Learning from the Past, Looking to the Future: Patient Monitoring and Digital Medicine

Not all parameters are relevant at all times – I would like to decide which ones to monitor on a case-by-case basis, and I imagine that plenty of colleagues feel the same. Apart from the added value for the patient, we also have to consider questions of technical feasibility, integration with existing workflows, and financial viability.

You just mentioned that data is incredibly relevant to modern medicine. Could you expand on this? What opportunities do you envisage, what fears might patients have, and what risks are evident to you and your colleagues? 

When I began working on patient monitoring, I did not foresee it becoming so important in the near future. But the quality and quantity of the data provided by the latest monitoring devices are driving the digital transformation of medicine. No system can be transformed without data. 

Then there’s the question of format. A pdf might be available digitally, but I can’t search the document easily, make it machine-readable, or send it to another device for analysis. I need data that is interoperable, that can be read by machines: this creates a basis for the targeted use of artificial intelligence too. It is important that the data fulfil certain standards. The data must be high quality and not contain any distortion or bias. For example, SpO2 sensors produced erroneous results for patients with darker skin because the sensors were less reliable in detecting oxygen saturation compared to when they were used on people with lighter skin. That must not happen.

Data security is also key, especially now that cyberattacks on universities and other public institutions are becoming more common. As a patient, I want my sensitive personal data to be secure and not fall into the wrong hands. Gathering data comes with huge responsibility. You need to guarantee that only authorized people have access and that the data are not altered, manipulated, or destroyed. Handling data securely involves fulfilling certain quality and security criteria. This keeps people’s fears in check so that they can embrace the benefits.

Can you explain the technical principles behind the monitoring alarm system?

Of course! These devices traditionally function using algorithms based on threshold values. The alarm only sounds when a threshold value is surpassed, so it is a very simple system. But if we keep going like this, we will be unable to maintain an overview of the ever-increasing number of threshold-based alarms. Even now, the problem is that up to 99 percent of these alarms are false positives. This can lead to alarm fatigue where medical personnel become desensitized to critical alarms. We need to mitigate this by evaluating the data in a smarter way, including with AI, as the amount of data is just too much for anyone to interpret off the cuff. Alarm systems based on threshold values emerged in the 1970s, so they are very old. I think we could do better today. In future, AI algorithms will be able to sound the alarm in intensive care units. They will be much more targeted, so they will go off far less often, but will have similarly high levels of sensitivity compared to the devices currently in use today. 

This brings us to the central focus of my clinical implementation research in digital health. The fact is that we sometimes implement systems that are not useful or are just bad in terms of technical execution, usability, workflow, and so on. In the field of implementation research, it has been observed that it usually takes 17 years for a new therapy or technology to reach patients. With such a long innovation cycle, it is hardly surprising that we are still making such little use of technology. Something has got to change. I feel that implementation research – and the resulting insights for practice – is a truly important and growing field, especially for digital medicine.

All kinds of digitalization projects are in the works at the Charité…

Absolutely! And we cannot keep reinventing the wheel. Instead, we need to find our place within the existing knowledge. A good example is the new hospital information system at the Charité. Implementing it will be a challenge. How can we ensure that it works smoothly right away? We should draw on the evidence-based, systematic evaluations from other hospitals which are published and freely available. But it is also clear to me that there is a gap between research and practice. The project management offices of hospitals usually do not consult the medical literature for the latest scientific insights on how to implement technology. It uses other resources, so I feel it falls to me, in part, to put the methods developed by researchers into practice here at the Charité. For all of us at the Institute of Medical Informatics, it helps that we are so closely involved in patient care – and our director Prof. Felix Balzer is also Chief Medical Information Officer (CMIO) of the IT Business Division at the Charité, meaning that he is responsible for the digitalization of healthcare. 

All in all, it is important to me to show that digital transformation brings real added value. In doing so, we must also consider the WHO Quadruple Aim and ask ourselves time and again: have we really improved patient satisfaction and health – or not?

Thank you for outlining the big picture. Let’s now turn to the event series that you are currently organizing thanks to our funding. The three events address the past, present, and future of patient care. 

That’s right. The first event took place on September 5, 2024. It focused on the early days of digital medicine, using patient monitoring as an example, and the clinical significance and ever-present challenges of implementing digital technologies were discussed. The keynote was given by Prof. Monika Ankele, the new director of the Berlin Museum of Medical History, and Prof. Volker Hess, head of the Institute for the History of Medicine and Ethics in Medicine at the Charité. One thing that I took away from this was that science communication looked very different in the past, when broadcasting a heart sound on the radio was enough to create that ‘wow’ effect.

After the talks, I moderated a panel discussion with four people who had experienced the early days first-hand. The former production engineer Reinhard Troll and the laboratory director Dr. Wilfried Scharner both worked in the measuring instrument factory in Zwönitz, East Germany, before and after the fall of the wall. The nurse Doris Grünewald was there when the first intensive care unit was built in the GDR and Dr. Michael Römer is a senior anesthetist, now retired. I was struck, for example, by what Ms Grünewald had to say about how new technologies were implemented. When ECGs were introduced in intensive care, specific medical staff were appointed as contact partners to communicate with the manufacturers. There were around 50 people in the audience from all kinds of different specialisms and they posed some great questions. All in all, the event series got off to a very successful start!

What have you got planned for the second and third events?

The second one about patient monitoring today is scheduled for October 15, 2024. It will take the form of an interactive world café where participants can actively exchange their knowledge and experience with each other and meet experts from research, industry, and healthcare. There will be four stations covering research, industry innovation, clinical use, and innovation management. This should enable the participants to gain comprehensive insight beyond their own expertise. We have been lucky enough to get Masimo, Dräger, and Philips as industry representatives. They all manufacture medical technologies that are used in here in the BeST and the various Charité clinics. 

The last event is scheduled for November 28, 2024. Participants will join forces with futurologists from Freie Universität Berlin to make predictions for the decades to come. The futurologists will introduce them to the backcasting method, and together we will define a desirable goal for the future. We will then identify what measures will be necessary to reach this goal. As a rule, you first need to be able to imagine something before it can become a reality. Backcasting is an exciting way to identify what exactly we can envisage for the future so that we can then decide if that is the future we want.

How did you come up with the idea for the event series and who is your primary target audience?

The idea came about during a patient monitoring roundtable designed to promote interdisciplinarity at the Charité and create a supportive environment for developing new ideas together. The roundtable is organized according to the mastermind principle, the idea that it is very difficult to come up with new ideas by yourself, but when you get together with, say, ten other people who share similar values and the same vision, suddenly lots of new ideas emerge which you would not have come up with alone. As a working group, we want to drive innovation, ideally improving processes and filling gaps in healthcare along the way. What makes our initiative special is that participants are really included as equals. Everyone has the opportunity to speak, and they feel empowered to do so as we keep things relatively closeknit. 

But we have expanded our reach considerably for the Yesterday, Today, and Tomorrow series. Our target group includes doctors, nurses, and patient representatives, as well as industry representatives. And anyone else who is interested is very welcome to sign up! If you are enthusiastic about this issue and want to create change, if you have a drive for innovation, then it is well worth taking part.

Last but not least, we would like to discuss your career trajectory. You were funded as a BIH Charité Digital Clinician Scientist from 2020 to 2024. Stiftung Charité was among the organizations that launched the general Clinician Scientist Program around 2010. Looking back, what did the Digital Clinician Scientist funding enable you to achieve?

It was crucial. I got my certificate just a few months ago and I probably wouldn’t be where I am today without that funding. In 2018, I only had one publication, and now it is 2024 and I’m done with my habilitation and am about to become a professor! All this could hardly have been possible without the protected research time granted by the Clinician Scientist Program. The funny thing is that I actually applied twice. The first time round I was unsuccessful because my PhD was only awarded cum laude, not magna cum laude, as was required at the time. At that point I was unsure if I would be able to continue in research. But I was accepted into the BIH Charité Digital Clinician Scientist Program the second time around thanks to two good publications. The rules changed a few years ago, and an excellent publication record can now be regarded as equivalent to the mark magna cum laude on a discretionary basis.

I had always been fascinated by digital health, but ten or 15 years ago it was associated more with gadgets and games and was not yet an established research field. Today it is totally different. I feel that the Charité and this program were really visionary back then in funding projects like mine.

Looking back even further, I remember standing awestruck outside the Charité while still in my Marburg student days and thinking: wow, what a university hospital! And now I work here with one foot in research and the other in the Department of Anesthesiology and Intensive Care Medicine. It’s worth persevering and never giving up!

Marike de Vries & Dr. Nina Schmidt
August/September 2024