Apotti: A Vision for Integrated Health and Human Services in Finland

An Insight from the 2016 Health and Human Services Summit

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In 2011, Finland’s healthcare and social services leaders faced an extremely challenging set of circumstances. To begin with, there were a number of troubling trends—including the aging of the Finnish population and an increase in the prevalence of chronic diseases—that portended a surge in demand for their services. At the same time, providers were dealing with increasingly complex cases—a difficulty that stemmed from the numerous clients and patients who had multiple conditions and were oscillating between the health and social services systems.

Unfortunately, the country’s healthcare and social services providers were ill-prepared to respond. This was in part because Finland remained heavily dependent on rudimentary technology. In particular, the country employed electronic medical records systems that allowed for basic data entry but did not permit more sophisticated data processing and analysis. As a result, practitioners spent a great of deal of time trying to document patients’ conditions and their histories, rather than treating them directly. Further complicating matters, there was minimal integration between the country’s healthcare and social services systems. Consequently, it was difficult to identify and provide a coordinated response to the most complicated cases. Simply put, Finnish officials lacked the technological and organizational sophistication to adapt to an increasingly ominous landscape.

Amid this difficult environment, healthcare and social services providers in Finland’s capital region came together to shift the tide. Specifically, leaders from Helsinki (Finland’s capital)—with financial support from the Helsinki and Uusimaa Hospital District (HUS) and the cities of Vantaa, Kirkkonummi, and Kauniainen—created a reform program called Apotti. By June 2015, Apotti would evolve into Oy Apotti Ab, a company that aimed to build capabilities that would enable it to extend its services to cover a wider scope in the future. However, its initial focus was local: the program would establish an integrated patient and client data system for healthcare and social services providers in HUS and the four participating cities. “Our promise,” explained Hannu Välimäki, Oy Apotti Ab’s Managing Director, “is a service which releases time for people.”

Apotti had the potential to help the participating organizations reach the integrative stage of the Human Services Value Curve. Nonetheless, to get there, they would have to traverse a difficult path marked by a number of challenging dilemmas. Could they develop a shared vision for a diverse group of stakeholders? Could they craft an organizational structure that illuminated a wide array of perspectives but still allowed for nimble decision making? What goals should they prioritize, and how should they design a software system and identify private sector partners to help them achieve those objectives? How would they justify the expense to the public? Simply put, could they make their vision a reality?

Background

Located in northern Europe and roughly the size of Arizona, Finland has a strong reputation for providing innovative and expansive social and healthcare services and producing excellent results. Among other innovations, the government is famous for offering expectant mothers a “Finnish Baby Box.” The box—which doubles as a baby’s first crib and contains toys, clothes, and sheets—is a key reason that Finland has one of the lowest infant mortality rates in the world. More broadly, the country is known for guaranteeing “social welfare and health services…as a basic and fundamental right of the whole population.” In part because of this broad support structure, Finland has a life expectancy of 81 years, one year higher than the average for countries belonging to the Organization for Economic Cooperation and Development.

May 2012-August 2013: Building A Team and An Effective Governance Structure

After formally launching the Apotti program in May 2012, Välimäki and his team focused on creating a shared vision—and, more broadly, fostering a common culture and understanding—for their endeavor. Developing this synergy was critical because Apotti brought together stakeholders from a wide array of backgrounds. For example, Välimäki was an IT professional, who had spent most of his career in the private sector; however, he would now be leading an initiative involving multiple public sector organizations. Similarly, the program involved leaders from different localities and providers from the healthcare and social services sectors, which, as noted earlier, had little coordination. At first blush, the divisions and disparities appeared stark.

Thus, Välimäki took steps to ensure that different stakeholders understood and embraced one another’s approach. To cite one example, healthcare professionals referred to the people they were treating as “patients,” whereas social services officials used the term “clients.” Välimäki emphasized that both identifiers were appropriate because they were now united by the common mission of improving the lives of the 1.6 million citizens they were serving. “We always need to talk about clients and patients,” Välimäki emphasized, “because we are now integrating the social care and healthcare system. That is very, very important.”

Välimäki complemented this shared vision with a staffing model and governance structure that allowed the team to draw on a wide array of opinions while still making quick, nimble decisions. Specifically, Välimäki hired 65 Apotti associates, who came from a wide variety of backgrounds (e.g., nurses, physicians, and social workers) and were therefore able to provide a “broad understanding of the workflows and strategies in their respective departments.” He also encouraged his associates to remain in close contact with 650 “subject matter experts” in the healthcare and social services systems. These experts were situated on the ground in their respective organizations but were also positioned to make observations and provide input on Apotti’s decisions for system design and implementation. Thus, senior-most officials were able to remain in touch with and learn from personnel on the frontlines of the reform effort while still maintaining a lean hierarchy so that they could move swiftly through the reform process.

This approach is telling for other agencies hoping to scale the Human Services Value Curve. Rather than immediately jumping to technological change and data-driven reform, Välimäki ensured that Apotti had a cohesive team and strong structure. In other words, he laid a human and institutional foundation for innovation.

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“We will adopt the world’s first information system that helps us to integrate social and healthcare services. For professionals, it is a tool of the future for serving clients and patients; for citizens, it supports self-care and better life management.”

Hannu Välimäki

Managing Director, Oy Apotti Ab

September 2013-April 2016: System Design, Procurement, and Pushback

In fall 2013, Välimäki and his team shifted their focus to defining the core objectives for the program and designing a system and identifying a vendor, Accenture, that could help them to achieve those aims. Following an extensive internal dialogue, they decided to prioritize six goals: 1) establishing “customer-centric operations”; 2) ensuring “uniform processes and procedures”; 3) maintaining “cost-efficient and high-quality operations”; 4) leveraging “knowledge-based management” and utilizing information; 5) maximizing “user satisfaction”; and 6) “employing “new and innovative methods of operation.”

To realize these objectives, Välimäki and his team felt that it was critical for the new information management system to have several core characteristics. One was that the program would function as an ecosystem that combined shared functionalities (e.g., scheduling) across social services and health care. This functional integration, as Välimäki explained, was critical to breakdown the silos separating the social services and healthcare systems. Another feature would be a series of applications that allowed users to connect easily with providers; there would also be a single login or authentication method for clients and patients, further augmenting Apotti’s customer-centricity. Finally, they would create a data portal to which all stakeholders would have access and through which providers could make use of structured data to serve clients and patients more effectively. Much like the organization itself, the Apotti program would have to be integrated, accessible, and able to synthesize diverse data quickly to facilitate nimble decision-making.

In April 2016, after a competitive Request for Proposals process, Apotti awarded the contract for building the system to Epic, a U.S.-based software company that impressed with its vision, programs, experience, and price. Nonetheless, Välimäki and his team had to overcome pushback before finalizing the contract and moving forward. The resistance included legal challenges in Finland’s Market Court, which, Välimäki said, stemmed in part from current vendors attempting to protect the status quo. Välimäki and his team also had to address fears among Finnish citizens about whether a foreign company could keep their data secure; to assuage peoples’ fears, Apotti emphasized that the data would be stored domestically. Finally, some questioned the accuracy of Apotti’s cost-benefit analysis, which anticipated that the 575 million Euro project would pay itself back within seven years. Apotti officials therefore presented extensive projections showing the anticipated benefits of saving time for providers, leveraging data, and ensuring more integrated care.

That Apotti officials faced so much pushback is instructive for officials striving to scale the Human Services Value Curve. Change is invariably controversial and likely to prompt criticism from stakeholders that benefit from the status quo. By responding constructively to skeptics, organizations can strengthen the case for reform.

May 2016 and Beyond: Beginning Implementation

By the end of 2016, Apotti had made significant progress. Among other signs of growth, the organization recruited 200 new employees; established a professional network with over 500 leaders; and signed a contract for infrastructure services with another leading vendor, Fujitsu. This gave the company the resources to begin the implementation process, with the first pieces of the system scheduled to go live in November 2018.

Nevertheless, challenges remained. Chief among them was that in January 2019, just a few months after the system would go live, the Finnish government planned to transfer control of health and social services from the country’s municipal governments to 18 newly established regional bodies. One of the largest healthcare and social services reforms in Finnish history, the restructuring would elevate the importance of integrating health and social services. However, it also raised the stakes, meaning that Apotti would receive even more scrutiny and that any delays or shortfalls were likely to be magnified.

Thus, as Välimäki and his team pressed ahead with their plans, they confronted both challenges and opportunities—an all-too-common experience for leaders and organizations ascending the Human Services Value Curve. However, they also took comfort in the fact that their product had the potential to improve the lives of millions of people and position Finland at the cutting edge of information management in the healthcare and social services sectors. As Välimäki summarized, “Apotti is a tool of the future.”

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“Our promise is a service, which releases time for people.”