Digital Healthcare: Population-Level Applications

Abstract

Digital technologies are now an essential part of daily life, and they have provided many solutions that were not possible before. According to the United Nations, the world population is now three times greater than in the mid-twentieth century. Equally public health demands have increased with different concerns and priorities at different points in time, for example, the use of vaccines to control major life-threatening diseases such smallpox and polio to molecular diagnostics for targeted therapies in cancers. Despite these advances, enabling access to these services remains very challenging. The emergence of digital technologies has made these services more accessible than before but has also introduced new complications to the system such as increasing demands on the operations of the system. In this chapter, we will discuss the latest developments in digital healthcare applications to ease population-wide public health challenges.

1 Introduction

China is the largest developing country and it was one of the first countries to implement digital technologies into society (Dai 2002), because it was recognized that digitalization could be a favourable solution to solve many of the issues that were being faced in China (Bongaarts 2009). Most of the country’s resources were diverted to develop their own telecommunication infrastructure. China developed its own standards for 3G to 5G (Lee and Yu 2022), knowing that a good digital platform would require a good and affordable infrastructure. China rapidly developed a secure and reliable digital payment system based on QR codes, in which a payment code is generated on the user’s mobile device instead of using credit cards or a contactless system. The emergence of digital payment laid the foundation for the development of digital health. According to a recent report published by the China Internet Network Information Center (CNNIC), China is estimated to have 1.051 billion internet users and 99.6% of them access the internet using their smartphones (CNNIC 2022).

Before digital solutions were implemented, hospital patients had to go through a series of steps to access treatment: making an appointment, waiting for consultation, consultation, inspection with diagnosis and payment with therapy. Figure 1 shows that the average time spent for a single visit to hospital was between 180 and 300 minutes on average and only 3% of this total time was spent in consultation. The lack of communication between patients and doctors caused major trust issues nationwide. There are currently 1100 internet hospitals registered in China and it is estimated that over 60% of second tier hospitals or above have online services. Figure 2 shows how internet hospitals changed the overall user experience compared with the previous system. The following sections introduce some background on the development of population-based applications in China.

Fig. 1

Shows the average time spent for a typical visit to a hospital in China

Fig. 2

Shows areas where digitalization has changed the patient interaction with healthcare services

At the beginning, digital health services were limited to the provision of information and payment functions. This eased the pressure on information counters, cashiers and accountants, and shortened queues for those who need to use the services. However, the benefits of digitalization were not fully exploited in the medical system. Technologies such as electronic medical records and online appointment systems were not popular with the management of the hospitals. Implementing new technology into the existing system creates concerns about how operations in the hospitals will be affected, especially since most of the hospitals in China are relatively large in terms of capacity due to the large population. A failure in the system can potentially be disastrous, therefore, many pilot tests were carried out to demonstrate that the new technology would work, and also to address the changes that would accompany the transition (Liang et al. 2020).

2 Digitization Period

In 2009 the Ministry of Health (presently known as the National Health Commission) published a guiding opinion about the execution of an appointment based reservation system in hospitals (China 2009). Since then, China has tested many digital solutions including digitised medical records, online appointments system, image information sharing, remote consultation, and online prescriptions etc. Many software developers emerged to create apps because of this, but the lack of uniform standards in these apps created a lot of challenges. For example, different branches of hospitals under the same institutions initiated different digital solutions at different times and settings, which resulted in many different apps that could not connect to each other. Users also became very tired by the endless registration process, and a lot of the work reverted to manual processes. Eventually, some apps were developed that provided solutions for such settings, for example, WeDoctor (also known as Weiyi) and Ding Xiang Yuan. Most of these platforms are informative in nature, and there are very few clinical applications. In addition to the developments in hospitals, in 2000 many cities began to set up demonstration zones to allow online purchase of non-prescription medications. Since then, the State Food and Drug Administration (SFDA) (presently known as the National Medical Products Administration) has issued regulations and monitoring systems to further define online medication services such as the business qualifications, service areas, standards, and specialised qualifications for targeted groups (Administration 2007). Despite small market occupancy, platforms started targeting pharmaceutical consumers.

As the coverage and speed of the internet increased, the increase in connectivity enabled the possibility of remote consultations. However, such consultations were not considered to be fully legitimate or recognised. In 2014, there was an official guiding opinion published by the National Health and Family Planning Commission with guidance on promoting remote medical consultation services (China 2014). The paper stated that remote consultation is limited to the referral from one medical institution to another. This is because the authorities could foresee chaotic impacts if remote consultation started from individuals to professionals. Instead, they preferred to start with two medical professional categories, who are under regulatory control. Such progress received much attention in the market, and a lot of the focus began to shift to how to move forward by proposing different future regulatory models and plans for how they should be set up. Meanwhile, the development of online medication purchases was a lot more complicated. There were a lot of illegal trading activities on the market, unlicensed entities or individuals sold registered or unregistered medications or licensed entities sold medications online that required prescriptions. The authorities understood that digital health would be incomplete if online medication services were not operated in a regulated manner. However, the areas of control exceeded the health authority’s coverage. After careful evaluation by the authorities, it was concluded that a healthy growth of online medication services would require the control of information technology, commercial business regulatory, cyberspace information management, police, and medication registration information. Hence, the first joint notice targeting illegal online selling of medications was published in 2013, the paper was published jointly by five departments: SFDA, Cyberspace Administration of China, the Ministry of Industry and Information Technology, the Ministry of Public Security and the State Administration for Industry and Commerce. At the same time, SFDA agreed to allow some of the more established and developed areas like Shanghai and Guangdong Province to have medication services on a third-party platform.

In addition to this development, informatics infrastructures such as cloud computing, artificial intelligence and big data created links between online and offline settings. The Opinions of the General Office of the State Council on Promoting the Development of “Internet plus Health Care” allowed hospitals to have the name “Internet hospitals” affiliated with their original registered name. This allowed them to give remote consultations and health management consultations for follow-up patients with certain common or chronic diseases (Council 2018). It also allowed a qualified third-party app to connect its services to these internet hospitals. Later in the same year, the term and concept of “Internet Hospital” were further defined (National Health Commission, 2018a, b, c), allowing online general practitioner registrations and follow-up of certain common or chronic diseases. The documents also limited the service to non-first-time patients. Later in 2016 strategic documents Health China 2030 listed digital health services as one of the national strategic goals (Tan et al. 2017). Immediately, many previously established third-party apps formed Internet Hospitals, and interestingly, some medical institutions closed their offline consultations. At the time of writing, according to the statistics from the National Health Commission, traffic for online medical consultations has increased 20 times, consultations with treatments have increased 17 times and those needing prescriptions has increased 10 times in the last 5 years.

3 Present Developments

At present, online medical services can be classified as either Business to Business (B2B), Business to Consumer (B2C) or Online to Offline (O2O). B2B and B2C are the most popular bases for the platforms. In hospitals, digitalization of healthcare led to the progression of prescription services to a direct-to-patient (DTP) model. This model has since further evolved into three different applications:

• (i) Prescriptions within the hospital

Digitalization for prescriptions within the hospital is the most common service provided by internet hospitals. Upon approval from the pharmacist, prescriptions are delivered to the patient’s home address. This service does not have any direct commercial value, but rather it is an added-value service. This model functions within the hospital’s information system (HIS) unit and does not involve any external platform. In contrast to conventional offline hospitals, this model demonstrates the capacity of internet hospitals, where users do not have to visit the hospital and regular follow-up can be done via smartphone, prescriptions can be issued upon approval by HIS, users can pay within the HIS, the approved and paid prescriptions are then transferred to the pharmacy for approval and the medication will then be dispensed and dispatched to users by logistics. Despite its capacity, this model is not always preferred by many because social medical insurance limits the potential financial margin for such services, and it creates a much bigger demand on the hospital workers.

• (ii) DTP through online shops

DTP through online pharmacy stores is how users mainly request specific medication products, then a doctor assesses if the user is apt to use such products (whereas the model described previously requires a prior consultation with a doctor). Once approved, this information will be transferred to internet hospitals and a prescription is issued and delivered to the user. This model has relatively larger financial initiatives compared to (i), so many of the procedures are very reproducible. However, the platform sets a lot of commercial rules, and often the entry requirements for such business are very demanding. Therefore, it is very difficult for one to copy such a model.

• (iii) Outsourcing of prescriptions

This is a model that evolved recently. Internet hospital prescriptions are outsourced to a platform that connects to online pharmacies. The platform checks the availability of the items in their shops and users can then view a list of shops that have the required medication in stock. Upon approval, the medication can be collected from the store or delivery can be arranged. For this system to function effectively, hospitals and pharmacies must use similar pharmacopoeia. This solution diverts the demands into pharmacies closer to the users.

4 Emerging Industries from Digital Health

The traditional medical industry in China can be divided into three parts: an upper stream that consists of medical device manufacturers and pharmaceuticals; a medium stream that comprises the offline hospitals that provide medical services; and a downstream that comprises the users that pay for these services that can be divided further into governmental expenses, public health expenses, personal expenses, and patient expenses. Internet hospitals increase the proportion of personal and patient-related expenses. Industries related to these developments include applications designed for making appointments and consultations, personal health management, online pharmacy shops, tools for doctors (including patient management and sustain educational app), digital payment applications (including commercial and social insurances), AI services (including imaging, diagnostic and medical record services) and digitised information services.

5 Case Study—Ping An Health

Ping An Health is an application developed by the Ping An Group which was originally an insurance company. The group initially had its own team of in-house doctors that then became the core of its health application. The application makes most of its profit from the consumer healthcare sector. Their source of customers is from personal, insurance, enterprise, and offline hospitals. In addition to the in-house doctors, they have taken advantage of remote consultation to acquire specialists from other parts of the country and abroad that led to the rapid growth of online health malls. The data gathered allows them to accurately target specific groups and this creates opportunities for advertising income within the app. From 2016 to 2020, the number of doctors in the app increased about three times from 797 to 2247 and currently there are 400 million registered users (one third of the population). While the group will continue to focus on its B2C customers, it is also looking to optimise the O2O user experience (Fig. 3).

Fig. 3

Shows the operational model for Ping An Health App

6 Limitations and Differences

Despite the big improvements and advances that digitalization brings, the following limitations have been observed through personal communications to frontline workers (anecdotal evidence meriting systematic future investigation). According to CNNIC, only one in five elderly people (over 60 years old) can complete online purchases and search for information online independently (CNNIC 2022). Many patients with chronic diseases have already developed routine habits and are unwilling to change to a digital platform. The lack of understanding of digital technologies creates a sense of insecurity and uncertainty for these users, so acceptance of new technology within certain groups requires additional education and communication to enable them to make the transition. In addition, the medication that the doctor wants to prescribe is not always listed in the directory.

It was also noticed that different sectors had different focuses. At the initial stage, public healthcare providers such as hospitals focused on building internal information systems, their primary aim being to transform the information they already had, whereas the applications platform focused more on providing guidance, doctors’ background, focus groups on specific diseases and user review experience. Eventually, the public sector will move on to remote services such as imaging, pathologies, consultations, and surveillance, whereas the applications will focus more on promoting the concept of preliminary consultation to the public as a tool for light consultation. At the later stage, it was observed that the public sector focused on providing medical services via Internet hospitals and transformed some of its offline services to online. Meanwhile, the applications focused on the integration of medical services, insurance and pharmacies, the purpose of this being to optimise the distribution of resources.

The differences between the digital health services provided by applications and information transformed within hospitals are that applications: (i) optimise the distribution of healthcare resources, (ii) empower digital healthcare services using tools such as AI-assisted systems to improve efficiency and capability, and (iii) connect multiple parties such as healthcare, medical insurance, pharmaceuticals, and diagnostics to avoid platform overlaps.

7 Future Perspectives

The Health China 2030 framework is designed to transform the medical healthcare landscape from diseases focus to a general health focus. The role of population-level applications is to act as backbone support to build a personalized health profile that enables more personalised health management solutions based on more accurate data generated. It is likely that offline medical settings will follow the trend of digitalization. The challenges are the connectivity and interactions between the three systems (hospitals, insurance, and pharmacies). The circuit of appointments, consultations, medication dispensaries and follow-up visits should be completed in a seamless fashion. Thus, integration of the three systems is the key to closing the gaps in the circuit. Furthermore, basic knowledge about digitalization technologies should be taught in schools to increase future understanding and acceptance of these platforms.

8 Conclusion

Based on the experience gained, it was concluded that population-level applications targeted different digital health services at different developmental stages. At the initial stage, most services were mainly information-based, such as information for appointments, online pharmacies with limited items, and basic operational information. The scope of applications was relatively small. Eventually, the manual appointment system was transformed to an online appointment system because telephone appointment systems were very well established, and it was easiest for users to adapt to this transition. For the near future, and once the online appointment system becomes established, it will be possible to use the system for preliminary consultations to reduce the pressure on the frontline. These services are accumulating in number and scope, and networks of digital wards are forming that will eventually become internet hospitals. Because the size of these virtual entities is so big, there will be heavy discussion on regulation and policies on this subject, that will enable population-level applications to grow in the right direction according to their capacities.