Digital Health: How can we assess environmental benefits?

Digitalisation and new technologies in medicine could reduce healthcare's environmental footprint. But a benefits-assessment method is still lacking.

About the author:
Lucas Thiery is the strategic director of the Digital Medical Hub of the university hospital AP-HP. He is also a co-founder of MedInTechs, the leading French trade fair specialising in digital health innovations, which takes place annually in Paris.

Translated from the original French version.

Can digital healthcare help protect the planet?

Today, it is possible to assess the overall environmental footprint of the health sector: on a global scale, 5% of all human greenhouse gas emissions (GHG: CO2, methane, ozone, nitrous oxide, halocarbons, etc.) are caused by national health systems.1

What are the main GHG emitting activities in healthcare? Let's take a look at the UK. According to the Lancet Countdown2 report on the carbon footprint of the National Health System, 62% of emissions come from purchasing, including pharmaceuticals and chemicals (32%) and medical equipment (19%). This is followed by emissions from the actual healthcare process (24%) and emissions from the transport of patients, their visitors and healthcare staff (10%).

An additional effect of the health sector is the release of air pollutants (nitrogen dioxide, ozone, carbon monoxide, sulphur dioxide and fine particles). Some of the processes that emit these gases and particles include the manufacturing and subsequent disposal of supplies such as pharmaceuticals, masks, and laboratory equipment, but also the transportation associated with the provision of care as well as the heating of buildings. All of these activities require the combustion of fossil fuels, the use of chemicals and the incineration of waste, all of which release pollutants into the atmosphere.

An immediate global challenge

On a daily basis, virtually the entire world population (99%) breathes air that exceeds the levels considered acceptable by the WHO.3 Air pollution alone is the 4th most important mortality risk factor worldwide.4,5 In Europe, it is responsible for an average of 350,000 deaths per year.  

A number of studies, particularly in France, have documented the impact of air pollutants on the rate of emergency room admissions and on the increase in mortality from respiratory and cardiovascular diseases.6, 7, 8

It is clear that if stakeholders in the health sector are to comply with the principle of primum non nocere, they must take steps to limit the pollution directly associated with their activities. Ensuring the care of an ageing population that is vulnerable to the effects of climate change and air pollution, improving the quality of care and containing the increase in health expenditure are three key issues for sustainable health systems.

At the same time, these limitations should not lead to certain types of treatments being abandoned because of the pollution they cause.

If we are to rethink the health system, we must urgently redefine the overall assessment of care in terms of 'co-benefits'.9 There is a need to examine ways of implementing more environmentally sound care that continues to meet the health, socio-economic and financial challenges that the sector is facing.

Achieving a consensus with the largest possible number of stakeholders, including those from civil society, is the key to reconciling these different approaches within a radically limited timeframe.

Telemedicine and digital therapy

The exponential increase in the number of remote consultations and the global emergence of telehealth – both in terms of digital therapeutic and professional solutions – offer initial evidence of the effectiveness of these new forms of care.

Aside from the number of transports avoided, it is necessary to include these approaches in a broader evaluation framework. In this way, all their "positive external effects" can be taken into account, discussed, assessed and evaluated. As an example, teleconsultations make it easier to monitor patients at risk on a regular basis, while allowing them to stay at home and remain more independent.10

Since the outbreak of the Covid-19 pandemic, the use of telehealth has seen a huge surge in popularity around the world. The speed with which digital communication has become part of mainstream health practices shows that the adoption of digital solutions can indeed transform health services in a remarkably short amount of time.

Leveraging digital technology, digital therapies could follow a similar trajectory to that of telehealth once the therapeutic benefits of these are proven.

Examples include algorithms for analysing symptoms and identifying the risk of relapse, cognitive behavioural therapy schemes, devices for remote monitoring of patients with chronic diseases, systems for adjusting treatment, such as smart insulin pumps, and personalised support programmes designed to encourage changes in behaviour (physical activity, nutrition, sleep, etc.).

Because these therapies are designed to encourage patients to be proactive, they help them to become more independent. In addition, they include a preventive dimension aimed at reducing the number of treatment procedures. Ultimately, digital solutions may help to avoid unnecessary and/or redundant treatments (e.g. poor record keeping of examinations), which in turn has a positive impact on the carbon footprint.

In renewing the patient experience and the analysis capacity of physicians, digital tools make it possible to rethink approaches to care. They improve the quality of care through enhanced coordination between health care providers. Though promising, it is still very difficult to quantify how the tools will reduce the environmental impact of health services for lack of adequate reporting tools.

Environmental impact assessment methods too short-sighted

Combining greater reliance on telemedicine with the use of digital therapies would be expected to optimise the treatment process, simply by eliminating certain procedures or elements that result in the use of GHG-emitting resources. This would include unnecessary and/or redundant forms of care arising from a failure to store or archive already existing data (from radiological and biomedical examinations, etc.).

But will this be enough to make the French health care sector emit considerably less CO2 and other air pollutants in the long term? A scientific answer to this question is not possible at present. At this point, we need to carry out an assessment before supporting the widespread use of these solutions merely based on the assumption that they have a positive carbon impact.

Key to our approach in the transition to a sustainable health system is to establish ways of weighing up the environmental impact and health benefits. Ultimately, we need to put these digital solutions to the test, and then look for "win-win" solutions, in other words devices that reduce the environmental impact while preserving or even improving the medical and socio-economic benefits. However, the health sector does not yet have this sort of system of accounting, something that contributes to our collective short-sightedness regarding the real benefits of the technologies developed.

Efforts are being made. In France, for instance, the "Bilan Carbone" assessment method was recently adjusted for the largest group of public hospitals (Assistance publique - Hôpitaux de Paris).11 The method provides a detailed assessment of GHG and pollutant emissions linked to certain types of activity (care services, equipment procurement and logistics, energy consumption in care units, patient and staff transportation etc.). However, Bilan Carbone is not designed to provide a quantitative assessment of the ratio of current carbon emissions to anticipated reductions in carbon emissions resulting from optimisation and prevention measures. 

As an illustration of this paradox, let us assume a digital therapy with a preventive aim, involving a cohort of patients wearing connected wristbands (the data collected being used to provide individualised advice). The environmental footprint resulting from the production and maintenance of the wristbands as well as the data tracking might be more than compensated for by the health benefits arising from the preventative effort (which, after n years, might reduce the number of treatment procedures performed)... Or it might not! Predictions in this area are risky in the absence of a suitable assessment methodology.

Although generic environmental impact assessment methods such as the Bilan Carbone, Life Cycle Assessment, Input-Output Analysis or hybrid methods12 quantify the emissions associated with certain equipment, they do not yet take into account the reduction of polluting emissions linked to medical procedures that have been rendered unnecessary thanks to the development of preventive care. Consequently, these methods must be urgently developed and adapted to the specificities of the health care sector to help establish a new evaluation practice.

Notes & References
  1. Manfred Lenzen, Arunima Malik, Mengyu Li, Jacob Fry, Helga Weisz, Peter-Paul Pichler, Leonardo Suveges Moreira Chaves, Anthony Capon, David Pencheon. The environmental footprint of health care: a global assessment. The Lancet Planetary Health, Volume 4, Issue 7 – 2020.
  2. Imogen Tennison, Sonia Roschnik, Ben Ashby, Richard Boyd, Ian Hamilton, Tadj Oreszczyn, Anne Owen, Marina Romanello, Paul Ruyssevelt, Jodi D Sherman, Andrew Z P Smith, Kristian Steele, Nicholas Watts, Matthew J Eckelman. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health (2021).
  3. Billions of people still breathe unhealthy air: new WHO data. World Health Organization (2022).
  4. Global Health Impacts of Air Pollution – Air pollution contributed to 6.67 million deaths in 2019. The Health Effects Institute (2020).
  5. Global Burden of Disease (GBD) Compare. Institute for Health Metrics and Evaluation – University of Washington (2020).
  6. Sasha Khomenko, Marta Cirach, Evelise Pereira-Barboza, Natalie Mueller, Jose Barrera-Gómez, David Rojas-Rueda et al. Premature mortality due to air pollution in European cities: a health impact assessment. Lancet Health Planet (2021) Published Online – January 19, 2021.
  7. Impact de pollution de l'air ambiant sur la mortalité en France métropolitaine. Réduction en lien avec le confinement du printemps 2020 et nouvelles données sur le poids total pour la période 2016-2019. Santé Publique France (2021).
  8. Selon les polluants atmosphériques, les effets immédiats sur les admissions aux urgences et sur la mortalité diffèrent. INSEE Analyses (2021).
  9. Rapport synthétique d'activités 2019 - 2020. Centre interdisciplinaire de durabilité (CID) – Université de Lausanne, Switzerland (2020).
  10. Purohit A, Smith J, Hibble A. Does telemedicine reduce the carbon footprint of healthcare? A systematic review. Future Healthc J. 2021 Mar;8(1):e85-e91. doi: 10.7861/fhj.2020-0080. PMID: 33791483; PMCID: PMC8004323.
  11. Premiers résultats du Bilan Carbone® de l’AP-HP sur l’ensemble de ses activités. AP-HP (2022).
  12. Designing a net zero roadmap for healthcare – Technical methodology and guidance. Health care Without Harm (2022).