International HIT Perspectives: In Spain, Healthcare IT Leaders Nurture Creativity—Out of Necessity

March 20, 2018
Healthcare IT leaders in Spain continue to move forward along a number of dimensions, in a healthcare system that remains short on cash, but which facilitates advanced interoperability--and decades-long experience with population health

This is the first in a series of articles highlighting developments taking place in healthcare IT within the Spanish healthcare system.

 The Hospital Universitario Puerta de Hierro Majadahonda, located in the upscale northwestern Madrid suburb of Majadahonda, is as modern as any in Spain. A 613-bed academic medical center with 3,000 professionals, it has been ranked in the top 10 hospitals in Spain by reputation. Furthermore, it has achieved Stage 6 recognition by HIMSS Analytics (the division of the Chicago-based Healthcare Information and Management Systems Society), whose EMRAM model for the adoption of electronic health record (EHR) technology has been applied both in the United States and internationally. The hospital has a high-availability, EHR (from the local Spanish software company Selene—which had been acquired by Siemens, and is now part of Cerner), with full barcoded meds administration. A major impediment to its reaching HIMSS Analytics Stage 7? Like most Spanish hospitals, Puerta de Hierro does not package single-dose medications, a Stage 7 requirement. That smallish fact, like so many others, speaks to differences in European and American hospital organization and culture.

Still, like a number of other major academic hospitals in Spain, Puerta de Hierro is one that is showing the way to a more technologically advanced future, says Juan Luis Cruz Bermúdez, whose Spanish title is “Coordinador, Unidad de Tecnologías de la Información y las Comunicaciones, Instituto de Investigación Sanitaria”—meaning that he is the IT director in the clinical research division of the hospital. He is also acting CISO for the hospital, and its former CIO.

Providing this foreign journalist with a comprehensive tour of the hospital’s operations, including IT operations last November, Cruz Bermúdez was quick to point out that some of the differences between the U.S. and Spanish healthcare systems reflect policy and strategic priorities, while others reflect financial issues and concerns. “As you’ll hear so often said here,” Cruz Bermúdez says, “we are underfunded for information technology, and need to use rely a lot on imagination” in order to fully serve hospitals’ communities. In Spain, as in the U.S., healthcare represents a high cost for the national governments of both nations; in Spain, though, hospital budgets can yo-yo up and down to some extent, depending on the priorities of the government in power at the time, in a parliamentary system in which parties can shift into and out of power relatively quickly.

Still, the Spanish healthcare system has done some things that make it more advanced than the U.S. healthcare system overall in certain very specific contexts, one of them being population health. Dr. Rosa Capilla Pueyo, the ED coordinator at Puerta de Hierro Majadahonda, notes that what in the U.S. has emerged as population health in the past several years, has been practiced, at the primary care level, in Spain, for over 40 years, as a matter of course. That is not surprising, given that spending constraints at the national level have meant a strong emphasis on managing care upstream. Indeed, Dr. Capilla Pueyo, a primary care physician who manages a special program for managing geriatric patients, including those with dementia who are in assisted living and long-term care institutions, to prevent extended hospital stays, reduce length of stay, and enhance health status, notes that, “By 2050, more than 27 percent of Europeans will be over 70 years old. That will be catastrophic. In Spain, population health management has been around for 40 or more years, and is simply called public health.”

Still, even with population health management programs that are advanced by U.S. standards, Spanish clinical leaders face some perhaps-universal issues. “One of the problems,” Dr. Capilla Pueyo says, is cultural, in terms of the population. It’s hard to educate people not to automatically use the emergency room. We need to engage in some very efficient triaging, and strong case management.” In that context, she and her colleagues are leveraging data and IT to support the ongoing development and expansion of algorithms and clinical pathways for managing such issues as COPD (chronic obstructive pulmonary disease), congestive heart failure (CHF), urinary tract infections, and diabetic ketoacidosis. “It is important for clinicians to follow these guidelines or pathways, both to improve patient outcomes and health status, and also to lower costs, in a government-run health system,” she notes.

Meanwhile, a program that Dr. Capilla Pueyo is leading, called “UAPI"—which stands for “La Unidad de Atencion al Paciente Institucionalizado,” or Inpatient Care Management Program—has averted 1,743 inpatient admissions in the past 12 months, through intensive care management of at-risk patients. It has also reduced the average length of stay of patients being care-managed in the program.

What’s more, other IT- and data-facilitated innovations are taking place in various departments and areas at Puerta de Hierro. Among them: the development of a consumer-facing app that is helping more than 1,500 cancer patients better participate in their care. Dr. Mariano Provencio, Cruz Bermúdez, and Consuelo Parejo, an engineer, have been leading this development effort. The app was created in late 2015. As Consuelo Parejo explains “OncoApp,” “It begins to guide the patient to manage his or her own symptoms. The patient can share his or her symptoms with the app, and the app will recommend actions, for example, to come to the hospital or take medicine. Or call the oncology department on the phone. It’s new in oncology in Spain.” And it represents, she says, “a more intelligent system.” That system will soon be making use of artificial intelligence. What’s more, she says, “We can follow you in your home, in your life, with wearables, etc.” The app has also been useful in that it provides for integrated appointment-making by patients, as well as the ability to send information campaigns to users regarding their profiles (such as info about clinical trials recruitment).

Built-in interoperability advantages in a single-payer system

One thing is certain: self-development and working within rigorous financial limitations are essential in Spanish healthcare IT. A small number of international electronic health record (EHR) vendors, most notably including the Kansas City-based Cerner Corporation, are active in Spain; but the majority of Spanish hospitals are relatively underfunded in terms of being able to afford international-level EHR information technology, everyone this journalist spoke with, agreed.

Still, within those limitations, there are numerous opportunities for operational innovation. Antonio García García, CIO at the Hospital Infantil Universitario Niño Jesús, a pediatric teaching hospital located on the busy Avenida Menéndez Pelayo, right across from the famous Parque del Buen Retiro (Retiro Park), says that the reality is that hospital IT leaders in Spain need to work as creatively and judiciously as possible. “We certainly can’t afford Cerner,” he says, referring to that vendor’s EHR, though he concedes that it would provide an advantage to be able to do so. Instead, the Niño Jesús Hospital self-developed its EHR, which García García says is working very well. What’s more, he has been able to achieve integration between the hospital’s EHR and its PACS (picture archiving and communications system), and García García is leading his team forward on further integration of clinical and other systems. “We operate on very small budgets here,” García García says, of the financial parameters set for hospitals in Spain. “But we’re able to achieve a lot on relatively small budgets.

One key advantage that Spanish healthcare IT leaders have over healthcare IT leaders in the US is a very fundamental one having to do with the two countries’ vastly different policy and payment landscapes. The Spanish healthcare system, like those of most western European nations, is strongly dominated by its government-financed, government-operated healthcare system. There is a small private sector of privately owned hospitals and medical clinics, which, like the private provider sector in the United Kingdom, acts to some extent as a safety valve on demand, allowing patients who don’t want to wait for elective procedures and other forms of non-urgent care, to access care more quickly—but it is relatively small, and even that system is connected to the government-run system.

And partly because of that, Spanish CIOs and other healthcare IT leaders are blessed with the advantages of a low level of bureaucracy, in terms of a single large payer, and also with the existence of a national patient identifier. Indeed, Spanish healthcare leaders are routinely astonished to learn that a national patient identifier does not exist in the United States. Having that national patient identifier means that a patient’s record is easily identifiable and discernable as unique, across the nation, making referrals and other forms of information-sharing extremely easy, compared within the U.S.

What’s more, as the OECD (Organization for Economic Cooperation and Development) stated in 2014, Spain spent 9.4 percent of its gross domestic product (GDP) on healthcare in 2011, compared to the United States’ 16.9 percent. Spain’s percentage of expenditure on healthcare was right in line with the expenditures of fellow western European countries Sweden (9.5 percent), Portugal (9.4 percent), Slovenia (9.4 percent), and Norway (9.3 percent), and exactly average among OECD countries (9.3 percent); but lower than those of the Netherlands (11.8 percent), France (11.6 percent), Switzerland (11.4 percent), Germany (11.3 percent), and Denmark (11.1 percent). Of course, even second-place Netherlands, at 11.8 percent, is far below the United States, at 16.9 percent; and of course, as the Medicare actuaries reported, the United States’ proportion of GDP spent on healthcare already reached 17.9 percent in 2016, and is headed towards a mind-boggling 19.7 percent by 2026—leaving the European nations far behind in relative spending.

In that context, it is interesting to read a portion of a transcript of an interview that took place on July 9, 2017, on National Public Radio’s “Weekend Edition program. American journalist Lauren Frayer told program host A Martinez about her experience with the Spanish healthcare system. As Frayer recounted it, “[A]s a legal resident of Spain, I'm entitled to coverage through a public health system there, taxpayer-funded health care for everyone. You pay a bit for prescriptions. But when I say a bit, I mean $2. No co-pays for doctor visits or specialists or anything. And on top of that public health care, I choose to buy private health insurance, through which I can find, if I want, an English-speaking doctor, get certain preventative care that might not be covered by the public system.”

Asked about her experience with the system, Frayer stated that “[I]t’s no frills. I mean, the hospitals are pretty rudimentary. You might not get a private room. But the care is of very high quality. Spain does, you know, interestingly enough, the most organ transplants of any country in the world.” What’s more, she noted, “[A]s an American being in the European health care system, what strikes me as strange—there's no money transactions. You know, there's no cash register in any hospital or doctor office here. This system is a little bit more analog, you could say. Only recently in Spain could you make specialist appointments through—in the public health care system by telephone. I've had to line up in the hospital basement with slips of paper. These are doctor referrals to make appointments with specialists. But you do get the appointments… [I]f you have something serious, you can see a doctor the next day. If you want to go to the dermatologist and, you know, have some moles checked out, for example, have some kind of non-urgent preventative care, in the public system, you might have to wait a month or two or even more.” In addition, she notes, “Doctors and nurses in Spain are sort of mid-range civil servants. Keep in mind the average salary in Spain is about $1,800 a month. Doctors make slightly more than that. But they are not millionaires usually. Anecdotally, I know a cardiologist who - you know, her salary is less than mine. I'm a freelance journalist. She recently started doing botox treatments on the side to supplement her income because that's much more lucrative for her. There are a lot of Spanish nurses and doctors who come here to the United Kingdom because the pay is better. And so Britain's National Health Service is a very diverse health service from - you know, there are workers from all over Europe working here.”

Francisco (Paco) Perez, president of HL7 España, sees all of this in a broad international context. “We continue to face financial challenges in terms of investment in healthcare IT,” Perez says; “at the same time, there is a great deal of ingenuity here, and we have a level of interoperability in our system that is very high.” What’s more, Perez notes, Spanish healthcare IT leaders are involved in numerous international healthcare IT organizations and conferences, and are very aware of developments across Europe and in North America. Spanish healthcare IT, he says, is not isolated from developments in other healthcare systems and countries.

That fact is underscored not only by the fact that some Spanish health system CIOs, among them Cruz Bermúdez and García García, have begun to seek credentialing by organizations like the Ann Arbor, Mich.-based CHIME (College of Healthcare Information Management Executives), which a few years ago modified its CHCIO certification program to allow European healthcare IT leaders to become certified. For example, European CIOS and other healthcare IT leaders have no need to learn the details of the meaningful use program or other U.S.-specific regulatory and policy requirements; but they are required to demonstrate an understanding of broad healthcare IT principles and knowledge.

Meanwhile, it remains to be seen what might happen with regard to the HIMSS Analytics EMRAM requirements around single-dose medication barcoding, for Stage 7 certification. In any case, what is clear is that Spanish healthcare IT leaders want their patient care organizations to achieve international-level recognition for their IT development and advancements. And what’s clear is that Spanish healthcare IT leaders, like their colleagues across western Europe, are continuing to press forward to improve their facilitation of the highest levels of patient care quality and availability.

In the next article in this series: Catalonia moves forward at the regional healthcare authority level.