Strategic Intelligence Monitor on Personal Health Systems Phase 3 (SIMPHS3) : operational guidelines for ICT-supported integrated care and independent living.
Date: 2015-09-30
Institutions: Institute for Prospective Technological Studies
Subjects: data collection, health care, health care system, health policy, information technology, new technology, organisation of health care, public health, research report

Strategic Intelligence Monitor on 
Personal Health Systems Phase 3 
(SIMPHS3) 

Operational Guidelines for 
ICT-supported Integrated Care 
and Independent Living  

Wilco Graafmans, Ramon Sabes-Figuera, 
Fabienne Abadie   

2 0 1 5  

Report EUR 27282 EN 

 
 
 
 
 
 
European Commission 
Joint Research Centre 
Institute for Prospective Technological Studies  

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All images © European Union 2015 

JRC96145 

EUR 27282 EN 

ISBN 978-92-79-48506-0 (PDF) 

ISSN 1831-9424 (online) 

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© European Union, 2015 

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Abstract 
The guidelines in this report have been developed as part of the Strategic Intelligence Monitor on Personal Health Systems 
Phase  3  (SIMPHS3)  project.  Twenty-four  ICT-supported  integrated  care  initiatives  in  the  EU  were  identified  which 
supported integrated care and/or independent living and were either deployed or promising large scale pilots. 
The aim of this report is to define a set of recommendations to guide the process of developing and implementing ICT-
supported integrated care and independent living, based on the experiences made in these 24 initiatives. 
The  intended  audience  for  this  guidance  document  are  those  who  work  on  the  development  and  implementation  of 
initiatives  at  an  operational  level,  such  as  professionals,  managers  in  healthcare  organisations,  regional  managers  of 
health or social care, health insurers, professionals’ organisations, etc. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acknowledgements 

We are indebted to the following experts who participated in the SIMPHS3 workshop of 17 March 
2015. They were invited to discuss a draft list of recommendations and share their experiences with 
the  implementation  of  ICT-enabled  integrated  care  or  independent  living  solutions.  Their  insights 
have been instrumental for the completion of this report:  

-  Cristina Bescos, Philips Hospital To Home/Telehealth (Spain) 

- 

John Crawford, IBM European Healthcare Solutions (United Kingdom) 

-  Marco d'Angelantonio, HiMsa (Belgium) 

- 

Toni Dedeu, Digital Health Institute (United Kingdom) 

-  Helmut Hildebrandt Gesundes Kinzigtal GmbH  / OptiMedis AG (Germany) 

- 

Thomas Meyer, Charité Hospital (Germany) 

-  Angelique Noordeloos, Zuydermarkt (Netherlands) 

-  Cecilia Pérez, Plexus (Spain) 

-  Modesto Sierra Callau, Sector Sanitario de Barbastro- Salud (Spain) 

-  Daniel Smedberg, Kommunförbundet Skåne (Sweden). 

1 

 
 
 
 
 
Table of contents 

PREFACE ............................................................................................................................................................... 3 

EXECUTIVE SUMMARY ..................................................................................................................................... 4 

1 

INTRODUCTION ........................................................................................................................................... 7 
BACKGROUND ........................................................................................................................................................................ 7 
OBJECTIVE OF THE GUIDELINES ........................................................................................................................................ 7 
STRUCTURE OF THIS REPORT .............................................................................................................................................. 9 

1.1 
1.2 
1.3 

2  METHODS ...................................................................................................................................................... 9 
OVERVIEW OF CASES IN SIMPHS3 ................................................................................................................................. 9 
ANALYSIS OF CASES .......................................................................................................................................................... 10 
EXPERT OPINION ................................................................................................................................................................ 12 

2.1 
2.2 
2.3 

3.3 

3.1 
3.2 

3  GUIDELINES .............................................................................................................................................. 13 
POLITICAL AND POLICY SETTING .................................................................................................................................... 13 
PREPARATION ...................................................................................................................................................................... 15 
3.2.1  Aims and objectives ............................................................................................................................................. 15 
3.2.2  Stakeholders ............................................................................................................................................................. 17 
CHARACTERISTICS OF THE ICT-SUPPORTED INTEGRATED CARE SOLUTION .......................................................... 18 
3.3.1  Functional characteristics ................................................................................................................................. 18 
3.3.2  Technical characteristics.................................................................................................................................... 20 
3.3.3  Resources ................................................................................................................................................................... 21 
ENABLING IMPLEMENTATION .......................................................................................................................................... 23 
3.4.1  At the level of the organisation ..................................................................................................................... 23 
3.4.2  Culture of readiness for ICT-supported integrated care .................................................................. 25 
3.4.3  Coordination between organisations .......................................................................................................... 26 
3.4.4  Professionals ............................................................................................................................................................ 28 
3.4.5  Acceptance by patients and other users .................................................................................................. 29 

3.4 

4  CONCLUSIONS ......................................................................................................................................... 32 

REFERENCES .................................................................................................................................................... 34 

DEFINITIONS .................................................................................................................................................... 36 

2 

 
 
 
 
 
 
Preface 

E-health is considered one of the key solutions that can help solve many of the challenges 
EU member states are faced with: an ageing population; a growing number of chronically ill 
people;  concerns  about  the  sustainability  of  healthcare  systems;  changing  patterns  in 
healthcare  delivery  to  promote  independently  living;  a  growing  availability  of  technical 
solutions; and shortages in  the healthcare workforce. In light of these societal challenges, 
there is a need to look  at the bigger picture and take a long-term perspective in order to 
promote  radical  changes  in  healthcare  and  social  care.  The  time  is  ripe  for  wider 
implementation  of  eHealth,  both  from  a  demand  perspective  (healthcare  systems)  and 
from a supply perspective (technology availability). There is a growing awareness about the 
need to move away from hospital care to care outside of institutions, and the importance 
of taking action before events happen rather than reacting, which is where ICT-supported 
integrated care comes into the picture. Exchange of information is a central element in this 
process. Solutions like remote patient monitoring, telehealth, telecare and electronic health 
records are all enablers for moving care outside healthcare facilities. This process not only 
affects healthcare, but also social care and therefore the overall organisation of care.  

The  guidelines  presented  in  this  report  focus  on  ICT-supported  integrated  care  and 
independent  living.  The  aim  is  to  contribute  to  the  development  of  ICT-supported  care 
delivery  currently underway in  European regions. This document  is based on  actual cases 
where innovative ICT-supported care practices have been implemented and scaled-up and 
allows us to learn about different strategies adopted to address this complex challenge. 

Like with any innovation project, being aware of the best available technology solutions or 
knowing  about  the  optimal  scenario  is  not  sufficient  to  introduce  the  required  changes. 
Modifying routine processes in healthcare is difficult because healthcare is a sensitive area. 
Health  professionals  cannot  afford  to  take  any  risks  when  trying  new  systems  for 
diagnoses and treatment as the life of their patients is at stake. Furthermore, healthcare is 
highly  personal  and  the  interaction  between  practitioners  and  patients  impacts  health 
outcomes. In ICT-supported care delivery, sensitive patient information is exchanged which 
requires that the highest security standards are complied with. In addition, the structure of 
healthcare  organisations  is  often  very  complex.  Hospital  staff,  for  instance,  cover  a  wide 
array of disciplines and often different processes and information systems have been put 
in place over time which makes integration difficult. 

The  complexity  that  characterises  health  and  social  care  delivery  may  be  one  of  the 
reasons  why  communication  technologies  have  been  taken  up  at  a  slower  pace  than 
expected  in  the  care  sector.  The  most  difficult  challenges  are  not  the  technological 
possibilities per se but their implementation and adoption into existing routine practices.   

The  saying  that  "The  proof  of  the  pudding  is  in  the  eating"  applies  well  to  the 
implementation of ICT-supported integrated care. All the ingredients may be there, but ICT-
supported integrated care will only succeed if it leads to better care delivery.   

3 

 
 
 
 
 
 
Executive Summary 

Background 

The recommendations presented in this report have been developed as part of the Strategic 
Intelligence Monitor on Personal Health Systems (SIMPHS) project, a multiannual research 
project undertaken by the Joint Research Centre (JRC, IPTS) in cooperation with DG CNECT, 
European  Commission.  The  aim  of  the  SIMPHS  project  is  to  foster  the  development, 
adoption  and  implementation  of  ICT-for-health  solutions  and  to  address  several  of  the 
most pressing challenges health and health systems are faced with today, such as chronic 
disease  management,  improving  the  sustainability  and  efficiency  of  health  systems  by 
unlocking innovation, enhancing patient/citizen-centric care and citizen empowerment. This 
report is part of the third and last phase of the project (SIMPHS3) which focusses on the 
analysis of best operational practices of integrated care and independent living services in 
European countries and regions. 

Aim 

The  aim  of  this  report  is  to  define  a  set  of  recommendations  to  guide  the  process  of 
developing and implementing ICT-supported integrated care and independent living, based 
on the experiences of a number of initiatives across the EU.  

The  intended  audience  for  this  guidance  document  consists  of  those  who  work  on  the 
development  and  implementation  of  initiatives  at  an  operational  level,  such  as  care 
professionals, managers in healthcare organisations, regional managers of health or social 
care, health insurers, professionals’ organisations, etc. 

Methods 

We  identified  twenty-four  ICT-supported  integrated  care  initiatives  in  the  EU  which 
supported  integrated  care  and/or  independent  living  and  were  either  already  deployed  or 
were large scale pilots. A qualitative analysis of the cases was carried out on two levels: in-
depth  within-case  and  across-cases  analysis.  The  analysis  followed  a  framework  which 
comprises a number of relevant dimensions for ICT-supported integrated care identified in 
the  scientific  literature.  The  dimensions  used  in  the  cross-case  analysis  include:  1) 
governance and policy; 2) care organisation and integration through ICT; 3) business models, 
funding  and  incentives;  4)  deployment  level  and  impact.  Based  on  the  24  SIMPHS3  case 
reports and the cross-case analysis, key elements for success and barriers were identified 
for the development of these guidelines. Recurring observations in the cases were used to 
formulate recommendations. The recommendations are therefore based on the experiences 
reported  in  the  analysed  cases  and  do  not  intend  to  give  a  complete  overview  of  all  the 
possible elements that ICT-supported integrated care implementation may entail.     

Recommendations 

The  following  recommendations  were  formulated  on  the  basis  of  the  above  analysis  and 
grouped in 4 main categories:  

Policy and political setting 

1.  Explore the regional/national political and policy context to identify potential 
blockers and enablers; develop a solution around the enablers, and define 
workarounds to resolve blocking elements. This includes mapping of existing 
resources in relation to the implementation context, Internet access, legislations etc. 

4 

 
 
Preparation 

Aims and objectives: 

2.  Especially in large projects/ programmes and in those with a long-term perspective, 
monitor the objectives and activities regularly, linking the different work packages to 
ensure that the ultimate objective can be achieved. If necessary, reconsider and 
fine-tune the objectives with key stakeholders.   

3.  Define and distinguish clearly between project/programme objectives related to the 
short-term (in a temporary setting) and longer-term objectives for mainstreaming 
(in a permanent setting).   

Stakeholders: 

4.  At the start and during the initiative, carry out a systematic inventory of 

stakeholders, including those who affect the initiative and those affected by it, in 
order to adapt the strategy to their particular circumstances.  

Characteristics of the ICT-supported integrated care solution 

Functional characteristics:    

5.  Make sure the eHealth solution in question is a good answer to a clear user need, 

focusing on care professionals and/or patients/citizens or other key stakeholders. In 
addition, design and plan awareness actions to make sure targeted users are 
engaged and know about the benefits of the new system. 

Technical characteristics:   

6.  Ensure that the eHealth solution is as user-friendly as possible and evaluate it in a 

practical setting with the users, e.g. Living Lab or pilot study. 

Resources: 

7.  Develop a sound business model which demonstrates the higher value of ICT-

supported integrated care over standard care. Alternatively or in addition, identify 
available funding schemes at the start of the initiative, for both short- and long-
term funding for mainstreaming.         

8.  Given the innovative nature of eHealth technology, explore suitable strategies for 
procurement and adapt procurement processes to allow for the development of 
technology-based solutions that answer the needs of care delivery optimally. 

Enabling implementation  

At the level of the organisation: 

9.  Starting an innovative eHealth strategy is costly: develop a business model/value 
proposition with those who make the financial investment and benefit from the 
outcomes, taking into account the financial and human resources requirements and 
the incentives needed to promote the use of the eHealth solution.  

10. Plan and organise training within the organisation affected by the new technology 

so as to allow for adjustment to new roles and processes. 

Culture of ICT-supported integrated care readiness: 

11. Initiate cultural change in organisations to promote the adoption of innovation and 
to stimulate communication, co-creation and cooperation between organisations. 

5 

 
 
 
 
Coordination between organisations: 

12. Check whether the policies of relevant stakeholder organisations are conducive to 
the uptake of the planned eHealth solution and devise strategies to address 
potential hindrances to implementation. 

13. Build on existing coordination and cooperation networks between stakeholder 

organisations as a starting point. 

Professionals: 

14. Involve professionals from the various sectors in the development and 

implementation strategy of the eHealth solution from the start. 

15. Appoint champions to advocate the initiative, monitor change management and 
define new roles for care professionals whenever required, to implement change 
and coordinate new care processes. 

Acceptance by patients and other users: 

16. Involve target users from the start in the development of the eHealth tools and the 
implementation strategy to answer their specific needs and adapt the solution to 
their capacities. 

17. Offer training and support to patients/citizens and other users so they can acquire 

the necessary ICT skills and quickly solve problems.  

6 

 
1 

Introduction 

1.1  Background 

The  guidelines  presented  in  this  report  have  been  developed  as  part  of  the  Strategic 
Intelligence Monitor on Personal Health Systems (SIMPHS), a multiannual research project 
undertaken by JRC IPTS in cooperation with DG CNECT. The aim of the SIMPHS project is to 
foster the development, adoption and implementation of eHealth and to address several of 
the  most  pressing  challenges  health  and  health  systems  are  faced  with  today,  such  as 
chronic disease management, improving the sustainability and efficiency of health systems 
by  unlocking 
innovation,  and  enhancing  patient/citizen-centric  care  and  citizen 
empowerment. SIMPHS started in 2009 with the analysis of the market for Remote Patient 
Monitoring and Treatment (RMT) within Personal Health Systems (PHS) from a supply-side 
perspective.  This  approach  was  complemented  in  a  second  phase  (2010-2012)  with  the 
analysis  of  the  demand  side,  focusing  on  eHealth  needs  of  healthcare  professionals, 
patients,  and  other  users  of  eHealth  solutions1.  This  report  is  part  of  the  third  and  last 
phase  of  the  project  (SIMPHS3),  which  focusses  on  the  analysis  of  best  operational 
practices  of  integrated  care  and  independent  living  services  in  European  countries  and 
regions. 

The  SIMPHS  research  aims  to  support  policy  initiatives  in  the  EU,  such  as  the  European 
Commission's Lead Market Initiative (LMI),  the eHealth Action Plan, the Digital Agenda for 
Europe (DAE) and more recently the European Innovation Partnership on Active and Healthy 
Ageing (EIP on AHA). There is a close link between the EIP on AHA and the analysis reported 
in  this  document  on  guidelines.  The  EIP  on  AHA  promotes,  inter  alia,  the  development  of 
ICT-supported integrated care in one of its Action Groups (B3), by collecting and analysing 
good practices. Some of the case studies included in the analysis of SIMPHS3 are also part 
of the EIP on AHA. 

In  SIMPHS3,  the  ultimate  objective  has  been  to  investigate  the  implementation  of  ICT-
supported integrated care and independent living in the EU to support further scaling up in 
Europe. The recommendations presented in this report identify a set of factors which lead 
to best operational practice, for use by those who pursue the deployment of ICT-supported 
integrated care and/or independent living. The guidelines are based on the analysis of 24 
successful or promising initiatives whose aim was to develop and implement ICT-supported 
integrated care and independent living. The overall approach for the SIMPHS3 research and 
the analysis of the 24 case studies has been presented in a separate report2, which is why 
it is only addressed briefly in the methods section of this report.  

1.2  Objective of the guidelines 

The  lessons  from  the  SIMPHS3  case  studies  have  been  the  starting  point  for  these 
guidelines  whose  aim  is  to  raise  awareness  of  key  elements  that  should  be  taken  into 
consideration  when  implementing  ICT-supported  integrated  care  and  independent  living 
solutions. Indeed, health and social care delivery is a very complex domain which requires 
the interplay of a number of actors and organisations  in order to deliver care in the most 
efficient  way  and  satisfy  individual  needs  in  the  best  way  possible.  Care  organisations 
themselves can be difficult to manage because of the variety of disciplines they cover and 

1   http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS3.html    
2   See http://publications.jrc.ec.europa.eu/repository/bitstream/JRC92703/jrc92703.pdf and  

http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS3.html  

7 

 
                                              
treatments they need to deliver. It would therefore be unrealistic to think that a simple tool 
could provide a recipe for the implementation of ICT-supported integrated care solutions in 
health and social care.  

These  guidelines  are  therefore  an  attempt  to  provide  possible  directions  for  the 
implementation of potential solutions, based on state-of-the-art experience from the field 
of  ICT-supported  integrated  care  and  independent  living,  as  analysed  in  the  SIMPHS3 
research. A number of guidance documents and toolkits3 for the implementation of eHealth 
have been produced in recent years and this report may therefore address topics already 
raised in other documents. Nevertheless, this document aims to provide recommendations 
on the barriers that require most urgent action and the facilitators which have played a key 
role in most recent, successful ICT-supported integrated care implementation initiatives. It 
does not  attempt  to give a complete overview  of all  the  issues involved in  ICT-supported 
integrated care as the projects analysed are too different and the related implementation 
constraints too many to allow us to do so. However, based on the case studies developed in 
SIMPHS3, we highlight the most important teething issues. The guidelines do not include all 
relevant aspects of the development and implementation of ICT-supported integrated care 
but highlight those topics that emerge most strongly from the experiences reported in the 
cases. They  should therefore be  regarded as additional guidance to prioritising key points 
for success.    

The intended audience for this guidance document are those who work on the development 
and  implementation  of  initiatives  at  an  operational  level,  such  as  care  professionals, 
managers  in  healthcare  organisations,  regional  managers  of  health  and/or  social  care, 
health insurers, professionals’ organisations, etc. The recommendations are not intended to 
provide  guidance  to  policy  makers  and  politicians.  This  follows  from  the  fact  that  the 
analysis of the initiatives is  mostly based on data gathered through interviews of experts 
directly  involved  in  implementing  ICT-supported  integrated  care  initiatives.  Thus,  these 
guidelines should be of interest to anyone involved in the planning and implementation of 
eHealth solutions in the context of integrated care and independent living. Given the variety 
of ICT-supported integrated care solutions and settings considered in  the analysis, not all 
recommendations  included  in  the  guidelines  will  apply  to  the  same  extent  to  a  specific 
initiative. 

These guidelines should also be seen in the context of the EIP on AHA as further support to 
the scaling-up efforts initiated by the EC through the EIP on AHA4. Indeed, several working 
groups in the EIP on AHA, more specifically Action Group B3 and C2, are analysing existing 
experience to support scaling up. At Partnership level, a twinning initiative was launched in 
2014 and several regions have now concluded joint agreements. The research in SIMPHS3 
and  more  specifically  the  guidelines  presented  in  this  document  seek  to  provide  further 
insights into what special effort and attention is needed when implementing innovative ICT-
supported integrated care solutions.   

3   http://www.local.gov.uk/health/-/journal_content/56/10180/4060433/ARTICLE ; 

http://www.integralhealthsolutions.co.uk/wp-content/uploads/integral-health-solutions-a-toolkit-for-care-
coordination-281013-version-2.pdf ;  

4   http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/scaling_up_strategy.pdf  

8 

 
 
                                              
1.3  Structure of this report  

Following this introduction, Section 2 discusses the methods used for the case analysis and 
the  development  of  these  guidelines.  Section  3  comprises  the  guidelines  in  four  main 
categories  of  recommendations.  The  recommendations  are  presented  along  with  some 
observations made in the various initiatives. The recommendations are often based on the 
analysis  of  several  initiatives,  although  only  a  few  may  be  mentioned  as  examples  to 
illustrate the recommendation. Finally, the conclusions are presented in Section 4.   

2  Methods 

2.1  Overview of cases in SIMPHS3 

The  selection  of  cases  has  been  described  in  detail  in  the  SIMPHS3  Report  on  the 
methodological  set-up  for  the  SIMPHS3  research5.  Table  1  provides  the  list  of  24  cases 
analysed in SIMPHS3: 16 of these cases were selected following the review of EIP on AHA 
initiatives and reference sites and the remaining 8 from scientific or grey literature sources, 
or in answer to specific client requests (see above report for more details). 

Case 

Region 

Brief description 

Table 1: Case studies overview 

FIRST WAVE 

ARIA  

BLMSE  

BSA  

CARTS  

eTrikala  

ETXEAN ONDO  

GESUNDES 
KINZIGTAL  

INAA 

MACVIA-LR  

NEXES  

Emilia-Romagna 
(Italy) 
Skåne Region 
(Sweden) 

Badalona, Catalonia 
(Spain) 
Cork and Kerry 
South-West Region 
(Ireland) 
Trikala municipality, 
Thessaly Region 
(Greece)  
Basque Country 
(Spain) 

Kinzigtal region, 
Baden-Württemberg 
(Germany)  

Twente 
(Netherlands) 
Languedoc-
Roussillon (France)  

Barcelona, Catalonia 
(Spain) 

Implementation  of  integrated  home  care  services  for  COPD 
patients. 
Improving  cooperation  between  home  care,  elderly  home  care, 
primary  care  and  hospital  care  to  better  coordinate  care  of  the 
elderly 
Integrated  care  organisation  offering  health  and  social  care 
services. 

Screening,  triage,  assessment  and  treatment  to  reduce  risk  of 
frailty and adverse outcomes in community dwelling older adults 

Telehealth/telecare  services  for  chronic  patients  and  the  elderly 
and social services to all citizens. 

Integrated person-centred care model for the elderly 

Integrated care and preventive services offered to the population 
covered  by  the  health  insurances  AOK  and  LKK,  based  on  a 
shared  savings  contract  between  Gesundes  Kinzigtal  and 
AOK/LKK. 
Helping  the  elderly  to  live  independently  for  longer  periods  in 
their own environment. 
Innovative  solutions  through  living  labs  to  improve  care  for 
chronic patients 

Integrated care services for chronic patients based on structured 
interventions  addressing  prevention,  healthcare  and  social 
support. 

OULU SELF-
CARE  

Northern 
Ostrobothnia, Oulu 
(Finland) 

Cloud  services  that  can  support  integrated  care  services  and 
allow  the  elderly  to  monitor  their  own  well-being  and  manage 
their own health. 

5   http://publications.jrc.ec.europa.eu/repository/bitstream/JRC92703/jrc92703.pdf  

9 

 
 
 
                                              
PDTA  

SAM:BO  

Brescia/Lombardy  
(Italy) 

Anticipatory  care  planning  to  manage  patients  with  chronic 
diseases (e.g. Dementia, Alzheimer) 

Region South 
Denmark (Denmark)  

Encouraging  local  health  and  social  care  actors  to  launch 
integrated  health  care  initiatives  through  shared  agreement 
protocols of collaboration. 

Interoperable 
integrated care services for the whole population of the region. 

infrastructure  enabling 

the  development  of 

Local  integrated  care  initiative  which  uses  a  population  pre-
screening  model  to  measure  patients’  risk  of  emergency 
admission  in  hospitals  in  order  to  deliver  anticipatory  care 
planning. 

Funding and stimulating the implementation of telecare projects 
in  the  local  community  by  health  partnerships  throughout 
Scotland. 

Self-care  and  family  care  support  service  provided  through  ICT 
installed at patients’ homes 

Remote monitoring of diabetes patients using mHealth 

Remote monitoring services to help the elderly live independently  

SOLE/FSE  

Emilia-Romagna 
(Italy) 

SPARRA  

Scotland (United 
Kingdom) 

TDP  

Scotland (United 
Kingdom) 

SECOND WAVE 

Borås municipality, 
Western Sweden 
(Sweden) 

Breitenstein, Lower 
Austria (Austria) 

Barbastro, Aragon 
(Spain) 

ACTION 

DiabMemory 

DREAMING 

Getafe's 
Integrated 
Care 
Programme 

Madrid (Spain) 

Integrated care programme for older in- and out-patients 

MOMA/Maccabi 

Israel 

Healthcare PPI  Galicia (Spain)  

Renewing 
Health 

Carinthia (Austria) 

Care  model  based  on  a  multi-disciplinary  24/7  advanced 
technology  call  centre  for  treatment  of  various  chronic  diseases 
(including remote monitoring)  

Public  Procurement  of  Innovation  projects  and  experiences 
developed in the healthcare system of Galicia 

Pilots to integrate telemonitoring solutions with existing systems 
for diabetes type 2 and COPD patients and assess impact of the 
system 

VHA 

USA 

Integrated care model for elderly veterans and their caregivers 

2.2  Analysis of cases 

Framework for analysis 

The framework used to analyse the cases was reported in detail in the SIMPHS3 Report on 
the  methodological  set-up  for  the  SIMPHS3  research6.  The  analytical  framework  is  based 
on  the  identification  of  the  most  relevant  elements  from  the  literature  and  the  previous 
work  carried  out  in  the  SIMPHS2  research  (Lluch  &  Abadie,  2013;  Villalba  et  al.,  2013). 

6   See footnote 5. 

10 

 
 
 
 
 
                                              
Figure 1 below depicts the initial analytical framework that guided our data collection and 
analysis.  

Figure 1: Framework for analysis 

The  inner  ring  shows  the  eight  facilitators  identified  by  Villalba  et  al.  (2013)  through  the 
qualitative  analysis  of  27  Telehealth,  Telecare  and  Integrated  Care  projects  implemented 
across 20 regions in eight European countries. These projects were investigated in SIMPHS2 
and  analysed  following  the  ten  key  principles  for  successful  health  systems  integration 
identified  by  Suter  et  al.  (2009).  Eight  main  facilitators  were  identified  among  these  key 
principles as necessary for successful deployment and adoption of telehealth, telecare and 
integrated care in European regions.  

The  outer  ring  captures  the  macro  context  including  the  overall  health/social  and  policy 
system  (supply  side)  and  the  socio-demographics  and  cultural  factors  (demand  side). 
Therefore the inner ring represents the micro and meso dimensions of the analysis. These 
are  based  on  the  review  by  Suter  et  al.  (2009)  which  identified  the  principles  that  were 
frequently  and  consistently  presented  as  key  elements  for  successful  integration  in  the 
reviewed scientific literature.  

Information on the cases was obtained following the elements in the above framework by 
means of questionnaire, telephone interviews and face-to-face interviews, as described in 
the SIMPHS3 Introduction to SIMPHS3 case studies7. The reports on the cases8 provided the 
material for the guidelines as presented in this report.   

Case analysis 

We analysed the data on two levels: in-depth within-case and across-cases. By combining 
different sources, we characterised each case as a self-contained whole with respect to the 
dimensions of our framework as shown in Figure 1. This analysis is presented in individual 

7   See: http://publications.jrc.ec.europa.eu/repository/bitstream/JRC96204/jrc96204.pdf  
8   See http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS3.html 

11 

 
 
 
                                              
case study reports mainly as qualitative and narrative accounts.9 The cross-case analysis is 
reported in the SIMPHS3 Report on Models of Organisation.10  

We began the cross-case analysis by grouping the initiatives according to the 'triggers' for 
the initiative: top-down, bottom-up, technology-driven and originating  from organisational 
changes  in  healthcare  delivery.  We  then  systematically  examined  the  following  aspects 
within  these  categories:  1)  governance  and  policy;  2)  care  organisation  and  integration 
through ICT; 3) business models, funding and incentives; 4) deployment level and impact.  

Based on the reports on each case and the cross-case analysis, we identified key elements 
for  success and barriers for  inclusion in  these guidelines.  We then examined the strategy 
adopted  in  the  various  initiatives  and  what  was  reported  as  either  a  'barrier'  to  or  a 
'facilitator' for the success of the initiative. Recurring observations in the cases were used 
to  formulate  the  recommendations.  The  analysis  is  qualitative  and  draws  on  examples 
found in the case reports.     

Complementary information from the literature 

The recommendations presented in this document originate from the findings in the cases 
studied. In addition we have contrasted our observations from the cases with the scientific 
literature and other sources so as to put our recommendations into a wider context. Hence, 
where  applicable,  a  short  description  is  given  of  similar  experiences  reported  in  the 
literature.  This  does  not  represent  a  systematic  review  of  the  literature,  as  this  was  not 
feasible within the scope of the project, but the review served to clarify further the context 
of the recommendation.   

As  part  of  this  literature  review,  we  also  checked  a  number  of  guidelines  and  toolkits 
published  in  recent  years  in  the  field  of  ICT  and  integrated  care.  The  structure  of  the 
guidelines  in  Section  3  is  therefore  partly  based  on  the  review  of  recent  toolkits  and 
guidelines, such as those developed by the CommonWell project, the blueprint developed in 
the  Momentum  project,  and  the  e-HIT  toolkit  (MacFarlane  et  al  2011).  For  each  of  the 
topics  identified,  we  provide  a  short  description  of  the  findings  from  the  case  studies, 
possible background information from the literature, and a recommendation.         

2.3  Expert opinion 

The guidelines are based on the observations made about practices implemented in the EU. 
Experiences  from  real-life  situations  were  the  starting  point  for  the  formulation  of 
recommendations for the implementation of ICT-supported integrated care initiatives. This 
qualitative  approach  meant  that  we  had  to  interpret  the  context  and  outcomes  of  the 
various  initiatives.  To  validate  our  interpretation  and  enhance  the  formulation  of  the 
recommendations, an expert workshop was held 17 March 2015 to discuss the content and 
structure of the draft guidelines. Experts were invited to contribute based on their hands-on 
experience  with  implementing  ICT-supported  integrated  care  initiatives,  their  insights  on 
specific relevant initiatives and/or their wider knowledge of the field. The kind of expertise 
represented  included  ICT  technology  development  from  both  small  and  large  companies, 
change management, implementation, processes, and policies  for eHealth implementation 
amongst others.  

The  initial  recommendations  prepared  by  the  authors  were  adjusted  to  take  into  account 
the points made by experts at the above workshop.       

9   See footnote 8. 
10   JRC Report JRC96146, forthcoming.  

12 

 
                                              
3  Guidelines 

3.1  Political and policy setting 

The  political  and  policy  environment  can  contribute  to  the  success  or  failure  of  the 
implementation  of  ICT-supported  integrated  care.  Especially  when  the  implementation 
involves  structural  changes  in  healthcare  and  social  care  systems,  the  complexity  of  the 
implementation  strategy  increases  and  the  policy  setting  is  likely  to  have  an  essential 
impact. The integration of health care often means changes in healthcare and social care 
organisation  at  different  levels,  for  example  at  the  workplace  and  at  political  level. 
Differences  in  goals  and  interests  across  organisations  on  different  levels  can  frustrate 
implementation (Plochg & Klazinga 2002). Therefore, for policy makers and those involved 
in political decision making, it is useful to be aware of the essential conditions required for 
an ICT-supported integrated care solution to be implemented successfully.   

At  health  system  level,  the  financing  of  healthcare  and  social  care  may  already  be  an 
important element. Ultimately, professionals and professional organisations should be able 
to  use  eHealth  solutions  as  part  of  their  routine  activities.  The  reimbursement  of  ICT-
supported integrated care activities should therefore be an integral part of the healthcare 
system,  which  is  often  not  the  case.  In  Germany,  innovative  financing  mechanisms  have 
been set up which have encouraged  regional health providers to invest  in  eHealth and to 
provide  innovative  and  cost-saving  solutions11.  The  way  healthcare  is  financed  partly 
determines  the  strategy  for  successful  implementation.  Often  the  healthcare  system 
dictates the window of opportunity, but if possible, it is important to make the appropriate 
changes to reimbursement and funding schemes in order to stimulate the implementation 
of  ICT-supported  integrated  care.  If  the  use  of  ICT-supported  integrated  care  is  not  fully 
recognised as a practice option and the investment in time and effort by those concerned is 
not  compensated  for  financially,  adoption  is  likely  to  be  hindered.  For  instance  in  the 
Netherlands,  the  healthcare  system  allows  the  payment  of  doctors  for  eHealth  services 
under  specific  conditions.  Follow-up  consultations  by  medical  specialists  can  be  done  via 
teleconsultation  and  are  paid  for  by  the  healthcare  insurers  as  part  of their  catalogue  of 
reimbursed  services.  This  option  is  voluntary  and  only  applies  to  follow-up  consultations 
after the patient-doctor relation has been established in a first face-to-face visit.12 

Citizens'  access  to  Internet  is  another  element  that  may  be  beyond  the  control  of  the 
organisations  implementing  an  eHealth  solution.  Especially  for  telehealth  and  mHealth 
initiatives, access to Internet may be essential for the use of specific tools. However access 
differs  greatly  across  EU  countries  and  regions  (Digital  Agenda  Scoreboard  2014  – 
Broadband  markets,  2014 13 ).  Limited  access  to 
its  use  by  both 
patients/citizens and professionals has been shown to be a barrier for implementation, for 
example in the SOLE initiative in Emilia Romagna (Italy), which aims to give patients online 
access to their health information.  

Internet  and 

In some of the initiatives studied, political decisions are being taken which are expected to 
dramatically increase the chances of take-up.  Organisation strategies  or  priorities  aligned 

11   See SMPHS3 Gesundes Kinzigtal (Germany) Case Study Report 

http://publications.jrc.ec.europa.eu/repository/bitstream/JRC93763/jrc93763.pdf  

12   See: 

http://www.nza.nl/1048076/1048090/BR_CU_2108__Prestaties_en_tarieven_medisch_specialistische_zor
g.pdf  

13   http://ec.europa.eu/information_society/newsroom/cf/dae/document.cfm?doc_id=5810  

13 

 
                                              
with integrated care facilitate a successful implementation. This is for example the case in 
Scotland where the legal framework (Public Bodies (Joint Working) Act in 201414) and the 
Joint  Improvement  Team  initiative15 increased  cooperation  across  healthcare,  social  care 
and  other  organisations,  and  fostered  the  implementation  of  telecare  initiatives  such  as 
those  promoted  through  the  TPD  funding  initiative.  In  Israel,  the  creation  of  the  Gertner 
Institute is another example of how the policy environment can be a key facilitator. Israel 
established  the  Gertner  Institute  as  a  national  centre  for  inter  alia  the  innovation  and 
application  of  technology  in  healthcare.  The  above-mentioned  political  decisions  aim  to 
make  the  assessment  and  management  of  chronic  patients  cost-efficient  and  clinically 
effective. This has been an important factor for success in the Maccabi initiative. 

On the other hand, a lack of political support may limit implementation as was the case in 
the Geriatrics Unit at Hospital Universitario de Getafe (HUG) and its Community Care Unit 
(CCU). Madrid's Regional Ministry of Health has not passed any law or reform to define a 
robust  framework  that  would  promote  telemedicine  or  eHealth  services.  The  CCU  has 
proven to be successful at local level, but the lack of a suitable legal environment hinders 
the scalability and transferability of the initiative. 

An  assessment  of  the  policy  context  should  be  carried  out  to  make  sure  the  framework 
conditions  are  sufficiently  conducive  to  successful  implementation  of  ICT-supported 
integrated care solutions. Specific laws and regulations determine opportunities  and risks, 
and  should  be  taken  into  account  when  establishing  the  ICT-supported  integrated  care 
solution  and  the  optimal  implementation  strategy.    Laws  and  policies  which  are  likely  to 
create barriers for implementation should be reviewed to identify unnecessary restrictions. 
Although it may often not be possible to change laws and regulations within the scope of 
the initiative,  it is important to be  aware of the difficulties legal barriers may cause. One 
should  strive  to  identify  the  various  pieces  of  legislations  that  would  enable  or  restrict 
implementation,  and  develop  the  ICT-supported  integrated  care  solution  and  strategy 
accordingly.  One  of  the  typical  barriers  faced  by  eHealth  implementation  are  regulations 
around  data  protection  and  privacy.  For  example,  the  Oulu  Self-Care  initiative  in  Finland, 
which developed a self-care platform based on sharing of health-related information, could 
not  be  fully  deployed  as  informal  carers  who  are  key  players  in  this  approach,  were  not 
allowed by law to access patient information.   

Explore  the  regional/national  political  and  policy  context  to  identify  potential 
blockers  and  enablers;  develop  a  solution  around  the  enablers,  and  define 
workarounds  to  resolve  blocking  elements.  This  includes  mapping  of  existing 
resources  in  relation  to  the  implementation  context,  financing,  Internet  access, 
legislations etc.   

14   http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/About-the-Bill  
15   http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/Joint-Improvement-Team  

14 

 
 
 
 
                                              
Illustrative case example 

Some  initiatives  may  benefit  from  favourable  political  developments  which  are  not  within  the 
control of the initiatives, but can greatly enhance the chances of mainstreaming eHealth solutions 
for  integrated  care.  For  instance,  cooperation  between  tiers  of  care  involved  in  the  self-care 
platform  initiative  developed  in  the  Finish  city  of  Oulu  are  expected  to  improve  if  and  when  the 
Finnish Parliament finally approves regulations in 2017 to integrate social care, primary healthcare, 
secondary  care  and  specialised  care  services.  Another  example  is  found in  Scotland,  where at  the 
time  of  writing,  legislation  was  being  enacted  to  merge  health  and  social  care  organisations  in  a 
single entity, which is expected to have a positive impact on the development of initiatives such as 
SPARRA/ACP  and  those  promoted by  TDP. In both cases,  the  new regulation  provides the enabling 
conditions for implementing eHealth solutions for integrated care.  

3.2  Preparation  

3.2.1  Aims and objectives 

The  involvement  of  different  stakeholders  in  ICT-supported  integrated  care  initiatives 
introduces  a  risk  that  goals  and  specific  objectives  are  not  necessarily  shared  among 
organisations.  In  the  BLMSE  (Better  Life  for  Most  Sick  Elderly)  initiative  in  Sweden,  the 
organisations  involved  seemed  to  have  diverging  objectives,  which  made  implementation 
more complicated. Similarly, in the case of the SPARR/ACP project in Scotland, the lack of 
its  diffusion.  The 
integration  between  (health  and  social)  organisations  hindered 
implementation  of  some  of  the  projects  developed  under  the  Telecare  Development 
Programme  (TDP)  in  Scotland  (UK)  was  affected  by  disagreement  about  the  expected 
results of the project and lack of cohesion among the local health and social care players. 
In  such  complex  projects  involving  large  numbers  of  stakeholders,  several  work  streams 
may be set up with specific objectives and timelines. At some point, all sub-projects should 
converge towards the same end result set in the overall objectives. However, when setting 
the objectives and planning the activities at the start of the project, it may be difficult to 
get a complete overview of all elements that need to be addressed. Not all essential steps 
in  the  initiative  may  be  known  from  the  start  and  the  situation  may  change  over  time.  
Setting objectives and defining work streams is at best an educated guess, anticipating the 
future  situation.  New  challenges  may  appear  during  the  course  of  the  project  which  may 
jeopardise the desired goals, such as changes in stakeholder organisations, in policy or even 
in the political balance of power.  

Several  initiatives  suggest  that  objectives  may  have  to  be  adjusted  during  or  after  the 
implementation  process.  For  instance,  as  part  of  the  eHealth  initiatives  deployed  in  the 
Emilia-Romagna region  of Italy (SOLE/FSE), individuals can directly access their  electronic 
health records through a dedicated website. However, at the time of writing, no more than 
3% of citizens had accessed their own records. This means that to reach the objectives set 
for  the  initiative,  some  further  action  may  be  needed  -  for  example,  to  raise  awareness 
among citizens about the benefits of using the system. The evolving conditions in which an 
initiative is being implemented call for regular monitoring of the initial objectives so as to 
anticipate  difficulties  and  react  to  changes.  The  initiatives  analysed  in  the  SIMPHS3 
research and other experiences support the idea of establishing an iterative process to set 
and monitor objectives, in order to be able to anticipate difficulties and react based on new 
knowledge  acquired  through  the  initiative  and  adapt  to  new  developments  in  the 
environment. 

15 

 
 
in 

large  projects/programmes  and 

long-term 
Especially 
perspective, monitor the objectives and activities regularly, linking the different 
work  packages  to  ensure  that  the  ultimate  objective  can  be  achieved.  If 
necessary, reconsider and fine-tune the objectives with key stakeholders.     

in  those  with  a 

Some  of  the  initiatives  in  this  analysis  aim  to  adopt  and  mainstream  an  ICT-supported 
integrated  care  solution.  In  setting  the  specific  objectives  of  an  initiative,  it  is  useful  to 
distinguish  between  the  "project"  phase  and  the  "mainstreaming"  phase.  The  challenge 
associated with both phases can be very different. In the case of a project, the structure of 
the initiative is temporary while in cases of implementation of e.g. an eHealth solution, the 
structure of the initiative will have to adapt to the permanent structures it operates in (or 
the other way round). These two distinct phases have also been referred to as "innovation 
adoption" which is the decision to use an innovation, and "innovation implementation" which 
is the period in which individuals and organisations become increasingly skilled, consistent, 
and committed in their use of an innovation (Klein 2005). The difference between adoption 
and  implementation  is  fundamental:  individuals,  teams,  organisations,  and  communities 
often adopt innovations but fail to implement them successfully.   

The  Scottish  Telecare  Development  Programme  (TDP)  initiative  clearly  distinguished  two 
types of initiatives to be funded: those at project stage and those for mainstreaming. The 
main  objectives  of  the  former  were  to  stimulate  local  communities  to  adopt  integrated 
home  care  initiatives.  The  latter  aimed  to  provide  adequate  pre-conditions  for  effective 
uptake of initiatives with high potential of diffusion within the entire local population.  

Another  approach  that  takes 
into  account  the  difference  between  project  and 
mainstreaming  is  that  of  the  Innovation  Unit  of  Barbastro,  the  Spanish  site  of  the 
DREAMING project. At the end of each project, the Unit and the healthcare management of 
the  area  concerned  evaluate  patient  and  stakeholder  satisfaction,  economic  aspects,  and 
quality of life. If outcomes are positive and there is an adequate business case, the service 
is  deployed to the local  health  area  as a first  step towards full deployment to the whole 
region.  In  all  cases,  the  lessons  learnt  and  barriers  identified  in  previous  experiences  and 
projects are incorporated explicitly when designing the next initiative. 

However, initiatives may not aim for large scale implementation. eHealth solutions can aim 
for a local setting and a specific topic, and may even benefit from not being dependent on 
a complex setting with many stakeholders and on changes in healthcare organisation. The 
initiatives in  SIMPHS3  range from pilot studies, such as the  Renewing Health  initiative, to 
final  implementation  strategies  such  as  the  Community  Care  Unit  (CCU)  in  the  Hospital 
Universitario de Getafe, Spain, or Gesundes Kinzigtal in Germany. 

The examples analysed in SIMPHS3 suggest that  not all of them are projects of a strictly 
temporary  nature.  Often  the  objective  of  an  initiative  is  to  mainstream  activities  into 
routine processes. In these cases, the project phase can be considered the starting phase of 
the whole initiative. The intervention in the temporary project phase should move gradually 
towards  mainstreaming  of  activities.  This  process  could  be  made  explicit.  However, 
initiatives  may  not  explicitly  define  long-term  objectives  and  rely  on  a  process  of  wider 
adoption of a good practice based on small-scale results. If mainstreaming is the goal, it is 
important that, for example, funding streams evolve from project to structural funding for 
implementation  in  routine  practice.  If  this  is  not  anticipated,  mainstreaming  may  fail 
because availability of resources is not arranged or  funding issues have to be  sorted out 

16 

 
 
after finalising the project, delaying the start of the implementation with the risk of losing 
momentum, which may lead to the initiative being dropped altogether.  

Define  and  distinguish  clearly  between  project/programme  objectives  related  to 
the short-term (temporary setting) and longer-term objectives for mainstreaming 
(in a permanent setting).       

Illustrative case example 

The  Scottish  Telecare  Development  Programme  (TDP)  initiative  put  into  practice  the  distinction 
between  project  and  mainstreaming.  Indeed,  the  TDP  funding  scheme  comprised  two  stages  with 
different objectives. In the first stage, over 50 projects were funded with a view to developing and 
evaluating  telecare  solutions.  Based  on  the  outcomes  of  these  projects,  only  6  telecare  solutions 
were  selected  for further funding  for mainstreaming.  The main  objective  in  the  first  stage  was  to 
stimulate  local  communities  to  adopt  integrated  home  care  initiatives  while  the  second  stage 
funding  aimed  to  fund  the  development  of  adequate  pre-conditions  for  effective  uptake  of 
initiatives  with  high  potential  for  diffusion  within  the  entire  local  population.  In  this  initiative,  the 
objectives  in  the  two  stages  were  clearly  different:  first,  developing  and  testing  in  a  temporary 
project setting, and second, the integration of the intervention into permanent structures. 

3.2.2  Stakeholders 

The  SIMPHS3  case  studies  and  various  toolkits  developed  in  Europe  for  handling 
implementation challenges suggest that managing stakeholders is an essential step in any 
initiative.  A  stakeholder  can  be  defined  as  any  organisation,  group  or  individual  who  is 
affected  by  the  objectives  and  activities  of  an  initiative.  In  other  words,  stakeholders  are 
those who influence the course of the project and those who are directly influenced by the 
initiative.  

In the Diabmemory initiative,  a prior stakeholder  analysis was  performed to define tasks. 
This analysis helped the leaders to determine stakeholders’ profiles to meet the needs  of 
the  project  and  the  position  of  the  different  stakeholders.  In  several  initiatives 
implementation  was  not  completely  successful  because  key  stakeholders  in  the  care 
process were not sufficiently involved in the planning and execution. This was the case in 
the Self-Care platform initiative in Oulu (Finland) which did not fully achieve its objectives 
because some of the care professionals and informal carers were not involved. Similarly, in 
the  telemonitoring  initiative  Renewing  Health  in  Austria,  not  all  the  relevant  actors  were 
duly taken into account. In this case, professionals outside the hospital did not have access 
to the required patient information, which jeopardised full implementation. 

Without  an  explicit  inventory  of  all  potential  stakeholders,  the  risk  of  running  into 
unforeseen resistance from some of them increases greatly.  

Depending  on  the  objectives  pursued  by  the  initiative,  different  stakeholders  may  be 
relevant at different stages in the process. More specifically, some stakeholders may have 
to  be  involved  more  heavily  during  the  project  phase  or  on  the  contrary  during  the 
implementation  phase.  For  instance,  organisations  dealing  with  policy  may  become 
increasingly relevant at the mainstreaming stage of the initiative. 

17 

 
 
 
 
An  exhaustive  inventory  of  the  relevant  stakeholders  may  not  always  be  feasible  at  the 
very start of the initiative. However, it is likely that most stakeholders are known to those 
involved  in  the  project  team.  In  very  complex  and  elaborate  initiatives,  an  overview  of 
relevant stakeholders can also be obtained by consulting the stakeholders already known, 
and asking them to identify additional stakeholders.  

There may be differences in terms of the impact a stakeholder may have on a project and 
the extent to which they support its objectives. Those stakeholders that are in a position to 
hamper  implementation  should  be  carefully  managed.  A  low  level  of  participation  in  an 
initiative may reflect insufficient stakeholder management and signal potential difficulties 
when  it  comes  to  implementation.  The  essential  stakeholders  should  be  carefully  briefed 
and encouraged to participate. The ARIA initiative in Italy is facing this type of problem in 
relation to healthcare professionals. The implementation of ARIA is mostly the result of the 
personal motivation of a few care professionals. For full implementation though, a majority 
of professionals would have to agree to commit to the new care processes which has not 
been achieved as yet. In this particular case, including professionals as major stakeholders 
in the inventory of stakeholders, and analysing both their attitudes towards the technology 
and the structure of the organisation  in which they operate could  have helped to develop 
an active strategy for wider deployment and helped to gain their support and commitment. 
An approach commonly used to get a clearer picture of all stakeholders is the mapping of 
stakeholders in a matrix according to their power and their interest (Bryson 1995).   

At  the  start  and  during  the  initiative,  carry  out  a  systematic  inventory  of 
stakeholders, including those who affect the initiative and those affected by it, in 
order to adapt the strategy and objectives to their particular circumstances.         

Illustrative case example 

There  are  several  examples  of  initiatives  whose  implementation  and  impact  has  been  hindered 
because  key  stakeholders  in  the  care  process  affected  were  not  involved.  The  self-care  platform 
implemented in Oulu, Finland has not yet fully achieved its objective of care coordination because 
some important actors in the care delivery process such  as social care professionals and informal 
carers  were  left  out  of  the  approach.  A  similar  issue  was  highlighted  in  the  Renewing  Health 
telemonitoring initiative implemented in Austria, where the health data collected was not accessible 
to  professionals  outside  the  Hospital  System,  reflecting  the  complexity  of  the  Austrian  healthcare 
system.  In cases like these, a systematic inventory of all relevant stakeholders and a mapping of 
their impact and attitudes towards the proposed changes would have  helped to  identify problems 
and the strategy could have been adapted accordingly. 

3.3  Characteristics of the ICT-supported integrated care solution 

3.3.1  Functional characteristics 

Results  from  practices  suggest  that  the  intervention  should  be  convincing  for  all  users, 
from  professionals  to  patients  and  citizens,  including  older  people.  If  the  major 
stakeholders do not feel a need to change their routine, it may be difficult to succeed with 
implementation (Klein and Knight 2005). At least one or more of the stakeholders involved 
should  feel  the  need  for  change.  Besides  the  need  for  the  intervention,  the  intervention 

18 

 
 
 
 
itself  should  be  examined  in  the  light  of  current  practices.  Ideally  the  initiative  should 
replace an existing routine, or add some new functionality. If the eHealth solution replaces 
an existing routine, it should have clear advantages in terms of inter alia user friendliness 
compared to the existing routine (Aiman Smith and Green 2002). If an eHealth solution is 
added  to  the  routine  care  process,  without  replacing  the  existing  practice,  this  may  be 
perceived  as  an  extra  workload  which  may  have  a  negative  impact  on  the  motivation  of 
users.  

Especially if the initiative is triggered by a technology  push or  is strongly influenced by a 
top-down approach, it is especially important to evaluate if there is a real need for it. The 
eHealth  initiative  in  the  Emilia-Romagna  region  of  Italy  (SOLE/FSE)  offers  access  for 
patients  to  their  electronic  health  records  through  a  dedicated  website.  However,  at  the 
time of writing, no more than 3% of the citizens requested access. It seems that not many 
patients  see  a need  to access their  electronic  health record  or  they may not be aware of 
the benefits that access to health data would bring them. In this case, earlier involvement 
of  patients  through  focus  groups  to  detect  which  data  is  of  main  importance  for  special 
target groups and then raising awareness among users and patients is required to ensure 
greater  uptake.  In  the  VHA  initiative,  user  perception  of  the  new  telehealth  services  is 
continuously  evaluated  through  patient  satisfaction  surveys,  which  moreover  empowers 
them to contribute with their ideas. 

Convincing  evidence  about  the  effectiveness  and  safety  of  the  ICT-supported  integrated 
care solution is also needed to stimulate the uptake. Scientific evidence for the purpose of 
implementing  an  eHealth  solution  should  ideally  be  related  to  the  use  in  actual  practice. 
This  means  that  efficacy  only  (in  a  controlled  research  setting)  may  not  be  convincing 
enough  for  implementation  purposes.  The  availability  of  effectiveness  studies  is  however 
limited. In the first initiatives piloted in Barbastro (Spain), there was a lack of evidence on 
the clinical effectiveness and on the cost-benefit of the intervention due to the use of an 
inadequate evaluation methodology. Three main types of problems were reported: the low 
number of patients involved in the clinical trials, the duration of the evaluation periods in 
studies which was too short and the lack of information on the impact of the intervention 
other than the effect on patients (such as changes  to the roles of professionals).  Lack of 
scientific  evidence  may  be  used  as  an  argument  not  to  proceed  with  implementation. 
Several elements which are possibly related to the lack of scientific knowledge may prevent 
smooth adoption of eHealth solutions (Al-Shorbaij et al 2013). Common arguments include 
the fact that interventions are costly, not well evaluated (effectiveness and safety) and do 
not fit into existing standards. In some initiatives, however, evidence of their effectiveness 
is available: for example, MOMA, a high quality Call Center for 24/7 assistance  to chronic 
patients.  MOMA aims to be a point of contact for counselling, information and education of 
patients  and  interaction  with  a  multidisciplinary  team  and  GPs  (who  are  the  case 
managers). The MOMA model has proven cost-effective for Maccabi Healthcare Services in 
Israel.    

An  ICT-supported  integrated  care  solution  that  is  versatile  is  more  likely  to  be  taken  up, 
especially if it provides an answer to a clear need For instance, eHealth solutions that are 
capable of supporting patients suffering from multi-morbidity have a much better chance 
than those focusing on only one chronic disease. If the eHealth solution does not have the 
functionality  to  cope  with  multiple  diseases,  this  may  be  very  impractical  for  users.  As  a 
consequence, the solution for the patient is very partial or multi-morbidity patients may be 
left out of the initiative. 

19 

 
 
Make sure the eHealth solution in question is a good answer to a clear user need, 
focusing on care professionals and/or patients/citizens or other key stakeholders. 
In  addition,  design  and  plan  awareness  actions  to  make  sure  targeted  users  are 
engaged, and know about the benefits of the new system. 

Illustrative case example 

An important factor for successful uptake of an innovation in routine practice is the need perceived 
by  the  users.  Especially  in  the  phase  when  the  implementation  is  starting  or  ongoing,  user 
motivation  is  a  critical  factor.  Once  a  new  practice  is  part  of  the  mandatory  standard  practice, 
individual motivation may be less important. In the initiative in the Emilia-Romagna region in Italy 
(SOLE/FSE)  for  instance,  citizens  are  given  access  to  their  electronic  health  records  through  a 
dedicated website. Giving access to citizens and professionals to the same data is efficient and can 
foster the coordination of care services. A key factor is the use by citizens.  However, at the time of 
writing,  no  more  than  3%  of  the  citizens  accessed  the  website.  Even  though  the  ICT  has  been 
deployed  and  the  system  is  working  well,  patients  do  not  seem  to  perceive  a  need  to  use  it. 
Solutions are being worked on to improve participation. 

3.3.2  Technical characteristics 

User motivation to work with the ICT-supported integrated care solution is a key factor in 
the  success  of  the  initiative.  This  motivation  is,  among  other  things,  related  to  the  user-
friendliness  of  the  eHealth  solution.  Smooth  functioning  of  ICT  tools  is  an  essential 
prerequisite for  uptake in practice.  Innovative technological innovations may be  especially 
unreliable  and  imperfectly  designed  (Klein,  2005),  which  can  have  a  negative  impact  on 
user motivation. In the telemonitoring pilot project in Austria, part of the Renewing Health 
initiative, the technical solution was  built in  the  simplest way  possible  to make it easy to 
use  for  older  patients/citizens.  The  approach  was  also  designed  so  that  limited  training 
would be required to use the eHealth solution, making scaling up more likely. In the projects 
developed  by  the  Innovation  Unit  of  Barbastro  (Spain),  the  technology  implemented  was 
based  on  systems  already  in  place,  making  scaling  up  easy  in  future  projects.  This  was 
done  by  designing  customizable  platforms  able  to  interoperate  with  existing  information 
systems.  Generally  speaking,  the  technology  used  should  be  flexible  enough  to  adapt  or 
evolve  according  to  the  latest  technological  developments.  In  addition,  eHealth  solutions 
should be multi-channel so as to offer users the choice they need to access information or 
services.   

A  possible  barrier  to  the  use  of  the  technology  is  the  lack  of  smooth  communication 
between systems. Interoperability is one of the most obvious prerequisites to be considered 
when  developing  and  implementing  eHealth  solutions.  This  factor  is  usually  taken  into 
consideration before the start of an initiative. However, a number of initiatives suffer from 
a lack of interoperability which often dooms them to fail. In the SOLE/FSE initiative, striving 
to  implement  an  Electronic  Health  Record  across  organisations  in  a  region  in  Italy,  172 
different  information  systems  were  found  to  be  in  use  and  interoperability  was  a  key 
challenge.  The  mainstreaming  of  telecare  solutions  under  the  Scottish  Telecare 
Development  Programme  (TDP)  also  faced  similar  difficulties.  The  sharing  of  information 
between social care and healthcare was also difficult because of the lack of interoperability 
in the ETXEAN ONDO pilot programme developed in Basque region in Spain. 

20 

 
 
 
Ensure that the eHealth solution is as user-friendly as possible and evaluate it in 
a practical setting with the users, e.g. Living Lab or pilot study.           

Illustrative case example 

The motivation  to  use an eHealth  solution is a  key  element  in  the  success  of  an  initiative.  This is 
true  for  both  those  receiving  care  and  those  providing  care.  Apart  from  few  technology-savvy 
professionals  and  patients,  most  users  want  a  system  that  works  and  makes  their  lives  easier, 
because  it  saves  time,  or  improves  their  quality  of  life  or  quality  of  care.  User-friendliness  is 
essential for wider uptake of technology and has been managed in several of the initiatives studied. 
The telemonitoring pilot project developed in Austria in Renewing Health was based on systems and 
interfaces which were kept as simple as possible in order to avoid resistance from older patients. In 
addition, it meant that the required training for professionals was neither too complicated to follow 
nor overly time-consuming. Technical solutions should also be flexible in order to facilitate scaling 
up. 

3.3.3  Resources  

An important characteristic of the ICT-supported integrated care solution is the cost of its 
implementation.  One  of  the  major  barriers  for  sustainable  implementation  of  an  eHealth 
technology  is  the  availability  of  resources.  Often  resources  are  available  in  the  project 
phase of an initiative because they are obtained from ad-hoc grants, but may no longer be 
available  for  the  implementation  and  scaling-up  phase.  This  is  particularly  true  of  EU-
funded projects which often lack a clear strategy on funding following project completion. 
One  would  expect  eHealth  solutions  to  be  clearly  cost-effective,  and  thus  intrinsically 
valuable  to  organisations.  However,  this  is  often  not  the  case  because  evidence  on  cost-
effectiveness is often lacking or very limited, and the evaluation period maybe too short to 
clearly  demonstrate  the  benefit  of  the  new  strategy.  Furthermore,  those  who  invest  in 
eHealth  services  do  not  always  directly  benefit  from  the  impact,  which  may  be  rather 
general  and  thus  a  barrier  for  further  implementation.  Even  when  benefits  can  be 
demonstrated, payoff may be delayed by several years in relation to the initial investment. 
Furthermore,  the  eHealth  solution  is  often  just  one  element  in  a  wider  change  strategy 
targeting care integration. The funding of an eHealth solution may therefore depend on the 
decision to fund the overall integrated care strategy.  

Several  initiatives  show  the  struggle  for  funding.  The  NEXES  project,  an  EU  co-funded 
project  which  aimed  to  deploy  integrated  care  services  for  chronic  patients  in  Barcelona, 
faced deployment difficulties due to limited national investment and funding programmes. 
The deployment of a screening and integrated care programme in the Netherlands (INAA) 
was  also  at  risk  at  the  time  of  writing  because  of  the  lack  of  long-term  financing.  Also 
austerity  measures  in  healthcare  may  jeopardise  deployment  of  new  initiatives.  The 
eTrikala  centre  in  Greece,  developing  telecare  services,  is  struggling  to  secure  long-term 
funding in a situation which is exacerbated by the economic crisis affecting the country. A 
telecare service that started in  2010 addressing primarily the elderly suffering from mild 
cognitive impairment was stopped 3 years later as a  consequence of the lack of funding.  
The  Gesundes  Kinzigtal  integrated  care  project  in  Germany  developed  an  alternative 
funding  model  in  which  a  long-lasting  shared-savings  contract  is  negotiated  with 
healthcare insurers so that Gesundes Kinzigtal benefits from their investments in eHealth.  

21 

 
 
 
In general these examples show that the step from a funded project to further deployment 
of an ICT-supported integrated care initiative is not easy and never happens automatically, 
even when a project is considered successful. It is difficult to demonstrate the benefit of a 
new  strategy  over  the  existing  routine  and  to  convince  decision  makers.  This  is  further 
complicated by political changes and budgetary pressures. 

Develop  a  sound  business  model  which  demonstrates  the  higher  value  of  ICT-
supported  integrated  care  over  standard  care.  Alternatively  or  in  addition, 
identify  available  funding  schemes  at  the  start  of  the  initiative,  for  both  short-
term funding and long-term funding for mainstreaming.    

A standard procurement process may not be suitable for innovative technological solutions 
in eHealth. The technical functionalities and the usability of the technology may depend on 
the  setting  in  which  it  will  be  used.  The  innovative  nature  of  eHealth  solutions  is  fraught 
with uncertainty. This is inherent to the lack of upfront knowledge on the exact scope of the 
solution required and the scale it should achieve. For instance, constraints related to public 
procurement rules have acted as a barrier in  the deployment of the  self-care platform  in 
the Oulu initiative in Finland. In the region of Galicia (Spain), different strategies have been 
implemented  for  procurement  of  technology  innovation  in  healthcare.  However  pre-
commercial procurement in the area of healthcare is rather new. Evidence is still lacking on 
the  outcomes  of  these  processes  and  on  how  innovative  technology  procurement  affects 
the  implementation  of  eHealth  solutions  in  practice.  Several  EU-funded  projects  on  pre-
commercial  procurement  are,  and  have  been  addressing  this  topic16,  for  example  the 
'STOPandGO' project17.  

Given the innovative nature of eHealth technology, explore suitable strategies for 
procurement  and  adapt  procurement  processes  to  allow  for  the  development  of 
technology-based solutions that answer the needs of care delivery optimally. 

Illustrative case example 

Procurement  of  innovative  technology  may  not  be  as  straightforward  as  the  purchase  of  other 
products. The main difference is that innovations come with uncertainties. They offer new solutions 
which aim to change practices. Solutions have to be developed according to the care needs and the 
implementation  setting.  For  instance,  in  the  Spanish  region  of  Galicia,  as  part  of  their  healthcare 
innovation  model,  two  complementary  public  procurement  processes  have  been  developed:  public 
procurement of innovative technology process and pre-commercial public procurement. The former 
has two consecutive steps: first, a technical dialogue with the market  which informs the following 
process of procuring the innovative technology. In the latter, different phases are established with a 
view  to  adapting  the  procurement  process  to  the  R&D  characteristics  of  the  required  services  or 
products. 

16   http://ec.europa.eu/digital-agenda/en/eu-funded-projects  
17   http://stopandgoproject.eu/  

22 

 
 
 
 
 
 
                                              
3.4  Enabling implementation  

3.4.1  At the level of the organisation 

Organisational  readiness  is  considered  an  important  predictor  for  the  success  of  the 
implementation of an innovation (Weiner  et al, 2009).  Models of organisational readiness 
include  elements  related  to  the  ability  of  professionals  to  drive  the  change  in  their 
organisations  and the capacity of the  organisation to make  a change. The capacity of an 
organisation  to  make  a  change  depends  on  financial  resources,  available  time  and  staff. 
Even the easiest strategies to implement require initial investments to start up (Repenning 
et al, 2002).  

In  some  of  the  initiatives  analysed  in  SIMPHS3,  limited  personnel  numbers  constituted  a 
barrier  to  deployment.  In  the  DiabMemory  initiative,  using  remote  monitoring  for  diabetic 
patients,  additional  tasks  were  given  to  the  healthcare  professionals  such  as  the 
recruitment and training of participating patients, and  support in  a technical helpdesk.  No 
new  staff  members  were  recruited  and  the  increased  workload  was  considered  a  major 
barrier  for  further  implementation.  Especially  when  the  new  tasks  do  not  replace  existing 
tasks  but  are  additional  to  the  routine  care,  numbers  of  personnel  may  have  to  be 
increased to cope with the changes.    

Incentives can be used as a signal to professionals that the use of an eHealth technology is 
a  serious  part  of  their  professional  work.  The  incentive  scheme  should  be  consistent  and 
aligned with the objectives of the initiative. A relevant incentive scheme, in monetary terms, 
was put in place in the integrated care initiative developed in in the Kinzigtal Region in the 
Southwest  Germany.  Healthcare  professionals  who  joined  the  programme  received 
additional  fees,  equivalent  to  about  5-10%  of  their  salaries.  In  other  initiatives,  however, 
the  lack  of  incentive  schemes  has  been  highlighted  as  a  serious  barrier  (e.g.  the  Scottish 
Telecare  Development  program  -  TDP).  Even  where  incentives  are  used,  if  these  are 
temporary  and  funded  from  outside  the  structural  financing  mechanism  of  care  pending 
full  implementation,  it  can  be  argued  that  they  jeopardise  structural  and  sustainable 
implementation.  The  pros  and  cons  should  be  weighed  carefully  as  temporary  incentives 
can lead to increasing costs in the long run. In addition, professionals may lack motivation 
to  integrate  the  service  into  their  routine  practice,  if  incentives  are  not  maintained.  An 
alternative is to focus on the added-value of the new services or solution (e.g. time saving, 
better service) in non-monetary terms.  

Few explicit business models are reported in the analysis of the initiatives in SIMPHS3. The 
costs and the impact of an initiative are often insufficiently clear.    

Starting an innovative eHealth strategy is costly: develop a business model (value 
proposition) with those who make the financial investment and benefit from the 
outcomes,  taking  into  account  the  financial  and  human  resources  requirements 
and the incentives needed to promote the use of the eHealth solution. 

The  adoption  and  implementation  of  an  innovation  may  lead  to  a  change  of  roles  and 
routines, and it may disrupt hierarchical structures (Klein 2005).  Doctors and nurses often 
struggle  with the changes in  roles (Adolfsson et al 2004), and may need  special  training. 
New  patterns  of  cooperation  in  ICT-supported  integrated  care,  in  which  patients  play  an 

23 

 
 
 
active role, may  affect  the traditional central role of the  GP. Changes may  also influence 
how  organisations  cooperate  with  each  other  and  roles  inside  the  same  organisation. 
Conscious  or  unconscious  resistance  to  the  uptake  of  innovative  technology  may  be  the 
result.  

In several of the SIMPHS3 cases there has been a change in roles or the creation of new 
roles.  In  the  Nexes  project  in  Barcelona,  nurses  were  given  a  new  role  as  part  of  the 
reorganisation  of  services  using  a  health  information  sharing  platform.  This  new  role 
included,  for  example,  the  monitoring  of  patients  and  regular  follow-up  activities. 
Patients/citizens  are  also  given  roles  in  some  initiatives:  for  example  in  the  Dreaming 
initiative,  citizens  were  encouraged  to  take  an  active  part  in  their  own  care  by  recording 
their  own  vital  signs  with  the  help  of  easily  used  devices.  For  this  role,  patients/citizens 
received  technology  training,  complemented  with  health  education.  In  the  Etxean  Ondo 
cases  in  the  Basque  Country,  a  case  manager  role  was  created  which  was  filled  by  a 
trained nurse.  

The  introduction  of  new  roles  and  processes  may  interfere  with  the  old  routines.  In  the 
Spanish  site  of  the  DREAMING  project,  which  deals  with  telemonitoring  projects,  it  was 
observed  that  appointments  to  visit  GPs  were  not  only  being  made  according  to  the  old 
routine on the  initiative  of patients/citizens and their  informal carers, but also as a result 
alarms  generated  by  the  telemonitoring  technique.  These  systems  were  interfering  with 
each  other  and  needed  coordination.  This  kind  of  interference  may  be  most  prominent  in 
the  initial  phase  of  an  initiative  and  is  likely  to  be  solved  during  the  course  of  the 
implementation.     

Training programmes on the use of technology are offered to healthcare professionals and 
users (patients, informal carers, and volunteers) participating in the projects developed by 
the Innovation Unit of Barbastro in Spain. It has been found that these programmes help to 
build  up  trust  between  patients  and  professionals,  and  also  helps  users  to  trust  the 
technology which fosters further implementation.  

Technical support is also a must as it helps to consolidate this trust. 

Training should be planned carefully as it implies extra investment of time and resources. It 
should happen close to the beginning of the implementation of the real solution and should 
be  taught  by  professionals.  The  sustainability  and  scaling  up  of  the  telecare  services 
offered  by  the  ACTION  initiative  in  Sweden  were  hindered  by  the  significant  amount  of 
training required to implement the service. 

Plan  and  organise  training  within  the  organisation  affected  by  the  new 
technology so as to allow for adjustment to new roles and processes.    

24 

 
 
 
 
Illustrative case example 

The introduction of a new eHealth technology in an existing organisation comes with the risk that 
the new processes interfere with the existing ones. This may not always be foreseeable at the start 
of the implementation. The result may be that the innovation brings confusion and inefficiencies in 
the organisation. In some of the initiatives, during a transition period, both the new way and the old 
way of providing services coexisted which led to higher use of care resources. This was the case in 
some  of  the  pilot  projects  developed  by  the  Innovation  Unit  of  Barbastro,  the  Spanish  site  of  the 
DREAMING project.  In their telemonitoring project,  patients  arranged to see  their GPs in two ways: 
firstly, by arranging visits themselves, or through an informal carer, and secondly, as a consequence 
of  the  alarms  generated  by  using  the  telemonitoring  system  and  the  related  collection  of  clinical 
data. However, once professionals and patients adapted to the new care process, this duplication in 
the  use  of  services  gradually  disappeared.  In  the  end,  most  consultations  were  triggered  by  the 
telemonitoring alarms based on the analysis of transferred data. This change was referred to as a 
“change  from  subjective  frequentation  to  objective  frequentation”.  Before  and  during  the  first 
phases of the DREAMING project, the users made appointments to see clinicians when they thought 
they had to. Once the project was consolidated, they ,made appointments only when there was an 
objective reason for doing so. 

3.4.2  Culture of readiness for ICT-supported integrated care 

Cooperation  and  communication  are  central  to  the  implementation  of  ICT-supported 
integrated  care  and  depend  on  the  culture  within  organisations  and  professional  groups.  
Culture  reflects  a  complex  concept  of  shared  beliefs  and  values  at  individual  and 
organisational  level,  which  in  the  case  of  eHealth  relates  to  pursuing  the  use  of  eHealth 
technology  for  the  benefit  of  healthcare  delivery.  The  culture  within  an  organisation  is 
considered  an  important  predictor  of  the  success  of  the  implementation  of  eHealth 
supported integrated care (Holahan 2004).  

In several of the SIMPHS3 cases, it was reported that cultural differences were hampering 
the smooth implementation of the interventions. In  the SAM:BO initiative, for  instance, an 
agreement  was  made  which  included  guidelines  for  cooperation  and  communication 
between  professionals.  Prevailing  organisational  cultural  differences  were  a  clear  barrier 
when it came to following these guidelines, limiting their implementation.  

Also the culture among patients and citizens may play a role in how changes in healthcare 
provision are taken up.  Differences between patient groups and countries have been found 
to have an impact (Wilkowska 2012). For example, older people may have a more positive 
attitude  than  younger  people  with  respect  to  the  use  of  eHealth,  possibly  because  of 
greater needs for care and more concerns about their health. Women also seem to be more 
positive  about  eHealth  than  men.  In  addition,  the  age  effect  could  be  related  to  the 
motivation of elderly "not to bother" others. Another challenge associated with the use of 
health technology by patients is the need to make people prioritise health and understand 
the  benefits  of  self-care,  as  they  are  used  to  relying  on  health  care  systems  and  care 
professionals.  

If the initiative involves changes in different organisations, e.g. social care and hospital care, 
one may have to consider how to bridge cultural differences between organisations before 
cooperation  becomes  possible.  To  support  this,  it  may  be  useful  to  consult  experts  on 
change management. In addition, lessons from the field of patient safety on the benefits of 
collaboration and of removing silos which have helped prevent errors can also be applied in 
the field of integrated care.  

25 

 
 
Building  a  positive  culture  for  innovation  and  cooperation  takes  time.  Some  of  the 
initiatives  in  the  analysis  have  a  long  history  to  build  on.  For  example,  VAEB  in  the 
Diabmemory initiative has been working on projects for integrated care since 2007 with the 
“Therapie Aktiv – Diabetes im Griff” initiative.  

Furthermore,  a  culture  where  failures  are  accepted  should  be  fostered.  Currently,  the 
prevailing  culture  in  healthcare  is  one  of  success,  even  though  a  lot  can  be  learnt  from 
failures. Equally, a culture of innovation where risk taking is valued, even in the absence of 
immediate returns, can be beneficial.   

The  projects  developed  by  the  Innovation  Unit  of  Barbastro  (Spain),  found  that  strong 
leadership  is  one  of  the  requisites  for  success.  This  is  confirmed  by  the  NEXES  project 
implemented in Barcelona where leadership was also found to be important throughout the 
initiative. Research in other areas of healthcare also shows that leadership is an important 
aspect  of  culture.  For  instance  to  promote  patient  safety  in  healthcare,  the  UK  National 
Quality Forum identified leadership as a key factor for a positive culture for change.   

Initiate  cultural  change  in  organisations  to  promote  the  adoption  of  innovation 
and  to  stimulate  communication,  co-creation  and  cooperation  between 
organisations.   

Illustrative case example 

The  culture  within  organisations,  both  corporate  culture  and  that  of  the  employees,  also  partly 
determines whether smooth cooperation can be achieved with other organisations. The analysis of 
the SAM:BO initiative shows clearly how the lack of cooperation between professionals and levels of 
care, resulting from differences in organisational culture, can be a barrier. This initiative relied on an 
agreement  that  set  out  guidelines  for  cooperation  and  communication  among  health  care  actors, 
together with standards on how to monitor the quality of the service provided and to support health 
care  management  processes  by  electronic  communications.  However,  it  was  reported  that  the 
adoption  of  these  guidelines  and  standards  was  limited  because  of  the  prevailing  organisational 
culture and some resistance  to change by professionals, which jeopardised the implementation  of 
and adherence to the new way of working. 

3.4.3  Coordination between organisations 

The  development  of  explicit  policies  to  foster  eHealth  solutions  by  involved  stakeholder 
organisations  is  an  important  factor  in  ensuring  success  of  an  initiative.  Without  an 
enabling  policy  context,  technological  innovations  often  fail  to  scale  up  as  they  lack  the 
necessary conditions for further implementation. The initiative in Trikala, Greece, which was 
triggered by a technology push, aimed to improve cooperation between different healthcare 
providers by encouraging the sharing of information. However no organisational integration 
among  the  care  actors  accompanied  the  introduction  of  the  new  technology  which 
hampered its wider implementation.  

Policy alignment has been recognised  as an important factor  in  the complex challenge to 
integrate care. Especially in complex interventions, such as the introduction of an electronic 
health  record,  many  different  stakeholders  can  be  involved,  such  as  the  various 
organisations  in  charge  of  care  delivery,  regional  and  national  governments,  financing 

26 

 
 
 
 
organisations  etc.  Different  and  sometimes  conflicting  policies  can  be  in  place  in  the 
different organisations, which may have to be aligned to allow successful implementation. 
The  ETXEAN  ONDO  pilot  experiment  in  Spain  was  fully  supported  and  financed  at  local 
municipality  level  in  the  Basque  Country  and  had  positive  outcomes.  In  order  to  scale  up 
however, the initiative needed the support of the departments of health and social care at 
regional and national level. The lack of policy support at these levels was highlighted as a 
significant  barrier  for  full  deployment  of  the  initiative  at  local  level.  Similarly,  other 
experiences  show  that  different  policy  frameworks  at  local  level  can  also  impede  the 
transfer of good practices. ACTION failed to achieve broader implementation due to a lack 
of alignment of policies among municipalities in the same region.  

Check whether the policies of relevant stakeholder organisations are conducive to 
the  uptake  of  the  planned  eHealth  solution  and  devise  strategies  to  address 
potential hindrances to implementation. 

Setting up cooperation across organisations requires energy and is time consuming. It will 
not  always  be  possible  to  build  effective  cooperation  between  organisations  within  the 
scope  and  timeline  of  an  initiative.  For  example,  joint  training  of  staff,  building  trust, 
clarifying  responsibilities,  etc.  may  be  needed.  In  some  initiatives,  building  on  existing 
cooperation  improved  greatly  the  chances  of  implementation.  In  the  TPD  initiative  in 
Scotland  for  instance,  51  telehealth  projects  were  financed  initially.  Of  these,  only 
successful  projects  received  further  funding  for  mainstreaming  the  telecare  solution.  An 
analysis  showed  that  only  those  projects  where  cooperation  was  already  in  place  were 
successful, mainly in the context of the Community of Health Partnerships which had been 
established  for  the  specific  purpose  of  fostering  collaboration.  In  Badalona  (Spain),  the 
organisation of the Badalona Serveis Assistencials (BSA) has been structured in a way that 
facilitates  coordination  and  cooperation  between  organisations  and  their  professionals, 
which  has  been  an  important  condition  for  the  implementation  of  integrated  care.  In 
Carinthia, the organisation that manages public hospitals, KABEG, played a key role in the 
implementation  of  the  Renewing  Health  pilot.  It  managed  the  telemonitoring  systems  for 
COPD and Diabetes and created communication standards to promote cooperation between 
stakeholder organisations,  including public insurance companies, nurses from the Austrian 
Red Cross and technology companies. Although the initiative showed that making protocols 
for cooperation is important, these protocols did not guarantee the complete integration of 
GPs and Red Cross Nurses. Building partnerships is more than an agreement on paper, it is 
also about building a culture of cooperation.  

Build  on  existing  coordination  and  cooperation  networks  between  stakeholder 
organisations as a starting point. 

27 

 
 
 
 
  
 
Illustrative case example 

Cooperation  between  organisations  is  one  of  the  key  elements  in  integrating  fragmented  care 
delivery.  Setting  up  good  cooperation  between  organisations  may  take  a  lot  of  time.  It  can  take 
years  to  agree  and  implement  the  conditions  and  the  way  of  working  together,  which  can  be 
impossible  in  projects  of  limited  duration.  Therefore  it  may  be  essential  that  initiatives  build  on 
existing  cooperation.  The  Telecare  Development  Programme  (TDP)  in  Scotland  (UK)  provided  a 
unique  opportunity  to  compare  projects  with  and  without  existing  cooperation  networks.  In  this 
initiative,  51  telecare  projects  were  funded,  and  only  those  that  were  considered  successful  were 
financed  for  mainstreaming.  The  analysis  of  the  programme  highlighted  that  these  successful 
projects  had  taken  place  in  contexts  where  adequate  communication  and  cooperation  between 
stakeholders  was  already  in  place  in  the  shape  of  Community  of  Health  Partnerships.  These 
partnerships  were  able  to combine  primary and  community  services  with  shared responsibility  for 
planning  and  delivery  of  personalised  home  care  assistance.  They  therefore  facilitated  the 
implementation of projects with an integrated care approach, like the telecare ones.  

3.4.4  Professionals  

The professional is one of the key players in the adoption and implementation of an ICT-
supported integrated care solution. Individual readiness for change is an essential condition 
for  organisational  readiness  for  change.  Nurses  may  deserve  special  attention  in  cases 
where they play a key role as the interface with the patient, be it in a hospital, outpatient or 
home  setting.  The  benefit  of  involving  professionals  at  an  early  stage  of  the  project  was 
shown  in  the  Dreaming  initiative.  In  this  multisite  telemonitoring  project,  it  was  reported 
that the inclusion of professionals improved the acceptance of the technology. It helped to 
lower  the  resistance  to  new  technology  that  can  be  perceived  as  a  threat  to  their  job 
security  or  something  that  could  impact  negatively  on  their  workload.  In  the  Barbastro 
project  site,  a  large  number  of  professionals  were  involved  which  contributed  to  raising 
awareness and interest. The Diabmemory telemonitoring initiative in Austria also reported 
good experiences as a result of the involvement of professionals at an early stage of the 
project.  Physicians  and  external  experts  were  directly  involved  in  the  development  of  the 
medical part of the strategy.  

Like any innovation, the implementation of an innovative technological tool comes with an 
investment in time and energy on the part of the user (e.g. training, time to adapt to the 
new  practice).  The  investment  should  be  worthwhile  for  the  user  who  should  perceive  an 
added-value from using the new procedure or system. The greater effort it takes, the more 
resistance users will feel. They must have enough confidence in the technology to remain 
motivated to use it. Another element is scale, i.e. if the technology can only be used for a 
few  patients,  it  may  not  be  worth  the  investment  for  professionals.  The  DIABMEMORY 
telemonitoring initiative  developed  in  Austria is a case in  point. GPs need to learn how  to 
access  data  from  their  diabetes  patients  collected  via  a  remote  monitoring  system. 
However,  because  GPs  can  only  monitor  a  small  number  of  patients  each  through  the 
system,  most  of  them  have  not  followed  the  necessary  training,  let  alone  adopted  the 
system. Furthermore, the technology does not replace standard practice, but comes on top 
of it. These factors combined act as a barrier to further implementation of the technology. 

Involve  professionals  from  the  various  sectors 
implementation strategy of the eHealth solution from the start. 

in  the  development  and 

28 

 
 
 
Changing the routines of healthcare professionals seems to be particularly challenging. This 
has to do with the nature of the healthcare services sector – indeed, it seems to be more 
risk averse than other sectors as patients' lives are at stake. This means that it may take 
extra efforts to convince healthcare  professionals  of the benefits of implementing  a new 
routine, new care pathways or of using a new technology as they must have the certainty 
that this will not put their patients at risk. In addition, as using eHealth tools also normally 
requires  changing  work  routines  and  doing  things  in  new  ways,  it  is  not  unusual  to  see 
some resistance to change.    

An  option  that  has  been  proven  useful  is  when  professionals  take  a  leading  role  in 
promoting the change as champions. Champions are professionals whose sound reputation 
in  the  field  generates  the  required  trust  from  colleagues  to  support  the  implementation 
process. This helps to develop the strategy with specific input from professionals and peer-
to-peer interaction during the implementation process. Another alternative is to create new 
roles dedicated to building commitment among those who have to use the solution. In the 
Better Life for Most Sick Elderly (BLMSE) initiative in Sweden, the position of ‘improvement 
leader’ was created to drive, inspire and facilitate the uptake of the initiative. These experts, 
who were appointed for three years and tasked with establishing leadership forums, have 
been key in facilitating change and boosting implementation.   

In the ETXEAN ONDO initiative in the Basque Country, a pilot programme for personalised 
care pathways, social workers were assigned new roles as case managers for the patients, 
in order to facilitate coordination and the introduction of new routines. As a consequence, 
they were in constant interaction with primary care nurses who in turn interacted with the 
GPs and facilitated smooth implementation. 

Appoint  champions  to  advocate  the  initiative,  monitor  change  management  and 
define new roles for care professionals  whenever required, to implement change 
and coordinate new care processes. 

Illustrative case example 

Champions  are  people  that  have  a  special  role,  promoting  the  implementation  process  from  the 
inside. Champions, who can be professionals or patients, actively advocate the change. This peer-to-
peer  approach  builds  trust  in  the  innovation.  In  the  Better  Life  for  Most  Sick  Elderly  (BLMSE) 
initiative in  Sweden,  the  post  of  improvement  leader  was  created  with  a view  to  driving,  inspiring 
and  facilitating  change  and  this  role  was  acknowledged  as  key  in  facilitating  the  initiative.  The 
professionals  with  this  role  were  in  charge  of  establishing  leadership  forums,  including  different 
health  and  social  care  professionals.  The  approach  was  considered 
important  for  the 
implementation process.  

3.4.5  Acceptance by patients and other users 

In ICT-supported integrated care, the ultimate goal is to integrate care services in order to 
optimise care delivery for the patient. In several initiatives, special attention was given to 
patients’ needs early on when developing the strategy. In the ACTION initiative in Sweden, 
user  feedback  on  their  experience  with  the  telecare  service  was  collected  from  the  very 
beginning. In the DREAMING initiative, it was also considered important to include patients 

29 

 
 
 
 
and carers from the beginning. Another common objective of integrated care initiatives is 
the wish to empower patients (or their carers) to manage their own care, putting them at 
the  centre  of  the  new  care  process.  The  ETXEAN  ONDO  initiative  was  designed  with  a 
patient-centred  approach  which  considered  not  only  the  patients’  needs,  but  also  the 
respective context of caregivers and families. The projects by the Unit in Barbastro (Spain) 
explicitly  anticipated  the  cognitive  and  physical  limitations  of  the  users.  Patient 
characteristics  were  given  prominent  weight  in  the  decision  about  which  technologies 
should be adopted. 

The adoption of services will also depend on the timeliness of the information provided and 
the  way  authentication  processes  are  implemented.  It  is  important  to  strike  the  right 
balance between security and ease of access so users are willing to use the services. Again 
involving users in the development process is essential 

The  concept  of  'living  lab'  has  been  used  in  the  MACVIA-LR  initiative  in  the  Languedoc 
Roussillon region (France) to integrate user experiences and needs into the development of 
processes. When  patients  and developers co-create strategy, users' wishes and capacities 
are taken into account. 

More generally, special attention should be given to the doctor-patient relationship which is 
still considered a key element for successful treatment. Some researchers have found that 
principles  that  apply  to  normal  face-to-face  contact  could  also  be  applied  in  modern  ICT 
(Sebasan et al 2014), which means that the human dimension of care delivery should be 
given due attention when designing new ICT-supported care processes. 

Involve target users from the start in the development of the eHealth tools and 
the  implementation  strategy  to  answer  their  specific  needs  and  adapt  the 
solution to their capacities. 

ICT-supported  integrated  care  solutions  often  target  older  users,  who  are  often  not  very 
skilled in using them. eLiteracy also differs between regions, countries and socio-economic 
groups.  Reduced  e-literacy  has  potential  consequences  for  mainstreaming  a  technology.  
Special  attention  should  therefore  be  given  to  the  skills required  and  specific  training  for 
patients  and  (informal)  carers  should  be  planned.  In  the  DiabMemory  initiative  in  Austria, 
diabetes patients were given the opportunity to receive education during three weeks in a 
rehabilitation  facility  to  learn  about  their  disease,  followed  by  training  on  the  use  of  the 
eHealth  remote  monitoring  equipment.    In  the  Renewing  Health  KABEG  initiative,  trained 
professionals  manning  a  call  centre  helped  non  e-literate  users  if  they  had  doubts  or 
problems when using the active devices. 

Acquiring the required ICT skills depends on the attitude of users towards a technology. A 
number of studies have been published, e.g. on the wish of the target group to use eHealth 
technology  in  the  context  of  telemedicine.  One  of  these  studies  showed  that  the  use  of 
telemedicine  including  online  consultations  was  perceived  positively  by  most  invited 
patients (Gradner et al 2014). Studies among elderly  generally showed a positive attitude 
towards the use eHealth tools (Cimperman et al, 2013).  

30 

 
 
 
 
Offer  training  and  support  to  patients/citizens  and  other  users  so  they  can 
acquire the necessary ICT skills and quickly solve problems.  

Illustrative case example 

The MACVIA-LR initiative in the Languedoc-Roussillon area launched several initiatives as part of its 
activities as a reference site of the European Innovation Partnership on Active and healthy Ageing, 
built around chronic diseases, ageing and handicap. The main objective of MACVIA-LR is to develop 
innovative solutions for a network of Living Labs in order to improve the care processes for patients 
affected  by  chronic  conditions  and  to  scale  up  innovative  solutions  within  this  framework  for  the 
benefit  of  patients  and  health  care  actors.  MACVIA-LR  has  launched  a  series  of  integrated  Living 
Labs (e.g. health and disease, health and innovation, health and autonomy) for real-life tests in an 
experimental  environment,  where  users  and  producers  can  co-create  innovative  solutions.  These 
Living Labs work as enablers of change by putting patients at the centre of the MACVIA-LR initiative. 

31 

 
 
 
4  Conclusions  

The  recommendations  in  this  report  reflect  the  broad  range  of  topics  involved  in  the 
development and implementation of ICT-supported integrated care, both at policy level and 
at  the  workplace.  A  general  observation  from  the  analysis  of  the  initiatives  is  that  large-
scale  implementation  of  these  innovations  in  healthcare  is  difficult.  This  was  further 
confirmed  by  the  limited  number  of  initiatives  deployed  in  the  field  of  ICT-supported 
integrated care and independent living which could be identified after extensive searches in 
both the literature and through contacts with experts dealing with ICT-supported integrated 
care  innovations.  Indeed,  24  cases were  identified,  of  which some  are struggling  to  scale 
up.  The  limited  number  of  deployed  ICT-supported  integrated  care  initiatives,  also 
contributed  to  limitations  in  our  selection  of  cases.  We  may  have  missed  important 
healthcare-integration  projects  with  a  light  ICT  component  and  we  may  have  missed 
important  eHealth  projects  where  the  healthcare  integration  component  was  less  obvious 
for our research.     

The  decision  to  include  as  far  as  possible  deployed  initiatives  was  based  on  the  point  of 
view  that  there  should  be  large-scale  use  of  eHealth  technology  in  Europe.  Larger  scale 
initiatives include more organisations and users and are likely to have a bigger impact on 
healthcare systems. In the workshop in which these recommendations were discussed (see 
Section  2),  some  examples  were  given  of  small-scale  initiatives  that  were  running 
successfully  as  "business  as  usual".  The  small-scale  nature  and  simplicity  of  some 
initiatives made it possible to work with only few organisations and in an environment with 
no conflicting interests or cultural differences. The analysis of initiatives suggests that we 
may  not  need  to  strive  only  for  large-scale  initiatives.  Small-scale  initiatives  which  have 
been proven to be successful may be adopted by others based on their small-scale success. 
Different  models  for  scaling  up  may  have  to  be  considered  and  analysed  in  relation  to 
implementation  science.  Nevertheless,  our  analysis  shows  that  small  projects  that  lack  a 
longer-term vision or the ambition to scale up from the start are especially likely  to stop. 
Projects should therefore be embedded in a larger vision or wider strategy in order to have 
more chances of deployment after the project ends.  

The  challenge  with  the  recommendations  in  this  report  relates  to  the  fact  that  real-life 
practices  have  been  taken  as  the  starting  point.  A  qualitative  analysis  extracted  valuable 
lessons  from  these  24  on-going  initiatives,  all  of  which  differ  in  objectives,  setting,  size, 
strategy, stage of deployment, etc. In other words, the material for the recommendations is 
very  diverse.  On  the  one  hand,  this  fits  the  reality  of  eHealth  implementation  around 
Europe.  On  the  other  hand,  it  makes  it  difficult  to  devise  a  systematic  method  to  extract 
valuable,  generalisable  lessons.  The  recommendations  should  therefore  not  be  read  as  a 
standard  for  development  and 
implementation  of  eHealth.  Anyone  using  these 
recommendations  will  first  have  to  decide  which  areas  are  relevant  for  their  specific 
initiative.  

One crucial issue to be addressed in the implementation of  ICT-supported integrated care 
solutions  is  how  to  make  further  progress  and  stimulate  the  uptake  of  eHealth.  Indeed 
technology  solutions  are  available  and  therefore  the  challenge  is  not  to  create  new 
technologies  but  scale  up  the  use  of  existing  ones.  It  is  our  hope  that  these 
recommendations will help raise awareness about the experiences of those working hands-
on with eHealth implementation and contribute to the scaling-up strategy promoted by the 
European Commission through the European Innovation Partnership on Active and Healthy 
Ageing platform. Last but not least, these recommendations may constitute a starting point 

32 

 
for the further development of tools and methods, which will allow us to learn more from 
other initiatives.  

33 

 
References 

Al-Shorbajia N, Geissbuhlerb A. Establishing an evidence base for e-health: the proof is in the 
pudding. Bull World Health Organ 2012; 90:322–322A. 

Al-Shorbaij N. Is there and do we need evidence on eHealth interventions? IRBM, WHO. 2013. 

Brennan, Patricia Flatley; Downs, Stephen; Casper, Gail (2010): Project Health Design: rethinking the 
power and potential of personal health records. In: J Biomed Inform 2010; 43 (5 Suppl): S3-5. 

Gardner Matthew R., Jenkins Sarah M., O'Neil Daniel A., Wood Douglas L., Spurrier Barbara R., and 
Pruthi Sandhya. Telemedicine and e-Health. -Not available-, ahead of print. 
doi:10.1089/tmj.2014.0037. 

Ghazisaeidi M, Ahmadi M, Sadoughi F, Safdari R. An assessment of readiness for pre-
implementation of electronic health record in Iran: a practical approach to implementation in 
general and teaching hospitals. Acta Med Iran. 2014;52(7):532-44. 

Helfrich CD, et al: Organizational readiness to change assessment (ORCA): development of an 
instrument based on the promoting action on research in health services (PARIHS) framework. Imp 
Sci 2009, 4:38. 

Holahan, P. J., Aronson, Z., Jurkat, P., Schoorman, D.. (2004). Implementing Computer Technology: A 
Multiorganizational Test of Klein and Sorra’s model, Journal of Engineering and Technology 
Management, (21), 31-50. 

Klein KJ, Knight AP. Innovation implementation: overcoming the challenge. Current Directions  
Psychological Science. 2005;14:243-6. 

Lehman WE, Greener JM, Simpson DD: Assessing organizational readiness for change. J Subst Abuse 
Treat 2002, 22(4):197–209. 

Lluch, M., & Abadie, F. (2013). Exploring the role of ICT in the provision of integrated care-Evidence 
from eight countries. Health Policy, 111(1), 1-13. doi: 10.1016/j.healthpol.2013.03.005 

MacFarlane A, Clerkin P, Murray E, Heaney DJ, Wakeling M, Pesola UM, et al. The e-health 
implementation toolkit: qualitative evaluation across four European countries. Implementation 
Science 2011, 6:122. 

Plochg T, Klazinga NS. Community-based integrated care: myth or must? Int J Qual Healthcare. 
2002 Apr;14(2):91-101. 

Sabesan S, et al. ,  Practical aspects of telehealth: doctor–patient relationship and communication.  
Internal Medicine Journal 44 (2014). 

Shea CM1, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing 
change: a psychometric assessment of a new measure. Implement Sci. 2014 Jan 10;9:7. doi: 
10.1186/1748-5908-9-7. 

Suter, E., Oelke, N. D., Adair, C. E., & Armitage, G. D. (2009). Ten key principles for successful health 
systems integration. Healthc Q, 13 Spec No, 16-23.  

Shaw RJ, Kaufman MA, Bosworth HB, Weiner BJ, Zullig LL, Lee SY, Kravetz JD, Rakley SM, Roumie CL, 
Bowen ME, Del Monte PS, Oddone EZ, Jackson GL. Organizational factors associated with readiness 
to implement and translate a primary care based telemedicine behavioral program to improve 
blood pressure control: the HTN-IMPROVE study. Implement Sci. 2013 Sep 8;8:106. 

Victoria J. Barr, Sylvia Robinson, Brenda Marin-Link, Lisa Underhill, Anita Dotts, Darlene Ravensdale 
and Sandy Salivaras. The Expanded Chronic Care Model: An Integration of Concepts and Strategies 
from Population Health Promotion and the Chronic Care Model Healthcare Quarterly, 7(1) November 
2003: 73-82.  

34 

 
Villalba E, Casas I, Abadie F, Lluch M. Integrated Personal Health and Care Services deployment: 
Experiences in eight European countries. International Journal of Medical Informatics 2013:82:626-
635. 

Weiner BJ.  A theory of organizational readiness for change. Implementation Science 2009, 4:67. 

Wilkowskaa W, Martina Zieflea and Firat Alagöza. How user diversity and country of origin impact 
the readiness to adopt E-health technologies: an intercultural comparison. Work 2012; 41: 2072-
2080. 

35 

 
 
Definitions 

ICT-supported integrated care: 

eHealth in the setting of integrated care.  

eHealth: 

eHealth  is  the  use  of  ICT  in  health  products,  services  and  processes  combined  with 
organisational change in healthcare systems and new skills, in order to improve health of 
citizens,  efficiency  and  productivity  in  healthcare  delivery,  and  the  economic  and  social 
value  of  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.  (European Commission 2012) 

A  non-exclusive  description  of  the  term  eHealth,  set  out  in  the  European  Commission’s 
eHealth Taskforce Report, comprising the following four interrelating categories:  

1. Clinical Information Systems  

a.  Specialised  tools  for  health  professionals  within  care  institutions  (e.g.  hospitals). 
Examples are Radiology Information Systems, Nursing Information Systems, Medical 
Imaging, Computer Assisted Diagnosis, Surgery Training and Planning Systems. 
b.  Tools  for  primary  care  and/or  for  outside  the  care  institutions  such  as  general 

practitioner and pharmacy information systems. 

2. Telemedicine and homecare, personalised health systems and services, such as disease 
management services, remote patient monitoring (e.g. at home), tele-consultation, tele-care, 
tele-medicine, and tele-radiology. 

3. Integrated regional/national health information  

Networks and distributed electronic health record systems and associated electronic health 
record systems and associated services such as e-prescriptions or e-referrals. 

4. Secondary usage non-clinical systems 

a.  Systems  for  health  education  and  health  promotion  of  patients/citizens  such  as 

health portals or online health information services. 

b.  Specialised  systems for researchers and public health data collection and analysis 
such  as  biostatical  programs  for  infectious  diseases,  drug  development,  and 
outcomes analysis. 

c.  Support  systems  such  as  supply  chain  management,  scheduling  systems,  billing 
systems administrative and management systems, which support clinical processes 
but are not used directly by patients or healthcare professionals. 

eHealth  can  thus  be  said  to  cover  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;  it  can  also  include  health  information 
networks,  electronic  health  records,  telemedicine  services,  and  personal  wearable  and 
portable communicable systems for monitoring and supporting patients. 

Innovation:   

An intervention (process, technology, etc) which is not used in the organisation(s) included 
in the initiative. It could be that this intervention is already used in other settings elsewhere.  

36 

 
Adoption of eHealth:  

The decision to start using an eHealth solution.  

Deployed eHealth:  

The eHealth solution is available and ready to use by any user or patient as a routine care 
service. 

Implementation of eHealth:  

The  actual  use  of  the  eHealth  solution  in  real  practice.  This  includes  the  integration  in 
routine processes and the extent of use.  

Initiative, case, eHealth solution: 

Used interchangeably to refer to the selected cases, i.e. projects or initiatives.  

eHealth solution and Intervention:  

The specific technological activities and tools that constitutes the core of the initiative. 

37 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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European Commission 
EUR 27282 EN – Joint Research Centre – Institute for Prospective Technological Studies 

Title:  Strategic  Intelligence  Monitor  on  Personal  Health  Systems  Phase  3  (SIMPHS3)  –  Operational  Guidelines  for  ICT-
supported Integrated Care and Independent Living 

Authors: Wilco Graafmans, Ramon Sabes-Figuera, Fabienne Abadie   

Luxembourg: Publications Office of the European Union 
2015 – 37 pp. – 21.0 x 29.7 cm 

EUR – Scientific and Technical Research series – ISSN 1831-9424 (online) 
ISBN 978-92-79-48506-0 (PDF) 
doi:10.2791/31536 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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JRC Mission 

As the Commission’s  
in-house science service,  
the Joint Research Centre’s  
mission is to provide EU  
policies with independent,  
evidence-based scientific  
and technical support  
throughout the whole  
policy cycle. 

Working in close  
cooperation with policy  
Directorates-General,  
the JRC addresses key  
societal challenges while  
stimulating innovation  
through developing  
new methods, tools  
and standards, and sharing  
its know-how with  
the Member States,  
the scientific community  
and international partners. 

Serving society  
Stimulating innovation  
Supporting legislation 

doi:10.2791/31536 
ISBN 978-92-79-48506-0