Establishing the value and business model for sustainable eHealth services in Europe

Workpackages

WP 1 Prioritised eHealth Services and Use Cases

Objectives

The objectives of Work Package 1: Prioritised eHealth Services and Use Cases are to identify and agree on a roadmap of use cases that should be deployed on large scale.

A number of candidate use cases have emerged from the epSOS, SemanticHealthNet and other European projects, but whilst the focus of the CEF is on cross-border use cases, Member States will wish to implement other use cases as well.  Hence, the number of use cases will grow over time, and it was decided that it was neither possible nor desirable to attempt to be explicit about the use cases to be implemented up to 2020 and beyond.   The aim of this WP has therefore been three-fold:

  • to identify a first set of known or expected use cases,
  • to classify and categorise the types of use case and
  • to define the process through which all stakeholders can bring forward proposals for use cases that can be progressed.

Achievements

In WT 1.1 (Identify examples, types and characteristics of use cases), M1 – M6, we identified candidate use cases started by gathering examples such as:

  • The four potential eHealth services eligible for CEF funding;
  • Health priorities such as: Integrated person centred care; Chronic disease management; Population health and research
  • Roadmaps: CALLIOPE, eHGI, SemanticHEALTH
  • Use cases input from the eHealth Interoperability Framework study, Antilope, EXPAND, PARENT and eSENS.

In addition, current materials from Member States (e.g. the United Kingdom and the Republic of Ireland) highlighted some shared challenges and shared opportunities for eHealth.  The identification of example use cases informed the classification of types of use case (e.g. by priority, value, dependence, etc.) to be considered in the following tasks.  There are several characteristics that could determine which use cases should be taken forward:

  • those given high priority
  • those deemed to add particular value
  • those which are necessary enablers.

The initial set of use cases was described D1.1 and the detail provided input to a stakeholder workshop held in September 2015.  That workshop considered the use cases and discussed the VALUeHEALTH assessment criteria.  Following this, detailed analysis based on the application of the criteria led to the identification of three priority use cases to be taken forward for detailed assessment in WP2.

The methodology can be used and adapted at the country level (using the same or a different set of use cases and criteria) in order to further prioritize and assess the risks related to different options to support local decisions.  Moreover, the value (cost-effectiveness/cost-benefit) of different priorities could also be assessed using advanced simulation modelling relevant to the deployment of specific use cases, in order to assist funding decisions.  The results could be mapped for the purpose of investment decisions, strategic alignment of health policy

On the basis of the analysis, the three assessment criteria that had the most influence were:

[6]     Improved access (to services)

[2]     Potential positive impact on number of individuals (patients, family, carers)

[1]     Potential positive impact on individual patients

Each of these are related to the business impact and intended outcomes of the use cases.

As anticipated in D1.1, for any given user – for instance a Member State – the business priorities and local context will be the main determinants of which use cases are most relevant to it. Therefore, the outcome of task WT 1.2 was more about demonstrating the analytical approach used in VALUeHEALTH, by producing a worked example, than delivering a single “answer” appropriate to all health IT investment challenges.

The analysis provided input to the third task WT 1.3 (Agree blueprint of initial use cases and approach for follow-on use cases), M4 – M9, which applied the above analysis to help identify and agree on a blueprint of use cases that will support the Member States in better planning their own national deployments, together with an approach to on-going maintenance, review and refreshing of the list of use cases.  The analysis undertaken identified the two high priority use cases as:

  • Safe Prescribing
  • Integrated care and self-management for long-term conditions.

These two use cases were then taken forward for further detailed analysis by WP 2, 3 and 4.  The second case (which is subtitled “Individual disease management”) is being explored in relation to two scenarios: a chronic condition (such as type 2 diabetes) and rare diseases.

Between T1.1 and T1.2, further detail was added to the use case descriptions.  This more formal structure has been used as a basis for capture of new use cases.  As the project progresses, WP1 continued to maintain an inventory of use cases. Together with the output from WPs 2, 3 and 4, the inventory provided useful input to WT 1.4 which reviewed the identified use cases.

The final task in WP1, WT1.4, re-considered the use cases from the perspective of the other WPs’ achievements, leading to the revised version of D1.2, called D1.3.  The aim of the task was to apply the analysis from other WPs to help identify, agree and maintain a blueprint of use cases that will support the Member States in better planning their own national deployments.  Whilst the initial expectation was for a simple list of prioritised use cases, it was found in practice that priorities vary from MS to MS and over time within MS, and that technological and other advances raise new opportunities not previously considered feasible.

For these reasons, it was not appropriate to attempt to define a “one size fits all” list of use cases.  Instead, Deliverable D1.3 developed an approach and an iterative process that enables each MS to maintain, review and refresh its own priority areas for action, dependent on its business needs, be they pan-European, national or regional.  The number of such use cases will continue to grow over time, stimulated by societal, political and technical developments.

The WP1 team has been closely involved with the sub-group set up by the eHealth Network to consider proposals for the revised Multi-Annual Work Programme to cover 2018-2021.  There are new business priorities and emerging issues in the light of the Digital Single Market, legal requirements such as those arising from the General Data Protection Regulation (GDPR) and electronic Identification and Authentication Services Regulation (eIDAS) as well as more specifically In the health and care sector, at cross-border and at national level.

D1.3 presents a reference model for use in prioritising components for investment.  The model has been derived from earlier work in CALLIOPE, the strategy handbook from the WHO, and modelled on the layers in the refined eHealth interoperability framework (ReIF).  The application of the model allows national eHealth leaders to plan for investments in new use cases.  The underlying process is cumulative.  With a reference model in place, each investment can be seen as building on what is already in place.  For each new use case, the costs incurred are only to be spent on the additional elements needed.

The approach is illustrated through application to the diabetes use case.  This process has shown how investments in core infrastructure provide a platform for subsequent facilities and that often, these supporting capabilities are generic and hence re-usable for other user cases.  Alongside this, review of architectural components might indicate the opportunity to refresh and renew core capabilities.

Overall, D1.3 has provided an approach to help decision-makers focus on the key components needed when developing eHealth infostructure and identifying areas that need core financial investment.  The approach has built on the work of the business model developed in VALUeHEALTH’s WP2, has adopted the principles and approach from WP3, and applied the results from WP4.  The materials have been discussed with stakeholders in WP5.

WP2 Business Modelling

Objectives

The objectives of Work Package 2: Business modelling, are:

  • To design an adaptable business model to enable the implementation and sustainable exploitation of eHealth interoperable  services by 2020 and beyond for progressively migrating from a CEF funded initiative to a self-financed model;
  • To develop customized value propositions that describe the expected benefits of interoperable eHealth services to health care providers and other stakeholders;
  • To assess the value (cost-benefit) of interoperable eHealth services to assist funding decisions;
  • To deliver a business plan for Member States to implement, operate and grow in-border and cross-border eHealth services beyond 2020.

Achievements

A first multi-expert business modelling task force (BM-TF) was set up and a workshop was hosted in Brussels on January 11-12, 2016. A second BM-TF workshop was hosted in Ghent on October 10-11, 2016 The purpose of the BM-TF is to provide strategic expert input on the following business modelling tasks:

  • Design and validate the multi-stakeholder value chain and customized value propositions;
  • Develop a business model (reference framework) to reliably create, deliver and optimize value for health data interoperability;
  • Align innovative sustainability strategies, including for multi-stakeholder engagement;
  • Establish the value of interoperable eHealth services for one or more prioritized use cases;
  • Guide the development of a robust business plan for implementing sustainable interoperable eHealth services.

Following the BM-TF workshops, a detailed report was produced summarizing the input provided on each of the above aspects relevant to the highest ranked priority use cases identified by WP1, namely: 1) Safe prescribing, 2) Integrated care and self-management for long term conditions for: i) diabetes, and  ii) rare diseases, also leveraging the role of European Reference Networks.  For each potential use case explored, the following business modelling aspects were defined by the BM-TF, namely:

  • Multi-stakeholder value chain and market segmentation;
  • Value propositions describing the expected benefits of sustainable interoperable solutions for all stakeholders;
  • Business model prototypes;
  • Sustainability strategies;
  • Cost-benefit/cost-effectiveness assessment methodology for assessing the value of seamless interoperable solutions compared to current standards.

Based on the expert opinions provided during the BM-TF workshop, a detailed position paper was then developed in order to explain and endorse the rationale for the VALUeHEALTH reference (business use) case to focus on the two top-ranked use cases delivered by WP1 (i.e. Safe prescribing and Integrated care and self-management for long term conditions), as applied to the optimal management of diabetes (within and cross-border), also covering to the potential role of the emerging European Reference Networks for cross-border specialty care.

Then, the VALUeHEALTH leadership organized two multi-stakeholder webinars. A first webinar was organized on April 19th with the BM-TF workshop participants in order to present and validate their collective input from the January workshop and build consensus on the proposed reference (business use) case.  A second webinar was then organized on April 26th, this time also reaching out to a broader group of European experts for presenting the VALUeHEALTH reference (business use) case and for building greater expert consensus. Lastly, a 3rd webinar was organized on October 3rd 2016 in order to provide a quarterly progress update to the stakeholders involved, to validate the business modelling approach, and to gather additional insights in preparation for the BM-TF workshop hosted in Ghent on October 10-11, 2016.

Considering the reference business use case, WP2 also developed three short clinical cases to reflect the three semantic interoperability scenarios developed by WP4. These clinical cases illustrate from a patient perspective how interoperable solutions could be implemented and exploited to optimize the management and self-management of diabetes within and cross-border, also leveraging the European Reference Networks.

Regarding the cost-effectiveness analysis (CEA), WP2 also organised and facilitated a scientific panel meeting with medical experts (i.e. diabetes specialist, emergency physician and two general practitioners). This meeting was hosted on January 18th 2017 in Brussels. The purpose of this expert panel was to: i) guide the  development of the CEA model so that it reflects current medical practices; ii) populate the model with robust scientific evidence. After conducting the CEA, WP2 produced a full technical report (Deliverable 2.2), as well as a scientific abstract for further dissemination. Importantly, using the VALUeHEALTH reference use case of Type 1 diabetes, the results of the CEA suggest that eHealth interoperable solutions appear to improve health system efficiency within and cross-borders, by being more cost-effective compared to current practices, and by enabling more patients to be optimally managed, and at lower costs. This new evidence will enrich the VALUeHEALTH value propositions for the primary funders of interoperable solutions (Member States), as well as for other stakeholders involved.

Lastly, jointly with WP5, WP2 participated in the co-creation and development of the VALUeHEALTH business plan (D5.3), with specific contributions as regards the financial assumptions, forecasts and value assessments (Chapters 7 and 8).

In order to establish a sustainable business model and business plan for use cases to be implemented and exploited by Member States in a sustainable manner by 2020 and beyond, WP2 has established a WP collaborative model with WP1, WP3, WP4 and WP5, and has successfully conducted all thethe following tasks, as planned:

  • Define the most relevant perspectives for the VALUeHEALTH business model, multi-stakeholder value chains, value propositions, cost-benefit assessment and business plan;
  • Consolidate the multi-stakeholder value chain for the reference (business use) case;
  • Design the most suitable business model prototype for the reference (business use) case and forecast the expected costs and revenues;
  • Align the descriptive value propositions (D2.1-M15) for all key stakeholders;
  • Develop a cost-effectiveness  assessment for the primary payers of interoperable solutions (D2.2-M22);
  • Develop the business plan (D2.3-M24) for expanding sustainable services to other use cases by 2020 and beyond;
  • Organize a follow up BM-TF workshop (October 2016) and webinars as appropriate.

WP3 Adoption and incentives roadmap

Objectives

Work Package 3: “Adoption and incentives roadmap” aims to identify appropriate incentivisation schemes and scale-up strategies for the optimal deployment of interoperable eHealth solutions in Europe. As a result, the efforts should contribute constructively to the directions of the CEF post-2020.

In Y2, the main task of WP3 has been to identify and investigate in detail relevant adoption challenges, success strategies and sustainable incentive schemes, provide recommendations how to best address these and thereby contribute to the final business plan in D5.3 through concrete recommendations and proposals for future CEF work on adoption, incentives and scale-up strategies.

Achievements

The main achievements are two deliverables: D3.1 “Adoption challenges and success strategies: Preparing for a draft adoption and incentives roadmap” and D3.2 “Adoption and incentives roadmap”. D3.1 was presented at the first review meeting and its content was described in the 1st Periodic Report.

The final WP3 deliverable, D3.2, concentrates on the adoption challenges and success strategies for interoperability in eHealth. Particular emphasis has been put on health data quality, health professional trust and accountability. The deliverable discusses in detail:

  • The strategic policy context:
    • Bismarck vs. Beveridgean systems;
    • CEF sustainability issues, in particular for services enabled by eHealth interoperability;
    • The impact and implementation challenges of the directive on cross-border healthcare, as well as recent EU policy developments.
  • Adoption challenges and success strategies:
    • Governance and regulation;
    • Care process interoperability and organisational culture;
    • The importance of non-financial incentives;
    • Relevant scaling-up initiatives.

The deliverable looks into existing lessons learned and evaluates incentivisation schemes that can be employed to bring stakeholders together for a common cause. Its aim is to assess the benefit of initiatives that are changing the current use of health IT products and services, as well as healthcare services as a whole, and distil a number of strategic approaches that are common to successful eHealth implementations. Many of these have a particular pertinence to integrated care.

  • Engaging with health professionals and key issues to address:
    • Liability issues relating to eHealth;
    • Concerns of healthcare – the example of epSOS;
    • The need for future work in this area.
  • The particular importance of data quality:
    • Motivations and incentives;
    • Strategies to improve data quality;
    • Results of a survey on data quality conducted together with i~HD;
    • The relevance of data quality from a ministry’s perspective; assessment and improvement of data quality from a hospital perspective.
  • The final recommendations focus on four areas, and suggest actions to:
    • Foster innovative use of health data;
    • Reinforce clinical engagement;
    • Assess the value of interoperable eHealth solutions, the information and knowledge base of the eHealth Business Unit.

This output served as a means to draw – together with WP5, WP2, WP4 – an actionable roadmap until 2020 and beyond for the EC, the post-Connecting Europe Facility (CEF), and the Member States.

WP3 team work involved numerous telephone conferences, support to / co-organisation of several workshops together with WP2 and WP5 as well as partial co-organisation of two i~HD Hospital Network workshops in Brussels on 09 February 2017 and 24 May 2017, focusing on data quality.

During the first of these two workshops, a preliminary questionnaire on data quality was handed to the audience. This questionnaire was refined and a second survey was conducted prior to the second workshop. The results were then discussed with the audience and contributed to the deliverable D3.2.

WP3 team worked closely with WP2 to ensure adoption & incentivisation issues were embedded in the September 2016 VeH workshop (09-10 June 2016, Gent) and in all follow-up events and activities, such as the WP2 workshop on 23-24 February 2017 in Brussels.

WP3 liaised closely with WP5 on the need for the project to place its work in the policy context of the CEF, and – in workshop format – to reflect the perspectives of key stakeholders – for example, the VeH workshop at the Athens eHealth Forum 2016.

Furthermore, WP3 liaised with important EU initiatives in the domain of eHealth-supported integrated care, due to its relevance to the VeH use case. In particular, the EIP on AHA Action Group B3, from which several key stakeholders were interviewed, including e.g., at the EIP on AHA Summit in December 2016 (empirica and EHTEL participated). Lessons learnt regarding the scaling up of eHealth innovations have been exchanged with projects and studies such as ScaleAHA, MAFEIP, SCIROCCO, CareWell, Momentum, etc. Regarding interoperability issues, WP3 benefited from close collaboration with eStandards, Trillium, OpenMedicine, ASSESS CT.

A final face-to-face meeting was held in Brussels on 20 June 2017, consolidating the perspectives and results of all WPs.

WP4 Design & Deployment Roadmap

Objectives

The main work package 4 objectives in focus for year 2 of the project have been to define the interoperability services and assets (the infostructure) needed to achieve the information flows for the VALUeHEALTH use cases, and to develop a design, implementation and deployment roadmap for the prioritised use cases.

Activities and achievements

The main activities undertaken during year 2, and its achievements, have been

  1. to elaborate the information flows that would be needed to support cross-border continuity of care for safe prescribing and long-term condition management, and to identify how these might be layered as extensions to the existing/planned eHDSI;
  2. to develop a roadmap for how these extended services might be designed and deployed at a European (EC and MS) level;
  3. to contribute indicative costs for these activities to the WP5-led business plan;
  4. to liaise with other interoperability specification harmonisation SDOs and initiatives, and in particular with the other CSA projects within PHC 34: eStandards, ASSESS CT and openMedicine.

The first two of these consumed the main effort within the WP, and are summarised below.

1. Information flows and asset development

This activity (continuing Task 4.2 from year 1) started from the prioritised business use cases and the technical use case descriptions of D4.1. Several European pilot projects were identified that have implemented diabetes share care scenarios. Project reports were studied, supplemented by occasional correspondence with relevant project members, in order to distil key learning from them that could inform the design and delivery of diabetes shared care summaries at a European level. These case studies highlighted the importance of clinical engagement, of achieving the right level of standardisation detail, and of ensuring that clinical workflows are aligned to making best use of shared diabetes information. This WP4 activity then examined the information flows that would be needed to support the three VALUeHEALTH user stories, and what additional interoperability assets should be developed at a European level in order to deliver these.  It considered the process needed to implement these additions at the level of clinical content standards (drawing on the work of eStandards on good practice for clinical content development), proposing examples of the asset bundles needed (since this project was not resourced to actually develop these assets). It then considered the technical services, in terms of gaps to be filled within the current eHDSI. This work suggested that changes for unplanned care should be handled as a Change Proposal, that activating the HCER needs a political / CEF governance decision, and that improving the Patient Summary for planned care should be effected though SDO specifications for a new clinical document (e.g. the improved International Patient Summary).

2. Design and deployment roadmap

This activity (Task 4.3) tracked the way in which the cross-border unplanned care design and deployment process has been structured through CEF Telecom calls for proposals and the accepted projects. Because growth in the eHealth digital services is required in order to reach the level of provision that might be sustained, WP4 has shaped its roadmap as a kind of CEF Telecom call, detailing the way in which a successful project (termed EPSIP) might be structured and enacted. In other words, pump priming of sustainable services is foreseen as initially requiring a further injection of public funding. The design of the work plan drew to some extent on the way in which the existing CEF work programmes have been structured, to some extent on learning from the diabetes integrated care case studies reviewed in D4.2, and using advice taken from those involved in the eHDSI (including members of the eHealth Network). The costing information also drew on similar experience.

WP5 Stakeholder Engagement and Endorsement

Objectives and Achievements

Within the overarching VALUeHEALTH (VeH) for business model innovation for sustainability of eHealth services, including for CEF supported cross border services, beyond CEF funding, the objective of WP5 is to ensure that -at the end of the project,- VeH should be in a position to present proposals for a business model and a business plan for sustainability beyond 2020 that are equally owned by the main actors in the value chain(s) who will collectively create, deliver and capture value. For this to be achieved, VeH has engaged and consulted with the broader stakeholder community and create synergies and common visions with the key stakeholders which have influenced the business plan  (D5.3.) and the expectation is that – will be influenced by it e.g. by reflecting on, adopting and adapting ways through which they can create, deliver and capture value, according to their role in the eHealth ecosystem.

In year 2, WP5 focused on two primary objectives i.e.,

  1. established the VALUeHEALTH the real life VALUe(HEALTH) chains, spanning across several layers of value production
  2. Elaborated the VALUeHEALTH Business Plan as a cross cutting project activity, consolidating the knowledge produced in the different WPs.

WP5 , in close cooperation with the project management ran and/or supported several Consultation and Consensus activities, including the Athens Value-Chains workshop and policy level consultation during the 2017 eHealth week.

Early work on value chain development started in January 2016 at the BMTF workshop, and was initially taken forward by consultation within the project and with selected experts.  In year 2, work on VALUeHEALTH chains was escalated and has concentrated on delivering the 5 interconnected VALUeHEALTH chains described in  D5.2. This deliverable explores how the current eHDSI tackles the challenges expressed in the VeH user stories and identifies current constraints and the potential created by setting up and maintaining of the CEF eHDSI, alongside the recent regulatory framework, and the eIDAS and the GRDP Regulations.  It then builds on these examples, in order to structure a number of value chains designed to demonstrate how value is created, captured and delivered by four types of actors: funders/sponsors; providers; users; and beneficiaries.  These value chains maybe envisaged as a cascade of value for the CEF eHDSI in enabling cross border connected health for long term care of diabetes across borders. Finally, the document lists a set of recommendations emerging as a result of these consultations on the common integrated future visions and convergent strategies and actions to be taken up by a critical mass of stakeholders in order to converge towards a sustainability plan for CEF beyond 2020.

Extensive consultation on Value chains with external experts took place in the second BMTF workshop in Ghent, in October 2016 and the proposals were further discussed with representative stakeholders, identified as key partners in the CEF sustainability, in the Athens Stakeholder workshop, also held in October 2016). As a result, a small number of value chains, that reflect our current perception of models and policies of Stakeholders, have been constructed. A second consultation with representatives from 4 MS and members of the European Commission (DG SANTE and DG CONNECT) was facilitated on March 15, 2017.

WP5 also delivered the  two-year Business Plan for a proposed EU eHealth Business Unit (EU eHBU) which is eventually envisioned to play a central role in the sustainability of the eHDSI, post 2020, i.e. after the end of the CEF programme. The plan has been elaborated within the context of the relevant CEF sustainability policies, as well as the eHealth specific priorities. The characteristics of the proposed eHBU are described together with options for its establishment, and the key services it will provide. This plan includes an analysis of the ecosystem in which the eHBU will operate, emphasises the strategic partnerships it will need to create, and considers other important success factors. The business plan proposes five main business objectives, and maps these to activities that will need to be undertaken in the eHBU's first two years, plus their indicative budgets. Finally, this plan offers a financial forecast and operating annual budget for the eHBU.