The push for digital health
By WHO definition, digital health is the “delivery of health care services where distance is a critical factor.” Because distance became a very critical aspect during the pandemic, everything under the umbrella of digital health, from the basic e-prescriptions to advanced digital therapeutics (DTx), made important leaps in 2020. Pharma companies and healthcare providers also made steps towards these technologies. In Italy, 47% of specialist doctors and 39% of GPs made teleconsultations during the pandemic last year, according to a report by Observatori.net. For instance, ASST Grande Ospedale Metropolitano Niguarda launched a televisit project to provide follow-up examinations to bed-ridden patients. Some Italian hospitals also used apps to monitor patients or bought inpatient remote monitoring kits to reduce direct contact. Globally, IQVIA reports that 90,000 new health apps were launched in 2020. The pandemic became instrumental in digital adoption and the shift to telemedicine, fostering investments in infrastructures like mobile apps for contract tracing and social distancing. The crisis became an opportune time to test the use of existing technologies to a wider scale and to push new technologies into being; but the practice of telemedicine, as well as the use of digital apps, have broader applicability beyond the pandemic, especially when it comes to the management and treatment of chronic disease patients. Pagine Mediche is Italy’s largest medicine platform and the first to create a Covid-19 chatbot globally. A recently published observational study indicated that the platform could predict spikes in the virus two weeks ahead of other KPI indicators. The same data collection apparatus could have great applicability in other disease management. IQVIA confirms that almost 50% of health apps are now focused on helping customers manage current health conditions like diabetes, mental health, or cardiovascular diseases, rather than focusing on wellness alone.
Traditional medicine saw the interactions between doctors-patients, pharmacies-patients, doctors-pharma suppliers, and patients-other patients, isolated and linear. But digitalization gives rise to a third dimension in which doctors, patients, pharmacies and pharma suppliers can interact and engage via multiple channels, and which the pharma companies, as the sole supplier to all three parties, can exploit and incorporate in their working models. In 2021, Italian company Alfasigma opened a support engine solely dedicated to physicians; “Doctors as You” works as an aggregating portal for online scientific research, also offering medical training development. On the customer-facing side, innovative pharma company NTC Pharma inaugurated NTC4You, which is already used by 80% of its customers, proving a real need in the market for such service. It is becoming more common for pharmaceutical companies, big and small, to develop digital channels and links vis-à-vis both the medical community and the patient community, oftentimes defining such communities digitally. Besides running a digital portal to share information with practitioners, Sicilian innovator SIFI Group pioneered a sound system for visually impaired customers who can listen to the information on the leaflet by scanning the QR code on the packaging. These types of close-patient engagement, facilitated by digital, are characteristic of a new healthcare model which puts the patient at the centre; akin to a consumer, the patient is presented with solutions, rather than mere products. Roberto Ascione, the CEO of Healthware Group, elaborated: “The life sciences company of the future will be focused on the patient’s journey, creating meaningful patient and consumer experiences, as well as implementing early diagnostics and data. In this scenario, tech companies, health insurers, and drug makers will be competing for the patient’s attention. I call this approach a shift from cure to care as part of a seek-and-care healthcare model, much more focused on prevention and wellbeing.”
Background Image courtesy of Pexels, cottonbro
From cure to care
Harmonium Pharma is an Italian company founded in 2013 dedicated to diabetes, a chronic disease affecting over 420 million people globally. Unlike the usual diabetes-focused company offering insulins or sugar monitoring devices, Harmonium instead focuses on the day-to-day management of the disease with everything that entails: “Besides the pharmacological therapy itself, chronic disease management also involves two other aspects: education and prevention. These are the areas where we position ourselves, seeking to create tighter links with the patient,” said founder and president Ugo Consentino. Chronic disease management has been traditionally left to the doctors and patients/caregivers, but pharmaceutical companies are playing a growing role in offering care, a role that is going beyond the offer of chemical, biological, or natural products. The Italian subsidiary of French company Ipsen launched the first website tailored to patients suffering from spasticity, a lingering side-effect occurring after a stroke. “Beyond spasticity” gives patients a go-to place to understand and manage their symptoms. Similarly, UCB (EBR: UCB), one of the world’s biggest pharma companies with strong expertise in immunology and neurology, uses digitalization to connect with epilepsy patients. UCB invested in Nile AI, a digital health company for the care management of epilepsy.
“The ultimate revolution for the industry will be the shift from a product-centric business model to one of ‘solutions’ that blend products and services tailored to precise needs.”
Stefano Collatina, Country Lead, Baxter Italy
Besides the service-like approach of such platforms, which offer awareness, practical advice, training, and perhaps even solidarity and a sense of belonging to a wider digital community, pharma companies are also deploying DTx used in the management of chronic diseases. Healthware Group, one of the world’s largest independent healthcare consultancies, has developed together with Finnish company Orion Corporation a VR-based therapeutic used in the management of severe chronic pain. Roberto Ascione, Healthware’s CEO, expects a serious marketplace transformation whereby pharma companies will not only be selling drugs, but also drugs plus software, and software-only therapies: “Sooner rather than later, approved prescription DTx will be either software alone or software plus pill, and my view is that the software will play the lion’s share of the therapy,” he said. Digital platforms, apps and DTx do not replace specialists, but they do create a third space, a digital one, as well as defining (and re-defining) physical spaces, including the home, the hospital, and the pharmacy. When Draghi covered in his speech the allocation of one billion euros to telemedicine as part of Italy’s recovery fund, he argued that telemedicine could make “the patient’s home the main place of care.” The pandemic clearly deterred chronic patients from visiting hospitals, and the reputation of hospitals as unsanitary may well persist past Covid. Stefano Collatina, Italy’s country lead of Baxter International, believes the perception of hospitals as hotbeds for viruses and bacteria will lead to the emergence of “out-of-hospital” care centers for chronic treatment, whereas the hospital shall remain secluded for acute and emergency treatment. Meanwhile, the pharmaceutical space is also transforming. According to Ugo Consentino from Harmonium Pharma, two types of pharmacies coexist today: the traditional one focused on straightforward drug provision and aggregating a large and diverse drug supply; and a second type that works as the first point of contact to the patient and whose personnel is trained in providing advice, diagnosis and consultancy. Harmonium Pharma sells its portfolio package under the “Diabetic Corner” brand to this second category of pharmacies: “Our partner pharmacies are not just a place where the patient can pick up prescriptions, but also a space to receive advice from trained staff, or even attend screening events or activities to raise awareness about the disease,” he explained.
“We seek to put patients at the same decision table with other stakeholders for decisions regarding their therapies. We consider that patients are experts of their disease, but not necessarily experts in hospital budgets or clinical terms, so we want to help them understand the medical jargon and input their views.”
Federico Chinni, CEO Italy, UCB Pharma
For all its merits, digital health cannot gain traction without the support of regulators and digital infrastructure. A recent study published in the Journal of Medical Internet Research found that the lack of clarity around telemedicine reimbursement inhibited a wider-scale adoption of telemedicine in Italy during the pandemic. Provisions for telemedicine had been introduced in the country since 2012 through an agreement between the government and the Regions known as “Telemedicine-National Guidelines” and last year, the government released other interim indications paying particular attention to televisits. In September 2020, The Health Commission of the Conference of Regions adopted a guideline identifying the conditions for remote medical assistance, which should make the reimbursement codes more explicit and easier to follow. However, while telemedicine is a more mature sector, DTx and the incorporation of software to treat, prevent, or manage a disease is a much less known terrain to which regulators around the world must learn to respond. There are 150 digital therapeutics currently available, and another 100 in development. Though not directly linked to the treatment of Covid, DTx’s ability to deliver medical interventions directly through patients and providing data-feedback is gaining significant importance in a patient-empowered, data-driven, and increasingly remote healthcare model. Last year, Germany was the first to introduce a reimbursement model for DTx, after having already passed in 2019 a provision allowing doctors to prescribe digital health apps to patients. These are reimbursable by the state. A DTx law is not existent yet in Italy, but Ascione believes this is underway. The CEO of Healthware Group and the founding adviser of Digital Therapeutics Alliance collaborated on a white paper put together by Tendenze Nuove to define the framework for DTx in Italy. Ascione thinks legal implementation should and must follow: “Many actions that had been waiting for the past 20 years were finally set into motion by Covid-19. (…) Global healthcare is dysfunctional and unequal, and digital is the sole way that healthcare can be effective and sustainable, especially as we could potentially confront bigger crises if we judge by global demographic changes combined with climate change.” Digital health could relieve the overburdened Italian healthcare system by triaging patients to televisits or digitally assisted therapies, as well as by replacing, where possible, the work of the practitioner. Italy has the largest share of medical doctors aged over 55 among all OECD countries, according to OECD Health at a Glance Indicators (2019), and a lower number of nurses compared to most European countries. Digitalization also helps with reducing the time for in-person medical visits, as Federico Chinni, the country lead of UCB Italy explained: “The first part of any doctor visit is filled with administrative tasks, so by registering drug history or symptomatology through the app, the consultation time can be more effectively spent.” Ultimately, digital health is important for the patient. The IQVIA report “Digital Health Trends 2021” found that digital tools have an increasingly positive impact on health outcomes. Finding effective means to promote adoption is therefore crucially important. In some cases, limited adoption does not permit the takeoff of digital apps: for instance, the Italian Immuni app introduced to act as a surveillance system in June 2020 didn’t lead to the desired effect because not enough Italians downloaded it. About 12 million have downloaded the app as of today.