Malta's primary care after the EPR: data governance, AI and the EHDS (Stefan Buttigieg)

[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, Tjaša Zajc. Today we're going to talk about the EU's smallest member states.

[00:00:20] Malta covers around 316 square kilometers and has a little over half a million residents, which also makes it the most densely populated country in the EU. Malta's public primary care has already crossed a line much of Europe is still approaching. The electronic patient record has run across government health centers since late 2019.

[00:00:48] Paper is close to gone and the question has shifted from how to digitize to what comes next. In this episode, you're going to hear from Dr. Stefan Buttigieg. He is a specialist in public health medicine at Malta's Ministry for Health and Active Aging, who recently moved from national e-health work into primary healthcare.

[00:01:11] As he likes to describe this shift, he's now focusing on the on-the-ground implementation of EHDS and has a significantly different view on what it will take for these big European projects to succeed. We discussed how did Malta manage to digitize very early on.

[00:01:34] It has been included in the My Health at EU system since 2019. And now to increase the AI literacy of its population, the digital ministry has a special offer for all residents if they decide to take a specific AI course. I'm not going to tell you everything so you can find out everything in this episode.

[00:02:02] Enjoy the show and if you haven't yet, make sure to subscribe to the podcast. See the Faces of Digital Health newsletter, which you can find at FODH.substack.com. That's FODH.substack.com.

[00:02:18] And also check out our YouTube channel because I now started working on Faces of Digital Health Intelligence, which is a video version of the newsletters that are produced. The first edition is about EHDS.

[00:02:42] Now let's dive in the discussion with Stefan to learn more about Malta's electronic patient record for primary care, how Stefan built the EHDS Explorer, why AI implementation is complex and potentially is not going to be in the future and more.

[00:03:20] Stefan, hi, and thank you so much for joining me on Faces of Digital Health to discuss a little bit about Malta's healthcare digitalization and more.

[00:03:33] I know that we spoke a few years ago and at that time you said that Malta, with its small population, but a part of EU, could be a great gateway and test bed for anyone that wanted to come to Europe and scale across Europe. Do you still share that opinion? Let's start with that. I still keep the same opinion. Of course, it comes with a little bit of maturity now because the more I get involved in the system, the more I learn about it.

[00:04:03] And in fact, very recently I moved from national, let's say, implementations and national EU implementation of digital health from the Information Management Unit to primary healthcare, where I'm much more involved with what's happening on the healthcare, where I'm much more involved with what's happening on the ground on a daily basis. So it's really much closer, I would say, to clinical care.

[00:04:27] And I would say that it was an interesting shift for me because sometimes when you are at a national level or higher up, you get detached a bit on what's happening on the ground and what are the challenges that are facing on the ground. And it's as if I move from EHDS at a national level to EHDS on the ground, which was great because this is the shift for the night.

[00:04:53] Now we need to really bring the regulation where there were a lot of policy discussions, a lot of challenges back and forth. I don't agree on this, now I agree on that, to actually implementing it on the ground, which is going to be our next big challenge, let's say, for the next four to five years, for sure. And it's going to require a lot of convincing because we need to keep longer.

[00:05:20] If we just stop there a little bit, as you said yourself, on the national level, you make this higher big picture plan. So when you moved to primary care, what were some of the things that surprised you? Or can you talk a little bit more about that insight that you started to get from primary care and how that made you reflect on your previous role as well?

[00:05:49] First and foremost, I think one of the biggest things that I noticed when I came here is that there is a lot of innovation going around. And sometimes we just don't have the opportunity because we're so driven with the daily operations. We just simply don't have time to talk to each other, let's say, about the great innovations or the great positive developments that are happening. That's, I would say, point number one. And of course, because that's happening, then there is room for even more development.

[00:06:18] And also, what I was really happy to notice, because primary health care, let's say, they fully digitalized their clinical documentation a little bit around seven years ago. And it was a little, it really felt like me going back to my roots. Because seven years ago, when they were deploying the electronic patient record, I was there. And first we started with one health center and second and three, four. And then I had to shift very quickly to COVID and go from a public health perspective. So I had to leave.

[00:06:48] So now coming back, I see the fruits of that investment right in front of me. Because now instead of us worrying, let's say, about how we're going to digitalize or how are we going to get everyone on board, which is the discussion still of some departments or of some hospitals, even around the island. And I'm not just talking about public hospitals, but I'm also talking about private hospitals who keep having these discussions and keep wondering how they're going to fully digitalize.

[00:07:17] In primary health care, the electronic patient record is there. There are no paper documentation anymore. Or if there is, it is really minimal. So there is this thing happening where all of a sudden we are saying, oh, no, what's next? And that what's next is happening right now. And one also thing I noticed, which is not purely digital, it is the culture. So here there is a really strong culture of quality.

[00:07:45] In fact, I myself, I had the opportunity to join a quality multidisciplinary committee, which would say, but aren't you digital? Why are you there? Why are you there? And I tell you one there, we need to be there as digital professionals because really and truly, the work we do over the board in digital health is really about ensuring the highest quality possible, the highest quality of care, the highest quality of patient safety.

[00:08:15] So this is how digital health will become truly meaningful by really being a part and parcel of the delivery of care. So it's normal to deliver care digitally. It is normal to ensure that there is digital safety, digital clinical safety, even how we design our interfaces.

[00:08:36] So now that's great because now that is the next step of quality that I really hope I have the opportunity to work over in the next months, years. Who knows? If I'm not mistaken, Malta has had the My Health at EU infrastructure or has joined the My Health at EU structure a long time ago in 2019. And you've been sending and receiving patient summaries since then, right? Yes, for quite a while.

[00:09:03] So this is, of course, not my current area of work. I've moved away from there. But I'm very happy that I worked with another colleague to give over this work. I can say that Malta is still committed and still delivering patient summaries. It has an ongoing as well EU project as well in relation to it, which is called Meme. M-H-E-M-E.

[00:09:26] And I'm very happy to say that now my role will also be to see how, for example, cross-border digital health services can have a stronger role even in primary care. That is the beauty of everything, how things are evolving. And sometimes when I reflect on this, it really feels like simply a eureka moment where when you see knowledge transferring between the different departments,

[00:09:51] and this happens not only just in governments like Malta's government, but across in other governments, when people shift and move around, a lot of the times the knowledge travels with them. So things that people in the, let's say, the receiving organization might not be aware of, they say, oh, wow, we can do that. So all of a sudden you start seeing these organizations evolving very quickly and learning as well.

[00:10:18] Now, of course, sometimes it's also about character, right? And how that person reacts and how that person kind of what they bring into the picture. But the more I spend time here, especially in primary health care, the more I see massive potential. And I'm also very lucky that I'm working on three main elements. I'm working on, let's say, or four. I'm working on digital across primary health care, looking at digital transformation.

[00:10:47] I'm working on cancer information systems, those head screening, especially. I'm working on immunization. So once again, it's all, and the last but not least, which for me is one of my most interesting and closest to my heart as well, is the electronic patient record for primary health care. Where I'm not going to go into the exact numbers right now, but we have millions of visits recorded since 2019. Millions.

[00:11:22] Millions. Yeah. And there is the potential I see, you know, right now to bridge what are the political priorities. So if you had a look, for example, at the political manifesto of the governing power, now the government, let's say the party in power right now, there was priorities mentioned relation to digital health and health data. So bridging those two together, the priorities of primary health care

[00:11:50] with the priorities of the government manifesto, the mandates that they were given, making that bridge is, I think, will be our next step to evolve as primary health care as an organization whilst really being closely linked to what we do. So you basically mentioned that electronic health care records have been implemented on the primary level and given that you're now also involved in EHDS and how that translates into primary,

[00:12:20] level. Can you talk a little bit about that? And also when it comes to EHDS, some countries still need to create their national contact points by March 2027. You've already done that, as we mentioned, seven years ago. Can we also talk about that? So what was the biggest challenge in creating a national health point?

[00:12:47] And then we can also go to all the primary care level applications and upskilling that's required for a successful move forward. When I was working on the National Contact Party, I was lucky enough to take over the work of my mentor, Dr. Hugo Adjus-Muskat, who had worked on this not only since 2019, but since 2012 literally was involved very early on.

[00:13:16] So I think as a country like Malta, being involved very early on and being involved at the European level in the activities overall and even showing as well that I believe one of the things that I noticed a lot in Malta is that we have like these, I would say, I used to call them pockets of excellence. But now if I reflect on them even a bit more,

[00:13:44] I would say now that they are like pillars of excellence. Because once you have these pillars, all of a sudden you start seeing other initiatives popping around because people are inspired by the work done in this, let's say, pillar of excellence. So they can build, it's like a foundation for other stronger initiatives. And this is for example what I'm seeing with primary care. But going a bit more into the EHDS and the contact point, so there's a long history with Malta being involved at the European level,

[00:14:13] which gave us an advantage. And also us being a small island gives us more the opportunity to be in touch with what's happening on ground. We're basically a telephone call away. Listen, what's happening there? Why this is not working out? And just call that person and try to figure out what the problem is. Now of course, being a small island as well also comes with its challenges. And you have different individuals focusing on different aspects.

[00:14:40] Sometimes they could be stretched as well because they have so many projects and they're trying to figure out where they focus their energy. So this happens a couple of times in small states. Now, from my side though, I am a person who can't stand still. So I decided to take this a little bit a step further. And in my journey in understanding the EHDS, I had the wonderful opportunity to vibe code.

[00:15:10] You might have heard about this. And I've worked on, since December of last year, I worked on EHDS Explorer. So basically, I took the regulation, like the PDF and HTML regulations that we were used to. And I said, listen, how can I make this a little bit more engaging, a little bit more interactive? And basically, as I was on my time off, in fact, people tease me that like,

[00:15:36] I should be working less when I'm taking my time off, not working more. And I decided just to sit down and start vibe coding my way to solve this issue. And of course, the first couple of tries, I made a number of mistakes. And at some point, I even had to take down the site to review all the content and make sure that it's accurate. So a lot of lessons learned on the way. But basically, more than 20,000 views later,

[00:16:05] basically, we have an EHDS Explorer that works, that it's accurate, that it's linkable. And also on it, I'm also working on implementation tracking, which is something that I have to improve much more because not each and every country is that open even to provide the information. Or there are some countries that provide a lot of information, whereas others provide less information, which is natural, happens everywhere. Is it? So when you say implementation tracking,

[00:16:33] that is actually meant for the whole, for whole Europe? Yes. So I'm basically tracking some basic things right now. I'm tracking who has additional health authority, which needs to happen by March 2027, and who has a health data access body. So if you go there, it might be in process, there might be some updates that need to happen. You actually know who has what. So that's one thing. Also, I'm also realizing, because of this tool that I developed,

[00:17:03] there were a number of people who are now developing their own focused niches of information. For example, last time, like this week, I discovered a new website called The Health Edge, which is building on the work of the HDS Explorer to focus purely on implementation tracking. And it's like a separate intelligence. It's not affiliated. Neither of mine is affiliated with the European Commission. It's an independent project. Nonetheless, there is some sort of, you know,

[00:17:32] working partnership, of course, going on. But this kind of keeps on happening. And it's interesting to see it evolve, because that means that there is interest in the HDS. And the HDS has the opportunity to be one of the biggest game changers happening in Europe. The same that happened in the U.S. when there was the very first regulation coming in, the 21st Century's Cure Act, the setting up of the ONC. So we're not talking rocket science here.

[00:18:01] We're talking about really important developments that had to happen in Europe. And also that reflect with work that's happening around the world. Around the world, I apologize. So this is beautiful to see it happening. It is also, it will also mean a lot of investment to be done across all the EU member states. It also requires a lot of culture transformation. People will have to realize that they have to change, that they have to improve the way they deliver care. And they need to use digital tools.

[00:18:31] And we also need to make sure that we really can't leave anyone behind. That means that if we use any digital tools, we need to make sure that we don't widen the gap. But actually, they bring it closer by looking at different levels. So that's kind of... A lot. A lot, yes. That's me. Sorry about this. If we go back to just the primary care in Malta. So what do you see as the biggest challenges

[00:18:59] in the implementation of things that need to happen now? So maybe first of all, what are the current priorities and where do you see the biggest challenges? What do you anticipate is going to be most difficult? So the interesting thing that I'm seeing is that overall in primary care, because we're generating so much data, data governance and data quality keep coming on the agenda up front and center. So I would say that one of our biggest priorities,

[00:19:29] in order also to prepare for the European Head Data Space regulation, is to double down big time on data governance. And not simply just doubling down data governance for the sake of data governance, but rather trying to understand as well how people work. And when understanding how people work, especially how they work with the APR, in the current way, with our electronic patient, you start seeing rooms for improvement.

[00:19:57] And this happens by simply having the right conversation with the right people. So for example, this week I had a conversation, which if I didn't grab the phone and try to talk to that person to try to understand what's happening, I would have never figured it out. Literally, I would have never received an email. I would have never done. So we simply just need to talk to people. And that's what's going to make all of this work a success by literally talking to people, going on the ground,

[00:20:27] saying, figure out, listen, why are you doing things in this way? We're noticing this. So having like all the data analysis and all the tools available for you is nothing without talking to the people on the ground. So this is what I'm seeing and what I'm discovering, that there needs to be work. And I am happy because I know that once the focus is and the priorities, especially on data governance, come up front and center,

[00:20:56] then we can upscale any initiatives in AI, in implementing disruptive technologies, in implementing new infrastructure, because I have kind of the data quality up front and center. So these are like all like consequential actions, like but positive consequences, right? Where people start and everything's, the ducks start kind of come start sitting in the order. So that's really, I would say,

[00:21:26] the biggest challenge ahead of us. Really refining, reshaping, but like really having a high quality product, moving from an acceptable product to high quality products, second, high quality services. I think that's going to be our next big shift happening within primary healthcare. What about AI? Are you already introducing anything in that realm? So yes, AI is happening

[00:21:55] in primary healthcare. AI is happening every day, I would say. Every day in the sense that first and foremost, like if you look at government of Molotov initiatives, they also have an impact as well on primary healthcare employees. And what do I mean by this? So knowledge workers, especially in the government of Malta, have access first and foremost to Microsoft's AI suite of tools, co-pilot. So already in the everyday tasks,

[00:22:25] and I found it extremely useful, for example, I love co-pilot for Excel. It has been a game changer for me. And sometimes when I get stuck, I'm like, listen, why is this not making sense? I literally use co-pilot in Excel and I get unstuck. So the amount of times that it has helped me in that level, and it's available, and it's across government. So this is the beauty sometimes of working like as a ministry for health, but across government, because across government initiatives affect

[00:22:55] something else, for example, the initiatives of AI for all. So the government of Molotov, which you might be aware of, now offers a program where you do a small course, a small AI literacy course. It's about six to eight lectures. Once you finish those, you have access to one year of chat GPT plus or one year of co-pilot. So the conversation is better. Is that just for clinicians? Is that for anyone? No, it's for everyone. It's for everyone. Everyone with an EID,

[00:23:25] literally. AI for all .gov.mt. So that's like a program. So which ministry created this certificate program? This is the, I would say, the digital ministry. So the digital ministry also covers economy, it covers innovation. I need to check exactly because I don't know all the remits of all the different ministries. But that wasn't, it was the focus of that ministry. Do you know, did you do the course? Do you know what it covers? I did it, I did it. I did it. And I got myself one free year of free chat GPT plus

[00:23:55] amongst my other subscriptions that I have in place. But joking aside, so I would say that. But from a practical point of view, and these have been mentioned in the past, there is a lot of work going on AI and breast screening and primary health care. So AI is going to have a stronger role in breast screening. There were a number of dives, have a look at the tendering platform, for example. For breast screening, you can see that there was a lot of investment in that side as well.

[00:24:24] and this now is expanding also the different aspects of primary health care. So there is potential, for example, for AI having a stronger role, for example, in our electronic patient record. There definitely is a role there, but basically this is the kind of, this is the kind of approach we're seeing. So there's bigger role for AI in primary and electronic patient records and also in the different specialized services that we deliver as well. So we deliver

[00:24:54] a number of specialized services to deliver ophthalmology, for example, diabetes. AI is definitely going to have a much, much stronger role there over the years. And there is a lot of background work going on to really make sure that we are ready across the board to be able to take the next step. Because what's interesting, people think of AI, oh no, it's just software. But in reality, especially if you want to do good, if you want to do good AI,

[00:25:24] you need to think about, for example, you need to think as well about the infrastructure, the hardware. The hardware is playing a really strong role. It is not to be underestimated. So this is the kind of work that we're seeing across the board where we have to not only just think about the software, but we also need to think about the hardware, the image, for example, the medical imaging device being connected to the server. The server needs

[00:25:53] to show in a specific way. There needs to be specific policies in place. So it's getting much more complex and much more intricate to implement AI. Because the AI is interesting even, for example, let's say, for screening, let's say, in ophthalmology, for example, you need to make sure that the, for example, that the fundus camera that is being used, for example, can connect well with the software and from the software it connects to different aspects. So there are

[00:26:23] all these intricacies with implementing AI. It's not simply about just implementing the software. You need to have a look at the full care pathway. Yeah. Because even if you have, if you implement the best AI, if it interferes with their current clinical workflow, you bring a lot of frustration on board. It gets, it doesn't get worth it anymore. Yeah. Did that happen? And then you end up diverting. Do you have an example where something

[00:26:52] was suggested but in the end wasn't successfully implemented? I would say we're still in, we're still in the early days, Tiasa. I won't be in a position, let's say, to comment on that. But I can tell you, I can definitely tell you that there is a lot of work happening on AI, let's say. And not, I wouldn't say just in primary healthcare because those I have visibility on, but I would say across the board. And the more we get involved with it,

[00:27:22] the more we get involved and the more these all of government initiatives, let's say, hit us in a good way, I might, the more AI starts becoming part of the conversation without wanting to. Where do you hope to be at the end of 2027 when it comes to healthcare digitalization on the primary care level in Malta? A wonderful question there. I really would like to, because

[00:27:52] it's, I don't like to use KPIs when it comes to measuring success, especially when it comes to AI. But really and truly, I would like doctors to find joy again in documenting clinical encounters. If I have, if I want to, I want, I want doctors to say, wow, I just, this AI subscribe tool that I used was working in the background, I didn't even realize it was there

[00:28:21] and then I had this care agent which supported me with writing up a ticket of referral based on what I documented in the encounter. Whilst I still felt safe doing all of this, because I know that the data is stored in an enterprise cloud, for example. So I really would like to help doctors find joy in documenting these encounters. Really, to really focus even more on the care aspect. They,

[00:28:51] it has been a game changer for many doctors in primary healthcare using the APR. but with every EHR implementation you always will have, and this is academically noted everywhere around the world, so this is nothing new. But as healthcare in Malta started digitalizing yet again, not yet again, but started digitalizing, started really going down the path of electronic health records, the challenges that happen with every EHR

[00:29:20] implementation are happening here as well. So these are the kind of things that we are now dealing with. We're now happy to say that maybe we are at a better opportunity when compared I would say to the US because the US when it comes to documentation they are super focused on billing. Now, thank God in Europe especially in Malta since we have a healthcare financing model which is focusing on the government

[00:29:50] being both a payer and provider of services the billing aspect and the financial aspect even though extremely important doesn't boil down on how much I'm going to ask the patient to pay. So like this, the documentation rather than being focused on the billing aspect is focused on the care which I feel proud to be a part of with all apologies to any American colleagues I have here who will listen to this podcast but honestly that is

[00:30:20] something I'm proud of as a European citizen I would say and even a Maltese citizen to really have my clinical documentation focused let's say on the clinical episodes rather than trying to figure out okay we do have coding in place in fact in primary healthcare we use SNOWED CD and ICD-10 as our standards I would say that the biggest challenge ahead of me is to making sure that doctors will move from simply I have to do this I have to document

[00:30:50] to finding joy again in documenting these clinical encounters you mentioned earlier that there's a kind of national program for anyone focused on digital literacy how about digital health or AI literacy what about AI literacy in healthcare are you also doing any upskilling there for clinicians or any

[00:31:19] programs how does that look like how is that managed in Malta I can tell you this as of right now I would say we don't have official programs for health professionals so generally speaking massive opportunity ahead of us to really entrench this work really bringing it up front and center really ensuring I would say one target that I would like to have in the next

[00:31:49] year and a half is to ensure that at least all primary healthcare doctors or primary healthcare professionals are aware at least of all the tools available at their disposition to start off from there let's say in the next year and tools they use

[00:32:19] protect data governance and ensure that everything was stored in such a way to make sure that the patient's data is protected so this is the priority for me that they're fully aware and fully trained on the suspect but I would like to point out one other comment here I think there is a very huge focus on literacy or AI literacy but honestly I think we're coming to

[00:32:49] a point where we really need to focus on delivering products that work seamlessly in what sense that sometimes I would if I had an option I would rather focus on developing electronic health records for example that have AI working in the background the doctors are aware of it but not necessarily having to be trained

[00:33:18] to use that AI but because the product is so intuitive it works so seamlessly that they don't need training that's all that it is so infused they are aware there are policies in place that they need to be aware of having a medical device and that medical device having an additional feature that that's it like the focus really needs to be on delivering care honestly like I would

[00:33:48] double down on that on delivering products that work so they won't even realize that AI is in the background like we had for many years so I would really double down on that at this stage you've been listening to faces of digital health a proud member of the health podcast network if you enjoyed the show do leave a rating or review wherever you get your podcast subscribe to the show or follow us on

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