Portugal: Centralizing Digital Health Decision Making and Solution Design

[00:00:00] Dear listeners, welcome to Faces of Digital Health,

[00:00:03] a podcast about digital health and how healthcare systems around the world adopt technology

[00:00:07] with me, Tjasa Zajc.

[00:00:13] If you're a healthcare policy nerd or just interested in how different healthcare systems

[00:00:19] are structured and how they approach digitalization,

[00:00:24] this episode is definitely going to be perfect for you.

[00:00:28] We're going to move to Portugal.

[00:00:31] I talked to Katia Susapinto, head of Global Digital Health and International Affairs at SPMS,

[00:00:38] which is a shared services organization of the Ministry of Health of Portugal.

[00:00:45] In this discussion, Katia explained the history of healthcare digitalization in Portugal.

[00:00:52] We also discussed a lot on all the work that has already been done for the European Health Data Space

[00:00:59] and many activities that are contributing to this huge European endeavor

[00:01:04] and are not really called EHDS, but are crucial for EHDS to come to life.

[00:01:12] She also mentioned how is Portugal going to use a budget of €300 million,

[00:01:18] which was set up to support the digital transition of the Portuguese health system

[00:01:25] and much, much more.

[00:01:27] So enjoy the show and if you have another minute or two,

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[00:01:46] So I'm really grateful to everyone who expressed their thanks on LinkedIn already

[00:01:52] with the previous episodes where we talked about Canada, where we talked about Catalonia

[00:01:58] and other topics.

[00:02:00] So yeah, pitch in with your opinion as well.

[00:02:04] It's going to help us make the show even better.

[00:02:08] Thank you!

[00:02:10] Now let's dive in.

[00:02:28] Katia, hi and thank you so much for joining me on Faces of Digital Health.

[00:02:32] For a discussion about healthcare digitalization, e-health and digital health strategy in Portugal.

[00:02:39] It's great to have you here.

[00:02:40] I haven't actually ever covered Portugal, even though Faces of Digital Health has been

[00:02:46] going and running for seven, close to eight years.

[00:02:50] So this is great, especially since Portugal has quite a few things that are advanced

[00:02:57] and has had them for a very long time.

[00:03:00] So welcome to this discussion.

[00:03:02] Thank you, Katia. I've been able to watch your work and I'm very glad that I can join you here

[00:03:10] and let you know what our perspective is, what is our perspective here in Portugal regarding

[00:03:17] digital health.

[00:03:18] Thank you!

[00:03:19] So if we start with the description of Portugal, how would you describe the country in the

[00:03:30] up to and who can look up to you and why?

[00:03:33] Which use cases are you perhaps most proud of?

[00:03:36] Let's start somewhere.

[00:03:38] Yes, it's always difficult to compare countries that have different history,

[00:03:44] different health systems and different frameworks for the development of digital health.

[00:03:49] But Portugal is for sure very proud of the work that it's been doing,

[00:03:53] either at the national level but also at the EU and international level,

[00:03:58] where we have been pioneering the collaboration at the EU level in several

[00:04:03] EU related projects, namely the MyHouse at EU and European Health Data Space.

[00:04:10] At the national level, Portugal is a country that more than 10 years ago

[00:04:15] the Ministry of Health created a national e-health agency that was SPMS,

[00:04:21] that is actually the youngest agency in the Ministry of Health

[00:04:25] and created this agency to centralize the procurement and development of information

[00:04:32] and technology within the national health service.

[00:04:37] This was in my personal view the major breakthrough that the Ministry of Health

[00:04:43] did in Portugal in order to evolve and for Portugal to be able at this point

[00:04:49] to have a very high maturity level in digital health services.

[00:04:53] This supported the Ministry of Health to overcome the project-based approach

[00:04:59] to the development of IT solutions in the Portuguese NHS,

[00:05:04] which is a very common problem that has been identified by several international agencies,

[00:05:09] the WHO, this approach that many health systems took

[00:05:13] of having a project-based approach to the development of IT solutions.

[00:05:18] In each institution, each hospital, each primary care center was able to select and

[00:05:25] develop specific applications and services to answer the same problem of all other hospitals

[00:05:33] and primary care centers in the country.

[00:05:36] So we more than 10 years ago started to look at the national landscape of IT services

[00:05:42] and we started a process of harmonizing and making sure that these services were either

[00:05:50] centralized or interoperable so that the digital national health could function as a whole

[00:05:56] in the same way that the physical national health service functions today as a whole.

[00:06:03] This supported us to have a high level and to achieve a high level of interoperability

[00:06:09] within the digital health solutions in the Portuguese NHS.

[00:06:14] We are very proud of several initiatives, one of them is the implementation of a unique

[00:06:20] mortality information system in the country where Portugal was the first country in Europe

[00:06:26] to have online real-time information about diseases that are responsible for causes of

[00:06:33] mortality in the country. And we are also very proud of our e-prescription, medical prescription

[00:06:40] software where in our country all prescriptions done by medical doctors to be dispensed in

[00:06:48] community pharmacies are already electronic and are done using either the software provided by

[00:06:56] the Ministry of Health or if they do not use so they need to be interoperable with our national

[00:07:04] prescription database so that we have access to all prescriptions that are done in the country

[00:07:10] in an electronic format. This is also very convenient for citizens that from a long time

[00:07:16] now are able to have their medical prescriptions on their cell phone and just use that to go

[00:07:23] to the pharmacy and dispense their medication. So we have been having a very wide perspective on

[00:07:30] the digital approach either looking at data collection for public health surveillance that

[00:07:36] it's a major responsibility of the Ministry of Health and the COVID-19 really showed

[00:07:42] how ministries and governments need to invest in having good public health surveillance systems

[00:07:49] and at the same time we are looking at the citizens needs and trying to have

[00:07:54] also the best solutions to make sure that digital services are seamlessly integrated

[00:08:01] within healthcare and that our citizens can make use of the best possible digital approaches

[00:08:08] to healthcare provision that are available. I think I have 10 follow-up questions on all

[00:08:16] the information that you just provided but one that I think we can start with in light of the fact

[00:08:21] that the European Health Data Space is being built. You mentioned that you were involved in the My Health

[00:08:29] at EU project and the EHDS and I think from the broader public perspective many people still

[00:08:36] don't know that even before we started talking about EHDS there was this My Health at EU that

[00:08:42] basically enables some countries to exchange some parts of patient data made with summaries or

[00:08:50] prescriptions. So can you just for a kind of general education share how you differentiate

[00:08:58] the My Health at EU project and how does that go together with the European Health Data Space

[00:09:05] since basically My Health at EU enables cross-border exchange of information and that's

[00:09:11] what we always mention when we talk about the European Health Data Space. So I can clarify there

[00:09:17] is really some confusion about what is the European Health Data Space really about and

[00:09:22] what is already there. First to let you know that of course this very comprehensive regulation

[00:09:29] that is the European Health Data Space and probably most health professionals already came

[00:09:34] across it and were able to see how comprehensive it is did not appear or was built up in a vacuum.

[00:09:43] It was based on several different pilot approaches that were supported by EU funded projects

[00:09:50] that started to develop the basis that then allowed us to identify the specific provisions

[00:09:58] that we should use to really build up the regulation that would support the European

[00:10:04] Health Data Space. One of these initiatives was the creation of a voluntary network

[00:10:12] of digital health agencies called the e-Health Network and the e-Health Network really connected

[00:10:19] EU countries as a reference network for digital health and connected the different experts

[00:10:25] from the different EU countries where we started to work together in order to make sure that cross

[00:10:31] border sharing of health data would really support citizens movement across the EU.

[00:10:38] And the vision and to make it very clear for everyone, the vision was for every citizen

[00:10:44] in Europe to be able to cross their countries borders and to receive care in any hospital

[00:10:50] across the EU exactly the same way it would be possible at home. That means that the medical

[00:10:57] doctor that would assist you in that hospital in a foreign country would be able to access,

[00:11:03] for example, all your online registries and data the same way that it can do in your

[00:11:10] national country. So this was the vision that allowed us using several different EU funded

[00:11:17] projects to work together with other EU member states to develop a service, a voluntary service

[00:11:27] at the time called cross border e-Health service. And then this service evolved and became to be

[00:11:37] called My Health at EU and is one of the fundamental pillars of the European Health

[00:11:44] Data Space. This infrastructure that it's called My Health at EU and that allows citizens to have

[00:11:52] their data available whenever they go to a foreign hospital within the EU. And at the same time

[00:11:59] allows them to have a medical prescription and to retrieve the medication in a pharmacy

[00:12:06] in a different country. So before that we were only able to use our medical prescriptions

[00:12:13] in our national country. We would not be able to use a medical prescription from a Portuguese

[00:12:19] medical doctor in other EU country pharmacies. But now we are able to do so. We are already

[00:12:27] connected with Portugal, for example, is already connected with 11 different EU countries through

[00:12:34] this infrastructure called My Health at EU. But this was before the European Health

[00:12:40] Data Space Regulation, a voluntary agreement between countries because we did not have a

[00:12:46] regulation, a legal framework to back up this digital healthcare service that will be provided

[00:12:54] cross border. Now with the European Health Data Space Regulation this will be possible and will

[00:13:01] be backed up by a legal framework that is defined by the European Health Data Space.

[00:13:07] And I think it will be really a major breakthrough to evolve this service that already connects

[00:13:13] several different EU countries. But of course on a smaller scale to evolve this service and to

[00:13:19] make sure it is a reality in every pharmacy and in every hospital or primary care center

[00:13:25] across the EU. And that we will be able to use healthcare services in any new member state

[00:13:34] exactly the same way that we can use in our home country.

[00:13:39] Thank you for that clarification. I think it's really important because when we talk about the

[00:13:44] great vision of the European Health Data Space, it's not difficult to understand the vision but

[00:13:50] with strategies it's always not about what you want to achieve but how you plan to get there

[00:13:56] and as you alluded to this has been already a long path. But maybe just before we move

[00:14:01] forward I would still like to learn a little bit more if there's anything you can share around

[00:14:06] how these individual connections were built between countries because you mentioned that

[00:14:11] the connections are voluntary, you were connected with 11 countries, there's many more countries

[00:14:16] in Europe. How did you see that development? What were the key factors of connecting

[00:14:23] infrastructures? Are these one-on-one connections or is there like a central hub where everyone

[00:14:31] connects? How is basically that infrastructure built? Yes, essentially the infrastructure it's

[00:14:38] built bilaterally so the communication is done bilaterally between the different member states.

[00:14:45] This of course taking into account a member state's autonomy regarding their healthcare services

[00:14:51] and so the connection is done bilaterally where different member states' pairs agree to exchange

[00:14:58] data. It evolves two different services, one of them is the transaction of the patient summary

[00:15:07] and the other it's the transactions as e-prescriptions. So these are two different

[00:15:14] services. One is intended for a foreign citizen to be able to have their information in a Portuguese

[00:15:21] hospital and the other way around a Portuguese citizen to be able to have their patient summary

[00:15:27] available in any other EU member states' hospital and the other service is intended to be used

[00:15:34] at the community pharmacies where we can have a prescription than anywhere in the EU and

[00:15:41] go to a pharmacy anywhere in the EU and have our medication available. These are the two

[00:15:48] different services that member states have been working on and there were several technical

[00:15:54] and interoperability guidelines that were selected and developed and that all member

[00:15:59] states agreed with at the technical level to make sure this would be a reality. This is

[00:16:06] generally known as the European Electronic Health Record Exchange format. So we identified common

[00:16:14] standards, common communication and interoperability guidelines and rules upon which we all agree that

[00:16:22] we will use two exchange data in a common format so that it can be retrieved and read in

[00:16:28] different countries the same way that it is retrieved and read in the country of origin.

[00:16:33] So this was the way it was developed and that's the reason why we started to develop this very,

[00:16:44] a very long time ago with several different initiatives and projects focused on different

[00:16:50] aspects of the European Electronic Health Record Exchange format. And we are now at the point

[00:16:58] where we are planning to expand these data types to include medical images, for example,

[00:17:06] laboratory results, hospital discharge reports. So we are already evolving to make sure that

[00:17:13] when we have the legal framework of the European Health Data Space there will be

[00:17:19] already available standards and technical guidelines that will support the development,

[00:17:26] the technical development of this data exchange to make sure it's faster and can be done in a

[00:17:34] seamless way and really prove value to our citizens. A lot of work before we can actually see the

[00:17:41] results, it always reminds me of that quote I think it's from Jeff Bezos that every overnight

[00:17:47] success is 10 years into making. So a lot of things are already happening and then at one

[00:17:52] point it might seem that everything is working from out of thin air or something. Yeah, that's

[00:17:59] completely right and it's complete at the point regarding the development of the European Health

[00:18:04] Data Space that it will probably look like that something that was started after the publication

[00:18:10] of the regulation but it was really started long ago. We talked a lot about electronic

[00:18:16] prescriptions and cross-border care and since Portugal has had electronic prescriptions for

[00:18:23] over 10 years I would like to ask you a little bit about that as well. Can you maybe talk a bit about

[00:18:29] the approach that you took? You mentioned that patients can get their prescription on their

[00:18:35] phones and go to any pharmacy that they want. We see that across Europe, it's not the European

[00:18:41] Union but for example in the UK the approach that they're taking, the NHS is taking with the

[00:18:47] electronic prescription service is that the doctor nominates which pharmacy the patient will go to

[00:18:54] and I just find that very interesting because yeah different countries really take

[00:18:59] different approaches. In some cases you can go to any pharmacy that you want. I know that

[00:19:03] in Slovenia that development was gradual. In the beginning when you went to one pharmacy

[00:19:09] you always had to go to that pharmacy. If you had a repeat prescription now they also updated that

[00:19:15] in a way that you can go to any pharmacy regarding of the type of the prescription that you have.

[00:19:21] So how did Portugal go about that and can you tell us a little bit more about the

[00:19:27] thing that the patient has? Is it like a QR code? Is it a message? How does that work?

[00:19:34] Yes, in Portugal citizens can go to any pharmacy to have their medication dispensed

[00:19:41] in the community pharmacy except if there is some special case for some special medicine but

[00:19:48] in the general medical practice citizens can use their prescriptions in a pharmacy of their choice

[00:19:56] and it's up to them to select the most adequate pharmacy or the ones that they simply

[00:20:03] want to choose to have their to buy their medication. Going back to your question regarding

[00:20:09] the way that our citizens can have their prescription available they will receive it

[00:20:17] in three different ways. They will receive it in their email so whenever a medical doctor

[00:20:22] issues a prescription, a medicines prescription you will have it in your email, in your

[00:20:28] cell phone, in the messages of your cell phone and also in our national NHS apps.

[00:20:36] So you can use either one of these three digital formats to show the prescription

[00:20:43] the dispensation codes in the pharmacy so that the pharmacist can retrieve your prescription

[00:20:50] online using their own software based on the codes that you provide them.

[00:20:56] So you can use three different ways you can use a

[00:21:01] pds document that you receive in your email if you can even print it out if that's something

[00:21:06] that it's more suitable. You can use codes that you receive as an sms in your cell phone or you

[00:21:13] can use your prescription that it's available on your personal area in your mobile app.

[00:21:19] More options so one of them for sure works.

[00:21:23] Generally the most used option is the one where you use an sms code that it's sent to you in your

[00:21:31] cell phone but there are other options and citizens can use them either to review the

[00:21:38] full prescription and so on but it's the only way to have your medication dispensed in a community

[00:21:46] pharmacy at the moment only in I would say very exceptional situations that would be possible

[00:21:54] to retrieve it in any other way but it's actually more convenient for citizens because you can see

[00:22:00] the information regarding your prescription the different types of options that you have

[00:22:05] and it's up to you to select the best option. You mentioned that one of the key

[00:22:11] things that really made a difference for the future of the development in Portugal

[00:22:17] was the establishment of the shared services of Ministry of Health SPMS which was established

[00:22:24] in 2010. Can you talk a little bit more about how that looked like if you try to go back in

[00:22:33] history because this sounds like a huge organizational change and these are usually very difficult

[00:22:41] to introduce when we're talking about the changes in healthcare systems that's why it's so difficult

[00:22:47] to compare healthcare systems because you can't just change them overnight there's too much

[00:22:52] history attached to the design that a specific healthcare system does so this must have been

[00:22:58] a huge change. Yes it was a huge change and it was done in a stepwise approach although

[00:23:06] legally SPMS was created in 2010 and started to to be built up let's say within the NHS as an

[00:23:15] agency in 2010 it started as a step-by-step approach picking up different projects and

[00:23:22] initiatives and IT solutions that were elsewhere managed in the NHS. I do remember how several

[00:23:31] services and even human resources coming from other agencies concentrated were concentrated within

[00:23:38] SPMS to make sure that we have an agency full of departments doing all of them doing the same way

[00:23:45] managing ICT solutions for the NHS that otherwise were being managed in different

[00:23:52] institutions across the NHS in other national agencies in hospitals in regional health

[00:24:00] administrations all of them were able to really manage and develop their own systems at the time

[00:24:06] and when SPMS was created the Ministry of Health started to centralize the management

[00:24:12] and development of all different software applications available in the NHS so it was

[00:24:20] done in a stepwise approach where each year additional ICT solutions were coming from

[00:24:27] different agencies within the NHS to to SPMS to start to be managed at SPMS but essentially

[00:24:35] even I was working in another agency in the Ministry of Health at the time and I was able to see

[00:24:41] the benefits of this centralization. I was already working with information systems that were managed

[00:24:47] in the institution I was working at the time and then they came to SPMS and I immediately

[00:24:54] started to realize the added value of the interoperability gains that came with the fact

[00:25:01] that we have a central agency responsible for managing all ICT solutions and being able to

[00:25:09] select the best way to answer a new digital service need that is not most times especially

[00:25:17] when we already have a lot of different ICT solutions to develop a new one it's to build

[00:25:23] upon what already exists and be able to develop the service to not make it the application for doctors

[00:25:31] to have to put data in several different ICT solutions to have then scattered data managed

[00:25:37] and stored in different places that the citizen cannot retrieve when they move from one provider

[00:25:44] to another. I immediately was able very few years after the creation of SPMS to be the

[00:25:51] to realize and to see the benefits of having a central agency within the Ministry of Health

[00:25:57] to start to have a governance approach to digital within the health care system.

[00:26:04] I'm going to refer to the UK again because there and probably elsewhere as well this shift in

[00:26:11] the mindset happened where the need for consolidation was recognized only a few years

[00:26:17] ago the NHS had over 200 commissioning groups that were deciding on funding for over 200 NHS trust

[00:26:25] and you can imagine how fragmented that system became until they finally said okay let's just go to

[00:26:31] 42 integrated care systems that are going to decide what's going to happen for a specific region

[00:26:38] in terms of procurement and then you also have further consolidations in things like projects

[00:26:44] such as one London that takes care of 10 million people and has five integrated care systems 1,400

[00:26:51] GB practices 42 NHS trusts to have a common strategy for how to connect the data for the

[00:26:58] population. I guess it's an interesting trend but speaking of centralization in Portugal so

[00:27:05] the SPMS can you talk a bit about what are the roles that it plays if I'm not mistaken it doesn't just

[00:27:15] set the guideline you also sit on top of IT projects so how what is actually developed in-house

[00:27:24] what's taken from the industry how does that collaboration look like?

[00:27:29] Yes SPMS there are different approaches across the EU as you were saying

[00:27:34] in our case we are not only the regulator we are at the same time responsible for the development

[00:27:41] and maintenance of ICT solutions within the NHS even if we use external contracts to perform our

[00:27:49] role but the responsible the ultimate responsible for the development and maintenance

[00:27:55] of the ICT solutions is really SPMS so this is a different approach from other EU countries

[00:28:02] where the central agency is only the regulator so we have these two sides we have this

[00:28:11] harmonizing role within the governance approach to digital health within the NHS and at the same

[00:28:17] time we actually develop and maintain several of the ICT solutions and the most relevant ones

[00:28:25] that are used by the Portuguese NHS of course this is a challenge but it was a specific objective

[00:28:33] of the Ministry of Health at the time to be the owner of the software applications the central

[00:28:40] software applications that were used in the Portuguese NHS to make sure we were able to

[00:28:48] make our decisions in the complete use let's say of the possibilities that are there for ICT

[00:29:00] development without being constrained by commercial interests or any other interests that may

[00:29:08] interfere with the government decision on how to evolve ICT solutions that is the reason why

[00:29:16] we are not only a regulator but we are essentially house responsible for development and management

[00:29:24] of ICT solutions and I can totally see why that makes sense especially from the

[00:29:33] public funding perspective you can control costs a little bit better through that

[00:29:38] approach you're not that attached to the changes in business models and pricing that

[00:29:44] software providers might have but Slovenia for example wants to go with a similar approach to

[00:29:51] establish an agency and basically have that central overview and control over the

[00:29:58] IT in different hospitals but the challenge that we have here is the workforce so how are

[00:30:05] you going to get people to work for the agency and is that agency going to be a competitive

[00:30:10] in terms of salaries and things like that how did you solve that and I also am wondering when

[00:30:17] as BMS was established where I would imagine that the software companies would be the loudest

[00:30:23] ones in saying that this is not going to work that this is not the right approach because

[00:30:29] I don't know you can't stay on top of trends the way the industry can or I don't know what

[00:30:34] other arguments there could be yes there were several I remember discussions at the time when

[00:30:41] this approach was taken by the Ministry of House it was a long time ago already of course there are

[00:30:46] challenges related to human resources but SPMS was established with a legal framework of a public

[00:30:53] enterprise so this allows us to be more competitive than a strictly public institute

[00:31:01] to make sure we are able to manage human resources and services and the provision of services

[00:31:08] done by private sector in a more of a much more flexible way to answer of course the challenges

[00:31:16] and the needs of ICT development and maintenance this means that we still collaborate with the

[00:31:23] private sector by contracting services but we are we decided in Portugal that we would be

[00:31:32] the owners and in charge of our main ICT solutions and this has been possible of course with

[00:31:39] challenges but the fact is that we are running and developing ICT solutions for the NHS for 15

[00:31:46] years now and this has been possible this does not mean of course that a long time

[00:31:54] we may change the way we do things or we may accommodate different ways of contracting

[00:32:02] the private sector for the development and deployment of ICT solutions within the NHS

[00:32:09] but I would say that making sure that we are really the owners and the responsibles for central

[00:32:18] ICT applications it's a core part of making sure that we have the best value for money when we

[00:32:28] are investing in digital health at least from our experience in Portugal and in our national

[00:32:35] context but I do know the challenges and we have had an exchange visit with Slovenia and we were able

[00:32:42] to really discuss that with them and I really remember discussing the human resources part

[00:32:49] but having providing public sector bodies with more flexible legal frameworks for human resource

[00:32:57] management will for sure support countries that want to evolve the same way that Portugal did

[00:33:06] in having sufficient legal and technical instruments to manage the human resources

[00:33:12] that are needed for digital health. One very open question about your opinion of what's

[00:33:22] impact do you think the size of the country had in enabling you to go in this approach because

[00:33:30] based on my observations the smaller the country the easiest it is the less decentralization

[00:33:37] that you have the less opinions it just makes things easier so I think we don't really talk

[00:33:43] often enough that Estonia has 1.3 million people so that definitely to me is an important factor

[00:33:50] when we talk about how successful they are in their digitalization Portugal has 10 million

[00:33:54] that's still a lot different than the US or the UK or Germany with a few many more tens of millions

[00:34:03] of people and regions and complexities. Of course there's no one solution that fits all

[00:34:10] countries that happens actually with health care systems we do not have a single solution for

[00:34:16] health care provision management and governance so it would be very unlikely that digital house

[00:34:22] could have a single best way to the provision of digital services that would fit all countries.

[00:34:29] Of course being a small country it helps you in several in several aspects especially when

[00:34:35] centralization of some of the responsibilities of the government and the state is a possibility

[00:34:43] for the provision of services and so in that sense smaller countries may may have an advantage

[00:34:51] when it comes to having centralized solutions and opting for a centralized solution that is not

[00:34:58] of course not even an option for countries that are too large to accommodate central solutions

[00:35:06] but that does not mean that we cannot there are several different good ways or right ways

[00:35:12] to achieve the same result so we really can accommodate the different approaches we have

[00:35:19] different experiences and different countries and even in the same country we might for specific

[00:35:26] services follow a different approach a different one that being having a central solution we

[00:35:31] might have an option that would be to have decentralized solutions for specific services

[00:35:39] on digital house it will depend actually the way that the services and the possibilities and

[00:35:45] the technology supporting health care will evolve that will show us how we should accommodate

[00:35:51] the different ways of providing the services but for sure in certain aspects smaller countries

[00:35:57] do have an advantage when they want to change things across the entire country.

[00:36:04] I mentioned very in the very beginning that Portugal has many electronic services and has

[00:36:11] had them for a long time apart from e-prescriptions I think also with lab testing you can just

[00:36:18] get an order and go to any lab that's close to you if I'm not mistaken is that right?

[00:36:26] Yes we are already implementing electronic lab prescriptions and results within the

[00:36:34] Portuguese electronic health record framework let's say so at the moment we are evolving in

[00:36:41] that project that it's already a reality with several private providers already connected

[00:36:46] and what this means is that medical doctors can prescribe electronically laboratory exams

[00:36:53] that can be done in different providers in the country and then when the results are available

[00:36:59] they are sent back to the NHS and they will be available in an electronic format for the NHS

[00:37:07] medical doctors and of course we'll then later on be available on the citizen's personal area

[00:37:15] within the national health portal so this is a project that we have started already

[00:37:22] we are achieving very impressive results with millions already of shared laboratory results

[00:37:29] within the NHS and we want to evolve to have also medical images available within the same

[00:37:37] service so that the most used diagnostic tests performed in the NHS are available for doctors

[00:37:46] and more and more as structured data formats that are flexible enough to then later on in the

[00:37:54] future accommodate for example they use clinical decision support systems based on AI

[00:38:01] that's the way we are progressing and that's a project that it's progressing very well

[00:38:06] so I hope when the European health status space comes to light Portugal will be already ready to

[00:38:13] share the laboratory results not only at the national level but also at the international level

[00:38:19] in 2022 a budget of 300 million euros was set up to support the digital transition of the

[00:38:28] portuguese health system can you elaborate a little bit what are the key plans for this

[00:38:35] funding what will be covered by this investment given all the things that you already have

[00:38:42] yes we had used our recovery and resilience funds to really upscale the digital transformation of

[00:38:50] the NHS so we built upon Portugal built upon the work and the strategy that was being followed

[00:38:58] and we scattered the investment in essentially four pillars infrastructure to make sure we would

[00:39:06] be able to use these funds to modernize the infrastructure available especially at the primary

[00:39:12] care level because that's something very fundamental to the functioning of everything

[00:39:18] related to ICT we focused also on citizens to make several different changes in our health

[00:39:28] information use these funds to make several different changes in our health information

[00:39:33] systems to make them more citizen centered so that citizens can more and more really access

[00:39:40] and use their health data that it's collected day after day in all portuguese

[00:39:46] NHS institutions we also focused our plan in health professionals there is more and more

[00:39:54] the realization that there's this technological burnout associated with healthcare provision

[00:39:59] for all healthcare professionals so part of our plans are really to simplify the use and the

[00:40:06] interface between the human professional and the digital face of the NHS so that

[00:40:13] this becomes really a way to simplify and to modernize processes and not a burden where data is inserted

[00:40:22] several different times and cannot be retrieved when needed at the point of care we really want

[00:40:28] to use the rf the rs funds to modernize the way the NHS is using data for secondary use purposes

[00:40:38] we have already developed several different solutions that use data that it's collected by the

[00:40:44] NHS to inform health-related decisions for public health surveillance for healthcare administration

[00:40:51] but we need to move on and to use more and more data and more and more data sources

[00:40:58] and develop database services that will allow health decision makers to make more

[00:41:04] data-driven decisions at the NHS level so what's your biggest challenge

[00:41:09] I think the biggest challenge that we have so far and that it's progressing already is the

[00:41:16] development of the national single electronic health record for every citizen so Portugal is

[00:41:24] creating even at the legal and regulatory level this single electronic health record

[00:41:30] for every citizen in the country that will be able to collect and retrieve your data your health

[00:41:37] data of course with your permission that it's collected in every public or private institution

[00:41:43] in the country so you would have a service that would be provided by the government that is

[00:41:49] in your personal area in the health portal where you could then authorize that all your

[00:41:56] data collected in the public and private sector to be centralized there and accessible to you and

[00:42:02] then you can show it and use it to every health professional that we need so we are at the

[00:42:07] moment creating the legal framework and the technical framework upon which every health

[00:42:14] institution public or private in the country would base the provision of the data to all

[00:42:22] Portuguese citizens so the vision is that when you come out of any dental clinic practice any

[00:42:29] hospital any private provider any laboratory in the country your data is already in your

[00:42:36] personal area in your single electronic health record and so this is one of the biggest

[00:42:42] challenges related to the primary use of data that we are investing in using

[00:42:49] the rrf funds and it will be a major breakthrough in the future in making data accessible to

[00:42:57] citizens and to health care professionals in the country it's really a fundamental step because

[00:43:02] we know that the health care of the future will be deeply based on good quality data we

[00:43:09] can easily imagine that doctors 10 20 years from now will not be able to make a diagnosis if

[00:43:17] you do not have certain types of information with you this is different from what happens now

[00:43:23] it's very different from what was happening 30 years ago that will be most probably the

[00:43:29] reality of the future and so we also strongly believe that a country any country but in

[00:43:35] this case Portugal will not be able to provide the best care if we do not have the best data

[00:43:41] available to to support the decisions and the diagnostic decision making of the precision

[00:43:48] medicine of the future it definitely is a an idea or a vision that i think we hear often

[00:43:58] when we talk about the future of health care however from the practical perspective i can

[00:44:03] imagine that it's a huge interoperability headache thinking of how you're going to unify and

[00:44:10] translate all the data and clean it to to basically have it ready for use for analysis prediction etc

[00:44:16] yes yes it's a big challenge it's difficult even for those of us that are working with

[00:44:23] data and information systems for a long time to really see it happen in a seamless and

[00:44:28] comprehensive way but it's happening and we are taking this sort of module based approach

[00:44:35] this step-by-step approach looking at priority categories of health data

[00:44:40] priority services and making sure that we are moving forward every year with more and more

[00:44:46] interoperable health information systems in the country i think the challenge that it's missing now

[00:44:53] for health care system is it's really to have a full integration between the digital health

[00:44:59] governance and the health governance and the health policy to make sure we have a national

[00:45:05] health plan that takes fully into account digital health when establishing national priorities when

[00:45:12] establishing screening programs when establishing the interventions that the NHS will select to

[00:45:19] deal with priority health problems in the country that is probably the biggest challenge to really

[00:45:26] make sure that we are using technology and digital health services to make sure we have

[00:45:33] better health for portuguese citizens also 10 years from now or 20 years from now

[00:45:40] maybe just one last question and your opinion and observation i liked how you basically

[00:45:47] mentioned that you're trying to create this full electronic health record on the national level

[00:45:52] where everything would be connected and similarly as in the beginning we talked about the confusion

[00:45:58] around the electronic health data space and my health at EU i think there's also a lot of confusion

[00:46:06] around what exactly is an electronic patient record on the national level many countries would

[00:46:12] say they have it that they have the electronic patient records because patients can access

[00:46:17] their patient summaries or their e-prescriptions but when you really look under the hood the

[00:46:23] situations are really different somewhere you just have a pdf lab results somewhere part of

[00:46:29] the data is structured part of it isn't so what's your comment around that which country

[00:46:35] is there a country that you're really impressed by or how do you see this confusion around

[00:46:42] what the national electronic patient record even is and what is the minimal data set that you need

[00:46:49] to call it yes it's so digital health since it's in the beginning and so the monitoring and evaluation

[00:46:56] of digital house within healthcare systems it's also in the beginning we need to realize that

[00:47:02] and so when we look at all these reports and comparisons we need to know that there is

[00:47:08] also a lot of work to be done in the methodology that we are using to compare different countries

[00:47:14] in regarding different services on different systems well of course you are right when we

[00:47:20] talk about an electronic house record we may be talking about very different things we may

[00:47:27] be talking about pdfs we may be talking about structured data we may be talking about

[00:47:32] several different data types sometimes only a very few data types are available

[00:47:37] to you in your record so it's difficult to have a clear picture at the moment my perspective is that

[00:47:44] as digital house will continue to be a more and more relevant part of healthcare systems the way

[00:47:50] the methodologies and the ways that we are measuring and selecting indicators to compare

[00:47:56] ourselves even at the national level or between countries between regions of the world will

[00:48:01] also evolve to make us to have a more specific picture of the different digital house services

[00:48:09] there are available but and so that's a challenge but independently of that I think the vision

[00:48:15] needs to be that our electronic house record is a service that it's provided to us a digital

[00:48:21] service that is provided to us where we can access all our house related data this is a vision

[00:48:29] that it's of course difficult to achieve and we can then add up saying in real or almost real time

[00:48:37] this is the vision that we all need to have as as public health agencies for an electronic house

[00:48:43] record the same that I was saying to you when we leave a healthcare institution the data that

[00:48:49] was collected about us our health related data is already in our mobile application let's say

[00:48:55] or in our electronic personal electronic house record available on the web and we can then send it

[00:49:02] or share it with another provider if we wish to do that I think it's the vision that it's needed

[00:49:07] for better healthcare provision and for better public health surveillance so both primary and

[00:49:12] secondary use will benefit for this vision for an electronic house record I would say that

[00:49:18] there isn't a single country in the world that is already able to provide this service to

[00:49:24] a citizen in a very if we look it in this very almost

[00:49:32] difficult to grasp vision where every single piece of our health data it's available to us in real

[00:49:39] time but it's a challenge that we all are pursuing and there are several good examples

[00:49:46] across the EU and outside the EU the United States Australia where we can see very relevant

[00:49:53] evolutions and approaches to making health data available but to have good comparisons as you are

[00:50:01] saying we need to evolve a little bit on the methodology that we are using to to measure and

[00:50:07] to produce the results I think it will happen with time the same way as it happens when we started

[00:50:13] to compare healthcare systems performance and do different studies on how we would compare the

[00:50:20] different healthcare systems performance between different countries it was not perfect when it started

[00:50:25] it's much much better now and I'm sure the the same will happen with digital health services

[00:50:32] I think you just gave me an idea for a new topic or an episode around data fears and data

[00:50:39] availability because I think when we talk about all data being in the electronic healthcare

[00:50:44] records usually what's mentioned is the psychiatric specific or mental health specific data and how

[00:50:51] that might not be shared as the same way as any other data and things like that so many

[00:50:59] open questions but yeah now I have another thing to think about in terms of topics

[00:51:05] consent management or consent management related to health data is a big topic that needs to

[00:51:11] come side by side with the electronic health record but the fact is that if we have our data

[00:51:17] available and we have a way to really give or not authorization or consent for sharing

[00:51:26] we are really in charge if we do not have the data available we are not able to consent

[00:51:32] or not consent about data sharing that may be available elsewhere and so this is really

[00:51:39] a reflection that we all need to do and it's a very urgent one as interoperability and between

[00:51:46] the different ICT solutions and electronic health records are growing more and more how we are really

[00:51:53] giving the citizen the possibility to control with whom their data is shared

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