Why has there been very variable implementation of eHealth services within the EU?

Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 20 WHY HAS THERE BEEN VERY VARIABLE IMPLEMENTATION OF eHEALTH SERVICES WITHIN THE EU? By: Margaret Ellis, Tony Cornford and Sofia Moreno-Perez Summary: Published data about eHealth services, both potential and actual, and their introduction within the European Union are observed and reported on. It was found that the levels and speeds of adoption are very variable. Some of the variables can be linked to the education and understanding of eHealth opportunities by some health professionals and policy makers. More readable data dealing with cost-effectiveness and user benefits would be of special value. Keywords: eHealth, Education, Integrated Approach, Cost Effectiveness Margaret Ellis is Lead Academic, LSE Enterprise, Tony Cornford is Associate Professor in Information Systems, Department of Management, London School of Economics and Political Science, United Kingdom. Sofia Moreno- Perez is an independent consultant, Madrid, Spain. Email: M.Ellis1@lse.ac.uk Introduction eHealth encompasses a growing range of demonstrably cost-effective policies, services and equipment available to support greater independence for European Union (EU) citizens. The term embraces telecare, telehealth (itself embracing telemedicine) and health informatics. As illustrated in Figure 1, there are overlaps. Nevertheless, these sub- divisions are useful, but a problem is they are not yet sufficiently inter-connected in the real world of health and social care. Telecare has now been a part of the policy dialogue in health and social care for over two decades. As with many other eHealth innovations, e.g., electronic patient records and electronic prescribing, it is experiencing a particularly slow and painful maturation. It is hard to argue that telecare has achieved in any substantial sense the status of a mature or ‘taken for granted’ component of systems or pathways of care for people living in their own homes. One reason may be that, in some EU Member States, social care and health care are administered separately and telecare pathways, which should link services are impeded by that boundary. Technology that facilitates more efficient procedures needs to be embraced and existing organisational structures adapted accordingly to achieve cost-effectiveness and better outcomes for service users. Telehealth encompasses those health care services delivered via telecommunications media, over any distance. Service delivery may be done in real time or stored and broadcast through media, ranging from simple telephonic conversations and Internet to video conferencing across national boundaries. The services could involve consultation, patient monitoring, diagnosis, prescription, treatment or even Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 21 surgery. Real-time telemedicine services may involve tele-cardiology, tele-dentistry, tele-mental health, tele-neurology, tele- nursing, or tele-rehabilitation. Outwith telemedicine, but within telehealth are remote keep-fit systems and health apps, etc. Many telehealth systems encourage self-care and personal responsibility for areas of health such as blood pressure and sugar level measurement which enable people to be treated at home, and so reduce hospital attendance and costs. 1 Health Informatics facilitates the collection, analysis, and dissemination, as well as access to health information. Thus, access to their medical data by patients, provided for 300,000 people in Estonia, 2 improved patient health outcomes and decision making, reduced health care costs, travel time, redundant diagnostic procedures and tests, waiting time and led to improved early diagnostic, administrative and communication capabilities. Other EU countries have been slower to adapt their systems and thus effect the improved outcomes and efficiency savings. Some media scare stories, which attribute a ‘big brother’ or intrusive nature to open access medical records, have discouraged development. Our review has disclosed a wide variation in levels of adoption of eHealth services in the EU. This article identifies and discusses some of the reasons. We argue that there are three key components that need to be coordinated in every eHealth initiative: 1. Suitable technology 2. The existing models of care with which the technology must integrate or which must be adapted to increase the efficiency enabled by the technology 3. The broader institutional settings, and the mobilisation of relevant interests, users and workforce personnel, around eHealth Facilitators and Blockers User-friendly technologies are now available in many areas of eHealth and their conceptual utility has been demonstrated. 3 User’ technology both develops and changes quite rapidly. It is generated by an active community of eHealth innovators who are eager to place new technologies, via the “Digital Industry,” literally into peoples’ hands. For example, the thriving App development sector has shown strong interest in consumer health as a core market. New products and services are continually being delivered. Both providers and the users need to be competent to appreciate both the capability and the limitations of the technology on offer. Education is the key to this, and the lack of it is the most apparent and continuing reason for both variable and slow introduction of eHealth services. ‘‘ Better-informed, bolder, timely decision-making is needed Currently, the existing supporting infrastructures for user technology, such as the reliability and availability of digital networks, accessible constellations of expertise and education, and supply chains with which ‘user’ communities (individuals, families or local care commissioners and providers) can confidently connect, is weaker than the current status of ‘user’ technologies themselves. However, it is encouraging that models of care and their funding in many EU countries are moving in directions that seem increasingly compatible with eHealth provision. Patient-centred care, which in part may involve the shift of health resources to primary care, and various efforts across Europe to integrate primary health care with social care are two examples. Innovation in models of care should be driven both by the reality of demographic change and by the increasing proportion of the population living with multiple chronic conditions. Changes are, in part, also driven by a growing perception that the old ways will soon become impractical both financially and organisationally. Provision of eHealth services can offer cost-effective solutions which users approve, as shown in Scotland and Newham. 4 Figure 1: eHealth and some of its constituent sub-fields eHealth Telecare Health Information Telemedicine Telehealth Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 22 Yet policy decision-makers are at times still not being presented with a clear, balanced case, including the cost- effectiveness of eHealth services, and so hesitate to agree changes for fear of increasing costs. Of course, an eHealth service that is not a better (cheaper, more reliable and more user-friendly) way of doing what we do now should not be considered. But eHealth services may, while involving radical or disruptive shifts away from current procedures, result in better services. Initial disruption leading to better future outcomes should be accepted. Better-informed bolder timely decision-making is needed. ‘‘ integrate appropriate multiple interest groups A large scale project in the United Kingdom, the Whole System Demonstrator (WSD) 2011, provided compelling evidence that telecare and telehealth were viable solutions for older and disabled people living independently and taking control of their own health and care. Furthermore, the WSD programme found that, “if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in Accident and Emergency”. 5 A follow- up scheme, “3MillionLives”, 6 offered services to 3 million users, but was then shelved. This is an example of a national government applying the brake to eHealth service development. In September 2014, NHS England published a new proposal, Technology Enabled Care Services (TECS), 7 which asks for Commissioners ‘to support the programme that takes the NHS into a new and exciting technological era that will help empower patients and improve health outcomes’. There is a very real danger that different schemes being introduced will not be inter-compatible or permit easy transfer of data. One section of TECS emphasises the need for cost-effective data. In consequence TECS is funding the evaluation of stakeholder schemes. Some innovative examples There are many examples of the effective- ness of eHealth services. We set out a few of them below. In 2010, the Scottish Government launched Reshaping Care for Older People,  8 including a national Telecare Development Programme to help people live at home longer – Scottish Patient at Risk of Re- admission and Admission (SPARRA) 9 – resulting in an estimated gross saving of €110.6 million (£78.8m) up to the end of the financial year 2013. Scotland is planning a coordinated system between health and social work, introducing legal requirements for these services to work together. In England, the East London Foundation Trust, used an eHealth service which provided for 353 people, with long-term conditions, to be treated at home rather than in hospital – ‘a virtual ward’ and reported a total gross saving of £597,940 (€839,500) and a total net saving of £162,826 (€228,600) over a twelve month period. In an earlier twelve month period, where 1,000 people were treated at home, approximately £500,000 (€702,000) was saved. Users not only approved of this eHealth service, but they had fewer infections, did not block hospital services, did not require transport to and from hospital, and were able to maintain normal contact with friends and families. In Sweden, 3 mobile telephones provided to people with mental health problems enabled them to select services on medication, housing, etc., and have greater direct control of their own health, reducing the need for hospital visits. In England, some general practitioners (GPs) have already established an open access system for their patients to access and read their own records. The Royal College of Physicians of London acknowledges that such access is cost- effective and encourages self-care. Their Landscape Review with NHS England will highlight the variability of introduction. Expansion is expected later in 2015. In Spain, the Andalusian e-Health Strategy 10 has enhanced the quality of life of its citizens and the coordination of their health and social carers through the integration of health information. It is cost-effective: ePrescription enabled early saving of €6.3 million; hospital admissions decreased from an average stay of 7.5 days in 2008 to 7.16 in 2012 and consultations in family medicine reduced by 16.11% from 2007 to 2012. In Catalonia, the government has established integrated technology (ICT) services, which are now well known to users and service providers. The main Pulmonary Medicine Department reached a significantly lower (10%) rate of early readmissions after discharge than those observed in the whole region (15%), in Spain (30 – 35%) or at EU level (30 – 35%), a pattern that is being repeated elsewhere in Spain. In 2007, the EU Ageing Well in the Information Society Action Plan acknowledged the demographic change in the European Agenda. The focus on the ageing population forced a change of vision, from the traditional acute illnesses approach to chronic conditions. eHealth appears as a necessary enabler of the change from reactive to preventive medicine to embrace the integrated ‘care & cure’ approach. Many initiatives have been launched at European political level with the aim of fostering a triple win: better quality of life for citizens, improved sustainability for public services, and new opportunities for the European Industry. Another EU report, Excellent innovation for ageing. A European Guide (2013), 11 includes more than 30 examples from twelve countries classified from one to four stars, although none has yet achieved the highest ranking. The need for more action EU officials are concerned that despite acknowledging changes in demography, too few Member States have addressed the need to plan and introduce eHealth services. At a March 2015 EU Summit, 12 the EU Digital Commissioner stressed the need for more digital services. “We Eurohealth INTERNATIONAL Eurohealth incorporating Euro Observer — Vol.21 | No.4 | 2015 23 want to continue this program, secure and deepen it, and for the quality of life of elder European citizens”. A broader understanding across the EU of what eHealth is, what it can do, and how it serves various interests and generates value, is urgently needed. While both technology and models of care matter, eHealth’s future is ultimately most dependent on its being able to integrate appropriate multiple interest groups. Thus, users and their representatives should press for greater access, involvement, and training themselves. In addition, special emphasis needs to put on the education of all health care professionals in computer/ communications technologies and, particularly, on its inclusion in their initial education syllabuses. Conclusion Where better education of the workforce, policy makers and governments exists, eHealth services have proved highly popular with users and are cost-effective. We are convinced that faster progress in the introduction of these services depends on placing more emphasis and more resources in appropriate education at all levels. This topic was addressed at European Knowledge Tree Group (EKTG) debates in 2015 at the House of Lords in London and the Ambient Assisted Living 13 Forum (AAL) in Ghent. EKTG are now planning for a Symposium in January 2016 in London. References 1 Padmanabhan R. Newham Model for Integrated Care. Presentation EKTG Symposium, House of Lords, London, July 2015. 2 Aaviksoo A. Estonian eHealth experience: combining efficiency & trust. Presentation EKTG Symposium, House of Lords, London, July 2015. 3 Ryden M. Assistive Technology for Persons with Psychiatric Disabilities. Presentation WFOT Congress Japan, 2014. 4 Martin M. Telecare development. Scottish Government Supporting People Matters. Issue 24, June 2007. Available at: http://www.gov.scot/ Resource/Doc/179830/0051123.pdf 5 Department of Health. Whole system demonstrator programme – Headline Findings. December 2011. Available at: https://www.gov.uk/government/ uploads/system/uploads/attachment_data/ file/215264/dh_131689.pdf 6 Department of Health. A concordat between the Department of Health and the telehealth and telecare industry. January 2012. Available at: https://www. gov.uk/government/uploads/system/uploads/ attachment_data/file/216757/Concordat-3-million- lives.pdf 7 Corlett K. Newham Model for Integrated Care. Presentation EKTG Symposium, LSE, London, 2013. 8 Reshaping care for older people web site. Available at: http://www.jitscotland.org.uk/action- areas/reshaping-care-for-older-people/ 9 Soto Alba JD. The Andalusian eHealth Strategy. Presentation Norwegian eHealth week, 2014. Available at: http://grimstad.uia.no/ehelse/ eHelseUKA2014/Presentations/Andalusian%20 eHealth%20Stragegy_Jose_Daniel_Soto.pdf 10 NHS Scotland. Scottish Patients At Risk of Readmission and Admission: A report on development work to extend the algorithm’s applicability to patients of all ages, June 2008. Available at: http://www.isdscotland.org/Health- Topics/Health-and-Social-Community-Care/ SPARRA/2008_06_16_SPARRA_All_Ages_Report. pdf 11 European Innovation Partnership on Active and Healthy Ageing. Excellent innovation for ageing A European Guide, 2013. Available at: http://www. ehealthnews.eu/images/stories/pdf/excellent_ innovation_for_ageing.pdf 12 Innovation for Active & Healthy Ageing. Final Report, European Summit on Innovation for Active and Healthy Ageing, Brussels, 9 –10 March 2015. Available at: http://ec.europa.eu/research/ innovation-union/pdf/active-healthy-ageing/ageing_ summit_report.pdf#view=fit&pagemode=none 13 Active and Assisted Living Programme web site. Available at: http://www.aal-europe.eu/ New HiT on Switzerland By: C De Pietro , P Camenzind, I Sturny, L Crivelli, S Edwards-Garavoglia, A Spranger, F Wittenbecher, W Quentin Copenhagen: WHO Regional Office for Europe Number of pages: 288, ISSN: 1817-6127 Freely available for download at: http://www.euro.who. int/__data/assets/pdf_file/0010/293689/Switzerland-HiT. pdf?ua=1 Life expectancy in Switzerland (82.8 years) is the highest in Europe after Iceland. The Swiss health system offers a high degree of choice and direct access to all levels of care with virtually no waiting times. As this new review of Swiss health care makes clear, public satisfaction with the system is high and quality is generally viewed to be good or very good. Despite this positive assessment a number of challenges remain. In particular, improving financial protection and fairness of financing is becoming important because rising premiums and an exceptionally high share of out-of-pocket payments place an increasingly large financial burden on households with lower and middle incomes.