Wouter De Ploey is the CEO of hospital network ZNA in the Belgian region of Antwerp. The network consists of 9 sites, employing 6,000 people and 600 doctors who take care of 5,000 patients a day.
We need to optimize the intermediate level of care, further reducing expensive hospital capacity and creating intermediate capacity in a way that it benefits everyone
in this interview, Wouter De Ploey talks about the role of hospital networks, the importance of electronic patient and health records, technology in healthcare facilities and the hospital sector in Belgium, with some hurdles standing in the way of a more distributed care approach.
Mr. De Ploey is convinced that ultimately technology will play a role in a radically rethinking of we manage a hospital in the future. However, that transformation won’t happen as fast than some would like to see since digital transformation in healthcare overall is slower in Belgium.
Moreover, there is still a lot of work concerning the essence (where, among others, electronic health record systems come in) and without having that essence right you can’t dramatically transform Wouter De Ploey says. This doesn’t mean that ZNA isn’t innovating or leveraging new technologies, well on the contrary.
Several changes which are needed to increase the quality of care and reduce the costs of healthcare require more initiatives, not in the least on the level of social security and healthcare insurance systems. For Wouter De Ploey an intermediate level of care is necessary and there is room to reduce the number of beds if the proper incentives are there. This intermediate level of care today is too expensive and it’s among others here that the current healthcare insurance and social security system stands in the way of change. This interview is part of a series at the occasion of the 5th Conference on Digital Health 2019.
The role of hospital networks: from critical scale and joint investments to a common information system
Wouter De Ploey, thank you for your time. Creating hospital networks was a program of previous governments and most likely will be on the agenda again. ZNA (ZiekenhuisNetwerk Antwerpen) already is a group as such, in fact the largest in Belgium. End 2016, ZNA and another group, GZA (Gasthuis Zusters Antwerpen), decided to start collaborating. Can you tell us more about this collaboration and what you aim to achieve?
Wouter De Ploey: 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.
One 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
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.
One of the ambitions is to have a common information system, something that is still a challenge for many Belgian hospitals?
Wouter De Ploey: 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 missed the opportunity in Belgium to go for one core EMR solution that all hospitals would adopt and on which they could then build additional functionality and allow for some differentiation
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.
EHR/EMR systems and the challenge of working around the care process
How do information exchanges happen today, for instance with first-line care providers and with hospitals outside of the network(s).
Wouter De Ploey: A part is still done with paper. You send letters to, for example, the primary care physician of a patient who was treated in the hospital with the diagnostics and the conclusions.
However, there are standards in the market that allow to develop an integrated file on a person by pulling data from different systems but that could use some improvement going forward. One could say that we missed the opportunity in Belgium to go for one core solution that all hospitals would adopt and on which they could then build additional functionality and allow for some differentiation. So, instead we have multiple suppliers of EMR systems in the market which we’re now trying to connect by having standards of information exchange between these different systems.
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 compliance and liability reasons (Wouter De Ploey)
General practitioners who have their own applications can pull from these hospital systems thanks to the existence of the mentioned standards and formats of information.
Interoperability of EHR/EMR systems has been an issue globally, in some regions user satisfaction is low with complaints on levels such as the data exchange possibilities, ease of use with slow systems and time-consuming text field operations etc. One of the other comments is that the systems are too focused on administration, billing etc. and not designed around the journey of the patient or the treatments.
Wouter De Ploey: 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.
The balance between hospital collaboration and competition as an innovation and improvement trigger
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?
Wouter De Ploey: 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.
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
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.
So, you are concerned that if everything is focused on networks and collaboration there might be no drive for people and hospitals to do better which in turn might lead to a deterioration of innovation and perhaps even care?
Wouter De Ploey: Exactly. Imagine that you would have one radiology unit for the city of Antwerp where everyone would have to go to get their scans etc.
What is the incentive for that center to perform in terms of new machines they could buy, better opening hours, deeper specialization by individual doctors and so forth?
When you have two radiology centers in the same city, however, that incentive is there and that’s why we need to make sure that somehow, we don’t remove all competition through the creation of networks.
Optimizing the length of stays in hospitals
As Frank Dendas from Philips said, care is too important to be managed based on economics alone but in order to keep care affordable for as many people as possible, we need to look at it as a business. And business means competition as well. 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. 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?
Wouter De Ploey: 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.
We’re moving towards a mix of approaches that is cheaper and more efficient and we’re not forcing people to stay longer in hospitals, well on the contrary. When the number of beds reduces, the number of ambulatory visits increases
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 one 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.
How the hospital sector can improve care and reduce costs according to Wouter De Ploey
One of the other speakers at the event, Leonard Witkamp, 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?
Wouter De Ploey: 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.
Telemedicine and similar approaches will create opportunities regarding the improvement and effectiveness of care, rather than dramatically change the hospital sector now
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. An example to illustrate what I mean: if you have a hospital with one cardiologist who sees a few patients a day versus a cardiological center in a major city where you have 20 cardiologists working together, in the second location you will have more efficient interventions, better quality and therefore less rework, etc. That will reduce the bill for the healthcare system as well. So, combining forces to create more critical sized units with better skills in my view is also a way that we will save money for the social security 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.
The challenges in realizing an intermediate level in a distributed care delivery model
That intermediate level seems like an issue. In mental healthcare, for instance, you have the possibility to seek a therapist and when things go bad hospitalization might be needed. A few hospitals have these small centers where people can stay for a short while and here and there you have intermediate levels but not many indeed and their capacity is quite low. What’s the challenge in realizing this intermediate level of care? Who should organize it?
Wouter De Ploey: That’s an important question: who should organize this indeed. Our psychiatry unit tries to collaborate a lot with people outside the hospitals in the neighborhoods, for instance in homes where people can stay after their hospital treatments and are taken care for by people who live with them together.
You need to create a financing of care hotels but here people get a little nervous of course because when you do that on a massive scale and rapidly the adjustments that need to be made in hospitals are gigantic
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’.
A matter of the repayment system, so government and politics but also healthcare insurance companies who say ‘we already pay so much, we can’t afford to pay this as well’?
Wouter De Ploey: Exactly. Irrespective of the brand, I have an insurance which fully pays me back my hospital room but what’s my incentive to move onto a care hotel after acute care when it’s not paid by the social security system and the insurer says it’s far too expensive for them to take up the entire costs of those care hotels. This means that something is wrong in the system that needs to be addressed.
And the only way to change this is when these insurers must pay less in other areas, for instance for the expensive hospital beds and if this doesn’t change, we are stuck. So probably we don’t have to expect a sudden massive change even if in the end things will change?
Wouter De Ploey: Indeed. It’s where the question regarding who is going to organize this comes back. Essentially you need to create a financing of these care hotels. But here people get a little nervous of course because when you do that on a massive scale and rapidly the adjustments that need to be made in hospitals are gigantic.
Imagine you would set up a care hotel here in Antwerp with somewhere between 200 or 300 beds and enter the coverage of stays in the social security system so they get paid back to a large extent as is the case with hospital beds: many patients would move out of the hospitals into these care hotels. The result would be an overcapacity in the hospital network system, and it takes time to reduce this capacity.
That’s the challenge with transformations in the organization of the healthcare system and especially the hospital system: you need to do it at the right pace and avoid that if you do it too fast one of the hospitals gets in financial distress
However, if you do it too slow, nothing changes since the incentives aren’t corrected. That’s where policy makers need to show leadership and set out a roadmap with what they want to realize by when in what regard so all stakeholders can properly prepare.
Digital transformation of hospitals: getting the essence right before radically transforming once the maturity level to do so is reached
Transformation of the system is perhaps rather slow now. What about digital transformation and innovation? There are quite some technologies on various levels, including that of hospitals, enabling them to save costs on things like maintenance and energy consumption or time through the location of hospital assets and so forth. As a former CIO you know all these solutions. Are you investing in any of them or using newer technologies in other areas?
Wouter De Ploey: 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. So, there are nuggets of innovation whereby individual services increase their own efficiency and effectiveness.
A lot of the initiatives as we see them in the hospital sector in Belgium overall are more about automation and digitization and less about transformation
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. Going through an accreditation process that also looks at the maintenance of equipment and stocks we noticed that we have around 40,000 pieces of equipment that need maintenance so automating this is a clear win.
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.
And we all aspire to have this situation whereby the process and transmission of data and information works very smoothly. However, that rethinking of the system is still going to take some time because we don’t have the core automation and patient filing systems in place yet.
Innovation to solve urgent challenges with a selective pilot approach
In a press release that was sent regarding the event, the city of Antwerp stated that Antwerp is an eHealth innovation hub, among others with its facilities and presence of researchers, innovation centers and so forth. Do you actively engage with this community?
In September we start tests with drones for the transportation of medical pharmaceuticals and of samples to overcome one of the challenges the city faces: traffic jams because of important infrastructure works
Wouter De Ploey: We conduct many conversations now and I expect this to increase. Compared to a year ago the number of conversations already increased a lot and we are looking to understand what these people are developing, what their intended audience is, what functions they enable and what the leverage is on the system.
And there are areas where we started to join forces with some. One example is the introduction of drones to facilitate the transportation of medical pharmaceuticals and of samples. The tests will start in September and the main goal is to see if flying these pharmaceuticals and samples from the rooftop of one hospital to another can help us overcome one of the challenges the city faces: traffic jams because of important infrastructure works, known as the Oosterweelverbinding.
So, we talk to a lot of the innovators, exchange ideas and then very selectively, like with the drones, sign up to be part of pilot groups to test something out.
The shortage of staff will drive the need to automate
What other challenges and solutions do you see for the future in hospitals?
Wouter De Ploey: We see a significant problem ahead in recruiting enough nurses and medical nurses to do all the work out there. To give you one statistic: for every ten nurses that retire, seven are graduating from nursing school.
In our hospital we have a running list of open positions for about 150 to 200 people. That creates a short-term problem whereby the lack of enough staff forces us to close certain capacities.
However, on the mid- to long-term, this situation will accelerate the drive to automate several processes so we can do the same amount of work or even more work with less people because the people are just not going to be there. I think that the shortage in the labor markets will drive automation and innovation.
The opportunities for technology in future hospitals according to Wouter De Ploey
With the automation of processes, you’re probably thinking more about things like robotic process automation or do you also consider using robots or cobots for routine tasks, to take care of the laundry for instance?
Wouter De Ploey: For the new hospital which we’re building in Antwerp we initially planned to use automated guided vehicles that would do the logistics within the hospital, such as laundry transport and handling, moving food up and down the floors etc.
In the end we didn’t do it because nobody was capable to give me a live example of a hospital that was running with such a park of automated guide vehicles. So, there isn’t a single hospital in the world where I’ve seen it – or at, least heard that it’s being used. This would otherwise have been a system that, if properly functioning, could help increase productivity quite significantly.
Would you say there is perhaps a bit too much hype regarding some technologies that could have an important impact? In fact, where do you see the main opportunities for technology in future hospitals?
Wouter De Ploey: 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.
Technology will creep in in all kinds of disciplines to improve the medical side of the equation. When it comes to running the hotel – because you can look at a hospital as being a hotel – technology will have a less dramatic impact in the next few years
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.
That’s clear. So, first automation and the essence, transformation and more impactful innovation in later stages. Thank you for your time!
Profile Wouter De Ploey
End 2015 Wouter de Ploey was appointed as new CEO of ZNA by the Board of Directors of the hospital network.
He succeeded Bruno Holthof, who had managed to build up a solid financial basis for ZNA, the largest health organization in Belgium, that was heavily loss-making when he came in. De Ploey also served as interim CFO and CIO at ZNA for some time.
Wouter De Ploey previously worked as management consultant and senior partner in the Business Technology Office of McKinsey & Company, that focuses on ICT issues. He joined McKinsey in 1992 and specialized in the financial sector.
Wouter De Ploey is also a member of the Board of Directors of BNP Paribas and VanBreda Risk & Benefits.
Next interview: mHealth expert Valerie Storms