We are immersed in a digital world. This is profoundly transforming our lifestyles, our relationships with others, our relationship to knowledge. New questions are emerging, on the societal, economic, technological and legal levels.
At the end of 2012, in the prestigious hemicycle of the Economic, Social and Environmental Council, stakeholders from business, higher education and research and public authorities, socio-economic leaders and students shared these questions and exchanged views in a major debate centred on three societal themes of everyday life: culture: "Does the connected man know everything? health: "what does the patient know - what does the doctor know? »the city: "how does the city open up to the digital citizen?".
"Addressing the question of Man - in the general sense, of course, of the human being, man and woman - in his digital environment, means both helping to inform our fellow citizens about what I would call the digital imperative and not rejecting the decisive contributions of a revolutionary advance in many ways". begins by declaring Jean-Paul Delevoye, President of the Economic, Social and Environmental Council.
"I have just pronounced the word 'revolutionary'." Yes, we are living a real revolution. As we do not yet see the ins and outs, we call the current situation a "crisis". In reality, it is rather a great or profound change that we should be talking about, under the double impact of energy and, of course, digital. The future is no longer the projection of the past, as was the case in the last century - I am thinking of the Soviet Plan or Alvin Toffler's futurology, for example, both of which drew a future drawn in advance - no, the future today calls the past into question. We are changing era, and we are beginning to know it. We are becoming aware of the need to adapt society, its structures and its leaders. We are becoming increasingly aware of the need to incubate innovation and encourage risk-taking. Digital technology is changing our social structures, our mental structures, our representations, our relationship to time, space and the other, and even the construction of our identity. Isn't the world's third largest community after China and India facebook, which surpassed one billion users in September 2012?
This revolution sometimes makes you dizzy: I was recently told that my i phone had twice the computing power of the computers used by NASA in 1970 for the Apollo 13 mission! More importantly, it affects all areas. » he continues.(...)
And to conclude: " I would like to stress that the digital world accompanies as much as it initiates, facilitates as much as it produces new practices. These are based on three pillars:
- Dissemination of information (but what about its prioritization, its understanding?)
- The emergence of the individual in his capacity for choice and expression (but what about his listening capacity? what about the collective bond?).
- The structuring of a society by the network more than by power, status or hierarchy, a society more horizontal than vertical, a society more to regulate than to control.
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The end of the world is not the end of the world. Let's enter this new era head on! With wisdom, but above all with enthusiasm.
Part Two / Health: What does the patient know? What does the doctor know?
– Relationships between health actors and patients at home: domomedicine, a new health system, by François Guinot, Honorary President of the Académie des technologies, Delegate for International Relations (Synthesis by Alain Brenac, ICT scientific secretary at the Académie des technologies).
Evolution of the patient-physician relationship and customization. I would like to focus first on the profound changes that the development of the digital (Internet) has caused in the knowledge - real or supposed - of "man suffering" and on the changes induced in his relationship with the physician and beyond with his environment, including those close to him. This evolution is illustrated by 3 new practices that tend to become generalized:
- a wide variety of symptoms can now be consulted on the Internet
- self-medication and buying "drugs" online
- the use of advice within the framework of specialised social networks (patients' associations).
The relationship with the doctor is transformed because the patient becomes an actor responsible for his or her own health. own health instead of the passive being waiting for the medical prescriptions he used to be before the advent of digital technology.
Furthermore, digital technologies are now making it possible to identify the knowledge necessary for the treatment of the patient. Instead of applying an average treatment to an average patient (for lack of knowing him better), the doctor is now working on developing a personalized treatment. of the patient. It is now better known how much the effects of the same treatment may differ from one individual to another in a population with the same pathology. However, the rapid development of the genomic approach today makes it possible to understand the patient's own identity at a cost of more and more reasonable. This can now be considered and treated by the health actor as a unique individual to whom personalized treatment must be applied. The Academy of Technology and Domomedicine.
I will now make a historical parenthesis to describe how the concept and then the project of Domomedicine emerged within the Académie des technologies and was then developed in the field. Born from an unexpected meeting between a Professor of Computer Science at Ecole Centrale, Christian Saguez, and a Professor of Medicine, Francis Lévi, a renowned oncologist, both of whom members of the Academy of Technologies, this new approach is intended to respond to the calls for patients who want to benefit at home from acts and care comparable to those they receive at home would have in a hospital environment thanks to the use of miniaturized technologies and not invasive and often communicating.
This constitutes a radical change in medical practice: in order to preserve social ties of the patient, it is a question here of gathering around him what is used to look after him contrary to the approach The classic one where the patient is forced to move from one "technical platform" to another of the hospital. The number of patients potentially concerned by domomedicine is significant: there are in France 1.2 million dependent people and 9.8 million chronically ill people and this represents a cost of of $56 billion a year. This figure unfortunately tends to increase with longer life expectancy.
At the instigation of the two promoters I have just mentioned, a report was produced that issued a a series of original recommendations that we wanted to implement. It is quickly appeared that local authorities (the right level seems to be the Region) were a partner indispensable for this implementation. And it is in the Champagne-Ardenne region that the project The "domo-medicine" movement has been able to find the political support and will necessary for an initial field experiments.
The patient at the centre of the health care system
There is now enough hindsight to say that this home follow-up allows for a better the pathology, particularly in the case of chronic conditions (AIDS or cancer entering the country). now in this category). It is further noted that as patients willingness to stay in their familiar environment, they develop a sense of belonging to the community. better acceptance of new technologies.
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A remark on the term "Domomedicine": this concept is the last avatar of the old term "Domomedicine". It includes all the features of "telemedicine" (or remote medicine), but it adds the essential notion of refocusing the patient at the heart of the healthcare system. Domomedicine profoundly changes the patient-physician relationship as noted above, but also has some implications for the patient's social and administrative environment.
This new medical practice will lead to new professions, in particular to ensure that coordination between the use of patient information collected by the different specialists involved. This is a direct consequence of putting the patient at the centre of the system.
Census of Domomedicine Projects
A number of pre-projects are currently committed and have found funding:
- Three projects at the European level (with funding of €1 million each)
- The French project, on a larger scale, in the Champagne-Ardenne region, involving 10,000 patients.
- The idea is making a mess of things and other local communities could quickly follow suit.
The implementation of such a project is complex because many factors must be taken into consideration in addition to the medical practice itself, such as liability issues (medical co-management, etc.) of the patient) or the types of business model to be put in place (e.g. fee-for-service payment, fee-for-hire, etc.). does it still make sense?).
The emergence of domomedicine will certainly offend many habits, but it is necessary to consider that, in addition to meeting patient needs and demonstrating improvement in can hope for on the therapeutic level, this young discipline has enormous potential for business start-ups based on technology integration and systems development, or even "systems of systems", necessary for its development.
About François Guinot :
Honorary President of the Académie des technologies, Delegate for International Relations, Doctor of Physical Sciences and Economics, François Guinot has spent his career in the chemical and pharmaceutical industry (CEO Rhône-Poulenc Chimie, DG Rhône-Poulenc Santé and bio Mérieux), where he has profoundly renovated the R&D and strategic innovation activities of several major groups.
President of the Academy of Technologies from 2005 to 2008, he is also President of the Domomedicine Consortium of the Champagne-Ardenne Region. He defines Domomedicine as a new health system, centred on the patient, the doctor and the health actors. At the heart of innovative projects, he emphasizes the global management of patients suffering from several chronic diseases, which requires inventing coherence in the use of technologies that contribute to the management of each of the pathologies concerned.
– Applications of digital technology to the problem of addiction, by David Gordon-Krief, Elected President of UNAPL on 5 February 2010 for a 3-year term of office. (Synthesis directed by Caroline Coutoutout, Engineer-Student of the Corps des Mines, Institut Mines-Télécom)
The ageing of the population, linked to longer lifespans, raises questions about major societal and economic issues. The increase in life expectancy is leading to an increase in situations of loss of autonomy among the elderly. To this revolution In addition to demographic change, there is also a change in morals, with a growing number of people in dependency situation wishing to stay at home. The maintenance of the social link is then revealed indispensable for the physical and moral well-being of these populations. Their care remains before a whole societal challenge, involving the establishment of new solidarities and a redefinition of the role of the family and health professionals. But it also raises financial issues, both for relatives and for public finances. New technologies are bringing new opportunities for elements of responses to all these issues. Investment in the development of tools The digital revolution is fundamental and will condition our future health infrastructures.
France is currently facing a paradox. On the one hand, the extension of the life expectancy and the the number of elderly people who wish to stay at home longer and longer is leading to growing needs for support, health monitoring and alertness maintenance intellectual. On the other hand, there is a desertification of health professionals and support (nurses, ...). How then to ensure the sustainability of the social link and the intellectual stimulation of elderly people who wish to stay at home, and thus limit their loss of autonomy? How can the health status of these populations be maintained? The rise of the new technology and digital technology provide many elements of response to these challenges.
Digital technology and associated communication tools, such as Skype, are used in a number of different ways. many areas related to maintaining social ties. Indeed, they allow a break in isolation, which is essential for the moral well-being of elderly people at home. It is also fundamental that they maintain an intergenerational link in order to limit a "syndrome". from a rapid "slide" to loss of autonomy and depression. Waiting for family events (the fall of the first tooth, the arrival of great-grandchildren ...) are for example the guarantors of a keeping these populations alive. Finally, language practice and intellectual stimulation - social connection and enabled by digital tools - are an important element of the key to delaying cognitive decline.
New technologies also provide elements of response for the monitoring of health status of the elderly at home. For example, the Internet allows for an almost continuous link with the doctor and health care professionals. Likewise, relatives can be notified in due course. real if there is a problem, without mobilizing costly resources.
This increase in curative, accommodation and addiction prevention needs puts It also challenges our social systems as it leads to increasing financing needs. The The costs of home support to ensure physical, social and intellectual comfort should be sustainable both for families and public finances. Here again, digital technology is bringing economic response elements, as an extension of the current companion system. It allows a less expensive home care service than specialized institutions, while at the same time allowing the limiting the rapid deterioration of health and cognitive functions. It is also job creation, with the need to develop solutions that are adapted to the needs of the prevention of dependency and the emergence of dedicated support professions.
The Committee on Dependence of the Economic, Social and Environmental Council (EESC) has recently worked on this issue of home support. The organization of the care system, the management of screening, reinforcement of home help, adaptation of habitats and infrastructure to meet new needs, or the training of caregivers and families are as much a part of the axes of reflection strongly linked to digital technology. The report therefore recommends support for development of new technologies, whose investments will condition our system and our response to addiction prevention. It also highlights the contributions of the The digital divide is a major obstacle for families, who often cannot cope with the loss of autonomy of a parent.
To conclude and reiterate the main ideas of this presentation: the ageing of the the increase from three to four - or even five - generations living together is raising major social issues. It results in an increase in the number of elderly people wishing to stay at home and whose physical and mental comfort should be maintained in order to slow their slide into addiction. The issue of social ties and the care system are the most important. pillars of the support that must be put in place to serve these elderly people.
Digital technology is emerging as a key element in this demographic and economic revolution. It responds to human issues, for example by enabling social ties to be maintained and by limiting cognitive decline. It is also at the heart of public health issues, limiting the arrival of the loss of autonomy and by improving the monitoring of the state of health of the elderly person.
Finally, he responds to major economic challenges, by limiting spending on specialized institutions and by ensuring job creation. Investment in new technologies is therefore fundamental in the redefinition of a health infrastructure adapted to these societal changes.
About David Gordon-Krief :
Elected President of UNAPL on 5 February 2010 for a 3-year term, he chaired the Economic, Social and Environmental Council's Temporary Committee on Old Age Dependency and steered the work of the social partners to propose to France the necessary reform of care for all persons with loss of autonomy.
– Is digital technology a lever for a new form of health democracy? Patient information as an indicator of health democracy, by Robert Picard, CGEIET's health referent, Antoine Vial, Public health expert, medical communication specialist (Synthesis by Hélène Serveille, General Mining Engineer, CGEIET)
The complexity of the problem of patient information justifies a two-voice, one-voice presentation medical and a more technology- and management-oriented voice. The CGEIET that feeds into the presentation is the result of observation and analysis work carried out with the support of an an interdisciplinary group of about 20 people, which allowed for in-depth listening work to be carried out and feedback from the field.
State of the art of patient medical information
Medical information reaches the citizen through two privileged distribution channels: that of the doctor, who enjoys a strong capital of confidence in the population, and that of the Internet. 70% of French people consider their doctor as the first provider of medical information. But the unfortunately do not have time for this and it is neither their priority, nor their competence--their training does not cover this aspect, so we are training hard-core scientists. Finally they may also be influenced, for example, by medical information and training which are overwhelmingly funded by the laboratories. Yet there are very few physicians have been trained to read critically, so this influence is not really perceived by them.
The Internet represents for the patient 70% access to information on health issues. This breakthrough of the internet in such a short time is due to its great accessibility: it is the information that I when I want it, when I want it, and at the level where I want it and where I can. The takeover bid and the offer However, there are different logics for the privacy of medical information on the Internet.
The public offer is essentially the work of the various organizations and institutions that work in the following areas in the health field. We observe that each of them tends to broadcast, on its own site, the information it produces, and the result is not legible, consistent for the citizen. We are in a supply-driven logic. Furthermore, although there has been a law since 2005 making it mandatory to the accessibility of public information sites to people with disabilities, we note that this is often not the case for public health sites.
Private supply is closer to use value, as it is the information with the highest wants to. The most consulted private sites are much more consulted than public sites. But this offer serves interests other than those of public health. Economic models that should not obscure the fact that the information is in fact free of charge and that it is in the process of being reality paid for by others. For example, we find that a drug is only cited if the laboratory that cites it is a factory has paid its share. And some sites propose, depending on the navigation of the citizen on a pathology, the online purchase of medicines not authorized in France.
So while there is tremendous potential for digital, we must also consider the potential for danger. In addition, there is no link between the medical information channel and the of these information sites, which are not interested in new patient interactions informed by internet and his doctor.
Here are the main lessons:
- a strong citizen appetite for medical information, exploited by the private actors that create economic value.
- a digitally-induced change in behaviour and the relationship between the citizen and the health care system, the patient and the doctor. If medical information is not enough to manage and heal his illness, the internet allows you to share your experience with other patients. There is a body of knowledge known as "secular" knowledge, derived from the patient's experience, which, when aggregated, completes the corpus of medical knowledge, and restore humanity to what medicine has forsaken.
- citizen information that is not considered by the State as a public health tool that can regulate the demand for health care, unlike in other countries. country. The State does not make medical information a regalian mission, even though there is a strong citizen appetite, so it is naturally the private sector that fills this void to sell his products.
- if public action is slow to fill this gap, it is also because it is powerless in the face of an offer teeming health technology. There's a multiplicity of sites. It certainly emerges from initiatives, but which are limited to ensuring the coherence of the sites' offer, supported by technical integration concerns more than by a response adapted to the needs of the patients.
- the barriers to be lifted for the use of technologies concern comfort of use and envy to use them, for the patient as well as for the doctor. The work of appropriation and mastery is still a long way off.
- new digital possibilities, such as the Cloud, big data, time capacity, etc., which are all part of the digital revolution. to integrate masses of data, for emergencies, or for the vigilance in front of the emergence of new diseases, are certainly real but still need to be explored. There is also a need to take ethical and deontological concerns into account before transposing these new technologies in the health sector.
Perspectives and recommendations
The Internet is cross-border, and from this point of view, it is impossible to regulate the health information content. Even the labeling requested from the HAS proved to be useless.
But we need to find a solution to the problem of the sale of illegal medicines on the internet and It is a question of police, customs, whose actions have been effective in other countries. sectors.
In addition, educating the Internet user to read medical information critically, "health" and "health education" is a priority. literacy" is not a reality. It is in fact put under the influence of the actors, who "educate"... in a drug-taking sense. Technologies are leading to new behaviours, but the health benefits of the patient still needs to be qualified.
In conclusion, the conditions for the effective implementation of a public health policy are as follows integrating citizen information are set out in the CGEIET's report "de l'information du patient to health democracy: challenges and conditions for an efficient use of technologies".
- winning healthy citizenship
- keep a watch on new information technologies and anticipate the ethical and social impacts of new technologies. societal
- to qualify and disseminate public content in a coordinated way, to make it complete and accessible and reliable
- undertake public education and training actions
- articulate, select and make explicit the priorities for public action.
About Robert Picard :
CGEIET's health referent. Since the end of 2004, within the General Council, he has been in charge of steering and carrying out studies and reports on the various aspects (uses, technologies, industrial aspects, services) of ICTs in the health and autonomy sector in liaison with the relevant services or agencies under the Ministries of Health and/or Solidarity. In this capacity, he has participated in several interministerial or parliamentary missions in these fields. He has been a member of the Comité d'Agrément des Hébergeurs de Donnés de Santé since 2006 and of the Scientific Council of the Centre National de Référence Santé since its creation (2009). He is the author of numerous CGEIET reports in Health. The most recent ones deal with the open design of health products involving the user ("Living Labs"), the use of social software in health and technologies for citizen health information.
About Antoine Vial :
Expert in public health, specialist in medical communication Until 2012, member of the "Quality and dissemination of medical information" Commission at the French High Authority for Health (HAS). Member of Prescrire's Board of Directors. Member of the French Public Health Society.
Author of :
- Information and Communication Technologies in the medico-social sector - (2010) CGEIET / Min. of Health)
- Quality Information for the French-speaking general public (2009) Prescrire
- Les Circuits de l'information médicale (1999) INPES
- Articles on medical communication in: Prospective and Public Health, Agora, Ethics and Health, Practices, les Cahiers de la Médecine, Revue du Haut Comité de Santé Publique, Sève, etc.