Prescriptions without boundaries

In the first quarter of 2018, the five EU Member States Sweden, Finland, Portugal, Croatia, and Estonia will embark on a path that has the potential to change European healthcare forever. Cross-border exchange of electronic patient data will finally exit project phase. Electronic prescriptions will be here to stay, and more is likely to come.

Grätzel von Grätz

It is time to stop piloting." When, during this year’s eHealth Week in Malta, Natalia Zylinska-Puta of the European Commission’s DG SANTE summarised what is in essence more than a decade of continuous work on the level of the European Commission in the field of cross-border digital data exchange in Europe, she sounded neither particularly proud nor particularly enthusiastic. She would have had reason to be both. After years of projecting, at times agonisingly slow – albeit constant – progress in Commission-initiated cross-border healthcare projects like epSOS, and ill-informed cross fire on behalf of some European Member States, a line will be crossed in early 2018. The European eHealth Digital Service Infrastructure will start operating.

What might not sound particularly exciting in the first place, in reality is more than that. Only in projects, and on a very limited scale, have European healthcare systems exchanged digital patient data so far. This time it will be different. Twelve EU Member States will start exchanging patient data in the first quarter of 2018 on a regular basis, using an "official" communication infrastructure that will be provided jointly by the European Commission and the national healthcare systems. Most of the twelve countries that have decided to become early adopters and go live in 2018 will exchange electronic patient summaries. Sweden, Finland, Portugal, Croatia, and Estonia will share electronic prescriptions. Five more countries are scheduled to join the network in 2019, and another wave is expected for 2020 with six more countries currently negotiating to join the club.

eHealth DSI: Central services won't store any data permanently

Without going into too much detail, the European eHealth Digital Service Infrastructure features a core services platform that is built and maintained by the European Commission, using "reusable" components from other digital service infrastructures that are evolving in the EU. This, Natalia Zylinska-Puta said, was very helpful to reach a certain level of interoperability between different business sectors. In addition, each Member State that wants to connect to the infrastructure has to set up a "National Contact Point" or NCP that acts as both dispatcher and integration hub for the national healthcare systems.

The central services won’t store any data permanently, said Zylinska-Puta. Instead, they are there to provide all the services needed to make crossborder exchange of healthcare data sets happen. They set up a secure connection. They forward incoming data from the NCP of one healthcare system to the NCP of another. And, importantly, they provide the semantics and terminologies needed to translate or, more accurately, transcode incoming documents on the level of the NCP into documents that the receiving healthcare system can work with.

Having agreed on all the standards and processes necessary to make this work Europe-wide is no small feat. And having reached the level of acceptance among Member States necessary to get more than 15, and soon more than 20 of them on board, is remarkable, since we are talking about healthcare, all this is voluntary. No Member State has to join, it is all a result of an ongoing dialogue process in another voluntary "club" of high level representatives of the national ministries of health, dubbed the European eHealth Network that came to life as a result of the EU directive on patients’ rights in – cross border – healthcare.

Tough months ahead in Sweden

But let us leave Brussels for a moment and go to Stockholm. Sweden is among the five countries that have agreed on working together to make cross-border electronic prescriptions a reality as early as February 2018. "From that time, we want to be able to send Swedish prescriptions abroad, and from 2019 we also want to receive prescriptions for dispensations," said Hans Andersson of the Swedish eHealth Agency.

As a country that uses electronic prescriptions almost entirely, Sweden is more than ready to be at the forefront of cross-border exchange of electronic prescriptions in Europe. But still, even for a country with this advanced prescription system, crossing the finishing line of the European eHealth DSI in time remains a challenge. "If we want to deploy in February 2018, we basically have to finish development in summer 2017. We will need the rest of the year to test the implementation and to do the necessary audits with the European Commission," Andersson said.

Communication is another issue that needs careful consideration. Most conimportantly, pharmacists have to learn about the new possibilities to send electronic prescriptions abroad. But also medical doctors need to be informed, because it is them, after all, who will see the Portuguese or Estonian patient, issue the prescription and make it available digitally. The patient, in this example, will then go to a Swedish pharmacy to get their drug. The pharmacy will register the patient’s ID and send the prescription data, provided patient consent is available, to the Swedish NCP which will then forward it to the Portuguese or Estonian NCP. After transcoding, the prescription will then end at exactly the same place that a prescription ends up which is issued in Portugal or Estonia.

Mapping the codes is among the biggest challenges

Andersson is optimistic that, in the end, everything will be ready in time. Among the toughest segments of the race so far was the semantic challenge to map the Swedish national code system to the European Master Value Set Catalogue. This mapping is not only necessary for electronic prescriptions, but also for the electronic patient summary, the second use case that the European Commission and the European eHealth Network have specified.

"From that time, we want to be able to send Swedish prescriptions abroad, and from 2019 we also want to receive prescriptions for dispensations."

For Dipak Kalra from the EuroRec Institute, it is the electronic patient summary that holds most promise in the long run. In Malta, he suggested to go for disease specific digital care summaries as an extension of the broader patient summary and make the application programming interfaces available to the ICT sector. This, he said, could bring users on the platform and would allow value to be generated through information brokering services once EU-funding dries out.

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Philipp Grätzel von Grätz

(Germany) specialises in medicine, health policy and, in particular, eHealth and information technology in healthcare. He is one of Europe’s leading journalists in the field and author of the German book Connected Health.

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