Despite good intentions, the choices that have been adopted are having a negative impact on the market which will have repercussions on public administrations.
Although it is too early to take stock of the impact of the PNRR on the digital transformation of healthcare, it is possible to formulate some reflections on the effects that have been had on the market and the consequences that these will have in the future.
The premises and intentions were to open the market to more operators, also involving startups and SMEs, simplify the purchasing process by shortening its time, create a procedural and contractual infrastructure to protect the regions and healthcare companies. The digital health tenders that Consip has announced arose from this framework.
What happened? Did the good intentions materialize?
Many suppliers, few players
The tenders saw the participation of many suppliers, including a dozen for RTI, which we can divide into three categories:
The major players in the market, with their own offer of healthcare solutions and services, generally in the position of agents or in any case with the largest shares; Large and medium-sized companies, often system integrators, without their own portfolio of specific healthcare solutions and services, usually with significant shares; Innovative startups and SMEs, included to meet the tender requirements and make the RTI offer proposition more modern, with small or very small shares (sometimes aggregated in consortia).
These are very heterogeneous groupings in terms of company size, portfolio of products / services, ability to access the market. The former, which have a robust presence on the market, are those that lead the groupings and “dictate the law”. The latter are involved in how to capitalize the shares, an operation which generally occurs in two ways: looking for products/services to offer on the market, even outside the perimeter of the RTI; enhance one’s position by creating a “quotas market”. Finally, the third parties, who have no presence on the market (or are extremely limited), are there trying to assert their small shares, hoping for the benevolence of the first ones.
All the other companies that are not present in the winning RTIs behave like startups and innovative SMEs.
Digital transformation by piecework
The tenders mainly involve the provision of professional services with daily rates. These can be used for “green field” development, i.e. the creation of solutions from scratch and/or the customization of existing solutions, their configuration, start-up, training and maintenance.
The tenders provide for the possibility for the client to acquire “ancillary services” and, among these, “services, products and market solutions relevant to the thematic areas of reference”, with a value of up to 50% of the entire amount . Finally, in the digital health tender 4, the possibility of acquiring the Electronic Medical Record as Software as a Service was included with tariffs (reduced) ranging from 14.20 to 15 euros per hospitalization, from 0.50 to 0, 70 euros for outpatient access (depending on usage brackets). The annual fee is therefore determined with a “pay per use” by multiplying the rate by the number of hospitalizations/accesses. For more information on this aspect, please refer to the article found here.
Ownership of the software
Article 22 of the framework agreement provides in paragraph 1 that “The Administration acquires the right of ownership and, therefore, of use and economic exploitation, of everything created by the supplier in execution of this contract (by way of example and by no means exhaustive, these are the software products and systems developed, the documents, of software procedures and more
of intellectual creations and original works), of the related materials and documentation created, invented, prepared or created by the supplier or its employees within the scope of or during the execution of this contract.” But that’s not enough, paragraph 2 further specifies: “The Administration may, therefore, without any restriction, use, publish, disseminate, sell, duplicate or
transfer, even partially, said materials and intellectual works.” while paragraph 3 defines that “The aforementioned rights must be considered acquired by the Administration in a perpetual, unlimited and irrevocable manner.”.
Utopia or illusion?
There are several aspects that deserve reflection, starting with whether Article 22 applies only to “green field” development or also to software provided as an ancillary service. In the beginning there is the concept that a supplier can develop a “product” ad hoc for an administration to which it cedes all rights. Unless it is extremely simple software, anyone who has experience of what it means to develop a product knows well that the resulting effort and costs cannot be amortized on a single customer; quality software development is an industrial practice that requires a horizon and a market that is at least national if not international. Public Administration is full of low quality software that cannot be defined as products. Is this what we want for the digital transformation of healthcare?
But there is another equally important aspect. Let’s assume that a supplier decides to accept the assignment and carry out what was requested. In doing so, it transfers its know-how into the product and then passes it on to the administration which can disseminate or sell what has been developed. For a company that creates and sells healthcare software, it would be a form of self-harm that could quickly lead to its bankruptcy. In short, it is a form of contract that is only suitable for companies that do not have their own products and therefore specific expertise in healthcare, with all that this entails in terms of quality and effectiveness.
Digital sovereignty
Then there are other consequences that represent an advantage for some. Foreign companies that develop and sell products are neither willing nor interested in operating in our market which in their opinion is immature and incomprehensible. This creates a sort of autarky or digital sovereignty which however has an important side of the coin: Italian companies cannot compete abroad in a market made up of products.
Between creativity and the art of making do
Italian companies are creative and know the art of making do and have thus learned to navigate rules, codes and relationships with customers. Other issues remain in the background, such as MDR certification, when required, the valorisation of the software also at a fiscal level (both for administrations and for suppliers), the guarantee, possible conflicts over intellectual property.
A big mess that derives from the idea of do-it-yourself software, from the illusion of avoiding lock-in phenomena on the part of suppliers, from the underestimation of the complexity of today’s software, from the lack of experience of those who set certain rules which perhaps, in his life, he has never worked in a company that produces software.
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