Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions - e-Health - making healthcare better for European citizens: an action plan for a European e-Health Area {SEC(2004)539}
Date: 2004-04-30
Institutions: European Commission
Subjects: EU policy, health care, health policy, information technology, public health

COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 30.4.2004 
COM (2004) 356 final 

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE 
EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

e-Health - making healthcare better for European citizens: An action plan for a 
European e-Health Area 

{SEC(2004)539} 

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COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE 
EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 

e-Health - making healthcare better for European citizens: An action plan for a 
European e-Health Area 

(Text with EEA relevance) 

1. 

2. 

2.1. 

2.2. 

2.3. 

2.4. 

2.5. 

3. 

3.1. 

3.2. 

4. 

4.1. 

4.2. 

Introduction.................................................................................................................. 4 

Challenges and expectations facing Europe’s health sectors and the role of e-Health 5 

e-Health: systems and services that benefit the health sector ...................................... 6 

Empowering health consumers: patients and healthy citizens..................................... 7 

Assisting health professionals ...................................................................................... 8 

Supporting health authorities and health managers ..................................................... 8 

e-Health: the third largest industry in the European health sector ............................... 9 

State of play ............................................................................................................... 10 

Examples of e-Health and its benefits........................................................................ 10 

Major challenges for wider implementation .............................................................. 12 

Towards the European e-Health Area: issues and actions ......................................... 15 

Action plan ................................................................................................................. 16 

Issue 1: Addressing common challenges ................................................................... 16 

4.2.1.  Health authorities leadership...................................................................................... 16 

4.2.2 

Interoperability of health information systems .......................................................... 16 

4.2.2.1. Patient identifiers......................................................................................................... 16 

4.2.2.2. Interoperability of electronic health records ............................................................... 17 

4.2.3.  Mobility of patients and health professionals ............................................................ 17 

4.2.4.  Enhancing infrastructure and technologies ................................................................ 17 

4.2.5.  Conformity testing and accreditation for an e-Health market.................................... 18 

4.2.6.  Leveraging investments ............................................................................................. 18 

4.2.7.  Legal and regulatory issues........................................................................................ 19 

4.3. 

Issue 2: Pilot actions: accelerating beneficial implementation .................................. 19 

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4.3.1. 

Information for citizens and authorities on health education and disease prevention 19 

4.3.2.  Towards integrated health information networks ...................................................... 20 

4.3.3.  Promoting the use of cards in health care .................................................................. 20 

4.4. 

Issue 3: Working together and monitoring practice................................................... 20 

4.4.1.  Disseminating best practices ...................................................................................... 20 

4.4.2.  Benchmarking ............................................................................................................ 21 

4.4.3. 

International collaboration ......................................................................................... 22 

5. 

Conclusions ................................................................................................................ 22 

ANNEX.................................................................................................................................... 23 

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1. 

INTRODUCTION 

e-Health matters. It can improve access to healthcare and boost the quality and effectiveness 
of the services offered. e-Health describes the application of information and communications 
technologies across the whole range of functions that affect the health sector.  

e-Health  tools  or  solutions  include  products,  systems  and  services  that  go  beyond  simply 
Internet-based applications. They include tools for both health authorities and professionals as 
well  as  personalised  health  systems  for  patients  and  citizens.  Examples  include  health 
information networks, electronic health records, telemedicine services, personal wearable and 
portable  communicable  systems,  health  portals,  and  many  other 
information  and 
communication  technology-based  tools  assisting  prevention,  diagnosis,  treatment,  health 
monitoring, and lifestyle management.  

When combined with organisational changes and the development of new skills, e-Health can 
help  to  deliver  better  care  for  less  money  within  citizen-centred  health  delivery  systems.  It 
thus responds to the major challenges that the health sector – which employs 9% of Europe’s 
workforce – is currently facing.  

e-Health  is  today’s  tool  for  substantial  productivity  gains,  while  providing  tomorrow’s 
instrument for restructured, citizen-centred health systems and, at the same time, respecting 
the diversity of Europe’s multi-cultural, multi-lingual health care traditions. There are many 
examples  of  successful  e-Health  developments  including  health  information  networks, 
electronic  health  records,  telemedicine  services,  wearable  and  portable  monitoring  systems, 
and  health  portals.  Today,  at  least  four  out  of  five  European  doctors  have  an  Internet 
connection, and a quarter of Europeans use the Internet for health information. 

European Community research programmes have been supporting e-Health for the last fifteen 
years. The co-financing allocated since the early 1990s has reached €500 million, with a total 
budget  about  twice  that  amount.  Many  research  results  have  now  been  tested  and  put  into 
practice. This has put Europe in a leading position in the use of electronic health records in 
primary care and deployment of health (smart) cards. These developments have contributed to 
the  emergence  of  a  new  “e-Health  industry”  that  has  the  potential  to  be  the  third  largest 
industry in the health sector with a turnover of €11 billion. By 2010 it could account for 5% 
of the total health budget. At present, the e-Health industry in Europe – mainly made up of 
small- and medium-sized enterprises – has a competitive advantage, but it still needs to enjoy 
a more favourable business environment.  

Member States have shown that they are keen to take an e-Health agenda forward1, drawing 
on best practices and experience from across the Union. This should enable a move towards a 
“European  e-Health  Area”;  a  framework  built  on  a  wide  range  of  European  policies  and 
initiatives. In describing this European e-Health Area, an emerging framework for concerted 
actions and synergies in e-Health is envisaged that provides a favourable environment for the 
integration  of  related  policies  at  a  Community  level.  Since  the  health  sector  in  Europe  is  a 

1 

Ministerial Declaration at Ministerial e-Health 2003 Conference. 
http://europa.eu.int/information_society/eeurope/ehealth/conference/2003/index_en.htm.   

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predominantly  public  sector  service,  most  of  the  challenges  and  actions  described  in  the 
Communication on ‘The Role of eGovernment for Europe’s future’2 also apply here.  

e-Health plays a clear role in the European Union’s eEurope strategy, and is key to achieving 
stronger growth and creating highly qualified jobs in a dynamic, knowledge-based economy - 
the vision set out by the Lisbon European Council in March 20003  4. To move ahead, action 
will be required within several important policy areas that range from research and the roll-
out  of  broadband  networks  in  telecommunications,  to  action  in  public  health,  and  work  in 
Member States that promotes  mobility  and  assesses  the  implications of European ageing on 
healthcare systems. 

2. 

CHALLENGES  AND  EXPECTATIONS  FACING  EUROPE’S  HEALTH  SECTORS  AND  THE 
ROLE OF E-HEALTH 

Healthcare  systems  around  the  globe  face  major  challenges5,  even  if  their  nature  and  scale 
varies  significantly  between  industrialised  and  developing  countries.  For  the  Union  these 
challenges include: 

•  rising  demand  for  health  and  social  services,  due  to  an  ageing  population  and  higher 
income  and  educational  levels.  In  particular,  by  2051,  close  to  40%  of  the  Union’s 
population will be older than 65 years old6; 

•  the  increasing  expectations  of  citizens  who  want the  best care  available,  and at  the  same 

time to experience a reduction in inequalities in access to good health care; 

•  increasing  mobility  of  patients7  and  health  professionals  within  a  better  functioning 

internal market8;  

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4 

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The Role of eGovernment for Europe’s Future, 2003. 
European Council (2000), Presidency Conclusions. Lisbon European Council. 23-24 March, 2000. 
COM (2002) 263 final. eEurope 2005: An information society for all: An action plan to be presented in 
view of the Sevilla European Council, 21/22 June, 2002. Brussels, 28.5.2000. 
COM(2001)  723  final  05.12.2001,  The  future  of  health  care  and  care  for  the  elderly:  guaranteeing 
accessibility, quality and financial viability;(6528/03, 20.02.2003) and Joint report by the Commission 
and the Council on supporting national strategies for the future of health care and care for the elderly. 
Within this context, the focus is on access to healthcare to everybody in an ageing society, with a high 
quality of health services and systems under conditions of higher expectations by citizens and shortages 
of  health  professionals,  but  with  the  necessary  financial  viability  and  sustainability  of  national  health 
systems among all Member States in the long term.  
Braun, A; A. Constantelou, V. Karounou, A. Ligtoet, & J-C. Burgelman (2003) Prospecting ehealth in 
the context of a European Ageing Society: Quantifying and qualifying needs. Final report. November 
2003. IPTS/ESTO: Sevilla, Spain. 
Patient  mobility  is  addressed  specifically  in  a  Communication  from  the  Commission,  COM(2004), 
entitled Follow-up to the high level reflection process on patient mobility and healthcare developments 
in the European Union.  
Regulation  1408/71  that  co-ordinates  social  security  legal  schemes  has  recently  been  amended  to 
streamline and modernise access to health care across borders, particularly when undue delays occur in 
the patient’s home Member State. In January 2004, the Commission adopted a proposal for a Directive 
on services in the internal market (COM(2004)2 final) which lays down a framework for the provision 
of services in the internal market, including health services, and for their reimbursement by the relevant 
health  insurance  institutions  when  healthcare  is  provided  in  another  Member  State.  It  should  also  be 
noted  that,  in  March  2002,  the  Commission  made  a  proposal  on  the  recognition  of  professional 
qualifications (COM(2002) 119 final) which includes medical professions. 

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•  the need to reduce the so-called ‘disease burden’9, and to respond to emerging disease risks 

(for example, new communicable diseases like SARS); 

•  the  difficulties  experienced  by  public  authorities  in  matching  investment  in  technology 

with investment in the complex organisational changes needed to exploit its potential; 

•  the need to limit occupational accidents and diseases, to reinforce well-being at work and 

to address new forms of work-related diseases10;  

•  management  of  huge  amounts  of  health  information  that  need  to  be  available  securely, 
accessibly,  and  in  a  timely  manner  at  the  point  of  need,  processed  efficiently  for 
administrative purposes, and  

•  the need to provide the best possible health care under limited budgetary conditions. 

This  focus  on  e-Health  is  part  of  a  broader  recognition  of  the  added  value  of  action  in  the 
health field at a European level. This is reflected in the Community Public Health Programme 
referred  to  in  Decision  1786/2002/EC11.  In  addition,  the  Commission  has  proposed  further 
steps  to  support  Member  States  in  the  on-going  reform  of  health  care  systems.  Progress 
should be monitored and benchmarked and the Commission has proposed applying the open 
method of coordination to health care and care for elderly persons12.  

The  Spring  Report  2004  offers  further  support  for  the  eEurope  action  plan  2005,  and  the 
Lisbon  strategy  in  improving  health  care  and  obtaining  efficiency  gains13.  Although, 
according to Article 152 of the Treaty, and particularly its paragraph 5, Community action in 
the field of public health must fully respect the competence of the Member States in the field 
of  health  care,  other  developments  –  such  as  e-Health  systems  and  services  –  can  have  an 
impact on health systems.  

2.1. 

e-Health: systems and services that benefit the health sector  

e-Health systems and services combined with organisational changes and the development of 
new skills are key enabling tools. They can deliver significant improvements in access to care, 
quality of care, and the efficiency and productivity14 of the health sector. A recent large-scale 

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14 

The disease burden is a measure of the health of a population and quantifies the total impact of disease 
in terms of incidence of mortality, disability, and the cost of illness.  
The costs of accidents at work and occupational diseases are between 2.6% and 3.8% of national gross 
domestic product in the various European Member States. For further details, see Communication from 
the  Commission  on  the  practical  implementation  of  the  provisions  of  the  Health  and  Safety  at  Work 
Directives. COM(2004) 62 final, February 2004.  
Decision  No  1786/2002/EC  of  the  European  Parliament  and  of  the  Council  of  23  September  2002 
adopting a programme of Community action of public health (2003-2008), OJ L 271 of 9.10.2002. 
See  the  Spring  Report  2004:  Delivering  Lisbon,  COM(2004)  29,  21.1.04.  The  Commission  is  taking 
forward these ideas in a Communication on the open method of co-ordination in the area of health care 
in 2004. The open method of co-ordination is designed to help Member States to develop progressively 
their own policies, and involves fixing guidelines, establishing quantitative and qualitative benchmarks, 
translating European guidelines into national and regional policies, and monitoring, evaluation and peer 
review  –  see  European  Council,  2000.  Presidency  Conclusions.  Lisbon  European  Council,  23-24 
March, 2000.  
Spring Report 2004: Delivering Lisbon, COM(2004) 29, 21.1.2004. 
eHealth systems and services can reduce costs and improve productivity in such areas as i) billing and 
record-keeping,  ii)  reduction  in  medical  error,  iii)  alleviation  of  unnecessary  care,  and  iv)  savings 

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survey  identifies  the  very  different  ways  in  which  different  Member  States  systems  and 
enterprises are addressing how the e-business aspects of e-Health can become key drivers for 
change, and productivity gains, in such areas as infrastructure and skills development, internal 
business  processes,  procurement  procedures  and  supply  chain  management,  marketing  and 
sales,  and  functions  of  the  extended  business15.  As  a  public  sector  service  industry,  around 
80%  of  the  cost  of  the  sector  is  human  resources.  In  both  the  old  and  new  Member  States, 
75% of all expenditure comes from public sources16. 

The  amount  and  complexity  of  health-related  information  and  knowledge  has  increased  to 
such a degree that a major component of any health organisation is information processing. 
The  health  sector  is  clearly  an  information  intensive  sector  which  increasingly  depends  on 
information and communication technologies. These technologies are supporting progress in 
medical research, better management and diffusion of medical knowledge, and a shift towards 
evidence-based  medicine.  e-Health  tools  support  the  aggregation,  analysis  and  storage  of 
clinical  data  in  all  its  forms;  information  tools  provide  access  to  the  latest  findings;  while 
communication  tools  enable  collaboration  among  many  different  organisations  and  health 
professionals. 

2.2. 

Empowering health consumers: patients and healthy citizens 

Both  as  patients  and  as  healthy  citizens,  people  can  benefit  from  better  personal  health 
education and disease prevention. They need support in managing their own diseases, risks – 
including  work-related  diseases  –  and  lifestyles.  A  growing  number  of  people  are  looking 
proactively for information on their medical conditions17. They want to be involved actively 
in  decisions  related  to  their  own  health,  rather  than  simply  accepting  the  considerable 
discrepancy  (‘asymmetry’)  in  knowledge  between  themselves  and  health  professionals.  e-
Health services provide timely information tailored to individuals in need. Specialised online 
resources  are  available  for  health  education,  safety  and  security  at  work,18  and  lifestyle 
management.  The  Commission  has  been  active  in  establishing  quality  criteria  for  Health 
related websites19 and accessibility of web sites20. 

Personalised  systems  for  monitoring  and  supporting  patients  are  also  currently  available  – 
examples include wearable or implantable communication systems for continuous monitoring 

achieved  by  business-to-business  e-commerce,  cited  in  P.M.  Danzon  and  M.  Furukawa,  e-Health: 
Effects of the Internet on Competition and Productivity in Health Care (2001) In The Economic Payoff 
from  the  Internet  Revolution,  the  Brookings  Task  Force  on  the  Internet,  Brookings  Institution  Press: 
Washington.  
Stroetmann  K.A.  and  V.N.  Stroetmann  (2004)  Electronic  business  in  the  health  and  social  services 
sector  –  Sector  Impact  Study  No.  10-I  (draft).  The  European  e-business  W@tch  2003/4,  European 
Commission, Enterprise Directorate General: Brussels/Bonn, February 2004. 
See footnote 15. 
Detmer, D.E., P.D. Singleton, A. Macleod, S. Wait, M. Taylor, and J. Ridgwell (2003), The Informed 
Patient: Study Report, Cambridge University Health, Judge Institute of Management: Cambridge, UK. 
March 2003. 
The European Agency for Safety and Health at Work offers a wide range of web resources on accident 
and  diseases  prevention  and  guides  of  best  practices  for  both  employers  and  employees.  See 
http://europe.osha.eu.int/. 
Communication on eEurope 2002: Quality Criteria for Health related Websites 
http://europa.eu.int/information_society/eeurope/ehealth/index_en.htm. 
COM(2001)  529.  eEurope  2002:  Accessibility  of  Public  Web  Sites  and 
http://europa.eu.int/information_society/topics/citizens/accessibility/web/wai_2002/cec_com_web_wai
_2001/index_en.htm 

their  Content.  

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patients’  heart  conditions.  These  systems  can  help  shorten  or  completely  avoid  the  stay  of 
patients in hospitals, while ensuring monitoring of their health status.  

Having  access  to  comprehensive  and  secure  electronic  health  records  has  been  shown  to 
improve quality of care and patient safety. This will facilitate appropriate treatment of patients 
in  providing  health  professionals  with  a  better  knowledge  of  the  patient’s  history  and  of 
previous interventions by other colleagues. If interoperable, given patient mobility, electronic 
health records will also improve conditions for treatment in other European Union countries.  

2.3. 

Assisting health professionals 

The  priority  of  medical  professionals  is  to  offer  best  quality  care  within  available  resources 
and,  above  all  –  according  to  the  Hippocratic  oath  –  while  doing  no  harm  to  the  patient 
(primum non nocere). However, unfortunately, medical errors still occur. Some of these might 
be  avoided21  by  making  good  use  of  e-Health  systems  that  can  provide  vital  information, 
alerts,  and  make  best  practices,  expert  advice  and  results  of  clinical  treatment  more  widely 
available.  

e-Health tools and applications can provide fast and easy access to electronic health records at 
the point of need. They can support diagnosis by non-invasive imaging-based systems. They 
support surgeons in planning clinical interventions using digital patient specific data, provide 
access  to  specialised  resources  for  education  and  training,  and  allow  radiologists  the 
possibility to access images anywhere. Thus, the workplace is being redefined and extended. 
Digital  data  transfer  enables  more  effective  networking  among  clinical  institutions  across 
Europe, and the creation of a European network of centres of reference – as is planned in the 
Communication  on  patient  mobility,  which  provides  for  this  initiative.  Electronic  health 
records also enable the extraction of information for research, management, public health or 
other related statistics of benefit to health professionals. 

e-Health  can  benefit  not  only  health  professionals  but  all  the  staff  employed  in  the  health 
sector including nursing, care, and administrative staff (in 2002, this was 17.5 million persons 
in  the  prospective  European  Union  of  25  Member  States  or  9.3%  of  total  workforce)22. 
Furthermore,  e-Health  can  contribute  to  achieving  a  safer  working  environment  for  health 
practitioners. (In the European Union, health and social services have an accident rate which 
is 30% above the average by sector of accidents recorded23. Most accidents relate to infectious 
diseases  and  dangers,  back  injuries,  and  shocks  and  hazards  associated  with  electrical 
equipment or compressed gases.)  

2.4. 

Supporting health authorities and health managers 

Health  authorities  and  managers  are  responsible  for  the  proper  organisation  and  running  of 
health  systems.  They  do  this  against  the  background  of  increasing  budgetary  pressures  and 
rising patient expectations. e-Health systems can play a major part in meeting those pressures 
by  making  the  health  sector  more  productive,  and  delivering  better  results  with  fewer 

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23 

Silber, Denise (2003) Comment améliorer le système de santé? Harvard University Colloquium, August 
2003. Espace Européen, October 17, 2003.  
Labour Force Survey 2002, published in 2003. See also Employment in Europe 2003: 
http://europa.eu.int/comm/employment_social/employment_analysis/employ_en.htm.  
Communication  from  the  Commission,  Adapting  to  change  in  work  and  society:  a  new  Community 
strategy on health and safety at work 2002-2006, COM(2002) 118 final, March 2002. 

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resources.  Unfortunately,  the  currently  available  paper-based  information  aggregation  and 
processing has major limitations.  

A proper management of public health and clinical health can be undertaken only on the basis 
of  comprehensive  and  high-quality  administrative  and  clinical  data.  Health  authorities  in 
Member  States  would  benefit  from  better  access  to  more  comparable  data  on  health  issues. 
There  is  a  need  for  data,  and  an  underlying  infrastructure,  that  help  health  authorities  to 
collaborate – for example, on how to tackle communicable diseases. 

Integrated and comprehensive data can be provided in good time using e-Health tools, such as 
electronic  health  records  and  support  for  care  flow  management.  Automatic  data  extraction 
from electronic health systems that operate according to Europe’s legal requirements on data 
protection and privacy24 could provide missing data that facilitates proper evaluation of much-
needed resources and eradicates the huge administrative burden of filling in separate forms for 
reimbursement  –  a  clear  example  of  a  productivity  gain  to  be  achieved  through  e-Health 
systems  and  services.  These  initiatives  form  a  definite  trend  in  the  aim  to  modernise 
healthcare systems25

.  

Increased networking, exchange of experiences and data, and benchmarking, is also necessary 
at the European level in the health sector. Drivers for this include the need for improvements 
in  efficiency,  and  the  increased  mobility  of  patients  and  health  professionals  under  an 
emerging  internal  market  in  services.  The  situation  requires  the  integration  of  clinical, 
organisational,  and  economic  information  across  health  care  facilities,  so  as  to  facilitate 
virtual enterprises at the level of jurisdictions and beyond26. 

e-Health  systems  can  empower  managers  by  spreading  best  practices  and  helping  to  limit 
inefficient  and  inappropriate  treatment.  This  is  the  single  most  important  step  in  releasing 
resources and ensuring broad access for everyone to quality care. In addition, e-Health opens 
new opportunities for people who live in remote areas with only limited healthcare services, 
as well as marginalised groups (such as persons with different degrees of disability, whether 
minor or more severe27 28). e-Health is already proving in Europe and in the developing world 
that  it  can  provide  a  platform  for  telemedicine  services  such  as  tele-consultations  (second 
medical opinion); telemonitoring; and telecare, either in the home or the hospital29 30. 

24 
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26 

27 
28 

29 

30 

Data Protection Directive 95/46/EC. OJ L 281, 23.11.1995. 
Spring Report 2004: Delivering Lisbon, COM(2004) 29, 21.1.2004. 
A.  Rossi  Mori.  Integrated  clinical  information  systems:  an  essential  resource  –  an  opportunity  for 
international cooperation. Draft in preparation February 11, 2004 for publication in the Swiss Medical 
Informatics Journal. Spring edition 2004.  
Employment and Social Dimension of Information Society, eInclusion working paper, 2003.  
Braun, A; A. Constantelou, V. Karounou, A. Ligtoet, & J-C. Burgelman (2003) Prospecting ehealth in 
the context of a European Ageing Society: Quantifying and qualifying needs. Final report. November 
2003. IPTS/ESTO: Sevilla, Spain. 
See L. Beolchi (editor) (2003) Telemedicine glossary, 5th edition, 2003 working document. Glossary of 
concepts,  technologies,  standards  and  users.  Information  Society  Directorate-General:  Brussels, 
Belgium, September 2003 for a wide variety of definitions particularly with regard to medically-based 
homecare. 
A number of best practices in the tele-consultation and telecare field were submitted as candidates to 
the  eHealth  2004  conference,  and  are 
the  associated  exhibition.  See, 
http://www.ehealthconference2004.ie and http://www.e-europeawards.org/. 

included  within 

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2.5. 

e-Health: the third largest industry in the European health sector 

According  to  a  recent  study31,  e-Health  is  emerging  as  the  new  “industry”  alongside 
pharmaceuticals and the medical devices sector. By 2010, e-Health spending may account for 
up  to  5%  of  the  total  health  budget  of  the  25  Member  States  from  just  1%  in  2000  (for  15 
Member  States)32.  European  businesses  have  every  opportunity  to  become  leading  global 
players in this new industry.  

Information  and  communication  technologies  have  played  a  key  role  in  the  pharmaceutical 
and  medical  device  sectors.  In  drugs  research,  new  technologies  are  helping  scientists  to 
simulate and aggregate data from clinical trials and to test new theories. The newest medical 
devices  are  equipped  with  powerful  software  that  aids  their  performance  and  safety  –  for 
example,  through  remote  monitoring  of  functions  -  and  that  provides  decision  support  to 
health professionals and/or patients.  

3. 

STATE OF PLAY 

3.1. 

Examples of e-Health and its benefits 

Fifteen years of regional, national, and international research and development in funding for 
e-Health  in  Europe  have  resulted  in  a  wide  number  of  applications  that  have  been 
implemented  in  several  Member  States33.  There  are  many  good  examples  of  e-Health 
initiatives at a national and regional level within the European Union34. Forty out of the over 
180  real-life  e-Health  solutions  submitted  were  exhibited  at  the  e-Health  Ministerial 
conference  in  2003.  Some  support  the  use  of  smart  cards,  others  are  large-scale  health 
information  networks  supporting  services  such  as  MEDCOM  in  Denmark,  EVISAND  in 
Spain, SJUNET in Sweden, and HYGEIANET in Greece35.  

There  is  considerable  demand  from  Member  States  for  further  action  to  promote  best 
practices  and  share  experience  in  this  area.  Currently,  for  example,  the  Employment  and 
Social Dimension of the Information Society collects best practices on the employment and 
social inclusion aspects of e-Health and healthcare in the knowledge society36.  

MEDCOM – Danish health information network 

31 
32 

33 

34 

35 

36 

Deloitte and Touche (2003) eHealth. Health Information Network Europe. Final report.  
The European e-Business Report - 2002/2003 edition. A portrait of e-business in 15 sectors of the EU 
economy - 1st Synthesis Report of the e-Business W@tch. Luxemburg: Office for Official Publications 
of the European Communities, 2003. ISBN 92-894-5118-1; Empirica, SIBIS, Benchmarking Highlights 
2002: Towards the Information Society in Europe and the US, May 2003. See http://www.sibis.org/. 
Applications  relating  to  health.  Fifth  research  and  development  framework  programme  1998-2002. 
Final  report.  April  2003  edition.  Information  Society  General-Directorate:  European  Commission, 
2003.  
The proven benefits of regional (community, district, county) health information systems are discussed 
in the guide to the exhibition of the Ministerial e-Health 2003 conference. 
Silber,  D  (2003)  The  Case  for  eHealth.  Presented  at  the  European  Commission’s  first  high-level 
conference on eHealth, May 22/23, 2003. EIPA, Netherlands. 
To date, the High Level Group on the Employment and Social Dimension of the Information Society 
(ESDIS) has focused on the safe and healthy usage of information and communication technologies at 
work  (SEC(2002)  372  and  (SEC(2003)  652),  as  well  as  on  the  the  potential  opportunities  of  online 
health  services  for  disadvantaged  groups  (SEC(2001)  412),  that  is  also  referred  to  in  a  Council 
Resolution on e-Inclusion adopted in October 2001.  

EN 

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MEDCOM  currently  handles  over  80,000  messages  daily.  100%  of  hospitals, 
pharmacies, emergency doctors, 90% of general practitioners, 98% of laboratories, 55% 
of specialists, and 20% of municipalities are connected to it. MedCom enables hospitals 
to use electronic referrals, and avoid data re-entry. The professional quality of referrals 
has  risen,  and  discharge  letters  are  stored  directly.  The  monthly  status  and  number  of 
messages per month can be monitored at www.medcom.dk. 

First  studies  suggest  that  MEDCOM  has  delivered  substantial  savings.  In  terms  of 
human resources, more than 25 thousand person-months are saved. Given the average 
monthly employee salary of €3,350, this translates into savings of €22.5 million. 

As the penetration of personal computers and use of the Internet in Europe increases, a critical 
mass of users - general practitioners, patients and citizens - is being created for the provision 
of online health care services. Eurobarometer surveys have shown a steady rise in the rate of 
Internet  connections  by  general  medical  practitioners37.  The  2002  Eurobarometer  survey38 
showed that an average of 78% of EU medical general practitioners were online, with - at the 
highest levels - 98% in Sweden and 97% in the United Kingdom. 

Internet and Health 
% Medical Practices connected to the Internet. June 2002

1 00 %

90 %

80 %

70 %

60 %

50 %

40 %

30 %

20 %

10 %

0 %

S

UK

FIN

DK

F

NL

I

A

IR L

LUX

B

E

D

P

EL

9 8%

97 %

94%

89%

76 %

72%

6 5%

57 % 57 %

5 4%

50 % 4 8%

42 % 40 %

2 4%

So urc e:  Eur op ean  Commis sio n (Eur oba ro me te r, Ju ne  2 00 2)

The  use  of  networks,  including  the  Internet,  to  deliver  patient  care  is  also  growing.  On 
average  in  the  European  Union  of  15  Member  States,  48%  of  medical  practitioners  use 
electronic health care records, and 46% use the Internet to transmit patient data to other care 
providers for the purposes of continuity of care. But a fully interactive use of the Internet to 
deliver care to patients through the provision, for example, of e-mail consultation (12%) or to 
enable  patients  to  book  appointments  online  (2%)  appears  to  be  only  in  its  early  stages. 
Figures  ranging  from  2000  to  2002  show  the  different  levels  of  Internet  connection  among 
Europe’s general practitioners, and the high levels of use for continuing education with low 
levels of use for telemedicine services.  

Eurobarometer EU 15 

GPs with internet connection 

2000 

44% 

2001 

77% 

2002 

78% 

37 
38 

Eurobarometer 2001-2003. 
Eurobarometer, 2002 http://europa.eu.int/comm/public_opinion/. 

EN 

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for continuing education 

to transfer patient medical data 

to offer telemedicine services 

34% 

9% 

5% 

70% 

37% 

7% 

72% 

46% 

12% 

Health  professionals  are  benefiting  increasingly  from  applications  that  improve  the  services 
they offer and reduce medical risks in Europe. These include online registers or databases for 
cancer prognosis, and fully integrated hospital information systems such as COHERENCE in 
Paris, access to electronic ‘libraries’, archives or databases containing data on evidence-based 
medicine, electronically-assisted prescription reducing error and cost, and teleconsultation in 
a  range  of  areas  such  as  neurology,  pathology,  and  psychiatry.  Other  examples  of  systems 
which can be used by patients and citizens, and other health consumers, include applications 
related to rare diseases, mental health forums and services, and primary healthcare call centres 
and kiosks such as NHS Direct in the UK. 

NHS Direct Online 

NHS  Direct  Online,  http://www.nhsdirect.nhs.uk/  established  in  1999,  provides  health 
information  online  and  access  to  a  24-hour  nurse  helpline  via  telephone.  Six  million 
people have accessed NHS Direct Online website in about two years. There were half a 
million  visitors  in  January  2003.  The  website  has  been  available  since  July  2000.  It 
gives information on over 70,000 physical national health service (NHS) sites providing 
health  services  to  the  public.  NHS  Direct  call  centres  direct  people  to  these  physical 
offices. NHS Direct has also put 200 touch screen kiosks in popular locations, equipped 
with  printers  and  accessible  to  wheelchair  users.  Locations  include  NHS  centres, 
chemists, libraries, and supermarkets. Around 300 people use each kiosk every month, 
which adds up to around 60,000 users a year. 

Systems such as these are giving patients more information about their condition and choices, 
so  that  they  can  take  more  responsibility  for  healthcare  decisions.  The  March  2003 
Eurobarometer  survey39  on  health  information  sources  shows  that  23%  of  Europeans  use 
Internet for health information. 41% of the European population considers that the Internet is 
a good source of information on health. 

3.2.  Major challenges for wider implementation  

Despite the availability and proven benefits, e-Health systems and services are not yet widely 
used  in  real-life  medical  or  health  situations.  In  many  places,  development  is  still  at  a  pilot 
phase,  often  financed  through  research  grants.  The  speed  of  organisational  change  is  often 
slow,  and  it  can  take  up  to  twenty  years  to  achieve  full  implementation.  A  broad  range  of 
challenges remain to wider implementation40.  

•  Commitment and leadership of health authorities, in particular related to financial and 
organisation issues, are essential elements for the successful deployment of e-Health. For 

39 
40 

Eurobarometer 58.0, March 2003. 
I.  Iakovidis  (1998)  Towards  Personal  Health  Record:  Current  situation,  obstacles  and  trends  in 
implementation  of  Electronic  Healthcare  Records  in  Europe,  In  International  Journal  of  Medical 
Informatics, vol. 52, no 123, pp 105 –117. 

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e-Health  to  improve  the  way  healthcare  is  provided,  it  must  be  combined  with 
organisational  changes  and  the  development  of  new  skills  in  users.  e-Health  was  often 
traditionally perceived by health authorities as a low spending priority. However, it is now 
seen  as  a  matter  of  substantial  importance  within  public  health  policies.  There  has  been 
rapid  progress  over  the  last  few  years  and  many  Member  States  –  such  as  the  United 
Kingdom and Slovenia – have now adopted strategic plans for the deployment of e-Health. 
Moreover,  organisational  and  cultural  approaches  relating  to  the  way  health  care  is 
delivered  varies  between  Member  States  and  between  organisations.  Typically,  in  the 
health area, the introduction of new applications, techniques, and medicines has been slow, 
yet  –  in  organisational  terms  –  the  introduction  of  information  and  communication 
technologies  has  developed  relatively  fast.  Hospitals  too  will  be  important  players  in  the 
evolution towards e-Health, and their involvement in adoption will be central to new forms 
of healthcare delivery. 

•  Interoperability  of  e-Health  systems.  Interoperability  should  enable  the  seamless 
integration of heterogeneous systems. This will allow secure and fast access to comparable 
public health data and to patient information located in different places over a wide variety 
of  wired  and  wireless  devices.  However,  this  depends  on  standardisation  of  system 
components and services such as health information systems, health messages, electronic 
health record architecture, and patient identifying services. Work has been launched within 
European  standards  organisations  to  answer  this  issue  partly,  but  the  take-up  of  e-Health 
interoperability  standards  has  been  slow  and  –  in  addition  –  to  achieve  actual 
interoperability is a separate task. Interoperable e-Health solutions should also support the 
technical platform for the implementation of such initiatives as the creation of a European 
network of centres of reference to promote co-operation across medical institutions across 
the Community41. 

•  User friendliness of e-Health systems and services. A top priority for health providers in 
using an e-Health system is speed in getting the desired, high-quality results. There is an 
absolute  need  for  fast  connection,  connectivity,  and  high  speed.  This  highlights  the 
importance of ensuring broadband connection for online health services and infrastructure 
for  regional  health  information  networks42.  Configuring  personal  preferences  to  ensure 
usability is also key. 

•  Lack  of  regulation  and  fragmentation  of  e-Health  market  in  Europe.  Most  e-Health 
solutions in the Union have either been designed by small- and medium-sized businesses 
or  are  developed  internally  by  specific  health  organisations.  The  lack  of  standards  and 
accreditation of products, together with different national regulations, have pushed up the 
cost  of  development  and  customisation.  This  has  held  the  e-Health  industry  back  from 
more substantial investment in e-Health solutions. Overall, health care systems are highly 
regulated  through  different  forms  of  national  regulation  yet,  at  the  same  time,  there  is  a 
need for improving legal certainty regarding the conditions for reimbursement of medical 
costs incurred in another Member State43.  

41 

42 
43 

These  latter  issues  on  centres  of  reference  are  addressed  in  a  Communication  from  the  Commission, 
COM(2004)  301,  entitled  Follow-up  to  the  high  level  reflection  process  on  patient  mobility  and 
healthcare developments in the European Union.  
COM(2003) 65 final Electronic Communications: the Road to the Knowledge Economy. 
Article 23 of the Proposal for a Directive on services in the Internal Market (COM(2004) 2 final, WP 
SEC(2003) 900 on the application of internal market rules to health services.  

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•  Confidentiality and security issues. Firstly, the confidentiality and protection of patient 
data is governed by the general European Union rules of data protection, as well as by the 
requirements  of  ePrivacy  legislation  regarding  communications  infrastructure44.  The 
requirement  for confidentiality makes health  information systems security critical. There 
is a provision within the general data protection directive to create a code of conduct for 
special domains such as health, but this has not yet been taken forward. Another important 
legal  issue  is  liability  in  the  event  of  problems  -  such  as  technical  malfunctions  of  the 
system, network, or provision of the service itself - that result in serious harm to a patient. 
While there are currently no specific guidelines or liability rules, as with any emerging or 
growing  area  of  practice,  only  the  increased  use  of  e-Health  applications  and  the 
performance  of  eHealthcare  will  make  its  potential  fully  visible  as  well  as  raising  any 
remaining legal uncertainties45. The electronic commerce Directive46, which creates a legal 
framework for the provision of information society services, also applies to the provision 
of online health services. The Directive, principally by virtue of its internal market clause, 
contributes to the legal certainty and clarity needed for the provision of online information 
society  services  throughout  the  entire  Community.  In  particular,  its  provisions  on 
information  and  transparency  requirements,  commercial  communications,  the  liability  of 
intermediary service providers, and the basic principles it establishes regarding electronic 
contracts,  provide  for  high  standards  in  the  provision  of  online  services  in  all  Member 
States, thus also increasing consumer confidence. Further steps might be considered if they 
could show that even greater legal certainty would reinforce patient confidence in e-Health 
services.  Similar  safeguards  for  qualifications  might  also  be  useful.  Building  trust  is  a 
prerequisite to the development of an information society, in e-Health probably more than 
anywhere  else.  Citizens  prefer  services  and  information  tailored  to  their  needs  and 
requirements, while knowing that their right to privacy is protected.  

•  Issues relating to the mobility of patients, including the cross border circulation of goods 
and services, among which e-Health services are of growing importance47. In this light, a 
European strategy is needed – which forms part of the current Communication on patient 
mobility  -  to  ensure  that  citizens  can  exercise  their  rights  to  seek  care  in  other  Member 
States  if  they  wish,  and  that  European  cooperation  can  help  systems  to  work  together  to 
meet better the challenges they face. Regulation 1408/71 has been recently updated to take 
these issues into account: it provides a streamlined framework for the assumption of costs 
arising from cross border healthcare, based on the tariffs and fees in force in the Member 
State  where  the  healthcare  is  delivered.  However,  to  benefit  from  this  equal  treatment 
provision,  the  social  security  institutions  may  be  allowed,  in  certain  circumstances  (most 
notably  hospital  care),  to  grant  an  authorisation  prior  to  the  delivery  of  the  care.  In 

44 

45 
46 

47 

See, for example, the Data Protection Directive 95/46/EC OJ L 281, 23.11.1995; Electronic Signatures 
Directive  99/93/EC  OJ  L  13,  19.1.2000;  or  the  Telecommunications  Privacy  Directive,  02/58/EC  OJ 
L281, 31.7.2002 that replaced 97/66/EC.  
Draft Commission Staff working document, eEurope 2002: Legal issues in eHealth. Unpublished.  
Directive 2000/31/EC of the European Parliament and of the Council of 8 June 2000 on certain legal 
aspects  of  information  society  services,  in  particular  electronic  commerce,  in  the  Internal  Market 
(Directive on electronic commerce), OJ L 178, 17.7.2000, p.1. 
Patient mobility is addressed specifically in a Communication from the Commission, COM(2004) 301, 
entitled Follow-up to the high level reflection process on patient mobility and healthcare developments 
in the European Union. 

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addition, in January 2004, the Commission adopted a proposal for a directive on services in 
the internal market which deals with the cross border provision of health care services 48. 

•  Stronger  cooperation  among  health  providers  across  Europe  is  needed  to  enable  wider 
implementation.  Hence,  the  establishment  of  European  networks  of  reference49  - 
recommended by the high-level task force on patient mobility in its final report in 2003 – 
could  provide  healthcare  services  for  conditions,  in  particular  rare  diseases,  requiring  a 
concentration of resources or expertise. Interoperable e-Health solutions will be needed to 
create the technical platform to implement such an initiative. 

•  Needs  and  interests  of  users.  The  take-up  of  e-Health  systems  and  services  would  take 
place  more  rapidly  were  the  needs  and  interests  of  the  user  communities  (health 
professionals, patients, and citizens) to be taken on board. In general, these should be better 
integrated into the development and promotion of e-Health.  

•  Access for all to e-Health. The equal access of all groups of society to health services is 
an  important  goal  in  the  public  health  policy  field.  There  is  a  risk  that  certain  parts  of 
society  -  such  as  lone  parents  of  families,  isolated  communities,  inner  city  communities, 
individuals  with  literacy  and  numeracy  challenges,  groups  of  immigrants,  homeless 
persons,  elderly  persons  and  disabled  persons  –  could  remain  excluded  from  the 
possibilities offered by e-Health (including Internet-based health services) if special efforts 
are  not  made  to  counterbalance  such  trends.  On  the  other  hand,  e-Health  can  offer 
considerable possibilities for the provision of health services  to such individuals, groups, 
and communities. 

•  Common  understanding  and  concerted  efforts  by  all  stakeholders.  No  single 
stakeholder  can  carry  through  implementation  successfully  on  its  own  without  the  active 
co-operation  of  all  the  others.  Each  of  the  stakeholders,  health  authorities,  professionals, 
consumers,  industry,  has  the  power  to  veto  an  implementation,  if  it  is  not  perceived  as 
beneficial. Only through concerted efforts by all stakeholders, can we ensure a successful 
implementation where all partners benefit, thereby creating a win-win situation.  

4. 

TOWARDS THE EUROPEAN E-HEALTH AREA: ISSUES AND ACTIONS 

e-Health forms part of the European Union’s eEurope strategy. It can play an important role 
in  achieving  stronger  growth  and  creating  jobs  that  require  higher  qualifications  within  a 
dynamic, knowledge-based economy. This vision was set out by the Lisbon European Council 
in  March  200050.  Moving  forward  involves  action  over  several  policy  areas  ranging  from 
research  and  the  roll-out  of  broadband  networks  in  telecommunications,  to  action  in  public 
health, and work in Member States promoting mobility of patients51 and assessing the impact 
of ageing on healthcare systems. A number of the actions outlined in this document build on 

48 

49 

50 
51 

See footnote 8. See also various European Court of Justice rulings such as Kohll C-158/96 (1998) ECR-
1931 and Decker C-120/95 (1998) ECR-1831. 
These  networks  or  centres  for  reference  are  envisaged  as  specialised  care  services  to  which  patients 
from  abroad  are  referred.  See  also,  OJEU  15.3.2003  062/21.  Community  action  in  the  field  of  public 
health (2003 to 2008). Work Plan 2003 (2003/C 62/06).  
European Council (2000), Presidency Conclusions. Lisbon European Council. 23-24 March, 2000. 
See  the  Communication  from  the  Commission,  COM(2004)  301,  entitled  Follow-up  to  the  high  level 
reflection process on patient mobility and healthcare developments in the European Union. 

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policy  measures  identified  in  the  eEurope  2005  Action  Plan  –  the  reference  point  for 
commitment to advancing the information society at European level – especially in the areas 
of  e-Health,  e-Government,  security,  broadband,  and  development,  analysis,  and 
dissemination of good practices.  

Though  healthcare  needs  are  different  in  scale  and  nature  in  developing  countries,  it  is  also 
worth noting that e-Health formed part of the results of the United Nations’ World Summit on 
the  Information  Society  in  December  200352,  and  the  World  Health  Organisation  is  now 
involved in a number of e-Health initiatives. 

4.1. 

Action plan  

The actions outlined below should allow the European Union to achieve the full potential of 
e-Health systems and services within a European e-Health Area. There are three target areas:  

•  how to address common challenges and create the right framework to support e-Health,  

•  pilot actions to jump start the delivery of e-Health, and  

•  sharing best practices and measuring progress. 

4.2. 

Issue 1: Addressing common challenges  

4.2.1.  Health authorities leadership  

European  Health  Ministers  have  already  shown  e-Health  leadership  in  their  Ministerial 
Declaration53  at  the  2003  e-Health  Ministerial  conference.  The  ministers  welcomed 
Commission  initiatives  to  explore  the  possibilities  to  promote  co-ordination  at  a  European 
level. They proposed to meet the targets and objectives laid down in the eEurope Action Plan 
and in the Programme of Community Action in the field of Public Health (2003-2008) set out 
in  decision  1786/2002,  and  liaise  with  other  Community  initiatives.  The  conference  also 
highlighted the importance of monitoring and benchmarking progress by developing an open 
method of co-ordination in this area. These words must now be transformed into action on the 
basis of regional and national e-Health strategies. 
By end 2005, each Member State is to develop a national or regional roadmap for e-Health. 
This should focus on deploying e-Health systems, setting targets for interoperability and the 
use  of  electronic  health  records,  and  address  issues  such  as  the  reimbursement  of  e-Health 
services. 

4.2.2. 

Interoperability of health information systems  

Member  States  have  expressed  the  need  to  support  actions  that  cover  the  development  of 
standards  addressing  the  interoperability  of  diverse  systems  and  services  and  to  explore  in 
particular  the  possibilities  of  open  source  applications  to  achieve  this  objective.  In  this 
context,  the  need  for  future  standards  is  clearly  emphasised  so  as  to  solve  interoperability 
concerns in a way which will benefit all stakeholders through the possible adoption of Open 
Source reference implementations for care services. In addition, an open and more free access 
to  future  and  existing  e-Health  standards  should  be  recommended,  taking  inspiration  from 

52 
53 

World Summit on the Information Society, Report and Plan for Action, December 2003. 
eHealth 2003, Ministerial Declaration, Brussels, 22 May 2003 
http://europa.eu.int/information_society/eeurope/ehealth/conference/2003/index_en.htm. 

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models such as the World Wide Web Consortium54. The exchange of experience in the use of 
open  standards  and  open  source  solutions  among  health  administrations  in  Member  States 
should be promoted. 

4.2.2.1.  Patient identifiers 

The  need  to  identify  a  person  unambiguously  is  an  important  component  of  the 
interoperability of health information systems. The eEurope2005 action plan already supports 
the  development  of  standards  for  a  common  approach  to  patient  identifiers  and  electronic 
health  record  architecture.  The  new  European  Health  Insurance  Card55  includes  a  patient’s 
personal  identification  number  as  part  of  the  data  allowing  people  to  use  the  card  to  get 
treatment outside their home Member State.  

By  end  2006,  Member  States,  in  collaboration  with  the  European  Commission,  should 
identify a common approach to patient identifiers. This should take account of best practices 
and  developments  in  areas  such  as  the  European  Health  Insurance  Card  and  identity 
management for European citizens. 

4.2.2.2.  Interoperability of electronic health records 

Achieving  a  seamless  exchange  of  health  information  across  Europe  requires  common 
structures and ontologies56 of the information transferred between health information systems.  

By  end  2006,  Member  States,  in  collaboration  with  the  European  Commission,  should 
identify  and  outline  interoperability  standards  for  health  data  messages  and  electronic 
health records, taking into account best practices and relevant standardisation efforts.  

4.2.3.  Mobility of patients and health professionals 

Within  the  European  Union,  patients  and  health  professionals  are  becoming  increasingly 
mobile. The Communication on patient mobility has made a number of proposals to manage 
the  challenges  resulting  from  this  development.  Recommendations  include  improving  the 
exchange of information, and establishing specialised reference centres on health information.  

The Communication on patient mobility is presented as part of an overall strategy on health 
care together with the present communication and that on the open method of coordination57. 

Work is already underway to improve information on patient mobility and mobility of health 
professionals  at  European  level,  and  is  being  taken  forward  in  particular  through  the  health 
systems working party under the information strand of the public health programme. 

54 
55 
56 

57 

http://www.w3.org/. 
OJEU of 27 October 2003. 
An ontology  defines  the  terms  used  to  describe  and  represent  an  area of knowledge,  and  are used by 
people,  databases,  and  applications  that  need  to  share  domain  information  (a  domain  is  a  specific 
subject area, such as health or medicine). See http://www.w3.org/TR/2002/WD-webont-req-20020307/. 
The open method of coordination in relation to health care is addressed in the Communication from the 
Commission  COM(2004)  304  -  Modernising  social  protection  for  the  development  of  high-quality, 
accessible and sustainable health care and long-term care: support for the national strategies using the 
‘open method of coordination’ . 

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4.2.4.  Enhancing infrastructure and technologies 

Building on eEurope’s focus on accelerating the roll-out of broadband communications, full 
use  should  be  made  of  broadband  to  support  e-Health  systems  and  services.  Broadband 
networks carry large throughput and can also save critical time in accessing the network and 
give sub-second  responses to information  queries which  can  often be vital in the context of 
healthcare.  They  can  bring  considerable  cost  and  performance  benefits58.  Availability  and 
affordability are also key to wide deployment. Service level convergence (operators offering 
services  on  top  of  fixed  lines  or  mobile  telephony)  opens  up  new  possibilities  for  e-Health 
applications.  Public  authorities  can  play  a  role  in  stimulating  both  supply  and  demand  for 
broadband, while Community funding may help to support broadband delivery in underserved 
areas. Programmes such as eTen59 or the new IDABC60 programme may also play a role in 
supporting  e-Health  applications  and  health  information  networks.  The  Commission  actions 
will  enable  the  deployment  of  Europe-wide  computer-supported  networks,  based  on 
broadband infrastructures and Grid61 technologies.  

During  the  period  2004-2008,  Member  States  should  support  deployment  of  health 
information  networks  for  e-Health  based  on  fixed  and  wireless  broadband  and  mobile 
infrastructures and Grid technologies. 

4.2.5.  Conformity testing and accreditation for an e-Health market 

There is need for a set of agreed attributes and norms beyond existing standards that define 
good quality products and services. Many countries have proceeded with accreditation of e-
Health  systems  that  are  becoming  models  for  other  regions,  such  as  those  in  the  United 
Kingdom  and  Belgium.  Another  example  of  conformance  testing  and  accreditation  is  the 
interoperability guidelines of Integrating the Healthcare Enterprise in Europe (IHE)62.  

By  mid  2005,  the  Commission  should  produce  a  summary  of  European  best  practices  as 
guidance for Member States.  

58 

59 

60 

61 

62 

GAO  Highlights  (2003)  Information  Technology.  Benefits  realized  for  selected  health  care  functions. 
GAO-04-224,  Report  to  the  Ranking  Minority  Member,  Committee  on  health,  Education,  Labor,  and 
Pensions,  U.S.  Senate.  United  States  General  Accounting  Office,  USA.  See  http://www.gao.gov/cgi-
bin/getrpt?GAO-O4-224 
The primary objectives of the eTen work programme focus on the use of reliable information networks 
for  health,  public  health,  and  prevention  on  a  trans-European  level.  eTen  concentrates  on  electronic 
health  and  insurance  cards  as  part  of  reimbursement  and  management  systems;  paramedical  support; 
online health systems; and homecare. Priorities in 2004 are to provide regional health authorities and 
health  care  providers  with  improved  access  to  cross  border  health  care  through  the  use  of  ‘smart’ 
identification  cards,  electronic  health  records,  cost-efficient  health  care,  access  to  quality  emergency 
medical  data,  and  support  to  health  authorities  in  assessing  health  needs  and  planning  capacity.  For 
more details, see http://europa.eu.int/eten/. 
COM(2004) 13 final, 2003/0147 (COD) Common position of the Council on the adoption of a Decision 
of  the  European  Parliament  and  of  the  Council  on  Interoperable  Delivery  of  pan-European 
eGovernment 
(IDABC). 
http://europa.eu.int/eur-lex/en/com/pdf/2004/com2004_0013en01.pdf. 
Grid technologies are defined as technologies that enable ‘co-ordinated resource-sharing and problem-
solving in dynamic, virtual organisations’. See Foster, I. and C. Kesselman (1999) The GRID, blueprint 
for a new computing infrastructure. San Francisco: Morgan Kaufman. 
See http://www.cocir.org/. 

to  Public  Administrations,  Business 

and  Citizens 

services 

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By  end  2007,  a  Member  States  should  adopt  conformity  testing  and  accreditation  schemes 
following successful best practices.  

4.2.6.  Leveraging investments 

A  shared  approach  among  Member  States  to  support  and  boost  investment  in  e-Health  is 
needed.  Regional  funding  structures  are  already  available63  (for  example,  INTEREG  III 
regional  funds)  in  the  European  Commission,  as  well  as  a  number  of  other  international 
collaboration activities. Additional funding that could leverage e-Health developments could 
be sought at the European Investment Bank. The Bank is currently investing in a very wide 
range of eligible projects - if they represent cost-effective health policy gain. The World Bank 
also  provides  possibilities  for  funding  international  e-Health  programmes  both  for  the 
European Union and worldwide.  

By  end  2006,  a  collaborative  approach  should  be  undertaken  among  Member  States  to 
supporting and boosting investment in e-Health.  

4.2.7.  Legal and regulatory issues  

There  needs  to  be  a  baseline  set  for  a  standardised  European  qualification  for  e-Health 
services in clinical and administrative settings. Furthermore, certainty of e-Health product and 
service liability within the context of existing product liability legislation would be beneficial. 
Information  and  communication  technology  developments  should  contribute  to  a  safer 
working  environment  for  practitioners;  and  greater  legal  certainty  with  regard  to  e-Health 
services  within  the  context  of  freedom  of  movement  of  people,  goods  and  services  is 
increasingly necessary.  

By  end  2009,  the  European  Commission,  in  collaboration  with  Member  States,  should 
undertake activities to:  

•  Set a baseline for a standardised European qualification for e-Health services in clinical 

and administrative settings. 

•  Provide framework for greater legal certainty of e-Health products and services liability 

within the context of existing product liability legislation. 

• 

Improve information for patients, health insurance schemes and providers regarding the 
rules applying to the assumption of the costs of e-Health services. 

•  Promote e-Health with a view to reducing occupational accidents and illnesses as well 
as supporting preventive actions in the face of the emergence of new workplace risks. 

63 

See in particular, the provisions of the Guidelines on criteria and modalities of the implementation of 
Structural Funds in support of electronic communications (Doc. SEC(2003) 895, 28.7.2003).  

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4.3. 

Issue 2: Pilot actions: accelerating beneficial implementation  

4.3.1. 

Information for citizens and authorities on health education and disease prevention 

In the context of its Public Health Programme, the Commission is preparing the establishment 
of  a  European  Union-wide  public  health  portal  that  will  provide  a  flexible  information 
technology  platform  to  disseminate  evidence-based  information  on  public  health  relevant  to 
European citizens, and to provide a single point of access to information on health.  

The  Commission  is  also  co-funding  the  development  of  a  set  of  quality  criteria  for  health- 
related  websites  (‘webseals’).  Its  aim  is  to  increase  transparency  among  health-related 
websites in the interest of serious service providers and users, ranging from citizens to health 
professionals. 

Strengthening of the Health Surveillance System for Communicable Diseases, with a focus on 
the real-time collection of clinical and laboratory data and analysis, will enhance the capacity 
of early warning at national level and Community levels. It will improve the surveillance of 
diseases of major concern and potential bioterrorism threats. 

Preparing  valid  and  reliable  statistical  information  on  provision  of  health  care  at  European 
level as requested by Member States and Commission Services alike will profit substantially 
from the unique patient identifier, common standards, and protocols. Better information will 
then be made available to decision-makers and the interested public in a more timely way.  

By  end  2005,  a  European  Union  public  health  portal  will  give  access  to  European  level 
public health information. Health portals shall offer dedicated information on safety at work 
and workplace health risks.  

By end 2005, there will be a strengthening of early warning, detection, and surveillance of 
health threats through enhanced information and communication technologies tools. 

4.3.2.  Towards integrated health information networks 

Health information networks link hospitals, laboratories, pharmacies, primary care and social 
centres.  Thus,  they  communicate  in  a  secure  manner.  Examples  include  standardised 
messaging  systems  such  as  e-prescription  and  e-referrals  or  the  provision  of  telemedicine 
services  such  as  teleconsultation  (the  provision  of  second  medical  opinion)  or  telecare  (the 
home monitoring of patients). 

By  end  2008,  the  majority  of  all  European  health  organisations  and  health  regions 
(communities,  counties,  districts)  should  be  able  to  provide  online  services  such  as 
teleconsultation  (second  medical  opinion),  e-prescription,  e-referral,  telemonitoring  and 
telecare.  

4.3.3.  Promoting the use of cards in health care 

There  are  two  types  of  cards  that  may  be  used  in  the  health  care  sector:  health  cards  and 
health  insurance  cards.  Health  cards  may  carry  emergency  data  (such  as  blood  types, 
pathologies, treatments) or medical records, or may allow access to these data over a secure 

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network.  Health  insurance  cards  allow  access  to  health  care  and  make  management  and 
billing easier.  

In  relation  to  the  European  health  insurance  card,  decisions  have  been  taken  to  kick  off  its 
deployment  as  from  June  1st,  2004.  It  will  replace  all  the  current  paper  forms  needed  to 
benefit  from  medically-necessary  care  while  on  a  temporary  stay  (for  purposes  of  travel, 
posting abroad, study, and so on). On the health side, the eEurope 2005 Action Plan states that 
actions  will  be  taken  to  build  on  the  European  health  insurance  card.  Activities  will  be 
launched  to  support  common  approaches  in  Member  States  that  are  related  to  electronic 
health records, emergency data sets, and electronic patient identifiers. 

Promoting  the  use  of  cards  in  the  health  care  sector.  Adoption  of  implementation  of  an 
electronic health insurance card by 2008.  

4.4. 

Issue 3: Working together and monitoring practice 

4.4.1.  Disseminating best practices 

Success  in  developing  a  European  e-Health  Area  will  draw  on  sharing  best  practices  and 
experience  across  the  Union,  as  systems  are  deployed  and  organisations  redesigned.  The 
Commission  must  play  a  central  role  in  spreading  this  activity.  The  experiences  could  be 
either bi-lateral or multi-lateral between or among Member States, since Member States may 
be  at  very  different  stages  of  development  and  implementation.  Attention  should  be  paid  to 
sharing experience in the use and impact of e-Health applications, and approaches to ensuring 
the  interoperability  of  diverse  systems  and  services,  while  respecting  the  multi-cultural  and 
multi-lingual  tradition  of  European  health  care  systems.  Open  source  applications  may  play 
an important role in achieving interoperability.  

e-Health should be supported by the widespread dissemination of best practices. These should 
include the impact on access to healthcare and on its quality, assessments of cost benefits and 
productivity  gains,  as  well  as  examples  of  addressing  liability  in  telemedicine  services, 
reimbursement schemes, and accreditation of e-Health products and services. 

In  2004,  a  high  level  e-Health  forum  should  be  established,  the  role  of  which  will  be  to 
support  the  Commission  services.  It  should  involve  all  necessary  stakeholders,  including  at 
national, regional, or local hospital authority levels, thereby enhancing the understanding of 
the Commission services with regard to the current and planned status of development of e-
Health  in  Member  States.  Its  task  should  be  to  follow  up  the  various  roadmaps,  and  to 
identify  further  actions  including  a  strong  focus  on  users  and  access  for  all  to  e-Health,  as 
well as to develop a strong evidence basis for the case for e-Health. The work of the e-Health 
forum  will  also  be  closely  associated  with  the  implementation  of  the  Community  Public 
Health Programme. 

During the period 2004-2008, Member States with the support of the European Commission 
will  organise  special  events  such  as  high  level  conferences  in  order  to  disseminate  best 
practices.  

In parallel, by the end of 2005, the European Commission, with contributions from Member 
States,  should  establish  an  effective  way  of  disseminating  best  practices  and  supporting 

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actions within the European e-Health area. 

4.4.2.  Benchmarking 

Progress also needs to be measured. Appropriate benchmarking on citizens’ awareness of e-
Health, and how citizens are using e-Health effectively and efficiently is essential for future e-
Health measures.  

This means assessing and quantifying the added value that e-Health is expected to deliver. It 
also  means  reviewing  how  e-Health  solutions  are  contributing  to  key  health  challenges, 
including  in  employment,  access  and  equity.  These  measures  should  be  accompanied  by 
proper  monitoring  of  e-Health’s  impact  on  health  and  health  care  in  the  Community.  All 
stakeholders should have a role in this process which should feed in to further improvements 
in e-Health systems and services.  

During the period 2004-2010, every two years, the European Commission will publish a 
study on the state of the art in deployment, examples of best practices, and the associated 
benefits of e-Health.  

By  the  start  of  2005,  Member  States,  in  collaboration  with  the  European  Commission, 
should  agree  on  an  overall  approach  to  benchmarking  in  order  to  assess  the  quantitative, 
including economic, and qualitative impacts of e-Health.  

4.4.3. 

International collaboration  

What we do in Europe on e-Health can have an important influence on meeting global health 
challenges  within  an  information  society.  This  can  complement  the  work  launched  by  the 
United Nations World Summit on the Information Society (WSIS) held in December 2003, as 
well as specific initiatives being developed by the World Health Organisation.  

An assessment of e-Health developments should be completed ahead of the second part of the 
World Summit to be held in Tunis in 2005.  

5. 

CONCLUSIONS  

e-Health offers European citizens important opportunities for improved access to better health 
systems. It can empower both patients and healthcare professionals. It offers governments and 
tax payers a means - through substantial productivity gains - to cope with increasing demand 
on healthcare services. It can also help to reshape the future of health care delivery, making it 
more citizen-centred.  

The  European  e-Health  Area  will  provide  a  framework  for  exchanging  best  practices  and 
experience. It will allow common approaches to shared problems to be developed over time. 
This  action  plan  focuses  on  specific  actions  to  bring  this  about,  so  that  by  the  end  of  the 
decade: 

•  The  European  Union  will  be  well  placed  to  measure  the  impact  of  e-Health  in  terms  of 
better access and better, more efficient, services as well as on the overall productivity of 
the healthcare sector. 

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•  e-Health  will  have  become  commonplace  for  health  professionals,  patients  and  citizens; 
and  e-Health  will  be  adequately  resourced  within  healthcare  budgets,  and  contribute  to 
boosting wider objectives, such as competitiveness, jobs and cohesion.  

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Overview of actions 

ANNEX  

Action 

Time 

Responsibility 

NB.  Within  each  of  the  issues  facing  the  e-Health  sector 
(addressing common challenges, pilot actions, and working 
together and monitoring practices), we list the actions to be 
taken sequentially. 

Issue 1: Addressing common challenges 

The Communication on patient mobility is presented as part 
of  an  overall  strategy  on  health  care  together  with  the 
present  communication  and  that  on  the  open  method  of 
coordination. 

Work  is  already  underway  to  improve  information  on 
patient  mobility  and  mobility  of  health  professionals  at 
European  level,  and  is  being  taken  forward  in  particular 
through  the  health  systems  working  party  under  the 
information strand of the public health programme. 

2004 

Commission 

By  mid  2005,  the  Commission  should  produce  a  summary 
of European best practices as guidance for Member States. 

Mid-
2005 

Commission 

By end 2005, each Member State is to develop a national or 
regional  roadmap  for  e-Health.  This  should  focus  on 
deploying 
for 
systems, 
interoperability and the use of electronic health records, and 
address  issues  such  as  the  reimbursement  of  e-Health 
services. 

e-Health 

setting 

targets 

End 
2005 

Member States 

By  end  2006,  Member  States,  in  collaboration  with  the 
European Commission, should identify a common approach 
to  patient  identifiers.  This  should  take  account  of  best 
practices  and  developments  in  areas  such  as  the  European 
Health  Insurance  Card  and 
identity  management  for 
European citizens. 

By  end  2006,  Member  States,  in  collaboration  with  the 
European  Commission, 
identify  and  outline 
should 
interoperability  standards  for  health  data  messages  and 
electronic health records, taking into account best practices 
and relevant standardisation efforts. 

End 
2006 

Member  States, 
Commission 

End 
2006 

Member  States, 
Commission 

By end 2006, a collaborative approach should be undertaken 
to  supporting  and  boosting 
among  Member  States 

End 

Member States 

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24 

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investment in e-Health. 

By  end  2007,  Member  States  should  adopt  conformity 
testing and accreditation schemes following successful best 
practices. 

During  the  period  2004-2008,  Member  States  should 
support  deployment  of  health  information  networks  for  e-
Health  based  on  fixed  and  wireless  broadband  and  mobile 
infrastructures and Grid technologies. 

2006 

End 
2007 

2004-
2008 

Member States 

Member States 

By  end  2009,  the  European  Commission,  in  collaboration 
with Member States, should undertake activities to:  

End 
2009 

Commission, 
Member States 

Set a baseline for a standardised European qualification for 
e-Health services in clinical and administrative settings. 

Provide  framework  for  greater  legal  certainty  of  e-Health 
products and services liability within the context of existing 
product liability legislation. 

Improve information for patients, health insurance schemes 
and providers regarding the rules applying to the assumption 
of the costs of e-Health services.  

Promote  e-Health  with  a  view  to  reducing  occupational 
accidents  and  illnesses  as  well  as  supporting  preventive 
actions in the face of the emergence of new workplace risks. 

Issue 2: Pilot actions: accelerating beneficial 
implementation 

By  end  2005,  a  European  Union  public  health  portal  will 
give  access  to  European  level  public  health  information. 
Health portals shall offer dedicated information on safety at 
work and health risks in the workplace.  

End 
2005 

Commission 

By end 2005, there will be a strengthening of early warning, 
through 
detection,  and  surveillance  of  health 
enhanced  information  and  communication  technologies 
tools. 

threats 

Promoting  the  use  of  cards  in  the  health  care  sector. 
Adoption  of 
implementation  of  an  electronic  health 
insurance card by 2008. 

2008 

By end 2008, the majority of European health organisations 
and health regions (communities, counties, districts) should 
be  able  to  provide  online  services  such  as  teleconsultation 
e-referral, 
(second  medical  opinion), 
telemonitoring and telecare. 

e-prescription, 

End 
2008 

Commission, 
Member States 

Member States 

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25 

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Issue 3: Working together and monitoring practices 

thereby  enhancing 

the  understanding  of 

In 2004, a high level e-Health forum should be established, 
the  role  of  which  will  be  to  support  the  Commission 
services.  It  should  involve  all  necessary  stakeholders, 
including  at  national,  regional,  or  local  hospital  authority 
the 
levels, 
Commission services with regard to the current and planned 
status of development of e-Health in Member States. Its task 
should be to follow up the various roadmaps, and to identify 
further actions including a strong focus on users and access 
for  all  to  e-Health,  as  well  as  to  develop  a  strong  evidence 
basis  for  the  case  for  e-Health.  The  work  of  the  e-Health 
the 
forum  will  also  be  closely  associated  with 
implementation  of 
the  Community  Public  Health 
Programme. 

By  the  start  of  2005,  Member  States,  in  collaboration  with 
the  European  Commission,  should  agree  on  an  overall 
approach 
the 
quantitative, including economic, and qualitative impacts of 
e-Health. 

to  benchmarking 

to  assess 

in  order 

2004 

Commission 

Start 
2005 

Member  States, 
Commission 

By  the  end  of  2005,  the  European  Commission,  with 
contributions  from  Member  States,  should  establish  an 
effective way of disseminating best practices and supporting 
actions within the European e-Health area. 

End 
2005 

An  assessment  of  e-Health  developments  should  be 
completed ahead of the second part of the World Summit to 
be held in Tunis in 2005. 

2005 

During  the  period  2004-2008,  Member  States  with  the 
support  of  the  European  Commission  will  organise  special 
events such as high level conferences in order to disseminate 
best practices. 

During the period 2004-2010, every two years, the European 
Commission  will  publish  a  study  on  the  state  of  the  art  in 
deployment,  examples  of  best  practices,  and  the  associated 
benefits of e-Health. 

2004-
2008 

2004-
2010 

 Commission, 
Member States 

Commission, 
Member States 

Member States,  
Commission 

Commission 

EN 

26 

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