COMMISSION STAFF WORKING DOCUMENT eHealth Action Plan 2012-2020 – innovative healthcare for the 21st century Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS eHealth Action Plan 2012-2020 – innovative healthcare for the 21st century
Date: 2012-12-06
Institutions: European Commission
Subjects: health care profession, health care system, health expenditure, information technology, innovation, labour mobility, new technology, population statistics, right to health, telemedicine

EUROPEAN 
COMMISSION 

Brussels, 6.12.2012  
SWD(2012) 413 final 

COMMISSION STAFF WORKING DOCUMENT 

eHealth Action Plan 2012-2020 – innovative healthcare for the 21st century 

Accompanying the document 

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 
eHealth Action Plan 2012-2020 – innovative healthcare for the 21st century 

{COM(2012) 736 final} 
{SWD(2012) 414 final} 

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COMMISSION STAFF WORKING DOCUMENT 

eHealth Action Plan 2012-2020 – innovative healthcare for the 21st century 

Accompanying the document 

COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN 
PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL 
COMMITTEE AND THE COMMITTEE OF THE REGIONS 
eHealth Action Plan 2012-2020 – innovative healthcare for the 21st century 

Disclaimer:  This  document  is  a  European  Commission  staff  working  document  for 
informative  purposes.  It  does  not  represent  an  official  position  of  the  Commission  on  this 
issue, nor does it anticipate such a position. 

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1. 

2. 

3. 

Introduction .................................................................................................................. 5 

The Context of the initiative ......................................................................................... 6 

The 2004 eHealth Action Plan ..................................................................................... 6 

3.1. 

An evaluation of the 2004 eHealth Action Plan........................................................... 7 

4. 

4.1. 

4.2. 

4.3. 

4.4. 

4.5. 

5. 

5.1. 

5.2. 

5.3. 

Problem definition........................................................................................................ 9 

Sustainability of healthcare and social systems ........................................................... 9 

Ageing population and growing incidence and prevalence of chronic diseases........ 10 

Mobility of patients and health professionals and shortage of professionals ............ 10 

Increased demand for high quality of care and investing in expensive technologies 11 

Slow deployment of eHealth tools and services ........................................................ 11 

Consultation of interested parties............................................................................... 12 

Stakeholder consultation ............................................................................................ 12 

Internal expertise........................................................................................................ 14 

External expertise and input....................................................................................... 14 

5.3.1.  Task Force Report ...................................................................................................... 14 

6. 

6.1. 

6.2. 

7. 

7.1. 

7.2. 

7.3. 

8. 

9. 

9.1. 

10. 

Evidence informed eHealth Action Plan 2012 – 2020............................................... 15 

Methodology .............................................................................................................. 16 

Results ........................................................................................................................ 17 

Vision and objectives of the eHealth Action Plan 2012 - 2020 ................................. 25 

General objectives...................................................................................................... 25 

Specific objectives ..................................................................................................... 26 

Operational objectives................................................................................................ 26 

Added value of and justification for acting at the EU level....................................... 26 

Next steps following the Communication.................................................................. 28 

Review by the Commission of progress made........................................................... 28 

Bibliography of evidence informed section ............................................................... 29 

ANNEX: Governance chart for interoperability ........................................................................ 0 

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EXECUTIVE SUMMARY 

The  eHealth  Action  Plan  2012-  2020  responds  to  the  requests  of  the  EPSCO  Council  in  its 
December  2009  Conclusions  on  Safe  and  efficient  healthcare  through  eHealth.  Notably,  the 
Council called upon the Commission for support "to bring forward eHealth deployment and 
actual use of Interoperable eHealth services within and between national healthcare systems" 
and to "update the eHealth Action Plan".  

Building on these requests, the operational goal of the Action Plan is to break down persistent 
barriers and realise the vision of the Europe 2020 Strategy in the area of eHealth. It aims to 
improve  the  quality  of  life  of  European  citizens;  provide  equal  access  to  high  quality  and 
sustainable health care systems to all European citizens; and enhance the competitiveness of 
EU industry in the area of eHealth.  

Since  the  adoption  of  the  first  eHealth  Action  Plan  in  2004,  significant  progress  has  been 
made.  Notably,  political  awareness  around  eHealth  has  risen  significantly.  This  has  led  to 
many  EU  Member  States,  regions  and  healthcare  providers  committing  to:  widespread 
deployment of eHealth solutions, enhancing legal certainty and improving technical guidance. 
While all the planned actions defined in the 2004 eHealth Action Plan  have been undertaken 
and progress has been made, challenges and barriers still remain. Many of the challenges are 
related to demographic change, an increase in the incidence of chronic diseases, the growing 
demand  for  high  quality  services  and  the  impossibility  to  increase  the  number  of  resources 
accordingly. Increased mobility of citizens (patients and health professionals) within the EU 
and a shortage of professionals also threaten the future health systems as well as the principle 
of equity. In the face of all of these challenges, eHealth can play a beneficial role. Today the 
range  of  possible  Information  and  Communication  Technology  (ICT)  applications  in  the 
health  sector  is  enormous.  The  technology  has  progressed  significantly  and  many  estimate 
that ICT implementation can result in care that is higher in quality, safer and more responsive 
to  patients’  needs  and,  at  the  same  time,  more  efficient  (appropriate,  available,  and  less 
wasteful). eHealth advocates point to the potential reduction in medication errors as a critical 
advantage  of  the  information  system  and  electronic  health  record  (EHR),  but  also  the 
improvement of accessibility  as a strategic instrument to decrease inequalities.  

The eHealth Action Plan  2012 - 2020 was developed following a public consultation drawing 
on expertise across the eHealth stakeholder community, the recommendations of the eHealth 
Task Force and the review of evidence. The new Action Plan has been designed following a 
methodology  of  evidence-informed  policy  development  which  confirmed  that  the  main 
barriers to deploying eHealth solutions are lack of users' awareness of the benefits, a lack of 
ehealth  literacy,  a  lack  of  evidence  of  cost-effectiveness  and  interoperability.  It  should  be 
noted that eHealth  penetration, digital literacy and  ICT use  vary widely across EU Member 
States. Socio-political and economic differences as well as variations in health systems, health 
outcomes  and  health  workforces  also  exist.  As  such,  the  cooperation  and  partnership  of  all 
Members  State  and  all  stakeholders  should  be  essential  to  achieve  the  goals  of  the  Action 
Plan.  

The main body of evidence for the effectiveness of eHealth services is currently concentrated 
in  three  areas:  health  promotion  and  prevention,  chronic  diseases  and  mental  health 
intervention.  While  there  is  evidence  of  the  effectiveness  of  telemedicine,  cost-benefit 

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analysis  is  often  lacking.  Going  forward,  such  evaluation  will  play  an  important  role  in 
ensuring the success and the sustainability of future health systems.  

The  findings  discussed  in  this  staff  working  document  point  to  a  number  of  practices  or 
approaches  that  could  be  employed  for  improving  and  accelerating  the  adoption  and  use  of 
health  ICTs.  As  these  typically  imply  trade-offs  with  competing  goals,  policy  makers  must 
determine whether the expected benefits from these practices are likely to outweigh the costs 
of  implementation  in  a  particular  situation.  This  document  highlights  an  absence  of  robust 
monitoring  and  evaluation  of  programmes  and  projects.  Measuring  the  impacts  of  ICTs  is 
difficult for a number of reasons, but would be crucial to demonstrate the real added value of 
eHealth solutions. Consequently, the new eHealth Action Plan is addressing evidence-based 
implementation of eHealth solutions, promoting evaluation and research including the Health 
Technology Assessment (HTA) approach in order to define the essential elements to ensure a 
successful and efficient deployment of eHealth.  

ICT implementation may have effects that are multidimensional and often may be uncertain in 
their reach and scope and difficult to control. In addition, the realisation of benefits from ICT 
implementation strongly depends on contextual conditions1. For example, moving to an EHR 
in its fullest form is not just a technical innovation; it is a cultural transformation. Changes in 
management are vital for successful uptake, and failure to build in processes for effecting the 
necessary  organisational  transformations  will  reduce  both  uptake  and  impact.  Participation 
and involvement of Member State in this process is essential.  

The adoption in 2011 of the Directive on the Application of Patients' Rights in Cross Border 
Healthcare2 and its Article 14 establishing the eHealth Network, marks a further step towards 
formal  cooperation  on  eHealth.  All  Member  States  are  now  participating  in  the  eHealth 
Network,  with  the  aim  to  maximise  social  and  economic  benefits  through  eHealth  systems 
and interoperability (one of the most important barriers). 

The actions focus on European added value by means of pan-European policy and legislative 
actions, transformative research and innovation, and interoperability and deployment in order 
to facilitate a common eHealth and wellbeing  innovation space, in which citizens' rights are 
protected,  their  mobility  across  the  European  Union  is  facilitated  and    equity  and  social 
cohesion for all is promoted. 

Considering  all  of  the  above,  the  Commission  will  work  to  achieve  following  operational 
objectives:  

– 

– 

– 

– 

1 

2 

achieving wider interoperability of eHealth services; 

supporting  research,  development  and  innovation  in  eHealth  and  wellbeing  to 

address the availability of user-friendly tools and services; 

facilitating  uptake and ensuring  wider deployment; 

promoting international cooperation. 

Improving  Health  Sector  Efficiency:  The  Role  of  Information  and  Communication  Technologies.   
OECD 2010. http://www.oecd.org/document/61/0,3746,en_2649_33929_45501565_1_1_1_1,00.html 
The Network was established under Article 14 of Directive 2011/24/EU on the application of patients' 
rights in cross-border healthcare, 
http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF 
, OJ L 88, 4.4.2011,p.45. 

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1. 

INTRODUCTION 

The  2004  eHealth  Action  Plan3  set  out  the  first  steps  necessary  for  widespread  adoption  of 
eHealth technologies across the EU.  

In  December  2009  within  the  framework  of  the  EPSCO  Council,  Member  States  adopted 
Council  Conclusions  on  Safe  and  efficient  healthcare  through  eHealth4.  In  these 
Conclusions,  the  Council  recognises  the  contribution  that  eHealth  can  bring  to  healthcare 
systems,  it  underlines  the  common  challenges  all  healthcare  systems  are  facing  and  called 
upon  the  Commission  for  support  "to  bring  forward  eHealth  deployment  and  actual  use  of 
Interoperable eHealth services within and between national healthcare systems". Finally, the 
Council specifically called on the Commission to "update the eHealth Action Plan". 

To respond to this call, to reflect the progress made so far in eHealth and provide support to 
Member  States  and  stakeholders  to  make  further  progress,  the  Commission  is  updating  the 
eHealth  Action  Plan.  The  new  Action  Plan  will  also  be  an  opportunity  to  consolidate  the 
actions  which  have  been  undertaken  or  planned  so  far  in  a  number  of  initiatives,  while 
providing for a global strategic vision on eHealth. This Action Plan also aims at stimulating a 
policy debate on how innovation can contribute to rethinking the way in which healthcare is 
provided today, by considering the latest developments in technology, innovative services and 
the growing impact of new media on the health and wellbeing systems. 

In this document: 

– 

– 

– 

3 
4 
5  

6  

eHealth  means  ICT  tools  and  services  for  health.  eHealth  covers  the  interaction 
between  patients  and  health-service  providers,  institution-to-institution  transmission 
of data, or peer-to-peer communication between patients and/or health professionals. 
records, 
Examples 
telemedicine  services,  wearable  and  portable  systems  which  communicate,  health 
portals,  and  many  other  ICT-based  tools  assisting  disease  prevention,  diagnosis, 
treatment and follow up.  

information  networks,  electronic  health 

include  health 

ICT for wellbeing is the use of ICT in products, services and processes, in order to 
directly or indirectly improve the quality of life and wellbeing status of EU citizens. 
Wellbeing  is  a  person’s  experience  of  positive  and  negative  emotions,  satisfaction, 
vitality, resilience, self-esteem and sense of purpose and meaning. Social well-being 
has  two  main  components:  supportive  relationships  and  a  feeling  of  trust  and 
belonging;  together  they  form  a  picture  of  what  everyone  really  wants:  a  fulfilling 
and happy life5 . It is increasingly recognized that the major factors of ill-health and 
the  major  assets  for  health  are  best  addressed  by  engaging  non-health  sectors  and 
citizens6. 

Telemedicine  is  the  provision  of  healthcare  services,  through  use  of  ICT,  in 
situations where the health professional and the patient (or two health professionals) 

http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2004:0356:FIN:EN:PDF  
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2009:302:0012:0014:EN:PDF  
New  Economics  Foundation  (2011).Measuring  our  progress:  the  power  of  well-being.  London,  New 
Economics  Foundation  (http://www.wikiprogress.org/images//Measuring_our_progress  webReady.pdf, 
accessed 30 May 2012) 
Governance for Health and Wellbeing in the 21st century.  
http://www.euro.who.int/__data/assets/pdf_file/0019/171334/RC62BD01-Governance-for-Health-
Web.pdf 

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are  not  in  the  same  location.  It  involves  secure  transmission  of  medical  data  and 
information,  through  text,  sound,  images  or  other  forms  needed  for  the  prevention, 
diagnosis, treatment and follow-up of patients. 

2. 

THE CONTEXT OF THE INITIATIVE 

The Europe 2020 Strategy emphasises that knowledge and innovation are key to help Europe 
exit the current socio-economic crisis7. In this context, it highlights the potential of Europe’s 
digital economy to help Europe achieve smart, sustainable and inclusive growth.  

The  Digital  Agenda  for  Europe  ('DAE')8,  one  of  the  flagship  initiatives  of  the  Europe  2020 
Strategy aims to deliver sustainable economic and social benefits from a digital single market. 
The  sustainability  of  healthcare  systems  is  identified  as  a  priority  area  which  can  greatly 
benefit  from  the  use  of  information  and  communication  technologies  (ICT)  by  enabling 
patient empowerment and continuity of care.  

Innovation  Union,  also  a  Europe  2020  flagship,  aims  to  improve  conditions  and  access  to 
finance for research and innovation in Europe, to ensure that innovative ideas can be turned 
into products and services that create growth and jobs. Launched under Innovation Union, the 
pilot European Innovation Partnership on Active and Healthy Ageing9, aims at increasing the 
average healthy lifespan in the EU by two years by 2020. This will be achieved inter alia by 
scaling up uptake of innovative eHealth tools and services which would lead to empowering 
citizens,  in  particular  older  people,  increasing  sustainability  of  healthcare  systems  and 
generating growth.  

The  new  eHealth  Action  Plan  2012  -  2020  builds  on  the  2004  eHealth  Action  Plan  which 
marked  the  beginning  of  closer  cooperation  between  EU  Member  States  in  the  area  of 
eHealth. This led, in 2008, to more formal cooperation through the Large Scale Pilot epSOS10 
and eGovernance Initiative. The establishment of the eHealth Network, set up under Article 
14 of the Directive on the Application of Patients' Rights in Cross Border Healthcare11 marks 
a further step towards formal cooperation on eHealth.12 The eHealth Network will be giving 
advice and endorsing guidelines. The Connecting Europe Facility (CEF)13 has been set up to 
facilitate the deployment of cross-border interoperable ICT services of general interest, also 
eHealth. This new instrument, taking over the expert work done by the eHealth Governance 
Initiative,  will  organise  expert  groups  for  cross  border  deployment,  including  at  the 
organisational level. (See the governance chart in the annex). 

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10

11

12

13 

EU2020 strategy, op.cit. p. 3. 
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2010:0245:FIN:EN:PDF 
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2012:0083:FIN:EN:PDF 
The epSOS pilot commits 23 National Health Ministries to work together for the deployment of interoperable patient summaries 
and ePrescription solutions throughout Europe. 
The  Network  was  established  under  Article  14  of  Directive  2011/24/EU  on  the  application  of  patients'  rights  in  cross-border 
healthcare, http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF 
, OJ L 88, 4.4.2011,p.45. 
The  Network  "aims  at  delivering  sustainable  economic  and  social  benefits  of  European  eHealth  systems  and  services  and 
interoperable applications, with a view to achieving a high level of trust and security, enhancing continuity of care and ensuring 
access to safe and high-quality healthcare". 
http://ec.europa.eu/commission_2010-2014/president/news/speeches-statements/pdf/20111019_2_en.pdf 

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3. 

THE 2004 EHEALTH ACTION PLAN  

The first eHealth Action Plan defined the following main challenges: 

• 

• 

• 

• 

• 

• 

Leadership  from  healthcare  authorities  and  providers,  in  particular  focusing  on 
financial and organisational aspects, which are considered essential elements for the 
successful deployment of eHealth.  

Market fragmentation, lack of interoperability, ineffective standardisation: The main 
reasons  for  market  fragmentation  are  related  to  lack  of  regulation  and  standards  at 
EU level, while healthcare systems remain highly regulated through various national 
regulations.  

Legal uncertainty  in deploying  eHealth (cross border) services, ineffective  funding, 
reimbursement, procurement and sustainable business models 

Limited  awareness  of  benefits  among  authorities  and  health  professionals:  the 
Action Plan identified the need for a European-wide public health portal that would 
be  a  flexible  information  technology  platform  to  disseminate  evidence-based 
information on public health relevant to European citizens, while providing a single 
point of access to information on health.  

Specific  concerns  on  privacy  and  protection  of  personal  data,  leading  to  lack  of 
confidence and wide acceptance: building trust is a prerequisite to the development 
of an information society as well as eHealth services.  

Insufficient  infrastructure  (for  example  the  lack  of  broadband  in  remote  areas, 
essential  for  telemedicine  services):  a  top  priority  for  health  providers  using  an 
eHealth system is the speed in getting the desired, high-quality results. Online health 
services can only work thanks to high speed broadband connections, which depend 
on appropriate infrastructures.  

3.1. 

An evaluation of the 2004 eHealth Action Plan 

Since its launch, the eHealth Action Plan has contributed to bringing forward specific priority 
areas  which  have  then  been  embedded  in  other  policy  initiatives  and  projects.  The  most 
relevant ones are presented below following the structure of the objectives of the 2004 eHealth 
Action Plan: 

Increased political awareness: 

Council Conclusions on safe and efficient healthcare through eHealth 2009;  

– 
–  Ministerial/conference Declarations14;  
– 
– 
– 

DAE key actions 13 and 14;  
European Innovation Partnership on "Active and Healthy Ageing";  
Article  14  of  the  recently  adopted  Directive  on  the  application  of  patients' 
rights in cross-border healthcare15 as regards mutual assistance and cooperation 

14 

15 

Member  States  have  strengthened  their  cooperation  in  the  field  of  eHealth  through  Ministerial 
Declarations following the annual eHealth Conferences (2003- 2010) and a set of high level meetings 
between State Secretaries (and/or equivalent level) to define European eHealth Governance. This shows 
that eHealth has risen in the health policy agenda and has developed growing political importance. 
http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/119514.pdf 

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among Member States, including on the local and regional level, for providing 
cross-border healthcare services; 

Technical guidance  

– 

European  Commission  Recommendation  on  cross-border  interoperability  of 
electronic health records systems 

Improving legal certainty  

– 

– 

Staff Working Paper on the Applicability of the existing EU legal framework 
to  telemedicine  services  –  a  follow-up  action  of  the  2008  Communication  on 
Telemedicine16.  This  Staff  Working  Document  analyses  the  EU  legal 
framework  applicable  to  telemedicine  services  and  aims  to  enhance  legal 
clarity in the sector ; 
Directive on the application of patients' rights in cross-border healthcare. 

Commitment to large-scale deployment of eHealth solutions: 

– 

epSOS  project17  –  defining  services  for  a  pan-European  electronic  patient 
summary  and  ePrescription  by  creating  building  blocks  for  the  future 
unification of the European Information Space and considerably increasing the 
innovation potential of European enterprises. 

Significant  progress  has  been  achieved  in  the  area  of  increasing  political  awareness, 
committing  to  widespread  deployment  of  eHealth  solutions,  enhancing  legal  certainty  and 
improving technical guidance.  

While progress has been made, the Report "Assessing the progress of the eHealth Action Plan 
for  the  period  2004  –  2010"18  describes  in  addition  to  the  achievements  the  remaining 
challenges.  These  include  those  actions  which  are  the  most  significant  in  their  implications 
and in their scale (and are indeed those which could be considered closest to a shift towards a 
European eHealth area): 

–  identification  of  a  common  approach  among  the  Member  States  for  patient 

identifiers; 

–  identification  of  interoperability  standards  for  electronic  health  records  (EHRs) 

among the Member States; 

–  adoption of common schemes for conformity testing and accreditation; 

–  creation  of  a  framework  for  greater  legal  certainty  of  eHealth  products  and 

services; 

–  provision of online services in telemedicine and ePrescription by the majority of 

European health organisations and regions. 

16 

17   
18 

EN 

Communication of the Commission on telemedicine for the benefit of patients, healthcare systems and 
society, COM(2008)689,  

http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2008:0689:FIN:EN:PDF 

http://www.epsos.eu/  
http://ec.europa.eu/information_society/activities/health/docs/policy/ehap_assess082011.pdf 

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4. 

PROBLEM DEFINITION 

4.1. 

Sustainability of healthcare and social systems 

The healthcare delivery systems in Member States are increasingly faced with the challenges 
related to the growing demand for high quality services and the impossibility to increase the 
number of resources accordingly.  

An ageing population, a higher incidence of chronic diseases and a shortage of financial and 
human  resources  devoted  to  healthcare  are  among  the  key  factors  leading  to  this  very 
challenging situation both for health and social care systems. If current trends of fertility and 
mortality continue there will be important changes in the age structure of the population with 
a huge impact on the macroeconomic situation in Europe. Eurostat projects that by 2060 the 
EU population will be both smaller and older than in 2008. Most countries will see a drop in 
both young (0-14) and working age populations (15-64). The number of people aged 60 and 
above in the EU is now raising by more than two million every year, roughly twice the rate 
observed  until  about  three  years  ago.  The  working  age  contingent,  the  main  contributor  to 
social  protection  systems  is  expected  to  fall  dramatically  from  67%  to  56%  of  the  total 
population. While the younger population shrinks, the share of the elderly (65+) and very old 
(80+) population in the EU is projected to grow by an average of 13% and 8% respectively. 

Public expenditure on healthcare is expected to grow by 1½ percentage points of GDP in the 
EU by 2060. Institutional and policy changes as well as demographic trends are expected to 
transform  our  societies  considerably,  undermining  intergenerational  solidarity  and  creating 
new demands on future generations. 

Healthcare  is  a  constantly  growing  component  of  public  finances.  The  share  of  total 
government spending on healthcare has grown since the 1990s with the increases exceeding 
inflation rates. Healthcare accounts for 9 % of GDP but represents between 12% and 15% of 
government  spending  in  most  EU  countries.  The  ongoing  economic  uncertainty  brings  into 
sharp focus the fact that current healthcare models are financially unsustainable. eHealth with 
its promise of more efficient and cost effective care is critical to the survival of the system of 
healthcare in Europe.  

On the other hand economists consider health as a component of human capital or add it to 
economic models as a variable termed “health capital”19. Being in good health has long been 
shown  to  impact  positively  on  investment  into  continuing  education,  reduce  the  natural 
human  capital  depreciation  rate  and  the  number  of  work  days  lost.  In  addition,  it  delays 
retirement and decreases hospital days – both of these contribute to systemic socio-economic 
sustainability.  

Without better tailored and more effective health and social care services, Europe's social and 
health models will be seriously jeopradised. For example, a recent report on health systems20 
emphasises  the  need  to  increase  effectiveness  and  efficiency  in  healthcare.  Reduction  of 
unnecessary use of specialists and hospital care while improving primary healthcare services 
and better use of personalised health systems can help deliver better and more efficient care.  

19 
20 

See sources from the economic literature discussed in Codagnone (2009a: p. 27) 
Joint Report on Health Systems, the European Commission and the Economic Policy 
Committee(AWG), 2010, 
http://ec.europa.eu/economy_finance/publications/occasional_paper/2010/op74_en.htm 

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A  study  '  European  countries  on  their  journey  towards  national  eHealth  infrastructures'21 
stated  that  when  looking  at  financing  sources  for  development  and  investment  in  eHealth 
infrastructures and applications, a mixed picture emerges. Across Europe, the primary sources 
of funding are government or quasi-public sources, e.g. the general budget for health, as well 
as  dedicated  ICT  budgets  or  special  levies  on  statutory  health  insurances.  Considering  that 
individual  service  providers  usually  do  not  have  an  incentive  to  establish  eHealth 
infrastructures for all, this result is not surprising. To compensate for market failure and allow 
a  network  effect  to  kick  in,  adopting  a  ‘public  good’  perspective  of  eHealth  infrastructure 
seems  warranted.  Recurring  public  budgets  dedicated  specifically  to  “the  reimbursement  of 
eHealth  services”  are  still  the  exception,  whereas  there  is  widespread  use  of  project-based 
sourcing.  Sometimes  private  and  public  insurance  companies  or  public  technology  or 
innovation agencies are involved in temporary financing. 

4.2. 

Ageing population and growing incidence and prevalence of chronic diseases  

As  life  expectancy  increases,  so  does  the  prevalence  of  chronic  disease.  Currently  chronic 
disease is a global epidemic which accounts for more than 60% of deaths22 and disability. The 
WHO recognised23 the rapidly growing magnitude of non communicable diseases that affects 
people  of  all  ages,  gender,  race  and  income  levels,  and  further  poor  populations  and  those 
living in vulnerable situations. The burden of chronic disease for the health and social system 
and  for  the  economy  and  work  force  is  enormous.  Improving  control  and  prevention  of 
chronic conditions is a global challenge. 

In fact, WHO is urging Member States to draw upon, based on national contexts, the policies, 
strategies,  programmes  and  interventions,  and  tools  on  the  prevention  and  control  of  Non-
communicable  Diseases,  in  order  to  promote,  establish  or  support  and  strengthen,  as 
appropriate, multisectoral national policies and plans.   

Patient empowerment is essential to support better control of chronic conditions. Against this 
backdrop there is clearly a need for improved quality and more accessible information online, 
increasing  awareness  and  promotion  of  healthy  lifestyles24  among  citizens.  In  this  context, 
innovative  systems  supporting  patients  to  better  manage  their  conditions  like,  remote 
monitoring devices, can also contribute to patient empowerment, leading to better managment 
and increased quality of life25.  

4.3.  Mobility of patients and health professionals and shortage of professionals 

Due  to  growing  levels  of  mobility  of  patients  and  professionals,  demand  for  cross-border 
services is rising. Patients need secure and standard access to these services in cross-borders 
situations. 

21  
22 

http://www.ehealth-strategies.eu/report/eHealth_Strategies_Final_Report_Web.pdf 
Monitoring Financial Flows for Health Research 2006: The changing landscape of health research for 
development. 71. 2006. Global Forum for Health Research 

23            http://apps.who.int/iris/bitstream/10665/23846/1/B130_R7-en.pdf 
24 
25  

Whether provided through web 2.0 or more traditional public and private information portals. 
See  JRC  IPTS  Strategic  Intelligence  Monitor  on  Personal  Health  Systems  Phase  2  Report  on  best 
practices and key drivers of success at http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS2.html 

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The mobility of patients26 and health professionals within the EU is increasing.27 On the other 
hand, new threats put at risk the future health system and its principle of equity. The number 
of practising physicians, general practitioners and practising nurses and midwives per 100,000 
inhabitants has increased in the EU taken as a whole since the 1970s25. At the same time, the 
health workforce is ageing. On average in the EU, more than 60% of physicians are more than 
45 years old, a proportion that has increased over time: from 44.4% in 1995 to more than 60% 
in  2008.  In  some  countries,  staff  migration  to  countries  in  need  of  staff  and  offering  higher 
wages can become a problem for the country of origin. A lack of and inadequately trained and 
practising staff combined with migration are undermining the capacity of Member States to 
ensure cost-effective delivery and equitable access to health care services. 

eHealth can play a role in addressing the current challenges of the health system, providing 
healthcare to remote areas while decreasing the inequalities and variability of clinical practice 
in  the  Member  States.  The  2010  EU  Citizenship  Report  underlined  the  role  of    eHealth  in 
facilitating cross border healthcare28. 

4.4. 

Increased  demand  for  high  quality  of  care  and  investing  in  expensive 
technologies 

In 2006 the Council of the European Union agreed to a set of Common Values and Principles 
in  EU  Health  Systems.  It  invited  the  European  Commission  to  ensure  that  these  values  and 
principles  are  respected  when  drafting  specific  proposals  concerning  health  services.  The 
overarching  values  considered  are:  Universality,  Access  to  good  quality  care,  Equity, 
Solidarity.  The  operating  principles  are:  quality,  safety,  evidence  based  and  ethical  care, 
patient  involvement,  redress  when  things  go  wrong,  privacy  and  confidentiality.  However, 
health inequalities persist across the EU.  

The  quality  of  the  healthcare  system  is  often  associated  with  the  use  of  sophisticated 
technologies and advanced, costly medicines. A rising demand for services in a situation with 
limited resources that is worsened by the recent economic crisis, makes cost-effectiveness one 
of  the  most  important  goals  in  this  area29.  Investing  in  quality  and  containing  cost  while 
providing  safety  and  equity  care  is  a  mandatory  goal  for  health  systems.  The  use  of 
interoperable  EHRs has been  identified as  a  major opportunity for more efficient and better 
quality healthcare. Other technologies to support administrative or clinical processes provide 
a theoretical framework to ensure the quality and safety of the system. The need to improve 
the  general  governance  (decision-making  and  management)  of  the  health  system  has  been 
tested by the Joint Report on Health Systems previously mentioned.  

26 

27 

28  

29 

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.  
EU  Citizenship  Report  2010  - Dismantling  the obstacles to  EU  citizens’  rights  COM(2010)  603  final 
(pp. 8 and 9). 

Joint  Report  on  Health  Systems, 
Committee(AWG), 2010, 
 http://ec.europa.eu/economy_finance/publications/occasional_paper/2010/op74_en.htm 

the  European  Commission  and 

the  Economic  Policy 

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4.5. 

Slow deployment of eHealth tools and services 

Clinical and healthcare workflows, care models, and business processes are significantly more 
complex  than  equivalents  in  other  sectors  of  the  economy  and  less  amenable  to 
standardisation and streamlining by conventional eBusiness systems. Below, the results of the 
public consultation and the available evidence demonstrate other reasons and barriers for slow 
uptake of eHealth solutions including: the lack of awareness of, and confidence in,  eHealth 
solutions  among  patients,  citizens  and  healthcare  professionals;  lack  of  interoperability 
between  eHealth  solutions;  limited  large-scale  evidence  of  the  cost-effectiveness  of  eHealth 
tools and services; lack of legal clarity for health and wellbeing mobile applications and the 
lack  of  transparency  regarding  the  utilisation  of  data  collected  by  such  applications; 
inadequate or fragmented legal frameworks including the lack of reimbursement schemes for 
eHealth services and the high start-up costs involved in setting up eHealth systems. 

Successful EHRs and ePrescribing are not quick wins; they are sustainable wins. It takes at 
least four, and more typically, up to nine years. Average time to annual net benefit of the nine 
sites is seven years.30 

5. 

CONSULTATION OF INTERESTED PARTIES 

5.1. 

Stakeholder consultation 

A public consultation on the eHAP ran from 31 March to 31 May 2011. It sought the views of 
interested parties on the proposed policy objectives to understand whether they were in line 
with their expectations while verifying whether there were additional areas requiring further 
action.  

The  draft  questionnaire  was  discussed  with  Member  States  representatives  within  the 
framework  of  the  i2010  subgroup  on  eHealth  (Ad-hoc  expert  group  on  eHealth)  during  its 
meetings on 15 September 2010 and on 19 January 2011, when it was informally validated. It 
was also presented during the European Health Policy Forum on 21 October 2010 and to the 
eHealth  Users  –  Stakeholders  group,  which  included  representatives  of  users  of  eHealth 
including professionals, patients and healthcare managers31. 

The consultation sought to validate four proposed objectives and to explore possible actions 
to be undertaken in the next years. The four objectives proposed were:  

Objective  1:  Increase  awareness  of  the  benefits  and  opportunities  of  eHealth,  and 
empower citizens, patients and healthcare professionals. 

Objective 2: Address issues currently impeding eHealth interoperability 

Objective 3: Improve legal certainty for eHealth 

Objective  4:  Support  research  and  innovation  in  eHealth  and  development  of  a 
competitive European market. 

30  

31 

Economic Impact of Interoperable Electronic Health Records and ePrescription in Europe (01-2008/02-
2009): 
http://ec.europa.eu/information_society/activities/health/docs/publications/201002ehrimpact_study-
final.pdf 
This group has been replaced by the eHealth Stakeholder group.  

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239  participants  contributed  to  the  consultation,  representing  a  wide  range  of  stakeholders 
including  non-governmental  organisations,  academia,  enterprises,  health  and  social  care 
providers and public authorities from many Member States.  

The  majority  of  respondents  underlined  four  main  actions  to  address  barriers  impeding  the 
deployment of eHealth that the European Commission should take:  

(1)  Supporting 

systematic 

evaluation 

of 

the 

benefits 

and 

costs, 

effectiveness/usefulness of eHealth solutions;  

(2) 

Improving interoperability and strengthening the evidence-based approach; and 

(3)  Facilitating cooperation between Member States and regions and,  

(4)  Exploring innovative financing and reimbursement schemes.  

Most  of  participants  (around  90-95%)  agreed  or  partially  agreed  with  the  four  main  actions 
mentioned above.  

Regarding specific actions for every objective, the majority of respondents believed that the 
main  instrument  to  increase  patients'  awareness  and  trust  on  eHealth  is  an  information 
campaign. Improving healthcare professionals' awareness and acceptance should be addressed 
through  the  inclusion  of  eHealth  in  medical  curricula  and  training  in  the  workplace; 
organising  information  campaigns  and  supporting  the  dissemination  of  good  practices  and 
results at professional conferences both at national and international level. Moreover, there is 
a strong need to provide evidence-based input and research and encourage the promotion of 
the benefits of eHealth by raising awareness as the evidence is being collected. According to 
71%  of  respondents,  the  Commission  should  support  the  deployment  of  ICT  systems  for 
clinical  use  (decision  support  systems,  EHR,  ePrescription,  Radiology  Information  Systems 
etc.). 

The  main  action  for  the  second  objective,  "address  issues  currently  impeding  eHealth 
interoperability",  is  taking  steps  to  advance  technical  interoperability  to  facilitate  de-
fragmentation  of  the  eHealth  market.  The  most  effective  way  of  supporting  European 
cooperation  is  to  harmonise  standards,  profiles  and  technical  specifications  used  to  ensure 
cross border eHealth interoperability.  

Regarding  legal  issues,  most  of  the  participants  thought  that  encouraging  professional 
associations, scientific societies and civil society representatives to promote the exchange of 
best  practices  through  the  development  of  guidelines  and/or  codes  of  conduct  for  eHealth 
services  is  an  important  area  of  action  for  the  Commission.  Data  protection  and  liability 
should  also  be  considered.  The  data  protection  reform  foresees  facilitating  the  adoption  of 
codes  of  conduct  to  improve  data  protection  in  all  sectors,  including  eHealth.  The 
Commission  encourages  the  drafting  of  such  codes  of  conduct,  to  be  approved  by  data 
protection authorities. 

The  objectives  should  be  supported  by  providing  funding  for  the  scaling  up  of  innovative 
eHealth  solutions,  for  example  by  facilitating  deployment  of  research  results  and  providing 
more  flexible  financing  mechanisms  to  support  research  and  innovation.  More  emphasis 
should be put on international cooperation to promote benchmarking and evaluation projects 
in order to provide evidence to support deployment of eHealth solutions and to support new 

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innovative solutions such as Virtual Physiological Human, Personal Health Systems and ICT 
for Public Health. 

The  full  Report  on  the  results  of  the  public  consultation  is  published  on  the  Commission's 
website32. 

5.2. 

Internal expertise 

The  Inter-service  Steering  Group  on  the  eHealth  Action  Plan  was  established  in  December 
2010 to support the drafting of the Communication. The following services were consulted: 
SG,  LS,  COMP,  DIGIT,  ECFIN,  EMPL,  ENTR,  ENVI,  JUST,  JRC,  MARKT,  REGIO, 
RELEX, RTD, SANCO, TAXUD33.  

The group held three meetings: 8 February 2011, 14 April 2011 and 25 April 2012.  

5.3. 

External expertise and input 

Member States, within the framework of the i2010 subgroup on eHealth (Ad-hoc expert group 
on eHealth) at its meetings on 15 September 2010 and 19 January 2011, supported the public 
consultation questionnaire. The latter was also presented on 21 October 2010 to the eHealth 
Users – Stakeholders group during the European Health Policy Forum.  

The eHealth Action Plan was discussed during the eHealth Week in Budapest in May 2011 
and  eHealth  Week  in  Copenhagen  in  May  2012  at  a  meeting  of  the  eHealth  Stakeholder 
Group.  

5.3.1.  Task Force Report 

As  requested  by  Vice-President  Kroes  and  Commissioner  Dalli,  a  Task  Force  of  thought 
leaders from politics, health and ICT was convened in May 2011. Its role was to examine the 
transformational  role  of  technology  in  addressing  the  major  challenges  facing  the  health 
sector. The Task Force was chaired by the Estonian President, Mr Toomas Hendrik Ilves and 
met  four  times.    Its  final  Report  was  presented  on  7  May  2012  at  eHealth  week  in 
Copenhagen.34  

The Report highlights the critical preconditions for implementing eHealth effectively:  

• 

• 

32 

33 
34 

Individuals are the owners and controllers of their own health data, with the right to 
make decisions over access to the data and to be informed about how it will be used. 
This principle is outlined in EU law  and  European jurisprudence but is rarely fully 
implemented in health systems.  

Large  amounts  of  data  currently  sit  in  different  silos  within  health  and  social  care 
systems. If this data is released in an appropriate manner and used effectively it could 
transform the way that care is provided. 

http://ec.europa.eu/information_society/activities/health/docs/policy/ehap2012public-consult-report.pdf 

Some DGs have changed since the launch of the ISSG 
http://ec.europa.eu/information_society/activities/health/docs/policy/taskforce/redesigning_health-eu-
for2020-ehtf-report2012.pdf 

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• 

• 

• 

The health sector has been slow to adopt new communication tools for a variety of 
institutional,  economic  and  personal  reasons.  However,  patients  will  increasingly 
demand  that  their  health  professionals  and  institutions  use  the  same  ubiquitous 
technology they use in everyday life. 

Full transparency on the performance of health professionals and institutions enables 
patients  to  make  more  informed  choices  about  where  and  how  they  want  to  be 
treated.  This  will  have  real  impact  on  resource  allocation  in  health,  as  funding 
follows the patients. 

Service providers need to be aware that there may be sub-groups  of the  population 
that  are  outside  the  reach  of  eHealth  tools  -  those  without  access  to  the 
internet/computers  and  individuals  that  choose  not  to  interact  intensively  with 
technology. 

The five recommendations presented in the Report are: 

1.  Create a legal framework and space to manage the explosion of health data. This needs to 
put in place the safeguards that will allow citizens to use health apps with confidence that 
their  data  is  handled  appropriately  and  subsequently  it  will  create  the  conditions  for  the 
integration  of  user-generated  data  with  official  medical  data  so  that  care  can  be  more 
integrated, personalised and useful for patients.  

–  Create  a  'beacon  group'  of  Member  States  and  regions  committed  to  open  data  and 
eHealth. A leadership group from regions and countries that have invested in eHealth 
applications  (such  as  Denmark,  Sweden,  Estonia,  Spain)  could  be  pioneers.  The  EU 
could  facilitate  such  a  group  and  finance  experts  who  can  evaluate  eHealth  projects 
from inception to delivery. 

–  Support  health  literacy.  As  doctors  are  no  longer  the  sole  arbiters  and  interpreters  of 
medical information for patients and as patients are playing a more active role, health 
data thus needs to be translatable into information that citizens understand. 

–  New rules are needed to define how to integrate official data and user data to create a 
more  holistic  picture  of  situation  of  the  patient  in  health  care  as  well  provide  early 
feedback for preventive care. Certification of applications should be based on a set of 
principles for how health related data should be treated rather than regulation. Health 
institutions must publish the data on their performance and health outcomes. 

–  Re-orient EU funding and policies - specific budget lines need to be agile, responsive 
and  should  foster  the  development  of  good  ideas  into  fast  prototyping  and  testing. 
Require  transparency  from  institutions  in  health  systems  through  procurement  and 
funding criteria.  

6. 

EVIDENCE INFORMED EHEALTH ACTION PLAN 2012 – 2020   

In  May  2005,  the  58th  World  Health  Assembly  adopted  a  resolution  acknowledging  the 
Mexico  Statement  on  Health  Research,  urging  Member  States  “to  establish  or  strengthen 

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mechanisms to transfer knowledge in support of evidence-based public health and health-care 
delivery systems, and evidence based health-related policies”35.  

The  eHAP  respects  this  resolution  and,  considering  the  hierarchy  of  evidence  to  decision 
making36  (table  1),  the  impact  assessment  upon  which  it  is  based  represents  an  additional 
scientific instrument to support and validate suggestions from experts and stakeholders who 
participated in the Public Consultation.  

Table 1: Designations of levels of evidence 37   

Level 
evidence  

of 

Study design 

I  

II  

III-1 

III-2 

III-3 

IV 

Evidence  obtained  from  a  systematic  review  of  all  relevant 
randomised controlled trials 
Evidence  obtained  from  at  least  one  properly-designed  randomised 
controlled trial 
Evidence obtained from well-designed pseudorandomised controlled 
trials (alternate allocation or some other method) 
Evidence  obtained  from  comparative  studies  (including  systematic 
reviews of such studies) with concurrent controls and 
allocation  not  randomised,  cohort  studies,  case-control  studies,  or 
interrupted time series with a control group 
Evidence obtained from comparative studies with historical control, 
two or more single arm studies, or interrupted time 
series without a parallel control group 
Evidence obtained from case series, either post-test or pre-test/post-
test 

The  objective  of  this  section  is  to  analyse  the  current  scientific  evidence  supporting  the 
objectives  and  actions  of  the  new  eHealth  Acton  Plan  according  to  the  evidence  informed 
policy recommendation38. 

6.1.  Methodology 

Considering the revised hierarchy of the evidence and following recent recommendations, a 
systematic  mini-review  of  systematic  reviews,  meta-analysis,  health  technology  assessment 
(HTA)  reports  and  other  policy  reports  in  response  to  specific  research  questions  has  been 
conducted. 

Research questions 

1. 

What are the main barriers and/or facilitators to deployment of eHealth solutions?  

35 

36 

37 

38 

on 

Health 

Assembly: 

Resolution 

World 
http://www.who.int/rpc/meetings/58th_WHA_resolution.pdf  World Health Organization 
Merlin t, Weston A, Tooher. "Extending an evidence hierarchy to include topics other than treatment: 
revising the Australian "level of evidence" BMC Med Res Methodol. 2009 Jun 11;9:34 
NHMRC.  A  guide  to  the  development,  implementation  and  evaluation  of  clinical  practice  guidelines. 
Canberra, ACT: National Health and Medical Research Council, Commonwealth of Australia; 1999 
Lewin S, Bosch-Capblanch X, Oliver S, et al "Guidance for evidence-informed policies about Health 
system:  Assessing  how  much  confidence  to  place  in  the  research  evidence."  PloS  Med  2012;  9, 
3:e1001187 

research. 

health 

2005 

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2. 

3. 

What  is  the  current  status  of  eHealth  in  the  EU  and  how  to  ensure  successful  and 
sustainable deployment of eHealth? 

What is the evidence of the effectiveness and efficiency of eHealth and what research 
areas  still  need  to  gather  large  scale  evidence  to  support  wide  deployment  of 
telemedicine by 2020?  

Literature Search 

In order to respond to the questions above, a specific and restricted search in different sources 
was conducted. 

In the context of the Methotelemed study39, the European Commission funded an exhaustive 
systematic review of reviews on effectiveness of telemedicine. The literature search included 
extensive  sources  and  databases  up  until  January  2009.  The  results  of  this  review  which 
included 80 scientific papers were published in a peer reviewed journal40.  

After this date, the current literature search was conducted in Medline (Limit: meta-analysis) 
and Centre for Reviews and Dissemination (DARE and HTA) from 2009 to February 2012. 
The  following  terms  were  used  for  search:  Telemedicine  [MeSH  Terms],  eHealth,  telecare, 
telehome, medical record system computerized [MeSH Terms].  

Policy reports were selected from European studies published since 2004, papers from WHO, 
OECD, and another studies supporting benchmarking activities.   

Papers  included  in  this  review  were  selected  based  on  the  following  criteria:  1)  Design: 
systematic  review,  meta-analysis,  and  evidence  based  policy  recommendations;  2) 
Intervention and technology: any eHealth solution or service which describes a specific and 
reproducible intervention for any health field; 3) Participants: any stakeholder; 4) Outcomes: 
information  about  primary  indicators/outcomes  obtained  with  a  reproducible,  scientific  and 
good quality methodology (minimising bias) is mandatory; 5) Answering at least one research 
question. 

Exclusion  criteria:  systematic  reviews/  meta-analysis  from  Medline  without  clear 
methodology in the abstract; interventions that are too complex or involving many different 
technologies making it impossible to extract individual outcomes.  

Initial  screening  of  identified  articles  was  based  on  their  abstracts.  Articles  from  electronic 
data  bases  lacking  an  electronic  abstract  were  initially  excluded.  The  documents  were 
classified according to research questions and objectives of the eHealth Action Plan. Data on 
the effectiveness of telemedicine were re-grouped by major topic.   

39 

40 

Methotelemed  study  Methodology  to  assess  Telemedicine  Applications  (02-2009/02-2010)  SMART 
208/0064 
http://ec.europa.eu/information_society/activities/health/studies/published/index_en.htm#Methodology_
to_assess_Telemedicine_Applications 
Anne  G.  Ekelanda,  Alison  Bowesb,  Signe  Flottorpc  "Effectiveness  of  telemedicine:  A  systematic 
review of Reviews". International journal of medical informatics 2010; 7 9 : 736–771 

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6.2. 

Results  

From  the  106  references  regarding  systematic  reviews,  meta-analysis  and  HTA  reports,  57 
documents  were  selected.  Additionally  to  20  policy  documents  or  studies  met  the  inclusion 
criteria. In total, 76 documents were analysed in order to respond to the research questions. 
All references can be found in the bibliography section. 

From 76 documents, 53 focused on telemedicine or eHealth service, 5 on health information 
systems and EHR, and 18 were benchmarking studies or policy documents which reported on 
eHealth in general.  

What are the main barriers and/or supporting factors to deploy eHealth solutions?  

Six papers reported information about the barriers or facilitators to deploy eHealth solutions. 
The main barriers were the lack of awareness of, confidence in the benefit of eHealth; lack of 
user-friendly  eHealth  solutions;  lack  of  interoperability  between  eHealth  solutions;  and 
limited large-scale evidence of the cost-effectiveness of potential improvements in healthcare 
processes.   

McGinn  et  al41  reported  a  systematic  review  on  users’  perceived  barriers  and  facilitators  to 
shared EHR implementation from 60 publications and they found that physicians, healthcare 
professionals  and  managers  share  many  common  supporting  factors  and  barriers.  Patients 
seem  to  have  different  views.  While  similarities  can  be  found  between  groups,  inter-group 
differences also show how the unique perspective of each user group needs to be taken into 
account. The results confirm that financial, time- related, and technical barriers are the most-
cited barriers to EHR acceptance and adoption for patients, professionals and managers.  

This point was also reported by a study on the benchmarking of acute hospitals42. According 
to medical directors, this situation might be due to prevailing interoperability problems. The 
medical directors identified interoperability between different departments’ electronic patient 
record systems as the largest barrier to their implementation - 46% agreed that it was a barrier. 
This  was  followed  by  the  lack  of  financial  incentives  for  the  staff  to  use  these  systems,  a 
barrier  that  is  more  evident  in  large  hospitals:  76%  of  medical  directors  in  large  hospitals 
agree that it is a barrier compared to only 46 % in the smallest hospitals. No clear barriers or 
impacts  were  identified  concerning  the  adoption  of  telemonitoring.  The  low  rate  of 
implementation  of  telemonitoring  might  be  explained  by  the  medical  directors’  lack  of 
perception  that,  in  their  hospitals,  it  will  lead  to  improvements  in  quality  of  care  if 
implemented.  Seventy-eight  per  cent  of  medical  directors  state  that  telemonitoring  would 
have little or no impact on the improvement of the quality of life of patients. 

Moreover,  patients  were  the  only  user  group  to  identify  supporting  factors  in  a  larger 
proportion than barriers and to consider autonomy (health empowerment and improved health 
self-management),  as  a  positive  EHR  implementation  factor.  Patients  highlight  two  factors, 
perceived  usefulness  and  motivation  to  use  EHRs,  as  main  supporting  factors  for 

41 

42 

McGinn C et al. Comparision of user group's perspectives of barriers and facilitators to implementing 
electronic health records:  a systematic review. BMC Medicine 2011, 9:46 
http://www.biomedcentral.com/1741-7015/9/46 
Deloitte  &  Ipsos  Belgium.  "eHealth  Benchmarking  III"  SMART  2009/0022.  European  Commission 
2011. 
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/ehealth_benchmarking_3_fi
nal_report.pdf 

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implementing EHR. Stakeholder groups identified43 the following important characteristics of 
an  Internet-based  virtual  clinic:  being  based  on  personal  needs;  having  the  facility  to 
communicate; being quick and easy to use. 

Other study44results indicated that consumers are ready to accept EHRs as long as they can be 
assured of the security of the system. Professionals' acceptance is a key factor in supporting 
deployment and usability of eHealth. Professionals play a relevant role in motivating patients 
to use ICT and to support self-management and autonomy. However, that is only possible if 
they  believe  eHealth  is  useful  and  effective.  Another  study  published  by  the  European 
Commission45 showed that European general practitioners (GPs) are positive about the role of 
ICT  in  health  care.  They  have  a  clear  idea  of  what  would  facilitate  a  wider  diffusion  of 
eHealth use. However, while eHealth users do not perceive any major barriers, non-users are 
more  critical.  A  lack  of  IT  training  for  GPs  is  probably  the  strongest  hindering  factor.  The 
former result is well in line with other data indicating that only a minority of GPs in Greece 
(38%), Latvia (29%), Poland (30%) and Romania (10%) receive IT support from professional 
service  providers  —  compared  to  74%  on  average  across  the  27  EU  Member  States  as  a 
whole. 

Patients'  attitudes  about  the  use  of  Web  messaging  and  online  access  to  their  EHR  were 
mostly  positive.  At  the  same  time,  clinicians  were  less  positive  about  using  electronic 
communication than their patients46 

Hardiker and Grant47 in a systematic review of 50 articles looking for barriers and factors that 
affect  engagement  with  eHealth  services,  recommended:    targeted  efforts  to  engage  those 
underserved  by  eHealth;  maximizing  exposure  to  eHealth  across  all  groups  of  society; 
improving  access  to  computers  and  the  internet;  appropriate  design  and  delivery;  ensuring 
content  is  relevant  to  different  audiences;  capitalizing  on  the  interest  in  Social  Computing; 
and clarifying the role of health workers in the delivery of eHealth. 

JRC-IPTS  found  within  its  analysis  of  Integrated  Personal  Health  and  Care  Services  in 
Europe,  found    that  the  frontrunners,  in  terms  of  eHealth  and  IPHS  deployment  (i.e.g. 
Denmark,  England  and,  Scotland),  show  a  combination  of  policy  towards  integrated  care, 
incentives framework and funding mechanisms in place. Moreover, they offer official portals 
for public health services providing access to health information to citizens, patients and even 
health professionals. In this manner, they encourage empowerment48.   

What  is  the  current  status  of  eHealth  in  the  EU  and  how  to  ensure  successful  and 
sustainable deployment of eHealth in the current socio-economic situation? 

43 

44 

45 

46 

47 

48  

among  General 

Armstrong  N  et  al  Stakeholder  perspectives  on  the  development  of  a  virtual  clinic  for  diabetes  care: 
qualitative study.  J Med Internet Res. 2007 Aug 9;9(3):e23. 
Chanabhai P, Holt A, Consumers are ready to accept the transition to online and electronic records if 
they can be assured of the security measures. MedGenMed. 2007 Jan 11;9(1):8.. 
Alexander Dobrev, Marten Haesner, Tobias Hüsing, Werner B. Korte, Ingo Meyer. "Benchmarking ICT 
use 
2008. 
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/gp_survey_final_report.pdf 
Hassol A et al. Patient experiences and attitudes about access to a patient electronic health care record 
and linked web messaging.J Am Med Inform Assoc. 2004 Nov-Dec;11(6):505-13.  
Hardiker NR, Grant M Barriers and facilitators that affect public engagement with eHealth services. J 
Stud Health Technol Inform. 2010;160(Pt 1):13-7. 
JRC  IPTS  Strategic  Intelligence  Monitor  on  Personal  Health  Systems  Phase  2  Country  Studies 
Summary and Evidence Consolidation. Available at http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS2.html 

European  Commission 

Practitioners 

Europe" 

in 

EN 

18 

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12 documents were analysed to respond this question.  

Health systems, health outcomes and the workforce in terms of number and qualifications are 
different  across  the  EU  Member  States.  Almost  half  of  all  Europeans  show  inadequate  or 
problematic levels of health literacy, according to the results of the European Health Literacy 
Survey  presented  in  November  2011  at  the  European  Health  Literacy  Conference.49  Low 
health  literacy  is  associated  with  reduced  use  of  preventive  services  and  management  of 
chronic conditions, and higher mortality. Health literacy is shown as a driver for change for 
equity and sustainability, influencing the health attitudes of healthy people, people at risk and 
patients. 

The Nairobi Call for Action50 emphasizes the need to support empowerment by ensuring basic 
education  for  all  citizens;  by  building  on  existing  resources  and  networks  to  ensure 
sustainability and enhance community participation; by designing health literacy interventions 
based on community needs and priorities in their political, social and cultural context and by 
ensuring that communities are able to access and act on knowledge and overcome any barriers 
to health. By improving people’s access to health information, and their capacity to apply it 
effectively,  health  literacy  is  critical  to  empowerment.  Improving  health  literacy  is  an 
important element of strategies to reduce health inequity. 

In general, all papers analysed showed that ICT penetration51, digital literacy and ICT use is 
very different in European countries52,53. European countries have made substantial progress 
towards modern eHealth infrastructures and implementations, thereby leading the rest of the 
world. Following the 2004 eHealth Action Plan the EU Member States committed themselves 
“to  develop  a  national  or  regional  roadmap  for  eHealth.”  Various  non-EU  countries  also 
followed this vision. In a study funded by European Commission54 reported that by the end of 
2006  most  of  the  EU  Member  States  had  published high level official policy  documents  on 
their eHealth implementation strategy. In 2010, almost all have detailed documents outlining 
concrete  eHealth  goals, 
their  past 
achievements. In line with the objectives of the eHealth Action Plan 2004, “health authorities' 
leadership” is visible across the EU. Table 2 identifies key fields of national level activities 
and the sometimes considerable increase recorded between 2006 and 2010: 

implementation  measures,  and  sometimes  also 

Table 1: Key fields of national level eHealth activities in the EU27 countries, 2006 and 2010 

49 
50 

51 

52 

53 

54 

http://inthealth.eu/research/health-literacy-hls-eu/ 
(World  Health  Organization)  2009.  The  Nairobi  Call  for  Action.  Final  draft.  World  Conference  on 
Health Promotion. 
Atlas eHealth country profiles: based on the findings of the second global survey on eHealth. (Global 
Observatory for eHealth Series, 1). WHO 2011. http://www.who.int/goe 
Ingo Meyer, Tobias Hüsing, Maike Didero, Werner B. Korte. eHealth Benchmarking (Phase II). 
European Commission 2009. 
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/ehealth_ii_bench_final_repo
rt.pdf 
Deloitte  &  Ipsos  Belgium.  "eHealth  Benchmarking  III"  SMART  2009/0022.  European  Commission 
2011. 
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/ehealth_benchmarking_3_fi
nal_report.pdf 

Karl A. Stroetmann, Jörg Artmann, Veli N. Stroetmann. "European Countries on their Journey towards 
ISBN:  978-92-79-19766-6 
National  eHealth 
http://ec.europa.eu/information_society/activities/health/docs/studies/eh_strategies/ehealth-
strategies_report012011.pdf 

Infrastructures".  European  Commission  2011. 

EN 

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Reported eHealth 
activities 

Total 2006 
eHealth ERA 

Total 2010 
eHealth 
Strategies 

Delta 

Legal activities 

Evaluation 

EHR Patient Summary 

ePrescription 

Telehealth 

Patient ID 

Professional ID 

Citizen card 

Professional card 

Standards 
(technical/semantic) 

Source: eHealth Strategies study, 2010 

14 

5 

27 

16 

23 

24 

13 

22 

7 

19 

22 

21 

27 

22 

27 

26 

22 

25 

18 

27 

8 

16 

0 

6 

4 

2 

9 

3 

9 

8 

Another  indication  of  the  strong  political  commitment  at  the  national  policy  level  is  the 
growing  establishment  of  permanent  administrative  support  structures.  Also,  the  current 
participation in the epSOS project (Smart Open Services for European Patients) undertaken by 
23 countries shows the political commitment and interest in the issues. 

However, other studies show that telemedicine services such as telehealth,  telecare (the home 
monitoring  of  patients)  or  health  information  networks  linking  hospitals,  laboratories, 
pharmacies,  primary  care  and  social  centres  often  remain  small  local  telehealth  or 
telemedicine  experiments,  or  there  are  only  plans  to  undertake  pilots.  Another  study55  
demonstrates  telemonitoring  of  outpatients  remaining  at  low  levels:  only  8%  of  European 
acute hospitals do it. Nevertheless, videoconferencing facilities are relatively common. They 
are  available  in  nearly  40%  of  the  European  hospitals  surveyed.  The  most  general  use  of 
videoconferencing  (64%)  is  for  consultation  between  internal  medical  staff  and  external 
healthcare providers.  

Since 2004, rapid development has taken place in the eHealth area in Europe where GPs56 use 
a basic ICT infrastructure consisting of computers (87%) and Internet connections (from 61 to 
81%). However, in some countries, the share of practices using a computer is as low as 65% 
(Malta, Romania) or 57% (Latvia). There are considerable differences between the countries, 
with broadband penetration ranging from 93% in Finland to 5% in Romania. 

55 

56 

EN 

Deloitte  &  Ipsos  Belgium.  "eHealth  Benchmarking  III"  SMART  2009/0022.  European  Commission 
2011. 
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/ehealth_benchmarking_3_fi
nal_report.pdf 
Alexander Dobrev, Marten Haesner, Tobias Hüsing, Werner B. Korte, Ingo Meyer. "Benchmarking ICT 
use 
2008. 
http://ec.europa.eu/information_society/eeurope/i2010/docs/benchmarking/gp_survey_final_report.pdf 

European  Commission 

among  General 

Practitioners 

Europe" 

in 

20 

   EN 

 
 
                                                 
 
The  electronic  storage  of  administrative  and  medical  patient  data,  the  use  of  a  computer 
during consultation with patients and other uses of ICT in healthcare are becoming more and 
more everyday practices. At the same time, there is still room for improvement when it comes 
to  electronic  networks  connecting  their  IT  systems  with  other  health  actors,  the  electronic 
exchange of patient data and electronic interactions with patients. From the data collected for 
this study, Denmark, the Netherlands, Finland, Sweden and the UK emerge as the European 
frontrunners in eHealth use by GPs. On the other side there is a group of countries where the 
use of eHealth at large or the use of advanced applications still leaves considerable room for 
improvement.  This  group  consists  of  Greece,  Latvia,  Lithuania,  Poland  and  Romania.  In 
between lies the large group of average performers, consisting of the remaining 15 Member 
States. A gap remains between readiness for use and actual use of eHealth. In 2007, further to 
connections to other health actors, the Internet and other, dedicated networks can also be used 
for  electronic  transfer  of  patient  data.  Use  rates  are  again  moderate  to  low  and  show 
considerable variations. 

What  is  the  evidence  on  the  effectiveness  and  efficiency  of  eHealth  and  what  research 
areas still need to build large scale evidence to support wide deployment of telemedicine 
by 2020?  

50  papers  on  the  effectiveness  and  efficiency  of  telemedicine  services  have  been  analysed. 
The  first  results  of  this  systematic  review  show  that  the  number  of  trials  and  projects  on 
telemedicine has dramatically increased in recent years. There is a great variability of trials, 
technologies,  interventions,  methodologies,  outcomes  and  indicators  which  made  the 
assessment  difficult.  In  general,  most  of  the  papers  confirmed  the  potential  benefits  by 
showing  data  on  effectiveness.  However,  cost-benefit  analysis  is  often  lacking.  Great  effort 
should be made in supporting strong evaluation, especially economic evaluation, to ensure the 
success and the sustainability of the heath system. 

Providing  decision  makers  with  direct  financial  figures,  statistical  data  etc.,  is  not  enough, 
since the ultimate strategic objective is to improve the efficiency and quality of clinical care 
through health ICTs. Methodological difficulties are further exacerbated by data limitations, 
definition  problems  and  the  lack  of  appropriate  sets  of  indicators  on  adoption,  use  and 
outcome  of  ICTs  which  can  be  compared  over  time,  within  and  across  countries  and 
comparing low cost technologies with expensive ones. Key elements should be investigated, 
for  example,  in  the  field  of  chronic  heart  failure,  more  large-scale  trials  are  required  to 
identify six key elements relating to telephone support and telemonitoring: the best healthcare 
practices including the optimal frequency of follow up; the patients who benefit; the levels of 
staffing  required;  patients'  views  on  the  user  friendliness  of  technologies;  evidence  on 
efficiency  and  organizational  models57.  At  this  point,  the  recent  publication  of  the  Whole 
System Demonstrator58 shows very good outcomes. These data could play a key role in  the 
future HTA and decision making process.59   

57 

Garcia Lizana F. Telemonitoring for chronic heart failure: not ready for prime time. Cochrane Database 
Syst Rev. 2010 Aug 9;8:ED000009 

58            Steventon A et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole 

59  

System Demonstrator cluster randomised trial. BMJ. 2012 Jun 21;344:e3874. doi: 10.1136/bmj.e3874 
Ongoing large scale pilot 'RenewingHealth', is pooling together the expertise of European experts and 
the know-how of local and regional healthcare providers who deliver telehealth services. This project is 
one  of  the  largest  multicentric  clinical  trial-type  exercise across  Europe in  the field of telemonitoring 
and telecare services that will fundamentally enhance the body of evidence on the effectiveness of such 
services. It involves nine countries, and is expected to cover eventually about 8,000 patients. 

EN 

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Findings illustrate the potential benefits that can result from ICT implementation according to 
four broad, inter-related categories of objectives61: increasing quality of care and efficiency; 
reducing  operating  costs  of  clinical  services;  reducing  administrative  costs;  and  enabling 
entirely new modes of care. 

The socio-economic gains are analysed in the study EHR IMPACT (01-2008/02-2009)60 to 
support ongoing initiatives and implementation work by the European Commission, Member 
State governments, private investors, and other actors. The study aims to improve awareness 
of the benefits and provide new empirical evidence on the socio-economic impact and lessons 
learnt from successfully implemented systems. 

The study shows that the average cumulative socio-economic returns (SER), but not financial 
return, is 78% over the evaluation timescales of between 9 and 13 years. This confirms that 
investments  in  interoperable  EHR  and  ePrescribing  systems,  if  pursued  with  the  necessary 
rigour,  are  worthwhile.  Once  the  value  of  benefits  begins  to  cover  costs,  the  net  benefit 
expands  and  becomes  substantial.  Annual  net  benefit  in  2010  reaches  between  €1.2  million 
for the smaller-scale sites and over €170 million fo r Diraya, which serves more than 8 million 
people.  The  annual  SER  increases  considerably  towards  the  end  of  the  time  scale.  The 
positive SER justifies the wider deployment of interoperable EHR and ePrescribing systems.  

The  EHR  IMPACT  study  shows  interoperability  is  a  prime  driver  of  benefits.  It  makes  life 
easier for different users and provides gains that rely on access to information regardless of 
place  and  time,  and  from  re-using  information  for  multiple  purposes.  Without  meaningful 
sharing and exchange of information, the gains would be marginal and not justify the cost of 
investments. 

Most of studies responded to three types of interventions: chronic conditions management (27 
papers), metal/psychiatric health (12 papers), and health promotion and prevention (8 papers). 
Eleven  documents  focused  on  different  interventions  or  aspects  like  teledermatology,  tele-
intensive care, telestroke, etc . 

(1) eHealth for improving chronic disease management: these interventions included tele-
homecare,  telemonitoring  in  general  or  for  specific  diseases  like  chronic  health  failure, 
respiratory diseases, diabetes etc.  

Most  of  the  papers  showed  some  benefit,  mostly  associated  to  reduction  in  hospital 
readmission.  However,  the  data  are  heterogeneous.  Successful  adoption  and  use  generally 
depended  on  the  simultaneous  implementation  of  new  service  delivery  models,  integrated 
models and organisational partnerships61.  

In an extrapolation exercise62, JRC-IPTS modelled the care institutions' eHealth adoption and 
expenditure  of  eHealth  by  care  institutions  focusing  ion  three  main  chronic  conditions 

60  

61 

62  

Economic Impact of Interoperable Electronic Health Records and ePrescription in Europe (01-2008/02-
2009): 
http://ec.europa.eu/information_society/activities/health/docs/publications/201002ehrimpact_study-
final.pdf 
Garcia Lizana F, Yanes Lopez V. Information and communications technologies in CHF management 
programmes. Organizational challenges and evidence status. Agencia de Evaluacion de Tecnologias 
Sanitarias (AETS)Madrid 2009 
http://www.isciii.es/htdocs/publicaciones/documentos/56_Tecnol_Inform_Comunic_en_ICC.pdf 
JRC  IPTS  Strategic  Intelligence  Monitor  on  Personal  Health  Systems  Phase  2  Impact  Assessment 
Report. http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS2.html 

EN 

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(Chronic  Heart  Failure,  COPD  and  Diabetes)  and  Telecare.  Moreover,  the  Commonhealth 
project63 has published outcomes on cost-effectiveness in several locations and guidelines for 
integrated eCare services provision based on the evidence they collected.  

The Internet can be part of an effective method to increase empowerment of patients who are 
e.g. suffering from diabetes, depression, infertility or arthritis. Because of the low quality of 
evidence  we  found,  the  results  should  be  interpreted  with  caution.  The  clinical  relevance  of 
the  findings  can  be  questioned  because  the  significant  effects  we  found  were,  in  general, 
small64.  However,  the  outcome  empowerment  usually  refers  to  achieving  self-efficacy, 
autonomy  and  control.  Although  many  researchers  underline  that  these  tools  are  closely 
related to the concept of empowerment, it is still unclear how empowerment is defined, how it 
should  be  measured  and  what  is  the  level  of  its  impact  on  health  outcomes.  These  gaps 
indicate the need for more unambiguous research outcomes that lead to better insight into the 
conditions  under  which  Web-based  interventions  are  effective  and  how  their  effectiveness 
could be maximized.  

Krishna  et  al.  65  conducted  a  review  of  25  papers;  and  concluded  that  standard  care  with 
reminders, disease monitoring and management, and education through cell phone voice and 
short  message  can  help  improve  health  outcome  and  care  processes.  However,  due  to  the 
possibility  of  bias  and  errors  in  the  review  process  and  the  unknown  quality  of  studies 
including these conclusions may not be reliable. 

(2) eHealth for mental health: Most of the studies in this area reported the same benefits as 
face to face consultation. Several authors supported the use of tele-psychiatry when traditional 
care is not possible (for instance waiting lists, shortage of professionals in rural areas, etc)66,67. 
However,  more  research  is  needed  to  identify  those  patients  who  benefit  and  to  conduct 
analysis of cost-effectiveness.   

Behavioural  therapy  through  the  Internet,  computer,  and  telephone  applications,  even  in 
substance  abuse  and  addiction  (alcohol  and  smoking  addictions)  are  at  least  as  effective  as 
conventional services68, especially when personalised and interactive settings are utilised.  

(3)  eHealth  impact  on  health  promotion  and  primary  prevention:  these  interventions 
included  health  promotion  on  healthy  behaviour  (physical  and  dietary  behaviour,  smoking, 
obesity, alcohol consumption). These findings demonstrate that online interventions have the 
capacity to  influence voluntary behaviours which are routinely targeted by social marketing 
campaigns. Given the high reach and low cost of online technologies, it may a good tool for 

63  

64 

65 

66 

67 

68 

CommonWell  is  a  project  co-funded  by  the  EC's  ICT  Policy  Support  Programme  at  four  sites  in 
Europe: UK, DE, NL and ES. http://commonwell.eu/norm/commonwell-home/.  
David Samoocha,David J Bruinvels, Nieke A Elbers,et al. Effectiveness of Web-based Interventions on 
Patient  Empowerment:  A  Systematic  Review  and  Meta-analysis.  J  Med  Internet  Res.  2010  Apr-Jun; 
12(2): e23. 
Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemedicine and e-
Health 2009; 15(3): 231-240 
Garcia-Lizana F, Munoz-Mayorga I. Telemedicine for depression: a systematic review. Perspectives in 
Psychiatric Care, 2010; 46(2):119-126 
Sloan DM, Gallagher MW, Feinstein BA, Lee DJ, Pruneau GM. Efficacy of telehealth treatments for 
posttraumatic  stress-related  symptoms:  a  meta-analysis.  Cognitive  Behaviour  Therapy  2011;  40(2): 
111-125 
Ohinmaa A, Chatterley P, Nguyen T, Jacobs P. Telehealth in substance abuse and addiction: review of 
the  literature  on  smoking,  alcohol,  drug  abuse  and  gambling.  HTA  report  2010.  Institute  of  Health 
Economics 
http://www.ihe.ca/documents/Telehealth%20in%20Addiction-
Final%202%20Arto.pdf 

Edmonton 

(IHE). 

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increased  public  health  campaigns  that  blend  interpersonal  online  systems  with  mass-media 
outreach.  Such  a  combination  of  approaches  could  help  individuals  achieve  personal  goals 
that, at an individual level, help citizens improve the quality of their lives and at a state level, 
contribute to healthier societies. 

Also,  Cugelman  B  et  al69  found  that  online  interventions  have  the  capacity  to  influence 
voluntary behaviours. On the other hand, Car et al 70 showed that due to the small number of 
studies  and  their  variable  methodological  quality,  the  evidence  is  too  weak  to  draw  any 
conclusions about implications for the design and delivery of interventions for online health 
literacy. There is a need for well-designed randomised control trials to investigate the effects 
of  such  interventions.  These  should  involve  different  participants  (in  terms  of  health  status, 
age, socio-economic group and gender) to analyse the extent to which online health literacy 
reduces  a  barrier  to  using  the  internet  for  health  information.  Trials  should  be  conducted  in 
different settings and should examine interventions to enhance citizens' online health literacy 
(search,  appraisal  and  use  of  online  health  information)  like  IT  training  courses,  measuring 
outcomes  up  to  at  least  one  year  after  the  intervention  to  estimate  the  sustainability  of  the 
intervention effects. 

7. 

VISION AND OBJECTIVES OF THE EHEALTH ACTION PLAN 2012 - 2020 

The proposed eHealth Action Plan will run from 2012 until 2020, mirroring the timeline of 
Europe 2020, the Digital Agenda for Europe and Innovation Union. 

The vision of this Action Plan is to utilise and develop eHealth to address several of the most 
pressing challenges of the first half of the 21st century: 

– 

– 

– 

– 

to  improve  chronic  disease  and  multimorbidity  (multiple  concurrent  disease) 
management and to strengthen effective prevention and health promotion practices;  

to increase sustainability and efficiency of health systems by unlocking innovation, 
enhance  patient/citizen-centric  care  and  citizen  empowerment;  and  encourage 
organisational changes; 

to foster cross-border healthcare, health security, solidarity and universality;  

to  improve  legal  and  market  conditions  for  developing  eHealth  products  and 
services.  

7.1. 

General objectives 

The  overall  policy  goal  of  this  Action  Plan  is  to  address  the  challenges  outlined  above, 
breaking down persistent barriers and realising the vision of the Europe 2020 Strategy in the 
area of eHealth.  

69 

70 

Cugelman B, Thelwall M, Dawes P Online interventions for social marketing health behavior change 
campaigns: a meta-analysis of psychological architectures and adherence factors. 
J Med Internet Res. 2011 Feb 14;13(1):e17. 
Car  J,  Lang  B,  Colledge  A,  Ung  C,  Majeed  A.  Interventions  for  enhancing  consumers'  online  health 
literacy. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD007092 

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7.2. 

Specific objectives 

(5) 

Improve the quality of life of European citizens 

(6)  Provide equal access to high quality and sustainable health care systems to all 

European citizens 

(7)  Enhance the competitiveness of EU industry through business and expansion of 

new markets. 

7.3. 

Operational objectives 

The Action Plan addresses following operational objectives:  

– 

– 

– 

– 

achieving wider interoperability of eHealth services; 

supporting  research,  development  and  innovation  in  eHealth  and  wellbeing  to 
address the availability of user-friendly tools and services; 

facilitating  uptake and ensuring  wider deployment; 

promoting international cooperation.  

The Action Plan emphasises cross-border activities but it should be noted that work done at 
the EU level has a strong effect at a national level and vice versa. Therefore, the Action Plan 
encourages  national  and  regional  authorities,  healthcare  and  social  care  professionals, 
industry,  patients,  service  providers,  researchers  and  the  EU  Institutions  to  work  together 
towards achieving the objectives listed above.  

It should be noted that all operational objectives are closely linked and mutually reinforcing. 

8. 

ADDED VALUE OF AND JUSTIFICATION FOR ACTING AT THE EU LEVEL 

Responsibility to define the way to organise and deliver health services and medical care lies 
within  the  Member  States.  In  several  other  areas  supporting  action  from  the  Commission 
would be possible, notably under Articles 168, 173, 179 or 114 TFUE.   

Taking action at EU level is particularly important given the Commission's role of coordinating 
Member States' actions and encouraging cooperation between them. Moreover, issues related 
to  cross-border  aspects  of  health  (for  example,  legal  uncertainty  in  particular  in  the  area  of 
recognition of qualifications and liability), identification of common barriers, coordination on 
common standards and aspects related to the internal market of eHealth applications, as well as 
the provision of evidence and methodology to assess the effectiveness of eHealth applications, 
are best addressed at EU level. 

Despite their primary competence in the field, Member States require and value the strategic 
and technical guidance of the Commission in this area71. The EPSCO Council has explicitly 
requested the Commission to provide such guidance by updating the existing eHealth Action 

71 

The majority of Member States agree that eHealth would provide a useful tool to meet the challenges 
faced by European healthcare systems.  

EN 

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Plan.  In  the  Council  Conclusions  of  1st  December  2009  on  safe  and  efficient  healthcare 
through  eHealth72,  Member  States  demonstrated  their  intention  "to  bring  forward  eHealth 
deployment  and  actual  use  of  Interoperable  eHealth  services  within  and  between  national 
healthcare systems".  

Member  States  also  called  upon  the  Commission  to  reflect  on  the  progress  made  so  far,  to 
ensure  more  coherence  between  health  policy  developments  and  eHealth  deployment  and 
identify  and  address  in  a  coordinated  manner  barriers  hampering  the  deployment  of  eHealth 
services  which  are  preventing  patients,  healthcare  systems  and  society  as  a  whole  from  fully 
benefitting from ICT. This shows that Member States welcome the contribution and the added 
value  the  Commission  brings  in  supporting  the  common  goals  of  ensuring  high  quality, 
efficient  healthcare  systems  also  through  the  use  of  ICT  solutions.  In  consistency  and 
complementarity  of  EU  level  actions,  Member  States  are  encouraged  to  develop  national 
eHealth  Strategies  according  to  international  recommendations73.  These  national  strategies 
should integrate the European Innovation Partnership on Active and Healthy Ageing objectives 
and targets 

This action plan responds to the call for support made by Member States in full respect of the 
principle of subsidiarity. The Action Plan also reinforces the common principles for healthcare 
in the European Union: universality, access to good quality care, equity and solidarity74. 

The  actions  focus  on  European  added  value  by  means  of  pan-European  policy  actions, 
transformative  research  and  innovation,  and  interoperability  and  deployment  in  order  to 
facilitate a common eHealth and Well Being  innovation space, in which citizens' rights are 
protected,  their  mobility  across  the  European  Union  is  facilitated  and    equity  and  social 
cohesion for all is promoted. 

The  European  Commission  can  provide  the  platform  not  only  for  sharing  best  practices, 
experts and lessons learned from number of pilots supported by national and EU programmes, 
but also can provide guidance on technical and legal framework developments to ensure cross 
border interoperability and legal certainty. The Commission's role in the area of building trust 
and  improved  user  acceptance  would  also  be  important.  A  European-wide  policy  initiative 
would as well support convergence for common solutions, avoid further market fragmentation 
and  prevent  Member  States  adopting  different  individual,  organisational  and  technical 
directions  and  missing  the  opportunity  to  build  a  common  basis  for  interoperable  eHealth 
applications. 

In  this  context,  the  policy  approach  in  the  Action  Plan  primarily  focuses  on  cooperation 
through  involvement  in  pilot  projects,  the  new  eHealth  Network  of  Member  States75,  the 
fruitful  exchange  between  health  ministries  of  the  Member  States  and  stakeholders,  the 
sharing of best practice, the use of the open method of coordination and the realisation of the 
Internal Market. 

http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/111613.pdf 

72 
73          National  eHealth  strategy  toolkit.  World  Health  Organization  and  International  Telecommunication 
Union 2012. http://www.itu.int/dms_pub/itu-d/opb/str/D-STR-E_HEALTH.05-2012-PDF-E.pdf 
Council Conclusions on Common values and principles in European Union Health Systems. 
The Network was established under Article 14 of .Directive 2011/24/EU on the application of patients' 
rights in cross-border healthcare, 
http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF, OJ L 88, 
4.4.2011, 

74  
75 

EN 

26 

   EN 

 
                                                 
9. 

NEXT STEPS FOLLOWING THE COMMUNICATION 

As  set  out  in  the  Action  Plan,  a  number  of  actions  will  be  implemented  at  the  EU  level  in 
2012 - 2020.  

9.1. 

Review by the Commission of progress made 

The Commission will closely monitor  the implementation of this  Action Plan and report on 
progress made and results achieved.  

EN 

27 

   EN 

 
10. 

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and meta-analysis  Archives of Internal Medicine 2011; 171(6): 498-506 

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ANNEX: Governance chart for interoperability 

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