Transforming healthcare systems the European way

It has been a number of years already since the European Commission embarked on a journey of bringing interoperability and international standards to help with digitising European healthcare systems. Way ahead of other parts of the world, the European epSOS project started to define a European patient summary based on international standards a decade ago.

Since then, the European patient summary has evolved beyond Europe and has found its way into the global endeavour to develop an “International Patient Summary” or IPS. The IPS, coordinated by CEN/ISO, is one of the most ambitious interoperability efforts with a clearly international agenda worldwide.

So far, internationally standardised patient summaries have not been in use much though, not even in Europe, where they had been invented. The healthcare IT reality in many parts of Europe is that most hospital and ambulatory IT systems tend to not be capable – or the IT providers not willing – to implement these datasets.

And – mirroring this reality – national electronic patient or health record projects are often not advanced enough to be able to create or read standardised patient summaries, making truly interoperable cross-border healthcare scenarios remain – to a large extent – fiction.


The European Commission has been well aware of these problems for years. And last year it decided to take another step and recommend a ‘European electronic health record exchange format’ or eHRXF. It was published earlier this year. The recommendation was widely considered to be a bold move, and sparked enthusiasm as well as nervousness. It draws on earlier work done by the European Commission, including an encompassing list of recommended IHE profiles that should be used to reach cross-border interoperability between European electronic health record projects.

In healthcare, though, the European Commission cannot do much more than recommend, since healthcare doesn’t fall into the responsibility of ‘Brussels’. One could argue that because the EU is responsible for digital infrastructures in general, it should also have the right to define healthcare IT related communication standards.

But this is not how the European Union works. To make cross-border interoperability a reality in Europe, national governments have to want it and actively implement agreed-upon IHE profiles and datasets like the IPS in their national healthcare IT projects.


This is exactly what is starting to happen now. In the context of the European eHealth Digital Service Infrastructure (eHDSI) under the Connecting Europe Facility (CEF), more and more EU Member States have been setting up National Contact Points for eHealth (NCPeH) that act as technical and semantic ‘adaptors’ between healthcare IT infrastructures of different Member States.

In January 2019, Finland and Estonia were the first EU Member States to be able to exchange ePrescriptions cross-border outside of pilot projects. Since then, more than 1,000 Finnish citizens have been able to go to a pharmacy in Estonia and retrieve medicine prescribed electronically by their doctors in Finland. In summer 2019, patient summaries will follow.

For the first time outside of pilot projects, medical datasets that summarise the disease history of an individual will move back and forth between EU Member States. One of the forerunners in implementing cross-border use of electronic patient summaries is Luxembourg, where the Agence eSanté, that coordinates the digitisation of Luxembourg’s healthcare system, acts as the NCPeH:

“Starting in mid-2019, visitors from other European countries requiring medical treatment in Luxembourg can benefit from this service,” Heiko Zimmermann, CDIO of Agence eSanté told HIMSS Insights. “Health professionals in Luxembourg will be able to consult the patient summary from the patient’s country of origin, to get an overview of the current health situation of the patient and to support the medical treatment.”


Healthcare workers, of course, have to learn about the new service. This is why Agence eSanté informs health professionals – especially general practitioners and emergency units – about the background and the usage of the new provided services within their medical workflow. “These services are fully integrated with the existing national eHealth Platform, providing health professionals with a single entry point and ensuring secure authentication,” according to Zimmermann.

In the beginning, the patient summary in Luxembourg will be a one-way road. As a next step, Agence eSanté will implement the bi-directional service, i.e. allow Luxembourg patients to benefit from retrieving their patient summary when treated by a foreign health professional abroad, based on an explicit consent from the patient. In relation to this, Agence eSanté is working with doctors and stakeholders of the healthcare domain, to evolve the patient summary into a structured document, aligned with both European Guidelines on Patient Summaries and the specifications of the CEN-IPS.


Luxembourg is not alone on the patient summary implementation field. The second Central European country in which doctors will be able to access patient summaries from other European countries, starting in the summer, will be the Czech Republic. And, once again starting in summer, Croatia will also enable its doctors to access patient summaries from abroad, with the focus being on patient summaries from Czech visitors in the beginning. Furthermore, Croatians travelling to Estonia will soon be able to get their ePrescriptions there.

The recent successes under the umbrella of the eHDSI efforts can be considered part of a wider trend: Central European healthcare systems are finally moving towards implementing international standards. Some countries, most notably Austria, have embarked on this journey early on. In Austria, nine million citizens are now registered for the largely IHE-based national electronic health record ELGA, that can be accessed via web browser or mobile app. Electronic medication lists as part of the ELGA system are currently being rolled-out, and from 2021 onwards, a digital vaccination application looks set to follow.

Austria is also planning to make its ELGA record accessible for medical providers beyond hospitals, doctors in private practice, and pharmacists. In July 2018, the country initiated a nationwide health worker registry in which physiotherapists, nurses, opticians and the like will have to register by 30 June 2019. This will allow health workers of all kinds to receive unambiguous digital identities, which is a prerequisite for taking part in the ELGA network.


Even Germany, well known for working with highly proprietary, very national healthcare IT standards, seems increasingly willing to make peace with IHE profiles. The national healthcare IT organisation gematik has recently published the first version of its technical specification for electronic patient records in Germany. A new law makes it mandatory for statutory health insurance providers in Germany to offer electronic health records that comply with gematik standards by 2021.

The gematik specification draws on a number of important IHE profile, including XDS. But for the moment at least, this can only be considered a careful approach. One of the reasons why Germany is much less at ease with IHE profiles than, for example, Austria, is the complex – and again very Germany-specific – communication infrastructure that the Ministry of Health is currently setting up, plus privacy requirements that exceed those in other European countries. In a rare public statement, IHE Germany has criticised the gematik specification, saying that, in its current fomat, it cannot be considered compliant with IHE at all.

There won’t be major changes to the German electronic patient record specification in the short-term though. Gottfried Ludewig, head of digitisation at the German Ministry of Health, has made it clear that the priority is not to be compliant with IHE but to have some sort of standardised electronic health record on track by 2021: “There won’t be further delays.”

Most healthcare IT stakeholders are aware that this will likely produce difficulties further down the road. But the decision has been taken. The EU says that by 2021, approximately 22 EU countries will have implemented cross-border exchange of ePrescriptions and patient summaries. It is highly unlikely that Germany will be among them. But at least there is a growing awareness that this should be the direction to move in.

This article was first published in the newest issue of the HIMSS Insights eBook, which looks at the digital transformation of healthcare across the globe, and can be accessed here. Healthcare IT News is a HIMSS Media publication.

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