Nordic potential for health and welfare innovation through collaboration between the public and private sectors

Transcription

1 Background analysis: Nordic potential for health and welfare innovation through collaboration between the public and private sectors Part one: Collaboration between public sector and private companies in promoting health care innovation (s. 2) Part two: Current and prospective investments in healthcare innovative solutions (s. 19) made by Implement Group on behalf of Nordic Innovation

2 PART ONE: Collaboration between public sector and private companies in promoting health care innovation Cost is the main driving force behind innovation in the health care delivery system Dennis A Ausellio, MD, Massachusets General Hospital. 1. Introduction: This paper sets out to identify which conditions and initiatives stimulate health care innovation in general and, more specifically, the establishment and thriving of new growth companies in the field of health care innovation in the Nordic countries. At the same time the paper seeks to identify opportunities and barriers to stimulating public-private collaboration and the growth of public and private enterprise within the field of health care innovation at a Nordic level As a point of departure a few observations should be made as to the development trends characterizing the Nordic health care delivery systems, and the ability of these systems to adopt new technologies. 1.1 Trends in health care It is well known, that we are facing a time with a growing population of elderly people and a growing number of people with long term conditions. Both of these demographic trends are expected to increase demand for health care services in the decades to come. At the same time, we are seeing two other major developments in the sector, in relation to the technological development and organizational development of health care systems in the Nordic countries. Technological development in the area of health care is impressive, and we are experiencing significant progress in the ability of highly specialized hospitals to treat effectively conditions, that were without a cure just a few years ago. Our growing understanding of the human genome has led to the development and implementation of new approaches and the development of new drugs, that have changed the lives of patients around the globe. This, however, has also led to a change in the way health care resources are distributed within the health care system. Exhibit 1 shows the development in resources spend in care for the 5% of patients in need of the most expensive procedures and drugs. 2

3 Exhibit 1: Proportion of total health care spending, spend on the 5% of the patient population in need of the most expensive procedures Udg. 5% patientmassen Udg. 95% patientmassen 25% 27% 32% 39% 75% 73% 68% 61% The chart shows, that the proportion of total resources within health care that is used for the care of 5% of the entire patient population has grown from 25% in 2000 to 32% in 2010, and is expected to grow to 39% in The consequence, off course, being, that resources dedicated to the 95% of the patient population suffering from more mundane conditions has been reduced from 75% to an expected 61% within a fifteen year period. At an organizational level this development coincides with a development in all of the Nordic countries, where specialized skills are concentrated on fewer specialized hospitals, and more and more treatment and care tasks are delegated to the primary care sector to general practitioners, district nurses, social workers etc. What this means is that there is an increasing need to apply innovative approaches and for the application of technologies that makes it possible to develop low cost procedures, building to a large extent on the active participation of the patient herself. It also means a need for development of mechanisms of knowledge sharing and remote consultation that enables lower skilled groups of employees to take responsibility for ever increasing parts of the total care-value chain. 1.2 The usage gap Another general trend, that characterizes health care systems, not only in the Nordic countries, but around the globe is the so called usage-gap. The usage gap illustrates the fact that the adoption of new technologies to health care for patients is not a swift process, but on the contrary a rather prolonged process of technology development, bringing to market, acquisition and implementation. This is the case, not only for the implementation of new medico-technological appliances or IT systems or applications, but also for new process technologies and procedures. 3

4 Exhibit 2: the usage gap The usage gap Possibilities/usage Technical possibilities Our ability to use it Time The point is not that innovation cannot take place in the Nordic health care sectors. On the contrary we have seen a rather impressive development within the sector in the last decades. The point is that innovation is not just a question of getting a good idea or developing a new solution to a problem. It is also very much a challenge of implementation and of making it possible for health care providers to harvest the benefits 2 Lessons to be learned from existing public-private collaborative efforts in the field of health care innovation Quite a number of regions or countries around the world have decided to promote the collaboration between the state and private enterprise in developing innovative health care solutions, be they new ICT systems or other kinds of technology, or be they different kinds of process innovation. This is due to three converging trends that characterize most affluent societies in the early 21 century: Public sector organizations are large spenders in the area of health care Due to the demographic development trends, and the increasing demand from citizens for new health care services, there is a need to develop innovative and less cost-intensive procedures and processes. There is a need in many highly developed countries to develop new growth opportunities, especially in the highly skilled segments with generally large margins. This means, that it is by no means obvious, that the Nordic countries should have a privileged market position in terms of succeeding in creating new growth opportunities in developing new technologies or innovative approaches to health care. Or, rather, that work needs to be done in order to identify the specific areas, where it is possible to develop, through public-private collaboration approaches or technologies that can be used to innovate health care within the Nordic countries and at the same time create opportunities for export and growth. 4

5 The fact that many other countries and regions have defined health care innovation as a prioritized area for the development of new business means, however, that a discussion of the how of developing growth opportunities within health care innovation, can take as a point of departure the experience done elsewhere. In this section, therefore, we will take a look at three types of experience of public private collaboration in the development of health care innovation: Three million lives a government initiated project to cater for the needs of 3 million people with long term conditions through the use of telehealth and telecare and through collaboration with industry. The Smart Care project in Brabant Region in Holland, where a system of grants has made it possible to initiate 11 health care innovation projects in collaboration between the public health care provider and private companies Collaboration between The Municipality of Esbjerg and Welfare Denmark in the development and prototype testing of distance-training software and equipment These cases have been chosen to draw attention to lessons that can be learned from three rather different approaches to promoting private-public collaboration in the field types of public-private collaboration As has been described elsewhere with regard to the collaboration between public authorities and private companies in innovation in health care we can distinguish between the five types described in exhibit 3 1. Five types of public private collaboration Public procurement Outsourcing Precommercial procurement Public-private partnership Public- private collaboration in innovation Specific deliverables Non defined deliverables Public sector act as a buyer of developed solutions The role of the public sector Increased participation of public sector in the development of solutions 1 Health Innovation in the Nordic countries. Nordic Council of Ministers

6 Public procurement is the most widespread form of public private collaboration, and in general refers to contexts where publicly run hospitals or nursing districts buy goods from private companies. In most cases what is bought is already developed solutions. The public authority can, however, contribute to innovation through the demand of customized versions of existing products, thus opening, perhaps new opportunities with other customers. Outsourcing is also widely used within the Nordic health care systems, perhaps more in Sweden than in the other countries. In outsourcing the public authority has delegated the responsibility for a particular health care task to a private company, for instance a privately run hospital or carecenter. Outsourcing does not in and of itself create innovation. It does however create possibilities for creating competition among different private companies on quality and cost, and thus also the possibility for new and innovative approaches to the solution of the issues at hand. Precommercial procurement describes the types of initiative, where the health care provider defines a particular need for a product or service, and invites private companies to enter into a collaboration, where the public authority issues an order for a product or service, that has yet to be developed. Public-private partnerships describes the situation, where the private company, through a contract with the health care provider assumes responsibility for the whole service, that is for the development of the service for the financing of facilities and for the operation. Public-private collaboration in innovation is a situation where a private company and the public health care provider enters into a relationship of mutual responsibility and shares the risk in the development of an innovative product or service. It is characterized by the fact that prior to entering the contract the problem and the solution are only vaguely defined, thus creating the possibility for radically innovative approaches 2.2. Three million lives (UK) Main objective The 3 Million Lives Programme aims to accelerate the use of assistive technologies in the NHS in order to improve at least 3 million lives over the next five years Three million lives is a government initative in the UK based on the findings in the so-called Whole Systems Demonstrator-project (WSD). The WSD is the largest randomized control trial of telehealth and telecare seen so far, involving approximately 6000 patients. Findings show that telehealth and telecare can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in emergency units. Building on these findings the british government has stated that three million people with long term conditions and/or social care needs could benefit from the use of telehealth and telecare service, and that collaboration between the NHS and private companies should work to make these services accessible for citizens. The following objetives have been defined: For Department of health and industry to work together over the next 5 years to develop the market and remove barriers to delivery. For Department of Health to create the right environment to support the uptake of telehealth and telecare including rewarding organisations for adopting and integrating these technologies in services by developing a tariff. 6

7 For industry to work with the NHS, social care and other stakeholders to simplify procurement and commissioning processes for telehealth and telecare services at scale. To put the NHS and UK industry at the forefront of telehealth and telecare globally, developing significant opportunities for UK plc. To promote the benefits that telehealth and telecare services can provide people in managing their health and care. See www. Form of public-private collaboration The 3 million lives project is essentially a decision at government level, that orders local commissioning bodies to enter into contract with private companies in order to make available across the country telehealth and telecare services. A number of standards have been defined as to the components of service and the design of services, information and technical standards, that the appliances and technologies have to adhere to 2. Interestingly, what is required for private companies is not just to develop and make available the technical solutions, but also to participate in the service user selection, the service and pathway redesign and the referral process involved in the referral of patients to telehealth and telecare services. What is required is, in other words, that private companies through their particular expertise in the field are asked not only to make the technology available, but also to ensure that the technologies are effectively implemented, and that the commissioning bodies, responsible for funding of healthcare services, are actually able to harvest benefits from the introduction of the services in question. In our perspective, this is not merely a case of public procurement, even if the technologies in question are already developed. It is a case of a somewhat closer and more interlinked partnership, where the expertise on the side of private companies is combined with the expertise within the NHS to develop and implement effective services. What is interesting about the 3-million lives project is also, that the objective of the project is to move from local projects on the effects of telehealth and telecare to a large scale implementation across relatively independent commissioning bodies around the country. This is made possible through the development of a framework for the collaboration between the commissioning bodies and private companies, that states the objective and defines the services, that must be implemented, but otherwise leaves room for local decisions within a relatively flexible framework for the contracts developed and signed between the parties, but obliging the parties to develop a positive business case prior to implementation Achievements so far The initiative started off in 2012 and no achievements have been reported so far 2 Recommendations from Industry on Key Requirements for Building Scalable Managed Services involving Telehealth, Telecare & Telecoaching. 3millionlives. 7

8 2.3 The smart care project (The Netherlands) Main objective The EU funded smart-care project is a project that seeks to promote a more integrated and effective approach to providing health and social care to older people across Europe. The project involves a number of regions in the development of more integrated approaches to the treatment and care of elderly people involving a number of regions around Europe, among these South Denmark (DK) and South Karelia (FI). The case referred in this section is the experience from the North Brabant Region in Netherlands. The smart care project in the region of North Brabant has lead to the establishment of a network of public authorities, private companies, universities, hospitals etc. with the common aim of developing and testing innovative approaches. In the period from 2009 to innovative projects were launched. The projects all aim at implementing ICT in treatment and care of the elderly, thus creating conditions for the elderly to be able to maintain their independence and lifestyle at later stages in their lives. Projects involve: A care and wellness center in Tillburg, accessible 24/7 Brainport: Early detection of dementia Telezorg:care and comfort services See The projects all have the aim of scaling up ICT projects already developed within the health sector in the region, thus ensuring that the projects developed respond to a pull from health care, that is, to a need analysed from within the health care sector itself. Form of public-private collaboration Funding is provided through the local administration of a EU reembursement. The projects are thus subsidized in order to overcome the barriers related to the implementation of user centered forms of technology. Subsidies can be obtained if projects adhere to a set of standards, firstly, that the end-users are actively involved in the projects, and so the projects involve the elderly, the chronically ill, the informal carers and professionals in the field. Each of the projects seeks to overcome barriers to the development and implementation of projects by establishing a formal collaboration a consortium between a care organization, a knowledge institution and a commercial part. According to the region of Noord Brabant, regional government has contributed to the process by hosting and facilitating the collaboration within the network of regional authorities, municipalities, private companies, care institutions, universities etc., to create a platform for exchange of knowledge and experience in the field 3. In relation to the typology of forms of collaboration between public authorities, mentioned above, this collaboration has affinities to the outsourcing model, since the contribution of the private party is to make available their development resources, but costs are carried by the local authority. 3 Edwin Mermans: Smartcare programme Province Noord Brabant, the Netherlands. 22. November

9 Achievements so far The establishment and functioning of the network between the different parties at the regional level is seen as strong and promising, and will, according to regional government officials, be continued after the project period, as a platform for knowledge sharing and for starting up new projects. 2.4 Collaboration between the municipality of Esbjerg and Welfare Denmark on the development of virtual rehabilitation module (DK) Main objective Welfare Denmark and the municipality of Esbjerg have developed a module for virtual rehabilitation making it possible to treat patients remotely. The platform at the same time allows physicians to see whether patients have completed their rehabilitation exercises, and making it possible to upload other relevant information to the system, further enhancing the platform s value to patients and physicians. Form of public-private collaboration As part of their strategy to develop less cost intensive procedures for rehabilitation, training and care for the elderly and chronically ill, the municipality entered into a partnership with Welfare Denmark, and made a modest initial investment Below US$ for the development of a module for remote training and monitoring. Welfare Denmark did not at the time have a developed module, but has through the dialogue with the municipality been able to develop the software and adjust it to the circumstances under which it will typically be used, that is the physical surroundings, the level of the computer litteracy of the typical user etc. Form the point of view of the municipality the aim has been to develop a technology, that they need, and at the same time create the conditions for a group of talented IT-specialists, with experience from the off-shore business, that is a dominant industry in the area, to develop a product that can be brought to market on a larger scale. In our view you can look at the collaboration between the municipality of Esbjerg and Welfare Denmark as a case of precommercial procurement in the sense, that the municipality defined the need to develop the platform form a product that was already being used in training in the offshore business. The municipality made a rather modest investment at a time, where the module had not been developed nor tested, and in that sense ran the risk of developing a concept that would not be implemented. Achievements so far In a case study of a 73-year-old utilizing virtual rehabilitation, as opposed to visiting a physical rehabilitation center in person post-operation, the reduced cost over a 3 -month period was approximately $2,500. The program is now being adopted across the entire Esbjerg municipality. The product is being launched on a broader scale and in collaboration with a number of other municipalities in Denmark, among others the municipality of Copenhagen The software has been given Microsoft international innovation prize in the open innovation category. Welfare Denmark is now planning in collaboration with Microsoft to launch the rehabilitation module on a global scale 9

10 3 Opportunities and barriers for the development of Nordic approaches to private-public collaboration on health care innovation The cases decribed in the section above, represents a very small fragment of the prolific activity taking place on a global scale to develop new technology and new approaches to making health care better, more safe and more cost-effective. They have been chosen to illustrate different approaches to the development through involving private companies in innovation of health care. Three million lives constitute a large scale initiative on part of the national government to create impetus within public-private collaboration for the dissemination and implementation at a larger scale of technologies providing telehealth and telecare for users. The smartcare project establishes at a local level the framework for collaboration and cocreation between local authorities for developing and implementing innovative technologies focusing on assisting the elderly and the chronically ill to be safe and sound within their own home The collaboration between the Municipality of Esbjerg and Welfare Denmark is a case of local entrepreneurship and network, where a need somewhat coincidentially meets up with a technology suited for satisfying that need. For the discussion of how governments and local authorities within the Nordic countries can contribute to the development of conditions for the development of innovative technologies, that can be brought to market on a larger scale, the interesting question is, what can be learned from these cases, and what that implies for the opportunities and barriers for working at a Nordic level with different modalities of private public collaboration Opportunities and barriers in relation to creating through the development of national initiatives promoting health care innovation, opportunities for startups and growth companies It is far too early to determine wheather or not the three million lives-project will prove successful in creating growth opportunities within the british health care ICT industry. From the point of view of health care it is interesting that the project seeks to implement technologies at al large scale that have been proven effective in a smaller scale. The opportunity to make available at a larger scale solutions, that have proven effective in a more delimited context thus creating a market for technmology and applied solutions. The usage gap chart (exhibit 2) illustrates the phenomenon, that organizations generally are rather slow to take advantage of new technological or organizational solutions. There are a number of reasons for this. Among these in the case of health care is the fact, that there seems to be a tendency, that large health care providers, be they hospitals or municipal care centers, prefer to develop their own taylormade solutions, rather than apply standardized solutions or solutions, that have been proven effective elsewhere. An example of this is the innumerous experiments that have conducted in the last 10 or 15 years aiming to develop telecare and telemonitoring solutions for patients with COPD. Every hospital or every primary health clinic for some reason felt it necessary to conduct their own experiment, the consequence of which has been, that we have seen a lot of small scale projects and hardly any large scale implementation. 10

11 This has meant, that we haven t seen the development of a commoditized market, where companies can develop and sell products and services on a larger scale. One of the virtues of the three million lives project is at a theoretical level at least it seems to balance the need to create a framework for large scale implementation with the need to customize solutions to the needs and institutional set up at a local level, thus creating a market at national level for telecare and telehealth hardware and software. What the public authority has done, in other words, is to state the overall objective to make these services available to three million people within a five year period, thus, making it clear for industry, that local commissioning bodies will be in demand of telecare and telehealth solutions, and in this way creating the impetus for intensified dialogue on the procurement of innovative technologies. The opportunity to make health care data available on a larger scale, enabling companies to develop technologies and solutions that are responsive to the current status of health care delivery and to the challenges health care providers are facing One of the strategies governments can follow in the pursuit of creating the conditions for the development of startups and growth industries is to make heath care data available on a larger scale 4. This is not merely a question of opening up for the development of a market for valueadding technological applications, like for example the mapping of the distribution of cases with type 2 diabetes, even if that is in itself a way to incentivize the development of innovative businesses. At the same time opening up data to the public is a way to improve the general analysis of the way health care systems work, how disease and health care problems are distributed in the population, which services are actually in demand etc. If we want to develop innovative solutions that are able to respond to the challenges we are facing, we need to improve our analysis of how the systems work, which dynamics are driving development and how that corresponds to the development in need for health care. If we believe the problem is volume, then we will develop capacity. If we believe and are able to support this claim through data that the problem is coherence and coordinated patient pathways, then it is more likely that we are going to develop solutions, that meet just those needs. The opportunity to open up for competition new sectors of public health care delivery in order to create at a Nordic level a market with competition on price and quality in different sectors The Nordic countries have pursued different strategies on the question of opening up different parts of the health care delivery systems for competition and the involvement of private entrepreneurs. Private Hospitals and private primary health care clinics are more widespread in Sweden. General Practitioners Clinics are all privately owned in Denmark and so on. The dominant model in the Nordic countries is, however, a model, where the responsibility for financing and expressing demands for service and the delivery of health care services is placed within the same public authority. Now, there is no evidence that health care service delivery becomes more innovative by being carried out by private entrepreneurs, as compared to being delivered by public authorities. But it has been demonstrated, that opening up for competition can induce innovation, no matter if the competition is exclusively on productivity or if competition is also on for instance health outcomes, on quality and on price. 4 US government chief technical advisor, Aneesh Chopra in: 11

12 If this is true, then opening up the markets within the Nordic countries for private sector entrepreneurs could create new solutions and could mean that private companies could develop solutions for the Nordic markets, that can at some later stage be marketed outside the Nordic region on the global market. Policy makers, then could consider how it is made possible for, for instance Swedish primary care centers to move into the Danish or the Norwegian market, or for finish entrepreneurs in care for the mentally disabled to move into the Swedish market etc. This could contribute to innovation of health care, especially if providers are evaluated and reimbursed based on health care outcomes, and not just on activities. One of the steps, that could be taken in this direction is to develop a new approach and a smarter way for public health care providers to issue demands, focusing more on health care outcomes, and less on the concrete activities, thus leaving room for more innovative responses to the issued needs Opportunities and barriers in relation to creating through development platforms opportunities for startups and growth companies The opportunity To create through development platforms conditions under which it is more feasible for public health care providers to open up for innovation, because initiatives are backed by industry and knowledge institutions A major barrier to adopting and implementing innovative technologies and solutions in health care provider organisations is quite simply, that decisionmakers do not feel that the case for implementing is that straight forward. Yes, they have heard of the potentials of developing a more integrated approach to psychiatric patients, thus integrating treatment and rehabilitation. But where is the convincing business case, where is the RCT study that proves effectiveness and efficiency of the new model? As a matter of fact, in many cases it is n where to be found, and thus decision makers run the risk of making decisions about implementation, that they will regret at some later stage, because it turned out neither to be cheaper nor better, than what used to be the standard practice. In that context creating, as they have done in the Smartcare project in North Brabant region, a platform where universities, health care providers and private enterprise can meet and discuss options and priorities, can provide a possibility for deliberating implementation decisions with highly qualified partners, thus to some extent splitting the risk of making a decision on implementation, and providing a framework for evaluating the actual implementation. The smartcare project also addresses the implementation challenge. As has been discussed elsewhere, the challenge of implementing innovative technologies and solutions is not only to get hold of or develop the innovative approach, but just as much to be able to implement it within the provider organization, thus making it possible to harvest the benefits and ensure the sustainability of the innovative approach. In the case of the smartcare project the consortia between health care providers, universities and private enterprise assume a common responsibility also for the implementation phase, thus making it more likely that the organization will actually succeed in harvesting the potential benefits, creating thereby impetus for other health care providers to move in that direction. Barrier: Does the project really deliver on the need to deliver better and cheaper health care if not it may contribute to the development of business opportunity, but will contribute very little to the development of health care delivery 12

13 One of the weaknesses of the platform project model for the implementation of innovative solutions in a collaboration between public health care providers and private companies is that even though it may in principle be possible to see that the need for innovation within health care and the need to create new business opportunities go hand in hand, this may in actual fact not always be the case. Looking at current trends in the welfare technology development, you can detect a tendency that technology developers are moving away from health care as such and in to the less regulated field of wellness and primary prevention for two reasons. The distance from technology development to bringing to market may be considerably shorter, due to fewer regulations. And by targeting not only the part of the population, that suffers from some kind of condition, but potentially the entire population makes for a significantly better business case. The long term effect on health and wellbeing may be significant, but it does not necessarily address problems, that health care providers perceive as imminent, and in those cases the interests of private tech companies and the interests of public health care providers may diverge. What you need to ensure, then, is that the push of innovative technology companies is balanced with the pull from health care providers, to ensure that the technologies developed and tested through the collaboration actually contributes to the development of quality, efficiency or cost-effectiveness of health care provision. Barrier: Projects often fail to challenge the core delivery model, and are thus at an organizational level treated as yet another pastime. It is hard to establish ownership at senior executive level and thus to be able through the development project to create change with impact. One of the defining characteristics of innovation is its disruptive nature. This means that to be truly innovative technologies and new solutions have to challenge the dominating health care delivery model within a particular area. It may challenge the way power is distributed between physicians, nurses and the patients. Or, it may challenge what is seen as a task for primary health care providers and when it hospitalization is needed, thus changing the reimbursement structure of the entire system. Many observers believe, that if innovation is to be seen as the main response to the challenges facing public health care provision, you cannot strip innovation of its essentially disruptive nature 5. Seen in that context you may discuss whether this kind of project platform can actually contribute to innovation in health care. The nature of development projects is that they are conducted by people working within the organization, but not within the line organization with clear reference to the established management structure. That is what makes development projects possible in the first place, because it gives project managers the liberty to work across lines of command. As most project managers will be able to witness, the flopside of that coin is that it hard to create real senior management ownership to specific development projects, and thus to create the impetus at senior level to implement project findings across the rather complex organizational structures that characterize hospitals and other health care provider organisations. Therefore, many development projects suffer the fate, that while enthusiasm is high in the project period, where progress is pushed by devoted project managers, the long term sustainability of project findings within the organization is in most cases difficult to ensure, because the evaluation was inconclusive, or because what is required in order to harvest benefits 5 Clayton Christensen, Jerome Grosman and Jason Hwang: How to Revive Health Care Innovation, Harward Business School Working Knowledge, march

14 is a more fundamental restructuring of the organization or patient pathways or authority structures etc Opportunities and barriers in relation to creating a local level initiatives that stimulate start -ups and growth companies in the field of health care innovation The history of innovations is ripe with stories of coincidence and personal relations as a major driving factor In the case of the municipality of Esbjerg and Welfare Denmark, the personal relationship between a senior executive within the municipality and technology innovators within the private company was essential. Both parties had to be able to understand that a technology developed for the off-shore industry could provide a solution to a need for more effective ways of enabling people to train at home, while still being supervised by professionals. As in many other cases in the history of innovation it was due to talent, personal relations and you might argue coincidence. The collaboration turned out to be a success, but both parties ran the risk of failure all along the way. An important lesson that can be learned from the story is that risk is part of innovation, and that in order to be able to stimulate innovation thorugh this kind of collaboration, you need executives who are willing to run the risk. The case of the municipality of Esbjerg is, off course not the only one, on the contrary, it could be supplemented by stories from, Iceland, Norway, Finland or Sweden. And if these kind of initiatives should be seen as building stones of a strategy to innovate health care through the collaboration between private companies and public authorities, these stories need to be told all around the Nordic countries, thus inspiring others to seek similar opportunities and to a more open attitude toward solving problems through collaboration with private companies. The case can also be seen as a kind of smart demand in the sense, that the professionals within the municipal health care delivery organization developed their understanding of the needs this technology had to meet, and through the dialogue between the municipality and the technology company this was tested against what was technically possible and vice versa. Barrier: It s hard to plan for A very important episode in Porsches development of the revolutionizing ceramic brake system was an encounter between a scientist and an engineer from R&D at Porsche during a train ride from one part of Germany to the other. A number of other anecdotes can be told about how the coincidential meeting between talented and visionary people from one line of work with people from other fields of knowledge leading to important innovative steps in the history of technology. Needless to say, off course, the weakness of this is that it is hard to plan for, and you cannot just walk around and wait for this kind of thing to happen. As mentioned above, you might improve the likelihood of this happening by inspiring the risk taking of senior executives. Another approach could be working to implement, what you might call an innovative culture in health care provider organisations, creating more incentives to develop internally new ideas and approaches or to seek ways of collaborating with external parties. As a matter of fact quite a few successful technology start-ups have been launched by professionals who developed an idea, a technology or a solution from within the provider organization, and, at a later stage stepped out to start up a new business. 14

15 A pivotal point here seems to be the concept of prototyping, that is the development of a prototype technology and solution, and using theprovider organization as a testbed for the solution in question. This is also essentially a question of leadership and og inducing an innovative culture within the provider organization. 3.4 Opportunities for developing Nordic strongholds within the global health care innovations market As mentioned above the market for developing and marketing health care innovative technologies is highly competitive. A number of large technology corporations see in this market an opportunity for growth and earnings. Bus, as has also been stated, it is a market with a considerable growth potential, and there is no reason to believe, that Nordic companies cannot compete in different arenas. From the perspective of this analysis, two properties of the Nordic health care systems seems to create opportunities to develop Nordic strongholds in the market: Firstly, the availability of global data with extremely high validity on demographic spread of particular illnesses, on patient pathways, on long term clinical results etc. makes for developing valueadding applications based on available data. The availability of data, at the same time enables very detailed analysis of patient pathways, of the allocation of resources to different parts of the health care system and to development in demand for health care services. This kind of analysis is necessary to develop a more profound understanding of how the health care system can develop and how it can be transformed in order to correspond to a higher degree with the needs and the distribution of needs within the population. Secondly, The highly interlinked nature of Nordic health care systems, where hospitals, carecenters, rehabilitation facilities etc. are integrated into the same overall organizational structure gives excellent opportunities to develop new health care approaches based on patient pathways and on the patient s user perspective. Building on inspiration from service management new approaches and organizational structures can be build, based to a larger degree on the patient s perspective and particular needs. This may benefit patients within the Nordic health care systems in the short term, especially the elderly and people with chronic illnesses, that have numerous contacts with the health care system. In the longer term it may also provide opportunities to develop innovative technological soltuions as well as concepts for organizing and reimbursing health care providers based on coherence and outcome and not just on activity and productivity. Thirdly, the possibility of collaborating between the five health care sectors in the Nordic countries, perhaps in a model somewhat a kin to the British three million lives project, issuing a number of overall objectives in providing innovative solutions to the users of health care, could represent a radically different approach to the procurement of products and services, that could open up for new solutions and the establishment of new kinds of partnerships between public health care providers and private industry. People within the health care innovation industry complain, that not only do they have to adhere to different standards and technical specifications between the five Nordic countries, the truth is, that the Regions in Denmark and Norway, The Län in Sweden, The Health Care Districts in Finland have not yet been able to agree in standards or the formulation of objectives, and this means, that in actual fact, we are, today, not talking about five different markets, we are probably dealing with 25 or thirty different markets, and this makes it very difficult for private industry to develop products and solutions targeting 15

16 the particular market. With a closer and more coordinated approach to making health care innovation possible within the Nordic Countries it would be possible to create real impetus for a focused and constructive dialogue with private industry on what solutions are needed, which technologies could be tried out, what kind of need innovative solutions have to meet. 4 Estimates of market potential The total market for health care innovation is tremendous. According to the WHO total global spending on health care amounted to 6,5 trillion US$ in From 2005 untill 2010 total spending grew by 43%, and there is no reason to believe that growth figures will level out in years to come 6 On the contrary the growth of the middle class in populous emerging economies like China, India, Brasil and the African continent will mean an increase in demand for professionalized health services. Total health care spending in Europe ascended 1,9 trillion US$ in 2010 or 29% of global spending. According to the OECD total health care spending in the Nordic Countries ascends 145 Billion US$, or 8% of total health care spending in Europe (EU27). The bulk of spending in health care is off course on personnel, drugs, facilities etc, but the shere size of the total market and the growth prospects indicate that the market potential for innovative technology and innovative solutions is immense. Estimate of market potential should be triangulated based on three different angles, depending on the availability of data Estimating the value of the market for health care innovation and the potential for Nordic companies within that market is extremely difficult. A commonly accepted approach to estimating market potential for particular companies or particular industries is illustrated in

17 exhibit 4. By triangulating between different sources of data, you can develop a reasonable estimate of the value of the Nordic market and from there move on to estimating the possibilities on the global market for health care innovation. In the case of health care innovation, however, we have very little data, and it has been outside the scope of this paper to conduct a market analysis. The estimate therefore has to build on available data and a number of assumptions as to the development within the health care sector in the years up till Mike Mancuso, CEO of Philips, major technology corporation, estimates that the global market for different ICT based applications (Comprising patient monitoring, value segment solutions, clinical informatics, therapeutic care and mother and child care) assumes 9,3 B Euro, or 12,1 B. Us$ in 2013, and is expected to grow by an average of 5% a year until 2025, reaching 20 B US$ 7. If the proportion on spending in innovative technologies parallels the part of global health care spending, that is spend in the Nordic countries, 2025 will see spending on innovative technologies in the Nordic countries ascending 345 million US$ in In 2013 total health care spending in the Nordic countries ascends 145 B US$. If we assume that this figure will grow by 3% a year for the next 12 years (building on the history of health care spending growing at 2 % above GDP growth for the last 50 years), in 2025 health care spending will be at 160 B US$ in today s prices in Different sources estimate that spending on Health care ICT infrastructure, hardware and software assumes 2-3 % of total health care spending in Following the growth in general spending, we expect ICT infrastructure costs to reach 4 B US$ in Thus total spending on innovative ICT based solutions in 2025 will reach approximately 4,5 B US$ in Form a more dynamic perspective, however, it seems fair to assume that spending on innovative, ICT based solutions will grow as a proportion of total health care spending during the next 12 years. Thus one could base an estimate on the assumption that, a part of total health care spending, spending on general ICT will grow by 10% a year from 2,5% in 2013 to 5,5 % in 2025, and that spending on innovative ICT based technologies will grow by 35% a year from 0,2% of total spending to 6,4% of total spending. Following these assumptions the total spending on health care innovation in the Nordic countries will reach approximately 20 B US$ in Building on the very crude assumption, that Nordic companies will be able to obtain a market share of 25% in the Nordic markets, it seems reasonable to estimate that market potential for Nordic companies will be in the range from 1 to 5 B. US$ 5 Conclusion The field of health care innovation is tremendously interesting from a political point of view in terms of the possibilities to create new solutions faced with the rather daunting challenges facing the industry, as well as from a commercial point of view due to the fact that on a global scale the market Is enormous and in search of innovation in technology, in organization, in patient pathways and in developing new approaches, that to larger extent involves the patient in treatment and care. 7 Boston/11_mancuso_ _IR.pdf 17

18 It is, however also a field of intense competition, and one must refrain from too optimistically assuming that the Nordic countries will easily be able to claim a privileged position within the market. There are, however, many ways in which the Nordic countries can in closer collaboration stimulate the development of innovative solutions and thus create possibilities for the development of new businesses. If public authorities and health care providers are to play a role in the development of the possibilities for private sector growth and opportunity, development of health care solutions need to address the fundamental challenges facing publicly financed health care provision, above all, the need to develop solutions, that mean that we are able to treat and rehabilitate more patients better for a lower cost. This means a string focus on cost effectiveness of new solutions and technologies, and making the development of new, more cost-effective solutions possible by developing new strategies of procurement and interacting with private industry. Just as essential is a strong focus on the implementation of new technologies and innovative solutions and making it possible for provider organizations to harvest the benefits. Too much energy and too many resources have been dedicated to develop and test new technologies in small scale projects, and too little has been devoted to the actual implementation of innovation, not just applying the new solutions, but actually making the restructuring of organizational structures and redesigning work processes happen in order to see the real impact of innovation. This is necessary in order to keep health care providers committed to collaboration with private industry. It also makes for a strong argument in the marketplace! This may, at first seem to be an obstacle, because innovation also requires investments and spending. At another glance, however, the need to develop more cost-effective procedures, technology and organizations may prove to be a strong engine for innovation in the years to come. Success in the market of health care innovation relies on the development of a thorough analysis of the strengths and weaknesses of the Nordic health care systems, and making this analysis open to all parties, so that new products, services and organizational models can be developed according to the needs in the sector and so that they actually constitute realistically implemented solutions making it possible for health care authorities to make better health care cheaper. 18

19 PART TWO: Current and prospective investments in healthcare innovative solutions The opportunities presented by ehealth and mobile technological platforms, greater information storage capabilities, new sensing technologies, and computing power are such that it is possible today to deliver care in wholly new ways. The health and care sectors have, however, been slow to make radical re-engineering moves. The depth of investment into current structures, professional innate conservatism, regulatory uncertainty, and the asymmetry of information and problems related to patient empowerment and accountability have held back change. OECD-NSF Workshop. Building a smarter health future The overall ranking remains relatively stable with Sweden confirming its innovation leadership. The performance of Denmark, Finland, Germany and Sweden is well above that of the EU27 average. These countries are the innovation leaders. European Commission, Innovation Union Scoreboard Introduction This paper discusses and estimates overall spending on healthcare research and development in the Nordic countries and levels of resources for and investments in healthcare innovation 8 in the Nordic countries. The paper includes a discussion on present and future types of and priorities on healthcare innovation in the Nordic countries. Healthcare innovation: A Lead Market A lead market can be defined as a market for innovative products and services or technological solutions with high growth potential. ehealth (can be regarded) as a lead market with potential in terms of growing demand and market growth opportunities. 9 Healthcare innovation is generally regarded as a field where investment and product development and the development of products and services will grow over the coming decades and as a field with big scale opportunities for market growth and business development. It is also generally recognized that achieving a significantly larger market for healthcare innovative products and services as well as increased business opportunities within the area of healthcare innovation will require public and private investments, but also a more flexible and growth oriented framework for publicprivate cooperation and partnerships. Present barriers (including legislation based barriers) to development and growth oriented interaction between 8 Throughout this paper, healthcare innovation is used as term, corresponding to a) research and development and market maturing of healthcare innovative solutions (products, services, applications), b) development and maintenance of the information technological platform, needed for healthcare innovative solutions to work and add value. 9 Accelerating the Development of the e Health Market in Europe, e Health Taskforce report, European Commission. 19

20 the public sector and the private sector need to be addressed. 10 Innovation and the healthcare systems The challenges of the healthcare systems in Europe, including the Nordic countries, are characterized by (expected) growing pressures on capacity and resources mainly due to the growing proportion of elderly and the continued increase in prevalence of chronic illness and long-term disease. 11 The combined effect of these trends is a rise, also, in the proportion of patients with co morbidity. On top of that, the resource oriented challenges might not be helped by the continued increase in expectations on flexibility and performance of the healthcare provider system and by the continued improvement of diagnostic and treatment possibilities. 12 Generally, healthcare innovative solutions are highlighted as one of the major strategic ways to deal with the challenges ahead and the need for transformational change. Healthcare innovation, thus, and seemingly in all countries, is seen as one of the most vital possibilities, when it comes to addressing the need for more cost-effective healthcare delivery. 13 Healthcare innovation what is it? There is no clear, generally accepted, definition on healthcare innovation or healthcare innovative solutions. Likewise, there is no general consensus on the exact nature and character and scope of healthcare innovation. 14 Naturally, the lack of a generally agreed definition on healthcare innovation and the lack of a precise scope for healthcare innovative solutions complicates the dialogue on market potentials and business opportunities within the healthcare innovation field. 10 Improve procurement by facilitating the expression of public demand through more innovation friendly procurement activities. Do. 11 Generally speaking, the age group of 65 years+ accounts for approximately 45% of overall healthcare costs. Also, prevalence of chronic diseases increase with age. Long-term illness is increasing not only because of a rise in chronic conditions, but also because of growing needs of monitoring and maintenance and controls (cancer patients, patients with degenerative disorders etc. 12 Generally speaking, in a perspective towards 2020 and 2025, there seems to be a kind of consensus on the need to reduce the proportion of GDP, used on healthcare. Over the last couple of decades growth in health spending, in many countries, have been above GDP growth. In the last couple of years, many European countries have reduced not only levels of growth in healthcare spending, but actual healthcare spending. 13 In a time of growing demographic pressure and economic constraint, innovation in healthcare is crucial in bringing better and more effective treatment to patients (and) in promoting better use of resources. Informal meeting of Ministers for Health. April Presidency Of The Council Of The European Union (The meeting also addressed what was called.. potentials for a significant business development and exports of (new, innovative) healthcare products and services. e-health is considered as the key factor in decreasing the costs for healthcare (in the coming decades). See note 1 above. 14 It goes without saying, that the levels of healthcare research and development / healthcare innovative spending and investment, given in this paper, must be regarded as very rough estimates. US $ PPP (purchasing power parity) is used throughout this paper corresponding to the common practice in the majority of documents and statistics on research and development spending / healthcare innovation investments. 20

21 There are a lot of different assessments of (potential) market sizes and growth rates for healthcare innovation but estimates are seldom based on crystal clear definitions and often on a variety of assumptions, when it comes to the exact nature of healthcare innovation. Several different approaches can be identified with regard to defining and scoping healthcare innovation. Two of the approaches seem to be widespread and dominating: The meaning and the scope of healthcare innovation are defined in words / sentences. The meaning and the scope of healthcare innovation are determined by listing what is regarded as the relevant kinds of innovation. Healthcare innovation and healthcare solutions are defined by WHO as simply the use of information and communication technologies in healthcare. 15 Other sources also define healthcare innovation and healthcare innovative solutions with idea generation and development of ideas for practical application in healthcare being just one of several examples. 16 Healthcare innovation can be seen also as a list of applications, systems, products and initiatives 17 as examples home based healthcare monitoring or treatment devices and applications data sharing systems and procedures between healthcare suppliers intelligent psychical facilities (in hospitals, in nursing homes etc. tracking devices, dementia and disabilities etc.) access for citizens/patients through communication technology to healthcare services and healthcare advise (portals, ebooking, econsultations etc.) As stated above, health innovation are almost always connected to the context of the healthcare challenges, due to demographic changes, the significant increase in chronic illness / long-term disease and financial constraints and seen as part of the strategy and the necessary means to address the threatening imbalance (in the healthcare systems) between needs and available resources and personnel. Health innovation, however, are also often mentioned in the context of business opportunities and needs for economic growth. Health innovation, thus, can be seen as a form of dual instrument supporting the healthcare systems in a context, where transformational changes and more cost-effective processes and deliveries are seen to be needed, and catalyzing business development and a growing market for new information and technology based healthcare solutions. 15 WHO, Global Observatory for e-health, Several Danish regions define healthcare innovation in this particular way. 17 The technologies and applications ans solutions enabled by broadband technology. To accelerate and improve the collection and analysis and usage of data to enable targeted and cost effective provision of services. ITU Telecom World

22 Public procurement in the Nordic countries. The public sectors in the Nordic countries are major buyers of services and products from private firms generally and especially within healthcare. The annual procurement of the Nordic public sectors amount to between 200 and 230 billion US $. Healthcare oriented procurement can be estimated at an annual level of 40 to 55 billion US $ including only recurring procurements and not including publicly funded constructions costs. 18 The estimated levels of public procurement include government procurement, but not procurement from publicly owned companies. Thus, the overall size of procurement affected or determined by the public sector can be estimated at a level, corresponding to 20% more than the figures mentioned above that is, approximately 50 to 70 billion US $. Apparently, there could be a huge potential for public procurement within the healthcare innovation field, and for public-private cooperation and co-shaping in developing and implementing healthcare innovative solutions especially, when (if) health innovative solutions are seen as an integral part of the needs for change and the needs for a more cost-effective and sustainable healthcare system in a perspective towards 2020 and Health oriented research and development including healthcare innovation The Nordic countries invest in research and development. Compared to the population sizes and levels of GDP and compared to international levels, the Nordic countries dedicate a relatively high proportion of resources to research and development. Overall, it is estimated that the annual spending in the Nordic countries on research and development amounts to approximately 50 billion US $. 19 It is estimated that the public sector spends billion US $ annually on research and development the level of the public sectors research and development spending amounting to approximately 30% of overall research and development spending. 18 Size of public procurement market, OECD, Selected Nordic country specific sources. Sweden and Finland have the highest level of public procurement as a percentage of GDP. Norway has the lowest level of public procurement as a percentage of GDP. Denmark and Iceland have significantly lower levels of public procurement than Sweden and Finland and significantly higher levels than Norway (as percentage of GDP). 19 See Figure I and the footnote for this figure. 22

23 Figure I 20 Research and development spending in the Nordic countries , ,2 8,4 8,9 2,5 0,1 0,2 7,2 4,1 4,4 National, public R & D budgets, billion US $ R & D expenditure, billion US $ In the Nordic area, Sweden and Finland use the highest percentage of GDP on research and development with Denmark also above Norway and Iceland. When it comes to public spending on research and development, Norway and Sweden use a higher proportion of GDP than the other Nordic countries. Looking at actual resources, dedicated to research and development, the levels (Figure I) reflect the relatively high level of GDP and public spending in Norway. 20 Figure I as well as Figure II and III: A) European Commission, EUROSTAT, Statistics Explained / B) Statistika Meddelanden, Statsliga anslag til forskning och utvikling. Statsbudgetanalysen C) Sundhedsinnovation og erhvervssamarbejde, Danske Regioner D) OECD. On research and development spending E) Selected Nordic country specific documents. F) Folketingets EU Oplysning, København, It can be assumed, that the overall public spending on research and development / research and development within the healthcare innovation field is larger than the estimated national research and development levels the regional and local levels also using resources on healthcare innovative solutions. It must be remembered, however, that major parts of the national level research and development budgets for healthcare innovation are distributed to and spent by regions and councils. 23

24 Figure II Research and development resources in the Nordic countries, % of GDP. 4 3,5 3,7 3,8 3 2,7 2,5 2 1,5 1 0,5 1,01 1,03 0,79 1,8 1,6 0,92 0,88 National, public R & D budgets, % of GDP Gross Domestic expenditure, R & D, % of GDP 0 Using % of GDP as the indicator, Sweden and Finland (along with Japan) have a very high level of research and development spending on a worldwide basis, they form a kind of first layer of countries, while Denmark, along with countries such as Germany and the United States, is part of a kind of second layer. Norway and Iceland are (again, based on percentage of GDP) in a kind of "third and fourth layer" along with countries like France, United Kingdom and Holland. Spending on research and development in the healthcare sector is generally high in the Nordic countries and in many of the EU countries amounting to between 20% and 25% of total spending on research and development. Based on this assumption, healthcare research and development spending in the Nordic countries can be estimated at a level, corresponding to billion US $ (overall) with public spending on healthcare research and development corresponding to 3,5-4,5 billion US $. As indicated above, generally the public part of overall research and development can be estimated at levels, corresponding to 30% (25-35%) of overall research and development spending. 24

25 Figure III Research and development in selected countries. % of GDP. Gross Domestic expenditure, R & D, % of GDP 4 3,8 3,75 3,5 3,45 3 2,7 2,65 2,65 2,65 2,5 2 1,5 2,05 1,95 1,85 1,8 1,65 1,65 1 0,5 0 SE FI JA DK AU GE US FR BE UK IC NO NL In relation to health, a major part of public research and development resources in the Nordic countries is dedicated to university based research and development. Typically, also innovative initiatives will be included in the universities research and development efforts within healthcare. Usually, a significant proportion of research and development spending in the private sector will be dedicated to treatment technology (new surgical equipment, new kinds of medicine etc.) and technology within the diagnostic field (radiology, CT, MR, PET etc.). In this context, research and development spending on new treatment and diagnostic equipment and technology is not regarded as part of the resources for and investments in healthcare innovation although some of the new treatment and diagnostic technologies can be said to form a kind of basic prerequisite for some of the healthcare innovative solutions. 21 A very large proportion of research and development spending on new treatment and diagnostic equipment and technology will be financed through private businesses and non-public funds. Even with the assumptions on university based healthcare research and the exclusion of development and research spending on treatment and diagnostic equipment and technology, it is rather difficult to give more precise estimates on the levels of research and development spending, directly related to healthcare innovation and healthcare innovative solutions. 21 There are two reasons for excluding research and development on new forms of treatment and diagnostic technology from healthcare innovation. First and foremost, healthcare innovation is seen in this paper primarily as a major possibility for supporting needed transformational change in the healthcare systems (with regard to organization, incentives, financing, the balance of capacity between primary and secondary sector, etc.). Secondly, healthcare innovation in the large majority of sources, used in this paper, do not include the treatment and diagnostic technology dimensions as part of the healthcare innovation concept. 25

26 Based on country specific analysis and publications, it is estimated that the annual level of public research and development investment, dedicated to healthcare innovation and healthcare innovative solutions in the Nordic countries correspond to approximately 200 million US $ or between 175 million US $ and 225 million US $ annually. Based on the above mentioned assumption on levels of public research and development spending within healthcare, as a proportion of overall healthcare research and development spending, total annual spending on healthcare innovative research and development can be estimated at a level, corresponding to approximately 900 million US $ or between 700 million US $ and million US $. Figure IV Research and development / healthcare innovation resources, summarized Research and devlopment resources. Public and private. Nordic countries. Billion US $ , ,9 Overall Healthcare Healthcare innovation Considering the way healthcare innovative solutions are promoted as a potentially major instrument in the context of healthcare challenges growing financial constraints, demographic changes, increases in chronic illness and long term illness and mental disorders it is hard to be impressed by the level of investment in research and development on healthcare innovation in the Nordic countries. Research and development spending on healthcare innovation, as estimated above, amounts to approximately 0,8 % of total healthcare costs in the Nordic countries. 22 This level has to be considered also in the context of public spending on ICT within healthcare in the Nordic countries corresponding to approximately 2-3% of total healthcare expenditure 22 GDP has been calculated in US $ (PPP) for all the Nordic countries, based on OECD statistics. Based on the percentage of GDP used for healthcare purposes, the overall healthcare spending in the Nordic countries has been estimated. The level of healthcare innovation spending has been related to this total estimated level of overall healthcare spending in the Nordic countries. 26

27 and a rather low level, compared to other public sector areas, and a very low level compared to standards in the private sector. 23 Healthcare innovation types and priorities As mentioned above, healthcare innovation is defined and clarified in many different ways. In this paper, we have chosen to work with a certain, specific categorization of healthcare innovation (Figure V). Figure V Types of healthcare innovation and healthcare innovative solutions Healthcare innovation and healthcare innovative solutions IT infrastructure (structured storage of data and information, facilities/applications, accessing and using data) Access to and sharing of data and information amongst healthcare suppliers (GP s, hospitals, councils, pharmacies etc.) Citizens/patients access to and use of healthcare supplier data and information Healthcare suppliers access to and use of patient data and information Home based healthcare solutions diagnostics and treatment (products and services) Intelligent physical facilities (in homes, in hospitals, in institutions) On the categorization of healthcare innovation and healthcare innovative solutions: Sharing of data amongst healthcare suppliers would include e-prescribing, transfer of medical information to other healthcare suppliers, e-conferences / Tele-Conferences, involving healthcare personnel in hospital and primary care settings, transfer of lab/ radiology results. Citizens/patients access to and use of healthcare supplier data would include access to information, stored in electronic patient records / patient administrative systems. The automatic / direct access of healthcare providers to patient information like medication and social support would be included in the category of healthcare suppliers access to patient data and information. Home based healthcare solutions would include GP-e-Consultations, e- Booking (for outpatient visits and clinical tests), access to healthcare advice e-portals etc., censors and treatment / monitoring devices in homes. Intelligent physical facilities would include build in monitoring possibilities in hospitals, in nursing homes, in disability housing and in sheltered accommodation. Based on the results of a Mini survey 24, the present prioritization and the present prioritization of resources / investments on the different categories of healthcare innovation has been 23 Center för ehälsa i samverkan, Handlingsplan , Stockholm Udvalgte lande specifikke kilder experts on healthcare innovation from all the Nordic countries have been asked to give their viewpoints on present healthcare innovative priorities and expected priorities and possibilities in a perspective towards 2020/ of the experts have responded. The experts are renowned capacities within the healthcare 27

28 visualized in Figure VI, below with the healthcare providers mutual access to and sharing of data and information being mentioned as the main area of priority, along with citizens / patients access to relevant data and information from the healthcare provider system. 25 Figure VI Prioritities on healthcare innovation. Present situation. % Access to/sharing of information - healthcare suppliers Citizens/patients access to healthcare supplier information Structured storage of / access to information Home based healthcare solutions (products and services) Healthcare suppliers access to patient data and information Intelligent housing facilities (censors etc.) The IT infrastructure category can be regarded as an especially important category. Healthcare innovative solutions are dependent on a solid IT infrastructure with structured storage of data and information. This category is a main and absolutely essential area also for the establishment and maintenance of electronic records systems and patient administrative systems. It is evident, that a major share of IT spending within the healthcare systems in the Nordic countries is dedicated to the (further) development) and maintenance of the robust and structured storage of data and information and to the (further) development, in a very broad sense, of the information and communication technology architecture and infrastructure. In general, the resources being spent on the overall IT architectural and infrastructural development and maintenance, thus, cannot be considered or only to a certain extent be considered to be part of the healthcare innovation spending. innovation field coming from public sector innovation organizations in the Nordic countries, both national and regional / local levels, from private business companies, involved in development and maintenance on healthcare innovative solutions, and from universities. Experts from Iceland, Finland, Sweden, Norway and Denmark along with experts from England and Austria have been asked to give their opinions and viewpoints on the prospects of healthcare innovation, healthcare innovative markets and the perspectives on strengthened Nordic coordination and cooperation within the field of healthcare innovation. 25 It is primarily the public spending / public prioritization, that has been estimated. 28

29 On the other hand, healthcare innovative solutions are dependent on the efficient storage of data and information, the easy access to and sharing of data and information, the efficient ICT architecture and infrastructure, etc. Figure VII Healthcare innovation and IT infrastructure Patient administrative systems, Electronic Patient Records, Community Healthcare systems, GP systems etc. Healthcare innovative solutions Communications and information technology infrastructure classification of data and information, storage of information and data, access to data and information, sharing of data and information etc. A flexible, secure and well-managed IT infrastructure including flexible access to tructured data and information is a prerequisite for large scale healthcare innovative solutions. This is a public and national task (or ought to be a national task) and must have the highest priority. Statement from expert, Mini survey. One of the main purposes of the Mini survey was to get viewpoints on the expected or needed priorities, when it comes to healthcare innovation and healthcare innovative solutions in a perspective towards 2020 / The two main themes and viewpoints on the foundation of healthcare innovation priorities can be summarized as follows: 1) Healthcare innovation must be seen as an integral part of a needed transformation of the healthcare systems towards more cost-effective and sustainable healthcare structures and solutions healthcare innovation and healthcare innovative solutions, thus, must not be seen as supplements, on top of the present healthcare systems, but as a major basis for making needed transformation possible. 2) Healthcare innovation must be focused on, and help implement, a major shift of balance in the overall healthcare system empowering citizens / patients to take responsibility for their own situations and their own disease / diseases, increasing the capacity of the communities to deal with a much larger share of the overall healthcare and social care activities and efforts and thereby creating a platform for a reduction in the need for hospital based diagnostics, monitoring and treatment. Importantly, it is stressed, there is a need for increases in public IT resource and investment levels with continuing low levels in the healthcare systems being incompatible with transformation needs. Thus, in a perspective towards 2020 / 2025, where the Nordic countries in a publically supported and strategic drive, promoting healthcare innovation and healthcare innovative 29

30 market possibilities increase resource and investment levels on healthcare innovation and increase public/private cooperation on healthcare innovation growth, it is regarded as important with the following prioritization: 1) IT infrastructure (structured storage of data and information, facilities/- applications, accessing and using data) 2) Access to and sharing of relevant data and information amongst healthcare suppliers (GP s, hospitals, councils, pharmacies etc.) 3) Citizens/patients access to healthcare supplier data and information Healthcare suppliers access to patient data and information 4) Development and usage of intelligent housing facilities (censors etc.) 5) Home based healthcare solutions (products and services) A cheap, flexible, secure and well-managed IT infrastructure is a prerequisite for large scale innovation of services and products. This is a national task and must have the highest priority Enabling and monitoring cross-sector business processes, represents the largest potential for quality improvement and cost saving. This is a largely public responsibility and cannot be done without focusing and getting results on IT infrastructure Exchanging data with the patient and devices in the patients home has some potential for reducing costs and a large potential for improving quality. It will largely be secured with an efficient IT infrastructure Should not be prioritized for public spending should be left for private innovation initiatives, possibly based on research projects, demonstrators etc., that can be publicly funded 30

31 Figure VI.1 26 Prioritities on healthcare innovation. Perspective towards 2020/ Structured storage of / access to information Access to/sharing of information - healthcare suppliers Citizens/patients and healthcare suppliers - shared acess to citizen/patient and supplier information Home based healthcare solutions (products and services) Intelligent housing facilities (censors etc.) Healthcare innovation growth in the Nordic countries. A supplementary purpose of the Mini survey was to get viewpoints on the possibilities of radically improving the prospects for Nordic companies and to create growing export opportunities for Nordic companies within the healthcare innovation field. No common viewpoints on the prospects of growth and for creating a Nordic market within the healthcare innovation field can be deducted from the survey. On the other hand, some of the responses are positive and give indications on possibilities for Nordic healthcare innovation initiatives, for increased cooperation amongst the Nordic countries on development on of specific healthcare innovative solutions especially, if some of the main barriers for public-private cooperation can be reduced, and if the determination of important IT and classification standards can be promoted to the national levels. Yes, it is realistic (to increase Nordic cooperation on healthcare innovation and to create a bigger Nordic market, and subsequently an export market for healthcare innovative solutions). We have a lot of data (in the Nordic countries) and by sharing them in an innovative way, the potentials for improving the performance of the healthcare are huge. We have successfully been providing system export in other areas, and there is no reason why this could not be done with healthcare innovative solutions and in the healthcare domain. Almost all countries have the same set of 26 It is primarily the public spending / public prioritization, that has been estimated. 31