VALUeHEALTH

The value of interoperability in healthcare

Healthcare services are typically organised on a national level, yet there are cases where patients require care while abroad. Cross-border eHealth interoperability will help ensure clinicians have the data they need to manage such patients safely, yet it is also important to establish a rigorous business case if these services are to be sustained, as Professor Dipak Kalra explains

The individual Member States of the

EU run their own national health services in their own ways, yet the European Commission (EC) does play a role in supporting the provision of cross-border care. The EC is presently establishing a European technical infrastructure and services to enable the secure communication of patient medical summaries and electronic prescriptions between European countries in authorised healthcare situations. However, while there are often cases where people require healthcare outside their own country, the numbers are dwarfed by national citizens using their own domestic healthcare services. “It is not sustainable to set up specific business models or develop special systems and services that only support this small patient number,” points out Professor Dipak Kalra, the Principal Investigator of the VALUeHEALTH project. An initiative funded under the Horizon 2020 programme, VALUeHEALTH, was set up with a clear remit. “We have investigated and now produced a business model and business plan for the sustainability of cross-border eHealth services,” says Professor Kalra. “That is, cross-border exchange of information between Member States, in relation to supporting the health of citizens who either cross borders and then need healthcare, or are deliberately referred to go across a national border to receive healthcare.”

eHealth services

This means exchanging patient-related data and supporting healthcare professionals to maintain some degree of continuity of care, in potentially multiple locations, which is a challenging task given Europe’s cultural and linguistic diversity. The initial cross-border services mainly support emergency care situations, which impact on relatively small patient numbers. It can be difficult for Member States to justify their contributions to the costs involved in cross-border eHealth services in comparison to their ICT spending on within border services, which encouraged Professor Kalra and his colleagues to look for mutually beneficial scenarios. “The starting philosophy of the project was to look for win-win scenarios in which an investment by countries in cross-border services would actually also support them with their own withinborder healthcare communications,” he outlines. The project partners worked with a wide range of European experts to identify situations in health and social care in which interoperability is most needed. “We developed a portfolio of business use cases, scenarios of health information exchange, which would be plausible and useful both within and across borders,” explains Professor Kalra.

A set of prioritisation criteria were developed to assess these use cases, and eventually two were prioritised, one of which was safe prescribing. When a medical professional is assessing a patient, it is clearly important to have the relevant background information about their medical history before issuing a new prescription. “The interoperability case to share information is to allow somebody

Roadmap of prioritised use cases

VALUeHEALTH work plan

Interoperability (EIF)

Legal Organisational

Adoption strategies & incentives

Business modelling

Business Model

Semantic Technical

Service implementation & deployment

Stakeholder engagement & endorsement

Management Business Plan

who is treating a patient to safely issue a new prescription - to ensure they have enough information about the patient that could inform a safe prescribing decision,” says Professor Kalra. The second use case was to go beyond the content of the current European emergency care summary, to make it efficient and useful to support continuity of care for patients with common, long-term conditions, such as diabetes. “The aim is to prioritise the information that would support somebody caring for a patient with a long term condition such as diabetes, to provide reasonably sound continuity of care for a patient,” explains Professor Kalra. “So in both situations we are dealing with an unfamiliar patient-clinician interaction.” The clinician may have no local records on the patient’s medical history, which will affect the quality of care they can provide. Professor Kalra describes a hypothetical example of a patient with diabetes who has experienced a hypoglycaemic attack while abroad. “Their blood sugar has dropped suddenly and unexpectedly – they’ve felt very dizzy and fallen on the floor in a shopping centre in a tourist town, and then been taken to hospital by ambulance,” he outlines. The clinician can restore the blood sugar back to normal levels fairly

quickly, but the bigger question is whether this is just a one-off event, or indicative of a bigger problem that needs more care and attention in the short-term, before the patient travels back home. “Do we need to admit this person to hospital and observe their blood sugar over a 24 hour period?” asks Professor Kalra. “This would lead to significant disruption for the patient and significant cost for the hospital, so there’s a big difference between discharging a patient and keeping them in hospital. What if the clinician had access to background medical information about the diabetes? What information would support them in making a more accurate decision?”

This is the kind of issue the project is investigating. Effective, efficient exchange of information on patients with long term conditions could lead to improvements in care both within and across borders, so it is closely aligned with

We have investigated and now produced a business model for the sustainability of cross-border eHealth

services. That is, cross-border exchange of information between Member States, to enable all European citizens to have safer healthcare all over Europe

the project’s wider agenda. “If we can implement a European-scale way of exchanging this information, then any country that doesn’t already have such a mechanism in place could re-use the same infrastructure,” points out Professor Kalra. Researchers defined these information flow scenarios, and from that went on to examine business models and value chains, which Professor Kalra says is important to the long-term prospects of cross-border eHealth services. “If this is to be successful and to be sustained, you need to assess the value across multiple stakeholders and the business benefits of adopting and sustaining this level of health information interoperability. This analysis has required the project to adopt robust business modelling methodologies. You need to look at all the stakeholders in the eco-system – some of those are going to have to invest financially to keep services going,” he stresses. “There are complementary investors in this area, for example, the ICT industry can play an important role.”

Many interfaces are required to enable interoperability and it will also be important to present the information clearly to clinicians. The data itself will also hold importance as a source of records which can be used to learn more about a condition, for example diabetes. “Which treatments are proving optimal? In which situations does health deteriorate unexpectedly requiring urgent intervention? Could that be anticipated? Public health systems could find this kind of information useful in planning services,” says Professor Kalra. The project has constructed several stakeholder value chains, that show how value is realised at each interaction. “We’ve developed those value chains, a qualitative business modelling framework, then on top of that we’ve undertaken some novel costeffectiveness modelling. The aim is to look at the benefit to an example health system if it was able to better treat patients in urgent, unexpected scenarios,” continues Professor Kalra.

Economic benefits

The focus in the project is on the economic benefits of interoperability, which is of course the measure by which infrastructure projects tend to be judged. The financial return could relate to costs saved, care interventions avoided, yet this is not easy to quantify. “We need to convince Member States that if they choose to put money into establishing a set of electronic digital services that support cross-border information flows for patients with long-term conditions, then this will give them a national healthcare benefit too and a financial return,” outlines Professor Kalra. Member States have already agreed to collectively share the cost of a pan-European infrastructure for sharing an emergency, basic medical summary, yet Professor Kalra believes that this is not enough on its own to bene t patients. “We’re going to make recommendations to the European Commission and to its Member States, through the eHealth network, to recommend that they further invest in enriching the summary, to include the data needed to improve treatment of several long-term conditions,” he says.

ALUeHEALTH

At a glance

Full Project Title

Establishing the value and business model for sustainable eHealth services in Europe (VALUeHEALTH)

Project Objectives

VALUeHEALTH is establishing how eHealth interoperability can create and deliver value for all stakeholders, for a sustainable market in scaling up cross-border services. We are developing an evidence-based business plan for interoperability, beginning with CEF support and later sustainable revenue streams for developing and operating self-funding priority panEuropean eHealth Services beyond 2020.

Project Funding

Estimated Project Cost: €999.818 Requested EU Contribution: €849.755

Project Partners

• Please see http://www.valuehealth.eu for full details.

Contact Details

Project Coordinator, Professor Dipak Kalra European Institute For Health Records c/o University Hospital Gent - Building 5K3 Unit of Medical Informatics and Statistics De Pintelaan 185 - 9000 Gent (Belgium) T: +32 475 97 3819 E: dipak.kalra@eurorec.org W: http://www.eurorec.org/

Professor Dipak Kalra

Professor Dipak Kalra is President of the European Institute for Innovation through Health Data, while he also serves as President of the European Institute for Health Records (EuroRec), Professor of Health Informatics at University College London and Visiting Professor of Health Informatics at the University of Gent.