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healthcare in
Europe
Closing the
stakeholder gap
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Report on an Engage Health
Cross-Stakeholder Conference
November 28th 2011
Sotel, Place Jourdan,
1040 Brussels, Belgium
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Building a consensus
on how to sustain
the future of Europes
healthcare systems
Engage Health Alliance Europe
2
On Monday, November 28th 2011, around 70 people representing different parts of the healthcare
community met in Brussels under the auspices of Engage Health Alliance Europe. The meeting
aimed to start building a cross-stakeholder consensus on how to ensure the sustainability of
Europes healthcare systems in the face of ongoing nancial crisis.
This White Paper is a record of that event.
Mat Phillips,
CEO,
Engage Health Alliance Europe
Report compiled by Kurt Soezen
Edited by Clive Nead, Mat Phillips and Alexandra Wyke
March 2012
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Introduction 4
Executive summary 5
Session I: The nancial crisis in Europes healthcare systems 8
Session II: Healthcare innovation during a nancial crisis 15
Session III: Pan-European healthcare and patient organisations 21
Session IV: Cross-border healthcare 28
Conclusion: Clarity of direction 33
Appendix 1: Summary of the presentations at Engage Brussels 35
Appendix 2: List of attendees 47
Contents
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Engage Health Alliance Europe was formed in late 2010 out of a belief that stakeholders from all
parts of the healthcare system have a role to play in planning the future of healthcare. Engage
emphasises the value that patient groups can bring to the planning process, and the importance of
the patient perspective.
In an effort to build a cross-stakeholder consensus on the future of healthcare, Engage holds two
major conferences a year. The rst was held in London in March 2011, and focused on the subject
of patient group and industry relationships. The second meeting, held in Brussels on November
28th 2011, was an opening step in the process of fashioning a dialogue on the future of Europes
healthcare systems.
This White Paper is an amalgamation of the discussions that took place during the November
2011 Engage Brussels meeting. The White Papers interpretation is that of Engage Health Alliance
Europe only, and should not be attributed to any particular attendee, speaker, chair or delegate. A
summary of the content of each speakers talk at the meeting can be found in Appendix I of the
White Paper.
Engage Health Alliance Europe would like to thank everyone who attended or supported the
November 2011 event. Engage looks forward to continuing to develop programmes of action with
you.
Engage Health Alliance Europe
Tim Ball
Caroline Davis
Liz Johnson
Clive Nead
Mat Phillips
Edna Wolstencroft
Alexandra Wyke
Introduction
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Building a consensus
on how to sustain
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healthcare systems
On Monday, November 28th 2011, around 70 people representing different parts of the healthcare
community met in Brussels under the auspices of Engage Health Alliance Europe. The meeting aimed
to start building a cross-stakeholder consensus on how to ensure the sustainability of Europes
healthcare systems in the face of ongoing nancial crisis. This White Paper is a record of that event.
Session I: The nancial crisis in Europes healthcare systems
The global nancial crisis has necessitated further containment of public expenditure on
healthcare, as called for by the International Monetary Fund (IMF).
However, even before the nancial crisis, healthcare spending was out of control, spurred on by
changing demographics, the adoption of unhealthy urban lifestyles, rising expectations among
educated younger people, and the increasing cost of innovatory healthcare products.
European nations hit hardest by the recession have also been those with the fastest-growing
healthcare bills.
Any cost-containment measures remain hampered by the fragmentation and lack of
coordination that pervades Europes healthcare systemsplus the absence of any political will
for major changes.
The healthcare systems of Greece, Slovakia, and, perhaps, Ireland, indicate what could happen if
economists have their way entirely in the running of healthcare systemsthe health of national
populations could suffer.
Session II: Healthcare innovation during a nancial crisis
The public purse can no longer unquestioningly afford to pay for the high prices of some
medicines. High prices discourage politicians and healthcare administrators from attempting to
iron out inequities in the healthcare system.
The process of R&D needs to be made more efcient. One way to do so is to reduce the
redundancy in the R&D system. Redundancy occurs when money is spent on developing
medicines which might later be rejected as cost-ineffective by government-appointed agencies.
That moneyhuge amounts of itis wasted.
Redundancy can be reducedeven avoidedif government and other important healthcare
stakeholders are allowed, at the earliest stages of the R&D process, to offer input as to what is
really needed.
The Innovative Medicines Initiative (IMI) is a new form of cross-stakeholder collaboration in
early-stage drug development. A collaboration between industry and the European Commission,
the IMI is now Europes largest public-private partnership (PPP).
Other innovative forms of collaboration for the purpose of innovation were discussed at the
Engage Brussels meeting, including co-creation or open innovation (varied communities with an
interest in R&D outcomes are engaged in the discovery-and-development processes).
Executive summary
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Social media allows the formation of virtual communities capable of better engagement with
patients and the members of the public who use medicines.
Session III: How to engage with patients
The patient experience is a complex one that touches all aspects of a persons life beyond
treatment and care.
The patient movement has arisen to tackle the broader human issues involved with managing a
medical conditionand, hopefully, to even help people prevent conditions from occurring.
Patient groups have also adopted an advocacy role, and seek to improve healthcare systems to the
benet of patients.
Patient groups, such as the European Cancer Patient Coalition (ECPC) and the European Kidney
Patients Federation (CEAPIR), have worked hard at developing tools for engaging with patients
(and their representatives) at both local and national levels.
The patient movement now needs to be embraced in healthcare decision-making processes.
Industry, too, has an important role to play in embracing issues of importance to patients.
Industry can catalyse its networking capabilities across the range of healthcare stakeholders with
whom it already engagesthe overall intention being to improve the patient experience.
One of the IMIs newest initiatives, the European Patients Academy on Therapeutic Innovation
(EUPATI), a cross-stakeholder alliance that includes business and patient groups, is a case in
point. Launched in February 2012, the EUPATI aims to involve patients in drug development.
DAWN 2 (Diabetes Attitudes Wishes and Needs) is a currently-running global study supported
by Novo Nordisk. It aims to determine the needs that patients have when they try to manage
their condition. Novo Nordisk plans to make the results of DAWN 2 available in the public
domain to provide patients with the evidence to make their case for change to HTA authorities,
government and other healthcare stakeholders.
Session IV: Cross-border healthcare
Opportunities exist within the EU for national healthcare systems to work together in a
harmonious way to create efciencies, and to improve the health outlook of all European citizens.
So great are the disparities between average and best practice across Europe that merely
implementing existing best practice consistently would provide major improvements across all
EU national healthcare systems.
The 2011 Directive of the European Parliament and Council on the Application of Patients
Rights in Cross-Border Healthcare is an opportunity for greater cooperation across borders.
Healthcare systems in different European countries can benet from a pooling of expertise and
from economies of scale.
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Many hurdles must be overcome, though, before cross-border cooperation can make such goals
attainableincluding difculties in deciding upon EU standards (pan-European medical data
are not readily available). In addition, the nancial recession has made European countries more
introverted, and, although EU citizens are far more mobile, sick patients prefer to stay at home.
Nonetheless, case studies of successful pan-European health initiatives do exist. One
example is the new web-based virtual community, Rare Disease Communities [http://www.
rarediseasecommunities.org], managed by EURORDIS, the European Organization for Rare
Diseases. Others are Health Consumer Powerhouses benchmarking system for consumer
satisfaction with national health systems, and also the campaign for the widespread adoption of
the European Charter of Patients Rights produced by Active Citizenship Network (ACN).
Conclusion
A tension evidently exists within governments and healthcare systems between the economic
imperative to cut costs in healthcare and the moral duty to provide high-quality healthcare to all
citizens. Economists will see the curbing of healthcare spend as virtuous. But, in some countries,
scal austerity packages are slowly eroding the capability of healthcare systems to deliver high-
quality services. The challenge is striking the right balance between thrift and patient safety. Factors
that should be considered by policymakers are:
How to liberate medical data, making it transparent.
Ensuring quality standards for healthcare information.
Improving efciency in healthcare.
Setting gold standards.
Granting doctors the right to use their discretion when prescribing.
Developing new stakeholder communities to offer input to healthcare innovation.
Harnessing the power of e-health.
Developing effective mechanisms for cross-stakeholder consultation.
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Session I:
The nancial crisis in Europes
healthcare systems
Total health expenditure as a proportion of GDP (2009 or nearest year) from
Health at a Glance, an annual report by the Organisation for Economic Co-
operation and Development (OECD)
An overview
Karen Taylor, head of Deloitte UKs new Centre for Health Solutions, opened the November 2011
Engage Brussels meeting with an overview of the current nancial crisis, and an estimate of how
healthcare might be affected.
She noted that national healthcare systems were in trouble even before the global nancial
meltdown. Healthcare spending has been rising across Europe for decades as populations contain
an ever-larger proportion of older people, and as the costs of long-term care increase. Individuals
are living longer, but increasing numbers of people are becoming chronically ill (sometimes
because of physically-inactive urban lifestyles). Diabetes is a case in point. In 2010, 6.9% of people
in Europe had diabetes; by 2030, the gure is expected to rise to 8.1%
1
. Sick people may also suffer
from more than one chronic disease (co-morbidity), adding further complexities to their treatment
and care.
Karen Taylor explained to the meeting that the most dramatic increases in healthcare spend are
evident in some of the European countries most heavily hit by the current scal crisisGreece,
Spain and Portugal. Public spending on healthcare in Portugal grew from 1.5% of GDP in 1970 to
7.2% of GDP in 2006; in Spain, from 2.3% to 6.0%; and in Greece, from 2.3% to 5.9%
2
. Moreover,
many of the more recently-incorporated EU Member States increased expenditure on healthcare
during the rst decade of the new millennium, seeking to put their countries healthcare systems
on a par with those in EU peers. The high cost of that investment policy now burdens these
aspirational countries.
1. Source: International
Diabetes Federation (IDF).
2. Bartosz Przywara,
Projecting Future Healthcare
Expenditure at European
Level: Drivers, Methodology
and Main Results, European
Commission Directorate-
General for Economic and
Financial Affairs, 2010 [see
http://ec.europa.eu/economy_
nance/publications].
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Further pressures have been placed on healthcare spending by younger people who are more
articulate than previous generations in demanding that healthcare systems meet their needs and
wants. Well educated, and armed with unprecedented levels of Internet-sourced information
about healthcare, demanding younger users of healthcare services refer repeatedly to the growing
inequities in the provision of medical care that occur when spending on healthcare varies from
nation to nation, or even within the same country (as it does in all European countriesthough
more in some than in others).
Ajai Chopra, the IMF and healthcare
Ajai Chopra is a Deputy Director of the
IMFs European Department, and oversees
the Departments work on various advanced
and emerging-market countries. He is also
currently the mission chief for the United
Kingdom. Ajai Chopra was previously in the
Asia and Pacic Department, and led the
IMFs Korea programme.
Stephen McMahon, CEO of the Irish
Patients Association (IPA), told the audience
at the Engage Brussels meeting about a workshop held in Ireland the
previous month. At that October 2011 event, Ajai Chopra, Deputy
Director of the European Department of the International Monetary
Fund (IMF), said that bad decisions by the global banking system
had caused the current nancial crisis, and that the self-regulatory
framework of the nancial markets failed to prevent any build-up of
risk.
1
Today, with all European nations carrying too high a public debt,
and all affected in some way by the global scal crisis, healthcare is
1. Ajai Chopra, Strengthening the Financial Stability Framework of the EU; address to the 2011 Dublin
Economic Workshop, Kenmare, Ireland, October 15th 2011.
widely viewed across the continent as a prime cost-cutting target. The
IMF has predicted that the nancial problems faced by healthcare
systems will intensify over the next two decades, exacerbated by
expensive advances in medical technology. Healthcare reform, insists
the IMF, will be a key scal policy challenge in coming years. The
so-called troika of the IMF, EU and the European Central Bank has
therefore proposed a variety of options for analysing and containing
public health expenditures, including:
1. Increasing patient cost-sharing, to control unreasonable patient
demand.
2. Eliminating tax exclusions to the private health insurance schemes
run by employers for their employees.
3. Modifying provider payments, to impose a harder budget
constraint capable of bringing greater efciency among health
professionals.
4. Improving the cost-effectiveness of evaluations for new and
existing technology, so that only technologies providing the
greatest overall benet are reimbursed.
5. Reducing the generosity of the publicly-nanced health benets
package, with access rationed through waiting lists and other
regulatory policies.
Source of text above and photo left: VoxEU.org
Life expectancies in
London fall from west
to eastas illustrated
by a journey on the
London Underground
3
3. Analysis by the London
Health Observatory using
Ofce for National Statistics
data revised for 2002-2006;
diagram produced by the
Department of Health (DoH).
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Warnings from Engage Brussels 2011
Medical innovations can help to ease the scal burden of healthcare spending, but the technology
itself often comes with a high price tag. Yet, most drugs (even the newest) still treat symptoms only,
rather than cure disease, and so do not diminish the populations burden of sickness.
Karen Taylor informed the Engage Brussels conference that the average cost of bringing a drug
from concept to patient is now US$1.3 billion. The process of drug discovery and development is
loaded with regulations that aim to improve the quality and safety of products. Meeting these high
standards is costly.
Meanwhile, the number of specialists has expanded across Europe to keep pace with the growing
complexity of medical technology. According to OECD data, specialists now exceed generalists in
numbera trend that has further swelled the cost of the healthcare workforce.
How governments are tackling healthcares nancial crisis
Governments across Europe have responded in two ways to the nancial crisis,
to the heavier demands on healthcare systems and to the increased cost of
innovation. They have tried to improve the productivity of healthcare systems,
and raise more capital funds through tax rises, insurance hikes, and increases
in patient co-payments.
Thwarted by fragmentation, uncoordinated planning and lack
of political will
Attempts to improve the efciency of the healthcare system have, thus far,
had questionable effects. Efciencies within hospitals free up beds more
quickly, for instancebut discharged patients still need outpatient care within
the community, so the overall level of activity within the healthcare system
is unchanged, or may even increase. In any case, the number of hospitals
in Europe stands in excess of need, and the average cost of a hospital stay
continues to rise.
Meanwhile, lack of co-ordination inside the wider healthcare system leaves
healthcare workers inappropriately located, with some elements of a healthcare
system overstaffed, and others struggling to cope with understafng. The UK National Health
Service (NHS) is a case in point. It tried to reform during the rst decade of the new millennium,
attracting better staff with increased pay-and-incentive schemes, and imposing novel work patterns.
But the reforms failed to alter fundamental working practices, and no cost efciencies resulted;
ironically, as healthcare spend rose, only infrastructure improved, not productivity.
The World Health Organization estimated in 2005 that 80% of diseases are preventableso
the potential for prevention to generate cost savings in healthcare budgets must be huge. But
governments still channel only a small fraction of their healthcare outlay into public health
interventions that hope to halt the rise of lifestyle-related conditionsmainly because most of the
Improving the management of
existing health spend
Techniques deployed are typically:
Taking expenditure out of the
hospital sector, and investing more in
community carechanging the skill
mix of the workforce.
Improving the healthcare systems take
up of technology.
More effective focus on earlier
diagnosis.
Emphasising the support of older and
more vulnerable members of society.
Investing in prevention and self care.
Source: Karen Taylor, Engage Brussels 2011
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benets accruing from preventive medicine do not become evident within normal political lifetimes.
Karen Taylor observed that the UK is a good example of the widespread trend towards non-
investment in prevention. Only 4% of UK healthcare spending is directed at public health initiatives.
Data to inform UK patients and to involve them in managing their own healthcare do exist, but,
in practice, the UK healthcare system, like that of virtually all other countries, is oriented towards
ghting res that have already broken out, not in preventing them from occurring.
In short, the failure of attempts to better manage costs can be attributed to a lack of transparency
that pervades the healthcare system, an absence of data on how to measure productivity, and a lack
of political will.
Raising further capital to fund healthcares costs is prevented by a lack of political desire to
impose higher levies on a cash-strapped public during a nancial recession. In Germany, the public
vehemently resist increases in their insurance premiums. German citizens already put up with
substantial sums being diverted from their salaries to pay for healthcare. A 2010 Deloitte survey
of 1,000 German healthcare consumers found that the respondents held a low regard for their
national healthcare system compared to that of citizens in other countries. German consumers
entertain mixed feelings about policy changes that affect their healthcare system. The majority of
Germans favour reduced insurance costs
4
.
Dangers ahead
Stephen McMahon, CEO of the Irish Patients Association (IPA), told the Engage Brussels meeting
that one of the longer-term results of the recent economic crisis might be that economists
ultimately take over prescribing decisions from doctors. Stopping such a prospect from being
realised, he said, will require more cooperation between policymakers, regulators, providers and
patients. At present, though, decision-making on how to reform healthcare in the light of the new
scal austerity has failed to involve patients (or even other key stakeholders).
Birgit Beger, Secretary General of the Standing Committee of European Doctors (CPME),
told the Engage Brussels meeting that she was hopeful that prescribing determined by economic
considerations alone would not become dominant:
The principle of justice in medical ethics gives healthcare professionals the responsibility to look at
the cost-effectiveness dimension of healthcare. However, pure economically-driven considerations would
be against fundamental EU principles, and contrary to the patient-centred care that has been proven to
lead to better health outcomes.
The rights of Europes patients to good healthcare are further enshrined in the 2005 Luxembourg
Declaration on Patient Safety, which stated: Access to high-quality healthcare is a key human right
recognised and valued by the European Union, its Institutions and the citizens of Europe. Accordingly,
patients have a right to expect that every effort is made to ensure their safety as users of all health
services.
5
Despite these reassurances, the case studies below show, rightly or wrongly, that the greater
emphasis being placed on scal austerity in healthcare is beginning to have a negative impact on
health outcomes.
The Innovative
Medicines Initiative (IMI)
is a new model for building
stakeholder partnerships in
the early phase of R&D.
Richard Bergstrm, Director General,
European Federation of Pharmaceutical
Industries and Associations (EFPIA)
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Revolution in the innovation process
Richard Bergstrm believed that one way of lowering the sizeable cost of innovation would be to
change the nature of the process of invention. The pharma industry factors redundancy into the
task of drug discovery. Many candidate drugs are tried; some go as far as testing in animals and
humans, only to be abandoned at a later stage for any number of different reasons. Among the
most important of these reasons is that, years after the R&D investments are made, society rejects
the discovery as not cost-effective. Such waste could be prevented if the people who decide whether
healthcare systems might benet from the introduction of a new pill or gadget were involved at
those early moments in the R&D process when pharma scientists simply put their heads together to
try to guess what the world of healthcare needs.
Richard Bergstrm noted that the Innovative Medicines Initiative (IMI), which began operating
in 2007, was born out of a desire to do just thisto build stakeholder partnerships in early-phase
R&D. The Initiative brings together industry, patient groups, and health providers under the
auspices of the European Commission and EFPIA. Each of the latter two are due to contribute 1
billion to the IMI in 2012, making the Initiative Europes biggest public-private partnership (PPP).
PPPs have many inherent advantages. With science becoming more complex, the need for
collaboration grows. Until recently, the IMI was mostly a European affair. But research cannot
always be bound by geographic boundaries, and, in June 2011, the Initiative formed a partnership
with the Critical Path Institute of Arizona, which shares similar objectives to the IMI.
The Innovative Medicines Initiative (IMI)
From the outset, the Innovative Medicines Initiative gave itself a double duty. Firstly, the Initiative
aimed to look at the state of play in R&D within both industry and academia. Secondly, it would try
to determine what new medical interventions society needed, but was not getting.
The simpler activity within the IMI remit has proven to be the setting of research targets (for
example, in 2012, the IMIs twin research priorities are tackling antibiotic resistance and building a
pan-European chemical-compound library and screening centre). The more difcult task is how to
make the R&D process more effective, exible, and capable of delivering the goals that the IMI sets.
One constraint on the IMI is that industry will provide it with capital solely for work conducted
in the pre-competitive phase of researchthat is, research which is too far up the earliest stages of
the R&D pipeline to be of any signicant commercial value.
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s
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Building a more efcient R&D system through other models of engagement
Manufacturing industry approaches consumers to nd out what they want as a rst step before
deciding what products are made and sold [see Ileana Weltes talk at the Engage Brussels meeting,
mentioned later in this report]. Yet the very idea of asking citizens about medical research goals
seems shocking to many healthcare scientists. Part of the reluctance to involve ordinary people
is rooted in the belief that medical science is just too complex for the population to understand.
But such notions are being dispelled. An Internet-savvy general public is not only interested in the
nuts and bolts of science, but is also more willing to question whether the whole scientic R&D
framework behind medical innovation works to societys advantage.
Jacqueline Bowman-Busato is the Executive Director of the European Platform for Patients
Organizations, Science and Industry (EPPOSI), a Brussels-based, independent, not-for-prot,
partnership-led, multi-stakeholder think tank. One of EPPOSIs major objectives is to examine how
policies governing innovation in healthcare can be changed to promote European citizens to be
integral in the process of creating new and improved products and services. Jacqueline Bowman-
Busato told the Engage Brussels meeting that if users of medical technology participate in each phase
of innovation, they are more likely to welcome what the results of that innovation has to offer.
The challenge then, said Jacqueline Bowman-Busato, is to develop the skills of listening, keeping
personal agendas in check, and going forward as a team.
She told the Engage audience that EPPOSI ran a March 2011 focus group looking at how
a bottom-up approach can facilitate effective innovation to provide new and improved
healthcare products and services. During 2012, EPPOSI hopes to develop evidence-based policy
recommendations on how to streamline the facilitation of a bottom-up approach to innovation
in healthcare. The results will ultimately be developed into a practical guide to creating healthcare
services with better input from the people who will actually use the innovation.
Rapidly-expanding social media networks will help healthcare innovators reach out to relevant
communities and to include users in their R&D programmes.
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The model for
co-creation
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Social media, health apps and e-health
As wireless technologies link up with smart phones, regular home monitoring becomes nancially
realistic. And as more medical data is committed to electronic format (and methods found
to standardise e-medical language), social media and e-health systems may hook up with one
another, so that doctor and patient can sustain contact outside the doctors ofce or the hospital.
Continuous feedback of personal vital signs
should enhance the performance of medical
therapies. The entire combination affords new
opportunities for radically different forms of
healthcare interventionsand novel scientic
exploration.
Two representatives from e-health industries
then described to the Engage Brussels meeting
their approach to innovation.
Skye Van Raalte-Herzog, CEO of California-
based company Expanded Apps, described to the
Engage Brussels meeting why and how the health
app revolution is taking hold.
The term app is an abbreviation of
applicationtechnological jargon for a computer
program. Apps are created by writers, designers,
programmers (usually called developers) to perform certain tasks, or to offer certain services.
Apps may be written to run on the Internet, on computers, or, more recently, on Internet-enabled
smartphones. Such phones travel everywhere with their owners, and so any health apps loaded onto
the devices can supply continuous serviceunlike the traditional ofce- or hospital-located doctor.
60% of the worlds population has a mobile (sometimes called cell) phone.
5 billion mobile/cell phones exist worldwide.
Mobile phones are owned and used even by some of the more vulnerable and hard-to-reach
sections of the population.
Mobile phones can be used by their owners around the clock, seven days a week.
The apps that run on the smart versions of mobile phones are often either free, or affordable to
even to the poorer members of society.
Apps can entertain, provide information, or help the phone owner organise their life.
Apps work instantly, so the services they provide to the phone owner are available at a moments
notice.
A sizeable proportion of health apps are aimed at health professionals. But increasing numbers
are now designed solely for patients. The best patient-oriented health apps can provide meaning
to patients who are trying to self-manage their medical conditions.
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219 million people in Europe use social mediaplacing the region ahead even of the usage levels
found in the USA. 52% of European social media users are men; 48% are women.
Not all social media users are young. Linkedin numbers 100 million member users, the majority
of whom are aged 55-plus.
Skye Van Raalte-Herzog explained that her rm, Expanded Apps, provides educational tools
which raise patients understanding of how their bodies and their health interrelate. Originally
funded by the pharma industry for health professionals, the companys apps are now offered to
the public (so competitive is the apps market that the prices of apps must be very low, bringing
health apps within easy reach of patients). A massive effort, utilising the input of medical experts,
goes into ensuring the accuracy of the data in Expanded Apps products. Expanded Apps partners
for health-related topics with content providers, such as McGraw-Hill and a medical animation
publisher. The medical animation is lively, yet scientically-accurate.
Skye van Raalte-Herzog told the Engage Brussels audience that the next important breakthrough
in health apps will be a transition from the provision of mere healthcare information towards
interaction with and between users. Health apps, noted Skye van Raalte-Herzog, have a tangible
future as a tool for self-care and as a means of promoting better health outcomes. Less than half of
health professionals adhere to ofcial evidence-based guidelines, as determined in clinical trials.
Health apps allow people to help themselves to the best healthcare information, take the right and
appropriate medicine, at the right time, and know when to seek medical advice, if necessary.
Ileana Welte, Head of Global Sales at Robert Bosch Healthcare GmbH, talked to the Engage
Brussels meeting about how her company (well known among consumers for its garden tools,
car safety systems and washing machines) moved into the healthcare market. The companys
knowledge of, and closeness to, ordinary consumers meant that Bosch entered healthcare from a
unique starting point and with a skill set unlike that of the more traditional medical manufacturers.
The Bosch approach was different immediatelythe companys healthcare subsidiary began by
nding out what the public most wanted from healthcare.