Is Femtech the Next Big Growth Opportunity in Health Care?

“The market potential is huge. There’s definitely an increasing appetite for anything in the world which is technology, and a realization that female consumer power has arrived — and that it’s arrived in health care.”

Michelle Tempest, Partner, Candesic
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Women’s healthcare enables better outcomes for women patients and consumers. Although women represent half of the planet’s population, tech companies catering to their specific health needs represent a minute share of the global technology market. This disparity is staggering, especially since women spend an estimated $500 billion a year on medical expenses, according to PitchBook. Tapping into that spending power, many apps and tech companies have sprung up in the last decade to address women’s needs, including tracking menstruation and fertility and offering solutions for pregnancy, breastfeeding, and menopause.

The term “femtech” was coined by Ida Tin, the Danish-born founder of Clue, a period and ovulation tracking app established in Germany in 2013. In the course of just a few years, it has grown to encompass a wide range of technology-enabled, consumer-centric products and solutions, including maternal health, menstrual health, pelvic and sexual health, fertility, menopause, and contraception, as well as several general health conditions that affect women disproportionately or differently (such as osteoporosis or cardiovascular disease).

In 2019, the “femtech” industry — software and technology companies addressing women’s biological needs — generated $820.6 million in global revenue and received $592 million in venture capital investment, according to PitchBook, a financial data and research company.

According to McKinsey, depending on scope, estimates for FemTech’s current market size range from $500 million to $1 billion. Forecasts suggest opportunities for double-digit revenue growth. In analyzing the current market, they found concentration in maternal health patient support, consumer menstrual products, gynecological devices, and solutions in fertility. Yet this is clearly, and promisingly, only the beginning of what FemTech can address. As they show in the graphic below, there’s still a lot of “white space” available for companies to develop more solutions to fill current gaps in the global market.

Image Credit: McKinsey, February 14, 2022

Another company, FemTech Analytics, estimates that the global FemTech Market Size accounted for $40.2 billion in 2020 and is projected to grow at an average CAGR of 13.3% from 2020 till 2025 to reach $75.1 billion. Despite increasing interest in recent years, the industry remains underestimated and has high growth potential. They show the market segmentation and distribution across the various segments in the graphic below:

Image Credit: FemTech Analytics

And within those various segments, FemTech Analytics has identified the product types as seen in the graphic below:

Image Credit: FemTech Analytics

What I love about FemTech Analytics’ market research reporting is that they’ve created a MindMap of all the companies that make up the FemTech market as of the end of 2021. You can access that MindMap here.

Some examples of companies developing products in the FemTech market include Clue, Elvie, MobileODT, Lattice Medical, and EndoDiag. Here’s a brief look at each company.

Clue – I mentioned Clue and its founder earlier. In an article on the company’s website, Ms. Tin recalled how she first had the idea for the app. In 2009, she found herself holding a cellphone in one hand and a small temperature-taking device in the other and wishing she could merge the two to track her fertility days, rather than manually having to note her temperature on a spreadsheet. Clue allows women to do exactly that with a few taps on their smartphones.

Image Credit: Clue

Elvie, a London-based company, has marketed a wearable breast pump and a pelvic exercise trainer and app, both using smart technology. Pelvic floor/kegel exercises have had known benefits for women for decades, especially post-childbirth, for strengthening bladder muscles, reducing the risk of pelvic prolapse, and improving sex. It’s the same core strength promise of popular activities such as pilates and yoga but without the easy availability of motivating group exercise classes. The wearable — for indeed, when in use, it’s ‘worn’ inside the body — has a companion iOS app that offers five-minute workouts to help the user learn how to exercise their pelvic floor muscle correctly and build up its strength, tracking progress within the app via a personal LV score.

MobileODT, a start-up based in Tel Aviv, uses smartphones and artificial intelligence to screen for cervical cancer. A smart colposcope — a portable imaging device that’s one and a half times the size of a smartphone — is used to take a photograph of a woman’s cervix from a distance of about a meter (3 feet). The image is then transmitted to the cloud via a smartphone, where artificial intelligence identifies normal or abnormal cervical findings. A diagnosis is delivered in about 60 seconds — compared to the weeks it takes to receive the results of a standard smear test (which, in developing countries, extends to months.)

Image Credit: MobileODT

Lattice Medical has developed a 3-D printed hollow breast implant that allows for tissue regeneration and is absorbed by the body over time. Post-mastectomy, the surgeon harvests a small flap of fat from the area immediately around the woman’s breast and places it inside the 3-D-printed bioprosthesis. That piece of tissue grows inside the implant and eventually fills it out. In the meantime, the 3-D-printed shell disappears altogether 18 months later. This product is in the very early stage of development, however. Clinical trials on women are expected to start in 2022, with the aim of getting the product into the market in 2025.

Image Credit: Lattice Medical

EndoDiag is a French medical technology company that allows early diagnosis of endometriosis and better management of the condition. Despite significant advances in non-invasive diagnostic methods, including imaging techniques such as ultrasound, MRI, or CT scans, currently only the removal of endometriotic lesions via laparoscopy under general anesthesia and their histological analysis enables the diagnosis of endometriosis with certainty. The average delay between disease onset and its effective diagnosis is estimated between 7 to 11 years. This significant delay due to the lack of a non-invasive diagnostic test leads to frequent misdiagnosis and associated unsuitable treatments, as well as to more severe cases as the disease may progress and damage other organs. They’ve developed a test called EndoDTect®, a blood test based on the analysis of a combination of biomarkers. Changes in their expression levels indicate if a subject has endometriosis or not. Combining high sensitivity and specificity, EndoDTect® has the potential to reduce diagnosis delays dramatically. Endodiag is currently conducting validation studies to confirm the predictive value of EndoDTect® for disease detection.

My take – Companies have a tremendous opportunity to develop products and services in this space and a willing audience ready to take advantage of them. Early movers can stake out opportunities in prominent white spaces identified in the McKinsey research, including by leveraging technology to address women’s health issues beyond reproduction and by helping to meet the needs of underserved populations such as low-income or minority communities. I think there are multiple use cases where FemTech will play an increasingly important role in the future. These include:

  • Improving care delivery: Virtual clinics such as Tia, innovative brick-and-mortar clinics such as Kindbody, and direct-to-consumer prescription delivery services like those of The Pill Club all enable women to access care in a more convenient, consumer-centric manner.
  • Enabling and supporting self-care: Trackers and wearables offered by companies such as Bloomlife, and at-home diagnostics like those provided by Modern Fertility, are among the FemTech solutions that are helping women take greater charge of their health and health-related data.
  • Improving diagnoses: Clinical diagnostics companies are pushing the scientific frontier to address unmet medical needs in areas such as endometriosis (DotLab) and preterm birth (Sera Prognostics).
  • Addressing areas that are often stigmatized: Companies are addressing what had been considered to be stigmatized topics head-on, such as menstrual health (Thinx), sexual health (Rosy Wellness), pelvic care (Elvie), and menopause (Elektra Health).
  • Delivering tailored care to underserved populations and culturally sensitive care: Solutions tailored for subpopulations are emerging for Black women (such as Health in Her HUE), LGBTQ+ populations (FOLX Health), and women in low- and middle-income countries (Kasha).

“Women Buy, Women Rule” – So says business guru Tom Peters. I couldn’t agree more. Because women are not just consumers but the primary healthcare decision-makers for themselves and their families, better health outcomes for women can lead to better outcomes for society. As women’s healthcare becomes an increasing priority, FemTech is rising to meet the challenge as it matches capital and talent with unmet needs. In a short period of time, FemTech has already demonstrated impressive early wins. And the actual disruption in the market lies ahead.

Will NFTs Be Used In Health Care?

“All in all, even though NFTs are still in their infancy, the technology might evolve in the future to become more compelling for patients to favor the agency it provides over their data.”

Dr. Bertalan Meskó & Dr. Pranavsingh Dhunnoo, The Medical, January 13, 2022
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Yesterday, Dr. Bertalan Meskó & Dr. Pranavsingh Dhunnoo published a thought-provoking article on The Medical Futurist website speculating whether NFTs might play a role in health care by allowing patients to monetize their health data. Here’s a link to their article.

I’ve long admired the work being done by Dr. Mesko and his team at The Medical Futurist Institute. This article had my head spinning. We’ve all heard the hype about NFTs for some time now, usually associated with some artwork or other collectible. But until this article, I had not given much thought to whether NFTs would be used in health care. I’ve written about the underlying technology of blockchain before. I understand the point the authors are trying to make here, and I agree with the potential to empower patients to control the use of their health data. However, I’m conflicted trying to balance the potential of the technology with the impact that NFT-mining has on the environment.

First, some basics for those unfamiliar with NFTs. NFTs (Non-Fungible Tokens) are defined as “unique, digital items with blockchain-managed ownership,” per NFT marketplace OpenSea. In short, NFTs represent digital assets — which can range from images to songs to videos to tweets to patient data — that are verified through blockchain technology. Owning NFTs allows individuals to claim exclusive ownership over these digital assets. Crucially, NFTs offer a way to monetize digital goods by authenticating their scarcity and provenance.

A debate has arisen over what ownership means in the context of NFTs. In many transactions, NFTs don’t represent the actual asset itself (nor IP nor reproduction nor copyright) but are solely a record of ownership. Despite the ballooning hype, the tech isn’t new. In 2017, people spent millions buying and selling “CryptoKitties,” digital collectible cats created by Dapper Labs, some of which sold for more than $100K.

As reported by CB Insights, several NFT marketplaces have emerged to capitalize on the soaring demand. OpenSea, for example, recently raised $23M led by VC firm Andreessen Horowitz. Other names in the space include Sorare, SuperRare, Nifty Gateway (which was acquired by Gemini), MakersPlace, Decentraland, Rarible, and more.

In health care, as Dr. Mesko points out, NFTs could be used to allow patients’ genetic data to be minted as NFTs, so the information will come with an inherent feature to be tracked. You would be able to see where it ends up and hold those who used it without your permission accountable since you are the sole owner of the data, as certified by the NFT authentication. Moreover, the NFT owner can enable a feature to earn money whenever a transaction occurs with the data. Think of companies like 23 and Me who are using the tremendous amount of genetic data they have amassed by selling their kits to conduct drug discovery for which they might make billions – while you get nothing, even though it’s your information.

A non-digital example in the news recently was the case of Henrietta Lacks. In 1951, Henrietta Lacks, a Black mother of five who was dying of cervical cancer, went to Johns Hopkins Hospital in Baltimore for treatment. Without her knowledge or consent, doctors removed a sample of cells from the tumor in her cervix. They gave the sample to a researcher at Johns Hopkins University who was trying to find cells that would survive indefinitely so researchers could experiment on them. They were reproduced billions of times, contributed to nearly 75,000 studies, and helped pave the way for the HPV vaccine, medications used to help patients with H.I.V. and AIDS, and, recently, the development of Covid-19 vaccines.

Last October, 70 years after Ms. Lacks died at Johns Hopkins Hospital and was buried in an unmarked grave, the World Health Organization honored the contribution she unknowingly made to science and medicine. During a ceremony in Geneva, Dr. Tedros Adhanom Ghebreyesus, the director-general of the W.H.O., presented the Director-General Award to Ms. Lacks’s son Lawrence Lacks. He was 16 when his mother died on Oct. 4, 1951. On Oct. 4, 2021, her descendants sued Thermo Fisher Scientific, a biotechnology company they accused “of making a conscious choice to sell and mass-produce the living tissue of Henrietta Lacks,” according to the federal lawsuit. The family said it demanded that Thermo Fisher pay $9.9 million and “disgorge the full amount of its net profits obtained by commercializing the HeLa cell line” to Ms. Lacks’s estate.

Proponents of NFTs argue that their use would prevent what happened to Henrietta Lacks to anyone else, especially in today’s world of genomic data and CRISPR technology.

Here’s my dilemma – I’m having trouble reconciling the potential benefits versus the immense environmental impact of proof-of-work (PoW) blockchains. The annualized carbon footprint of the Ethereum network alone is estimated to be almost 16 megatons of CO2 — comparable to the carbon footprint of Lithuania — while it consumes 34 terawatt-hours of electricity, similar to the power consumption of Denmark, per Digiconomist. As such, NFTs might not be outright commercially viable soon. But alternatives for NFT minting are in the works that could use a fraction of the computing power currently involved in their transactions. Then there is the issue of whether companies offering digital health services will want to adopt the technology. They might not be particularly excited by the idea of sharing their profits with patients. I admit that I’m not a big fan of cryptocurrency, so that’s probably coloring my opinion on this topic. I don’t think that NFTs will dramatically impact health care any time in the near future. Lots of hype. Lots of challenges. And sharing potential revenues with patients isn’t in the corporate DNA of life sciences companies – and won’t be any time soon.

Health Care Disruptors to Watch in 2022

“Futuristic and disruptive technology implementation should be a key goal for every business. It ensures an efficient, intelligent, data-driven yet secure environment.”

Ashwin Muthiah, Chairman, AM International
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One of my favorite thought exercises during my fifteen-plus year tenure at Sg2 was to sit in a conference room at the end of every year with ten to fifteen really smart people (news flash – all my colleagues at Sg2 are really smart people, and I’m almost over my Imposter Syndrome) and have a spirited discussion on what we would include in our annual Disruptors to Watch webinar in January.

After doing that for so long, the exercise almost becomes a part of your professional DNA. So, in Q4 every year, I start looking at all of the Tech Trends for the next year online and thinking about what will rise to the top of my list. Unfortunately, you won’t get the collective benefit of my friends at Sg2 here, just one old guy’s opinion about the potential key technology disruptors in health care for 2022.

Before I begin, however, I want to acknowledge some thoughts shared by Nick Neral, Director, Panda Health, in a LinkedIn post this past week:

“If you research digital health trends of 2022, depending on the website, you’ll find “beyond” telemedicine, home health, digital therapeutics, predictive analytics and more. If you ask health systems what they’re actually working on the answer is very different…..Implementing nothing. (Yes, many don’t have the resources for anything new)….The digital health trend in 2022 and 2023 is going to be how can we do more with less.”

Nick Neral, Innovation & Strategy Director, Panda Health, LinkedIn post, December 9, 2021

I agree with Nick’s comments. He’s spot on here. In this environment, it’s challenging to try and implement new technologies when you’re running as hard as you can to handle the flood of patients jamming your ER and ICUs in the middle of a pandemic. My intention here is not to promote technology for technology’s sake, but to highlight technologies that I believe can remove some of the onerous administrative burdens we place on our front-line professionals and give them time back to do what they went into the profession for in the first place – care for patients and their families.

With that said, after working through my list of over fifty technologies that I’ve been tracking in 2021, here are my top picks for the coming year.

Voice technology takes center-stage

“We are at a very interesting time for healthcare and voice technology, because of the computing power. We’re already starting to see some radical changes in the way we experience the healthcare journey,”

Teri Fisher, physician and clinical assistant professor at the University of British Columbia

I’ve written on this topic earlier this year. Since that July post, however, there have been several announcements that lead me to believe that 2022 will be the year that voice technology sees broader adoption. There have been advances in the ability for voice technology to advance telehealth progress, notably that a mix of modalities – between chatbots, text, and voice – will provide patients with the right tool for the right time in the right place. Dr. Fisher, quoted above, is the author of an excellent book on Voice Technology in Healthcare, published by HIMSS, that I highly recommend if you want a deep dive into the topic.

But why now? I believe three significant drivers will push this into the mainstream over the next twelve months: technology evolution, the ongoing pandemic, and big tech moves in health care. Let’s take them one at a time:

Voice technology evolution – As noted in the quote above, increases in computing power have accelerated the use of voice-assisted technology in health care. The global smart speaker market is poised to see a continued annual growth rate of nearly 24 percent through 2023, according to research by Technavio. Researchers expect massive market growth in the biomarker segment alone, reaching 147.59 billion USD by 2028. (For an excellent overview of this segment, here’s a link to a post from The Medical Futurist) An IHS Markit Technology report predicts more than 900,000 such devices will be used in healthcare by next year, and diverse initiatives are already in motion. Combining voice technology with AI and machine learning and coupling those with edge computing and faster 5G networks, you have a perfect storm for increasing adoption at multiple points along the care continuum.

The ongoing pandemic – Beyond just the use of voice-enabled chatbots and voice-enabled telephone triage systems, the pandemic has forced families to manage their health care issues, including dealing with kids or parents at a distance. This has created the demand for deploying smart speakers in the home, school, assisted-living facility, or other care locations to enable an easy, zero-user-interface way for loved ones to initiate calls, monitor activity, or deal with emergencies. Physicians have increased their use of voice-enabled technology to create visit records, thus minimizing the additional work required to complete EHR notes for patients.

Big tech moves – Last year, a pilot project at Cedars-Sinai placed 100 Amazon Echo devices in patient rooms throughout the hospital. Using an Alexa-powered platform, users may speak to access entertainment options and, if needed, request staff assistance. Boston Children’s Hospital targets parents with KidsMD, an Alexa skill that offers information about common ailments and medication dosing. Another, the Mayo Clinic First Aid skill, was launched by the Mayo organization to suggest care tips for non-emergency situations. Atlanta-based Thrive Senior Living is leveraging Google and Amazon smart speakers to support a custom suite of applications that route requests and questions to care teams. A test run found that residents liked the approach, and employees came better equipped to assist patients thanks to the information they received on a connected mobile app. And finally, in my Tech News This Week post last Saturday, I reported on Amazon’s announcement of their new direct-to-consumer subscription offering, Alexa Together, aimed at families caring for elderly members who are still living independently but need extra support. Here’s a short video highlighting how BayCare implemented Alexa devices in 2,500 patient rooms across 14 hospitals:

Video Credit: BayCare Health System, posted December, 2020

And, just yesterday, Microsoft announced it is shelling out a hefty $19.7 billion for Nuance Communications, a pioneer in voice recognition and natural language understanding, to bolster its ambitions in the healthcare market.

All of these point to 2022 being a significant inflection point in using voice-enabled technology in health care.

At-Home Lab Tests

This is another area that has seen rapid growth and development over several years. And the pandemic requirement for ongoing testing for COVID-19 got patients used to going to their local pharmacy and buying in-home tests regularly. Patients can access a wide range of analyses determining their lab markers and blood results. No need to meet anyone, go anywhere.

And there are countless at-home lab tests already cleared by the FDA. Here’s a link to the FDA database of cleared, over-the-counter lab tests. The rise of companies like imaware, EverlyWell, LetsGetChecked, Health Testing Centers, UltaWellness, Walk-In Lab, and MyLabBox has spurred continued growth in this area. For example, the imaware platform provides over 20 different types of advanced home-based health tests. The company also offers telemed physician oversight, helping people control their health. During the pandemic, they launched a collaboration with virtual care company Wheel to deliver clinician-administered at-home COVID tests. They will indeed have more ideas under development. Patients can get easy access to dozens of at-home tests. Here’s a link to the kits available from mylabbox.

Here’s a link to a comparison of Best Blood Tests based on In-Depth Reviews from Consumers

With market growth calculated to value over $7.6 billion by the end of 2028 and a CAGR of over 5.4% during the forecast period of 2021-2028, it seems clear that these will have a significant impact on testing and care coordination in the coming year.

Health Systems Data Companies – Data as the new health care currency

We’ve been hearing about big data and data as a strategic resource for over a decade now. But, there have been developments over the last eighteen months that signal that the industry has awoken to the fact that the trove of data they are sitting on is valuable and an asset to be mined.

Case in point – Truveta. Twenty of the largest U.S. health systems, led by Providence, have formed a startup to pool patient information, aiming to streamline efforts to analyze anonymous data to improve care, develop better therapies and drugs, and promote more equitable treatment of underrepresented groups. The Seattle-based startup is led by former Microsoft Corp. executive Terry Myerson, who ran the software maker’s Windows business. As of this writing, Truveta partners with around 20 medical providers, aggregating regular de-identified data from 42 American states and myriad patients representing about 16% of all U.S. clinical care into its collection. It has built a software service that allows researchers and other users to ask questions about the collected data. Here’s a short video featuring the Truveta Health System founders discussing their vision for saving lives by using data:

Video Credit: Truveta

“We want to allow people to study human health. When they do, we want to make sure they’re a studying data set that’s consistent with the whole population. The transparency, the data on the data, is something fundamental we want to bring to the table.”

Terry Myerson, CEO, Truveta, Health Evolution interview, February, 2021

Another example that generated a firestorm of protest and even led to a Federal investigation was Ascension Health’s partnership with Google. Ascension and Google say the project could lead to better outcomes for patients. Privacy experts also said it appears to be permissible under federal law. But one professor told the Journal “the optics are bad” because patients and doctors weren’t informed, and several U.S. senators expressed concern. It is unclear what the departure of Dr. David Feinberg to head Cerner means for the arrangement if anything. But the partnership is another example of the accelerating trend to aggregate, de-identify, mine, and monetize these vast data resources.

Want more proof? Beckers Healthcare did an outstanding job of reporting on the growth of these partnerships in 2021. As of their June posting, they identified 38 Big Tech partnerships in healthcare this year: Amazon, Google & more. The “horse is out of the barn” on this one. So don’t expect any slowdowns in the area in 2022.

Digital Health Insurance

Digital has begun to reshape health insurance markets. According to McKinsey, payers in the United States have been slow to digitize. They are still behind other industries in their use of artificial intelligence and automation, as well as in customer satisfaction. They’re now starting to catch up. Both incumbents and disruptors are making substantial and growing investments in digital programs.

Just last month, Bain Capital announced that Enhance Health, LLC, a new technology-enabled, digital health insurance brokerage and care navigation platform focused on serving the Medicare Advantage market, launched with $150 million of total capital. Headquartered in Ft. Lauderdale, Florida, Enhance Health will serve both the Medicare and individual and family plans segments of the health insurance market.

And, Enhance Health is not alone. Digital Insurance is another digital-first insurance company now adding healthcare to its portfolio of offerings. OneDigital went to market as the new generation in health and benefits. Focused on creating harmony between people and technology, today, OneDigital delivers benefits solutions, including a sophisticated combination of strategic advisory services, analytics, compliance support, technology, and HR capital management tools.

And, of course, there’s Oscar Health. Oscar Health Insurance began in 2012 and offers health insurance to residents of Arizona, California, Colorado, Florida, Georgia, Kansas, Michigan, Missouri, New York, New Jersey, North Carolina, Ohio, Pennsylvania, Tennessee, Texas, Iowa, Oklahoma, and Virginia. Coverage may soon be available in other states. The Oscar app is downloadable and compatible with Android and iOS. The app offers 24/7 doctor-on-call services. The company operates in partnership with Mount Sinai Health System. The company provides health insurance wellness incentives for being active, tracked using free wearables. There are low-deductible options available. There are five tier plans—secure, bronze, silver, gold, and platinum—covering between 60% and 80% of medical expenses.

“Ten years from now, I think we’ll have contributed to lowering health-care costs, and that remains our far end goal and what we do everything at Oscar.”

Mario Schlosser, CEO, Oscar Health, Interview, Yahoo Finance, March, 2021

There are real benefits that will continue to drive these developments. Those payers that invest thoughtfully in human-centric digital transformation are beginning to see the value, including material changes in member satisfaction and trust, increased revenue from digital branding and improved sales tools, and double-digit reductions in administrative costs. In addition, stronger member relationships are often leading to lower medical costs. Watch this space…..

Cognitive Automation Takes On Administrative Work

Cognitive automation is a new and fast-emerging technology in digital transformation. It is one of the key IT trends in healthcare, and its popularity is expected to increase in 2022. Cognitive automation generally combines natural language processing, machine learning, and computer vision technologies into a platform to increase decision velocity in health care.

This technology makes it possible to process zettabytes of data within seconds, thereby providing decision-makers with recommendations readily available and backed with real-time data. The end goal of this emerging healthcare technology is to establish a self-driving enterprise whereby operational processes are automated.

Cognitive computing has also enhanced patient engagement and improved access to services. Researchers are leveraging the potential of cognitive systems to make clinical trials more comprehensive and valuable, making this a critical technology development in health care. Key players operating in the cognitive computing in the healthcare market include Apixio, MedWhat, Healthcare X.0, Apple Inc., Saffron Technology, Inc., Nuance Communications, Inc., Google LLC, Microsoft Corporation, and IBM Corporation.

“Technology should work for people, not the other way around.”

Brad Becker, former Chief Design Officer for IBM Watson, Knowledge@Wharton interview, November, 2014

The global cognitive computing and analytics market has been projected to be valued at $95 billion by 2022, at a Compound Annual Growth Rate (CAGR) of 42.9% during the forecast period. North America, followed by Europe, is expected to be the most significant revenue-generating region for the cognitive analytics vendors in the next five years. So, a lot of investment in the space coupled with a pressing need to remove some of the administrative and operational burdens from the shoulders of front-line health care professionals will drive the growth in this area over the next eighteen to twenty-four months.

2022 will be another challenging year in health care. We’ll still see pressure on our systems from the ongoing pandemic. Investments in new technology will be constrained because of financial and resource availability. I’m betting that many posts you’ll see from me next year will focus on the issue of – time: giving time back to our frontline professionals to provide care, having patients spend less time navigating the complexities of our crazy health system, reducing the time to diagnosing and treating diseases, and creating time to allow everyone to achieve a healthy balance in our lives. If any of the technologies I’ve listed above can help us accomplish that, we all win.

Digital Health: What We Can Learn From Other Countries Experiences

“Twenty percent of Estonians will have used our DNA analysis service by the end of this year and know which diseases they are susceptible to and how they can take appropriate precautions.”

Kersti Kaljulaid, Former President, Estonia – Interview in Der Spiegel
Image Credit:

Last week I received a book recommendation based on my previous reading on my Kindle device. The title was: The Year in Tech 2022: The Insights You Need from Harvard Business Review. I immediately purchased and downloaded it. Chapter three caught my eye – Want to See the Future of Digital Health Tools? Look to Germany. The chapter summarizes an online HBR article published the previous year (more on Germany later). And it got me thinking about whether there might be additional lessons to be learned from other countries as well. So, I set off to do some research. It turns out we can learn a lot.

The lead quote for this post, from the former President of Estonia, was a real eye-opener for me from a country we rarely discuss. Imagine a country where citizens will have their genetic profiles integrated into the digital health system with individual risk scores and pharmacogenomic information. When they go to the doctor, they will get fully personalized, genetic risk-based diagnosis, medication, and preventive measures. Estonians are very comfortable using e-services and sharing their data when necessary. Citizens are brought up with the philosophy that they own their data. However, it’s both the public and private sector’s job to use this data in the best way possible—to run their shared services smoothly and improve life in Estonia. Some essential facts:

  • In Estonia, 95% of health data is digitized
  • 99% of prescriptions are Digital
  • 100% of billing is done electronically
  • 94% of citizens are covered by national healthcare

They started to build their digital health system 20 years ago, and within the next few years, the Baltic country will reap the benefits of a transparent, blockchain-based, digital health system hooked on genetic data. The first fully digitized republic certainly sets the direction for other countries to follow. How have they done it? During the last twenty years, project e-Estonia has wired up the entire Baltic nation. The specific services that the government is involved with, legislation, voting, education, justice, banking, taxes, policing, and, naturally, healthcare, have been digitally linked across one platform, X-Road. Citizens can vote through their laptops, sign contracts with their digital signature, or use their chip-IDs when surfing around in the business and land registry – knowing that their data is secured through the blockchain and open to everyone. By having 78.1 percent of public bureaucracy digitized, the country also saves around 2 percent of its gross domestic product. For a deeper dive into the Estonian digital health experience, check out this excellent post from Dr. Bertalan Mesko and his team at The Medical Futurist Institute.

Next, let’s look at Finland, which ranks among the three strongest health technology economies globally. For centuries Finland has been collecting data precisely. And they also have been working for a long time to have their health and social care data digitized and harmonized. Finland has the National Data Exchange Layer, the equivalent of the Estonian X-road (starting to see a pattern here?). The interesting thing about this is that data can be exchanged, even between these two countries. They also have Kanta/My Kanta for Health data. These services are widely used by patients, even though they are relatively new. The system grants access to all healthcare information that the public system has about the person enquiring. People can renew electronic prescriptions, view records related to their treatment, store their living wills and organ donation testament, and consent to or refuse the disclosure of their personal data.

How about Denmark. The world’s third happiest country has one of the most advanced digital health systems alongside an elaborate and concise national digital health strategy for the next four years. The document emphasizes the importance of the cooperation of every healthcare actor through the easiest and fastest way, technology, with a clear purpose: to build an integrated network focusing on patients and looking at the person as a whole, not just at the individual diagnosis. Information on causes of death has been collected since 1875, and cancer incidence has been registered for the whole country since 1943. The Danish National Patient Registry has been keeping records that date 30-40 years back, making it one of the oldest nationwide hospital registries globally.

Another area where Denmark invests heavily is genomics-powered precision medicine – and things are moving fast. The Danish parliament adopted the law to establish the National Genome Center in 2018, and they built up their dedicated supercomputing infrastructure in 2019, began large-scale whole-genome sequencing to build up their accompanying genome database in July of that year. They believe that within the next five years, they will at least do 60,000 whole-genome sequences – at a minimum. Once again, The Medical Futurist Institute gives us a deeper understanding of the situation in Denmark in this post.

The health system in Sweden is founded on the principles of equal access and regional autonomy. Sweden recently updated its national eHealth vision, which now states that, by 2020, all residents aged 16 or over should have access to all health-related information documented in county-funded health and dental care. Two things enable this; a national patient portal and a national health information exchange platform. Although the county councils are autonomous and can prioritize which eHealth services to focus on, the decision was made at a national level that patients should only have one way to reach healthcare. A national patient portal, ‘’, is available for anyone seeking healthcare or health-related information in Sweden.

Sweden has chosen to implement a national Health Information Exchange (HIE) platform to facilitate the communication between different health information systems and eHealth services. The national HIE platform enables a single point of connectivity for client applications, making all Swedish EHRs appear like a national, virtual EHR. And citizens are responding. Preliminary results of a national patient survey among PAEHR users in Sweden indicate that the overwhelming majority of patients who have accessed the PAEHR are positive about it. Almost 90% of respondents completely agreed, and 8% partly agreed with the statement, “Having access to ‘Journalen’ is good for me.”

Now back to Germany – In late 2019, Germany’s parliament passed the Digital Health Care Act (Digitale-Versorgung-Gesetz, or DVG) — an ambitious law designed to catalyze the digital transformation of the German health care system, which has historically been a laggard in that area among peer countries. The timely introduction of the DVG means that Germany is poised to set an example for other countries in seeing what works (and what does not) in the adoption and diffusion of digital technologies for improving patient outcomes.

Perhaps the DVG’s most important provisions are its formalization of “prescribable applications” (Digitale Gesundheitsanwendungen, or DiGA), which include standard software, SaaS, and mobile as well as browser-based apps, and the creation of the Fast-Track Process, an accelerated regulatory path for companies to take their digital health applications to market. Following a streamlined review, an app can be added to a central registry of apps that can be prescribed by physicians and psychotherapists and will be reimbursed by all of Germany’s statutory health insurance providers, which cover 90% of the population of roughly 73 million individuals. The Fast-Track Process is run by the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte, or BfArM), which plays many of the same roles in Germany that the FDA does in the United States); BfArM also maintains the DiGA registry. The first five apps have already been added to the registry and offer support for patients to manage conditions including tinnitus, obesity, agoraphobia, osteoarthritis, and insomnia.

DVG promises to provide a standard care environment for manufacturers of new digital health tools to evaluate pricing strategies and understand how digital health applications fit into health care practice and patients’ everyday routines. The importance of such a major country mandating that all insurers have to pay for digital health apps is hard to overstate. With at least 50 apps currently already in the Fast-Track process and hundreds expected over the coming years from manufacturers worldwide, evaluation studies will create a wealth of data on how digital tools for remote patient care work in practice, which other payers and health systems can learn from. They will also be valuable in convincing health care providers — for whom evidence is of paramount importance — of the value of digital tools, both generally and in particular use cases.

Here’s a recently published update on the German DiGA journey with data through November, 2021.

So what can we learn from these examples? – There are several common elements to these national digital health programs that we could benefit from. But, and this is a crucial challenge, we would have to make major structural, payment, regulatory and legislative changes to how we currently operate. Here are my three major observations:

Interoperability is essential – Whether it’s X-Road in Estonia, My Kanta for Health in Finland, the National Patient Registry in Denmark, or in Sweden, the data is interoperable and accessible across all sites of care, and in some instances, across country borders. Contrast that with our experience. Ask the question: “What have the American people gotten for their $35 billion HITECH investment?” The answer is not much. Silos abound. Compiling a single, comprehensive patient record is impossible. We have no national patient identifier to prevent mixing patient records. Cybersecurity is dismal at best. All of this is in a country that spends more than 17% of GDP on health care and has an administrative overhead estimated to be over 8%.

Image Credit: OECD, 2019

Patients own their health and genetic data – Most citizens in the countries discussed above are brought up with the idea that they own their data, can control who has access to it and for how long. In those countries that are doing genetic profiles of their citizens, the patient controls the information and its use – in some instances, using blockchain technology to maintain security and authorization of access. Here, the accepted norm is that your provider “owns” your data. And although you can request a copy of your patient records, you’ll likely be charged for the privilege and will either receive the information in paper form on a disk that is of little use. While patient data advocates like Dave deBronkart Jr, widely known as e-Patient Dave, a cancer patient, and blogger who, in 2009, became a noted activist for healthcare transformation through participatory medicine and personal health data rights, and others push for this, progress is slow.

“Owning a copy of your personal data does not change property law, medical record requirements, or hinder the advancement of science. But it does build health equity by giving everyone equal access to their lifetime medical data.”

Juhan Sonin, Annie Lakey Becker and Kim Nipp, Stat First Opinion, November 15, 2021

Data ownership gives each of us the keys to our health puzzle and insight into how our data is used outside medical appointments to further research, innovation, and better health care for all. It gives us the keys we need to care for ourselves and our loved ones, and to build health in our communities and our country at large. Data ownership unlocks the path to achieving our health and wellness potential.

Including an individual’s genetic information is critical to personalized care. – In addition to Estonia, the NHS in the UK, Iceland, and the UAE have plans to sequence the DNA of large segments of the population to make citizens’ lives better. Here in the U.S., Boston Children’s Hospital had a five-year program where parents of newborns had the option of having the child’s DNA sequenced to test whether that information helps guide the care of babies and monitor how pediatricians and parents react to knowing it. Phase 1 of that study wrapped up in 2019. These plans likely won’t be perfect at first. But other nations looking to implement their systems might build off those, and citizens will be the ones to benefit.

Digital health tools development is a complex, multifaceted, and highly dynamic environment. While significant implementation challenges remain, I’m confident that there is a better chance of preparing for whatever is coming next by demonstrating the best practices of how other governments, regulators, and developers tackle the challenges of today.