Innovation at Charité, The Problems With DiGAs and the German Market (Dorothée Marie-Louise Döpfer)

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology. With me, Tjasa Zajc. In today's episode, you're going to hear about the German market for digital health startups,

[00:00:18] the innovation approach at Charité, one of Europe's largest university hospitals, the challenges with digital therapeutics in Germany and beyond, and more. I spoke with Dorothée Marie-Louise Döpfer, Deputy Head of Digital Labs,

[00:00:36] Program Manager of the Digital Health Accelerator and Community Building at Charité University Medical Centre in Berlin. Dorothée also shared her thoughts about the expect and impact of AI on healthcare systems in Europe. Enjoy the show and if you haven't yet, check out our newsletter.

[00:00:57] You can find it at fodh.substack.com. And if you will enjoy the show, make sure to subscribe to the podcast to get the next episodes automatically in your podcast player and leave a rating or review wherever you get your podcast. Now let's dive in.

[00:01:35] Dorothée, thank you so much for joining this discussion on Faces of Digital Health where we're going to talk a little bit about healthcare innovation and startups in Germany and also how is Germany positioned in the digital health space.

[00:01:50] Maybe just as an introductory question, 2023 has been quite turbulent for digital health. Where do you see the space at the moment in terms of the optimism and the general impression of the potential that we have around digital health technologies and their impact on healthcare?

[00:02:15] First of all, thank you for having me and for the invitation. As you know, I'm German so I don't know if the glass is always half full or half empty so I tried to be very half full today.

[00:02:26] Let's say 2023 was rough especially for startups and especially in the way of funding but when it comes to digitalization in healthcare in general, I think we are on a pretty good road because everybody tries to make a stretch to make things going on, things moving.

[00:02:44] Are we already there? No at all. I think we are very on the bottom of the ladder but I think there's still potential and for 2024 there's lots of things to do and I hope we get a little bit more open to new technologies and we don't over-regulate everything.

[00:03:01] How would you position Germany in Europe? France is really pushing hard the agenda and the positioning as the leader in the digital health space in Europe. Where do you see that Germany is on that scale? So there was a comparative study coming out a few months ago

[00:03:22] where Germany is really downhill. In the world when you compare Europe and other countries on top is Denmark, Canada, Israel and Estonia of course and Germany is pretty down there. The reason is the infrastructure problems we have. I would say Germany really has to move on

[00:03:42] although when everybody talks about the digital health application reimbursement then Germany is on top. So I think France is in the middle on the infrastructure side. They are really good now on the digital reimbursement side because they opened it brought up.

[00:03:59] But Germany, they don't want to hear this but it has still a long way to go especially when it comes to infrastructure to synchronization of records of prescriptions. So yeah that's where I would position Germany. You lead an accelerator for startups inside Charité.

[00:04:19] I have a bunch of questions there and the insights about the German market but let's start with the accelerator. How is it positioned inside the hospitals? How do you operate? The accelerator was formed seven years ago from my boss

[00:04:37] and the former CFO of the Berlin Institute of Health which is partly integrated in the Charité. So what we are a clinical incubation program that is focusing on digital health solution but most people will think we just build digas, no we don't.

[00:04:54] We take everything in our program that has a medical need come from head to toe, we're from cancer to mental health from organites to heart surgery and everything that has a digital component is in our program. What is very special about us, we only work with clinicians

[00:05:13] and researchers coming out of the system of Charité and Berlin Institute of Health which has to do something with our funding setup because we are funded by the German government and this is like mainly institutional funding. And there we work with the teams towards their solutions.

[00:05:30] How do clinicians get into the accelerator? So what's the incentive for them? Is it just research projects to which extent are these ideas actually developed into full blown companies? So there are different kind of motivations. So for researchers it's sometimes they want to make their research matter

[00:05:51] so they come out of their lab and they sell everything it's just papers but I really would like to do something for patients and that's nice in a university hospital so when you do basic research or research you're still close to patients so that works.

[00:06:04] Then some of them they are like scared their scientific career won't go further and they see their colleagues especially in the US and other countries who have founded companies on the side so they see themselves as a way to maybe explore different kind of career path

[00:06:21] and then for the clinicians either they want to do something for their patients because in everyday patient care they are like this needs to be better this has to work differently so they come really with something they have seen that's a problem in the system

[00:06:36] or they are like so driven they would like to do something for the healthcare system and make things more effective and that's why they would like to found a company and for some of them when you're on an academic career path

[00:06:51] it cannot hinder you to find a company. And do you track the success of the company so you mentioned it's the program is 7 years old what are some of the biggest successes to which extent the ideas go beyond something that's detected at Charité

[00:07:11] and can actually also be used in other places often times there's the pilot question or problem where it's applicable to one institution but it can't be scaled elsewhere. So this is something we explore from the very beginning so we don't find anything that is just a silo solution

[00:07:31] so if there's just a problem at Charité that's nothing for us. For us it's important that medical need needs to be a broad medical need it needs to be scalable either to Germany, German speaking countries or to other countries and it needs to benefit patients

[00:07:45] or healthcare systems in general that's number one super important So far we have 44 projects in the program we just onboarded 9 more they will start in February we have so far 10 and a half spin-offs the one is supposed to found at the end of this year

[00:08:02] one exit of these spin-offs one is raising Series B and the others are funded one of our successes one has a selective contracting and we track if they're still alive if they're good we are still in contact and we still see what we can do for them

[00:08:16] and what we like as well is that our graduates come and talk to the younger physicians so they see a little bit the reasons why they have done it why they still go for digital health founding a company or a licensing deal

[00:08:30] why it matters to explore different kind of careers because if I tell them I'm an epidemiologist by training they tell me what do you know about founding a company And what are some of the success stories So what kind of companies for example inspire you most

[00:08:46] what would you emphasize as the key northern stars So because our teams are so different so I think one of the teams we always love to talk about is a team that founded at the end non-for-profit and they're operating in Madagascar so they found a pay wallet

[00:09:05] that helps to reduce the death of pregnant women in Madagascar by better prevention and care So that is one of the things where everybody's like why did you go for this but the impact, the social impact was so important for us

[00:09:20] and we were like if this works that would be great you can scale it you can use it for other countries in southern hemisphere that's why we were super excited about one of our biggest successes is a company called Aaragnostics

[00:09:33] and they work in the field of digital pathology they're raising at the moment a series B and this has been one of our fastest teams growing has now over 100 people employed here in Berlin and they're exploring more options and then maybe another company that has lots of impact

[00:09:53] it's a solution that works on ICUs and they help to prevent severe side effects after heart surgery for example in a bleeding it comes and if you detect it too late you have to do re-surgery and people are more likely to stay long on the hospital

[00:10:10] with severe side effects but the physician who found this was like wow during the night shift I don't have the time and all the data is there but who has the time to detect everything so you build an algorithm that can predict from minute number one

[00:10:27] until you come out of surgery the probability to get an inner bleeding it's CE certified it's deployed at different kind of university hospitals and they have opened this solution up for different kind of other indications like renal failure and this is just in Germany scaled just across Germany?

[00:10:47] at the moment and the difference Aagnostic works with all pharma companies and they have already spread to other sites not outside of Germany depending on what the companies are X-cardiac is the other company is maneuvering in Germany because they work in ICUs they work with hospital information systems

[00:11:08] so every hospital information system works a little bit differently and the infrastructure, data structure all this kind of things so yeah, they are like working in Germany and we have a few other teams they are like building up and they might spin off next year

[00:11:22] they might target already other markets and how do you see that startups are doing when trying to scale to other markets the reason I'm asking this is that when I speak with entrepreneurs across Europe everybody says that it's really difficult to scale or to enter Germany

[00:11:41] just because of the cultural expectation that Germans buy German products so I wonder what's your comment or insight on that and also how do your startups approach other markets especially in the dark region which I'm assuming is the first go-to market that they try to reach out to

[00:12:03] I think it's not so much Germans prefer German products but you have the same problem when you try to enter the French market for example everybody wants its own data so it works for your own population and we don't have one system fits all hospitals

[00:12:22] so that's why they prefer probably working with German products because they have been tested and developed on German sites with a German infrastructure where you're already struggling when you try to scale to other hospitals these kind of things so I think it's more the infrastructure boundary

[00:12:42] and then the data and the level of technology you have I was recently in another discussion in the UK and we talked in general about digitalization and infrastructure and how you can scale your digital health solutions towards Africa, Asia, other regions

[00:13:03] and one of the things we talked about were hindering was the different kind of level of digitalization of infrastructure of health literacy so this is of a thing so I think we have the same boundaries when we go for example to France

[00:13:20] we need to set everything up for the French market all these kind of things and the same when you look into the US market we have quite of a bit of experience we need US data we need US data to be accepted we need unbiased data

[00:13:34] because they have different populations they might have different kind of parameters where they measure the success of a solution so you always need to think very early what is your market what is the next market and what's the best way to scale

[00:13:50] because it's not only in the market scale you can scale in indications for example if we look on the second question was the dark market we always say German speaking market because digital health solutions work for the German speaking market and that's more than Germany, Switzerland and Austria

[00:14:08] so that's where we look and it always depends on the indication and if for example the treatment regime is the same because if they're different in the countries it's very hard to find one solution fits all how would you describe other markets in the dark region

[00:14:26] based on your insights for example Belgium, Austria Switzerland is there a favorite one that startups go to as the first point when expanding from a personal perspective I always recommend Austria when startups come international startups and they come without a pocket because the Austrians

[00:14:50] even we speak the same language they are much more interested to try to meet new things they're like more eager to probably pay out of pocket if it's a benefit for them while the German system because we have this very structured healthcare system where every

[00:15:10] citizen pays a lot into their healthcare funds they are not really willing to pay anything out of pocket because of the high cost they already have Switzerland I also film with Switzerland and I heard from startups it depends when you are in the medical device area

[00:15:26] Switzerland is quite interesting and there's a few trials on the digital side I have not heard so much I think if it's a solution that really benefits patients or users there I am sure they are willing to pay out of pocket otherwise Belgium is pretty interesting

[00:15:42] it's a very small country nobody really talks about them but probably there will be the third country they will start to be very enbursment for digital health solutions like DIGAS and it seems to be very easy and they are very excited about these kind of things

[00:15:58] but you have to know Belgium market is a small market and you need three languages to enter the Belgium market so it's probably the language barrier might be a little bit over hurdle so you need to support all three languages if you want to enter the market

[00:16:12] as I know Belgium when you would like to have a picture of the market you need the Dutch, the French and the German language so depending probably on your disease but they are all official languages so for example when I talked about the German speaking market

[00:16:26] part of Denmark like small towns of Belgium speaking German so if you have users there of course they can use the solution or if you have a German community in South America so if they are interested to use the solution

[00:16:38] they can use it but probably not with reimbursement then you mentioned DIGAS and this is definitely the thing that Germany is most known about in the digital health space but it also went from extreme excitement about framework existing making it easier for solutions to actually

[00:17:00] be reimbursed by all healthcare insurance just by going through one regulatory process however there's also been struggles after one or two years where basically because the prices of solutions get adjusted after a year that the solution is in the system some companies are struggling with just the business

[00:17:24] side of their solutions because the prices get decreased by healthcare insurance companies so how do you see DIGAS in terms of their success, in terms of how much they are actually prescribed by clinicians, used by physicians, where do you see the challenges? So I have to admit

[00:17:46] I'm one of the very critical voices in the system but from the background I come from the clinical setting. This DIGAS are not really working for the clinical setting because it can be only prescribed in the release management or when you work in this kind of

[00:18:02] ambulance, jury, Psy what I heard in the interaction with the health insurance is they are very frustrated about the prices because they say it's too expensive for an add-on therapy because the digital halt add-on doesn't really reduce the standard therapy. It's an add-on

[00:18:22] to maybe help with patient adherence to make the patients happier but this is an extra burden on the healthcare system where we already like really suffering and then on the clinician side it's yeah but sorry there are so many solutions on the market

[00:18:36] we don't have the time to assess the solutions and even a few years ago they did not even get free access so now they get free access but there is like really lots of discussions if this is allowed not and so the clinicians say listen

[00:18:50] and lots of those solutions they need heavy explanation to my patients I don't have the time and then I saw lately there was a big report from one of the health insurance companies they said they need to show a positive effect on the medical benefit for patients

[00:19:06] but lots of the clinical studies or the surrogate parameters they hand in they are so unclear we don't really see if they can prove that they have an effect so it's all those kind of questions and then the other thing is the advertisement was very big every start-up

[00:19:30] from all over the world was so excited so they came to Germany and then there was a bummer because they could not use their own data so everything they showed they said yeah it's nice you have this but have you tested this on German data no I haven't

[00:19:44] so then they needed to restart again then they had to enter the process and they were like I thought this is easy but you need money it takes time and then when you are just in this kind of on this website it doesn't mean you are in

[00:20:00] in between a year you have to prove you have this medical benefit for patients and then as you mentioned at the beginning you have a nice price but after the latest I think 18 months it's renegotiated and then it's cut quite a bit

[00:20:16] because of course the health insurance cannot pay as long for this long prices the idea itself I think everybody agrees is really good it just in the execution it's lots of things they need to change and this I think what they learned over time the processes will probably

[00:20:36] change a little bit France for example they opened it up for higher regulated classes B and 3 which is not in Germany at the moment it's just 2A and this is something they consider in Germany as well and then how to bring this prescription in the clinic as well

[00:20:52] but yeah so it's very conflicted the economical side is a massive problem and so I'm not very positive about this at the moment but I still have hope that the idea with a little bit more work and rethinking and not just advertisement and feedback

[00:21:14] for example from the start ups from other countries from start ups they have failed we can make it a little bit better because for example one of the things there were a few digital health solutions on the market and there were deegas and now they are not anymore

[00:21:28] because they didn't see this positive benefit for patient but there was a massive discussion if it was actually the product or were the physicians who didn't prescribe it or the patients not using it properly we need to find different kind of measures to see

[00:21:44] if the solution has really a benefit or it has no benefit and it's just like some add on or something so I think lots of work I was a bit surprised when you said that basically the insurance companies see deegas more as an add on

[00:21:58] to the existing therapies because by definition digital therapeutics are supposed to be standalone solutions that have proven therapeutic impact so when you look a little bit into the catalogue we have lots of different kind of categories one of the most expensive digital health deegas are solutions

[00:22:18] that need to be adjusted by either a physician or a speech therapist so that's a personalized individualized therapies who support the initial therapy super important very expensive but they need lots of time from the experts so that's one kind of the therapy we have lots of cognitive behaviour

[00:22:40] therapies on the other hand there are more stand alone but you still need interactions you still need feedback if they are working and then is a different kind of other bunch so I think what came as solutions and what was planned differs a little bit

[00:22:58] so that's why I never talk about digital therapeutics because only a few of them probably fit in this category others are digital health solutions they are an add on for therapy I think the whole digital health space in terms of the mobile apps

[00:23:16] went from people having this idea that just because you create an app people are going to use it to people realizing that digital health apps are only going to work in combination with the human interaction to actually going towards digital therapeutics that are

[00:23:32] supposed to be stand alone solutions but heavily tested through clinical trials so I don't know what's your prediction or expectation in terms of where the market is going to develop where does digital actually help in healthcare and where do we still need to figure things out better

[00:23:54] so I think where healthcare systems especially in Europe struggle at the moment the most is infrastructure and the lack of personal of people at the moment I see a massive benefit especially with chat GBT and these kind of things to make administrative processes smaller for the healthcare workers

[00:24:16] because they need to spend more time on patient care and with all the administrative stuff at the moment they don't have the time so this is where I think some of the digital health efforts will have in the next few years to make the system supported by

[00:24:34] AI based solutions more effective so physicians have more time to take care of the doctors you mentioned just the main mobile apps I think the market will be done in a few years because patient monitoring things patient adhering things you can copy paste it it's nothing special anymore

[00:24:56] so I think it will go more towards AI and drug development finding more personalized therapies with the help of digital health add on solutions to support patients when they cannot see their physicians because there's not enough time and then I think to help in the better communication

[00:25:19] direct communication between healthcare provider healthcare assistants doctors and patients I think this is where it's going and probably the other part which is very boring probably for lots of startups is information because it's very hard still very hard to find the right information

[00:25:40] for your disease this kind of things physicians don't have the time so curated information with the help of chat tbt I think that's where it goes as a German citizen what would you say is your experience with healthcare in the digital sense so

[00:26:00] doing things through mobile app accessing your patient data in the digital means how would you characterize Germany as digital for patients and what are you potentially excited about in terms of where things are going on the national level so even I co-run the digital health accelerator

[00:26:20] in my private life I'm not very digital the only thing what I use is like the web portal of my health insurance and this works very well but the eProscription I have never used because it has not come along to me so far

[00:26:34] I think there's lots of potential let's see in the future but I would be excited if everything is just in one solution and I could access for example like I think it's Estonia I have my healthcare record I can tell hey you can use this

[00:26:52] for clinical trial no please don't share this so just manage with opt out options what I would like to share what I don't like to share I'm not regulated by federal laws federal scarce so that would be my dream just to decide as a citizen

[00:27:12] what I want to do, what I don't want to do but I don't see Germany going there we tend to forget that while Germany is a good or is a big market it's also federated through states that can decide on different things

[00:27:26] I don't know to which extent do you observe that startups struggle because of that and I see startups always come to Berlin because they would like to work with the Charité which is a very good brand one of the biggest university hospitals

[00:27:38] in Europe and then they come with a solution that's cloud based but you cannot get patient records coming out of the Charité it's again the Berlin hospital law but for example you can use the cloud in Bavaria or Bremen or something

[00:27:52] so when I talk to these startups I always say do you come here because you need special data and you would like to work and that's why you would like to do this or you would like to test it in general

[00:28:04] because then you need to maybe go to a different kind of state to then maybe get your solution tested because it's not possible because of the state law yes so federalism is a massive problem we have the same problem for example with our colleagues in Italy

[00:28:18] so for example in Lombardia it's very digital, everything is working but other parts are not digital at all so I think you have to do lots of market research and lots of background research when you try to enter the European markets and inside of the country

[00:28:36] the very fractured system so that is a very big challenge for startups maybe just one last question I've been thinking a lot about what the expectations are about the future of digital health in the upcoming years and I think that there's a lot to be excited about

[00:28:54] the advancement of precision medicine with the move towards giving patients a very personalized experience we see that especially in the US things going in that direction but I can't get rid of the feeling that healthcare is going to get increasingly expensive especially in Europe where we still

[00:29:18] will need a lot more funding to actually digitize everything so where do you see the balance between healthcare improving because of digitalization and healthcare struggling even more because of the needed investment I think there's really good examples for example we have probably heard about the e-prescription

[00:29:42] so it was delayed for a few years because physicians needed extra infrastructure which they needed to buy and be reimbursed for and for example in a big university hospital bringing something in like an e-prescription it's not just a click on a button it's heavy work for the IT

[00:30:03] you have to change everything you have to find out what are the needs of the different kind of units so I always try to explain it like making the Titanic moving so that's this kind of act and this has lots of struggles because this needs money

[00:30:19] and there's so many if you want to change something in a big university hospital this is costly this is a change in flow and workflows it's a change in methods you have to consider all the infrastructure and the extra supplies so that's a big problem

[00:30:39] so that's why I'm always like the ideas politics have is great on the one hand who is paying for it and implementing it it's like the most important part but lots of times the people who think about these kind of things forget about the implementation

[00:30:59] for example e-prescription as well at the moment everybody said oh it would be lovely to have this and it's great and we try but then I was like what about elderly people or people who have daily care how do they get their prescription

[00:31:13] oh we still have paper for them we always have this in-between limbo we push forward and then something is not working and then we have on the side a backup that's always paper so I think what I would love for the future think from the beginning

[00:31:31] about all the obstacles and try to make it more effective and easier for big tankers like university hospitals who have not heavy funding and most of the funding needs to go into patient care to get these things going that's fodh.substack.com stay tuned