Where is Healthcare IT in Europe in 2024? (Tomaz Gornik)

[00:00:00] [SPEAKER_01]: 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

[00:00:15] [SPEAKER_01]: Europe has high ambitions when it comes to cross border care and the utilization of patient data,

[00:00:24] [SPEAKER_01]: so regardless of where patients seek care in Europe, clinicians could access their data,

[00:00:30] [SPEAKER_01]: who patients could access their prescriptions and pick up their medications in pharmacies,

[00:00:36] [SPEAKER_01]: even outside their own country. However, there's also a lot of skepticism around the U.S. Health data space and how feasible it is and how soon could we actually see it come to fruition.

[00:00:51] [SPEAKER_01]: So in today's episode, we are going to focus on healthcare IT and the current state of healthcare IT in 2024.

[00:01:00] [SPEAKER_01]: I spoke with Tomaz Gornik, the CEO of Better.

[00:01:05] [SPEAKER_01]: Tomaz has been working in healthcare IT for over 30 years and we discussed what is the data platform in healthcare?

[00:01:14] [SPEAKER_01]: What motivates vendors to not lock customers in their systems?

[00:01:20] [SPEAKER_01]: Here's the S-Eploitation from the healthcare IT perspective, the power of legislation and tender processes in shaping the future of digital health.

[00:01:31] [SPEAKER_01]: So enjoy the show and if you haven't yet, make sure to subscribe to the podcast wherever you listen to your podcasts.

[00:01:38] [SPEAKER_01]: And also check out our newsletter, you can find it at fodh.substack.com that's fodh.substack.com

[00:01:49] [SPEAKER_01]: and enjoy our in-depth insights around different topics in healthcare and digital health.

[00:01:59] [SPEAKER_01]: The last edition, so the September edition of 2024, focused on why countries struggle when it comes to digital health strategies and the newsletter summarizes what speakers from the past episodes of F-O-D-E�.

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[00:02:38] [SPEAKER_01]: Thank you, I really appreciate your input.

[00:02:41] [SPEAKER_01]: Now let's dive in.

[00:02:58] [SPEAKER_02]: The last thank you for taking the time for a discussion about healthcare IT in Europe, the developments that we've seen in the last 10 years and even more.

[00:03:10] [SPEAKER_02]: Better is five years old this year but actually the company itself was just renamed five years ago.

[00:03:17] [SPEAKER_02]: You've been working in healthcare for over 30 years and I want to start with your observation of the trends that we see in healthcare IT in general.

[00:03:29] [SPEAKER_02]: A lot of problems stem from the fact that legacy software is hard to update so what does in 2024.

[00:03:39] [SPEAKER_02]: Good software mean and what's great software.

[00:03:44] [SPEAKER_00]: Thank you, thank you for the questions and thank you for having me on this show.

[00:03:48] [SPEAKER_00]: So I think in the last few years what we are noticing is that a lot of the software that was put in during the period of fast digitization is now getting old.

[00:04:01] [SPEAKER_00]: So we see a lot of vendors which have outdated software and of course as a consequence a lot of the customers are using software which is way past its lifetime.

[00:04:11] [SPEAKER_00]: Covid accelerated some type of a new process but what I hear from CIO is that it's extremely hard to find software which they would like a modern architecture based on some principles which as we are also advocating for which is separation of data from applications excellent UX UI.

[00:04:33] [SPEAKER_00]: And then of course modular software instead of a megasuite.

[00:04:39] [SPEAKER_00]: And you touched on an important point it's not just that the software is hard to update or is inflexible it's also it's extremely hard to put in even if it's a new project.

[00:04:50] [SPEAKER_00]: So we see customers struggling to go live in years after purchasing a product and this comes from basically two things one is that I think a lot of the software in healthcare.

[00:05:03] [SPEAKER_00]: Has gotten to complex for its own good.

[00:05:06] [SPEAKER_00]: I do not believe that such complexities needed it's probably the result of vendors just adding things to existing software instead of coming up with a new approach.

[00:05:18] [SPEAKER_00]: And the other thing is of course that the software is monolithic is inflexible is holding data in the silos of the application and of course cannot evolve like a modern software architectures allow applications to do.

[00:05:35] [SPEAKER_00]: So I do believe we're at this inflection point where many CIOs are asking what should I buy what should I do and cannot find good answer.

[00:05:45] [SPEAKER_02]: Do we have an example in healthcare where a vendor would slowly sunset a product and parallely build a new one based on new technology because that's one of the challenges that once you have this huge software that's took years to develop.

[00:06:04] [SPEAKER_02]: It's really difficult to add new faster better technology to that same old technology and generally speaking that's the solution fine times to actually invest in this new technology in parallel and leave the fast behind.

[00:06:20] [SPEAKER_00]: Absolutely in in in some way this is called the innovators dilemma right how do you disrupt yourself and.

[00:06:28] [SPEAKER_00]: The problem in healthcare I think is that these systems are incredibly hard to replace one stair put into production, which means that the current vendors maybe do not feel the same urgency as another domains outside of healthcare.

[00:06:43] [SPEAKER_00]: We're software gets changed much more rapidly here any HR is almost impossible to replace so the vendors have a sense of safety that maybe changes not going to happen or it's going to be too slow.

[00:06:55] [SPEAKER_00]: So what we are seeing is that mostly the vendors that have lost a major deal due to the fact that they have older software.

[00:07:04] [SPEAKER_00]: Are the ones who are thinking about the approach you mentioned which is how can you keep serving customers while at the same time replacing certain functionality with a modern architecture and yes we have quite a few examples of the largest example that we have is.

[00:07:22] [SPEAKER_00]: We have a large part of the network that we have in the field and in the Nordics.

[00:07:25] [SPEAKER_00]: They have now about 60 hospitals which are running I would call a hybrid which keeps some parts of their previous system but now has over 800 forms.

[00:07:37] [SPEAKER_00]: Implementing new functionality on top of new architecture inside the same HR so I call this a hybrid and the nice thing about this it's a gradual approach.

[00:07:47] [SPEAKER_00]: It will take them probably five years to replace most of the functionality and you have to remember another thing so we as a company work with most the clinical data so there's a whole other segment on the chart which is which is the patient administration system.

[00:08:04] [SPEAKER_00]: Which we don't deal with and of course it's much harder to so it's very difficult to find business cases because most of these deployments are tied to single markets so you will find vendors that have many solutions because of this problem.

[00:08:21] [SPEAKER_00]: And the patient administration system is almost always local or requires a lot of so it becomes a business problem how do you cover the needs of many countries with very different reimbursement systems insurance claims and so on with patient administration system.

[00:08:41] [SPEAKER_00]: So we have decided to focus on the clinical side where there's a lot more similarities between countries and the way health health system users use software.

[00:08:51] [SPEAKER_02]: Looking from the government or regional decision makers perspective, while they can do if they want to be more modern is that they can mandate standards that need to be used and then vendors need to adapt and this is what Catalonia did and we covered this with Jordipera in a film called Saluti in one of the previous episodes.

[00:09:14] [SPEAKER_02]: But I thought it was really interesting the example that you mentioned when a vendor decided to disrupt itself.

[00:09:21] [SPEAKER_02]: Given that better is a health care IT company can you imagine that type of transition within your company what would it mean for the company to actually do that parallel development.

[00:09:34] [SPEAKER_00]: And to be honest we did the same thing right so we did this 10 years ago so we built a system and started replacing it piece by piece with the new technology.

[00:09:45] [SPEAKER_00]: We are running a few hospitals here in Slovenia and every iteration the parts of the code get replaced with the new architectures based on low code.

[00:09:55] [SPEAKER_00]: We're well aware of that and I think obviously it adds an additional cost but it prepares you to be ready for the future so I think this is an ongoing process which must happen in all software companies which are working to be here for a long time.

[00:10:12] [SPEAKER_02]: How do you see the future development of health care IT in the upcoming years?

[00:10:19] [SPEAKER_02]: Because of the European health data space there's going to be additional investments for health care digitalization in Europe.

[00:10:26] [SPEAKER_02]: Can you talk a little bit about that your expectations, fears, worries?

[00:10:31] [SPEAKER_00]: Yeah I was just at a conference where we talked a lot about the impact of EHDS and the consensus among the group of mostly CIOs and decision makers.

[00:10:40] [SPEAKER_00]: Was that yes yes we'll bring new investment which is always welcome.

[00:10:46] [SPEAKER_00]: But of course the issues that countries and health systems really have is how to get the initial data in good enough quality and enough data to make clinical decisions before sharing it with others.

[00:11:01] [SPEAKER_00]: So I think we haven't solved this problem in a lot of places.

[00:11:06] [SPEAKER_00]: We were with some of the most advanced health systems like Denmark and even they have issues on putting the data together before being able to share it across Europe.

[00:11:15] [SPEAKER_00]: So I think again if the EHDS directive comes with extra funding and a push towards standardization, it's going to help the local systems.

[00:11:25] [SPEAKER_00]: But this has to happen before we think about sharing data abroad.

[00:11:31] [SPEAKER_00]: And I do believe that Al-Kovid did a similar push.

[00:11:34] [SPEAKER_00]: In fact in Europe we have the RF, the recovery in resilience funding which is adding another set of funding to digitize health care and then even I think cyber security breaches are fueling the next wave of investment.

[00:11:52] [SPEAKER_00]: And there is a big push for instance in Italy to move the entire public sector to cloud for cyber security reasons.

[00:12:00] [SPEAKER_00]: So there are many initiatives which are bringing you funding into health care IT and I think that's fantastic.

[00:12:06] [SPEAKER_02]: If we just go step back to explain EHDS for those that might not know it so the idea is that the European countries would be able to exchange data and patients would be able to access their data.

[00:12:20] [SPEAKER_02]: Regardless of where they seek care in Europe, this is something that has been an idea for over 15 years probably and there have been several European projects that have established pilot projects to support how this could be done.

[00:12:36] [SPEAKER_02]: And if you look a little bit deeper we see that on the country or regional levels.

[00:12:42] [SPEAKER_02]: There's already a huge challenge of actually exchanging data and enabling to a patient to get their data within one country.

[00:12:52] [SPEAKER_02]: Where do you, so this is something that needs to be solved first before we go more rather?

[00:12:57] [SPEAKER_02]: And I'm wondering what kind of examples of good practices are you observing that are solving this issue?

[00:13:04] [SPEAKER_02]: So the issue of integrating data, connecting data, exchanging data regardless of different software vendors, different standards used to get to this single patient record.

[00:13:18] [SPEAKER_00]: Yes, you have so you are right that I think the countries are struggling to do this at any level even city level regional level country level.

[00:13:28] [SPEAKER_00]: And I think it's obvious that before they do that it's hard to talk about exchange at the level of Europe, at the European levels.

[00:13:35] [SPEAKER_00]: But each this is basically two things one is the ability of the data to follow the patient across borders for care and the other is the secondary use right so so the idea that research could benefit from having data put together.

[00:13:52] [SPEAKER_00]: I think it's these two are quite separate but both of them rely on having quality data at the level of the patient wherever he lives here she lives.

[00:14:01] [SPEAKER_00]: So I think we're never we're not close to that there is examples there are some examples of this being done 10, 15 years ago we were part of a project called Epsos which tried to do this initially.

[00:14:16] [SPEAKER_00]: A lot of good came from that but realistically I think in practice the Nordic countries were able to exchange prescriptions which was already a big benefit.

[00:14:26] [SPEAKER_00]: You also have to think about what are the use cases and some people say oh it's tourism it's medical tourism it's people moving around I think the priority should be to do this inside our regional country because that's where you get 95% of your care.

[00:14:42] [SPEAKER_00]: So unless you can do that then EHS is still a long way from being a reality.

[00:14:49] [SPEAKER_00]: But I think focusing on the region is what most countries are doing so we see this in the NHS with the 42 integrated care systems we see the same in the Nordic countries.

[00:15:02] [SPEAKER_00]: We see the same in Spain we see the same in France now and the idea is that basically except for acute care what is more and more important is chronic care and basically following the patient to where actually this care is given and it's outside of the hospital enlarge majority of cases.

[00:15:22] [SPEAKER_00]: So what this means is that you need to have basically consistent data across your health region and this is where we focus on now we have a lot of projects in the UK.

[00:15:33] [SPEAKER_00]: Obviously the projects in Catalonia and Wales in Slovenia are all at this level and the funny thing is it's almost always a unit of two to three million so that's how the ISSs are set up that's how in Slovenia the national level is set up.

[00:15:49] [SPEAKER_00]: We see that this is a unit of enough complexity but also not overly complex because what these big countries have found is that to do this in an in England or Germany or France is extremely difficult.

[00:16:05] [SPEAKER_00]: You might be able to do something at the document level like France has done or the NHS but basically to have a really high quality actionable structure data at the national level is incredibly hard.

[00:16:21] [SPEAKER_00]: So they started focusing on regions and the way they did this is what made I think the change possible and that if the money starts flowing to the region for them to give it to hospitals.

[00:16:32] [SPEAKER_00]: Because that gives them influence on what the hospitals buy and makes it much easier to exchange because they can say now you cannot have this application because it will not fit into our ecosystem.

[00:16:42] [SPEAKER_00]: So this is a big change obviously and we are seeing this happening in other countries obviously Catalonia is where head they're actually thinking even further ahead.

[00:16:52] [SPEAKER_00]: So their idea is to standardize data wherever it appears and then of course putting that data together is extremely easy.

[00:17:00] [SPEAKER_00]: The other countries are saying okay let's select a few applications and then try to unify that data through the use of exchange standards.

[00:17:11] [SPEAKER_00]: Of course if you can do the first one what Catalonia is doing that's the best because you have data for instance for medications in the same format across the country and you're very flexible as long as you have the legal right you can do many things or with that data.

[00:17:26] [SPEAKER_00]: But of course that also means rewriting applications by new applications which work in this way and this is going to take a lot of time.

[00:17:34] [SPEAKER_00]: But in other cases I think the big value of this legislation is the push for standards and the funding these two I think are going to be the biggest the biggest benefits from your peer legislation.

[00:17:47] [SPEAKER_02]: I always like to simplify things as much as possible so it's easier to understand and imagine them.

[00:17:55] [SPEAKER_02]: So if we take everything that you mentioned on an example say we have a hospital that has a legacy system and wants to modernize it or a country such as the Netherlands where there's huge discussions around how to connect regions.

[00:18:13] [SPEAKER_02]: How do they actually do that what do they focus on in terms of standards in terms of technology so how do they do it.

[00:18:23] [SPEAKER_00]: It was a difference between hospital and region but in a hospital especially in Europe you would there is no more greenfield so you would expect them to have any HR and a patient administration system at least.

[00:18:35] [SPEAKER_00]: So as I said initially that it's incredibly difficult to replace an HR almost impossible.

[00:18:43] [SPEAKER_00]: So what we are telling customers and what we see now being adopted in the market is that they have a new HR they have issues with flexibility they cannot add things they cannot get the data out.

[00:18:57] [SPEAKER_00]: They cannot build innovation so what they do is they put a platform next to that EHR and start developing the innovative applications on that and then somehow integrate with the old system.

[00:19:10] [SPEAKER_00]: One way to do that is to take the data out from that old system through HL7 or any exchange mechanism and then another thing which they're doing is they're pushing.

[00:19:20] [SPEAKER_00]: The forms developed on top of the innovation platform back into the HR so for the end user it looks like part of that application.

[00:19:29] [SPEAKER_00]: Not all applications can accept that mostly they can it's their standards on how to do that it's called context launch.

[00:19:36] [SPEAKER_00]: And this creates this whole many problems first of all local teams or smaller vendors can actually start participating bring innovation.

[00:19:45] [SPEAKER_00]: While the old system keeps the lights on for running the business side of hospital and then you can chip away at more and more functionality and this is not unique to healthcare if you think about what happened with the ER piecebase the enterprise resource planning.

[00:20:04] [SPEAKER_00]: Which predates the HRs by at least 10 years in the 90s we used to have this best of read approach which we would take the best possible application and then connect them all together into one system.

[00:20:17] [SPEAKER_00]: This created a lot of issues with integration or lack of integration or users having to use many applications so we got the megasuit.

[00:20:26] [SPEAKER_00]: Even think of that as SAP is the best example which is already all pre integrated and this is what the monolithic systems of today are.

[00:20:35] [SPEAKER_00]: But what is happening with these systems in the ER piecebase is that the marketing department decides to buy Salesforce even though they have CRM inside SAP.

[00:20:45] [SPEAKER_00]: Because it's easier to use it's more user friendly they can charge by number of users it's easy to enter into an agreement and sometimes the department has their own money so they start shrinking the core I call it time the megasuit.

[00:21:04] [SPEAKER_00]: And then somebody in HR says okay I want work day and somebody marketing says I want hotspot that's on.

[00:21:10] [SPEAKER_00]: So I believe the same thing is happening now in the HR space because there is no way a single company even if it's epic has a monopoly on innovation.

[00:21:20] [SPEAKER_00]: There are many innovations that need to happen and we need to find a way to augment the current ER with innovation and I think this by model or we call it post modern approach is the right way to go.

[00:21:34] [SPEAKER_00]: So this is the care provider.

[00:21:36] [SPEAKER_02]: But I just want to clarify one thing so we mentioned that a platform gets put on top of the existing systems next to it.

[00:21:45] [SPEAKER_02]: So can we just explain exactly that so what is a platform in this context because we are talking about a platform economy there's a lot of platforms out there it's a little bit of a buzzword.

[00:22:00] [SPEAKER_02]: So what types of platforms do we have in healthcare and what which one are you talking about so I'm talking about something we call a digital health platform.

[00:22:11] [SPEAKER_00]: So digital health platform is a term that was defined by gardener two years ago and it means software which has three layers so there's a data layer.

[00:22:20] [SPEAKER_00]: There's an application building layer meaning low code so something to help you quickly build applications and then there's a UX UI layer which is usually known as a portal.

[00:22:32] [SPEAKER_00]: So a portal tools to quickly build applications and a data layer that's what a platform digital health platform means.

[00:22:39] [SPEAKER_00]: So this is software that's quite a few vendors we are one of these vendors obviously we work with something called OpenEHR which is a format for structured health data.

[00:22:51] [SPEAKER_00]: We try to standardize the data from the beginning so the idea is why would different applications store data in a different format creating all these problems we're talking about when we talk about interoperability if they could all use the same format.

[00:23:08] [SPEAKER_00]: And we find that there's not really a technical reason for not using a common format it's usually business reasons vendors traditionally have tried to lock customers to their data models so that they would have a harder time replacing their software somebody else's.

[00:23:25] [SPEAKER_00]: Now of course this cannot benefit the customer this is actually a vendor issue and we see now a new generation of vendors will understand this and are trying to offer this and value of having open data to customers.

[00:23:37] [SPEAKER_00]: And as we see just recently two three last two three years this is really taking off.

[00:23:44] [SPEAKER_00]: Now if you look at it from original or a country level this is fantastic because if you can have data with applications from different vendors in the same format this creates a much easier path to interoperability in a region or a country.

[00:24:00] [SPEAKER_02]: Now one question what motivates vendors to actually take this approach because as you mentioned from the business perspective it's better to just lock customers in because it's going to be more efficient.

[00:24:15] [SPEAKER_00]: And that's short term thinking because obviously look for us as a small company we cannot compete with at the concern or on functionality.

[00:24:25] [SPEAKER_00]: What we can't compete with them anyway because we are too small but a vendor could compete by changing the model and convincing the customer that this is the model they want.

[00:24:34] [SPEAKER_00]: And that's what's happening we now have tenders at Carlinzca at in Catalonia demanding this model so obviously the market forces the vendors.

[00:24:44] [SPEAKER_00]: The fact that some vendors cannot compete at Carlinzca because they don't have open a char is a big problem.

[00:24:51] [SPEAKER_00]: The same in Catalonia the same now in Slovenia and so on as the market starts to demand this the vendors will adapt.

[00:24:58] [SPEAKER_00]: The other thing is in this happened with some of the earlier doctors is that like I said in the beginning they lost a tender against one of these big vendors and they saw they could not compete headhead with epic which is the biggest vendor.

[00:25:12] [SPEAKER_00]: So they tried to change the game and convince customers that this makes sense for them which it does.

[00:25:19] [SPEAKER_00]: So obviously the ultimate is market pull and I think it's the responsibility of the procurers.

[00:25:26] [SPEAKER_00]: So governments hospitals to think what's best for them and I think when you explain it it's quite obvious to them that it's fantastic if all the vendors have the same format so that I don't have issues of putting this data to.

[00:25:39] [SPEAKER_02]: We started this question by also mentioning the importance of design in healthcare in the platform you mentioned the UI layer that's important and this is really crucial for reducing the burden on clinicians to have to use this solutions.

[00:25:58] [SPEAKER_02]: However if we look if we go into hospitals and look at software a lot of it still looks like it was built in the 1990s.

[00:26:06] [SPEAKER_02]: And it's still continuing the development is still continuing. So how do you what are the trends actually when it comes to design in healthcare?

[00:26:19] [SPEAKER_02]: How do companies approach it, how did they make sure that the user experience is something that's at their forefront because at the end of the day it can also impact patient safety.

[00:26:31] [SPEAKER_02]: If your systems are too different the users might get confused.

[00:26:36] [SPEAKER_00]: Yeah, you have to understand that most of the HR software that we used to day came from billing systems.

[00:26:43] [SPEAKER_00]: Right revenue cycle management was the driving force because the business case was built around the fact that if you had an electronic health record you could actually charge for more services because you could identify them and build for them.

[00:26:56] [SPEAKER_00]: It's quite different UI for billing than it is for clinical users. So I think this was usually the next step in the evolution and unfortunately a lot of vendors just took the same approach.

[00:27:10] [SPEAKER_00]: So we are now seeing new vendors take design seriously because you're writing pointing out patient safety issues of course usability burnout all of these things but you do have to realize that as we tried to collect more quality structured data from clinicians we are putting a bigger burden on them.

[00:27:30] [SPEAKER_00]: So the only way to solve this problem is to collect data in different ways through a better design better UX new methods of collecting data either it's voice video so on devices obviously.

[00:27:42] [SPEAKER_00]: So everything needs to change and I believe design is crucial here because there's a big difference between well once there's a difference between a user and from experience in let's say telecoms or bank and clinical use what we found is because we worked in those industries as is usually in those institutions the boss can tell the users what they're going to use.

[00:28:10] [SPEAKER_00]: In health care a lot of times you have to convince the end user especially the powerful clinicians and sometimes they have the option of saying no I'm not going to use this and so.

[00:28:20] [SPEAKER_00]: I think that makes it even more important that you have design which which works which is a good user experience and of course don't forget that we are now getting an regeneration of clinicians who have lived.

[00:28:35] [SPEAKER_00]: In a different era and are used to using everything from mobile to online services to great UX they demand much more than the previous sets of users.

[00:28:44] [SPEAKER_02]: In public systems sometimes there's not enough funding to actually support all these desires what I can think when you were discussing the importance of design and having a good user experience was that we often don't talk about how the whole hospital architecture.

[00:29:04] [SPEAKER_02]: And the capabilities that they already have in fact the software so if you have old computers if the network is poor then the software might be great but it's still not going to work so as a vendor what are you most frustrated about when it comes to a healthcare software and what do you see or wish it would change in.

[00:29:28] [SPEAKER_02]: Say the next 10 years because sometimes the answer is better connectivity across the country and that's way a problem that's way beyond healthcare.

[00:29:38] [SPEAKER_00]: Yeah I'll give you an example so in with a few very users we have to support things like Internet Explorer 10 which is already end of life limited functionality we cannot move on with new applications and that's a real problem but there's nothing we can do.

[00:29:54] [SPEAKER_00]: So you're right healthcare traditionally has been underfunded on the digital front with these new fundings changes coming and obviously as.

[00:30:05] [SPEAKER_00]: The student makers see the value in digital they are willing to invest a little more but it's quite complex investment it's not just Wi-Fi it's everything from enough computers to new ways of collecting data device connectivity there it's quite a complex ecosystem which of course costs cost a lot of money.

[00:30:24] [SPEAKER_00]: So I would add another problem which I think is even bigger and that is lack of stuff to actually make sure that the implementation is done right we see this in many markets some are better than others you can it seems to be a little better than others they understand.

[00:30:41] [SPEAKER_00]: And the fact that about 50% of the success of the project is the implementation not to software itself so change management things like this and we are seeing improvements here but.

[00:30:54] [SPEAKER_00]: In some countries the system is understood and they expect the vendor to just install and configure and deal with the end users which is the wrong approach.

[00:31:03] [SPEAKER_00]: So I think having a big enough team and this is one of the advantages the big vendors have they can demand the big enough team on the customer side to make sure that the installation is successful and they have enough funding for that.

[00:31:17] [SPEAKER_00]: So smaller vendors are at disadvantage here because the funding for the whole project is usually not enough and of course it does not include all the upgrades of all the other systems which affect.

[00:31:31] [SPEAKER_00]: The efficiency of the software or the use of the solution.

[00:31:35] [SPEAKER_00]: I don't have a silver bullet here the good news is the prices of equipment are falling the it's becoming more and more powerful we can do a lot more on devices which we already have so bring your own device.

[00:31:47] [SPEAKER_00]: But I just think it needs very forward thinking CIOs to understand the whole and that's why some of them are successful and some of them are not.

[00:31:56] [SPEAKER_00]: We just had a situation in the NHS I won't name the trust or the ICS but they were defunded big time so have the team left because they saw they could not do any of the projects.

[00:32:08] [SPEAKER_00]: And the designers standard the CIO even asked why do we need all this digital if you have this type of an environment it's very hard and it's not going to succeed.

[00:32:18] [SPEAKER_00]: But that's just one example we have a lot more positive examples you mentioned Catalonia there's a lot of trust in the NHS even here in our calm country in Slovenia.

[00:32:27] [SPEAKER_00]: I think things are now moving most due to pressure from Europe and the funding that's coming.

[00:32:32] [SPEAKER_02]: Where do you see the role of AI in all these problems because at least theoretically speaking you could summarize a lot with AI you could use AI to help with standards so how do you see that this is going to impact the problems that we were discussing.

[00:32:55] [SPEAKER_00]: So this was another this was the second part of the discussions we had last week in in Barcelona.

[00:33:02] [SPEAKER_00]: There were two schools of thought one is oh we have to be very careful and the other is just do it and let's solve the problems when they arise.

[00:33:10] [SPEAKER_00]: So I think the way I look at is I separate three different domains for AI and healthcare one domain is how do you build better applications quicker.

[00:33:19] [SPEAKER_00]: This doesn't fall under in European regulation you can actually be much more efficient in building software and better software at that using a lot of the AI tools.

[00:33:31] [SPEAKER_00]: So here I think there is no debate you need to start using things like design to code things like helping us build solutions quicker testing solutions all of this stuff is not different than in other in any other industry.

[00:33:43] [SPEAKER_00]: The second part is efficiency of the care process so here I think it's perfectly doable today to improve patient flow to improve the way we make appointments to enhance the efficiency of the administrative workers and healthcare I think there's no issues there.

[00:34:03] [SPEAKER_00]: And there's no reason to hold back. Then we get to the clinical use where of course we have a lot of issues because it's many times part of clinical decision support and we have we get into all these issues whose responsible and all of these and here I don't have a good answer to be honest and neither the people we talk to but here we have these two two schools of thought I do think we need to test pilot and try.

[00:34:31] [SPEAKER_00]: Now whether we put it into full production with disclaimers and people still rely on that and what happens then it's not different than decision support from the past right.

[00:34:42] [SPEAKER_00]: Many people devised the right of all these things come into play and I don't think we have a idea how to solve these things but I do agree with the ones that say we shouldn't hold back you know.

[00:34:53] [SPEAKER_00]: I like in this sort of way I explain it to physicians mostly is one use case which is apparent to me is that when you go bowling with your child and you put up those side rails so that anybody even the child can throw the ball in and hit the pegs.

[00:35:10] [SPEAKER_00]: That's where I think AI is usable today to alert on things that could go wrong if physician makes a mistake.

[00:35:20] [SPEAKER_00]: Now whether it can set diagnosis and things like this that's another area, another expert so I would be afraid to do that.

[00:35:28] [SPEAKER_00]: The summarization is also not clear cut because what if you forget something in the summary.

[00:35:33] [SPEAKER_00]: So as long as you can test and prove that the summarization is 100% correct, you should be okay.

[00:35:41] [SPEAKER_00]: But we are now as a company in the process of doing just that but I think for instance not taking and to be called ambient voice recognition is a no brainer because it produces a document which the doctor would type anyway he can check for errors.

[00:35:56] [SPEAKER_00]: I would call more that efficiency it's not even clinical use it's efficiency and I see no no reason not to start immediately with that.

[00:36:06] [SPEAKER_02]: And a lot of course with the stuff like you as have already adopted that the whole with good results as I understand you know.

[00:36:14] [SPEAKER_00]: If you were into hospital and watch the amount of things that clinicians in administrative staff and nurses need to do, I think there's huge role for efficiency gain using new tools.

[00:36:25] [SPEAKER_00]: Just the process of scheduling appointments is a major hassle for both the patient and the administration.

[00:36:32] [SPEAKER_00]: And I think we can do a lot better there.

[00:36:35] [SPEAKER_00]: And of course better utilization resources is one of the ways, one of the few ways we have to improve weighting times and things like that and it's a big focus.

[00:36:44] [SPEAKER_00]: We all agreed at the conference we probably will not get the amount of people stuff that we will need.

[00:36:51] [SPEAKER_00]: So we need to be much smarter with existing resources.

[00:36:53] [SPEAKER_02]: And that refers also to the vendors because they have to run sustainable businesses and that's really difficult when you work with government, when you work with the NHS.

[00:37:05] [SPEAKER_02]: That has a specific times when the funding is available and it can take years for the results to come out.

[00:37:12] [SPEAKER_02]: Then somebody can object to the results and the whole process needs to be repeated so time flies.

[00:37:17] [SPEAKER_02]: How do you make sure that you are sustainable and what kind of changes do you see in business models that kind of are helping healthcare providers, healthcare vendors to survive?

[00:37:34] [SPEAKER_00]: Okay. I would say you have to make a big distinction between the new vendors, the startups and the smaller companies and existing established vendors because for the established vendors this is actually an advantage.

[00:37:47] [SPEAKER_00]: Because because of this problem it's incredibly hard to throw out a vendor.

[00:37:53] [SPEAKER_00]: So once you are in a trust you have unless you do something very wrong or cyber attacks are now one of those things.

[00:38:02] [SPEAKER_00]: It's extremely hard to replace a vendor and software in healthcare.

[00:38:07] [SPEAKER_00]: But of course that also means it's extremely hard to get in which is the problem for the smaller companies if you're talking about sustainability on their business.

[00:38:18] [SPEAKER_00]: We as a company are now on this, I would say breaking point where we have enough contracts that we can survive even if a large deal slips,

[00:38:27] [SPEAKER_00]: which three or four years ago is not the case. You are right, some deals take a very long time. The extreme examples 10 years.

[00:38:36] [SPEAKER_00]: You need to have a business that survives that and I would argue that the biggest problem is for the smaller innovative companies to get to that level of sustainability.

[00:38:46] [SPEAKER_00]: But once you're there I wouldn't say it's harder because it's harder for the newcomers, which has an established company, it makes it easier for you.

[00:38:56] [SPEAKER_00]: So it's a blessing and a curse. Once you get over that hump of having enough recurring revenue so that you can sustain the business, then I don't see such a big problem.

[00:39:07] [SPEAKER_00]: It's still much slower than other industries but this, like I said before, has its advantages.

[00:39:12] [SPEAKER_00]: But to get to that point isn't incredibly hard. That's why most startups fail.

[00:39:16] [SPEAKER_00]: And I would add another thing which makes things even worse is that most companies do not succeed in going across border with their solutions in health care IT.

[00:39:27] [SPEAKER_00]: Forget the multinationals that's a different story but the smaller companies really struggle because every one of these systems is different.

[00:39:36] [SPEAKER_00]: It's mostly public tendering, at least in Europe, which means that you need to have a lot of things in place to be able to even bid.

[00:39:44] [SPEAKER_00]: Now you can use partners which has its own problems. But I think what we hear from investors that is quite, I won't say unique but quite positive about our companies that we are in 25 markets with the same solution.

[00:40:00] [SPEAKER_00]: And as I hear this is quite rare.

[00:40:03] [SPEAKER_02]: So what's your advice to help your startups or companies that do want to scale? The do want to go to different markets? How can they do that successfully?

[00:40:13] [SPEAKER_02]: How did you do it when you first entered a new market? What's your kind of consistent recipe or ingredient?

[00:40:23] [SPEAKER_00]: To be honest, we didn't grow very fast. It's only the last few years that we're growing fast. Before we were growing quite slowly because of these issues that I mentioned.

[00:40:32] [SPEAKER_00]: So it came to our advantage that we went after a few markets and in each market we got some deals. So that altogether it would be sustainable. If we had focused just on one market, we probably wouldn't be in business today.

[00:40:45] [SPEAKER_00]: Now that said the UK is our largest market. It's about half of our business but it took three years to get the first customer.

[00:40:53] [SPEAKER_00]: And probably five, six years to become a sustainable business just this part. So there's no silver bullet. Obviously there's different types of markets even in healthcare.

[00:41:05] [SPEAKER_00]: You have the out of pocket which or the B2C as we call it which is a completely different market and it has the same dynamics than somewhere else in the world.

[00:41:16] [SPEAKER_00]: Of course we are in the B2B enterprise market which I don't know if there's any shortcuts. Of course you should find the right partner if you find any institution that is innovative and wants to share a little bit of the risk and pay you to develop for them.

[00:41:31] [SPEAKER_00]: That's all things you can do. But each country is completely different and some countries we struggle still today.

[00:41:37] [SPEAKER_00]: And then of course there's a lot of legwork and connecting the right people and finding if you have an innovative product it's obvious you have to find the early adopters or even the innovators as they call them.

[00:41:50] [SPEAKER_00]: And those might give you the initial funding but they will not be the same customers to go after in the mainstream as they call it. So you need to jump to that it's called the Casm by focusing on a small or on a focused market and do the best you can there and finding people who actually would like a solution like that.

[00:42:13] [SPEAKER_00]: I don't think there's any silver bullet you can use all this social media and everything but in the end you have to find these these first customers will trust you enough to take a little bit of risk.

[00:42:27] [SPEAKER_02]: It was again how do you build trust when you still don't have much to show.

[00:42:34] [SPEAKER_00]: The way we did it was first of all in 30 years we have never failed the project, right?

[00:42:39] [SPEAKER_00]: We actually haven't even lost a customer. Obviously you need to have this I would say almost culture of going above and beyond what the customer wants and actually solving their problem no matter what not looking at the contract because.

[00:42:52] [SPEAKER_00]: In public procurement it's a little bit different the contract is usually signed by somebody else was actually not going to use the software.

[00:42:59] [SPEAKER_00]: And there's not simple ROI mechanisms as they are in private business to show if something is working or not it's basically you have to actually make the user satisfied and that creates a lot of work.

[00:43:12] [SPEAKER_00]: So having these early adopters be extremely satisfied to share the because these people do talk to each other, right?

[00:43:19] [SPEAKER_00]: So we have some really good advocates of our company in several key institutions now in Europe and we can use them as a reference.

[00:43:28] [SPEAKER_00]: And that's extremely important because you have to realize that healthcare is riskabverse. So we're dealing with serious problems here solutions have to be as we say they must do no harm which is not easy with software there's a lot of things that can go wrong.

[00:43:43] [SPEAKER_00]: So you actually need people who are willing to take a little bit of risk as customers.

[00:43:50] [SPEAKER_00]: Now when you get over that it's a different story. Of course you need to have all the integrations you need to have all the documentation partnerships support for different devices all of that to make it a compelling offering but initially.

[00:44:03] [SPEAKER_00]: You need to offer something different which has to be better than what was there before. And you actually need to have to find that one usually the best is a clinical champion and you know they can see value in this that's your starting point.

[00:44:22] [SPEAKER_02]: What's your biggest challenge as a company?

[00:44:24] [SPEAKER_00]: There's two things I think. One is how to grow the company and keep this same culture that I think helps us a lot.

[00:44:32] [SPEAKER_00]: And we will need to grow fast because we see a lot of opportunity now.

[00:44:36] [SPEAKER_00]: I was talking initially about seeing a void in the market for good solutions.

[00:44:41] [SPEAKER_00]: The CEO is telling us they do not know what to buy because of the lack of appropriate solutions on the market.

[00:44:47] [SPEAKER_00]: And the other one is cyber security. As we move to cloud I think this is a real threat not just for the customers but for companies as well.

[00:44:57] [SPEAKER_00]: We have seen examples of companies going under because of cyber attacks.

[00:45:01] [SPEAKER_00]: So I think these two are the biggest ones. I'm not worried about are we on the right track are we providing enough value all of that I believe we are but we need to grow the team quickly and that's never easy and we do need to figure out or to constantly be a vigilant for cyber attacks.

[00:45:25] [SPEAKER_02]: As a CEO and as somebody that needs to set the direction of what the company is going to invest its resources in that requires knowing what's happening on the market and what's trends are currently seen in healthcare.

[00:45:40] [SPEAKER_02]: So what are you most excited about and how do you see that healthcare?

[00:45:45] [SPEAKER_02]: Let's limit ourselves to Europe is going to develop in say next five to ten years.

[00:45:51] [SPEAKER_00]: Healthcare or healthcare IT.

[00:45:54] [SPEAKER_02]: That's an interesting one.

[00:45:55] [SPEAKER_00]: Yeah it is because I don't believe that they have to go hand in hand obviously if you move the healthcare IT faster and healthcare isn't catching up.

[00:46:05] [SPEAKER_00]: I think it's underutilized if you do the opposite.

[00:46:08] [SPEAKER_00]: I think we always ask governments do have a health IT strategy and then they will always say I but we don't have a health strategy so how do we do health IT strategy so it.

[00:46:18] [SPEAKER_00]: Obviously they're intertwined but what I see is some of the stuff we talked about so moving the focus of care to closer to the patient in some cases to the home but to the GP to outside of the hospital which are mostly for acute patients.

[00:46:35] [SPEAKER_00]: Then the second one which actually comes from this first one is care coordination.

[00:46:42] [SPEAKER_00]: I think there's a lot of opportunity to coordinate care as soon as it's outside of the hospitals in most cases it's not coordinated so this is the key and then the third one is to enable those two I think to focus on the data because.

[00:46:56] [SPEAKER_00]: In healthcare data is different than in other industries so if you think about just the issue of security which we talked about before.

[00:47:05] [SPEAKER_00]: If somebody steals your bank account data you open a new bank account.

[00:47:09] [SPEAKER_00]: If somebody steals your genomic data that's it, you cannot change it.

[00:47:13] [SPEAKER_00]: This is one aspect the other aspect is the longevity of data right you would like to have data from cradle to grave.

[00:47:19] [SPEAKER_00]: This creates all kinds of problems for applications because none of them will last at long so if I think about and obviously that's our mission is to help solve these problems through data and to gather this data we need to build new applications quickly which brings us into local and then of course.

[00:47:39] [SPEAKER_00]: To have them be used by users we need to provide excellent UX so it's all connecting to this idea of having the same data across a region country sometimes maybe sometimes maybe Europe even though that's still a long way off.

[00:47:55] [SPEAKER_00]: But not having these issues when you try to make a consistent care record to get a full picture of patient state where you have to go out and get data from all different places which is totally semantic link or here and it's really hard to.

[00:48:10] [SPEAKER_00]: So I think yeah the focus on data, care collaboration or coordination and actually moving or following the movement of care which is now moving outside of the hospital.

[00:48:21] [SPEAKER_02]: In essence a better user experience for the clinicians, for patients and in essence also for governments.

[00:48:30] [SPEAKER_02]: Thank you so much for taking the time today and sharing your perspective on the development of health care and health care.

[00:48:36] [SPEAKER_00]: Thank you. Thank you for having us.

[00:48:39] [SPEAKER_01]: You will listening to faces of digital health, a proud member of the health podcast network.

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