Denz: EU eHealth strategies ‘not connected to reality’

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The EU’s top-down agenda setting on eHealth strategy is not connected to reality, argues the European Health Telematics Association (EHTEL) in an interview with EURACTIV. 

Dr. Martin Denz is the president of the European Health Telematics Association (EHTEL). 

To read a shortened version of this interview, please click here.

What is telemedicine and what is its relation to eHealth, as we generally just hear about eHealth? Is telemedicine about the delivery of health care whereas eHealth is more the overall infrastructure? 

eHealth is as much about policy framework as it is about a large scale infrastructure and a precondition to apply health care with modern tools. Telemedicine or telehealth is about implementing health care on the ground by using modern tools. 

The vast majority of EU countries have eHealth strategies but they are absolutely not connected to the healthcare delivery reality. 

The UK National Health Service’s (NHS) multi-billion – officially £9 billion but more than £20 billion in real terms – project on the informatisation of health care, for example, is great but completely driven by politicians and business engineers and now, as they want to spread it out to health professionals, they have a very turbulent landing phase. 

Telemedicine is just about reconnecting the top-down process with the bottom-up. The whole eHealth activity is on track. We have done the right activities, we have accomplished a marvellous agenda setting but results show that we now urgently need to reconnect health care. Because health care is healthcare delivery and activities between healthcare professionals and patients. 

What’s the current state of telemedicine (care at a distance) in the EU 27? 

Until now we have had different and even simultaneous and parallel stages of telemedicine and it has been mainly driven by medical specialists and hospitals or centres. 

There are three stages of development. The first is about the classical niche activities, such as teleradiology and telesurgery, which are still not population-based nor oriented towards modern services but around structures, mainly hospitals and medical specialities. These activities have never really been connected to the overall health care delivery process. 

Since end of the nineties we have seen a surge in ‘add-on activities’. These are about existing healthcare structures and processes which begin to adopt e- and tele-technologies, such as teleconsultation, -monitoring and -counselling as well as disease management. This is the current stage of development we are in. But there is still no intention to change structures or healthcare systems. It is just continuing health care as we have delivered it until now and accelerating or optimising it by additionally using ‘e’ or ‘tele’. But it is not combined with reflection on the reorganisation of health care. 

The third stage is the crucial point. We need to gear up towards integrated service delivery. And this is about a paradigm shift. Until now we were focused on curing diseases and gathering more acute care understanding, thus geared more towards a medical condition approach and less towards the health-enhancing one. We now need to enlarge the concept from the traditional method of disease management towards new and innovative concept focusing more on personal health behavioural support. 

Your recent press release highlights the role of SMEs in the delivery of future health and social care through telemedicine. Can you explain how and when this may happen? 

The SME concept is nothing new. It is just that we lack awareness of it because the approach in eHealth until now was first, top-down (policy understanding) and second, heavily IT industry-oriented. Therefore, we have completely missed out the SME part of the process. 

Health care always occurs in an SME environment and even in a local environment. We can of course talk about organisational and infrastructural aspects which can be systemised on a larger scale but health will always be delivered at local level. The key point is to develop organisational models which are better adapted to deliver integrated health and social services on a local and regional level.

Coming back to the practical consequences – if I am talking about new healthservice industry – it reflects the occurring paradigm shift [towards integrated health service delivery] and it is already happening. There are already elements of this new approach. The old approach was the isolated medical doctor not connected to the overall processes and the other approach was about IT industry which had absolutely no understanding of culture and services in health care. So it is about finding a third way in between. 

We already see projects of integrated health care delivery where the patient is supported over the whole care cycle – either acute or chronic care – and this is driven by innovative health professionals who have a new and better understanding of management, about processes and also about IT integrated into their professional activities. On the other hand, it is also a new kind of IT industry more geared towards providing infrastructure and systems that are flexible and adaptable to the needs defined buy those new innovative, entrepreneurial health professionals. 

Can you explain give me some examples of telemedicine services delivered by SMEs? 

SMEs are already delivering telemedicine services. We will never have ‘the complete integrative health care provider.’ and it also does not make sense, but elements of this puzzle are already here. 

On the one hand, the US Kaiser Permanente for example, as part of their integrated health care delivery plans, has an excellent understanding of continuity of care and integrated services. We also have telehomecare activities in the US and Europe. 

In the Netherlands we have the example of “care groups” for chronic disease management, which are independent legal entities directly contracting with payors. 

Then we have the whole breed of companies which are already delivering healthcare activities in the field of disease management, such as Vitaphone, which delivers telemonitoring support in call centres specifically for heart patients. 

In Germany we have this Integrierte Versorgung – which means integrated healthcare delivery. It is still disease-oriented but is trying to build up continuous support of patients. 

The Swiss Medgate is a call centre operated by highly skilled and trained medical doctors, who provide, by phone, diagnostics and even therapeutic interventions. Then there are also innovative professionals connecting general practitioners to allow them to work in networks, instead of isolation. It is about integrating healthcare systems and not any IT devices. Integrated practice units is also upcoming. 

Michael Porter, in his ‘Redefining Health Care‘, namely showed from an economic point of view that we are too oriented towards cost-containment instead of using IT to enhance quality and to deliver better services to have better health outcomes over the full cycle of health care. 

Who will pay for these services delivered by SMEs? 

This is exactly the point. It is not about reshaping the health professional to become telemedicine specialists, but for them to use the tools, like the telephone, in the delivery of care. So, the whole question about cost is a wrong approach, because in health care we are currently only talking about cost and not about quality. 

Of course, first, we need to change the incentives and create incentives to invest in innovation and high medical quality ouptput. Secondly, there will be a double development – the new service delivery activities will be reimbursed by a mix of statutory reimbursement and others, not only private reimbursement by individual patients, but there will also be new business plans and logic. 

So, if we are trying to deliver and enhance health and not only cure diseases, it is also about additional activities. Just look elderly citizens at home, who of course often are patients but do not define themselves as such, because it may only be, for example, about high blood pressure. So, it is important to have high quality nurses and doctors, but the other part of healthy living and keeping people healthy is also having food delivery or someone cleaning at home. This is at least as important, if not more important than an isolated medical action. 

For this payors have to rethink how and for what they want to pay: fees for isolated service acts which are not sustainable from a medical and economical point of view, or for a patient’s overall outcome (e.g. capitation fee) which will generate a better medical result and at the same time as a “welcome side-effect” a positive impact on costs! And last but not least, economical effects should not only be measured at a local administrative level, but at its overall effects on national economies. 

So, thinking about telehomecare, we can imagine having an integrated, holistic, very practical approach to living. You can combine food delivery with telehomecare services – thus enlarging the approach we have had until now. We are still discussing on how to finance this – so if we are in an integrated health care delivery organisation in the widest sense of the term, this organisation will automatically perceive that if they deliver overall services, their insured patients and people overall are in a better health and by this we do have cost reduction. 

Making isolated medical interventions is not sustainable at all. This is the point – we have to use technology to deliver integrated services over the full cycle of care. 

So, the medical care part could be eventually reimbursed whereas the social care services would be paid for by the citizens? 

Cross-financing and subsidising are of course a solution, but financing will depend on new business models. 

What are the prerequisites for booming health and social care service delivery by SMEs? 

Our recent report shows what has not been done. In this report we addressed the persons in charge of eHealth strategy in all EU countries national ministries of health. We asked them how telemedicine is situated in their strategy and how they are implementing it. The answer was rather weak. We have a lot of nice eHealth strategy papers oriented towards implementation, but in reality all eHealth strategies are not addressing or suggesting procedures on how to implement eHealth. Some elements are already going on, but completely independently. This is what I mean when I say that we have a top-down agenda setting, which is fine, but which is not connected to reality. 

We wish to show what’s already going on and demonstrate that there are already pieces of the puzzle being implemented to reconnect the policy and the delivery levels. 

Secondly, we of course need to do something concrete. For this purpose EHTEL is launching a taskforce on sustainable telemedicine to which it will invite all those organisations and people that are already building on elements for this third way. Its first priority will be disease management and long-term care and to bring together private companies and national organisations to define methodologies and common approaches in view of, for example cross-border care. 

The problem in Europe on telemedicine is that we are all conducting isolated pilot projects, which have no sustainability and are not even defining telemedicine coherently. We can’t build a large market on this, if the current projects, even high-level, are conducted in isolation. 

What is your main message in the eHealth conference? 

The EU has perfectly done its homework around 2005-2006 and now has an overall understanding and framework for eHealth and we also have different strategies – but this is just an agenda-setting to now undertake the concrete implementation. 

eHealth is the overall framework for policy and conceptual approach as well as an infrastructure and architecture and there is still a lot to be done. Part of this infrastructure is telemedicine and telehealth. So we now just need to move towards implementing health care delivery based on the possibilities offered by the whole eHealth infrastructure and architecture. 

A major thing that EHTEL is also trying to do is to bridge the gap between policy makers, IT providers and health professionals who all understand health and health care differently. We do not represent isolated interest but provide a platform for all stakeholders in order to achieve a common goal of integrated services. 

It is about integrating different systems – not IT systems but overall systems, human and organisational systems. We already have all possible IT solutions, so technology is not the problem. The problem is to have a common understanding of our organisation of health care and healthcare systems overall and its more human, redesign and organisation development aspects. Therefore my personal definition of eHealth is that it is “change management of health care systems by using ICT”. 

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