eHealth Practice in Europe: where do we stand?

Catherine ChronakiSecretary General, HL7 Foundation

ESC e-Cardiology WG

eHealth Practice in Europe• eHealth as the use of Information and communication technologies in the

practice of health care– Electronic health records (EHR)– Healthcare information exchange cross-jurisdictions– Personal health records– Telehealth, telemedicine and remote monitoring

• Vision of the learning health system and issues with digital health• Benchmarking eHealth adoption – OECD eHealth study, WHO atlas• European Commission initiatives to support cross-border eHealth

– eHealth Digital Services Infrastructure– eStandards, ASSESS CT, and openMedicine

• Reflections on the role of the ESC and its members

Vision of the Learning Health SystemA healthcare system that • Draws on the best evidence to provide the care most

appropriate to each patient, • Emphasizes prevention and health promotion, • Delivers the most value,• Adds to learning throughout the delivery of care• Leads to improvements in health.

2oo6, NIH

Question: What is the role of e-health in the learning health system?

It's time to get doctors out of EHR data entry

Source: HIMSS Insights 2015

Concerns with wide adoption of EHRsUnintended clinical consequences of broad EHR adoption: • reduced time for patient-clinician interaction• new and burdensome data entry tasks to front-line clinicians• more patients, lengthened workdaysFrustrations lead to decreased satisfaction with professional work life.Moreover:

1) Interoperability among EHR systems is nascent. 2) Electronic Health Record Systems have a steep learning

curve and limited usability.Ref: Payne TH, et al. Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs. J Am Med Inform Assoc 2015;0:1–11

Atlas of eHealth Country profiles• 126 countries, 2005, 2009, 2013, 2015, (2016)• eHealth foundations• Legal frameworks for eHealth• Telehealth• Use of eLearning in Health Sciences• Electronic Health Records (EHRs)• mHealth• Social media• Big Data

Defines medical jurisdiction, liability or reimbursement of eHealth services such as telehealth

Addresses patient safety and quality of care based on data quality, data transmission standards or clinical competency criteria

Protects the privacy of personally identifiable data of individuals irrespective of whether it is in paper or digital format

Protects the privacy of individuals’ health-related data held in an EHR

Governs the sharing of digital data with health professionals in other health services within country with the use of an EHR

Governs the sharing of digital data with health professionals in health services across countries with the use of an EHR

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

31%

46%

78%

54%

34%

22%

40%

55%

96%

74%

55%

36%

46%

61%

93%

86%

75%

43%

Legal Frameworks for eHealth (1 of 2)

EU+Norway+Swiss+UK European Region WHO (126 countries)

Governs the sharing of personal and health data between research entities

Allows individuals electronic access to their own health-related data when held in an HER

Allows individuals to demand their own health-related data be corrected when held in an EHR if it is known to be inaccurate

Allows individuals to demand the deletion of health-related data from their EHR

Allows individuals to specify which health-related data from their EHR can be shared with health professionals of their choice

Governs civil registration and vital statistics

Governs national identification management systems

0%10%

20%30%

40%50%

60%70%

80%90%

100%

39%

29%

32%

18%

28%

76%

65%

53%

43%

47%

34%

49%

81%

70%

68%

61%

68%

46%

68%

93%

79%

Legal Frameworks for eHealth (2 of 2)

EU+Norway+Swiss+UK European Region WHO (126 countries)

primary care facilities manage patients online

Radiology images exchange in acute care

Synchronous telehealth capability in acute care

access to test results online by patients

e-appointment booking by patients

e-request perscription renewal refill

secure messaging with patients

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

26

10

7

0

3

3

0

5

12

8

0

2

2

4

2

9

15

31

26

26

27

Maturity of eHealth solution in 30 European Countries (OECD, EU)

>75% 50-75% <50%

Ref: Zelmer J, et al. International health IT benchmarking: learning from cross-country comparisons. J Am Med Inform Assoc 2016;0:1–8

European Interoperability framework

• eHealth Digital Services infrastructure

– Organizational framework– National Contact points– Multilateral agreements– Master value set catalogue

(MVC)– Use cases

• patient summaries• electronic prescription• Registries• Reference networks

www.estandards-project.eu

eHealth Digital Services InfrastructureeHDSI or eHealth DSI is the initial deployment and operation of services for cross-border health data exchange under the Connecting Europe Facility (CEF).Focus: Patient Summary, ePrecription/eDispensation(2015-2019)

How to do eStandards for the Digital Age?At a rapid face of just-in-time disruption, Standards Developing Organizations need to cooperate • to deliver timely, affordably

quality, interoperability, knowledge• to look outside• to listen to the users• to rethink standards and tools that

support their full lifecycle• To deliver live eStandards

June 24, 2015 eStandards Annual Review13

Base Standards

Use Case basedStandards Sets

Assurance and Testing

LiveDeployment

Feedback and Maintenance

Tooling and Education

Forums and Monitoring

Assessing SNOMED CT for Large Scale eHealth Deployments in the EU: recommendations.

1. need for a coherent EU Strategy for eHealth addressing adoption of terminology resources and optimizing benefits of semantic interoperability in health data

2. SNOMED CT best candidate for a core reference terminology for large-scale eHealth– part of a terminology ecosystem with WHO ICD and others, multilingualism,

and clinical communication with multidisciplinary professional and lay language– Be adopted incrementally with terminology subsets for priority use cases

3. Mechanisms should be established to facilitate and co-ordinate European Member State co-operation on terminology and semantic interoperability, – common areas of governance across Terminology centres and eHealth

competence centres

Equivocal identification of medicines

When scanning the medication barcode, enhanced information appears:

– Whether it is the right medication

– Medication product characteristics are highlighted for the patient (e.g. Considering allergies, preconditions, etc).

ID........................

PrescribingApp

Patient App

European Medicines Database

Treatmentdata

Productdata

PersonalProduct

data

EU Patient Summary GuidelineEU patient summary guideline defines patient summary as the “minimum set of information needed to assure healthcare coordination and continuity of care”

• Emergency or unplanned care refers to “the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly”

• Other EHR summaries– Emergency data set– Continuity of care record– Encounter report– Discharge summary– 2nd opinion– Clinical patient summary– Disease specific summaries

• Around the world many variants of the same basic types of patient summariesDec 4, 2014

Patient Summary Clinical data for unscheduled care

• Alerts– Allergy: Allergy description, Agent– Medical Alert information

• Medical history– Vaccinations (Disease, Brand, Date)– Problem (Problem, Onset, Resolution)– Surgical Procedures (Type, Date)

Patient Summary Clinical data (con’t)Medical Problems• Current problems / diagnoses

(description, id, onset)• Medical devices and implants

(Device & implant description, id, date)• Major surgical procedures (<6 mon)• Treatment recommendations • Autonomy/Invalidity

Patient Summary Clinical data (con’t)Medication summary• List of current medicines

– active ingredient, – brand name, – strength, – dose, – units per intake, – frequency, – duration, – onset

Patient summary for unscheduled care (con’t)

• Social history• Pregnancy history• Physical findings (e.g. ABP)• Diagnostic tests – blood group

Is this patient summary sufficient to you?

What do theMember States think about the Patient Summary Guideline?

In terms of its value, availability of infrastructure, and sustainability

Status and Future directions of EHRs (AMIA 2020 EHR task force)

• Simplify and speed documentation– decrease data entry burden for the clinician– separate clinical data entry from data reporting– EHRs enable systematic learning and research during routine practice

• Refocus on regulation– improve data exchange and interoperability– reduce the need for re-entering data– prioritize patient outcomes over new functional measures

• Increase transparency and streamline certification & Foster innovation– EHR vendors use standards-based application programming interfaces (APIs) and data standards to be open

• EHR In 2020 must support person centered care delivery– promote the integration of EHRs into the full social context of care– Improve the designs of interfaces so that they support and build upon how people think What would be your recommendations?

Ref: Payne TH, et al. Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs. J Am Med Inform Assoc 2015;0:1–11

Electronic Health Record: wish list• researchers, so they can advance our understanding of disease and

health care processes; • clinicians, so they can provide safe and effective health care; • administrators, to reduce their reliance on a single-source EHR; • software developers, so they can develop innovative solutions to

address limitations of current EHR user interfaces and new applications to improve the practice of medicine; and

• patients, so they can access their personal health information no matter where they receive their health care.

Extract

Transmit

Move

Embed

Exchange

Ref: What makes an EHR “open” or interoperable? Sittig DF, Wright A J Am Med Inform Assoc 2015;0:1–3.

Learning Health System Goal• By 2020, 90 % of clinical decisions will be

supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence.

2oo6, NIH

What can we do to make this happen?

Healing is a matter of time, but it is sometimes also a matter of opportunity.

Hippocrates (460-370BC)

“. . . For the secret of the care of the patient is in caring for the patient.”Dr. Francis W. Peabody, October 21, 1925