Pediatric ophthalmologist Dr. Joan Prat Bartomeu had been mulling over the fact that children with misaligned eyes — a condition called strabismus — are often misdiagnosed. It’s a mistake that frequently leads to less-effective surgical interventions, which in turn necessitate follow-on procedures that hugely inflate the costs of the condition, not to mention the impact on the children and their families. Prat knew the misdiagnosis problem had a simple cause: Clinicians lacked a good way to objectively measure the extent of the eye misalignment. Was there a high-tech solution?
Luckily, Prat works at a hospital that’s based in a top-notch ecosystem of med-tech innovation, and he was able to tap into a wealth of resources to support his quest to develop a diagnosis aid. The result was a helmet-mounted laser and camera measurement system capable of automatically catching clear signs of the disorder. With help from his hospital’s innovation department, Prat co-founded a company called BcnInnova to manufacture the device, called GazeLab. Direct sales launched in May of 2013, and the helmet is now in use at pediatric hospitals around the world.
Another day at the Stanford Medical Center in California’s Silicon Valley, or maybe one of the Harvard-affiliated hospitals around high-tech-heavy Boston? Actually, Prat’s hospital, Sant Joan de Déu, is based in Barcelona, the urban hub of the Catalonia region of Spain. Like its American regional counterparts, Catalonia has developed a healthcare community dense with world-class medicine and readily available capital. There’s also plenty of entrepreneurial enthusiasm and expertise ready to serve physicians, life-science researchers and engineers who hope to develop healthcare innovations.
But unlike U.S. innovation centers, which have developed organically around top technology universities, Catalonia’s leap to healthcare pathfinding was a carefully orchestrated government creation. The regional government began by establishing the Catalan Institution for Research and Advanced Studies (Institución Catalana de Investigación y Estudios Avanzados, or ICREA) in 2001, which poured money into public research and technology centers through a government-funded grant system. Since its inception, the organization has paid over US$531 million (€500 million) to subsidize salaries for international researchers to work in one of the many institutions in Barcelona. Some 30 percent of those grants went to research in health and life sciences, more than any other field.
Numbers from hospitals, biotech firms and private healthcare providers are exploding. Catalonia’s 734 healthcare-related companies posted a yearly revenue of US$15.2 billion (€14.36 billion) in 2014, up 24 percent from 2013. Those 2014 revenues composed 7 percent of the Catalan GDP, up 25 percent from 2013. Seventy-five new companies were founded between 2013 and 2015. Catalonia leads R&D investment in biotech in Spain, with 28.7 percent of the total in 2014. Of the European Research Council (ERC) grants that go to Spain, Catalonia was awarded 53 percent between 2007 and 2015. Catalonia had three universities on the 2014 university ranking QS Top 50 under 50 years old, the most per million inhabitants in Europe, and the region produces 29 percent of all life sciences publications in Spain. Even in the midst of economic crisis and austerity, as the rest of Spain reduced public research and development spending by 18 percent between 2009 and 2014, Catalonia’s dropped less than 4 percent. This surge in spending on innovation has led to some impressive improvements in the healthcare system, including in top-of-the-line hospitals in Barcelona.
The pediatric hospital Sant Joan de Déu is emblematic of Catalonia’s new wave of innovative healthcare delivery. As you walk into its new lobby, opened in 2016, it’s easy to forget you’re in a hospital at all. Enticing play structures sprout from the floors and walls, and galactic orbs and bird sculptures dangle from the ceiling. A twisting slide invites children to zip from upper to lower levels in style. (A sign discourages adults from giving it a try.) In the outpatient facility, soft lighting slowly cycles through a rainbow of colors, and the monitors and IV-poles are fashioned into futuristic tree shapes to match the nature-themed decorations. “And no hospital smell!” beams Jorge Juan Fernández, the hospital’s director of e-health and coordinator of the facility’s use of online care, telemedicine, mobile apps and social media.
Under its progressive director general, Manel del Castillo Rey, funding projects that improve care quality and efficiency have become a central focus of Sant Joan de Déu’s healthcare model. In 2009, it became the first hospital in Spain to have a department devoted specifically to driving innovation. In 2010, Fernández, a graduate of London School of Economics, was appointed the hospital’s — and all of Spain’s, if not all of Europe’s — first director of digital health.
Rey’s vision was to listen directly to ideas from physicians on the floor, says Fernández. “Whenever we innovate, we try to start from an unmet clinical need from somebody in the hospital,” he explains. “So it’s not somebody from the outside trying to sell us the technology, it’s somebody from the inside who needs to do something, and we try to move this idea, if it makes sense, all the way until it reaches the patient.” Prat’s strabismus helmet was only the first project where the hospital collaborated with a Spanish or global company. Under the direction of Rey and Fernández, the hospital’s department of innovation has gone on to pioneer over 50 projects that have generated revenue for the hospital — while simultaneously cutting costs, improving outcomes and increasing the value of treatments. Thirty-five of those projects are still active.
Take the idea of Dr. Marta Ramón Krauel. As Sant Joan de Déu’s head of endocrinology, Ramón noticed that young people with diabetes often would show short-term improvements, but those improvements wouldn’t last. So she approached the innovation department to see if it could design some kind of software program to engage kids directly. The department came up with a set of mobile phone apps that do everything from providing nutritional information and education to tracking steps and helping patients set exercise goals. The apps also let clients engage with their peers and parents in fitness competitions. Fernández says that since the apps launched, children — and their parents — are getting healthier and keeping more weight off longer, at minimal cost to the hospital.
The innovation investments are starting to pay dividends, not only for the entrepreneurs and their tech firms, but for the hospital itself. While Catalan healthcare companies attracted over over US$100 million (€100 million) of investment from 2013 to 2015, collaborations between startups and hospitals like Sant Joan de Déu can be profitable for both. “Startups approach us with ideas for pilot programs,” says Fernández . “They get what they need — access to our fully equipped clinical research unit, our brand, our patients — and we charge a fee and receive a portion of the revenue if it’s successful. It’s a win-win situation.”
The collaborations come as Sant Joan de Déu has garnered international recognition in the last few years, becoming one of the top five European pediatric hospitals in published research papers. The hospital is expanding its capacity quickly, reporting that it has increased discharges by more than 20 percent, births by 30 percent, outpatient visits by 15 percent, same-day surgeries by 100 percent and day-hospital care by more than 200 percent. The hospital now treats more international patients than ever, including clients from across Europe, the Middle East, Northern Africa and Latin America, all of which brings in more revenue and prestige. It has received the IASIST Top 20 award for excellence in healthcare results and outcomes in Spain 16 times — every year since the award was founded by the healthcare consulting company in 2000.
But Sant Joan de Déu and other hospitals in Catalonia aren’t in it alone — both public and private support has made these achievements possible. Biocat, a public-private company, facilitates collaborations and connections among universities, private life-sciences-research companies, startups and hospitals. Among its client partners is Sant Joan de Déu and the GazeLab company BcnInnova. Biocat CEO, Dr. Albert Barberà, describes the company’s work as having a “platform approach” intended to create a “robust healthcare ecosystem.”
Biocat aims to increase both the success of healthcare startups and the value of healthcare delivery in hospitals by facilitating collaborations between the two. “Stimulating technology and economic innovation is great, creating more jobs and getting people working,” says Barberà. “But at the end of the day, our mission is to have an impact on healthcare, giving patients better care and better quality of life.”
International presence is another key part of Biocat’s strategy. Not only does Biocat help Catalan companies break into global markets, like the U.S., Japan, and Canada (China is an emerging market, though according to Barberà, “our companies are a bit intimidated”), but it has shared its regional innovation model with developing nations. In 2015, Biocat led a Catalan delegation of doctors, hospital managers and researchers to Bucaramanga, Colombia, to participate in the health conference Foro de Salud Competitiva. In addition to presenting the Biocat innovation model at the conference, representatives visited three top hospitals in the region, which has one of the largest middle classes in Colombia and strives to be a pioneer in Latin America’s healthcare sector. “The more we get our model out there, the bigger impact we can have,” says Barberà.
That impact is starting to show. Fernández tells the story of Sant Joan de Déu’s first time attending a conference of the International Society for Pediatric Institutions (ISPI) three years ago. It was the only hospital from Spain and one of the few from Europe invited. A delegation from a U.S. hospital presented a project using a technology strikingly similar to GazeLab. “We were terrified, and the first thing we did was go home and call Dr. Bartomeu,” says Fernández. “‘Oh sure,’ he’d responded. ‘We sold them two units a few months ago.’” It was a good sign that Sant Joan de Déu’s innovation model can compete internationally.
Biocat’s so-called “d-HEALTH,” or design health, program is another initiative aimed at getting entrepreneurs into the healthcare system. D-HEALTH Barcelona is a nine-month Masters program that brings together interdisciplinary teams of people with backgrounds in medicine, engineering, management and design to draft, prototype and implement a new healthcare product or service. It was launched three years ago with funding from the Catalan Health Department and is based on Stanford University’s Biodesign Fellowship. Its cohorts are divided between three of Barcelona’s premier hospitals: Institut Guttmann, Hospital Clínic, and Sant Joan de Déu. Instead of bringing ideas to the hospital, “the fellows dialogue with the doctors, nurses and patients, to hear their actual needs,” says Biocat’s Barberà. “This results in ideas grounded in proven gaps in the hospital’s care. Since the fellows look at problems differently, doctors can look differently.” Sant Joan de Déu’s Fernández is actively involved with Biocat and the d-HEALTH initiative, serving as head of academics of Biocat’s Moebio, the arm that coordinates d-HEALTH Barcelona.
The most successful program to come from the d-HEALTH initiative so far has been the medical device company usMIMA. The project sprouted from Institut Guttmann, which specializes in treatment of neurological disorders. The d-HEALTH fellows developed a non-invasive, non-pharmacological belt treatment for chronic constipation. After raising more than US$1 million (€1 million) in funding in two years, the company started selling the product online for US$530 (€500). According to Fernández, usMIMA was the only Spanish company selected to participate in the MassChallenge U.K. accelerator program, a program that nurtures startups by connecting them with mentors and investors while providing free support during a four-month stay in London.
The Catalan government’s health and economic departments have long been onboard with healthcare innovation, but managing risk and reducing spending has moved to the forefront now that financial pressure from the economic crisis has mounted. Catalonia has Spain’s oldest regional Health Technology Assessment agency (which has a long history of changing acronyms from its creation in 1991). Currently called the Agència de Qualitat i Avaluació Sanitàries de Catalunya, or AQuAS, it is charged with determining and recommending best practices for public hospitals to measure and increase value. In 2012, AQuAS introduced a number of programs for reducing overdiagnosis and overtreatment. Even larger general hospitals are adapting: Hospital Clínic de Barcelona has integrated a mini health technology assessment protocol into its evaluation of new ideas, which gives administrators immediate, adapted data on the potential savings a change in technology or practice will yield.
Despite all the upbeat news, big challenges lie ahead. Spain’s nationwide economic crisis has resulted in some troubling trends, including a US$11 billion (just under €10 billion) drop in Spain’s public healthcare spending from 2009 to 2013. Catalonia’s public R&D investment began to dip in 2009, after a decade of steady growth. And a battle rages in the country — as it does in much of Europe and in the U.S. — as to whether illegal immigrants should have access to free public healthcare.
But so far Catalonia’s commitment to its innovation ecosystem has proven resilient, and new sources of funding paired with increasingly efficient business models are helping hospitals adapt to the new economic realities. As a result, the innovation continues apace. Even Sant Joan de Déu’s Prat, the pediatric ophthalmologist, is taking advantage of the ongoing support, aiming his camera-equipped helmet at a new challenge: diagnosing schizophrenia early on, when it may be more treatable. That would be another victory for young patients, most importantly. But it would also be one for medicine, commerce and, as well, Catalonia.
— Alex Freedman
Alex Freedman is a freelance healthcare writer based in Portland, Oregon.