How is Italy digitalizing healthcare in its 20 regions?

[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. Different countries in Europe face different challenges when it comes to healthcare digitalization.

[00:00:22] It's not just about the different structure of healthcare systems and reimbursements, it's also about how big a country is. Larger countries are divided into regions and each of them can act as an autonomous entity deciding on the rules of digitalization. In this discussion, you will hear a little bit more about Italy.

[00:00:45] I spoke with Marco Foraccia, CIO of the Local Health Unit in Emilia region in Italy, who sheds the light on regional disparities, opportunities for improvement and strategies for vendors seeking to enter the Italian healthcare market.

[00:01:01] We discussed challenges in digitalization in Italy, opportunities with the EU resilience and restructuring program funding, the need for cultural transformation when it comes to digital transformation, and also advice for vendors considering entering the Italian market.

[00:01:50] Enjoy the show. Why do countries struggle with healthcare with generative AI? Why do countries struggle with healthcare digitalization and more? Also, if you haven't yet, make sure to subscribe to the podcast wherever you listen to your podcasts. Now let's dive in.

[00:02:23] Marco, hi and thank you so much for joining me here on Faces of Digital Health to discuss a little bit more on the digitalization strategy in Italy, the level of basically digital transformation that has happened in healthcare in Italy, especially in your region.

[00:02:42] You are basically leading a region of hospitals that are very high on the digital maturity, at least based on the measurements through HIMSS maturity models. So I really want to learn more about that. And maybe we can start with the country perspective. So Italy has 20 regions. It's fragmented.

[00:03:07] What does that mean for healthcare digitalization on the national level from the patient perspective? How would you describe what patients have and don't have in terms of patient portals, e-prescriptions, access to their data, and what happens if they go from one region to another to seek medical care? Thank you again for inviting me. This is a difficult question because, as you said, Italy is divided into 20 different regions.

[00:03:35] Actually, from the healthcare point of view, it's 21 because one region is split in two, so it's even more complicated. And that's very unfortunate from many aspects, from many points of view, starting from the actual healthcare organizations, from the healthcare services provided. It's all a little bit mixed up. And the digital level, actually, the digital approach towards our patients, our citizens, it's actually fragmented itself also.

[00:04:03] So you don't really have a single perspective because a citizen from Lombardy up in the northern Italy has a completely different perception of the digital services from a citizen in Puglia or Sicily on the other side of Italy. And this is a major issue, actually, because, of course, there is no real strategy behind it. There have been no real guidelines in the past. So everybody has gone in different directions.

[00:04:29] In some areas, even like my region, from many points of view, all organizations have been kept independent in the way they approached for many years, the digital collaboration with their citizens. And therefore, even within the region, you might have very different approaches from every town to the other. So that's very absurd. The actual only single project that so far was managed at the central level and actually works,

[00:04:57] it's the national e-prescription system. And the reason behind it, we might think about it, we might a little bit take some hints about it, is the fact is that it was managed by the Ministry of Finance. The e-prescription project was not managed by the Ministry of Health. It was managed and highly sponsored by the Ministry of Finance. So that gives an idea that there are some side aspects of this project that were, in a way,

[00:05:25] more compelling, more intense in the way they were sponsored than most digital health projects. So this is a starting point, and this is a big issue, the fact that everything is fragmented. What does that mean? Do then patients seek care in different regions because the care provision is different? Exactly. So what happens usually is that citizens migrate from one region to the other.

[00:05:52] That happens all the time and in different directions according to where the specialties are. Mostly it's from southern Italy to northern Italy, but it's not always like that. It depends on many, on the specialties, on the kind of fields that you're interested in, and the kind of specialists you need. And every time you move, you have a completely different approach towards digital collaboration, digital interaction.

[00:06:15] And that is an issue because a citizen from Naples has no idea how to book a CT scan in Emilia-Romagna region up in the north. They have no idea. They have no way to actually do it. And so in this case, digitalization being fragmented is actually posing some barriers towards citizens actually moving from one region to the other because all the digital ecosystems are different, all the digital interactions, the digital portals are different.

[00:06:45] So the citizens are lost when they move from one region to the other. So what kind of discussions are occurring on the national level to overcome this issue of cross-region access to information? Are there any discussions? This also reminds me of Germany that has a similar problem. So I don't know to which extent you are looking at what they are doing to get ideas on how this could be solved in Italy.

[00:07:13] We are definitely looking at the German experience. And on paper, even Italy has some, has had from starting from 2017, a digital program for actually having a uniform electronic health records at the national level. Unfortunately, this was a program that didn't really take off and give results in the sense that it was implemented at the regional level.

[00:07:40] So some regions actually implemented it and some others did not implement the convergence towards an electronic health record, which would have been if the project were interoperable from region to region. The idea being is that if some patient comes to Emilia-Romagna, to my town and take some examinations,

[00:07:59] the results, the reports would go back to their hometown through the interaction and interoperation between our regional electronic health record and the other region's electronic health record. This didn't work. What happened basically is that a few regions, mostly up in the north, developed the regional electronic health record. So now, starting from the funded by the National Resilience and Reconstruction Program, the PNRR, from the European Union,

[00:08:29] I knew what we call the second version of the national electronic health record has been implemented, mostly changing some aspects, some technical aspects, but mostly the funding part was the major breakthrough in the sense that all regions now were funded from in a top-down manner, from the national government to actually implement it. So they had no excuse, basically. They had to implement it. And it is becoming a reality, actually.

[00:08:55] All the regions are now starting to build these electronic health record systems, and these are natively interoperable. So we are starting, actually, to see data, clinical data, being shipped from one region to the other, with a national, actually, perspective, because this is also the portal that will bring us to the European health data space. The idea behind it is that this is how the binning blocks of the European health data space.

[00:09:21] It is, actually, we're getting numbers, and the numbers are saying that it is being implemented. For some regions like mine, it's not a major breakthrough because we had already implemented the first version. So for us, it was already in place the fact that different healthcare organizations within the region were able to inter-exchange information. Now this is moving towards a national. So it's one step towards building national strategy, a major step, but it's the first step.

[00:09:50] Of course, there are many other aspects that are still behind the scenes, which is basically being interoperable not only in terms of exchanging information and reports, but also exchanging from an operative way, in the sense that being able to actually book and make reservations for clinical services anywhere in Italy, anywhere in any region. That's the further step that we will need to work on at the national level.

[00:10:19] So is that, I'm wondering what drives that development, which is promising or sounds promising. To which extent do you think that the strong impact comes from the demands that we will see with the European health data space? And also, what is the role of the resilience funds from the European Union that were given after the pandemic to encourage digitalization of healthcare systems around Europe?

[00:10:49] But it's definitely a key aspect of the whole project in the sense that the funding comes with deadlines, basically. And the two things make it possible. And the deadlines are both at the top-down level in the sense that you have to contribute to the national electronic health record, the fascicolo sanitario elettronico, because you have been given money and you have been given deadlines. So this is actually happening.

[00:11:15] Okay, we might be late in some regions where Italians, but anyway, we will get there. We are seeing the numbers growing. At the same time, though, there is a key aspect that has been actually understood by the national government that you have to also to work from the bottom up in the sense that you cannot actually ask some regions, some areas of Italy to contribute with data to the national electronic health record if they did not collect the data electronically.

[00:11:41] So if you want to ship the data up to the national and then to the European level, you have to collect them data. And this is basic digitalization of healthcare organizations. So a significant amount of funding has also been devoted to this basic digitalization level. Hospitals. We are giving for granted that every hospital has a PAC system for managing radiology. We shouldn't, because in some area that wasn't the case.

[00:12:10] And so they're building PAC system, laboratory information systems, EMR systems, because we also need to build the basics, building blocks. So what happens is basically that it is working, but it is working at a different pace from region to region. The regions that were already advanced are now shipping all their information to the national electronic health record, and it's working perfectly.

[00:12:33] My area, the network of hospitals I do manage, they ship over 98% of their clinical data to the national electronic health record. And that's all the clinical data because we are a completely digitized infrastructure. Some areas are shipping everything they have, but the problem is that they do not have as much information because most of it is still paper-based. And these areas of Italy, these regions, have to basically run,

[00:13:00] to basically make up for the delays that they have summed up in the last 20 years of slow digitalization. So the national project, it is working. You see the numbers growing. Unfortunately, it's going at a different pace. We will need to wait a little longer for the regions that are behind to actually build the building blocks. And then, of course, as they progress in building basic digitalization,

[00:13:27] more information, more clinical data will be shipped to the national level and to the European level. Can you talk a little bit more about the differences between the regions in terms of digitalization? How is that being tackled from the perspective that you try to get all the regions on the same level? Are there any specific strategies or do you just accept that some regions are more advanced than others? That's a fact. Okay.

[00:13:55] The first step has been measuring it, which is not something obvious. The first time that actually a national institution, the national ministry of health, imposed the measurement of digitalization level to all healthcare organizations. They've chosen the HEMS model, the EMRA model, because it's probably one of the most common and widely used. And so this has been a first step to measure what the situation was.

[00:14:22] And the situation, of course, showed up numerically, analytically, something that we already knew that some areas of Italy, unfortunately, hadn't developed a digital strategy. They did not have a strategy and therefore they did not develop a digital maturity level. And so this was actually a good starting point for actually setting up the different strategies, imposing the digital strategies in some cases from the national government to the regional governments.

[00:14:50] And so this is how it's being implemented. And probably we will see how much it will work because it's mostly based on funding, measurement, and giving a clear strategy. There's one key aspect that is missing, which is building a digital culture within the organizations. Because organizations like the one I work in, we did not only invest on technology. We did not only invest on a long-term strategy.

[00:15:20] We also invested on a digital mindset of all our clinicians, all our workforce. And this is not something that you... How did you do that? How did you do that? Because I know that like we spoke in the past and you mentioned that, that the change needs to be cultural, organizational, and technical. But how do you build that digital culture? We've built it in many years, step by step. Okay. So there are no key ingredients for doing that in a couple of years.

[00:15:49] The colleagues that call me and ask me, give me some suggestions. Listen, I've done this in the last 15 to 20 years. Therefore, it's hard to give you a suggestion that will work in a couple of years. Part. What we focus mostly is the fact that introduction of digital technologies has to show it value. It doesn't have to be imposed on clinical colleagues, on doctors, nurses, and all our workforce.

[00:16:16] They have to perceive the value of the technology that they're given. A radiologist, when he or she adopts a new CT scan, a new technology, they're usually excited because they see the value of the technology they're using. The same should happen with every digital technology that we provide our clinicians. And showing, focusing on the value is a key aspect. My job.

[00:16:41] My job is not only selecting a technology that solves a little tiny problem. It's selecting a technology and showing the value that this technology will bring to all different stakeholders. In many cases, digital solutions are mostly focused on financial aspects. Therefore, there are some stakeholders who will be happy about the technology. There is finance department, the HR department. But when you introduce a technology, it has to be a win strategy.

[00:17:10] You have to look at the complete picture of all the stakeholders and try to find the key aspects of value for all the stakeholders. That's a key aspect. And that's what we've been focusing on. In my organization, all the development of the digital strategy is project-based in the sense that you start a project, you set the measurement levels you want to reach, you get there, and then you measure. And every project has to make clear what the value will be for all the stakeholders.

[00:17:38] When I go to a department and tell them we will start with this new EMR project, I also have to tell them this is what you will gain. The advantages for you and your patients will be this and this. The effort we are going to ask you is for this reason, okay? It will be hard. We will have hard times. There will be times where you will hate me. But we are doing this for this and this reason.

[00:18:02] And I'm the one who's promising you that if we go ahead and if we go beyond the problems that we will have in the next few months, we will reach those values and those aspects. And this is a key aspect. In many cases, digitalization is brought on as a technology project. And there isn't this interaction with the stakeholders to actually have them perceive the overall value.

[00:18:27] When they get into this loop, it's also a hyped effect, which is very exciting. When my clinicians get excited about a project with me, I'm as happy as I can be. When instead I need to impose something, that's really hard. That is so hard. Absolutely. And so how do you know what's the next thing going to be when you are looking at technologies?

[00:18:52] I just recently spoke to a representative of an organization who said that vendors too often come because they want to sell what they already have without really asking what a client needs. So obviously, when you build a product, you want to scale it. But that doesn't necessarily always address what is actually needed in healthcare.

[00:19:20] We always get to the same aspect, the concept of value. When you start a project, you have to know if the project will bring value. And there are two different aspects in bringing value. First of all, target the proper target. Okay. I'm targeting a specific need. How much value there is behind that need? Is it a very narrow need that will not bring enormous value? Or is it something that's very simple but will have enormous value to the overall organization?

[00:19:49] Sometimes there are small projects that face only one little tiny aspect, but it's widespread all over the organization and the impact. The overall value is enormous. Another aspect is backgrounds. Every project has to rely on solid grounds. So basically every project should start from actually measuring the maturity level behind it. Okay. Are we ready for that technology? Okay. We want to buy new AI technology. Okay.

[00:20:18] Are we ready for that? If we buy that technology and it's targeted towards bringing a lot of value, are we ready? Do we have the prerequisites? That's something that very often is not done. Some organizations just simply buy technology for the sake of it because it's very fancy and they do not realize that they cannot actually use it as much as they would want to. And the vendors have a big role in this.

[00:20:43] I always challenge my vendors telling them, would you refuse to sell me something if you saw that it would be useless for me? And they usually smile at me because, of course, their job is to sell stuff. But I think the maturity from their side should also be assessing whether the client, the customer, is ready for the technology they're getting. And for example, I was talking with a colleague that sells very advanced clinical decision support systems.

[00:21:12] And I said, okay, we have assessed that in my organization, that tool is very advanced tool based on AI also. We'll be used extensively because we have an EMR that can host that technology. But would you actually sell the same technology to my neighbors or to another region where they have no EMR? And he said, I have to bring money back to my company. I would sell it to anybody that simply wanted it. And that's sad.

[00:21:42] That is sad because in many cases what happens is that technology is sold and then simply sits there useless and brings no value. Yeah, absolutely. A huge problem. One of the challenges is also that sometimes governments or organizations don't really know how to go about public procurement. They don't have that knowledge.

[00:22:03] So one of the speakers in the previous episodes who is a consultant basically mentioned that one of the challenges is that consultants get brought in and no local capacity is then built by governments to retain that knowledge and to be able to use that knowledge when the next need arises. So how do you see that?

[00:22:25] The challenge that sometimes people that are decision makers don't really have enough knowledge to be able to procure the right solutions, which is a huge issue. Because especially, for example, if you look at the European funding, as you, I believe, mentioned, the funding ends end of next year, end of 2025. So we will have to have results if you want to just not have to return the money to the European Union.

[00:22:54] And I'm sure that many organizations are struggling with that. So what's your view around all that? And also, how is the whole European funding deadline that's coming up impacting you and Italy? That's a huge question, I know. Yeah, I won't. The first aspect is that having relied on a maturity model developed by an external organization like HIMSS in this case,

[00:23:18] that it was a good choice also in terms of guiding organizations towards the next step. Okay? So what basically happens is they assess you, that you get a level of three. In order to get to four, this international organization tells you that these are the next steps. Do not pursue any major project, advanced project, because the next step is step four. There's no going beyond that. And that was very serious. I appreciated that very much.

[00:23:47] So from this, I don't know if it was meant to be that way or it was just occasional. But anyway, the national strategy, from this point of view, was very mature in the sense that it gave a clear direction towards the investment of every single organization. So making up for this lack of vision and value-based procurement, which would be needed. This was a good choice.

[00:24:11] On the other hand, we have the issue that on the actual operational side and project management, program management side, we are lacking resources, human resources. And that's, I believe it's a worldwide situation. It's not an internal situation because I talk with my colleagues worldwide and they are having a hard time finding professionals trained in digital health

[00:24:36] and with a robust experience to go to follow these major projects like these. And what we are trying to do at the national level with our association, I'm also the vice president of the Association of CIOs, Italian CIOs in Healthcare. We're trying to actually promote also an educational level. We need to get younger generations into the management of digital health.

[00:25:04] And this is hard because you have to grab them right after university, even during their college years, to actually get them into this special field. I've worked in manufacturing. I've worked in R&D for the development of medical devices. I've seen several fields. But the digital health management field is very peculiar. You need to be trained in that.

[00:25:28] Because it's very cross-functional, you need to have a very good understanding of the healthcare field, of the medical field. And you have to have a very good understanding also of the digital sciences. So basically, it's a little bit too late thinking about this now because we have a few billion euros to actually invest right now. And we have very few people around Italy and even around Europe that can actually manage such large projects.

[00:25:57] It is an issue and it will be actually one of the major reasons why we will be late. The deadline is next year, the end of next year. Actually, there are some intermediate deadlines even in June 2025. And many projects will not be finished. And one of the main reasons is that they will not have been followed by project managers or program managers that had proper training in the digital health field. And we knew that from the beginning.

[00:26:27] We tried to do our best. But that will be one of the main reasons why many projects will actually not meet the deadlines. It's a huge issue. So do you think the deadlines will be prolonged a bit? I have no idea. That's mostly on the political side. We are seeing from the numbers that a significant percentage of the funding will not probably meet the deadlines in terms of completion of projects.

[00:26:54] And being the PNRR, the Reconstructional Resilience Program, and an all-in, so to speak, program, funding program, in the sense that you have to complete 100% of the targets. There's no in-between deadline, in-between target. There will be some discussion on actually extending some deadlines, I believe. We'll see if that will be possible.

[00:27:18] Otherwise, we will have some major issues because there are some areas of Italy and some organizations that are lagging behind a lot. But mostly not because of funding, because the money is there. In some cases, there's an issue with the vendors that are overwhelmed by all these projects. But in many cases, it's also an issue of the local organization that didn't have the proper professionals to actually bring the project ahead and meet the deadlines.

[00:27:47] What would your advice be to vendors that are trying to go to the Italian market? I read somewhere that with the new government since 2022, there's a bigger push to support domestic ICT companies over global tech giants. I'm not sure if that's true or not. But what's your advice in terms of market access?

[00:28:10] The market access has been completely messed up by the PNRR, the National Reconstructional Resilience Program, because the procurement has been centralized at the national level. And they've had these major procurement processes done by the national agencies.

[00:28:29] And these major tenders basically were all assigned to major Italian players because they had the knowledge to actually put all the little pieces in place to actually win the national tenders. As medium to even large companies from outside of Italy would have had a hard time actually getting into these procurement processes because they're peculiarly Italian, unfortunately.

[00:28:55] So what happens is basically is that the market now has been basically completely overwhelmed by these already sold basically tenders. So the only way to actually get into the market right now is actually partnering with these major Italian players. Because actually that's they need it.

[00:29:16] Because these major Italian players that actually want all these tenders, they've won way beyond their capabilities in terms of being able to actually do these projects. Therefore, they're looking for partners because there's no way they can actually provide all the services and all the products that they want the tenders to actually do. They are looking for partners. That's the way an external player can get in Italy right now.

[00:29:45] Unfortunately, it's very abnormal. I would say that the market has been in a way very much distorted by all this situation, especially for small players. Small players have been cut out of all the major developments. That's very interesting. So how, like the question that I kept thinking when you said that basically the vendors that want tenders can't execute what they promised. How do you assess what's offered to you?

[00:30:14] One of the bigger challenges that is also present in procurement of larger solutions or several years long projects is that it's really difficult to check and verify the claims that vendors do in tenders. In the past, when we used to do the tenders ourselves, we used to approach everything from a very value-based approach in the sense that we did not pay for installation.

[00:30:42] We paid for results for clinical applications. So that solves the issue because when you ask to an industry partner, I will pay you. Let's build a partnership, not only a vendor, a consumer approach, but a partnership. And you will be paid based on the results that our systems, the system that we will implement, the clinical system, based on the results that you'll get. Results can be number of patients being admitted and managed.

[00:31:11] Could be the satisfaction of users, of clinical users. There are many ways to actually measure the final value of a digital solution. Unfortunately, with these national tenders, we went back to the installation-based payment, which is very sad because on many aspects it has been going back. But this is what's being currently implemented.

[00:31:38] We try anyway to get to the heart of our vendors and tell them, listen, if you want to have a strong partnership with us also for the future, and if you want to have a reference site, the site that you want to show off how good you've been in your development of this digital solution, then let's make it work. Unfortunately, this left up the commitment of the vendor.

[00:32:04] It's not something that is written down on the contract as we would have done in the past and as it probably should be done in the future. But currently, unfortunately, it's still payment on installation, which is very sad. You've been listening to Faces of Digital Health, a proud member of the Health Podcast Network.

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