The Future of the Consulting Room Lies at Home

More care from home also demands more from the patient. How do you keep healthcare accessible to everyone?

'We know that some patients find fewer hospital visits and more control over their medical condition very pleasant. You see this trend in society as well, for example with the rise of smartwatches that allow people to monitor their health at home. At the same time, we recognise that not everyone is equally digitally literate, and some people prefer in-person appointments. However, if we manage to shift part of the care to the home, it actually creates more room for those who prefer face-to-face consultations with a doctor.

It's a misconception to think that we will replace everything with technology and that everyone will have to use apps. We need to offer solutions for a broad group. Ultimately, the doctor and patient remain jointly responsible for the care trajectory. The difference is that the structure of this care will look different, giving patients more control. I see this as a positive development. I believe we should encourage people to take more ownership of their health, including in terms of prevention. It's up to doctors to provide information and deliver the right care when needed.'

What are the obstacles to bringing about a transition in healthcare?

'We face several challenges. One is financing. If you add something to the healthcare system, something else must be removed. We notice that insurers and governments are hesitant to fund the digitisation of healthcare. Additionally, some initiatives run into legal and regulatory hurdles, particularly regarding privacy. For example, if technology is classified as a medical device, the EU's MDR regulation has applied since 2021 to ensure safety and quality. While this is important, the downside is that it costs a lot of money and time to demonstrate compliance with all the strict requirements and obtain certification. Furthermore, it can be difficult to get certain research questions approved by medical ethics committees (METC). As a result, it doesn't always succeed in implementing something in daily practice, or it takes a long time. And if something takes too long, there's a risk that the technology or tool becomes outdated.'

What do you hope the Flagship will ultimately achieve?

'I would find it wonderful if we could continue this in the long term, for example in the form of a centre of expertise. Other countries are also struggling with healthcare challenges and working on improvements, but what we're doing here in Rotterdam and Delft is unique. Thanks to the Flagship, we can demonstrate the value of technology to both Dutch and international healthcare. In the first few years, we've already taken significant steps to improve home-based care. That's very motivating. Helping to advance healthcare step by step—that's what gets me out of bed every day.'

Does this mean the physical consulting room will eventually dissapear?

'I expect it will. I think that, in the long run, hospitals will primarily be places for surgeries and acute care. The healthcare system will undergo a major transformation, and the relationship between healthcare providers and patients will look very different. Through the smart use of technology, patients will have much more access to their own medical data and will be able to do more themselves. The doctor will oversee this from a distance, equipped with the most up-to-date medical knowledge. In twenty years, we'll look back at our current system as functional but inefficient.'

How long will it take before this becomes reality?

'Some innovations are already a reality, such as the monitoring of pregnant women and patients with pulmonary fibrosis. Sometimes, reality catches up with us. When we started the Flagship, we discussed a system where conversations between a doctor and a patient could be recorded using intelligent recording devices and documented in a report. The big advantage is that the doctor doesn't have to constantly look at a screen but can focus on the conversation. If you take this further, you could even use keywords from the report to automatically place an order with the pharmacy. Due to all the developments in AI and tools like ChatGPT, this is already being applied in some places.

The major challenge lies in changing the healthcare system as a whole. DRIFT—a research institute at EUR specialising in transition science—has beautifully demonstrated that we are on the eve of a transition in healthcare. What you often see in a system on the verge of collapse is that all kinds of repairs are made to things that no longer work. This is currently happening in healthcare. People are working on partial solutions, while everyone knows that radical change is needed. With our multidisciplinary approach, we can give this transition the necessary direction.'

How do you create such a cost overview?

Kay: 'One of the care pathways we're looking at is acute obstetric care, as part of the PregnaDigit project. Using a methodology called time-driven activity-based costing, we compare the costs of hospitalising a woman with a complex pregnancy versus her measuring her own blood pressure and creating an ECG of her unborn baby at home. For example, hospital admission involves higher costs for staff and bed occupancy, but home measurement devices also come with costs. In a model, I examine all these costs in great detail. Ultimately, this results in a difference. I hope to have the cost overview for acute obstetric care at Erasmus MC and home monitoring ready by the end of this year.

In another project, SUITS, which focuses on home monitoring for pulmonary fibrosis, we take an even broader approach and include societal costs. If someone has to go to the hospital, it means they may temporarily be unable to work. Often, a partner or family member also has to take time off to accompany them, which incurs additional costs. When you include these costs, you get a different model than if you only look at the costs for the healthcare provider. There are, therefore, multiple ways to assess the costs of digital interventions or shifting care to the home.'

You're also looking at alternative financing models. How do you ensure that more home-based care is beneficial for all parties?

Kees: 'One possibility is to move away from fee-for-service and look at shared savings. In this financing model, healthcare providers and insurers agree to share the cost savings. Instead of focusing on lost revenue, you look at the cost savings achieved by moving care from the hospital to the home. You essentially compensate the hospital for the financial disadvantage over a certain period. This approach shifts the incentive from volume-based (the more care, the more revenue) to value-based, where the interests of the hospital, insurer, patient, and society are central—both in the short and long term.'

Kay: 'The shared savings model also gives hospitals an incentive to test or research an innovation in the first place. With the current financing models, they often back out even before or during the pilot phase because they fear lower revenue or added complexity. Yet, an innovation may prove beneficial in the long run. If there's no room to test an innovation, it will never make its way into standard practice. It's also important to first determine whether an innovation replaces existing care or adds to it. In the latter case, it almost always becomes more expensive—and that’s not what we want.'

What are the main challenges?

Kay: 'One of the biggest challenges is convincing parties that we need new financing methods. Change almost always meets resistance. Healthcare has traditionally been slow to adopt innovations, especially when it comes to introducing new treatments and medications. This is understandable, as every aspect must be thoroughly tested before implementation. However, it's unfortunate that this conservative approach has also seeped into other areas of healthcare, such as financing models. If there were more room for innovation there, it could yield benefits much faster. I would love for our research to provide a scientific foundation that enables real-world changes to take place.'