00:00:00
G_NIUS: Hundred Days to Success is the podcast from G_NIUS, the Guichet National de l'Innovation et des Usages en e-Santé. With Lionel Reichardt, meet e-health innovators and key experts to help you succeed in your projects.

00:00:20
Lionel Reichardt: Hello everyone. You're listening to 100 Days to Success, the podcast aimed at innovators and entrepreneurs in the digital and healthcare sectors, as well as anyone curious about this field. This podcast is produced by G_NIUS, the Guichet National de l'Innovation et des Usages en e-santé. In this, the thirtieth episode of the second season of the podcast, 100 Days to Success, I'm delighted to welcome Laura Létourneau, Ministerial Delegate for Digital Health, on the subject of "Bilan des trois premières années de la DNS, la Direction Numérique en Santé au sein du Ministère de la Santé et de la Prévention". Laura Létourneau, good morning.

00:00:57
Laura Létourneau: Hello.

00:00:58
Lionel Reichardt: 2019 - 2022, three years that changed the face of digital healthcare in France. For the benefit of the healthcare innovators and entrepreneurs listening in, could you remind us of the genesis and broad outlines of this shift in digital healthcare?

00:01:10
Laura Létourneau: The genesis was at the end of 2018, in a report that was done by Dominique Pon and Annelore Coury, which referred to the somewhat depressing state of play of digital healthcare in France, saying that we spend our time talking at length about round tables, patient actors, city-hospital coordination, deciding on health and medico-social, but in reality and partly because of digital, it's not true on the ground. Because the biology report does not pass from the laboratory to the attending physician, to the hospital, to the EHPAD, etc., but rather to the patient. Also, as citizens, we don't have access to our own data. How can we collectively do better tomorrow? Because we all have a share of responsibility. We - public authorities, healthcare professionals, patient associations, software publishers - are all doing our bit. As public authorities, we've done our bit by defining, firstly, why we're doing digital healthcare. Secondly, the what: what, quite simply, do we want to do? What is our vision, and how do we translate it into a roadmap? Three: how do we implement this roadmap? Most importantly.

00:02:12
Laura Létourneau: On the why, we have defined a doctrine and a framework of values by saying that we want to make digital health in France and Europe that is digital health, ethical, humanistic, citizen. Digital technology is not an end in itself, but it is unfortunately an indispensable means of driving the transformation of the healthcare system towards more personalized, preventive medicine, and so on. On the subject of what, we have defined what we call the logic of the platform-state. We said that to urbanize healthcare information systems, we need to draw inspiration from the governance model of a city, which defines the right role between the public and private sectors. In a city, the public authorities make the rules - the highway code, the town planning code and so on. In digital healthcare, they set the rules for interoperability, ethics and security, but they also create the basic infrastructures that enable exchange and sharing. Roads, bridges, the sewage network, the electricity network in a city and the digital commons in digital healthcare, with the infamous shared medical record that has come out of the ground with Mon espace santé, with secure messaging, with e-prescription, with the shared diary, with coordination tools, and so on.

00:03:15
Laura Létourneau: On the other hand, in a city, the public authorities don't make all the individual houses. It's the external ecosystem that makes them, civil society and the private sector. In the same way, when it comes to digital healthcare, we, from Avenue de Ségur and the seventh arrondissement of Paris, obviously don't make all the digital healthcare services for professionals and citizens. That's for the private sector and civil society to do. Our role as public authorities is to check that these digital services comply with the rules - interoperability, security, ethics - and that they are connected to our digital commons. Just like individual houses, they have to respect the town planning code and they have to throw their sewage into the sewer system and not into the next-door neighbor's garden. That's on the what.

00:03:57
Laura Létourneau: On the how. How do we implement this vision of a platform state and the thirty underlying actions of the roadmap? Firstly, we need to coordinate public authorities at both national and regional level, something that didn't exist before. We need an orchestra conductor. The orchestra conductor is the Digital Health Delegation. Secondly, and even more importantly, we need a highly successful co-construction of the political formula with all stakeholders. The "classic" stakeholders, healthcare professionals, establishments, patient associations, but also - and this is a major innovation in the roadmap - with manufacturers, start-ups, major groups and historical publishers directly, because they are the ones who are making digital healthcare happen in the field and with citizens and patients, including directly. This is what we've done with the Comité citoyen du numérique en santé, with citizens selected by lot. After three years, this doctrine has been rolled out thanks to the absolutely spectacular mobilization of the entire ecosystem and all the stakeholders, each of whom played their part. The state platform, with its rules and infrastructures, is 90 percent developed. My health space is out of the ground. There's a whole raft of innovation and international initiatives that have also moved forward at full speed, notably under the French presidency of the European Union.

00:05:10
Lionel Reichardt: As you mentioned, this roadmap had five major orientations, some thirty actions. It's perhaps a little difficult to ask you this question, but of these thirty or so actions, which do you think have contributed most to helping innovative healthcare entrepreneurs? Is there one that was particularly difficult to implement, or one that you prefer?

00:05:31
Laura Létourneau: There's one that may be my preference, because it's not sexy. I'm not going to talk about digital therapeutics, artificial intelligence, blockchain, all that super glamorous stuff. I'm going to talk about something that isn't sexy, but is key and is one of the major problems for digital health entrepreneurs today, which is that health is highly regulated in general and so is digital health. This is to be expected, given the issues of personal data protection, security, the digital divide and so on. Having this State platform with its rules and infrastructures that are clear, pragmatic, state-of-the-art, shared and made legible via G_NIUS, the Guichet National de l'Innovation et des Usages en e-Santé (National e-Health Innovation and Usage Window) we're talking about today, and that are applied and respected, is very rare. Today, 50% of the law is not applied. With very proactive ex-ante and ex-post control logics. In reality, it's essential for entrepreneurs and manufacturers in the digital health sector in general to understand the rules of the game, plan investments and be able to anticipate. That's the first thing. It's not sexy at all, but frankly, it's key.

00:06:38
Laura Létourneau: Then, on top of that, as you know, there are two major funding programs that have been released as part of this roadmap, which we would never have dared to hope for. The first is the Ségur digital health program, which will invest 2 billion euros with funding from the European Commission and the European Union, and which will free up health data for both primary and secondary use, by doing the same bad work of collecting data wherever it is found, in towns, hospitals and the medico-social sector, and circulating it smoothly and securely. There's no point in talking about artificial intelligence if we don't even have the data to hand. We know that the "most difficult" thing is to go and tap into the pipes to get this data up and running. First funding program.

00:07:20
Laura Létourneau: Second funding program, very much focused on innovation and entrepreneurs, 650 million euros, again from France relance and the European Union. The digital health acceleration strategy, which also includes a whole range of actions. It's almost a second roadmap in itself, following the life of a digital health entrepreneur's project. It starts from the ground up. In other words, training healthcare professionals in digital technology and, conversely, training digital entrepreneurs in healthcare and research topics. Because it's essential to have human fertile ground to ensure that these innovations take hold and to have a transfer of innovation, from research subjects of the word digital, etc. to industrial subjects. First point.

00:08:00
Laura Létourneau: Second point, we then need to have third-party experimentation sites so that entrepreneurs can break through the door, for example hospitals and go and test their digital services in production. We know how complicated this is today, and that we need to bring the world of healthcare closer to the world of start-ups and economic development in general. This is one of the actions in our strategy. We need to set up third-party experimentation facilities in all our healthcare, medico-social and other establishments, to bring these two worlds closer together. Beyond that, we need to scale up, and I'd almost say above all. This has been the big problem with e-health for years, and it's the one we're trying to crack with this strategy, by saying that digital services must not remain gadgets. Unfortunately, that's still often the image they have. We need to be able to really assess their medico-economic benefits. The public authorities have released 100 million euros to help evaluate the medico-economic benefits. This is key. Beyond subsidies and grants, we need to find sustainable business models. That's why, as part of the Social Security Finance Bill, we have released two market access and reimbursement windows for medical devices and remote monitoring.

00:09:13
Laura Létourneau: At the interface between these two programs, we have a key tool which is Mon espace santé, which is therefore at the interface between the Ségur Numérique which will free up data and the acceleration strategy which will use this data for innovation, research, etc. As you know, Mon espace santé has native components taken from the State platform: a medical record, secure messaging today and tomorrow, a shared diary. But it also has, and this is the consecration of the State platform, a catalog of digital applications, where we will reference all digital services, provided they respect the rules and connect to our infrastructures. Always the same thing. So it's essential that all entrepreneurs apply to this one-stop shop to gain visibility, and to be able to pride themselves on being reliable, interoperable and secure. There are also requirements concerning the quality of medical content, the digital divide and accessibility. Then, to have access to data that they would not otherwise have had access to, since they can have access, if the patient agrees, if security requirements are met, etc., to the data in the medical record, to data present in the medical record, in the diary of data they would never have managed to retrieve otherwise, to use this data and render an additional digital service they would not have been able to develop had they not had access to this freed-up data.

00:10:32
Lionel Reichardt: In 2017, you co-authored a book, Uberisons l'État! Before others did. You've spoken to us several times about the platform state. Can you redefine it for us? Also, do you think you've succeeded in uberizing the State in healthcare?

00:10:45
Laura Létourneau: In Uberisons l'État! before others take over, we first explain the threat to public services, in this case from private players, notably GAFAM, in areas that are highly regalian - digital identity, security, etc. - and somewhat less regalian, such as national education and healthcare. You all have an application on your iPhone called Santé, which is My Health Space, but it is not sovereign and its general interest is not guaranteed by the public authorities. The threat is not a fantasy. We say in the second part of the book that we shouldn't stop there and cry, that this threat is objectively problematic, beyond the demonization of GAFAM or their fascination. That objectively, putting the arguments flat, it is problematic, but that we must take advantage of this set in motion to finally steer the modernization of public services within a framework of values that seems acceptable to us and much more quickly than previously by uberizing public services or more precisely, by platforming and even meta platforming public services.

00:11:45
Laura Létourneau: How do we apply this meta platform? It's been said that we need to practice judo, and that the meta platform model is the GAFAM model, from which we need to draw inspiration. To explain this, we take the example of Uber, saying that Uber, when we take a closer look at this model, in reality relies on the Google Maps geolocation system, on the distribution of its service through stores, either Apple's or Google's, via the digital identity of Facebook Connect and through the data management of Amazon Web Services. If it hadn't been able to rely on all these technological infrastructures built by others, in this case the GAFAMs, which are meta platforms, platforms of satellite platforms, Uber is a satellite platform like Airbnb, like BlaBlacar, etc., and in reality Uber would never have been able to uberize its sector and go so fast. What we're saying is that in public services, all these technological infrastructures and meta-platforms must be public, because they must be neutral and the general interest must be guaranteed by the public authorities. It's a question of democracy.

00:12:48
G_NIUS: We don't want the framework for interoperability, security, etc..., to be imposed by the App Store in healthcare. We want it to be imposed by the public authorities as part of the listing in the Mon espace santé catalog. Of course, these are constraints, because we have to comply with interoperability and ethical and security rules, but it's for the benefit of citizens. But what we also have to understand, and the message I want to get across to entrepreneurs, is that this is also an opportunity. As I was saying, Uber would never have succeeded in concentrating on matching supply and demand, if it had had to reinvent a system of geologists, digital identities, and so on. In the same way, for example, Vite Ma Dose, to take an example from civil society, during Covid, was able to rely on Pro Santé Connect, the sector-specific identification brick that is the equivalent of FranceConnect, but for healthcare professionals, to deploy its service in all vaccination centers, without having to do the enrolment as we say. This means identifying and qualifying all healthcare professionals to check that they have the right to access personal health data. Coding the Pro Santé Connect button on its digital service in two days saves three months of deployment, since we haven't enrolled the healthcare professionals ourselves.

00:13:55
Laura Létourneau: In the same way, I gave the example of the Mon espace santé service catalog earlier. Thanks to Mon espace santé and these native bricks, and the Ségur de la Santé behind them, entrepreneurs will be able to access data that they wouldn't have access to if it hadn't been for the work done with the public authorities. The platform state or the meta platform state, to be perfectly accurate, is really a case of having your cake and eating it too. In other words, it's innovation as close to the ground as possible, made possible in particular by entrepreneurs, and/or because the two worlds shouldn't be pitted against each other within a framework of ethical, humanist and civic values, guaranteed by the public authorities. It's a win-win situation. For the public, for the private sector and, ultimately, for citizens.

00:14:35
Lionel Reichardt: It's very clear. After three years at the helm of DNS, you're about to hand over the reins. What do you see as the major challenges for digital healthcare in France from now on? What advice do you have for your successor?

00:14:48
Laura Létourneau: My first piece of advice is to build on all this and not give up on this roadmap. Digital technology is like ecology. It's all about infrastructure, and you have to plan ahead. You can't change gear every six months. On the other hand, the advantage of digital technology over ecology is that it brings almost everyone together. In other words, everyone, every spectrum of the political spectrum, agrees that it's essential to transform the healthcare system, that we have to go ahead and that we have to do so within a secure, ethical and interoperable framework. We've said that, we've said nothing. The hardest thing is not to make a roadmap, it's not to publish decrees, it's to do it.

00:15:26
Laura Létourneau: We need to be hyper-determined and remain hyper-voluntarist about rolling out this roadmap and ensuring that these impacts and uses are visible in real life for healthcare professionals, for citizens. This is happening with Segur, with Mon espace santé, now that we've finished building the state platform and all the foundations of the house, but we really have to keep going in this direction, and at a fast pace. That's extremely important. You can't go on at the speed of plate tectonics. We have to keep up a high pace, in line with the logic of the small, rapid steps we hold dear, so neither the small, slow steps nor the big steps that never happen. This is important. Why is it important? Because it's important for change management that we slow down. It's not just that we're going slower, it's like riding a bike, it's that when we slow down, after a while, we fall off. To crack certain subjects, sometimes there's a story of rhythm.

00:16:14
Laura Létourneau: If we'd had six months and not three weeks to get the European Commission and all the member states to vote on European ethical principles for digital health, we wouldn't have managed to get them passed. It's because we had three weeks that we were able to get everyone on board and agree. There are also extremely important issues of digital sovereignty, as well as health sovereignty. Because we, the public authorities, are in competition with certain private players who want to be the State platform in the place of the State, in addition to the role already assigned to them in the logic of the platform State. It's essential to move quickly to propose alternatives, to keep up with society's expectations. It's a question of democracy. I'm not at all worried about the fact that not only will this be an ongoing process, with a whole host of additional subjects to be added in terms of data, uses, etc., but also about the fact that it will continue at a high pace. That will depend on us, the public authorities, but it will also depend on you, the whole ecosystem, to make sure that you continue to do your part.

00:17:21
Lionel Reichardt: To conclude, Laura Létourneau, what advice can you give to entrepreneurs, to innovators who would like to innovate in healthcare in France?

00:17:28
Laura Létourneau: I'd say, think of public power as allies. Get into a mode of thinking that's a little complex, but not that complex, where the public and private aren't opposed, but we're in a state of the XXIᵉ century, where there's an alliance that's not naïve or demanding, but an intelligent alliance between the public and private in the service of the general interest that's defined by this platform-state. I'm really counting on you to join in this dynamic, just as you have done for the past three years, to give your all and help us transform the healthcare system. In the same way, you can really count on us and the public authorities in the years to come too.

00:18:12
Lionel Reichardt: Laura Létourneau, thank you. Our episode is coming to an end. Thank you for listening. Thanks again to our guest for his availability. Don't hesitate to subscribe to the podcast on your listening platforms. We look forward to seeing you soon for a new episode of 100 Days to Success.

00:18:32
G_NIUS: Those who are making e-health today and tomorrow are on the G_NIUS podcast and all the solutions to succeed are on gnius.esante.gouv.fr.