Integration Along the Value Chain – Redesigning Care Around the Patient

Tobias Koesters:
Welcome everyone. I think we have an amazing panel today. I'll start with a quick overview of the topic at hand. Care delivery is often designed around how systems want to deal with the patient, and that has grown historically over time, and not necessarily around the patient's needs. From the point of view of an integrated provider or patient, you could almost say these existing pathways or care models are broken. Hospitals and many systems remain too often the gatekeepers to a system, and I think we are in a world now where we understand that that shouldn't be that way. And many hospitals are also investing in outpatient facilities to capture the patient early on.

It's essentially a lose-lose situation and I have amazing panelists today that are changing these pathways, that are redesigning the pathways, and that will talk a lot around it. We have many investors in the room and many of your businesses are investor-backed and they are paving the way to change this value chain integration. And just to point towards a few of these providers. Now the slides are... Yeah, we have an amazing panel participation also of this group. We have Henrik from Ramsay Santé, we have Stefano from Humanitas, we have Fady and we have Clemens and they're all going to share their views how REGINA MARIA, how GIG, how Ramsay Santé and Humanitas is changing this pathway, and demonstrating case studies how was done against almost all odds of the systems. And I'm looking forward to the sessions, and I'm passing on now the clicker to Stefano who's going to start with the Italian view of it.

Stefano Bison:
Thank you very much. Thank you, Tobias. Thank you all. Bonjour. I'm an outsider to the sector. I've been in the group for one year only. I come from twenty-plus years of financial services and I'll try to give you a bit my and Humanitas view around why. And you said it, so I will mention you, why the healthcare delivery is broken.

Before we start, just very quickly for those of you not knowing us, Humanitas is the leading Italian teacher research hospital. We have research, we have a university, 11 hospitals. We are the first one in terms of size by revenue in the private healthcare market, and we now have 22 medical care, which is the business I manage. So our outpatient operations that are growing very fast.

Just to give you a few KPIs on top of what's already in the slide, and around 20% CAGR over the last four years, organic growth. So it's a sort of a startup entering the maturity phase 350,000 unique patients served every year, 1,000 visits... Sorry, 1 million visits, and 1,000 clinical doctors operating in our facilities. 52% of which are structurally part of Humanitas group.

So this is the first interesting part of the business I run. We are thoroughly integrated with the hospitals and with the rest of the group. So we try to build around the clinical excellence of Humanitas Hospital. And then not just deliver the standard accessibility last-mile care and diagnostic to the market, but we try to build in hub-and-spoke model, a system that brings the best of the clinical excellence of Humanitas that has been for three years in a row the best hospital in Italy to the community.

The underlying idea is to move away from the hospital centricity that was the history and the excellence of the group, towards a more patient-centered and community-based care. How we going to do it? We are building of course a bigger network. We're going to double it in the next three years through selective and profitable growth. So it's a mix of greenfield, brownfield, and M&A. We are building around, let's say, our already excellent customer experience but we're trying to continuously ameliorate and follow what are the customer needs around the patient experience both on the digital and on the phygital side. We're a strong believer or the phygital approach, and we believe it's sort of in the brand that human will be at the center of the care delivery.

And then topic of today, we are building innovative patient-centered care pathways. How we are doing that? We are sort of putting, once again the brand is suggesting it, we are putting the patient at the center. And I would say also our internal customer, which is the clinician, at the center of this redesign of pathways.

We already have a program up and running on psychology, we call it psychocare. We are now in these days a new one around gastroenterology, and I'll be elaborating in a second. But then we are building other pathways around obesity and overweight management, sleep disturbances, pain, ortho and rehab, women's health. We are studying one on longevity. Of course you must have a longevity offer at some point in these markets, and potentially also ophthalmology.

But this is just, let's say, to say the way we are approaching the pathway. So how we are prioritizing them, I would say based on epidemiology. So it's strongly data-driven. So why gastro, for example, of which I will be speaking in a second? Because 40% of people suffer from in Italy from one or another gastrointestinal issue. 50% of those are functional, so it's severely impacting their lifestyles. And less than half of those, actually one third tries to have an access to cure.

How we're going to do that? Once again we need to sort of change the paradigm of current care models which are siloed and very fragmented, bringing to low patient experiences and low adherence to cures. So in the end they're not delivering the quality and not really solving customer problems. To a model that is multidisciplinary. So we force different specialist with specific privileges to work together in a cluster model. Oftentimes we make them sit together in the same centers and we are specializing some of the centers to have all the potential answers to the patient problems at the same time. So this is factor number one.

Factor number two is creating this continuity of care. We've seen it yesterday, many panels and presentations. The pathways are broken and they have many blocks and, let's say, breaking points. We are trying to create this continuity thanks to a continuous administrative support. So for the moment we are building secretaries, basically, that are helping the customer follow the plan. In the future we will implement also of course automation and AI.

And last but not least, it needs to be comprehensive. So how we make the comprehensive care and we address all the issues that you see here in the slide? We integrate the medical care therapy with daily counseling. So we are building a team of, and we already have many actually, of nutritionists and psychologists that work aside the clinical doctors so that they can build the correct answer to the patient problems. So this is our way of looking at integration.

Tobias Koesters:
Very impressive, Stefano, and some very encouraging outcomes. I think we'll come back to a couple of those items with questions. I may pass over to Henrik to talk about how Ramsay Santé implemented your approach.

Henrik Brehmer:
Hello everyone, and thank you so much for having me. Ramsay Santé is, what you see on the slide here is the mix of our service lines in our five countries of operation, and you can see it's fairly diversed along the value chain or the patient pathway. We are really, embarked a journey a couple of years back where we wanted to really build our own ecosystem in the countries where we are, and we are gradually doing that along the patient pathway.

So the word integration is really important to us where we try to serve the patient, not just in a transactional care, coming and going out and never see you again, but building loyalty and relationship even before the patient becomes a patient. So that is what we really try to achieve in our countries. You can say that in France, we are fairly hospital focused, inpatient business. In the Nordic countries and Italy, it's more of an outpatient kind of setting.

Going one step further, this is a few examples, how we build service offerings, taking care of the patient along the patient pathway. So in the prevention area we do a lot of digital contacts, health advice and stuff like that. Monitoring of chronical ill patient and so forth. A lot of use of digital functionality.

Primary care, we now investing in primary care in all our countries of operation. The last one is France, building up a structure where we add on to our network of hospitals in our clusters in France. In the hospital setting, we are doing a lot of outpatient and day care business here in France. Being hospital focused, I think it's important to really drive the outpatient side of the business. We have in Sweden introduced in one of our hospitals an AI tool for mammography, which is also published in the Lancet years ago, where we have driven productivity up to 50%, moving out one radiologist from screening the imaging. And the AI is very accurate and we are further building on that.

At home growing for us. We do a lot of advanced home care where we follow the patient from hospitalization back home, and a lot of remote monitoring too. Then obviously we build a lot on integration with digital tools. I will talk about that just in a minute, and we are obviously a lot focused on the medical quality outcomes.

So here is an example how the people actually, or the patient really enter our ecosystem, whether the digital front door, but we also go further in the value chain in order to drive referrals between our different care settings. So we do referrals both digital and physical. So we really try to leverage the fact that the patient can go in a digi-physical care setting. And what you see here is that we have, I think it says yes, 60% of the bookings within Capio's own sort of settings. Which means that we keep the patient in our ecosystem and can follow the patient, and that is good not only for us but mostly for the patient to have this continuity of care.

Finally, this is an example of what we do with the digital service. We have built a platform, and this is a Swedish example where the patient can enter in all our care centers proximity care center that is, have a digital access for patients and they can access and answer questions, do their [inaudible 00:13:26], and then get access digitally, or physically for that matter. And when the care centers are closed, we move them digitally into a sort of national digital service where they get advice or treated. And if they need physical care, they are booked in Monday morning at the care center.

This is a very effective and seamless patient pathways for our patients. And we are also now starting to integrate the secondary care side of things, where you can actually transfer the patient to digitally into a secondary care treatment from the proximity care.

And, finally, to say that in the primary care setting, you don't have physical access to all the expertise that you might need, but this system does also allow us to invite, let's say, a cardiologist and an orthopedic surgeon or any other specialties into a patient interaction in order to expand on the competencies and advice around the patient.

So we are on a journey, we are continuing to build, and I think we have done good so far, but there is lot more to do when it comes to digital services. It's huge potential.

Tobias Koesters:
Thank you, Henrik. Moving on further south and east again to Fady, who built with his team an amazing proposition to the Romanian payer but also to the Romanian patient. Over to you.

Fady Chreih:
Thank you, and good morning to everybody. So let me just... Yeah. So we are the largest leading healthcare provider in Romania and also the leading healthcare provider in Serbia, operating under MediGroup as a brand in Serbia, REGINA MARIA in Romania.

I will talk a little bit about our digital assets, but first just one slide about who we are. We are an integrated healthcare provider. We started, what Stefano was saying, that they started with hospitals and now they're developing their outpatient network. We started actually the other way around. We started with our outpatient network and building up the infrastructure for hospitals. And now we operate roughly, in both countries, we are roughly 14,000 people in hundreds of locations and having more than 5 million visits every year in Romania. And our organic growth is very similar to your organic growth in both countries.

I think what is most important, and I will start my presentation with asking the audience one question. Can you tell me how many of you have already a healthcare app that enables patients to look at their electronic medical record and do bookings? Can you just raise your hands? Okay. So someone not me asked this thing at HBI I think four or five years ago and there were three people in the audience, now we are more, that have done that. And I think and I do encourage everybody to look at that. I think it's extremely valuable and it really pays off. It's a big headache, but I think it really pays off.

And I'll just go to what we do, and I think just this is an effect, I would say, and not a cause. This is how our patients recognize our service and brand. And the red part, if you look, it's REGINA MARIA, the other colors are our competitors. We are in a privately paid setting quite a lot. So our mindset is very focused on getting patients and convincing patients as a brand powerhouse. And it shows, again, we think truly about our digital assets that helped us a lot getting to these numbers.

And what we do, we've been doing for quite a lot of years, a digital pathway. So we worked together with a lot of medical teams, management teams, finance teams, marketing teams on what does it mean integrating healthcare and how we create value. And the most important question that we asked as a team was how can we empower patients, and let patients do a lot of stuff and not tell them what to do? And everybody's talking about empowering patients and everybody's talking about putting patients in their center of activities and so on. But at the end of the day, very few of hospital operators or integrated operators are really doing that.

So we structured in three parts what we can do for medical integration, what we can do for the operations, and what we can do on IT because there were other presentations about IT legacy systems, cybersecurity, privacy and so on. So we structured this digital pathways, and we said how are we going to construct our digital assets? So we went through all these many years ago we looked at what is our wish list, what is our North star, what others are doing in US or in Europe, and we started our own pathway.

So where are we right now? We are right now at 62% of all our interactions and you've seen that we do more than 5 million per year. 62% of them have an electronic referral. So that means that we can really capture what doctors are suggesting as treatments, as follow-ups to patients in 62% of all our interactions. Even more than that, 56% of our patients are not having a transactional relationship with us. We consider a transactional relationship, they come for a blood test or for a consultation, and then they go out of the system or they go somewhere else.

So we track also from the consultation, from the diagnostic, if there is a referral, how many of them are coming back, how many of them are using our services. And we are trying through patient pathways, trying to match their needs with also the capabilities of our network to offer that need in their location, in their city or in their region.

And what we consider, we established, to be honest, from other sectors, retail sectors that if you have more than three other segments, so segments for us, meaning how we are internally organized, so labs, imaging, hospitals, outpatient and so on, if you have more than three of products accessed, that means that we've done something right and we are right now at almost 30% of our whole patients are using more than that, which is great. We are working on that quite a lot.

And the only thing that I will show, I'm going to end my presentation, is all the digital infrastructure. Our key one is related to our healthcare app, which is in our region, the most downloaded app both on Google and Apple Store. And when I say that, it's a living organism that we invest quite a lot in significant CapEx, I would say, but we are now in the millions of bookings, millions of downloads, and we've reached the limit where 48% of our appointments are done completely by the patients.

So we don't interact, they are doing it by themselves. They are watching, they are talking with us, they are doing their own appointments. And our focus is very, very much on how can we empower patients to handle their own care, of course with our digital pathways done behind the scenes, but trying to get as much as feedback as possible from our patients. Thank you.

Tobias Koesters:
Thank you, Fady. It's really amazing how you're shaping the Romanian healthcare system and how patients interact with the providers. Now passing on to Clemens, who obviously is, has to tear down some walls in an existing healthcare system in Germany, which are very siloed and, yeah, look forward to see how you're doing it.

Clemens Guth:
Yeah. Yeah. Good morning and thank you for having me. I'm going to cover the rest of Europe now, or pitch in with Germany. GIG, we are an outpatient provider focused on internal medicine. And basically the challenges we face in Germany are probably quite similar to other countries in that it's very siloed. And obviously healthcare has always been thought of as from the delivery side but, yes, of course we should think about the patient because where does the value get created? It's the medical condition of the patient that we treat.

And Germany is special in that there's a massive overcapacity of hospital care. There's no other country in the western world that has as many hospital beds than Germany, and there's a lot of service being delivered in hospitals that in every other country is being done as an outpatient service. And the outpatient service in Germany, again, is hyperfragmented. So most of the physician work in a single practice. And while that worked many, many years ago, that's now difficult. Medicine become too complex for a single doctor to serve a patient fully.

Also, the German outpatient model is based on self-employment. So it's all the Baby Boomers that work 50, 60 hours a week serving these patients, and the newer generation just doesn't want to follow that model. Care is increasing, our demand is increasing and the overall result is, while Germany spends a lot on it, 13% of GDP, it's just not sustainable in terms of cost, patients are reasonably unhappy, and worst of all, outcomes are average. Now, if you were to say if we spend a lot of money and get great outcomes, that would be, okay, fair enough, it's a decision to take. But to spend a lot of money and to get average outcome, work needs to be done.

And that's where we pitch in. What we are trying to do is shift care into the outpatient setting. And what is needed in our mind is obviously integrated approach. It is not going to be the single doctor in a single practice that's going to treat the patients, and we've seen great examples of how care should be integrated, and that's what we're trying to do with our group. The challenge there is trying to... How do you get people work together? You need to get people a co-located, it's easier to work together if you're nearby. It's easier to work together if you have a common IT infrastructure and backbone and ways to exchange data and medical knowledge. And that's what we're trying to do within the group, within the practices.

Also, the model of self-employment is probably very unique to Germany, that most of the doctors then are managers and physicians, and they'd much rather be physicians rather than managers. So a lot of people seek employment, and it makes total sense because obviously the division of labor, we can do better doing the admin side, and we can free up the doctors actually serving the patient. And that's where AI and technology and all these things come into play, and that's what we're trying to build up in the group. It's a very strong centralized service where we help the doctors focus on the actual clinical care rather than the admin side.

And all of this, in my mind, is the only way to solve the German healthcare crisis. It's way too expensive and way too costly. Most hospitals, the hospital sector is chronically underfunded. And not only do we have too many, and too many inpatients, but we are also competing for the same staff. So wouldn't it be better to move it into the outpatient setting and it'll be more convenient for the patients, it's more cost-efficient and outcomes are better, and for the overall system, I think that will have a great benefit.

The way we think about it and... We started with cardiology being the mother of internal medicine, and we group all the other internal medicine around it because internal medicine provides about for 30% of all hospital admissions. And compared to other countries, we could probably save on half of them. And that's what we do, and that's the network we're building obviously with services along the value chain of the patients, be it the lab or be it the telemedicine. And where we at today is 55 locations, 175 doctors. We're not quite at your size yet, but it's working well, and I truly believe that's the way forward to solve the German healthcare crisis. Thank you.

Tobias Koesters:
Clemens. Great. Thank you to the panelist for a short overview of how you are integrating your pathways. We're going to open up now to the audience to raise questions. We have microphones in the room, so whoever wants to go first, raise your hand and ask any questions around this topic to the panelists, if there are no questions to start with, I can maybe start, and have prepared some questions. And you can think about a couple of questions, but, Adrienne, do want to go first?

Speaker 6:
Thank you to all the panelists for really interesting presentations. We've been talking about integrated care pathways for many, many years, decades even. Could the panelists comment on why we haven't made more progress quicker? How can we really accelerate through this?

Tobias Koesters:
Go first, Henrik.

Henrik Brehmer:
I think the way you design the patient pathway and still it's just, as mentioned, in silos and by speciality and you don't look across the patient pathway. I think that is sort of an attitude that the industry have had. The other thing is the explosion of technology now, which can really support the patient pathway to make things easier both for the patient and the service offering. The access not only the first way as I mentioned or the first contact but also further along the patient pathway. And combining these digi-physical pathways is really powerful. So I think technology will drive more and more of these more coherent patient pathways, but it's obviously up to the industry and to us and others to be brave and take this on.

Stefano Bison:
Can I integrate quickly? I don't know if I'm the best position to talk since I'm in the sector only since a year, but maybe exactly because of that, I developed my feelings about this topic. The sector and I think this is something we all in the room need to admit is lagging very much behind other sectors in terms of digitalization. So I very welcome what has been just said.

We are waiting for this wave to hit. And funny enough, I've done 10 years in banking and 10 years in insurance, and every time I move sector I say this last sector is 10 years behind the previous one. So given that banking is not exactly yet at Amazon level, this gives us more or less where we stand. Of course you need to have a pathway or many pathways that are longitudinal. Now we call them longitudinal. And the problem here is in absence of digitalization and of continuous data exchange between the different facilities and the different operators taking care of the customer or the patient, as we say. It's very difficult.

And the second thing is that I think is being said in another panel this morning, it's very much a change management issue because there's human in the loop patient, they want to see a person and when you have a person taking care, all the digitalization is much more difficult. And all the orchestration of the pathway, actually all the burden of the orchestration is left to the patient.

Typically, it's not the clinician taking care of it. The clinician is sending you the, at best, the medical record and then he disappears, and the patient is left with the burden of orchestrating the care pathway. So no surprise that then adherence is lower than 50% because you forget you don't do the medication, you don't do the follow-up visit, et cetera, et cetera. So I think a lot has to be done together with clinicians.

So that's also part of the paradigm shift I was mentioning before, we need to work with the clinicians, that they want to do. And I totally agree, the clinicians and not the managers, and take off a part of the administrative burden on their side, and at the same time do the same with the patients.

Clemens Guth:
If I can add to this historic being a medic myself, the training in itself is very siloed. You produce a lot of doctors coming out of the system that think in these categories, cardiology, gastroenterology, oncology, and the training needs to change. We need to have positive examples. Obviously, digitalization can be huge accelerator. On top of it, you have all sorts of entrenched stakeholder interest, a highly regulated system. And to top it all, often a reimbursement system that favors doing things in your silo and doing a lot of volume.

Now, it's more than often showed, and Germany is a prime example for this, consuming more healthcare doesn't mean better healthcare. Just because you go to the doctor more often than other people doesn't mean you're healthier. What should really matter is outcomes, clinical outcomes. And of course we can produce better clinical outcomes working together, but there needs to be something in it for everybody. And if the incentives are misaligned, keeping you in the hospital and you get three, 4,000 euros for it versus having you in the out setting for a hundred euros. Now, some people may be inclined to keep them in the hospital. But it's changing.

Stefano Bison:
And just super quickly on incentives because I think it's really a matter of incentives here to doctors especially, because if we keep incentivizing them in their own silos on the specific pathology, nobody's really taking care of the person as a person, no? And so, all the burden in this case of administering the different pieces that will need to go together, other healthcare professionals such as psychologists or nutritionist to solve the patient need, because that's customer centricity, solving the patient need, solving the patient problem, it's on us administrative staff, no? So it's like giving incentives between patient, the administrative staff running operations, and the doctors are not aligned at all.

Fady Chreih:
For us, if I can answer a little bit different to your question, I think we see patient pathways very well done in some areas, like breast cancer, IVF, ophthalmology, we've seen them all over Europe, US and so on, very well executed. Where is the pain? The pain is on the finance system. There is no incentive to do patient care integration of that because you are paid transactionally. You are paying transactionally doctors, so there is no need for integrated healthcare.

We run a value-based healthcare so we run subscriptions. We have subscriptions more than 1 million people who are subscribed to us. So we are highly incentivized financially, and not only financially and also clinically, to take very well care of a certain large population. So we have a financial incentive, let's say, as an organization to look at patient pathways. So I think to your question why we are so slow, as long as the payment system follow the money. If the payment system is not changed, things are not going to change so easily.

Tobias Koesters:
Yeah, I mean it's interesting that you say why are we so slow. I think what you created in Romania is actually moving in light speed in healthcare services terms, and you obviously had the opportunity and you didn't need to break as many barriers as in more developed systems. For example in Germany, which I know best. But I think it's truly amazing to see how you can disrupt and you can be disrupters versus existing other systems if you have that wide-space opportunity and if you're truly, truly innovative.

Fady Chreih:
But even if you have that, you still have the challenges that everybody had said here on doctors for instance, making them working together, or on great doctors who have long lists of patients that they don't need to work with anyone because anyway they are the star or the superstars of a country. So why bother, at the end of the day? So you are trying, as you said, through management, through administrative and so on to look at these patient pathways and try to do a change management of optics, which is very hard after you've been trained 25 years or how many years that you are just there to treat a certain thing.

And the issue is, going back to your question, I think the issue that we all have in healthcare right now is even deeper because it's a catch-up on integrating. But now patients want from us personalized healthcare. Everybody's talking now about, "I want personalized healthcare, genetics. I want a doctor who understands more broader my healthcare issues, preventive care, not disease care." So I think it's another catch up that now everybody I think is trying to play in the next 10 years.

Tobias Koesters:
Thank you very much. Any additional questions from the audience? The front.

Speaker 7:
Thank you. Thank you to all the panelists. Question about integration along the value chain. It seems like you've all opted for a very integrated model at the end. Is it possible to do the same through cooperation between different players? So it's the path that you've chosen, but is it possible?

Tobias Koesters:
Who wants to help start?

Fady Chreih:
I can.

Tobias Koesters:
Fady, do you integrate other providers?

Fady Chreih:
Yes. So, for instance, I'll give you a very quick example. We do a lot of oncology, chemo surgery, consultations, diagnostic post, pre. We were not doing radiotherapy or nuclear medicine, and we have partnered up with three players who are doing that. They are part of the medical boards, tumor boards. We do seamlessly patient pathways. We have a contact there, we do the appointments for our patients to them and so on.

We decided this year to enter that as well. There are benefits of controlling the quality, clinical quality and so on once it's under your roof. But we see also the benefits of incubating an idea with partners as well as long, and I go back, as long as the incentives are aligned. And for us, for me, it was very clear that if you align financial incentives then everybody's aligned. If you are not aligning financial incentives, no matter how people will say that they really care about patients, at the end of the day they will track financials.

Tobias Koesters:
Clemens, Henrik, Stefano, any other examples where you integrate other providers where you collaborate?

Clemens Guth:
I think the same goes for us. I don't think you can nor do you need the whole value chain, and we work very closely with hospitals and on the slide says 10 plus we probably have even more where we have same medical standards, we're financially aligned. Some of our staff work part-time there, they work part-time with us, and that works very well. As long as you've got the same goal and the same information basis, that's totally works.

Stefano Bison:
Just to quickly add on this, so the short answer is, yes, it's definitely possible. I fully sponsor Fady that you need to have financial incentives aligned and the clinical incentives, I would say. And this is the reason why we don't because given that our North Star is quality, we want to have full control. So we'd rather lose a bit of opportunities but be fully integrated in the value chain and keep short of everything in house. My fear is that even if you align incentives, then aligning clinical quality when working with a partner can be tricky, and of course you lose a bit of control.

Tobias Koesters:
Question there in the back. Can we have a mic please? Can you just raise your hand again?

Speaker 8:
Hello? I have a question for Mr. Fady. Thank you. I've actually been a user of your chain in the past and I've used your app, and I was curious if patients are also interested in the interactive tools, like self-diagnosis or telemedicine, or they're strictly interested in checking up their patient file, their results, and they strictly use it when they have a need? Are you interested in making the app more usable from a day-to-day basis, or just using it for consulting and only strictly checking their results? That's my question.

Fady Chreih:
Thank you for that question. Very good question. So in the life of an app, the number one question that you ask yourself, how much do you want the app to be used on your phone? Because we all know we have a lot of apps on our phones that are not being used. And how often does a healthcare app should be used? Nobody knows the answer. I mean, if anybody knows it, it'll be great. We tried in US to the... We decided that it's very expensive for us as an operator to start doing APIs with all the wearables and we decided that due there are so many wearables from Aura to different winners or losers on the wearable market that we are not going to integrate them because we said it will be a late entrant on this market due to cost.

So we are very much focused on making sure that patients are getting access not only to their electronic medical record, not only to their lab test, not only to appointment booking, to telemedicine, we have more than 2 million now per year telemedicine consultations.

But also what we are doing now, we are doing a lot of patient pathways where we are trying to help them with pop-ups and different things, and it's working very well. We've implemented it last year. Where if you went to a doctor, you have a referral to some lab test or imaging, you just receive a notification of saying, "Hey, you have this lab test. Would you like to schedule an appointment, or you have already done it outside of the network?" So we are not invasive but we are trying to help them.

So this is completely done... What we were doing with nurses or people, now we are doing it through the app. So this is our focus and this is how we want to do it. The most researched thing on our app is info about doctors. Also on our website, also on our app. Because we have 3,600 doctors in Romania, people are looking at, in a city we might have 100 gynecologist. So ladies are going to look at, "Okay, what's the difference between the 100 gynecologists? How should I choose one?" So there is a lot of looking at doctors. So, I hope I answered your question.

Tobias Koesters:
Very much. Any final question from the audience? In the back. I think we have one minute to answer them. Yeah.

Speaker 9:
I'm just interested, given that we're in quite a risk averse industry, if not very risk averse industry, from a change management point of view for changing pathways, changing behavior of doctor, what has some of the biggest challenges that you've done and any tips as we all try to make changes in this risk averse industry?

Tobias Koesters:
Thank you. I think, Clemens, as a medical doctor, do you want to answer that?

Clemens Guth:
And thank God they're risk averse, or we are risk averse, because it's the life of our patients that we're dealing with. So I think it's communication, sitting the right people together, doing small pilot and obviously feedback loops. So I don't think there's more magic to it than that. It's getting people along on this road and the journey and aligning them on the same kind of North Star has worked really well for us. But their doctors want to be heard.

Henrik Brehmer:
If I just can build on that.

Tobias Koesters:
Sure.

Henrik Brehmer:
I think for sure that's the way. I mean, you need to involve people and I don't think one should underestimate the power of change management when you digitize your patient pathway or use other terms of technology. If you don't have a plan and you really know what to change, don't invest a penny in digital functionality because then people will continue to work the way they were always done. So involving people in the way you want to change working procedures and all those things and give them the why, to bring people to work with it and tell the why. That, I think, is a very, very important thing that we are working a lot with when it comes to changing the way we work with the patient and our staff in order to benefit from what technology actually gives us.

Stefano Bison:
Telegraphically. If I can echo, it's in this sector, you don't sell the opportunity, this is what I learned, but you sell the reason why. To echo what has been said, you need to change it. So sell the issue and not the opportunity, because with the opportunity you're not going to move a lot of people. Everybody's too scared of changing.

Tobias Koesters:
Thank you very much. Thank you to the audience, and apologies to the ophthalmology panel who's two minutes we now stole,, but thank you to the panelists-

Stefano Bison:
Thank you.

Tobias Koesters:
... for the good discussion and [inaudible 00:45:43].

Clemens Guth:
Thank you.