To improve access to care, reduce hospitalizations and lower the use of acute emergency services, the European countries’ healthcare authorities are pushing for the routine implementation of telemedicine. Notably, French authorities recently entered negotiations with the labor unions of practitioners with the objective to set the rules and pricing for Teleconsultation and Tele-expertise.
What is telemedicine?
Telemedicine allows healthcare professionals to remotely evaluate, diagnose and treat patients with the help of Information Technologies. Initially thought as a way to treat remote patients with minimal or no access to care, Telemedicine is more and more perceived as a tool for routine, convenient medical care by both patients and healthcare professionals. In practice, the conception of telemedicine solutions requires expertise from several industry segments:
- IT infrastructure: network, communications protocols, data storage, etc.
- Hardware: connected objects, medical devices, etc.
- Software: applications, web platform, algorithms for data analysis and visualization, etc.
What are the benefits?
Telemedicine can allow older and disabled patients to live at home longer and avoid the need to move into skilled nursing facilities. It can also reduce the number of hospitalizations, and readmissions, thus reducing hospital costs. It increases access to specialists for remote patients. Telemedicine thus improves the quality of life of patients, eases healthcare professionals work, cuts down costs for governments and insurance companies and limit out-of-pocket expenses for patients.What are the different segments of Telemedicine?
There are 4 main segments of Telemedicine corresponding to different uses as explained in figure 1.
HCPs: Healthcare professionals
What are the the underlying technologies?
These four segments of Telemedicine are based on three IT protocols: Store-and-forward, interactive and remote monitoring, as explained in figure 2.
What are the main telemedicine initiatives in the 5 major European countries?
- United Kingdom: already well established public and private services
In the UK, the NHS has clearly recognized Telemedicine as a priority for many years. First, authorities massively invested in Telemedicine through various pilot projects: 3millionlives campaign, All-Wales Telemedicine Development Program, NHS England Call to Action, Whole Systems Demonstrator Project (one of the largest randomized trial aimed at evaluating the effectiveness and cost-effectiveness of telemedicine), etc. These initiatives mainly targeted heart failure, diabetes and Chronic Obstructive Pulmonary Disease. Having learned from these initiatives, the NHS then launched “GP at hand”, a service offering reimbursed consultations to patients all across the UK. Private players are also well positioned on the segment, with companies such as Push Doctor and Babylon Health proposing well designed, easy-to-use platforms for on-demand teleconsultations.
- France: telemedicine practice about to strike up
French authorities started to seriously address the telemedicine question in 2014 with the “Digital Health” national plan, which targeted four therapeutic areas (diabetes, kidney failure, heart failure and hypertension) and aimed for 1 million patients managed with telemedicine in 2020. Recently, France went a step further as the 2018 healthcare budget law included teleconsultation and tele-expertise as recognized medical acts, with reimbursement levels likely to reach traditional consultations levels. Moreover, France benefits from a highly dynamic entrepreneurial activity with many startups developing solutions and devices in partnership with regional healthcare authorities (e.g. Applichimio) and hospitals. Though, these players have not yet been able to raise enough funds to widely deploy their solutions. Industrial players can benefit from the support of the French Society of Telemedicine which promotes usage towards patients, healthcare professionals and treatment centers.
- Germany: a technologically advanced healthcare system but limited telemedicine initiatives
Germany has one of the most technologically advanced healthcare infrastructures in Europe. The e-health card (eGK, launched in 2011), widely used to manage patients and reduce healthcare expenditures, is based on an IT infrastructure which could integrate Telemedicine applications in the near future. In this purpose, a criteria catalogue has recently been established to provide guidance on what telemedicine solutions should demonstrate to obtain reimbursement and be supported by the infrastructure. But up to now, Telemedicine usage has been limited to pilot projects in Bayern, Nurnberg and Sachsen (e.g. Diabetiva) and no standardized reimbursement code currently exists.
- Italy and Spain: an interest in telemedicine at the local level but limited national initiatives
In Spain and Italy, several actions are being taken at the local and regional level. In Italy, initiatives (mainly in heart failure) are supported by regional health authorities while in Spain, recognized treatment centers with solid financial resources, such as the Institute Carlos III, are pushing for the development of technologies and their assessment in clinical trials. In both countries, although technology assessment platform and guidelines (“Pact for Digital Health” and “Horizon scanning” in Italy, “Platform of Innovation in Telehealth Systems” in Spain) are being created, the lack of national investments to fund widescale initiatives currently limits the development of Telemedicine.
What are the main barriers to the widespread adoption of Telemedicine?
Despite clear benefits and numerous initiatives in major European countries, several barriers stand in behind the widespread adoption of Telemedicine.
While national legislations increasingly recognize Telemedicine as a medical practice, significant limitations still apply. At the national level, HCPs often need to register and get an authorization to perform Telemedicine. International web-based Telemedicine platforms also need to assess whether their registered doctors can practice out of the country where the obtained their diploma. In Europe, the EU Directive on patient’s rights in cross-border healthcare eases this process: the HCP only needs to comply with the requirements of his Member State and does not need a license in the patient’s country. Yet, this barrier exists with non-European countries. As a comparison, in the US, the policies governing Telemedicine vary widely across the country. Some states allow cross-border delivery of healthcare via Telemedicine, while others still ban it entirely.
If a patient can be treated by any doctor within the EU, the regulatory frameworks for HCPs and the definition of what constitutes a medical act differ between Member States laws. Other legal barriers are being currently discussed such as requiring a first face-to-face visit, asking for a written or verbal consent from the patient for any Telemedicine procedure each time, particularly concerning Tele expertise.
Pricing & reimbursement
The reimbursement of Telemedicine is not yet fully democratized in developed countries compared to traditional medical acts. While negotiations are ongoing in France regarding the pricing of Telemedicine, the reimbursement of Teleconsultations and Tele expertise by social security is currently limited to specific populations: chronic and rare diseases patients, and patients in underserved rural areas, retirement homes or medical-social residences. For privately insured patients, although many Teleconsultation platforms (e.g. in France:Medaviz, MédecinDirect, Medicitus, Axa Assistance, MesDocteurs) have already obtained reimbursement of their services from insurers (20M patients concerned in France) without restrictions, most patients are not aware of it due to a lack of communication.
In the US the coverage and reimbursement of Telemedicine services, when existing, is also often limited to patients residing in underserved rural areas.
Equipment and training
Beyond basic audio-video communication procedures, Telemedicine requires the use of sophisticated equipment: the systems should secure data collection, guarantee patients’ data privacy as well as ensure the quality of clinical data transmitted. Both HCPs and patient need to be trained on the equipment. In a context of increasing healthcare spending (ageing population, increasing access to care…) and tight budgets and even tough Telemedicine is supposed to decrease healthcare costs overall, the initial investment to equip all healthcare facilities and patients’ homes will be extensive. Furthermore, technical and organizational alignment of hospitals’ systems is crucial and the various Telemedicine devices and solutions need to be interoperable to enable massive usage across the value chain.
Conclusion: a nascent market ripe for massive adoption
As always in the healthcare industry, it takes much more time for innovations to be adopted than in other industrial or consumer markets. But European countries have a solid case for Telemedicine. In all major countries, pilot projects and clinical trials have demonstrated the medical efficacy and cost-effectiveness of Telemedicine. Industrial players are increasingly investing in the field and many startups managed by tech veterans, used to short innovation cycles, are quickly growing and releasing their solutions. Although legal, financial and educational barriers still prevent the massive adoption of telemedicine, there is no doubt the new generation of patients and healthcare professionals, used to on-demand services, will embrace the Telemedicine revolution. European governments, eager to find ways to reduce their healthcare expenditures, have already started to lay the foundation of Telemedicine-based healthcare systems and will continue to push in this direction.