Welcome to our third speaker interview at the occasion of the 5th Conference on Digital Health 2019. Keynote speaker Wouter De Ploey, CEO of ZiekenhuisNetwerk Antwerpen, talks about his views on technology and transformation in the hospital sector.

Wouter De Ploey, the CEO of of ZiekenhuisNetwerk Antwerpen (ZNA) runs a hospital network with 9 sites and 6,000 employees that is amid integration talks with another hospital network in the Antwerp region.

He believes that technology will play a role in radically rethinking how we manage a hospital in the future too. However, that transformation will happen slower than some would like to see. There is still a lot of work concerning the essence he says.

At our event Mr. De Ploey, among others, focuses on the case of electronic patient records and the role of hospital networks in digital transformation.

The role of hospital networks

The Belgian government wants to create hospital networks. End 2016, ZNA and another group, GZA, decided to start collaborating. Can you tell us more?

Our initiative started before the government came up with this new model of developing networks of hospitals in Belgium. So, we were a bit ahead and the ambition level is slightly different.

I think that the network idea of the government is still one of independent hospitals that collaborate on a contractual basis with each other whereas our goal in the end is almost a full integration over time.

We’re testing out different ways of collaborating such as combining services to get more critical scale for competences that can be developed, obviously joint procurement to save on the procurement cost side, joint investments etc. In other words: the logical goals one wants to achieve when joining forces with another party.

Electronic patient records: the missed opportunity in Belgium

One of the ambitions is to have a common information system, something that is still a challenge for many Belgian hospitals?

Indeed. GZA has a system in place that’s no longer supported by the suppliers, so they need a new system and we basically have a fragmented landscape. In some of our sites we have one system, in others another system and in some everything is still paper-based. So, we quickly agreed we would do a joint procurement process to decide on which electronic patient system we would work.

We developed the RFP together, evaluated the possible candidates and we now have a few suppliers left in the running. If we pick one the idea is to develop one instance of the application on which both hospitals would run so we’re not just selecting the same software package, but we would have one solution in place on which both hospital groups would work and that would obviously be a strong foundation for integrating services in the future.

Interoperability of EHR/EMR systems has been an issue globally, in some regions user satisfaction is low. One often heard comment is that the systems are focused on administration, billing etc. and not designed around the journey of the patient or the treatments.

That’s true. When hospitals are deciding on which applications to take, often you see a process that is steered by finance and procurement who mostly have their objectives and there is also a tendency to collect all the information that is needed to defend the hospital in case of liabilities.

So, there is a compliance aspect that can’t be overlooked and is part of the reasons why such systems often are more a controlling system than a system that is geared toward supporting the care process itself.

Hospitals are documenting every step that is taken, not only because that supports the doctors and the patients in their care process but also because they want to collect all that information for these compliance and liability reasons.

Optimizing the hospital sector

In a recent article you pointed out that there was very little talk about competition in the current discussions on the transformation of healthcare delivery in Belgium with this focus on hospital networks. Why did you feel it was important to remind this?

Historically, in almost every middle-sized and certainly every large city you had two or more hospitals competing and competition in the end means trying to attract patients through a better infrastructure, better reputation, better specialists, investments in the latest technologies, you name it.

Now the government asks these hospitals to join forces in a network to combine their activities and to decide where they want to offer which services in this integrated and collaborative way. De facto this means that the competition between hospitals as we knew it is reduced. This might be perfectly fine because with hospital networks you move the competition to another level than that of individual hospitals and can build the critical scale which you need to develop the services needed in the future on a network level.

Still, I observe that, whereas in the past people were so much in favor of the competitive model, nowadays competition is almost labeled as something bad while collaborative networks are perceived as the ultimate dream.

What I wanted to point out is that we need to make sure that somewhere in the system incentives remain to compete with networks to stimulate the innovation that inevitably comes out of this competitiveness.

At the same time hospitals are asked to downsize, there is a move towards a more distributed model with, for instance, ambulatory care and care closer to the patient, also to reduce costs. How do you see the role of hospitals here as the population is aging, there are more chronic diseases and, overall, healthcare costs are on the rise?

There are definitely opportunities for efficiency gains in the hospital system that are not about making people work harder than they already do but rather because technology does change and because the views on how long people should stay in the hospital for care are changing and, among others enabled by technology.

In Denmark, a hip replacement for instance is a matter of day hospitalization: you enter the hospital in the morning, by lunchtime you have a new hip and by the end of the day you’re sent home with all the instructions of how to manage pain and other recommendations. If you need a hip replacement in Belgium, that still means a few days in the hospital.

So, there’s certainly an opportunity to optimize the length of stay in our hospitals which often means a reduction of that length as has been happening for some time now. That enables you to reduce the bed capacity of the sector and the numbers clearly show that when the number of beds reduces, the number of ambulatory visits increases.

We’re indeed moving towards a mix of approaches here that is cheaper and more efficient and we’re not forcing people to stay longer in hospitals. Well on the contrary: we’re giving incentives to people to go home early enough so that this efficiency gain will happen. I think that from the government perspective on of the objectives in organizing the move to hospital networks is a rationalization of bed capacity, which is maybe a bit easier to organize on the level of a network than trying to do it alone as a hospital.

The different ways hospitals can reduce costs and the need for an intermediate care level

One of the other speakers at the event says that hospitals are too expensive to be sustainable and sees more opportunities in technology-driven remote care approaches whereby the role of healthcare professionals changes in the scope of this more distributed care model. What are your views on such approaches on better quality care and in reducing costs? Are they the way to go or do you see other ways to make gains?

Personally, I don’t think that telemedicine and similar approaches will dramatically change the hospital sector now. I believe they will rather create opportunities regarding the improvement and effectiveness of care.

As an example, take an image that was taken through an MRI of patient who might have cancer in one of his organs. If one expert looks at it and he can easily send the image over to another expert, they might come to a better diagnostic by collaborating compared to someone always having to do it alone. So, quality of care is where telemedicine and other technologies can really help a lot in my view. The reduction of costs is more related to what I just described: the reduction of the length of stay in beds and thus of beds.

A second way to enhance quality and save costs is the creation of larger units of experts which then become more efficient in their medical activities with better quality outcomes and therefore a less expensive system.

On top of the reduction of the length of stay and this creation of larger expert units, a third thing we need to do is increase the capacity of systems which are less expensive outside the hospitals.

A hospital bed is an expensive place to keep a patient, so you want to move them out. However, it’s not always obvious that they can immediately go home.

And thus, the intermediate level of care is something we need to optimize, further reducing the expensive hospital capacity but creating this intermediate capacity in a way that it benefits everyone. For me those are the levers in terms of where we could realize benefits, save costs and gain overall.

In intermediate forms of care in general you have what we call care hotels which are put next to an acute hospital and where you have less infrastructure, less medical staff, less nurses but still some supervision. The rooms in these care hotels are cheaper to run and I believe they will be a good environment to take care of people on the intermediate level.

The reason why this isn’t done more and doesn’t work yet is quite silly: for a patient in Belgium it might be cheaper to stay in an expensive hospital bed than in such care hotels where intrinsic costs are lower. And that has everything to do with the social security system that pays the costs of a hospital stay but not of care hotels. So, we need to change some of these wrong incentives that come with the current repayment system. That’s a first element.

Secondly, as a hospital it’s sometimes difficult to see who is working outside the hospitals on a day-to-day basis with patients at their homes or in different places. To get all this coordinated you need resources and right now all actors in the sector are looking at each other but there is no real initiative to say ‘okay, let’s organize, connect and orchestrate all this’.

Digitally transforming hospitals in Belgium: where we are and go

What about digital transformation and innovation? Are you investing in any of them or using newer technologies in other areas?

At this moment the investment in many innovations isn’t made yet because we need that uniform electronic patient system first. It’s the foundation that has the data and supports the processes and thus the basic layer of what you need to have. So, that’s the first step, for this year.

Most of the innovation in the network today comes out of certain units with their own systems. We have, for instance, innovative applications and solutions in areas such as emergency services and cardiology.

We’re also investing in the automation of inventory management and maintenance management since this is something you can do without the electronic patient file system and the business case is clear.

Now, I will be very frank and open: it’s true that a lot of these initiatives as we see them in the hospital sector in Belgium overall are more about automation and digitization and less about transformation.

The sector is behind when compared with, for instance, the financial services industry and a lot is about putting in place those automated processes where there are still manual interventions, rather than radical innovation. So, essentially the hospital sector is now mainly doing what others have done.

You’ll see across the sector that everyone is on one hand implementing electronic patient file systems and on the other looking at how to automate certain processes. Yet, it’s essential to do this because without having the essence right you can’t transform.

Once there’s a certain level of maturity, you will get more investments in the usage of technology in radically rethinking how we manage a hospital in the future.

The dream is obviously one of a fully integrated process around the patient that starts from the moment the first symptoms are noticed, through the consultation of a general practitioner for a first diagnosis and a possible referral to a specialist to a potential surgery, stay in the hospital, post-care stage and so forth.

The main opportunities for technology in hospitals

Where do you see the main opportunities for technology in future hospitals?

 In running the hospitals there is still a lot of old-fashioned technology in the infrastructure that can help us to innovate whereby it’s a matter of creating the right incentives for everyone to move ahead.

However, I think that where technology plays a key role that will continue to become more important all the time is in better diagnostics and then we’re talking about the example I gave before regarding radiology where people can share files and do joint assessments of what’s happening to a patient.

Technology will creep in in all kinds of disciplines to improve the medical side of the equation, meaning having a good diagnostic, better care, effective care, etc. That’s where technology will play an increasing role and really change things.

When it comes to running the hotel – because you can look at a hospital as being a hotel – and in running the labs, the supply chains, etc. technology will have a less dramatic impact in the next few years, because as said we still must realize the basic and important things.

Read the full interview with Wouter De Ploey