Once considered by Forbes “the world’s youngest self-made woman billionaire”, Elizabeth Holmes, former CEO of Theranos, promised, back in 2004, that “one tiny drop can change everything”. Considered by then as the female Steve Jobs, she dropped Stanford to start Theranos, a Sillicon Valley start-up whose technology would allow to run blood test using only a drop of blood. The technology, once treated as trade secret, soon proved to be inaccurate, forcing investigation by the Federal Drug Administration in the USA. In January 2021, Elizabeth Holmes was found guilty of four counts of fraud by lying to the investors in Theranos . She is expected to appeal the decision.

The Theranos-Elizabeth Holmes is a pandora’s box in the digital health entrepreneurial world.  From one side, we promote young businesspersons to create innovative ideas and develop revolutionary companies. We also expect them to “Move fast and break things” as the Meta’s CEO used to say. Those days are over. We expect young entrepreneurs to be bold and racy and secretive of their unique inventions.

However, during all these years we were probably blinded by the astounding nature of their inventions. Steve Jobs is no longer here. And we can count pioneering inventions, once a generation, in a handful. From an intellectual property perspective, most are improvements.

It’s time for accountability.  Elizabeth Holmes’s example should probably guide our young entrepreneurs to surround them with bright and insightful professionals and engineers. To ask questions -a lot-, to have doubts, and to feel a lot of pride of their invention when it’s proven that it works. A hundred times. And then a hundred times more.

However, Elizabeth Holmes verdict should not imply a negative view towards entrepreneurs, or even more, female entrepreneurs. Probably the contrary. This should boost the role of women in companies, allowing more women to run creating, developing and heading technology companies.

A warning sign. This judgment should be interpreted as a conviction against fraudulent entrepreneurs (beyond gender) and individuals trying to take advantage of an industry that for too long has been lenient towards the grandiosity of self-proclaiming successful technology.

This decision might imply the end of the messiah role of the entrepreneur, leading us to a promised cloud. The Thomas Edison inspired “Fake it ‘til you make it” Silicon Valley mantra will certainly be revised, and probably shelved for good.

This might probably inspire all young entrepreneurs to inject accountability into their endeavors. And finally, this might also influence other companies (and former social media startups) that have shown a very complicit corporate behavior towards their users, data protection and respect of young users in such a risky environment as smartphones.

This could be, maybe, the start of a more ethical, responsible, and engaged role of businesspersons in the future, instead of an irrational idolatry of innovators

The tiny drop that changed everything…

UPDATES on the case from our content partner pharmaphorum:

Taking only into consideration the growth since 2020, we have witnessed that the pandemic has increased the acceleration of digital tools. There is no way back in the certainty that digital health care is here to stay.

But at what cost for our environment and our social values?

We cannot help but realizing that the global impact of these digital innovations is considerable from a sustainability perspective. Traditionally, health care is an important consumer of resources and a consequential source of multiple environmental footprints. Hospitals are energy intensive buildings, pharmaceutical companies are large consumers of water, Insulin pens, after use are mostly discarded in landfills.

Global health care has an approximate impact of around 1% to 5% of the total global impact (this is comprised of Greenhouse gases, Nitrogen, Scarce water use, Particulate matter, Nitrogen oxide -NOx and Sulfure dioxide -SO2).

The growing role of digital identity of patients

Digital patients have become the cornerstone source of data collection. Patients create structured and unstructured data that, in turn, is transformed through data science into commercial data strategies.

Global patients, armed with smartphones, have accepted to share data using trusted applications that gather personal and sensitive information and feed predictive algorithms for (not only) health purposes. Digital health care applications are using data that was not originated for health purposes.

In the near future, companies processing data should treat patient data as a “coherent health data loop” -both structured and not structured- and alimented by different actors, most of them will not essentially be health care.

The role of the Sustainable Development Goals reshaping healthcare

Sustainability in the health care sector should not just be perceived as an environmental strategy.

Taking into consideration some of the SDGs, we discover that the link with health care becomes a universal approach:

• SDG 3: Ensure healthy lives and promote well-being for all at all ages
• SDG 10: Reduce inequality within and among countries
• SDG 12: Ensure sustainable consumption and production patterns
• SDG 13: Take urgent action to combat climate change and its impacts

We realize that sustainability in this sector will have a global impact, including the understanding of the access to health, the right of access to care, the respect of workers and first respondents’ rights, developing a social concern for the staff, the awareness of the gender gap.

Unfinished business…?

Inequalities on access to data and data infrastructure

The current data paradigm that we experience as a society should not blind us in believing that all people have an almighty access to digital infrastructure.

Different factors must be considered, as smartphone penetration and internet presence are not uniform around the world. And even if there is large access to technology, smartphones and internet, there are gaps in terms of bandwidth, quality of connections or hardware and many cultural and local issues. This can bring consequential inequalities, as basic limitations to a full access to technology will reduce the access to basic care.

Distortions on the deployment of the digital transformation

We have seen that in certain companies the adoption of digital transformation strategies sometimes involves an extremely analog vision of digitization (a symbolic transition towards digital records but directly connected to paper).

An important factor for data health care providers will be to properly manage the data governance across multiple platforms in the ecosystem. Data will not only be multiplied, but power over data will be held by patients across the system. Therefore, a more robust governance of the data circulation will be necessary.

Time to drawdown

Digital health care (as many other industries) will have to set drawdown as a priority. Creating industry strategies that will have less impact on the environment and on society as a whole. Health care is very carbon intensive, and the US health care system alone gathers around 25% of the world’s health care greenhouse gas emissions.

Impact of the global health care supply chain structure

The current supply chain structure is extremely carbon intensive, and this is also consequence of the localization of production facilities, pharmaceutical companies and distributors, vendors and patients in general.  The stress that the global health care supply chain has suffered during the 2020 pandemic is a testimony that measures must be taken to tackle accessibility with a sustainable approach.  This calls to consider the possibility to diversify the source of (closer) supply chains from different vendors and do not rely on a unique (and far) supplier. Major suppliers could be strategically placed to source to regions, reducing the carbon footprint and also increase availability. A specific regulation of licensing of Intellectual property and pharmaceutical patents should also be discussed, to speed up supply processes of essential components in urgent situations.

Clearly, a more global appreciation of the situation is required. In that case, the industry and the regulators will be able to better design the future sustainable policies.

…But hope on the horizon

However, not all is lost. We can assert that digital health care has the potential and elasticity to adapt and generate efficiency for sustainability. 

Digital and IT health is the biggest circular economy in the sector.

The increased use of big data has an important positive consequence in terms of infrastructure and more efficient electronic medical records. The constant rising of the of medtech industry implies the redesign of the patient pathway and the recognition of the patient’s rights over their personal medical data. This includes, obliviously, increased power on prevention thanks to the use of connected and integrated devices and solutions from Artificial Intelligence in the processing of large and worldwide medical imaging.

A new business model: Sustainable health care.

A patient-centered industry is not a new vision for health care 4.0. The customer experience must be reimagined increasing the value over the way the user not only enjoys the digital experience, but mostly trusts in it.  Teleconsultations are understood to be a carbon emission palliative.

Under regulations like GDPR in the European Union, users have become more aware and demanding of respect of their basic rights. This also implies that users will become more sustainability demanding in the future. The industry will have to prove their data accountability and the way they are contributing to the global drawdown, which will probably include a new reuse, refurbish and recycle policies, and understanding that these policies will also be a driver for the company’s reputation.

Conclusions and proposals

The goal for the next years will be to understand that sustainability implies good business. Companies across the digital health care sector will certainly insert sustainable policies into their agenda, from reducing carbon and climate footprints from their systems and hospitals, increasing renewable energy and decarbonize the supply chains.

The role of the “demanding patient” will be key in the next few years. A patient/user that compel companies to be climate responsible and zero-emission certified might be a change factor in the industry, in the same way data protection regulations are bringing the power back to the user. 

1. Al Knawy B et al., The Riyadh Declaration: the role of digital health in fighting pandemics. Lancet. 2020 Nov 14;396(10262):1537-1539. doi: 10.1016/S0140-6736(20)31978-4.

2. Lenzen et al. The environmental footprint of health care: a global Assessment, Lancet Planet Health 2020; 4: e271–79 

3. Richard Bartlett, Adam Somauroo, and Christian Zerbi, How the medtech industry can capture value from digital health 

4. Deloitte (2020) COVID-19: Managing supply chain risk and disruption. Deloitte Global. Deloitte. 

5. Peter-Paul Pichler et al 2019 International comparison of health care carbon footprints, Environ. Res. Lett. 14 064004

6. Travieso Florencio, Healthcare Data: A Holy Grail for Data Monetisation, Healthcare Management, Volume 21, Issue 7, 2021. 

For those less familiar with the notion of blockchain, this technology consists of a chain of digital transactions (chained digital records) that are incorporated into an immutable structure that is confirmed and verified by the members who share the information. There is no centralized storage of information and it cannot be deleted or copied. Much of the fundamental characteristics of the blockchain reside in its ability to increase the security and traceability of the information contained in the chain, which makes it essential for the digital health sector.

Blockchain includes the potential to revolutionize the health sector, since it places the patient (user) in the center of the scene, allowing her or him to directly control the information protocol at all times, as well as being able to customize the distribution of the personal data on the shared network.

The companies that are in charge of exploiting this technology will have to find a way to adapt to the current operating conditions that the use of blockchain entails in the sector, but notably they will have to provide trust and transparency to users. A similar example can be a pedagogical step that has been taken in the European Union with the GDPR (General Data Protection Regulation, 2018), which has created awareness among users about the importance of managing personal data.

In blockchain we host the enormous technological hope of maintaining a single, unalterable and longitudinal record that each patient can demand at all times in terms of security and privacy. This respect is appropriate between the patient and the doctor and the insurance company, as well as any other actor in the health ecosystem.

Applications and benefits

Blockchain has the vocation to be present in most layers of the health ecosystem. The benefits that exist are multiple. The system will make it possible to unify the multiple identities of the patient through different health platforms, giving the user the possibility to decide and control (consent) the access and processing of information by any actor (Despotou et al., 2020).

By unifying the information, registers can be made compatible throughout the different platforms, thus facilitating the interoperability between the systems, a situation that today is a real obstacle. Faced with user concerns about the way their data is processed, blockchain allows the removal of certain intermediaries, and the user maintains the direct access to the distribution list.

Transaction costs can be reduced as a consequence of the reduction in intermediation. Blockchain allows an update of the patient’s information through the different networks where the information has been hosted.

Thanks to the blockchain, the use of smart contracts can be extended in a generalized way by different service providers in a consistent way.

Other applications of the blockchain consist of being able to ensure the validity of drug supply chain, notably in developing countries, in order to avoid the circulation of counterfeit products. This can also help to guarantee the quality of the product and the respect for the cold chain, for example.

Consent, control and access

This giant step for the patient could be revolutionary. Blockchain will allow to identify and authenticate the patient’s and its personal information (eventually, sensitive/genetic content), as well as its registry of medical prescriptions (Zhang et al, 2018) in a large number of health platforms. With one important caveat: Patients may give (or deny) access to different borrowers, or allow limited access to certain information, in relation to particular treatments or pathologies. Annotations, certifications, exam results and prescriptions will be stored on the blockchain. The system can also ensure the monitoring of patients treatments, reminders and, of course, payments for services (transactions through smart contracts).

Some limitations

It is likely that, over time, market players will know how to circumvent the specific limits of blockchain, since currently the system presents some limitations.

One of them is linked to the novelty of technology. The system probably will still have to operate for about ten years in order to fully adapt to the specific characteristics of the market. The use of cryptocurrencies (and, for instance, NFTs – non-fungible tokens – more recently) will allow us to learn in detail the dangers and eventual limitations of the system and the ways to foresee solutions.

An important obstacle that blockchain finds in the digital health sector is linked to the mistrust that large pharmaceutical companies generate in a large part of the patients. Not only as a consequence of the great benefits of these companies, but also because of their dominant positions in the drug market and, little by little, personal data (Pérez Campillo, 2020). Added to this is the lack of transparency in their processes and the monopoly that they naturally exercise in the management of pathologies.

It should also be noted that the mere use of the blockchain does not free operators from cybersecurity compliance. Risks persist, especially at the level of user terminals and providers. Complementary protocols should be established, especially since the current databases will remain in force for a longer time, and it will be necessary to guarantee a certain level of compatibility and security between both systems (Evangelatos, 2020).

Blockchain may allow a democratization of the circulation of patients’ personal information, as well as increasing the user’s power over the final control over such information. At the same time, it is likely that by increasing the level of data in circulation, this could lead to fairer and more dynamic health services. An example of balance to consider will be the next rollout of vaccine passports, which will imply, in many ways, a restriction to people’s individual freedoms (Murphy, 2021).

Blockchain could bring trust and transparency on health data management: companies must create solutions that understand the importance of the respect of personal data and that can be properly used by patients. This will imply the creation of value from the multiplication of data units shared by users via blockchain, thanks to the trust in the system. This can be done on the basis of the understanding by patients that thanks to the increase in the volume of health data, it will be possible to obtain better diagnoses and more appropriate therapies.

The key for healthcare professionals and technology developers will be to reconcile the technological potential with the need for security and privacy of patients’ personal data.

References

• https://www.newmedicaleconomics.es/innovacion-y-nuevas-tecnologias/la-vacunacion-y-blockchain-oportunidades-desafios-y-privacidad/
  
• https://www.computerworld.es/tendencias/la-oms-se-apoya-en-el-blockchain-para-crear-certificados-de-vacunacion-contra-la-covid19
• Evangelatos, Nikolaos ; Özdemir, Vural ; Brand, Angela, Blockchain for digital health : Prospects and challenges. In OMICS: A Journal of Integrative Biology. May2020, Vol. 24 Issue 5, p237-240. 4p. , 2020 – p237-241
• George Despotou ; Jill Evans ; William Nash ; Alexandra Eavis ; Tim Robbins ; Theodoros N Arvanitis; Evaluation of patient perception towards dynamic health data sharing using blockchain based digital consent with the Dovetail digital consent application. A cross sectional exploratory study, in Digital Health, Vol 6 (2020), 2020; https://doi-org.ezp.em-lyon.com/10.1177%2F2055207620924949
• Heather Murphy, A look at Covid-19 Vaccine ‘Passports’ Passes and apps around the globe.
  https://www.nytimes.com/2021/04/26/travel/vaccine-passport-cards-apps.html
• Pérez Campillo, Lorena, An approach to big data and health blockchain and their involvement in the protection of personal data Revista de Derecho y Genoma Humano; 2020, Issue 51, p547-567, 21p
• Zhang, Peng ; White, Jules ; Schmidt, Douglas C. ; Lenz, Gunther ; Rosenbloom, S. Trent; FHIRCHAIN: Applying blockchain to securely and scalably share clinical data in Computational and Structural Biotechnology Journal 2018 16:267-278 , 2018 – p267-279.
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