LAUSR

Traditional care models are unlikely to sustain the escalating growth in patient needs and health-care costs in high-income economies. Digital medicine innovation holds promise to help reduce inefficiencies in health-care delivery, improve access, increase quality, and make medicine more personalised and precise in an era of increasing budget constraints. With increasing global investments in digital health there is much anticipation to see whether these promises will be realised. With its many start-up enterprises Israel encourages digital innovation and this culture will help tackle some of the key challenges facing the country’s health systems, as Rafael Beyar and colleagues highlight in their Viewpoint for the Lancet Series on health in Israel. There has been strong growth in the number of new digital health companies established in recent years, with 385 locally founded companies in 2016. These companies are an important part of a thriving life sciences start-up industry that has had a major impact on the country’s economy with more than US$7·2 billion in multiple mergers and acquisitions in 2015, a sizeable increase from the preceding year. Israel was also an early adopter of digital health technologies in clinical practice, with big data analytics, telemedicine, and online patient engagement widely incorporated into daily clinical care. For example, Clalit Health Services (Clalit) care providers have been prioritising older patients at-risk of deterioration in health status according to predictive modelling for more than a decade, and many additional predictive models for future illness and acute exacerbation are used in daily practice. Maccabi Health Services began piloting predictive analyticsbased care in 2015 for early detection of colon cancer. These practices overall have been referred to as an international benchmark. These initiatives have not increased health-care costs. Israel’s health-care expenditures have been stagnant at less than two-thirds of the average for Organisation for Economic Co-operation and Development countries per person, yet ranking among the top five of 172 countries in achieving the lowest risk of premature death due to key non-communicable diseases. In view of these data and Israel’s high life expectancy, Israel was ranked among the top countries on Bloomberg’s health-care efficiency scale in recent years. Some of the attributes that allow for this digital health innovation can probably be replicated in other health systems. We suggest that these practices are driven by the confluence of four national attributes—what we call Israel’s four Is. The first is Israel’s information technology infrastructure and its historical data repositories. In Israel, every resident is entitled to a wide range of health-care services that are provided by one of four not-for-profit national health services and insurance funds, which are known as sick funds. In the late 1990s, these providers pioneered the integration of electronic health records in their clinics. Securely archived in central data warehouses, these data serve as a platform for data-driven innovation, rapidly translated into practice. For example, the data warehouse of Clalit has nearly two decades of extensive identity-documentation-tagged, geo-coded, person-level detailed inpatient and outpatient clinical data (ie, diagnoses, laboratory results, medication prescription and dispensing, and imaging studies) on its 4·4 million members. This clinical data repository offers a unique testing ground for new data-driven care models, while maintaining strict patient privacy and advanced cyber-security standards. The second attribute is Israel’s integration of care and data with interoperable data flow. The structural integration of the four sick funds responsible for providing lifelong care for Israel’s population has meant that care Published Online May 8, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)30876-0