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Health is just one but an important component of Cross-Border e-Government Services (CBeGS) for administrations, businesses and citizens. This is primarily addressed by what is known as eHealth covered by the European Commission’s (EC COM 356) e-Health – making healthcare better for European citizens: an action plan for a European e-Health area issued in April 2004. This segment is actively being addressed by a large eHealth community across Europe and beyond. The main areas in common with CBeGS include:
health insurance domain / health insurance card
health tourism
patient / citizen / professional identification
interoperability of a secure infrastructure across Europe
patient, citizen & professional mobility
quality, equity and solidarity of care available
access procedures for all
motivation and incentives to use and make use of
health data for public administrations and businesses
Problem Statement.
Health is one of the public services which has a keen interest in the need for modernisation which must encompass looking beyond national boundaries. At the heart of this are the implementation of information flows between co-operating administrations and healthcare deliverers; availability of interoperable infrastructure and horizontal platforms between national IT systems and the encouragement of cross border services of direct and practical benefit to patients, citizens and businesses.
Today neither eHealth nor CBeGS are ready for each other – there are major disconnects between the two threads and some specific areas which require urgent and broadly based action:
open and affordable networks (common tariffs)
common datasets, standards, multi-lingual and clinical nomenclature
harmonisation of health information sharing and transfer policies
electronic health record systems across Member States
collection and availability of clinically acceptable data
practical user requirements statements (both clinical and citizen)
awareness and education programmes, networks and fora to encourage involvement and support of the relevant stakeholders
Action plans to provide industry with the basis for investment programmes
A CBeGS community linked to, and working with the eHealth community
Status Quo
The healthcare sector is the subject of active attention from regional and national governments throughout Europe. The main issues in relation to Information fall under three headings:
Access
Quality
Costs
Citizens (and all other stakeholders) want more and better information and they want simple secure access to this information wherever they may be (in Europe and beyond)
Healthcare is safety critical. Patient safety, risk management, clinical and managerial governance are very much in the spotlight of attention.
Demographic changes in Europe are well documented but have significant implications for healthcare. More high usage consumers, a declining percentage in the workforce supporting healthcare costs, the growing incidence of chronic disease, new cultural and lingual groups, dispersal and mobility.
Healthcare costs continue to rise despite all the efforts of governments and others.
These are not new issues but they are becoming more immediate, better understood by citizens and voters, and in some places they are becoming unmanageable in the current environment. The information industry has for many years been looking to address these issues yet it becomes increasingly clear that technology is not on the critical path. In broad terms the technology required by healthcare in terms of information is available; most if not all of it is already being used in some form in other sectors and Internet provides a ready made working platform. Yet IT investment is almost the lowest of any major sector (with the sole exception of construction) and only a third of that for government.
This is not to say that little has been achieved. There are many strong initiatives across Europe from the Nordic countries, UK, Netherlands, Slovenia and in the Andalucian region of Spain to name a few.
Europe has been active for many years in the areas of standardisation, the use of cards and, telemedicine. The recent commitment of the EC and the ministers of the Member States to eHealth and the Action Plan is a major step forward. There are groups within the eHealth community providing some vehicles for discussion, skills and experience transfer ( eg EHTEL, EHMA, ISFT, …). There is work already under way in many of the Member States and in the EC through the Interreg, IDA, & TenTelecom programmes and elsewhere in DG INFSO and DG SANCO. But this is still only scratching the surface.
The main barriers are People, Culture and Politics and this is exacerbated by the scale and complexity of the sector, the sheer numbers of people working in healthcare and interacting with healthcare. Every body wants to make it better but no-one knows how. There is also the complication that healthcare modernisation raises strategic and long term issues outside the political lifespan of individual governments
This then is the background to Health and Cross-Border eGovernment Services. Everybody in Health will tell you that Health is “different”. Much of this is conventional thinking, rationalisation of difficulty or ignorance. But the culture is different, the implications of information are essentially multi-directional and involve not just privacy but ethics and serious decisions which profoundly affect quality of life and in many cases life and death scenarios. The large proportion of the process models involve interaction between citizen and professional; governmental involvement is mostly about policy, aggregated information, monitoring and control, and about politics. Most importantly health is in the early throes of transformation – the current models are unsustainable and this will have significant implications for cross border healthcare services.
There is still much to be done to create the environment in which we can deliver the sorts of cross border services that European citizens expect.
Much of the information that is needed is not yet available; some of it is not even collected at present; the culture of access is constrained by vested or professional interest, organisational complexity and regulatory inconsistency. For much of the information there is no common nomenclature across Europe among professionals let alone among citizens or between citizens and professionals..
There is currently:
- no focus within the EC for eHealth – many directorates have responsibilities in these areas and the constraints of the RTD programme continue to frustrate progress.
- no common vision, no broad focus, no consensus about eHealth.
- no education and awareness programme to allow eHealth to be based on sound bottom up experience and support
- a serious shortage of skills and experience in the replication of user oriented systems to deliver the required benefits.
- no agreed business case for either eHealth from which can be derived the motivation and incentives for the various players (suppliers, administrations, health providers, clinical professionals, insurance companies, patients / citizens)
- little or no agreement on infrastructure, platforms and tools.
Some or all of this may be true for CBeGS?
The transformation of initiatives into European baseline work is seriously hindered by the lack of a common vision and a European delivery programme This true even where much good work has been done - the card community has yet to become a mainstream activity. The health insurance card is a limited step forward but it remains an isolated product set searching for a market and is not integrated into any overall view of CBeGS. The work on standards has yet deliver practical and accepted answers
The EC Action plan for eHealth, in itself, will not deliver the implementation programmes to make it all happen and does not have sufficient stakeholder involvement. Industry platforms and the Internet are important vehicles but there is as yet no European equivalent of the UK eGif platform or a common industry inclusive approach.
Overall the issues are not being approached in an integrated and holistic way.
At the recent Dutch Presidency conference Shaping the EU Health Community held in the Hague, the session on Cross Border Care produced a set of outcome statements which summarise current perceptions:
People want easy access to care of high quality, quickly and nearby
When abroad, patients need trust in clinical quality; information on their clinical history; information on the availability, scope and (where appropriate) the cost of care
Professionals need common datasets and nomenclature for information exchange; good practice guidelines; clear understanding of the scope of their responsibilities and sensible incentives
Industry is looking for more flexible investment policies, procurement rules, and staff mobility procedures
The lack of coherent health policies and fragmentation within EC activities are a major hindrance.
The internal market may have a detrimental effect on equity and solidarity.
This reflects closely the IDABC Conference theme – CBeGS is for administrations, for businesses and for citizens and these services need to be accessible, trusted and of practical benefit at all levels including the point of care.
This is not to say that such services are not needed, are not realisable or that there is no value in them. In addition there is a need for a holistic approach to the sourcing, targeting and provision of these services (e.g in the citizen’s mind the organisational distinction between health and social care does not exist)
Services are needed in many areas but the priorities for EU25 are:
- Mutual recognition of clinical qualifications (flexibility of service, risk management and confidence for the patient)
- Access to electronic health records available to clinicians at the point of care 24/7 across EU25 is a fundamental need for all stakeholders.
- Point of care clinical networks for emergency, elective and casual references as well as for the development of health tourism for European and global citizens
- High quality comparative health data for public administrations, planning, emergencies, epidemics, research.
- Good practise references and research material to address treatment issues at a European level of postcode, regional and national variances.
- Common pharmacopoeia descriptions, cross references & treatment protocols
- Comparative data on outcomes, treatment, prescription, counter-indications
- Self help / self management support services for chronic, ageing and long term care
- Access to citizen services like NHS Direct in UK across Europe in native language and linked to national systems (along the lines of roadside and financial services).
Challenges
These are significant and multi-level:
European level. Agreement with the Member States regarding the sensible subsidiarity boundaries and links. Some sort of co-ordinated programme from the EC for eHealth, including its association with an overall eGovernment programme. This includes scenario scoping, component prioritisation, and the programme management of multiple parallel activities. This means also datasets, interoperability, access, nomenclature, multi-lingual norms, regulatory harmony (e.g transmission and sharing of medical records, pharmaceuticals, safety and risk standards)
National and regional level. Clear agreement about subsidiarity principles and the roles and responsibilities at the various levels.
Vehicles / networks for stakeholder involvement, collaboration and mutual benefit. This also means extending the definitions of stakeholders to include broader definitions within Administrations and Businesses.
Requirements – simple statements of needs of those involved plus a co-ordinated view of the interactions, dependencies and synergies between these
Multi-level business cases including those for cross border services
Enabling easy productive information sharing between partners, institutions, administrations, patient groups, clinical groups
Consideration of which services are “rights”, which are essential for administrations, which can be seen as “added value” and for whom, which services can be charged for and to whom.
For most of these challenges, these are early days; healthcare must address some of the prerequisites outlined above before progress can be made in the development of more general services.
What can IDABC do to help.
IDABC represents an important opportunity for eHealth. While eHealth is only a small part of eGovernment (and as yet not a mainstream component) it represents an area of huge investment (7.5% of European GDP and rising), closely linked to European aspirations for its citizens in terms of quality of life, of critical importance to politicians in every country and increasingly seen as an economic growth indicator. It also has close links with social care and social services –though these are often obfuscated by structural separation and differing cultures.
Existing experience, initiatives, good practice, standards and cross-fertilisation from eGovernment are an important supporting element for eHealth. The health insurance card illustrates the point – in its first instantiations it is purely administrative, providing a framework for balancing the costs and overheads of an increasingly mobile population. It does nothing per se for health BUT it opens the door, it starts the process, it forces health to start looking at what has to be done to include health data. IDABC can be the agent of other opening doors in both directions.
The key areas are:
Act as an enabler for implementation, focussing on the broad spectrum of players and activities required and the infrastructure / networks fundamental to sharing health information
Encourage and stimulate a wide awareness / consultation programme across the stakeholders and the Member States including industry and citizen / patient groups
Work on common issues (business cases, user requirements, implementation guidelines & mechanisms, infrastructure, scale & complexity,…) to complement activities within Member States and the eHealth community
A forum for exchange of ideas and information, good practice, problem resolution
Establish effective networks of collaboration (building on existing ones where available) to support multi-stakeholder and cross-sector implementation
The opportunity to develop synergy in the application and replication of CBeGS which will include health (e.g common infrastructure, acceptance criteria, service delivery points, broader portfolio)
Identify and validate models for incentives and motivations at all levels
Encourage practical research on CGeBS acceptance, scale / complexity and replication models.
Conclusions:
The immediate task in eHealth, as in eGovernment, is to influence opinion towards favouring new approaches, considering HOW rather than WHY. Indications from existing intra-national initiatives are that citizens, administrations and businesses will welcome these sort of services, providing they are useful, simple and practical. They have to be services that people want to use. There are concerns in all sorts of areas and these can only be addressed by experience of working and successful examples.
CBeGS and the IDABC programme offers a wider platform for success, for sharing experience and good practice, for helping to build confidence and acceptance within the user community. The complexities of healthcare are primarily at organisational and process levels and for eHealth to play its part in the transformation of this crucial sector, it will benefit greatly from the three IDABC distinct activities: support for trans-European projects; horizontal platforms and tools; encouragement. EHealth has to build on mainstream services rather than perpetuating isolation and duplication. Successful eHealth will contribute greatly to the overall success of the eGovernment sector. The eHealth community wishes the IDABC well and looks forward to contributing and participating in its activities.
Bibliography:
Silicon Bridge Research Limited Understanding the Market for eHealth. Study Report for DTI and NHS Information Authority; Summary Report March 2002. Basingstoke: Silicon Bridge Research. 2002
Commission of the European Communities e-Health – making healthcare better for European citizens: An action plan for a European e-Health area Brussels; Commission of the European Communities, April 2004; COM (2004) 356 final
Economist Special Report The health of nations July 17th 2004
Bywater M, Lessens V Health Information Network Europe; the 2003 eHealth report Diegem; Deloitte & Touche, 2003
Doupi P, Ruotsalainen P, NykanenP et al. Presentation: eHealth in Europe: where do we stand? MEDITRAV Project WP Assessment. Tromso Telemedicine Conference. Tromso: September 2003
Bend J Public Value and e-Health. London Institute for Public Policy Research 2004
European Commission eHealth Research report for Cork eHealth Conference May 2004 Mapping the Potential of eHealth: Empowering the citizen through eHealth Tools and Services Wilson P (European Health Management Association), Leitner C & Moussalli A (European Institute of Public Administration - EIPA). Maastricht; EIPA 2004
European Commission eHealth Research Report for Brussels eHealth Conference May 2003 The case for eHealth Silber D. Brussels; European Commission 2003
European Commission Enabling Good Health for All: A reflection process for a new EU Health Strategy Byrne D EU Commissioner for Health and Consumer Protection. Brussels; European Commission 2004
David Lloyd-Williams: eHealth – a dilemma for Europe? Article for British Journal of Healthcare Computing & Information Management (BJHC&IM) December 2004
First published as a paper for IDABC Conference 17-18th February 2005
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