The digitization of healthcare in the European Union is proceeding at a brisk pace but is also fraught with challenges. The European Commission is seeking to provide EU citizens with comprehensive, and easily accessible digital healthcare through its Digital Single Market strategy. The creation of the Digital Single Market will involve the integration of countless healthcare tools, insurance companies, and national systems which are at varying stages of digital capacity.

With an aging population and shrinking workforce, the EU is making the transformation and integration of its national health systems an imperative. The 2018 Ageing Report concluded that the number of people aged 64 or older was expected to increase from 178 million as of 2016 to 228 million in 2070. Furthermore, the WHO views the shortage of healthcare workers relative to the general population as a significant concern. Core indicators show that while there has been an increase of 10% in the number of healthcare staff over the past decade, there is still a significant shortage of doctors and nurses with the necessary qualifications. The age of doctors is also increasing, with nearly one out of three being over the age of 55, which creates a need for more medical graduates. The specialist-to-general practitioner ratio is also high in the European region, at 3.2 specialists to 1 GP.

The number of healthcare professionals relative to population also differs considerably between member states. According to the WHO, some countries have five times more doctors than others, with Germany, Austria, and the Scandinavian countries coming out on top. Some countries, meanwhile, have nine times fewer nurses than others, which is of great concern in the context of care for the elderly. The nurse-to-physician ratio also varies; it could be high as between 4 and 5 nurses per doctor as in Finland or Ireland, or <1 nurse per doctor as in Greece.

Towards a single digital market in healthcare

With a lower number of able-bodied people to care for the elderly and infirm as time goes on, manual and analog solutions for providing healthcare look increasingly less efficient. Healthcare digitization would allow the elderly, bed-bound patients, and/or patients with chronic diseases to access care remotely and with shorter wait times. Given the high disparities in care level between EU member states, digitizing and harmonizing healthcare standards would allow beneficiaries to access quality care regardless of location; either remotely or in person.

To help address the ongoing imbalances and demographic trend towards an older population, the European Commission drafted the 2018 Communication on Digital Transformation of Health and Care in the Digital Single Market. The Communication outlines the general strategy for carrying out this aim on the European level, and identifies three key priorities underlying the scope and function of a digitized healthcare system.

Firstly, citizens must secure access to their health data. This would be achieved through the building of cross-border services such as patient summaries and ePrescriptions while applying the GDPR, and working on technical specifications for health data exchange. The Directive 2011/24/EU currently sets the conditions under which an EU citizen may travel to another EU country, receive medical care, and get reimbursed by their home country. The implementation of this aspect of the Digital Single Market will make use of existing networks of National Contact Points, existing guidelines of the minimum list of elements to be included in a medical prescription, and the European Reference Networks of healthcare professionals that enable Europe-wide virtual panels of clinicians to treat rare and complex diseases.

The 2019 Recommendation on a European EHR Exchange Format seeks to build on e-Health Digital Service Infrastructure through the Connecting Europe Facility (CEF) program. The CEF is a pan-European infrastructure facility fund that seeks to develop trans-European infrastructure projects in the areas of telecommunication, energy, and transport. Utilizing funding from the CEF in part, the first exchanges of patient summaries and ePrescriptions took place between Estonia and Finland in January 2019, and 22 member states are expected to join this exchange of information by 2021. A recommended exchange format for interoperability between existing electronic health records, between countries is being implemented through the project Refined eHealth Interoperability Framework (ReEIF) – the latest iteration of the European Interoperability Framework, which seeks to provide a common set of standards, vocabulary, and protocols towards an integrated digital health system.

The second priority of the 2018 Communication states that medicine should be increasingly personalized through a shared European data infrastructure. In the European context, legislation such as the GDPR makes “direct” sharing of health data difficult, however “indirect” sharing is still possible. Increased sharing of anonymized medical and genomic data aims to enhance Europe’s capabilities in improving patient outcomes and conducting medical research. The “1 Million + Genomes Project” is a prime example of this initiative, where on April 10, 2018, also known as Digital Day, 13 EU countries signed a pledge to sequence one million human genomes by 2022 and make them universally available on the continent to researchers and healthcare professionals.

The European Union is increasingly taking steps to leverage the power of Big Data to improve patient outcomes. By investing in research such as Horizon2020 and forming Public-Private Partnerships, working towards a continent-wide network of data processing facilities and investing in the GÉANT Network, investing in supercomputing, and building a Telecoms Single Market, the European Union is increasingly moving towards an infrastructure conducive to high-volume data sharing that is guided by integrated Big Data standards and data protection rules. “Big Data for Better Outcomes”, a project of the Innovative Medicines Initiative (IMI), hosts platforms for large healthcare datasets put out by research institutes and medical centers. In February 2020, a milestone was reached when the first batch of real-world data from prostate cancer studies was added to their PIONEER platform.

Finally, the last recommendation is that citizens must be empowered with tools for user feedback and person-centered care. According to the European Commission, 90% of citizens expect to have access to their own health data and 80% are ready to share data and provide feedback on treatment quality. There is still much to be done in the area of legislation pertaining to telemedicine, which the WHO defines as the use of telecommunications technology to deliver healthcare outside of traditional health-care facilities. However, the EU has acknowledged that portable medical devices, wearables, mobile health apps, and AI/Big Data technologies underpinning these are intended to facilitate communication between patients and providers in real-time during the treatment process, the monitoring of chronic disease symptoms, and make providing feedback easier.

The previously mentioned initiatives have allowed the telemedicine market to develop to a considerable degree. Additionally, a 2018 market study commissioned by the European Commission showed that there have been several EU-wide deployment mechanisms that have proved successful in telemedicine and mobile health deployment. The Scandinavian countries, especially, have developed a dynamic market in the digital healthcare space, with the highest revenue-per-capita of any region.

Barriers to Implementation

However, cultural barriers still exist in the adoption of digital solutions throughout the EU. There still remains a high degree of differentiation between various healthcare systems. The Digital Economy and Society Index Report of 2019 showed that while approximately 50% of EU citizens endorse the idea of digital health services, use of e-Health services in the year 2019 varied between 50% of the number of patients in Finland and Estonia, and <10% in Germany and Cyprus. EU-wide, almost half of general practitioners used e-Health services to exchange medical data. However, while 98% of physicians in Denmark made use of EHR technology, Poland scored below 20%. However, while Poland has digitized health records on the state level, Germany is still 1-2 years away from achieving this milestone.

Additionally, digital healthcare implementation may be difficult in older or more impoverished populations who lack digital literacy, even though these segments are often those in the most need. This new trend is still often viewed with suspicion, especially through the lens of personal data protection, while doctors and patients often feel that digitizing healthcare threatens the traditional doctor-patient relationship that often has an emotional dimension.

COVID-19 as a New Imperative

In recent months, the COVID-19 pandemic and the resulting social distancing measures have shown a light on European healthcare systems’ strengths and weaknesses in responding to large-scale public health crises. With most of Europe on lockdown as of this writing, the need for remote health monitoring; for example, of those in self-isolation or government-imposed quarantine; has become all the more imperative in the eyes of policymakers.

The need to track the current pandemic spread and other public health crises in the future has led to several government and industry-led initiatives and hackathons. The Federal Republic of Germany, which has historically lagged in digitization, recently organized the largest hackathon in the world to date, called #WirVsVirus, to source possible solutions for solving the pandemic. This resulted in over 1,500 digital solution proposals. Other European nations plan to hold similar events in which contributions towards solving this public health emergency are open-sourced.

Conclusion

To overcome challenges, the European Union bodies will continue to facilitate greater communication with the public and national governments about what digitization means for healthcare, create a favorable regulatory environment for data sharing and technology development, and work with individual member states to implement a common set of standards while improving data protection compliance. Further clarity and communication is needed on how the GDPR applies to the digital transfer and storage of medical data in particular, and how national peculiarities fall within this framework, in order to reassure healthcare professionals of legal liability.

If the recommendations of the 2018 Communication are implemented EU-wide, an integrated cross-border service infrastructure would allow electronic health records, e-prescriptions, and patient summaries to be transferred between member states seamlessly in a manner that respects medical privacy. A common interoperability framework would facilitate such communication between healthcare service providers both in-person and remotely. Increased pooling of data for research would ensure better research and treatment outcomes, and an enhanced capacity to respond to large-scale public health emergencies like COVID-19. Finally, supply of innovative digital-based solutions, such as those from hackathons and private industry, would be easily facilitated.

To that end, the EU will find itself in a good position to become a digitally-transformed healthcare ecosystem, and use cutting-edge research and development to improve care and access for its citizens.