New EU laws allowing patients to travel across borders for health care will be key for the development of e-health services in Europe, according to policymakers. However, incompatible IT systems remain a major obstacle to fulfilling that promise.
Negotiations on the Cross-border Healthcare Directive are expected to be wrapped up by the end of the year and could pave the way for a revolution in health technology.
First, a number of barriers must be overcome, including the lack of interoperability between IT systems used by health services. In some hospitals, the computer software used by the radiology department is not compatible with the system used in the emergency department.
On a grander scale, sharing test results and medical imaging between hospitals can prove challenging, making cross-border cooperation a real challenge. On top of this, language and terminology differences, as well as data protection concerns, make sending information between member states problematic.
There are also calls to amend the new directive to encourage the development of virtual "reference networks," with industry lobbyists and patient groups arguing that the days of "bricks and mortar" centres of excellence could be over if experts can connect online and access patients from anywhere.
One of the promises of eHealth is to allow patients with rare diseases to access specialist centres from anywhere in Europe. This would save time, money and stress associated with travelling to see specialist doctors. This, say patient advocates, can only be achieved if there is investment in equal education levels and Internet access.
What will it cost and who will pay?
A conference at the European Parliament last week (12 October), sponsored by the Association of Chartered Certified Accountants (ACCA) and Hanover Communications, heard that studies have demonstrated clear cost savings from applying technology to health care.
However, there is some scepticism that hidden costs – such as training staff – will gobble up some of the money saved by cutting down on duplication and travelling. The prospect of creating new roles, such as "telemedicine assistants", will also require reforms that have historically proven difficult when faced with entrenched professional cultures.
Getting doctors and nursing staff on board will be the key factor that decides whether eHealth succeeds, as will improving health literacy and earning patient trust in new systems, according to stakeholders.
Clauses in the Cross-border Healthcare Directive covering eHealth were watered down by EU health ministers but have been strengthened by MEPs who see the new rules as a chance to boost quality of care, save money and stimulate a new market for high-tech companies.
Bulgarian MEP Antonyia Parvanova (Alliance of Liberals and Democrats for Europe), who hosted an eHealth event in the Parliament on 28 October, said she is convinced that eHealth can contribute to patient safety and innovation in the health technology sector. However, she said interoperability between systems remained a huge challenge. She said technology is now an indispensible part of health care and can provide real added value if national and European authorities cooperate.
Parvanova added that while there are excellent examples of best practice in how eHealth can be applied, the Parliament has to take account of the situation across Europe.
"Some rural areas have no doctors and poor Internet connectivity and we must consider those patients as well as those with access to top class services," she said.
Patients will still need someone to interact with, said Parvanova, and the public will not be satisfied if they are expected to talk to a screen. eHealth would have a profound impact on the health workforce and this demands more attention, she added.
Discussing the Cross-border Healthcare Directive, Parvanova warned against viewing it as a panacea for Europe's health problems. She said the European Council had weakened what the directive says about eHealth but the Parliament is determined to restore this and make sure it survives in the final compromise text.
"We are not trying to intervene in the financing of health services – that is for member states – but we believe eHealth can boost access for patients in need of specialist care," she said.
John Dalli, EU commissioner for health and consumer policy, said new technologies can help put patients' rights, patient safety and access to health services at the heart of policymaking.
"Technology will also save health professionals' time if they don't have to move around from one hospital to another to provide services. We can have a few centres of excellence accessible even to those who do not live nearby. For patients with rare diseases this is particularly important. We can have focal points of expertise that can then deliver services to all corners of Europe," he told EURACTIV.
The commissioner said the main problem holding back progress is interoperability of eHealth technologies.
"Systems must be able to speak to one another within hospitals, between hospitals and ultimately across borders. Political will is needed to make eHealth a reality. Member states are responsible for health but we must bring people together to discuss cooperation if we want to make the most of eHealth and cross-border collaboration. We need interoperability and information exchange in order to ensure continuity of care and safe emergency care delivery. I believe interoperability can come about without infringing on national competence in the area of health. I will also seek to embed e-health in the new innovation partnership on healthy ageing announced by the Commission last week," he said.
Dalli added that he hoped the consensus reached at the end of the cross-border health debate will set the right terms for a legal framework for implementing eHealth.
"When investing in healthcare, sustainability is essential. In economic terms, eHealth can help make savings by cutting out duplication of work and reducing the travelling costs for patients. That's on top of the qualitative societal benefits it will bring for service users," he said.
Neelie Kroes, EU commissioner for the Digital Agenda, said connectivity is crucial if Europe is to reap the benefits of eHealth, and legal certainty is also key.
"The directive on patients' rights in cross-border care is instrumental in this regard. I attach a great deal of hope that an ambitious text for eHealth will emerge from the final discussions in Parliament and Council about this directive," she said.
Dean Westcott, deputy president of the Association of Chartered Certified Accountants (ACCA), said an EU-backed project launched in by the accountancy organisation has demonstrated the value of new health technologies. The research, based on a telecardiology programme in the Lombardy region of Italy, showed how new models of disease management could reduce costs and improve services for patients.
"Health systems are under pressure from ageing population, rising costs of new technology and medicines, heightened patient expectations and global economic challenges. Everybody is looking for solutions. We, at ACCA, firmly believe eHealth has an important role to play in delivering efficient and effective health care," he said.
The telecardiology project allowed heart problems to be detected early by collecting data from patients in the community and sending it for analysis by hospital-based experts.
"This provided firm evidence of a clinical benefit of telemedicine applied to cardiology and set out a roadmap for more focused use of healthcare resources and can help reduce inpatient and outpatient hospital visits. For GP patients, it meant earlier identification of problems which potentially helps avoid costs in the long run," said Westcott.
He said citizens benefit from less travelling and fewer hospital stays which results in less anxiety. "We showed significant cost benefits, increased quality of care, cost effective means of delivering health services. The scope for cutting costs while improving quality is absolutely enormous," Westcott said.
Dr Simonetta Scalvini, responsible for telemedicine services at the Fondazione Salvatore Maugeri, Italy, said it is time to stop caring for diseases and start looking after patients. She said there is evidence that telemedicine can reduce mortality while increasing quality and cutting costs.
However, Scalvini said it is now time to investigate the optimal business model and to work on patient education in order to ensure buy-in from service users. She also noted that "the biggest problem" in applying new technology is resistance from doctors. The medical profession must change its mentality, she said.
"The cost savings from tele-monitoring arise from avoiding hospital visits. This requires an initial investment but will have long-term benefits," she said. The Lombardy region has recently introduced reimbursement for home monitoring services and is now testing telemedicine for cardiac, lung, rehabilitation and hospice care, according to Scalvini, who said the systems can improve patient compliance with treatments.
Nicola Beddington, director of the European Patient Forum, said setting the right framework for health technology is enormously important and that the Cross-border Healthcare Directive will become the bedrock for eHealth. She said she was pleased that MEPs had reinforced the importance of interoperability after member states had watered down this element of the new law.
Beddington stressed that patients must be involved at every level if eHealth is to work. She said terminology and semantics will also be important in communicating the idea behind eHealth to patients all over Europe.
"Terms like eHealth and telehealth mean nothing to most patients. We need to earn their trust and build confidence among patients and health professionals. We also have to realise that privacy and security are fundamental to patients," he said.
However, Beddington added that privacy issues are more sensitive for some patients than others, noting that people with embarrassing or life-threatening conditions might be more concerned by privacy than others. "It's not one-size-fits-all. We need minimum acceptable standards to help roll out health technologies and must also pay more attention to health literacy issues," she said.
Petra Wilson, senior director of the European Health and Care Team at Cisco's Internet Business Solutions Group, said eHealth can do a great deal to improve patient access to health care. Discussing the Cross-border Healthcare Directive, she said European reference networks – which help health professionals to share expert knowledge – need not be made of bricks and mortar.
"European reference networks shouldn't be buildings. Insofar as possible it should be virtual. We should be using technology to ensure we only travel where absolutely necessary," said Wilson, calling on MEPs to ensure that this is reflected in the final text of the Cross-border Healthcare Directive.
Dr Pierre Espinoza, a doctor at l'Hôpital Européen Georges Pompidou, said European reference centres can be developed using video consultation. He was part of a six-month pilot project in Paris which linked a specialist geriatric service with a large teaching hospital using technology that allowed the hospitals to share images and have live video interaction with patients. It meant specialists could review ECG results remotely while a telemedicine assistant helped the patient to interact with the technology.
"One of the main benefits is that a specialist hospital can be integrated into a big university hospital. We have used this system to facilitate hundreds of consultations by 20 specialists who share the telemedicine station. Dermatologists can see patients' bedsores, cardiologists can see patients and review their ECG scans. All the while, the patient is interacting with the telemedicine assistant – a new job for a healthcare professional who can use all the new technology available in this field. For geriatric patients with dementia, it's particularly important that they are dealing with a person rather than just being asked to talk to a camera," he said.
Dr Espinoza said the technology has helped to break down silos between medical disciplines and cut patient journey times down from five hours to just 30 minutes.
Uwe Buddrus, managing director of HIMSS Analytics Europe, said best practice examples show that ICT can cut costs and boost standards of care but it does not always lead to improvements. Hospitals, he said, still have a long way to go to make the business case for investment because they lack the tools and information to support their decision.
"The worst thing you can do is implement something that doesn't have buy in," said Buddrus.
Pascal Garel, CEO of HOPE, the European Hospital and Healthcare Federation, said he is generally positive about what technology can do to change health services but warned there is a long way to go before the potential is realised. Based on experience working in hospitals, he said health workers have seen a series of technological failures over the years which can breed a degree of scepticism.
"We have a fragmented system –within hospitals, between hospitals, and between health and social services. It is feasible to reduce the amount of time spent in hospitals but we have not yet seen this applied in all areas. We have to change very strong professional cultures in hospitals, which is difficult. There are a lot of vested interests but patients have been travelling for care for years and we have to address this," said Garel.
Monika Kosinska, secretary-general of the European Public Health Alliance (EPHA), an NGO, said technology cannot be an end in itself and warned against deploying "technology for technology's sake". Interoperability, she said, is a huge barrier within hospitals, within regions and between countries.
Kosinska warned that health inequalities will persist unless all patients are equipped to access eHealth services. This will mean stepping up health literacy programmes. She also warned of hidden costs involved in making the transition to delivering care in a new way.
"We have to ask whether there are hidden costs. What will it cost in terms of training and retraining? Staff are the biggest cost so we must ask what new eHealth technician roles will mean for staffing budgets," she said.
Anna Lefevre Skjöldebrand, chief executive of Swedish Medtech and chair of Eucomed's eHealth taskforce, said the problems in capitalising on eHealth are not technological. She said privacy and legal issues must be addressed if technologies are to be deployed, adding that health care has been slow to embrace change.
"To young people, the world is global. Information is available everywhere. But go to hospitals and it's not always possible to view your records electronically, even though the technology exists. We need a patient-centred healthcare system and to ensure that health professionals are benefiting from eHealth," she said.
Fabian Zuleeg, chief economist at the European Policy Centre (EPC), said a great deal of emphasis in the debate on eHealth has been on the need to invest in order to save money. However, he pointed out that public financing will be very scarce in Europe for some time to come.
"Where will the investment come from? We have to look at the corporates, public private partnerships and the profit-motive in the provision of health care. Some of the funding may have to come from the patients themselves," he said.
Florian Lupescu of the European Commission's directorate-general for the information society, said patients crossing borders have the right to receive the best possible care but Europe must ensure the appropriate mechanisms and legal framework are in place.
"eHealth can make this possible. The possibility for systems to understand each other despite languages, and cultural differences is a key asset we cannot afford to miss. We have the political commitment from health ministries, strongly stated in the Council conclusions last year. We have the support of stakeholders, patients associations, professionals, consumers groups. They all acknowledge and value the key role of technology in improving citizens' lives and supporting dynamic and modern healthcare systems. We know that eHealth is a crucial economic sector employing many Europeans and with a huge potential for growth. Now we need the legal certainty," he said.
Lupescu said legal uncertainty is one of the main barriers and called for the directive on cross-border health to be "clear and ambitious", saying it could open the way to innovation in health care if it is strengthened.
"We need the instrument to enable the connectivity of systems. We need to bring the technical achievements into the mainstream of decision making and legislation. We need technical developments to serve research today, for better and more effective medicine tomorrow," he said.
Luc Maes, programme manager for eHealth in the Belgian government, said member states need a shared long-term vision but should also seek out "quick wins" to help gain trust by showing how health technologies can be used in daily life.
He said the Belgian example – with its different languages and cultural differences – is a microcosm of the challenges Europe faces in deepening connections between countries.
"We decided there would be no central storage of healthcare data but worked to ensure safe electronic data exchange between all actors in healthcare," he said.
He proposed using the open method of coordination to work out comment conceptual framework underpinning eHealth in Europe, and then allow member states to develop their own action plans in line with these agreed principles.
Daniel Forslund, deputy director of the Health Care Division at the Swedish Ministry of Health and Social Affairs, said eHealth solutions can be a catalyst for change throughout the system but more must be done to communicate with the public about its potential.
"Let's face it, we've been pretty poor at describing eHealth to the public and health professionals. You don't win elections talking about interoperability standards – we have to think about how to talk about this subject and show how all the bits and pieces of eHealth reform fit together. We have to show that the cost in lives and money lost will be much higher if we don't invest, and we need to give this message to politicians," he said.
Forslund said cooperation between member states is essential and there is a growing acceptance that "we cannot solve these problems one country at a time".
Health systems are primarily the responsibility of the member states, but in some cases, as confirmed by several European Court of Justice (ECJ) rulings since 1998, EU citizens may seek health care in other member states, with the cost covered by their own health systems.
This can occur in instances where health care is better provided in another member state, for example, for rare conditions or specialised treatment. It may also be the case in border regions, where the nearest appropriate facility may be situated in another country.
However, health services remained excluded from the general Services Directive in spring 2006 (the so-called 'Bolkestein Directive'), despite the many ECJ rulings showing that they are to be considered as an economic activity and that Community law applies to them.
To provide clarity and legal certainty on the issue as well as support for co-operation between national health systems, the European Commission decided to establish an EU framework to ensure cross-border access to healthcare services.
eHealth, one of the priorities of the EU's i2010 programme to boost innovation and jobs, aims to provide user-friendly and interoperable information systems for patients and health professionals across Europe.
Finding secure way to share information is key to making cross-border healthcare work, but there are several technical and semantic hurdles to be overcome.
- 27 Oct.: European Parliament public health committee to vote on amended Cross-border Healthcare Directive.
- Jan. 2011: Full sitting of European Parliament to vote on directive.