Establishing the value and business model for sustainable eHealth services in Europe
VALUeHEALTH was an EU funded R&D project within the Horizon 2020 Framework Programme running from 2015-04-01 untill 2017-06-30.
VALUeHEALTH was set up with the remit to develop a business model and business plan for the sustainability of cross-border eHealth services: for cross-border exchange of information between Member States, in relation to supporting the health of citizens who either cross borders and then need healthcare, or are deliberately referred to go across a national border to receive healthcare. This means exchanging patient-related data and supporting healthcare professionals to maintain some degree of continuity of care, in potentially multiple locations.
The VALUeHEALTH project objectives were:
VALUeHEALTH has therefore investigated how eHealth interoperability can create, deliver, and capture value for all stakeholders, to justify a sustainable market in scaling up cross-border interoperability. VALUeHEALTH comprised a rich multi-stakeholder consortium of experienced partners and funded experts, to bring together many essential viewpoints to undertake the work plan and to champion its results. Starting with the cross-border interoperability use cases already approved by the eHealth Network, the VALUeHEALTH partners engaged with multiple stakeholders though a robust methodology to prioritise use cases relevant to Member States for cross-border and also within border health service business needs. The project has examined the technical and organisational strategies needed to deliver these additional use cases, and the multi-stakeholder value chains that are needed to sustain the funding of these services. Finally, the project has integrated these perspectives into a recommended business plan for the immediate years following the existing period of public funding.
VALUeHEALTH has now completed the development of an evidence-based business plan for sustainable interoperability, with sustainable revenue streams for developing and operating priority pan-European eHealth Services beyond 2020.
Background: the problem being addressed
The individual Member States of the EU run their own national health services in their own ways, yet the European Commission (EC) plays an important role in supporting the delivery of cross-border care. The EC is presently establishing a European technical infrastructure and services to enable the secure communication of patient medical summaries and electronic prescriptions between European countries in authorised healthcare situations. This is known as the eHealth Digital Services Infrastructure (eHDSI), and is part of a wider multi-sectoral set of digital services connecting European Member States, funded through a mechanism known as the Connecting Europe Facility (CEF).
VALUeHEALTH recognises the importance and value to Europe of enabling patients to be cared for safely when they become unexpectedly ill or have an accident when visiting another European country, for work or leisure. The design and implementation of the unplanned care patient summary (the guidelines on a non-exhaustive patient summary data set and on electronic prescriptions, endorsed by the eHealth Network in 2016) have the potential to support safer clinical decision making and treatment in such situations, where clinicians might have no or only limited medical information to help them to assess the patient. The project findings back the present investments made in establishing the eHDSI.
However, it is widely recognised, and has been made clear through the VALUeHEALTH project’s expert networks and meetings, that the proportion of healthcare activity expended today in supporting cross-border unplanned care is very low in most European countries, and that it is difficult for health systems to justify to their electorates the investments already made and future funding for an infrastructure dedicated exclusively to this purpose. It was not considered sustainable to set up specific business models or develop special systems and services that only support this small cross-border patient number.
The initial cross-border services mainly support emergency care situations, which impact on relatively small patient numbers. It can be difficult for Member States to justify their contributions to the costs involved in cross-border eHealth services in comparison to their ICT spending on within border service. The starting point of the project was to look for win-win scenarios in which an investment by countries in cross-border services would also support them with their own within- border healthcare communications. On the advice of its experts and multi-stakeholder network, VALUeHEALTH proposes that the best way to enable the sustainability of historic and future investments in a European cross-border eHealth infrastructure is to increase its value to Member States, by enriching the situations in which it would be used and useful, and to do so in ways that offer complementary support to within border health care. This is because patients experience either unplanned or planned care needs at one-off healthcare locations within their own countries as well as when they are abroad, where the clinicians providing this care today lack vital medical information.
VALUeHEALTH activities undertaken
The VALUeHEALTH project partners worked with a wide range of European experts to undertake a careful analysis of scenarios that could add value to the existing unplanned care scenarios, by defining a list of additional business use cases (scenarios of health information exchange) which would be feasible to deliver and useful both within and across borders. A set of prioritisation criteria were developed to assess these use cases, and through a robust methodology two were prioritised, one of which was safe prescribing. When a medical professional is assessing a patient, it is clearly important to have the relevant background information about their medical history before issuing a new prescription. The second use case was to go beyond the content of the current European emergency care summary, to make it efficient and useful to support continuity of care for patients with common, long-term conditions, such as diabetes. Effective, efficient exchange of information on patients with long term conditions could lead to improvements in care both within and across borders, so it is closely aligned with the project’s wider agenda.
For the practical purposes of VALUeHEALTH, diabetes was taken as a “running example” throughout the project; however, it is only one example and the results of VALUeHEALTH do not presume that diabetes will be taken as a European priority for implementing its results. However, the diabetes example does usefully illustrate the value of shared condition-specific information to MS health systems.
Whilst it may seem logical that the most prevalent long term conditions should be prioritised when constructing these extended summaries, VALUeHEALTH has also noted the importance across Europe of rare diseases, and of the possibly greater clinical urgency of sharing rare disease diagnosis and treatment data. What is further needed in emergency is for the emergency physician to connect to rare disease resources so as to know what to do and mainly what to avoid, and to refer the patient – once stabilized – elsewhere.
With the starting premise of enhancing the cross-border eHealth information flows to deliver greater value, the project convened a Business Modelling Task Force (BMTF) to examine in detail the actors who need to be involved and motivated to contribute to collective success, and what the value propositions would be for each. It further built on the work and ideas of this set of actors to develop value chains that showed how this value can be realised only when the actors are correctly aligned, since the value to each is not usually returned as a direct and immediate response to their investments or efforts.
The Business Model Canvas was used to model more formally the ways in which the value propositions could be realised: who are the customers that will pay, who are strategic partners to help co-create the solution and ensure its acceptance, and what are the main activities that need to be undertaken to deliver collective value. VALUeHEALTH considered carefully which perspective to take when designing this canvas. After much consultation, VALUeHEALTH elected to focus the Business Model Canvas on the physical or virtual entity or structure designated with the responsibility for managing and coordinating (or contracting out) the new pan-European shared cross-border eHealth services that will be established via the CEF. The project was aware that other projects such as eSENS examining the organisational models and governance of post CEF sustainability of the CEF building blocks, and took this into account.
A cost effectiveness analysis from a health systems perspective was also carried out, in order to assess the value of eHealth interoperable solutions compared to current practices for the optimal management of patients with Type 1 diabetes, as the reference use case. Considering a scenario of unplanned care services within and across two European countries for the optimal management of this condition, the results of this cost-effectiveness analysis suggested that significant added-value could be generated from investing in such enhanced eHealth services, enabling more Type 1 diabetes patients to be optimally managed, and at lower costs, within and across borders in Europe.
The information flows for the diabetes business use case and the interoperability assets and services needed to deliver them were also examined. Notwithstanding the fact that implementing a new use case will also require interventions in several other areas, the project found that much of what is needed in terms of the eHDSI is already in place. Additional investments would be needed only in so far as necessary to build on the existing unplanned care infrastructure. Indeed, the major implications of VALUeHEALTH’s proposals are to convey more information through the existing infrastructure and add incrementally additional needed services such as the HealthCare Encounter Report. This is especially important for moving from unplanned to planned and shared care use cases. VALUeHEALTH has proposed an EC project-like roadmap for how these additional components might be developed and deployed across MS and at a European level.
Several kinds of organisational change are also needed to take advantage of these enhanced cross border services which should improve trust and accountability in sharing data and sharing care. For example, data quality challenges to ensure that accurate and complete enough patient summaries can be generated to adequately inform the recipient about the patient. VALUeHEALTH has in particular examined the strategies for improving data quality, working with a selected group of European hospitals.
The final VALUeHEALTH business plan itself, brings the main findings of the project together, and especially draws on the Business Model Canvas, as proposals to be considered by the eHealth Network and the European Commission. This two-year Business Plan proposes the establishment of an EU eHealth Business Unit (EU eHBU) which is envisioned to play a central role in the sustainability of the eHDSI, post 2020, i.e. after the end of the CEF programme. It sets out the top five business plan objectives, as activities to be fulfilled by the EU eHBU during its first two years of operation, after being successfully set up and rendered operational. It outlines the financial scheme that is proposed through this plan, and a financial forecast, emphasising a mixed model of public funds, non-monetary (in-kind) contributions, and commercial revenues.
The results of VALUeHEALTH have been distilled into a series of recommendations, to be considered for adoption and submission for decision by the eHealth Network, after it has also investigated the funding implications. These recommendations for the sustainability of eHDSI services were presented to the eHealth Network in May 2017, to multi-stakeholder audiences at the eHealth Week conference in Malta, also in May 2017, and to CEN TC/251 in June 2017 (with other SDOs in attendance.
The recommendations themseves are reproduced below.
VALUEHEALTH recommendations for the sustainability of eHDSI services
It is recommended that MS and the European Commission consider the establishment and the provision of the operational mandate, through an appropriate legal instrument, for a European Union (EU) “eHealth business unit” (eHBU) which may be a stand-alone entity, or a unit within a nominated entity, within the ambit of the European Commission (EC) and the Member States.
Ensure this entity has sufficient start-up financial underpinning and access to growth capital to enable it to reach self-sustainability, through the following business plan proposals.