How TIMELY is changing the healthcare sector - An interview with Dr. Boris Schmitz
In today's interview, we talk to Dr. Boris Schmitz, primary researcher at Witten/Herdecke University and expert in eHealth-based solutions in cardiac rehabilitation. Dr. Schmitz is leading the TIMELY study, which is investigating patient needs in Germany and Spain. He shares exciting insights into his current research and the future of digital healthcare with us. You can read more about this in the following interview, which took place in March 2025.
About
Dr. rer. nat. Priv.-Doz. Boris Schmitz has been Head of Research at the Department of Rehabilitation Sciences at Witten/Herdecke University in Witten, Germany, since January 2020.
Research focus:
Molecular exercise physiology, prevention and treatment of cardiovascular diseases, molecular biomarkers for monitoring individual training effects.
Areas of expertise:
Hypertension, atherosclerosis, transcriptional regulation, molecular biology, gene expression regulation, microRNA, epigenetics, exercise physiology, sports science, health promotion.
Additional affiliations:
Leibniz Institute for Atherosclerosis Research (PhD student, 2007-2010, Münster)
Universitätsklinikum Münster (Principal Investigator, 2014-2019, Institute of Sports Medicine)
Universitätsklinikum Münster (Researcher, 2011-2014, Department of Internal Medicine D)
KU Leuven (Visiting Scientist, 2012, Department of Cardiovascular Sciences)
Dr. Schmitz, can you give us an overview of the main objectives of the TIMELY project?
TIMELY promotes a heart-healthy lifestyle by digitally supporting the key elements of rehabilitative care. The focus is on risk reduction, medication, exercise, daily activity, smoking cessation, stress management and nutrition. There is a particular focus on sport and information: the "Educated" area offers understandable insights into the disease and its risk factors. Behavioral change techniques help to establish healthy routines by providing motivation, feedback and goal tracking. The aim is to support patients beyond the rehabilitation phase until a healthy lifestyle is integrated into everyday life as a matter of course.
How realistic is it that patients will achieve their health goals with TIMELY? Are there average values for exercise, sport or smoking cessation? And to what extent do they follow the WHO recommendations of 150-300 minutes of cardio per week?
The exercise recommendations for sick and healthy people hardly differ. Despite possible restrictions, many patients are able to achieve the recommended 150-300 minutes of exercise per week. The main barriers are not so much physical fitness as a lack of time and motivation. Work commitments in particular make it difficult for some people to integrate sufficient exercise into their everyday lives. Nevertheless, experience from rehabilitation shows that many patients can achieve the minimum recommendation of 150 minutes by consciously changing their routines - often with just 20 minutes of activity every day.
Quitting smoking, on the other hand, is usually an intrinsically motivated decision that is often made after a drastic health event such as a heart attack. Research shows that external support is only effective to a limited extent. Many patients stop smoking before or during rehabilitation, and the number of ex-smokers continues to rise in the first six months afterwards. While smoking prevention campaigns have been very successful in recent years, there is a lack of comparable education about the importance of exercise for heart health. Greater social awareness could help to establish healthy behaviors more sustainably in the long term - a challenge that goes beyond TIMELY.
How many of the cases included in TIMELY are smokers or former smokers?
At the beginning, the number of ex-smokers was around 40%. However, many patients stop smoking immediately after a health event, such as a heart attack, often because they are convinced that smoking was the cause. After the first phase, only around 15-20% remain who continue to smoke. The majority therefore make the decision to stop smoking directly after the event, without any additional intervention.
What are the main causes of the diseases? Are the patients on average very overweight? Or is it rather their age, that they have had unhealthy lifestyle habits for many years?
Around 50% of the development of cardiovascular disease is genetic. Many patients have genetic disorders in lipid metabolism that are inherited. A positive family history plays a central role, especially in patients who otherwise have no obvious risk factors such as obesity, smoking or lack of exercise. An early onset of cardiovascular disease in the family, especially in women, significantly increases the risk for subsequent generations. In such cases, it is important to take early countermeasures with intensive drug treatment. In addition to genetic factors, classic risk factors such as long-term smoking are also among the main causes. Even after years of quitting smoking, smoking remains a risk factor as the body does not forget the negative effects. Lack of exercise also plays a key role, as many patients are not active enough to reduce their risk.
Is this mainly about the increased LDL cholesterol, or how should we think of it?
LDL cholesterol is the most important parameter we address in the treatment of lipid metabolism disorders, as it is directly linked to the risk of cardiovascular disease. While other factors such as apoB and Lp(a) are also risk factors, they are not treated as intensively in practice as the therapeutic options are currently limited. High Lp(a), for example, cannot be treated effectively and there are only limited therapeutic approaches, such as apharesis, a type of dialysis to reduce lipid levels, which is only used in very specific cases. Treatment strategies currently focus on reducing LDL cholesterol with statins and other drugs in order to reduce the risk. In addition to drug therapy, lifestyle changes such as regular exercise, smoking cessation and a healthy diet play an important role. Future therapies, especially antisense RNA technologies, may offer new options for treating lipid disorders, but for now the focus remains on traditional medication and risk minimization through behavioral changes.
Can LDL, apoB and Lp(a) levels be influenced by diet and lifestyle measures? Is it possible to regulate these values through a targeted diet, particularly in the case of genetically determined, early elevated LDL cholesterol - such as inherited from parents?
Hardly. The possibility of controlling LDL through diet is very limited. If the intake of cholesterol from food is reduced, the body reacts by trying to stabilize the existing LDL level by releasing more lipids from the liver into the blood. This makes it practically impossible to reduce an already elevated LDL level through diet alone. However, a healthy diet in combination with statins can have a supportive effect and possibly achieve a small improvement of around 5%. The really high LDL levels cannot be adequately regulated by diet. If food intake is reduced, the liver even reacts more strongly by releasing more cholesterol. Additional therapy with drugs such as ezetimibe can further reduce LDL levels by around 10% by reducing the absorption of cholesterol into the liver. In combination with statins, which prevent the release of LDL and inhibit its deposition in the blood vessels, a certain effect can be achieved, but the scope remains limited. In this respect, diet and medication can improve LDL levels by perhaps 10 to 15 % overall, but the main effect comes from the medication.
To what extent does diet play a role in patients with HF?
Nutrition plays an important role in heart failure patients, especially when it comes to proper education about what a healthy diet actually is. Patients are often misinformed about this, which is partly influenced by the advertising industry. One example is the widespread assumption that eating lots of fruit or fruit juice is healthy. In reality, however, fruit juice often contains a high amount of fructose, which can not only have a negative impact on long-term blood sugar levels, but also puts a strain on the liver, as fructose goes straight there. It is therefore very important to educate patients about these connections.
This project has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 101017424. The content reflects the views only of the authors, and the European Commission cannot be held responsible for any use which may be made of the information contained therein.
What role does artificial intelligence play in the project and how can it improve the prevention and treatment of patients?
Artificial intelligence plays a central role in our project, especially where large amounts of data come together. In healthcare, especially in prevention, we face the challenge of limited financial resources. Individualized care for every patient - even online - would simply not be financially viable. This is why we use AI in a targeted manner to efficiently analyze large amounts of data. Our systems collect various health data, for example from blood pressure monitors, activity trackers or questionnaires. If a person were to analyze all this information manually every day, it would be almost impossible to implement. AI helps us here by separating relevant from less relevant data and showing caregivers, therapists or case managers which patients need special attention.
One example: If a patient shows consistently stable blood pressure and activity levels, the AI recognizes that there are no abnormalities here. Close monitoring is not necessary - a weekly check is sufficient. However, if another patient shows significant deviations, whether in blood pressure, movement patterns or even emotional state, the AI sounds the alarm and indicates that a closer look is required. In this way, AI enables targeted and efficient care by identifying those patients who actually need support.
The project targets the entire care chain. From early diagnosis to aftercare. How is the continuity and completeness of the data in the platform ensured?
This is primarily a technical challenge. In recent years, however, we have made considerable progress in the stability and security of such systems. One important aspect is the cybernetic infrastructure that enables reliable transmission, storage and mirroring of data. I am not an expert in this area, but developments in recent decades have shown that the error rate in data transmission has been significantly reduced.
In the past - around 20 years ago - around 20% of data either did not arrive at all or arrived incorrectly, according to experts. Thanks to modern transmission methods, automated data checks and intelligent mirroring systems, we now have completely different ways of ensuring the continuity and completeness of data. This is essential, because we are not only responsible for the data itself, but also for ensuring that it flows correctly and completely into the platform.
How do you see the role of e-health and mHealth, i.e. mobile health, in the future of cardiology patient care?
E-health and mHealth will play a central role in cardiology care - not only in Germany, but throughout Europe. We are facing several challenges: There are too few specialists, too few registered doctors and at the same time more and more patients. As cardiovascular diseases are strongly linked to age and our society is getting older, the need for medical care is constantly increasing. We can no longer cope with this growing demand with the existing structures. In order to relieve the burden on the healthcare system and ensure that patients receive targeted care, we must increasingly rely on digital solutions such as mobile health. These make it possible to better manage patients and ensure that only those who actually need a personal examination visit the doctor's practice. Otherwise, we are heading for a collapse of the healthcare system. We are already seeing this development today: health insurance contributions are rising massively and many people are unable to get an appointment with a specialist because there is simply not enough capacity. Digital solutions are therefore not a luxury, but a necessity in order to ensure cardiology care in the future.
Mental health plays a crucial role in our project and was already firmly planned in the first version of TIMELY. Even though the full implementation is still in progress, this aspect will definitely be integrated. Around 30% of our patients show signs of anxiety or depression. I can't say for sure whether this rate differs significantly from the population as a whole. But we know from the conversations we have with patients and from the questionnaires we evaluate: People with severe psychological stress often do not take sufficient care of their physical health. A severely depressed person will not simply do sport, even if it is medically advisable - simply because they lack the strength to do so.
This means that the mental state has a significant influence on the healing process. In your opinion, is there enough awareness of this in everyday medical practice?
We see extreme cases time and again: Patients who don't leave their homes for months after being discharged or don't even unpack their suitcases. Such situations show how profoundly mental health can affect recovery. It is therefore crucial to recognize mental stress at an early stage.
This is where TIMELY comes in: Through regular questionnaires and mood assessments, we can identify conspicuous changes. If a patient is in a critical phase, we need to ask specific questions, clarify the causes and - if necessary - offer support at an early stage. This can take the form of a coach or therapist before the situation deteriorates dramatically. Because once depression is deeply rooted, the road is often long and arduous. And if patients then have to wait months for a place in therapy, this can have serious consequences. Early detection in the field of cardio-psychology is therefore essential. Mental stress is a significant risk factor for the recurrence of cardiovascular diseases such as heart attacks. TIMELY consciously integrates this aspect into its preventive measures in order to protect not only physical but also mental health and thus improve care in the long term.
How do cardiology telemedicine centers (TMC) in Germany benefit from TIMELY?
Cardiology telemedicine centers (TMZ) benefit significantly from TIMELY, both in Germany and internationally. If you consider a TMC as a large cardiology practice that provides continuous care to its patients, the advantage is obvious: TIMELY enables targeted patient management.
The practices not only see the patients regularly online, but also continuously receive up-to-date health data. This means they know, for example, whether a patient exercises regularly, measures their blood pressure and generally shows a high level of adherence to treatment. Such patients do not necessarily have to come to the practice. Even if they request an appointment, the doctor can use the data to give the all-clear. This is a considerable advantage for the entire healthcare system, but also for the individual practices. TIMELY helps to identify patients who do not require urgent personal care. This creates more capacity for those who actually have acute or serious problems and need to be examined on site. In this way, the limited resources in the healthcare system can be targeted to where they are really needed. Only in this way will it be possible to provide adequate care for all patients in the long term.
What are the next steps for TIMELY after the project is completed and what are the long-term goals?
The project is expected to be completed in May 2025, but the next steps are already clearly defined. We have three main goals: Firstly, we want to position TIMELY as a program within the German pension insurance scheme. We are also planning to make the system accessible to statutory health insurance patients in Germany via the GBA procedure. Another important step is the expansion into Spain, where we want to introduce TIMELY in private cardiology practices. In Spain, such additional services for patients with statutory health insurance are widespread and offer great potential for integrating TIMELY into the local healthcare market. With these steps, we not only want to further improve patient care in Germany, but also establish TIMELY internationally as a valuable tool for efficient and sustainable cardiology care.