A closer Look at eHealth
Interview with Professor Stephan Jonas | Chair for Digital Health of the Technical University of Munich and Head of the Institute for Medical Informatics at the Bonn University Hospital
Professor Jonas studied computer science at RWTH Aachen University (2009). He was awarded a doctorate from the University Hospital of RWTH Aachen in conjunction with the Yale University School of Medicine (2014). He was subsequently in charge of the Mobile Health (mHealth) Research Department at the Institute for Medical Informatics of the University Hospital of RWTH Aachen. In 2019 Professor Jonas was appointed to the Chair for Digital Health of the Technical University of Munich. He has been Head of the Institute for Medical Informatics at the Bonn University Hospital since 2021.
The Federal Ministry of Health has stated "eHealth groups together applications which use the opportunities offered by modern information and communication technologies (ICT) to support the treatment and care of patients." Is this also your definition of eHealth?
I personally feel that the regulator's definition is good because it is clearly meant to be far-reaching. The Medical Devices Regulation defines it as any software used for the diagnosis, prevention, monitoring, prediction, prognosis, or alleviation of disease. It is clear here that eHealth is about more than just the treatment and care of patients. Health does not start when a file is opened for a sick patient: it starts with the maintenance of good health and prevention. eHealth or digital health covers all these aspects of health.
When looked at this way, the range of its potential uses is almost boundless. On the one hand and thanks to the wide availability of smartphones, people are able to take the initiative to protect their own health with preventive measures without having direct contact with experts, for example through fitness applications. At the other end of the spectrum telemedicine, which also forms part of eHealth, not only allows patients and doctors to contact each other but also makes virtual consultations between intensive care units possible - something that requires higher standards of security and different equipment.
Speaking of telemedicine, has the Covid-19 pandemic promoted this area of medicine and will it become even more important in the near future?
Yes, but its potential has not been exhausted. Many doctors and therapists resorted to teleconsultations during the pandemic; fundamentally speaking, these are a video call for professional purposes. By that I mean that the "analog" process of a visit to the doctor has been directly transferred into a digital dimension in exactly the same way that digitalization in hospitals has generally only changed paper files into digital documents. In essence, digitalization is a disruptive process which also challenges all existing procedures and structures to optimize processes and shape them around the user.
Thus, there should be much more to telemedicine than pure video calls. One big advantage that is not yet being exploited is the transmission of medically relevant data from the user's smartphone to medical specialists. Examples of this would be patients' diaries or ECG charts from a smartwatch. Digital communication has the advantage that this data could be uploaded before an appointment with the doctor and an evaluation could be performed by a specialist if necessary, a medical service or even AI, and jointly interpreted with the doctors during the appointment.
Another example: if I use my smartphone as a pedometer at the time when being treated by a physiotherapist, the therapist can automatically receives this data. Then, he could see for himself whether there had been any progress since my hip surgery. This information could also be sent outside office hours. In this way my physiotherapist could see whether I was achieving my therapy objective or it was not feasible for me. Modern sensors and cameras in smartphones can also record parameters such as joint angles. Doctors can use this information in a telemedical setting. The system could display to what extent a shoulder joint is currently moveable. A person’s pulse can also be measured using a smartphone camera. All sorts of data could also be recorded almost incidentally. In a traditional settings, additional time and resources would have to be allocated for this. This is the direction we ought to take if we are to completely exhaust the possibilities of telemedicine. But we are still a long way from this.
mHealth is all about mobile applications where the possibilities extend from sports apps to online eye checks like the ZEISS Online Vision Screening and to diabetes management apps which are now available on prescription in Germany. Is it really possible to group these different applications together even though their "health-related value-added" varies considerably?
No: there is a whole host of different opportunities and categories. For example, an app which treats an illness and an app I use to keep myself fit are fundamentally different in very many respects. The first is a DiGA, a digital health app or an "app on prescription". These are different from many other apps in that it must be crystal clear that they are medical devices. This means that they are used with a quite specific objective, in a quite specific area and for a specific period of time for the prevention, diagnosis or treatment of a specific illness. These DiGAs possess a specific and proven effect and the healthcare system will therefore pay for them.
A further category is the duration of use. Personal "diagnosis apps" such as Ada Health into which I enter my problems and symptoms almost in the same way as I would describe them during a visit to my doctor, tell me the most likely underlying causes or illnesses. I use this app at one particular moment in time. Then there are apps that work over a period of time. These are, for instance, fitness and nutritional apps which only provide meaningful results if they are used systematically over a prolonged period. Apps can also be grouped according to their output. If the app is a prevention app, I am trying to avoid something; if I am feeling unwell and want to know what it is, I use a diagnosis app; or I use a therapy app to treat an illness. The range is inconceivably wide. mHealth apps can't all be squeezed into a single category; they are more like a bouquet composed of many different colored flowers.
In the areas of prevention and diagnosis you hear about apps that were actually developed for communication purposes for example, but depending on the ways they are used it is possible to detect whether the user is suffering from depression.
Yes, they really work. We have developed an app capable of detecting depression by the way a social media message is composed. The technology has been tuned to pick up the same linguistic signals which we as people notice in a general way or psychologists specifically notice when we speak. Examples are prevailing moods of negativity, changes in lifestyle or even thoughts of suicide.
So, let's turn now to the topic of data protection. It often happens that I, as a consumer, can no longer gauge how much data I am disclosing and what it is being used for. How can I protect myself?
We leave a huge digital footprint whenever we use our mobile apps. Just look at the authorizations you have given to various apps or your voluminous search history with your favorite search engine. A vital and fundamental distinction has to be made between data that is processed and stored only "at home", that is to say on your smartphone, and data processed and stored in the Cloud. You might well be indifferent about location data disclosed to a weather app but it is probably quite a different matter as soon as your medical history comes into question. This is particularly a problem with illnesses which unfortunately still carry a stigma, for instance an HIV infection or psychiatric illness. If I have an app which records the progress of my HIV infection or my depression, that really is worth protecting. But all data stored centrally in the Cloud can be tapped, be it with good or ill intent. You should also keep this risk at the back of your mind when you decide to download a specific app. In addition, the location of the provider of the app plays an important part in the protection of my data: is the provider based in the EU and therefore subject to the GDPR, or is it based in a country that doesn't follow these standards?
In actual fact no-one can say nowadays what can be figured out in the future by interpreting the data. When registering with Facebook ten years ago probably no-one concerned themselves with the question of the extent to which the data shared there could manipulate elections, or that it was possible to identify psychological illnesses from the posts. The same applies to the data relating to health that is currently being collected. Today I record my temperature and pulse to identify my level of health and fitness. But this data can also be used to diagnose, for instance, if I am pregnant. Individual items of data carry an incredible range of information and knowledge can be derived from this information. A further point is that new sensors are being constantly launched in the market that supply new information. In such cases no clinical experience exists either on the use of such sensors or on the data that they collect. Therefore when a provider markets a new sensor or app, you can't expect the man or woman in the street or even experts to be capable of knowing or assessing the purpose for which these sensors or apps can be ultimately used.
These are the risks which often come into play in relation to the subject of digitalization. Let's look again at the positive aspects of digitalization. In your opinion what are the major possibilities and opportunities of eHealth and mHealth applications?
There are definite opportunities in the field of prevention, for example related to sports or nutrition, where the initial barrier preventing the use of an app or at least checking it out is much lower than searching for a sports medicine specialist or nutrition consultant. Going to see the last two is associated with a certain obligation which I don't want to commit to initially. In addition, the availability and speed of the distribution of mobile apps is much wider and faster. I can copy and download an app as frequently as I want, but the same doesn’t hold for a sports medicine specialist (yet).
Apart from this, I think that the subject of sport has moved much more to the forefront of peoples’ thinking as a result of fitness apps and trackers. If the sporting activities of my friends and acquaintances are highly visible on social media, this increases my motivation to take up a sport.
At the same time eHealth and mHealth applications can add to the field of medicine by increasing the quantity and quality of data. If data is captured over a lengthy period, even if only in digital diaries kept by patients themselves such as migraine apps, correlations can be established earlier or interventions more precisely targeted. This was impossible in the past as it is not practical to assess analog diaries efficiently over long periods.
In the long term, medical care in the countryside will only be possible with digital aids such as telemedicine, intelligent sensors and customized health programs delivered by mHealth or eHealth applications. The legal framework for their use is now clearly in place.
This also helps cope with demographic change. In this respect is there a country that is a trailblazer in the adoption of digitalization in healthcare and cooperation between government agencies and healthcare insurers?
The Scandinavian countries and Austria too have a significant advantage in the digitalization of medicine. This is due to the way data is exchanged and merged between the various healthcare actors in these countries. If all my medical data is available in one place, I can download it and, for example, use an app which develops and customizes an exercise or nutritional plan from all the data. The plan is therefore more effective because of the personalization.
Thank you very much for this wide-ranging interview.