Medical Device Daily Contributing Writer

BRUSSELS — The European Commission hailed a “significant start on the journey toward fully implemented e-health” in its summary report from the annual high-level conference held in Malaga, Spain, in April 2006.

Roadmaps for e-health were submitted by 21 countries at the request of the health commission of the European Union (EU). The roadmaps described programs for electronic health records (EHRs), along with the use of “smart” health cards and e-prescription systems.

More good news arrived when Germany and France — representing 30% of the EU’s population of 493 million — said they would launch national programs for e-health by mid-2007. By their size, strategic position and economic muscle, France and Germany are powerful influences and the traditional leaders of the union.

At a high enough level, the broad-based movement to e-health in Europe seems a virtual paradise for healthcare information technology (IT) companies, suggesting opportunities for massive sales. Spending for hardware, software and IT services is expected to double by 2010 to 16.34 billion ($8.2 billion) annually, according to an estimate from Frost & Sullivan (London).

About 75% of spending is controlled by the public sector, suggesting one-stop national authorities for decision-making. These authorities share a sense of urgency to quickly cut costs and operate care systems more efficiently, and they share the conviction that IT can help.

Finally, the updated E-Health Action Plan 2010 issued by the European Commission describes an IT utopia featuring linked-up, externally connected networks enabling online access for general practice physicians and, significantly, also for citizens. Lab reports, consultations and imagery will be digitally warehoused, while communications and data retrieval will be tightly secured for cross-border exchanges.

The vision of a single European E-Health Area begins to get fuzzy with a closer focus on the true state of e-health. The commission’s report, citing a country-by-country analysis from the Health Information Network Europe (HINE), concludes that “we still have some way to go,” acknowledging a highly fragmented development across the EU.

Are Europe’s hospitals ready?

The HINE report shows operating efficiencies have been the main focus for hospital IT investment to this point in Europe, while clinical information systems “have not received appropriate attention.” Clinical buy-in for e-health has been “painfully slow,” the report says. “Systems are under-deployed, with sub-optimal use of functionality.”

Credited as the largest survey of Europe’s hospitals ever conducted, the report compiles results received from 5,032 hospitals of more than 100 beds. The full survey was conducted in 2004 across 15 countries. Three countries were then added, and continuous updates from major markets were included in the 2006 findings. A revised version of the report is due in April at this year’s HINE conference in Berlin.

Started as an EU project in 2001, HINE today is a consortium of companies managed by Deloitte Belgium that includes Hewlett Packard, Siemens, SAP, Microsoft, Agfa, Philips Medical Systems and iSOFT, which underwrote the study.

HINE sets four levels of IT sophistication among Europe’s hospitals and finds 98% at the first level, using a patient administration system. The second level was reached by 90% of the hospitals with a tested and proven master patient index system.

The report’s most significant finding is a sudden drop in healthcare IT capabilities at the third level, defined as advanced medical records with clinical ordering. Less than 20% of Europe’s hospitals have scored this high on HINE’s hierarchy for e-health.

“The gap between the second and third levels of sophistication centers on issues for document management systems and processes,” Baudoin Lejeune, a manager with the HINE project, told Medical Device Daily. “This area is waking up, but European hospitals still have enormous work to achieve.” In other words, he said, “If you want to put in an accounting system, no problem. But creating a medical dossier is a different story. For that you need to gather all the actors around a table. It is different for every hospital and in every country. A one-size-fits-all solution is sure to fail.”

The report suggests Europe’s hospitals are currently struggling with integrating disparate systems toward the creation of an electronic health record (EHR). While more than 50% of hospitals reported an EHR system installed, the HINE report questions this result by zooming in on the required component systems, such as medical document management, order communication and clinical reports. Only one-third of hospitals reported having one or more of these capabilities. Austria, the Netherlands, Sweden and the Nordic countries scored above the European averages in this area.

Ahead of the release of the 2007 report from HINE, the details from the current report previously reserved for subscribing companies were made available to Medical Device Daily.

The report shows a significant jump in the number of computer workstations per hospital moving from the first to the second level of IT sophistication. While there is little change in hardware moving toward an EPR system, hospitals reaching the fourth level with decision-support systems (physician order entry) report an average of 1,614 workstations, or an average of 1.5 per bed and 2.5 staff per computer.

The HINE survey reports that 40% (2,092) of acute-care hospitals in Europe operate with separate local area network-based systems; another 30% report full integration of their systems; but less than 12% of hospitals report full integration, externally connected.

The migration to integrated and connected networks will be a closely watched finding for the updated HINE report to be published later this year, as 2,265 hospital IT departments reported an intention to upgrade.

Almost all hospitals reported using a Windows operating system, though Unix is used in 43% of hospitals and Linux runs at 29%.

The number of mobile workstations, such as handhelds or laptops, is very low in Europe compared to a survey of 103 American hospitals that reported 49% implementation. In the largest European countries, 3% to 7% of workstations are mobile.

On average across Europe, one in three hospitals is linked to general practitioners, not including fax and e-mail. Yet only 16% of hospitals provide direct access to patient information. Belgium is the most-connected with GPs (96%), followed by the Nordics and the UK.

The looming menace: Interoperability

The HINE report underlines the reality that despite the overarching ambitions of the EU, healthcare IT remains local in Europe and the current successes are being built ground up, not top down. And while the EU holds a central position, legally it does not have any power over healthcare decisions, which by treaty are left to the discretion of member states. The same holds true in some countries where regional authorities enjoy considerable autonomy with regard to healthcare.

The menace looming on the horizon for e-health in Europe is the inherent incompatibility emerging among homegrown systems, each of which responds to specific needs in different regions but can’t exchange patient information across borders.

In the large markets of Spain, Italy and Germany, decisions about healthcare belong to regional authorities, not to the national minister. Spain has benchmark e-health programs in Andalusia and Catalonia, but from the national level cannot assure interoperability for citizen records. In Italy a council of the 22 regions is seeking standards among programs emerging in Lombardy, Tuscany and Rome.

Germany successfully won over its 16 federated regions for reforming a troubled healthcare system, including an agreement to create a national authority to develop and manage the IT infrastructure. The new German system centers on the GesundheitKarte (eGK), a processor-equipped smart card that currently is in pilot programs serves only as an identity card, but which is a “flat PC” capable of carrying physician notes, images, support e-prescriptions and, significantly, serves as the key to hand over control of medical records to citizens.

In France, decisions about healthcare systems come from Paris and many hospital staffers, including doctors, are employees of the state. The report last summer of a personal health dossier to be built up by pathology, rather than region-by-region, set off a uproar among medical professionals, and the July 1 launch date has all but officially been scrapped.

In the UK, the National Health Service (NHS; London) directs an ambitious 6.2-billion program called Connecting for Health hailed as “the largest civilian IT project” because it applies England’s smart procurement government to build a public healthcare infrastructure using private companies. The program came under a cloud in September when Accenture (New York) quit as a main contractor to implement iSoft’s Lorenzo system, leaving 1.9 billion on the table for Computer Science (El Segundo, California), which agreed to take over. Members of Parliament called for investigations and HealthInsider reported the move as “a body blow for the NHS IT modernization program, raising tough questions.”

Trust the business case

“The obstacles to e-health in Europe are not technical,” said Kees Smedema, chairman of Healthcare IT for COCIR, the European Coordination Committee of the Radiological, Electromedical and Healthcare IT Industry, whose members include Siemens, Philips, IBM, Oracle, Agfa and Microsoft.

“There are different visions, roadmaps and specifications for eHealth solutions between EU members states and even within members states,” Smedema told MDD. No one questions the strength of the vision or the technology. Instead, he said, “the major barrier for European e-health today is the lack of sound business and reimbursement models.

“When there is a sound business case, interoperability will be developed,” he said. “If there is no business case, the development of interoperability standards does not help.”

Although the EU lacks a mandate for healthcare, it is helping, Smedema said, citing the development of identity standards for patient and practitioners, and standards for the exchange of electronic information. “The European Commission, of course, sees some member states which do not like its involvement in harmonization of healthcare,” he said.

But ultimately “Europe needs one market for healthcare in order to be able as an industry to produce for a large European market instead of for 25 different markets,” Smedema said. “Industry needs the economy of scale, especially if European industry wants to compete in the world.”