Digital Health Strategy in Spain and Catalonia (Jordi Piera Jiménez)

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology with me, Tjasa Zajc. Catalonia, a region in Spain, published a new Healthcare Digitalization Strategy in 2017.

[00:00:24] The strategy sets a new path of the healthcare IT infrastructure based on an open platform approach focusing on data persistence with the use of OpenAIR data specification. In this discussion, you will hear from Jordi Piera Jiménez, Director of the Digital

[00:00:43] Health Strategy Office at the Catalan Health Service and Director at OpenAIR International representing organizational members. We discussed specifics of the Spanish healthcare market, how far Catalonia came since 2017, how is Catalonia building, using and updating a multi-morbidity scoring system for patients which enables easier clinical decision making.

[00:01:11] We also discussed cybersecurity attacks that happened in the past and how they ultimately impacted improvement in information security measurements and much, much more. Enjoy the show and if you haven't yet, make sure to subscribe to the podcast wherever you listen to your shows.

[00:01:32] You can also find the episodes on our YouTube channel and make sure to also check out our newsletter. It's only published once a month, but when that edition comes out, it always offers an in-depth overview of a specific topic such as should we give up on digital therapeutics,

[00:01:54] why women's health is everybody's concern and more. Go to fodh.substack.com. That's fodh.substack.com. Now let's dive in today's discussion. Jordi, hi and thank you so much for joining me for a discussion on the digital health strategy of Catalonia.

[00:02:29] We've met in person, so I feel comfortable with starting with a little bit of a provocative question. I hope that's okay. Yes, before I had. Okay, so I recently spoke with the Medtech company. They have a medical device and they sell it globally.

[00:02:45] And I said to them, what do you think about the Spanish market? And they said, you know what, the Spanish, you come there and they just want to change your product completely. What would you say to them? What are your experiences? Yeah, that's possibly true.

[00:03:00] We have a market which is very well positioned in terms of digital health adoption, I would say. And digital health leaders have very strong mindsets and ideas on how this should work. So I fully understand that the poor guys who try to put their product in here because

[00:03:18] we are very keen on making fit our purpose and possibly not their purpose. So I'm sure that they are completely right about this view. Do you have any advice when it comes to working on the Spanish market in terms of the cultural specifics?

[00:03:33] Every culture, there's good things that are usually good to know. The first that you need to know is that effectively within the Spanish market, you have 17 different health care systems. So basically, Spain is split among 17 regions and each of these regions have different

[00:03:51] information systems, health information technologies and different leaders. So you need to be ready to negotiate with different cultural settings. And same as everywhere else in Europe, it's not the same as when you are talking

[00:04:05] in the northern part of Italy, for example, than when you are working with the southern part of Italy. So in Spain, it basically happens in the same way. I would say that the other thing that you need to consider is that it's an NHS based system.

[00:04:21] So we have a unique public insurance which is funded by tax and therefore the business model needs to be something very clear that benefits overall the savings I would say for the overall health care system. Obviously, you need to improve the quality of care.

[00:04:41] But when it comes to focusing or positioning the product, savings for the NHS need to be very clear because that's the way that we reimburse such solutions. If I'm not mistaken, Catalonia is among the more developed regions in terms of healthcare digitalization.

[00:04:59] And in 2017, you designed a new strategy on how you want to move things forward. If we go back in time when the strategy was in the process of being written, can you take us through the whole process?

[00:05:15] What kind of use cases or countries or regions did you look at globally? What did you take as your North Star or existing digital infrastructure in healthcare that you wanted to get closest to?

[00:05:28] I have to say that the process so here we decided that we would do a digital health strategy which was following a bottom up approach. So basically, we involved plenty of stakeholders within our ecosystem and in fact,

[00:05:43] it's participated by more than 300 people across Catalonia, both from the public, the private, also industry side. So we were able to capture a lot of different views when building this and no consultancies were involved. As part of the process, we did a benchmark on different, I would say,

[00:06:06] international approaches. So what we did in there was looking at systems which were more or less our same sizing and that also had a similar financing system such as so NHS based NHS based system. So we looked into other regions of Spain, we looked into New Zealand,

[00:06:25] we look into the Nordic countries because of this, because they are very similar to us when it comes to the insurance model and also to the sizing of the country. I would say that we were impressed and we liked a lot the different strategies

[00:06:41] that had been put in place in the Nordic countries. The Nordic countries have always been very advanced in terms of digital health adoption and in there what we saw is even the strategy of some EMR vendors

[00:06:55] with the idea, I would say to tackle or to harness the power of health data. And that was something that it was very clear for us that we had to redesign our health information technologies around data.

[00:07:09] So seeing the Nordic countries and the EMR vendors, the main EMR vendors, almost all the EMR vendors in the Nordic countries trying to harness this power of data was quite significant for us. We looked into Deeps in Norway, we looked into Cambio in Sweden,

[00:07:25] we looked into Tieto in Finland and all the approach that they followed with this. And then if I have to say a North Star or a project or an architectural design that we like the most, I have to say or I have to acknowledge that when we

[00:07:42] were writing the strategy, it's when it was published, the report from the Aperta Foundation in the UK named Defining an Open Platform in Healthcare. And for me that was eye-opening because that was basically what we wanted to do,

[00:07:58] but we didn't really have a name on how to name all these ideas about putting data in the center, data being open to everyone, everyone being able to reuse using open standards. And this report from the Aperta Foundation was really for us the North Star

[00:08:15] and that's what we are trying to implement within all these years. Can you elaborate further what does the open platform approach mean for you? Because Spain and Catalonia have a long history of digitalization, so on the one hand you're very advanced in that sense,

[00:08:31] but that also means that you have a lot of legacy systems. In your presentations you often mention that there's just in Catalonia 16,000 silos of information. So what does the shift from the existing system to the new system mean for you?

[00:08:49] The open platform for us means it's a completely new approach on how to approach the deployment of health information technologies. Basically it's instead of allowing everyone and every service provider organization and every third party or software developer to develop,

[00:09:08] so to say their solutions based on the standards that they want to. Basically what we do is try to put some rules into how to interact with our systems, with the idea to build a unique electronic health record for our citizens.

[00:09:24] This is built on the idea that if we use open standards to represent clinical knowledge within the technical landscape and we are able to agree on this beforehand, then information will flow more seamlessly than it does now.

[00:09:41] And we will be able to add more value and escape the current limitations of interoperability. And that's the idea of the open platform. Then yeah, you are completely right. We have a system which has many different legacy systems.

[00:09:57] We did some counting back in 2017 and we accounted for, as you mentioned, 16,000 silos of information. The question is that in here we have a very fragmented ecosystem of service provider organizations. And this is different to other regions of Spain where they have a single

[00:10:18] provider linked to the public insurance here in Catalonia. And this is due to the historical evolution of the Catalan healthcare ecosystem. We have many different providers with different legal status, I would say. And historically all these organizations have had the ability to decide on their health information technologies.

[00:10:40] So moving or shifting from a model in which they have had the autonomy to decide on their health information technologies to a model in which we want to set up some rules centrally from the Catalan NHS, so to say,

[00:10:56] is tricky because basically you are removing part of the autonomy that they used to have. I have to say that in 2017 when we started the strategy, we found a lot of resistance from the service provider organizations, but I would say that

[00:11:14] after the pandemic and after some cyber attacks that our hospitals have faced, I think that now everyone acknowledges that it's better to have, I would say a coordinated or a federated governance model in which we and the NHS are at

[00:11:32] the center of this governance model of health information technologies. And our service provider organizations are able to be part of it and try to move all of us together because if not, we are investing a lot of money

[00:11:45] and we do not take up at the end of economies of scale. Since you mentioned the federated approach of data storage, can you talk a little bit about that? If we look at Spain more broadly, not just Catalonia, Spain, I think in one

[00:11:59] of the presentations that you had, you mentioned that Spain doesn't want to have a centralized repository and it's currently just exchanging data. So how is the progress happening in that sense? And how does that compare to what you're trying to do in Catalonia? Here it's what you say.

[00:12:17] There's a difference in between the regional approach and the ministry level approach. So basically we in the regions as we manage health care, because Spain is not a centralized state as opposite to France, for example, here the

[00:12:33] regions have a lot of power and they have full competence when delivering healthcare services. And this entitles us to be able to pull all the information related to healthcare from the inhabitants of the region. So at the Spanish level, we have also a single EHR, which is built

[00:12:54] out from the regional ones. The problem is that at the level of the ministry, they don't have competence to build this EHR by collecting all the information. Basically the Ministry of Health acts as a dispatcher of information. So it handles requests from one region to the other region.

[00:13:12] So basically when from one region you are asking about information for a Spanish citizen, a query goes into the 17 systems and each of the 17 systems is answering with information about this specific patient that we have.

[00:13:27] And while it works quite handy when we are talking about such a big thing as Spain is, we are talking about almost 50 million inhabitants and it's possibly the only way to do such. As far as for now, we've been working on interoperability standards

[00:13:46] and now we are thinking about a better future by agreeing beforehand, so to say on the information to be exchanged and advancing towards true semantic interoperability in between the regions. When we talk about data exchange, which data matters, which doesn't,

[00:14:06] looking at the new approach that you're going towards, what is going to happen with the existing data that you have? So are you just starting from scratch and starting to collect the data in the new format from now on?

[00:14:22] What are you going to do with the past data? Is there any migration translation going to happen? How are you looking at what data is important and what can be left behind? Here, the approach as you mentioned, I think it's double.

[00:14:37] On the one hand, every new piece of software that we develop, anytime that we are publishing a tender and we have the opportunity to replace some old legacy, we are storing data in the new format, which in our cases, it's no secret. It's open air, open EHR.

[00:14:56] So basically everything which is new, it's natively open air. And in all of our tenders and all of our ecosystems know that we are going in this way and therefore all the systems that we design and procure are thought in this way.

[00:15:11] But obviously we have, I would say 30 years of legacy data. And here we are doing our best to migrate this data to the new format. It's not always possible because obviously the current model to represent clinical knowledge within the technical landscape that we have

[00:15:29] selected is very rich when it comes to the semantics and we have all legacy data that it's not so rich semantically speaking or even with years, we don't really know the specific meaning of this information.

[00:15:43] We are deciding as we go which data is worth migrating and trying to transform to open air and to all the standard terminologies and vocabularies and which one is not. For example, now we have managed to migrate all the information that

[00:15:59] was stored in the shared electronic cell record of Catalonia into open air, this means translating HL7 version 2 artifacts into open air. It's not ideal what we have done. We know that, but it's better than nothing.

[00:16:15] And then your question about which data is relevant and which data is not relevant. The question is I would say that all data matters and all data is relevant, even though we have the feeling now that it's going to be used just once.

[00:16:29] And we have the example of genomics for it. I think it's a very good example. Genomics, it's a science that is advancing a lot. And right now out from a genomic sequence, we are able to identify or characterize certain diseases.

[00:16:44] But as science advances, we are able to identify or characterize more and more diseases out of the same genomic sequencing. Is it worth storing that genomic sequencing and as science advances, is advancing people looking for new diseases? That I think it's worth it.

[00:17:03] Right now we consider that all data is meaningful and we want to save, so to say, from the past as much as possible. And that's the approach that we are taking. Yeah. Yeah. In that example, I agree that the data that's basically not changing

[00:17:21] on the patient level is important. But if you think of a crying patient that we seek for 30 years, do you really want to have the information of every day of that patient's hospitalization or is the discharge letter of each hospitalization enough? Yeah, I know what you mean.

[00:17:37] Or there may be discussion whether the lab results from 30 years ago are worth it. We may have the feeling that they are not worth it, but I will put you another example, which is possibly better than genomics for this purpose. We are trying to predict patient trajectories.

[00:17:56] When we are trying to predict patient trajectories, we are using some risk stratification algorithms. We are packing diseases into groups and we are looking about the future evolution of such diseases using a population based approach. So basically what we are doing is packing all the Catalonian citizens

[00:18:17] into disease groups and we are trying to observe them within the past 30 years or 40 years or whatever information we have from theirs and see where they end up with their disease. For this purpose, all the information that we have is interesting.

[00:18:32] We don't really know whether using this, now everyone will call them AI approach. I prefer saying advanced analytics. All the information is meaningful and maybe seeing the progression of the lab results over 30 years, we may get some insights from there.

[00:18:53] So in principle, we are trying to, as I mentioned before, trying to save as much data as possible and then we will see what we do with it. We are now bringing in more and more data science capabilities into the NHS. I would say same as everywhere else.

[00:19:11] And we are starting to get very interesting insights. And I truly believe that we will be able to predict patient trajectories by profiling you and comparing to patients from the past. Yeah, I recently had a discussion with Arthur Olek from Germany and I said

[00:19:27] that one of the use cases when it comes to predictions and prevention, one of the best or most interesting use cases to me is if you just analyze billing data, because in healthcare, when you bill something, you have to specify what you're billing for.

[00:19:43] And if you just compare trajectories of patients with the same disease and what somebody that has had that disease for 20 years has gone through, you might be able to predict what the next thing for this second patient that's lower down the trajectory might be.

[00:19:59] And with that, we might design better preventative measures than the one size fits all scanning programs that we currently have. So I think that has huge potential. There's the research on claims databases, as we call them, or billing information has been in place for many years.

[00:20:19] We have developed a risk stratification algorithm, right? Describing what you just mentioned. They are named, we name them adjusted multi morbidity groups. And for us it's very helpful. And I will give you a couple of examples on the usages that we have given to this.

[00:20:38] But they do the same job as the GRDs from 3M or the AGDs from the John Hopkins. But we have proven that our ones have better performance than those because they are basically built, they are not a black box for us and they have been

[00:20:56] built on population level data from the Catalonian population. And also they have been adopted in all the other Spanish regions. We are able to give this continuous index of multi morbidity status. So how well or how bad is your health?

[00:21:14] And it's a continuous number that unique for you. So if you interact with the healthcare system, you will have this number. This number we have made it available in all the EMRs, EHRs in Catalonia. And it's used on the clinical side for clinical decision-making.

[00:21:32] For example, we are able to decide on admission pathways based on your AMG numbers. So medical doctors, primary care centers decide whether you are entitled to see the GP or you should go into the community nurse depending on the motivation of your consultation and also on your AMG.

[00:21:52] So we are tailoring admission pathways, but also we are using it, for example, during COVID times, we use it for public health policy makings. When we had to decide who should get vaccines first in the context

[00:22:06] of a limit of vaccines, because we didn't have enough for all the population. What we did was using the scoring of the AMGs to tell our public health leaders, listen, it's not worth to start vaccinating people by age range

[00:22:25] because we have people which is aged maybe 18 years old, seven years old, that according to the multi morbidity status, they have higher risk of COVID death, ICU admission or hospitalization. So first let's prioritize the people at higher risk and then let's go by age range.

[00:22:47] So things like this you can do when using this type of data. Now, as you were mentioning from your conversation with Arthur, the next frontier is predicting the trajectories. How do you see the potential challenges or errors that might

[00:23:05] happen when these kinds of predictions scores are already in place? I can give you, I can actually give you a personal example. So I'm a chronic patient and when the COVID vaccines came out, I obviously wanted to get vaccinated as soon as possible.

[00:23:21] So I got the AstraZeneca vaccine, which later like in a year or even more turned out to be very problematic in terms of blood clots and luckily I just luckily, I also am on anticoagulants because of the complications related to multi morbidity.

[00:23:42] So in a way I actually by getting vaccinated, if I wasn't on anticoagulants, I would put myself into additional danger because I was initially marked as a riskier group. So do you know what I'm trying to get to?

[00:23:58] So sometimes we may think that specific groups will be better off because they're at higher risk, but because we don't know everything yet about new medications or vaccines, we might actually put some patients in more danger.

[00:24:16] When it comes to risk scores, there's always this question, what was the initial definition of the criteria that defines the score? And if over time, the scoring system needs to be updated and upgraded. So how do you manage that?

[00:24:34] So continuous updates, the same way as AI that needs to be revamped for data drift or accuracy drift. So it's not like when you design it, it's not a fixed solution forever. Yeah. Yeah. That's, that's a very good question.

[00:24:51] As I said, this specifically the AMGs, for example, which is this risk stratification algorithm that we've been working for many years now. For us, it's not a black box. We really control the specific weights, each disease, medication, whatsoever will add to your multi-morbidity score.

[00:25:15] We do this at a population level. We are very careful when doing this or when adding new variables into the scoring and I will put you an example. The last thing that we are adding to the scoring is the social determinants

[00:25:29] of health, which is it's not only the way we see you in the claims database or the billing database, which is well facts, right? It's really facts that you have this diagnosis, you have had these procedures, you have had these admissions, ta-da-da.

[00:25:46] It's not only this, but it's also how are you at home, which is the income of your house called ta-da-da, which is things that we know that may have a huge impact in your health status, whether you live alone or not, ta-da-da.

[00:26:00] And also trying to add lately the personal perspective when it comes to quality of life and also adding the perspective of the patient reported outcomes. We have recently launched a solution on patient reported outcomes and we are seeing how is this going to affect the scoring?

[00:26:18] And I can tell you, I feel it's obvious, but if your perception of your quality of life is bad, your comorbidity scoring, I believe that it needs to worsen. So we are quite really careful when doing such calculations and we are continuously updating or recalculating your risk scoring.

[00:26:39] In fact, we are calculating once per week the risk scoring of every Catalonian citizen with all the new data that we have in the system. We could do it daily, but we feel that well, back in the day we were doing it monthly.

[00:26:54] Now we are doing it weekly and we feel this is enough. And this, we are doing our best with this to really be able to tailor the scoring to each individual's condition, something else. And then it's clinicians, obviously the ones that have the last word

[00:27:12] when deciding what to do with you and when deciding on treatments. And there is obviously with example that you put external factors. Nobody knew, we were suspecting that vaccines were approved in a record time. That development of such things may last for three, four years.

[00:27:32] And these were done in months. It was really a possibility that things could go wrong. And proof of that is that some of these vaccines have been now forbidden and taken out of the market. And these external factors, our risk stratification algorithm cannot control.

[00:27:50] So here I think it's a mix of these two things and how fast these vaccines were developed. Yeah, it's always in healthcare, the risk benefit analysis, what is better for the patient. I don't want to make this whole discussion about this risk scoring, but it's fascinating.

[00:28:07] So just one last question. When it comes to updating the models and the weights, how does that happen? Do you have clinicians for different patient groups? Do they meet once a year to review and add the latest findings from

[00:28:24] research studies in terms of the impact on the progression of a disease? How do you manage that? This is basically done internally by people working in the NHS. It's a group of epidemiologists, statisticians and obviously medical doctors

[00:28:45] that work together towards deciding on which information is relevant and how to weight this information. Obviously we need to have a nice amount of this information in order for us to be able to weight this, to weight this.

[00:28:58] Every time we get a new source of information, and for example now we have managed to have full connection with the social services which before was not legally possible. So now we are assessing how to introduce this with this team of internal people.

[00:29:16] We are not using or we are not bringing in specialists from different areas. Basically it's our group of epidemiologists and internal medical doctors that work here at the Catalan NHS and highly supported with our statisticians who in fact were the ones that designed and developed the overall thing.

[00:29:40] If I go back to the broader digital strategy in Catalonia, in 2024 the strategy was designed in 2017. What's different today compared to 2017? I think I mentioned a bit of this before but back in the day I would say

[00:30:00] we had a lot of resistance from our service provider organisations because basically we were going against their autonomy when deciding the implementation of health information technologies locally but the pandemic was in between and that was a game changer because it showed the

[00:30:21] strengths of our healthcare system but also it showed the weaknesses and health information technologies at that point in time were also paramount and everyone was able to see maybe we should be more coordinated. In fact it was within the pandemic times when we started through federated governance.

[00:30:42] Basically we met every week with all hospitals to see in order to make different decisions and to help them centrally from the NHS. This had never happened before. Second thing, it was that we have also had a couple of cyber attacks

[00:31:01] in big hospitals here in Catalonia and this has put I would say all the risks associated to health information management on the table and the truth is that not all of our service provider organisations have had the same ability to adapt all their infrastructures

[00:31:23] to safeguard them properly and here we have had to do a lot of work introducing the Catalan Cyber Security Agency within the healthcare sector in order to safeguard all these infrastructures. All of this I think has created the sense that we need to move from

[00:31:44] a model in which everyone was deciding on their own to a more coordinated model in which the NHS sits in the middle and well by sitting in the middle taking advantage of economies of scale. So this has permitted for example that now we have a central digital

[00:32:07] imaging archive, a central PAC system which was impossible to think about in the past. Back in the day every hospital would have its own PAC system and they would be hosting this PAC system within their data processing centres.

[00:32:22] Right now we have a central one and all the hospitals they work as a federation and this means that they don't have all the images that they have been storing for many years. All the big chunk of images are stored in the central repository

[00:32:40] and then they just have maybe the last two years or the images that they use the most and now I mean communications are very good so basically they can download all the images that they want for the

[00:32:52] next day or even real time so we can just go into public cloud infrastructure which is more efficient, which is more safe and secure and with this we save a lot of money. So we are doing this with digital imaging, we are doing this with

[00:33:10] digital pathology, we are doing this with genomics so all these different infrastructures that were consuming a lot of storage capabilities and also were high risk to maintain the infrastructures secure from cyber attacks. Now we are moving them into the cloud and now everyone is in line with

[00:33:32] doing this and I think this is a big change from the past. Did I understand correctly that a new cyber security agency for healthcare was established? No, we had a Catalan agency for cyber security but they were just

[00:33:48] collaborating with us centrally with the NHS and they were helping us to safeguard the NHS infrastructures which is some longitudinal services that we provide to all the ecosystems so for example the shared electronic health record of Catalonia, our patient portal, the remote consultations, the patient reported outcomes.

[00:34:09] All these solutions we have developed them with security by design because we have the Catalan agency of cyber security deeply rooted here in the NHS but this agency was not working with our service provider organizations you must think that we have more than 160 service provider organizations in Catalonia.

[00:34:31] We have 69 hospitals, 400 primary care centers, 100 intermediate and long-term care facilities, 400 community mental health centers. It's more than 1,000 healthcare facilities all across the ecosystem with different legal status and all of those haven't had the same ability to protect their infrastructure so now

[00:34:55] the Catalan agency of cyber security has put in place some dedicated resources into healthcare and they are helping all these different healthcare facilities to better protect themselves. We started with an assessment, a current assessment of the cyber security status and I can tell you that the results were

[00:35:19] really scary. They could go inside of every single organization in less than two minutes. They would plug themselves and hack all of them in less than two minutes but crazy things they would go in there and plug a machine

[00:35:33] in which was plugged to the land of the hospital, plug themselves into the land and with a laptop sitting in there go into everything in two minutes. After this assessment now we are putting measures on top and we are continuously monitoring what's going on in terms of these

[00:35:51] different organizations. Obsolete sense of operating systems, we have found a lot of Windows XP deployed in real life, a lot of solutions with no support, lack of updates, all these things now the Catalan agency of cyber security is helping them to be more prepared for cyber.

[00:36:10] Another topic that we could totally go into but I'm trying to focus so we don't go too far and waste time. One thing that I was wondering is so there's a lot of providers of a lot, there's a few providers of open air platforms.

[00:36:27] There's an international community that builds archetypes but how well developed do you see that the open air space is when it comes to solutions? What do you miss in that sense? How much can you actually choose from?

[00:36:43] How much do you actually plan on building on your own in terms of the end applications? Even though open air has been in there for 20 years that there hasn't been the momentum to acknowledge its value, let me say in such a way.

[00:37:00] I think that the idea was brilliant and the engineering that is behind that continues to be valid nowadays so it means that it's really well done and I really appreciate the effort that everyone was back in the day at open air made into there and

[00:37:18] everyone who is putting effort nowadays. But the fact that, and I truly believe that we were not ready for such a good idea and we were not ready because we believed that everyone could go on their own or develop their

[00:37:33] own solutions and then with interoperability we would be able to link everything. And this was also in the best interest of big EMR vendors which obviously they don't want to change the way they store health data within their systems because we all know that

[00:37:54] most of these EMR systems are 30 to 40 years old. Nobody knows what's built down in there and they don't want to disclose this and especially I would say the American ones, they have no interest in sharing the data. It's a model which is super, super different as the

[00:38:12] European one in which patients are really the owners of this data. So systems were not mature enough to realize the power of storing data using a common way to represent clinical knowledge within the technical landscape and standard terminologies and vocabularies are an initial step but they

[00:38:35] do not suffice to fulfill the complexity of the medicine domains. And this has made that the market of open air solutions is not mature enough. There are some early adopters and some true believers that we need to thank them, I would say the perseverance into

[00:38:56] this and I'm talking about better in Slovenia, I'm talking about cold 24 and talking about ocean informatics in Australia. There is some from runners that have been in there for many years and they have been the true believers and the one that they have maintained the flame.

[00:39:17] And then you have some newcomers, newcomers that have seen the opportunity on open air and that they are doing massive investments also thanks to the support of the public sector such as for example Vita Group in Germany, MedBlox in India.

[00:39:35] The group they have done a lot of investments in this but great deal of the investment crumbs from the HiMed project which is a public initiative within German hospitals and then from us from the Catalan Health Service that has

[00:39:50] put a lot of money on the table and it's allowing them to develop their products and it's been always like this. It's been the public sector the one that has been able to take risky investments. So we have I would say partners or industry partners

[00:40:04] that have been in there forever. They have very good solutions, very well established in the market that cover I would say when it comes to the platform and also when it comes to some tooling portals, forms tools that and then you have

[00:40:22] newcomers that are also starting to cope with also with this space and now we have alternative platforms so we have EHR Base which is an alternative platform to the better platform which I think it's good because in the market you need to have

[00:40:38] different options and it's not realistic to believe that one of these providers will be able to cope with all the market needs because this is ramping up and when the American market realizes that this is the way to go there will be a competition and there

[00:40:55] will be true lack of providers. Right now I would say that what we are lacking from is well more providers that are developing the foundations of Openair and talking about platform and talking about tooling in general around Openair helping transformations from Openair to Fire,

[00:41:15] from Fire to a Mob to do all these different tooling needs to be developed and then what we are missing it's also I would say finalist products or solutions so products that apps small ones big ones that can be directly plugged in on top

[00:41:34] of an Openair CDR a better has a solution for electronic prescriptions that you can natively plug it in the Openair CDR but there's still space for lab solutions, risk solutions you have also I don't know nursing solutions or even fully EMR solutions you have the Nordics

[00:41:57] I talked about this at the beginning Dips has done things in Openair you have Cambio they are building their EMR in Openair you have Tieto they are building their EMR in Openair I would say that we need more EMR vendors and more end product

[00:42:14] solutions that's what we are missing and tooling in general. So if I asked you based on the things how based on how things are going right now what do you think you will tell me if I get back to you in 10 years and ask you about the reflections

[00:42:30] on development of the Catalan infrastructure and the Openair market more broadly? That's a complicated one when it comes to Catalonia we all need a lot of resilience when working from the public sector it's really difficult to cope with the speeding here and how

[00:42:53] slow we are and it's also easy to understand that the dynamics of the public sector the very long bureaucratic processes and also the fight against the legacy systems it's a tough one here at the end we may have the right ideas but the legacy systems are deeply

[00:43:11] rooted in our day-to-day activities and they have been in here for many years and removing a system for example that is being used by all of our G and I'm talking about maybe 15 000 concurrent users per day within the last 30 years removing this and replacing

[00:43:32] it for a new solution it's a tricky process but we have compromised ourselves that by 2030 we will have an EU MR EHR which is full Openair that has the longitudinal view that will replace the solution that currently they are using in primary care but also the solutions that

[00:43:53] they are using in specialized care in our ecosystem and therefore I hope that we will have been able to succeed in this that's one thing regarding to Catalonia so basically the message is we will be able to finally build all this legacy and move

[00:44:11] towards the vision of the open platform different providers being able to develop on the platform really making it open and having a marketplace of solutions and then us being able to develop this EHR and implementing it then when going to the

[00:44:31] broader I think that we will be able to see more and more adoption across the globe systems are becoming mature and they are starting to see the limitations of interoperability you must think that the US just to put you an example the

[00:44:51] US it was year 2010 and the adoptions of the adoption of EMRs, EHRs was less than 50 percent in 2010. In year 2000 we already had 100 percent digital when it comes to EMR, EHR. In 2007 we had the EHR with the longitudinal view and the US still was lagging behind. Obama had

[00:45:18] to put a lot of money on the table he put a lot of millions on the table for everyone to go to the EMR, EHR and they have decided to go to the monolithic approach so basically paying one vendor to deliver everything but

[00:45:34] American citizens move and they move across insurance they grow they move across states and eventually they will have to link this so I would say that they are lagging behind 10-15 years and even a bit more than that and they will eventually realize that

[00:45:52] they can go one option which is the monolithic approach everyone uses epic and then yes it's full interoperability but it's also lockdown or lock-in to lock into to them and killing the innovation in the ecosystem or go open and foster innovation in your ecosystem

[00:46:11] and everyone being able to construct solutions on top of the idea of the open platform. I hope that in 10 years time we will see more than this possibly not in the US, in the US I hope that we will have some frontrunners

[00:46:26] that will decide this you have people that has the vision in theirs but I believe that Europe will be leading this ahead from all the other ones. And the final question in November on the 5th and 6th of November you're going to be in the UK

[00:46:44] for the Open Air Annual Conference what's your presentation going to be about? Yes I will be there and I think that you should also be there. I will be there. And everyone who is listening should also be there because I believe it will be

[00:47:00] a very interesting meeting of like-minded people. I will talk, I will be talking in there about something that you are getting the the exclusive news about this because we haven't announced this before so I've been working with the Spanish Ministry of Health

[00:47:20] and on behalf of the Spanish regions on I would say a strategic reflection process on how to advance the current model of health information technologies in Spain. I said before that we have a national EHR which is built from the regional ones

[00:47:38] and this national one is built of summaries of the regional ones but we want to advance and make the information that we have in the central one more granular and this EHR is built on classical interoperability which means that we have been agreeing afterwards. The

[00:47:56] amount of information that we are able to change and understand is limited. In short it's that we have conducted a consensus process using a scientific approach in between the regions, scientific societies and the Spanish Ministry of Health involving around 200 experts in medical informatics from Spain and

[00:48:21] we have decided towards the future and how this future for the health information technologies paradigm in Spain should look like. So I will be presenting the results of this process which was also validated by a panel of international experts in medical informatics and I'm advancing you that the

[00:48:43] conclusions also include the use of open air for clinical modeling at the Spanish level and then the mappings towards fire resources emerging from this clinical modeling in open air and clinical consensus in open air in Spain. We have a lot of tradition of well federated models such as

[00:49:04] this one and I think it will work pretty well so I will be presenting how we build this process from a methodological perspective and also the results. Now you definitely gave many people a reason to attend the event and I'm sure in three months

[00:49:23] time there's even going to be more known than it is today so Jordi thank you so much for sharing all the information today and we will continue the discussion I guess in the UK. I look forward to it. Thank you for having me.

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