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Rinnakkaistallenteet Yhteiskuntatieteiden ja kauppatieteiden tiedekunta
2018
eHealth in integrated care programs for people with multimorbidity in
Europe: Insights from the ICARE4EU project
Melchiorre MG
Elsevier BV
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© Elsevier Ireland Ltd
CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/
http://dx.doi.org/10.1016/j.healthpol.2017.08.006
https://erepo.uef.fi/handle/123456789/5178
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Health Policy
jo u rn al h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
eHealth in integrated care programs for people with multimorbidity in Europe: Insights from the ICARE4EU project 夽
Maria Gabriella Melchiorre
a,∗, Roberta Papa
a, Mieke Rijken
b, Ewout van Ginneken
c, Anneli Hujala
d, Francesco Barbabella
a,eaCentreforSocio-EconomicResearchonAgeing,NationalInstituteofHealthandScienceonAgeing(INRCA),Ancona,Italy
bNetherlandsInstituteforHealthServicesResearch(NIVEL),Utrecht,TheNetherlands
cEuropeanObservatoryonHealthSystemsandPolicies,BerlinUniversityofTechnology(TUB),Berlin,Germany
dDepartmentofHealthandSocialManagement,UniversityofEasternFinland(UEF),Kuopio,Finland
eDepartmentofHealthandCaringSciences,LinnaeusUniversity,Kalmar,Sweden
a r t i c l e i n f o
Articlehistory:
Received7December2016
Receivedinrevisedform25June2017 Accepted5August2017
Keywords:
Multimorbidity eHealth
Integratedcareprogram Olderpeople
Europe
a b s t r a c t
Introduction:Careforpeoplewithmultimorbidityrequiresanintegratedapproachinordertoadequately meettheircomplexneeds.InthisrespecteHealthcouldbeofhelp.Thispaperaimstodescribethe implementation,aswellasbenefitsandbarriersofeHealthapplicationsinintegratedcareprograms targetingpeoplewithmultimorbidityinEuropeancountries,includinginsightsonolderpeople65+.
Methods:WithintheframeworkoftheICARE4EUproject,in2014,expertorganizationsin24European countriesidentified101integratedcareprogramsbasedonselectedinclusioncriteria.Managersofthese programscompletedarelatedon-linequestionnaireaddressingvariousaspectsincludingtheuseof eHealth.Inthispaperweanalyzedatafromthisquestionnaire,inadditiontoqualitativeinformation fromsixprogramswhichwereselectedas‘highpotential’fortheirinnovativeapproachandstudiedin depththroughsitevisits.
Results:Outof101programs,85adoptedeHealthapplications,ofwhich42focusedexplicitlyonolder people.InmostcasesElectronicHealthRecords(EHRs),registrationdatabaseswithpatients’dataand toolsforcommunicationbetweencareproviderswereimplemented.Percentageswereslightlyhigher forprogramsaddressingolderpeople.eHealthimprovescareintegrationandmanagementprocesses.
Inadequatefundingmechanisms,interoperabilityandtechnicalsupportrepresentmajorbarriers.
Conclusion:FindingsseemstosuggestthateHealthcouldsupportintegratedcarefor(older)peoplewith multimorbidity.
©2017PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Chronicdiseasesarethemaincauseofmorbidityandmortal- ityinEurope,andby2030theseareestimatedtocausethedeath of52millionpeopleintheEuropeanRegion[1].Furthermore,an increasingnumberofpeopleinEurope(about50million)aresuf- feringfrommultiplechronicconditionsormultimorbidity[2,3], ofwhich60%arepeopleaged65yearsandolder[4].Thisleads topoorqualityoflifeandhighhealthcareutilization,reflectedin forexampleelevatednumbersofprimarycareconsultationsand
夽OpenAccessforthisarticleismadepossiblebyacollaborationbetweenHealth PolicyandTheEuropeanObservatoryonHealthSystemsandPolicies.
∗ Corresponding authorat: Centre forSocio-Economic ResearchonAgeing, NationalInstituteofHealthandScienceonAgeing,(INRCA),ViaS.Margherita,5, 60124Ancona,Italy.
E-mailaddress:g.melchiorre@inrca.it(M.G.Melchiorre).
hospitaladmissions[5].Thecomplexhealthandsocialcareneeds ofmultimorbidpatientsposeagreatchallengetohealthsystems andsocialservicesandrequiresnewtailoredintegratedapproaches thatarepatient-centered,proactiveandwell-coordinated.Italso couldbenefit frominnovativetechnologies tosupportpatients’
self-management and improved multidisciplinary collaboration betweenteamsofprofessionalsand/orinformalcaregivers[6–8].
However,Europeanhealthsystemsarenotyetdesignedtodeliver thecomprehensivecarepeoplewithmultimorbidityneed,since careservicesarestillfragmentedandsingle-diseasesoriented[9], andnotfullysupportedbyeHealth.
AccordingtothedefinitiongivenbytheEuropeanCommission, eHealthis“theuseofICTsinhealthproducts,servicesandprocesses combinedwithorganisationalchangeinhealthcaresystemsandnew skills,inordertoimprovehealthofcitizens,efficiencyandproductiv- ityinhealthcaredelivery,andtheeconomicandsocialvalueofhealth”
[10].ThisincludesInformationandCommunicationTechnologies
http://dx.doi.org/10.1016/j.healthpol.2017.08.006
0168-8510/©2017PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
(ICTs)thatcouldpotentiallyimproveself-management,informa- tionsystems,remotemonitoringandindependentlivingsolutions [11].eHealthtoolscouldplayakeyroleforabetterintegrationof healthcareandsocialneeds.Thisistruenotonlyinhospitaland institutionalsettings,butalsoincommunitycare.
EuropeancountrieshaveimplementedsomegeneraleHealth toolsintheirhealthcaresystems,butwedonotknowmuchabout theirlevelofimplementationinprogramsorpracticesthatprovide integratedcareforpeoplewithmultimorbidity.eHealthdevelop- mentoverthelastdecadesincludedmainlytheimplementation ofhealthinformaticsinhospitals,primarycareandinstitutional settings,withuseofpatients’ Electronic Health Records(EHRs) [12–14];theuseoftelemedicineandtelehealthservicesallowing remotemonitoringofchronicconditions[15,16];theavailabilityof someintelligent/assistivetechnologiesathometoincreaseinde- pendencyandsafetyofthepatients[17]andsupportforthefamily caregivers[18,19].Concerningtelecareforolderpeople,estimated levelsof implementationof social alarmsand similar solutions variedacrosscountries,withrelativelyhighvaluesintheUnited KingdomandIreland(14–16%ofolderpeoplecovered),medium- highinDenmark,FinlandandSweden(6–10%),andlowcoverage inagreatpartoftheremainingcountries(lessthan3%).Moreover, themainprovidersofhometelehealthservicesweremainlylocal initiatives[20].AmorerecentWHOglobalsurveyoneHealth[21]
showedthat62%ofMemberStateshavenationalpoliciesaddress- ingtelehealth.
There is some evidence showing benefits of using eHealth [12,15,17,19].Forinstance,eHealthapplicationsenableimproving coordination/integration and continuity of care between pro- fessionals by enhanced opportunities for digital data sharing, communicationandconsultationatadistance,whichalsoreduces healthcare utilization costs [22]. Moreover, patients can over- comebarriersforaccessinghealthcare servicesand alsobenefit from better monitoring and continuity of care, improved self- care/managementandindependentlivingathome(especiallyfor theolderpeople).Yetvariousregulatory,technicalandeconomic barriersexistthatmaylimittheadoptionofeHealthtechnologies [17,20,23],inadditiontolacking/limiteddigitalskillsorcultural resistanceofpotentialusers,especiallyolderpatients[24,25].
Onthewhole,studiesuseavarietyoftermsinterchangeably (e.g. telecare/telemonitoring, telehealth/telemedicine) and gen- erally investigatetheuseof eHealthfor chroniccare, and only indirectly target people with multimorbidity. Moreover, these studiesmainlyfocusonthegeneralpopulationratherthanspecific groupsliketheelderly.Toourknowledge,literaturewithaspe- cificfocusoneHealthimplementationinintegratedcareprograms orpractices forpeoplewithmultimorbidity isvirtually lacking.
Therefore,ourresearchquestionsare:
1TowhatextenthaveeHealthapplicationsbeenimplementedin integratedcareprogramstargetingpeoplewithmultimorbidity inEuropeancountries?
2Whatarethe(reported)outcomes/benefitsoftheuseofeHealth applicationsinintegratedcareprogramstargetingpeoplewith multimorbidity?
3Whatarethe(reported)barriersfor(further)implementation?
Theseresearchquestionsarefurtherexploredwithregardto possibledifferencesbetweenadultsandtheelderly(over65years old).
2. Methods
Thecareprogramsthatareanalyzedinthispaperoriginatefrom theProject“InnovatingCareforPeoplewithMultipleChronicCon-
ditionsinEurope”(ICARE4EU).Thisprojectwasinitiatedin2013 tocontributetotheinnovationofcareforEuropeancitizenswith multiplechronicconditionsbygainingmoreinsightintopoten- tially effectiveand efficient patient-centered, multi-disciplinary careapproachesthathavebeendevelopedandimplementedin31 Europeancountries[3].
2.1. Inclusioncriteriaoftheprograms
Programswereconsidered forinclusion in thesurvey when meetingallthefollowingcriteria,whichwereidentifiedviaalitera- turereviewandagreedbythepartnersoftheICARE4EUConsortium [26]:
–targetadult people(aged18 andolder) withmultimorbidity, defined as two or more medically (i.e. somatic, psychiatric) diagnosed chronic(notfully curable)or longlasting (atleast six months) diseases, ofwhich at least onehasa (primarily) somatic/physicalnature;
–include formalizedcollaboration(s) betweenat leasttwo ser- vices;
–involveoneormoremedicalservice(s);
–areevaluable/evaluatedinsomeway;
–currentlyrunning(2014),orfinishedlessthan24monthsago,or startwithinthenext12months.
2.2. Datacollection
Inafirststep,informationonprogramswascollectedwiththe supportofexpertorganizations/programmanagersineachcountry includedinthestudy.Alistofpotentialcountryexperts–working inorganizationsinthefield–wasconstructedforeachofthe31 countriesoftheEuropeanregionincludedinthestudy,andval- idatedwithinputfromallpartnersoftheICARE4EUConsortium (ownextensivenetworkandrelevantexpertise),accordingwith thefollowingselectioncriteria:theorganizationisaformalbody;
hasexpertiseonmulti-morbiditycare;canprovide/accessto(by anextensivenetworkofexperts)reliableinformationoninnova- tive,multi-disciplinarycareapproaches/programsforpeoplewith multiplechronicconditionsinitscountry;thecontactpersonfrom theexpertorganizationisfluentinEnglishandhastheroleofcoor- dinatingthevariousactorswhowillprovideinformationforeach program/initiative.
Countryexpertswereapproachedviaemailandaskedtoverify whether their organization meets the above mentioned selec- tion criteria and would be able to participate in the survey, also by providing someevidence of theirexpertise (e.g. publi- cations, CV, organization and personal web pages). They were askedtosearchandidentifyexistingcareprograms/approaches at a nationalor regional level (orlocal,if information is avail- able), and toreport detailed information onallintegrated care programsfocusingonmultimorbidityintheircountry,bymeans ofa linktoaweb-surveyand fillingin anonlinequestionnaire foreacheligibleprogram/initiative,alsowiththesupportoftheir expertnetworkandprogrammanagers/leaders.Theonlineques- tionnairewasavailableinelevenlanguages(whenEnglishwasnot knownbymanagersofprogramssupportingthecountryexperts in filling inthe questionnaire)and contained a shortintroduc- tionwithinstructionsandgeneralquestions(e.g.informationon patients,qualityandevaluationoftheprogram).Keyelementsof multimorbiditycarewereaddressedfromthefollowingperspec- tives:patient-centerednesse.g.involvementofpatient/familyin thedevelopmentofthecareplan;managementpracticesandpro- fessionalcompetencies,e.g.collaboration,integration,exchangeof informationamongprofessionals;financingmechanisms/systems use,e.g.public/privatefunding,reimbursementmechanism;and
useofeHealthtechnologieseventually adoptedwithinthepro- gramsthemselves,toenhancetheprevention,diagnosis,treatment andmanagementofhealth/diseases.
Accordingtotheabovementionedinclusioncriteria,thecoun- tryexpertsidentifiedinitially 189integratedcare programsfor patientswithmultimorbidityin25Europeancountries(outof31 countriessurveyed).Afterafurthercriticalreviewperformedby theICARE4EU partners,inordertoverifytheiractualeligibility, 77programswereexcludedfordifferentreasons,includingalack ofmultimorbidityfocus,unavailabilityofevaluationresults,ora lackofpropercarepractices(e.g.,initiativeswereonlyprotocolsor guidelines).Furthermore,dataon11Frenchprogramswerenot complete due tostaffproblems of therelated expert organiza- tion,andtheseprogramswerediscardedforthepurposesofthis analysis.Thusthefinaldatasetconsistsof101programsfrom24 Europeancountries.
Inasecondstep,eightgoodpracticeswereselectedforanin- depthcasestudyanalysis,includingsitevisitandfurtherqualitative datacollection(i.e.purposefullyselectinginformation-richcases) [27].Tothisend,theprojectteamassessedthe101programson thebasis of quantitative and qualitative criteria. Each program wasscoredinfivedimensions:(1) ageneralscore (e.g.evalua- tiondesign,perceivedsustainability andtransferability),andan indicationofitslevelof(2)patient-centeredness,(3)integration ofcare,(4)useofeHealthtechnologiesand(5)itsinnovativeness infinancingmechanisms.Thisledtoidentifythe‘top’eight‘high potential’programs(intheranking)tobeobjectofcasestudyanal- ysis.TheseprogramswereoperationalinBelgium,Bulgaria,Cyprus, Denmark,Germany,Finland,theNetherlandsandSpain.Weused aqualitativecasestudymethodology,thatallowsunderstanding complexphenomenawithintheircontexts,byexploringindivid- uals(e.g.programmanagers,keycareprofessionalsfromvarious disciplinesorservices),organizations,relationshipsorprograms using multiple data sources [28,29]. Site visits were organized to integrate the quantitative survey data and to gain insights inintegratedcarepractices,byscrutinizingcontextsandrelated ordinaryactivities[30].Informationweregatheredbyusingacom- monmethodologicalframework(e.g.withdetailsonparticipants andorganisationofinterviews)forconductingsemi-structuredin depthinterviewswithprogramstaffandeventuallypatientsand theirfamilycarers(approximatelyfiveinterviewsperprogram).
Atopicguide-questionnairewasusedin allsite visits,inwhich weaskedtheirexperienceswiththeprogramandfurtherdataand reflectionsoveritsimplementation.Wealsocollectedrelevantpro- gramdocumentsifavailable(e.g.interimorfinalreports,program evaluations).Allinterviewswereconductedeachbytwomembers oftheICARE4EUprojectteamandwererecorded.Atranslatorwas arrangedwhennecessary.Intervieweesreceivedthedrafttextof thecase reportforvalidation,andapprovedthefinalreport.All intervieweessignedawritten/informedconsentformandanagree- menttorecordtheinterviewsandpublishtherelatedcasereports.
Theresultsofthesevisitsaredescribedineightcasereportsthat werepublishedontheICARE4EUwebsite(www.icare4eu.org),and areeditedfollowinga commontemplate withsectionsforeach keydimensionofmultimorbiditycareusedintheproject(patient- centeredness,integrationofcare,useofeHealthtechnologies,and financingmechanisms).Forthispaperweonlyanalysedinforma- tionfromthose highpotentialprogramsthatincludeaspectsof eHealth(i.e.sixoutofeightprograms).
2.3. Measures
Withregardtothetype ofeHealth,literatureprovidesmany examples which seem relevant to support integration of care in programs or practices targeting peoplewith multimorbidity [20,31–33].Inthisrespectwedistinguishedfourcategoriesbytheir
mainfunctions,andinordertostructurefindingsbyaccountingfor thediversityofeHealthoptions,webuiltaclassificationbyadapt- ingelementsoftheconceptualframeworkfromtheChronicCare Model(CCM)[34]andtheeHealthEnhancedChronicCareModel (eCCM)[35].ThefourtypesofeHealthareICTtoolsfor:Remote Consultation,MonitoringandCare;Self-Management;Healthcare Management;andHealthDataAnalytics[36].
1Remote Consultation, MonitoringandCare: ICTtools providing remote interaction between patients and health profession- als at distance (e.g. consultations and visits by telehealth and telemedicine services, continuous monitoring of specific conditions). Specific toolsfor thecommunication are on-line scheduling ofclinicalappointments, ePrescriptionsand direct communicationwithhealthcarestaff.
2Self-Management: ICT tools (e.g. computers, tablets, mHealth, wearabledevices,otherassistivetechnologies)providinghealth adviceandreminders,andpromotingabilitytoself-care,usedby patientstolivemoreindependently.Alsotoolsusedbyinformal carerstoco-managecareactivitiesorforsupportingtheirown psychologicalandsocialneeds.
3HealthcareManagement:ICTtoolsforimprovingtheintegration, qualityandefficiencyofcareprocesseswithinandbetweencare providers(e.g.EHRsand health informationsystems onindi- vidualsfortheirsharingbetweenprofessionals;personalhealth records – PHRs– managed by patients). Moreover,ICT tools canbeused tomanage thecollaborationandcommunication betweencareprofessionals(e.g.eReferralsystems).
4Health DataAnalytics: ICTtoolswhich analysedatainpatient databases and/orclinicalevidence for prevention,monitoring andtreatmentpurposes,forinstance:decisionsupportsystems (DSSs)usedbyhealthprofessionalsforclinicaldecision-making;
risk stratificationsystemsfor monitoringthehealth dataofa regionalornationalpopulation,andidentifyingpeoplewithspe- cifichealthrisks.
Furtheraspectsthatwereanalyzedinthestudyarethetrain- ing on use of eHealth for care providers and patients; data security/privacy when using health information technologies;
innovationineHealthtoolsspecificallydevelopedfortheprogram.
Toexplorepotentialbenefits[e.g.19]andbarriers[e.g.20]ham- peringtheadoptionofeHealthwithinthemappedintegratedcare programs,weaskedforagreement/disagreementofmanagerswith regardto:
–fivepotentialimprovementsconcerningthequality,integration andmanagementofcare,thequalityoflifeofpatientsenrolled, andcost-efficiencyoftheprogram;
–twelve potential barriers concerning inadequate national eHealth legislative framework, funding, ICT infrastructures, technical-ICTsupport;lackofskillsinusingeHealthamongcare providersandpatients;generalculturalresistanceandresistance bycareprovidersandpatients;uncertaintyaboutcostefficiency;
compatibility/interoperabilitybetweendifferenteHealthtools;
privacyissues.
2.4. Dataanalysis
For thispaperwehavefirstanalyzed thequestionnairedata onthe101integratedcareprogramstargetingpeoplewithmul- timorbiditywithregardtosomegeneralcharacteristics,andthen moreindepthontheiruseofeHealthsolutions(e.g.frequenciesand bivariaterelations).WethenanalysedtheidentifiedeHealthsolu- tionsontheir(reported)outcomesandthe(reported)barriersfor (further)implementation.ThebivariaterelationbetweeneHealth aspectsandageofpatientsinvolvedintheprogramswasalsoana-
lyzed.Insightsonprogramsforpeopleaged65years andmore, comparedtotheprogramstargetingadultpeople(aged18+years) ingeneral(i.e.programsnotspecificallytargetingolderpeople,but withoutexcludingthem),werereportedwhenrelevant.Thesta- tisticalsoftwareSPSS15.1wasusedtocarryoutthequantitative analyses.
Moreover,qualitative informationfromsixsitevisitsofhigh potentialprograms provided additional insights withregard to benefitsandbarriersandhowprogramshaveusedeHealthtools intheircaredeliverytopeoplewithmultimorbidity.Thequali- tativedataanalysiswereperformedbyexploringthecasestudy reportsfromtheeHealthperspective,usingaskeywordstheterms presentedintheparagraph2.3andTable2ofthispaper.Amanual codingprocesswasperformed[37]andledtoconventionalcon- tentanalysis[38] withthepurposeofidentifyinginterrelations andcausalrelations betweenkeyprogram elementsconcerning primarilyimplementationandoutcomes.
3. Results
3.1. IntegratedcarepracticesinEuropeancountries
Among the 101 integrated care programs mapped by the ICARE4EUstudy,50specificallytargetedolderpeople.Countries withthehighestnumberofprogramsidentifiedareSpain(n=15), Greece(n=9),andGermany(n=8),whereasfromAustria,Portugal, Slovenia,SwitzerlandandtheUnitedKingdom(UK)onlyonepro- grammettheinclusioncriteria.Furthermore,82%ofprogramswere stillrunningatthetimeofthequestionnaire.Theprofileoftheorga- nizationsincludedintheanalysisandtheircharacteristicsarethe following(Table1):
–themainobjectiveis increasingthelevelof multidisciplinary collaboration(80%oftheprograms),in additiontoimproving patientinvolvementandcarecoordination(both71%).Reducing hospitaladmissions(69%)wasalsomentionedaskeyobjective;
–regardingthetypesoforganizationsandcareprovidersinvolved, primarycarepractices(70%)andgeneralpractitioners(81%)were respectivelymostoftenmentioned;
–regardinglevelsofintegrationwithhealthcaresystems,imple- mentationand geographical coverage, 42% of programswere fully integrated, 77% overall were operating mainly at a local/regionallevel,and78%coveredbothruralandurbanareas.
3.2. IntegratedcarepracticesusingeHealthapplications
Outof101programsidentifiedin24countriesbytheICARE4EU project,85includedeHealthtools,ofwhich42focusedexplicitly onolderpeople.Thescaleoftheinitiativesremainedmostlylocal and/orregional(78%),although62%oftheprogramsoperateatboth policy/managementandpatientcarelevels,45%wereintegrated intotheregularhealthcaresystem,and82%coveredrural/urban areas.
A wide variety among the tools in these 85 programs was foundand subsequently classified in four categories (Table 2).
ThethreemostusedeHealthapplicationswereEHRs(71%),reg- istration databases with patients’ health data that can support decision-making(64%)anddigitalcommunicationbetweencare providers(47%),whichcomeunderHealthcareManagement,with aslightlyhigheruptakeofthesetoolsamongprogramsfocusing ontheelderly(respectively,76%, 67%,and 52%).OthereHealth applicationsthatcouldbeespeciallybeneficialtomeetthevery complexhealthneedsofmultimorbidpatients,suchasthosesup- porting self-managementof patients(e.g. electronicreminders, computerizedtools),computerizeddecisionsupportsystemsfor
Table1
Generalcharacteristicsoftheprograms(%).a
Allprograms N=101 Mainobjectives
Increasingmultidisciplinarycollaboration 80
Improvingcarecoordination 71
Improvingpatientinvolvement 71
Reducinghospitaladmissions 69
Organizationsinvolved
Primarycare 70
Generalhospital 57
Universityhospital 41
Careprovidersinvolved
GeneralPractitioner 81
Medicalspecialists 66
Integrationlevel
Fullyintegratedintheregularhealthcaresystem 42 Well-establishedandcomprehensiveprogram 33
Smallscale(pilot)program 26
Implementationlevel
Regional 30
Local 29
Local/regional,aspartofanationalprogram 18
National 14
National,aspartofinternationalprograms 7
International 3
Geographicalcoverage
Bothruralandurbanareas 78
Onlyurban 16
Onlyrural 6
aTheprogramswereidentifiedinthefollowing24Europeancountries:Spain, Greece,Iceland,Germany,Italy,Finland,TheNetherlands,Denmark,Sweden,Lux- embourg,Bulgaria,Cyprus,Belgium,Croatia,Malta,Lithuania,Norway,Ireland, England,Austria,Portugal,Slovenia,Latvia,andSwitzerland.Noeligibleprogram wasidentifiedinRomania,CzechRepublic,Hungary,Poland,Slovakia,andEstonia.
InformationonFrenchprogramswasincompleteandthusexcludedfromtheanal- ysis.
professionals,andmonitoring/interactionatdistance,arelessused bytheprogramsandnotyetwidelyimplemented.Inparticular, self-managementonlinedecisionsupports(4%)weretheleastfre- quentlyimplementedtools.Although47%ofprogramsusedigital healthcarecommunicationsforsharinginformationbetweendif- ferentcare providers(see above)only 29%ofprograms(31%of programsfocusingontheelderly)usesuchsystemstoalsocom- municatewithpatients.Furthermore,themostfrequentlyadopted formofelectronic/remotehealth consultationby providerswas monitoringofpatienthealthstatusparameters(33%ofprograms, 45%ofprogramsfocusingontheelderly).
Furtherinformationgatheredbythesurveyshowedthataccess toEHRswasmainlyallowedtomedicalcareprovidersinvolvedin caredelivery(58%)ratherthanpatients(10%),andoverhalfofthe programsprovidedtrainingontheuseofeHealthtoolstothecare providers(52%),butonly24%providedittothepatients(ortheir representatives,e.g.carers).Thesepercentagesareslightlyhigher forprogramsaddressingolderpeople(55%and26%).About70%of thesurveyedprogramsassuredprivacy/confidentialityofmedical information,59%addresseddatasecurity/riskmanagement, and 57%disclosedallnecessaryinformation neededbyapatientfor makinganinformeddecision.Theseaspectswereevenfoundless inprogramstargetingtheelderly,with36%ofthemnotaddress- inganyoftheseissues.Concerninginnovation,in30programs(of which18 focusingontheelderly)outof 85programsadopting eHealthsolutions,toolswerespecificallydevelopedforthepro- gram.
Table2
eHealthtoolsimplementedintheprograms,bycategories(%ofprograms).a
AllprogramsN=85 ofwhichfocusedexplicitlyonolderpeopleN=42 RemoteConsultation,MonitoringandCare
Monitoringofhealthstatusparametersbyproviders 33 45
Communicationbetweencareprovider/patient(incl.ePrescription) 29 31
Monitoring/interactionatdistance(e.g.byvideo,phone) 27 36
On-lineappointmentscheduling 26 21
Registrationofhealthstatusparametersbypatients 25 29
Self-management
Electronicreminders 26 24
Computerizedself-managementtools 25 29
On-linedecisionsupports 4 5
Healthcaremanagement
Databaseswithpatients’healthdata 64 67
ICT-basedcommunicationbetweencareproviders 47 52
Systemsprovidingwarningmessages/recommendations/information 35 36
eReferralsystems 33 31
Electronicreminders 27 31
PHRsbused 18 21
PHRsbplanned 7 5
EHRsbused 71 76
EHRsbplanned 13 10
WhocanaccessEHRs
Relevantmedicalcareproviders 58 58
Allrelevantcareproviders 47 50
Patients 10 11
HealthDataAnalytics
Computerizeddecisionsupports 35 29
On-linedecisionsupports 15 17
aThistableispartlyadaptedfromapublicationoftheauthors:[36]Barbabellaetal.
bEHRswereusedin60programs(32focusingolderpeople)andwereplannedin11programs(4focusingolderpeople);PHRswereusedin15programs(9focusingolder people)andwereplannedin6programs(2focusingolderpeople).
Fig.1. BenefitsofusingeHealthtoolsincludedintheprograms(%agreeing).
3.3. Potentialbenefits
ICARE4EUfindingsseemtosuggestsomepotentialbenefitsof eHealth,asreportedbyprogrammanagers.Amongtheprograms usingeHealth,95%reportedthatmanagementprocessesimproved, 93%agreedthatcareintegrationwasenhanced,and86%confirmed thatqualityofcareprovidedhadincreased(Fig.1).Benefitswere alsoreportedintermsofcost-efficiencyoftheprogram(76%)and inthequalityoflifeofpatientsenrolled(70%).Thesebenefitswere alsoreported(withslightlyhigherpercentages)forprogramstar- getingtheelderly.
General benefits emerging in the project survey were also supportedbysitevisitsofthesixhighpotentialprograms.Improve-
mentsofmanagementprocesses,asenhancedcarecoordination andintegration,seemvisibleintheGesundesKinzigtalprogram inGermany[39],where thephysicians shareEHRsand canuse digital benchmark information to compare their prescriptions.
AnotherexampleisthesharingofEHRs,notonlyamongphysi- ciansbutalsoamongpatientsintheprogram,asoccursintheClinic forMultimorbidityandPolypharmacyinDenmark[40],wherea RegionalElectronicPatientJournalisusedtoaccessinformationon apatient’smedicalhistory.TheINCAprogramintheNetherlands alsoplanstoimplementcareprofilesforpatientsthatareaccessi- blebyprofessionalsandpatientinadedicatedon-lineapplication [41].
Thepotentialbenefitsofadvanced decision supportsystems (DSSs)anddatamanagementarevisibleintheStrategyforChronic CareintheValenciaRegioninSpain[42].Thisprogramoperatesa computerizedDSSforprofessionalsbyconnectingavailableclini- calevidenceonadequatetreatmentsandbestpracticeswiththe complexprofileofmultimorbidpatients.Anotherexampleisthe FinnishPOTKUproject[43],whichemploysacomputerizeddeci- sionsupporte-toolforGPs.Thissystemconnectsevidencebased medicalinformationwiththepatientrecordsandprovidesindi- viduallycustomizedcareguidance,remindersandwarnings.Inthe SpanishStrategyforChronicCare[42]thequalityofcareprovided tothemostcomplexpatientsreportedlyimprovedbecauseapopu- lationstratificationsystemenablesidentificationofat-riskpatients followedbyatargetedpreventiveandproactiveintervention.
eHealthtoolscouldalsoimprovethequalityoflifeofpatients with multimorbidity living at home. For example, the POTKU projectinFinlandstimulatesself-managementusinginstruments thatempowerpatientstocheckcopingbehaviorsandadherenceto treatment,whichareaparticularchallengeformultimorbidper- sons[43].
Finally, remote monitoring and therapies at a distance can improveaccesstohealthcareservicesandthequalityoflifemul- timorbidpatientsespeciallyinrural/deprivedareas.Forexample, theTeleRehabilitationprogrammanagedbytheNicosiaGeneral HospitalinCyprusprovidesacardio-respiratoryrehabilitationser- viceatadistance[44].Thisserviceappliesadvancedtelemedicine servicestopatientsafterdischargefromhospital.Ithasmanaged toreducereadmissionsandthusprovedtobecost-effective,while atthesametimemaintaininggoodsatisfactionamongusersand healthprofessionals.
3.4. Potentialbarriers
As shown in Fig. 2, various barriers hampered the use of eHealth tools in integrated care programs. As reported by the programmanagers,theseinclude:inadequatefunding(60%);com- patibility/interoperability problemsbetween differenttools and inadequatetechnical/ICTsupport(55%both);lackingITinfrastruc- ture(53%);thelackofskillsinusingeHealthamongpatientsand providers(respectively,52and45%);andthelackofadedicated legislativeframework(50%).Otherbarriersthatwerementioned rangedfrom22to40%wereuncertaintyoncostefficiencyofthe program,privacyissues,andculturalresistancetoadopteHealth toolsbyproviders(33%)andpatients(22%).Therearenolargedif- ferencesbetweenprogramstargetingadultsorelderly.However, greaterthan10percentagepointdifferenceswerefoundin“lack oftechnologicalskillsamongcareproviders”(occurredmoreoften amongprogramsfocusingontheelderly)andinadequatefunding (mainlyreportedinprogramsforthegeneralpopulation).
FurtherinsightsconcerningbarriersfortheadoptionofeHealth werealsogatheredfromthesixabove-mentionedpromisingprac- tices. Questions/issues related to funding are reported in two programs.First,theStrategyforChronicCareintheValenciaRegion inSpain[42]usesICTssolutionsasafundamentalpillarbutithasto befinancedfromusualcarefundingoftheregionalhealthsystem.
Second,theTeleRehabilitation programin Cyprus[44]doesnot haveanyfinancialincentivesforstafforforpatientstoparticipate intheprogram.
Compatibility/interoperabilityproblemsemergeinseveralpro- grams. First, the POTKU project in Finland [43] is challenged byincompatible informationsystemsbetweenhealthand social care.Second,theDanishprogram ClinicforMultimorbidity and Polypharmacy[40]suffersfromdifferentIT-recordingsystemsin hospitals,whichmakesitmoredifficulttoutilize/exchangepatient recordsamongclinicians.
SeveralexamplesofbarriersareseenintheGesundesKinzigtal programinGermany[39].IthasalimitedITinfrastructureinthe remoteareasofKinzigtalandthemajorityofthetargetpopulation (relativelyhighaverageage)isreluctanttoadopteHealth,alsodue tolackoftrustregardingdatasafety.Lastly,thelimitedelectronic skillsofsomepatientsalsopreventahighlevelofself-management intheINCAprograminNetherlands[41].
4. Discussion
The ICARE4EU study reports the pioneers or good practices inintegratedcareprogramswhicharecurrentlyimplementedin Europe.Theoverallfindingspresentedinthispaper,inthelightof theadaptedconceptualframeworkwederivedfromtheCCM[34]
andtheeCCM[35],seeminparticulartosuggestthateHealthhas somepotentialtosupportintegratedcareformultimorbidity.How- ever,thefactthatthesurveywasbasedonthepersonalexpertise andperceptionofcountry-expertsandprogrammanagers,with- outexploringfurtheractors(suchaspatientsandtheircaregivers) duetoprojectconstraints,posesproblemsregardingreliabilityand objectivityoftheiranswers,andthiscontextshouldthusleadto somecautionintheinterpretationofresults,inparticularthose concerningthepositivepotentialofeHealth.
TheresultsfromtheICARE4EUstudyshowonthewholehuge variationintheadoptionofeHealthapplicationsinintegratedcare programsformultimorbidityinEurope.MostwidespreadareEHRs, followedbyregistrationdatabaseswithpatients’healthdatathat cansupportdecision-makinganddigitalhealthcarecommunica- tion(usedmostlytocommunicate amongproviders).Moreover initiativesfocusingontheelderlyshoweda somewhatelevated uptakeofthesetoolscomparedtoallprogramscombined.Other eHealthapplicationswithparticularrelevanceforprovidingper- soncenteredintegratedcaretopeoplewithmultimorbidity,such asadvanced electronicdecisionsupportsystems forphysicians, self-managementsupportofpatients,andelectronicsystemsfor telemonitoringcareprocessesarenotyetwidelyimplementedand revealgreatpotentialforimprovement.Thelattertwoinparticu- larhinderthepossibilityofageing-in-placeforolderpatientswith long-termconditions[45],thatisintheirhomeorinotherliving settings/facilities,withinthecontinuumofcare[46].
This high use of EHRs, and the limited adoption of more advancedeHealthsolutionsarealsoconfirmedbyavailableliter- ature,althoughmoreingeneralthanasspecificapplicationsfor peoplewithmultimorbidity.Inotherwords,thereisalackofstud- iesintheliteratureprovidingevidence(intermsofbothclinical andeconomic indicators)tosupporttheintroductionofICTsin integratedcareprograms,andavailabledatashowaquitelimited progressofeHealthimplementationspecifictomultimorbiditycare inEurope[21,32].Europeancountrieshaveindeedadoptedgeneral andlimitedeHealthservices,andfromsuchacontextcomeinturn negativeconsequences(aslackingdedicatedeHealthsupport)for peoplewithmultimorbidity.Inparticular,policyinterventionsin EuropehavefocusedmainlyonEHRsandinformationsystemsin acuteandsecondarycaresettings[13],whereastheimplementa- tionanduseofeHealthbyGPsandprimarycareisfarlessadvanced [14].Furthermore,literatureontoolsforHealthcareManagement andinformationsystemsforriskstratification,thatisanalysisof bigdatasetsatthepopulationlevelandrelatedHealthDataAna- lytics,arenot yetdevelopedandmappedfor multimorbidityin Europe,althoughsomepromisingresultsforothertargetgroups arereferred[21,36].Itistohighlightalsothatafewstudieshave addressedpeoplewithmultiplechronicconditionsbecauseclini- calresearchandhealthcareorganizationarestillinfluencedbya disease-orientedapproach[9].
Fig.2. BarriershamperingtheuseofeHealthtoolsincludedintheprograms(%agreeing).
Ourstudyalsoprovidesinsightsintheroleofpatients(ortheir familycaregivers).Theyarelessinvolved(thanproviders)intheuse ofeHealthtools,havelessaccesstoEHRsandonlyhavefewoppor- tunitiesforspecifictrainingandeducationservices.Withregard tosharingofelectronichealthinformationwithpatients,weonly foundfewexamplesthatenablethis[40,41].Moreover,ensuring privacyandsecurityofpersonalmedicalinformation,aswellas providingallnecessaryinformation relatedtotheuseofhealth technologybyprofessionalstopatients,areimportantaspectsthat arenotyetfullyimplementedbyallthemappedprograms.These constituteimportantbarriersforawiderdeploymentofeHealth.
Inparticular,lackingprivacyofpatientsandsecurity/protectionof medicaldatacannegativelyimpactsocialacceptanceoftelecare [25].MoreencouraginglyfindingsfromarecentWHOsurvey[21]
showedthat80%ofMemberStateshavenationallegislationtopro- tecttheprivacyofhealthdatainelectronicformat,whichclearly indicatesastrongnationallevelcommitmenttoeHealth.
Furthermore, different infrastructural, policy and practical barriers hinder the further development and implementation of eHealth tools in multimorbidity care. We mainly found:
(1) inadequate funding/incentives mechanisms, (2) compatibil- ity/interoperability issues between different tools/systems, (3) inadequatetechnical/ICTsupport and infrastructure,(4) lacking skills inusing eHealthamong patients(which is alsolinkedto lackingtrainingopportunitiesforpatientsmentionedabove),and providersand(5)lackingdedicatedlegislativeframeworks.Obvi- ously,manyoftheseareinterrelatedandtheyarenotexclusiveto programstargetingpeoplewithmultimorbidity.
Limitedfundingcannegativelyimpactinvestmentinadequate ICTsupportandintrainingservicesforbothusersandproviders [23,26].Inaddition,inadequatefundingcouldhamperinnovation.
Ourresultsshowedthatonlyin30outof85programs,eHealth toolswerespecificallydevelopedforthatprogram.Inmostcases, existingapplicationsortoolswereusedwithonlyfewadaptions.
InadequateICT infrastructures,which alsolimitinteroperability between different tools, hinder the integration within existing healthcaresystems[25,47]andtheintegrationbetweendifferent providers[48].
Otherimportantissueshighlightedinpreviousstudiesarethe lackofelectronicskillsamongpatientsandproviders,whichper- haps also nurtures (cultural) resistance in using eHealth tools [49,50].This seemsunfortunateas a positive attitudeand per- ceptionamongphysicianscouldplayanimportantroleinmaking hometelehealthservicesmoreacceptablefortheelderlypopula- tion[51].
LiteraturealsofoundthatdifferentlegalframeworksandEHR systemsamongcountries[52]aswellaswidelydivergingviews among European policymakers, make it hard to find common groundandthuslimittheuseofeHealth[53].Inparticular,clearleg- islativeframeworks(e.g.eHealthpolicyandstrategy)andexplicit attributionofresponsibilitiesatEuropeanandnationallevelseem lacking[54].
Despitethesebarriers,somebenefitsofeHealthhaveemerged, althoughonlyfromtheviewofcountry-expertsandprogramman- agers,andinsomecaseswithslightlyhigherrelevanceforprograms targeting theelderly.These benefitsseemfirst of allrelated to
thesupportofcareintegrationandcoordination amongprofes- sionalsbymeansofsharedEHRsanddigitalcommunication,but alsoto decision making of professionals by meansof DSSs for selectingappropriatetreatmentsandbestpractice.eHealthfurther seemstoenablethefollowing:remoteconsultationsthusallowing accesstohealthcareservicesinparticularforpeoplewithcomplex needs; self-managementfor people withmultimorbidity living athome;riskanalysisandproactiveintervention.Moreover,risk stratificationsystemcanconstituteagoodtoolforsupportingthe monitoringofpeopleathealthriskorwithcomplexprofiles,lead- ingtobetterpolicyandpracticesforprevention,earlydetectionand treatmentofmultiplehealthproblems[36].Literatureinparticu- larsuggeststhateHealthadoptioninthehealthcaresectorcanbe effectiveinreducingcarefragmentationandimprovingcontinuity ofcare,whichisespeciallyimportantforelderlyandmultimorbid patients,duetotheinvolvementofmultipleprofessionalsdealing withmultiplediseases[55,56].Lastly,remoteservicesinparticular seemstoempowerpatientsbygivingthemtoolstoself-manage andlivemoreautonomousintheirhomeandenablethemtokeep livingin deprivedand rural communities,thus increasingtheir qualityoflifeandpossibilitytoaccessadequatecare[15,25,57].
Inparticulartelehealthseemstobea“safeoption”fordeliveryof self-managementsupport[58].
Apartfromtheabovementionedpotentialbenefits,itseems thateHealthprimarilysupportstheintegrationofcareratherthan, forinstance,thecost-effectivenessofthedeliveredcare.Thisrep- resentsasatisfactoryoutcome,sinceoneofthemajorgoalsand functionsof eHealthisindeed toenablebettercareintegration betweendifferentproviders,actors,institutionsorservices.Fur- thermore,theeHealthtoolsmappedrepresentusuallyacomponent withincomplexintegratedcareprograms,wherethedifferentcom- ponentsneedtobeevaluatedtogetherinacomprehensiveway –ratherthanontheirown–becauseofexistingsynergyeffects, alsoinconsiderationoftheimpactonpatients’qualityoflifeand cost-effectiveness.
Ourfindingsseemthusinlinewithpreviousevidenceandthe Chronic CareModel,showing that thekey challengefor multi- morbiditycareistoorganizeandprovideanintegratedsystemof chroniccare[59],alsobyprofilingthedifferentneedsofpatients for population-based interventions [60], and by enhancing an effective“collaborativecare management”byboth patientsand professionals/healthcareproviders,thussupportingself-care[61].
Literatureshowsinparticularthatwhenthewell-establishedCCM isexpandedaseCCMwiththeadditionofeHealthtechnologies[35], itcanfurtherimprovehealthoutcomesforpeoplewithchroniccon- ditions,supportpatient-providerinteractions[62,63],andenhance self-management[64,65].Moreover,giventhatinspecificeHealth educationisacrucialissueforself-care,animportantexpansionof theCCMregardstheadditionof“eHealthEducation”,inorderto provideconsumers/patientswiththenecessarydigitalhealthliter- acyskills[66].Accordingwithourfindingsindeed,thelackofdigital skillsamongpatients(andproviders)wasanimportantbarrierto implementingeHealth.
Theoverallfindingspresentedinthispaperseemthustohave identifiedonthewholesomeofthekeyfactors(e.g.barriersand benefits)fortheimplementationofICTsupportinintegratedcare andalsotherelatedrequiredchanging/challengesinthemanage- ment.Thepositivereportsofthecountryexpertorganizationsand managersinterviewedintheICARE4EUstudyareindeedconsis- tentwithbasicaspectsofchangemanagementwhicharereported intheliterature[67].TheadoptionofeHealthformultimorbid- ityimpliesindeedtocreatea“vision”fordirectingthe“change”
effort,todevelopstrategies foraddressingthe“vision”itself,to supportthe“change”processwithnewapproachesbyencourag- ingboththerisktaking(againstthestatusquokeeping)andthe teamwork.However,thereportsfromcountry-expertsandpro-
grammanagersinvolvedinourstudymighthaveunderestimated criticalproblemsandissuesoccurringduringtheimplementation ofeHealthservicesinthehealthcaresector.Therolesofpartici- pants/respondentsinoursurveycouldindeedhaveinfluencedtheir almostpositiveviewsontheseissues.Asliteraturesuggests[68,69], complexeHealthprogramscouldraiseproblemsintheirimple- mentation,thusrequiringtobeadaptedandrefinedinduecourse, inordertomeetappropriatelytheneedsoftheusersandrequired qualityofservices.
Therearesomehealthpolicyimplicationsthatcouldbecon- sideredtoexploitthepotentialofeHealthforcomplexneedsof peoplewithmultimorbidity[36].Inthisrespect,thefollowinggen- eralindicationscouldbehighlightedforsupportingtheadoption andimplementationofeHealthsolutionsformultimorbiditycare inEurope:definingcommonpublichealthobjectivesand prior- ities for peoplewithmultimorbidty; developing adequatelegal andfundingframeworksforlargescaleimplementation;carrying outcomprehensiveeducationalcampaignsthataddresstrainingof patients,familycarersandhealthprofessionalsondigitalhealth literacy;supportingabetterinteroperabilityofEHRsinEuropean healthcaresystems,introducingpersonalizedmedicineservices;
promotingnewregulationsregardingmobilehealthsolutionsfor self-management;adoptingregional/nationalpopulationstratifi- cation systems, toenable continuousmonitoring and proactive interventions;promotingDSSstoimprovethehealthprofession- alsdecisionmaking process.Theselast twomeasurescouldfor instancehelpGPs andspecialistsinswitchingthefocusofmul- timorbiditycarefromadisease-orientedtoaproactiveapproach for healthpromotion and prevention.Relevant,fora successful deliveryofintegratedcareingeneral,andforICTdeploymentin particular,seemstobealsoan integratedgovernance structure withtheinvolvement/cooperationofallstakeholdersandindus- try,inordertodevelopsolutionsmeetingbothusersandservice needs[70].
To date the added value and benefits of eHealth solutions remainpartlyunder-investigated.Itisessentialthatinthecoming yearseHealthinvestmentsareconsideredasafactorofproduc- tionandintegratedintothestrategicresourcemix/decisions[71].
Future/further empirical research is thus needed, in particular large-scaleresearch studiesand trialsevaluating the impactof eHealthtools forinstance onpatientsand caregivers, on(cost) effectiveness,andhealthoutcomes,thusovercomingthecurrent fragmentationof fundingover many small-scale studies,which oftenproduceinconclusiveorpartialresults.Inparticular,studies aimedatverifyingeffectiveness,efficiencyandimpactofeHealth solutions for people with multimorbidity are crucial to have cost-effectiveeHealthsolutionsforthesustainabilityandquality improvementoflong-termcare(LTC)systems[72].Investingin researchoneHealthapproachescouldfurtherreinforcetheinte- grationbetweenhealthandsocialcare.Peoplewithmultimorbidity have indeed complex needswhich should be metby compre- hensive services [73]. Investing in such research could finally implementthesharingofknowledgeandgoodeHealthpractices amongdifferentcountriesandcareproviders.Moreover,although considerableevidenceindicatesthattheCCMisavalidintegrated frameworkforimprovingcareandqualityoflifeofpeoplewith chronicandmultimorbidconditions[74],andthateHealthtoolscan strengthenandenhancethesuccessfulCCM[35],furtherresearch seemsimportanttotestandverifytheeCCMasenhancedversion.
5. Limitations
TheICARE4EUstudypresentssomelimitations,aspartlyantic- ipatedintheDiscussionsectionofthispaper.First,ouroverview ofrelevantprogramsinEuropeancountriesreportstheperceived
impactofeHealthtechnologiesthatwasbasedonlyontheviews ofservicemanagers,withoutincludingtheimpactofeHealthon qualityoflifeandqualityofcareasperceivedbypatientsandtheir caregivers,ortheimpactonintegrationofcareasperceivedbycare providers.Second,weweredependentonthepersonalexpertise ofcountry-expertsandprogrammanagersparticipatinginthesur- veys.Insomecasestheymaynothavehadcompleteknowledge ofallcareapproachesoperatingintheircountries,orhavebeen biasedintheirreporting,giventhatmanagersmightbeinclined topositivelystatetheachievementsoftheirprograms.Third,the impactwasassessedbyabinaryresponse(agree/disagree),which isinsensitivetoobtainpartial/smallimprovements.Fourth,only eightselectedprogramscouldbevisitedinthescopeofthisproject, whichmeansthatwehadtorelyonlyondatafromtheweb-survey forthemajorityofprograms.Thismayhaveledtolimitedavailable insightsfromdailypracticeintohoweHealthisadoptedandused.
Fifth,wemappedeHealthaspectsthatwereconsideredrelevant formultimorbiditycare,butcomprehensivenesscannotbeguar- anteed.Despitetheselimitations,hamperingthegeneralizability offindingsinparticularwithregardtothepotentialbenefitsof eHealth,anddespitetheadditionalfactthatthescaleoftheinitia- tivesremainedmostlylocaland/orregional,webelievethatwhat isnewinourstudy,withregardtosimilarfindingsonthestatus ofeHealthadoptionanduse,isthenumberofeHealthinitiatives whichweremappedinthecontextofmultimorbiditycare.The85 programsstudiedinthispapercontributedtoraiseknowledgein thefield.
6. Conclusion
Manyhealthsystemsarelookingatwaystoimproveefficiency, effectivenessandqualityofcare.Inthisrespect,eHealthseemsto havepotentialindealingwiththeincreasingnumbersofpeople withmultimorbidity,whichwillincreasinglytesttheresilienceof healthsystems.
The ICARE4EU findings, although in the light of some methodologicallimitations,indicatevariousanddifferenteHealth initiatives in Europe, and also that eHealth applications could supportthe carepractices, by creatingnew integratedservices forpeoplewithmultimorbidity,amongthemmanyolderpeople living in thecommunity. However,suchservices rarelyexploit thefull potentialof eHealth.Europeanhealth systemspromot- ing ageing-in-place for patients with long-term conditions also needtopromoteinfrastructureandguidelinesintheeHealthsec- tor.WemainlyfoundadoptionofEHRs,followedbyregistration databaseswithpatients’healthdataanddigitalhealthcarecommu- nication,whichareimportanttoolsforenhancingcareintegration and coordination,but theyare notthe mostadvanced applica- tions.Advancedelectronicdecisionsupportsystemsforphysicians, self-managementsupportofpatients,andelectronicsystemsfor telemonitoring care processes are not yetwidely implemented butholdpotentialtoimprovepersoncenteredintegratedcarefor (older) peoplewith multiplechronic conditions. Unfortunately, inadequate funding, incompatible and inadequate ICT systems, lackingskillsamongpatientsandprovidersaswellasunclearleg- islativeframeworks toooftenform insurmountable barriersfor wider employment and implementation of eHealth services in thehealthcaresector.Thegoodnewsisthatthesebarrierscould becomedriverswhenadequatelymanaged[75].Thiswouldamong othersrequirepoliticallyprioritizingthedevelopmentofadequate legalframeworksandfundingmechanismsforeHealth,aswellas fosteringanICTinfrastructureandprovidingadequatetrainingand supportsystems.Furthermore,againstthebackgroundofanage- ingpopulation,thebigchallengecouldbetomovefrom“healthcare technologies”to“well-beingtechnologies”.Thiswouldhelpolder
peopletohaveabetterlifestyleandabetterqualityoflife,which wouldhelpdelayorpreventthemfrombecomingaffectedbymul- timorbidity[76].
Fundingsupport
ThispublicationarisesfromtheprojectInnovatingcareforpeople withmultiplechronicconditionsinEurope(ICARE4EU)Project,which hasreceivedfundingfromtheEuropeanUnion,intheframework oftheHealthProgramme2008-2013oftheEuropeanUnion,Grant number20121205.Durationoftheproject:2013-2016.
Conflictofintereststatement
Theauthorshavenoconflictsofinteresttoreport.
Acknowledgments
Theauthorswishtothankallthecountry-expertsandthepro- grams managerswhocontributed totheICARE4EU project.The contentofthispaperisthesoleresponsibilityoftheauthors;itcan- notbeconsideredtoreflecttheviewsoftheEuropeanCommission oranyotherbodyoftheEuropeanUnion.
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