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In Catalonia, Health IT Governance Rises Above the Political

June 6, 2018
by Mark Hagland
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The chief executive of Catalonia’s healthcare IT agency shares insights on the progress he and his colleagues have been making in HIT development in that region of Spain

Those who have been following the political scene in Spain lately know that the politics around the independence movement in Catalonia, that country’s wealthy northeast region, has become very intense of late. Certainly, the debate around the future of Catalonia remains heightened and controversial.

But beyond the news headlines, Catalonia (in Spanish, Cataluña; in Catalan, Catalunya)—whose land mass of 12,400 square miles is about the size of the state of Maryland, but whose population of 7.5 million is closer to that of Virginia—is a region noted for its economic and cultural vitality and ingenuity.

What’s more, because of the governmental landscape in Spain and Catalonia, healthcare information technology is in some ways very well-situated in terms of its overall governance. As in nearly all of the western European nations, healthcare is largely government-run in Spain. What’s more, Spain is governed through an architecture of autonomous regions, including Catalonia, which is governed by its own Parliament and regional government, the Generalitat de Catalunya.

Under the governmental architecture of the Generalitat is the Ministry of Health of Catalonia, and, managing the healthcare information technology resources of the Ministry of health, is the TICSalut Foundation. As the TICSalut Foundation’s website explains, “The TicSalut Foundation is an agency within the Ministry of Health that works to promote the development and use of ICT and networking in the field of health, acts as an observatory for new trends, innovation and monitoring of emerging initiatives and provides services for the standardization and accreditation of products. The implementation of ICT in the health sector is now unstoppable and is seen as one of the most transformative elements in the health sector of the future. The fact that the health sector in Catalonia covers 100 percent of citizens within a framework of universal and public coverage, together with the involvement of a variety of agents, organizations, suppliers and subsidiary industries, puts the health sector in an excellent position to act as an economic innovator and energizing influence in the use of new technologies.”

Late last year, Healthcare Informatics Editor-in-Chief Mark Hagland met with Francesc Garcia-Cuyàs, director of the TICSalut Foundation in Barcelona, to discuss some of the innovations taking place in Catalonia, and his perspectives on the Catalan, Spanish, and European healthcare IT development issues, and the comparisons between the Spanish and American situations, with regard to interoperability, health IT investment, and systems integration. Below are excerpts from that interview.

Mr. Garcia-Cuyàs, please tell me a bit about the governance and management aspects of the healthcare system in Catalonia, with regard to healthcare IT development and management?

In the Catalan healthcare system, each hospital has its own information system. But over the course of time, we have been creating full interoperability among all the hospitals in the region. We began an intensive IT harmonization initiative in 2006, and have been evolving it forward ever since.

We have developed a regional plan for digital health, a strategy for healthcare delivery, and for informatics. Our philosophy is that the technology must serve to support specific projects, as well as supporting digital transformation, and the patient experience, among other priorities. Our overall system encompasses both primary care information systems and medical specialty-based systems. And every hospital and outpatient center is able to share electronic health record-related data in our repository; all our hospitals, primary care clinics, and specialty medical practices, are connected. We have a national healthcare system that provides complete integration of EHRs, and allows for nationwide data-sharing, as appropriate. What’s more, all our local and patient care organization repositories are connected. Also, we’ll be moving everything to the cloud soon.

Meanwhile, in Catalonia, we’ve got 7.4 million patients in our regional system, with 18 percent of them over the age of 65, and 2 percent living with at least one chronic illness.


Francesc Garcia-Cuyàs
 

Tell me about some of the more advanced capabilities in your system?

Yes, we’ve got electronic prescribing, and pharmacy automation, including an integrated electronic prescription system across the entire nationwide healthcare system. What’s more, patients can check their personal electronic health records from their smartphones. We have all test results stored in our EHR. One of our goals is to be as people-centered as possible. We believe that by giving patients relevant information, they will participate in working to improve their health status.

Would you say that the overall regional health information system in Catalonia is one of the most advanced in Spain?

Yes, it really is; Catalonia has advanced faster than some of the other regions here; in fact, other regions are busy copying what we’ve been doing here.

What have been and continue to be, the biggest challenges for you and your team, in managing this very large regional health information system?

There are two. The first is helping our providers to manage the care processes of our citizens who are living with chronic illnesses. The other is moving forward into leveraging artificial intelligence-based tools, particularly to participate in robust data analytics.

But you have been moving forward in that area?

Yes, we have; we’ve been moving forward into predictive analytics, for example. Predictive analytics will be very helpful in a number of areas. We have an office of artificial intelligence, and we’re moving into the use of both machine learning and deep learning. One of our goals is to help to facilitate the success of a number of specific projects in our healthcare system, and to help individuals working on those projects to integrate their use of AI tools into their work. For example, we’re currently working on a report on our progress as healthcare system around care management. AI would be very helpful in that work.

What are something the projects you and your team have been working on recently?

We’re making progress in areas such as the expansion of the use of electronic signatures, and we’ve got three pilot projects moving forward in that area and others.

Have you achieved barcoded medication administration yet?

Yes, that exists. One element that is helpful in that regard is that the dispensing of prescription pharmaceuticals is highly regulated in Catalonia. Only official pharmacies are allowed to dispense medications; it’s not like in the United States, where commercial drugstores have pharmacies. Our pharmacies are state-controlled. Those kinds of commercial drugstores are allowed only to sell over-the-counter medications.

What might happen in the next few years?

We hope to be able to articulate a strategy to introduce more technology into the social sector. In fact, we have an office dedicated to research in that area. Things like some kind of digital café, and other resources that would create greater patient/healthcare consumer engagement around educating patients about their medications, and so on.

What have been some of the learnings on the journey forward so far?

One has been that, in developing new technologies, we need to work closely with physicians and nurses, in order to develop optimal solutions. Digital care is complex, and clinicians need to be part of determining what works and what doesn’t.

Sidebar: Digital Transparency in Catalonia

In one section of its website, the healthcare administration of the regional government of Catalonia, the Generalitat, includes this information about digital data transparency and access in Catalonia:

“The Government of the Generalitat de Catalunya has committed itself to the opening of public data, with the aim to make them transparent to the public, in addition to promote the use and re-use of the information generated by the Administration. The data are grouped in a common portal according to the standards promoted by the International World Wide Web Consortium (W3C). The “Open Data Gencat” project follows international trends around open data and navigation, according to the appropriate boundaries around privacy, security, and property that apply in each case, according to the Government Agreement of November 2010.

The Department of Health of the Generalitat is working for many of the data collected from the Observatory and other health interests to continue the process of opening in a coordinated manner with the Gencat portal, where you can see all the files available related to health issues. The files released allow, in addition, for the development of data visualization tools, and for the ongoing monitoring of the ongoing progress of DiagnostiCat, a portal of the Catalan Institute of Health that shows almost in real-time data for diagnostics of diseases that are presenting in a large majority of primary care centers in Catalonia.”

 

 


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Walgreens, Microsoft Ink Strategic Deal to “Transform Healthcare Delivery”

January 15, 2019
by Rajiv Leventhal, Managing Editor
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Observers are pointing to the agreement as a clear sign that the two companies are looking to fend off Amazon’s increasing push into healthcare

Walgreens Boots Alliance Inc. and Microsoft Corp. are joining forces on a major seven-year healthcare partnership that will aim to “deliver innovative platforms that enable next-generation health networks, integrated digital-physical experiences and care management solutions.”

The companies announced today that they will combine the power of Microsoft Azure, Microsoft’s cloud and AI (artificial intelligence) platform, healthcare investments, and new retail solutions with WBA’s customer reach, volume of locations, and outpatient healthcare services to accomplish their goals: to make healthcare delivery more personal, affordable and accessible.

While innovation in healthcare has occurred in pockets, officials of the two companies believe that “there is both a need and an opportunity to fully integrate the system, ultimately making healthcare more convenient to people through data-driven insights.”

As part of the strategic partnership, the companies have committed to a multiyear research and development (R&D) investment to build healthcare solutions, improve health outcomes and lower the cost of care. This investment will include funding, subject-matter experts, technology and tools, officials noted in the announcement. The companies will also explore the potential to establish joint innovation centers in key markets. Additionally, this year, WBA will pilot up to 12 store-in-store “digital health corners” aimed at the merchandising and sale of select healthcare-related hardware and devices.

Executives noted that the companies will focus on connecting WBA stores and health information systems to people wherever they are through their digital devices. What’s more, the integration of information will enable valuable insights based on data science and AI that can allow for improvements such as supporting the transition of healthcare data into more community-based locations and sustainable transformation in healthcare delivery.

And by working with patients’ healthcare providers, the companies will look to proactively engage their patients to improve medication adherence, reduce emergency room visits and decrease hospital readmissions. Core to this model is data privacy, security and consent, which will be key design principles, officials stated.

Just last month, Walgreens Boots Alliance announced that it would work with Verily, an Alphabet company, to develop a medication adherence pilot project. Industry observers are already attesting that the Walgreens-Microsoft collaboration is an obvious sign that the two companies are trying to counter Amazon's growing healthcare footprint.

“Improving health outcomes while lowering the cost of care is a complex challenge that requires broad collaboration and strong partnership between the healthcare and tech industries,” Satya Nadella, CEO, Microsoft, said in a statement today. “Together with Walgreens Boots Alliance, we aim to deliver on this promise by putting people at the center of their health and wellness, combining the power of the Azure cloud and AI technology and Microsoft 365 with Walgreens Boots Alliance’s deep expertise and commitment to helping communities around the world lead healthier and happier lives.”

Notably, the companies will also work on building an ecosystem of participating organizations to better connect consumers, providers—including Walgreens and Boots pharmacists—so that major healthcare delivery network participation will provide the opportunity for people to seamlessly engage in WBA healthcare solutions and acute care providers all within a single platform.

In an emailed statement reacting to today’s news, Forrester analyst Arielle Trzcinski noted, “The technology focus will enable Walgreens to put in place a critical backbone to enable a more connected experience for the customer/patient, as well as support broader interoperability.”

And speaking to the difference between retail pharmacies and traditional care providers, Trzcinski said that retail pharmacies offer an opportunity to engage with the patient much more frequently than at an office visit, giving an example of how chronic care patients see their pharmacist frequently, while some figures indicate that the average diabetic patient sees his or her provider once every six months.

“This gap creates an opportunity for the pharmacist to help monitor the patients’ health and prompt the patient to receive preventative care in the retail clinic or through a virtual care visit. Using an enterprise health cloud, like Azure, you create a more connected ecosystem so that we can share that data with the patient’s additional providers, track outcomes, and intervene earlier when an issue arises,” he said.

Trzcinski also pointed out that up to 20 percent of hospitals are at risk for closure in 2019—according to Morgan Stanley—with most of them located in rural areas. “Consumers will turn to retail locations like Walgreens, Walmart, and CVS for convenient care options as well as virtual care delivery to fill the gap,” he asserted.

Through this agreement, Microsoft becomes WBA’s strategic cloud provider, and WBA plans to migrate the majority of the company’s IT infrastructure onto Microsoft Azure, officials said. Microsoft also plans to roll out Microsoft 365 to more than 380,000 Walgreens employees and stores globally.

 “WBA will work with Microsoft to harness the information that exists between payors and healthcare providers to leverage, in the interest of patients and with their consent, our extraordinary network of accessible and convenient locations to deliver new innovations, greater value and better health outcomes in health care systems across the world,” said Stefano Pessina, executive vice chairman and chief executive officer of WBA.


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“Revolutionizing” Healthcare: How Non-Traditional Players are Shaking Up the Sector

January 15, 2019
by Rajiv Leventhal, Managing Editor
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Traditional healthcare stakeholders will not be able to slow down new industry entrants such as Amazon, one leading consultant attests

In late November when Amazon announced that it was launching a machine learning service that will aim to mine data from electronic health records (EHRs), company officials, in a blog post, noted that the software, Amazon Comprehend Medical, is “a HIPAA-eligible machine learning service that allows developers to process unstructured medical text and identify information such as patient diagnosis, treatments, dosages, symptoms and signs, and more.”

Two of Amazon’s specialists—Matt Wood, Ph.D., a machine learning expert, and Taha Kass-Hout, M.D., a former FDA chief health informatics officer—noted that a core issue in healthcare and health IT today is that a large amount of critical data is stored as unstructured medical text, such as medical notes, prescriptions, audio interview transcripts, and pathology and radiology reports. “This means that being able to identify this information can be a manual and time-consuming process, which either requires data entry by high skilled medical experts, or teams of developers writing custom code and rules to try and extract the information automatically,” they outlined, adding that Comprehend Medical will instead aim to specifically allow developers “to identify the key common types of medical information automatically, with high accuracy, and without the need for large numbers of custom rules.”

Following the announcement, industry observers were quick to react to Amazon’s latest aggressive push into healthcare, with one consultant for Impact Advisors, Liam Bouchier, a principal with the firm, noting that this latest initiative is simply another example of Amazon “doing what it does best”—working to analyze large data sets as a means to gain meaningful insights into the consumer through a variety of different ways. “This concept does make some in the healthcare industry uncomfortable,” he added.

Another healthcare consultant—Michael Abrams, managing partner at the St. Louis-based Numerof & Associates—agrees that the initiative is exciting at the surface, and believes it speaks to a much larger issue in the health IT market: responding to a significant need to do something constructive with the voluminous amount of data that stakeholders already own.

Taking a step back, Abrams, in a recent interview, explains that one of the core issues that has arisen from healthcare’s digital shift is that having access to digitized data is different from being able to use that data to streamline decisions or improve quality. “Because hospitals rushed to digitization in response to extrinsic [financial] incentives [as part of ARRA/HITECH], they wanted to qualify for federal subsidies, but hadn’t really developed the internal capability to use the data. So, for the most part they are still very early on that learning curve, and the notion of aggregating data, data manipulation, and the insights you can draw from aggregating data, is still a new concept, Abrams says. He adds, “Now that [organizations] have these [EHR] systems and are saddled with substantial upkeep, it’s important to find a way to make it pay off.”

He contends that much of the healthcare delivery community is obsessed with “big data,” but the truth is that “they have hardly scratched the surface using the data they already own.” Abrams asserts, “Many of them don’t understand their own internal operations and don’t understand the cost of doing business— what it costs them to do a knee replacement, for example. All they know is at the end of the year, if they are profitable, it’s all good. Every corner convenience store has SKUs on everything they sell, and they know what the profitably is on every item. How many hospitals can say that? Not many,” he attests.

But according to what Amazon has said regarding its machine learning capabilities, this new software can re-digitize patient records and other clinical notes, analyze them, and pull out key data points, Abrams explains. “This is a very strategic move for Amazon because it already has advanced capabilities in natural language processing. Amazon Web Services has been selling this kind of text analysis software to markets outside of medicine for some time. They have a significant advantage,” he says.

A Vendor Community Satisfied with the Status Quo

An updated brief from the Office of the National Coordinator for Health IT (ONC) last summer revealed that health IT giants Epic and Cerner have continued to maintain the largest EHR market share (22 percent and 24 percent, respectively), based on the proportion of hospitals that reported using the developer's certified products.

These results, though unsurprising, signify to Abrams an oligopoly in that Epic and Cerner account for about half of the hospital market share, with the top-five vendors in this space accounting for roughly 85 percent of the market share. “When you have an oligopoly, you have a lot of large, slow-moving entities,” says Abrams, who also believes that as consolidation increases in the provider market, leading to fewer larger players among hospital systems, it makes it “almost incumbent upon vendors to also become fewer and larger, in order to have a balance of power.”

What’s more, Abrams attests that the EHR vendors with the largest market shares “regard their propriety code and the closed nature of their systems as a defense against encroachment by other, perhaps hungrier players who don’t have that market share. The status quo of a lack of interoperability suits the dominant players,” he says.

Can New Entrants Be Slowed Down?

With all this in mind, while health IT vendors have traditionally been content with incremental change, Abrams strongly believes that outsiders such as Amazon, Apple, and Google “bring the technology and commercial savviness to dramatically shake up what’s been generally a very complacent industry.” He adds, “Players like Amazon have their eye on the next big thing.”

Indeed, the traditional players and the healthcare delivery organizations are, on at least at some level, “terrorized about what these technology companies are going to come up with next,” he says. Consider that in just the last year alone:

  • Amazon, Berkshire Hathaway, and JPMorgan Chase & Co announced they were teaming up on an initiative to improve satisfaction and reduce costs for their companies’ employees.
  • Amazon said it would be part of another endeavor related to healthcare—to remove interoperability barriers and to make progress on adoption of health data standards. For this project, Amazon is teaming up with Microsoft, Google, IBM, and others to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project.
  • Apple, of course, also had a big announcement in early 2018: that it would be testing its new Health Records feature out with 12 hospitals, inclusive of some of the most prominent healthcare institutions in the U.S. Since that time, more than 100 new organizations have joined the project,  according to Apple. The idea behind the feature is that consumers could see their medical records right on their iPhones.

As such, prior to the past year when non-traditional players began moving more and more into healthcare, providers were “reasonably comfortable with moving as slowly as they could because they thought they had a good fix on the level of pressure and the pace of change that they might expect from the government,” says Abrams.

Adding to this thought, he notes that providers—with the help of industry trade associations—could negotiate with the government on the speed at which certain regulations might come down the pike, depending on how ready stakeholders are. But, Abrams adds, “Nobody can say ‘slow down’ to Amazon; when they want to do something, they are going to do it, and if they have a better solution, it could very well revolutionize the industry.”


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Should Apple Join the Amazon/Berkshire/JPMorgan Joint Healthcare Venture?

January 10, 2019
by Rajiv Leventhal, Managing Editor
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Apple should get involved with the Amazon, Berkshire Hathaway, and JPMorgan Chase & Co joint healthcare venture that the companies announced last year, said Jim Cramer, television personality and former hedge fund manager.

According to a CNBC report this week, Cramer—the host of CNBC's Mad Money and whose charitable trust also owns shares of Apple—said that J.P. Morgan CEO Jamie Dimon would have to be the one to bring Apple involved in the venture, since Warren Buffett's Berkshire Hathaway owns a huge stake in the tech stock that could appear "self-serving.” Said Cramer, “It is really time for, I think, that ecosystem to embrace the Apple ecosystem."

As Healthcare Informatics noted in a news report published last January, “With an ambitious-sounding, if vaguely worded, announcement, three corporate giants—Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. announced Jan. 30 that they were launching an initiative to improve satisfaction and reduce costs for their companies’ employees...The three companies, which bring their scale and complementary expertise to this long-term effort, will pursue this objective through an independent company that is free from profit-making incentives and constraints. The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost.’”

Although not many details are known about this collaboration, the organizations named Atul Gawande, M.D., as CEO of the initiative, back in June.

Meanwhile, in August, Amazon said it would be part of another endeavor related to healthcare—to remove interoperability barriers and to make progress on adoption of health data standards. For this initiative, Amazon will be teaming up with Microsoft, Google, IBM, and others to jointly commit to support healthcare interoperability by advancing healthcare standards such as HL7 (Health Level Seven International), FHIR (Fast Healthcare Interoperability Resources), and the Argonaut Project.

Over the past year, industry observers have had their eye on non-traditional healthcare players such as Amazon and what they can bring to the table from an innovation and cost-cutting perspective. One recent survey of 100 healthcare organization leaders found that most C-suite executives do have their eyes on Amazon to shake up healthcare.

Apple, of course, also had a big announcement in early 2018: that it would be testing its new Health Records feature out with 12 hospitals, inclusive of some of the most prominent healthcare institutions in the U.S. Since that time, more than 100 new organizations have joined the project,  according to Apple. The idea behind the feature is that consumers could see their medical records right on their iPhones.

In a recent interview with Cramer that aired this week, Apple CEO Tim Cook attested, “I believe, if you zoom out into the future, and you look back, and you ask the question, 'What was Apple's greatest contribution to mankind?' It will be about health.”

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