific disease, but holistically. These experts coordinate with doctors on an ongoing basis. Comparable to a rehabilitation clinic, only digital and long-term.


This relieves the medical profession and through the holistic coaching they probably also receive comprehensive information that makes it easier to decide on the right form of therapy.

Dähn: Yes. What also helps optimise treatment and is being promoted in the USA can be described with the buzzwords data science and artificial intelligence. For example, by analysing a very, very large amount of data from patients, patterns or, as I call it, populations can be formed: Groups of so-called virtual twins with matching identification criteria. If I then achieve therapeutic successes with patients who match these populations, then I can also use the knowledge for other "twins" and thus target the therapy even more precisely. Because new data is constantly flowing in, this is a learning system that is constantly changing and adapting to new circumstances via AI. There are mathematical data models that can be used to extrapolate patient populations and determine probabilities of how who will react to which drug and when.


Which companies are leading in this field?

Dähn: I see the big tech companies in the USA as being way ahead, such as GAFA+M, i.e. Google, Apple, Facebook, Amazon and Microsoft, which have high data quality. They have been developing algorithms for large populations that allow accurate predictions for a long time. There are many competent market observers who claim that sooner or later algorithms will be as valuable as the drugs themselves and also generate the same turnover. And we're talking about many billions of euros. Germany and Europe are lagging behind here and, in my opinion, should not leave the field to these tech giants from overseas without a fight.


How can you score points against this superpower, which has so much money that it can first cross-finance the health business with search engine or smartphone profits in order to exclude competitors like Johanniter from the market, who cannot afford to work uneconomically for long?

Dähn: All the important market participants need to cooperate more. Because when it comes to digital transformation, we are all in the same boat. We as Johanniter can contribute our 900 years of experience. Our assets are patient retention and loyalty, medical excellence, high quality healthcare. We want to use digital means to network our services even more, to condense them and make them more efficient. Then share our insights with others and also learn from others - be it from similar providers, be it from start-ups like HUM Systems, to become a big player in digital ourselves.

Humanfar: I share the view that we need to develop our own solutions here in Europe. Time and again, we meet potential partner companies that flip us the bird in plain German because they think that we don't stand a chance with our ideas against the US corporations or Asian providers anyway. But I think we have the potential to stand up to the competition together with strong European partners and to build up something of our own, which will then probably also be more in line with our specific needs and values in Germany and Europe. We should have the courage to experiment, to simply go ahead and join forces. It is not too late.


Finally: Wishful thinking. What, Mr. Dähn, would you wish for the future?

Dähn: I would wish for the medical "tricorder" from Star Trek in the 23rd century. This is a portable scanner from Starfleet and is used to examine people. It can scan injuries and pathogens and monitor the biofunction of the patient. Partially, it also already treats, and everything is fine.

Humanfar: We are working on it.