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International HIT Perspectives: In Spain, Healthcare IT Leaders Nurture Creativity—Out of Necessity

March 3, 2018
by Mark Hagland
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Healthcare IT leaders in Spain continue to move forward to advance IT development within their national system
The famous "Cuatro Torres," or "Four Towers," dominate the tony Paseo de la Castellana in Madrid, and represent the new Spain

This is the first in a series of articles highlighting developments taking place in healthcare IT within the Spanish healthcare system.

 The Hospital Universitario Puerta de Hierro Majadahonda, located in the upscale northwestern Madrid suburb of Majadahonda, is as modern as any in Spain. A 613-bed academic medical center with 3,000 professionals, it has been ranked in the top 10 hospitals in Spain by reputation. Furthermore, it has achieved Stage 6 recognition by HIMSS Analytics (the division of the Chicago-based Healthcare Information and Management Systems Society), whose EMRAM model for the adoption of electronic health record (EHR) technology has been applied both in the United States and internationally. The hospital has a high-availability, EHR (from the local Spanish software company Selene—which had been acquired by Siemens, and is now part of Cerner), with full barcoded meds administration. A major impediment to its reaching HIMSS Analytics Stage 7? Like most Spanish hospitals, Puerta de Hierro does not package single-dose medications, a Stage 7 requirement. That smallish fact, like so many others, speaks to differences in European and American hospital organization and culture.

Still, like a number of other major academic hospitals in Spain, Puerta de Hierro is one that is showing the way to a more technologically advanced future, says Juan Luis Cruz Bermúdez, whose Spanish title is “Coordinador, Unidad de Tecnologías de la Información y las Comunicaciones, Instituto de Investigación Sanitaria”—meaning that he is the IT director in the clinical research division of the hospital. He is also acting CISO for the hospital, and its former CIO.

Providing this foreign journalist with a comprehensive tour of the hospital’s operations, including IT operations last November, Cruz Bermúdez was quick to point out that some of the differences between the U.S. and Spanish healthcare systems reflect policy and strategic priorities, while others reflect financial issues and concerns. “As you’ll hear so often said here,” Cruz Bermúdez says, “we are underfunded for information technology, and need to use rely a lot on imagination” in order to fully serve hospitals’ communities. In Spain, as in the U.S., healthcare represents a high cost for the national governments of both nations; in Spain, though, hospital budgets can yo-yo up and down to some extent, depending on the priorities of the government in power at the time, in a parliamentary system in which parties can shift into and out of power relatively quickly.

Still, the Spanish healthcare system has done some things that make it more advanced than the U.S. healthcare system overall in certain very specific contexts, one of them being population health. Dr. Rosa Capilla Pueyo, the ED coordinator at Puerta de Hierro Majadahonda, notes that what in the U.S. has emerged as population health in the past several years, has been practiced, at the primary care level, in Spain, for over 40 years, as a matter of course. That is not surprising, given that spending constraints at the national level have meant a strong emphasis on managing care upstream. Indeed, Dr. Capilla Pueyo, a primary care physician who manages a special program for managing geriatric patients, including those with dementia who are in assisted living and long-term care institutions, to prevent extended hospital stays, reduce length of stay, and enhance health status, notes that, “By 2050, more than 27 percent of Europeans will be over 70 years old. That will be catastrophic. In Spain, population health management has been around for 40 or more years, and is simply called public health.”

Still, even with population health management programs that are advanced by U.S. standards, Spanish clinical leaders face some perhaps-universal issues. “One of the problems,” Dr. Capilla Pueyo says, is cultural, in terms of the population. It’s hard to educate people not to automatically use the emergency room. We need to engage in some very efficient triaging, and strong case management.” In that context, she and her colleagues are leveraging data and IT to support the ongoing development and expansion of algorithms and clinical pathways for managing such issues as COPD (chronic obstructive pulmonary disease), congestive heart failure (CHF), urinary tract infections, and diabetic ketoacidosis. “It is important for clinicians to follow these guidelines or pathways, both to improve patient outcomes and health status, and also to lower costs, in a government-run health system,” she notes.

Meanwhile, a program that Dr. Capilla Pueyo is leading, called “UAPI"—which stands for “La Unidad de Atencion al Paciente Institucionalizado,” or Inpatient Care Management Program—has averted 1,743 inpatient admissions in the past 12 months, through intensive care management of at-risk patients. It has also reduced the average length of stay of patients being care-managed in the program.

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