Implementation and Development of Hospital-Based Health Technology Assessment in Poland: A Qualitative Research

Introduction

Health technology assessment (HTA) in Poland has primarily focused on pharmaceuticals, evaluated by the Agency for Health Technology Assessment and Tariffication (AOTMiT). With increasing hospital investments in hardware, diagnostics, and organizational improvements, along with the rising need to accurately assess the costs of implemented solutions, Hospital-Based Health Technology Assessment (HB-HTA) has begun to develop.

To facilitate HB-HTA implementation across the Polish healthcare system, a project was conducted from 2019 to 2022. The project involved the National Health Fund (NHF), the National Institute of Cardiology in Warsaw (NIKARD), and Lazarski University (UŁ). This study aims to build on that project.

Purpose of the Study

The purpose of this study is to analyze the potential for developing HB-HTA in Polish hospitals, utilizing the experiences of participants. It seeks to identify the benefits and barriers associated with implementing HB-HTA units in these facilities.

Methods

This research used a qualitative approach, analyzing in-depth interviews with hospital representatives who participated in the HB-HTA project. The Nvivo12 program was used for this analysis.

A structured questionnaire covering the pre-project, design, and post-project phases was administered to respondents from five of the seven hospitals involved in the pilot phase, during which HB-HTA reports were prepared for select medical technologies. The remaining two hospitals declined to participate. The Ethics Committee of the Jagiellonian University Medical College approved the study.

Results

Hospital representatives indicated that the HB-HTA methodology allows for the assessment of investments in facilities using appropriate data. Project participation enhanced employees’ skills, improving their ability to conduct literature reviews in medical bibliographic databases. However, complete HB-HTA implementation in Poland is still pending, as hospitals do not yet receive adequate organizational and financial benefits.

Participants suggested that the methodology itself should be adjusted to better meet the needs of individual facilities.

Key Findings

• HB-HTA Methodology Benefits: Enables assessment of investments based on data.
• Skill Development: Improved literature review skills among hospital staff.
• Implementation Barriers: Lack of significant organizational and financial benefits.
• Methodology Modifications: Need for customization to suit facility needs.

Conclusion

Hospitals involved in the HB-HTA project are making progress in analyzing the implementation of innovative solutions, though not to the extent initially intended in the project design.

Introduction

Health technology assessment primarily involves justifying the inclusion of health services or drug technologies in a list of services reimbursed by the public insurer. Poland has a dedicated advisory institution, the Agency for Health Technology Assessment and Tariffication (AOTMiT), which assists the Minister of Health in making decisions about public funding for specific solutions.

The Role of AOTMiT

• Established in 2005.
• Advisory role to the Minister of Health.
• Deals with tariffication of health services.
• Evaluates health policy programs.
• Collaborates with hospitals for data transmission.

AOTMiT operates under the Act on Healthcare Services Financed From Public Funds (1). While the agency has an established position, Poland lacks both comprehensive regulations and extensive experience at the hospital level for assessing therapeutic and diagnostic technologies.

Data from hospitals have not been fully integrated into the process of evaluating medical services and incorporating innovations into the guaranteed services package funded by public payers. Hospitals had a limited role in HTA and often faced low financing for services evaluated by AOTMiT, resulting in financial instability.

Changes associated with modern medical technologies at the hospital level require the participation of many actors in the healthcare system. There is a noticeable trend among Polish healthcare facilities to develop various technologies, such as the da Vinci or Versius robots. The year 2022 was particularly significant for medical robotics, with a considerable increase in the number of surgical robots.

Trends in Medical Robotics

• Significant increase in surgical robots in 2022.
• Growth in robotic procedures in both public and private centers.
• Decrease in private robotic procedures due to increased National Health Fund valuations.
• Prostatectomies are a common procedure.

Medical robots represent an area of interest for those involved in incorporating modern treatment techniques or equipment to enhance diagnosis and facilitate the development of medical facilities. Such technologies could be assessed using the HB-HTA methodology, providing data to stakeholders to make more expedient financing decisions. HB-HTA also provides a methodology for disseminating new technologies, and facilitates hospitals in setting priorities.

Other bodies in healthcare, such as the Ministry of Health, are also involved in planning and coordinating implementation of new technologies, including e-health projects, the Medical Research Agency, and the E-Health Center. The Department of Innovations manages these initiatives.

Department of Innovations Responsibilities

• Managing e-health projects.
• Supervising the Medical Research Agency.
• Overseeing the E-Health Center.
• Planning and coordinating new technology implementation.
• Preparing guidelines for healthcare digitization.

The Evaluation Instrument of Investment Motions in Health Care (IOWISZ) plays a significant role in organizing hospital investments in Poland. It is a tool for voivodes and the Minister of Health to evaluate investment advisability, ensuring that new investments are made where they are most needed and will benefit patients the most (8). The IOWISZ IT system is used for investment opinion requests, evaluations, and opinions. The system aims to enable service providers to develop based on local health needs once they obtain a positive opinion (9).

The Hospital Assessment of Innovative Health Technologies (HB-HTA) project was intended to support the implementation of innovative medical technologies in hospitals, enhancing the IOWISZ methodology. The project was conducted by the National Health Fund (NFZ), the National Institute of Cardiology in Warsaw (NIKARD), and Lazarski University (UŁ) and financed by the National Center for Research and Development, implemented from 2019–2022.

The project included two design phases: research and implementation (10). The research phase led to the creation of six theoretical models for HB-HTA implementation (11–16). These models were developed based on surveys, patient surveys, ethical aspects analysis, literature reviews, and interviews.

Each HB-HTA implementation model followed a structured scheme, including analysis of stakeholders, the HB-HTA process, stakeholder analysis, competence potential, finance, barriers, and opportunities (19). The project identified the roles of various healthcare institutions participating in the HB-HTA network, including hospitals, AOTMiT, the National Health Fund, the Ministry of Health, regional authorities, and external HTA units.

In the pilot phase, selected hospitals were tasked with preparing HB-HTA reports using a specific methodology. Seven hospitals, known for their research and innovative technology implementation, were chosen to participate. These hospitals included the Military Medical Institute in Warsaw, the University Medical Center in Gdańsk, the Lower Silesian Cancer Center in Wrocław, the University Hospital in Kraków, the Central Clinical Hospital of the Medical University of Łódz, the Center of Child Health in Warsaw, and the National Institute of Cardiology in Warsaw (20).

Participating hospital personnel received intensive training in HB-HTA, leveraging the knowledge from the project. Pilot HB-HTA units were established in these hospitals to conduct assessments of innovative medical technologies.

Technologies Assessed

The assessed technologies included:

• Da Vinci robotic surgery system integration.
• Integrated care center for advanced COPD patients.
• Improvements to cervical cancer diagnosis processes.
• Evaluation of implantable ECG recorders.
• Evaluation of bipolar ablation for cardiac arrhythmias.
• Assessment of retinoblastoma management.
• Evaluation of myocardial perfusion using multi-slice computed tomography.

The aim of this study is to indicate how HB-HTA should be further developed in Poland based on the analysis of in-depth interviews (IDIs) with representatives of five out of the seven hospitals that participated in the pilot phase of the HB-HTA project. Furthermore, the study aims to identify the obstacles and opportunities for further HB-HTA implementation at the level of Polish hospitals. This will help answer questions regarding innovation development and the adoption of HB-HTA methodology in medical entities in Poland.

Methods

Study Participants

Five hospitals involved in preparing HB-HTA reports agreed to participate in the study. The other two hospitals declined due to no further HB-HTA activities. A total of five participants from the pilot phase took part in the study.

Participants received an electronic invitation explaining the study’s purpose and interview topics. The head managers of the hospitals selected the interviewees based on their involvement in the HB-HTA project. Informed consent forms were used. Participants prepared HB-HTA reports between October and December 2021 and presented them at a Polish HB-HTA conference in February 2022.

Participants attended training courses from Lazarski University and were identified as HB-HTA leaders within their entities. Their selection was based on their experience with the HB-HTA project and their contact with Lazarski University. The hospitals were chosen based on analysis of HB-HTA networks in Western Europe. The participants were selected based on their HB-HTA experience and their contact with Lazarski University.

Study Design

A qualitative in-depth interview study was conducted with hospital representatives. Interviews were recorded, transcribed, and translated into English (conversation transcripts can be found in Supplementary materials (Supplementary Data Sheets 1-5)). The interview questions were sent to the respondents before the interviews. The interview scenario was prepared by two members of the research team (IKB and MF). It was divided into three parts: pre-project phase, design phase, and post-project phase.

The interviews were conducted online via MS Teams between February and March 2024. Each interview lasted 20 to 30 minutes. The questions were according to a previously developed scenario (Table 1). Each interviewee answered the same questions during a single session. All interviewees responded freely to the questions. In total, five individual interviews took place. The interviewees were not in the same sessions.

Figure 1: Maciej Furman.

Table 1: Table 1. Study group characteristics. This research was prepared through internal discussion between the research team (IKB, MGS and MF) regarding the most suitable questions for exploring the implementation of HB-HTA in Polish hospitals. Of the seven selected hospitals invited to participate in the study, five representatives took part in the research. From the aforementioned seven hospitals, five were selected for inclusion in the study.

Ethical Considerations

The study was anonymized, with information limited to the employee’s function and institution. Each interview was labeled with a number from 1 to 5. Consent to conduct the study was obtained from the Research Ethics Committee of the Jagiellonian University Medical College.

Data Analysis

Content analysis (thematic analysis) was performed using the Nvivo12 program. The coding method was based on the description of presented positions (Description focused-coding). The content of the interviews was analyzed by two members of the research team (IKB and MF). Concepts were defined and categorized based on the responses and related questions. The researchers coded the frequency of each concept and the number of times the code was repeated in the interviews. The data was divided into subcodes. Ultimately, five overarching concepts, including eleven codes and ten subcodes, were analyzed. The results are shown in Table 2.

Figure 2: Iwona Kowalska-Bobko.

Table 2: Table 2. Concepts, codes and subcodes from analyzed interviews with hospital representatives.

Results

Project Familiarity

Respondents learned about the HB-HTA project from various sources. One respondent (P3) was responsible for organizing the project at the beginning, representing one of the consortium members. This indicates hospital entities were facilitators for introducing HB-HTA at the level of Polish healthcare system: “We were the initiators of the idea itself, so this question does not directly apply to us” (P3). Polish medical facilities were initiators of implementing HB-HTA into the Polish healthcare system.

Sources of Information

The remaining participants cited websites and facility directors as the main sources of information. Directors and management boards were interested in the project. “I found the information on the Internet, but our director and the director of the Institute of Cardiology also exchanged information” (P2). They were active in getting to know the project’s goals: “On the GrupaBiznes website I found a document with an invitation to the HB-HTA pilot project and our director also got interested in the project” (P4). “I am not sure exactly how the hospital found out about the project, but the HB-HTA team was formed by the contemporary director” (P5).

Hospitals that were selected for the study showed a strong willingness to implement innovations regularly: “We are an innovative institution, and we place great emphasis on that field. We try to take part in multiple projects” (P1). Participants also indicated that decision-making based on a well-established and scientific methodology would lead to more reasonable choices for costly solutions. Knowledge about HB-HTA may contribute to more justifiable tender decisions: “We, as an entity, wanted to participate in something new, innovative. During the project, not everyone knew what HB-HTA was. We wanted to learn about this methodology and improve the way we purchase equipment” (P5). The proper organization of data is also essential to make the right decisions related to the area of data analytics: “Recently, our department has been expanded to include an analytical part, which will enable us to undertake all activities fully consciously. This was the crucial factor for us to participate in the project” (P2).

Healthcare Service Valuation

Some participants wanted to develop HB-HTA in Poland because they had concerns that valuations prepared by the national Agency for Health Technology Assessment were repeatedly unsatisfactory and did not correspond to actual costs: “We wanted to implement this project because our institute has the appropriate capabilities to support the Polish HTA Agency in the process of preparing analyses and activities in the field of health technology assessment” (P3). Hospitals have often faced problems with valuations that were too low. Data from HB-HTA analyses could provide better service valuations.

Evaluation of New Technologies

For some hospitals, the possibility of gaining a tool for assessing the implementation of modern solutions was motivaiting: “There was a need to develop a way to evaluate new technologies and we also needed an appropriate methodology for that” (P3). The HB-HTA methodology would enable a systematized approach to implementing innovations in their facilities.

Methods for Assessing Technologies

All respondents indicated that they had conducted short, internal analyses before the project started. They completed external applications under IOWISZ. However, they felt that current solutions, such as IOWISZ, are not ideal, and that technology assessment is carried out ad hoc. The IOWISZ methodology is not solely concerned with medical technology evaluation and does not directly inform decision-making processes: “Health technologies had not been assessed in an informed way before” (P3).

Previous assessment activities were informal: “I think that such a question [about internal analyses before the project] could probably be answered comprehensively by the management, although I know that previously such analyses had been carried out internally” (P4). Respondents noted that IOWISZ’s role was not appropriate for assessing solutions implemented in hospitals: “The only thing was submitting applications under IOWISZ, i.e., as part of the assessment of the advisability of the investment” (P3). Inconsistencies may occur, because IOWISZ is not binding at the decision-making level: “IOWISZ is not that simple—there are some decision points in IOWISZ that do not influence decision making. There is a lack of consistency in the assessment under IOWISZ, for example the National Health Fund may give a negative opinion, and the decision will still be positive at the political level. It does not make sense” (P3). HB-HTA has not fully developed in the post-project phase: “The team has been formed, but at the moment we do not conduct any procedures in accordance with the HB-HTA methodology. Our responsibility is preparing assessments in a traditional way without HB-HTA methodology” (P5).

Benefits of Participation

The project offered the opportunity to learn about articles from medical scientific databases and to compare health technologies from different hospitals. Interviewees have experience in departments, such as financial departments, and had never before dealt with the analysis of clinical trials: “We analyzed both the clinical, research, and organizational issues at the level of our hospital. The creation of systematic reviews occurs in research aspects of clinical trials, but the reviews are not used for organizational issues related to, among other things, work organization” (P1). The project taught proper data analysis skills; “We learned how to use the acquired data appropriately” (P2). Moreover, the activities in the assessment of modern medical technologies can be systematized, and the project gave them a structured methodology: “The analyst team developed methodological tools to use for preparing accurate assessment of medical technologies” (P3).

Figure 3: Małgorzata Gałązka-Sobotka.

Workshops facilitated by the project also enabled the exchange of experience: “Another advantage was contact with people from other hospitals and investment and design departments” (P4). Teams in hospitals had previously not dealt with health technology assessment in detail nor used scientific databases: “The HB-HTA methodology includes not only financial analysis, but also other comprehensive activities, such as analyses of articles from the Pubmed database. We were not guided by medical reasons and the people responsible for financial analysis did not search for materials in Pubmed” (P5). HB-HTA made it possible to consider the purchase of technological solutions not only from the perspective of costs, but also from the processes of implementing a solution. HB-HTA also provides a new perspective on medical technology assessment, resulting from a literature review: “An important experience was certainly learning to take into account the costs of not only the purchase of technology, or any investment in technology, but also bearing in mind all the costs associated with the organization, coordination, and management of various types of projects. We approached HB-HTA from the perspective of the entire procedural change of a given project” (P1).

• Systematic Analysis: Provides structured methodology, including analysis of both clinical research and organizational aspects.
• Skills Development: Enhanced ability in data analysis and literature reviews.
• Collaboration: Facilitated exchange of experience between hospitals.
• Holistic Perspective: Allows to consider multiple factors.

Organizational and Financial Changes

Respondents stated that HB-HTA requires financial resources and interest from various healthcare institutions. No hospital in Poland currently fully benefits from the use of HB-HTA. They need to maintain project teams: “In my opinion, implementing HB-HTA takes both time and money. We have already prepared the methodology, but we need to be more aware of it” (P3). Lack of financial stability could cause failures. One of the main problems is a lack of funding for HB-HTA teams: “However, one of the main problems that resulted in the lack of implementation of HB-HTA in Poland is the lack of financing for HB-HTA teams” (P5). Hospitals will need more visible benefits of HB-HTA and stability of employment of people responsible for HB-HTA in hospitals: “When the entity does not see any benefits, but rather the problems that pile up, it is difficult to convince it to use such a tool” (P1). Facilities are struggling with maintaining staff, which affects further activities toward HB-HTA; “The primary condition is to maintain the team that worked on the project” (P3).

Data Sharing and Management

Respondents noted problems in data exchange, since it often uses archaic information gathering methods: “So, if we do not improve the standard of data exchange between stakeholders, this will only cause discouragement and simply a waste of time on data processing that is not necessary. This is a waste of time, often of very expensive or very busy specialists. Returning to the aspect of data exchange, the exchange of data on implemented activities is certainly necessary. Currently, it is not possible to exchange data between units because we do not have a platform for exchanging information” (P1). Weak information exchange can lead to dysfunction in medical facilities. Moreover, HB-HTA requires resources and staff and standards: “There is no additional financing for this, so there is little interest in preparing this type of document. Such activities require time and commitment” (P5).

Methodology of HB-HTA

Participants commented that the HB-HTA methodology may be too extensive, and one facility shortened it to suit its needs. However, some respondents also believe that parts of the report cannot be removed, because it would reduce the chance of drawing correct conclusions from the HB-HTA report. The majority of interviewees pointed out that parts of the report were too long and repetitive and were time-consuming to prepare or read: “HTA reports of some drugs are often very broad studies, several hundred pages long. Even if the HB-HTA report were 30 pages long, it would be difficult for the hospital director to read it. The directors of medical entities simply do not have time for that. This could be shortened in an internal document of a summary. The director should get the one-page summary” (P4). The component parts were well described and organized, but some were repeated: “The one drawback of HB-HTA methodology that could be improved is the fact that many actions were repetitive. The component parts of the methodology themselves were well describe and organized, but some of them were too often repeated in the report” (P5). The interviewees often simplified the method of description: “Creating the full HB-HTA report, even for such a large facility as ours, is a difficult task. We have retained the methodology, but we have significantly simplified the method of description and argumentation” (P1). Information needs to be well described and accessible: “HB-HTA was sent directly to the management team. However, the director needs support from analysts because he does not have time to read 20-page documents. We need to provide information on how to decide if we should implement a given technology. Personally, I think this report is very broad. Preparing a literature review is a very difficult task. It could be shortened to a description of 2–3 sentences by describing the benefits of using a given solution” (P4).” Shortened, simplified documents could encourage entities to implement HB-HTA.

Benefits, and barriers related to HB-HTA implmentation, are presented in Table 3.

Table 3: Table 3. Benefits and barriers related to HB-HTA implementation.

Discussion

The facilities involved indicated that the HB-HTA methodology helps systematize knowledge and base management decisions on data. Hospital representatives also highlighted that there were existing teams formed as part of the pilot study, and continue to be assessing the technologies that were introduced. The guidelines for creating the reports may be adapted to a business analysis, with more significant benefits. HB-HTA should be supported by central institutions (the Ministry of Health, the National Health Fund) to further develop.

Many interviewees referenced the Instrument for the Assessment of Investment Applications in the Health Sector (IOWISZ). IOWISZ organizes healthcare investments. The IOWISZ opinions are limited by the source of information (22). The respondents participating in the study pointed to chaos around IOWISZ. It has weaknesses in making investment decisions and it is not fully binding, as it results from political factors.

Organizational activities should resolve clinical issues through HB-HTA, because the effectiveness of a given therapy, its safety, profitability, and impact on the hospital budget should be considered. HB-HTA has been developed not only in Poland, but also as part of the AdHopHTA project, in which experiences were exchanged regarding the forms of health technology assessment at the hospital level in nine selected European countries (Austria, Denmark, Estonia, Finland, Norway, Italy, Spain, Switzerland, and Turkey) (23).

AdHopHTA Project

The AdHopHTA project raised not only scientific issues but also organizational and documentation-related ones. Respondents expressed a need for HB-HTA reports that are more based on business aspects, and less on clinical aspects or scientific literature. Also, they indicated that methodology created by project team should be simplified. The hospital employees’ work is multifaceted and their directors have to familiarize themselves with several pieces of information at once. These respondents postulated for staff training. Lazarski University organizes post-graduate studies in the field of HB-HTA.

In 2023, the Act on Quality in Healthcare came into force (24). Basing decisions on an HB-HTA report could assist better management techniques in medical facilities. HB-HTA can also take into account perspective of pro-quality indicators, increasing funds, and this can include the reorganization and staff adjustments for the healthcare department activities. HB-HTA could be an important aspect of improving the assessment of investment and implementing tools that optimize clinical, consumer, and management activities. The study indicates the direction in which HB-HTA should be developed. This research was conducted on a small group. Approximately 70% of the hospitals participating in the pilot phase were surveyed, and the interviewees understood all questions asked. Other stakeholders responsible for medical innovations can be taken into account (from Ministry of Health, National Health Fund, Polish HTA Agency).

Finland is a country where hospital districts and the Finnish Agency for Health Technology Assessment, FinoHTA, were invited to develop HB-HTA. These institutions created a program for process management of medical solutions. The University Hospital in Helsinki was the first to carry out mini- reports. A study of the development of HB-HTA in France showed that hospitals use this methodology for informational purposes in making decisions about implementing a given innovation. Clinical hospitals feature the most developed level of HB-HTA (26). The process of formalizing HTA has been divided into four stages:

Stages of HTA

• Independent unit, in which HB-HTA is developed through unofficial contacts.
• Stand-alone unit, with external cooperation and a team of specialists.
• Integrated unit, with limited specialists.
• Integrated specialist unit.

In Poland, the first HB-HTA model has the greatest chances of developing. Polish healthcare institutions are not particularly interested in supporting hospitals. The HB-HTA model established in the project indicated the roles of many actors, such as coordinating role with the Ministry of Health. This form of HB-HTA, was not successful due to a lack of activity. For example, the Ministry of Health has not implemented regulations supporting the development of health technology assessment in hospitals.

Conclusion

Hospital Health Technology Assessment in Poland at the hospital level still requires extensive activities and the interest of various healthcare institutions. There are no incentives for using HB-HTA methodology. Hospital employees have implemented assessment methodology. This would make assessing modern technologies more widespread and systematic. HB-HTA needs institutional support, both organizationally and economically. It is recommended to have funding, to determine shape of HB-HTA team and understanding from the management staff. Further development is required.

Data Availability Statement: The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics Statement: Written informed consent was obtained from the individual(s) for submission of any identifiable images or data.

Author Contributions: MF: Conceptualization, Data curation, Formal analysis, Methodology, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing, Project administration, Software. MG-S: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing. IK-B: Conceptualization, Data curation, Formal analysis, Investigation, Software, Supervision, Validation, Writing – original draft, Writing – review & editing.

Funding: The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers.

Supplementary material: The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2024.1426420/full#supplementary-material

References: (1-26) (See original document for references).

Keywords: HB-HTA, in-depth interviews, qualitative study, hospitals, medical technologies.

Citation: Furman M, Gałązka-Sobotka M and Kowalska-Bobko I (2024) Implementation and development of hospital-based health technology assessment in Poland from the perspective of hospital representatives: qualitative research. Front. Public Health. 12:1426420. doi: 10.3389/fpubh.2024.1426420

Received: 05 June 2024; Accepted: 25 September 2024; Published: 08 October 2024.

Edited by: Sonu Bhaskar, National Cerebral and Cardiovascular Center, Japan.

Reviewed by: Ana Paula Macedo, University of Minho, Portugal; Guenka Ivanova Petrova, Medical University Sofia, Bulgaria; Anjan Pal, University of York, United Kingdom.

Copyright: © 2024 Furman, Gałązka-Sobotka and Kowalska-Bobko. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted that does not comply with these terms.

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Corresponding author: Maciej Furman, bWFjaWVqLmZ1cm1hbkBzdHVkZW50LnVqLmVkdS5wbA==