Access to medicine
Everyone in France is familiar with SOS Médecins, an emergency medical service which provides advice and sends doctors straight to the patient - and now there’s an app to replace it. Available in France since spring 2017, Docadom offers to put patients in contact with doctors by computer or smartphone. Pierre Blanchard, Managing Director of the start-up, says that “you can have a GP come to your house in just three clicks, by entering your address and credit card information.” The cost of the visit and the time to arrival are calculated based on an algorithm and geolocation system which identify the doctor who can reach the patient fastest. Is this a potential solution to the issues with access to care which affect much of the French population? Particularly in areas where there are not enough doctors? And more broadly, to what extent can the use of digital resources, by both doctors and patients, contribute to resolving those issues?
The idea behind Docadom, as described in its marketing materials, “was based on three observations: the increasing difficulty in getting an appointment quickly, the saturation of emergency rooms, and the decreasing number of new doctors setting up practices. There was a gap, so we are closing it with an additional care offer.” In exchange for 10% of the cost of the consultation, Docadom is essentially offering to compensate for the healthcare system’s organisational flaws. Should we be glad to see the rationalisation of supply and demand in an area where medical structures are struggling to develop new, more efficient and effective models? Or should we be worried by the “Uberization” of medical emergencies? Answering these questions, and expanding that response to the promises and limits of digital from the perspective of equality in healthcare, demands that we first look at the issues involved in access to medicine in France and worldwide.
Healthcare inequalities in developed countries
The key issue in preserving equality of care today is eliminating medical deserts. A brief survey of France shows that healthcare varies widely by region. In the rural Tonnerrois region of north-central France, for example, patients have to travel miles to find a general practitioner. Statistics show that Normandy has 1,587 individual medical practices and 2,447 shared practices, for a total of 9,691 doctors, including in hospitals. The Provence Alpes Côte d’Azur region, on the other hand, has 4,968 individual practices, 5,408 shared practices, and a total of 20,316 doctors.
A map from Hoscare shows the distribution of emergency rooms across the country. It highlights the difficulty in finding care in under thirty minutes in the Limousine region, while the offer between Grenoble and Annecy is “huge”. The map shows that while some regions are “overmedicalised,” other neighbouring regions are virtually abandoned.
Going without care for financial reasons
Healthcare inequality is not just caused by unexpected demographic shifts. It is also generated by emerging social inequalities. Due to a profound economic crisis, certain populations no longer exercise their legitimate rights to healthcare. According to a study by Odenore (the Observatory on non-use of rights and services), ordered by France's national insurer, the Caisse nationale d'assurance-maladie, and published in March 2017, 26.5% of people enrolled in national insurance chose to do without care in 2016. This study of 29,000 people who visited one of eighteen primary insurance centres also revealed that 39% of insured respondents had gone without dental implants (no price cap until 2017), 34% had done without basic dental care despite regulated pricing, followed by specialist consultations (27%), ophthalmology (20%) and glasses (19%).
In France, low income is directly correlated with poorer health. At age 35, managers’ life expectancy exceeds that of labourers by 6.3 years. Older figures from the Insee or the IRDES (Institute for research and documentation on the healthcare economy) confirm the Odenore study’s findings that an increasing percentage of the population is doing without care. The figures for 2011 varied from 10% (Insee) to 26% (IRDES) and the 2013 figures ranged from 21% (Insee) to 36% (IRDES). These significant variations are explained by the way survey questions are phrased: the more precise the question, the higher the figure. In any case, even in the most optimistic scenario, the indicator shows a clear increase in the number of people choosing not to obtain care and thus not exercising their rights.
North-south inequalities in healthcare
The healthcare gap and social inequalities worldwide have dramatic consequences, particularly on families. The poorest households have a mortality rate for children under age five which is nearly double that of the richest households. And their risk of growth delays is twice as high. According to the World Bank, 400 million people worldwide lacked access to the most basic healthcare services in 2016. Ethiopia has just 3 doctors per 100,000 inhabitants, while France has 332 per 100,000 (WHO, 2016).
Simple, inexpensive solutions are, however, emerging. In Africa, 500 million people have a mobile phone. That’s less than half the population, which limits the impact of these initiatives, although the figure does increase regularly. Charities and healthcare organisations have started using mobiles to decrease disparities in access to basic care. Basic phones can now be used to monitor the health of isolated individuals who lack the infrastructure for quick access to care. Unicef’s RapidSMS programme, for instance, offers pregnant women support from volunteers using very inexpensive mobile phones. Support is provided by SMS, so smartphones aren’t needed. While this can’t replace doctors, it does save time in establishing a diagnosis.
The potential benefits of genomics
Computer power is also coming to the aid of patients and doctors with a tool which would have been unimaginable just a generation ago: DNA sequencing. Its cost has decreased dramatically, dropping from over $10 million in 2007 to $1,000 in 2017 in hospital settings, and as little as $100 or $200 when done by private companies using a “simplified” format. With DNA sequencing, patients’ genetic mutations can now be quickly identified. Take the example of Isabelle B., who has been diagnosed with lung cancer. In two months, after cells are extracted from her tumour, sequencing shows an ROS1 mutation. This genetic information means she can use targeted treatment. This precise identification means she can take two gel caps of a new molecule, Crizotinib, instead of going through chemotherapy.
Is the price of progress threatening medicine for all?
But while these advances, which are also available for leukaemia and breast cancer, exceed our wildest hopes of ten years ago, they are also threatening to weaken a healthcare system already undermined by rising costs. Zilkori, the commercial name of Crizotinib, costs 800 euros per day, for an annual cost of 292,000 euros. In France, it is covered by public insurance. But that is a rare exception. In countries with less generous public coverage, Isabelle B. would have to take out expensive private insurance, likely forcing her to mortgage her home.
This economic note is crucial. Therapeutic hyper-precision, which necessarily depends on industry due to the complexity and cost of the research involved, raises a terrible societal choice. Healthcare yes, but at what cost and for whom? Does the fact that digital tends to increase the transfer of medical innovation to the private sector mean we are heading towards a world where medicine is subject to whims of major pharmaceutical groups’ shareholders? That would be the polar opposite of France’s public insurance scheme, known as Sécurite Sociale, created as a strong response to the need for solidarity in 1945. In essence, under this social contract the healthy pay for the sick, the rich pay for the less fortunate, and the young pay for the old.
Providing better care to provide care to more people?
The increased use of IT in private practices and hospital alike is generating tremendous amounts of data. This data is extremely useful in improving medical decisions and providing better care, faster. We can leverage this efficiency to provide care for more people at the right time. The use of algorithms to process medical data is now offering spectacular results.
One notable example is that of Sahlgrenska Hospital in Sweden, where the orthopaedics department started using data analysis to manage its patients. The system takes into account far more details including medical information, and is updated more regularly than traditional patient management and appointment booking software. The result: an 18% reduction in negative outcomes. Repeat interventions dropped 17%, freeing up time for the surgeons, who were able to increase their interventions by another 44% while slashing wait times for hip and knee operations by 40 days. The use of computer power to manage basic appointments enables better care and makes it possible to see and care for more patients.
Apps in professional telemedicine
Docadom’s arrival on the medical “market” is just one of the innovations brought in by new technologies. Without going as far as using the word “Uberization,” virtual healthcare service accessible by computer or mobile are increasingly widespread. Examples include information and appointment booking platforms like Doctolib and Mondocteur, e-commerce sites for medication (1001pharmacies) and optics, and specialised directories like pagesmed.
The most promising area for professional telemedicine applications, is, however, as operational responses to medical deserts. One example is CardioPad, invented and developed by a young man from Cameroon. This tablet can be used by non-specialist doctors, nurses, or even social workers to address the lack of access to cardiology services in a country that has just 31 cardiologists for 18 million inhabitants, a rate of 1.7 specialists per million inhabitants (see the article What (connected) doctors?). "). Another striking example is Medic Mobile, a free application which helps healthcare workers, including nurses’ aides, nurses, midwives, and more broadly village communities in twenty-three African and South American countries diagnose issues and even in some cases provide emergency care.
The key to accessing knowledge on diseases: applications connecting patients
On another level, communities of patients with chronic diseases, like Carenity or Patientsworld, share information on their diseases, the medications they take, side effects encountered, and more, making healthcare-related knowledge more accessible than in the past.
Thyroide.com connects people who have had operations or are currently patients, who support each other in their medical journeys, reassure one another, and share experiences and knowledge. These communities offer a key psychological asset for private disease management, at a time when the ever more efficient and sophisticated hospital machine all too often avoids human connections to focus on a coldly impersonal technical approach. This type of medical application, reflecting today’s “knowledgeable patients,” who are increasingly aware of the details of their disease, can recreate connections at a time when they are desperately needed.
Increasing transparency on the care offer
Broader access to healthcare data can make healthcare more democratic by making public health policies more transparent. It can also allow patient groups to influence those policies. For example, Renaloo, an association of kidney disease patients, wanted to understand which patients with terminal kidney failure were the priorities for kidney transplants, which is more effective and less expensive for insurers than dialysis. Faced with the lack of access to SNIIRAM, the public insurance database which contains the database of reimbursements by France's public insurer, it commissioned researchers to perform a study, which confirmed its hypothesis: there are serious social inequalities in transplant access. Renaloo was able to pinpoint the hospitals and clinics which encourage dialysis, since it brings in a recurring and comfortable revenue stream. An analysis which could have been done sooner and more transparently.
Open source medicine
In a healthcare economy made up of patents and regulatory monitoring, the development of other approaches, like replicable, low-tech, open-source research is an epistemological revolution. Several projects already exist, like the EchoPen, a low-cost ultrasound device incubated at La Paillasse. EchoPen brings together smartphone technologies and urgent medical needs. Too few patients have access to ultrasounds, since they require expensive machines used only by radiologists. Ultra-portable devices do exist, but at prohibitive prices. The open source ultra-stethoscope should offer new resources to general practitioners in medical deserts or doing medical missions. They could use it to quickly distinguish between life-threatening emergencies and false alarms. The free application Medic Mobile, which we already mentioned, is also open source.
The Maker Nurse project represents another extension of the “geek” world into healthcare. Based on the Makers movement, it lowers the barriers between ideas and implementation. Maker Nurse connects great ideas from nurses with DIYers who have the full support of MIT. Maker Nurse provides the machines and trains staff in the Maker Health Spaces. These spaces, located inside hospitals, have top fablab tools and are open to care providers so they can create and build tools to improve patients’ lives. Coordinators help them learn to use the tools (3D printer, laser cutter, etc.). Maker Nurse, the Japanese version of which is called Fab Nurse, has already created a pill counter, a mechanical, programmable rocker, a shower bed, and even a glow in the dark pill box.
But “medicine for geeks” remains marginal and requires new forms of guarantees and approval processes. If you wanted to use a 3D printer to make your own medication at home, who would certify its quality and safety? After the biotech start-up boom of the 2000s, the emergence of this form of “open medicine,” which will of course require strict regulation, may be a part of our future health, the “feeling of physical, mental and social well-being” as defined by the World Health Organization.