From eHealth strategies to eHealth services in Europe: the long road from concept to reality

Portoroz 07 May 2008In eHealth, the European Commission is now moving from research to deployment. At the 6th eHealth conference in Portoroz, Slovenia, commissioner Viviane Reding renewed her call for action, pointing to the achievements that have already been made. It will take time and effort to make telehealthcare a reality, according to Rolien de Jong, innovations manager at The Hague-based Meavita Healthcare. Presenting the experiences of her company at the eHealth 2008 meeting in Slovenia, Rolien de Jong pointed out that in order to make the breakthrough, it's the providers who are taking the risk - not once, not twice, "but again, and again, and again".


"Europe is faced with the challenge of an ageing population and ever increasing mobility among its citizens", stated the European Commissioner for Information Society in her opening speech at the Portoroz conference. In truth, however, she was not actually there: her speech was transmitted from Brussels by video streaming. But the delegates applauded, nevertheless. It was an IT event, after all.

Viviane Reding recalled recent steps that were taken by the European Commission under the framework of the 2004 eHealth action plan in order to support the implementation of eHealth products and services all over Europe. "In the last four years, we have heavily increased funding for eHealth, we have encouraged interoperability and worked towards a legal framework for eHealth services."

Most recently, a Europe-wide survey among General Practitioners was published that showed a high usage of the internet and of electronic data storage solutions among doctors all over Europe. "But comparably few doctors actually exchange health information on-line, mainly because of interoperability problems that we still have to solve", stated Viviane Reding.

One key step in this direction will be the recommendations on the cross-border interoperability of electronic health record systems. "The recommendations will provide principles on how to achieve interoperability especially in cross-border settings", stated Viviane Reding. The cross-border interoperability of eHealth infrastructures is also what the "SOS large-scale pilot project" is all about. This is certainly the most visible step that the European Commission has taken to move from eHealth research to eHealth deployment in Europe.

The project was presented in detail by the Swedish state secretary, Karen Johannson. Under Swedish leadership, the "SOS project" involves twelve European countries that are already working on national eHealth infrastructure solutions. The goal is to make these national solutions interoperable, so that personal medical data can be accessed all over Europe.

There are two services that will be developed in a first step: a patient summary which contains basic medical information such as diagnoses or laboratory results, and an electronic prescription service with an electronic medication list. "With these applications, we are finally moving from eHealth strategies to eHealth services in Europe. eHealth is now mature enough to take this step", stated Karen Johannson.

The European Commission announced in Portoroz that the contract for the SOS project will be signed before the summer break. What has already been reached is an agreement on the structure of the management board. It will consist of one representative of each ministry of health of the contributing Member States. "This is really the first time that we have had a board like this in the health care sector on a European level", stated Karen Johannson. In addition, 31 IT companies are involved in the project. "What we are particularly proud of is that the standard organisation IHE will join the team for developing the new eHealth services. All in all, this is certainly the largest and most ambitious European Union project in the health care domain we have ever seen."

Despite the difficulties of large-scale telehealth deployment, Meavita Healthcare, Rolien de Jong's company, has recorded some results that she said "pointed in the right direction". According to a study, home-monitored patients say they feel a greater level of self-sufficiency and safety. Acceptance seems to be dictated by the seriousness and progression of a disease: for instance, diabetes 2 patients used the system twice a week, whereas patients with advanced chronic obstructive pulmonary disease (COPD) used it six times a week. "It really became part of their lives", Rolien de Jong stated.

"From a certain stage of a disease, people just want to know that somebody cares. The feeling that you're being taken care of is one of the major benefits of telehealthcare, as it gives psychological relief in difficult situations", Rolien de Jong stated.

And yet the barriers are still significant: innovation and technology are not always good for older patients, nurses are concerned that their places of work are turning into high-tech cockpits and there is a danger of non-verbal signals being missed, which can impact negatively on the quality of care.

But just one year after implementation, the telehealth solution is beginning to deliver results: hospitalization has been reduced for COPD patients, while diabetes control has a lower referral rate to hospitals and practice visits are falling.

Meavita Healthcare currently has around 100 diabetes 2 patients and 50 COPD patients linked to its telehealthcare systems. A plan to link 12.000 employees to the system has been halted owing to high resistance from those who were concerned about being electronically linked to their employer. The return on investment (ROI) for the company also proved too low.

"Telehealthcare can work", concluded Rolien de Jong. The quality of life of patients and nurses can be improved when using telehealthcare solutions as a "personal coach", she stated. But ensuring successful implementation is a question of extreme professionalism and careful communication: advice should be given on the basis of a behaviour profile that takes into account the treatments a patient receives, nutritional habits and activity levels. "Analyse the need, make a strategic plan, consider the cultural aspects and communicate at all levels - again, and again, and again."

The technical interoperability of eHealth services is one thing. But the structure of health care systems and payment schemes is at least as important for a broad acceptance of eHealth solutions. Within the framework of its health-IT project, Elettra Ronchi, co-ordinator of health-IT activities at the Organisation for Economic Cooperation and Development (OECD) analyses this field.

"When it comes to health care systems, all OECD countries are struggling with questions of affordability and efficiency", statd Elettra Ronchi. This struggle is mirrored by a steady increase in health care spending: "There are big differences between the various countries, but the average percentage of GDP that OECD countries pay for their health care system is steadily growing."

Information and communication technologies can be seen as a tool for increasing the efficiency of health care systems. But this is not self-selling: "In our view, it is necessary to realign the economic incentives. The governments have significant leverage here, as they are the major funders of health care provision", stated Elettra Ronchi. On average, 73 percent of total health care spending in the OECD countries comes from public sources, be it tax money or money from public insurance companies. Even in the allegedly "private" United States health care system, almost half of total health care spending is actually government spending.

For the OECD, the key to a broader acceptance of ICT solutions in health care is changes in the payment modalities. Economists argue strongly in favour of "pay for performance" schemes. These schemes make high-quality care financially attractive for the health care provider, and at the same time act as a catalyst for ICT usage, in particular in primary care. As an example, Elettra Ronchi highlighted the United Kingdom pay for performance scheme that was introduced in 2004: "25 percent of the GP's income is now related to a set of 146 evidence-based quality indicators. Since the introduction of the scheme, the quality of care has increased significantly in many areas - as has payment for GPs."

More importantly from an eHealth-point of view: investment in IT and the use of IT tools has significantly improved: "A high quality ICT infrastructure and a high level of computerization have been absolutely critical to the success of this and other pay for performance schemes", stated Elettra Ronchi. The reason is that gathering and reporting quality-relevant data is much easier when it is done electronically.

So pay for performance schemes can support the deployment of eHealth solutions. Elettra Ronchi stressed that this is true not only for accounting software, but also for electronic medical records, since many quality-relevant medical data needs to be extracted from the medical documentation. "Merely paying for the technology and setting it up in the doctor's office is not a good enough reason for doctors to decide to use ICT", was Elettra Ronchi's message to the European eHealth community that assembled in Portoroz.

New Member States can benefit from past European eHealth experience, according to Zofija Kukovic, Minister of Health, Slovenia. As far as Zofija Kukovic is concerned, eHealth is more than just technology: it is a way to bridge the gap between the health care systems of "old" and "new" Europe. With its national health card programme, Slovenia is one of Europe's pioneers when it comes to national eHealth infrastructures.

"It is one of the priorities of the Slovenian presidency of the European Council to lessen the gaps between old and new European Member States", stated Zofija Kukovic. She sees information and communication technologies in general and eHealth services in particular as suitable tools for reaching this goal.

In particular, the bottom-up interoperability process for eHealth services initiated by the European Commission could help new Member States to reach European Union averages more quickly, according to Zofija Kukovic. For Member States with eHealth projects in their early stages, best practice examples and the experience that will be gathered in the "SOS large-scale pilot project" on interoperability can be useful tools when it comes to deciding which technology to use.

Slovenia is currently in the process of upgrading its existing health insurance card system. The cards were originally issued between 1998 and 2000. Not only do they contain administrative patient data; 82 percent of citizens have also agreed to the storage of data on medicines they have received. And more than 1000 people have electronically stored their decision on the post-mortem donation of organs.

The goal of the system upgrade, which will take place from late 2008 onwards, is to renew the existing health insurance card scheme for Slovenian citizens and provide digital certificates to securely access personal medical data and to authorize access by, for instance, medical doctors. New professional cards for health care workers will also be issued, again with digital certificates for secure access to personal medical data, for electronic prescription and for electronic medical referrals. Ultimately, an on-line system for the direct and secure exchange of medical data will be set up, beginning with an exchange of data between health care providers and health insurance companies.

In parallel to this infrastructure project, Slovenia is also running a number of innovative eHealth services, for instance a teleradiology network, a homecare project for COPD patients and a web-based solution for care management in depression. Most recently the "eBirth service" was implemented in a pilot phase in three maternity hospitals. eBirth allows for the electronic registration of newborn babies in the Central Register of the Population of Slovenia and accelerates administrative procedures related to child birth both for parents and for health care providers.

The source for this article is HealthTech Wire.

Leslie Versweyveld

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