The Evolving Regulatory Paradigm of AI in MedTech: A Review of Perspectives and Where We Are Today

Artificial intelligence (AI)-enabled technologies in the MedTech sector hold the promise to transform healthcare delivery by improving access, quality, and outcomes. As the regulatory contours of these technologies are being defined, there is a notable lack of literature on the key stakeholders such as the organizations and interest groups that have a significant input in shaping the regulatory framework. This article explores the perspectives and contributions of these stakeholders in shaping the regulatory paradigm of AI-enabled medical technologies. The formation of an AI regulatory framework requires the convergence of ethical, regulatory, technical, societal, and practical considerations. These multiple perspectives contribute to the various dimensions of an evolving regulatory paradigm. From the global governance guidelines set by the World Health Organization (WHO) to national regulations, the article sheds light not just on these multiple perspectives but also on their interconnectedness in shaping the regulatory landscape of AI.

[Asymmetries between national articulation and the autonomy of state governments in implementing health technologies to fight COVID-19 in Argentina]

Argentina, as other countries, showed several public policies related to the health technologies implemented to fight and treat the COVID-19 pandemic. This study sought to analyze how articulation vs. cooperation and autonomy vs. division of powers between entities occurred in Argentina, exploring asymmetries between several entities in implementing public policies related to health technologies during the pandemic and the influences of other actors. For this, a documentary research was carried out related to 2020-2021 (technical reports published by the World Health Organization, national agencies and scientific societies, laws, court decisions, press, and research and in-depth interviews with members of the Argentine Ministries of Health). The processes and results of decision-making in the Ministries of Health were analyzed, outlining the coverage and orientations of each technology and the political party in power in the province. This study found heterogeneous results and processes between Ministries and disputes within them. It also observed the poor adherence to official guidelines due to technical-political criteria (power relations, social, media, academic, judiciary, and legislative pressure). Some cases showed a strong tension between the government and its opposition over the discussion of technologies. Each province in Argentina has autonomously defined its policies on health technologies for COVID-19, and decision-making in public administration was disorderly, complex, and non-linear during the pandemic.

A legal overview of the use of messaging platforms in healthcare

Medical interventions are becoming more complex day by day. Moreover, compared with the past, more healthcare professionals take part in the same intervention in the field of medicine. The use of technology in medical interventions has also increased. This change in the health sector brings together several legal discussions. In this study, the legal consequences that arise from the treatment processes carried out by the residents and resident educators (registerers / attending physicians), the exchange of information between them, and the usage of some messaging platforms, especially WhatsApp, in this process will be analyzed.

Natural hydrogels R&D process: technical and regulatory aspects for industrial implementation

Since hydrogel therapies have been introduced into clinic treatment procedures, the biomedical industry has to face the technology transfer and the scale-up of the processes. This will be key in the roadmap of the new technology implementation. Transfer technology and scale-up are already known for some applications but other applications, such as 3D printing, are still challenging. Decellularized tissues offer a lot of advantages when compared to other natural gels, for example they display enhanced biological properties, due to their ability to preserve natural molecules. For this reason, even though their use as a source for bioinks represents a challenge for the scale-up process, it is very important to consider the advantages that originate with overcoming this challenge. Therefore, many aspects that influence the scaling of the industrial process should be considered, like the addition of drugs or cells to the hydrogel, also, the gelling process is important to determine the chemical and physical parameters that must be controlled in order to guarantee a successful process. Legal aspects are also crucial when carrying out the scale-up of the process since they determine the industrial implementation success from the regulatory point of view. In this context, the new law Regulation (EU) 2017/745 on biomedical devices will be considered. This review summarizes the different aspects, including the legal ones, that should be considered when scaling up hydrogels of natural origin, in order to balance these different aspects and to optimize the costs in terms of raw materials and engine.

Models of Governance for Innovation in Medicine and Health Research

Personalised medicine, digital innovations, and neuro-technologies all offer significant potential benefit for human health and welfare, but also raise complex governance challenges. A variety of approaches have been adopted in the governance of innovative medicines and health technologies, including risk assessment, ethics and self-governance. Recently anticipatory or 'upstream' modes of governance have garnered favour. Anticipatory regulation demands a closer relationship between regulators and innovators, to shape the trajectories of the technology. In the EU context, responsible research and innovation has emerged as a key mechanism of governance. This is linked but distinct from a human rights governance which has the advantage of exerting both legal and moral force. What is needed in the healthcare context are governance models which ensure human rights considerations are taken into account from the earliest stages of innovation, to maximise the likelihood that developments are from the outset beneficial and oriented towards protecting ethical values.

Divergence and Convergence of Royalty Determinations between Compulsory Licensing under the TRIPS Agreement and Ongoing Royalties as an Equitable Remedy

Patent rights are recognized as a property asset with an attendant right to exclude. However, recent policy developments highlight that the right to exclude is not inviolable. This paper explores two rapidly evolving exceptions to patent exclusivity, both of which take the form of compulsory licenses. First, under the international Agreement on Trade-Related Aspects of Intellectual Property Rights ("TRIPS"), national governments can compel patent owners to out-license technology in service of greater good. These egalitarian compulsory licenses improve access to technology but undermine patent value. Second, compulsory licenses are increasingly relied upon as an equitable remedy in U.S. patent litigation. Typically referred to as "ongoing royalties," these court-mandated compulsory licenses are a modern alternative to injunctions against adjudged infringers. TRIPS compulsory licenses and ongoing royalties arise under independent legal frameworks, but necessarily invoke parallel economic considerations. While the wisdom of each has been discussed at length by others, this paper explores principles of royalty determination employed in each context. Considering both frameworks, an analysis of where each succeeds and fails is provided, together with an exploration of optimized royalty frameworks.

The Streetlight Effect: Regulating Genomics Where the Light Is

Regulatory policy for genomic testing may be subject to biases that favor reliance on existing regulatory frameworks even when those frameworks carry unintended legal consequences or may be poorly tailored to the challenges genomic testing presents. This article explores three examples drawn from genetic privacy regulation, oversight of clinical uses of genomic information, and regulation of genomic software. Overreliance on expedient regulatory approaches has a potential to undercut complete and durable solutions.

Regulation of Stem Cell Technology in Malaysia: Current Status and Recommendations

Stem cell technology is an emerging science field; it is the unique regenerative ability of the pluripotent stem cell which scientists hope would be effective in treating various medical conditions. While it has gained significant advances in research, it is a sensitive subject involving human embryo destruction and human experimentation, which compel governments worldwide to ensure that the related procedures and experiments are conducted ethically. Based on face-to-face interviews with selected Malaysian ethicists, scientists and policymakers, the objectives and effectiveness of the current Guideline for Stem Cell Research and Therapy (2009) are examined. The study's findings show that the guideline is rather ineffective in ensuring good ethical governance of the technology. A greater extent of unethical conduct is likely present in the private medical clinics or laboratories offering stem cell therapies compared with the public medical institutions providing similar services, as the latter are closely monitored by the governmental agencies enforcing the relevant policies and laws. To address concerns over malpractices or unethical conduct, this paper recommends a comprehensive revision of the current stem cell guideline so that adequate provisions exist to regulate the explicit practices of the private and public stem cell sectors, including false advertising and accountability. The newly revised Malaysian stem cell guideline will align with the Guidelines for Stem Cell Research and Clinical Translation (2016) of the International Society for Stem Cell Research (ISSCR) containing secular but universal moral rules. However, a regulatory policy formulated to govern the technology remains the main thrust of empowering the guideline for compliance among the stakeholders.

Invention in Dermatology: A Review

Dermatologists are among the most inventive physicians, trained in the multiple disciplines of medical dermatology, surgical dermatology, and dermatopathology. Many of the advances in dermatology practice have been derived from inventive colleagues who identify opportunities for improvement in practice, develop viable prototypes to address these practice opportunities, and persevere through the hard work of developing new technologies to advance the practice of dermatology. In this article, we will review the basic elements of invention, patents, and the range of outcomes associated with the pursuit of invention. Examples of innovative dermatologic technologies and approaches will be reviewed. Opportunities abound for dermatologists to contribute to the advancement of medical care through invention in our specialty. J Drugs Dermatol. 2019;18(9):904-908.

Knee replacement

Knee replacement surgery is one of the most commonly done and cost-effective musculoskeletal surgical procedures. The numbers of cases done continue to grow worldwide, with substantial variation in utilisation rates across regions and countries. The main indication for surgery remains painful knee osteoarthritis with reduced function and quality of life. The threshold for intervention is not well defined, and is influenced by many factors including patient and surgeon preference. Most patients have a very good clinical outcome after knee replacement, but multiple studies have reported that 20% or more of patients do not. So despite excellent long-term survivorship, more work is required to enhance this procedure and development is rightly focused on increasing the proportion of patients who have successful pain relief after surgery. Changing implant design has historically been a target for improving outcome, but there is greater recognition that improvements can be achieved by better implantation methods, avoiding complications, and improving perioperative care for patients, such as enhanced recovery programmes. New technologies are likely to advance future knee replacement care further, but their introduction must be regulated and monitored with greater rigour to ensure patient safety.

Mitochondrial Replacement Techniques : Examining Collective Representation in Emerging Technologies Governance

In this article, I draw on research carried out in Europe, primarily in Germany, on patients' and scientists' perspectives on mitochondrial replacement techniques (MRTs) in order to explore some of the complexities related to collective representation in health governance, which includes the translation of emerging technologies into clinical use. Focusing on observations, document analyses, and interviews with eight mitochondrial disease patient organization leaders, this contribution extends our understanding of the logic and meanings behind the ways in which patient participation and collective representation in health governance initiatives take shape. My findings highlight the ways in which a commitment to a global mitochondrial disease patient community and a sense of patient solidarity influence expressions of support with regard to legalizing mitochondrial replacement techniques. My analyses illustrate how normative practices and expectations of participatory governance potentially foreclose opportunities for sustained collective patient engagement with the complex ethical, social, and political dimensions of emerging technologies and may silence diverse and potentially dissenting embodied and lived responses to the prospects of particular technological developments.

A Framework for Incorporating Patient Preferences Regarding Benefits and Risks into Regulatory Assessment of Medical Technologies

BACKGROUND

In response to 2012 guidance in which the US Food and Drug Administration's (FDA) Center for Devices and Radiological Health (CDRH) stated the importance of patient-centric measures in regulatory benefit-risk assessments, the Medical Device Innovation Consortium (MDIC) initiated a project. The project was used to develop a framework to help the Food and Drug Administration (FDA) and industry sponsors understand how patient preferences regarding benefit and risk might be integrated into the review of innovative medical devices.

METHODS

A public-private partnership of experts from medical device industry, government, academia and non-profits collaborated on development of the MDIC patient centered benefit-risk framework.

RESULTS

The MDIC Framework examines what patient preference information is and the potential use and value of patient preference information in the regulatory process and across the product development life cycle. The MDIC Framework also includes a catalog of patient preference assessment methods and an agenda for future research to advance the field.

CONCLUSIONS

This article discusses key concepts in patient preference assessment of particular importance for regulators and researchers that are addressed in the MDIC Framework for patient centered benefit-risk assessment as well as the unique public-private collaboration that led its development.

Regionalization as an approach to regulatory systems strengthening: a case study in CARICOM member states

Improving basic capacities for regulation of medicines and health technologies through regulatory systems strengthening is particularly challenging in resource-constrained settings. "Regionalization"-an approach in which countries with common histories, cultural values, languages, and economic conditions work together to establish more efficient systems-may be one answer. This report describes the Caribbean Regulatory System (CRS), a regionalization initiative being implemented in the mostly small countries of the Caribbean Community and Common Market (CARICOM). This initiative is an innovative effort to strengthen regulatory systems in the Caribbean, where capacity is limited compared to other subregions of the Americas. The initiative's concept and design includes a number of features and steps intended to enhance sustainability in resource-constrained contexts. The latter include 1) leveraging existing platforms for centralized cooperation, governance, and infrastructure; 2) strengthening regulatory capacities with the largest potential public health impact; 3) incorporating policies that promote reliance on reference authorities; 4) changing the system to encourage industry to market their products in CARICOM (e.g., using a centralized portal of entry to reduce regulatory burdens); and 5) building human resource capacity. If implemented properly, the CRS will be self-sustaining through user fees. The experience and lessons learned thus far in implementing this initiative, described in this report, can serve as a case study for the development of similar regulatory strengthening initiatives in resource-constrained environments.

[Use of data: legal and ethical aspects]

Health care professionals and organizations, in carrying out their activities, consistently handle information related to identified or identifiable (even indirectly) natural persons, therefore "personal data". The application of Legislative Decree 30 June 2003 n. 196--the Code concerning the protection of personal data--as integrated by the pronunciations of the authority tasked with the application of such a complex legislation, the Authority for the Protection of Personal Data, consequently follows. The aforementioned legislation is seldom fully applied even 12 years after its publication, and even so not properly or with the adequate level of care. As a consequence, the data processed is often not adequately safeguarded, and compliance is hindered at an organisational level: this is particularly true with reference to the state of the art in medical technology, which is characterized by the utilization of ICT technologies such as the ones used with clinical registries and the Electronic Health Record. This chapter shows that, even when processing personal data that is of a sensitive nature, and at the same time of great importance, it is possible to reconcile the need to access and manage information with the protection of the individuals to whom such information refers to. This possibility is however closely linked to the awareness of the issues involved, awareness that in turn comes from an indispensable knowledge of the different aspects of that complex legislation.

[Health agencies and biomedicine: a new technocratic legitimity and a strategy to share power]

The role of health agencies in the field of biomedicine does not appear today anymore as a question of systemic approach but much more as a question of implementing the bioethical principles acknowledged in the legislation and by the different stake-holders of the biomedical techniques.

Career imperative. Is it legal? Is it ethical?

This paper gives sample ethical case vignettes and discussions that will be presented at the 36th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC'14) special session of the Ethics and Professional Responsibility Committee. The session includes additional cases with audience participation and panel discussions.

Employment rights of people with diabetes: changing technology and changing law

Though the treatment of diabetes has advanced remarkably, the law and many employers have not always kept pace. New insulins, delivery systems, and monitoring systems give people with diabetes exceptional control over their blood sugar and virtually eliminate serious complications such as hypoglycemia and hyperglycemia. Changes in the law, particularly the Americans with Disabilities Act and its 2008 amendments, give people with diabetes greater rights and employment opportunities than ever before. Despite these advances, many employers continue to use blanket bans or ill-considered standards to bar people with diabetes. Efforts to break down these remaining barriers are ongoing through employee litigation and through the American Diabetes Association's collaboration with entities that set occupational standards.

Considerations for an institution for evaluation of diabetes technology devices to improve their quality in the European Union

All medical devices used for self-monitoring of blood glucose (BG), insulin injection, continuous subcutaneous insulin infusion, and continuous glucose monitoring in the European Union (EU) must have a Communauté Européenne (CE) mark. However, the approval process for obtaining this mark is different from that used by the European Medicines Agency in the EU for drugs or by the Food and Drug Administration in the United States for such medical and in vitro diagnostic devices. The notified bodies involved in the CE mark process perform this evaluation in cooperation with the manufacturers. They have only limited diabetes know-how; they have to handle all kinds of medical devices. There are devices for therapy on the market in the EU (i.e., they have market approval) that do not fulfill quality requirements, as indicated, for example, in the international norm ISO 15197 for BG test systems. Evaluation of the performance of such systems is usually provided by the manufacturers. What is missing in the EU is an independent institution that performs regular and critical evaluation of the quality of devices used for diabetes therapy before and also after their market approval. The work of such an institution would focus on BG test systems (these represent two-thirds of the market of medical devices for diabetes treatment) but would also evaluate the performance of other devices. It has to be clarified what legal framework is required for such an institution and how it can be financed; probably this can be done in a shared manner by the manufacturers of such devices and the health insurance companies. Positive evaluation results should be a prerequisite prior to any reimbursement for such devices.

Development of a personal health monitoring system--the IT-systems industry view

The Development and Implementation of PHM systems require a different approach than typical application development processes. Based on a practical example it is described how ethical and legal aspects will be considered during the development process. The result is a cohesion and adoption of different methods with defined interaction points to reiterate the solution design by legal and ethical aspects.

Legal aspects of personal health monitoring

Personal health monitoring (PHM) can be defined as comprising all technical systems, processing, collecting, and storing of data linked to a person. PHM involves several legal issues that are described in this paper. This article analyses firstly the short term actions that are needed at the European level to allow personal health monitoring in respect of the interests and rights of patients such as the need to have more harmonised medical liability rules at the EU level. Introducing PHM implies also legal action at the EU level on the long run. These long-term actions are related to e.g. the way in which hospitals are organised in their relation with healthcare professionals and with other hospitals or healthcare actors. The paper analyses finally also how health monitoring projects may change the traditional (non-)relationship between patients and pharmaceutical/medical device industry. Today, the producers and distributors of medicinal products have no specific contact with patients. This situation may change when applying telemonitoring projects and may require new legal rules.

The right to enjoy the benefits of scientific progress: in search of state obligations in relation to health

After having received little attention over the past decades, one of the least known human rights--the right to enjoy the benefits of scientific progress and its applications--has had its dust blown off. Although included in the Universal Declaration of Human Rights (UDHR) and in the International Covenant on Economic, Social and Cultural Rights (ICESCR)--be it at the very end of both instruments -this right hardly received any attention from States, UN bodies and programmes and academics. The role of science in societies and its benefits and potential danger were discussed in various international fora, but hardly ever in a human rights context. Nowadays, within a world that is increasingly turning to science and technology for solutions to persistent socio-economic and development problems, the human dimension of science also receives increased attention, including the human right to enjoy the benefits of scientific progress and its applications. This contribution analyses the possible legal obligations of States in relation to the right to enjoy the benefits of scientific progress and its applications, in particular as regards health.

The secret to health information technology's success within the diabetes patient population: a comprehensive privacy and security framework

Congress made an unprecedented investment in health information technology (IT) when it passed the American Recovery and Reinvestment Act in February 2009. Health IT provides enormous opportunities to improve health care quality, reduce costs, and engage patients in their own care. But the potential payoff for use of health IT for diabetes care is magnified given the prevalence, cost, and complexity of the disease. However, without proper privacy and security protections in place, diabetes patient data are at risk of misuse, and patient trust in the system is undermined. We need a comprehensive privacy and security framework that articulates clear parameters for access, use, and disclosure of diabetes patient data for all entities storing and exchanging electronic data.

Federalism and technological change in blood products

Recent research has shown how federalism affects health care finance, health care reform, and health policy innovation. The purpose of this article is to extend this research program to study the linkages between federalism and technological change. It does so using comparative case studies spanning five countries to examine innovation and diffusion of two blood technologies-enzyme-linked immunosorbent assays (ELISA blood tests) and heat treatment-in response to the threat to the blood supply posed by HIV during the 1980s. Prior research has produced three contradictory models of the federalism-innovation relationship. This article attempts to resolve these contradictions, posits new hypotheses, and highlights sources of omitted variable bias that have important implications for understanding technological change. The case studies show that overall decentralization, rather than federalism alone, aids technological progress by allowing its supporters to "venue shop" around political resistance. Decentralization also makes the state less vulnerable to capture by status-quo interest groups. Moreover, political decentralization may have a positive effect on technological diffusion, but a far weaker effect on innovation. Thus, prior research that conflates these two effects should be revisited.

Who does the numbers? The role of third-party technology assessment to inform health systems' decision-making about the funding of health technologies

BACKGROUND

There is an increasing number of health-care systems using economic evaluations to inform decisions about the reimbursement of health technologies. There are usually two separate elements of this process: assembling relevant evidence and undertaking analyses (technology assessment), and decision-making. In most systems, technology assessment is undertaken by the manufacturer of the technology. In a few, "third-party" assessment is used.

METHODS

In the United Kingdom, the National Institute for Health and Clinical Excellence used a combination of third-party and manufacturer assessments between 1999 and 2005. After this point, a Single Technology Appraisal program (using manufacturer-based assessment) was instituted for some technologies. Here the role of third-party assessment is considered in this from of decision-making. The article reviews the requirements of economic evaluation to support decision-making, and considers the extent to which each type of assessment is likely to meet these requirements. It also attempts to address whether the two forms of assessment differ in their impact on decision-making using a comparison of the decisions made by National Institute for Health and Clinical Excellence (NICE) (under its multiple-technology appraisal system) and the Scottish Medicines Consortium (SMC), which relies on manufacturer assessment.

RESULTS

The comparison is limited by the small number of technologies considered by both bodies. Nevertheless, it suggests that there are potentially important differences between the two bodies, with NICE generally placing more restrictions of the use of technologies.

CONCLUSIONS

The article concludes that there are potential advantages to third-party assessment, but its cost and timing may preclude its use for all new technologies. A hybrid arrangement is suggested where third-party assessment is used in particular circumstances.

Science, biomedical technology and biolaw

Starting from legislative recognition of the grounding principles of human rights, the authors describe and comment upon the Council of Europe's Convention on human rights and human dignity confronted with scientific discoveries and also upon the Oviedo Convention of 1997 for the protection of Human Rights and dignity of the human being with regard to the application of biology and medicine. The authors specify that, given the promise made by Romania to observe international obligations, the Romanian law no. 2/1998 on organ and tissue transplantation abrogates the stipulations of the law 3-1978 and also includes 9 appendices which, being part of the law, guarantee in addition the observance of its provisions. All these regulations on the relationship between science and human rights have determined an evolution from the fatality of natural risks to current compensations, as an expression of human solidarity. They have determined the transition from social and vocational paternalism to personal autonomy and personal guarantees of independence and freedom. All these developments are faithfully reflected by comparative legislation on the use of life science outcomes on persons as they presently are. This is also reflected in Romanian legislation concerning tissue and organ transplantation and in mental health legislation.