EHTO TELMED: The Impact of Telematics on the Healthcare Sector


	Updated: Sep 17, 97
TELMED

3.3.3 Underlying trends in the distribution of applications

In this section we look beyond the mainly descriptive analysis of the preceding section to consider the inter-relationships between the various 'building blocks' used in the applications audit, through the use of multi-variate analysis methods including crosstabulation, correlation, cluster and discriminant analysis. The main aim of this comparative and 'clustering' exercise was to begin to unpick what economic, institutional and regional factors are both stimulating and inhibiting the growth of telematics applications for healthcare in Europe.

i) Maturity of the market

As discussed above in Section 3.2.2, established services represent only a small proportion of the applications currently being implemented in healthcare, the majority of provision being in the form of pilot and R&D projects. These patterns are also marked by differentiation with respect to the type of applications being implemented, and the organisations involved. So, for example, crosstabulation of the status of applications (R&D, pilot or established) with type of organisation (commercial, government, EU programme) and applications environment showed that over 25% of HIS, medical imaging and telediagnosis applications environments were established systems, whereas 60% of tele-emergency applications and 75% of decision support systems were R&D projects.

Similarly commercial organisations accounted for over 50% of the institutional actors involved in HIS, EPR and EDI applications, whereas the dominant institutional representation in community health and tele-emergency applications areas were national and regional government institutions. Drawing together the crosstabulation and correlation analyses carried out, a broad picture of an evolving market emerges (as portrayed schematically in Figure 13) which is as yet immature, but where established services based on medical imaging and hospital information systems, driven by commercial organisations, are beginning to consolidate a market position. This is reflected in the established position of teleradiology and telepathology applications utilising medical imaging and inter-site distribution systems. Major infrastructure projects providing the basis for the more widespread take-up of telematics based services are currently being undertaken largely through government programmes, in partnership with commercial organisations and regional health authorities, piloting EDI, HIS and EPR networks. The most experimental and under-developed applications areas at present are in the decision support and teletraining areas. At the same time, a more community-based telematics healthcare regime, based on open networks of integrated 'telehealth' services, rather than closed, 'off the peg' specialist telemedicine is beginning to consolidate, mainly in the form of regional community care.

Set against this broad context for Europe as a whole, however, regional variations in the market are discernible. Hospital Information systems are relatively better established in the UK and in France, where there is also a stronger commercial involvement, as there is in EDI and EPR development and implementation. In the Netherlands, government intervention has been most pronounced in relation to the development of HIS and EDI infrastructure, and in building up the basis of community health care networks. We turn in more detail to spatial issues in the following section.

ii) National and regional factors

Cross matching the distribution of applications environments with the prevailing pattern of scenarios of use (both as defined above in Section 3.3.2) suggests a more meaningful portrayal of indicative types of generic applications embedded within particular spatial and organisational settings. The results of this analysis suggest the following trends:

Single site scenarios - those which involve the provision of services within a single bounded organisational context - are strongly associated with the utilisation of HIS applications (45% of HIS systems are single site based), and with decision support (48%) and telediagnosis systems (35%).

Inter-site networks, typically involving transmission of data exchange between local networks of hospitals, focus on the implementation of medical imaging applications environments (32% are in the form of local inter-hospital networks), telediagnosis, decision support and tele-emergency (around 30%).

Regional scenarios reflect the broadest configurations of applications environments, typically integrating telediagnosis, community healthcare and tele-emergency services within EDI-based telematics infrastructure networks and using EPR data storage architectures, which are themselves linked to national EDI systems.

Taking the analysis to the national level, the distribution of applications environments and scenarios of use show marked variations in development and take up of telematics for healthcare, reflecting different stages in market maturity, geographical factors associated with aspects such as physical and demographic barriers to innovation diffusion, and variations in levels of financial and political investment.

Figures 14 to 26 illustrate these variations in the form of relative scores on a 'location quotient' factor for each European state surveyed in the applications audit in terms of the nine main applications environment types identified, and the five main 'scenarios of use'. A given location quotient shows the relative ratio of provision of a given nation state for a particular applications environment or scenario. The closer the quotient is to 1, the closer that country is to the 'average' distribution for Europe as a whole. Scores below 1 indicate a relative under-representation and above 1 a relative over-representation compared with Europe as a whole.

The Figures show:

The notion of a 'North-South divide' has been a recurring theme in the literature on European social and economic cohesion. Such a polarisation can be identified in relation to telematics for healthcare provision. As discussed above, the widespread diffusion of products and services, and the movement away from single applications 'telemedicine' environments utilising closed networks, to more integrated, open-networked 'telehealth' scenarios will be underpinned by the availability of extensive trans-European infrastructure provision. However, as this report has shown, basic infrastructure provision like EDI networks is still mainly in the pilot stage, and, as Figure 14 illustrates, is concentrated in northern European states, and is under-developed in Greece, Spain, Italy and Portugal.
Exceptions to this pattern are Germany and Scandinavia. In Germany, largely, it would appear for reasons connected with a political tradition of individualised data recording, telematics for healthcare has tended to focus on programmes designed to promote a national data registration culture based on smart cards. In Scandinavia, telemedicine has a more established tradition than anywhere else in Europe, one that has been driven by problems associated with delivering healthcare to remote regions, and reflected in an established base in medical imaging (Figure 15).
France and the UK present the most comprehensive range of telematics provision, showing strong representation across almost all the applications environments identified. In part, the relatively advanced state of the art in telematics for healthcare in these two countries has been underpinned firstly by long-established 'centres of excellence' for medical R&D, based, for example, in research centres in London, Edinburgh and Toulouse, and secondly by governmental investment at a national and European level. Set against this broad level of representation, investment in training has run at a very low level in France, whereas, in contrast, the UK is probably Europe's leading centre in this field, and is also over-represented in the domain of telediagnosis.
Outside Northern Europe, and taking into account the low level of investment in 'basic' telematics infrastructure and services, such as EDI, hospital information systems and electronic patient records, countries such as Italy, Spain, Greece and Portugal have concentrated primarily in decision support applications to facilitate the diffusion of know how from specialists to non-specialist clinicians; in tele-emergency services, and in community health systems. This mainly reflects the need to provide services for users in remote and rural areas. However, within major cities, there are pockets of more centralised telematics implementation based on installing networked hospital information systems.
These cities would appear to be at the forefront of the trend towards developing regional healthcare networks integrating a range of medical and social services. As Figure 25 shows, such regional networks are as well-represented in Italy and Greece (for example around Bologna and Athens) as they are in France, the UK and the Netherlands.
In contrast, the devolution of service provision from specialised to primary care networks outside these emerging regional contexts (identified as a key future trend by many of the experts consulted by TELMED) is still in its infancy. As Figure 23 shows, only in Belgium, Austria and the UK has there been any real advancement in the provision of telematics for GP-based networks.

A more extensive, country-by-country assessment of current levels of utilisation of telematics products and services for healthcare is set out in Annex II.

Figure 14