Euphoria eu-project-proposal

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PROPOSAL PART B
Call identifier: 3.4 empowering patients and supporting widespread deployment of
telemedicine services
Proposal ACRONYM: EUPHORIA
Full title: European wide Up-scaling of Personalized eHealth services Opting for
Rapid International Adoption
Name of coordinating person: Prof. Vivian Vimarlund
List of participants
Participant
no
Participant organization
name
Participant
shortname
Country
1 Jönköping International
Business School
JIBS Sweden
2 Jönköping County Council,
Qulturum/Futurum
JCC Sweden
3 Jönköping Academy for
improvement of Health and
Welfare, Jönköping
University, Sweden
JA Sweden
4 Erasmus University
Rotterdam, institute of
Health Policy and
Management
EUR Netherlands
5 Health Portal Rijnmond HPR Netherlands
6 Netherlands institute for
ICT in healthcare - Nictiz
Nictiz Netherlands
7 Patients Know Best PKB England
8 UCL Medical School UCL England
9 Apollo S.A. Apollo Greece
10 PC SYSTEMS PC Greece
11 Intermunicipality Health and
Welfare Network
IHWN Greece
12 National School of Public
Health
NSPH Greece
13 Generali Hellas Insurance
Company S.A.
GHIC Greece
14 Datasel Datasel Turkey
15 International Kent Hospital Kent Turkey

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Table of contents
PROJECT PROFILE ................................................................................................. 5
SECTION B1. RELEVANCE ..................................................................................... 7
B1.1 Project objectives.............................................................................................. 7
1.1.1 Challenges for Europe .................................................................................. 7
1.1.2 Aims and Objectives of EUPHORIA.............................................................. 8
1.1.3 Selected eHealth services............................................................................. 9
1.1.3.1 Personal health records........................................................................ 10
1.1.3.2 Self-management diaries...................................................................... 11
1.1.3.3 Online appointment tools...................................................................... 12
1.1.3.4 e-Consultation ...................................................................................... 13
1.1.3.5 Telemonitoring...................................................................................... 14
1.1.5 Evaluation of eHealth.................................................................................. 14
1.1.5.1 State of the Art in the field of socioeconomic evaluations ..................... 15
1.1.5.2 Socio-economic evaluation: The model used in this project.................. 16
1.1.5.3 Qualitative evaluation to capture user experiences............................... 19
1.1.6 Business model........................................................................................... 21
1.1.7 EUPHORIA eHealth Portal.......................................................................... 23
1.1.8 Innovative Aspects...................................................................................... 25
1.1.9 Value for Users and Expected Benefits....................................................... 26
B1.2 EU and national dimension ............................................................................. 28
1.2.1 Relevance to National Strategies and Initiatives.......................................... 28
1.2.1.1 Sweden, Jönköping County Council ..................................................... 28
1.2.1.2 The Netherlands................................................................................... 28
1.1.2.3 England................................................................................................ 29
1.1.2.4 Greece ................................................................................................. 29
1.1.2.5 Turkey .................................................................................................. 30
1.2.2 Relevance to EU Strategies and Initiatives.................................................. 30
B1.3 Maturity of the technical solution ..................................................................... 31
1.3.1.1 Infrastructure............................................................................................ 31
1.3.1.2 Personal Health Records ......................................................................... 32
1.3.1.3 Self-management Diaries......................................................................... 34
1.3.1.4 Online Appointments................................................................................ 34
1.3.1.5 e-Consultation.......................................................................................... 35
1.3.1.6 Telemonitoring ......................................................................................... 35
SECTION B2. Impact .............................................................................................. 37
B2.1 Target outcomes and expected impact............................................................ 37
B2.2 Longterm viability ............................................................................................ 39
B2.3 Wider deployment and use.............................................................................. 41
SECTION B3. IMPLEMENTATION.......................................................................... 43
B3.1 Consortium and key personnel........................................................................ 43
3.1.1 Sweden....................................................................................................... 43
3.1.2 Netherlands ................................................................................................ 46
3.1.3 England ...................................................................................................... 50
3.1.4 Greece........................................................................................................ 52
3.1.5 Turkey......................................................................................................... 57
B3.2a Chosen approach.......................................................................................... 61
3.2.1 The overall strategy of the work plan........................................................... 61
3.2.2 Technical work............................................................................................ 62
B3.2b Work plan...................................................................................................... 63
3.2.4 GANTT chart............................................................................................... 63
3.2.5 Workpackage list......................................................................................... 64

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3.2.6 Deliverables list........................................................................................... 64
3.2.7 Workpackage description............................................................................ 66
3.2.7.1 Workpackage 1: Inventory and preparation .......................................... 66
3.2.7.2 Workpackage 2: Socio-economic Evaluation Model ............................. 67
3.2.7.3 Workpackage 3: Business Model.......................................................... 69
3.2.7.4 Workpackage 4: Infrastructure.............................................................. 70
3.2.7.5 Workpackage 5: Personal Health Records ........................................... 72
3.2.7.6 Workpackage 6: Self-management Diaries........................................... 74
3.2.7.7 Workpackage 7: Online Appointments.................................................. 76
3.2.7.8 Workpackage 8: e-Consultation............................................................ 77
3.2.7.9 Workpackage 9: Telemonitoring ........................................................... 79
3.2.7.10 Workpackage 10: Communication, Synthesis and Dissemination....... 80
3.2.7.11 Workpackage 11: Project Management.............................................. 82
3.2.8 Summary of staff effort................................................................................ 84
3.2.9 Risk assessment......................................................................................... 85
B3.2c Project management ..................................................................................... 87
3.2.10 Organizational and responsibilities structure............................................. 87
3.2.11 Project Control.......................................................................................... 91
3.2.12 Implementation and dissemination strategy .............................................. 91
B3.3 Resources to be committed............................................................................. 93
B3.4 Indicators ........................................................................................................ 95
B3.5 Security, privacy, inclusiveness, interoperability; standards and open-source. 98
3.5.1 Security and Privacy ................................................................................... 98
3.5.2 Inclusiveness and accessibility.................................................................... 99
3.5.3 Interoperability .......................................................................................... 100
3.5.4 Standards and open source...................................................................... 100
Annex I. Description of the eHealth servies in the consortium ............................... 102
I.i Sweden.......................................................................................................... 102
I.ii The Netherlands............................................................................................ 103
I.iii England........................................................................................................ 106
I.iv Greece ......................................................................................................... 107
I.v Turkey........................................................................................................... 109
Annex II. References............................................................................................. 111
Annex III. Biography of Expert Advisory Board...................................................... 114
Index of Tables
Table 1. eHealth services to be up-scaled in the countries of the consortium............ 9
Table 2. Value indices............................................................................................. 22
Table 3. Participants of the EUPHORIA consortium ................................................ 43
Table 4. Workpackage list ....................................................................................... 64
Table 5. Deliverables list ......................................................................................... 66
Table 6. Staff effort.................................................................................................. 85
Table 7. Risk assessment ....................................................................................... 86
Table 8. Expert Advisory Board............................................................................... 89
Table 9. Work Package Leaders ............................................................................. 89
Table 10. Work Package Board............................................................................... 90
Table 11. Stakeholder group ................................................................................... 90
Table 12. Budget plan ............................................................................................. 93
Table 13. Indicators................................................................................................. 97
Index of Figures
Figure 1. Challenges for eHealth in Europe............................................................... 7
Figure 2. The three levels of the evaluation model .................................................. 17
Figure 3. The design of action research .................................................................. 20
Figure 4. Strategy of the EUPHORIA pilots ............................................................. 61
Figure 5. GANTT chart ............................................................................................ 63

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PROJECT PROFILE
Proposal ACRONYM: EUPHORIA
Proposal full title: European wide Up-scaling of Personalized eHealth services Opting
for Rapid International Adoption
Information on the proposed service/solution
The aim of the EU is to stimulate the wider deployment of telemedicine services in
Europe, including personal health records. In the EUPHORIA project we will up-scale
a selection of such eHealth services in five countries: Sweden, the Netherlands,
Greece, England and Turkey. The services are: personal health records, self-
management diaries, appointment tools, e-consultation, and telemonitoring. The
services have been piloted already in Sweden, the Netherlands, Greece and England
and a pilot will be set up in Greece. All PHRs are based on the CCR/CCD standard.
For wider deployment of eHealth in Europe we develop the EUPHORIA eHealth
Portal. This portal stimulates social interaction between users (and other
stakeholders) and eHealth developers, and acts as a platform for cooperation
between eHealth developers. Moreover, the portal provides virtual showcases of
European eHealth services.
Target users and their needs
The target users of the services that are up-scaled are citizens and patients in the
aforementioned countries. Some services are for chronically will patients. In general,
patients in Europe want to have access to their medical record; a Personal Health
Record can give them their information in an integrated way.
Usage
A large group of patients in the participating countries (regions) already use the
services. An approx. number of 1,9m EU citizens have already used some part of the
eHealth services that are to be up-scaled in the project (mainly in Sweden and The
Netherlands). The up-scales only will engage an additional 120.000 users in a
controlled and coordinated way.
Technology
Several personalized eHealth services will be up-scaled in this project
Content
The personal health records need content from the information systems of healthcare
providers (hospitals, general practitioners)
Sustainability
All the aforementioned numbers (see section Usage) warranty national wide rapid
adoption of the up-scaled services after the end of the project. Furthermore, a EU
oriented portal (a social mesh) is also developed for EU wide knowledge diffusion
and professional collaboration that also features a novel kind of eHealth
“marketplace”. This unique combination (the national up-scaled services and the EU
portal) is expected to multiply the project’s deliverables (services) usage and
Sustainability. Lastly all up-scaled services are owned by project partners that
already have invested significantly on the existing services and are expected to
invest much more on the up-scaled versions of their services.
Ownership
The services belong to the healthcare organizations. However, this project will deliver
a marketplace on the internet where the open source components of the services can
be found.

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Information on the project phase and impact
Number of users The number of users differs for each of the pilots and
varies per country. In total, we aim at an approx. number of
120.000 EU citizens to be using the up-scaled eHealth
services in a controlled and coordinated manner (often in
the domain of a patient or Health oriented network).
Furthermore, an EU wide portal will serve EU citizens for
targeted and social media aware information.
Location: Sweden (Jönköping County Council), The Netherlands (Rijnmond region),
Greece (Athens region), UK (Devon region), Turkey (Izmir)
Information on what already exists
A technically tested prototype of the service exists?
In Sweden (My Healthcare Contacts), England (Patients Know Best), and the
Netherlands (Health Portal Rijnmond) these portals already exist. All these portals
are secured websites that present the services of this project (and also services and
services that are not part of this project) in a uniform way. In Greece and Turkey,
portals will be developed for the integration of their services. In Greece the portal is
based on the existing services / installations of e-ppokrates and Smart Insurance. In
Turkey the portal is based on the existing information system of the pilot hospital.
The section. “Maturity of the technical solution” details the existing eHealth services.
A business plan has been developed already for the service? Yes
A service already exists? Yes
Further localization work is needed? No
Further integration work is needed?
Yes – in the Netherlands all services will run on a secured portal platform. The
access via DigID and UZI and single sign on by SIAM is needed.
No other integration deems essential for the smooth operation of the up-scaled
services as functional sections / subsystems of the national portals in all the
countries.
Existing prototype/service
 Personal Health Records: Health Portal Rijnmond (NL), Patients Know Best
(UK), Smart Insurance (GR), Avicenna PHR (TR),
 Self-management Diaries: Health Portal Rijnmond (NL), Patients Know Best
diary (UK), Avicenna Patient Diary (TR)
 Online Appointments: Health Portal Rijnmond (NL), My Healthcare Contacts
(SE), Avicenna Appointment System (TR)
 e-Consultation: Health Portal Rijnmond (NL), Patients Know Best (UK), My
Healthcare Contacts (SE)
 Telemonitoring: e-ppokrates (GR), Avicenna Tele-Monitoring platform (TR)
If running service exists
Location(s): My Healthcare Contacts (SE), Health Portal Rijnmond (NL), Patients
Know Best (UK), Smart Insurance (GR), e-ppokrates (GR), Avicenna (TR)
Number of users: My Healthcare Contacts (600000+), Health Portal Rijnmond
(2000+), Patients Know Best (800+), Smart Insurance (8000+), e-ppokrates (1000+),
Avicenna (1000+)
Ownership: My Healthcare Contacts (JCC), Health Portal Rijnmond (HPR), Patients
Know Best (PKB), Smart Insurance (Apollo), e-ppokrates (PC), Avicenna (Datasel)
Sustaining the service: My Healthcare Contacts (JCC), Health Portal Rijnmond
(HPR), Patients Know Best (PKB), Smart Insurance (Apollo), e-ppokrates (PC),
Avicenna (Datasel)

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SECTION B1. RELEVANCE
B1.1 Project objectives
1.1.1 Challenges for Europe
In the coming decades, the national healthcare systems in EU countries will be under
constant stress resulting from various megatrends. These include aging populations,
budgetary constraints in an insecure financial landscape, personnel constrains as
fewer people will work in the healthcare sector, and continued attempts to improve
quality in and equality of access to healthcare services. (Figure 1) As the demand for
healthcare services grows, stakeholders concurrently search for structures that will
enable them to continue to provide high quality care at lowest costs. There is also
increasing emphasis on encouraging and stimulating self-management of disease
and empowerment among patients.
Figure 1. Challenges for eHealth in Europe.
(Reference. Vimarlund, et al. The Swedish eHealth Network, Capturing the Value of IT in Health
and Social Care, WoIT, 2011)
During the last 20 years, eHealth services have been proposed as crucial
components for addressing several different problems in healthcare. In the
Workprogramme eHealth it is narrowed defined as “telemedicine services” and
“personal health/medical records” (Workprogramme 2011, pp. 24-25) These broad
definitions cover services that support patients with the administration of their
disease (access to medical data, access to information, online scheduling of
appointments), or even with managing their disease (as an alternative to current
services such as face-to-face consultation with a physician). eHealth products and
services have been piloted in many ways, and some are even used by large groups

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of patients. Many services, however, have yet to achieve their full potential within
local and national health systems, hindering further synthesis of systems for both
patients and professionals at the EU level.
Moreover, with regard to the aforementioned EU-wide megatrends, healthcare
systems in Europe must find new ways to focus, adapt and prioritize resources, while
simultaneously anticipating future needs with greater accuracy and confidence. This
is difficult because decisions on healthcare made today may result changes in the
public health status/resource demand/resource usage only after significantly longer
period of time; typically 5-20 years, but sometimes even more. Therefore, new tools
and practices are urgently needed for guiding the health political decision making
towards effective solutions that are coherent in both shorter and longer time frames.
As stated in the Digital agenda 2010-2020 for Europe, one of the objectives of the
European ICT policy is to maximize the social and economic potential of ICT to
provide better healthcare services. The challenge for Europe, thus, is not only to
realise EU-wide use of eHealth services, but also to make evidence-based cost-
effective choices on the type of services to implement.
In the EUPHORIA project, a consortium of organizations from five European
countries take up these challenges. They want to contribute to the European wide
Up-scaling of Personalized eHealth services Opting for Rapid International Adoption.
For this, we have developed a business model which will be applied to a carefully
selected group of eHealth services that are implemented and up-scaled in five
countries in Europe.
The partner countries in the EUPHORIA consortium are: Sweden, the Netherlands,
Greece, England and Turkey. These countries were chosen because they represent
variation in the important aspects of healthcare that may influence how specific
eHealth services are implemented; for example, differences in how healthcare
services are funded or in the progress that has been made in implementing
innovative eHealth services. The chosen countries also allow for taking into account
broader cultural considerations in a comparative framework, with three countries from
(North)Western Europe, and two from Southern Europe.
1.1.2 Aims and Objectives of EUPHORIA
This European project aims to increase the efficacy of eHealth, and by this to
improve the health of EU citizens. In particular the EUPHORIA project will contribute
to one of the main goals of the Commission: maximizing the social and economic
potential of the internet by supporting the widespread deployment of eHealth services
through an evidence-based business model. We also believe that Member States
and can learn a lot from each other when developing and evaluating eHealth
services. One of the goals of this project is to contribute to this dissemination of
knowledge and technology. For this we develop the EUPHORIA eHealth portal,
which contains platforms for patients (and patient organizations), policymakers and
entrepreneurs.
The EUPHORIA project has three specific objectives:
1. To use a generic model to evaluate a selection of ready existing eHealth
services on its effects to all stakeholders at micro, mezzo and macro level
2. To up-scale these services in five European countries, and share our
experiences with the services and the up-scaling process within the
consortium and with the other Member States.

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3. To direct and actively engage the maximum number of actors from all areas
of eHealth to the EUPHORIA eHealth Portal.
We expect three results of this project.
Firstly that there will be more citizens in Sweden, the Netherlands, England, Greece
and Turkey who use eHealth services. In total, we intend to reach over 1.000.000
patients and healthcare professionals, to become active users of the services.
However, because most of the services are already used by large groups of patients,
we are confident that the number of users will increase even more after the project.
For that matter, up-scaling efforts are not only related to the amount of users, but
also to the functionalities of the services and interoperability with other services.
A second result of this project will be an improved understanding of the way various
business models for eHealth work out in practice. In this project we bring together
expertise from Sweden, the Netherlands and Greece on business model
development, deployment and evaluation. The insights of this project will be made
available to the rest of Europe.
Thirdly, a result of this study will be an eHealth portal for Europe. We intend to
spread our knowledge and technology to the other Member States, by inviting SMEs,
patient organizations and policy makers to become members of the EUPHORIA
eHealth Portal, and use all the features.
In the next paragraphs we provide a more extensive background of our concept.
1.1.3 Selected eHealth services
We selected five types of eHealth services for our project: personal health records,
self-management tools, online appointment tools, e-consultation, and telemonitoring.
We chose these services because they are an exemplar for the variety of eHealth
services in Europe. Some are for all patients, others specifically for patients with
chronic diseases, or the elderly. Moreover, these five selected services aim at a
variety of quality dimensions: effectiveness, efficiency, safety, timeliness, patient
centeredness, and equity. (IOM, 2001) For example, personal health records improve
patient-centeredness, safety and timeliness (of information), while telemonitoring has
effects on efficiency and equity. By selecting this wide range of services we are
confident that we can make general recommendations for eHealth policy in Europe at
the end of this project.
Table 1 shows which services will be scaled up in which country.
Country →
Service ↓
Sweden Netherlands Greece England Turkey
PHR X X X X
Self-management
diaries
X X X
Appointments X X X
e-Consultation X X X
Telemonitoring X X
Table 1. eHealth services to be up-scaled in the countries of the consortium
The project is organized around these five service types. We think that the main
strength of a European project is knowledge exchange, and we believe that we can
learn a lot from each other while implementing our own systems in our own national
context. That is why in this project for each of the service types we set up a pilot that
involves more than one country. Although the self-management diary in the

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Netherlands is based on different technology and has a different look & feel than the
diary in Turkey, both participants share the same goals: supporting self-management
of chronically ill patients. By being in a pilot project together, they can exchange their
ideas and experiences and use this to improve their services. This ‘managing
diversity’ is a challenge, but also a deliberate choice for the organization of this
project.
In the consortium, Turkey holds a special position. They will be the first test bed for
the wider deployment of the knowledge and technology created in the EUPHORIA
project. The services they will improve and test, build on the experiences in the other
countries with online appointments, self-management diaries, and Tele-monitoring
and the integration of these services with a Personal Health Record and Hospital
Information System.
1.1.3.1 Personal health records
A recent study by Deloitte and Ipsos (European Commission, 2011) shows that 65%
of European hospitals have a common electronic patient record system and picture
archiving and communication (PAC) system. But it also shows that, “Both electronic
patient record systems and PACs are less accessible form outside the hospitals by
external healthcare providers (24% for electronic patient record systems and 27% for
PACS) or by patients. Only 4% of hospitals in the survey grant patients online access
to their electronic patient record” (European Commission, 2011: pp 14).
One of the aims of Europe, and also of the national policies of the individual Member
States is to give each European citizen access to his or her medical data (Com,
2010: Key action 13 and 14, pp 29/30). According to international and national law,
patients are the owners of their data and they must give informed consent to
healthcare professionals to use this data and to send it to other healthcare providers
involved in their care.
Personal Health Records – accessible via the internet – can thus be regarded as
tools that put this patient right into practice. We define a PHR as a web-based health
record that contains an accurate summary of the health and medical history of an
individual from all healthcare organizations where the patient is treated. A PHR is
presented to the patient in a user-friendly way, and the patient can add data to this
record. The PHR is owned by the patient and anyone who has the necessary
credentials can view the information. The PHR is recorded and stored by software
that has the capability to print, encrypt, back-up, import and export data from various
types of sources (Tang et al, 2006; Kaelber et al, 2008, Detmer et al, 2008).
There are several advantages of PHRs for both patients and professionals. If a PHR
brings together data from different providers in one place, this has potential to
improve efficiency and safety in healthcare. If healthcare providers from different
organization can use each others’ data, they do not have to collect it themselves.
When the professional does not have to spend time searching for relevant
information, this reduces inefficiencies and costs and also alleviates unnecessary
care (e.g.: repetition of requests for information, lab tests and other evaluations)
(Danzon et al, 2001). Furthermore, decision made on the basis of complete and
actual information, lead to better integrated care. A reduction in duplicate tests and
other work will not only save money but also be more convenient for patients. Since
PHRs can capture important patient background information such as allergies, they
can also improve patient safety. We also know from research hat many patients

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(from percentages of 35% till 68%) find errors in their medical record (Ross & Chen-
Tan, 2003; Golodetz et al, 1976). This discovery can also help improve safety.
Moreover, PHR encourages patient involvement, education and improved relations
between healthcare professionals, healthcare organizations and patients, because,
when properly designed, it:
 is patient focused,
 gives patients easy and understandable access to their health information,
 prevents that patients have to repeat same information over and over,
 stimulates the patient to be more involved in their healthcare.
Thus, patients can also actively use their PHR for managing their disease, by, for
example adding data and sharing it with their clinician. This will stimulate the patient
to be more involved in and informed about their healthcare, leading to improved
patient/physician relationships. Studies have shown that the more patients are
involved in their own care, the less stress they place on the limited resources of the
healthcare system (O’Connor et al, 2009).
In the EUPHORIA project, Personal Health Records in the Netherlands, Greece,
Turkey, and England will be up-scaled. These PHRs have in common that they build
on the CCR/CCD standard (see B3.5). More information about these specific
services is provided in § 1.3.1.2.
1.1.3.2 Self-management diaries
Chronic illness continues to place a large burden on the healthcare services of most
European countries, leading to a gap between supply and demand. Increasingly,
more effective interventions are needed to help patients manage illness within their
daily lives. A key concept in this regard is self-management. Within the well-known
Chronic Care Model (CCM), self-management is defined as: the ability to manage
one or more chronic conditions (symptoms, treatment, physical and psychosocial
consequences, and life style changes) and integrate them in day-to-day life with the
aim of achieving optimal quality of life (Wagner, 1998). Self-management is effective
when individuals are capable of monitoring their own health conditions, and
demonstrate cognitive, behavioral and emotional reactions that contribute to a
satisfying quality of life. (Barlow et al, 2002)
Effective self-management demands skills such as problem solving, decision-making,
resource utilization, forming partnerships with healthcare providers, and taking action
(Lorig & Holman, 2003). Since the ultimate goal of self-management is optimal
quality of life and less dependency of healthcare professionals, self-management
exceeds the healthcare domain: it is set within the context of the family, is a lifelong
dynamic process of self-monitoring/self-evaluation, and involves a paradigm shift in
chronic care delivery. Therefore, self-management programs incorporate eHealth
services that support this process by: connecting patients and various medical
professionals; offering home-based education, support, and self-management tools
like diaries; and/or monitoring patients.
When persons with a chronic condition use eHealth self-management tools, they
acquire better insight into their personal health situation and become better equipped
to handle their illness and make decisions related to care. Moreover, most self-
management tools also lead to increased self-efficacy and better quality of life, as
well as prevent exacerbation of the effects of illness. This facilitates systematic goal-
setting and better adherence to treatment. This is important for healthcare
professionals because better adherence means fewer complications, fewer
unplanned visits, and ultimately, a reduced demand for care. Where visits are

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necessary, patients are informed and better prepared, because they can find reliable
information on their illness and treatment based on evidence based guidelines in
their self-management tools.
Self-management Diaries are online interfaces that bring together different data and
information about the patient’s condition. The patient can enter his/her own data, but
can also access data related to e.g. hospital lab tests or medication. The diaries
enable tracking progress over time and supporting treatment with tips and other
evidence-based information about the condition. A benefit of the diaries is that the
acquired data can be used in scientific research. A prerequisite to this use is the
anonymization of the data and the attainment of informed consent from the patient.
In the EUPHORIA project, self-management diaries in the Netherlands, England and
Turkey will be up-scaled. More information about these specific services is provided
in § 1.3.1.3.
1.1.3.3 Online appointment tools
For both patients and healthcare organizations, internet appointments have many
advantages over most traditional methods like phone calls or visits to make an
appointment. The benefit of internet appointments for the patients is being able to
book appointments anytime, from anywhere and to choose a time that best fits their
needs. The benefit of internet appointments for healthcare organizations is that a
reduction in costs through, for example, a reduced need for administrative staff to
answer phone calls for making appointments1
. Healthcare organizations also have a
better access for their patients and research has shown that the number of no-shows
and cancellations dropped, because patient are more committed to appointments
they make themselves. (Berry et al, 2003)
In an interview last year with EHI, the Welsh NHS IT agency said: “What we found
from the 2.000 people that we asked was that the priorities they had were ordering
repeat prescriptions and booking appointments online - rather than having direct
access to their medical records.” Also in 2007, Informing Healthcare carried out
research which found that around 78% of people wanted to be able to order repeat
prescriptions, book an appointment with their GP or update their details online.
There are several ways of making internet appointments. One is by sending an email
and getting a confirmation on the suggested date and time by email. Another way is
via a web-based system that is connected to the planning system of the healthcare
organization. The patient can see what timeslots are available and can choose a time
he wants. A third way is internet appointments routed through a triage program: the
patient or GP must first answer a few questions, and then receives advice regarding
the amount of time needed and, if relevant, the different healthcare professionals that
must be seen. After receiving this advice the patient can book an appointment.
1
Information from the Windmill Health Centre, indicating a typical time of 2.5 minutes to book
an appointment or process a repeat prescription by phone. They assume an average
receptionist salary of £8 an hour, plus 30% in overheads (a total saving per transaction of
42.9p). Annual savings are based on 261,580 GP appointments booked in February 2010,
multiplied by 12 months suggest a saving for the NHS of £1.3M administration costs each
year, and frees up 16,349 days of staff time
(http://www.ehi.co.uk/features/item.cfm?docId=341)

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In the EUPHORIA project, appointment tools in the Netherlands, Sweden and Turkey
will be up-scaled. More information about these specific services is provided in
1.3.1.4.
1.1.3.4 e-Consultation
The US Institute of Medicine encourages flexible consulting as a key strategy for
improving the quality of healthcare. It notes that: “access to care should be provided
over the Internet, by telephone, and by other means in addition to in-person visits…
Instead of a $65 office visit and a half-day off work, a 2-minute e-mail communication
could meet many patients' needs more responsively and at lower cost.” (IOM, 2001;
Car et al, 2004).
e-Consultations can be held using secured email or chat and video consultation.
Email and chatting are user friendly, efficient and can facilitate asynchronous
communication and can both be used for preventive and non-urgent healthcare or
health education. Emails can be sent at any time and from anywhere (via computer,
mobile phone) by patient en healthcare professional. Video consultation can be used
to support urgent and non-urgent communication between healthcare provider and
patient. Video consultation allows seeing each other and ‘reading’ the non-verbal
language or viewing body parts. e-Consultation that can be stored on the internet or
at the personal computer also gives patients an opportunity to review the information
to improve understanding or to share this information with relatives.
The benefit of e-Consultation for the patient is that it reduces the need for travel. Not
only does this save time, money and inconvenience for the patient, it also avoids the
harm of travel, for example, for patients such as the wheel-chair bound thalidomide
patients who use Patients Know Best online consultations with their London-based
neurology specialist. Furthermore, for some patient groups e-consultation improves
safety. Cystic fibrosis patients are sensitive to infections of other CF-patients they will
meet in the waiting room their clinic. E-Consultation also increases the access to
care for patients living in a remote area or offers patients the possibility to consult
with their chosen specialist rather than their local generalist to get the best care.
Finally, an important benefit of e-consultation via email and chat is that some patients
can discuss more easily their feelings or private concerns, because it is more
anonymous and enables patients to take their time in writing and rewriting until they
are satisfied with how the information is formulated and/or their concerns are
expressed. (Car et al, 2004; Moyer et al, 1999)
One benefit of e-consultations for healthcare professionals is that they are time-
saving, especially in the case of email, due to a lack of face-to-face small talk as a
social aspect. Also, research shows that medical doctors that use e-consultation are
more productive compared to the ones doing visits. Healthcare professionals can re-
use a lot of content in routine questions and in this way serve several patients at the
same time. Another benefit is the possibility to consult colleagues prior to responding,
in order to provide a more considered response to the patient.
The challenge in e-consultation is to avoid the potential disadvantages. For example,
the disadvantage of email and chat is the lack of subtle emotive cues from vocal
intonation and physical demeanour that may cause communication errors. Also the
inability to visually examine the patient or to use a clinical viewpoint may increase the
risk of diagnostic errors. Video consultation can, however, reduce these risks.

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In the EUPHORIA project, e-consultation services in Sweden, the Netherlands and
England will be up-scaled. More information about these specific services is provided
in § 1.3.1.5.
1.1.3.5 Telemonitoring
Telemonitoring represents a separate area in the scientific field of Health Informatics.
The concept of teleHealth or telemedicine has been around for as much as the
concept of internet has. Telemonitoring, as a subset of general the general scientific
field of telemedicine, focuses on bridging distances between healthcare providers
and consumers mainly due to distance issues (for peripheral / rural areas hard to
reach by daily transportation means) or due to the fact that national / regional
Healthcare systems need to support a significant number of transactions per citizen /
patient case most of those easily tackled automatically by ICT systems mainly by
reading portable / wearable devices data coming from sensors that monitor major
Health condition status like heart rate, blood pressure, diabetes related measures
etc. In various studies, the clinical effects and cost-effectiveness of telemonitoring for
chronically ill patients have been studied. (Paré et al, 2010) However, research also
suggests that telemonitoring is actually more than a digital replacement of face-to-
face contact, as it also changes the way healthcare is delivered and the roles of
patients and physicians. (Oudshoorn, 2009) Just like with other self-management
tools, they change the lives of patients. Most times that change is for the better, but
not always. Self-management and telemonitoring tools should have an optimal fit with
the daily routines of patients, to be used satisfactorily.
In the EUPHORIA project, telemonitoring services in Turkey and Greece will be up-
scaled. More information about these specific services is provided in § 1.3.6.
1.1.5 Evaluation of eHealth
Evaluation of eHealth services is essential for all stakeholders: not only healthcare
organizations, professionals, and patients, but also for the developers of eHealth,
governments (often as financiers of health, IT-development or both) and society as a
whole. Policymakers need insight into the outcome of solid evaluations of services
and their implementation, in order to make informed decisions about investments in
eHealth; healthcare organizations and patients need this information to be able to
choose between different services; and developers need evaluation to improve their
products. From an EU perspective, all these types of evaluation are valuable. The
goals of the EU are to deploy eHealth in Europe. For this we need services that have
proven to improve quality of care (that is: to improve the effectiveness, efficiency,
patient centeredness, timeliness, safety and equity of healthcare), but also services
that have a sustainable underlying business model.
An evaluation design should be chosen that minimizes potential bias (internal
validity) and maximizes generalizability (external validity) (Shadish et al., 2002). This
is true for all research, but is especially important in the translational approach of
many EU projects. The PSP call specifically recommends the use of socio-economic
analysis to analyze the benefit and success of scaling up and disseminating the
various eHealth services within and between partners of the consortium. One of the
objectives of the EUPHRIA project is to perform such a socio-economic evaluation of
eHealth and to state its effects for the patients, organizations and society at large.
However, as Greenhalgh and Russell (2010) point out, the assumptions, methods,
and study designs common to evaluations in many contexts may be ill-suited to the

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particular challenges of evaluating eHealth programs – especially in politicized
situations where goals and success criteria are contested. Moreover, Black et al.
(2011) argue that it is vital that eHealth technologies be evaluated against a
comprehensive set of measures, ideally throughout all stages of the technology’s life
cycle. In both articles, the authors are of the opinion that more attention should be
paid to socio-technical factors, in order to maximize the potential for successful
implementation and adoption. The idea that research be done in all stages of a
technology’s life cycle suggests the need for multiple evaluation strategies. For this
reason, we argue that additional research is necessary within the project and should
be used to supplement socio-economic analysis.
EUPHORIA project uses a mixed-methods evaluation (Creswell, 2003). Because we
believe that good evaluation is a sine qua non for any large project, we made this
evaluation one of the central themes of our proposal, and we also use the expertise
of the universities of the consortium to perform this evaluation.
The evaluation consists of three phases:
1. an evaluation of the selected services on various levels, using a socioeconomic
evaluation model; in order to classify the services and identify intended goals and
aims ex-ante;
2. a qualitative evaluation of the pilots in this project, using action research and
actively involvement of the users;
3. an ex-post evaluation of the effects of the up-scaled services on various levels,
using a socioeconomic evaluation model.
The combination of qualitative methods with an innovative socio-economic analysis
model will give a clear picture of actual projects and also demonstrate which
elements of the services have real potential for (cost) effectiveness.
In the next paragraphs our approach to these two types of evaluation – the (mainly
quantitatively oriented) socio-economic evaluation and the qualitative evaluation of
the pilots – will be described extensively.
1.1.5.1 State of the Art in the field of socioeconomic evaluations
Investments in eHealth are based in part on expectations of improving inter-
organizational networks, reducing costs, controlling resource allocation, and
achieving a higher standard of quality of services promoting disease management
and wellness. Innovators face major challenges in meeting increasing demands for
healthcare services with limited resources. A major impediment for investments in
eHealth services, however, may be a lack of evidence of their economic impacts on
end-users, organizations, stakeholders and society as a whole. While pilot studies
indicate good clinical efficacy of eHealth services at the intra-organizational level,
less is known about the cost-effectiveness of such services. Economic
considerations in these studies often are limited to hypothetical discussions, rather
than actual analyses. For example, they discuss the potential value of patient-centred
services to consumers and methods for developing business models that transition
from a payment-per-visit model (prospective payment principle) to a payment-per-
episode-of-care model, or for quantifying the direct cost of the technology in use.
Many challenges must be overcome before eHealth can achieve its greater potential.
One challenge is to design systems that truly support the workflow in the complex
environment of healthcare. Another challenge is to develop services that support
both internal and external stakeholders’ demands, i.e., adaptation to work and home
environment, patient-driven services, and networks for interchange of knowledge,

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follow-up and feed-back. In addition, it is essential to construct user-friendly eHealth
services and to maintain the focus on patient data, but at the same time designers
must provide useful and satisfactory systems at a reasonable cost and in a
reasonable amount of development time. Furthermore, such services should
contribute toward lowering the ever increasing cost of care, supporting occupational
activities, and increasing the exchange of knowledge among healthcare personnel.
Issues such as job satisfaction, workers’ needs, work practices and skill
enhancement resulting from eHealth implementation need to be analyzed.
Evaluations performed as partial studies provide no accurate answer as to how to
combine efficiency, effectiveness and business process benefits derived from
eHealth implementation and use. Therefore, these studies often have been confusing
for decision-makers and stakeholders. More recent studies with an intra-
organizational focus have tried to evaluate savings due to improved quality of project
information, savings due to productivity improvement and cost reductions, and
transformational benefits of clinical eHealth services using frameworks such as
Return of Investment (ROI), Internal Rate of Return, and Payback Period, or using
such approaches to describe users’ requirements and organizational effects.
However, they have failed to consider both induced benefits apart from direct savings
and the efforts needed to enable the change: overcoming user resistance, training
and technical support, and achieving management support.
Good economic evaluations of patient-centered eHealth based services have to be
performed as a comparative analysis of alternative courses of actions in terms of
both their costs and consequences. The main problem in evaluating patient-centred
services today usually is tracing and delimiting the consequences from an eHealth-
based service. Benefits may occur only after a time lag which is needed in order to
make necessary changes in organization and work practices, and sometimes they
may arise in unexpected parts of the system. (Vimarlund & Olve, 2005)
1.1.5.2 Socio-economic evaluation: The model used in this project
The model for the EUPHORIA study has been developed by the eHealth researcher
network in Sweden and has been tested to evaluate eHealth services at the national
level. (Vimarlund et al., 2011) The method we use in the model allows healthcare
providers to evaluate the contribution of eHealth services in different health and
social care contexts, including an analysis of the impact of eHealth both at the
administrative and operational level.
The model is divided in three levels, defined by the amount of integration between
the technology and the users, in the use of eHealth services and the level of
progression IT allow. From the microsystem to social networks. (Fig. 2)

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Figure 2. The three levels of the evaluation model
(Reference. Vimarlund, et al. The Swedish eHealth Network, Capturing the Value of IT in Health
and Social Care, WoIT, 2011)
Level 1: Information retrieval for healthcare providers and healthcare receivers at the
micro level.
This level is characterised by an intra-organizational perspective and includes
eHealth investments in systems or services that aim to support local healthcare
organizations. The contribution of eHealth services is making the communication
channels between healthcare personnel more effective, accessible and rapid.
Patients benefit from the use of eHealth solutions as a consequence of an
improvement in communication processes and an increasing quality of the
information services needed to make more efficient decisions and from a more
secure information processing.
The societal benefits from eHealth services at this level are not always directly
related to economical savings for the organization or the funder, but they are related
to social values like improved accessibility, improved quality, the healthcare
receiver’s safety and more efficient use of resources, which in turn leads to direct
savings of administrative recourses. Example of indicators of success at this level
are:
 More effective time allocation within the main activity;
 Lowered risk for incorrect information processing;
 Shorter lead times in communication between different actors;
 Customization of simple services, flexibility and options;
 Rationalization of the organization at micro level;
 Logistic improvements;

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 System support for resource allocation and management of the organization.
Level 2: IT integration on intra- and inter organizational level. This level is
characterized by a multiple organizational perspective and regards IT investments in
systems or eHealth services that supports cooperation, communication and
improvement of work flows between several different healthcare organizations.
Mayor improvements in communications patterns as well as a diminishing of lead
time for communications and for delivery of services is expected as a direct
consequence of a vertical integration of the information.
At this level there are, besides effects at the micro level (single healthcare units),
some concrete improvements regarding the security, service quality and
rationalizations of the providing of services for the healthcare receiver are expected.
A prerequisite for reaching the benefits that eHealth investments can bring on this
level is that there are secure and stable networks between hospitals, primary care as
well as municipal- and private healthcare providers.
Indicators of success at this level are mainly related to optimization of the use of
scarce recourses and with the rationalization of the organization at both the inter-
organizational and intra-organizational level. They contribute to:
 Coordination and sharing of administrative and/or clinical information
 Increased possibility to rationalizations of different steps and instances
 Cost reduction and more effective use of resources within single healthcare units
and for different actors
 Improvement of the information logistical processes
 Improved healthcare quality and improved security for the healthcare and service
receiver by synchronization of efforts and information as well as increased
possibilities for joint planning of healthcare efforts and services
 Continuity in joint healthcare planning through the use of eHealth tools
 Possibilities for rationalization, coordination and integration of different processes
for faster production of services
 The healthcare and service receiver will have better information along with the
improvement of security and secrecy
Level 3: Virtual networks, individualized services for healthcare receivers and
healthcare providers. This level is characterized by having a patient focused
perspective. IT investments are principally doing in systems or eHealth services
where the healthcare receiver is active and could initiate a request for a service along
with a communicative interaction with a healthcare provider. At this level, the end-
user of the eHealth service directly influence the demand and production of the
services.
The benefit indicators are therefore foremost in the development of services that
makes it possible for the healthcare and service receiver to be more active in his or
hers own healthcare through stimulating increased insight and increased
understanding of different healthcare efforts for the sake of his or her own health.
Goals and expectations behind the investments in this kind of services are:
 More effective use of resources at the micro level (for the healthcare team
connected to a healthcare receiver)
 Improved level of service for the healthcare and service receiver as well as
relatives
 More secure information processing
 Reduced time for administrative work for involved organizations

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 Improved security for the healthcare and service receiver
 Support for internal information exchange between healthcare providers
 Rationalization of the organization and planning as a consequence of increased
knowledge in questions of interest for the healthcare and service receiver
The eHealth model: its use and possibilities
The model is an instrument that identifies and classifies the benefits from IT
investments at different levels for different actors. The indicators that the model
includes mirrors the effects at the micro-, inter- and intra organizational as well as
societal level regarding rationalization gains, possibilities for optimization and value
adding factors that IT investments gives directly or indirectly to the organization, the
healthcare and service receiver and the society. This applies for the micro-, inter- and
intra organizational as well as the societal level regarding rationalization gains,
possibilities for optimization and value adding factors. The indicators of success also
show how IT supports the organizational development, towards new business
opportunities and increased organization intelligence, the formation of new virtual
networks and the societal effects of this.
Decision makers can use the model as a practical instrument to plan eHealth
services by identifying the requirements that new technical solutions ought to fulfil,
the model could further be used to investigate the effects and benefits that IT ought
to have for the organization, the healthcare and service receiver and for the society
by identifying the requirements and effects that are fundamental at the micro-, intra-
and inter organizational level.
The model thereby offers indicators in areas where effects are possible and in what
way they could be expressed. The model doesn’t include clinical/medical effects like
healthcare quality. There are other instruments for that kind of measures. At a
longitudinal follow-up on IT investments, the effect indicators could be transformed to
economical measures to price and evaluate changes, degree of innovation and
compare effects of efforts at a national level. By using the model the progress from
simple to more advanced benefits from different IT solutions could be described, in
other words from benefits at the local micro level to benefits for the society and third
party. The model could then be a tool to plan efforts and to consider indicators for
progression from systems that supports the micro level to systems that integrates
and supports inter organizational or virtual networks.
1.1.5.3 Qualitative evaluation to capture user experiences
Our evaluation will also include a series of traditional and innovative qualitative
research methods. Qualitative data enables the researchers and companies to give a
more in-depth description of both project interventions and the contexts in which
projects are embedded. Therefore, such a design will not only yield empirical
evidence on the effects of the projects actually realized, but also provide insight into
the effective aspects of the services and the alterations in the care process (work
practices change, responsibilities are redistributed and new modes of communication
emerge).
In the pilots, we will use an action research approach. (Kemmis,1988; Coghlan &
Brannick, 2001). This means that the evaluators (the researchers) continuously
interact with the other actors in the project. They will collect data, perform analyses
and syntheses, and give that data back to the project members. This results in ideas
for improvement, which will be implemented and evaluated. This will be a continuous
cycle, as qualitative research is an iterative process. (Fig. 3)

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Figure 3. The design of action research
In order to enroll patients to actually use the technology, it is imperative to include
them in the earliest phases of the process. (Oudshoorn et al., 2004; Greenhalgh &
Russell, 2010; Black et al, 2011) With many information technologies, mistakes can
be made early in the design process by failing to account for the needs and diversity
of users (Oudshoorn et al, 2004). This is also the case with most of the e-health
applications, which configure the user as a well-trained or skilled computer user
(anywhere from the young middle class to the wealthy adult); however, those who
stand to benefit most (elderly and/or chronically ill) generally do not fit this image.
The work being done in the project will therefore focus on how these patients can be
supported in using e-consultation, without increasing the cost or burden for
professionals. We have therefore included plans in the pilots for conducting focus
group interviews with key actors in the various target groups of the services
(including the national stakeholder groups). These group interviews will focus on both
the applications (how do the users use and experience these services) and the
promotional materials and will therefore be crucial to identifying the different needs of
various sub-populations in the community. We plan to create diverse mixes of focus
groups, with some being age or health-condition related and others being a mix of
ages, genders and other classifications. The more homogeneous groups will allow for
discussing concerns and issues in-depth, while the mixed groups will facilitate
interaction across gender and age lines, which is also important to the community-
building and knowledge-transfer aspects of the project. All data will be registered on
audio tapes. The focus groups will also be recorded on video, as long as this does
not inhibit the group process, and all data will be transcribed. The absolute number of
focus group interviews to be held will depend on the service in question.
The integration of new internet services in healthcare offers the opportunity to
develop and use innovative research methods. (Jones, 1999) Much work has been
done in the field of ethnography to create new methods and adapt existing methods
for use online. (Jacobson, 1999; Seymour, 2001; Paul, 2005) Approaches using
these methods are generally referred to as Netnography or Virtual Ethnography
(Dominguez et al., 2007). Increasingly, qualitative researchers using virtual
ethnographic methods employ e-mail, chat, and social media services (such as blogs
and twitter) to gather data. In cases where projects intend to reach target groups that
utilize such services and in cases where these very services are being scaled up,
such research methods can be used to provide helpful insights about users and use.
We will integrate these methods where applicable to contact and interact with specific
target groups as part of our evaluation. The EUPHORIA eHealth portal (see §
1.1.6.2) will be used as a platform for this Netnography.

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In the EUPHORIA project eHealth services will be prepared for wider deployment In
this case, special consideration of user needs (especially patients) is important.
1.1.6 Business model
In the EUPHORIA project, we use the results of the socio-economic evaluation model
to develop business models for the selected services. These business models will be
tested, implemented and evaluation during the pilots.
Because the EU emphasizes the importance of wider deployment of e-Health
services, business models are a key aspect of evaluation and deployment. Few
innovations succeed without a good business model that balances costs and values.
Because eHealth services differ in their targets and expected value, different
business models are needed in practice. Moreover, differences in external factors
such as national policy, legislation and economic infrastructure also have to be taken
into account when developing business models for eHealth. For example, for
preventive services we need other models than for curative services; and for a
country with a state-funded health system we need other business models than for
countries with different forms of (regulated) competition in healthcare.
In the course of the EUPHORIA project, a variety of services are being tested and
up-scaled in the different countries of the consortium. This juxtaposition will offer a
unique opportunity to develop profound insights about how different business models
play out in practice, as well as how they compare with one another. As a point of
departure for describing the various business models, we will use a generic
framework that builds on the results of the evaluation phase. The model comprises a
powerful and innovative mix of simple methods and techniques carefully aligned to
present not only the metric for each value proposition but also its measurable
potential in respect to business processes (simplicity) and rapid adoption
(leadership). The three central dimensions of the business model will be described
below: Enumerated value propositions, Clustering and Rapid Adoption.
Enumerated Value Propositions
The common denominator for all Actors involved in a business model and the
building block of the model itself has to be Value. It is widely accepted from all
relevant literature that any business model creates and manages value for all Actors
and Stakeholders. The business model has to be crystal clear to each and every one
of the Actors and Stakeholders involved regarding the value it creates and manages
for them. Specifically, each Actor and Stakeholder has to be presented with a value
proposition that deals with numerical expressions of the value at hand. The latter is
essential for the Actors and Stakeholders mainly due to the reason that value
expressed in numbers is computable and therefore manageable so it is fairly easy for
the Actor / Stakeholder to translate the value at hand to their ecosystem specifics. In
this way, Actors and Stakeholders undertake commitments that tie them to the
business model at hand based on clear programs and schedules that stem directly
from the enumerated value each Actor / Stakeholder see in the business model.
Some examples of these value indices, for the three levels of eHealth, and for the
various stakeholders are listed in Table 2.
Micro level
Citizens  Number of extra services added
 Financial benefits (discounts etc.) for proven loyalty to healthcare
providers via the PHR logs
 Number of personal network peers in health condition oriented
networks

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 Number of Medical Professionals that provide access for advice via
PHR aware social media
Medical
professionals
and their
organizations
 Number of patient visits avoided by asynchronous communication
means (paid service: lasts less than a traditional visit)
 Financial benefits for providing advice in PHR aware social media
under an HCP or HON umbrella
 Number of extra customers from remote areas
 Number of personal network peers in health condition oriented
networks (for use in extreme cases)
Payers  Costs saved by avoiding unnecessary visits
 Revenue from utilizing medical professionals from their networks for
Health advice (through portals or PHR aware social media)
 Number of new communication / market channels analog to the
number of customers on line
Mezzo Level
National
Governments
 Financial benefits by saving costs on unnecessary visits to medical
professionals and inpatients time
 Financial benefits from public HCPs resource management and
workflow optimization
Macro level
European
Union
 Bridging gaps (in number of Health IT services) between Users needs /
business drivers and Developers skills via a common European
eHealth market place electronic service
 Number of peer to peer eHealth - SME synergies and cooperation for
the exchange and development of generic reusable software modules
aligned with human Health conditions’ needs
 Number of peer to peer eHealth - IT SME synergies and cooperation
for the development of national wide PHR electronic services based on
generic reusable software modules which provides near de facto
interoperability.
 Number of European Citizens using the up-scaled services
 Carbon footprint reduction from EU-wide deployments of eHealth
services such as e-consultation.
Table 2. Value indices
Based on the evaluation model in § 1.1.5.2 and an analysis of the different national
contexts (which is part of the preparatory work in this project), we will carefully select
the value indices for each of the services.
Health as the ultimate Value of eHealth
The ultimate value of eHealth services for both patients and society is health. This
value is primarily expressed in terms of quality of life, well being, and patient
satisfaction. However, determining and quantifying these outcomes of eHealth
implementation has proven to be very difficult (Goldzweig et al, 2009).
In many cases, the goals of implementation are stated in terms of (IT related)
structure and process indicators, and evaluation of outcomes is disregarded.
Moreover, IT implementations differ considerably because of transition from legacy
systems and integration with the existing IT structures and processes. Translation of
evidence is therefore often difficult, thus causing the generation of more robust
evidence to be difficult.
Moreover, intended effects of eHealth may need many years to be measurable on a
societal (or European) level. The EUPHORIA we hypothesize health values that that
can be meaningfully included into business model for eHealth, and research those for
the services that will be up-scaled in the Netherlands.

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Clustering: Less is more
Modern business models are usually based on complex systems that may refer to
state of art technology such as enterprise systems that are addressed to large
populations, market predictions and customer behavior forecasts, antagonistic
business drivers such as costs and revenue prerequisites and so forth. It has
become clear to business model designers that complexity has been established as
the core characteristic of the problem base of any modern business model. Although
this complexity is unavoidable and complex systems theory methods and tools are
predominantly the scientific approach to finding solutions that can meet the
challenges of the aforementioned problem base, the core modules and functions of
any modern business model should be simple if not laconic. Simplicity in design
assures, among other more obvious benefits, smooth communication of the business
model to anyone involved. That is particularly critical for access to funding that is
usually based on reviews and evaluations of people not necessarily scientifically
literate with complex systems theories and methods but perfectly capable for a
critical evaluation of the business model ability to create and manage value for all.
Put simple, as far as access to funding is concerned less is more for business
models.
In the EUPHORIA project we strive for a balanced set of value indices that reflect the
variety of stakeholders and the three levels on which the value can be measured:
micro level (individual patient), mezzo level (organization) and macro level (society).
Rapid Adoption: Innovation coupled with proof of concept at the first sight
Leadership is expressed in number of followers. In the business model domain the
optimal (larger possible) number of followers clearly comes when innovation is
coupled with proof of concept. As innovation stands for anything novel and proof of
concept clearly refers to metrics (of an established system), coupling both is
restricted in the area of experimentation of novel methods and techniques to existing
organizations (and / or schemas). Furthermore it is evident from the aforementioned
leadership definition (number of followers) that strong leadership should be the
predominant characteristic for wide and rapid adoption of the value proposition of any
business model. Therefore, business model designers should secure
experimentation (usually in the form of piloting) and be cautious for initial metrics of
adoption from the pilots’ early implementation.
In the EUPHORIA project we stimulate rapid adoption in three ways. Firstly by our
selection of services which are successful in the base countries. These services have
already proven their value to the different stakeholders. Secondly, by creating a
strong stakeholder group of patient organizations who can act as advocates for the
wider deployment of the services. Thirdly, we make optimal use of the dissemination
deliverables, such as the EUPHORIA eHealth portal, which will be discussed in the
next paragraph.
1.1.7 EUPHORIA eHealth Portal
One of the main deliverables of this project will be the EUPHORIA eHealth Portal.
The eHealth portal will be featuring three distinct functionalities. The first will be an e-
Health Actors Social module, the second an e-Health products & services virtual
showcase and the third an e-Health developers collaboration space. These
functionalities will operate as follows:
The EUPHORIA eHealth portal will contain three sections:

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1. eHealth Actors Social Module
This section of the portal will provide all eHealth Actors identified in a country
(starting with the ones engaging to the up-scales of the pilots – projects) with all
essential modules of social collaboration, with an indicative list of such modules
being: forum, blog (for each individual user), micro-blogging feed, wiki, RSS,
newsletter, social media connectors etc. The purpose of that social module is to
provide a direct link next to any other part of the portal (the services section, the
virtual showcase and the developers’ collaboration space) through a “standout”
button thus engaging everyone to the “action” at hand. In this way, according to the
type of “action” that takes place at a particular time, the user will be redirected to the
social networking service which is best fitting i.e. from the eHealth services provision
bug or law infringement reporting the user should be redirected to the social feed,
from the developers space to the documentation wiki, from the product / services
virtual showcase to the corresponding health condition forum topic etc.
Special care in this module design (and the corresponding buttons) will be given to
patient organizations starting with the members of the stakeholder group of the
EUPHORIA project.
2. eHealth Products & Services Virtual Showcase
In this section a virtual showcase will be set up featuring rich multimedia use
functionalities. All features of each product / service that is embodied in the portal will
be presented here along with full documentation and video material. Separate
section for use case will be allocated and button from the social module will be
carefully place to redirect traffic to the social module for further engagement related
with the features, technology and most importantly the optimal use of these features
in real life settings. Again specific focus will be allocated for the patients and the
patient organizations by embedding mainstream social media platform/ sites buttons
from real life patient social pages to the relating show cases in order to import patient
oriented traffic from the major social networking site directly into the showcase
3. eHealth Developers Collaboration Space
This section will operate along-side the virtual showcase following this pattern: on the
central / home page of each portal there will be a banner link prompting eHealth
developers to collaborate to certain development projects. This banner will direct
them to a developers’ community forum with ticketing functionality (collaboration
space). At this collaboration space any user / actor of the portal can place a bid for a
project i.e. building specific plugins for a specialized patient need, examining
software for security/ privacy issues etc. A similar button (to the banner) will be
embedded next to each product / service presented on the portal. Lastly, mainstream
social media platform/ sites from eHealth developers and relevant eHealth IT
professional’s pages and sites will be embedded.
The EUPHORIA eHealth Portal is accessible via a link or button on the portal
websites of the consortium members. Some of the features are, during the course of
the project, protected with login and password to the consortium only. We will use it
for internal knowledge exchange and evaluation with our stakeholders (the
Netnography approach that has been described elsewhere). However, during the
project, more and more information will become publicly available, and all three
features of the portal will be fully operational at the end of the project.
Users of the EUPHORIA eHealth portal
The EUPHORIA eHealth portal will act as reference and meeting point of EU citizens
being a de-facto European eHealth services Centre. The benefits for the average EU
citizen are tailored-made according to the relationship that the citizen has with
eHealth services. Specifically:

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Patients
Patients will turn to the eHealth portal to ask for specific information about their
condition and how an eHealth service can help them improve their quality of life. This
information will be delivered to them through the portal’s social plugin where patients
and patient advocates / organization comment on the eHealth services available. The
social plugin will be active for eHealth services that are available or for the ones that
are in development phase thus giving the patient a chance to positively affect
eHealth services from such early stage as development.
eHealth SMEs and individual developers
SMEs and individual developers will be given the chance to commit to projects
placed by eHealth consumers such as Hospitals, clinics, doctors, patients etc. on a
micro-project scale. This is expected to boost their market exposure. On the same
time actual development will be able to utilise invaluable feedback from both patients
(consumers) and academics / experts from the early stages thus enhancing adoption
possibilities and use of state-of-at techniques and tools
Healthcare professionals
Healthcare professionals will have a single point of reference regarding a 360 view of
contemporary eHealth service development and use. Additionally and most
importantly Healthcare professionals will have the opportunity to examine eHealth
services not only as live/ functional “showcases” available on the portal but also the
complementary contributions of the patients themselves (through the social plugin)
AND the accreditation level from the on-going evaluation of the Academics/ experts.
Policy makers
Policy makers of the European Union will have a single point of reference to an
active policy tool that embodies in frequent and recurring times the latest knowledge
from an active e-Patient community AND an eHealth services market productivity/
collaboration platform. Thus, policy makes will have a 360° view of the decisions that
they have to make, based on the policy tool’s best practices and recommendations
and a “showcase” of the services themselves featuring evidence of adaptation on
behalf of the users/ patients (social plugin).
1.1.8 Innovative Aspects
The innovative aspects of this project are:
1. Promoting new cross-sector collaboration that will lead to solutions that align
patients’ needs and answer socio-economic challenges in light of increased
demand-driven innovation initiatives
2. Evidence based learning sampled at the EU-level, which will give a broad
understanding of the pre-requisites and conditions in which different services
should work optimal. To our best knowledge there is no project today that
compares, evaluates and extends empirical experiences with up-scaling eHealth
services, based on a validated evaluation model
3. The methodology used to capture the effects of eHealth has already a proven
value (in Sweden) and is using socio-economics for evaluation of the eHealth
services to up-scale. In addition we will cross reference their health content with
current standards for health informatics content and relate that with the value to
the patient. This makes the approach highly innovative resulting in an innovative
way of choosing the healthcare domains to offer in Member States that clearly will
fit current and future European guidelines.

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4. The deliverables of EUPHORIA can fundament other European projects like
epSoS and semantichealthnet with values extracted from the empowerment of
the patient. The consortium thinks that such values are lacking at this moment,
which makes EUPHORIA innovative in this way.
5. There is not yet a European platform for all stakeholders, with the wide range of
functionalities the EUPHORIA eHealth Portal will offer.
1.1.9 Value for Users and Expected Benefits
The selected eHealth services
The health and quality of life of patients can be significantly improved through the use
of innovative eHealth services that enable secure and user-friendly online access by
patients to their personal health data and integrated health records, as well as
associated services including scheduling appointments online and supporting chronic
disease management processes. The services selected for the EUPHORIA project
arguably empower patients to take a more active role in managing their health and
lifestyle and enhance the continuity and quality of care by reducing duplication of
tests or examinations and making patient information available in multiple settings.
At the start of the project, the benefit of the selected eHealth services compared to
other services in Europe is limited. For example, the self-management diaries in this
project are not better (but also not worse) than other diaries in other countries.
However, because we designed this project with continuous improvement cycles and
exchange of knowledge and experiences, we trust that at the end of the project, the
services have significantly improved usability and user satisfaction. One exception to
this is the personal health records. All PHRs use the CCR/CCD standard and this
has many benefits for both patients and healthcare professionals (see § 1.1.8 and §
B3.5).
Evaluation model and business model
The project EUPHORIA will deliver a crisp business model framework with respect to
the roll out at large of eHealth services in order to make the right choices related to
European incentives to be used by payers, regions and national bodies. The use of
the evaluation model of the Swedish eHealth network to capture the benefits of the
services in other countries and other social contexts, is innovative. We trust that this
knowledge has great value for policy makers on a national and European level.
EUPHORIA eHealth Portal
Besides delivering a prototype inventory of eHealth services available along with
ratings and values cross-referenced with CCR items and privacy measures, the
project EUPHORIA creates a prototyped test bed for these eHealth services
available to all Member States: the EUPHORIA eHealth Portal. An indicative, but no
restrictive, list of benefits of the EUPHORIA eHealth portal is the following:
 Providers
o European Health IT Software Companies will be provided with a pan-
European channel, ideal for marketing purposes since the marketplace
will feature a rich showcase for any software added including demo
functionalities.
o Individual Health IT professionals/ entrepreneurs will be given the chance
to showcase their work and thus actively engage the market i.e. by
committing to specific local services their proximity market should need
based on the software available on the market place (depending on the
specifics of the licencing – open source option initially included with the
TOLVEN software platform)

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 Consumers
o Hospitals, Medical Centres, Medical Professionals and Small clinics will
be provided with a variety of optimal pre-procurement options and
software screening and online testing
o Patients will be actively engaged in the Health IT software development
though the portal’s social plugin. Furthermore, patients will be able to
directly make use software able to host their PHRs in a meaningful way.

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B1.2 EU and national dimension
The EUPHORIA study brings together five European countries: the Netherlands,
England, Sweden, Greece and Turkey. These countries represent variation in the
important aspects of healthcare that we want to capture; for example, differences in
funding structures for healthcare services, in approaches to patients, and in reasons
for and progress of innovative eHealth services. The chosen countries also allow for
taking into account broader cultural considerations in a comparative framework,
because the five EUPHORIA partners represent Western Europe (England and the
Netherlands), Scandinavia (Sweden) and Southern Europe (Greece and Turkey).
Each country in the consortium has a different situation with respect to national
programs and economic structures for eHealth development. These differences are a
result of different governance structures for healthcare, the nature of current policies
or the national political climate, and variations in the financial/economic aspects of
innovation. Although all European countries more or less actively seek to reach
health goals as defined at the EU-level, there is room for different approaches to
reaching these goals. EHealth strategies are therefore always local strategies that
simultaneously align with and differ from the strategies of other EU Member States.
1.2.1 Relevance to National Strategies and Initiatives
1.2.1.1 Sweden, Jönköping County Council
In 2005, the Swedish government launched a national IT strategy for health and
welfare. This strategy was renamed in 2010 to National eHealth to mark the transition
from technical and infrastructural issues to the utility for the population and
healthcare providers. The Swedish Jönköping County Council (JCC) provides the
test environment for the demonstration. The healthcare provided by JCC includes
three hospitals and 35 healthcare centres in the 13 municipalities of the county. Care
for patients with chronic diseases is provided by physicians, nurses and allied health
professionals at hospital departments, clinics and health centres. Quality indicators
and treatment data on patients are collected, analysed and shared in the national
quality registers. Jönköping County Council is renowned for its quality improvement
work and clinical research, which are focused on clinical process and outcome
improvement, prevention and self care, and patient safety.
1.2.1.2 The Netherlands
For the past 20-30 years, the Dutch government has actively stimulated the growth
and distribution of information technologies in order to improve the effectiveness,
efficiency and safety of Dutch healthcare. Especially during the last decade, a new
dimension has been added to this picture: the patient has increasingly become the
central actor in national policy. This is evident, for example, in research funds
provided by the government for national and regional programs related to chronic
disease management and in recently developed policies strengthening the rights and
legal position of patients. One of the nationally-established rights that local health
institutions are currently working toward is providing patients with access to their own
medical information, generally located in electronic databases and health records in
hospitals and primary care (GP) offices/practices.

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Such efforts were recently set back when the Senate voted down a law necessary to
ensure further development and distribution of a national Electronic Patient Record
(EPR). Whereas the national government wanted an EPR with national coverage,
many actors now prefer a regional approach to development, whereby current
practices for information exchange between primary and secondary care institutions
are couched in more stringent policy related to privacy and the protection of personal
data/information. The Rijnmond region serves as an example for the other regions in
the Netherlands. The National IT Institute for Healthcare in the Netherlands (NICTIZ),
a key player with respect to national eHealth developments and standards, has given
its support to regional developments and has recently explicitly expressed its support
for Health Portal Rijnmond. Moreover, following the experiences in Rijnmond, they
intend to implement CCR/CCD as a national standard for health information
exchange between healthcare providers, and as the basis for personal health
records.
1.1.2.3 England
After the centralized, provider-focused Connecting for Health (CfH) failed (despite 10
years of investment), the new UK government began looking for decentralized,
patient-led solutions to existing problems in the health system. CfH had been initiated
as part of the UK government’s commitment to improve efficiency and quality of care
by doubling spending for National Health Service IT. In May 2011, after multiple
vendor failures, the National Audit Office announced that CfH had failed, and that it
would never succeed.
The new government is taking a different approach for several reasons. First, there is
no more money for large centralized projects. Solutions and innovation from the
private sector are sought instead. Second, the backlash against CfH from healthcare
professionals who lost their autonomy has been considerable. There was a similar
backlash against movement patient data under centralized control. Decentralized
approaches are preferred. And finally, the agenda of patient choice as the path to
improving NHS quality and costs is supported by all political parties.
The UK government’s Information Revolution white paper said that patients should
be in control of their medical records. Patients Know Best is the first and currently
only provider with a patient-controlled medical records system integrated into the
NHS. It currently has five deployments in various regions and for different patient
groups that will be further developed during this project.
1.1.2.4 Greece
A national eHealth roadmap for Greece was launched by the Ministry of Health and
Social Solidarity in 2006. It is based on a critical review of the national 2002-2006
ICT Action Plan “ICT in healthcare” and incorporates new policies aligned with the
European eHealth Action Plan (2004).
The European Commission concludes in her Country Brief that, “In Greece, the
development of an electronic patient record is a major objective and a priority of the
National Health System upon which all related services will be based. The
development of patient summaries is also in planning for administrative/demographic
as well as emergency care data. For this, a complete set of specifications has not yet
been issued. However, harmonisation of legislation is required before implementation
can take place.” (Angelidis et al, 2010)

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Greece has participated in several small-scale and large-scale pilots (some on a
regional level) on ePrescription, telemonitoring, e-Consultation and call centers. In
addition, Greece participates in various European and International standardisation
activities and adoption of specific standards is pending. However, although the Greek
eHealth roadmap (2006-2015) recognises the importance of telemedical services,
legislative issues are obstructing nationwide implementation of such projects as
doctors cannot be reimbursed by public insurance schemes for telemedical care.
(Angelidis et al, 2010) Furthermore, Greece is a country in transition, with a difficult
economic situation. Consequently, any plans for healthcare developments,
particularly in light of the social insurance reform, are in a state of transition, too.
1.1.2.5 Turkey
In terms of healthcare services, Turkey faces the challenge of providing secure and
adequate healthcare services to a large, widely–spread, mostly rural population. One
of the main strategies of the Turkish Ministry of Health is to implement and further
improve mobile healthcare services in order to reach the remotest areas. Another
important issue is the increasing prevalence of chronic diseases. According to the
data of Turkey’s National Burden of Disease Study; a high percentage of deaths is
due to non-communicable chronic diseases (e.g. Ischemic Heart Diseases, COPD,
Pulmonary Cancers, Diabetes Mellitus, etc.). These comprise the top 20 national
causes of death and constitute an important burden for the health system.
In 2003, Turkey initiated the e-transformation reform project. One of the major parts
of this reform is transforming the health system, with working groups established to
assess the current situation and produce administrative decisions and determination
of the reform strategy. The e-health vision is setup as “The improvement of
healthcare services by developing a secure health information platform that enables
healthcare providers, health professionals and citizens, easy and safe access to
health related information by using latest information and communication
technologies”.
IT related projects started between 2003-2011 include:
 Citizen Electronic Health Records built in Family Physician project
 Central Hospital Appointment System (CHAS)
 Roll-out and generalizing the use of “Sağlık-Net” (National Health System):
o A part of the national Health Transformation Programme (HTP) initiated
by the Ministry Of Health.
o All health institutions and facilities sends patient visit and treatment data
(health datasets) in HL7 V3 messages to the data center in the MoH.
These will be extended after 2011 to include:
 Chronic disease management: Tele-consultation (Family Physician)
 Finalizing Patient rights and privacy legislations
 Enabling access to the Sağlık-Net EHR.
The EUPHORIA project will bring the experience and Know-How in an effective and
economical way to the Turkish health market.
1.2.2 Relevance to EU Strategies and Initiatives
The ICT PSP aims to stimulate smart, sustainable, and inclusive growth of ICT by
accelerating the wider uptake and best use of innovative digital technologies and
content by citizens, governments and businesses. It further addresses obstacles
hindering further and better use of ICT-based products and services in domains such

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as healthcare, as well as the integration of systems between different Member
States.
The project EUPHORIA clearly addresses the key aspects of this Digital Agenda,
including patient empowerment and the provision of adequate healthcare in all
European Member States. The eHealth services we selected for this project all aim at
these EU goals of patient empowerment and quality of care. For example, availability
of a PHR to the patient in whatever form, be it paper, usb-stick, home-based server,
or website, along with commonly accepted security measures and adequate privacy
protection options, is crucial to empowering the patient. It is obvious that such PHR
plays a central role in the service of home health devices. EUPHORIA does some
groundbreaking work which can be used for later European guidelines in the area of
healthy aging and home monitoring. Moreover, EUPHORIA intentionally uses the
current standards of epSoS and aims to propose extensions based on the
researched value recognized by European patients. Additionally, the elements of the
epSoS-defined patient summary will be benchmarked against the value of use by the
patient and the validity regarding CCR/CCD and HL7 RIM.
Interoperability testing will be executed using HITCH tools
(http://www.eurorec.org/RD/HITCH.cfm), if appropriate. EUPHORIA will exchange
lessons learned and adjusted tools to the project HITCH in order to support the free
nature and one-stop-shopping for interoperability testing as intended by HITCH.
The tested eHealth services will be labeled with indicators on quality, interoperability
and usefulness from a patient's point of view. EUPHORIA will built this according to
expertise available in the Thematic Network EHR-Q tn
(http://www.eurorec.org/RD/index.cfm) which labels and certifies EHR systems, and
EUPHORIA will put lessons-leaned and know-how online in the thematic network.
B1.3 Maturity of the technical solution
In this project a varied selection of (personalized) eHealth services will be up-scaled.
Consequently, there is not one technical solution. For each of the selected services
we provide a short description of the current state of affairs. Annex I provides the
reader with more detailed background information from each country.
We start with a paragraph on infrastructure issues in the separate countries.
1.3.1.1 Infrastructure
The services that are deployed will be made accessible in each country via a
national/regional portal website. While most health portals can still be defined in the
traditional sense as ‘gateways’ or ‘entry points’ to information located ‘elsewhere’ on
the web, we regard the integration of proprietary software technologies as an
important characteristic of present-day health portals. Featuring various types of
interactive content and communication, they provide new functionalities and services
for a rapidly expanding and diversifying audience. The strong growth of initiatives in
this field has led to an increasing variety of health portal typologies; new hybrid forms
frequently emerge, each with their own distinctive combination of focus, goal, scope,
origin, accessibility and degree of interactivity. A noteworthy phenomenon in this
context is the development of portals that are simultaneously serving providers and
recipients of healthcare.
In Sweden (My Healthcare Contacts), England (Patients Know Best), and the
Netherlands (Health Portal Rijnmond) these portals already exist. All these portals
are secured websites that present the services of this project (and also services that