(by Christoph Sager and Katja Winkler)

Within the first quarter of the 21st century, a continuous trend of small, innovative enterprises trying to enter established industries in the search for scalable business models for health interventions can be seen. This is also true for the health sector. Especially the occurrence of new technologies and ubiquitous devices like smartphones created unknown possibilities for startups to enter areas formally only open to medical experts.

Startups Discovering the eHealth Sector

A study by Ernst&Young published in January 2018 found young enterprises operating in the health sector to receive the third largest share of venture investment in Germany. This trend has a rapid momentum with investment almost doubling from €291m in 2016 to €522m in 2017 . The investment into health startups focuses mainly on the areas Life Sciences (€374m) and Digital Health (€113m), whereby the first was backed by a single Initial Public Offering of a medical research company.

Categorizing eHealth Innovations

The term eHealth covers various methods that use information and communication technology to improve health or enable health prevention over distance . Hence, innovations can range from mobile applications tracking the sleep cycle of users to live-saving devices which alert the hospital in case of emergency. In this article, common categories, covering these and other approaches innovating the health industry will be introduced. First, a look on stakeholder needs is necessary to get insights.

What are the primary stakeholders of eHealth and who may be the main beneficiary of new information technologies? The customer, more specific the patient, will profit of enhanced and more comfortable treatment and health care . Moreover, there are health providers like hospitals, doctors or pharmacists. Lastly, the payment for the treatments needs to be clear. If the payer is not the patient, this responsibility falls to the government or some health insurance company. Besides the monetary part, governments are also in charge of establishing regulations and fostering research. For the simplicity, these two actors are put into one category (following the suggestions made by Lambooij and Hummel in ) .

Figure 1 shows a selection of interests for each stakeholder and places them in between if there are overlapping interests. Proceeding with this information, the needs are categorized into four broader dimensions (Figure 2) which can serve as a classification of health innovations.

Promises of Different Classes of eHealth

The oldest problems in digitization of health are missing standards or inconsistent information . Exchange of data between doctors and other health care providers is often slow or disrupted due to a lack of exchange channels and limited exchange between health care sectors . Also, patients often have trouble understanding the medical language spoken by their doctors, often due to low health literacy . Information and communication technology, especially the internet, makes communication and central storage much simpler and more comfortable. Furthermore, it enables the access to health knowledge via phone or computer . Consequently, this is a major area of innovation and constitutes the first class called Health Information.

Ubiquitous devices like smartphones or small gadgets already contain lots of small sensors, which can collect health-related data quite accurately. This data can not only be used to monitor symptoms of known illnesses, but also to make diagnoses, which the users were not aware of before . Diagnosis, therefore, represents the second category.

In addition to diagnosing of and informing about illnesses, is a machine also capable of curing a disease? This is a question to be answered by research in the upcoming years . Within the Treatment section, some start-ups are presented in the following.

The fourth category is Administration. The development of modern societies gave rise to an increasingly complex system of health coverage. For optimal outcome, collaboration and exchange of knowledge is needed. However, due to the lack of a secure infrastructure to exchange this knowledge, health providers so far are reluctant to the sharing of sensitive information. Nevertheless, a health information platform could be the foundation for innovators .

Presenting Selected Health Innovations

The following section presents one selected innovation for each of the categories described above. Besides the description of each product, its utility is introduced.

Diagnosis: SkinVision

Skin cancer is a widespread disease, and lots of people develop moles that have to be checked regularly. Yet, appointments at dermatologists are rare and can be expensive. “SkinVision” is an app-based diagnosis tool (Figure 3) that tries to tackle this problem. Customers take a picture of their mole, and an algorithm is calculating the probability of cancer with a sensitivity of ~80% . According to SkinVision, a new study declaring a higher sensitivity is still going through peer-review. In addition to a one-time diagnosis, the app reminds the user to take another picture after some time to detect changes and monitor the progress. In the case of a high-risk indication, the photo will be transferred to and analyzed by a trained dermatologist. More information related to that app can be found at the company’s website https://www.skinvision.com.

Health Information: Was hab’ ich?

Patients repeatedly have trouble understanding the professional language of doctors. Often health providers do not have the capacity to explain a diagnosis in an understandable way. “Was hab’ ich?” (German for “What do I have?”, Figure 4), a Dresden-based charitable company, translates medical reports free of charge into everyday language that is easy to understand for non-medic (only available for German). Students of medicine engage voluntarily in the translation, the website is funded by donations. The founders started the project after realizing that patients are increasingly interested in learning about their diseases and being engaged concerning the treatment. Further information is available at https://washabich.de/.

The latest product of the organization is “Patientenbrief” (German for “patient letter”), which aims to create comprehensible discharge documents. The content explains the type of disease in simple terms and describes the treatment as well as what the patient should be doing after leaving the health facility.

Administration: Vivy

Electronic Health Records play an important role in eHealth innovations since some services rely on the connection of health stakeholders to exchange information. “Vivy” is the app of a German startup aiming to develop a solution for this problem (Figure 5). The company was selected in a public announcement of a collection of health insurers and is backed by Allianz, another private insurer. The application provides an interface to request medical documents and store them on the smartphone. Subsequently, it is possible to share the documents with doctors. Moreover, it provides features like a digital medication plan, a vaccination record and emergency details. More information can be found at https://www.vivy.com/.

The platform is open to all medical partners and more than 25 million customers of cooperating health insurers are already able to use it. However, in August and October 2018 the application received a lot of criticism when security experts detected several vital security flaws in the system which could have potentially revealed sensible health data (Presentation at the 35C3). The operator announced in a public statement to have fixed the problems.

Treatment: Tinnitracks

In Germany, more than three million people suffer from tinnitus, which generates a constant ringing in the ears. “Tinnitracks” is a mobile application that treats chronic, tonal tinnitus with music (Figure 6). The so-called “Tailor-Made Notched Music Training” (TMNMT) is based on current findings in the neurosciences and aims to reduce the perceived tinnitus volume . Patients first have to visit their otologist to determine the frequency of their tinnitus accurately before getting access to the Tinnitracks application. The software then filters the available music of the patient and alters the sound while playing. The company of Tinnitracks, Sonormed, cooperates with public and private insurers that bear the costs for their customers, but the service is also available for direct payers. Find more information at www.tinnitracks.com/.

Outlook

The use-cases and applications presented above show that eHealth services are present and can be a solution to many problems. Still, there exist some challenges that have to be addressed. So far, mainly two issues can be identified.

First, it is hard for users to assess the quality and scientific foundation of eHealth services. A solution can be audits and standards executed by public institutions or media sites testing and validating the applications. A more straightforward approach would be accessible and health research would be more transparent. Scientific studies build the base of most eHealth services and have already been peer-reviewed. Unfortunately, some of these papers are hard to find or hidden behind paywalls. It should be standard practice to report about the results of those studies in open access journals retrievable for everyone.

Another challenge concerning all services handling sensitive health data are security and privacy. Popular certificates for acknowledging data security already exist but security flaws have also been found in tested applications. Enforced best practices and standards could also improve this situation, like two-factor authentication (already mandatory in banking) or bug bounty programs (rewarding security hole reports). Additionally, cryptography can only ensure a temporary security, due to increasing computing power and new architectures. Decentralization could be considered for new systems processing eHealth data so that a directed hack would only reveal parts of the stored data.

All in all, a stable development of new promising health services using information and communication technologies can be seen.

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