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e-Health
a UEMS perspective
14th annual "National Medical Specialty Training Conference"
Turkish Medical Association, Ankara, 29 Nov 2008
Peter M. Pattynama, MD, PhD
Professor of interventional radiology
Erasmus university Medical Center
Rotterdam (NL)
President, UEMS radiology section
Rapporteur, UEMS working group on e-health
[email protected]
e-Health
• e-Medicine
Electronic Patient Record
Professional-to-Professional telemedicine (teleradiology, pathology)
Professional-to-Patient telemedicine (telemonitoring)
• e-learning
Postgraduate Medical Specialist Training (residents)
CME/CPD programs (medical specialists)
Where do we stand today?
• e-Medicine
Much activity
New European Commission initiatives to promote e-Medicine
Market developments
UEMS position in response
• e-learning
Efforts mainly by medical specialty organisations
UEMS accreditation for e-learning
e-Medicine: European Context
Increased demand for healthcare, higher cost
• Ageing population
• Growing prevalence of chronic disease
• Better quality, more therapeutic options
Decrease of active workforce
Spirit of EU
• Free movement of persons, goods, services and capital
Economic incentives
• Market potential of e-Medicine for EU
• Creating economic growth and jobs to EU citizens
Similar but Different !
Patient mobility: Cross-border healthcare
• Driving principle: consumer choice
• Patient’s own choice to go abroad
• Free movement within EU
• Provider: National healthcare system of another EU country
e-Medicine: Cross-border healthcare
• Driving principle: Free market, Global competition, comparative
advantage, cost control, capacity issues
• Not the patient’s choice, patient stays within his own EU country
• Provider: for-profit commercial player with global reach
• May be located in (low wage-) countries outside EU
Hoped for prospects: e-Health
Spirit of EU
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eHealth, as ICT solutions for patients, medical services and payment
institutions can help deliver better care for less money;
“ eHealth, one of the priorities of the EU's i2010 programme to boost
innovation and jobs …”
eHealth, One of the first six lead markets: markets in which EU industry
can develop a global competitive advantage ..”
Market potential for eHealth estimated as 1/3d of world market or 20
billion euro per year.
cf: EU pharmaceutical market 205 billion
EU medical technology
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UEMS position
UEMS’s Bratislava declaration 2007
1. e-Medicine is becoming everyday’s practice in EU
2. e-Medicine has the potential to significantly improve quality of care.
Quality must have priority over increased cost-efficiencies.
3. Electronic patient records are inevitable, and will contribute to higher
standards in medical specialisation and healthcare.
4. However, UEMS is concerned about recognized risks to security of
data, confidentiality, medical ethics and the law.
Therefore, UEMS commits itself to promote and control
- respect for security and privacy of persons
- respect for medical ethical principles
- validity of electronically stored health information
- quality of electronic medical education and training
UEMS response
Creation of a working group on e-health, October 2008
Aim:
To review and to discuss e-Health issues
To formulate views on e-Health matters as they relate to professional practice
and to patient-related issues for specialist doctors in the European Union.
The WG will prepare policy papers for approval by the UEMS Council, as
statements of the UEMS point of view.
European Commission documents
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Proposal for directive on cross-border healthcare, July 2, 2008
Recommendation on e-Health records, July 2, 2008
Communication on Telemedicine, Nov 4, 2008
EU documents and law (1)
EU rules
• are automatically part of national law of all EU member states
• Aim is to arrive at one common judicial system
EU directives (recommendations)
• Guidelines that should, in one way or the other, be incorporated in
national law
• Aim is to make national law systems more similar
EU communications
• Soft power to influence EU member states
• The European Commission takes a position
EU law (2)
Health care follows “principle of subsidiarity” (i.e., should be handled
by the lowest authority possible) (1992 treaty of Maastricht)
Management of national health care systems are decided by each
of the EU member states for themselves
But the European Court of Justice ruled that:
“EU treaties apply also to health care”
EU directives and recommendations (!) supersede national law even if
this has implications for national health care
EU law (3)
EU directives with direct implications for national health care
• Can apply to environmental health issues to protect citizens
Directive 96/29/EC Euratom (radiation exposure in medicine)
• Or to social issues to protect workers
Directive 2004/40/EC EMF - electromagnetic fields directive (MRI?)
• Or to internal market & consumer protection
Directive 2000/31/EC “e-Commerce directive” (telemedicine)
EU law (4)
• EU laws are prepared by 37 Directorate Generals
(Compare: ministries)
• Under authority of a EU Commissioner (compare, minister)
• Large organizations of civil servants
• Headed by Director-General (civil servant)
Directive 97/43/ Euratom
Directive 2004/40/EC - EMF
DG Health and Consumer Protection
• SANté & protection des Consomateurs = SANCO
Euro Commissioner: Androulla Vassilliou (Cyprus)
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Management of national health care systems are decided by each
of the EU member states for themselves
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Programs for
Consumer protection
Public health
Food safety
European Parliament
Europarliament resolution, 23 May 2007:
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Cross border issues are a matter for the EU
EU members states insufficiently promote health care
which restricts patients’ rights
Cross border health care will grow and will increase quality and accessibility
Patient and professional mobility ensures free movement of citizens
Wants member states to actively support e-health and telemedicine
Legal and reimbursement issues need to be solved
European Commission
Consultation of the public on patient mobility 2006-2007
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Most respondents favored community action on health services:
Growing scale of cross border health care
Need for greater clarity about judicial limits
Expect EU support to improve quality and safety of health care
Support national health systems by establishing EU networks,
centers of reference to share information and innovations
European Commission indicated that patients safety and mobility
will be a key political priority for 2008
Where are the doctors …?
To the European Commission and the DGs there are only a few relevant
groups representing doctors in the EU to consult with:
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CPME – Comité permanente/Standing committee of European doctors
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UEMO – European Union of General Practitioners
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UEMS – Union Européenne des médecins spécialistes
European union of medical specialists
For practical reasons, the scientific organisations representing the >39
medical specialties, are not consulted on a routine basis
This is why we should use UEMS as a vehicle to get our message across
Directive on Cross-border Healthcare
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proposal, July 2, 2008, COM(2008)414
to be discussed in Europarliament December 2008
Prepared by DG SANCO
Directive on the application of patients’ rights in cross-border healthcare
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goal: clarify entitlements for EU citizens to receive non-emergency health
care in other EU member states (without prior authorization)
enhance patient mobility across internal EU borders
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contains art. 16 on “E-Health”:
will achieve measures necessary for interoperability of information and
communication technology systems in the healthcare field
to ensure safe, high-quality and efficient data transferral across borders
focus on technology issues and protection of personal data
Communication on Telemedicine
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Nov 4, 2008, COM(2008)689
Prepared by DG Information Society and Media (Commissioner Reding)
Communication on telemedicine for the benefit of patients, healthcare
systems and society
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goal: increase and broaden telemedicine services, i.e., delivery of
healthcare including diagnosis, treatment and monitoring at a distance
across Europe.
Professional-to-Professional vs Professional-to-Patient telemedicine
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Calls for specific action of member states
building trust and acceptance of telemedicine
facilitating market development
bringing legal clarity
Telemedicine currently explicitly NOT a medical act in many member
Recommendation on eHealth records
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July 2, 2008, COM(2008)3282
Prepared by DG Information Society & Media (Commissioner Reding)
Recommendation on cross-border interoperability of electronic health
record systems
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goal: improve sharing of medical data across institutions and across
borders within EU
contains basic principles and guidelines for ensuring that doctors can
access vital information about their patients, wherever such information
may be located in Europe
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UEMS and ESR position
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Teleradiology (telemedicine!) is a reality
In essence, is positive: improves quality and accessibility to radiology services
Technical issues not limiting, neither patient acceptance, nor quality of service
Practice of telemedicine should be well regulated
to ensure quality of care & patient safety
(and we have seen bad examples of unregulated teleradiology …)
Issues in Telemedicine
A
Risks regarding responsibility & accountability
Teleradiology providers: commercial for-profit firms inside/ outside of the EU
B
Legal/medical risks:
Telemedicine not a medical act?
interpreting without clinical context
C
Uncertain how teleradiology will be implemented
involvement of local radiologists?
Bad UK-example: No involvement of local radiologists
NHS hires teleradiology capacity
Good EU examples: local radiologists are primarily involved
Isolation from clinical context
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Teleradiology services are remote
Have limited access to patient files, current and historic lab data, imaging studies
No face-to-face conferencing with treating doctors
Medical-ethical concern
The interpretation of an imaging study will change according to this additional information
(the clinical context)
This will result in overcautious, or vague reporting: “defensive medicine”
Calling for extra unnecessary/inappropriate tests, driving up costs and waiting lists
Legal concern
Many EU countries require by law that all available information should be used
when interpreting radiology examinations, to ensure optimal quality of care
Dans E, et al. Tijdsch Gezondheidsrecht [J Health Law] 2008,32: 187
Clinical context (1)
• Metastasis of cancer !
Clinical context (1)
• Lab:
Alk. Phosph. = 216 IU / l
• Metabolic disease (Paget) !
Clinical context (2)
• Lung cancer !
Clinical context (2)
• CT of 5 years prior:
Unchanged
• Irrelevant, benign nodule !
UEMS (and ESR) position
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B
Risks regarding responsibility & accountability
Legal/medical risks
Telemedicine should be classified as a medical act
Doctors offering telemedicine services should be held to the same
professional and medical-ethical standards as doctors who offer
standard (non-telemedicine) healthcare services
Regulation of telemedicine is the responsibility of the EU member state
where the patient seeks treatment
Directive on Cross-border Healthcare
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•
•
proposal, July 2, 2008, COM(2008)414
to be discussed in Europarliament December 2008
Prepared by DG SANCO
Directive on the application of patients’ rights in cross-border healthcare
•
goal: clarify entitlements for EU citizens to receive non-emergency health
care in other EU member states (without prior authorization)
enhance patient mobility across internal EU borders
•
•
•
•
•
contains art. 16 on “E-Health”:
will achieve measures necessary for interoperability of information and
communication technology systems in the healthcare field
to ensure safe, high-quality and efficient data transferral across borders
focus on technology issues and protection of personal data
UEMS position
The directive should not only address IT-aspects of telemedicine but also
general principles of quality and safety of patient care:
To art. 16 about e-Health should be added:
Specific telemedicine services should be classified as medical acts.
The use of telemedicine should adhere to the same professional medical
quality and safety standards as conventional health care
Communication on Telemedicine
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Nov 4, 2008, COM(2008)689
Prepared by DG Information Society and Media (Commissioner Reding)
Communication on telemedicine for the benefit of patients, healthcare
systems and society
•
•
goal: increase and broaden telemedicine services, i.e., delivery of
healthcare including diagnosis, treatment and monitoring at a distance
across Europe.
Professional-to-Professional vs Professional-to-Patient telemedicine
•
•
•
•
•
Calls for specific action of member states
building trust and acceptance of telemedicine
facilitating market development
bringing legal clarity
Telemedicine currently explicitly NOT a medical act in many member
UEMS position
UEMS welcomes many of the principles put forward in the communication on
telemedicine. In fact, these should be incorporated in the Directive on
Cross-border healthcare
“Specific telemedicine services should be classified as medical acts.
This principle ensures that adequately regulated health services are not
replaced by less regulated telemedicine services.”
We welcome the call for actions regarding
Development of reimbursement schemes for telemedicine
Training for health professionals
Bringing legal clarity
Recommendation on eHealth records
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•
July 2, 2008, COM(2008)3282
Prepared by DG Information Society & Media (Commissioner Reding)
Recommendation on cross-border interoperability of electronic health
record systems
•
goal: improve sharing of medical data across institutions and across
borders within EU
contains basic principles and guidelines for ensuring that doctors can
access vital information about their patients, wherever such information
may be located in Europe
•
UEMS position
UEMS welcomes the recommendation but thinks several issues need to be
further addressed:
•What characteristics should an international e-Health system have to be a useful
tool for patients and professionals?
•What level of security is desirable and should physicians’ organizations
participate in monitoring the safety of the system?
•What level of centralization of data storage is desirable (the level of individual
hospitals, regional or national, or supranational)?
•Should summary or detailed patient records be available?
•How should access privileges be governed? Should there be registries where all
users will be certified?
•How much privacy should the system assure? Should there be an emergency
access to patient records that will not require patient’s authorization?
•What terminology and classifications should be used in interoperable medical
records?
E-Health
• e-Medicine
Much activity
European Commission initiatives to promote e-Medicine
Market developments
UEMS perspective
• e-learning
Efforts mainly by medical specialty organisations
UEMS accreditation for e-learning
e-Learning in radiology
• European radiology has recognized huge potential of e-learning
• Radiology is especially well-suited for e-learning (for the same
reasons that teleradiology is so successful!)
• European Society of Radiology has initiated e-learning projects:
ESR electronic congress
ESOR Virtual School
ESR electronic congress
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Since 2003, the annual ECR meeting uses an all-electronic format for
scientific exhibitions
All congress abstracts are available in electronic format
All slide presentations are electronically kept
The various subspecialty societies have followed suit, CIRSE, ESGAR,
ESMRMB, ESCR, ESSR, (plus the American SIR)
The ESR electronic congress comprises:
• over 11,750 abstracts
• over 1,060 PowerPoint™ presentations to download
• over 280 recorded lectures / webcasts
• over 3,740 electronic exhibits
accessible for ESR-members via one single platform.
ESOR Virtual School
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The ESR organizes so-called GALEN-foundation courses in the context of its
European School of Radiology
Aim: to harmonize radiology training in Europe
Aimed at radiology residents in years-1, 2, and 3
Taught by eminent European faculty
Abdominal, cardiovascular, chest, neuro-, muskuloskeletal radiology and
oncological imaging
These courses have been made available in electronic format in the “virtual
school”
accessible for ESR-members via one single platform
e-Learning in radiology
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There is ample study material for e-learning available on-line
Yet, a true beneficial effect is unknown
(Turns out to be less popular than initially anticipated?)
Potential reasons
• e-learning material only recently available
• not clear how e-learning can be incorporated in regular training:
not yet award-system for e-learning in radiology training (but this could be
the responsibility of national radiology societies!)
• until recently, no award-system for e-learning for CME/CPD
Our professional responsibility
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Promotion of e-learning is our responsibility
The European Commission has relatively lack of in-depth expertise
of medical field & problems
Trust in doctors to provide directions, guidelines
View that such appropriate guidelines will become incorporated in
law
It is critical that we, as professionals, develop and publish our view
on the use of e-learning in postgraduate medical specialist training
Developed by specialists
Endorsed by mother specialty (ESR)
Brought into the political discussion through UEMS
UEMS position
Accreditation of e-learning materials by EACCME
Adopted in Copenhagen, 11 October, 2008
European Accreditation Council for Continuous Medical Education:
Other, non-traditional means of CME/CPD are acceptable to obtain credits,
including audio recordings, video recordings, and on-line websites.
These materials and the providers have to comply with the EACCME quality
standards
The credits are valid in those member states that have a recognition agreement
with the EACCME
Where do we stand today?
• e-Medicine
Much activity
New European Commission initiatives to promote e-Medicine
Market developments
UEMS position in response
• e-Learning
Efforts mainly by medical specialty organisations
EACCME accreditation for e-learning
E-learning responsibility of the medical field
Prof. Peter Pattynama (NL)
President, UEMS radiology section
[email protected]