Medical Device Daily Contributing Writer

E-health in Europe was quite literally all over the map at the end of 2006, with pockets of progress reported across more than 20 countries in a benchmark study prepared for the European Commission.

Yet because each country, and even regions within countries, pursues different approaches to electronic management of healthcare, a menacing incompatibility is growing each year that threatens the ultimate goal of harmonizing systems to support cross-border treatment and payment.

The European Commission Action Plan for e-Health called for member states to have established, by the end of 2006, interoperability standards for the key element in e-health, the electronic health record (EHR). That deadline passed without needed recommendations.

“Despite the fact that most of the parties agree on the benefits of the e-health solutions, there are difficulties of coherent and integrated implementation of e-health systems in such complex environment,” said G rard Comyns, head of the commission’s Information and Communication Technology for Health unit.

More bluntly put, “the European Commission is struggling with their mandate in healthcare,” according to Kees Smedema, chairman of the Healthcare IT Committee for COCIR, the Coordination Committee of the Radiological, Electromedical and Healthcare IT Industry. “There is no standard in Europe for EHRs or for interoperability between EHRs,” he said.

The commission’s eHealth Impact benchmark report delivered in May 2006 puts the blame for fragmentation on the lack of a clear cost-benefit for IT investment.

The study identified 100 credible e-health programs and selected 10 as exemplary practices for detailed cost-benefit analysis. The headline conclusion was that the benefits gained from implementing e-health systems are two times greater than the cost of implementing them.

In 2007, the study team will continue and be joined by Health Information Network Europe (HINE), a health IT industry association managed by Deloitte Consulting, to apply the cost-benefit analysis methodology to 120 more e-health programs.

HINE also will release early this year an update to its own benchmark study, “Are Europe’s Hospitals Ready for eHealth?” The 2005 report, covering 1,250 hospitals in 18 countries, showed the larger nations of France, Italy, Germany and the UK ranking lowest for computer-based storage of electronic patient records and electronic links to general practices, while the smaller countries of the Nordic region consistently ranked far above the European average.

In 2003 the Nordic countries joined with neighboring Poland, Germany and Lithuania to form a seven-country program with the aim of developing a model for transnational cooperation in Europe. A three-year project phase, Baltic Sea Region Interreg III B, divided activities into four work packages and is expected to conclude this year.

Two of Europe’s smallest nations, Denmark and the Czech Republic, were singled out in the eHealth Impact study for excellence in integrating individual patient records with the infrastructure of healthcare.

Alexander Dobrev, who led the eHealth Impact study team, said, “most other countries are still at the planning or implementation stage” with e-health projects.

Medcom, the Danish health data network, connects general practitioners, hospitals, pharmacies and relevant community-based social care agencies. The system has grown from 1.2 million electronic data transfers in 1994 to more than 33 million in 2005. In that same time, coverage of healthcare activities grew from 5% to 80%.

IZIP, which in Czech means Internet Access to Patients’ Medical Information, started seven years ago as a joint project between the country’s largest insurer and a group of physicians. Today the Czech Ministry of Informatics reports 725,768 citizens have created electronic medical files and the system is used actively by more than 7,000 medical workers at 4,569 medical facilities, including 28 hospitals. The IZIP group said that program reached “critical mass” in 2005 and growth is now exponential.

Two regional programs identified as benchmark practices in the HINE study are in Lombardy, Italy, and Adalusia, Spain.

Andalusia’s Diraya initiative — Diraya meaning “knowledge” — integrates health information of citizens in a digital health record shared through 9,500 work stations with 91,000 healthcare professionals at 1,459 primary care centers and 34 public hospitals.

In Lombardy, a healthcare extranet links records for more than 9 million citizens from 15 local health authorities to 160,000 healthcare employees, 8,150 physicians, 212 hospitals and 2,500 pharmacies. In 2005 the system registered in excess of 17 million transactions.

These four programs share two signature features that have emerged in Europe’s interpretation of e-health systems:

• Patient control of access to health records removing control from healthcare providers.
• “Smart” cards, plastic identity card embedded with either a memory chip or microprocessor, for both patients and providers.

In 10 European nations, the patient right to control health records has the force of law. In these nations, health records can only be accessed by healthcare professionals with patient permission. The exception is data to be used for emergency care, which is compiled in consultation with a physician and immediately accessible to caregivers.

The issue has not yet been decided in Italy, where the policy of the Lombardy program contrasts with a centralist approach in nearby Tuscany. The IT infrastructure in Tuscany is built around a central repository of information controlled by the regional health authority, while in Lombardy the IT infrastructure is similar to others in Europe that apply a peer-to-peer architecture enabling the storage of pieces of information about a patient throughout a distributed server network.

In the distributed server model, two keys must be presented to assemble a patient’s medical dossier: the card held by the patient with the appropriate personal identification code (PIN) and the card of the requesting healthcare provider with PIN.

A second security feature of a distributed network is the physical separation of the complete medical record. To illegally assemble a patient record without the encrypted information on the patient’s smart card would require hacking an unknown number of different secured servers over separately secured connections and then an extreme patience to reconstruct the pieces.

The smart cards used in personal banking have built confidence in the chip-and-PIN technology and these cards have been routinely adopted for e-health initiatives. The basic version is a plastic card with a modest memory chip. Used in France and the Benelux nations for more than 10 years, the card was credited with reducing bank card fraud by 90%.

The newer generation already on the market has been described as a flat PC with a microprocessor capable of running software and an expanded memory capacity.

In December the newest generation of smart card chips was outlined in Paris by a consortium of manufacturers who agreed on shared standards before breaking up to begin the fierce competition to win shares in growing markets for smart cards in banking, national identification, driving licenses, passports and access control, such as building security or transportation systems.

E-health applications represent 32% of the near-term market opportunities in the business plan projected by the consortium.

Chips used in the second-generation version of smart cards were embraced by Microsoft (Redmond, Washington) during the roll-out of the new Vista operating system to serve as a “trusted platform manager,” giving individual users greater control over access to their private world increasingly found on computers.

The smart card consortium, Inspired, said the next generation of highly capable processing chips on cards would create a “trusted personal device,” specifically demonstrating capabilities for interaction with e-health systems at its public event. With the card, a patient carries a complete medical history and the encrypted information pathways to digital images, consultations and treatments, said Laurent Manteau, coordinator of the Inspired project

“Privacy is a freedom,” he said. “In a world of ubiquitous computing with continuous threats to sensitive personal data, these cards change the paradigm. It is a small and personal device that enables trusted operations with other entities” for an increasingly mobile population.

(Tomorrow: Is Europe’s IT infrastructure ready for e-health?)