Assoc. Prof. Dr. Giedrius Vanagas, Lithuanian University of Health Sciences, Kaunas, Lithuania

Lithuania started to implement its own National eHealth Service System (NESS) in 2005. In May 2007, the eHealth system development strategy for the period 2007–2015 was prepared. The creation of a common, user-friendly health information service for Lithuanian residents, patients, physicians and health care administrators is the main focus and vision of the NESS development strategy in Lithuania. It is expected that by 2013 the majority of General Practitioners (GP) institutions, primary health care institutions and other health care institutions will use the eHealth record system and have access to the NESS client services. The quality of supervision and data archive solutions are most important, and the Lithuanian NESS should prepare for integration into the European eHealth system. In general, it is expected that these processes will lead to a higher level of public awareness and people’s involvement in protecting their own health, as well as more effective use of available resources for the provision and expansion of health care services, based on modern ICT technologies.
Full implementation of NESS in Lithuania will require funding from different sources (National and EU funding schemes) and ideally this should be allocated at the start of the project, but the processes are very slow and can also be related to human resource problems in the Lithuanian health care institutions (HCIs).

What do we know about barriers implementing eHealth systems?

Many studies have identified a large number of barriers to the implementation of NESS. These can be classified as situational barriers (including time and financial concerns), cognitive and or physical barriers (including physical disabilities and insufficient computer skills), liability barriers (including confidentiality concerns), and knowledge and attitudinal barriers. They are likely to differ from country to country, and from institution to institution. Implementation is also heavily dependent on the traditions and education systems of each country. But the most important barriers are those related to human resources and this is particularly the case in Lithuania. We have very well trained IT specialists and programmers but they lack knowledge and competence in health care processes and an understanding of clinical pathways. We also have very well trained medical staff, of course, but they sometimes lack understanding of IT implementation processes, project management, etc. So, we see a major lack of suitable mid-level staff who can be trained to work with IT implementation projects in the field of health care, standards, fund raising, etc., who are familiar with national and international strategies in the field of eHealth, and who could propose IT solutions to different health care processes. Cutting across all these categories, it is clear that medical-clinical practice in the Lithuanian HCIs must undergo a major structural and ideological reorganisation, before it can be fully integrated with and enjoy the benefits of NESS.

So, is it important to have e-Health specialists? And, if so, what competences should be acquired during university studies?

Today, Information and Communication Technology (ICT) is used in many areas of the health system, including hospitals, doctors' practices, pharmacies, insurance services, etc., constituting what is commonly referred to as eHealth. We clearly understand that eHealth will play an increasingly vital role in the future of health care, and this points to the need for eHealth specialists both now and in the future – specialists who will advance the deployment of an eHealth system. We need professionals who will acquire, develop and maintain eHealth technologies and supporting infrastructures and integrate them with clinical workflow, health care process information flows and associated business processes to optimise the adoption and use of EHRs.
It is important to note that, in order to answer to some of these questions in Lithuania, we implemented a questionnaire survey in which top administration staff (e.g. directors, medical directors, heads of administration) from selected Lithuanian HCIs were asked about future plans in the field of eHealth at their HCI.
The results of our study highlight a readiness within Lithuanian HCIs to implement the National eHealth Strategy: 95.6% of Lithuanian HCIs have plans to start or expand use of NESS in the next few years; But 77.9% of HCI administrators said that they lack eHealth specialists to start implementing NESS in their institution. Our study also identified some other barriers to NESS implementation in the Lithuanian HCIs. These included cost, technical issues, system interoperability, concerns about privacy and confidentiality, and a lack of a well-trained eHealth specialist work force to lead the process.
HCI head administration staff expect eHealth specialists to have wide competences, combining ICT application in health care, ICT management, eHealth processes management and knowledge of eHealth strategies. These specialists should have the skills to manage all integration processes in the HCIs. One of the objectives of the Lithuanian eHealth strategy has been to start eHealth training programmes at Lithuanian higher education institutions, but none of these has yet been started in 2011.
In conclusion, we need eHealth in university education at Master’s level for wide range of specialists. eHealth education programmes for society in general and patients in particular is the next most important issue if Lithuania is to accelerate eHealth system deployment and National eHealth Strategy implementation.

Prof Dr Roland Trill, Project Leader and Head of the Master Course "eHealth" in the Department of Business Studies, University of Applied Sciences Flensburg

Acceptance can be understood as the short form of voluntary approval of a person or a 'thing'. In our case it refers to the approval of using eHealth technologies or applications. The range covers complete to non-existent acceptance. It is therefore useful wanting to measure this acceptance. It is only possible to question and discuss the how and the why when the characteristics of acceptance can be measured. Developing an ‘eHealth Acceptance Index’ is therefore a central but also sophisticated task. Issues to be discussed in a second stage would be, for example:

• Why is the acceptance of new technologies greater in Sweden than in Germany?
• How have the technologies been implemented in these countries?
• Which user basis existed before the technologies were implemented and to what extent is this responsible for the speed at which acceptance developed?

Acceptance requires active handling – usually involving innovations. It is subjective and depends on conscious or unconscious judgement. Acceptance as a thing, therefore, does not exist! It is, in fact, differentiated between according to target groups and individuals. As a result, the instruments which create acceptance must be specifically and conscientiously designed.
At the first level we differentiate between ‘Professionals’ and ‘Citizens/Patients’ user groups for ICT for Health. We specifically identify these groups in all our measures and adapt the instruments accordingly. The issue here is: Are the selected instruments the correct ones?
The free will decisions are primarily characterised by

a) Information.
ICT for Health communicates eHealth knowledge via training courses, publications (such as on the project website), etc.

b) Own experience.
Doing and experiencing it yourself is probably the most successful approach – as we wish to achieve in our project using pilot runs.

c) Recommendations by colleagues, family, friends, for example, but also by other reference groups.
The stronger the individual reference to the person, the higher the recommendation is seen as trustworthy. A good example are medical associations, which exert a considerable influence as multipliers.The individuals must be ‘collected' for the procurement, i.e. their level of experience and knowledge must be considered when designing measures. This starts right from the language selection: Thus a multi-lingual portal is being developed at ICT for Health.

Why is it at all necessary to address the acceptance of eHealth? The challenging aims at the national and European level can only be achieved if professionals and citizens accept eHealth technologies or applications i.e. use them without question. Therefore research regarding the question of how acceptance can be achieved and solidified must become a core issue in eHealth studies. Let us discuss the following issues, among others:

• How important is an ‘eHealth Acceptance Index’?
• What influences acceptance? How important are these influencing factors, and are there differences between the different countries?
• Which information and media are of particular importance for creating acceptance?
• What role do emotions such as worry, etc. play?
• Which networks of relationship are to be included in the discussions in the countries?
• How should pilot runs be designed in order to be fully effective?
• Which role does the level of education, age, etc. play in the readiness to concern oneself with new things?

We will be a great deal further once we have initial answers to these questions. In this context, our ICT for Health project can take on an important role.

Jaakko Pihlajamäki, Director of the South Ostrobothnian Health Care District

In Finland there used to be 250 primary health care centres and 20 hospital districts in secondary health care. Today the number of primary health care centres is radically lower, about closer to 100. Each centre and hospital district has been responsible for making its own decisions regarding the use of ICT. There has been fierce and uncontrolled competition between system producers in the market, with each health centre or hospital striving to be a pioneer in adapting and using new technology. Finnish health care ICT is consequently very diverse, with more than ten major patient record systems in use. This creates a lot of barriers to the efficient use of electronic patient data and in transferring data from one system to another.

There has been growing demand for a national health care ICT policy. In the mid-2000s, the government decided that, even if there was a range of different patient information systems, there should be only one central national archive from which any service provider – with patients’ permission – could access data. This would necessitate the creation of a standardized and structured patient record system. In response to this vision, huge investments have subsequently been made by hospitals and primary care health centres in order to achieve the desired goal.

There are now three main areas in which major efforts have been made in developing eHealth: (1) ePrescription and the national prescription centre, which is anticipated to be in use by the end of 2012; (2) eArchive, which should be in use by 2014; and (3) the patient user interface, through which patients will be able to check what is in their records, add their own health information and communicate with health professionals.

A dedicated office at the National Institute of Health and Welfare is responsible for coordinating the development of eHealth. Hospital districts, responsible for organizing the secondary health care of the population in their area, are now also charged with guiding primary health care along the path towards the national eArchive. Area-wide systems, where the hospital district and associated health centres share a patient database, have now been established in many districts.

There has been criticism about the cost and slow speed of eHealth development in Finland. Some have even suggested that we should go back to the starting point with paper patient records and mechanical typewriters and build a totally new single national system from the clean table. But the fact is that the urgent need for information in modern medicine does not allow for such backwards steps. The aging population and numbers of chronically ill people make it more vital than ever to accelerate the use of ICT in changing the health care system.

While the creation of a national system is difficult and costly, more difficult by far is the development of a system in which data can be used internationally. The most crucial factor for cross-border data use is the development of international standards. Dicom, HL7, CDA and other standards offer a good starting point for the broader use of data but there is much work left to be done especially at the European Union level.

Lotte Beck and Mette Atipei Craggs, Region of Southern Denmark
Like every region in Europe, the Baltic Sea Region is facing the demographic challenge of an aging population and an increase in the number of people suffering from chronic diseases. As the demand for health care increases, the ICT for Health project believes that eHealth is a user-friendly, safe and cost-effective way to improve the supply of health care. The social capacity, knowledge and acceptance of citizens and medical professionals to utilise eHealth technologies is a basic condition for the implementation and further development of innovative technologies for use in the health care sector. A previous study (2007) by the eHealth for Regions project reveals a lack of eHealth acceptance in the Baltic Sea Region. One of the aims of the ICT for Health project is to measure whether or not the acceptance of eHealth has increased over the past four years in the Baltic Sea Region. This will be done via a questionnaire survey focussing on eHealth acceptance among citizens and medical professionals.

Barriers and Key Drivers

When implementing eHealth solutions, the occurrence of barriers is inevitable. These exist on an organisational, legal and technological level. On all levels, a change of mindset is crucial, as one significant barrier is a fear of technology. Thus awareness, both of the citizens, politicians, medical professionals and media is essential. Taking Denmark as an example, media involvement has especially been of great importance and is one of the reasons why people are accepting eHealth solutions.
Numerous eHealth solutions are still suffering from a lack of evidence from a professional point of view. This is often because projects working towards the implementation of eHealth never make it beyond the pilot stage. Thus results from these projects fail to trigger any significant progress in the eHealth area.
Currently the acceptance of eHealth is not discussed sufficiently throughout the Baltic Sea Region. However, the focus on and debate about ICT and the acceptance of eHealth differs from region to region. In Denmark there is a stronger focus on initiatives concerning technologies for the delivery of health care than might be the case in other regions in the area. We therefore encourage readers to discuss the degree of eHealth acceptance in their own region and how, together, we might change the mindset of citizens and medical professionals in using and accepting eHealth technologies.

The Current State in Denmark

The present political landscape in Denmark is dominated by discussions concerning the welfare state. Elections are coming up and politicians emphasise that the welfare state is not only endangered, but is also something necessary to uphold. The Danish population relies on the Danish welfare state - especially when it comes to the provision of health care. Regardless of political persuasion, politicians agree that the increasing demand for health care, both in terms of volume and quality, must be met. Thus decision makers are looking for solutions to meet the demographic challenge mentioned above. One of these solutions lies within eHealth technologies, especially ‘welfare’ technologies (user-driven technologies that provide or assist users with public or private welfare services or products). In this connection, several national initiatives, the Danish Growth Council, the Social Democrats and the Socialist People’s Party, as well as regional initiatives in the Region of Southern Denmark such as Welfare Tech Region, Velfaerdsteknologi.nu, INVIA, and the Innovation Centre of User-driven Innovation, have presented initiatives focusing on technologies for the delivery of health care.

A recently published survey by KMD shows that a majority of Danes thinks that the public sector must develop and offer more technological solutions. Only one in five opposes the use of more technology in the health care sector. At the same time, Danes are supporting the use of video communication. The survey shows that seven out of ten are open to the use of new technologies such as video communication in the care units of the municipalities, for example. Furthermore, it shows that those who are opposed to new technologies within health care are mostly elderly citizens over the age of eighty.
In Denmark, examples of eHealth solutions for the provision of health care for the chronically ill include, among others, the patient briefcase for COPD patients, telemedical ulcer treatment for diabetes patients, and the implementation of technology from the completed “PERSONA” project in the municipality of Odense. Furthermore, Danish citizens have access to their own health information on the Danish eHealth Portal, prescriptions and referrals are sent electronically, etc. Some of these, as well as other cases, will be published in an ICT for Health project report on good practice cases of the use of ICT in the Baltic Sea Region.

Conclusion

From the ICT for Health project point of view, we can draw the conclusion that the acceptance and awareness of eHealth is essential in addressing the current demographic challenge faced by many European countries. From a Danish point of view, we can conclude that many initiatives have been introduced, but that we still have a long way to go. Therefore we find it essential to learn from other projects and countries, and look forward to following and participating in this important debate.