The health connection

Colin Forsyth considers the many challenges involved in introducing electronic communication systems to improve the quality of patient care in Europe

In June 2002 the Department of Health in England published Delivering 21st Century IT Support for the NHS - A National Strategic Programme, and just four months later, the National Programme for IT was formally established and the programme that is designed to bring about a modern integrated IT infrastructure for the National Health Service (NHS) was under way.

The underlying principle is encapsulated within the statement that 'the National Programme for IT is creating a multi-billion pound infrastructure, which will improve patient care by enabling clinicians and other NHS staff to increase their efficiency and effectiveness'. Trying to understand the project as a whole can seem, at times, quite difficult. There are technological, cultural, legal and conceptual issues to name just a few. But identifying and then implementing such a project is not unique to England.

In May, a two-day symposium in Stockholm updated delegates on progress within the Baltic States of two e-health projects that have to deal with all of the issues identified above, together with those associated with having to manage the international issues that also arise. The partners in this development are Denmark, Estonia, Lithuania, Norway and Sweden.

In contrast to that of the NHS, the aim of the Baltic state's project is: 'Baltic e-health will promote the use of e-health in rural areas of the Baltic Sea Region by creating a large trans-national infrastructure for e-health, the Baltic Sea Healthcare Network. The aim of the project is to illustrate that e-health is an effective means in increasing access to healthcare of high quality in rural areas, and thereby contributes to counteracting rural migration.'

The additional focus on the social and economic impact of rural migration adds an extra facet to the IT imperative that is not always explicitly identified within the UK. Yet the sociological benefits of effective access to healthcare are implicit within the NHS' overall targets.

Identification of the challenges faced and the solutions implemented formed the focus of the conference. Research within the Baltic States had identified the relative socio-economic importance of healthcare within rural populations, especially the potential impact it could have on rural depopulation. In addition, the ageing populations, lack of specialist services in remote or rural areas and the general economic migration from poor areas, can also lead to greater strains on healthcare services. One of the key solutions to ensuring access to effective services by these rural communities has been to develop e-health and telemedicine services, and the opportunities of e-health is an area within which the ACCA has worked in partnership with the European Commission to identify the financial and service benefits achievable. This can be through the transmission of images to specialist centres, the sharing of health knowledge and telemedicine facilitating remote consultations between clinicians and patients. Though the conference was not completely absent of discussion around IT infrastructures, the message was very similar to that within the UK - that e-health is not an IT solution in itself, it is about patient care. The challenge then thrown down was around how the IT infrastructure is utilised. Like healthcare provision itself, the IT infrastructure is there, available but also continually evolving. Healthcare managers, when developing strategies, need therefore to ensure that developments in IT, and how the IT services themselves are changing, are incorporated into overall healthcare strategies.

Challenges

Development of e-health solutions across the Baltic States has been both wide ranging in scope (literally as regards geography), but has been specific in its focus: the construction of an IT infrastructure and the demonstration of the opportunities this provides through pilot projects in ultrasound and radiology. The partners within this project have had to face many challenges, not least building the technology, but on this front there was confidence that this had been met. It has also been necessary to ensure that, across the project, there has been a common understanding of IT systems and the opportunities and challenges that they bring with them. In addition, there have been conceptual challenges; the experience of the project was that most people are treated within five miles of their home, yet the project is putting in place an international network.

That said, any project will face barriers to its success, and it is how these are managed that will, in many ways, determine the likely outcome. It could be considered that an international IT system would face a wide range of issues, and in one sense it did. However, the outstanding impression was that the challenges faced were remarkably similar to any other project. Certainly, there were significant cultural issues (in this instance, not least around language and politics), but this can also be true for local projects. The major issues covered were:

• infrastructure - specific processes looking at access to multiple systems have been developed to answer the issues around security and of ensuring there are common standards (both cross-border and across hospitals)
• legal - detailed legal agreements have been developed that have had to address issues such as information security, responsibilities, local legislative frameworks, language and consensus around what such an agreement should include. Frameworks covering core issues such as confidentiality, re-imbursement, patient's right, etc, have been developed so that they are 'transportable' between different parts of the projects. These will then be adapted to meet the specific needs
• organisational - considerable efforts have gone into working with local organisations and clinicians to ensure that the cultural issues have been addressed. Local IT infrastructures have been built to ensure organisations can link into the international network, and the project team has also had to ensure the solutions match the financial frameworks (e.g. methodologies concerning the re-imbursement of episodes) and working practices. Developing an 'all inclusive' solution has helped break down barriers and ensured the concerns of all interested parties are addressed. Having a flexible solution has been critical both to meet local needs, but also to address changes as they arise. Finally, proving the solution has been essential. The use of small pilots has allowed the success of the solution to be demonstrated to users.

Up until this point the project has focused on proving the solution, both at a local level and across borders. The next phase is moving towards 'business as usual'. E-health has become an integral part of the healthcare environment and it is how health professionals use this tool that will have a major impact on healthcare services in the future. However, it must be recognised that it is only part of the solution and not the answer in itself, and it was this theme that was revisited as the conference closed. IT solutions will give different levels of benefits, and types of benefits, in different areas. If IT solutions are to be embedded and utilised effectively, it is this variation that must be embraced so that solutions are fully inclusive.

ACCA has worked in partnership with the European Commission on projects identifying the substantial productivity benefits available from e-health solutions, and these benefits will need to be realised to help offset the increasing demands on healthcare. This work, and that within the Baltic States, has identified that e-health can provide productivity gains as well as generating service benefits concerning access to services, quality issues and the empowerment of both patients and healthcare professionals. The Baltic States' projects demonstrate that there can be international co-operation to develop e-health services, yet there are many other IT developments going on across Europe where there does not seem to be the same level of integration. This could well be because developing national solutions is a challenge in itself. The danger is that when those solutions are developed, will they talk to each other and will the benefits be realised? Will we end up with a series of national models that will not communicate across borders? As regards mobility, though a resident may not travel very far, what we are seeing is significant cross-boundary migration. The question for the UK and across Europe is whether future health systems provide health services that are accessible, equitable and effective in such an environment. The Baltic States are certainly looking to address this issue today rather than tomorrow.

References

1. NHS Connecting For Health, www.connectingforhealth.nhs.uk/about/
   background/index_html, 2007
2. Baltic eHealth, www.baltic-eHealth.org/default.htm, 2007
3. The NHS Plan, Department of Health, www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
   AndGuidance/DH_4002960, 2000
4. Rural eHealth Report, Baltic eHealth, www.baltic-ehealth.org/default.htm, 2007
5. eHealth as a Facilitator of Transnational Co-operation on Health, B Thorsten, B Henning, K Helli, S Lars, S Owe and V Alfonsas, Seinäjoki University of Applied Sciences, 2007
6. The Cost Benefit of Electronic Patient Referrals in Denmark, www.accaglobal.com/members/publications/sector_booklets/healthcare_
   sector, 2007
7. Telecardiology in Italy: Benefits from a Telemedicine Network Connecting Chronic Patients, General Practitioners and Healthcare Provider Organisations, www.ehealthconference2006.org/pdf/Scalvini.pdf, 2006

Colin Forsyth is the finance manager of West Essex Primary Care Trust and a member of ACCA's health panel.