“how can central europe contribute to achieve the goal of

1StrategicPlan:HowcanCentralEuropecontributetoachievethegoalofaEuropeaneHealtharea

StrategicPlan

“HowcanCentralEuropecontributetoachievethegoalofaEuropeane‐Healtharea”

PreparedbytheSPESproject(SupportPatientsthroughE‐servicesSolutions1)

‐‐‐0‐‐‐

This document represents an informal position of the SPES project about the progress and future of e‐Health,Telemedicine and AAL for patients in the Central Europe Area. The data collected in this document have been

provided voluntarily by the SPES partners and partners of the other involved projects. This document does notrepresent inanywaythepositionof theEuropeanCommission,nor theCentralEuropeProgrammeorotherpublic

bodiesfundingtheSPESprojectorinvolvedintheprocessofmodernisationofthehealthsysteminEurope.

1TheSPESProject(http://www.spes‐project.eu)isimplementedthroughtheCENTRALEUROPE(http://www.central2013.eu)Programmeco‐financedbytheERDF–EuropeanRegionalDevelopmentFund.


Tableofcontents

INTRODUCTION .........................................................................................................................................................3

SUMMARIZATIONOFTHEANALYSISONACTIVEE‐HEALTHPROJECTS........................................................................6

COMMUNITY/SOCIALREQUIREMENTS......................................................................................................................................7TECHNICAL/OPERATIONALREQUIREMENTS ...............................................................................................................................8STRATEGIC/EXPLOITATIONREQUIREMENTS ...............................................................................................................................8

THROUGHAEUROPEANE‐HEALTHAREA.................................................................................................................10

THEVISION ......................................................................................................................................................................10THEMISSION ....................................................................................................................................................................10SWOTANALYSIS ..............................................................................................................................................................11

STRATEGICPLAN......................................................................................................................................................14

GENERALOBJECTIVES .........................................................................................................................................................14SCENARIOS ......................................................................................................................................................................14METHODOLOGY................................................................................................................................................................16

CONCLUSIONS .........................................................................................................................................................19

ACKNOWLEDGEMENTS ............................................................................................................................................21


Introduction

Themainaimof this StrategicPlan is toencourage theadoptionofTelemedicine,e‐HealthandAmbientAssistedLivingsolutionsintheEuropeanArea.

TheEuropeanUnionisfacingunprecedenteddemographicchanges(ageingpopulation,lowbirthrates, changing family structures and migration) that will have an impact on several sectors.European population is becoming old very quickly and this situation is leading to a scenario inwhichthesupporttoelderswillnotbegrantedonlybytheactivepopulation,asitwasinthepast.

Figure 1 shows the Eurostat’s projections2 in population composition, covering theperiod from2011to2060,givingaclearoutlookoftheincreaseoftheelderpartofthepopulationinthenextdecades.Inparticular,thepeopleover65yearsoldwillpassfrom17,5%in2011to29,5%in2060.

Figure1:Eurostat'sprojectionsfrom2011to2060Inthepastfewyears,thecostforcareprovision,withrespecttotheGNP,hasshownadefiniteboostduetoseveralfactors:

‐ newmedicinesortechnologiesareavailableonthemarket;‐ themean age of population has raised and hence increased the cost of population care

provision;‐ economiccrisishasimpactedonalltheEuropeanCountries,reducingthelevelofrichness

ofthisterritory.Theprojectionsshowthat thecost forcareprovisionwill continuously raisewithrespect to theGNPoftheEuropeanMemberstates.2 Eurostat web site: http://epp.eurostat.ec.europa.eu/statistics_explained/index.php/Population_structure_and_ageing


Differentactionsandinitiativesareonthefieldtocreateamoresustainablehealthsystem,abletocontinuetotakecareofpopulation,inparticularofelderpeople.Makingeldersmoreactive,providingthusmoreopportunities,decreasingthesocialexclusionofthispartofpopulationandrationalizingcostsandresourcesarethemostpromisingactionsthattheMembersStatesandtheEuropeanUnioncanperforminthenextfuture.

Lisbon strategy for growth and jobs sets the target forthe employment rate of older people at 55% for the2020 and to 60% in 20503: the quality of life andpossibilities for this part of population have to changeaccordingly.CENTRALEUROPEprogramme4made the “demographicchange” one of the most challenging opportunities forthe present and future periods: it is a horizontalchallenge that intersectsother actions. Theprogrammealso sets to improve inclusion of elderly anddisadvantaged groups to help minimise the negativeimpactofdemographicchange intheregionsofCentralEurope.

TheSPESprojectisaninitiativeco‐fundedbytheCentralEuropeProgrammetoimplementseveralpilotswiththeaimofreducethe impactthat illnessorelderlyhaveonthe life of population. Even if the pilots involve a smallnumber of people, the real purpose is to demonstratethat technologies caneffectively increase thequality oflifeofpatients.

The project aims also at demonstrating that solutionsbasedonnewtechnologies increasethesustainabilityofthehealthcaresysteminseveralways,as,forexample,byreducingthenecessityofgoingtomedicalstructures,reducingthentheoverallcost of the medical care. The adoption of these technologies implies a re‐organization of thestructureofthecaresystem,are‐engineeringoftheprocessofsupportingpatientsandprovidingservices,andthisrepresentsthehighestbarrierthathastobeovercome.

3“EUROPE’SDEMOGRAPHICFUTURE:FACTSANDFIGURESONCHALLENGESANDOPPORTUNITIES”publishedbytheEuropeanCommission–Dir.forEmployment,SocialAffairsandEqualOpportunities,20074CentralEuropeProgrammeoftheEuropeanCommission–http://www.central2013.eu

Figure 2: Projected change in publicspendingonhealthcare(in%ofGDP)


ThetechnologiesusedinSPEScomefromAmbientAssistedLivingsolutions,telemedicineande‐Healthdevicesandsocialexclusiontools:thesearethemostpromisingsolutionsforimplementinghealthcareserviceswithalittledirectimpactonthehealthcaresysteminuse.

Togetherwithademonstrationof thepositive impactof technologies, theSPESproject aimsatincreasingtheawarenessinseverallayersofpopulation,fromthedifferentgroupsofpatientsandtheirrelatives,tohighrankingpoliticiansanddecisionmakers.

Thisdocumentaimsatpresentingastrategyplantoreachamoreefficientandlow‐coste‐Healthareainwhichthepopulationrepresentsanactivepartofdifferentsocialgroups,startingfromtheexperiencemadeinSPES.

Itpresentsthemethodologyusedtoapproachandmeetactivestakeholderswhoareworkinginthesameareaoftheprojectandtoanalyseinputscollectedinthesemeetings.Inparticular,thefocus is on the requirements that come from the experiences and suggestions provided by thestakeholdersthroughaquestionnaire.

Inthesecondpartofthedocument,youwillfindtheStrategyPlanthatcanbederivedfromtheserequirements,theactionsinthefieldofhealthcareandthedirectexperienceofthepartners.

Asaconclusion,avisionofthefutureinthefileoftelemedicineisprovided.


Summarizationoftheanalysisonactivee‐Healthprojects

TheexperiencemadeduringtheimplementationoftheSPESprojectrepresentsaverygoodbasetoidentifymajorconstraintsinintroducingtechnologiesinthepresentsystemsofhealthprovisionandininvolvingpatients,inlargepartelders,intoaninnovativeproject.

However, itdoesnotcoverallaspectsofprovidinghealthcareservicestopopulation, it involvesonlyasmallnumberofpatientsasactivepartofthepilotanditwillhavealimitedimpactintheevolution of the services into the local contexts. This limited impact is due to different factors,among them theuncertaintyon theReturnof Investmentsand thenecessary re‐engineeringofprocessesthattheuseofnewtechnologiescarrieson.

Thisexperiencehashighlightedsomeconstraints,limitationsandbarriersbut,also,opportunitiesandchallenges for furtherdevelopments in this field thatcan improvetheoverallqualityof theservicesprovided.

Being a small projectwith a limited number of partners, SPES aimed at collecting information,data, experiences andbestpractices from theother initiatives active in the same local areas inwhichSPES isoperating, to identifykey factorsofsuccessor failure.TheSPESproject realised4different meetings with relevant local stakeholders in the 4 cities involved in the pilots thusincreasingtheprojectvisibilityandhavingthepossibilityofinterviewingparticipants.

Theanalysisoftheactiveprojects,bestpracticesandon‐goingactivitiesintheCentralEuropeareaistheindicatorofthehealthstateoftheresearchanddevelopmentinthefieldsofe‐HeatlhandTelemedicine.

Theinvolvedstakeholderscomefromdifferentrealities,fromsocialservicestopublicinstitutions,fromlargehospitalstosmallresearchprojectsrepresentingthevarietyofactorsactiveinthefieldof telemedicine. For this reason, the answers to the same question are completely different,demonstratingthataclear,sharedandprecisevisionoftelemedicinehasnotyetbeenreached.However, the interested participation of stakeholders provided a lot of inputs to the project,whichareatthebasisofthefollowinganalysis.

During the stakeholdermeetings, the partners collectedmore than 100 “Telemedicine sheets”describingdifferent actions,both running and completed, implemented intoa specific territory.Thesesheetsgiveapartialimageofthestateofdevelopmentofresearchprojectsinthefieldoftelemedicine,e‐HealthandAmbientAssistedLivingsolutionsforelderorillpeople.Theproposedformatwouldfocusattentiononseveralspecificaspectsmorethanresultsorimpactrealisedbythe project. The idea is to identify some key factors that made the project successful or not,elementsthatcharacterisetheprojectfromtheideationtotheimplementation.

The results of these analyses are available on the “Green Paper” produced by SPES thatsummarizestherequirementsfromstakeholders.


Expectedinputsfromstakeholdershavetoanswerthreedifferentquestions:

1) Whichcommunity/socialaspectsshallbeidentifiedinasuccessfultelemedicineproject,intermsofinvolvementofrelevantgroups?

2) Whichtechnical/operativeelementscanbedefinedinasuccessfultelemedicineproject,intermsofnewtechnologies,toolsandsolutions?

3) Whichstrategic/exploitationstrategyisnecessarytoimplementasuccessfultelemedicineproject,intermsoffunding,involvementofinstitutionsanddecisionmakers?

Theanswerstothesequestionshavebeeninsertedintothreegroupstoidentify:

‐ Community/social requirements: the importance of the involvement of relevantstakeholdersinthedesignofatelemedicineservice;

‐ Technical/operation requirements: technical constraints in the deployment of atelemedicinetoolatlocallevel;

‐ Strategic/exploitation requirements: strategic aspects in developing telemedicinesolutions.

Resultsarereportedinthefollowingsections.

Community/socialrequirements

Alargepartofinterviewedpeoplehassaidthattheinvolvementofalltypologiesofstakeholders(end users, health operators, technology providers, public authorities) in the design of atelemedicine project seems to play a key role. Regarding the involvement of the patients (endusers), the consultation with this category of stakeholders represents, of course, a priority,especiallyifthetestingofnewdevicesismadeonpeoplesufferingofphysical/mentaldisabilities(likedementiaandhandicapsinthecaseoftheSPESproject)whereatrust‐buildingrelationshipwiththeendusers,hastoberealized.Generally,evenifitseemstobeeasiertoinvolveclientsofalreadyestablished realities (health services’ assistedpatients, hospital lists, private companies‘clients),thecooperationandinvolvementofprivateindividualsmayprovidemoreinsightintoendusers’needsandrequirements.

Theinvolvementofprivatecompanies(likehealthservices,technologyproviders,SMEs)playsalsoamajorroleinthedesignofatelemedicineproject.Amoredetailedcost/benefitsanalysisoftheenvisagedplatformsandactionsmayleadtoamoreefficientinvolvementofallthetypologiesofthisgroupofstakeholders.

From the economic point of view, private insurances can also play a relevant role in financingfinalisedprojectsoftelemedicineandindesigningservicestosupporttheirclients.

Equally, the participation of public authorities in the implementation of a telemedicine serviceseemstobeparticularlyimportant,ifcoherencewithnational/localguidelines(ifalreadyexisting)andreal interoperabilitywithother telemedicinesystems(national/regional/transnational/cross‐


border) want to be pursued. National laws and bureaucratic regulations, but also financialavailabilities and Health policies, are aspects that have to be taken into account for thedevelopmentofalocal/crossborderoperatingtelemedicinesystem.

Technical/operationalrequirements

Usabilityby theendusersseemsto remain themost importantaspect in thedevelopmentofatelemedicine system. The characteristics of the systems are developing, today, towards“simplification”, with easy to use characteristics, especially for patients with limitations inmovements or with mental diseases. Ergonomic and simple solutions represent therefore themainfocusoftheresearchapplicationintothedeploymentofeffectiveandefficienttelemedicinesystems.Regardingthecommunication(betweenendusersandhealthproviders),theplatformsshould give simple, needs‐oriented access to a series of services (pooling together themedicaldatacommunicationwithentertainmentofsupport).Inthisregard,visualuserinterfaceshavetobe improvedandoptimized.A lessoncouldcomefromthemobilephonemarket:even ifyoungpeople prefer smarter and advanced phones, elders want to have a usable object, with largebuttons,cleardisplayandveryfewinformation.

Operationalandtechnicaldecisionshavealsototakeintoconsiderationthepsychologicalaspectofthepatientsandthelackoffamiliaritywithanewelectronicsystemaccompanyingtheirdailylife.MostoftheprojectscontactedbySPEShighlighted,infact,thenecessitytoalwaysoperateatrainingactivityintheimplementationandadoptionofanewtelemedicineprojectwiththeendusers,soastobuildtrustandbuildanacceptableleveloftechnologyacceptance.

On the technology providers’ side, it appears that, since the market is growing rapidly, theadaptationtonewproductsisessential,aswellasthelinksandcontactswithotherplayers(suchasindustry,healthservicesproviders,publicauthorities).Furthermore,forsomeofthecontactedprojects,ascompaniescannotaffordtorelyentirelyontheirownresearch, theyshould insteadbuyorlicenseprocessesorinventions(i.e.patents)fromothercompanies,soastoincreasetheircompetitivenessinthenationalandinternationalmarket.

Lackofprominentstandards for interactingwithdevices,dataexchangeandnetworkingamongdifferentorganizationsat leastatNational level, isoneof themost important limitations in theevolutionofservicesofe‐HealthandTelemedicine.

Strategic/exploitationrequirements

Fromanoverallanalysisofthemappedprojects,itappearsclearthatthesourceoffundingcomesfromdifferentorigins,namely:Europeanprogrammes(likeFP7,ERDFandothers),jointEuropeanand Member States programmes (Ambient Assisted Living), local resources (regions andmunicipalities) and private investments. The involvement of private actors (in the technologydevelopmentbutalsointheinvestment‐relatedaspects)canplayakeyroleforthedevelopmentofe‐Healthsystems.


Fromastrategicpointofview,telemedicineseemstobegoodfortheenhancementofcarestaff,likenursesand,generally,professionalsworking in thecareservices,even if the involvementofgrandphysicians intelemedicinepilotsmaybeendangeredby,sometimes,thelackofeconomicincentives (as in thecaseof Italy).Regarding the improvementofhealthprofessionals’ skills viatelemedicine,itseemsthat,inCzechRepublic,thereistheurgentneedtolegallysolvetheissueconnectedwith competences for long termcare, including theuseof assistivedevices, servicesandICT.

Requalification of healthcare service staff with new skills seems to be a clear obstacle in theadoptionoftelemedicinesolutionsande‐Healthinstrumentsduetodifferentaspects:

• thecostsofthisrequalificationshouldbepaidbysocialservices;

• theROIofthesecostsisnotwelldefined.

Lastly, the identification of a clear legislative framework is another key element to enable acommunity of stakeholders to interact outside local and national contexts and the nationalcustomswhenprovidinghealthcareservices.Whileseveralinitiativesarecarriedouttosolvethisproblem,solutionshavebeenoftena“workaround”tolegislativeframeworks,withtheresultthatthewholeprocessofexchangingdataisstronglylimited,andsometimes,notsatisfactory.


ThroughaEuropeane‐HealthArea

Thevision

“The future is a smarter,more efficient and reactive health care system able to guarantee thesame level of quality in eachEuropeanCountry. Telemedicinewill be themainstream forhealthcareprovisionintheEuropeofthefuture”.

Even ifambitious, this is thevisionofTelemedicine inEurope in thenext fewyears.ThehealthcaresysteminEuropewillbesmarter tobeabletoquickly integratenewsolutionsandprovidenewservicesinabetterway.Itwillbemoreefficientbecausethecurrentcostsofserviceswillbeunsustainableinthenearfutureforthelargestpartofthecountriesintheworld.Itwillbemorereactivebecausepeoplearedemandingbetterservicesandsocietyischangingmorequicklythaninthepast.

Inthelastfewyears,newtechnologieshavechangedcompletelysomeaspectsofthereallifeofthepopulation,reducingdistanceswithimprovedcommunication,“augmentingreality”perceivedbysensesandpervading the lifeofpopulation.Thesetechnologies,on theotherside,havehadveryweak impactonsupportingpeoplewithdifficulties in theirdailymanagement. It is time toenlargetheuseofthesetechnologiestosupportpeoplewithdifficultiesanddebilitatingillnessesinlivingbetter,longerandinahealthyway.

Themission

“Improvingthequalityoflifeofpopulationbybroadeningtheuseofnewtechnologies,increasingawareness on theopportunitiesanddisseminating theknowledge asmuchaspossible”. This isthe mission of a project, like SPES, aiming at improving the use of telemedicine and e‐healthtechnologies. In fact,medicaldevicesandotherrelatedsolutionsare improveddaybydayfromproducers to increase the quality of the proposed solutions and to simplify the use of thesedevices by the patients. On the other hand, care provision systems are often subordinate toconstraintsdifferentfromthepurepatients’well‐being,forexampleeconomicfactors,andledbydifferent actors, like politicians and managers. By enlarging the use of new technologies andincreasing awareness on different layers of population, it will be possible to influence thebehaviourofseverallayersofpopulation,notonlyatdecisionmakers’level,toreachtheobjectiveofasmarterhealthcaresystem.Asageneralrule,thedisseminationofresults,even ifnotfullysuccessful, is thekey factor toageneral improvementofproposedsolutionsand, finally, to thequalityoflifeofpatients.

Telemedicine is, also, an excellent channel to improve communication between patients andhealthcareproviders,alsorepresentinganexhaustivetoolforeducatingpeopletoanactiveandhealthyageing.


SWOTAnalysis

Most health systems are severely overburdened: this is the experiencemade, everyday, by thelargestpartofthepopulationintheEuropeanCountries.

This means they are constantly challenged by the need to make difficult decisions aboutcompetingpriorities:severalsolutionspromiseanimprovementofthesystemandofthequalityofservices,butthetimespanis,often,toolong.

Sincee‐Healthcurrentlylacksastrongevidencebasetoverifyitsimpactonhealthoutcomesandhealthsystems,itisunderstandablethatitsadoptionisverylimited.

Atthemoment,thelargestpartoffundingisallocatedonprogrammesotherthane‐Healthones,reflectingthedecisionmakers’lackofinterest.

Ontheotherside,SPESexperiencedemonstratesahighlevelofacquiescencefromthepatients,readinessofsomepartsofthehealthcaresysteminacceptingandintegratingtelemedicineintoworkingservicesandthematurityofseveraltechnologiesalreadyonthemarket.

Thefollowingswotanalysistriestosummarizetheidentificationofkeyelementsinatelemedicineproject that can determine the effectiveness of the results obtained through the adoption of atelemedicinesolution.

The swot table contains the internal factors and external factors, both positive and negative,whichcanbeindividuatedinatelemedicineproject.

Strengths S WWeaknesses

‐ Maturetechnologies;‐ Stronginterestbydifferentstakeholders

(careproviders,patients’organizations);‐ Stronginvolvementofpatients;

‐ Costs;‐ Successrate;

Opportunities O TThreats

‐ Rationalizationofcosts;‐ Increase of the quality of offered

services;‐ Sustainability of the whole system of

careprovision;‐ Overcome several barriers in people’s

moving;

‐ Unclearlegalframework;‐ Not well defined strategy at European

Level;‐ Relevantpolicies;‐ Lowlevelofgeneralawareness;


Internalfactors

Severalstrengthscharacterisetheinnovationinthecareprovisionsystemlike:

‐ Mature technologies: technologies have been developed in the past and are still underdevelopment by several producers. Research is led by industries to offer commercialsolutions.Severalstandardsandsupportingsolutionsforcommunication,datasharingandmedicaldataanalysiscanbeadaptedtospecifictelemedicinecontexts;

‐ Stronginterest:severalstakeholdershavestronginterestintheevolutionofthehealthcaresystemdue toseveral factors, someof thembeing ineluctable, like the increasingof thelifeexpectancy;

‐ Strong involvement of patients: contrary to the past, groups of patients have theopportunity to enter into the process also as active actors leading to a more positiveimpactintotheirlifeandreducingtheriskoffailure.

Ontheotherside,weaknessesarerelevantdueto:

‐ Costs:finalcostsoftheadoptionprocess,thatoftenimpliesaninternalre‐organizationofseveralactors,cannotbedefinedprecisely.Takingintoaccountthefactthattelemedicineisnotoneoftheprioritiesfordecisionmakers,itrepresentsastrongweaknessforthefulladoptionoftelemedicinesolutionsdevelopedinaproject;

‐ Success rate: together with costs, success rate or acceptance of new technologies bypatients isdifficulttoevaluateanddependsonunpredictablefactors. Infactadoptionofnewtechnologiesdoesnotonlydependonthequalityofthesolutionsbutalsoonseveralexternalfactors(liketheinvolvementofdecisionmakersorlegalframeworks);

Externalfactors

Opportunitiesare:

‐ Rationalizationofcosts:the largedemandofrationalisationofservicestothepopulationthat,inshortperiod,willbecomeeconomicallynon‐sustainable;

‐ Increase of the quality of offered services: togetherwith the rationalizationof costs, thedemandfrompopulationforageneralincreaseofqualityoflifeinelderly;

‐ Sustainability of thewhole systemof careprovision: the sustainability of thehealth caresystem in Europe is threaten by several factors, among them the economical crisis anddemographicchanges.Telemedicinesolutionscanimprovethesustainabilityofthehealthcaresystembysupportinginnovativeservicestopatients.


‐ Overcome several barriers in people’s moving: free movement of people inside theEuropean countries will lead to a general reduction of several barriers among differentstates, like the freecirculationofbankdataandmedicaldatawithina strictandpreciselegalframework.

Ontheotherside,threatsare:

‐ Relevant policies: telemedicine is not considered as relevant as “traditional” solutions inprovidingcareservices.Thisispartiallyduetofactorssuchasthelowlevelofawarenessonthepossibilitiesoftelemedicine;

‐ Lowlevelofgeneralawareness:thelackofknowledgeconcerningthepossibleapplicationsof telemedicine in several layers of population and decisionmakers is one of themostimportantthreats,strictlyrelatedtothepoliciesandregulations.

‐ Unclearlegalframework:severaldifferentlawsinteractindesigningtheframework,fromthelegalpointofview, inwhichtelemedicinecanmove. Inparticular,thetreatmentandexchange of medical data have to respect several constraints imposed at European,NationalandRegionallevel.Insomecases,theselawsforbid,defacto,themanagementofdatainanautomaticway;

‐ Notwelldefinedstrategy:atEuropeanlevel,thestrategyisnotwelldefinedanddifferentmember states are adopting different approaches, often incompatible. The lack of aguidance in choosing the approach will jeopardize the solutions adopted across theEuropean countries, leading to a future incompatibility of different systems based oninteroperable,small‐scalesolutions.


Strategicplan

General objectives TheStrategicPlanproposedbySPESaimsatachieving thegoalofaEuropeane‐Healtharea, inwhichtelemedicinesolutionscansupport,effectively,thecaresystemsinseveralscenarios.This objective can be reached by increasing the opportunities and decreasing the threats of atelemedicineproject,pavingthewaytoasharedandsmartersolutionforcareprovision.Internal factors impact inadifferentwaysonspecificprojects: forexample thedevelopmentoftechnicalsolutionsbasedonwirelessstandardscanbeveryusefulinseveralsituationsinsteadofsolutionsbasedonwiredstandards,whilecostsarestronglyrelatedtodifferentcontexts.

Ontheotherside,externalfactorshaveverylargeimpactsontheexploitationoftheresultsandcontinuationofactivities,andofteninfluencethesuccessiveadoptionofdevelopedsolutions.

The external factors are the keys to improve the impact of the telemedicine projects alreadyrunning in the European area, leading to a general improvement of e‐Health adoption in thememberstates.

TheStrategicplanwilldescribeactionsthatcanbetakentoreducethethreatsinatelemedicineprojectandincreasetheopportunities.

Scenarios

As ina largenumberofsectors,newtechnologies, inparticular InformationandCommunicationTechnologies,are impacting theHealthsector inavery relevantway,creatingnewservicesandimprovingthepresentsystems.Ontheotherside,economicalcrisisisforcingrelevantinstitutionsto re‐visitt their organizational structure, the way they provide services and interact withpopulation.

Inthepresentscenario,differentEuropeancountrieshavedifferenthealthcaresystemsthatareunabletoshareanytypeofdataineverysituation,eventhemoreriskyforthepatient.

Keyroles,inthisscenario,areplayedbythefollowingactors:

‐ decisionmakers(politicians);

‐ insurancesandeconomicdecisionmakers;

‐ medicaldevicesproducers;

‐ caregiversinstitutionsandorganizations;

Inthisscenario,theroleplayedbypatients,patients’organizationsandtheirrelatives is limited,withfewpossibilitiesofbeingmoreinvolvedandbecomingrelevant.Inparticular,decisionsupon


personal health and behaviour are not shared among different actors and not agreed withpatients.

Informationandcommunicationtechnologiesarenotexploitingalltheirpotential inthepresentscenario:data communication ismade through“old‐style” solutions, like faxandprintedpaper,andtherelevantdocumentsarekeptbythepatienthimself.Thiscreatessituationsinwhichthesedataarenotavailable(forexampleincaseofemergencyinwhichthepatient isunconscious)orpartial(lostdocuments).

Inthefuturescenario,theroleplayedbypatients,patients’organizationsandrelatives,hastobestrengthenedduetoseveralfactors:

‐ telemedicineisenablingthecare‐at‐homesolutions,involvingnecessarilythepatientsandtheirfamilies;

‐ sustainabilityofhealthcaresystemacrossEuropecanbereachedonlywithanactiveandhealthy ageing of the largest part of population: this necessarily leads to a stronginvolvementofpatientsinmanagingtheirhealth;

‐ preventionofillnessisoneofthekeyconcepts:healthpopulationmeansreducedcostsforcaresystems;

‐ innovationintechnologieswillnotonlyimpactonlargemedicalcontexts,likehospitals,butwillalsoinvolvesmallenvironmentslikepatients’housesorday‐carecentres;

Furthermore,movement of people across European Countries requires a way to storemedicaldata(butnotonly) inawaythatallowstheaccessofthesedatafromdifferentlocationsandbypeople speaking different languages. The development of communication standards andontologieswillplayakeyroleinthedevelopmentofsuchsolutions.


Figure3:e‐Healthenablesinnovativeapproachestocareleadingtomoresustainabilityandbetterqualityoflife

Theobjectiveofthetransformationisclear:tohaveamodelforhealthcaresystemsenablingthesuccessfulsupporttonewtypesofcareprovisionandnewscenariosinhealthsectors.

Inthismodel,e‐Healthplaystheroleofanenablerforseveralinnovativeapproaches,likeCare‐at‐home,PreventionandcontinuousInnovation,thatleadtoabetterqualityoflifeforpatientsandtoanimprovedsustainabilityofcostofservices.

Methodology

HowcanEuropecreateane‐Healtharea?Opportunities and threats for a telemedicine project have been identified: these are externalfactorsthatinfluenceboththesuccessfulresultoftheprojectitselfandthefutureadoptionandexploitationoftheseresults.Several projects have created evidence of the possible achievement through telemedicinesolutions, have provided several results in implementing these solutions in real contexts withpatients,havetestedseveralapproachesevenatinternationallevelandhavedevelopeddifferentstandardsforcollaboration,documentexchangeanddatarepresentation.Theseresultsaresparseinprojectdatabases,literature,experiences,deliverabledocumentsetc.,butarenotexploitedinfull. The first challenge is to aggregate all of these pieces of knowledge, in such a way as toeffectivelydrivethisaggregationintoanoperationalenvironment.Byselecting,forexample,thebettersolutionthatintegrateswithotherstoprovideasustainableenvironment.Enabling standards have been produced in the last few decades that allow the data exchangeamong different organizations in a secure way. These standards cover all aspects related toinformationsharing,fromdocumenttemplates,toelectronicdatatransportationandontologies.Theresultisadisorderedcollectionofsolutionssometimesincontrast,sometimesinteroperable.


Aggregating these solutions into a well defined schema, selecting the better opportunities andaskingtheresearcherstodevelopmissingelementsisthewaytoreacharealimplementationonanoperationalenvironmentthatsoftwaresolutionscanuse.Telemedicineapplicationsare,still,stand‐alonesolutionsdrivenbytheparadigmoftechnology‐push, like other technology‐driven markets: it is necessary to move towards the creation ofservices that can be easily integrated along the chain of the care provision and driven to theparadigmofdemand‐pull.On the other words, sometimes the development of medical devices is originated by marketopportunities more than the end users’ needs and, then, does not respond to specificrequirementsandnecessitiesoftechnology.Inthemarketofsolutionsfore‐Health,differentsolutionsarestand‐alone,developedonspecificrequestsbyprofessionalcustomerswhoexpressneedsthataresatisfiedwithtailoredsolutions.An example can be the implementation of the Electronic Health Record in Italy: the ItalianGovernmentimposedtotheRegions,whichareinchargetoorganizeandmanagethehealthcareservice,toimplementanEHRbeforethe2015.Thisisleadingtoasituationinwhich20differentEHR systems, one for each Region, will be developed as stand‐alone solutions, that is notintegrated and not interoperable. This situation can be avoided only by the definition of acommon,sharedandwellidentifiedsetofrequirementsthattheseEHRshavetorespect,amongthemtheinteroperabilitybetweendifferentimplementations.TheEuropeanCommission,togetherwithalldecisionmakersatNational,RegionalandLocallevel,candrivetheprocesstoreachaneffectivee‐Healthareathroughseveralactions:

1) todefineaclearandsharedpolicyontelemedicinethatcanrepresentaguidance forallmemberstatesandamodelforallothercountries;

2) toidentifyalegalframework,sharableamongcountriesandnotincontrastwithNationallaws,thatdefinestherulesformanagingmedicaldataandrelevantinformationonhealth

statusofthesingleperson;3) to support the creation of a common shared set of

standardsfordataexchange,takingintoconsiderationthe necessity of collaboration between a complexnetwork of actors but, at the same time, able toguaranteethehighestdegreeofdatasecurity;

4) toincreasethegeneralawarenessonthesesolutions,and in general on the health problem in Europe,through the definition of publicity campaign onpreventionofillnessesandwellbeing.

These elements constitute the pieces of the puzzle thatrepresentsthehealthsystemintheEuropeanarea,inwhich

Figure4:Puzzlepiecescomewell

togethertocreateapositivecircle


eachMemberStatehasitsownregulationsdespitetheothersandcollaborationsamongdifferentsystemsisnot,even,imagined.Asinarealpuzzle,thesepiecesfitwelltogethertocreateavirtuouscircle,improvingeachothertoincreasetheoverallimpact.In fact, defining EU Policies implies the identification of legal constraints inwhich the e‐Healthsolutions can be developed. The legal framework enables the selection, and eventually thedevelopment, of necessary standards for communicatingand sharing information. The standarddevelopment increases the awareness on the effectiveness of the effort of implementing a e‐HealthareainEurope,andthisinfluencesalsothepolicies,increasingtheinterestofseverallayersofpopulationintheproblemanditssolution.


Conclusions

Europeareaisfacingdemographicchangesduetoseveralfactors:‐ thelongerlifeofpopulation;‐ migration between countries and, in the same country, from different areas to large

agglomerates;‐ theimpactoftheeconomiccrisisonseverallayersofpopulation.

DatafromEurostatrevealthat,by2060,morethanonethirdofthepopulationwillbeagedmorethan65and,thus,requiringparticularattentionfromsocialandhealthcareservices.Different studiesalso suggest that,onpeopleagedmore than65,medical issuesare related tobraindecadenceandchronicdiseases.Thesefactorshaveastrongimpactontheorganizationofthehealthcareservicesand,ingeneral,onsocialservicesmanagement,becauseofseveralelements:

‐ the cost of such services is higher that in the past, becomingunsustainable in the shortperiod. Higher costs are originated by better quality of care, expensive machinery andmedicals;

‐ movement of people requires integration of migrants in the new contexts, with re‐modulationofservicesinmigrants’countriesoforigin;

‐ the crisis reduces the economic possibilities of people andGovernments, leading to thenecessityofre‐organizingservicesandreducingcosts.

E‐Health can act as enabler for a set of innovative approaches to healthcare provision as, forexample,theCare‐at‐home,PreventionandcontinuousInnovationinservices.Theseapproacheshavetwomajorobjectives:

‐ the raise of the quality of life of the population in the European Area, mainly thedisadvantagedpartofit,likeeldersorpeopleaffectedbychronicdiseases,and

‐ theoptimization of services, leading toabettersustainability of thehealthcare systemseveninthenextfuture.

E‐Healthsolutionshavebeentestedinseveralresearchprojectsfor long,providingasetofbestpractices,standards,softwareandtechnicalsolutionsormedicaldevicesthatcanbequicklyandeasilyintroducedintothehealthcaresystem.TheexperiencemadeintheSPESproject, inwhichthepartnershipintendedtouseonlymedicaldevicesalreadyonthemarketintegratedthroughanadhocdevelopedplatform,showsthatalotofsolutionsareavailableandcanbequiteeasilyintegratedintothehealthcaresystem.Thesameresultarisesfromotherprojectswithsimilargoals.Maindifficultiesinintegratingseveraldevicesintoa single softwareplatformarecausedby the fact that commercialproductsare thoughtasstand‐alonesolutions,oftensoldinpairswithaspecificsoftwaresolution,withalittleinterestby


producers in implementing communication standards or opening the softwareby providing, forexample,toolsfordevelopment.Fromthesideoftoolsintegration,severalinitiativesarerunningbutwithnoclearoutcome:inthelatest Horizon2020 calls, the European Commission is looking for proposals able to individuatestandardsandsolutionsthatcanconstitutethebasisforaninteroperableenvironment.However,theuseofICTsolutionsintoahealthcaresystemopensalotofissuesthatthee‐Healthprojectshavetoface:

‐ datasecurityhastobeimprovedfortransmissionandstorageofsensibledata;‐ standardisationofdescriptivedocumentsandreferenceontologiesofterms;‐ definitionofcommonprotocolstoexchangedmedicaldocumentsinelectronicformat;‐ privacyissues.

TheexperiencemadeintheSPESproject indicatesthatseveral“business”modelsforhealthcareprovision havebeen adopted from thedifferent countries involved in the project: froma quitecompletelycentralisedsysteminCzechRepublictoamixedsystem,withalotofdifferentactors,incountries likeItalyorAustria.Aharmonizationofthesesystemsbythecreationofacommonvision of healthcare provision can represent a guidance for theMember States in re‐designingtheirsocialservices.The definition ofmethodologies and standards accepted by the European Commission, and insomewaysupportedby it, in the fieldofhealthcare, isoneof the requiredsteps to reduce thegeneral failureof researchprojects in telemedicine, that,areoftenabandonedafter theprojectclosure.Finally,thedefinitionofaclearandextensivelegalframeworkatEuropeanlevel,mayleadseveralcountriestodefinethelegislativecontextforhealthcareprovisioninawaythatcanbecompatiblewith thoseof theother countries, reducing thebarriers that anelectronicdocument, likeane‐Prescription,hastoovercomeeverytime.


Acknowledgements

TherearemanypeoplewhohelpedtheSPESprojectduringitsimplementation.Wewould like to thank the Central Europe Programme and people from Joint Technical Secretariat for

supporting the project and helping the partnership to successfully complete their activities in the SPESproject.

WewouldliketothankallthestakeholderswhoattendedthemeetingorganizedbytheSPESprojectandsharedtheirknowledge,experiencesandlessonslearned.Thisknowledgeisthebasisofthiswork.

Finally,wewouldliketothankallthepeopleinvolvedintheproject:patientsandtheirrelatives,doctors,caregiverswhospentalotoftimeintestingthedevicesandtheplatforms,providedfeedbacktotheSPESprojectpartnersandhelpedustoimprovethequalityofthefinalresult.

OurspecialthanksgototheExecutiveCityCouncillorforPublicHealthandSocialAffairsandMrs.MarianneKlicka,theThirdPresidentoftheVienneseProvincialParliament,fortheirkindness.

“how can central europe contribute to achieve the goal of

Documents