Tech Giants

in Healthcare
TECH GIANTS
IN HEALTHCARE

AILEEN BERGHOLD
CONSTANZE HÜBNER
BJÖRN SCHMITZ-LUHN
CHRISTIANE WOOPEN
TECH-GIGANTEN IM GESUNDHEITSWESEN

EXECUTIVE
SUMMARY

Tech giants are the primary forces driving digital health(-care) behavior and healthcare provision,
transformation forward. In the medium to long run and thus individual and public health.
these firms, which can exercise exceptional mar-
ket power, may be able to profoundly change the The healthcare products and applications developed
range of healthcare services offered in the market- by tech giants are mostly based on huge amounts
place, and indeed reshape the nature of existing of data drawn from different areas of life, which they
healthcare systems. Particularly in case of publicly evaluate using so-called artificial intelligence (AI)
financed systems that are organized by sectors1 tools to assess the presence of diseases; calculate
and based on the principle of solidarity, this could risks and expected needs; identify and develop diag-
lead to a paradigm shift in the way healthcare is nostic, therapeutic and preventive measures; and
shaped, delivered and consumed. The focus of care connect and optimize care processes. In collecting
is shifting from traditional therapy to prediction, the data needed by such systems, the companies
prevention and precision medicine. The boundaries largely use their own products and services. Many
between sectors are becoming more permeable, and such products, such as smartphones, are widely
ultimately dissolve in favor of patient-centered care. used and primarily serve purposes other than health,
In addition, research and day-to-day healthcare are though companies additionally develop their own
moving closer together, creating opportunities to new devices and systems for health care applica-
build learning healthcare systems. tions. They also engage in health research, very
often in cooperative ventures of various kinds. In
In this study, we use the term “tech giants” to refer some cases, they operate hospitals, networked care
to technology companies that are unique regarding systems or health insurance companies.
their expertise in digital technologies, and the great
extent of financial, human and technical resources All of this activity is changing the digital (health)
at their disposal. In most cases, these companies skills required of those who work in health care,
initially established themselves in another area of creating new job profiles and professional respon-
business activity. By entering the healthcare market, sibilities. The increasing importance of data and
they are pursuing both their own economic interests technological know-how is giving the tech giants
and – according to their own statements – the goal a market position that, in many senses, resembles
of using digital innovations to significantly improve a traditional monopoly. In this role, they have broad
influence over other actors’ market access, but also

1 In some health care systems, the provision of health care services in the in- and outpatient sectors as well as rehabilitative care
can have major systematic differences. For example, the German healthcare system generally distinguishes between in-patient
clinical and out-patient ambulatory care as well as in- and outpatient rehabilitative care. Each of these sectors follow varying
rules for the administration and reimbursement of medical care, leading to sectoral boundaries in the way healthcare can be
obtained.

4
 Health-related products and
applications for healthcare Science, research
professionals and development

Health-related products Healthcare system

and applications for (e. g., hospitals, outpatient
patients and users care, health insurance
providers)

Tech Giants
in Healthcare

FIGURE 1: Areas of application examined

Source: Authors, Bertelsmann Stiftung

have, de facto, the authority to shape individual against discrimination, and even health and self-
and societal expectations and demands, effectively determination. Tech giants in the United States,
determining the boundaries of what is deemed Europe and Asia differ with regard to the type
possible in healthcare. Power of this kind can erode and scope of their impact.
the freedom of choice within a social market econ-
omy, and undermine the degree to which the social This study features a number of examples to
framework itself is democratically determined. highlight the tech giants’ diverse activities in the
healthcare sector. In addition, it presents, as an
Thus, when viewed in terms of high-level ethical overwiew, an ethical analysis of some particularly
principles and values, the tech giants’ activities relevant change processes being driven in large
in the healthcare sector present both significant part by tech giants, and concludes with eight
opportunities and risks. For example, they provide recommendations for productively engaging with
modern technologies that can be used to promote tech giants to improve healthcare while avoiding
health and self-determination, improve access to ethically significant risks.
medical care, protect privacy and optimize care
processes. At the same time, however, there are
significant risks with regard to privacy, protection

5
TECH GIANTS IN HEALTHCARE

CONTENTS

1 Introduction 10 3.2 Technologies for patients and users 38

3.2.1 Wearables and apps 38
1.1 Starting Point 10
3.2.2 Virtual assistant systems
1.2 Who are these tech giants? 12 and digital avatars 45
1.2.1 Disruptive innovation 16 3.2.3 Augmented reality (AR)
and virtual reality (VR) 49
1.2.2 The moonshot mindset 17
3.2.4 Summary 49
1.3 Research interest and
key research questions 19 3.3 Technologies for healthcare
professionals 51
3.3.1 Wearables and apps 51
2 Methodology 21 3.3.2 Virtual assistant systems
and digital avatars 54
2.1 Exploratory literature review 21
3.3.3 Augmented reality (AR)
and virtual reality (VR) 57
2.2 Qualitative expert interviews 23
3.3.4 Summary 58
2.3 Ethical analysis 23
3.4 Healthcare system 60
3.4.1 Healthcare cloud computing 60
3 Tech giant activities in healthcare 25 3.4.2 Blockchain technologies 64
3.4.3 Medical technology and
3.1 Foundations 27
biotechnology 66
3.1.1 Machine-readable digital data 27
3.4.4 Robotics 69
3.1.2 Algorithmic systems and
3.4.5 Service provision structures 71
artificial intelligence 29
3.4.6 Health Insurance 73
3.1.3 Summary 36
3.4.7 Pharmaceuticals supply 74
3.4.8 Mobility and logistics 75
3.4.9 Healthcare market 76
Partnerships, programs and projects 76
Investments and spin-offs 88
Acquisitions 92
3.4.10 Summary 95

6
 CONTENTS

3.5 Science, research and development 97 5 Conclusions and

3.5.1 Featured example: Rare diseases 104 recommended actions 147
Recommended actions 150
3.5.2 Summary 106

Bibliography 156
4 Ethical analysis 108

4.1 Introduction 108 Authors 197

Legal notice 198
4.2 Ethical values and principles 110
4.2.1 Human dignity 110
4.2.2 Freedom and self-determination 111
4.2.3 Health 112
4.2.4 Privacy 113
4.2.5 Security 114
4.2.6 Justice and solidarity 114
4.2.7 Sustainability 116
4.2.8 Democracy 117

4.3 Transformation in healthcare

and the healthcare system 118
4.3.1 Strengthening data-based
prediction, prevention and
precision medicine 120
4.3.2 Multidimensional change in
competencies of healthcare
professionals 128
4.3.3 Monopolization and dissolution
of sectoral boundaries due to
digital healthcare 134
4.3.4 Linking everyday care and
research to a learning healthcare
system 140

7
TECH GIANTS IN HEALTHCARE

ACRONYMS AND ABBREVIATIONS

AADE American Association of Diabetes Educators CT computer tomography

AAL Ambient Assisted Living CVC corporate venture capital
ACC American College of Cardiology CZ Biohub Chan Zuckerberg Biohub
ACS American Cancer Society CZI Chan Zuckerberg Initiative, LLC
ADA American Diabetes Association DAX Dragon Ambient eXperience
AGG Allgemeines Gleichbehandlungsgesetz; DER Deutscher Ethikrat; German Ethics Council
General Act on Equal Treatment DFG Deutsche Forschungsgemeinschaft;
AGI artificial general intelligence German Research Foundation
AHA American Heart Association DGQ Deutsche Gesellschaft für Qualität;
AHS Apple Heart Study German Association for Quality
AI artificial intelligence DHSC Department of Health and Social Care UK
AIMIS AI Medical Innovation System DiGA Digitale Gesundheitsanwendung; Digital Health Applications
Amwell American Well DKG Deutsche Krankenhausgesellschaft e.V.;
ANI artificial narrow intelligence The German Hospital Federation
API application programming interface DL deep learning
AR augmented reality DLT distributed ledger technology
AS adaptor set dpa Deutsche Presse-Agentur; German Press Agency
ASR automatic speech recognition DVG Digitale-Versorgung-Gesetz; Digital Healthcare Act
AWS Amazon Web Services DWP Diabetes Wellness Program
B2B business-to-business EbM evidence-based medicine
BDI Initiative des Bundesverbands der Deutschen Industrie e. V.; EC European Commission
The Federation of German Industries ECG electrocardiogram
BfArM Bundesamt für Arzneimittel und Medizinprodukte; ECHR European Court of Human Rights
Federal Institute for Drugs and Medical Devices EEG electroencephalography
BGI Beijing Genomics Institute e-health / eHealth electronic health
BMBF Bundesministerium für Bildung und Forschung; EHR electronic health record(s)
Federal Ministry of Education and Research EP European Parliament
BRAC Bangladesh Rural Advancement Committee eSIm embedded subscriber identity module
BWA Burrows-Wheeler Aligner EU European Union
BWEL Breast Cancer Weight Loss Study EU-GDPR European General Data Protection Regulation
BWH Boston’s Brigham and Women’s Hospital FAA Federal Aviation Administration
BWH Brigham and Women’s Hospital FAIR Facebook AI Research
C2C customer to customer FAZ Frankfurter Allgemeine Zeitung
CBICA Computing and Analytics FDA U. S. Food and Drug Administration
CDC Center for Disease Control and Prevention FDP Freie Demokratische Partei; Free Democratic Party
CDHI Center for Digital Health Innovation FHIR Fast Healthcare Interoperability Resources
CDSS clinical decision support system(s) Fred Hutch Fred Hutchinson Cancer Research Center
CEO Chief Executive Officer GAFAM Google, Amazon, Meta (formerly Facebook), Apple, Microsoft
CFR Charter of Fundamental Human Rights of the European Union GATK genome analysis toolkit
CHD coronary heart disease GBE Gesundheitsberichterstattung des Bundes;
CHLA Children’s Hospital Los Angeles Information System of the Federal Health Monitoring
CMO Chief Medical Officer GDP gross domestic product

8
 ACRONYMS AND ABBREVIATIONS

GE General Electric NLP natural language processing

GG Grundgesetz; Basic Law NLU natural language understanding
GHA German Health Alliance NPO non-profit organization
GHP German Health Partnership NYU New York University
GKV Gesetzliche Krankenversicherung; statutory health insurance OECD Organisation for Economic Co-operation and Development
GMCC Global MediXchange for Combating COVID-19 OTC over-the-counter
GPS Global Positioning System PAI Partnership on AI
GPU graphics processing unit(s) PATH Program for Appropriate Technology in Health
CFR Charter of Fundamental Human Rights of the European Union PCOS polycystic ovary syndrome
GSK GlaxoSmithKline PDA personal digital assistant(s)
GV Google Venture PET positron emission tomography
HIP Health Innovation Port PHR personal health record(s)
HIPAA Health Insurance Portability and Accountability Act PKV Private Krankenversicherung; private health insurance
HITRUST Health Information Trust Alliance POCT point-of-care-testing
HL7 Health Level Seven International PPP public-private partnership
HPD Healthcare Provider Directory QS quantified self
IBM International Business Machine Cooperation RCT randomized controlled trial
ICD10-CM International Classification of Diseases, SAP Systemanalyse Programmentwicklung; System Analysis
Tenth Revision, Clinical Modification Program Development
ICT Information and Communication Technology SAP HANA SAP High Performance Analytics Appliance
ICU Intensive Care Unit SDK software development kit
IIG Institute of Immunology and Genetics SGB German Social Code
iOS iPhone Operation System sNFL serum neurofilament light chain
IoT Internet of Things SPD Sozialdemokratische Partei Deutschlands;
IRIS Intelligent Retinal Imaging Systems Social Democratic Party
IT information technology StMGP Bavarian State Ministry of Health and Care
ITU International Telecommunication Union SVR Sachverständigenrat zur Begutachtung der Entwicklung
Leopoldina Deutsche Akademie der Naturforscher Leopoldina e. V. im Gesundheitswesen; German Council of Health Experts
MDR Medical Device Regulation TI telematics infrastructure
m-health mobile health TS terminology server
MH-Guide Molecular Health Guide™ UCL University College London
MIC Medical Informatics Corporation UCLA Health University of California Health Department,
MITeC Medical Innovation and Technology expert Center Los Angeles
ML machine learning UCSF University of California, San Francisco
MMAR Clara Train Medical Model Archives Modification UDHR United Nations Declaration on Human Rights
MoU memorandum of understanding UK NHS United Kingdom National Health Service
MRI magnetic resonance imaging UMCU University Medical Center Utrecht
MS multiple sclerosis VR virtual reality
NASA National Aeronautics and Space Administration Wearable(s) wearable electronic device(s)
NGO non-governmental organization WHO World Health Organization
NGS next-generation-sequencing WKO Wirtschaftskammer Österreichs; Austrian Economic Chambers
NIEHS National Institute of Environmental Health Sciences WW Weight Watchers
NLM National Library of Medicine

9
TECH GIANTS IN HEALTHCARE

1
INTRODUCTION

1.1
STARTING POINT

It is impossible to imagine our world today without digital transformation. The digitalization of
products, processes and structures is having a sweeping impact across all areas of individual and
social life.

In the healthcare sector too,2 the extent of digital data collection and processing is growing
exponentially, and digital trends and technologies3 are increasingly converging. Both Topol (2013)
and Hahn and Schreiber (2018) speak of a “super-convergence” that is laying the foundations for
a new approach to medicine. The German healthcare system has only just begun to navigate its way

2 “A state’s healthcare system includes all regulations, measures, technical resources, facilities, professions and persons that have
the goal of promoting, maintaining, establishing or restoring the health of the population. Accordingly, the healthcare system in
the broader sense encompasses all activities, both public and private, performed either by professionals or laypeople, that center
on health” (Labisch and Paul 1998: 123).

3 Both the current discourse and the recent literature include the terms “digital health” and “e-health.” In this regard,
digital health can be understood as “the use of modern ICT [information and communication technologies] in healthcare to
increase quality and efficiency, and to heighten the focus on patient needs” (Angerer et al. 2019: 6). The category of e-health
(electronic health) encompasses “electronically supported activities and systems in healthcare that collect, make available,
and / or evaluate patient data and other medical information remotely, using techniques that are not yet widely regarded as
standard” (Matusiewicz and Thielscher 2017). This consequently includes telematics and telemedicine (e. g., telediagnostics
and teletherapy). In Germany, the Digital Healthcare Act (DVG) (Gesetz für eine bessere Versorgung durch Digitalisierung
und Innovation, adopted on Dec. 9, 2019, BGBl. I: 2562) sets the goal of gradually networking all actors and institutions in
the country’s healthcare system via a secure telematics infrastructure (TI). We note in passing that it is not currently possible
to draw a clear distinction between digital health and e-health, and that the terms are used inconsistently and sometimes
synonymously. According to the WHO (2011) definition of m-health (mobile health), this is an aspect of e-health that has
not been uniformly defined to date. For the purposes of that organization’s Second Global Survey on E-health, m-health
was defined as “medical and public health practice[s] supported by mobile devices, such as mobile phones, patient monitoring
devices, personal digital assistants (PDAs), and other wireless devices” (European Commission 2014: 3). “This includes
applications (…) such as lifestyle and health apps that can be networked with medical devices or with sensors (e. g., in wristbands
or watches), as well as personal notification or assistant systems, health information and medication reminders delivered via
SMS, and wirelessly delivered telemedicine services” (ibid.).

10
 INTRODUCTION

toward digital transformation.4 Nonetheless, these developments have kindled great expectations
regarding the ability of new medical practices to meet the demands of the future (Topol 2015).5

Given the healthcare sector’s considerable economic importance,6,7 it should come as little surprise
that digital transformation in the sector is increasingly driven by tech giants that previously had
little to do with healthcare, but do have considerable experience developing and using information
and communication technologies (ICT) in various areas of life. Apple CEO Tim Cook has even mused
about the company looking back one day and realizing that its greatest contribution to humanity
will have been in the area of healthcare (Pearl 2019).

As they enter this field, tech giants are pursuing a variety of individual business models, for
instance by expanding the features and applications of existing proprietary products and ser-
vices (e. g., wearables), investing in cloud technologies, or introducing private services that extend
beyond those offered in the publicly regulated healthcare system. These offerings may be centered
on science, research and development tasks (e. g., AI and healthcare cloud computing); lifestyle
(e. g., mobile apps); or healthcare interventions directed toward specific diseases. Strategically,
technology companies are seeking to enter the healthcare market8 via partnerships, collaborations
and alliances, as well as by acquiring or investing in startup companies (Kindermann and Linde-
mann 2018; Yildirim et al. 2016).

Tech giants still play a relatively insignificant role in Germany’s healthcare sector. However,
they already engage in a wide spectrum of activities internationally, ranging from offering and
administering medical care (including the construction of hospitals) and the financing of health-
care services (including health insurance) to facilitating the digital exchange of information
between various actors, devices and structures.

In the long run, tech giants are likely to carve out strong positions for themselves in the healthcare
sector. In a survey conducted by the Roland Berger management consultancy, 61 % of the experts
polled said they were convinced that “large tech corporations will be an integral part of the health-
care system by 2025” (Choueiri et al. 2019: 10).

4 “The term ‘digital transformation’ refers to a significant body of active changes in everyday life, the economy and society
due to the use of digital technologies and techniques, as well as their effects” (Pousttchi 2017).

5 For example, the implementation of a personalized, preventive, predictive and participatory healthcare system – so-called
P4 medicine – would serve as an exemplary illustration of such changes (Flores et al. 2013).

6 Healthcare spending in Germany totaled € 410.8 billion in 2019. This was a 4.9 % rise compared to 2018, roughly in line with the
rate of increase in previous years. Healthcare spending accounted for 11.9 % of Germany’s gross domestic product (GDP) in 2019.
Within this total healthcare expenditure, 56.7 % or € 233 billion was attributable to the statutory health insurance (SHI) system
(Federal Statistical Office, April 6, 2021). Globally, healthcare spending totaled $ 8.5 trillion in 2019 (WHO 2021d).

7 According to management consultants Roland Berger GmbH, the digital health market is expected to grow to € 57 billion in
Germany, € 232 billion in Europe as a whole and € 979 billion worldwide by 2025 (Choueiri et al. 2020: 7).

8 The term “healthcare market” refers to that area of the market in which halthcare services and products are the object of
economic activity. It is divided in turn into the primary and secondary healthcare markets (Krimmel 2005). The former
represents the exchange of traditional healthcare services and interactions between healthcare-provision structures. The services
and products within this category are financed by private health insurance (PHI) plans and statutory health insurance (SHI)
systems. The customer base within the primary healthcare market is made up of patients or persons undergoing treatment. The
primary market is regulated by stricter legal frameworks than the secondary healthcare market (Damm et al. 2010: 1-3). The
secondary healthcare market includes health-related services and products that are not covered by private insurance, statutory
insurance programs or other public insurance entities; this includes items and services such as nutritional supplements, fitness
courses and over-the-counter drugs. In this case, the customers are not exclusively people who are already ill. Rather, the focus
is on preventive services, and on maintaining good health (ibid.; Krimmel 2005).

11
TECH GIANTS IN HEALTHCARE

1.2
WHO ARE THESE TECH GIANTS?

The literature currently contains no clear definition or criteria indicating which technology
companies should be identified as tech giants. The literature review performed for this study
revealed that the terms “tech superstars,” “tech corporations,” “tech giants,” “big tech,”
“online giants,” “large digital companies” etc. are for the most part used synonymously.

Writers referring to tech giants often do so using the acronym GAFAM.9 This refers to the
technology companies Google LLC. (or for short,10 simply Google; its parent company is Alphabet
Holding Inc. (Alphabet)), Apple Inc. (Apple), Meta Platforms Inc. (Meta; formerly Facebook Inc.),11
Amazon.com Inc. (Amazon) and Microsoft Corporation (Microsoft). Most of these U.S. companies
are based in Silicon Valley, a region close to San Francisco known for its high number of technology
companies and startups (Schulz 2018).

The five GAFAM companies were all among the top seven of the world’s 100 most valuable
corporations in 2021. Apple, with a market capitalization of € 2.515 trillion, led the list, followed
by Microsoft at € 2.178 trillion and Alphabet at € 1.693 trillion (values as of December 2021)
(Sommer 2021). According to reports in early 2022, Apple was the first publicly traded company
to reach a market capitalization of $ 3 trillion. This is just under Germany’s total annual economic
output (tagesschau.de 2022). GAFAM companies together generate more than $ 800 billion in
revenue annually, exceeding the output of Switzerland’s economy, for example (2020 GDP: about
$ 751.9 billion) (Sommer 2021; Desjardins 2019; WKO 2021).

The GAFAM companies also have a number of subsidiaries and spin-offs, such as the Alphabet
subsidiaries Verily Life Sciences LLC (Verily; previously Google Life Sciences) and Calico Life
Sciences LLC (Calico).

Silicon Valley has become the epitome and symbol of disruptive technologies and developments:
“Not only because this is where the backbone of the technology industry is located, with the
region’s thousands of large companies and startups, but also because this is where the vision-
aries and utopians gather, the big dreamers and the reckless. Because here the money flows like
nowhere else in the world – billions of dollars in venture capital every year. A perfect breeding
ground for big ideas and world-changing developments” (Schulz 2018: 15).

9 Following Facebook’s decision to rename itself as Meta, this acronym should now be GAMAM.

10 Within this study, the tech giants will generally be referred to by their short names.

11 Facebook announced that the company would be renamed Meta at the end of October 2021 (Meta 2021).

12
 INTRODUCTION

As new technological developments are tested, introduced but in many cases also ultimately
discarded,12,13 “vast quantities of investor money are effectively burned year after year”
(Böttinger and Weiß 2019: 7). This allows even ideas whose success is far from certain to be
tested.14

A number of other technology firms beyond the GAFAM companies, many originally from non-
health fields, are also involved in healthcare. This list includes South Korea’s Samsung Group
(Samsung); the U.S. companies Intel Corporation (Intel) and NVIDIA Corporation (NVIDIA); the
Japanese technology company Sony Corporation (Sony); and the Chinese conglomerates Huawei
Technologies Co. Limited (Huawei), Alibaba Group Holding Limited (Alibaba) and Tencent Holdings
Limited (Tencent). Moreover, a number of other technology companies that are already well estab-
lished in the healthcare sector are today moving increasingly into the digital healthcare market.
This group includes SAP SE (SAP), Germany’s most valuable company (market capitalization:
€  149 billion), and Siemens AG (Siemens) with its spin-off Siemens Healthineers. Siemens ranks
only slightly lower than SAP among the world’s 100 most valuable corporations, with a market
capitalization of € 125 billion (Sommer 2021). The Dutch Koninklijke Philips N.V. (Philips) and
the U.S.-based International Business Machines (IBM) can also be placed in this category.

With this background in mind, we will in this study use the term “tech giants” to refer to tech-
nology companies that are unique regarding their digital technology expertise and resources, and
which have vast financial means at their disposal. In most cases, they have achieved economic suc-
cess and established a market position based on their activity in other areas of business. By enter-
ing the healthcare market, they are pursuing both their own economic interests and – according
to their own statements – the goal of using digital innovations to significantly improve healthcare
behavior and healthcare provision, and thus both individual and public health.

For the purposes of this study, we have selected 16 tech giants for review, with the goal of reflect-
ing the full range of such companies’ activities, while also taking different world regions into
account (➔ Table 1, Chapter 3). In late 2021, 13 of these tech giants were included in the ranking of
the world’s 100 most valuable companies using the metric of market capitalization (Sommer 2021).

12 Google, for example, frequently discontinues new cost-intensive inventions and developments; a highly incomplete list of
such products and services might include Google TV, Google+, Google Nexus, Picasa and Google Allo (Böttinger and White 2019;
Ogden n. d.).

13 With its virtually unlimited capital, Alphabet has invested in a wide variety of so-called moonshot projects (➔ 1.2), some of
which have been discontinued in recent years. According to the company’s own statements, Alphabet has invested $ 2.3 billion
in these projects since its inception, and has recorded a total of $ 24.3 billion in losses (Canales 2021).

14 Norman and Verganti (2014: 91-93) refer to research and development projects of this kind as “tinkering”: “When some-
one plays around with a product or a technology with no goal in mind – neither for enhancement of meaning, nor for
practicality – we call it tinkering. Tinkering can lead to brilliant insights and new products but when such results happen,
they are completely accidental.”

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TECH GIANTS IN HEALTHCARE

FIGURE 2: Revenues for 16 tech giants (2020 / 2021)

$ 469.82 bn AMAZON

$ 168.09 bn MICROSOFT

$ 256.74 bn GOOGLE / ALPHABET

$ 117.93 bn META (FACEBOOK)

$ 365.82 bn APPLE

$ 16.68 bn NVIDIA

$ 79.00 bn INTEL

$ 57.35 bn IBM

Source: Authors. Data: statista.de, Bertelsmann Stiftung

14
 INTRODUCTION

$ 22.18 bn PHILIPS

$ 31.59 bn SAP
$ 84.82 bn SONY
$ 71.13 bn SIEMENS
$ 233.72 bn SAMSUNG

$ 112.68 bn ALIBABA

$ 140.30 bn HUAWEI

$ 75.75 bn TENCENT

15
 TECH GIANTS IN HEALTHCARE

1.2.1
DISRUPTIVE INNOVATION

In any discussion of tech giants, the issue of disruption or disruptive innovation quickly arises.15
Pousttchi (2017) defines this as follows: “The term disruption is used if the changes occur sud-
denly, with a clear break from the past being evident, for instance through the digital transforma-
tion of an existing competitor or a competitor newly entering the market.”

Disruption is associated with processes of change and renewal that “replace and in some cases
even completely displace (…) traditional business models, products and services” (Angerer et
al.2019: 10).

However, even when a healthcare system is undergoing digitalization, the changes being imple-
mented cannot be described across the board as disruptive innovations. Norman and Verganti
(2014) distinguish between incremental and radical changes. While incremental innovations bring
about modifications within a given framework of solutions, radical innovations transform the
framework itself, thus leading to new and unique solutions that have the potential to be disruptive
(ibid.: 82).
Radical change

Tech-push Technological
innovation epiphany
Technology

Incremental change

Meaning-driven
Market-Pull innovation
innovation
(Human Centered Design)

Incremental change Radical change

Systemic relevance

Figure 3: Types of innovation

Source: Authors’ own illustration based on Norman and Verganti 2014, p. 89, Bertelsmann Stiftung

15 See inter alia: Meskó et al. (2020), Angerer et al. (2019), Gushurst et al. (2018), Piepenbrink (2019), Levina (2017),
Coupette (2014), Kaufman (2018), Hahn and Schreiber (2018).

16
 INTRODUCTION

Figure 3 illustrates how the combinations of these two types of changes, each brought about by
new technologies and changes in these technologies’ systemic importance, combine to produce four
different types of innovation. For example, market-pull innovation is a development that leads to
incremental and continuous improvement. Technology-push innovation, by contrast, uses radically
new technologies to create incremental changes in the market. Meaning-driven innovation leads to
entirely new areas of utility and application through technologies that are experiencing only incre-
mental development over time. Finally, technology epiphanies are disruptive innovations emerging
from the application of radically new technologies; these in turn contribute to profound systemic
change (Norman and Verganti 2014: 89-90). In German, disruptive innovations are also referred
to as “Sprunginnovationen” (Federal Ministry of Education and Research 2021).

In summary, it would not be accurate to describe all digital developments or all of the tech giants’
activities in the healthcare sector as disruptive innovations – even though, according to the experts
interviewed in this study, many of the technology companies’ digital solutions do in fact hold the
potential to be disruptive.

1.2.2
THE MOONSHOT MINDSET

Paired with the tech giants’ efforts to push radical innovation into all areas of human life is the
narrative that Silicon Valley is the “center of global progress” (Schulz 2018: 15). The prevailing
sentiment there is also referred to as “moonshot,” “moonshot thinking” or the “moonshot mind-
set.” The moonshot concept was popularized by Google founder and former CEO Lawrence “Larry”
Page,16 and refers to the early-1960s vision of manned lunar landings that was promoted by U.S.
President John F. Kennedy and others (Schulz 2018). Eric “Astro” Teller heads Alphabet’s X Devel-
opment LLC research division (short version: X; known as Google X until 2016), which calls itself
The Moonshot Factory (X – The Moonshot Factory 2020a). Teller offers the following explanation:
“Our use of the term ‘moonshot’ isn’t literal; it’s more of an emotional blueprint. A moonshot is
about looking beyond where you can actually see and envisioning an answer that doesn’t seem
reasonable – and pursuing it anyway. It’s about doing things that sound undoable but if done
could redefine humanity” (Teller 2019).

Thus, moonshots entail research into and the development of groundbreaking technologies
intended to contribute to radical solutions for problems experienced worldwide (see Figure 4).

The explicit mission of X, the Google-associated think tank and research facility, is to develop
highly innovative technologies that might one day make the world a “radically better place”
(Teller 2019). Health challenges are among the great current problems in our society that moonshot
thinking seeks to solve (Kovarik 2018).

16 The “moonshot mindset” or “moonshot thinking” takes the approach of solving a problem within a particular field that seems
unsolvable due to efforts to alter and modify its history, acceptance and growth rate (Roy 2020). This approach long predates
Page; its origins stretch back to the so-called waterfall methodologies of the 1950s, which were designed to identify potential
grounds for project failure at the point of a project’s beginning (Haigh 2018).

17
TECH GIANTS IN HEALTHCARE

Huge
Problem

Moonshot

Breakthrough Radical
Technology Solution

FIGURE 4: Moonshot
Source: Authors’ own illustration based on X – The Moonshot Factory 2020b, Bertelsmann Stiftung

These ambitious and almost utopian-sounding visions are meant to be realized with the help of
the “‘10X’ philosophy”17 (Schulz 2018: 103). According to this, every innovation should be 10 times
better than the status quo (Schulz 2018: 103; X – The Moonshot Factory 2020b). X’s Teller explains:
“The secret? It’s easier to get people to work on making something 10X better than to get them
to help make it 10 % better. Huge problems fire up our hearts as well as our minds. When you’re
aiming for a 10X gain, you can’t just slog through it. You have to find whole new ways of doing
things, and lean on bravery and creativity – the kind that, literally and metaphorically, can put
a person on the moon” (Teller 2019).

A moonshot mindset can also be used to solve intermediate problems or create intermediate
products and services. At worst, this merely results in the collection of valuable data, while in the
best case, it solves problems that can give a boost to one or more established companies or startups
(Diamandis 2015).

Critical voices, on the other hand, make a distinction between this term and innovations more
generally, arguing that while all moonshots can be considered radical innovations, not all innova-
tions are moonshots (Mention et al. 2019: 3-4). For example, moonshots always address significant

17 This philosophy is also one of the 10 components of the moonshot mindset concept. Other components of this corporate
philosophy include “Fall in love with the problem” and “Tackle the monkey first” (X – The Moonshot Factory 2020b).

18
 INTRODUCTION

societal problems (Mention et al. 2019), while innovations may relate to more restricted market
or societal domains (Taylor 2017). In addition, some critics argue that today’s implementation of
moonshot projects has nothing in common with what was achieved by the actual moon landing
(Haigh 2018). Moonshot approaches can of course lead to failure as well.18 Nevertheless, to encour-
age moonshot thinking, some propose that a “failure bonus”19 be offered for projects that ulti-
mately fail (Huckman et al. 2018).

1.3
RESEARCH INTEREST AND KEY RESEARCH QUESTIONS

This study has several goals: to gain insights into tech giants’ current and future activities in the
healthcare sector, to reflect on how they are affecting healthcare systems’ established structures
and operating principles, and to present recommendations for action that are based on an ethically
sound analysis.

The specific questions guiding the research include the following:

҉ What products and services are tech giants already using or developing specifically for the
healthcare field?
҉ Which areas of the healthcare sector and healthcare delivery are particularly attractive from
the perspective of tech giants?
҉ What activities are planned for the digital transformation of healthcare provision and the
healthcare sector more generally?
҉ What ethically relevant opportunities and challenges are associated with the tech giants’
activities in the German healthcare sector, particularly with regard to the provision of healthcare?
҉ How much power will the tech giants be able to develop in the healthcare sector, and what form
will this take?
҉ What measures and structures can be recommended as a means of dealing with the tech giants’
healthcare activities – that is, in enabling these activities to be shaped and used according to
ethical standards?

To date, no overview of the tech giants’ healthcare activities has been provided that is informed
by an ethical analysis and which also includes a discussion of the opportunities and challenges
involved. Numerous studies have addressed the issue of m-health (mobile health), which encom-
passes products and services such as wearable electronic devices (wearables) and health and medi-
cal apps.20 In addition, a number of publications have examined the ethical considerations of health
in the digital age, dealing with issues such as digital self-determination, privacy, data protection,
discrimination, justice and solidarity.

18 See footnotes 12-13.

19 Google’s X already uses methods of this kind, providing project teams with a “failure bonus” (Huckman et al. 2018).

20 See inter alia Young et al. (2019), Kim et al. (2019a), Kim et al. (2019b), Kramer et al. (2019), Soliño-Fernandez et al. (2019),
Albrecht (2016).

19
TECH GIANTS IN HEALTHCARE

By contrast, this study is the first to present a more comprehensive account of the activities of
tech giants in the healthcare sector, as well as an ethical discussion of the associated opportuni-
ties and challenges for healthcare systems. Woopen and Mertz (2014) enumerate four functions
of ethics as an integral part of a broadly understood assessment of technology. Following their
proposal, and given the high ethical relevance of technological developments (legitimation), we
focus on technologies deemed to be of particular ethical significance, along with their impact (con-
ceptualization). In doing so, we seek to include a broad range of scholarly and practice-informed
perspectives, while evaluating and discussing these technologies using different ethical standards
as a basis (evaluation). From this discussion, we subsequently derive recommendations for action
(justification of norms).

20
 METHODOLOGY

2
METHODOLOGY

2.1
EXPLORATORY LITERATURE REVIEW

This project began with a cross-disciplinary exploratory review of the literature addressing
issues relevant to tech giants in the healthcare sector. Because the subject under review has
to date received only sporadic attention by the literature included in research databases, the
search was extended to include other publications such as journal articles and so-called gray litera-
ture (e. g., corporate press releases and the mission statements of various companies). This research
was conducted between May 20, 2020 and September 30, 2020, with additional in-depth research –
where needed – being conducted through early January 2022. Further developments after that date
could not be taken into account.

Search terms and keywords were identified through an examination of journalism articles
in various daily and weekly newspapers, press releases from large technology companies, and
independent searches conducted with online search engines (i. e., USB Cologne21 search portal
and Google search). In a next step, our research focused on both multidisciplinary databases
(i. e., JSTOR, Google Scholar, Web of Science, and Nexis Uni) and those targeting a specific
discipline (i. e., PubMed: medicine / medical ethics; PhilPapers: philosophy; BELIT: bioethics; Econ-
BIZ: economic and social sciences; Business Source Complete: economics). Both German and English
search terms were used. As is common with an exploratory research method, no inclusion
or exclusion criteria were defined that would have prevented the identification of potentially
significant literature in advance. This approach led to the integration of relevant publications
from related topics, such as big data, into the analysis. It allowed for the inclusion of gray
literature as well.

21 Catalogue of the University and City Library of Cologne and the shared subject and institute libraries (KUG), the catalogues
of Cologne public libraries, German unions, periodicals, and selected international catalogues.

21
TECH GIANTS IN HEALTHCARE

The review included publications in German and English only. Given the growth in tech giant activ-
ity in healthcare over the past decade, an additional parameter was set to include only
publications published since 2010. However, publications prior to 2010 were taken into account if,
for example, they were essential to providing a comprehensible estimation of technological devel-
opments. Selections were initially made on the basis of a publication’s title and abstract; a full-
text review determined which items were to be retained or removed from the final list. Publications
addressing developments such as m-health and big data without explicitly naming specific compa-
nies were also included.

Finally, the bibliographies of each selected publication were analyzed to identify further relevant
articles or authors (snowballing). This resulted in a total of 825 eligible publications (including
press releases and gray literature).

In the course of the exploratory literature review, four application areas (presented in more detail
in chapter ➔ 3) were identified in which the activities of tech giants can significantly contribute to
the digital transformation of healthcare. The first two areas relate to products and services that are
aimed at patients and users on the one hand and at individuals in the healthcare professions on the
other. The third area includes system-relevant activities in healthcare provision, and the fourth
represents the activities of tech giants in science, research and development. The ethical implica-
tions of the tech giants’ activities in the four application areas are discussed in chapter ➔ 4.

Technologies for patients and users

Technologies for healthcare professionals

Healthcare systems

Science, research and development

FIGURE 5: Areas of application relevant to the study

Source: Authors, Bertelsmann Stiftung

22
 METHODOLOGY

2.2
QUALITATIVE EXPERT INTERVIEWS

In order to gain insights from different areas of practice, the research questions were translated
into interview questions. A total of eight guided, non-standardized qualitative interviews were
conducted with experts (Kaiser 2014; Bogner et al. 2002) from different fields of research and
entrepreneurial activity. Representatives from the industries of pharmaceutics, medical devices,
and AI-focused software and technology were interviewed. Representatives from the regulatory
and investment sectors were also included, as was an individual representing a trade organization.

The interpretive social science method of paraphrasing (Heinze and Klusemann 1979, 1980; Heinze
1987) informed the analysis of these interviews. In a first step, two researchers independently
created paraphrases of the respective interviews, which they then substantiated to each other.
This was followed in a second step by a joint critical examination and revision of each paraphrase,
which resulted in a formulation of the core statements elicited during each respective interview.

2.3
ETHICAL ANALYSIS

The ethical analysis draws upon those ethical principles and values anchored in legally guaranteed
rights and freedoms that are also the focus of ethics bodies acting in an advisory capacity in the
field of digitalized healthcare:22 human dignity, rights to freedom and self-determination, health,
privacy, security / safety, justice and solidarity, sustainability and democracy. Forming a two-
dimensional matrix, the experts’ paraphrased core statements were assigned to the ethical prin-
ciples and the four application areas mentioned above: (1) technologies for patients and users, (2)
technologies for individuals in healthcare professions, (3) healthcare system, (4) science, research
and development.

With the literature review and analysis of interviews as a basis, the ethically relevant potentials
and challenges posed by the activities of tech giants in healthcare were discussed.

22 See inter alia European Group on Ethics in Science and New Technologies (2021), High-Level Expert Group on AI (2021),
German Data Ethics Commission (2019), German Ethics Council (2018).

23
 TECH GIANTS IN HEALTHCARE

T
BE

)
K
A

O
H

O
LP

EB

FT
/A

G
SO

T
A
N

S
N
LE
BA

EI

EN
(F

EN
S
ZO

IA

SU
RO
AW

IP
G
LE
BA

Y
A

C
ID

EM
O
A

TE

IL

N
ET

N
PP

IC
M

P
M

O
LI

PH

SO
SA

SA

TE
IN
IB

SI
H

N
G
A

A
Technologies for patients and users /
healthcare professionals

Artificial intelligence l l l l l l l l l l l l l l l

Wearables and apps l l l l l l l l l l l

Virtual assistant systems and digital avatars l l l l l l l l

Augmented reality and virtual reality l l l

Healthcare system

Healthcare cloud computing l l l l l l l l l l l

Blockchain l l l l l l l l l l

Medical technology and biotechnology l l l l l l

Robotics l l l l l l l l l l l

Service provision structures l l l

Insurance in the healthcare sector l l

Pharmaceuticals supply l l l

Mobility and logistics l l l

Partnerships l l l l l l l l l l l l l l l l

Investments l l l l l l l l l l l l l

Acquisitions l l l l l l l l l l l l l l l

Science, research and development

Science, research and development l l l l l l l l l l l l l l l l

TABLE 1: Overview of tech giant activities in relevant application areas

Source: Authors, Bertelsmann Stiftung

24
 Tech Giant ACTIVITIEs in Healthcare

3
TECH GIANT ACTIVITIES
IN HEALTHCARE

Tech giants are targeting different areas of healthcare provision in a variety of ways. In this study,
we examine four different areas of application:

҉ Technologies for patients and users

҉ Technologies for healthcare professionals
҉ Healthcare system
҉ Science, research and development

The boundaries between these areas are not always clear-cut, so cross-references may be included
as needed.

25
TECH GIANTS IN HEALTHCARE

26
 Tech Giant ACTIVITIEs in Healthcare

3.1
FOUNDATIONS

The collection of machine-readable data and the use of algorithms to process this data form
the foundation of digital products and applications offered by the tech giants in healthcare.

3.1.1
MACHINE-READABLE DIGITAL DATA

“Data is an important economic asset in today’s world (…). The manifold possibilities for collecting,
linking, evaluating and further processing data on a mass scale in digital form open up prospects
for new business models and enormous potential for economic value creation” (Piepenbrink 2019).

The collection, preparation and processing of large datasets form “the business foundation of
digital transformation and the tech giants” (PwC 2018; Böttinger and Weiß 2019). “Big data”23 is one
of the key terms in present debates concerning the societal changes driven by technology (German
Ethics Council 2017b). Hahn and Schreiber (2018: 331), for example, believe that a transformation
to highly efficient digital medicine can only take place if the growing volumes of data are efficiently
analyzed and interpreted. Today’s tech giants have highly developed technological infrastructures
that are well suited to this task. Their activities are also partially rooted in the idea “that decipher-
ing biology and understanding disease is ultimately a data problem and can therefore be solved, at
least in part, by software experts” (Schulz 2017).

In the health and medical sector, data is often personal health data, such as treatment data relating
to individual patients from everyday clinical practice or diagnosis- and treatment-related billing
data for health insurance companies. According to the European General Data Protection Regulation
(GDPR),24 certain data fall into a category requiring special protection, mostly according to Art 4 of
GDPR. No. 15 of GDPR: “personal data related to the physical or mental health of a natural person,
including the provision of healthcare services, which reveal information about his or her health sta-

23 The term “big data” is understood in different ways. As an umbrella term, it can be understood as “a bundle of newly developed
methods and technologies” that “enables the collection, storage and analysis of a large and arbitrarily expandable volume of
differently structured data” (Research Services of the German Bundestag 2013: 1) or, put differently, as “the processing of large
quantities of data, with the aim of discerning patterns and thus gaining novel insights” (German Ethics Council 2017b: 11).
Consistent with the English terms, big data is often characterized by the three Vs (Research Services of the German Bundestag
2013; Antes et al. 2017): These include the amount of data (volume) that is “produced in unimaginably large quantities through
continuous digitization processes” and is estimated to double every two years (Research Services of the German Bundestag
2013: 1). Since 2020, IBM (2021h) has even assumed the amount of medical data to double every 73 days. Another characteristic
is the speed (velocity) by which the data flow takes place permanently and continuously due to “networking and electronic
communication” and with which the data must be simultaneously processed (Research Services of the German Bundestag 2013:
1). The third essential characteristic is the heterogeneous nature (variety) of the data, which come from differently structured
and highly complex sources. Two additional characteristics are frequently cited as well: veracity (truthfulness and accuracy) and
(business) value (material value), the concrete determination of which appears to be difficult (Antes et al. 2017: 38-39).

24 Since its entry into force on May 25, 2018, the GDPR has regulated the collection, processing, use and transfer of personal data
throughout the European Union: Regulation (EU) 2016/679 of April 27, 2016, L 119/1 of May 5, 2016, p. 1.

27
TECH GIANTS IN HEALTHCARE

tus.” Their processing is generally prohibited and permitted only under specific requirements (see
Art. 9 GDPR).

In Germany, legislators recently enacted the Digital Healthcare Act (DVG), which specifies the
permissibility of the processing and sharing of health data of persons insured in the Statutory
Health Care scheme (SHI) for research purposes in the context of the European requirements
(especially Art. 9(2)(j)(4) and 89(1) GDPR) for the German legal sphere.25 In principle, all non-
personal data or personal data collected and processed with the consent of the data subjects are
not covered by the prohibition of the GDPR to process them (Art. 9(2)(a) GDPR). This often
concerns data generated by patients or users themselves (lifelog data; patient-generated health
data) or outside controlled study environments (real-world data).

Health-related big data applications require the broadest possible access to datasets that encom-
pass diverse types and sources of health data (Schulz 2017; Hänisch 2016). This poses questions
regarding privacy and data security as well as informational and digital self-determination
(Piepenbrink 2019). These and other aspects are discussed in chapter ➔ 4 as part of the ethical
analysis. One must likewise examine whether and to what extent collections of health data should
be in the hands of tech giants and what, if any, associated risks society is willing to take for
health-related innovations.26

One example illustrating this issue is the data sharing arrangement in the partnership between
Google DeepMind and the UK National Health Service (UK NHS) which has been controversially
debated in the public (Ballantyne and Stewart 2019: 321) (➔ 3.4.9). Project Nightingale from Ascen-
sion and Google provides a further example (Krüger-Brand 2020: 376) (➔ 3.4.9). The case currently
pending before the European Court of Justice (ECJ) against the tech giant Meta (formerly Facebook)
in connection with the merging of users’ data from different social platforms also shows the explo-
sive nature of how tech giants handle health data (Handelsblatt 2021).

Aspects of informational and digital self-determination are also affected if, for example, AI-based
de- and recontextualizations of data obscure the degree of their sensitivity, or if initially anon-
ymous data, for example in connection with a multitude of other data of different natures, allow
the re-identification of a specific person. In addition, the relinking of data can be used to create
profiles on behavioral patterns from the combination of consumption and health data on healthy
or unhealthy eating habits, for example, and to form risk groups (German Ethics Council 2017b;
Meier 2019) (➔ 4.3.1 and ➔ 5).

Experts interviewed for this study are convinced that tech giants will intensify their core business
of data acquisition in the future and develop entire ecosystems of data-generating and data-
processing products and services. Many technology companies maintain their own digital infra-

25 See Fn. 3.

26 According to Böttinger and Weiß (2019: 7-10), the actual business model of the tech giants is based on collecting as much
behavioral data as possible by means of the health-related products and services offered, and on creating personal profiles
of users aimed not only at influencing their decisions in the future, but also at making them. For further elaboration, see
Piepenbrink (2019), Zuboff (2019), and the German Data Ethics Commission (2019). For further reference, see also Couldry
and Mejias (2020).

28
 Tech Giant ACTIVITIEs in Healthcare

structures (cloud computing) to facilitate the merging and processing of these comprehensive
data sets (➔ 3.4.1).

3.1.2
ALGORITHMIC SYSTEMS AND ARTIFICIAL INTELLIGENCE

Processing large quantities of data and generating insights requires algorithmic systems, most
of which fall under the category of artificial intelligence, including machine learning and deep
learning (Data Ethics Commission 2019: 57-62).

Machine learning (ML) is “a rapidly growing subfield of computer science that deals with
models and methods of data analysis and is interwoven into a wide range of application areas. (…)
In most cases, a specific statistical model is ‘trained’ using data. In the typical case of automatic
classification, systems use specific training data sets to ‘learn’ computational rules that classify
or categorize data in a particular way” (German Ethics Council 2017b: 72-73).

In a further development, deep learning (DL) “replicates processes along hierarchically organized
layers, similar to the mode in which neural networks operate in the human brain. Each layer uses
the results of the previous layer and processes them further to produce new results. Given the
increasing volume of data and increased computing power, the networks in use today contain more
interconnecting intermediate layers than ever before. The key difference to traditional methods
is that in Deep Learning, the process of extracting characteristics has also been automated to a
large extent and models can often be trained directly with raw data. This can reduce dependence
on complex pre-processing steps, which can also include developer biases and intuitions” (German
Ethics Council 2017b: 74).

In current usage, different forms of self-learning algorithmic systems are referred to using the term
“artificial intelligence (AI)” (Data Ethics Commission 2019: 59; German Ethics Council 2017b: 75).
A distinction is made between „artificial narrow intelligence“ (ANI), “artificial general intelligence”
(AGI) and „super intelligence“. ANI can solve “well-specified tasks;” AGI is intended to handle
“a wide range of tasks, possibly without human intervention” (Data Ethics Commission 2019: 59),
which is not yet possible. Meanwhile, “super intelligence” describes a hypothetical system that
not only mimics, but also exceeds human intelligence and develops self-awareness (Escott 2017).

AI is widely regarded as the “most pressing, exciting, promising – but also dangerous – technology
issue in the world since man learned to split the atom” (Schulz 2018: 64). The medical field is
one of the most prominent and rapidly growing fields of application and investment in artificial
intelligence (Kaufman 2018; German Ethics Council 2017b).27 Numerous hopes and visions for the
future are formulated (see, among others, Topol 2019a; Hütten 2019; Ferryman and Winn 2018);
for example, that AI-based applications will lead to substantial advances in the clinical areas of

27 Following its acquisition of Nuance Communications Inc., a company specialized in AI, in 2021, Microsoft CEO Satya Nadella
announced: “AI is technology’s most important priority, and healthcare is its most urgent application” (tagesschau.de 2021b).

29
TECH GIANTS IN HEALTHCARE

Tech giants and artificial intelligence

(Selected URLs for current projects and recent publications)

ALIBABA PHILIPS
➔ https://damo.alibaba.com/pubs/ ➔ https://www.philips.com/a-w/research/research-
programs/ai-research-at-philips-research-north-
AMAZON america.html
➔ https://www.amazon.science/publications ➔ https://www.philips.com/a-w/research/
downloads-and-publications.html
APPLE
➔ https://machinelearning.apple.com/ SAMSUNG
research?page=1&tag=Health ➔ https://research.samsung.com/artificial-
intelligence
GOOGLE ➔ https://research.samsung.com/research-papers/

➔ https://research.google/research-areas/health- paper/search
bioscience/
➔ https://research.google/teams/brain/ SAP
➔ https://ai.google/research/ ➔ https://www.sap.com/about/company/
➔ https://deepmind.com/research innovation/open-access-research-publications.
html?sort=title_asc
HUAWEI
➔ https://www.huawei.com/en/technology- SIEMENS
insights/industry-insights/technology/ai ➔ https://www.siemens-healthineers.com/medical-
➔ https://e.huawei.com/en/publications/global/ imaging/molecular-imaging/mi-clinical-corner/
ict_insights scientific-and-clinical-publications
➔ https://www.siemens-healthineers.com/en-us/

IBM magnetic-resonance-imaging/published-studies
➔ https://research.ibm.com/artificial-intelligence ➔ https://www.magnetomworld.siemens-
healthineers.com/publications/magnetom-flash
INTEL ➔ https://www.siemens-healthineers.com/Covid-

➔ https://www.intel.com/content/www/us/en/ 19/Covid-19-resources
research/publications.html
SONY
META (formerly Facebook) ➔ https://www.sony.com/en/SonyInfo/sony_ai/
➔ https://research.fb.com/publications/
TENCENT
MICROSOFT ➔ https://ai.tencent.com/ailab/en/paper/?page=1
➔ https://www.microsoft.com/en-us/research/
blog/
➔ https://blogs.microsoft.com/ai/

NVIDIA
➔ https://www.nvidia.com/en-us/research/
ai-playground/
➔ https://research.nvidia.com/publications

30
 Tech Giant ACTIVITIEs in Healthcare

prevention,28 diagnostics29 and treatment30 as well as in science and education (Krüger-Brand 2020;
Choueiri et al. 2019; Schulz 2018; PwC 2018, 2017).

However, AI-based technologies can pose considerable risks of discrimination and stigmatization;
their mode of operation is often even beyond the understanding of the developers themselves
(“blackbox medicine”), and they can also be used for controversial purposes, such as surveillance.31
The ethical aspects are discussed in chapter ➔ 4.

Tech giants are investing heavily in the development of AI-based systems and applications.
This also includes significant competition in the recruitment of “AI talents”32 (Lewis-Kraus 2016).
The following are examples of the activities of the tech giants in the realm of AI.

GOOGLE has “essentially been a machine various medical care providers as well as govern- GOOGLE /
ALPHABET
learning project” since the company’s founding mental and academic partners (Google Health n. d.
Google Health
in 1998 (Schulz 2018: 77). Google and Alphabet d, b, c) (➔ 3.5). One focus at Google Health is com-
Google Brain
CEO Sundar Pichai has repeatedly emphasized that puter vision, which is used in the fields of medical
Google is transforming itself into an artificial intel- imaging and diagnostic applications (Meskó et al. DeepMind

ligence company (Pichai 2017a, 2017b). That goal 2020: 14) (➔ 3.5). DeepMind
Health
is reflected in the health sector, for example, in
numerous research projects, as well as in high levels In 2011, the company launched its Google Brain
of investment (Schulz 2018: 78). research unit as a project of the Alphabet subsidi-
ary X. The team at Google Brain is engaged in the
The Google Health division, founded in 2006,
33
research and development of deep learning algo-
attempted to collect electronic health data in the rithms and AI applications, including in the area of
form of an electronic health record (EHR) and healthcare provision. Researchers at Google Brain
derive recommendations in an initial project that have developed, for example, TensorFlow, the
was discontinued after a few years (Meskó et al. world’s leading open-source machine learning plat-
2020: 8–9). Since then, Google Health has focused form (Lewis-Kraus 2016). Google Brain has been a
on numerous research projects related to applica- division of Google AI ever since the unit, dedicated
tions for everyday clinical practice and works with

28 Wearables and apps are considered promising with regard to AI-assisted health promotion and prevention because they can
collect and monitor vital data and, in case of deviations from the norm, provide a warning to the affected patient and also to
healthcare professionals (➔ 3.2 and ➔ 3.3) (Hahn and Schreiber 2018).

29 For example, AI-based ultrasound and X-ray technologies will be able to independently identify diseases as diagnostic imaging
procedures. These technologies also hold promise in the diagnosis of rare genetic conditions by, for example, using facial
recognition, because the machines can process a large amount of information about rare diseases from databases, whereas
physicians have often only seen a few cases, which can make a correct diagnosis difficult (Winkler et al. 2020; Gurovich et al.
2019; Schulz 2018).

30 In the area of treatment, AI-based systems can provide support in, for example, intraoperative procedures by improving
endoscopic navigation or 3D visualization during computer–assisted surgery, in addition to other applications (Central Ethics
Commission of the German Medical Association 2021).

31 See, among others: Central Ethics Commission of the German Medical Association (2021), WHO (2021a), Mozur, et al. (2020),
Johnson (2020), Data Ethics Commission (2019), Robbins (2019), Floridi, et al. (2018), Kaste (2018), Pasquale (2015).

32 Meta (formerly Facebook) promises up to seven-figure starting salaries to talent in the field of AI, for example (Kaufman 2018).
Apple has responded by paying developers up to $ 180,000 in stock options in order to get them to stay with the company
(Heming 2021).

33 According to statements by Dr. David Feinberg, head of Google Health, Google is already a health company, with health
aspirations written into its DNA since the company’s inception (Google Health 2019).

31
 TECH GIANTS IN HEALTHCARE

exclusively to AI research, was founded (Meskó et projects (Meskó et al. 2020: 10–15) (➔ 3.4.9).
al. 2020: 8). In 2019, the team at DeepMind Health and the
app Streams were incorporated into the Google
In 2014, Google acquired the London-based startup Health division (King 2019), which has also been the
DeepMind, which is focused on artificial general subject of public controversy (➔ 3.4.9). DeepMind
intelligence (AGI). For the development of applica- achieved a breakthrough in November 2020 as part
tions in the healthcare sector, the company founded of AlphaFold (CASP), when it succeeded for the first
its DeepMind Health offshoot, which developed the time in determining the 3D shape of proteins based
medical smartphone app Streams (➔ 3.3). DeepMind on their amino acid sequences using deep learning
Health became involved in numerous partnerships (Callaway 2020).
and was also the subject of criticism for some of its

APPLE APPLE has dedicated its Apple Machine Learn- Apple’s AI / ML Residency Program provides
Apple ing Research division to AI research projects. participants in the one-year program with ML
Machine
In July 2017, Apple launched the Apple Machine and AI training as well as courses on developing
Learning
Research Learning Journal to provide an overview of the AI-based solutions and products (Apple Machine
company’s current projects in health-related Learning Research 2022).
AI research and other areas (Insel 2017; Apple
Machine Learning Research 2021a, 2021b).

META META (formerly Facebook) uses AI to reduce Facebook AI Research (FAIR) and New York
(formerly
the sharing of misinformation or false information University (NYU) Langone Health are collaborating
Facebook)
on its platforms about topics such as COVID-19 on fastMRI, an AI-based medical imaging research
AI-based
applications (Facebook AI 2020b; Jakob 2019). In the course of project (fastMRI 2020) (➔ 3.5).
fastMRI this process, Meta says it worked with more than
60 independent organizations that fact-check and
label the content in question (Facebook AI 2020b).34

Meta also uses AI in some countries to identify

people at risk of suicide on the social network
facebook. The technology evaluates not only what
the person is writing, but also comments that are
posted in response. If a person is assessed as being
at risk, staff members then decide whether to
inform the police (Kaste 2018) (➔ 4.3.1).

34 In late 2021, Frances Haugen, a former product manager at Facebook’s unit dealing with misinformation, lodged serious
allegations against Facebook (now Meta). Speaking before the U.S. Subcommittee on Consumer Protection, Product Safety
and Data Security, she accused the tech giant of putting corporate profits ahead of the well-being and safety of users and basic
societal principals such as democracy by, among other things, knowingly using algorithms “that amplify divisive and harmful
content” (tagesschau.de 2021f, 2021e).

32
 Tech Giant ACTIVITIEs in Healthcare

AMAZON is pursuing numerous activities in the Amazon Translate is a neural machine translation AMAZON
field of AI, such as the development of AI-assisted service that the company claims can produce highly Amazon
Rekognition
recognition and translation programs. Amazon accurate and authentic translations (AWS 2021c).
Video
Rekognition Video, for example, includes a
Amazon
deep learning video analytics function that can Amazon Comprehend Medical is an ML-based nat- Transcribe
detect, track and extract objects, faces and content ural language processing (NLP) service that extracts Medical

from video (Walker 2017). This could ultimately health data and information from medical texts. Amazon
Translate
be relevant for medical imaging in the healthcare The data can be used for health analyses, in the
Amazon
sector. execution of clinical studies, for pharmacovigilance Comprehend
and to provide an overview. They can also be Medical
With Amazon Transcribe Medical, an automated linked to medical ontologies such as ICD10-CM35 Amazon
Alexa
speech recognition (ASR) service, speech-to-text or RxNorm. The aim of Amazon Comprehend
36

capabilities can be used. The service is used in a Medical is to make all medical and health informa-
wide variety of medical fields. According to Amazon, tion easily accessible and retrievable (AWS 2021a).
the service can be used to precisely transcribe
conversations between doctors and patients, for Amazon’s virtual assistant Alexa is also AI-based
example (AWS 2021b). and is already being used intensively in the health-
care sector (➔ 3.2).

MICROSOFT is running numerous AI projects Microsoft is also collaborating with Nuance MICROSOFT
such as the Microsoft Healthcare NExT initiative, Communications, Inc. on Project EmpowerMD, Microsoft
Healthcare
which aims to transform healthcare by lever- which processes conversations between physicians
NExT
aging existing AI and the Azure Cloud (Microsoft and patients, integrates the content into electronic
Microsofts
Feb. 16, 2017) (➔ 3.4.9). health records (EHR) and automatically provides AI for Good
a medical summary. The system uses a large num- Initiative

Microsoft’s AI for Good initiative is the umbrella ber of algorithms designed to recognize complex Project
EmpowerMD
for various programs such as AI for Earth, AI for natural language and process its content. The
Project
Humanitarian Action and also AI for Health (➔ 3.4.9 system is designed to learn from all interactions Hanover
and ➔ 3.5), which are designed to address major and thus to help ensure the best medical outcome Novartis AI
crises and pursue UN sustainability goals in (Microsoft Research 2019; Microsoft News Center Innovation Lab
cooperation with non-governmental organizations Oct. 17, 2019) (➔ 3.4.9).37 Microsoft
(Azure) Health
(NGOs) and other humanitarian organizations.
Bot Service
Microsoft along with, for example, IBM is also part Microsoft’s Project Hanover, launched in 2016,
of the UN International Telecommunication Union’s aims to advance the technological foundations of
(ITU) platform AI for Good, which is dedicated to machine reading for precision medicine. It combines
achieving these sustainability goals using AI and, deep learning and probabilistic logic. The project
to that end, brings innovators together with is currently focused on molecular tumor research
“problem owners” (Microsoft 2022; ITU 2021; as well as on generating evidence from real-world
Smith 2018).

35 International Classification of Diseases, Tenth Revision, Clinical Modification.

36 RxNorm links clinical drug use names to drug vocabularies used in pharmacy management and drug interaction software to
ensure standardization of drug names across systems (National Library of Medicine (NLM) 2021).

37 Project EmpowerMD works with the system Dragon Ambient eXperience (DAX), which records and processes doctor-patient
conversations during everyday visits (Microsoft 2021a).

33
 TECH GIANTS IN HEALTHCARE

healthcare provision in conjunction with clinical Microsoft’s (Azure) Health Bot service is an
trials (Microsoft Research 2016). AI-based platform designed to support the integra-
tion on virtual assistants and chatbots (Microsoft
Microsoft is collaborating with SilverCloud Health, 2021c; Microsoft Research 2021a) (➔ 3.3).
to support its digital health platform with AI-based
applications (Meskó et al. 2020: 6) (➔ 3.4.9).

Microsoft is working with the pharmaceuticals

company Novartis as part of the Novartis AI Innova-
tion Lab (Evans 2020) (➔ 3.4.9).

IBM IBM’s Watson Health seeks to create solutions for The AI Horizons Network is a global network of
IBM Watson the healthcare system using AI, data analytics and researchers initiated by IBM to further develop the
Health
blockchain technologies. Data and knowledge are use of AI, natural language processing (NLP) and
AI Horizons
harnessed to support well-founded decisions in the related technologies (IBM Apr. 28, 2020) (➔ 3.4.1
Network
healthcare context, to increase efficiency in com- and ➔ 3.5).
panies and in the healthcare sector, and to improve
clinical trials (IBM 2021h) (➔ 3.2 and ➔ 3.4.9).

INTEL INTEL and the Center for Digital Health Innovation In partnership with the Center for Biomedical Image
Deep Learning (CDHI) at the University of California, San Francisco Computing and Analytics (CBICA) at the University
Analytics
(UCSF) are collaborating to jointly deploy and of Pennsylvania Medical School and 29 other
Platform
validate a deep learning analytics platform. It healthcare institutions, Intel is using federated
is designed to improve medical care by helping learning38 to develop AI to help detect brain tumors
clinicians make better treatment decisions, (Council 2020; Proffitt 2020).
predict patient outcomes and respond more
nimbly in acute situations (Meskó et al. 2020: 56;
UCSF Jan. 18, 2017).

NVIDIA NVIDIA Clara is a platform and application NVIDIA Clara Train SDK is an application frame-
NVIDIA Clara model that aims to drive healthcare innovation work designed to support the sharing of data and
NVIDIA Clara and precision medicine through the use of AI knowledge between hospitals and medical facilities
Train SDK
and intelligent computing. The areas of genomics, through federated learning in ways that allow
observation of the health status of patients, algorithms to be trained without jeopardizing the
medical imaging and drug development are its privacy of patients. The collaborative learning model
focus (NVIDIA 2021d; The Medical Futurist 2018) is intended to allow different institutions to work
(➔ 3.3, ➔ 3.4.3 and ➔ 3.5). together safely and thus contribute to a global
model (Wen et al. 2019) (➔ 3.4.3).

38 Federated learning allows an AI model to be trained using local data samples. To improve model accuracy, local models are
shared in the network and fed into a global model that is shared with all users (Fraunhofer Institut 2022).

34
 Tech Giant ACTIVITIEs in Healthcare

SIEMENS, by its own account, holds several automate complex diagnostic procedures (Siemens SIEMENS
hundred patents relating to machine learning (ML) Healthineers 2020a) (➔ 3.3). AI-based
applications
and has developed numerous AI-based health-
care-related applications that are designed not
only to optimize healthcare workflows but also to

SAP offers cloud and AI-based platforms that data, secure medical documents and patient SAP
are designed to schedule appointments and opera- information and store all data-based information AI-based
platforms
tions, simplify documentation, equip patients with (Approyo 2019).
specialized apps and programs, provide analytics
and insights for predictive purposes, improve
medical procedures through accurate real-time

HUAWEI provides various AI-based services with HUAWEI

its Huawei Cloud for, among other things, combat- Huawei Cloud
ing COVID-19 (Huawei Cloud 2021b) (➔ 3.2, ➔ 3.4.1
and ➔ 3.4.9).

ALIBABA Health is collaborating with three environmental information and analysis to steer ALIBABA
hospitals in China on a first-of-its-kind medical medical decisions), as well as online medical services Alibaba
Health
AI lab. The lab will be used to test how AI can and personal health management (Business Insider
KI-Labor
be used to support diagnostic as well as clinical Intelligence 2018).
decision-making processes. Other areas in which
AI is slated for use include intelligent medicine
(including general data use, biotechnology,

TENCENT operates three major AI labs to support TENCENT

AI-based medical research and other applications: Tencent
Medical AI Lab
Tencent Medical AI Lab, Tencent YouTu Lab and
Tencent
Tencent AI Lab (Tencent 2019) (➔ 3.5).
YouTu Lab
Tencent
AI Lab

35
TECH GIANTS IN HEALTHCARE

3.1.3
SUMMARY

Tech giants have massive capabilities for collecting and processing data, even if it comes from
disparate sources. A wide variety of AI systems are being developed and deployed to analyze and
process the data. Developments in healthcare range from general storage and analysis platforms
to disease-specific applications. The aim is to further develop precision medicine by collecting
the relevant individual data as comprehensively as possible, but also to clarify medical-biological
relationships such as fundamental metabolic processes, and to optimize care processes.

With the help of AI systems in imaging, speech recognition, virtual assistance systems or the
development of a digital twin, both individual treatment and the care process are to be optimized.
In 2019, the market for AI in healthcare was $ 3.48 billion, and it is expected to reach $ 40.12 billion
by 2026, growing at an annual rate of 41.8 % during the forecast period (Medgadget 2020). Other
estimates suggest that global spending on AI in the healthcare sector will grow at an annual rate
of 46.2 % during the projected period to $ 67.4 billion by 2027, which would be nearly 10 times the
$ 6.9 billion spent in 2021 (MarketsandMarkets Research 2021).

2026
(projected)
$ 40.12 billion
2019
$ 3.48 billion

FIGURE 6: Market for AI in healthcare

Source: Authors. Data: Medgadget 2020, Bertelsmann Stiftung

36
TECH GIANTS IN HEALTHCARE

3.2
TECHNOLOGIES FOR PATIENTS AND USERS

This chapter presents digital products and services produced by the tech giants that are offered
to and used directly by patients. It is also concerned with users who utilize health-related
technologies outside the context of professional healthcare for the purposes of improving or
maintaining their own health and preventing disease, and consequently cannot (yet) be referred
to as “patients.”

3.2.1
WEARABLES AND APPS

Wearables and apps play a prominent role in the mobile health field (m-health). Development
in this area is moving very rapidly, and the market is very dynamic.39 To date, m-health products
and services have focused primarily on the lifestyle and prevention markets, as well as on the
management of chronic conditions such as diabetes, obesity, depression and cardiovascular dis-
eases (Bienhaus 2016). Many wearable devices can also be connected with one another or be linked
to social platforms and networks, thereby allowing, for example, users to compare their athletic
performances with others.

Wearables can be described as “electronic devices worn on the wrist, head, ears, clothing or skin
that can be directly connected to the web via a wireless (e. g., Bluetooth) link to a smartphone or
tablet. Such devices have smart sensors that can measure and process a broad range of physical
and physiological variables. When they are implanted under the skin, they are called ‘insideables.’
Depending on the application and the way the device as worn, a distinction can be made between
smartwatches, smart glasses, headsets, smart earphones, technology tattoos, fitness trackers,
running watches, smart clothing, smart jewelry, etc.” (Mischak 2017: 278-279).

The associated software components, usually referred to as apps, can also be distinguished based
on their context of use. For example, a distinction is made between health apps, which are used
to manage, maintain and improve one’s own health; medical apps, which deal with the diagnosis,
therapeutic treatment and monitoring of (primarily chronic) conditions; and pure lifestyle apps,
which address issues such as fitness and wellness (Schüz and Urban 2020: 192). From a legal per-
spective, the question of whether a health-related app is deemed a medical device is also relevant;

39 Many of the tech giants’ m-health innovations have already been replaced by newer innovations, or have been driven out of the
market by other developments. These include the Samsung Simband, a smartwatch described by Samsung as an “investigational
device” that was intended to act as a “window into the wearer” (Sullivan 2017; Samsung Simband 2018). According to media
reports, the initial presentation of the Simband prototype in 2014 has not been followed by any further releases of this product.
In 2014, the Simband would have been in direct competition with the not-yet-released Apple Watch. However, by 2017,
Simband had lost market relevance, and it can be assumed that Samsung abandoned the project (Sullivan 2017). For its part,
Microsoft took its Microsoft Band (a second-generation smartwatch with an associated app) off the market in 2019 (Microsoft
Support 2019).

38
 Tech Giant ACTIVITIEs in Healthcare

in the EU, this makes it subject to the special rules contained in the regulation on medical devic-
es,40 which cover issues such as market entry, evaluation, testing and monitoring. This is primarily
based on whether the items or apps in question are “intended to be used, alone or in combination,
for human beings for (…) a specific medical purpose .”41 Additionally, in Germany for example,
there is the question of whether the costs for a health-related app are eligible for reimbursement
through the statutory health insurance (GKV) system. This is dependent on whether it is classified
and recognized as a Digital Health Application (DiGA) under the requirements and regulations con-
tained in the Digital Healthcare Act (DVG).42

APPLE has already positioned itself in the health- as from other providers (Meskó et al. 2020: 19).43 APPLE
care market with a complex ecosystem of wearables The Apple Health app serves as a platform that Apple
Health App
and apps that are designed to be user-friendly and allows patients and users to combine and analyze
Apple Watch
easily connected to other devices or the internet. their own medical data along with other self-gener-
The overall size of the global m-health market, within ated health and lifestyle data (Krüger-Brand 2020: Apple
Research App
which Apple is a key player, is expected to reach a 378).44
Covid-19-App
value of $ 311.98 billion by 2027 (Smith 2020).
Interfaces
The Apple Watch is another wearable device. for Covid-19-
Using Apple’s applications often requires access to Now available in its seventh generation, this smart Contact-
Tracing-Apps
an iPhone. iPhones accounted for a 15.2 % share wristwatch was first introduced to the lifestyle
of all new smartphone sales globally in the third market in 2014 as a health and fitness tracker.
quarter of 2021 (Tenzer 2021); other estimates The company has integrated new functions into
indicated that this share was as high as 23.4 % in the Apple Watch with each new generation; over
the first quarter of 2021 (tagesschau.de 2021a). time, the goal is to transform it into a full-fledged
Apple led the global smartwatch-sales market in medical device (Meskó et al. 2020: 22). While it
the first quarter of 2021, with a 33.5 % market has long been able to measure data associated
share, followed by Huawei with a 8.4 % share with sports activities, for example, it has since the
(Koetsier 2021). Other sources estimated that fourth generation been able to record an electro-
Apple’s market share was as high as 52.2 % cardiogram (ECG) via the AliveCor KardiaBand, and
(Macdailynews 2021). thus display the user’s heart rhythm and heart rate
(Apple 2020; Krüger-Brand 2020: 378) (➔ 3.4.3).
The company launched its Apple Health app in
2014. Distributed as preinstalled software on newer By using the Apple Research app, Apple smartphone
iPhone versions, this can aggregate health-related and smartwatch users can participate in Apple stud-
data from the iPhone and the Apple Watch, as well ies, and even organize them (Apple 2021c) (➔ 3.5).

40 Parliament and Council regulation (EU) 2017/745 of 5 April 2017 on Medical Devices, L 117/1 of May 5, 2017 (Medical Devices
Regulation, MDR).

41 These are, in particular, the diagnosis, prevention, monitoring, prediction, prognosis, treatment or alleviation of disease; the
diagnosis, monitoring, treatment or alleviation of injury or disability, or measures intended to compensate for such a condition;
or the examination, replacement or modification of the anatomy, or of a physiological or pathological process or condition, etc.,
see Art. 2 MDR.

42 See footnote 3.

43 Apple acquired Gliimpse, a startup that specialized in aggregating and organizing health data, in 2016. In 2018, Apple added
the ability to integrate proprietary medical data from medical institutions into the Apple Health app (Meskó et al. 2020: 19-20).

44 The Apple Health app complies with the Fast Healthcare Interoperability Resources (FHIR) standard published by the Health
Level Seven International (HL7) organization, which has established itself as a global interoperability standard “for data
exchange between healthcare software systems” (Krüger-Brand 2020: 378).

39
 TECH GIANTS IN HEALTHCARE

Apple also provides a COVID-19 app that informs 19, without any involvement by health authorities,
individuals who have received coronavirus tests using the so-called Exposure Notifications Express
of their test results (Meskó et al. 2020: 22-23). system (Laaff 2020; Federal Ministry of Health
2021a).
In April 2020, Apple introduced its own application
programming interface (API) that was, co-developed Apple has thus pursued a wide variety of activities
with Google, for COVID-19 contact-tracing apps. in the area of technologies for patients and users.
This subsequently served as a de facto standard It is clear today that smartphones themselves – and
for most European mobile-phone-based contact- thus also Apple’s own iPhone, particularly used in
tracing apps (Fanta 2020; Sharon 2020), such as conjunction with the company’s own apps (e. g., the
the German Corona-Warn-App (Federal Ministry Apple Health app), third-party apps and compati-
of Health 2021a) (➔ this chapter, SAP). In addition, ble connectable wearables (e. g., Apple Watch) – are
as a part of their collaboration, the two tech giants increasingly gaining significance as medical devices
created technology for Android- and iOS-based in their own right, both with regard to healthcare
smartphones that allows users to anonymously provision and medical research (Topol 2015).
report contact with a person suffering from COVID-

GOOGLE / GOOGLE Wear OS is a Google-built operating with a 4.2 % share, as of the first quarter of 2021
ALPHABET
system derived from Android and developed fur- (Koetsier 2021).
Google Fit-App
ther for mobile devices. It is compatible with numer-
Fitbit &
ous smartwatches, and allows these to be synchro- The Google Health Studies app is intended to
Fitbit App
nized with smartphones. Among other things, the encourage patients and users to contribute to
Google Health
& Google smartwatches can be used to monitor health and medical research (Google Play Store 2021b) (➔ 3.5).
Health Studies fitness goals, with the resulting information being
App
used to facilitate these goals’ achievement (Google In addition, Google’s search engine (Google Search)
Interfaces
for Covid-19- Play Store 2021e). The Google Fit app can be used provides the ability to search for information on
Contact- on smartwatches and smartphones, with all data common medical conditions, symptoms and treat-
Tracing-Apps
synced across the devices. The app was developed ment options online – although there are certainly
mit Apple
in partnership with the World Health Organization challenges with regard to assessing the quality of
(WHO) and the American Heart Association (AHA) health information on the internet.45
(Google Play Store 2021a).
Google Health, according to the company’s own
Fitbit, which was acquired by Google in 2021, pro- statements, is intended to help improve women’s
duces smartwatches and other tracking devices that physical and mental health, using an online self-as-
can measure a user’s pulse, stress level, sleeping sessment questionnaire on the issue of postnatal
patterns and blood oxygen levels, and can derive a depression (Google Health 2020).
cardiac waveform (ECG) from the information gath-
ered. The Fitbit app can be used to analyze and syn- For a discussion of Google’s collaboration with
chronize the data collected (Maehner 2020). Fitbit Apple on the API for COVID-19 contact-tracing
ranked fifth in the global smartwatch market, apps, see the discussion of Apple in this chapter.

45 This problem is not discussed in this study. For further information on the topic and related research, see, for example, projects
such as OriGes (https://ceres.uni-koeln.de/en/research/projects/origes-ii).

40
 Tech Giant ACTIVITIEs in Healthcare

META (formerly Facebook) offers a tool called Cardiology (ACC), the American Heart Association META
(formerly
Preventive Health, an opt-in feature that can be (AHA), and the Centers for Disease Control and
Facebook)
added within the social network’s Facebook app Prevention (CDC). The tool currently provides
Preventive
that provides U.S. users with recommendations for preventive health screening recommendations Health
health checkups. The recommendations are made for cardiovascular diseases, cancers and the flu
based on guidelines issued by the U.S. American (Facebook 2020).
Cancer Society (ACS), the American College of

PHILIPS ’ SmartSleep Deep Sleep Headband is a or can call up an overview of past measurements. PHILIPS
headband intended to analyze and improve sleep The personal data is additionally supplemented by Philips
SmartSleep
patterns. Designed in collaboration with physicians subjective data from digital health questionnaires.
Deep Sleep
and researchers, its target market is individuals eCareCompanion is intended to be used with Headband
who regularly sleep less than six hours per night additional tools including a scale, a wireless blood Philips
(Philips 2021i, 2021f). The SmartSleep Snoring glucose meter, a finger pulse oximeter and a blood SmartSleep
Snoring
Relief Band uses vibrations to guide users into a pressure monitor. These devices report the data Relief Band
side sleeping position, with the goal of preventing measured to the eCareCompanion, which then Philips
snoring. It uses a position-measuring device to processes it (Philips 2021c, 2021d). The company HealthSuite &
HealthSuite
determine whether users are lying on their backs also offers the mobile HealthSuite Health app,
App
or not (Philips 2021j). which is intended to support users who want to
Philips Heart
change their habits by allowing them to measure Health Program
The Philips HealthSuite is a cloud-based platform their own vital signs and providing them with health
for connecting different healthcare devices. Clinical advice (Philips 2021e).
data and other data from any Philips device can
be aggregated and analyzed within the Health- The Philips Heart Health Program, an app-based
Suite. Medical and nursing staffers at healthcare health program, is intended to help reduce risk
institutions can access patient health data, as can factors for cardiovascular diseases by encouraging
the patients and users themselves. The Health- users to make lifestyle changes. It provides users
Suite consists of the eCareCoordinator app, which with a personalized health plan that helps them
is designed for physicians (➔ 3.3), and the parallel increase their physical activity and improve their
eCareCompanion, which was developed to help diet and sleep patterns, among other features
patients become more actively involved in their own (Philips 2017).
treatments, and to improve their personal health
management. Patients can perform functions such
as entering vital signs and blood-pressure values,

AMAZON’s Care app, is currently reserved for referrals via video chat (Amazon Care 2021; AMAZON
employees of Amazon. The app is intended to Amazon March 17, 2021). Amazon
Care App
facilitate access to high-quality telemedicine-based
Amazon
healthcare services. To this end, a team of doctors The Amazon Halo Band is a fitness wearable that
Halo Band &
and nurses is available at all times to provide was launched in 2020. Instead of a display, it has Halo App
services through the app. A text function can be two integrated microphones and an optical sensor
used to obtain advice on any health topic. Users used to measure the user’s heart rate. In addition
can also obtain advice, diagnoses, treatment or to the heart rate, Amazon Halo can also monitor

41
 TECH GIANTS IN HEALTHCARE

and analyze a user’s sleep patterns (Mühlroth 2020). users develop health-promoting habits. Amazon
With the Tone feature, the device’s microphones Halo Labs partners include John Hancock,48 8fit, the
can be used to analyze the user’s voice. In addition,
46
American Heart Association (AHA), Headspace and
the device can be used to generate a 3D body-fat WW49 (formerly Weight Watchers) (Amazon August
model. Amazon Halo works with the Halo app,
47
27, 2020). Amazon faces a serious challenge with its
which runs on both the iOS and Android operating Amazon Halo line, as the market is already crowded
systems. Among its other features, the Halo app with different wearables (Erum 2020).
offers workouts designed with the goal of helping

SAP SAP Health Engagement, a cloud-based application, alized home care. Additionally, they are expected to
SAP Health is built on SAP’s HANA cloud platform. It aims to increase patient participation in studies (SAP News
Engagement
improve interactions and the exchange of informa- Center April 19, 2016).
Corona-
tion between patients, physicians, healthcare pro-
Warn-App
viders and other actors in the healthcare system. In cooperation with Deutsche Telekom and others,
By enabling real-time sharing of patient data, it SAP also developed the German Corona-Warn-App
allows medical personnel to make beneficial inter- in 2020 on behalf of that country’s federal govern-
ventions at an early date, with the goal of improv- ment. This software program enables citizens to
ing care and boosting cost efficiency. The applica- notify other app users if they have been diagnosed
tions are intended to provide support for people with COVID-19 (Federal Ministry of Health 2021a;
who have chronic diseases or are receiving person- SAP News Center June 17, 2020).

SAMSUNG SAMSUNG’s Health app identifies daily activities wristband that records and displays vital-sign data
Samsung and habits, and analyzes them with the aim of via the Samsung Health app (Samsung 2021a).50
Health App
helping users improve their nutrition and live a
Samsung
healthier lifestyle. It includes a pedometer, an The Samsung Galaxy Watch and Galaxy Watch
Gear Fit2 Pro
analysis of eating habits, and a sleep and stress Active2 are smartwatches that include an
Samsung
Galaxy Watch tracker. In addition, the app includes exercise accelerometer, a barometer and a heart rate

Samsung programs focused on weight loss and increasing monitor, among other features.51 Thus, the devices
My BP Lab endurance. There is also a news feed that offers can monitor workouts, record and display the user’s
Samsung Smart personalized information on health topics (Google progress, and compare the results with those
TV-Plattform
Play Store 2021d). The Samsung Gear Fit2 Pro is a produced by other users (Samsung 2020). Samsung
Rehabilitation
program
NEJM Catalyst
46 Users then see an evaluation of their communication patterns in the app, with the idea that they can learn how to communicate
better and more positively (Mühlroth 2020).

47 Users can view the 3D body-fat model in the app, and test how they would look with different body-fat percentages (Mühlroth
2020).

48 U.S. life insurance company John Hancock has already integrated Amazon Halo into its Vitality Program. Participants in the
program receive a free three-year membership to Halo. The Vitality Program is focused on helping people live more active
lifestyles and improve their overall health. It also includes wearables from other tech companies (Amazon August 27, 2020).

49 For example, Amazon Halo users can transfer data on their activities from Halo to the WW app, and have this converted into
so-called FitPoints, which in turn can be counted toward the calorie balance in the diet app (Amazon August 27, 2020).

50 In addition, it has a built-in GPS feature and a music player. The Gear Fit2 Pro also has additional apps available that derive
from a collaboration with U.S. sporting goods manufacturer Under Amour. These include MapMyRun (which records jogging
routes) and MyFitnessPal (which tracks calorie consumption) (Samsung 2021a).

51 The watch also includes a “running coach” that provides exercise advice, along with a feature that invites users to practice
breathing techniques in order to handle stressful situations more effectively (Samsung 2020).

42
 Tech Giant ACTIVITIEs in Healthcare

held an 8 % share of the global smartwatch blood pressure and heart rate, by means of the
market in 2021, making it the third-largest supplier optical sensors built into the Samsung Galaxy S9
(Koetsier 2021). Other analysts estimated Samsung’s and S9+ phones. App users are invited to participate
Q1 2021 share of the global smartphone market at in three-week studies being conducted by the
around 19 %, making Samsung the second-largest University of California, San Francisco (UCSF)
provider after Apple, which had a market share of (Samsung February 26, 2018) (➔ 3.5).
around 24 % (tagesschau.de 2021a). Some sources
note that Samsung took over the position of smart- The Samsung Smart TV platform is an application
phone market leader in the third quarter of 2020 designed for the company’s Smart TV. For example,
with a global share of 23 % (Beltrame 2020), while the company has struck partnerships that give
others called it the second-largest provider in the Samsung Smart TV users free access to health and
second quarter of 2021, with a 24 % share (Google- fitness services such as the Calm app’s meditation
WatchBlog 2021). programs or the Fitplan app’s workout programs
(Reid 2020; Fitplan 2020).
Working in partnership with NEJM Catalyst, Sam-
sung has also developed a technology-supported, Samsung is collaborating with American Well
evidence-based rehabilitation program for heart- (Amwell) on a telemedicine platform (LiveHealth
attack patients. This program can be loaded onto Online) accessible within the Samsung Health app,
smartphones and connected to specially configured which is available through many Samsung devices.
wearables (Swaney 2019). For example, the platform offers an “Experts”
feature that allows users to engage in video con­
Samsung’s My BP Lab is both an app and a study. sultations with Amwell physicians (American Well
The app measures the users’ stress in everyday life, April 24, 2017; Meskó et al. 2020: 54).
along with associated physical reactions such as

HUAWEI’s Health app provides patients and activities. It mainly supports running-based sports HUAWEI
users with professional guidance regarding physical (Google Play Store 2021c). Huawei
Health App

ALIBABA has launched My Health Service, a free treatment of COVID-19 or pneumonia (Xinhua ALIBABA
online medical advisory service intended to ease January 27, 2020). My Health
Service
pressure on hospitals during the COVID-19 pan-
Alipay Health
demic, according to the company’s own statements. Alibaba’s Alipay Health Code app has played a role
Code
Users can directly access the advisory service via in the Chinese government’s pandemic-management
the Taobao shopping platform or the AliPay pay- programs. Specifically, it has served as a means of
ment service, and view real-time pandemic data controlling citizens’ daily lives and mobility during
provided by China’s National Health Commission. the COVID-19 era, as it transmits a user’s health
According to Alibaba, hundreds of doctors from status using three color categories and integrated
across China offer their services through the app. quick response (QR) codes.52 However, according to
In January 2020, around 90 % of the questions critics, there has been no precise explanation iden-
submitted were related to the prevention and tifying exactly what data is used to assign users to

52 A green code allows unrestricted mobility. Yellow codes can result in seven days of home isolation, while red codes trigger
a two-week quarantine (Mozur et al. 2020).

43
 TECH GIANTS IN HEALTHCARE

the different color categories. The New York Times quarantined or barred from using subways and
has called this a mass experiment in the use of visiting other public spaces due to a suspected
data to regulate the individual behavior of citizens. COVID-19 infection (Mozur et al. 2020).
The app dictates to users whether they will be

TENCENT TENCENT Health, a service platform within the target market. The tool is intended to calculate risk
Tencent Health WeChat app, attracted more than 1 billion active assessments as students go back to school. This is
in WeChat
users during the first quarter of 2021 (Iqbal 2021). done by asking the user to answer questions about
Digital
Launched in 2019, it allows patients and users his or her body temperature, possible conspicuous
Health Card
to engage in online medical consultations, make symptoms, and whereabouts over the past two
Covid-19-
Health-Tracing- appointments, and access health information and weeks. After assessing the answers to these
App other health services. The platform is expected to questions, the app outputs a color-based QR code
Tencent be expanded gradually to different regions in China. on the smartphone. According to Tencent, the app
Medipedia
The WeChat application allows Tencent to reach a allows educational institutions to check on their
total of 500 million insured people. Users can also students’ health statuses (Li and Goh 23.03.2020;
pay for hospital stays and medication using WeChat Müller 2020).
Pay. According to Tencent, nearly 10,000 medical
institutions support payments via WeChat. Tencent Medipedia is a health information
WeChat’s Digital Health Card is expected to sharing platform established in 2017. It provides
function analogously to the Chinese Health ID Card, users with information on the prevention, diagnosis
recording medical data from various hospitals and and treatment of diseases, including issues having
other medical facilities. According to Tencent, the to do with rehabilitation. The content is conveyed
company is promoting this Digital Health Card so as through texts, photos, videos, 3D visualizations and
to enable the public to receive the best online and AI-based assistants. The platform has a partnership
offline patient care (Tencent 2019). with WebMD, an international healthcare informa-
tion platform (Tencent 2019).
Tencent has also embedded a COVID-19 Health
Tracing App in WeChat, with high school and
college students in China serving as its primary

Tech giants have developed a wide variety of network-linked wearables in forms such as
smartphones, smartwatches, fitness trackers and wristbands, as well as countless health apps
including medical and lifestyle apps, all of which can be used to collect and process vast amounts
of health-related data in real time. They are designed to monitor vital parameters, including the
recording of electrocardiograms. They enable patients and users to participate in research studies,
and open up the possibility of online medical advice and behavioral monitoring. During the coro-
navirus pandemic, they have been used to generate automated notifications when a user may have
come into contact with infected individuals, as well as to restrict access to public transportation
and other facilities based on health status.

The tech giants’ wearables and apps aimed at patients and users have to date focused primarily
on the lifestyle, wellness and prevention markets.

44
 Tech Giant ACTIVITIEs in Healthcare

Globally, around 445 million wearable devices were sold in 2020 (Tenzer 2022a; IDC 2021), with
the forecast for 2024 rising to around 632 million units (Tenzer 2022b; IDC 2020). The leader in
this market is Apple, which had a global market share of around 34 % in 2020 (IDC 2021). In the
second quarter of 2020, approximately 656 million health and fitness apps were installed. Revenue
in the segment for the same period was $ 328.5 million (Chapple 2020). According to 2018 fore-
casts, the market for mobile health apps was expected to grow to $ 11.2 billion worldwide by 2025
(BIS Research 2018). However, by 2020, the size of the global m-health app market was already
estimated at $ 24.93 billion (Fortune Business Insights 2022).

2024 FIGURE 7:
2020
(projected)
445 million items Global sales of wearables
630 million items
Source: Authors. Data: IDC 2020; IDC 2021,
Bertelsmann Stiftung

3.2.2
VIRTUAL ASSISTANT SYSTEMS AND DIGITAL AVATARS

Patients and users can also make use of virtual assistant systems and digital avatars. This latter
category can be defined as “computer-based artificial and graphical representations of a person
that assist people with a task” (Angerer et al. 2019: 12). Other types of virtual assistant systems may
not mimic a human to the same degree. Perhaps the most widely known such services today are
the voice-based digital assistant systems in smartphones and other wearables, which are based on
automated speech recognition and voice analysis processes (Kalis et al. 2018; German Ethics Council
2017b: 76). Numerous health applications for such tools have already been developed53 or are conceiv-
able, from reminders to take medication to the provision of medical information to recommendations
of various kinds (Krüger-Brand 2020; Champeaux 2019). In the following section, we outline some
of the tech giants’ activities in the field of virtual assistant systems and digital avatars.

53 A number of the tech giants’ products and applications in the field of virtual assistant systems and digital avatars have already
been replaced by newer innovations or pushed out of the market by other developments. For example, Google Allo was an
instant messaging service that had implemented the Google Assistant intelligent assistant function. The Smart Reply function
also answered users’ questions. Allo gained new information as it monitored users’ behavior, which helped it in turn become
more personalized (Holland 2016a). Meta’s (formerly Facebook’s) M was a virtual assistant that could automatically carry out
tasks for users, including such chores as purchasing items and making reservations (Kelly 2015).

45
 TECH GIANTS IN HEALTHCARE

AMAZON AMAZON distributes its AI-based voice assistant Developed in collaboration with Boston Children’s
Amazon Alexa Alexa, which accounted for 69 % of smart speaker Hospital, the Alexa-enabled MyChildren’s app assists
Amazon Echo sales in the U.S. market in the period from 2016 to parents and medical staff in conducting home-based
2021 (Bishop 2021a). post-operative care for children who have recently
undergone heart surgery (Meskó et al. 2020: 37;
Some analysts predict that it could become the Hecking 2019; Kohlhagen 2019). Specifically, parents
digital doctor of the future. Amazon intends to use can use MyChildren’s to view their children’s health
Alexa to help improve healthcare, for instance by records, send messages to care teams, and access
providing immediate services such as identifying other services related to their child’s hospital care,
mild illnesses at home and making treatment such as a payment feature and appointment man-
recommendations that could save patients and agement functions. Another Alexa application, the
users from having to consult a doctor (Meskó et al. KidsMD digital health platform, provides general
2020: 34-37). Alexa is already being used in stud- information on diseases and medications.
ies to increase the physical activity of patients who
have suffered or are suffering from oncological Amazon is also working with pharmaceutical
conditions, by providing them with guidance and company Merck & Co. on an Alexa-based program
support from the voice assistant in their recovery to help diabetes patients manage their conditions,
process (Hassoon et al. 2020; Hassoon et al. 2018). for example by providing dietary advice and monitor-
In addition, Alexa has been used in a study that ing self-reported glucose levels (Luminary Labs LLC.
relied on the voice-activated service to facilitate the 2017).
transfer of health data to electronic databases by
medical and nursing staff (Bhatt 2020). One example of Alexa’s potential applications in
Germany is the TK Smart Relax service offered by
In 2018, Amazon established a team tasked with the Techniker Krankenkasse (TK) health insurance
improving Alexa’s ability to provide healthcare fund. This provides TK customers with access to
support to chronically ill and elderly people. The an Alexa function that plays soothing sounds from
company’s collaboration with German startup Ada nature or guides them through relaxation exercises
Health gives it access to a large AI-based database
54
(Krüger-Brand 2020: 377).
of diseases and symptoms, which will be used to
infer users’ health statuses based on their self- Alexa is also used as a voice-based assistant to
reported symptoms (Meskó et al. 2020: 37). access medical information. For example, since
Amazon holds a patent for Alexa relating to the 2019, people in the United Kingdom’s state-run
use of voice analysis to deduce the health status health insurance system have been able to post
of patients and users (Krüger-Brand 2020: 377). their medical questions directly to Alexa through
a project carried out in partnership with the U.K.
The multifaceted use of the Alexa digital voice National Health Service (NHS) (DHSC 2019). To
assistant could allow Amazon to develop new answer these questions, Amazon Echo,55 the smart
healthcare business models by analyzing a Alexa home device, searches through the informa-
large amount of voice data from different users tion that has been published on the NHS website
(Hecking 2019). (Lake 2019).

54 Ada Health operates the Ada app, which lets patients and users seek medical advice via an AI-based chatbot. This system asks
users about their symptoms and complaints, and uses the answers to derive possible diagnoses and further recommendations
(Ada 2021).

55 Industry analysts estimate that over 20 million U.S. households had more than one Amazon Echo device as of June 2021
(Bishop 2021a).

46
 Tech Giant ACTIVITIEs in Healthcare

GOOGLE Duplex supports a new virtual assistant for Disease Control and Prevention (CDC), the GOOGLE /
ALPHABET
feature called Google Assistant. Google Duplex has World Health Organization (WHO), Johns Hopkins
Google
been in a test phase since May 2018. It has already Medicine, the American Lung Association, the
Assistant
been introduced in parts of the United States and American Heart Association (AHA), and the
Google
is increasingly being expanding into other interna- American Diabetes Association (ADA). The Duplex
tional markets (including Canada, the U.K. and application is designed for organizations and Covid-19-
Australia). Using Duplex, Google Assistant can use companies (including hospitals), and can be inte- Pathfinder

a human-sounding voice to contact businesses or grated into their websites (Verily 2021b). Google
Nest
doctors and make appointments, for example. The
use of AI-powered assistants is expected to save Google Nest (formerly Google Home) is part of
time resources in the healthcare sector, while also Google’s smart home series of products. The Google
streamlining planning processes (Tillman 2021; Nest Hub is a smart home tablet that can be oper-
Catley 2018). ated via gesture and voice control, and can monitor
and analyze sleep patterns using sleep sensors,
The COVID-19 Pathfinder, created by Google among its other capabilities (Google Store 2021;
subsidiary Verily Life Sciences (Verily), provides Amadeo 2019) (➔ 3.4.9).
information about the coronavirus, helps patients
and users understand their symptoms and the
potential severity of the disease, and provides
personalized information. This information is
drawn from trusted sources such as the Centers

APPLE Siri was introduced in 2011 along with algorithm processes, the more powerful the soft- APPLE
the iPhone 4s, and was the first voice-controlled ware becomes (Yoffie et al. 2018). Siri shortcuts Apple Siri
assistant in the virtual assistant market (Yoffie et al. can be used by patients and users to perform tasks
2018; Frommer 2010). It adapts to users’ individual such as tracking and analyzing daily activities, such
speaking styles, searches and preferences, and thus as fluid intake and hygiene tasks. The software then
personalizes the results it provides in the form of provides recommendations based on these patterns
recommendations, answers to questions, links (Apple March 01, 2019).
to other services and other actions. The software
uses a natural language processing (NLP) algorithm
for its speech analysis. The more information the

SAMSUNG developed an AI-powered digital NEON, and was developed by the Samsung spin-off SAMSUNG
avatar in 2020, in what it has called an “artificial STAR Labs. The company has indicated an interest Artificial
Human
human” project. The company has said the avatars in using these avatars as service providers in the
NEON
can feel and empathize with conversations – just like healthcare sector (Lever 2020).
real people. The associated AI technology is called

47
 TECH GIANTS IN HEALTHCARE

TENCENT TENCENT has partnered with Babylon Health56 to as a primary-care physician. The service provides
Babylon provide the Babylon Chatbot, an AI-powered virtual patients and users with possible diagnoses, after
Chatbot
assistant, within the Babylon Health app (Choueiri which they can take further steps themselves as
et al. 2020: 6). According to Babylon Health, the needed (Babylon Health 2021).
chatbot can detect most health problems as well

Virtual assistant systems and digital avatars offer tech giants the opportunity to collect a huge
range of health-related data from within users’ everyday lives. Numerous different providers’
voice assistants in particular have enabled a wide range of AI-based services that, as in the case of
wearables and apps, have to date focused largely on the lifestyle and prevention markets, especially
in the home environment. Digital assistant systems open up a rich spectrum of possible health-
related services. For example, they could provide users with initial medical screenings, supply
medication recommendations and order any medications desired, and offer support for home-based
post-operative care.

Globally, the size of the virtual assistant market was $ 5.82 billion in 2020. Analysts have forecast
a growth rate of 28.5 % between 2021 and 2028 (Grand View Research 2021), which would pro-
duce a projected market size of $ 51.9 billion in 2028. It has been estimated that 8.4 billion digital
voice assistants would be in use by 2024, a quantity that exceeds the size of the world’s population
(Business Wire 2020; Moar and Escherich 2021). In Germany, around one-third of the population
were using voice assistants by 2019 (FAZ 2019); by 2020, this figure had risen to just under one-
half (Gehm 2020).

2028
(projected)
$ 51.9 billion
2020
$ 5.82 billion

FIGURE 8: Global market volume of virtual assistants

Source: Authors. Data: Grand View Research 2021, Bertelsmann Stiftung

56 Babylon Health is a U.K.-based digital health startup. Its goal is to use AI to detect diseases and assess health-related conditions
and implications after the input of user data (Sturman 2020). Babylon Health and Tencent engaged in their first joint project in
2018. Tencent offered Babylon Health the opportunity to deploy its AI-based service on WeChat. The two companies did not enter
into licensing agreements regarding user data (Ram 2018). In 2021, Babylon Health and Tencent announced that they had ended
their partnership after failing to agree on the allocation of the venture’s shares (Thomson 2021).

48
 Tech Giant ACTIVITIEs in Healthcare

3.2.3
AUGMENTED REALITY (AR) AND VIRTUAL REALITY (VR)

Augmented reality (AR) and virtual reality (VR) have been described as “computer-generated real-
it[ies]” (Angerer et al. 2019: 12). In 2020, Apple CEO Tim Cook singled out augmented and virtual
reality as one of the tech giant’s most important future areas of business, stating that augmented
reality (AR) would become Apple’s “next big thing” (Köbe 2020).57 In contrast to the applications
discussed above, however, few examples within this area have actually reached the market.

SAMSUNG offers a virtual reality solution with dence. The Samsung Gear VR headset has been SAMSUNG
its Samsung Gear VR headset. In a joint project with used for research purposes in a partnership with Samsung Gear
VR Headset
IrisVision, the company developed software for the Cedars-Sinai Medical Center in Los Angeles and
headset that can fill in missing areas of the visual appliedVR, a consulting and contracting firm. In
field for people suffering from age-related macular 2018, the project completed a randomized trial with
degeneration. Samsung says this will make a vital 120 patients suffering from acute pain (Rhew 2018).
contribution to expanding older people’s indepen-

Only a few augmented reality (AR) and virtual reality (VR) products aimed at patients and users
have as yet been released.

3.2.4
SUMMARY

Tech giants offer patients and users an entire universe of health-related products and services. The
focus to date has been on wearables, apps and virtual voice assistant systems. Most of these products
and services have addressed the wellness, lifestyle and prevention markets. They typically involve
the collection and processing of a huge amount of digital data from different areas of life, and are
usually associated with AI applications. They help patients and users perform tasks such as obtaining
health information, networking with service providers, recording health data, and treating certain
diseases and conditions. Strikingly, Asian tech giants in particular have used their applications to
monitor and control behavior, which includes limiting access to public areas. This is done by linking
the collection of data to numerous aspects of everyday life up to and including basic payment func-
tionalities. With this wide range of offerings and their significant market penetration, tech giants
may well be able to raise user awareness regarding the importance of maintaining and improving
health as an important part of daily life, and thus enhance the importance attributed
to prevention. The ethical issues associated with this phenomenon are discussed in chapter ➔ 4.

57 As yet, Apple has given no more specific indications of future planned products in this area (Köbe 2020).

49
 Tech Giant ACTIVITIEs in Healthcare

3.3
TECHNOLOGIES FOR HEALTHCARE PROFESSIONALS

This chapter focuses on the technologies and applications designed for use by healthcare workers.
This includes all health professionals such as long-term care workers, nurses, clinicians and med-
ical staffers, psychotherapists, physiotherapists, occupational therapists, music and art therapists,
ecotrophologists, emergency medical technicians and many others.

3.3.1
WEARABLES AND APPS

Having provided basic comments regarding wearables and apps in healthcare in section ➔ 3.2,
in the following, we provide examples of the tech giant offerings that target professionals working
in the health sector.

GOOGLE’s corporate unit DeepMind Health intended to facilitate medical progress, strengthen GOOGLE /
ALPHABET
has developed the mobile healthcare app Streams, prevention, and increase life expectancy (Rawal
Streams
which applies AI technology. The app keeps 2020; Google Health n. d. b).
Automated
clinicians informed in real time of their patients’
Retinal Disease
condition by tracking and assessing app-based test The Medical Google / iSearch Science, an app from Assessment
results and can, for example, provide assistance in U.S.-based software firm Best Surgical Education, Google
predicting cases of acute renal failure (DeepMind LLC, combines Google Search with natural language Health Search

July 31, 2019) (➔ 3.4.9). AI to identify current studies, research and knowl- The Medical
Google / iSearch
edge regarding a given issue or clinical question. Science
Together with a group of opthalmologists, Google By automatically adding search-specific search Care Studio
Health developed an AI-assisted diagnostic imaging terms, the app achieves a broader range of results.
application (Automated Retinal Disease Assessment, The app also aids users in identifying the most
ARDA) for use in evaluating retinal fundus photo- recent and relevant scientific studies (Best Surgical
graphs to detect diabetic retinopathy in patients Education 2021, 2020).
(Google Health n. d. e; Gulshan et al. 2016).
Google’s Care Studio is a U.S. Health Insurance
Google’s Health Search engine is being developed Portability and Accountability Act (HIPAA)58-
to structure health data and information in electronic compliant software designed to support clinicians
health records (EHR) and other sources of patient by streamlining healthcare records and information.
data provided by devices such as Fitbits in such a Clinicians can, for example, use the software to
way as to improve their accessibility and search- quickly locate specific information in a patient’s
ability for health professionals. The tool will even- health record or to create visualizations of data
tually be made available to patients as well, and is regarding a specific set of patients. There is also

58 Act of Aug. 21, 1996, Pub.L. 104-191, containing rules relating to privacy set forth in 45 CFR 160, 162, and 164.

51
 TECH GIANTS IN HEALTHCARE

a Care Studio app that allows users to view all infor-

mation on their smartphone (Google Health n. d. a).

PHILIPS PHILIPS’ HealthSuite includes the app-based confidence and lead to more reliable heart function
Philips Philips eCareCoordinator, which provides outpa- assessments (Philips 2021a, 2018a).
HealthSuite
tient care staff real-time access to patient health
Philips eCare-
data so that they can, for example, make adjust- Philips offers online clinical seminars, in English,
Coordinator
ments to therapy measures when needed (Philips for physicians and hospital administrative staff on
Philips
HeartModel 2021d) (➔ 3.2). issues relevant to treating COVID-19. In response

Philips Dynamic to the pandemic, the company has also created a

HeartModel Philips’ HeartModel and its successor Dynamic portal for healthcare professionals through which
HeartModel are clinical applications that enable they can access COVID-19-related resources such
cardiologists to assess cardiac functions relevant to as instructional videos on proper disinfection tech-
the diagnosis and treatment of patients with cardio- niques as well as information regarding a variety of
vascular disease. The application uses 3D speckle COVID-19 treatment solutions (Philips 2021h).
technology to track individual frames throughout
the entire cardiac cycle. Additional measurements of
items such as muscle mass help increase diagnostic

SIEMENS SIEMENS has developed several AI-based solutions Siemens’ syngo.via, an intelligent imaging software
AI-Rad that are designed to support healthcare professionals for use in radiology, is designed to streamline
Companion
by automating complex procedures. These include image assessment and reporting workflows in areas
AI-Pathway
the AI-Rad Companion, a cloud-based solution to such as pulmonology and cardiology. Through the
Companion
support routine medical imaging activities (Siemens platform syngo.via OpenApps, users have access to
Mitral View
Educational App Healthineers 2021b), and the AI Pathway Compan- innovative clinical apps from Siemens Healthineers
Siemens ion, which is designed to optimize disease-specific and its partners (Siemens Healthineers 2021s,
Syngo.via treatment pathways (Siemens Healthineers 2021a). 2021t).
Siemens
Health­ineers
Teamplay Together with the U.S. company Abbott,59 Siemens Siemens Healthineers’ teamplay digital platform
Digital Platform developed the Mitral View Educational App for use connect is a platform designed to foster interoper-
Connect
in cardiology and heart surgery. The app is designed ability across departments and institutions in the
Digital
Ecosystem to educate clinicians who use 3D TEE (ultrasound healthcare sector and to promote the exchange

Healthcare diagnostics) for visualizations of the heart during of information between actors such as healthcare
Provider mitral valve procedures by demonstrating the differ- providers in compliance with international security
Directory
ent positions and angles in the imaging process. standards. The electronic health record (EHR) is a
Electronic
Health Record It provides images of a normal mitral valve and core staple of the platform’s focus. The platform

Terminology those of primary and secondary mitral regurgitation also provides users access to AI-powered appli-
Server (Siemens Healthineers 2021l, 2021c). cations for use in data-driven health decisions.
Adaptor Set Patients, too, are to be given access to their per-
Naeotom Alpha sonal medical and clinical data. The platform is the

59 In addition to healthcare technologies and the early identification of relevant global healthcare trends, Abbott focuses on health
diagnostics, cardiovascular therapy, medical devices, diabetes management, medical nutrition and the development of generic
drugs (Abbott 2021).

52
 Tech Giant ACTIVITIEs in Healthcare

result of a collaboration between Siemens Healthineers 2021i). The EHR from Siemens
Healthineers and IBM, with Siemens Healthineers Healthineers can be used as a platform by health-
maintaining control over the patient registry and care providers or companies and offers patient-re-
IBM managing the document index. The platform lated data exchange. The application also provides
will also be opened up to third-party providers for patients to have access to their own EHR
and their applications according to the company (Siemens Healthineers 2021i).
(Siemens Healthineers 2021u; Siemens Health-
ineers and IBM Dec. 8, 2020). Siemens Healthineers developed the first-ever
photon-counting computed tomography system for
Siemens Healthineers Digital Ecosystem is a cloud- clinical applications, garnering the division’s senior
based platform that integrates and interconnects staff a nomination for the German Future Prize
medical data with service providers, payers, patients (Siemens Healthineers 2021x). The technology
and Siemens’ partners to create a network able has enabled immense advancements in medical
to optimize diagnostics and treatment (Siemens imaging, such as ultra-high resolution scans and
Healthineers 2021g; Pfannstiel et al. 2020: 100). reduced radiation exposure levels. In late 2021,
Siemens Healthineers unveiled Naeotom Alpha,
Siemens Healthineers is also developing several the world’s first photon-counting CT scanner, which
other e-health solutions. These include the Health- has been approved in the United States and Europe
care Provider Directory (HPD), an electronic health (Siemens Healthineers 2021y).
record (EHR), a Terminology Server (TS), and an
Adaptor Set (AS), which facilitates the interopera-
bility of standardized healthcare networks (Siemens

SAP’s “Betten-Management@SAP,” a bed-manage- SAP’s Connected Health Platform (formerly SAP SAP
ment solution developed during the COVID-19 Foundation for Health), which is based on SAP Betten-
Mana­gement@
pandemic for the Rhine-Neckar region and the HANA Cloud, supports various applications in
SAP
German city of Heidelberg, makes it possible to precision medicine and research. It allows for large
SAP Connected
coordinate hospital beds in real time and thus amounts of data from different sources to be pro- Health Platform
streamline patient transferals and the use of inten- cessed and analyzed in one system (Zabłocka 2017).
sive care resources. An interactive geomap helps
medical staff coordinate the processes along (SAP
June 25, 2020).

HUAWEI Cloud has provided several AI-based HUAWEI

services during the COVID-19 pandemic. These Huawei Cloud
include, for example, a screening service that can AI-based
services
help healthcare professionals better assess CT scans
of a patient’s lungs by automatically segmenting
lung lesions and measuring lesion volume (Huawei
Cloud 2021b).

53
 TECH GIANTS IN HEALTHCARE

The wearables and apps offered by the tech giants with healthcare professionals in mind have so
far focused primarily on accessing patient data, monitoring disease-relevant parameters, diagnos-
tics (particularly AI-assisted image analysis), as well as treatment recommendations and providing
an overview of efficient treatment pathways. Storage systems and analytic platforms are opening
up access to disease-related scientific expertise and large data sets, which can be used to develop
proprietary applications. Apps also foster networking activities between the various players in the
healthcare sector and optimize care processes.

3.3.2
VIRTUAL ASSISTANT SYSTEMS AND DIGITAL AVATARS

For a basic introduction to the use of virtual assistance systems and digital avatars in healthcare,
please refer to the comments made in ➔ 3.2. A curated selection of tech giant efforts targeting
healthcare professionals in this area is provided in what follows.

AMAZON AMAZON ’s voice-activated assistant Alexa is taking hospital rooms holding COVID-19 patients with
Amazon Alexa on tasks in the Smart Hospital Room Pilot Project Amazon Echo Shows devices, which allow caregiv-
at Los Angeles’ Cedars-Sinai Health Center in trial ers to monitor and connect with patients remotely
scenarios whereby patients can communicate (Meskó et al. 2020: 38) (➔ 3.2).
hands-free with medical staff and control devices
such as TVs (Meskó et al. 2020: 37). New York
provider Northwell Health has also begun equipping

IBM IBM’s Watson Health offers an entire ecosystem assistant are adapted to individual contexts, such
IBM Watson of technologies, applications and consulting services as location (IBM 2020b; Jones 2020). During the
Health
that are designed to help various actors in the COVID-19 pandemic, the tool has been applied
Watson
healthcare sector improve healthcare while render- in at least 22 countries, including Poland (i. e., the
Assistant
ing it more efficient and organizations more resil- Polish Ministry of Health) and the United States
IBM Medical
Sieve ient. Examples include IBM Watson for Genomics, (i. e., in Austin, Texas) (Meskó et al. 2020: 37-38).
IBM Watson Oncology, IBM Watson for Drug
Discovery, Watson Care Manager and Watson IBM’s Medical Sieve project is developing a cogni-
Assistant (IBM 2021h). tive assistance system to aid radiologists in clinical
decision-making. The system uses vast data sets of
IBM’s chatbot Watson Assistant can be used as a digital and ultrasound imaging and documentation
virtual assistant that provides automated replies to in an effort to detect anomalies. Diagnostics involv-
COVID-19-related questions relevant to healthcare ing the interpretation of imaging are supported with
facilities. As an AI-based tool, the assistant draws a summary of information from the patient’s record,
on trusted information sources to respond to which is generated by the IBM Watson Patient
pandemic-related questions involving issues such Imaging Synopsis, and thus provides a clinical con-
as government support and information regarding text that is relevant to the decision-making process.
COVID-19 symptoms. Responses provided by the The core idea of such systems is to battle cognitive

54
 Tech Giant ACTIVITIEs in Healthcare

fatigue among physicians by providing clinical deci- the analysis of imaging material (IBM 2021e;
sion support that allows for tailored-to-the patient Kohn et al. 2014)
treatment. These systems are thus also intended to
provide a reprieve from repetitive activities such as .

INTEL and IBM, as well as other companies such as requiring pain management (Dickinson 2015). INTEL
Kaiser Permanente, are partnering with Intelligent Another avatar, “Holly,” which was developed by Sophie
Digital Avatars Inc. (iDAvatars), the startup behind CodeBaby, a company that acquired iDAvatars Holly
the avatar “Sophie” (Dill 2018), which features in 2016 and whose software is based on IBM’s
human-like qualities and is designed to evaluate Watson, can be used to walk patients through a
a patients’ health records while recording its inter­ health check-in (Dill 2018; CodeBaby 2020, 2021).
actions with them. Bayer HealthCare, for example,
has already begun using Sophie with patients

GOOGLE is partnering with Suki AI, Inc. by Google Glass is a wearable device used in health- GOOGLE /
ALPHABET
implementing the AI-powered and voice-enabled care and other areas as a virtual assistance system
Suki
digital assistant Suki within the Google Cloud. (Google Glass n. d.; Sutter Health 2021). In the
Google Glass
Designed to relieve healthcare professionals of healthcare sector, Sutter Health is equipping
administrative tasks, Google claims that working clinicians with the technology so that they can
with Suki reduces the amount of time spent on spend less time on documentation and more on
completing health data documentation by 76 %. caring for patients. This is made possible through
Suki understands natural language and can perform another partnership between Sutter Health and the
tasks such as taking notes and retrieving informa- documentation platform Augmedix (Sutter Health
tion from electronic health records (EHR) (Google 2020).
Cloud 2021c; Suki AI 2019).

MICROSOFT’s (Azure) Health Bot Service, a Centers for Disease Control and Prevention (CDC), MICROSOFT
cloud-based platform, is designed to help health- Providence, Novant Health, and the Virginia Mason Microsoft
(Azure) Health
care organizations and institutions such as medi- Health System, are using the service to provide
Bot Service
cal facilities, pharmaceutical companies and health users with information about the disease and how
insurers integrate virtual assistants and chatbots to assess symptoms, while recommending potential
that provide information and services. Designed to next steps (Microsoft April 4, 2020).
provide patients and users a conversational health-
care experience, the service links AI with natural
language capabilities in providing access to relevant
evidence-based healthcare services and information
(Microsoft 2021c; Microsoft Research 2021a).
In the context of the COVID-19 pandemic, health-
care organizations in the United States such as the

55
 TECH GIANTS IN HEALTHCARE

SONY SONY’s NUCLeUS smart digital imaging platform allows for the real-time broadcast of intricate
Sony NUCLeUS streamlines the aggregation of high-resolution surgical procedures to students in classroom
video content across a hospital network. By making environments, as is currently the case at Liverpool’s
it possible for healthcare professionals to manage, Alder Hey Children’s Hospital. Sony’s NUCLeUS
distribute and store 4K, HD, SD and 3D video is also in use at St. Jansdal Hospital in the Nether­
content across systems, the platform promotes lands, where it saves surgical staff time, makes
efficiency and improves workflows. Using NUCLeUS remote consultations a reality, and streamlines the
can enhance surgical imaging workflows in operat- coordination and use of equipment (Meskó et al.
ing rooms during advanced surgical procedures. In 2020: 54-55).
addition to allowing surgeons to share and discuss
images and footage with colleagues remotely, it also

NVIDIA NVIDIA is researching technologies to improve for AI-powered digital assistants in healthcare and
Digital Human and expedite AI-powered digital human creation. surgeons in particular, as the technology will allow
Creation
In targeting this goal, NVIDIA uses natural language them to run through patient care scenarios, includ-
processing (NLP) technologies such as Ensemble ing surgical procedures, as often as needed (Yuen
Health AI to construct conversations between real 2021).
and digital humans. NVIDIA sees great potential

PHILIPS PHILIPS is creating digital twins, a technology that has been tested with a Google Glass headset.
Digital Twin that is being powered by AI (➔ 3.5). The company The data displayed on the peripheral area of the
Technology
speaks of “adaptive intelligence,” emphasizing the glasses is color-coded, which allows the person
Adaptive
importance of human knowledge and judgment in performing the operation to identify clinically
Intelligence
situations where the technology is applied (Philips relevant information without having to focus
2018c). One example is Philips’ avatar-based tool specifically on precise numbers (Pfarr et al. 2019).
for monitoring a patient’s vital signs during surgery

ALIBABA ALIBABA Cloud launched the ET Medical Brain Alibaba’s research institute, DAMO Academy,
ET Medical service in 2017. Designed to support healthcare developed an AI-enabled system in early 2020 to
Brain
professionals, the virtual assistant uses AI in medical diagnose COVID-19 within 20 seconds and with
Doctor You
imaging to improve, for example, tumor diagnostics. 96 % accuracy. Using CT scans of the lungs, the
DAMO system is designed to detect infection with the virus.
Academy
The diagnostic system Doctor You, which is used The system’s deep-learning algorithm was trained
in early cancer detection procedures, is another with more than 5,000 confirmed COVID-19 cases
example of the service’s application (Bajpai 2017). according to Alibaba’s news hub Alizila (Li 2020).

TENCENT TENCENT established the AI Medical Innovation Tencent, determines whether the tissue is abnormal
AI Medical System (AIMIS), an AI-powered medical imaging in less than four seconds. AIMIS delivers 90 %
Innovation
service, in partnership with the Chinese govern­ accuracy in diagnosing esophageal cancer, 95 %
System
ment. The service feeds medical images of a in pulmonary sarcoidosis, and 97 % with diabetic
Tencent Miying
patient’s tissue into its AI which, according to retinopathy, and is said to be a powerful aid for

56
 Tech Giant ACTIVITIEs in Healthcare

clinicians when it comes to making the right Tencent Miying, a product of Tencent Youtu Lab,
diagnosis (The Medical Futurist 2019; Meskó et al. is expected to support more than 100 hospitals
2020: 61). in China with oncology diagnostics, help reduce
workloads among medical staff and increase the
precision of clinical diagnoses (Tencent 2019).

The tech giants are also offering virtual assistance systems for application in healthcare pro-
fessions. These systems are primarily intended to optimize each step in the treatment process,
increase efficiency in routine activities, reduce administrative burdens, and enhance the resilience
of healthcare organizations.

3.3.3
AUGMENTED REALITY (AR) AND VIRTUAL REALITY (VR)

Introductory considerations regarding the use of augmented reality (AR) and virtual reality (VR)
in healthcare were presented in section ➔ 3.2. Below, a selection of tech giant products and services
in this area that target healthcare professionals is presented.

META (formerly Facebook) offers its Oculus Quest involving rare but life-threatening scenarios, META
(formerly
virtual reality (VR) goggles for use in the world of particularly in pediatrics, to help medical staff and
Facebook)
gaming.60 In an initial collaboration with Children’s students prepare for emergencies (Kohlhagen 2019:
Oculus Quest
Hospital Los Angeles (CHLA) in the United States, 53; Oculus 2018).
the product will be applied in mock training sessions

MICROSOFT’S augmented reality (AR) product is collaboration with Case Western University in the MICROSOFT
the HoloLens headset (Kohlhagen 2019: 53; Meskó United States, while software applications for use HoloLens
et al. 2020: 29). The company cites applications in with HoloLens are being developed in partnerships
the health sector that range from “real-time ultra- arranged with companies such as CAE Healthcare
sound simulations in different parts of the body to and Medivis (Meskó et al. 2020: 29).
the use of 3D deep-learning holograms for birth
preparation courses, virtual heart surgery training
and interacting with virtual patients” (Kohlhagen
2019: 53). HoloLens is already being deployed in a

60 In December 2020, Germany’s independent competition authority, the Bundeskartellamt, initiated proceedings against Facebook
to review the fact that operating the glasses requires users to have a facebook account, a requirement that was introduced by
the company in October 2020 (Bundeskartellamt Dec. 10, 2020).

57
 TECH GIANTS IN HEALTHCARE

PHILIPS PHILIPS’ Ambient Experience for Healthcare flows in more than 1,000 projects involving room
Ambient Project is the outcome of years of research in design design solutions (e. g., dynamic lighting, colors,
Experience
thinking that delivers improved satisfaction among sounds) that are tailored specifically to a facility’s
for Healthcare
Project patients and staff as well as more efficient work- needs (Philips n. d. b).

The tech giants offerings in augmented and virtual reality technologies currently find application
primarily in the education and training of young medical professionals.

3.3.4
SUMMARY

Increasingly, today’s health professionals must deal with large sets of data. AI-based applications
that use these datasets provide support in various ways, including assistance with decision-mak-
ing, optimizing treatment processes, and facilitating the exchange of knowledge and data between
various actors in the healthcare system. These applications can help improve the quality of care
while easing the burden on healthcare professionals.

In order to achieve these goals, healthcare workers require increasingly stronger digital skills. As
healthcare becomes increasingly integrated and digitalized, responsibilities and job requirements
are shifting within the health professions. The ethical issues associated with this phenomenon are
discussed in chapter ➔ 4.

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TECH GIANTS IN HEALTHCARE

3.4
HEALTHCARE SYSTEM

The following section focuses on those tech giant activities that affect healthcare provision
systemically and are thus likely to transform the healthcare system as a whole.61

3.4.1
HEALTHCARE CLOUD COMPUTING

The current generation of health-related data is characterized by extreme speed, continually

increasing volume and a high degree of complexity (Sha M and Parveen Rahamathulla 2020).
Cloud computing serves to organize and manage this vast amount of data and ultimately to
improve healthcare. The infrastructure of clouds consists of components for the ingestion, storage
and processing of data (ibid.: 1015-1017). Cloud offerings include, among other things, “storage,
infrastructure, software, a platform and analytics” (Weichert 2018: 36).

Cloud-based programs that are used in healthcare provision must be in compliance with country-
specific regulations, such as the European General Data Protection Regulation (GDPR) or the Health
Insurance Portability and Accountability Act (HIPAA) in the United States, to protect patients’
sensitive health data. There are numerous public cloud providers in existence that offer solutions
for data management within the healthcare system. Among them are many tech giants, led by
Amazon, Google and Microsoft, which together have a 68 % share of the European cloud market
(current as of 2021) (Martin-Jung 2021). Selected activities of tech giants pertaining to cloud
computing in healthcare provision are examined below.

FIGURE 9: Amazon, Google and Microsoft –

share of the European cloud market 2021
Source: Authors. Data: Martin-Jung 2021, Bertelsmann Stiftung

68 %

61 The designations used for the relevant service areas are based on a differentiation and further development of the explanations
developed by Kohlhagen (2019: 51).

60
 Tech Giant ACTIVITIEs in Healthcare

AMAZON became one of the first companies market. This position, the report notes, comes AMAZON
to introduce a cloud computing solution, called both from the company’s pioneering efforts to Amazon
Web Services
Amazon Web Services (AWS), back in 2006 in an establish the technology as well as active efforts
Amazon
effort to keep up with the rapidly rising volume to suppress competition (Subcommittee on Anti-
Neptune
and usage of data. In 2019, Amazon controlled trust, Commercial and Administrative Law 2020: Technology
almost 50 % of the global public cloud market 319). Numerous public institutions and other com-
(Meskó et al. 2020: 36; Schulz 2018: 97; Su 2019). panies now rely on AWS, including the U.S.-based
In the Q3 2021, AWS was the beneficiary of 32 % Cleveland Clinic, many of which have even devel-
of all global expenditures on cloud infrastructure oped their own applications based on the platform
services. These are services that included infra­ (➔ 3.4.9). In 2018, AWS introduced the cloud-based
structure and platforms either as private or shared service Amazon Neptune Technology, which enables
infrastructure (Canalys 2021). The Subcommittee the processing of highly complex linked data (Meskó
on Antitrust, Commercial and Administrative Law et al. 2020: 36).
in the U.S. House of Representatives determined
in a report published in October 2020 that the
company enjoyed a dominant position in the

GOOGLE Cloud Life Sciences (formerly Google unstructured medical texts with the help of machine GOOGLE /
ALPHABET
Genomics) is a Google Cloud product designed learning and transforms it into machine-readable
Google Cloud
to store, process and share large biomedical and data (Google Cloud 2021b).
Life Sciences
genomic datasets in the biological sciences and
Google Apigee
bioinformatics sectors (Google Cloud n. d.; Meskó Google Workspace, formerly G-Suite, is also a tool Healthcare APIx
et al. 2020: 12) (➔ 3.4.9). Google Apigee Healthcare that can contribute to simplifying healthcare pro- Google Cloud
APIx is a Google Cloud product for the design, vision through cloud-based solutions. For example, Healthcare API

protection and publishing of digital interfaces that documents and patient information can be worked Google Health-
care Natural
can be used by hospitals, for example, to connect on collaboratively in real time using Google Drive Lanuguage API
physicians, nurses and patients through various (Verbrugghe 2020). Google
apps (Google Cloud 2021d). Google Cloud Health- Workspace
care API enables the development of healthcare
solutions within the Google Cloud that can be used
by the clinic and for analytics (Google Cloud 2021a).
Google Healthcare Natural Language API analyzes

APPLE’s iCloud can synchronize health data across APPLE

all of a user’s devices. That data can be recorded iCloud
and processed using Apple’s Health App (Apple
2021b).

61
 TECH GIANTS IN HEALTHCARE

MICROSOFT MICROSOFT Azure Security and Compliance Microsoft Genomics is also part of the Microsoft
Microsoft Blueprint – HIPAA / HITRUST Health Data and AI Azure cloud service (Microsoft 2017) and is a
Azure
is a cloud-based service used in the healthcare service of Burrows-Wheeler Aligner (BWA) and the
Microsoft
sector. It enables medical institutions, for example, Genome Analysis Toolkit (GATK) for the secondary
Azure
Security and to collect, store and analyze data from patients. The analysis of genomic data. Areas in which Microsoft
Compliance system offers an implementation and automation Genomics can be applied include cancer treatment
Blueprint – function and includes step-by-step documentation, and precision medicine (Microsoft Genomics 2018;
HIPAA /
HITRUST a cybersecurity model and additional features for Microsoft 2017) (➔ 3.4.9).
Health Data automated cloud implementation (GitHub 2019).
and AI
In 2021, Azure secured Microsoft a 21 % share of Microsoft Cloud Healthcare includes data models,
Microsoft
the cloud computing market, making the tech giant APIs and integrated healthcare-specific components
Genomics
the second-largest provider worldwide after Amazon with a variety of cloud applications and services
Microsoft
Cloud with its AWS solution (Canalys 2021). Microsoft’s from Microsoft. The focus is on patient care (arrang-
Healthcare quarterly revenues increased by 22 % in Q3 of 2021 ing appointments online, referrals, etc.), the use of
to $ 45.3 billion, largely thanks to its cloud business. patient data and additional services relating to infor-
That same quarter, Microsoft Cloud revenues rose mation relevant to patient care (Microsoft 2021b).
by 36 % to $ 20.7 billion (Bishop 2021b).

IBM IBM Watson Health Cloud is part of Watson Health

IBM Watson Technology. The health data platform is intended to
Health Cloud
accelerate regulatory and review processes and is
able to support, for example, life sciences compa-
nies with their innovation processes (Buisan 2017).

SAP SAP’S open-cloud platform HANA is a service for revenues from its cloud services grew at the fastest
SAP S/4HANA the development of cloud applications. SAP HANA rate in five years in 2021 (tagesschau.de 2021d).
Cloud
is a database server with various functions and an
SAP Data
in-memory database62 that can rapidly process large The SAP Data Warehouse Cloud stores a vast
Warehouse
Cloud quantities of data. In addition, Online Analytical amount of data. The application is tailored to com-

SAP Business Processing (OLAP) and Online Transactional Pro- panies and IT users and offers immediate access to
Technology cessing (OLTP) boost the system’s speed. Using data via predefined business content and interfaces
Platform
various services, functions and tools, companies for the integration of data from a wide variety of
SAP Analytics
Cloud are able to develop applications and deploy them or sources (SAP n. d. a).
the corresponding data in real time (SAP n. d. b). The
SAP S / 4HANA Cloud for patient billing is included The SAP Business Technology Platform includes
in the HANA cloud platform. AI can be used to a variety of tools, including SAP Integration Suite,
process and automate payments and cost analyses, SAP Extension Suite and SAP Conversational AI,
for example. With the help of SAP S / 4HANA Cloud designed to simplify patient management in the
tools, improvements can be made to the efficiency hospital sector. The functions and the data they
of patient management in the treatment context generate are linked to the cloud platform HANA
(SAP Deutschland SE & Co. KG April 9, 2019). SAP’s and centrally managed. The SAP Analytics Cloud

62 In-memory databases save data in a main memory, allowing for quicker access (Loos et al. 2011).

62
 Tech Giant ACTIVITIEs in Healthcare

is designed to simplify additional steps follow- More detailed information about SAP’s bed man-
ing patient admission, including monitoring (SAP agement solution for the inpatient care sector in
2021b). selected regions of Germany can be found in sec-
tion ➔ 3.3.

SAMSUNG Cloud can be linked to the Samsung SAMSUNG

Health App and synchronizes all data on all of a Samsung Cloud
users’ end devices in real time. The data is protected
using Samsung Knox Security63 (Samsung 2021c).

HUAWEI Cloud provides a variety of AI-based pandemic, making its technologies available free HUAWEI
services for hospitals and research facilities for of charge to hospitals and research institutions for Huawei Cloud
epidemic control through its research platform rapid AI-assisted diagnostics based on CT quantifi- EIHealth
EIHealth. They include viral genome detection, cation results, for example (Huawei Cloud 2021b;
screening methods and AI-assisted CT screening. Huawei Technologies Co., Ltd. April 7, 2020).
EIHealth was also used during the COVID-19

SIEMENS Healthineers Digital Marketplace aims of their institution” by providing access to health- SIEMENS
to promote the use and maximize the potential of care applications (Siemens Healthineers 2021q). Siemens
Healthineers
health data by establishing a “digital health ecosys- The Digital Marketplace makes the digital solutions
Digital
tem” involving healthcare sector stakeholders (Sie- from Siemens Healthineers and its partners avail- Marketplace
mens Healthineers 2021h). More specifically, the able in a curated portfolio (Siemens Healthineers
solution is designed to support “healthcare service 2021h).
providers with the selection, testing, acquisition and
operation of digital solutions according to the needs

ALIBABA Cloud offers AI-supported healthcare Cloud), Intel and the Beijing Genomics Institute ALIBABA
solutions to address challenges in healthcare provi- (BGI). The platform offers a wide range of services Alibaba Cloud
sion in China and around the world. In March 2017, in the field of genome sequencing and other BGI Online
the services ET Medical Brain and Doctor You, both Omics technologies. (Bajpai 2017; BGI 2021).
intended to support healthcare professionals, were Alibaba Cloud’s annual revenues increased year-
introduced through Alibaba Cloud (➔ 3.3). In addi- on-year by 50 % to $ 9.176 million (Business Wire
tion, Alibaba Cloud is cooperating with Wuhan 2021).
Landing Medical-Tech Co. in a cancer research
project. The year 2016 saw the introduction of
BGI Online, the first comprehensive bioinformatics
analysis platform supported by Aliyun (Alibaba

63 Samsung Knox is an application that functions as an integrated security layer from Samsung, whose tool Samsung Knox
Configure can be used for hospital IT. The application is intended to increase the security of company data and simplify device
management by IT administrators (Manage Engine 2021; Snyder 2018).

63
 TECH GIANTS IN HEALTHCARE

TENCENT TENCENT Cloud published a COVID-19 platform services include, for example, the facilitation of
Tencent Cloud in April 2020 with the goal of supporting companies, virtual medical consultations and the provision of
medical facilities and governments around the world reliable and up-to-date health information (Tencent
in the fight against the pandemic. The cloud-based Cloud April 13, 2020).

Tech giants are very active in healthcare cloud computing, as it provides the indispensable basis
for the efficient handling of huge volumes of data. Large scales are possible for tech giants thanks
to their massive financial resources and corresponding concentration of personnel, skills and tech-
nological resources. They are thus able to store exponentially growing amounts of data and process
it for a variety of purposes using AI systems.

3.4.2
BLOCKCHAIN TECHNOLOGIES

Blockchain is defined as “a subset of distributed ledger technology (DLT) and constitutes

a decentralized database. Entries are combined in a series of blocks that are linked together.
A consensus mechanism and cryptography ensure the authenticity and immutability of database
entries” (Angerer et al. 2019: 12).

AMAZON AMAZON Web Services (AWS) (➔ 3.4.1) has, Firmiano 2020). AWS is seen as a key player in
Amazon Web in cooperation with a public sector player, intro- the blockchain market (Fortune Business Insights
Services
duced a blockchain solution for the registration 2021).
Blockchain-
of patients that structures health information
solutions
with the aim of making it available to healthcare
facilities securely and efficiently (Ravanini and

MICROSOFT MICROSOFT recommends that healthcare Azure Cloud to develop blockchain prototypes
Azure organizations use its Azure Blockchain Workbench, to address the organization’s particular needs
Blockchain
a solution that can be used in conjunction with the (Houlding 2018).
Workbench

IBM IBM’s blockchain solutions have proven particu- should provide a comprehensive overview of patient
Blockchain- larly useful during the COVID-19 pandemic, information and join all system stakeholders in a
solutions
according to the company. IBM offers blockchain “supply chain ecosystem” (IBM 2020a). IBM’s
solutions for the healthcare and biological sciences blockchain solutions can be implemented flexibly
sectors, touting their “trust, transparency and and tailored to the specific needs of each company
data integrity,” in addition to other benefits (IBM with the help of IBM’s blockchain consulting
2021b). Blockchain services operating in this area services (IBM 2021c).

64
 Tech Giant ACTIVITIEs in Healthcare

SAP’s blockchain-based center, called SAP Infor- enables the elimination of returned counterfeit SAP
mation Collaboration Hub for Life Sciences, makes products before they can be reshipped (SAP News SAP Information
Collaboration
it possible to track pharmaceutical products and Center Jan. 16, 2019).
Hub for Life
Sciences

SAMSUNG uses blockchain technology for SAMSUNG

example for decentralized health apps (Health Blockchain-
solutions
DApps) (Samsung 2021b).

HUAWEI has made the platform Blockchain HUAWEI

Service (BCS) available, through which healthcare Blockchain
Service
sector contract templates can be accessed (Huawei
Cloud 2021a).

ALIBABA has been cooperating with Chinese is an extension of the existing Alibaba Cloud system ALIBABA
authorities since 2017, leading to the imple­ (Suberg 2017; Forkast.News 2020). Ali Health
Blockchain
mentation of the Ali Health Blockchain, which

TENCENT announced a partnership in 2019 with WeChat. Healthcare facilities and insurance TENCENT
Shuidi / Waterdrop (➔ 3.4.9). They aim to establish companies are also to benefit from blockchain Blockchain-
solutions
a blockchain-based medical and insurance solution technology, for example in invoicing or secure data
that will be integrated into Tencent’s messenger app storage (Forkast.News 2020; Suberg 2019).

PHILIPS’ Healthcare division includes the Philips purpose of researching blockchain solutions for the PHILIPS
Blockchain Lab, aimed at linking stakeholders from healthcare industry (Blockchain Healthcare Review Philips
Blockchain Lab
the technology and healthcare sectors for the 2019).

INTEL launched the Pandemic Response Technol- ation with the US-American Centers for Disease INTEL
ogy Initiative (PRTI) in the wake of the COVID-19 Control and Prevention (CDC) for a contact-tracing Pandemic
Response
pandemic to explore opportunities for blockchain app in the COVID-19 pandemic. The technological
Technology
technology. Over 200 projects have since been foundation includes the Intel Xeon Scalable platform, Initiative
started, all utilizing Intel technology within the which in combination with Intel Software Guard Blockchain-
initiative. In partnership with ConsensSys Health, Extensions (Intel SGX), is to provide more secure solution

Intel announced in late summer 2021 the develop- storage (Wayner 2021).
ment of a privacy-friendly blockchain tool that can
be used for research activities. This technology is
also being used by the company Leidos in cooper-

65
TECH GIANTS IN HEALTHCARE

Tech giants are primarily deploying blockchain-based technologies for health-related applications
in areas where the traceability of data flows is particularly important in terms of the function of
the application in question and the security of those from whom the data originates. The market
size of blockchain technology in the health sector was $ 281 million in 2020 and is expected to
reach $ 6.17 billion by 2027 (Global Market Insights 2020).

FIGURE 10: Market size of blockchain

2027 technology in healthcare
(projected)
Source: Authors. Data: Global Market Insights 2020,
2020 $ 6.17 billion Bertelsmann Stiftung
$ 281 million

3.4.3
MEDICAL TECHNOLOGY AND BIOTECHNOLOGY

Medical technology focuses on “the use of technical devices for the diagnosis and treatment of
diseases” (Information System of the Federal Health Monitoring 2021). A wide range of medical
technologies are covered, from pregnancy tests to imaging procedures such as MRIs. Medical
technology is relevant for prevention, diagnostics, monitoring, treatment and caregiving
(MedTech Europe 2020).

The Organization for Economic Cooperation and Development (OECD) defines biotechnology
as “the application of science and technology to living organisms as well as parts, products and
models thereof, to alter living or non-living materials for the production of knowledge, goods
and services” (OECD 2013: 156).

Technologies that have become widely known, such as ultrasound and X-ray, are just as relevant
as comparatively new technologies, like genome analysis and cellular engineering in stem cell
research (Wintermantel and Ha 2009). Medical technology and biotechnology procedures are
making an ever greater contribution to the advancement of precision medicine, which focuses
on predictive, preventive and therapeutic options tailored to individual patients.

66
 Tech Giant ACTIVITIEs in Healthcare

PHILIPS has transformed itself since 1990 fair IFA, highlighting a clear focus on users (ibid.: PHILIPS
“from an electronics company to a health coach” 55). The tech giant seeks to drive digitalization Philips
Connected
(Telgheder 2016) by continuously restructuring the in the area of medical technology and, as part of
Personal Health
company and reorganizing its areas of business that effort, is equipping clinics in Germany and Innovations
(Kindermann and Lindemann 2018: 39-40; Philips elsewhere with state-of-the-art, networked devices
2021b). Since the spin-off of the lighting segment,
64
(Philips 2019b, 2019a, 2020a) (➔ 3.4.9). Through its
the focus has been on the “so-called ‘health con- activities, the company is creating a complete, inte-
tinuum,’ in which professional diagnostics are to be grated ecosystem – from technologies for individual
linked with monitoring, diagnostics and household users to large-scale medical devices for healthcare
products for a healthy lifestyle (…)” (Kindermann facilities. The data volumes generated converge in
and Lindemann 2018: 48). As early as 2016, the the company’s own platform, called Philips Health-
company presented its Connected Personal Health Suite (Philips 2021c) (➔ 3.2 and ➔ 3.3).
Innovations at the international technology trade
65

SIEMENS spin-off Siemens Healthineers AG An additional example of digital solutions SIEMENS

focuses on the development of digital health provided by Siemens Healthineers is Enterprise Siemens
Healthineers
solutions, medical imaging, laboratory diagnostics Imagine IT, which is designed to support work
Advanced
and point-of-care testing.66 The company’s goals processes and administration in the daily operations
Therapies
include pushing forward the digitalization of the of healthcare facilities by way of comprehensive
Enterprise
healthcare system in general and the development networking (Siemens Healthineers 2021j). Imaging IT
of precision medicine in particular (Siemens Health- In addition, Siemens Healthineers developed BioMatrix
ineers 2021w, 2021m). Siemens Healthineers BioMatrix Technology, which adapts to individual Technology

Advanced Therapies refers to the implementation anatomic differences of patients in imaging, for Siemens
Healthcare
of “modern imaging procedures and software example, thereby boosting precision and improving Diagnostics Inc.
applications (…), [which support] the entire course the efficiency of the treatment process (Siemens Siemens
of therapy, from initial diagnosis to treatment plan- Healthineers 2021d). Healthcare
Laboratory LLC.
ning and support during surgical interventions to
aftercare” (Siemens 2021a). The clinical solutions Siemens is also active in medical technology
of Advanced Therapies include application areas and biotechnology with additional corporate
such as cardiology, neurology, oncology, surgery, offshoots. Siemens Healthcare Diagnostics Inc.
infectious diseases and COVID-19 (Siemens Health- develops clinical diagnostic and therapy services.
ineers 2021k). With the acquisition of Corindus These include blood gas monitoring and hema­-
Vascular Robotics, Inc., the Advanced Therapies tology services as well as data management solu-
division has been augmented by a “precision robotics tions for the prevention, diagnosis and treatment
platform” (Siemens Healthineers Nov. 4, 2019) of diseases (Bloomberg 2021). The Siemens Health-
(➔ 3.4.9). care Laboratory LLC offers biopharmaceutical

64 Medical technology is increasingly becoming a focus of the tech giant’s activities. Philips has acquired numerous companies
in the field of medical diagnostics and was only still active in three sectors by 2007: Lighting, Consumer Lifestyle and Health.
The Health division became the continually growing focus of the company. In 2016, Philips spun off Lighting, its original field
of business (Kindermann and Lindemann 2018: 40-48).

65 Included in the offerings are electronic toothbrushes that are able to transmit data to apps (Philips Sonicare FlexCare Platinum
Connected toothbrush) and the app-based Philips Heart Health Program, which is designed to help users minimize lifestyle-
based risk factors for heart disease (Kindermann and Lindemann 2018: 55; Philips 2017) (➔ 3.2).

66 Point-of-care testing (POCT) refers to decentralized, laboratory diagnostics. These are laboratory procedures that can be
performed in close proximity to the patient (Luppa et al. 2017: 4).

67
 TECH GIANTS IN HEALTHCARE

services, such as the development of therapies the corresponding solutions (Siemens Healthineers
and diagnostic tests as well as the marketing of 2021p).

APPLE APPLE AliveCor KardiaBand, the armband that displaying heart rhythm and heart rate, providing an
AliveCor integrates with the Apple Watch (fourth generation alert when the heart rhythm deviates from normal.
KardiaBand
or later) and which has been certified and approved It has been approved in Europe as a medical device
by the U.S. Food and Drug Administration (FDA), is with CE certification (Apple 2020; Krüger-Brand
able to record an electrocardiogram in addition to 2020: 378).

INTEL INTEL offers a variety of hardware and software into the platforms, allowing for near real-time
Hardware and components for medical imaging. These include medical image analysis, which enables more rapid
software for
standardized computing platforms designed to sim- decision-making (Intel Corporation 2021).
medical imaging
plify imaging. Intel has integrated edge computing

SONY SONY’s medical technology solutions are expected ogies (Sony 2021a). Sony’s digital imaging platform
NUCLeUS to provide significant qualitative improvements for NUCLeUS is of particular importance to healthcare
minimally invasive and microsurgical imaging proce- professionals in this regard (➔ 3.2).
dures through high-definition 3D and 4K technol-

In addition to cloud-based data processing, a wide range of medical technology and biotechnology
products and services – with differing emphases – also play a significant role for the involvement
of tech giants in the healthcare industry. Procedures and products related to imaging, in addition
to omics technologies and other laboratory technologies, are currently a focus.

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 Tech Giant ACTIVITIEs in Healthcare

3.4.4
ROBOTICS

Robotics includes the development, production and control of robots (Bendel 2021). Robots
can be understood as “sensorimotor machines that have at least three distinct levels of free
mobility” (Woopen and Jannes 2019). They can be built to resemble humans or they can take
on more abstract forms (ibid.). With advances in the development of artificial intelligence along
with software, mechatronic and electronic innovations, robotics will also develop further and
increasingly support more health-related application areas. There are, for example, applications
within clinical medicine, such as surgery, radiology and molecular medicine, as well as in care
and rehabilitation (Stallkamp and Langejürgen 2019: 84; Angerer et al. 2019: 12).

Robotics have become increasingly relevant for the field of nursing in particular, which is partly
reflected in the significant number of research projects and new companies active in this area
(Stallkamp and Langejürgen 2019; Weichert 2018; van Wynsberghe 2016). Robotics-based solutions
fuel hopes that healthcare provision can become more efficient without compromising quality, thus
relieving the burden on health workers (Stallkamp and Langejürgen 2019: 99).

AMAZON Web Services (AWS) has developed using a PR2 robot developed by Willow Garage67 AMAZON
an open-source hospital simulation, with which (Hansen 2020). Amazon
Web Services
companies in the healthcare sector can run robotic
Robotic
simulations. The simulation was tested, for example,
simulation

META (formerly Facebook) announced in Novem- ReSkin is a source of extensive contact data that META
(formerly
ber 2021 that its research department FAIR (➔ 3.5) can serve AI advancement in the area of “touch-
Facebook)
has developed tactile technologies that provide based tasks” and can support healthcare provision,
Tactile
robots with a sense of touch. One of those is particularly in tasks that require greater sensitivity Technologies
ReSkin, a robot “skin” made up of sensors and (Tarantola 2021). ReSkin
wearables that were developed in cooperation with
Carnegie Mellon University. According to FAIR,

SIEMENS Healthineers has made CorPath GRX robotic systems, Siemens Healthineers is pursuing SIEMENS
available, a robotics-based system for radiological the vision of “performing minimally invasive proce- Siemens
Healthineers
and cardiological procedures (Siemens Healthineers dures more precisely, faster and more effectively”
CorPath GRX
2021e; Corindus 2020; Siemens Healthineers (Siemens Healthineers Aug. 8, 2019) (➔ 3.4.9).
2021o). With the acquisition of the technology
company Corindus Vascular Robotics, Inc., one
of the world’s leading specialized companies for

67 Willow Garage, Inc. is a company that develops hardware and open-source software for robotics technologies. PR2 is a research
and development platform created by Willow Garage for robotic systems (Vizologi 2021).

69
 TECH GIANTS IN HEALTHCARE

PHILIPS PHILIPS has signaled its intention to increase its

Robotics- activities in robotics-assisted care with the appoint-
assisted care
ment of a new robotics executive (Mageit 2021).

IBM IBM relies on Robotic Process Automation (RPA), of tasks to be imitated and performed automatically.
Robotic Process an automation technology designed to complete According to the company, the increased automation
Automation
administrative tasks such as filling out forms. will make processes more efficient, optimize data
With RPA, APIs and user-interface interactions are entry and save time and money in addition to pro-
linked, allowing human processes in the completion moting more rapid decision-making (Williams 2021).

INTEL INTEL offers a variety of technologies which can provide solutions for robotics in healthcare both to
Robotic be used for the development and deployment of hardware manufacturers and to software providers
solutions
robotics in the healthcare sector. They include (Intel 2021).
applications in surgical assistance and service
robots. According to Intel, six different technologies

MICROSOFT MICROSOFT and CMR Surgical announced in May anonymized data from surgical procedures were
Versius 2021 that they were working together on the next collected and analyzed on a miniature storage
Silica generation of CMR Surgical’s robotics-supported device that is capable of storing this data for tens
surgery system Versius. In Microsoft’s project Silica, of thousands of years (CMR Surgical 2021b, 2021a).
developed as part of the Microsoft Cloud, clinically

NVIDIA NVIDIA’s deep learning technology NVIDIA

NVIDIA Jetson Jetson AGX Systems can be used, according to the
AGX Systems
company, for embedded robotics in various fields,
including healthcare (NVIDIA 2021f).

SAMSUNG SAMSUNG presented Ballie in 2020, a personal devices in the household environment and,
Ballie robot designed to assist the elderly with the help according to the company, meet the needs of
of AI. With its sensors and cameras, the small, its user (Landi 2020).
spherical robot can communicate with other end

SAP SAP’s technology Intelligent Robotic Process

Intelligent Automation, which is integrated into SAP’s Cloud,
Robotic Process
is used by Zuellig Pharma. The technology allows for
Automation
the digitalization and automatization of manual
processes (Andree 2020).

70
 Tech Giant ACTIVITIEs in Healthcare

SONY has developed, in cooperation with Harvard directional movement. The robot is primarily SONY
University, a miniature operations robot (Mini- intended for use in surgery requiring delicate Mini-RCM
RCM), which was inspired by origami: It is built skills. It has not yet been deployed in real-world
up in layers and cut by laser to allow for flexible operational settings (Holt 2020).

When it comes to products and services of robotics for the current healthcare industry,
tech giants do not (yet) play a role that is comparable to their significance in healthcare
cloud computing. Their products are primarily used in the areas of surgery, imaging, care and
service.

3.4.5
SERVICE PROVISION STRUCTURES

The activities of tech giants focused on establishing structures for primary care / service
provision within a specific and nationally regulated healthcare system are currently limited
to the United States and China. The focus of such efforts is on the interlinking of technologies,
health-related services, healthcare facilities and various stakeholders in the healthcare provision
industry. One example is telemedicine care facilities in the United States.68

APPLE began building healthcare facilities in 2018. reported that Apple is currently developing an APPLE
Initially, the tech giant began providing care to app called HealthHabit, which is also only available AC Wellness
employees and their families at two clinics it opened inside the company and is designed to connect
in California’s Santa Clara County, but a group of its employees with AC Wellness (Jercich 2021).
such clinics is planned (Armbruster et al. 2018). Apple has touted the service by saying that close
Apple has declined to provide much information connectivity between patients and healthcare pro-
to the public regarding its so-called AC Wellness fessionals is provided by various technologies and
clinics. The website, however, indicates that apps, both in a treatment setting (e. g., hospital)
AC Wellness is convinced of its ability to deliver and from home. At the same time, the open-source
high-quality healthcare and a unique experience approaches of these technologies are expected to
to its patients. “We believe that having trusting, facilitate medical research (Apple 2021a).
accessible relationships with our patients, enabled
by technology, promotes high-quality care and
a unique patient experience,” the site states (AC
Wellness 2020). In addition, Business Insider has

68 It is estimated that more than 25 % of all medical consultations in the United States already take place via telemedicine
channels (Flumignan et al. 2019).

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 TECH GIANTS IN HEALTHCARE

AMAZON AMAZON offers its employees and their families “in-person care,” Amazon Care offers personal
Amazon Care virtual and in-person healthcare through Amazon consultations with healthcare professionals and
Care (Amazon March 17, 2021), described as drug deliveries in select cities and regions (Amazon
“a kind of virtual doctor’s office” (Mirza 2020). March 17, 2021). Both telemedicine consultations
As part of virtual care, a variety of digital channels and in-person care is provided by Care Medical,
relating to healthcare provision are offered, all of which is exclusive to Amazon (Dodge 2021).
which are based on the Amazon Care app. Care Amazon Care launched in 2019 for employees
Chat and Video Care are the two telemedicine in the greater Seattle region and was expanded in
applications that facilitate virtual patient inter- September 2020 to the entire state of Washington
action with medical professionals (Amazon Care (Rathenow 2020). In early 2021, the company
2021). Through Amazon Care, patients are able to announced it would be making Amazon Care
book appointments and they receive summaries of available to employees in all 50 U.S. states and also
their diagnoses and the treatments discussed. With to other companies (Amazon March 17, 2021).

TENCENT TENCENT Doctorwork established the first clinic care providers and offers 24,000 health-related and
Tencent Trusted of its own in Beijing in 2018: the Tencent Doctor­ wellness-based mini programs. With the implemen-
Doctors
work Clinics (Finch 2018). As a product of the tation of the WeDoctor app, Tencent has also made
merger of Tencent Doctorwork with the startup it possible to set up appointments online for consul-
Trusted Doctors, there are now 50 clinics belong- tations with 290,000 doctors and 2,700 hospitals
ing to the newly named Tencent Trusted Doctors (Choueiri et al. 2020: 5-6).
(Tuna 2019a). Through its proprietary app WeChat,
the company integrates 38,000 accounts of health-

In individual cases, tech giants are building structures for the provision of health services that
could in principle be expanded in the future. Initially, the focus has primarily been on hospitals
and on networked and thus cross-sector healthcare provision association with hospitals, mostly for
the company’s own employees.

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 Tech Giant ACTIVITIEs in Healthcare

3.4.6
HEALTH INSURANCE

Only very few tech giants offer their own health insurance. Currently, there is Oscar Health in the
United States and WeSure in China. The U.S. insurance company Haven Healthcare69 was dissolved
at the end of February 2021, according to media reports (Toussaint 2021; Son 2021).

ALPHABET finances Oscar Health, a U.S. health GOOGLE /

ALPHABET
insurance company. It offers telemedicine services,
Oscar Health
based on a technology platform and the digital pro-
files of the insured (Oscar Health 2021; Heimlich
2021).

TENCENT’s app WeChat owns the integrated and Taikang Insurance and others) and foreign TENCENT
platform WeChat Intelligent Healthcare, which has, insurance companies (including AXA Insurance WeSure
since 2017, included the service WeSure, along and others) (WeSure Dec. 18, 2019; Digital Finance
with other applications (Meskó et al. 2020: 61-62). 2020). WeSure creates risk calculations that are
WeSure is a platform for the purchase of all types of generated from the existing profiles and insurance
long-term insurance policies. It already has 50 million policies70 of WeChat users (Digital Finance 2020).
customers and a total of 100 million registered
users (Digital Finance 2020). The company works
with the 20 largest Chinese (including PICC, Ping

Tech giants (so far) only offer health-related insurance policies sporadically. As with technologies
for patients and users, it can be seen here too that Chinese offerings extend well beyond the health
sector.

69 Haven Healthcare, a joint venture established in 2018 between Amazon, JPMorgan Chase – the largest bank in the United
States – and Berkshire Hathaway – Warren Buffet’s holding company – wanted to “offer solutions to sink healthcare costs and
to make the complex system of hospitals, physicians pharmacies, insurers and pharmaceutical companies more transparent
and cheaper” (Werner 2018). To do so, Haven Healthcare created a health insurance program for the 1.2 million U.S.-based
employees of the three companies, thus circumventing insurance contracts with third parties (Meskó et al. 2020: 33-34; Juul
2019). In mid-2021, it was announced that JPMorgan Chase would keep Haven going without Amazon, but with other healthcare
organizations (Ennis and Pifer 2021).

70 Initially, WeSure offered smaller add-on policies for smartphones and other electronic devices that collected data necessary for
risk assessment (Digital Finance 2020).

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 TECH GIANTS IN HEALTHCARE

3.4.7
PHARMACEUTICALS SUPPLY

Tech giants are increasingly active in the area of pharmaceuticals delivery. First and foremost,
they cooperate with established pharmaceuticals companies and acquiring startups (➔ 3.4.9),
but they have also started to produce their own medicines and are becoming increasingly active
in drug distribution.

AMAZON AMAZON is concentrating its efforts in the 2020). Doctors can send prescriptions directly to
Amazon pharmaceutical sector on the sale and distribution the mail-order pharmacy, with the patient’s linked
Basic Care
of over-the-counter and prescription pharmaceuti- Amazon account then used to trigger delivery of the
Amazon
cals (Meskó et al. 2020: 34; Köbe 2020). Although
71
medication – with the company supplying its Prime
Pharmacy
over-the-counter (OTC) medicines have long been customers free of charge (Blasius 2020; Egert 2020;
part of Amazon’s offerings in the United States, 72
Schersch 2020).
the company introduced its first over-the-counter
line in the U.S. market in 2017 (Borsch 2018; Meskó Initially, the offering was limited to the U.S. market,
et al. 2020: 34). The Amazon Basic Care line of but the Amazon Pharmacy trademark has also been
products includes 60 over-the-counter medications, registered in Canada, the United Kingdom and
including pain relievers, anti-allergy medicine and Australia (Meskó et al. 2020: 35). In August 2020,
hair-growth remedies, produced by Perrigo (Borsch Amazon Pharmacy was also registered as a Euro-
2018). Basic Care is linked with Health Navigator, pean Union trademark and included in the European
which allows users to, for example, enter symptoms Business Register (Rohrer 2020; Blasius 2020).
to access Basic Care products (Alashe 2019). An expansion of the service to the German market
seems likely since Amazon has more customers
In 2018, Amazon acquired the online pharmacy here than in any other EU member state. The intro-
PillPack (Farr 2019b). At the time of the acquisition, duction of the e-prescriptions, planned for January
Pillpack already possessed pharmacy licenses in 2022, will be particularly helpful to the company
all 50 U.S. states. The acquisition makes it possible (Egert 2020; Federal Ministry of Health 2021b).
for Amazon to integrate existing infrastructure and
know-how (Ballentine and Thomas 2018; Werner
2018). Patients can receive their medications on
an as-needed basis, pre-packed and pre-sorted –
and they are no longer reliant on healthcare profes-
sionals for the correct dosage (Barton and Brandt
2018).73 The acquisition of Pillpack was accompa-
nied by the launch of Amazon Pharmacy (Blasius

71 Amazon has been in possession of wholesale drug licenses in at least 12 U.S. states since 2017 (Meskó et al. 2020: 34).

72 In the United States, distributors are allowed to sell over-the-counter medicine, which is not possible in Germany (Borsch
2018).

73 The service is primarily targeted at patients with chronic conditions who must take a variety of medications on a regular basis.
In addition to dosage information, the packages of medication also include precise instructions on administration (Barton and
Brandt 2018).

74
 Tech Giant ACTIVITIEs in Healthcare

SAMSUNG has established itself in the pharma- biosimilars (Samsung Bioepis 2020).74 Samsung SAMSUNG
ceuticals sector with the founding of two spin-offs. is hoping to secure a 30 % market share in the Samsung
Biologics
One of those is Samsung Biologics, which has been biopharmaceuticals industry by 2023 (Inside IT
Samsung
producing biopharmaceuticals since 2011 (Samsung 2021).
Bioepis Co. Ltd.
Biologics 2020a), and the other is Samsung Bioepis
Co. Ltd., which was founded in 2012 and produces

ALIBABA has integrated the Tmall Online ceutical and health-related products, such as over- ALIBABA
Pharmacy into its platform Alibaba Health to the-counter medications and health-related devices Tmall Online
Pharmacy
provide users with a large selection of pharma­ (alizila 2015).

Tech giants are increasingly active in different areas of pharmaceuticals supply. Their products and
services are primarily focused on distribution and logistics, particularly of over-the-counter drugs,
but also on production. Amazon has already established an online pharmacy in the U.S. Samsung
is the only tech giant thus far that is seeking to become a player in the pharmaceuticals industry
through its two spin-offs (Samsung Biologics and Samsung Bioepis).

3.4.8
MOBILITY AND LOGISTICS

Individual tech giants have taken initial steps to enter the mobility and logistics sector.

GOOGLE’s Wing drone project, which was are subject to strict Federal Aviation Administration GOOGLE /
ALPHABET
launched by Google’s “X” division, became an (FAA) rules. In order to become licensed, projects
Wing
Alphabet subsidiary in 2018. The firm’s all-electric like Wing participate in the FAA Unmanned Aircraft
drones transported first aid kits, water and food Systems Integration Pilot Program (Bradbury
during their first official delivery flights, which 2020).75
were conducted in Australia (Hemmerdinger 2020).
The drones were also deployed to deliver items like
medicine and prescription drugs in the U.S. state
of Virginia during mandated COVID-19 lockdowns
(Block 2020). In the United States, drone deliveries

74 “Biosimilars are copycat versions of biopharmaceuticals, that is, biotechnologically produced drugs” (VfA 2019).

75 Amazon has also been licensed to use drones for future package deliveries in the context of its Amazon Prime Air service
(Bradbury 2020).

75
 TECH GIANTS IN HEALTHCARE

AMAZON AMAZON Prime Air is partnering with Amazon According to the Wall Street Joural, Amazon already
Amazon Pharmacy to transform the airplane, logistics and sells medical supplies and aims to become a major
Prime Air
pharmaceutical industries by adding drone delivery supplier to hospitals and medical facilities across the
services to the drug shipping market. A new United States (Paavola 2018).
technology will also allow prescription drugs to
be delivered by drone (Goulding 2020).

A few of the tech giants have begun to enter the mobility and logistics sector, focusing primarily on
drone projects.

3.4.9
HEALTHCARE MARKET

Tech giants are tapping into the healthcare market through a variety of activities. Partnerships and
collaborations, as well as joint projects and programs, play an important role here. In addition to
acquiring other companies, tech giants are also investing strategically in various startups and their
own spin-off projects. These activities allow them to gain significant market access and acquire the
expertise they need to successfully expand into the healthcare market (Kindermann and Lindemann
2018: 54). A growing number of increasingly diverse cooperations are anticipated among the various
established healthcare actors and tech giants, a development that will prove instrumental in
shaping the future of healthcare and healthcare delivery (see, among others, Krüger-Brand 2020;
Choueiri et al. 2020; Choueiri et al. 2019; Juul 2019; Hahn and Schreiber 2018). The experts inter-
viewed for this study share this assumption.

PARTNERSHIPS, PROGRAMS AND PROJECTS

By working in partnership with others on projects, initiatives and programs and thereby pooling
their knowledge, expertise and resources, stakeholders such as companies or academic institutions
can achieve more in addressing complex issues than they might on their own. Public-private
partnerships (PPP), that is, cooperative agreements between two or more private-sector and
public-sector parties, are seen as particularly promising options in this regard. PPPs can include,
for example, partnerships between private and public hospitals, outpatient care providers, phar-
maceutical and medical technology companies, IT companies and non-governmental organizations
(NGOs). The forms they take can vary from project-specific collaborations to long-term strategic
alliances to complex multistakeholder consortia (Ballantyne and Stewart 2019: 316-317; Yildirim et
al. 2016: 3-5).

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 Tech Giant ACTIVITIEs in Healthcare

GOOGLE / ALPHABET conduct a variety of includes lab data, treatment data and hospital GOOGLE /
ALPHABET
collaborations and projects with several companies, records from millions of U.S. patients across
UK NHS –
research centers and institutions in the healthcare 21 states (Copeland 2019). The joint project is
Google
sector. highly controversial, as neither doctors nor patients DeepMind
have been informed that health data will be shared Partnership

UK National Health Service (UK NHS) – Google and stored within Google Cloud. Google and Ascen- Project
Nightingale
DeepMind Partnership sion, on the other hand, claim that their actions are
Alliances with
Google’s activities in healthcare are driven by compliant with privacy and security regulations as pharmaceutical
DeepMind Health, among others. Google’s acqui- stipulated by the U.S. Health Insurance Portability companies
sition of DeepMind has enabled the company to and Accountability Act (HIPAA), which allows data Google Cloud
partnerships
process and apply big data for use in developing to be shared as long as it is used to improve care
and alliances
its AI-driven systems and applications. For exam- (Hurtz 2019).
Further
ple, Google DeepMind collaborated with the UK exemplary
National Health Service (UK NHS) to develop an Alliances with pharmaceutical companies partnerships

app for kidney diseases (Ballantyne and Stewart Google’s spin-off Verily Life Sciences, LLC (Verliy)
2019: 321; Hawkes 2016). As part of the partner- maintains long-term strategic alliances with pharma-
ship, the NHS supplied the tech giant with a total ceutical companies such as Otsuka, Novartis, Pfizer
of 1.6 million fully complete patient records in and Sanofi in order to advance drug research and
2015. This included personal data that had been development (Farr 2019a) (➔ 3.5).
stored with NHS, which contained sensitive infor-
mation regarding abortions, drug abuse and a Google Cloud partnerships and alliances
person’s HIV status, for example. Google DeepMind Google Cloud has maintained a partnership with
used this data for the Streams app, which is used the U.S.-based Mayo Clinic since 2019. As part of
in the context of kidney conditions (➔ 3.3). the partnership, the clinic uses the Google Cloud
Healthcare API to improve data capabilities and
The fact that this data was shared became a subject interoperability (Meskó et al. 2020: 11).
of public controversy, especially since the company
had not obtained the informed consent of insurance Another cooperation, namely that between Google
holders to share the data (Ballantyne and Stewart Cloud and the Broad Institute of Harvard and MIT,
2019: 321; Hern 2017). In 2019, the Streams app enables the connection of Cloud Life Sciences
and the DeepMind Health team were incorporated infrastructure with the research institution’s
into the Google Health division. This move prompted genome analysis tools (Meskó et al. 2020: 12).
further controversy, as DeepMind had provided Together with these and other healthcare companies,
assurances at the outset of its collaboration with research centers and healthcare providers, such
the NHS that the health data it received would as the Brigham Research Institute at Brigham and
not be linked to Google products or services (King Women’s Hospital (BWH), the Ontario Institute for
2019; Hern 2018). Cancer Research and the Wellcome Trust Sanger
Institute / European Bioinformatics Institute, Google
Project Nightingale: Ascension-Google Partnership Cloud forms the Global Alliance for Genomics and
Since 2018, Google has partnered with Ascension, Health. This alliance is dedicated to developing
a major U.S. healthcare service provider featuring common approaches for the secure and effective
150 clinics and several outpatient healthare facilities, sharing of genomic and clinical data within the
on Project Nightingale (Hurtz 2019). According to cloud (Meskó et al. 2020: 12; Writer 2014).
the Wall Street Journal, the project allows Google
access to a massive set of health-related data that

77
 TECH GIANTS IN HEALTHCARE

Other exemplary partnerships Google for Startups Accelerator is a three-month

Google leads a partnership with Mount Sinai program designed to support startups in a variety of
Hospital in New York City that involves using the areas including health, wellness and fitness through
platform Google Nest in COVID-19 hospital wards measures like workshops, mentoring and strategic
to electronically record the health status of patients support (Frank 2021).
and collect data on the illness (Meskó et al. 2020: 17).
Google is also an entrepreneurial founding partner
Verily Life Sciences, LLC (Verily), is leading partner- of Singularity University, a globally connected
ships with Stanford and Duke universities on a learning and innovation community that seeks to
longitudinal study, Project Baseline (Meskó et al. foster startups and networks in AI, robotics and
2020: 11; Krüger-Brand 2020: 376) (➔ 3.5). digital biology and medicine through executive
education, high-profile conferences, innovation
Together with GlaxoSmithKline (GSK), Verily
76
consulting, and other programs (Singularity Group
founded the startup Galvani Bioelectronics to n. d. a, n. d. b).
research bioelectric microimplants (Donner 2020).

APPLE APPLE maintains numerous research projects as NGOs and humanitarian organizations. In addition
Partnerships with various partners that include universities and to bringing expertise on the subject of AI to the
with universities
research and healthcare institutions (➔ 3.5). broader public, PAI aims to inform the public of the
and research
institutions risks and security issues involved with the use of
Partnership The Partnership on AI (PAI) is an organization AI (PAI 2021a, 2021b).77
on AI seeking to communicate the opportunities provided
Partnership by AI and its potential in the context of, among Since 2014, Apple and IBM have been working
with IBM
other things, public health, sustainability and together to deliver AI-based enterprise solutions
education. PAI is backed by tech giants such as and cloud-based services by leveraging the syner-
Apple, Meta (formerly Facebook), Google, Deep- gies of Apple’s ML and IBM Watson (IBM 2020c;
Mind, Amazon, IBM, Samsung and Microsoft, as well Apple July 15, 2014).

META META’s (formerly Facebook) partnership with

(formerly
Children’s Hospital Los Angeles (CHLA) regarding
Facebook)
the Oculus Quest virtual reality goggles is discussed
Oculus Quest
in section ➔ 3.3.
fastMRI
Chan Zucker-
berg Initiative, Comments on the Facebook AI Research (FAIR)
LLC. and New York University (NYU) Langone Health
partnership regarding fastMRI, and comments
on the Chan Zuckerberg Initiative, LLC, (CZI) can
be found in section ➔ 3.5.

76 As a U.K.-based pharmaceutical company, GlaxoSmithKline (GSK) focuses on the development and production of vaccines,
medicines and general health products for consumers (GSK 2021a, 2021b).

77 However, media reports highlight that NGOs in particular are not satisfied with the organization’s communication of
critical aspects (Johnson 2020).

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 Tech Giant ACTIVITIEs in Healthcare

AMAZON cooperates with Care Medical in Amazon’s Alexa AMAZON

providing the telehealth service Amazon Care There are a large number of partnerships and Care Medical
(➔ 3.4.5). As part of Haven Healthcare, Amazon projects associated with Amazon’s AI-powered Partnerships
with Amazon
entered into a joint venture with JPMorgan Chase voice assistant Alexa (➔ 3.2).
Web Services,
and Berkshire Hathaway in 2018 which, according i. a. Illumina,
to media reports, was dissolved at the end of A COVID-19 tool developed by the U.S. Mayo Cleveland Clinic

February 2021 (Son 2021; Toussaint 2021) (➔ 3.4.6). Clinic is being implemented with Amazon Echo AWS support
program
and Amazon Echo Dot devices to help patients
Partnerships
The cloud-based Amazon Web Services (AWS) with handling and preventing coronavirus symptoms and projecs
solution, including Amazon Neptune Technology, (Meskó et al. 2020: 38). associated
with Alexa and
is used by partners such as Illumina for genome
Amazon Echo
sequencing and data storage (Meskó et al. 2020: For details regarding Amazon’s collaborations with
Collaborations
36). Partners are also developing their own applica- the UK National Health Service (UK NHS), Boston with the UK
tions on the basis of AWS, such as the U.S. Cleve- Children’s Hospital, Ada Health, Merck & Co., Inc., NHS, clinics and
pharmaceutical
land Clinic’s clinical neurology app (Meskó et al. Techniker Krankenkasse (TK), and KidsMD and the companies
2020: 36). AWS is launching a first-of-its-kind Smart Hospital Room Pilot Project with Los Angeles’ KidsMD
support program for healthcare startups in 2021 Cedars-Sinai Health Center, see sections ➔ 3.2 and Smart Hospital
that includes ten selected companies. Some of the ➔ 3.3, respectively. Room Pilot
Project
items in development by the startups include voice
assistants, virtual reality (VR) technologies, and
remote monitoring programs. Amazon supports
the program’s startups with financial resources,
expertise and its brand, said Ulrike Deetjen, a
partner at management consulting firm McKinsey
(Rybicki 2021).

MICROSOFT HoloLens is already being used mated system (among other things) for data storage MICROSOFT
in a collaboration with U.S.-based Case Western on artificial DNA at the Molecular Information HoloLens, i. a.:
Reserve University and the Cleveland Clinic as part Systems Laboratory (Ceze et al. 2019; Woopen Case Western
Reserve
of the Health Education Campus. By providing a et al. 2020).
University
holographic simulation of human body parts from
Cleveland Clinic
different perspectives, HoloLens replaces the use of Microsoft’s AI and cloud partnerships
CAE Healthcare
human cadavers in medical school anatomy courses
Medivis
(Snyder 2019) (➔ 3.3). Microsoft Healthcare NExT
Molecular
Healthcare NExT (New Experiences and Technolo- Information
Further partnerships with other organizations gies) is an initiative launched in 2017 that is aimed Systems
Laboratory
such as CAE Healthcare and Medivis are developing at a profound transformation of healthcare through mit University
software programs for HoloLens that are of benefit the use of AI and cloud-based technologies. This Washington
to surgeons in planning procedures before an oper- goal is to be achieved by combining research, AI Microsoft
Healthcare
ation and which prove helpful during operations and the pooled expertise of the initiative’s partners.
NExT
(Meskó et al. 2020: 29). To unlock new opportunities for AI applications in
healthcare, the initiative is investing in resources
In 2019, Microsoft developed in partnership with such as the Microsoft AI in Health Partner Alliance,
the University of Washington the first-ever auto- whose members receive training, access to Micro-

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 TECH GIANTS IN HEALTHCARE

Microsoft AI
for Health, i. a.:
soft’s technologies, expertise and data (Microsoft Another AI for Health partnership involving the
Novartis AI Feb. 16, 2017). Integrative Brain Research Institute at Seattle
Innovation Lab
Children’s Hospital and Veritas Genetics entails
PATH
Microsoft AI for Health developing a database of genetic and phenotypic
IRIS
Microsoft AI for Health is a five-year program data for infant mortality and Sudden Infant Death
Cascadia Data
Discovery within the Microsoft AI for Good initiative (➔ 3.1) Syndrome (SIDS) research79 with Microsoft Genom-
Initiative that is designed to provide research institutions ics and Microsoft Azure (Microsoft Switzerland
Further with access to resources, technologies and exper- Jan. 30, 2020a; Bangur 2019).
partnerships
associated to tise in addressing global health challenges. This
Microsoft AI, involves, for example, a $ 40 million investment in PATH (Program for Appropriate Technology in
Microsoft Cloud
AI research in healthcare. The program focuses Health) is a non-profit organization (NPO) funded
and Microsoft
Genomics with on (1) research on the prevention, diagnosis and by AI for Health that operates in more than
universities, treatment of diseases; (2) protecting against global 70 countries. PATH aims to leverage AI in improving
clinics and
health health crises; (3) reducing inequalities in access to access to healthcare and in developing strategies
companies healthcare (Microsoft Switzerland Jan. 30, 2020a; for disease diagnostics and treatment (PATH 2021,
Project Microsoft 2020). Jan. 29, 2020).
EmpowerMD
Hospital Exam
The Novartis Foundation is part of the AI for IRIS (Intelligent Retinal Imaging Systems) is also
Room of the
Future Health program, which combines the former’s part of the AI for Health initiative. IRIS provides
Partnerships pharmaceutical expertise with Microsoft’s AI and cloud-based diagnostic imaging technology for
with Microsoft data management knowledge. Established for this diabetic retinopathy applications (IRIS 2020, 2017).
Azure and Mi-
crosoft (Azure) purpose, the Novartis AI Innovation Lab aims to
Health Bot help shorten the amount of time needed for the The Cascadia Data Discovery Initiative (CDDI), as
Service
research and development of drugs, while reach- part of AI for Health, is a collaboration of the Fred
ing more patients faster and reducing costs (Evans Hutchinson Cancer Research Center, BC Cancer,
2020). The Data42 platform, which uses AI to the University of British Columbia, the University
generate insights from clinical trial data, is used of Washington eScience Institute, and the Knight
to support these goals (Novartis Switzerland Cancer Institute at Oregon Health & Science Uni-
2021).78 One example involves Microsoft and versity. The CDDI focuses on enabling biomedical
the Novartis Foundation partnering to develop data-sharing in a robust data ecosystem. It thereby
AI-enabled health technology in creating an aims to facilitate data-driven research while fos-
intelligent image atlas for use in detecting leprosy. tering and expediting the exchange of information
By enabling the early detection of the disease, between the initiative’s participating institutions
the goal here is to help prevent nerve damage (Fred Hutchinson 2021a; Fred Hutchinson News
among affected patients (Novartis Foundation Service Jan. 29, 2021).
July 29, 2020; Microsoft Switzerland Jan. 30,
2020b).

78 Novartis uses clinical trial data collected and stored over the past 20 years for this purpose, which includes approximately
20 petabytes of data from 2,700 individual Novartis studies. While Novartis has thus far been able to collect and merge the data,
it has not yet been able to sufficiently analyze it. This data could prove significant particularly with regard to efforts to examine
correlations between diseases and medications (Novartis Switzerland 2021; Mijuk 2020).

79 Data from the U.S. Centers for Disease Control and Prevention (CDC) on this issue, which already includes 26 million births and
deaths, was used to start with. This data was then supplemented with additional U.S. datasets covering a total birth period of
six years, which allowed for the identification of various correlations, including an increased likelihood of SIDS associated with
the smoking behavior of pregnant women (Lee 2019).

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 Tech Giant ACTIVITIEs in Healthcare

AI for Health also supports international scientists Microsoft’s (Azure) Health Bot Service, which allows
conducting research on COVID-19 by providing for the creation of AI-based virtual assistants (➔ 3.3),
financial resources, scientific expertise, and AI and is being developed and applied in collaborations
cloud computing-related resources (Meskó et al. with healthcare organizations such as Premera Blue
2020: 31). Cross and Quest Diagnostics (Roach 2019).

Other Microsoft AI and cloud partnerships Microsoft Azure is engaged in another partnership
Microsoft engages in other AI-related partnerships, with software company Epic aimed at creating
such as that with the University of California, cloud-based solutions in healthcare (Meskó et al.
Los Angeles (UCLA Health) aimed at developing 2020: 28).
predictive algorithms aimed at disease prognosis
(Meskó et al. 2020: 27). Microsoft Genomics is used in a collaboration with
the Klein Lab at the Ichan School of Medicine at
Microsoft Azure is also used in the context of Mount Sinai to analyze large genomic datasets and
various partnerships involving monitoring applica- archive the files (Microsoft Customer Stories 2018).
tions for chronically ill patients. Examples include
those with Finland’s Helsinki University Hospital, At St. Jude Children’s Research Hospital, Microsoft
the U.S. telemedicine company Hope Care, and the Genomics has been used in pediatric cancer
Portuguese Cova da Beira Hospital Center (Meskó research and in building the St. Jude Cloud platform,
et al. 2020: 30). which provides genomic data in pediatric oncology
(Meskó et al. 2020: 28; St. Jude Cloud 2021).
Microsoft Azure helps empower a number of
institutions such as UCLA Health through its For details on Microsoft’s partnerships with
platform that allows users to store and manage the pharmaceutical company Shire and the NGO
clinical and research data. The platform thus helps EURORDIS, see section ➔ 3.5.
accelerate clinical research and the delivery of
patient care (UCLA Health May 30, 2019). IBM maintains numerous partnerships in the
context of its Watson AI-driven supercomputing
At Project EmpowerMD, Microsoft conducts project. Watson Health collaborates with companies
research with the University of Pittsburgh Medical and institutions to improve clinical decision-making
Center (UPMC) on an AI-driven system designed to processes by reducing diagnostic errors, optimizing
assist medical staff that was implemented in 2019 therapies and making personalized medicine
in a collaboration with Nuance Communications Inc. possible (Meskó et al. 2020: 40).
at the Hospital Exam Room of the Future (Meskó et
al. 2020: 26; Microsoft News Center Oct. 17, 2019) An alliance with Apple, Johnson & Johnson and
(➔ 3.3). Medtronic is creating large fitness, nutrition and
vital-sign datasets from Apple iPhone and iPad
In 2019, Microsoft began collaborating with Silver- users. Pharmaceutical company Johnson & Johnson
Cloud Health, the provider of a digital platform that and medical technology company Medtronic also
offers mental health services. Microsoft’s AI-driven provide health-related data that will be analyzed
technologies will be combined with SilverCloud by Watson Health to develop personalized health
Health’s expertise to deliver personalized mental offerings, such as health apps for patients (Dow
health care, including early detection and treatment Jones & Company April 14, 2015).
interventions (SilverCloud Health Oct. 2, 2019).

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 TECH GIANTS IN HEALTHCARE

IBM IBM is partnering with a handful of healthcare For details on IBM’s partnership with Graticule, see
Partnerships facilities, research labs and universities to test its section ➔ 3.5.
associated with
technologies (IBM Hybrid Cloud and IBM Watson)
IBM Watson
with companies, in the real world. The U.S. Mayo Clinic is just one INTEL’s cooperation with the Broad Institute of
universities such institution (IBM 2020d; Streed 2020). Harvard focuses on genomics research (Intel
and research
institutions i. a.: Corporation 2020a).

Mayo Clinic In 2016, Watson Health partnered with Quest

Quest Diagnostics to launch the Watson for Genomics During the COVID-19 pandemic, Intel has also
Diagnostics application, which features algorithms designed to worked with the Medical Informatics Corporation
Alliances with interpret publication data and draw on genetics in (MIC) in supporting the Sickbay platform to help
Apple, Johnson
determining individualized treatment options. The coordinate ICU bed capacities (Meskó et al.
& Johnson and
Medtronic application is available in numerous clinics in the 2020: 57).
United States. At the Portuguese Germano de Sousa
Group, Watson for Genomics is applied to accelerate
the interpretation of genomic analyses. In 2019,
the Swiss university hospital Hôpitaux Universitaires
Genève (HUG) began implementing the application
in its medical decision-making processes based
on individual genetics (Meskó et al. 2020: 41-42).

INTEL INTEL is also partnering with General Electric (GE)

Broad Institute Healthcare to advance AI-based medical imaging
of Harvard
technology (Intel Corporation 2020b).
Medical
Informatics
Corporation The company also partners with ConsensSys and

General Electric Leido in the area of blockchain technology (Wayner

Healthcare 2021) (➔ 3.4.2).
Partnerships
with companies
and universities For information on Intel’s partnerships with the
University of California, San Francisco (UCSF), and
the University of Pennsylvania, see section ➔ 3.1.

For details on Intel’s partnerships with Dell

Technologies and Translational Genomics (TGen),
please refer to section ➔ 3.5.

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 Tech Giant ACTIVITIEs in Healthcare

NVIDIA maintains partnerships with numerous Cloud, Microsoft, and Intel (Covid-19 HPC NVIDIA
institutions that use NVIDIA Clara in their research Consortium 2021; Meskó et al. 2020: 46). NVIDIA
Clara, i. a.:
projects, including Johns Hopkins University and
John Hopkins
King’s College London (Meskó et al. 2020: 45) In the context of its Deep Learning Institute,
University
(➔ 3.5). NVIDIA partners with Tencent and other firms.
King’s College
One goal of its partnership with the Chinese London
The NVIDIA Inception program funds health-related multinational is to provide developers and research- NVIDIA
AI and deep learning-focused startups such as ers training in AI and the opportunity to deepen Inception
Program
Qure.ai and Infervision, among others (NVIDIA their technical expertise. Another is to integrate
Partnerships
2021a; Meskó et al. 2020: 46) (➔ 3.5). NVIDIA NVIDIA’s graphics processing units (GPU) into with start-ups
also collaborates with many startups focused on Tencent’s cloud. The two tech giants also plan to associated
to Covid-19
COVID 19 research by providing them NVIDIA Clara work together in developing new training capabilities
research
technologies (Meskó et al. 2020: 46-47) (➔ 3.5). in AI research (Estes 2017; NVIDIA 2021e).
Covid-19 High
Performance
NVIDIA is part of the U.S. government-led COVID- For details on NVIDIA’s partnership with Recursion, Computing
Consortium
19 High Performance Computing (HPC) Consortium, see section ➔ 3.5.
Deep Learning
which aims to support COVID-19 research by Institute
fostering collaboration among leading academic
institutions and the private sector. Other members
include IBM, Amazon Web Services (AWS), Google

PHILIPS is collaborating with the University two of the Port’s participating organizations PHILIPS
Medical Center Utrecht (UMCU) by using the tech (HIP 2018). University
Medical
giants’ technologies to monitor COVID-19 patients
Center
remotely (Philips 2020b). Partnering with the Philips has been equipping cooperating clinics with Utrecht
Rostock University Medical Center in the pilot the latest technologies, such as ultrasound and Universitäts­
project HerzEffektMV, Philips aims to help
80
X-ray equipment, since 2018. In Germany, Philips klinik Rostock

improve care for patients with heart conditions by has recently entered into long-term strategic Health
Innovation
providing the center with hardware and the apps partnerships with municipal hospitals in Cologne Port
required (Kindermann and Lindemann 2018: 55). (Kliniken der Stadt Köln) and Munich (Städtisches Alliances with
Klinikum München), among others (Philips 2019a, German clinics
The Health Innovation Port (HIP) enables startups 2019b, July 12, 2018). German
Health Alliance
to collaborate with established actors in the health-
care sector. By providing the infrastructure and German Health Alliance (GHA)
networks needed to form partnerships, the initiative The German Health Alliance (GHA) is an initiative
aims to incubate the co-development of ideas and of the Federation of German Industries (BDI) that
new business models. German health insurance emerged from the German Healthcare Partnership
provider Techniker Krankenkasse (TK) and the (GHP) and currently comprises 113 member organi-
German hospital chain Asklepios Kliniken are just zations, including Philips. The companies within

80 The pilot project HerzEffektMV merges patients’ medical records and data from wearables into a Philips database that patients,
health professionals and other healthcare service providers have access to. The Rostock University Medical Center coordinates all
persons involved and is responsible for ensuring that patient care and treatment is adjusted immediately in accordance with any
change in the patient data collected (Kindermann and Lindemann 2018: 55).

83
 TECH GIANTS IN HEALTHCARE

the network are based in different sectors such For details on Philip’s partnership with Huawei,
as industry, civil society, and science and research. see section ➔ 3.5.
The network aims to strengthen health infrastructure
and improve access to health-related resources
(GHA 2021).

SIEMENS SIEMENS is engaged in a partnership with the gies for minimally invasive procedures with the
Städtisches municipal hospital in Braunschweig, Germany help of imaging procedures and testing these in
Klinikum
(Städtisches Klinikum Braunschweig) that focuses a practical clinical setting (Radboud University
Braunschweig
on the hospital’s medical technology equipment Medical Center Dec. 22, 2020). Another collabora-
Partnerships
associated (Handelsblatt 2018). tion with the Radboud University Medical Center
to Simenes involves detecting breast cancer in its early stages.
Healthineers
Digital Eco­ Siemens Healthineers has established nearly Syngo.Breast Care, an AI-powered application
system, i. a. with 2,000 partnerships in 50 countries as part of its developed by Siemens Healthineers, is being used
Combinostics
Digital Ecosystem platform designed to provide here to assist radiologists in evaluating large mam-
Partnership
participating healthcare providers access to digital mography datasets (Siemens Healthineers 2020b).
with Radboud
University health-related innovations. This includes, for
Medical Center example, Siemens Healthineers’ collaboration with Siemens Healthineers is also partnering with
and Technology
expert Center the firm Combinostics that uses its cNeuro cMRI Novartis in developing and bringing to market
regarding Syngo application in brain imaging techniques for the early diagnostic biomarker tests (serum neurofilament
Breast Care
detection of neurodegenerative diseases (Siemens light chain immunoassays, sNFL) used in diagnosing
Partnerships
Healthineers March 6, 2018). multiple sclerosis (MS) and other neurological
with Novartis
regarding disorders. This partnership is expected to increase
biomarker tests Siemens Healthineers is cooperating with the Siemens Healthineers’ expertise in developing
Netherlands’ Radboud University Medical Center in clinical diagnostic solutions (Siemens Healthineers
Nijmegen at the Medical Innovation and Technology Sept. 21, 2020).
expert Center (MITeC) by developing new technolo-

SAP SAP is partnering with the startup Iristrace, which Droice Lab, one of the startups at the SAP.iO
Iristrace provides a cloud-based platform for optimizing Foundry program in New York, focuses on using AI
SAP.iO Foundry workflows by making data collection and analysis to help physicians provide better care to patients.
New York
more efficient. During the COVID-19 pandemic, Targeting the merging and processing of patient
Initiative, i. a.
Droice Lab Iristrace’s COVID Patient Record Management app data, Droice Lab has already merged 50 million
has been used to monitor real-time data for every- patient records in collaboration with healthcare
thing from bed occupancies to medical devices. service providers and insurers across the United
The app supports healthcare service providers by States and Europe (Galer 2020). Droice Hawk is
allowing them to collect, analyze, and share infor- AI-based medical data analysis technology designed
mation more efficiently. Stored in the SAP Data to ingest and understand patient and medical data
Warehouse Cloud, the collected data is analyzed from diverse sources (SAP 2021a; Droice Labs
by the SAP Analytics Cloud (SAP News Center 2021).
Sept. 29, 2020).
For a discussion of SAP’s machine learning research
in the Brain Age Project, see section ➔ 3.5.

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 Tech Giant ACTIVITIEs in Healthcare

SAMSUNG is partnering with Welldoc and the the biotech company Kineta, Inc. (Samsung Biolog- SAMSUNG
American Association of Diabetes Educators (AADE) ics 2020b). Diabetes
Wellnes
on the launch of the Diabetes Wellness Program
Program with
(DWP) (Rhew 2018). Samsung is an official partner of Breezie (Breezie Welldoc and
2021a, 2021b).81 the American
Association
Together with U.S. provider Kaiser Permanente, of Diabetes
Samsung is developing a home-based cardiac reha- The tech giant is also engaged in a partnership with Educators
bilitation program that uses Samsung smartwatches eCaring82 that aims to optimize care management Partnerships
regarding
and the HeartWise app to monitor patients’ heart with the help of Samsung devices. The Samsung
Samsung
rates and activities (Landi 2020). Galaxy Tab tablet plays a key role in these solutions. Smartwatches
eCaring’s customers include hospital chains and with i. a.

Through a partnership with Medtronic, mobile those providing nursing or home care services Kaiser
Permanente
devices can be used to monitor the health status (Williams 2016; Belic 2015).
Medtronic
of chronically ill patients (Rhew 2018).
Calm
In a cooperation with Billy,83 (formerly Curo),
Fitplan
Through collaborations with companies in the Samsung’s SmartThings is used in home (remote)
Echelon
sports and fitness sector, such as Calm, Fitplan monitoring contexts for the elderly (Ray 2019).
Partnerships
and Echelon, Samsung Smart TV users can access Samsung’s Gear Watches and SmartThings tech- regarding
exercise units and instructions to take part in sports nology are also used in a similar cooperation with Samsung
Biologics, i. a.
programs (Meskó et al. 2020: 54) (➔ 3.2). Reemo84 (Holland 2016b).
with Kineta
Further
In addition, Samsung is partnering with care Information on Samsung’s partnerships in the partnerships
providers in developing a coaching and wellness app context of the Samsung Gear VR headset can with health
companies,
to help monitor cardiac patients’ health with the use be found in section ➔ 3.5. i. a. with
of the Samsung Gear Watch (Meskó et al. 2020: 53; Breezie
Rhew 2018). Samsung’s cooperation with American Well eCaring
(Amwell) with the Live Health Online Platform Billy
Through its Samsung Biologics division, the com- is discussed in section ➔ 3.2. Reemo
pany cooperates with various partners, including

81 Breezie is an open platform designed for senior care providers. It allows providers to customize tablet interfaces and thus
digitalize, personalize and extend the reach of the care they provide. Breezie can also serve as a voice-controlled assistant and
be integrated into a smarthome environment (Breezie 2021b, 2021a).

82 eCaring is a software platform for nursing care providers that allows for the easy and intuitive documentation of care activities.
Through the eCaring app, users can set reminders to take medication, and they can retrieve easy-to-read overviews of patients
and their current requirements (eCaring 2020). According to eCaring, the app also collects patient-relevant clinical data, tracks
data on their medications and behavior, and aggregates their data, thereby helping people in need of care stay at home and out
of the hospital (Belic 2015).

83 Billy is a smarthome device used primarily in Australia that tracks the daily activities of seniors who wish to continue living
at home. Billy is able to recognize changes in regular day-to-day activities and, after an initial familiarization phase, offer
suggestions or alerts. The device is linked to an app that can share this information with family members or long-term care
providers, for example. Billy learns using smart analytics and ML, but without the use of cameras or microphones. Instead,
behavior is observed through motion and multipurpose sensors, which communicate with a hub that coordinates the input and
sends signals to the app (Billy 2020).

84 Originally developed for use in smarthome devices, Reemo’s gesture control technologies are now being developed for use in
wearables designed for seniors. The technology is linked with a health monitoring platform through which movements, heart
rates, current locations, etc. can be recorded and also allows for emergency calls to be made. This means that seniors stay
connected with family members and other long-term care and health service providers, but can continue to live independently
in their own homes (Holland 2017; Reemo Health 2021).

85
 TECH GIANTS IN HEALTHCARE

SONY SONY’s mSafety is a comprehensive B2B platform

mSafety in the mobile health and wellness services sector.
The mSafety wearable device records data regarding
a patient’s or user’s physical activity and exertion
levels, their vital signs, and sleep patterns
without requiring connection to a smartphone
(Sony 2021b, 2021c).

HUAWEI HUAWEI has been cooperating with Philips in in Ecuador (Quito Sur Hospital, Ceibos Hospital
Partnership China since 2016 by maintaining a cloud-based Guayaquil) in an effort to limit waiting times and
with Philips
platform and Internet of Things (IoT) solutions to contain the spread of the disease (Meskó et al.
Partnership
for healthcare (Meskó et al. 2020: 49). 2020: 50).
regarding
Visualized
Drug Screening Huawei Cloud, in partnerships with the research Huawei Cloud has launched the Anti-COVID-19
platform and
Shennong institutions of Huazhong University of Science & Program, which provides business, technological
Project website Technology, Xi’an Jiaotong University, and Beijing and market support to Huawei Cloud business part-
on Covid-19
Genomics Institute (BGI), has launched a Visualized ners (Huawei Technologies Co., Ltd. April 7, 2020).
Anti-Covid-19-
Drug Screening Platform for COVID-19 and a
Program
website called the Shennong Project to support
the development of drugs to treat COVID-19 (Hua-
wei April 15, 2020; Meskó et al. 2020: 50). In addi-
tion, an AI-based diagnostic tool for the disease has
been implemented using CTs at two collaborating
hospitals

ALIBABA ALIBABA’s health division, Alibaba Health Informa- In April 2019, Alibaba and GlaxoSmithKline (GSK)
Partnerships tion Technology Limited, is engaged in partnerships launched a joint business plan to establish a health-
with healthcare
with 23,000 healthcare service providers, including care strategy built on big data, marketing models
providers
physicians, pharmacists and nutritionists, who carry and innovative service offerings for the Chinese
Global
MediXchange out more than 50,000 online consultations every market. The companies aim to improve outreach
for Combating day (Meskó et al. 2020: 60). to Chinese customers and provide more effective
Covid-19
health services (GlaxoSmithKline April 2, 2019).
Partnerships
with The Alibaba Foundation is a participating partner
GlaxoSmith in the Global MediXchange for Combating COVID- For a discussion of Alibaba’s Ali Health partnership
Kline
19 (GMCC) program, which aims to facilitate online with Bo’ao Winhealth Rare Disease Medical Center,
communication and collaboration across borders see section ➔ 3.5.
in the context of the COVID-19 pandemic through
AI and cloud computing capabilities (Meskó et al.
2020: 61).

86
 Tech Giant ACTIVITIEs in Healthcare

TENCENT maintains partnerships with the also communicating them to clinical staff and TENCENT
pharmaceutical companies Merck and Novartis physicians. The goal here is to prevent or at least Partnerships
with pharma-
(Choueiri et al. 2020: 5). Tencent and Merck entered push back a return visit to the hospital (Novartis
ceutical compa-
into a strategic collaboration agreement in 2019 2020, 2021). nies, i. a.:
that has several aims, including the creation of Merck
improved access to healthcare services through In another partnership, Tencent and Huma85 are Novartis
digital platforms and more patient-centric health- working together to establish and build a network Partnerships
care management. Tencent plans to bring AI, for research on Parkinson’s disease. The two firms with compa-
nies, i. a.:
big data and cloud computing capabilities to the are working together on a study to determine how
Huma
collaboration. The use of digital products and smartphone cameras can be used to detect the
Babylon Health
services is expected to improve public knowledge progression of the disease (Huma 2021b, 2021c).
RareStone
of various medical conditions and diseases, includ-
ing their symptoms and treatment options (Merck For a discussion of Tencent’s partnership with
Group Jan. 23, 2019). Novartis and Tencent have Babylon Health, see section ➔ 3.2. For details on
teamed up for the AI Nurse project, an AI-based Tencent’s partnership with RareStone, see section
disease management tool developed specifically ➔ 3.5.

for the Chinese market and for people suffering

from heart disease. Patients can use the tool to
document and monitor their own vital signs, while

Tech giants maintain a tremendous variety of partnerships and networks through which they
carry out a vast array of healthcare projects and programs. Given the sheer number and broad
scope of these efforts, which range from short-term projects to long-term alliances, it is difficult
to maintain a clear overview of all of them. In most cases, partnerships and alliances are cultivated
between universities, government healthcare agencies, private healthcare institutions, other tech
companies and pharmaceutical companies.

85 Huma (formerly Medopad) is a software startup that uses digital biomarkers to facilitate proactive patient monitoring through
wearables and apps (Plato Technologies Inc. Apr. 16, 2020; Huma 2021a).

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 TECH GIANTS IN HEALTHCARE

INVESTMENTS AND SPIN-OFFS

Tech giants are also expanding through their corporate venture capital (CVC) equity investments.
This kind of activity involves investing capital in external healthcare startups and / or in-house
spin-offs. From 2016 to 2020, annual investments by GAFAM companies alone increased from
13 to 38 investment deals, with Google leading the pack at 15 such investments, followed by
Amazon with 14. The number of investments made by GAFAM companies in 2021 was 36 (CB
Insights 2021).

2016: 13

2018: 24

2020: 38

2021 (projected): 36

FIGURE 11: Annual investment activity, GAFAM companies

Source: Authors. Data: CB Insights 2021, Bertelsmann Stiftung

GOOGLE / GOOGLE / ALPHABET – The phrase “The Alpha- CapitalG, another investment arm of Alphabet, is
ALPHABET
bet of Investment” (Meskó et al. 2020: 9) has been also funding companies such as Verily Life Sciences,
23andme
invoked to refer to the fact that the tech giant has LLC (Verily), Oscar Health and Practo Technologies
Doctor on
invested massively in other firms, including numer- with venture capital (Prendergass 2018; Meskó et
Demand
ous healthcare companies (Juul 2019; Prendergass al. 2020: 10). Having started as a research project
Flatiron Health
2018). Referred to as Google Venture (GV), the
86
within Alphabet’s research division X Development
Clover Health
company invests primarily in life sciences and in LLC, Verily was later spun off to become its own
Decibel
Therapeutics so-called frontier tech. Of particular interest to the division. Since then, it has been involved in numer-

Collective company are those businesses active in healthcare ous research projects as an independent research
Health services, health information technology, diagnostics company in the life sciences (Pousttchi et al. 2019;
Spruce Health and therapy, as well as AI, robotics and hardware Meskó et al. 2020) (➔ 3.5).
SpyBiotech development (Meskó et al. 2020: 9). Firms such as
23ANDME is a U.S. biotech company that analyzes individuals’
Verily 23andme, Doctor on Demand, Flatiron Health,
genetic data. Its analyses are based on submitted saliva samples that
Oscar Health Clover Health, Decibel Therapeutics, Collective are screened for genetic diseases, other predispositions, and infor-

Practo mation on geographic origin (23andMe 2021a, 2021b).

Health, Spruce Health, and SpyBiotech are among
Technologies
just a few examples of companies in which Google DOCTOR ON DEMAND is a U.S.-based online video telemedicine

Venture (GV) has invested (Prendergass 2018). company (Doctor On Demand 2021).

86 In 2019, Google / Alphabet, along with Microsoft and Tencent, were responsible for more than 70 % of all investments in digital
health companies and startups. With 57 companies in its portfolio for that year, Google / Alphabet was the most active investor
(Meskó et al. 2020: 9).

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 Tech Giant ACTIVITIEs in Healthcare

FLATIRON HEALTH is a U.S. healthcare technology company that COLLECTIVE HEALTH is a U.S.-based tech company that provides
works with cancer centers and companies in the field to accelerate a health benefits platform intended specifically for employees.
cancer research and improve the quality of cancer care by extracting The platform provides an overview of the scope of health services
meaningful information from cancer patient data (Flatiron Health provided by a wide range of companies and helps users find the
2021). service they need (Collective Health 2021; Hackett 2021).

CLOVER HEALTH is a U.S. health insurance company (Clover SPRUCE HEALTH is a U.S.-based company developing a telemed-
Health 2021). icine platform providing video telephony communication between
doctors and patients, digital payment options and digital reminders
DECIBEL THERAPEUTICS is a U.S. biotech company dedicated of consultations (Spruce 2021).
to developing therapies designed to restore or improve hearing
and balance (Decibel Therapeutics 2021). SPYBIOTECH is a UK company that has developed a platform to
accelerate vaccine development for infectious diseases, cancer and
chronic illnesses (SpyBiotech 2021).

AMAZON invests in GRAIL, while its offshoot, OWLET BABY CARE is a U.S.-based company providing monitoring AMAZON
products and technologies, including a surveillance camera and sleep
Amazon Alexa, invests in Owlet Baby Care and GRAIL
monitoring capabilities, for use in monitoring newborn and infant
Aaptiv (Prendergass 2018). health (Owlet Baby Care 2021). Owlet
Baby Care
AAPTIV offers a workout app that combines workouts with
GRAIL is a U.S.-based biotech startup in the field of early cancer Aaptiv
detection. It was founded in 2016 and has since received funding coaching and music offerings during a workout (Aaptiv 2021).
from a variety of investors, including Bill Gates, Bezos Expeditions,
Google Venture (GV), Tencent and Johnson & Johnson. GRAIL aims
to improve early diagnoses in oncology through blood testing and
is conducting a large clinical trial in genomic medicine (Shih 2018;
Crunchbase 2021b; Grail, Inc. 2017).

APPLE’s spin-off is active in developing the com- APPLE

pany’s proprietary AC Wellness clinics (AC Wellness AC Wellness
2020) (➔ 3.4.5).

virtual reality-assisted therapeutic systems that are applied

MICROSOFT invests in companies such as MICROSOFT
in neurorehabilitation efforts (Kinestica 2021).
DNAnexus and Welltok, and supports firms like DNAnexus
Kinestica, Eva Diagnostics / Entia and NIBS EVA DIAGNOSTICS / ENTIA is a UK medical technology Welltok
company that develops virtual oncology solutions designed
NeuroScience Technologies and Jintronix as part Microsoft
to improve cancer treatments (Entia 2021).
of its own Microsoft ScaleUp program (Prendergass ScaleUp
Program,
2018). NIBS NEUROSCIENCE TECHNOLOGIES is an Israeli company
i. a.:
that has developed a system targeting the non-invasive monitoring,
evaluation and treatment of brain diseases (NIBS NeuroScience Kinestica
DNANEXUS is a U.S.-based company that has created a global
Technologies 2021). Eva Diagnos-
network for genomic medicine through the use of cloud computing
and bioinformatics (DNAnexus 2021). tics / Entia
JINTRONIX is a Canadian company focused on developing 3D
biomedical software for use in physical and cognitive rehabilitation NIBS
WELLTOK is a U.S. company providing an ML-enabled platform
in the healthcare and other sectors (Welltok 2021).
efforts (Jintronix 2020). NeuroScience
Technologies
KINESTICA is a Slovenian medical device company that designs, Jintronix
develops and markets medical devices for use in sensor-based and

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 TECH GIANTS IN HEALTHCARE

IBM IBM Watson is providing venture capital to APOGEN BIOTECHNOLOGIES is a U.S. biotechnology company
focused on developing a new approach to cancer therapy that
Pathway healthcare companies such as Pathway Genomics /
eliminates the development of drug resistance in patients (ApoGen
Genom-
OmeCare, ApoGen Biotechnologies, Petra Pharma Biotechnologies 2021).
ics / OmeCare
and Modernizing Medicine (Prendergass 2018).
ApoGen PETRA PHARMA is a U.S.-based pharmaceutical company with
Biotechnologies specialization in novel enzyme targets, which are important in
PATHWAY GENOMICS / OMECARE is a U.S. company that
Petra Pharma the development of therapies for cancer and metabolic diseases
performs DNA laboratory analyses to determine genetic dispositions
(pre-IPO Pharma 2021).
Modernizing (OmeСare 2021).
Medicine MODERNIZING MEDICINE is a U.S. company that developed the
Electronic Medical Assistant, a cloud-based electronic health record
(EHR) system (Modernizing Medicine 2021).

INTEL INTEL’s investment arm Intel Capital invests SANO is a U.S. company specializing in the development of sensors
designed to measure metabolic data (Lavine June 6, 2015). Sano was
Sano venture capital in several healthcare companies,
acquired by One Drop in 2020 (One Drop April 13, 2020).
Minha Vida including Sano and Minha Vida, a health and
wellness portal founded in 2004 (Prendergass 2018;
Intel Corporation April 5, 2012).

PHILIPS PHILIPS invests as Philips Ventures87 and Philips several hospitals across the United States and Canada (Bright.md
May 27, 2020).
Mytonomy Health Technology Ventures Fund in more than
Carevive 100 health-related startups, including Mytonomy, BABYSCRIPTS is a U.S.-based company providing a virtual
Systems obstetrics care management platform for mothers and babies during
Carevive Systems, Orbita, Bright.md, Babyscripts,
Orbita pregnancy, birth and the first few years of a child’s life (Muoio 2019).
LindaCare, DEARhealth, LeQuest and Xealth (Philips
Bright.md 2021g). LINDACARE is a startup focused on cloud-based remote monitoring

Babyscripts solutions. The LindaCare OnePulse platform, which is designed

specifically for patients with implantable cardiac electronic devices,
LindaCare MYTONOMY is a U.S.-based company focused on cloud-based
is partnering with Philips’ IntelliSpace to improve follow-up care
services in the healthcare sector that include an online health
DEARhealth education platform for patients (Philips March 22, 2018).
(LindaCare Aug. 28, 2019).

LeQuest
DEARHEALTH is a U.S. company that emerged from a University of
CAREVIVE SYSTEMS is a U.S.-based company that has developed
Xealth California (UCLA) project. DEARhealth provides AI-based solutions
a platform for cancer care management designed to improve
for personalized chronically ill care (DEARhealth July 18, 2019).
patients’ experience with treatment. The platform supports health
professionals with developing personalized treatment plans and
LEQUEST is a Dutch company that develops digital, interactive and
provides patients information regarding the general course of cancer
simulation-driven training technology for healthcare professionals
therapies (Vaidya 2021).
to improve their use of medical devices and software. LeQuest and
Philips are collaborating to combine these online training opportuni-
ORBITA is a U.S.-based tech company developing AI solutions for
ties with Philips’ Affiniti ultrasound system. The combination of the
use in voice recognition technologies and chatbot applications. This
two systems aims to improve clinical workflow efficiency and clinical
AI solution is designed to help healthcare institutions and healthcare
professionals’ understanding of how the devices and software work,
providers provide their patients with virtual healthcare assistance
as well as their ability to handle them (Philips Oct. 7, 2020).
(Orbita May 28, 2020).

XEALTH is a U.S.-based company with a platform for managing

BRIGHT.MD is a U.S.-based company focused on creating opportu-
digital health solutions that makes it easier for medical staff to
nities to automate processes in the healthcare sector. The company’s
identify effective digital health tools for patients (Xealth June 20,
flagship project, SmartExam, is an AI-powered telemedicine plat-
2019).
form that has already been integrated into the systems used in

87 Philips Ventures’ mission is to foster collaborations with and investments in healthcare startups in the areas of health
promotion, prevention, diagnostics, therapy and home care services. At the company’s centers around the world, Philips’
innovation team, investment team, and operations team provides startups assistance with the development process (Philips
2021g, 2021k).

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SIEMENS spun off its medical technology business SIEMENS

in 2016 in the form of Siemens Healthineers Siemens
Healthineers
(Siemens Healthineers 2021v).

ALIBABA has investments in the Chinese Meinian to improve its cloud computing platform. ALIBABA
hospital chain Meinian OneHealth. Back in 2017, As of 2019, Alibaba owned 14.4 % of the chain’s Meinian
OneHealth
Alibaba Cloud formed a collaboration with shares (Tuna 2019b; Shumin 2019, 2020).

TENCENT invests in several health-related KARIUS is a U.S. biotech company that was founded in California TENCENT
in 2014. It develops technologies that use DNA fragments obtained
startups and partners with some of them. Examples Shuidi
from blood tests to detect infectious diseases in their early stages
include Shuidi, iCarbonX, inui Health (Scanadu), (Ravet 2017). iCarbonX
Karius, HomeHero, CliniCloud, and Circle Medical inui Health
HOMEHERO is a U.S. company founded in 2014 offering a platform
(Farr 2017; Varadharajan 2017; Bruno 2019). for hiring in-home caregivers. It features an online portal where Karius
users can view potential caregivers’ (“Heros”) video profiles and HomeHero
SHUIDI (also known as Waterdrop) was founded in 2016 and background checks (HomeHero June 30, 2015).
operates multiple healthcare platforms. The company aims to
CliniCloud
use crowdfunding as a means of supporting the Chinese health CLINICLOUD is an Australian startup with headquarters in California Circle Medical
insurance system (Bruno 2019; PitchBook 2021). (Crunchbase 2021a). The company has developed a digital stetho-
scope and a non-contact medical thermometer for at-home use.
ICARBONX is a Chinese startup founded in 2015 that delivers Both devices connect with an app and store the user’s recorded
AI-powered genomic data analysis and is often hailed as a unicorn vital-sign data on their smartphone or on a cloud server (Lim 2015).
in the biotech field (iCarbonX 2021; Varadharajan 2017).
CIRCLE MEDICAL is a U.S. company that has developed an app that
INUI HEALTH (previously Scanadu) is a U.S. medical technology allows patients to contact and consult with physicians. The app can
company engaged in the development of tools such as medical be used for emergencies as well as preventive care (Pai 2015).
wearables (Livingston April 27, 2015). After relaunching in 2020
under its new name, inui Health, the company was acquired by Israeli
startup Healthy.io. inui Health has focused on developing a smart-
phone-based in-home urine testing system and a digital platform.
inui Health continues to receive funding from Tencent (Farr 2020).

Tech giants are investing heavily in external companies and their own spin-offs. In some cases,
they are establishing extremely complex corporate structures that are active in different areas
of the healthcare sector. Health-related AI startups are the preferred recipients of most of these
investments.

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ACQUISITIONS

Another strategy pursued by tech giants looking to expand into the healthcare sector is to acquire
external companies and startups.88 While GAFAM companies’ investment activities have risen
steadily since 2016, a downward trend can be observed with regard to annual acquisitions, as the
number dropped from 50 to 35 over the same period. With only 16 buyouts projected for 2021, the
downward trend continues (CB Insights 2021).

2016: 50

2018: 43

2020: 35

2021 (projected): 16

FIGURE 12: Annual acquisitions, GAFAM companies

Source: Authors. Data: CB Insights 2021, Bertelsmann Stiftung

GOOGLE / GOOGLE / ALPHABET acquired London-based

ALPHABET
Artificial General Intelligence (AGI) startup Deep-
DeepMind
Mind in 2014 and smartwatch producer Fitbit in
Fitbit
late 2019 (Meskó et al. 2020: 10-16).

APPLE APPLE acquired Gliimpse in 2016, which built a sleep tracking devices that can be connected to
Gliimpse personal health data platform for aggregating and apps designed for iPhones and Apple Watches
Beddit sharing health data (Meskó et al. 2020: 19). In 2017, (Krishnan 2019; Meskó et al. 2020: 19).
Apple acquired the startup Beddit, which develops

META META (formerly Facebook) acquired the fitness Labs, which uses software to “[develop] the
(formerly
software provider Moves and virtual reality pioneer technology to control digital devices with your
Facebook)
Oculus in 2014 (Prendergass 2018; Constine 2014). mind” (Wagner 2019a; Woopen et al. 2020: 4).
Moves
In 2019, the tech giant acquired the startup CTRL-
Oculus
CTRL-Labs

88 According to the October 2020 report examining competition in digital markets published by the U.S. Congress’ Subcommittee
on Antitrust, Commercial and Administrative Law, acquisitions are a commonly pursued strategy by the market-dominant
tech giants Facebook (now Meta), Google, Amazon and Apple (Subcommittee on Antitrust, Commercial and Administrative Law
2020).

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AMAZON acquired in 2019 the telemedicine tion itself in the telemedicine healthcare market AMAZON
company Health Navigator, which features an online (Meskó et al. 2020: 34). Amazon shook up the Health
Navigator
symptom-checking tool that allows for a remote pharmaceutical sector in 2018 when it acquired the
PillPack
diagnosis (Shope 2019; Krüger-Brand 2020: 376- online pharmacy PillPack (Meskó et al. 2020: 34-35)
377). By allowing Amazon to provide “diagnostic (➔ 3.4.7).
and clinical management software, as well as smart
language processing services” (Krüger-Brand 2020:
377), the acquisition will help the tech giant posi-

MICROSOFT acquired Nuance Communications Voice recordings are stored in the cloud, where they MICROSOFT
Inc., a speech recognition and AI company, for are then connected with the technical libraries of Nuance
$ 20 billion in spring 2021. Nuance is increasingly individual research facilities (tagesschau.de 2021c;
focusing on the medical sector, offering software Microsoft News Center April 12, 2021).
packages for healthcare professionals that can,
for example, process dictation for medical reports.

IBM acquired Truven Health Analytics, Merge EXPLORYS, as part of IBM Watson Health, offers a cloud-based IBM
platform that relies on electronic medical record data and provides
Healthcare, Explorys, and Phytel in 2015 and 2016 Truven Health
analytic tools for use in evaluation processes. Open to life sciences
Analytics
(Prendergass 2018; Rhee 2021). companies, the platform is expected to help battle data silos in
healthcare (IBM 2021d). Merge
TRUVEN HEALTH ANALYTICS provides analytic services Healthcare
PHYTEL is developing automated solutions as part of IBM Watson
with health data as part of IBM Watson Health (IBM 2021g). Explorys
Health to promote patient engagement (IBM 2020e).
Phytel
MERGE HEALTHCARE provides AI imaging solutions as part of
IBM Watson Health (IBM 2021f).

INTEL acquired Israeli startup IDesia Biometrics in INTEL

2012 (Prendergass 2018; Savitz 2012). IDesia
Biometrics
IDESIA BIOMETRICS offers biometric authentication solutions
(Idesia Biometrics 2021).

PHILIPS acquired ultrasound equipment producer PHILIPS

ATL Ultrasound in 1998. In 2000, it acquired nuclear ATL Ultrasound
medicine specialist ADAC Laboratories and home- ADAC
Laboratories
care specialist Agilent Technologies Healthcare
Solutions Group. This was followed in 2001 Agilent
Technologies
by the acquisition of the medical division of the Health­care
British group Macroni (Kindermann and Lindemann Solutions
Group
2018: 40).
Macronis
medical division

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SIEMENS SIEMENS and Siemens Healthineers (since 2016) CONWORX TECHNOLOGY, a German company, offers point-of-
care testing (POCT). The company also develops interface and data
Dade Behring carried out a series of acquisitions from 2007 to
management solutions (Siemens Healthineers Nov. 8, 2016).
MobileMD 2021, which have included the following companies:
Dade Behring, MobileMD, Penrith, Neo New EPOCAL, a Canadian company, develops blood gas diagnostic
Penrith
procedures as well as point-of-care solutions for measuring blood
Neo New Oncology, Medicalis, Conworx Technology, Epocal, gas levels (Lück 2017).
Oncology Fast Track Diagnostics (FTD), Corindus Vascular
Medicalis Robotics and Varian Medical Systems (Crunchbase
FAST TRACK DIAGNOSTICS (FTD), a Luxembourg-based company,
develops molecular diagnostic tests for infectious diseases. Unlike
Conworx 2021c). other clinical tests, FTD’s tests can differentiate “between viral,
Technology
bacterial and other infectious diseases” (Siemens Healthineers
Epocal DADE BEHRING is a U.S. company that specializes in laboratory Dec. 15, 2017).

Fast Track diagnostics, and in-vitro diagnostics in particular (Siemens Health-

CORINDUS VASCULAR ROBOTICS, INC., a U.S. company, as one
Diagnostics ineers 2021f).
of the world’s top robotic systems specialists, developed the Cor-
Corindus MOBILEMD is a U.S. company that develops the technology for Path GRX, a robotic platform for vascular intervention procedures
Vascular health information exchange services that increase connectivity (Siemens Healthineers Oct. 29, 2019, 2021e) (➔ 3.4.4).
Robotics among healthcare providers and institutions (Miliard 2011).
Varian VARIAN MEDICAL SYSTEMS, INC. is a U.S. medical technology

Medical PENRITH, a U.S. company, is developing ultrasound imaging systems company that uses AI to develop therapies for the early detection

Systems (Arrowsmith Aug. 22, 2012). of diseases such as cancer, as well as treatment and radiation
therapies, and imaging software (Höpner 2020). For example,
NEO NEW ONCOLOGY, a German medical company, is developing the company developed the ARIA information system, which
the NEO cancer diagnostics platform, which enables physicians to consolidates cancer patients’ data into an electronic health record
find customized treatment options for their patients (VentureCapital (EHR) (Siemens Healthineers 2021r). The company’s acquisition
Magazin 2016). by Siemens Healthineers was completed in April 2021 (Siemens
Healthineers April 15, 2021).
MEDICALIS, a U.S. company, is developing an imaging clinical
decision support tool and solutions designed to increase operational
efficiency across multivendor environments and thus optimize
workflows (Miliard 2017).

TENCENT TENCENT’s offshoot Tencent Trusted Doctors,

Tencent Trusted which emerged from the merger of Tencent
Doctors
Doctorwork and the startup Trusted Doctors,
acquired 25 clinics in 2019 (Tuna 2019a; Meskó
et al. 2020: 62).

As a result of their massive financial volume, today’s tech giants can take over successful startups
to bundle capacities and thereby expand their market position even further. Their activities in this
area focus primarily on acquiring AI and telemedicine startups.

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3.4.10
SUMMARY

The tech giants are active in different ways in all aspects of healthcare provision, but to varying
degrees of intensity. Healthcare cloud computing, which is used to organize, manage and analyze
complex healthcare data for a variety of purposes, is an extremely important area for the tech
giants. They are also somewhat active in the area of blockchain technology, which can improve
data flow traceability and help ensure the security of those from whom the data originates. Tech
giant processes and products in areas such as medical imaging are taking on an ever-growing role
in the medical technology and biotechnology sectors. There are only a few cases of tech giants
creating structures for the provision of medical services, most of which relate primarily to hospitals
and networked systems for healthcare staff in particular.

Tech giants have become increasingly active in different areas of the pharmaceutical supply chain
industry. While their products and services are primarily found in the areas of distribution and
logistics, they are also engaged in manufacturing. The products and services offered by tech giants
in areas such as robotics, mobility and logistics, and health insurance have thus far played a minor
role in the healthcare sector. Tech giants nurture a wide variety of partnerships and networks
through which they can conduct short-term joint projects on clearly defined issues and also form
long-term alliances within the sector. Primarily, they cultivate partnerships and alliances with
universities, government healthcare agencies, private healthcare institutions, other tech giants
and pharmaceutical companies. Tech giants are exceptionally active in investing in other compa-
nies, fostering spin-offs, and engaging in acquisitions, generally preferring to invest in or buy
up health-related AI startups.

Due to their high market penetration – which is largely a result of their vast (technological)
expertise and access to massive amounts of data – tech giants are increasingly taking on an
outsized role in the healthcare sector. By optimizing the means of preventive and personalized
medicine, their products, services and structures can contribute to improved and more efficient
healthcare provision. However, there are risks involved as traditional stakeholders could become
dependent on the tech giants’ expertise, capacities and resources. This vulnerability could be
exacerbated by the tech giants’ steadily growing dominance in markets beyond the healthcare
sector as well. The ongoing facilitation of networking within the healthcare sector and between
the healthcare and lifestyle sectors by technology could radically transform established healthcare
structures and the distribution of responsibilities among stakeholders. This could go so far as
to create new, parallel structures in healthcare provision. The ethical issues associated with this
dynamic are discussed in chapter ➔ 4.

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3.5
SCIENCE, RESEARCH AND DEVELOPMENT

Science and research allow for the systematic and methodic acquisition, reflection and dissemina-
tion of knowledge. Article 5 (3) of the German constitution, the Basic Law, guarantees the freedom
of science, research and teaching. The term “research and development (R&D)”, commonly used
in the corporate context, is defined as the “search for new knowledge using scientific methods
and in a planned form,” according to which research is understood as “the general acquisition
of new knowledge” and development as “its initial concrete and practical implementation.” The
knowledge gained can “extend to products as well as to (manufacturing) processes and product
as well as process applications” (Voigt 2018).

When it comes to research on large and diverse sets of data, which is the primary focus of the
tech giants, research and development is first and foremost about finding correlations through
the use of AI-supported big data applications (➔ 3.1). Informatics technologies are expected to
“significantly change and even improve the process of gaining scientific knowledge” (Wiegerling
et al. 2019, S. 402). The following are examples of the activities of tech giants in science as well
as in R&D.

ALPHABET’s subsidiary Calico Life Sciences, As an independent research company in the field GOOGLE /
ALPHABET
LLC. (Calico), Verily Life Sciences, LLC. (Verily) of life sciences, Verily is involved in numerous
Calico
(formerly Google Life Sciences), and Google Deep- collaborations and projects of various kinds (Kohl­
Verily
Mind (Health) are establishing a strong presence hagen 2019: 53). Started as a research project
in health-related research (Kohlhagen 2019: 53). Google Health
within Alphabet’s X Development LLC. research
& Health
division, the company spun Verily off in 2015. The Studies App
Calico has been operating as a biotechnology goal is to research and develop technologies and DeepMind
company since 2013 and is “one of Google’s most applications for collecting and analyzing health data Health

ambitious ventures” (Kohlhagen 2019: 53). The aim (Verily, n. d.). “Our mission is to harness the world’s Googles Breast
Cancer Weight
of Calico is to research the processes of human health data so we can live healthier lives,” says Loss Study
aging and use that data to help people live long and Jessica Mega, Verily’s medical and scientific director. Google
healthy lives (Calico 2021). Calico partners with (Schulz 2018: 94). Research
numerous companies in the biotechnology sector as
part of that work. For example, it has a partnership Verily, in collaboration with Stanford Medicine and
with C4 Therapeutics to conduct research into new the Duke University School of Medicine, is conduct-
medicines and another with AbbVie for research ing a reference study: the Project Baseline Health
and development focused on new treatments for Study. Molecular, genetic, psychological and other
age-related diseases (Calico July 27, 2021, March data have been collected from 10,000 participants
23, 2017). since 2017. The test subjects are set up with mobile
sensors and undergo weekly examinations. The goal
of the study is to “map the whole health of a person”
(ibid: 107) and determine what makes a person truly
healthy (Verily 2021a; Schulz 2018: 107).

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TECH GIANTS IN HEALTHCARE

Verily has extensive strategic alliances with the precision – compared to ophthalmologists – and
pharmaceutical companies Ostuka, Novartis, Pfizer predict the progression of the disease within the
and Sanofi to advance clinical research. Among next six months (Yim et al. 2020; Wiggers 2020).
other things, support is to be provided for opti-
mized recruitment possibilities and the participation Google’s Breast Cancer Weight Loss Study (BWEL)
of test subjects in studies. For example, Verily uses is a collaborative study conducted together with
health-related Google searches to identify potential the U.S. National Cancer Institute and the Dana-
study participants (Farr 2019a). The company is also Farber Cancer Institute. Being overweight or obese
conducting further research projects on the devel- is associated with a higher risk of breast cancer and
opment and use of robotics, AI and virtual reality recurrence (Dana-Farber Cancer Institute, April 27,
(VR) in the field of surgery (Schulz 2018: 94). 2016). The BWEL study90 seeks to prevent cancer
recurrence by bolstering participants’ health-pro-
Google Health, through its support of DeepMind moting behaviors. As part of the study, a virtual
Health89 (➔ 3.4.9), is running diverse AI-based, care network of patients, healthcare professionals
health-related research projects in the field of med- and researchers is to be built, along with a database
ical imaging and diagnostics as well as in genomics. to discover relationships between activities, sleep
To that end, it is partnering with numerous health- cycles and dietary habits and improve prevention
care providers as well as state-managed and aca- options (Dana-Farber Cancer Institute, October 11,
demic institutions (Google Health n. d. c, n. d. d). 2016; Ligibel 2019; Wicklund 2018).
For example, Google Health is carrying out a study
on AI-based early detection of acute renal failure Google Research is engaging in technology-enabled
(Tomašev et al. 2019; DeepMind July 31, 2019). research and development to solve challenges in
Google DeepMind Health is collaborating with diverse research fields, including health and life
Northwestern Medicine on a clinical trial to explore sciences. That includes human-computer interaction
how AI can improve the diagnosis of breast cancer, to support the research (Google Research n. d.).
and other maladies (McKinney et al. 2020; Google,
February 25, 2021). In another study, DeepMind The Google Health Studies app is designed to
Health is partnering with the Moorfields Eye encourage patient and user participation in
Hospital National Health Service Foundation Trust health-related studies by allowing participation
and the University College London (UCL) Institute of within the app (Google Play Store 2021b).
Ophthalmology to develop AI-based retinal disease
detection applications to assist ophthalmologists
(DeepMind, August 13, 2018; Fauw et al. 2018).
In a study published in 2020, DeepMind Health
reported that an AI-based retinal imaging diagnostic
solution it developed could detect age-related
macular degeneration with the same or greater

89 The DeepMind Health division was merged into the Google Health division in 2019 (King 2019).

90 The BWEL study includes a total of 3,200 overweight and obese participants from the United States and Canada with stage II
and stage III breast cancer. The study began in August 2016. Participants were divided into two groups. Group 1 is provided
with health education on healthy eating and exercise. Group 2 receives the same educational program as well as a personal
mHealth coach (Ligibel 2019). This is made possible through a partnership with Fitbit. The company’s Fitbit Charge HRTM
fitness tracker is used to record a person’s activities and pulse. In addition, the Fitbit Aria Wi-Fi Smart Scale is used to measure
weight, BMI, lean mass and body fat percentage and link them to an online Fitbit profile. The total package is rounded out with
the FitStarTM, a video-based exercise service available to participants on their mobile devices (Dana-Farber Cancer Institute,
April 27, 2016).

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APPLE is providing software development kits Together with the University of Tübingen, a APPLE
(SDKs) as open source to support researchers and study was published to provide insights into what HealthKit
developers in developing further applications for smartphone use can reveal about the mental and ResearchKit
smartphones (Krishnan 2019). cognitive state of users (Rauber et al. 2019). CareKit
Apple
Since 2014, Apple has offered digital interfaces In addition, a study was conducted in collaboration Heart Study

(APIs) for smartphones with the HealthKit, with with Eli Lilly and Company and Evidation Health, Covid-19
Wearables
which users can provide their health data (Horton Inc. to develop parameters that enable wearables Project
2020). For example, the blood glucose values of to identify cognitive decline (Chen et al. 2019). Apple Women‘s
HealthKit users were used in a study to develop Health Study

a new model for predicting blood glucose levels As part of the Apple Women’s Health Study, the Apple Heart
and Movement
in type 1 diabetics (Miller et al. 2020). Harvard T.H. Chan School of Public Health worked Study
together with Apple and the National Institute of Apple Hearing
The ResearchKit, launched in 2015, is designed to Environmental Health Sciences (NIEHS), a National Study
help develop mobile applications that can collect Institute of Health (NIH), to gain insights into how Further studies
with universites
data and information for medical research purposes different factors can affect the menstrual cycle and
and healthcare
(Kohlhagen 2019: 52). This can facilitate the gynecological diseases. Cycle data from the iPhone institutions
recruitment of test persons, the collection of and / or Apple Watch will be used to develop inno- Apple Research
relevant examination parameters using a smart- vative products for use in this field. (Harvard T.H. App

phone in everyday life and the coordination of Chan 2021).

medical studies in their entirety.
In collaboration with the American Heart Associa-
CareKit, launched in 2016, aims to help develop tion (AHA) and the Brigham Research Institute at
mobile apps that facilitate improved home care, Brigham and Women’s Hospital (BWH), the Apple
particularly for chronic conditions and pre- and Heart and Movement Study will examine the
post-operative care (Krishnan 2019). relationships between physical activity and heart
health. The aim is to gain a better understanding
In partnership with the Stanford University of early warning signs and to support interventions
School of Medicine, Apple conducted what it has in this area (BWH 2021).
dubbed the Apple Heart Study (AHS) to evaluate
the accuracy of its Apple Watch’s ECG function in The Apple Hearing Study examines noise exposure
diagnosing irregular heart rhythms such as atrial and its effects on hearing health through a partner­
fibrillation (Stanford Medicine 2021). ship between the University of Michigan School
of Public Health and Apple. The noise exposures
Similarly, a study was conducted in collaboration of test persons through headphones and ambient
with Stanford University on how app use can noise are measured over the long term to generate
predict cognitive abilities in older adults (Gordon insights into the effects. According to the Univer-
et al. 2019). sity of Michigan School of Public Health, the study
results will help inform public health policies and
The Healthcare Innovation Lab at the Stanford preventive measures for maintaining hearing health
University School of Medicine is conducting a (University of Michigan 2021).
COVID-19 Wearable Project to detect COVID-19
using wearables such as the Apple Watch (Stanford
Healthcare Innovation Lab n. d.).

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 TECH GIANTS IN HEALTHCARE

Apple’s Research App is designed to allow Apple app informs users about current studies on issues
smartphone and smartwatch users to independently like women’s health, autism diagnostics and treat-
coordinate their participation in Apple studies. The ments for Parkinson’s disease (Apple 2021c).

META META (formerly Facebook) has a division called the aim of researching and developing new treat-
(formerly
Facebook AI Research (FAIR), which is working ments (Krüger-Brand 2020: 377; Crow 2017; Kutter
Facebook)
together with New York University (NYU) Langone et al. 2016). Chan and Zuckerberg’s vision is “to
fastMRI
Health on a research project called fastMRI. The cure, prevent or manage all diseases by the end
facebook
goal is to generate MRI scans more quickly by of this century” (Crow 2017: 767). In this context,
The Human
Cell Atlas using AI to create high-quality imaging from lower- the Human Cell Atlas Project is a vital effort to build
Project resolution image data that is captured at a faster a public database bringing together diverse molecular
rate (fastMRI 2020; Choueiri et al. 2019: 5). More data from hundreds of laboratories into a single
broadly, FAIR is working to advance AI in both basic atlas of human cell types. Within that project, CZI
and applied research through collaborations (Face- is partnering with the Wellcome Trust’s Sanger
book AI 2020a; Pousttchi et al. 2019). Institute, the Chan Zuckerberg Biomedical Research
Center (CZ Biohub) and committee members from
The social network facebook is a significant tool numerous institutions. The CZ Biohub is an inde-
in terms of recruiting study participants in behav- pendent non-profit organization founded by Chan
ioral health research by reaching potential subjects and Zuckerberg in San Francisco that is helping to
whose recruitment might otherwise be difficult implement CZI’s vision by developing technology
(Pedersen and Kurz 2016). platforms for medical research (Crow 2017: 768).
The CZ Biohub maintains partnerships with the
Together with his wife Priscilla Chan, founder American universities UC Berkeley, UCSF and
and CEO Mark Zuckerberg established the Chan Stanford (CZ Biohub 2020).
Zuckerberg Initiative, LLC. (CZI) in late 2015 with

AMAZON AMAZON’s cloud-based solution Amazon Amazon’s health division also has a small group
Amazon Web Services (AWS), including Amazon Neptune of researchers, Grand Challenge, that also operates
Web Services,
Technology, is being used for numerous research under the codename 1492 or Amazon X and
i. a.:
projects, including, for example, at the U.S.-based conducts research into secret projects in areas
Beth Israel
Deaconess Beth Israel Deaconess Medical Center, to explore like innovative health technologies and cancer (Hale
Medical Center the potential of machine learning (ML) for health- 2018). According to media reports, Amazon is also
University care. In response to the COVID-19 pandemic, the working with the Fred Hutchinson Cancer Research
of Califonia,
San Francisco company is working together with the University Center, which focuses on research projects for the

Grand Chal­ of California, San Francisco (UCSF) on a program in early detection and treatment of cancers, to apply
lenge / 1492 / which AWS-assisted genome sequencing is used to ML in cancer prevention and treatment, although
Amazon X
acquire insights into COVID-19 and other infectious few other details are publicly available about this
Fred
diseases (Meskó et al. 2020: 37-38). collaboration (Kim and Farr 2018, 2017). It is publicly
Hutchinson
Cancer known, however, that Amazon has a seat on the
Research Board of Trustees91 of the Fred Hutchinson Cancer
Center

91 The Board of Trustees of the Fred Hutchinson Cancer Research Center also includes leading executives from other tech giants,
including Microsoft CEO Satya Nadella (Fred Hutch, July 11, 2016).

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 Tech Giant ACTIVITIEs in Healthcare

Research Center and that it provides the organization to COVID-19 and other topics (Fred Hutch April 17,
with support through funding for projects relating 2020, July 9, 2019).

MICROSOFT Research conducts extensive processing (NLP) (Microsoft Research 2021b). MICROSOFT
research activities in the fields of intelligence Microsoft’s Research Asia Lab launched a website Microsoft
Research
(including AI and others, see section ➔ 3.1), systems in April 2020 called COVID Insights that serves as
Microsoft AI for
(such as on data platforms and analytics, see a portal for current analyses and studies relating to
Good Initiative
section ➔ 3.4.1), and theory, as well as in other COVID-19 (Meskó et al. 2020: 31).
Project
scientific fields such as medical, health, and Hanover
genomics (Microsoft Research 2021c). The latter Information about Microsoft’s AI for Good Initiative Microsoft
area includes numerous projects and publications and Project Hanover can be found in section ➔ 3.1, Genomics

on the application of novel computational tools and information on Microsoft Genomics can be found in Microsoft AI
for Health
analytical techniques that it says will help transform section ➔ 3.4.1 and information about Microsoft AI
Microsoft
healthcare and empower people to lead healthier for Health and Microsoft Healthcare NExT can be Healthcare
lives. Research topics include COVID-19, deep found in section ➔ 3.4.9. NExT
learning toolkits and biomedical natural language

IBM has established the AI Horizons Network, sity of Stuttgart since 2020, for example (IBM April IBM
a global network of scientists, to further develop 28, 2020). The projects address global challenges in AI Horizons
Network
the use of AI in research projects and experiments a variety of fields, including health and the environ-
as part of a long-term partnership with the Univer- ment (IBM 2021a).

INTEL and Google Cloud have joined the U.S. in the United States (Healthcare Global 2021; INTEL
National Institute of Health’s (NIH) All of Us All of Us Research Hub 2021). All of Us
Research
Research Program, which is collecting biomedical
Program
data from study participants in the U.S. to explore Information about Intel’s research projects with
Further
relationships between various factors such as life- the University of California San Francisco (UCSF) research
style, socioeconomic status and environment and and the University of Pennsylvania can be found in projects with
universities
health. The stated goal of the project is to reduce section ➔ 3.1.
healthcare disparities and improve health out-
comes for under-represented groups of people

NVIDIA’s graphics processing units (GPU) are second largest GPU company, with a 20 % market NVIDIA
integral hardware components in computers used share in the third quarter of 2021 (Dow 2021). NVIDIA GPU
for sophisticated research projects worldwide, Researchers at the Mayo Clinic in the U.S., for NVIDIA Clara
Imaging & Clara
regardless of explicit partnerships with the tech example, use NVIDIA’s GPU to infer the genetic
Parabricks
giant (Meskó et al. 2020: 45). Second only to Intel, information of brain tumors without having to
NVIDIA
which has 62 % market share, NVIDIA is the world’s perform a biopsy (Halabi 2017). Inception
Program

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 TECH GIANTS IN HEALTHCARE

NVIDIA Clara92 is a platform and application which is used to assist physicians in detecting
framework for healthcare researchers that supports lung cancer. During the COVID-19 pandemic,
accelerated computing and AI in imaging and its application in Wuhan, China, has helped and
genomics, in addition to other areas. The aim is to continues to help with the early detection of
create innovation and advance precision medicine COVID-19-related disease through lung screenings
(NVIDIA 2021d). Infervision, a Beijing-based startup (Alarcon 2020). NVIDIA’s Clara Parabricks has been
and member of the NVIDIA Inception network, deployed in numerous genome analytic research
used NVIDIA graphics processing units (GPU) projects – to develop a vaccine against COVID-19,
and NVIDIA Clara Imaging and over 400,000 lung for example, as well as in other projects including
X-rays to train an AI algorithm (Simonite 2019; the development of robots for disinfection and con-
Powell 2018). That AI application has been tactless temperature measurement of potentially
incorporated into InferRead CT Pneumonia, infected individuals (Meskó et al. 2020: 46-47).

PHILIPS PHILIPS has used AI-based “digital twin” technol- In one research project together with neurotech-
Digital Twin ogy to develop a digital twin of the human heart nology and design companies, Philips’ Hue Lighting,
Technology:
(HeartModel). Digital twins are virtual models of SmartTV and Lifeline Medical Alert products will be
HeartModel
systems that are updated dynamically and are linked together so that patients with neurodegener-
Mind Control
“connected” to their physical counterparts. This ative conditions can control them using “mind
technology will help analyze systems in real control.” The aim is to give patients the ability to
time, prevent problems and test innovations in overcome mobility limitations by using brain com-
virtual environments before they are introduced mands. A tablet app will translate these commands
into everyday care (Philips 2018b). and connect them with other devices. Users can
use the Emotiv headset to send commands either
by way of mind commands or muscle commands
(Philips n. d. a).

SAP SAP’s Machine Learning Research is conducting SAP is also pursuing the goal of optimizing health-
Brain Age an AI research project, the Brain Age Project, in care processes and, to that end, conducted research
Project
cooperation with Ludwig Maximilian University into an application in cooperation with the Helios
SAP Connected
(LMU) in Munich that aims to jointly develop new Clinic hospital in Berlin that attempts to predict
Health Platform
methods of supporting doctors and patients with waiting times for emergency admissions (SAP News
innovative, ML-based treatment approaches Center Nov. 21, 2018).
(Haegerich 2018).93
For more information about SAP Connected Health
Platform (formerly SAP Foundation for Health), see
section ➔ 3.3.

92 NVIDIA Clara Parabricks provides off-the-shelf software for primary, secondary and tertiary analyses of genomic data. It has
applications in population genomics, cancer genomics and RNA sequencing projects (NVIDIA 2021c). NVIDIA’s Clara Imaging is
an AI-based application framework for medical imaging. The target group includes data scientists and researchers who create
complex datasets and develop collaborative methods for training reliable AI models and end-to-end software for scalable and
modular AI applications (NVIDIA 2021b).

93 The Brain Age Project used 1,000 anonymized, publicly available MRI scans of healthy subjects to train an ML model designed to
identify anatomical signs of aging in the brain (Haegerich 2018).

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SIEMENS Healthineers maintains a global research 2021n). Like Philips, Siemens is involved in the SIEMENS
and development team with a focus on patient- research and development of AI-based digital twin Siemens
Healthineers
centered and demand-driven healthcare in the technology (Siemens 2021b).
Diagnosis and
clinic. The areas of work and stated goals include
treatment
the optimization of working processes in treatment, approaches
simplified data preparation and optimized diagnosis Digital Twin
and treatment approaches (Siemens Healthineers Technology

SAMSUNG’s My BP Lab is both an app (➔ 3.2) Feb. 26, 2018; UCSF Feb. 25, 2018). The study SAMSUNG
and a study resulting from a collaboration between and the use of the app is intended to improve the My BP Lab
Samsung and the University of California San measurement of blood pressure through smart-
Francisco (UCSF). Users of the app are invited
94
phones and wearables (My BP Lab 2021; Banks
to participate in a three-week study at UCSF. 2020).
Participants are asked to monitor their stress
levels and subjective and emotional well-being, Explanations of Samsung’s research projects in the
provide daily behavioral information (sleep, exercise context of the Samsung Gear VR headset can be
and diet), and record their blood pressure through- found in section ➔ 3.2.
out the day using a smartphone. The researchers
are hoping to use the app to collect and analyze
a comprehensive data set on measured stress,
subjective well-being and blood pressure (Samsung,

TENCENT is entering the research scene with TENCENT

three major AI-related labs designed to support Tencent
Medical
medical AI-based research: Tencent Medical AI Lab,
AI Lab
Tencent YouTu Lab and Tencent AI Lab. The first is
Tencent
focused on research into new digital biomarkers for YouTu Lab
detecting and predicting diseases; Tencent YouTu Tencent
Lab explores AI-based medical imaging (see Tencent AI Lab

Miying, section ➔ 3.3) and Tencent AI Lab is focused

on the overall process of medical care, providing
solutions in areas such as AI-based diagnostics and
treatment (Tencent 2019).

94 Samsung and the University of California San Francisco (UCSF) first partnered in 2014 to develop new sensors, algorithms
and health technologies in preventative health. The partners set up a lab for the purpose – the UCSF-Samsung Digital Health
Innovation Lab. Samsung is actively promoting both the patenting of technologies developed at the Innovation Lab and the
incorporation of developments emanating from UCSF’s Center for Digital Health Innovation (CDHI) into the Innovation Lab for
further research and enhancement with Samsung’s expertise (Pai 2014).

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3.5.1
FEATURED EXAMPLE: RARE DISEASES

“In the European Union, a disease is considered to be rare when it affects no more than five
in 10 000 people. Since there are more than 6 000 different rare diseases, the total number
of people affected is high despite the rarity of the individual diseases”95 (Federal Ministry of
Health 2021c).

Rare diseases, also called orphan diseases, are chronic and possibly life-threatening diseases
that are often genetically linked (Kaplan et al. 2013: 148), although there are also rare infectious
diseases. In most cases, there is uncertainty about the exact cause(s). Rare diseases are often
discovered at birth or during childhood, but the largest share is discovered in adulthood (Orphanet
2012). Around 30 % of children who suffer from rare diseases die (de Vrueh et al. 2013: 11).

One major challenge is the lack of reliable epidemiological data (de Vrueh et al. 2013: 11). As a
result, there is very little general knowledge about rare diseases, so diagnoses are often made
too late and after lengthy and burdensome paths through the healthcare system, or not at all. The
number of drugs96 and specialists available around the world is also limited. Still, there are efforts
to accelerate the development of medications for rare diseases, “orphan drugs,” by shortening
testing and approval periods, for example97 (de Vrueh et al. 2013: 18–22).

ALIBABA ALIBABA Ali Health, in partnership with Bo’ao addresses the problem of the lack of availability
Alibaba Winhealth Rare Disease Medical Center, launched or affordability of innovative treatments for rare
Ali Health
the Global Drug Information Platform for Rare diseases. Ali Health’s technologies, including AI
Global Drug
Diseases in September 2021. The information and cloud computing, are expected to augment
Information
Platform for platform includes a health service network that the platform (Winhealth Pharma 2021).
Rare Diseases is available both online and offline. The platform

HUAWEI HUAWEI and Philips are collaborating in the area

Collaboration of cloud-based AI to use big data to infer relation-
with Philips
ships between specific groups of people, geographic
areas and rare diseases (Huawei 2021).

95 WHO’s definition: “In the EU, a disease is considered to be rare when the number of people affected is less than 5 per 10 000.
There are between 5 000 and 8 000 rare diseases, most of them with a genetic basis” (Kaplan et al. 2013: 148).

96 In the clinical development phases of these drugs, challenges include an insufficient number of patients, a lack of
validated clinical points of reference (surrogate endpoints, biomarkers) and ethical issues (e. g., use of placebos) (de Vrueh et al.
2013: 22).

97 In Germany, however, under the German Medicines Market Reorganization Act (AMNOG), orphan drug status does not lead to
shorter approval times (VfA 2018).

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IBM is seeking to close the data-to-study gap in understanding of disease progression by examining IBM
rare diseases in a partnership with Graticule. To the natural history, comparing the effectiveness Collaboration
with Graticule
achieve this, data from IBM MarketScan Research and safety of medical devices in everyday care and
Databases and IBM Explorys Therapeutic Datasets learning new insights about new drugs that are not
will be used to accelerate research and solve the yet approved for reimbursement (Watson Health
problem of difficulties in recruitment for clinical 2021).
trials. IBM and Graticule hope to gain a better

INTEL is collaborating with Dell Technologies sciences sector. Goals included improving genomic INTEL
and the non-profit Translation Genomics Research pipelines to rapidly obtain results and identify Collaboration
with Dell
Institute (TGen) in an effort to detect, treat and help treatment options within the clinically relevant
Technologies
prevent rare diseases faster. As part of the project, timeframes. At the same time, an emphasis was and TGen
the partners built a high-performance computing placed on lowering costs and protecting private
(HPC) infrastructure in 2012 designed for the life data (Intel, n. d.).

MICROSOFT partnered in 2018 with the pharma- others, at the helm (Fernández 2018; Global MICROSOFT
ceutical company Shire and the NGO EURORDIS Commission on Rare Disease 2019). As part of Collaboration
with Shire and
to accelerate rare disease diagnostics, incorporating its work with the Commission, Microsoft in 2021
EURORDIS
technologies such as ML, intelligent triage and virtual launched the RareNavigator, a tool that gathers
Global Com-
consultations. A blockchain-based patient registry customized information using the Azure Health mission to End
was also created as part of the project. Together, Bot – both from caregivers and families with a child the Diagnostic
Odyssey for
they created the multidisciplinary Global Commission with a rare disease. The tool is limited to a pilot Children with
to End the Diagnostic Odyssey for Children with a project in the San Diego area, but there are plans a Rare Disease
Rare Disease, with Microsoft’s Chief Medical Officer to expand it to sites in Ireland and Australia (Meade
(CMO) of Worldwide Health, Simon Kos, among et al. 2021).

NVIDIA is tapping deep learning to advance drug Recusion’s goal is to discover 100 new treatment NVIDIA
discovery for rare diseases. As part of its NVIDIA approaches by 2025. In pursuit of that goal, robotic NVIDIA
Inception
Inception Virtual Accelerator Program, NVIDIA is arms are conducting around 100,000 experiments
Virtual
collaborating with the startup Recursion to analyze each week, resulting in the creation of about 2 mil- Accelerator
image date from (pathologically altered) cells. lion high-resolution biological images (Salian 2019). Program,
Kooperation
i. a. with
Recursion

SAMSUNG Bioepsis is analyzing data from treatment with a biosimilar (SB12) from Samsung in SAMSUNG
patients with the rare blood disorder paroxysmal a multicenter Phase 3 study (Pulse 2021). Bioepsis
nocturnal hemoglobinuria (PNH) who are receiving

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TENCENT TENCENT is collaborating with RareStone to build mation and services relating to rare diseases.
Collaboration an ecosystem focused on rare disease patients in Innovative digital solutions are to be used for this
with RareStone
China. The partnership aims to promote education, purpose (Global Genes 2021).
social awareness and improve accessibility to infor-

3.5.2
SUMMARY

The tech giants are extremely active in health-related science, research and development.
Their activities, often pursued in collaboration with academic institutions or healthcare companies,
benefit from their ability to collect, refine and process enormously large data sets from a variety
of sources within and outside the healthcare system. The focus is on developing innovative
products and services that either target specific diseases or diagnostic tools or develop and deploy
cloud technologies and AI models to support studies by other actors in the scientific system. The
tech giants are thus gradually becoming indispensable and, as such, powerful participants in the
health-related sciences – with all the advantages and disadvantages that come along with that.

In addition, the increased integration of data collected outside of controlled study environments
by patients and users themselves means that the lines between research, everyday care and the
lifestyle sector are increasingly blurring. The large amounts of data and their AI-supported
analysis also enable research on rare diseases to be advanced in many ways.

The ethical issues that arise in connection with the activities of the tech giants in science,
research and development are discussed in chapter ➔ 4.

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4
ETHICAL ANALYSIS

4.1
INTRODUCTION

Health technologies affect fundamental values such as life, health, liberty and justice. They are
therefore of broad ethical significance, in the sense that they can both promote and endanger the
realization of these values. For example, a clinical decision support system that uses AI could help
improve the evidence basis for a treatment decision in a case of cancer, and thus significantly pro-
long the patient’s life. However, if used unreflectively or with bad underlying data, the same tool
could also lead to treatment decisions that endanger the patient’s life (Braun et al. 2021). At the
global level, technology could on the one hand help people in remote regions obtain healthcare ser-
vices, and thus promote equity of access; on the other hand, it could also widen the so-called digital
divide (➔ 4.3.1), and thus represent a step backward from the perspective of distributive
justice (Ibrahim et al. 2021; Topol 2019; Marckmann 2016).

The challenge of exploiting the opportunities of technologies while avoiding the risks as far as
possible has long been reflected and systematically addressed in technology assessment. Such
evaluations also consider technology’s fundamental role in shaping aspects of individual and social
life. In this context, four distinct functions of ethics can be seen as framing the nuanced discussion
and evaluation of technologies: 1) legitimation, 2) conceptualization, 3) evaluation, and 4) justifica-
tion of norms (Woopen and Mertz 2014).

LEGITIMATION refers to the ethical obligation to identify any negative consequences associated
with a given technology at an early stage, while also ascertaining and advancing the technology’s
positive effects (Woopen and Mertz 2014: 42).

CONCEPTUALIZATION describes the necessity of ethically justifying the process used to evaluate
the technology. This evaluation will inevitably reflect societal attitudes, which means that values
such as health, life, well-being, safety, justice and the prudent use of scarce resources may be
conceptualized and weighed differently at different times and places. The conceptualization

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function also entails the claim that those affected by a given technology should participate in and
help shape the technology assessment process, so as to reflect a broad spectrum of different views
and “counteract the much-deplored loss of democracy” (Woopen and Mertz 2014: 43).

EVALUATION, in its essence, refers to the idea that an ethically informed assessment of what
constitutes potential harm or potential benefit must go beyond a mere gathering of facts. Rather,
these facts must be evaluated in terms of their ethical relevance. This demands expertise in the field
of ethics, including the ability to “reconstruct, classify and evaluate normative arguments
and frameworks, and to proceed in a manner consistent with ethical theory” (ibid.: 45).

JUSTIFICATION OF NORMS, finally, consists in the fact that the process of creating technology
standards should take place for ethical reasons as well, and not solely for purely technical or
bureaucratic reasons, or for the advantage of the standardizers themselves (ibid.: 45). A distinction
must initially be made between legal, economic and social grounds and ethical factors, even if the
former can also be ethically relevant. When technologies are of global significance, a cross-cultural
dimension should be taken into account (ibid.: 46).

Legitimation

FIGURE 13:
Conceptualization
Ethics Functions of ethics
Source: Authors. Data: Woopen
and Mertz 2014, Bertelsmann
Evaluation Stiftung

Justification of Norms

The goal of the ethical analysis is to point out and describe the complexity of the technological
transformation being led by the tech giants in the healthcare sector, to promote discussion about
it, and to develop recommendations for action that can promote desirable innovations and avert
potentially negative consequences. This corresponds to an ethics-by-design approach, a strategy
that is currently becoming more prominent particularly in the field of AI development. Under this
framework, development and design teams reflect upon ethical factors as an integral element of
their entire process, both before and during the technology’s deployment, rather than considering
these factors only after development has been completed. One element of this concept is the initial
use of a participatory process to identify and eliminate potential problem areas (Brey and Brandt
2020).

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4.2
ETHICAL VALUES AND PRINCIPLES

The following ethical analysis of the tech giants’ health-related activities is based on eight
values and principles (Data Ethics Commission 2019) that refer to the fundamental rights and
freedoms enshrined in documents including the Charter of Fundamental Rights of the European
Union (CFR),98 the European Convention on Human Rights (ECHR),99 the Universal Declaration
of Human Rights (UDHR),100 and, for example, the Basic Law of the Federal Republic of Germany
(GG).101,102 These eight values and principles are:

҉ Human Dignity
҉ Freedom and Self-Determination
҉ Health
҉ Privacy
҉ Security
҉ Justice and Solidarity
҉ Sustainability
҉ Democracy

4.2.1
HUMAN DIGNITY

“Human dignity is a principle that presupposes the unconditional value of every human being,
prohibiting such practices as the total digital monitoring of the individual or his or her humiliation
through deception, manipulation or exclusion” (Data Ethics Commission 2019: 14).

Drawing on the Basic Law of the Federal Republic of Germany (GG), the Charter of Fundamental
Rights of the European Union (CFR), the European Convention on Human Rights (ECHR) and the
United Nations Declaration on Human Rights (UDHR), human dignity is considered as being the
first, most fundamental principle. Although there is no universally valid, ubiquitously accepted
definition of human dignity, there is widespread agreement on a core aspect of the term: that
human beings, in themselves, possess an unconditioned value that is not linked to any other

98 Charter of Fundamental Rights of the European Union, OJ 2010/C 83/02.

99 Convention for the Protection of Human Rights and Fundamental Freedoms of 4 November 1950.

100 Universal Declaration of Human Rights, of December 10, 1948, UN A/RES/217-A-(III).

101 Basic Law for the Federal Republic of Germany (GG), of May 23 1949, BGBI. 1; as amended on 29 September 2020, BGBI. I, 2048.

102 Given the scope of this work, it is impossible to provide a comprehensive account here of the many different facets and ways of
conceptualizing individual values and the trade-offs between them. However, the study identifies the authors’ standpoint on
these subjects, and contains references to related literature.

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 ETHICAL ANALYSIS

specific capacity or characteristic, and does not first have to be acquired by any action, deed
or fulfilment of condition.

Human dignity entails a social claim to value and respect that prohibits actions making persons
into a “mere object” of state action, or which subject them to treatment that fundamentally fails
to invariably recognize them as autonomous individuals.103 On the one hand, this obliges the state
to respect its citizens’ human dignity and fundamental rights. On the other, the state, by means
of regulation, must also protect its citizens against violations of these rights by third parties.

As early as 1486, Giovanni Pico della Mirandola referenced the idea of human dignity in his Oratio
de Hominis Dignitate,104 in which he placed particular emphasis on the principle of freedom:
“‘The nature of all other creatures is defined and restricted within laws which We have laid down;
you, by contrast, impeded by no other restrictions, may, by your own free will, to whose custody
We have assigned you, trace for yourself the lineaments of your own nature’” (Pico della Mirandola
1956).105

In Article I of the Universal Declaration of Human Rights, the United Nations also says that
“all human beings are born free and equal in dignity and rights (…)” (UN 1948), thus indicating
that human dignity is intertwined with human freedom. The human being is therefore entitled
to respect solely because he is human;106 he is not subject to any classification.

According to this understanding, people can utilize technology in order to “realis[e] human ideas
and objectives more effectively and rapidly and with fewer errors” (Data Ethics Commission 2019:
43). However: “At the same time, the notion that technology should serve humans rather than
humans being subservient to technology can be taken as incontrovertible fact” (ibid: 14).

4.2.2
FREEDOM AND SELF-DETERMINATION

“Self-determination is a fundamental expression of freedom, and encompasses the notion of

informational self-determination. The term ‘digital self-determination’ can be used to express the idea
of a human being as a self-determined player in a data society” (Data Ethics Commission 2019: 14).

Freedom and self-determination are fundamentally intertwined. There are a variety of different
definitions for each, all subject to a rich array of interpretations. In the case of the first concept,
a distinction can be made between positive freedom – according to which individuals develop and

103 See, for example, the decisions of the German Constitutional Court, BVerfGE 27, 1, 6; 45, 187, 228; 109, 133, 149 f.; 117, 71, 89.

104 English translation: “Oration on the Dignity of Man”.

105 Translated by A. Robert Caponigri in Pico della Mirandola (1956).

106 “(…) the value which is inherent in every human being and which does not need to be acquired (…)” (Data Ethics Commission
2019: 43).

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TECH GIANTS IN HEALTHCARE

pursue their own self-chosen goals – and negative freedom, referring to the absence of external
obstacles (Carter 2016; Berlin 2002).

Self-determination is understood here as “the possibility of realizing one’s own plans of actions
and decisions on action. [This] is a fundamental anthropological idea whose realization depends
on empirical circumstances” (German Ethics Council 2013: 111). It is human beings’ autonomy
that makes this possible. This refers to “the fundamental ability of humans to engage in sensible
reasoning, exchange reasons for actions with other individuals, and make responsible decisions
on their own initiative. This ability marks humans as moral beings” (ibid).

In the digital space, the focus is on informational self-determination and digital self-determi-
nation. The constitutionally recognized principle of informational self-determination essentially
refers to “the authority conferred on the individual to, in principle, decide themselves on the
disclosure and use of their personal data.”107 For example, the state is prohibited from collecting
or using data unless it has a legal basis for doing so that strikes an appropriate balance between
the right to informational self-determination and the interests of the state. Moreover, the state
must also ensure that its regulations sufficiently balance the interests of the private actors
involved – for example, those of the data subjects and the companies that use their data. Europe-
wide Regulation of this type is found primarily in the General Data Protection Regulation (GDPR).108

Digital self-determination refers to an actor who, on the basis of sufficient information about
differing possibilities, makes a voluntary decision based on his or her own personal values regard-
ing how to handle his or her own data, the digital exchange of information, and the use of digital
products or applications, and then acts accordingly (Mertz et al. 2016). “Digital self-determination
always goes hand in hand with digital accountability” (Data Ethics Commission 2019: 44).

4.2.3
HEALTH

“Health is a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity” (WHO 2006: 1).

With this sentence, which the World Health Organization (WHO) wrote into the preamble of its
constitution in 1946, the organization emphasized its biopsychosocial conception of health. It
regards the possession of the best possible state of health as a fundamental right. In the U.N.
Social Covenant,109 this was included as “the right of everyone to the enjoyment of the highest
attainable standard of physical and mental health.” This is not meant to imply that people can be
in a completely optimal state of health at all times. Rather, the goal is to ensure that the standard

107 See, for example, the decision of the German Constitutional Court, BVerfGE 65, 1 ff.: “Under the modern conditions of data
processing, the free development of the personality presupposes that the individual is protected against the unlimited
collection, storage, use and disclosure of his or her personal data.”

108 See above footnote 3.

109 International Covenant on Economic, Social and Cultural Rights of 16 December 1966, UN A/RES/2200-A-(XXI).

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 ETHICAL ANALYSIS

of measurement being used relates to the achievement of the best possible level of individual and
public health in every case. This goal is to be realized through appropriate access to good health-
care and the creation of health-promoting conditions, while also taking the social determinants of
health into account (WHO 2008; Krennerich 2020; WHO 2021c; Wulf 2016; WHO 2004). The WHO
emphasizes that all people have the same right to health, and that this is essential for the attain-
ment of peace and security110 (WHO 2006). The right to health is also enshrined in Article 35 of the
EU Charter of Fundamental Rights.111

4.2.4
PRIVACY

“The right to privacy is intended to preserve an individual’s freedom and the integrity of his or her
personal identity. Potential threats to privacy include the wholesale collection and evaluation of data
about even the most intimate of topics” (Data Ethics Commission 2019: 14).

Within the philosophical discourse, there is no uniform definition for the concept of privacy.
Aristotle uses the term to distinguish between a public, political level (polis) and a private,
familial or domestic level (oikos) (DeCew 2018). This distinction implies that different entities
have different responsibilities with regard to setting rules: 1) the state in the public sphere and
2) the individual in the private sphere (ibid.). According to the conception of privacy stemming
from the so-called Age of Enlightenment still valid today, every person simply has the right
“to be let alone” (Warren and Brandeis 1890).112

The principle of privacy is intertwined with human dignity and self-determination, including
informational self-determination. Thus, everyone has the right to protect their own privacy even
within the public sphere (DeCew 2018; Data Ethics Commission 2019)113 – and, in so doing, the
right to lead a self-determined life. This also includes personal control over “who may access
which personal information relating to him or her, and when and for what purpose they may
do so”. The state protects privacy through “legislative measures to regulate the responsible use
of personal data” (Data Ethics Commission 2019: 45).

110 “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without
distinction of race, religion, political belief, economic or social condition. The health of all peoples is fundamental to the
attainment of peace and security and is dependent upon the fullest co-operation of individuals and states” (WHO 2006: 1).

111 See Article 35 of the Charter of Fundamental Rights of the European Union, OJ 2010/C 83/02: “Everyone has the right of access
to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and
practices. A high level of human health protection shall be ensured in the definition and implementation of all Union policies
and activities.”

112 See Warren and Brandeis (1890: 193).

113 See also the German Constitutional Court’s decisions, VerfGE 115, 11, 183 ff.; 101, 361, 383; 99, 185, 193; 65, 1 ff.

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4.2.5
SECURITY

“The principle of security relates not only to the physical and emotional safety of humans but
also to environmental protection, and as such involves the preservation of vitally important
assets. Guaranteeing security entails compliance with stringent requirements, e. g. in relation to
human / machine interaction or system resilience to attacks and misuse” (Data Ethics Commission
2019: 14).

In its Universal Declaration of Human Rights, the United Nations included the right to security:
“Everyone has the right to life, liberty and security of person.”114 This also includes the right to safe
products, safe working and living conditions, and a safe living environment, for example through
the government’s creation of generally binding safety standards. The societal need for protection
from physical, social and emotional harm is also served by an enforceable claim for compensation
for harm caused by unsafe products, for example (Mohan 2003).

The principle of security is relevant at a number of different levels. For example, it encompasses
the protection of physical and mental health or integrity (e. g., in human-machine interactions),
as well as protection of the environment and public safety. In addition, security includes the
protection of privacy, as this can relate to the collection and use of data, among other concerns
(Data Ethics Commission 2019: 45).

4.2.6
JUSTICE AND SOLIDARITY

“In view of the vast amounts of power being accumulated using data and technologies, and the new
threats of exclusion and discrimination, the safeguarding of equitable access and distributive justice
is an urgent task. Digitalisation should foster participation in society and thereby promote social
cohesion” (Data Ethics Commission 2019: 15).

Ideas about justice serve to determine the “basic coordinates of a morally and legally grounded
structure of relationships” (German Ethics Council 2017b: 219). As concepts of justice have evolved
since Aristotle’s time, different thinkers have come to distinguish between different types of jus-
tice. This includes distributive justice, which relates to the distribution of scarce resources accord-
ing to a specified external standard. Another variety is compensatory justice, which mandates that
damages caused by a criminal act or a breach of contract, for example, must be compensated for on
the basis of their magnitude, and thus independently of any external standard. Finally, the list also

114 Art. 3 Universal Declaration of Human Rights, see above, footnote 100.

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includes procedural justice, stating that just conditions arise because of and through just
procedures.

This inventory is rough at best, and a variety of further nuances are evident in each case. Explicit
conceptions of social justice emerged beginning with industrialization in the 19th century. They
differ, for example, in whether “justice” refers to something attained or to a demand; to equality
of opportunity (for instance under a capability approach)115 or equality of outcome; or to the status
of individuals or the status of groups (along with their related claims). Although there may be
consensus that social justice is something good and desirable, it may in any given case involve
mutually incompatible and mutually exclusive ideas. However, these ideas have a common goal:

“As a normative principle of social relations, justice requires that the arbitrary privileges of indi-
viduals or certain groups be overcome by determining what is appropriate to each in a rational
manner, that each person be given equal consideration in the actions of others, and that differences
in treatment require a consensual justification” (German Ethics Council 2017b: 222).

In legal terms, the principle of equality enshrined in Articles 20 and 23 of the Charter of
Fundamental Rights of the European Union,116 is of key importance. The state is, simply stated,
generally prohibited from treating substantially equal entities unequally –, unless this is based on
sufficiently weighty factual grounds, and is done so in reasonable proportion to the disadvantages
suffered by the individual.117 In addition, there are absolute prohibitions of unequal treatment based
on enumerated characteristics.

Justice and solidarity are closely linked, but are not coincident. Solidarity has numerous facets,
ranging from the sense of belonging, to the creation of a group that stands up for a common goal,
to mutual support under conditions of scarcity (Woopen 2008). Most conceptions of solidarity share
a number of key elements: “The concept of solidarity denotes prosocial behaviors, practices and
dispositions, as well as institutional, political and contractual regulations, the purpose of which
is to assist others” (German Ethics Council 2017a: 25).

Most authors also agree that to be able to speak of solidarity, the element of prosociality must be
supplemented by corresponding actions or the assumption of costs – understood in a broad sense
– such as those of a financial, social, emotional or temporal nature (German Ethics Council 2017a:
25). “Solidarity is frequently understood as complimentary to – and often subsidiary to – the
concept of justice” (ibid.). Underlying solidarity is the fact that “it regularly emerges against the
background of a group’s common goals, in the face of a common challenge or from a shared idea of
the good life within a mutually supportive community”, as in the case of the German welfare state
(ibid.: 25).

115 See, for example, Sen (1979), Sen (2009), Daniels (1990), Nussbaum (1998), Nussbaum (2015).

116 See above footnote 98.

117 See especially BVerfGE 55, 72, 88.

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TECH GIANTS IN HEALTHCARE

Thus, solidarity is not to be regarded as neutral, but can rather be seen as “standing between the
just and the good” (German Ethics Council 2017a: 228) or as “just compassion” or “compassionate
justice” (Woopen 2008). In the area of digital healthcare, technology can help strengthen solidar-
ity, but can also undermine and weaken it (Data Ethics Commission 2019: 47).

4.2.7
SUSTAINABILITY

“Digital developments also serve sustainable development. Digital technologies should contribute
toward achieving economic, ecological and social sustainability goals” (Data Ethics Commission
2019: 15).

There is no uniform understanding of the concept of sustainability. The most widely used defini-
tion comes from the 1987 Report of the World Commission on Environment and Development ‘Our
Common Future’: “Sustainable development is development that meets the needs of the present
without compromising the ability of future generations to meet their own needs” (UN 1987: 37).

As the concept of sustainability has developed over time, various models118 have emerged that all
include the three dimensions of social, ecological, and economic sustainability (Pufé 2014: 17-18).
These are also reflected in the United Nations’ 17 Sustainable Development Goals (SDGs),119 which
seek to further sustainable development at the social, environmental, and economic levels in
all countries by 2030 (UN 2015; Data Ethics Commission 2019: 47). Tech-based innovations can
contribute to realizing sustainable development goals, for example by making resource use more
efficient (Data Ethics Commission 2019: 47). At the same time, they also demand the utilization of
immense quantities of resources, for instance through the perpetually rising demand for energy,
which is unsustainable and may be associated with negative impacts on the environment (van
Wynsberghe 2021; WHO 2021a; Data Ethics Commission 2019).

Sustainability goals are closely related to the demands of justice. This includes intra- and inter-
generational justice (Pufé 2014: 20). The former concerns aspects related to the equitable global
distribution of growth and prosperity and the use of resources, especially against the background of
a gap between the Global South and the Global North (ibid.: 16). Intergenerational justice touches
on issues of global responsibility for future generations (Data Ethics Commission 2019: 47). In
Germany, for example, the protection of the natural foundations of life is also constitutionally
enshrined in Article 20a of the Basic Law.

118 See: Three pillar model, the overlapping-circles model and the sustainability triad (Pufé 2014: 17–18).

119 The Sustainable Development Goals include e. g. “good health and well-being” (SDG 3), “responsible consumption and
production” (SDG 12), and “climate action” (SDG 13) (UN 2015).

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4.2.8
DEMOCRACY

“Digital technologies are of systemic relevance to the flourishing of democracy. They make it possible
to shape new forms of political participation, but they also foster the emergence of threats such as
manipulation and radicalization” (Data Ethics Commission 2019: 15).

Etymologically speaking, democracy is rule by the people, with the term containing elements of
the Greek words demos (people) and kratos (rule or power) (Kuyper 2015; Keane 2009). In short,
democracy is a political order in which citizens govern themselves through a decision-making
process in which each has more or less the same rights (Kuyper 2015).120

Digital technologies are “in a complex manner systemically relevant for the development of funda-
mental rights, (…) for democracy, (…) [and] for an open societal debate” (Data Ethics Commission
2019: 46). Education and training also play a central role in “safeguarding the free democratic basic
order,” in which the democratic principles of the state are guaranteed and the fundamental rights
enshrined in the constitution are protected. Among their other effects, these institutions impart
technical skills and thereby create “the participation of citizens in the shaping of society – a pro-
cess that is of critical and fundamental importance for democracy” (ibid.).

120 “(…) a political practice in which individuals govern themselves through some form of equitable decision-making process“
(Kuyper 2015).

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4.3
TRANSFORMATION IN HEALTHCARE AND THE HEALTHCARE
SYSTEM

Observers have long placed high hopes in the prospect of a fundamental, digitalization-driven
transformation of the healthcare sector. As often envisioned, this would entail the collection and
processing of vast amounts of data generated by a wide range of sensors gathering data in, on and
outside the human body, with analysis supported by the use of artificial intelligence. The trend is
seen as an opportunity for the widespread introduction of patient-centered precision medicine
(Topol 2015), although potential problems of many different kinds are also being discussed (IBC
2017; German Ethics Council 2018). This transformation has today progressed to different degrees
in different countries (Thiel et al. 2018), and is dynamically reshaping the industry, shifting
boundaries and even dissolving intersectoral borders. In the following sections, we highlight
a number of these changes, and discuss them on the basis of the values and principles outlined
above.

These developments have not been driven exclusively by tech giants, as many other sectoral actors
have also had a significant influence. However, the tech giants have played a dominant role. This
is due to their disproportionately greater technical capacities and competencies, as well as their
financial and thus also personnel resources. The sum of these advantages allows them to occupy
a monopoly-like position. As described in chapter ➔ 3, the large companies offer a wide range
of health-related products and applications for patients and users as well as for healthcare profes-
sionals. They are also active in the science, research and development fields, and provide additional
support for such activities through cooperative ventures and partnerships. In some cases – although
these remain only a few – they are even developing and establishing healthcare structures such as
hospitals and integrated care services, and operating their own health insurance programs.

Ultimately, tech giants are advancing digital healthcare, and have the potential to become indis-
pensable actors within the healthcare sector – making it dependent on them in at least some areas.
In general, European tech giants have tended to focus on producing specific devices and appli-
cations for clinical areas or individual conditions, while U.S. tech giants have accumulated their
power to shape individual and social life, including the market, by gathering huge amounts of data
from different areas of life, and then basing business models and projects on this resource. For
their part, Chinese companies also collect huge amounts of data, but their products and applica-
tions are additionally used to assess and control users.

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 ETHICAL ANALYSIS

The collection of large amounts

Strengthening
➔
of health-related data from different areas of life
and real-time data processing by AI systems is leading
to a shift in focus in the medical field
data-based
➔ Sometimes referred to as P4 medicine
prediction,
(preventive, predictive, personalized and participatory); prevention and
individualized, personalized, or stratified medicine;
disease interception; or precision medicine precision medicine

➔ A need to constantly update

health profession skill sets in
Multidimensional the provision and organization

change in competencies of healthcare services

Change in health professions’ required

of healthcare
➔
skills and self-conception

professionals ➔ Emergence of new health professions

➔ Redesign of education, training and

continuing education programs

➔ Traditionally separate sectors

become less distinct and begin to merge due
to the digital availability of health data in a
highly digitally networked system
(integration of outpatient, inpatient and
Monopolization
rehabilitative sectors; public and private sectors) and dissolution of
➔ Great financial, human and technological
sectoral boundaries
resource advantages give tech giants a lead in
collecting and processing huge amounts of data, due to digital healthcare
and in the (further) development of AI systems

Data from everyday healthcare is generated,

Linking everyday
➔
combined and processed for research purposes

care and research ➔ Research findings are systematically

introduced into everyday care
to a learning
Everyday care and research are linked
healthcare system
➔
in a regulated cycle of knowledge generation
and knowledge application

FIGURE 14: Transformation in healthcare and the healthcare system

Source: Authors, Bertelsmann Stiftung

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TECH GIANTS IN HEALTHCARE

4.3.1
STRENGTHENING DATA-BASED PREDICTION, PREVENTION AND
PRECISION MEDICINE

The multifaceted debates over the future of digitalized healthcare have produced numerous visions
for the future, ranging from incremental transformations to the creative destruction of current
medical practices and structures (Topol 2015; Thuemmler and Bai 2017; Topol 2013). Many observ-
ers agree that one major advance in particular – a shift in the healthcare field’s focus from thera-
peutic care to prevention – is likely to have a positive impact on both individual and public health.
This development is being facilitated by the accumulation of large amounts of health-related data
from different areas of everyday life, often collected by users and patients themselves, paired with
the real-time processing of this information by AI systems. This represents an important, if not
yet sufficient step in the transformation toward a “no longer reactive, but rather preventive and
personalized medicine, which would be made possible by the precise knowledge of individual risk
factors, subjective states and the possible side effects of the medications administered” (Research
Services of the German Bundestag 2013: 2; Friele et al. 2020).

A variety of different terms are used to refer to this new type of medicine, each focusing on
different aspects. For example, U.S. biomedical scientist Leroy Hood has introduced the term
“P4 medicine,” which characterizes healthcare as being preventive, predictive, personalized and
participatory; to date, this concept is developed primarily within the oncological field. As a catch-all
term, it refers to healthcare that engages patients and users in the care process more fully than is

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typical today; prefers preventive to curative goals; and tailors treatments to the individual to a greater
degree than is currently the norm (Topol 2015; Sharon 2017; Swan 2012; Ekman et al. 2011; Hood 2013).
Other experts refer to individualized, personalized or stratified medicine (Woopen 2011); to “disease
interception” (Jessen and Bug 2019); and to precision medicine (German Medical Association 2020a).

By predicting risk factors and building individual risk profiles based on a variety of data such
as diet, exercise and sleep patterns, and consumption habits, it is possible to make recommenda-
tions regarding behavior and treatments that can prevent the development of illness or reduce its
severity. Digital self-tracking by means of wearables and apps – also known as “lifelogging” or, as
an approach followed by a whole movement, the “quantified self” (Quantified Self 2021) – enables
data on vital parameters to be collected, combined and analyzed in conjunction with behavioral and
environmental data. The resulting data stream allows deviations from normal levels to be detected
quite quickly, so that both users and medical personnel can be swiftly informed (➔ 3.3, Google
DeepMind’s Streams app).

Users, patients and care providers can thus engage in proactive action, promptly taking any
steps necessary to increase the chances of staying healthy or of detecting diseases at an early HEALTH

stage (Hahn and Schreiber 2018: 342). For example, ambient assisted living (AAL) environments
create synergies by linking smart home applications, virtual assistance systems and telemedicine
technologies, collectively contributing to prevention and early detection, and helping to increase
patients and users’ independence and quality of life (➔ 3.3 Philips Ambient Experience for Health-
care Project) (Manzeschke et al. 2016; Rubeis 2020). This can improve residents’ health and quality
of life, and support them in making behavioral changes.

However, for such improvements to occur, patients and users must actually implement the
measures recommended, and make changes to their lifestyle. As smoking-cessation, exercise
and diet-change programs have long shown, this is often a difficult hurdle. Thus, the actual
efficacy of these applications needs to be examined in greater detail. However, tech giants generally
place a low priority on such follow-up studies. This is because their business models are already
successful enough once a product such as a wearable has been sold, or an app has been downloaded
and used for a short amount of time.

Self-tracking can also “promote an exaggerated pursuit of optimization that is detrimental to

health, along with a medicalization of ‘natural’ life processes” (German Ethics Council 2017b: 120).
In extreme cases, it can involve bringing the conduct of a person’s entire life, or at least large parts
of it, under health-oriented scrutiny. As desirable as health-promoting behavior may be, health
is not the highest good toward which all behavior in life should for ethical reasons be directed.
In addition, a one-sided fixation on health matters, continuous self-observation using technical
devices, and the determination of one’s own individual risk of developing certain diseases such
as Alzheimer’s, for instance through genomic analysis or the identification of biomarkers, can be
associated with elevated levels of psychological and physical stress (ibid.: 198) (Woopen 2016, V1).

The mass digital collection of data with the goal of optimizing health and guiding behavior leads
to a kind of “datafication” of the human being – that is, a “transfer of physical, sociological or
psychological conditions into informatically coded datasets” (Wiegerling et al. 2019: 445). This
transfer into the digital cannot capture everything about a human. Much in fact cannot be trans-
lated into a binary logic. Above all, this excluded category includes the subjective perspective from

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which a person perceives their own self and everything around them, and from which they assign
meaning to the world.

The complexities of a person’s perception, feelings and actions cannot be captured digitally; nor
can the experience of meaning in life. The self, the I, experiences a meaningful or not meaningful
life as a unit of body, mind and feeling. According to this view, dealing with the person as if he
or she could be completely digitized would not do justice to the essence of their being, or to their
dignity as a human. In addition, this could lead over the long term to a loss of differentiated indi-
vidual personalities, due to the emergence of a data-based “one-dimensional image of man” (Selke
2016: 329). To preserve individual freedom and self-determination, this should be countered with
a preventive approach that would in any case be desirable in itself.

The construction of comprehensive individual profiles based on algorithmic analysis of personal

HUMAN data also raises questions about the integrity of the personality, another issue relevant, amongst
DIGNITY
others, to human dignity and freedom. The construction of personal profiles, or “profiling” is
defined under Article 4 (4) of the GDPR121 as “any form of automated processing of personal data”
carried out “to evaluate certain personal aspects relating to a natural person, in particular to anal-
yse or predict aspects concerning that natural person’s performance at work, economic situation,
health, personal preferences, interests, reliability, behaviour, location or movements.”

Ultimately, profiling “involves making deductions (drawing conclusions) on the basis of input
data” that may involve actual or perceived “properties” of the individual or serve as a prediction
of future behavior (Data Ethics Commission 2019: 99). This generates privacy risks, along with the
possibility that personality profiles could be used to control and manipulate people (ibid.: 36).

Thus, “the individuality of the person can be considerably reduced by the normative power of data”
(Heyen 2016: 6), a circumstance that would limit that person’s freedom and narrow his or her
opportunities for self-determination.

Technical improvements in prediction and prevention, and in the early detection of diseases, offer
patients and users more options as they make decisions and act. This consequently gives them
more responsibility. It expands the space for self-determination in which users can and must
weigh for themselves the advantages and disadvantages of digital self-tracking technologies as
used for health purposes. Assessing trade-offs in this way is an element of digital literacy, and is
necessary in order to engage in digital self-determination. Digital literacy in the healthcare context
is here understood to refer to the ability to select and use digital technologies in accordance with
one’s own values; to operate them correctly; and to find, critically evaluate and use health infor-
mation online (Woopen et al. 2016: 34).

The increasing quantity of readily accessible health-related knowledge is also changing patients and
FREEDOM users’ role in the relationship between physicians and patients (Ekman et al. 2011; Skär and Söder-
AND SELF-
berg 2018), as well as in the integrated healthcare context. On the one hand, this can help empower
DETERMINA-
TION patients, and lead to a more efficient, partnership-based and self-determined treatment process.
The new relationship relativizes health professionals’ traditional monopoly on knowledge, which

121 See above, Footnote 24.

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 ETHICAL ANALYSIS

Examples of technologies relevant to security and privacy

ALIBABA META (formerly Facebook) GOOGLE

According to a New York Times The facebook social network contains One controversial aspect of virtual assistant
analysis, the COVID-19 Alipay functions that identify supposedly systems is the capability to listen continu-
Health Code contact-tracking suicidal persons, to the extent allowed ously and analyze all voice-based informa-
system provides real-time data on by locally applicable data protection tion (Subcommittee on Antitrust, Commer-
whether someone is an infection regulations. For example, Meta (for- cial and Administrative Law 2020: 314).
risk, while also sharing this infor- merly Facebook) monitors what people For its series of smart home products, for
mation with the police, potentially write online, as well as the reactions of example, Google has already had to admit
creating a model for new forms those who respond. If these processes to flaws in its compliance with data security
of automated social control that identify a person suspected of being rules. Media reports have indicated that the
could persist long after the end of suicidal, employees decide whether to devices had the capacity not only to listen
the pandemic (Mozur et al. 2020) inform the police (Kaste 2018) (➔ 3.1 after activation (“OK, Google.”), but also to
(➔ 3.2). and the nuanced reflections of German constantly analyze and process everyday
Ethics Council (2017b: 246-247)). sounds (Krempl 2020; Quach 2020) (➔ 3.2).

can in turn free patients from the constraints of physician paternalism. As patients and users par-
ticipate and assume more responsibility, this contributes to a “democratization of medicine” (Topol
2015). In the P4 context, digital technologies not only facilitate data collection and processing, but
also communication and networking, and thus participation.

On the other hand, there is also a risk that patients and users may find themselves overwhelmed.
If basic skills such as health literacy, digital literacy and digital health literacy are overtaxed, this
can produce situations in which data is not collected and classified correctly; this may in turn lead
health professionals to initiate inadequate courses of treatment, endangering patients and users’
health (German Ethics Council 2017b: 161).

The digital collection and processing of personal data, especially in networked systems, raises
far-reaching questions about the protection of privacy and security. PRIVACY

Technologies that primarily fulfill non-health functions in everyday life, such as smartphones and SECURITY

digital voice assistants with their various applications, demand particular attention in this regard.
These devices blend diverse functions such as telephoning, playing games, communicating via social
media, navigating the internet, searching for information, listening to music, measuring various
aspects of the user’s behavior and so on. In a networked world, this creates myriad tracking pos-
sibilities, and presents a gigantic challenge with regard to protecting privacy. Shoshana Zuboff has
coined the term “surveillance capitalism” to describe this phenomenon (Zuboff 2018). To be sure,
the collection of a broad range of data types from within a person’s everyday behavior could help in
constructing risk profiles for individual patients and users, subsequently leading to better preven-
tion-focused recommendations – provided, at least, that these recommendations are scientifically
grounded. However, such a system also risks undermining privacy protections and even the integrity
of the personality.

Health is known to be influenced quite significantly by socioeconomic determinants (WHO 2004).

In some cases, the use of digital technologies and applications can positively influence these JUSTICE AND
SOLIDARITY
determinants for some people, or at least offset disadvantages. Strengthening prevention could
be particularly beneficial for such groups, with digital technologies thus contributing to greater

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equity. For example, it is conceivable that low-threshold digital access to health information could
compensate for relatively low educational attainment, which is an important determinant of health.
However, access alone is not enough; potential users must also have the motivation and sufficient
skills to take advantage of this access, and must ultimately change their behavior. There appears to
be considerable need for further research and development in this area in order to design services
so that they actually have this kind of impact, particularly among groups of relatively low socio-
economic status (see, for example, Satterwhite Mayberry et al. 2019).

In this regard, digital health services could be an excellent means of closing care gaps in underserved
areas such as rural regions, and of reducing health inequalities more broadly – for example, by offer-
ing telemedicine services specifically to groups that previously had little or no access to medical care.
However, this requires that these groups also have the technical ability to access and use the digital
services. The widespread availability of smartphones today serves as a good starting point. But this in
itself is not enough, given that disadvantaged socioeconomic conditions are often closely associated
with low levels of digital and health literacy (Stormacq et al. 2019). If the hoped-for benefits of digital
health technologies are indeed to create equity of access across the population, the aspects of digital
skills and user motivation must also be taken into account (see, for example, Western et al. 2021).

The experts interviewed for this study predict that telemedicine and hybrid healthcare solutions
will make significant future contributions to closing care gaps in rural areas. Moreover, they expect
these technologies to help reduce global health disparities. However, some also fear an expansion
of the social phenomenon known as the “digital divide” or “digital gap” (Ibrahim et al. 2021;
Cornejo Müller et al. 2020; Marckmann 2020; IBC 2017). The digital divide refers to inequality in
access to digital services and products. This can be associated with a variety of causes and contexts
(education, socioeconomic status, age, etc.) (Cornejo Müller et al. 2020; Schüz and Urban 2020). In
some cases, populations within a given country or entire national populations worldwide already
experience major inequities in accessing healthcare services; if the digital divide were to addition-
ally place digital healthcare services out of their reach, these populations would find themselves
subject to multiple disadvantages and discrimination (Cornejo Müller et al. 2020). The WHO and
OECD report that in certain regions of the world, socioeconomically better-off individuals have
extensive access to good-quality digital infrastructure; this circumstance already leads to the
systematic exclusion of certain groups, a fact which became increasingly evident during the
COVID-19 pandemic, for example (WHO 2021a; OECD 2020).

The potential for discrimination due to the use of algorithmic and in particular AI-based technologies
also raises questions relevant to justice. Such systems can produce systematically biased or incor-
rect results due to the use of incomplete or biased datasets122 to train the AI systems, for example.
Technical and methodological decisions, such as the choice of variables when setting optimization
objectives, can also yield poor-quality results. This can lead to specific individuals and groups (such
as women, ethnic minorities, people with rare diseases, people with disabilities, or intersex and
transgender people) being unjustifiably systematically disadvantaged or excluded (Data Ethics Com-
mission 2019: 167-168; Central Ethics Commission of the German Medical Association 2021, A7).123

122 See, for example, the facial recognition technologies separately produced by Amazon and Google (Wiggers 2019; Kühl 2015).

123 See, for example, Central Ethics Commission of the German Medical Association (2021); WHO (2021a); Data Ethics Commission
(2019); Gianfrancesco et al. (2018); Orwat (2019); Obermeyer et al. (2019); O’Neil (2018); Weichert (2018); Cain (2015).

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For example, in the United States, it has been shown that at the point of being released from the
hospital, women with coronary heart disease (CHD) had on average received lower-quality care
than men with the same condition, and that this was associated with a higher mortality rate after
three years (Li et al. 2016). If this underlying mortality data were used to train an AI system with-
out adequate consideration of the data relating to treatment disparities, this could influence the
results and recommendations produced by the AI system in such a way that women would continue
to receive worse treatment than men (Baumgartner 2021).

Sociologist Stefan Selke has coined the term “rational discrimination” in reference to the social
effects of widespread self-measurement (Selke 2016). Typologically, Selke locates this social
phenomenon between “social discrimination”, which places people at a disadvantage on the basis
of group-specific characteristics (age, gender, ethnicity, etc.), and “statistical discrimination”,
which occurs when incomplete information about people is supplemented by probabilistic assump-
tions (origin, qualifications, etc.). Rational discrimination occurs when “individual values are
compared with group, average or ideal values” that have been defined in advance as standard
or normal values, and which might be referred to as “the corridor of human evaluability”
(Selke 2016: 323-324).

Questions of equity also arise with regard to use of technologies to determine health insurance
companies’ tariff and premium structures. For example, in a statutory health insurance system
based on the principle of solidarity, as exists in Germany, “designing health insurance tariffs
fairly (…) requires balancing the idea of equity with regard to policyholders’ ability to pay with
the conditions of a healthcare system financed on the basis of solidarity” (German Ethics Council
2017b: 224). The German state-managed health insurance system is fundamentally not designed
to take individual risk levels into account when calculating premiums, as it is based on the principle
of solidarity; this means that every insured person, as part of an extended community of risk, is
equally entitled to receive help in a situation of need, regardless of why or how he or she is in that
situation. Thus, for all insured persons, premium levels are equally based on the individual capacity
to pay, and not on the individual risk of falling ill.

Nonetheless, it is also possible to create incentives for healthy behavior within this system, for
example in the form of benefits or bonuses provided to those who adhere to certain behaviors.
However, within the various kinds of insurance models based on behavioral and lifestyle data,
certain groups are problematically excluded from perks. This may be because there are certain
actions they are unable to take – for example, wheelchair users cannot count steps – or do not
desire to take. There can be various reasons for not wanting to take such actions, including a wish
to protect one’s privacy. Since living conditions are often not subject to individual control, the
principles of solidarity require that, when health insurance tariffs reward preventive measures by
providing policyholders with financial bonuses, these benefits are available to all insured persons to
the same extent, and that the policyholders can consciously decide for or against their use (German
Ethics Council 2017b: 224-225).

Health insurers could even make preventive behavior obligatory, or introduce a principle of fault
into the system – for example, if a failure to act preventively had a negative impact on the insur-
ance benefits provided. However, this would lead to a loss of solidarity, and would fundamentally
undermine the solidarity-based nature of the system. This said, it is not completely unimaginable
that individuals could be required to contribute to the costs of treatment made necessary by their

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own actions. In this regard, it should however be borne in mind that due to the complexity of bio-
logical mechanisms, it is rarely possible to trace the causal origin of an individual condition back to
a specific patient’s behavior. Rather, such relationships can usually be only depicted in a statistical
way (Schmitz-Luhn 2015: 123-130).

Technology-based innovations can improve the efficiency of resource use, for instance by optimizing
SUSTAIN­ administrative processes and the provision of care. In this regard, they can help to achieve econom-
ABILITY
ically and ecologically sustainable development goals (Data Ethics Commission 2019: 47). Yet such
innovations themselves consume immense amounts of resources, for example due to the perpetually
rising energy requirements associated with AI development and the use of blockchain technologies
(van Wynsberghe 2021; WHO 2021a; Data Ethics Commission 2019). Numerous studies have testified
to AI technologies’ high levels of carbon dioxide emissions and related environmental impacts.124

UNESCO’s International Bioethics Committee (IBC), in its “Report on Big Data and Health,”
additionally points to the mountains of e-waste generated by the ever-shorter product cycles
characterizing items such as smartphones and wearables, as well as all the environmental and
social sustainability issues associated with the extraction of the rare earths for use in electronic
devices (IBC 2017). Preventive care can reduce costs both with regard to individual treatment and
within healthcare-sector structures more broadly. However, these savings must also be compared
with the costs incurred by engaging in more comprehensive prevention. The final evaluation must
be based not only on which option results in greater financial savings, but also on societal values
such as the value of health.

IN SUMMARY, technology provides opportunities to significantly increase the importance of

prediction and prevention as compared to therapy and rehabilitation – ideally with the consequence
that illnesses can be prevented or detected early, thus reducing their severity. Technologies such
as digital self-tracking mechanisms and recommendation systems can promote behaviors that
preserve and promote good health. This in turn expands users and patients’ options for decision-
making and action, gives them more individual responsibility, and increases the degree to which
they participate in their own care. Changing roles in the relationship between physicians and
patients, as well as in an integrated care environment more generally, can make treatment pro-
cesses more efficient and give them a more partnership-based character, while also facilitating
a democratization of medicine. However, patients that fixate single-mindedly on health issues,
leading their lives disproportionately in accordance with the dictates of health, risk harming
themselves both psychologically and physically.

AI-based systems, algorithmic profiling mechanisms, and possible tracking and monitoring
capabilities all create further challenges associated with potential discrimination and manipulation.
If patients and users lack skills in using the technologies, this can also produce health risks.
Technology can create or expand access to health-promoting digital resources and healthcare
services; however, it can also exacerbate inequities. This is also true of data-based insurance tariffs
and bonus models. The intensive use of resources and the associated environmental impact, the
generation of large amounts of electronics waste, and the need to mine rare earths to manufacture
electronic devices also pose challenges in terms of sustainability.

124 See, for example: Strubell et al. (2019); Preetipadma (2020); Agravante (2020).

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TABLE 2: At a glance – Opportunities and challenges in strengthening data-based

prediction, prevention and precision medicine

Opportunities Challenges

Individual and public health outcomes are improved Natural life processes and lifestyles may increasingly
through the prediction, prevention and early detection be viewed through a medical lens.
of disease.
Risks may be poorly understood, and individuals may
lack the skills to deal with risks appropriately.

Digital self-tracking mechanisms and recommenda- Health becomes seen as the most important value in life,
tion systems can encourage behaviors that preserve and to the extent that all other values become subordinated to
promote good health. health like in a kind of health dictatorship.

As people become more informed, they expand their A fixation on health issues and constant self-tracking
options for self-determined decisions and actions. can create psychological and physical stress.

A one-dimensional, reductionist view of human beings

may develop (datafication).

Algorithmic profiling can contribute to discrimination

and manipulation.

The scope of people’s individual responsibility Individuals may feel overwhelmed by responsibility,
expands. and develop feelings of guilt.

Patients can become more empowered in their The relationship between doctors and patients can
relationship with physicians and in integrated healthcare be jeopardized by incorrect information and dysfunctional
settings. communication.

People with poor digital-health literacy may find

themselves overwhelmed, or even suffer harm.

Treatment processes become more efficient and People who lack skills in dealing with health-relevant
partnership-based. technologies (digital literacy, health literacy) may be exposed
to health risks.

The expansion of patient participation and Tracking and surveillance technologies pose privacy
responsibility promotes a democratization of medicine. and security risks.

Individuals and groups with poor digital skills or poor

access to technologies face greater risks of discrimination.

Digital technologies can compensate for the Inequalities in access to digital products and services
health disadvantages associated with socioeconomic may be worsened (digital divide / digital gap).
determinants.

Digital healthcare offerings can help close gaps Algorithmic or AI-based systems pose discrimination
in care and reduce health disparities. risks, and can be associated with barriers to access.

Health-promoting behavior can be encouraged The direct or indirect introduction of a fault principle
through behavior-based insurance tariffs or health- slowly undermines the solidarity-based nature of the
insurance bonuses. statutory health insurance system.

Optimizing supply and administrative processes can The technology-driven increase in energy and resource
lead to a more efficient use of resources as well as the consumption produces negative social and environmental
realization of sustainable development goals. effects.

A large amount of electrical-device waste is created.

The intensified mining of rare earths leads to

environmental, economic and social sustainability problems.

Source: Bertelsmann Stiftung

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4.3.2
MULTIDIMENSIONAL CHANGE IN COMPETENCIES OF HEALTHCARE
PROFESSIONALS

If day-to-day medical practice evolves into digitalized healthcare as envisioned by the advocates
of P4 medicine, healthcare professionals will need different skills than those most commonly found
today. This will include being able to deal with information technology systems and incorporate
them critically into one’s own actions; being willing and able to work in a patient-centered way
both in networks and in healthcare teams; being willing and able to communicate with increasingly
well-informed patients who have access to their own health data; and being able to take responsi-
bility for engaging in critical reflection when using algorithmic systems, especially AI-based deci-
sion support systems. The skills demanded of healthcare personnel, and thus also the self-con-
ception of the healthcare professions themselves, will change considerably. School curricula and
training and continuing education programs will have to be realigned accordingly.

Healthcare professionals are already being confronted with continuously growing volumes of
patient data, from which they have to select and evaluate the data relevant for their decisions
on care (Central Ethics Commission of the German Medical Association 2021). In this regard,
technologies such as clinical decision support systems (CDSS) (e. g., Siemens Healthineers AI-
Rad Companion ➔ 3.3) and virtual assistance systems (e. g., IBM Medical Sieve ➔ 3.3) can play a key
role in day-to-day medical practice. This is producing a shift in the profession’s core set of compe-
tencies. Traditionally, health professionals have served as the sole experts when treating patients;
now, this role is evolving into a mediation or advisory function between technologies and patients,
and physicians take responsibility for assessing the recommendations and findings produced by
data- and AI-based technologies.

At the same time, practitioners are dealing with potentially better-informed or at least more
comprehensively informed patients, who are taking a much more self-determined approach to
their personal healthcare, and are able to (help) shape the care they receive (Skär and Söderberg
2018). Yet patients still need a kind of intermediary in the treatment context who combines digital
competencies with medical expertise in a meaningful way, and who can use these skills to con-
struct adequate treatment plans. This shift will also require healthcare professionals to develop
and cultivate new skills such as digital health literacy (SVR 2021: 272-277). This dynamic gives
rise to a number of issues, primarily relating to the transformation of medical job profiles and the
emergence of new jobs; however, as technologies become increasingly integrated into everyday
treatment practices, additional concerns relating to safety, reliability and the allocation of respon-
sibility will also emerge.

The use of technology can save time and reduce physical and psychological burdens on healthcare
HEALTH workers, thereby protecting their own health. For example, administrative tasks have been shown to
consume approximately 17 % to 24 % of physicians’ workdays. This expenditure of time correlates
with lower levels of professional satisfaction (Woolhandler and Himmelstein 2014; Rao et al. 2017),
is detrimental to patient care (Rao et al. 2017), and can produce unnecessary costs (Erickson et al.
2017).

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The potentially saved time offered by various technologies can also lead to lower levels of phys-
ical stress for medical staffers. For example, radiologists who regularly analyze large volumes of
imaging material increasingly suffer from eye fatigue that can affect the quality of their diagnostics
(Waite et al. 2017). Overall, the incidence of job-related psychological distress is higher within the
health professions than in the general population. This is associated with long working hours and
demanding situations, among other factors, and can also be correlated with a lower quality of care
(EXPH 2019: 21; Shanafelt et al. 2012; Amoafo et al. 2015; Tziner et al. 2015). Accordingly, by easing
the burden on healthcare professionals, technological support has the potential to have a positive
impact on the quality of care, as it could reduce the volume of human-made diagnostic or treat-
ment errors (Stillman 2018; Rahimi et al. 2018; Sutton et al. 2020). However, this requires that the
systems used for such purposes, such as CDSS tools, produce safe and reliable outcomes.

Technological support provides healthcare workers with more time, thus allowing them to practice
their profession more freely and in a more self-determined manner. Ideally, they can use this extra FREEDOM
AND SELF-
time to focus more fully on patients, especially by engaging directly with them. This can increase
DETERMINA-
the subjectively perceived quality of care, boost patient satisfaction and improve patient adherence TION
to treatment plans (Chandra et al. 2018). In addition, costs are reduced, and improvements in
physician-patient relationships and patient satisfaction correlate with improved health outcomes
(Kenagy et al. 1999; Lobo Prabhu et al. 2018; Kennedy et al. 2014).

However, healthcare professionals can use the time they gain in a self-determined manner for
patients’ benefit only if they are not prevented from doing so by external incentives or motives that
have little to do with patient well-being. The volume-based billing system currently used in most
German inpatient care settings does not provide incentives for a “value-based care” approach (Por-
ter 2010), or for the consequent increase in the quality of care. Rather, there is a danger that more

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and more patients will be processed using automated tools, or that the number of relatively well-
paid staffers will be reduced (DKG 2019; German Ethics Council 2016).

When technologies such as bots and avatars begin playing a part in or even altogether replace
the interpersonal relationship, there is a risk that the relationship between patients and health-
care professionals becomes further depersonalized (Remmers 2019). This is a problem, as human
contact is considered indispensable in healthcare (European Parliament 2016). Furthermore, it has
been observed that practitioners make riskier decisions in virtual consultations than when engaged
in face-to-face conversations (Lee et al. 2015), which means patient safety may suffer as a result.
The treatment process is not limited solely to making the correct clinical diagnosis; rather, empa-
thy and communication are also vital (Meskó et al. 2018), requiring healthcare professionals to
possess human and communication skills that go beyond the realm of purely medical expertise.

Technologically supported process optimization can simplify workflows considerably, making them
safer and saving both time and money. Yet automating and standardizing workflows, as well as the
use of CDSS systems, can also narrow healthcare professionals’ freedom of decision and therapeutic
flexibility. A considered balance between these factors is thus necessary. Such decisions should not
be made solely with a view to economic advantage; rather, staff members’ self-determination and
patient well-being in particular must also be taken into account. That said, physicians, for example,
may in some cases be happy to relinquish responsibility for a treatment decision to a technological
system such as a CDSS; practitioners can experience great psychological strain due to their own
errors, even if these are only subjectively perceived (Rodiewicz et al. 2020; Sirriyeh et al. 2010).

Nevertheless, treatment decisions always include decisions about values. On the one hand, the
practice of evidence-based medicine is based on scientific knowledge, which can now be processed
and made available more efficiently by algorithmic systems than is possible simply by individual
physicians reading professional journals. On the other hand, it is grounded in medical experience
derived from treating many different patients. At the same time, evidence-based treatment must
always be oriented toward the well-being of the patient. This means that the patient’s self-
determination must always be taken into account via a partnership established between doctor
and patient (German Ethics Council 2016) – something that cannot be replaced by algorithmic
systems. Due to their complexity, human feelings and emotions, which are a critical aspect of this
relationship between physician and patient, cannot be represented in technological models (Cabitza
et al. 2017). For this reason, CDSS mechanisms, for example, can contribute important information
to joint decisions, but should not be given full responsibility for making them.

“Humans are morally responsible for their actions, and there is no escaping this moral dimension.
Humans are responsible for the goals they pursue, the means by which they pursue them and their
reasons for doing so” (Data Ethics Commission 2019: 40).

The potential for freer and more self-determined professional practice can also be illustrated
in the nursing field, using an example from the area of palliative care. The use of so-called deep
learning neural networks for the purposes of technology-based decision support in such settings
has improved the quality of care, while additionally enabling non-physician staff members to act
more independently of physicians and be more proactive with patients (Avati et al. 2018). This
points to the possibility of extending nursing staffers’ occupational competencies through the use

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of appropriate technologies, without the need for ongoing supervision by physicians or continuous
consultation in each individual case.

The future is likely to bring substantial shifts in the sector’s skill requirements, changes in
job profiles and even a revised understanding of professional roles. As such, there is a risk that
the current generation of healthcare personnel will be overwhelmed by the rapid digital develop-
ments within care settings. If cooperation between people from different health professions is to
function smoothly in integrated care environments, responsibilities must be clearly distributed.
Those involved must have a basic understanding of the competency profiles of the different profes-
sions involved, including the new job profiles as necessary. In addition, there is a growing risk that
technologies will cause more stress and thus generate more inefficiencies than they eliminate. This
strain can be produced by the imposition of new time burdens; the use of new technologies without
sufficient training; and a (subjectively) perceived loss of self-determination, responsibility and
security (Virone et al. 2021; Safi et al. 2018).

People required to use new technologies can be subject to so-called technostress, described by
psychologist Craig Brod as a person’s inability to deal with technologies in a healthy manner
(Virone et al. 2021; Brod 1984). This phenomenon is directly associated with the way such tech-
nologies are designed or integrated into the work environment; for example, less complex tech-
nologies are perceived by users as being more user-friendly (Virone et al. 2021). A lack of digital
literacy is also a barrier to the use of new technologies. This is sometimes due to a lack of openness
and a mistrust of new technological developments, although low-quality digital infrastructure can
also play a role.

This distrust can also relate in part to a desire to protect one’s own privacy as an employee or other
healthcare professional. Tracking and monitoring technologies intended to optimize care processes PRIVACY

and the quality of care can turn into far-reaching elements of control that fail to protect employ-
ees’ privacy and personal integrity sufficiently. However, this complex problem is not specific to
the health professions, as it appears to a similar degree in other professional settings (Data Ethics
Commission 2019; EGE 2019).

Potential dangers can also arise when AI-based solutions themselves function in a way that
developers do not entirely understand. Especially in the case of deep learning approaches, such
systems and their results are not fully transparent, externally comprehensible or explainable
(see Pasquale 2015; Floridi et al. 2018; Robbins 2019; Montani and Striani 2019). This so-called
black box medicine poses numerous risks with regard to the ability to adequately review decisions,
and with respect to possible discriminatory effects (Žliobaitė 2017; Obermeyer et al. 2019) (➔ 4.3.1).
For example, AI systems trained with biased datasets can produce diagnostic and treatment recom-
mendations that are inadequate and harmful to individual patients.

Another problem can arise when past misdiagnoses or inadequate medication prescriptions are
included in the data used to train AI system (Zikos and DeLellis 2018). Inaccurate results can be SECURITY

“correctly misinterpreted” (Cabitza et al. 2017: 517; Caruana et al. 2015) by the algorithm; however,
they will directly jeopardize patient safety in the medical treatment context if human experts fail
to reflect on such errors in a professional and technologically competent manner, and do not act
accordingly. These risks generating a problematic diffusion of responsibility, which in turn creates

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far-reaching liability and burden-of-proof issues should treatment errors and adverse events
occur (Magrabi et al. 2019).

At the same time, an overreliance on technology can impair a user’s professional skills (Sutton et
al. 2020). The use of technology not only requires a diverse set of competencies; it also substitutes
for skills and abilities that are no longer acquired or trained, potentially contributing to de-skill-
ing (Hoff 2011; Cabitza et al. 2017). Thus, when technical systems fail, healthcare workers can no
longer respond appropriately, which can become a safety issue for both staff and patients (Cabitza
et al. 2017; Tsai et al. 2003; Povyakalo et al. 2013). In addition, an excessive trust in technology
among healthcare workers can lead to a loss of confidence in the self (Cabitza et al. 2017).

Another safety problem can be brought about by so-called alert fatigue. When algorithmic systems
set off alarms too frequently, practitioners tend to disregard them, even though they may be draw-
ing attention to something of clinical importance (Sutton et al. 2020).

In terms of sustainability, integrating technological support into everyday treatment practices

SUSTAIN­ can help make healthcare more economically and socially sustainable (Hütten 2019; Willyard 2019;
ABILITY
Topol 2019a; Kohn et al. 2014; Piccininni 2018). Technologies that support diagnostic imaging offer
a good example in this regard (Bizzo et al. 2019; Bhatia et al. 2020). In addition, CDSS evaluations
indicate that practitioners’ adherence to evidence-based medical guidelines (e. g., mammography
and colonoscopy guidelines) can be improved, which correlates with better treatment outcomes
(Murphy 2014). In the long run, this may also be more cost-effective, for example by leading
to lower hospitalization rates (Khan et al. 2010; Contreras and Vehi 2018; McCowan et al. 2001;
Murphy 2014). This in turn could help make healthcare more economically and medically sustain-
able. However, the environmental sustainability problems caused by energy- and resource-inten-
sive digital systems must also be taken into account (➔ 4.3.1).

IN SUMMARY, new technologies offer opportunities for health professionals to practice their
profession in a more evidence-based, efficient, self-determined and patient-centered way,
while also meeting patients’ growing desire for greater participation in the treatment process.
In addition, new technologies can improve care quality in a sustainable and cost-effective way
through improved diagnostics, by providing treatment recommendations and by optimizing
processes. At the same time, the use of clinical decision support systems (CDSS) requires a high
level of digital literacy, and raises further questions regarding the distribution of roles and the
associated diffusion of responsibility. There is a potential for time savings, with the time gained
being used to care directly for patients, and especially for direct interpersonal interaction. However,
this advantage is offset by the current lack of incentives to use the resources gained accordingly.
Any development in which automation processes could lead to an increasing dehumanization of
treatment processes should without question be resisted.

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TABLE 3: At a glance – Opportunities and challenges presented by the multidimensional

change in competencies of healthcare professionals

Opportunities Challenges

Healthcare professionals can be relieved Introducing new technological systems can create security risks
of time, physical and psychological burdens. and inefficiencies.

The use of complicated digital systems can overwhelm healthcare

professionals.

The allocation of responsibilities may be unclear, resulting in liability

questions in the event of treatment errors, among other issues.

Tracking and surveillance technologies may violate healthcare

professionals’ privacy.

Technological support can enhance digital Healthcare professionals with inadequate digital skills may become
literacy and increase personal safety. insecure or overwhelmed, leading to safety risks.

Integrated healthcare provided by teams The allocation of responsibility can become unclear in integrated
drawn from different health professions can healthcare settings, or when technical support systems are involved.
improve the quality of care.
Responsibilities and lines of accountability may be misjudged if
some team members’ skill sets are not known or misjudged.

Improved diagnostic and therapeutic Technologies will not be used if healthcare professionals do not
capabilities can improve the quality of care. recognize their benefits.

Automation and the depersonalization of care can create safety

risks.

Systematic biases and a lack of transparency in algorithmic systems

(black-box medicine) can create discrimination risks.

Healthcare professionals lose skills that are replaced by the

functioning of technological systems, and can no longer apply these skills
when such systems fail.

Integrated healthcare environments can A lack of motivation, poor communication skills and inadequate digital
place a stronger focus on the patient, thus literacy among healthcare professionals impede the development of
allowing for more patient-centered care. patient-centered care.

Automated procedures can dehumanize the treatment process.

Instead of producing more time for treatment and conversations with

patients, technological advances may result in a reduction in the number
of healthcare professionals.

When delegating decisions to clinical decision support systems

(CDSS), healthcare professionals may not give adequate consideration
to patients’ self-determination rights.

Technology-supported process Technological systems can potentially lead healthcare professionals

optimization can make work practices more to abdicate responsibility, while also limiting their options for treatment.
time- and cost-efficient.

Healthcare professionals can exercise Predetermined decision-making and action options, especially when
their professions in a more self-determined overly strict or difficult to understand, can limit health care professionals’
way as the scope of possible actions self-determination.
expands.

New job descriptions are emerging in the The distribution of responsibilities and the skill sets needed to carry
healthcare sector. out specific health jobs are unclear.

Source: Bertelsmann Stiftung

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4.3.3
MONOPOLIZATION AND DISSOLUTION OF SECTORAL BOUNDARIES
DUE TO DIGITAL HEALTHCARE

The tech giants’ activities are also transforming underlying healthcare structures. In a highly
networked system, the digital availability of health data renders sectoral boundaries125 techno-
logically permeable, or even eliminates them altogether. For example, it allows multidisciplinary
healthcare teams to work together on patient cases (patient-centered care), regardless of whether
the individual is receiving inpatient or outpatient care, or whether the care being provided is
primarily preventive, therapeutical or rehabilitative.

The outpatient, inpatient and rehabilitative sectors are thus becoming increasingly intertwined.
Moreover, links between the public and private sectors, driven by collaborative partnerships within
an otherwise competitive system, are also influencing progress in healthcare (Yildirim et al. 2016: 3;
Kindermann and Lindemann 2018: 54). To develop and implement their technological innovations,
tech giants need to collaborate with industry and clinical partners, for example. Conversely, these
partners are also dependent upon the tech giants. This is because the large tech companies have a
considerable head start in the digital healthcare field, especially in terms of their financial ability to
invest in new developments, structures and highly skilled staff. They have the technological capa-
bility to collect and process huge amounts of data, and are leaders in the development of AI sys-
tems (➔ 1.2 and ➔ 3.1). In the area of cloud computing, which is vital both for digital health research
and the provision of care, the tech giants have incomparably large capacities (➔ 3.4.1). All of this
makes them strong and ultimately indispensable actors, especially in data-intensive areas. Indeed,
technological progress in this digital realm seems almost inconceivable without their participation
– a circumstance that gives them a monopoly-like position.

The German healthcare system is currently made up of “fragmented care structures” that “make it
SUSTAIN­ more difficult to care for patients in a coordinated and cross-sectoral way” (Klauber et al. 2019: 5).
ABILITY
However, opportunities for data exchange within the healthcare sector promise to create value by
saving time, decreasing costs and improving quality (Klauber et al. 2019: 51; Wibbeling and Raida
2019: 8-9). This in turn can contribute to social and economic sustainability. Such technologies and
practices can help avoid the cost inefficiencies caused by information loss between practitioners,
unnecessary (duplicate) examinations and uncoordinated treatment processes (Klauber et al. 2019:
5; Haas 2017: 31-35).

Digitally networked structures and systems, such as the networked storage of health-related
data, can provide healthcare system actors with cross-sectoral access to comprehensive patient
information that can be integrated into a variety of applications. This can make collaboration in
the healthcare sector more effective, efficient and secure (see, for example, Siemens Healthineers

125 In some health care systems, the provision of health care services in the in- and outpatient sectors as well as rehabilitative care
can have major systematic differences. For example, the German healthcare system generally distinguishes between in-patient
clinical and out-patient ambulatory care as well as in- and outpatient rehabilitative care. Each of these sectors follow varying
rules for the administration and reimbursement of medical care, leading to sectoral boundaries in the way healthcare can be
obtained.

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 ETHICAL ANALYSIS

Teamplay Digital Platform Connect, ➔ 3.3). Experts regard cloud technologies as the key to real-
izing these gains. Such systems can also be of use in the long-term care sector. Especially in the
context of inpatient care, technological solutions can help medical facilities and practitioners focus
on patients’ well-being, allowing them to meet competitive demands in terms of specialization,
service volumes and personnel (Matusiewicz et al. 2017: 106-107).

Digital expert systems, large databases and integrated diagnostic solutions also offer an oppor-
tunity for intradisciplinary collaboration, for example by allowing “interdisciplinary diagnostic
teams with massive computer support” to communicate directly with one another through a shared
technology platform (Hahn and Schreiber 2018: 336). This allows medical institutions to increase
their quality of care and enhance treatment efficiency, and enables physicians to invest more time
in direct patient contact (Matusiewicz et al. 2017: 83). Connectivity is thus becoming a key compet-
itive factor (Hahn and Schreiber 2018: 336).

As these sectoral boundaries increasingly dissolve, the secondary healthcare market and other
health-related areas of life should also be integrated more tightly into the digital healthcare envi- FREEDOM
AND SELF-
ronment. This can help ensure that patients are more involved in the entire process of treatment,
DETERMINA-
from the point of hospital admission to rehabilitation and follow-up care. Younger patients in TION
particular are asking for coordinated data sharing across sectors (Böttinger and Weiß 2019: 29),
which can also facilitate their self-determination.

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A thoroughly digitally networked and centralized system poses the risk of excluding people who
JUSTICE AND have no or only limited access to digital health services – perhaps because they lack the requisite
SOLIDARITY
technical means (such as a smartphone) or have minimal digital skills, and are therefore unable
to take advantage of health services made possible by digital applications (e. g., in the area of
telemedicine). Such a system would not meet ethical requirements relating to equity of access
or participatory justice. Under such circumstances, these individuals would likely receive a poorer
quality of care and be in poorer health than participating, networked patients, thus producing
a problematic two-tier digital medical system (dpa 2018; Misslbeck 2019; Hardt 2021: 471).

Similarly, certain groups of people could be excluded if, for example, tech giants were to offer
high-quality integrated care exclusively to their employees and their dependents. Examples of
this today include Apple with its so-called AC Wellness Clinics, and Amazon with its Amazon Care
telemedicine service (➔ 3.4.5). The large corporations could, theoretically, open their own health-
care facilities accessible solely to very wealthy patients. However, a statutory healthcare system
based on the principle of solidarity must keep a close eye on the market share held by private
insurance and care, while always ensuring that financially less able citizens have access to the
solidarity-based system. There is also a risk that the statutory and private healthcare sectors
may compete for scarce resources such as skilled nursing personnel.

A digital divide is additionally becoming apparent at the system level. If established healthcare-
system structures and their actors are unable or unwilling to adopt the technologies and processes
developed by and with tech giants, perhaps due to inadequate regulation or a lack of technical skill,
they may fall behind their peers elsewhere in the world. This in turn could ultimately undermine
the quality of care. In fact, experts have argued that the German and European regulatory environ-
ments could dissuade technology companies from rolling out their advanced products and services
there. Particularly in the German and European contexts, market and regulatory conditions are
inhibiting the transformation to digitalized healthcare, because “separate remuneration budgets
for the outpatient and inpatient sectors, a lack of financing incentives for the acquisition of digital
solutions, and an often uncertain return on investment (…) make investment in the digital future
unattractive” (Matusiewicz et al. 2017: 48).

This raises the question of whether and how technologies, applications and structures developed
by the tech giants can be incorporated within or complement the state-managed care system.
In addition, it is worth asking whether in Germany, for example, there is a risk of displacing the
ethically well-founded, state-managed solidarity-based system, thus exacerbating the healthcare
sector’s potential dependencies and purely economic incentive structures. Conversely, policymakers
and other analysts must consider whether inadequate regulation and a lack of technical skills in the
sector may hinder or even preclude opportunities to digitalize healthcare with the tech giants’ help.
Hahn and Schreiber (2018) argue that disruption and cooperation need not be contradictory (Hahn
and Schreiber 2018: 340). Moreover, highly efficient digital processes in particular can enhance the
incentives created within a “value-based care” approach (Porter 2010), which can, in turn, increase
the level of care and improve public health. Nevertheless: “Whoever has access to data will domi-
nate the market. This is true in the field of digital health as well” (Krüger-Brand 2020: 375).

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The tech giants’ data-based activities in the healthcare sector have enabled them to dominate
certain areas of the market.126 This has resulted in a “fierce battle to accumulate data” between
the sector’s large actors (Baas 2019: 10), who are training algorithm-based systems and develop-
ing applications on this basis. The presence of a competition-driven network industry within the
healthcare market poses the risk that “oligopolies led by only a few dominant players” will develop
(Hahn and Schreiber 2018: 340), which in turn may produce data- and technology-driven depen-
dencies.

These dependencies have ethically significant implications for science and research in particular
(➔ 3.5 and ➔ 4.3.4). Tensions and asymmetries may emerge, because “technology can undermine DEMOCRACY

democratic structures, and its development takes place outside of democratic controls” (Woopen
and Mertz 2014). Questions of justice also arise in this context. Companies possessing monopo-
ly-like power could influence access to and the distribution of healthcare, for example with regard
to specific services. Scenarios involving a more subtle exercise of power are also conceivable. For
instance, by exploiting data monopolies in a nontransparent way, companies could effectively
exclude certain users, thus violating the tenets of participatory justice (German Ethics Council
2017b: 224).

Given their immense financial resources, tech giants may be able to further strengthen their
monopoly-like positions by absorbing potential market rivals through acquisitions, especially
by buying AI and telemedicine startups (➔ 3.4.9). Because the giants are already large, and have
very significant market penetration, they can offer startups significant scaling effects.

Amazon’s activities in the pharmaceutical sector illustrate the impact of monopoly-like structures
that extend across different, previously separate market segments. The company has 118 million
Amazon Prime customers in the United States alone, representing about one-third of the country’s
total population. Providing access to medicines for this massive customer base offers it significant
opportunities within the pharmaceutical sector. The company analyzes its customers’ individual
search queries to provide them with related drug advertisements and personalized medication
suggestions. Its online ordering system, along with delivery mechanisms requiring little direct
contact, give Amazon a key competitive advantage over other large pharmacy chains (Egert 2020).

The presence of centralized, cross-sectoral platforms that collect large amounts of data also raises
security issues. A so-called hospital 4.0,127 in which all systems are networked, could become an PRIVACY

attractive target for cyberattacks. “The sabotage of vital healthcare infrastructures and the theft of
personal patient data serve as business models for extortion 4.0” (Matusiewicz et al. 2017: 52), and SECURITY

can result in serious privacy and security consequences. However, European cooperation could help
facilitate secure data access, and so-called data trust centers could provide better data protection
than is possible for small individual actors. The European Health Data Space initiative, for example,
is moving in this direction (European Commission 2021).

126 In October 2020, the U.S. House of Representatives Subcommittee on Antitrust, Trade and Administrative Law released a report
on the issue of competition in digital markets. It concluded that the companies analyzed (Amazon, Apple, Facebook (now Meta)
and Google) held significant and durable market power in individual areas, in some cases reaching the level of monopoly power
(Subcommittee on Antitrust, Commercial and Administrative Law 2020).

127 “In the near future, all hospital functions will be networked, from the hospital information system (HIS) and the connected
medical devices all the way to the building services and administrative functions, producing what might be called a hospital 4.0”
(Matusiewicz et al. 2017: 51).

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The tech giants thus have unmatched financial power, and benefit from technologically driven
scaling effects. Their products and services are helping to dissolve boundaries between the health-
care system and everyday life. These capabilities bring with them the ability to shape and influence
people’s lives even well beyond the healthcare market.

Charting the bounds of this impact requires asking questions that extend beyond healthcare
itself:

҉ What is the focus of research efforts?

҉ What products are being developed for which users and patients?
҉ Which applications for preventing diseases or optimizing integrated care processes are seen as
particularly interesting?
҉ What terms and conditions are required by the various products and applications currently on
the market?
҉ Do low-income countries and individuals also have access to digital healthcare and health-
enhancing products and applications?
҉ Which lifestyles are defined as being particularly healthy and supported by digital media, and how
are they rewarded?

If tech giants approach these issues using purely economic criteria, they will wind up pushing
social and cultural lifestyles and perceptions, and thus individual lives and society as a whole,
farther toward a market-oriented logic – even though some desirable progress with regard to
individual and public health can also be expected. Indeed, they are already wielding such influence
today via products and services that do not have a primarily health-related application, such as
smartphones and social-media platforms. Should the market develop further in this direction, it is
unclear whether or to what extent individuals would be able to develop and realize self-determined
conceptions of a “good life” differing substantially from those professed and promoted more or
less subtly by the tech giants.

What institutions and processes can ensure that technologies are used in the service of the people
and the common good? What mechanisms can preserve people and societies from being forced to
conform with the tech giants’ visions for the future?128 It has long been apparent that regulating
the tech giants and their activities in a way that leverages their potential while also minimizing
undesirable effects is a highly complex proposition. This balance is certainly of great significance
within the German healthcare system. Yet within Germany, healthcare-system digitalization has
proceeded at a slow pace (Thiel et al. 2018). The sector is already highly regulated, and the profit
outlook for the tech giants is often relatively dim. Given these factors, policymakers and others
should pay greater attention to digital healthcare’s unrealized potential.

128 On this complex issue, see also Zuboff (2018). The video available via Savov (2018) is also interesting in this regard.

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 ETHICAL ANALYSIS

IN SUMMARY, the increasingly interlocking nature of the healthcare field, with barriers between
sectors dissolving due to the tech giants’ health technologies, is creating the potential for cost-
efficient, sustainable and patient-centered care that can benefit everyone in the healthcare field.
However, there are also major challenges regarding participatory justice and equity of access, secu-
rity, and the tech giants’ monopoly-like market positions. With their enormous data, technological
and financial power, these companies can shape the healthcare sector right down to its fundamen-
tal structures. They can build parallel systems, and can shape and influence individual lives, and
even society itself. In so doing, they subtly weaken individual self-determination, and flatten social
and cultural diversity. However, the German healthcare system, with its very comprehensive and
far-reaching regulation, is resistant to domination by the tech giants.

TABLE 4: At a glance – Opportunities and challenges presented by monopolization

and the dissolution of sectoral boundaries due to digital healthcare

Opportunities Challenges

Efficient cross-sectoral collaboration between In Germany and Europe, overregulation and a failure
multidisciplinary healthcare teams promotes more to implement integrated digital structures have impeded
patient-centered care, and thus also health, safety attempts to realize the potential of digital healthcare
and sustainability. technologies.

Professional associations’ political activities and a lack

of data interoperability have also slowed development.

Efficient networking helps improve data access Poorly designed systems and cyberattacks create
and data exchange. privacy and security risks.

Badly designed rules and structures can inhibit data

access and data exchange.

Integrated, patient-centered care can strengthen The equality of access and participatory justice can
patient self-determination. be limited by a lack of technical resources and insufficient
digital skills.

There is great potential to add value with regard Private or even exclusive healthcare offerings and
to time and financial resources, as well as in the quality unequal access to digital resources can undermine justice
of care. and solidarity.

If tech giants and their datasets are insufficiently

involved in the further development of digital healthcare
functions, this could hamper potential value creation and
inhibit innovation.

Networking, collaboration and the promotion Tech giants can inhibit justice and solidarity by
of “value-based care” approaches can contribute to influencing the operation of state structures or even by
sustainable development while dealing effectively establishing parallel structures.
with diversity.
If tech giants gain substantial power to shape individual
and social life through the development of monopolies
and dependencies (data-driven, technological and financial
power), this can lead to a loss of freedom and diversity.

Source: Bertelsmann Stiftung

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4.3.4
LINKING EVERYDAY CARE AND RESEARCH TO A LEARNING
HEALTHCARE SYSTEM

In the following, we define research as “a process based on the core activities and principles
inherent in the scientific method (methodology, systematics, need for evidence, verifiability,
openness to criticism, willingness to revise), used to discover, interpret and transmit knowledge”
(Weichert 2018: 97).

One idea prevalent in the research community today is the so-called End of Theory thesis, which
contends that “information technologies will significantly change and even improve the process
of scientific knowledge discovery” (Wiegerling et al. 2019: 402). Proponents of this thesis assume
that “the increasing quantity and quality of data processing in the sciences will increasingly allow
non-empirical elements (‘theory’) to be dispensed with” (ibid.: 401; Antes 2016). By expanding the
volumes of data to be analyzed and using highly sophisticated data processing techniques, it should
be possible to gain insights that “lie beyond the reach of previous scientific methods” (Wiegerling
et al. 2019: 402). This relates not only to individual disciplines, but to the concept of scientific
knowledge and scientificity in general (ibid.: 403).

In the health sector, this involves generating, synthesizing and processing diverse types of
health-related data from a variety of sources. These include 1) research data from clinical trials,
2) treatment data from regular inpatient and outpatient care, 3) diagnosis- and therapy-related
billing data from health insurance funds and other insurers, 4) data generated in everyday life,
outside of specific healthcare or research settings, including by patients and users themselves,
and 5) “synthetic data” generated artificially on the basis of real datasets, for instance to train
algorithmic systems.129

Methodologically, the use of AI to analyze large datasets entails a fundamental problem, in that
techniques of this kind identify patterns and correlations, but do not prove causalities. However,
evidence of causal relationships is crucial for medical research and the evidence-based medical
interventions derived from it. Against this background, it is possible to draw fundamental scientif-
ic-theoretical and methodological conclusions with respect to rendering the correlations discovered
via big data-based analyses useful for evidence-based medicine (EBM). Nonetheless, scientists
have warned against accepting the promises associated with big-data-based knowledge acquisition
too uncritically (Antes 2016; Liang and Kelemen 2016).

There is the hope that research drawing heavily on data captured within patients and users’ every-
day lives and care processes, for example using various forms of sensors, can help make complex
phenomena more predictable, increase the reliability of prognoses and accelerate the discovery of
new phenomena (Wiegerling et al. 2019). In this regard, the tech giants have considerable advan-
tages relative to public sector entities, as they have access to much larger volumes of data and more
powerful analytical capabilities (German Ethics Council 2017b: 116; see Wilbanks and Topol 2016).

129 See, for example: Nikolenko (2019); Drechsler und Jentzsch (2018); Wolfangel (2021).

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The conditions under which companies and other entities grant access to their data pools are
important, both for the public in general and for the research community in particular.130 Nation- JUSTICE AND
SOLIDARITY
ally and especially internationally, numerous obstacles make it difficult to access and exchange
data for research purposes. Private companies, hospitals and research groups tend to consider and
treat the data they collect as their own property, and regularly reject external requests to use it
(German Ethics Council 2017b: 222-223; Weichert 2018: 99). More and more inaccessible data silos
are emerging, a fact that may lead to a commercialization of research activities and of the scientific
generation of medical knowledge more broadly.

The withdrawal of data from the public sphere also indirectly creates a problem from the ethical
perspective, since it undermines the equality of opportunity and weakens participatory justice
(German Ethics Council 2017b: 223). If companies and other entities unjustifiably obstruct access
to collections of data, this will force researchers and others to expend new effort and incur addi-
tional costs, all avoidable, to collect the relevant data on their own. This can limit the exploitable
potential of data, and may push private companies to gather data solely for the purposes of making
a profit (German Ethics Council 2017b: 223), in turn also undermining important sustainable devel-
opment goals.

Tech giants often use proprietary technologies – with the participation of patients and users –
to collect, aggregate and analyze data in an automated way (patient-generated health data). The
resulting datasets open up new potential for the scientific and research sector, by creating a

130 For more on this topic, see Mittelstadt and Floridi (2015) and Data Ethics Commission (2019).

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“significant quantitative and qualitative expansion of the data base with a new density of detail”
(German Ethics Council 2017b: 120). An expanded and diversified store of research data and
knowledge can lead to more precise stratifications in the preventive, diagnostic and therapeu-
tic medical fields. In addition, this could accelerate the acquisition of information and knowledge
(ibid.: 121).

However, most individuals and groups do not have unlimited access to data-generating and
data-processing technologies (➔ 4.3.1 and ➔ 4.3.3). This can produce conditions in which research-
ers have only incomplete or fragmentary data at their disposal, leading in turn to flawed scientific
findings and potentially even flawed treatment recommendations derived from this data. In some
cases, this imperfect data excludes or underrepresents certain classes or categories of people; the
findings or recommendations based on such data can consequently contribute to discrimination,
or even damage patients’ health.

Furthermore, with regard to ensuring that data is both valid and reliable, there is a methodological
problem in that the unstructured data collected from patients and users cannot be adequately vali-
dated (German Ethics Council 2017b: 161). This lack of quality control can produce broad variations
in the quality of the data and resulting outcomes (German Ethics Council 2017b: 121; Liang and
Kelemen 2016).

In addition, this “nontransparent and encapsulated data analysis” (German Ethics Council 2017b:
116) generates challenges with regard to transparency and reproducibility, and hampers the ability
to reflect critically on the process of acquiring scientific knowledge. Some observers fear that
this could inhibit “medical progress” and that the tech giants’ vast market power could frustrate
“methodological plurality in the study and interpretation of health data” (ibid.), especially since
the formation of data monopolies could prevent other actors’ market access (ibid.: 115). Over time,
the scientific community may become increasingly dependent on the entities that hold these data
monopolies (➔ 4.3.3).

These creeping monopolistic structures (➔ 4.3.3) are linked to another set of problems relevant
to justice. On the one hand, researchers could be prevented from defining and pursuing their own
research goals (German Ethics Council 2017b: 223; Becker 2019). Potential conflicts of interest,
lobbying, and infrastructural or financial dependencies could endanger the freedom of research
and constrain researchers’ activities. Such factors could influence research goals – for example, as
companies channel support toward findings with a high potential for profit – and entice research-
ers out of the field of public research into private and primarily profit-oriented knowledge genera-
tion. On the other hand, public-private partnerships (PPPs) between research institutions and tech
giants can contribute to the investigation of complex research questions by pooling knowledge,
expertise and resources, thus facilitating activities that would be impossible for a single institution
to perform alone (Yildirim et al. 2016: 3; Kindermann and Lindemann 2018: 54). Examples of this
include Intel and Google’s collaborations with the National Institute of Health (NIH), Apple’s work
with the Harvard T. H. Chan School of Public Health and the NIH, and Meta’s (formerly Facebook)
projects with New York University (NYU) Langone Health medical center (➔ 3.5).

However, as healthcare institutions and companies share and exchange data in the context of
research and development PPPs, this can raise issues related to informational self-determination,
security and privacy. Sharing data, as well as storing and processing data centrally, can produce

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 ETHICAL ANALYSIS

risks even if that data is initially anonymized or pseudonymized. For example, it is technically
possible to de-anonymize or de-pseudonymize data of this kind, especially when different datasets
are merged. Moreover, some datasets, such as certain genetic data, are difficult to anonymize by
their very nature (Packhäuser et al. 2021; Lanzerath et al. 2019; Stoeklé et al. 2019).

Some technological solutions already exist today that combine increased data-handling security
with the ability to conduct data-based research activities. For example, so-called swarm learning
or swarm intelligence constitutes a significant technological innovation enabling decentralized
datasets to be evaluated according to predefined rules (Warnat-Herresthal et al. 2021; Rüdiger
2020). Swarm learning allows data to be analyzed where it is stored – at the “edge” node, as the
edge computing field terms it – rather than at a centralized location. Under such a system, the data
is fed locally into learning algorithms, most often neural networks, with only the results of the
data processing being passed back to the overall system or network via blockchain (Rüdiger 2020).
This allows global health-related data to be integrated into a network without the data itself being
shared, and without the need to store it in a central location (Warnat-Herresthal et al. 2021).

Ultimately, the everyday provision of care could evolve in tandem with research activities into
a learning healthcare system guided by a multilevel governance model. Today, more than € 1 billion HEALTH

is spent on healthcare in Germany every day (approximately 65 % of which comes from social
insurance contributions) (Federal Statistical Office of Germany June 2, 2021). Under a learning
system, data associated with these healthcare functions could be evaluated by the research commu-
nity, with the survey mechanisms meeting researchers’ high requirements for data collection and
data quality. The findings could then in turn be fed rapidly back into the care domain, supported
by information technology tools such as clinical decision support systems (CDSS), for the benefit of
all patients. This would allow a considerable amount of existing data from the clinical environment
to be used to generate knowledge and evidence. To date, such advances have instead been made
almost exclusively by implementing separate costly long-term studies, a mechanism that itself
is becoming increasingly impractical due to increasing stratification. The research findings could
be integrated more quickly into practice settings, and the subsequent results could in turn be eval-
uated scientifically, thus creating an ongoing cycle of learning.

This could even enable more people to participate in the progress, enhancing participatory
justice, because a learning healthcare system of this kind would prove especially beneficial to JUSTICE AND
SOLIDARITY
patient groups that are otherwise difficult to include in randomized clinical trials. For example,
very old people taking many medications simultaneously could be better protected against side
effects, because patterns of adverse interactions could be identified more quickly in large datasets.
Similarly, a system of this kind could avoid problems of poor external validity – that is, when
clinical trials’ findings prove for various reasons not to be confirmed in everyday care.

Finally, the trend toward precision medicine – in which therapies are tailored to each specific
patient on the basis of his or her individual data, rather than being essentially identical for every-
one with the same overarching diagnosis – requires a closer connection between daily healthcare
practice and the research community.

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TABLE 5: At a glance – Opportunities and challenges presented by linking everyday

care and research to a learning healthcare system

Opportunities Challenges

Systematic scientific analysis of healthcare AI-assisted analysis of large datasets identifies

data leads to new insights. correlations and patterns, but not causal
relationships.

Various stakeholders may not respect the “FAIR”

principles for research data sufficiently.

A lack of transparency and insufficient access

to data make it difficult to fully understand the results
produced by algorithmic systems, and prevent critical
reflection on them.

When healthcare data is shared or stored centrally

for research purposes, this produces security and privacy
risks.

Complex phenomena become increasingly Systematic biases exhibited by technological

predictable, predictions become more reliable and systems trained on the basis of inadequate data can
new phenomena can be discovered more quickly, undermine justice.
even for patients who are difficult to integrate into
Data monopolies and data silos that interfere with
clinical trials.
data access and data sharing impede innovation and
diversity.

Access to a broader base of data contributes Publicly funded research can be weakened by
to more precise stratifications in preventive, diagnostic inadequate data access (data silos) and out-of-date
and therapeutic activities. technology systems as it competes with tech giants,
and is increasingly losing its influence in defining important
research questions.

Pooling knowledge and resources via public-private Limited access to data-generating and data-processing
partnerships (PPPs) enables the study of complex research technologies gives rise to discrimination and exclusion
questions. risks (digital divide).

New technological solutions (such as swarm learning) Heterogeneous data quality and a lack of
increase the security and privacy of data processing. interoperability between data from different sources
inhibit innovation.

A learning healthcare system with a multi-level The tech giants’ market power threatens the
governance model (cycle of learning) can promote freedom of research and the freedom of researchers
individual and public health and strengthen healthcare themselves, because financial and infrastructural
delivery. dependencies can influence the choice of research
goals, for example.

Professional associations’ political activities and

lobbying are hampering the digitalization of the healthcare
sector.

Insufficient political will, a lack of digital infrastructure

and insufficient digital skills can prevent or slow the
development of a learning healthcare system.

Source: Bertelsmann Stiftung

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 ETHICAL ANALYSIS

IN SUMMARY, tech giants can help forge links between everyday healthcare and healthcare
research, with the goal of creating a perpetually learning healthcare system. However, a variety
of challenges must be overcome in order to take advantage of the resulting opportunities. Some
of these challenges arise from the tech giants’ monopoly-like positions with regard to their control
of data and access to algorithmic systems. Others relate to methodological problems, for example
in connection with AI-supported research. In addition, it will be necessary to meet ethical require-
ments, such as those relating to freedom of research, equity of access and distributive justice,
privacy protections, and the need to prevent discrimination against the people whose data are
used.

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5
CONCLUSIONS
AND RECOMMENDED
ACTIONS

To date, (health) policy response to growing tech-giant activity in solidarity-based, statutory

healthcare systems in Europe has, especially in Germany, been rather limited, despite the fact
that these companies have the potential to fundamentally transform the healthcare and medical
research sectors. Given the strength of regulation in the European and the German contexts and
the low level of profitability yielded by the tech giants’ offerings in the statutory, publicly funded
healthcare systems as the German one, it’s unlikely that the German systems will quickly be
“taken over” by the tech giants or that a parallel system will emerge anytime soon in the country.
However, these firms’ products and applications, as well as their collaborative activities with other
companies, research institutes and actors, can play an important role in making healthcare more
effective and efficient while, at the same time, driving a shift to patient-centered healthcare within
a system structured primarily by sectors.

The tech giants have the capacity to complement and transform state structures for providing
care in ways that conform to ethical standards and thus significantly advance any lagging adoption
of digital technologies in healthcare, as is the case in Germany. This will require, however, estab-
lishing sound regulatory frameworks. Given the tech giants’ focus on profitability and scalability,
involving them more thoroughly could facilitate economically driven incentives in the care sector
that work against the goals of patient well-being, fair working conditions for healthcare profes-
sionals and the principle of solidarity. These issues should be accounted for in policymaking.

Though the influence exercised by the tech giants on digital healthcare is obvious and powerful,
it is also in some ways subtle. Their influence is obvious and powerful when – for example, in
the case of U.S. and Asian companies – the wide use of smartphones featuring health apps and the
companies’ ability to directly collect and process user data makes it difficult to avoid using their

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products and services. The tech giants are also leading the way in developing technologies for use
in specific clinical areas such as radiology. European companies in particular are concentrating on
these clinically defined areas. Asian tech giants are also characterized by the fact that they are even
more blatant than their U.S. or European counterparts about combining data derived from various
areas of life, including those related to personal health. They also use this data to monitor, evaluate
and control citizen behavior as a means of enforcing their own or, in the case of China, government-
mandated requirements.

The more subtle influence of tech giants manifests in the ways they are impacting various clinical
areas through strategic partnerships that include investing in other companies and acquiring start-
ups. By engaging in these activities, they are consolidating their capacity to shape and define the
goals of the healthcare system and research, as well as what is desirable in healthcare.

In this context, areas of single potential can, over time, generate cumulatively positive effects.
By the same token, currently latent risks could in the long run combine to produce systemic risks.
Moving forward, it is important to continually monitor and review the dynamics of these counter-
vailing tendencies.

The example of health insurance companies leveraging technologies to determine their tariff and
premium structures underscores a slowly sprawling development that potentially belies the princi-
ple of solidarity upon which the German system is built, most notably by instituting health insur-
ance models and premiums based on behavior and lifestyle (➔ 4.3.1). For example, by incorporating
technologies and applications that allow people to digitally track their own activities, incentives are
created to reward healthy behavior through bonuses. The German Federal government’s coalition
agreement for 2021-2025 signed by the Social Democratic Party (SPD), Alliance 90 / The Greens
(Bündnis 90 / Die Grünen) and Free Democratic Party (FDP) in December 2021, aims to strengthen
the conditions needed for such measures, stating “They [public health insurers] increasingly have
the option of granting insurees monetary bonuses for participating in prevention programs.”131

Although these incentive systems generally reward behavior that maintains and promotes good
health, certain groups are de facto excluded from any such perks (➔ 4.3.1). If access to benefits were
to be systematically blocked, or if certain types of behavior were to be deemed obligatory and the
failure to comply were to have a negative impact on the insurance benefits provided (sanctions),
this could undermine solidarity and fuel the public’s willingness to challenge the principles upon
which the German system is built.132 This kind of development would presumably take place incre-
mentally over the long term and be subtle enough in many respects to remain unnoticed by many,
at least in the beginning. Nevertheless, these potential effects should be thematized in current
debates on the importance of preventive health behavior (➔ Recommended action #1).

The example of increasingly stratified preventive and precision medicine through algorithmic
profiling illustrates the fact that the activities of tech giants can also have contradictory short-
and medium-term effects (➔ 4.3.1). Using data and technology to generate personalized risk-factor

131 Coalition agreement p. 88, line 2910 f.

132 Notable in this regard is the recently uttered demand in Germany to raise statutory health insurance premiums for those not
vaccinated against COVID-19 (Spiegel 2021).

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 CONCLUSIONS AND RECOMMENDED ACTIONS

profiles that can assist in predicting the risk of disease and disease progression will undoubtedly
be seen as a positive effect. However, any use of risk profiles to discriminate against, manipulate
or somehow violate the integrity of an individual, possibly even in areas beyond healthcare, is
likely to be viewed as a negative consequence that should be avoided (➔ Recommended action #7).

Developments in the healthcare sector that have the potential to dissolve sectoral boundaries while
also facilitating the creation of monopolies or oligopolies among a few tech giants illustrate the
ambivalence of the long-term effects involved (➔ 4.3.3). Digitally networked structures and systems,
as well as cross-sectoral collaboration in healthcare, can help advance a more consistent assess-
ment and design of patient-centered care. In addition, these developments can deliver benefits in
terms of time and cost efficiencies as well as an improved quality of care – thus a positive develop-
ment. At the same time, they are also associated with the creation of market dominance, which can
involve dependencies. Companies able to exercise monopolistic or oligopolistic power could have an
outsized say in issues relevant to the access and distribution of healthcare services, and they would
have the capacity to prevent other actors from innovating. This ambivalence should be addressed
by a clear political commitment to patient well-being as the paramount ethical guide in advancing
the digital transformation of the healthcare system (➔ Recommended action #3).

Infrastructural and financial dependencies are also likely to have an impact on R&D and research
communities (➔ 4.3.4). The emergence of entities that hold data monopolies, are able to prevent
others from accessing their data and can potentially interfere with research goals could eventually
jeopardize independent research and the independence of individual researchers. This, in turn,
can affect who has the power to interpret and leverage specific scientific findings. Given their
enormous financial resources, tech giants can further consolidate their quasi-monopolistic position
by absorbing potential competition within the market through acquisitions. They are gradually
able to monopolize data, technology and financial capacities in the area, and thus could potentially
consolidate their power to determine the course of future developments. This runs counter to a
social economic regime that is grounded in the principles of a liberal democracy. The aforemen-
tioned potential opportunities and risks should therefore be taken into account when designing
government support measures targeting innovation (➔ Recommended action #4).

Informed by the ethical analysis featured in this publication, the following recommended actions
address social and political considerations relevant to the transformation of healthcare and the
healthcare system more broadly. They are thus implicitly relevant for tech giant activities as well.

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RECOMMENDED ACTIONS

1 Conduct public debates on the value of predictive health screening and preventive
health behaviors

2 Promote digital (health) competencies

3 Take a clear policy position on the role of tech giants in healthcare

4 Use government support to facilitate innovation beyond tech monopolies and oligopolies

5 Advance risk-adapted regulation of artificial intelligence in the EU

6 Incorporate an ethics-by-design approach into the design, development and use of AI systems

7 Legally prohibit the use of health-related risk profiles to discriminate in non-healthcare

settings

8 Develop a strategy for a learning healthcare system

1 Conduct public debates on the value of

predictive health screening and preventive
health behaviors

Recent data- and technology-based developments driven primarily by tech giants that are facilitat-
ing predictive, prevention and precision medicine are having a profound impact on social cohesion
and how we perceive ourselves and others (German Ethics Council 2017b). Public debates as well
as those conducted among policymakers themselves should address the following: What is the
role of health in relation to other areas of life and society? What changes are needed to a health-
care system that engages with both the primary and secondary health markets? What role should
the tech giants, which have a monopolistic or oligopolistic position in these markets, play in this
context?

An awareness of systemic impacts is also relevant – at both the societal and political levels.
Thus, despite all the medical benefits generated by modern P4 medicine, these developments may,
in the long-term, undermine the principle of solidarity if previously non-systemic elements – such
as personal culpability in the development or aggravation of an illness through certain types of
behavior or the failure to take preventive action – become relevant features of the healthcare system.
In addition, any measures related to predictive, preventive and precision medicine should be
subject to evidence-based monitoring and evaluation. Accountable actors in the healthcare system
should develop measures that are designed to counteract the individual and systemic risks identi-
fied in chapter ➔ 4.

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2 Promote digital (health) competencies

Digital skills, which include digital health literacy, are essential to informed public debate and
the adept use of digital healthcare products and applications. It is important that people learn
early on how to properly operate and handle health-related technologies. Given the rapid pace of
technological development, these competencies will have to be purported early and continuously
throughout the course of their lives. Digital skills should therefore be developed and strengthened
from kindergarten through retirement. The German Ethics Council advises that these skills should
already be taught at school “as an interdisciplinary task in all subjects” (German Ethics Council
2017b: 271-272). This includes developing skills in managing risks, especially since predictive
statements about health are usually only an indication of potential risk.

3 Take a clear policy position on the role

of tech giants in healthcare

Those who use the technologies applied in the healthcare system play a special role in its trans-
formation, and they also bear a specific responsibility in this regard (see SVR 2021). This includes
patients and users as well as healthcare professionals (WHO 2021a; Topol 2019b), decision-makers
in the variety of healthcare institutions representing service providers and Germany’s self-govern-
ing corporatist bodies, and researchers and research institutions (➔ 4).

Adapted job profiles should be promoted, as should additional job profiles. Responsibilities asso-
ciated with specific jobs in integrated care also need to be redefined. This should entail ensuring
the reflective use of technologies as well as an ethically informed critical awareness and evaluation
of these technologies – one that considers the roles played by those shaping the technologies and
their framework conditions. Ensuring easy-to-understand messaging that reaches specific target
groups is also relevant in this regard. A key factor here involves integrating the growing number
of opportunities associated with technology into curricula for the health and medical professions.133
Given the risk of a blind faith in technology, measures that provide guidance in the event of tech-
nological failure should be defined and taken (WHO 2021a). Being able to take a clear policy stance
on the role of tech giants in healthcare is conducive to creating such structures and policies.

133 For example, if algorithm-based systems are used in the context of a specific treatment, it should be clear to the health
professionals involved that technology can be of assistance to – but cannot replace – people. The European Ethics Council
emphasizes in this context the primacy of human action and oversight, as well as accountability (European Group on Ethics
in Science and New Technologies 2019).

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4 Use government support to facilitate innovation

beyond tech monopolies and oligopolies

Public investment in the data economy and the development of algorithmic systems, including AI,
should primarily foster innovations that conceive of data as a common good rather than a com-
modity (IBC 2017). In keeping with the principles of a social market economy and solidarity-based
healthcare, governments should act accordingly to prevent monopolistic structures from devel-
oping among suppliers in the healthcare market (Weichert 2018; Hoffmann et al. 2015). Whereas
public-private sector partnerships can help counteract monopolistic tendencies among companies
working across the data chain (Ballantyne and Stewart 2019), regulatory frameworks and funding
programs are needed to influence how data is accessed and leveraged so that smaller actors can
deliver innovations, particularly those targeting the common good (High-Tech Forum 2021).

In order to counter the unequal distribution of data that emerges from the monopoly-like control
exercised over this data (➔ 4.3.3 and ➔ 4.3.4), we need instruments able to guarantee authorized
individuals and / or groups access to this data (German Ethics Council 2017b). This issue should
also be integrated into the design of the European Health Data Space. This may involve establish-
ing regulated data trusts (Data Ethics Commission 2019). Technological solutions such as synthetic
data (➔ Recommended action #6), edge computing and swarm intelligence (➔ 4.3.4) can be of help
when it comes to using large volumes of data efficiently without compromising data privacy and
having to rely on centralized datasets.

Encouraging voluntary and participatory engagement, as well as creative efforts to acquire indi-
viduals’ consent to share their data can help promote data-sharing (WHO 2021a). To enable the
secondary use of health data in research and partnerships pursued among various institutions and
actors, the creation of relevant interfaces and interoperability for products like the electronic health
records (EHR) must be supported. Establishing such capabilities can prove useful, particularly
when it comes to validating and benchmarking AI solutions, for example (WHO 2021b). Sustainable
development goal considerations (European Health Data Space), such as the need to reduce and
optimize algorithmic systems’ energy and resource consumption should be integrated into deci-
sions regarding government investment in the data economy (Data Ethics Commission 2019).

On their way to becoming a tool within the German healthcare system, Digital Health Applications
(DiGAs) are now available as a benefit covered by statutory health insurance. One of the eligibility
prerequisites stipulated by the Digital Healthcare Act (DVG) is that such applications serve to
detect, monitor, treat or alleviate an illness, injury or disability. Applications designed to help
prevent disease, however, are not recognized as a DiGA. Given the considerable health benefits
and economic potential offered by preventive medicine, it would be prudent to expand the list of
eligible applications to include those targeting prevention. It would also be advisable to expand the
pool of those with access to tech giants’ data to include other researchers and companies so that
they, too, can develop innovative applications.

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 CONCLUSIONS AND RECOMMENDED ACTIONS

5 Advance risk-adapted regulation of artificial

intelligence in the EU

The European Union should enable and regulate a sufficiently differentiated, risk-appropriate
approach to AI systems (Data Ethics Commission 2019) and thereby ensure that innovation in this
area is not inhibited, but fundamental rights and freedoms – such as human dignity, self-determi-
nation, privacy, equal treatment and personal integrity – remain protected (European Commission
April 21, 2021). Analogous to the European General Data Protection Regulation (GDPR), this regula-
tion should also cover products and applications that companies based outside the European Union
develop or use in the EU. It would thus also affect the relevant activities of tech giants in health-
care and other sectors.

The goal here is to ensure a safe and non-discriminatory use of AI that promotes rather than
destroys public trust in technological innovation and which allows for meaningful human
control even in cases involving highly automated algorithmic systems. Ideally, this regulation
would include enforcing minimum standards in an ethics-by-design approach.

6 Incorporate an ethics-by-design approach into

the design, development and use of AI systems

Ethical considerations should be incorporated into the development of algorithmic systems from
the outset. In line with the ethics-by-design approach,134 so-called ethical requisites are “baked
in” to the development of a technological model, which involves proactively applying moral
principles throughout the process of development and deployment (WHO 2021a; Brey and Brandt
2020). The approach can be viewed in terms of a five-layer model, from the more abstract to
the more specific: (1) ethical values that must be upheld and enhanced, not violated; (2) ethical
requisites as conditions to be met by the system in terms of it embodying specific values through,
for example, its functionality and data structures; (3) ethics-by-design guidelines for individual
steps in development processes; (4) ethical principles are mapped on to the various components
of individual AI methodologies used in development; (5) tools and methods that are aligned with
ethical requisites independently of AI methods used in the development community (Brey and
Brandt 2020: 9).

If an ethics-by-design approach is incorporated into the development of AI systems in the

healthcare sector, this should be reflected in both European and national approval and certification
procedures for new applications and products. The approach should also be taken into account in
risk-adequate AI regulation. Similarly, given the intensive use of energy and resources involved

134 See, among others, the SHERPA Project, the SIENNA Report, and the expert opinion of the Data Ethics Commission (Brey et al.
2021; Brey and Brandt 2020; High-Level Expert Group on AI 2021; Data Ethics Commission 2019).

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in the development of AI technologies and in accordance with the United Nations’ Sustainability
Development Goals (UN 2015) (➔ 4.2.7), environmental sustainability requirements must also be
drafted that apply to the tech giants as well. Potentially helpful examples include requiring com-
panies to disclose their energy footprints135 and directing public funds toward AI-based systems
designed to track environmental impacts and the optimization of resource use (van Wynsberghe
2021; Data Ethics Commission 2019). In addition, the development and use of AI models must be
proportionate to their purpose,136 and models should be designed, for example, that use smaller,
carefully screened datasets and thus reduce their carbon footprint (WHO 2021a).

7 Legally prohibit the use of health-related risk

profiles to discriminate in non-healthcare settings

Legal regulations should be created to prevent health-related data – and the risk profiles
generated by them – from being used in areas unrelated to healthcare or medical research in
ways that are inappropriate, discriminatory, manipulative, or otherwise violate the integrity of the
personality. This could involve for example, prohibiting the use of such profiles in job searches or
when purchasing life insurance (➔ 4.3.1). This requires defining the legal provisions for prohibiting
exploitation, for example, within the context of the EU anti-discrimination directive (2004/113/EG)
and according national legislation.137 In order to protect personal integrity, limits should also be
placed on the creation of risk profiles for various aspects of life without the consent of the individ-
ual from whom the data originated (Data Ethics Commission 2019).

According to expert commissions, in order to protect health data and health-related risk profiles
while at the same time promoting the use of data for science and research and development, a
regulation “regulating the use of sector-specific health data” would be helpful (SVR 2021: XXVIII).
The goal is to agree on a common legal and technical framework for the secondary use of data
among EU countries in cross-border health research (ibid.) In addition, it should be examined
“whether the possibility of processing on a legal basis without a consent requirement or opt-
out option can be created for healthcare data that are considered particularly relevant for health
research, as is possible under European law on the basis of Article 9 (2) of the GDPR” (SVR 2021:
232). Such legislation could also involve specifying regulations for the handling and sharing of
data on the part of the tech giants, thus counteracting their monopoly-like position.

135 Emissions from different technological systems can be calculated and compared in an effort to reduce carbon emissions
(van Wynsberghe 2021; Strubell et al. 2019). Lacoste et al. (2019) proposed the Machine Learning Emissions Calculator for this
purpose, Henderson et al. (2020) developed an experiment-impact-tracker framework, and Anthony et al. (2020) built on this
to develop the Carbon Tracker. Establishing or even mandating such calculation processes in technology development, carbon
emissions and impacts can be made transparent and thus factored into the development process.

136 Institutions such as the European Commission should develop a “proportionality framework” for assessing whether the training
and tuning of an AI model is proportional to its carbon footprint (van Wynsberghe 2021).

137 General Act on Equal Treatment (AGG) of August 8, 2006, BGBI I: 1897, 1910; as amended on April 3, 2013, BGBl I: 610.

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 CONCLUSIONS AND RECOMMENDED ACTIONS

8 Develop a strategy for a learning healthcare

system

To implement technologies in healthcare, policymakers should draft a strategy to establish

a learning healthcare system. This includes creating a multilevel governance framework that
ultimately enables and promotes a cycle of learning in which data from everyday medical care
are subject to scientific analysis and then rapidly incorporated into efforts to improve care. This
should involve taking a multistakeholder approach and launching initiatives that draw on financial,
organizational, human and technological resources (WHO 2021b; UN Secretary-General’s High-
level Panel on Digital Cooperation 2019). In addition to governments and politicians, representa-
tives from civil society, the research community, industry and business should also be brought
into the process, as well as other groups thus far excluded from the discourse, such as older people,
people with disabilities, the chronically ill, rural populations and indigenous groups or people with
a migrant background (UN Secretary-General’s High-level Panel on Digital Cooperation 2019).

The political actors and self-governing corporatist bodies involved in multilevel governance should
remain mindful of ethical requirements such as data protection, security, the protection of privacy
and personal integrity, freedom of research and protections against discrimination (WHO 2021b).
Efforts targeting these issues have the capacity to facilitate the creation of a learning healthcare
system that engages all healthcare actors in advancing knowledge and which can harness the tech
giants’ potential in ways that prove beneficial to society as a whole.

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 Authors

AUTHORS

Aileen Berghold, M. Sc. is a German-trained health economist who supervised

the study as a research associate at the Cologne Center for Ethics, Rights,
Economics, and Social Sciences of Health (ceres) at the University of Cologne.

Constanze Hübner, M. Sc. is a German-trained health economist and research

associate at the Cologne Center for Ethics, Rights, Economics, and Social
Sciences of Health (ceres) at the University of Cologne, where she helped
develop the study as well as several other projects on health literacy.

RA Dr. iur. Björn Schmitz-Luhn is a legal scientist and used to serve as

Managing Director and Scientific Coordinator of the Cologne Center for Ethics,
Rights, Economics, and Social Sciences of Health (ceres) at the University of
Cologne. In October 2021, he has taken on the role of Managing Director and
Scientific Coordinator at the University of Bonn’s recently established Center
for Life Ethics.

Prof. Dr. med. Christiane Woopen has been the Heinrich Hertz Chair of Life
Ethics in the Transdisciplinary Research Area “Individuals, Institutions and
Societies” at the University of Bonn since October 2021. There she is Director
of the recently established Center for Life Ethics. Formerly she was Director of
the Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health
(ceres) at the University of Cologne, where the study was developed.

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TECH GIANTS IN HEALTHCARE

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