Science and Technology Roadmapping: implications for eHealth

Issue: Recent S&T roadmapping studies have focused on the potential of various emerging information and communication technologies to help meet the challenges faced by European healthcare systems dealing with an ageing population, the enlargement of European Union and growing healthcare budget constraints. Roadmaps are an effective and intuitive way to present and analyse the causal and temporal relations in these roadmaps.

Relevance: Roadmaps are valuable for policy-makers or executives with limited time to grasp at a single glance the various dimensions, whether scientific and technological, economic, political or social, of such a complex issue as eHealth.

Technology roadmapping is a widely used methodology, employed by individual companies, entire industries and public research institutes (Da Costa et al. 2003) as a way of bringing together various stakeholder perspectives so as to develop an overview of how a technological field, or an industry is likely to develop over a set future period. This approach can be applied to analysing the scientific and technological, economic, political and social dimensions of a wide range of fields, and the interactions between them. It is therefore highly appropriate to a complex area such as eHealth (see Box 1).

In August 2002, the IPTS and the European Science and Technology Observatory (ESTO) launched a project aimed at developing science and technology roadmapping (S&TRM) as an input into policy making at European level. The project was underpinned by three main issues:

What are the major societal challenges facing Europe?
What are the emerging technological responses to these challenges?
What are the pathways between these challenges and responses?

Two pilot roadmaps, addressing these questions in particular contexts, have recently been completed:

"The Healthcare Technologies Roadmap: Effective Delivery of Healthcare in the Context of an Ageing Society," (Braun et al. 2003);
"Ambient Intelligence in Everyday Life" (Friedewald, Da Costa 2003).

In the Healthcare Technology Roadmap (HCTRM), Information and Communication Technologies (ICT) were identified as a core technological cluster, comprising a range of developments relevant for the prevention, diagnosis and monitoring of illness, its treatment and aftercare, as well as in supporting information systems and services. Conversely, in AmI@Life, health was one of six key application areas for ambient intelligence technologies.

The ICT cluster of HCTRM and the health application area of AmI@Life overlap significantly. While these two roadmaps were constructed relatively independently, their results concur to underline the particular relevance of the development of eHealth.

Increasing demands on European healthcare systems are a consequence of the changing demographics¹ and economic development of Europe. The effective delivery of healthcare represents a challenge to which a combination of emerging technological developments could respond. The HCTRM set out four key drivers of change emerging over the next decade to shape the future of healthcare delivery.

• The ageing of the population will have significant implications, particularly for pension systems, public sector budgets, and healthcare delivery. However, demographic change offers opportunities to improve the quality of life of older people, and new business possibilities for industry.
• With enlargement of the European Union, rights and access to quality healthcare may be threatened by changes in the structuring and financing of healthcare systems. These may be compounded by the utilization of cross-border services and shortages of skilled labour, particularly if healthcare professionals seek better paid jobs in the present EU15.
• The key technological breakthroughs impacting on healthcare include developments in computers and robotics, genetic engineering, pharmaceuticals, and the growth of replacement tissues and organs².
• Changes in health policies and systems are a consequence of growth in public sector expenditure on health over recent decades. More recently, health systems have sought to reduce costs while improving quality and accessibility. The new EU public health programme (Official Journal 9/10/2002) is promoting a more integrated and intersectoral health strategy, encouraging cooperation between Member States.

Within this context, there is a clear danger of a widening of the 'health gap' between regions and social classes. A recent report delivered to the European Council (European Commission, DG Employment and Social Affairs 2003) examines the challenges faced by healthcare systems in the European Union and the need to ensure a good balance between three objectives:

• Broad and Equal Access to Healthcare relies heavily on governments taking responsibility for structuring and financing healthcare systems. Insurance status or the place of residence should not condition access to a specific treatment. However, disparities in organizations and financing influence medical practice, for instance in the area of minimally invasive surgery and telecare. Ideally, healthcare professionals should use the best technologies available, and in so doing, facilitate their dissemination.
• High Quality Healthcare Delivery depends on the one hand on the increased empowerment and greater expectations of healthcare consumers, and, on the other on the awareness of, and access to, healthcare innovation among professionals.
• Financial Sustainability of Healthcare Systems relies on balancing policy and legislation with market forces within the healthcare industry, particularly sustained investment in R&D activity, to ensure the availability and accessibility of healthcare services for all citizens.

The combination of the above drivers and policy challenges provided the context in which the HCTRM examined emerging technologies and AmI@Life the health application area.

The HCTRM, was an issue-driven study in which eHealth was considered from a technological perspective. The basic methodology centred on a matrix-based framework in which to describe and analyse the current state of healthcare technologies (Footprint Matrix) and to articulate a vision of the future situation (Matrix 2020).

The objective of AmI@Life was to examine the potential of full integration of "Ambient Intelligence" (AmI) in everyday life, thereby raising the issue of universal access to new technologies and functions. AmI refers to a vision of the future of ICTs which puts human beings at the centre, i.e. where technologies are designed for people rather than people having to adapt to technologies. People would be surrounded by intelligent intuitive interfaces embedded in all kinds of objects and environments and capable of recognizing and responding to the individual needs in a seamless, unobtrusive and often invisible way (Ducatel et al. 2001).

Within AmI@Life, health was one of six major application areas considered from a demand perspective. Since Ambient Intelligence is truly cross-cutting, most ICTs have been examined. AmI@Life complements the HCTRM with intermediate pictures, major milestones, potential breakthroughs or disruptions and critical paths for the developments of key technologies and functions.

In the HCTRM Footprint Matrix, the following ICT developments were shown as currently having a major impact on the delivery of healthcare:

The integration of ICT, medical imaging and robotics, which is improving surgical treatment by making it less invasive, reducing risks and reducing the length of hospital stays;
e-Health, which embraces ICT-driven activities transforming the delivery of healthcare (Richardson et al, 2002), and includes telecare (health and social care provided remotely, generally to people in their own homes) and telemedicine (the provision of health care and education at a distance, using telecommunications technology);
Decision Support Systems and Bio-informatics, which contribute to and support diagnosis, prognosis, studies, prescriptions and other treatment options. The connection of the locus of healthcare delivery and national electronic information networks can help improve diagnosis, treatment and aftercare.

The HCTRM Matrix 2020 sets out a vision of relevant emerging technological developments and issues in their application. In particular, telecare was found to be a key eHealth-related application for improving the quality of life and longevity of patients, particularly older and disabled people in rural areas (Tang et al. 2000; Bradley et al. 2003). With an ageing population, financial constraints and growing acceptance of the delivery of healthcare at home will mean that demand will be high, as has been borne out by various pilot telecare projects (Curry et al. 2002).

The main goal is the provision of customizable telecare, which can be easily deployed and adapted in individuals' homes to meet their particular needs. This relies on a number of key enabling technologies, which include high-speed wireless communications, digital interfaces, database and data mining technologies, sensors and actuators. Specific applications will include passive devices to detect accidents and hazards; memory aids; lifestyle and physiological monitoring systems; specialized telephones and videoconferencing; speech recognition for data capture and computer command; and mobile devices to connect with computer systems during the patient care process.

Telecare will be also integrated into assistive equipment, such as walking sticks, bath seats, grab rails, and wheelchairs, particularly in the context of the smart home. Health applications for AmI technologies have been found to be very demanding but also very promising, in terms of improving the process of care delivery and facilitating linkages between the different actors. However, although prototypes can be expected within the next 3-5 years, widespread use of most of these applications is not expected until 2010.

Bringing together the implications of the two roadmaps, patients should benefit from improved quality in the prevention and treatment of illness and in aftercare and rehabilitation thanks to improved capabilities in the measurement, recording, and analysis of data and to the increasing availability of minimally invasive surgery and telecare.

Healthcare professionals will benefit from easier access to patient-specific information and to general professional information. They will be able to match measurements and observations with recorded information about the user, even including data such as eating habits. Later on, when gene-based treatments become available, healthcare practitioners will be able to access the patients' genetic data. Given the current early state of development of pharmacogenomics, relevant integrated information systems are not likely to be available in all EU healthcare systems until 2020. Patients might one day also carry smart-cards containing such genetic data.

Healthcare professionals will also be able to take advantage of AmI-based decision-support systems and support services in health management and administration. For instance, prototypes for the identification and authentication of medical personnel and patients should be available within the next two years, with wider introduction possible after 2007.

Wider diffusion of health information and education systems, already feasible, will facilitate better informed encounters with patients and with other care professionals. Advanced applications using mobile communication are likely to become available after 2004.

The availability, as early as 2005, of sensor technologies will underpin advances in alert and alarm systems and robotics. These will be further developed with the availability of micro actuators after 2006.

As a consequence, monitoring, which relies mainly on the combination of sensors monitoring vital functions and networking technologies, will particularly benefit from the development of AmI technologies. The first prototypes of AmI-based monitoring systems should appear in about five years while 'intelligent' and context sensitive monitoring systems are unlikely to be feasible before 2020, given the high degree of uncertainty surrounding the development of Artificial Intelligence.

AmI-based prediction and diagnosis relies on data monitoring, and after 2007, should develop from the measurement of predefined indicators, such as blood sugar level and heart rate, to knowledge-based systems capable of diagnoses based on a range of indicators. Tele-consultation is already in use ( e.g. on ships), and will embrace AmI technologies as they become available. The need for visual communication between patients and healthcare professionals will be met by widespread availability of broadband networks.

On the 2020 horizon, telecare and minimally invasive surgery should be widely used together.

Ultimately all AmI-related functions in the health field are likely to tend towards convergence in a single system. The overall healthcare system will benefit from the optimization of resource use, scale economies, better use of public health information and a more highly-skilled workforce. There may also be major implications for the organization of care, with more delivery in the community and minimization of inappropriate admissions, long stays and readmission. There will be increased emphasis on chronic disease management and support for patient self-management.

Possible areas for further research in the field include artificial intelligence tools for screening clinical data and alerting physicians; expert systems for decision support; and nanotechnology and its convergence with biotechnology. The future opportunities for industry include: construction of smart homes and retrofitting of the existing housing stock; production of sensors and sensor systems; compilation and maintenance of large, searchable databases.

The provision of healthcare across Europe is becoming much more complex. The roles and responsibilities of the institutions, practitioners and even users are changing. The general trends which will influence policy considerations include:

• increased blurring of boundaries between public and private sectors;
• more emphasis on prevention of illness;
• growing pressure for moving healthcare from expensive intramural settings (e.g., hospitals) to extramural settings and the community itself;
• transformations of the organizational structures and the workforce driven by the introduction of new technologies into the system;
• stronger decentralization and individualization of healthcare;
• development of networking, especially in secondary healthcare structures due to better access to information;
• development of trans-European R&D capacity and healthcare provision;
• development of new tools to monitor healthcare expenditures.

In particular, the implications of the development and diffusion of e-health for the three objectives defined by the European Council include:

• Broad and Equal Access to Healthcare. E-health developments affect both information and provision of healthcare. However, the privacy of patient information remains a source of concern.
• High Quality Healthcare Delivery. The measurement of the 'quality of healthcare' remains an issue for further research. The advances in eHealth will impact on the potential to evaluate healthcare quality.
• Financial Sustainability of Healthcare Systems. The major cost factor for healthcare systems has traditionally been (skilled) labour. However the growing cost of medical systems stems from the increasing use of technology that once it becomes available, may be used indiscriminately by physicians to provide a return on investment.

The main drivers and factors influencing the diffusion of healthcare technologies, including eHealth, have been identified as: the cost of development and provision, research and development, availability of skills, organization of healthcare system, ethical concerns, cost of use and reimbursement. Most of these factors are healthcare provider, industry, system or policy related.

Future deployment of eHealth is conditioned by an adequate understanding of the social context by the public authorities, healthcare providers and other stakeholders. Without appropriate government policies it is unlikely to occur (Barlow et al. 2003). Key areas for policy intervention include:

• Encouraging patient (user friendliness) and service (infrastructure and skills) accessibility;
• Encouraging dialogue between stakeholders on conflicting themes: ethical issues, data privacy, etc.;
• Legal and ethical framework: confidentiality of personal data, respect of privacy threatened by automatic monitoring of lifestyles, ethics, patient involvement in decisions over his/her own treatment, need for personal forms of care and support, etc.;
• Provision of objective, comprehensive, readable, accurate and up-to-date information on medicines to the public;
• Provision of training in technologies for general practitioners;
• Mechanisms for reimbursement or payment for services;
• Health education and training to reduce the 'health gap';
• Public and professional acceptance of technologies.
• Systematic evaluation of e-health outcomes at the patient and at the whole system level using robust evaluation methodologies so as to overcome healthcare professionals' concerns.
• Support for the emergence of a new type of care professional, the 'telecarer'.
• Availability of standards for interoperability and compatibility of technical systems.
• Deployment at European, national or regional level depending on the viable scale for the particular service and taking into account the local specificities.
• Mechanisms to foster learning across projects and localities and develop a coherent knowledge base.
• Encouragement for the inclusion of telecare and telemedicine in mainstream care delivery, without being overly prescriptive but developing an institutional framework which allows care providers to use it as an option when appropriate.

In the two roadmaps, examination of the key trajectories of scientific and technological development in their socio-economic context, with the contributions of expert knowledge and opinions, has identified and illuminated issues of concern for policy. The ability of the roadmaps to generate perspectives on policy implications demonstrates the potential value of the roadmapping approach in policy intelligence.

eHealth, delivery of healthcare, science and technology roadmapping, S&TRM, policy intelligence

Notes

1. Life expectancy at birth has increased by six years in the EU on average from 1970 to 1996 and is now between 75 years and 79 years in all Member States.

2. The global HCT & pharmaceutical market in 2001 globally was 600 billion US$, with HCT representing one third and pharmaceutical two-thirds (Eucomed).

• Barlow, J, Bayer, S, Curry, R. Fitting in - the design of pilot telecare projects and their integration into mainstream service delivery, Journal of Telemedicine and Telecare, 2003.
• Bradley, D., Brownsell, S., Porteus, J. Assistive technology and telecare. Forging solutions for independent living, Bristol: Policy Press, 2003.
• Braun, A., Boden, M., Zappacosta, M., (eds), Healthcare Technologies Roadmap, The Effective Delivery of Healthcare in the Context of an Ageing Society, Working Document, 2003, http://esto.jrc.es/docs/HealthcareTechnologiesRoadmapping.pdf
• Curry, R.; Trejo-Tinoco, M.; Wardle, D., The use of information and communication technology to support independent living for older and disabled people, Report prepared for the Dept. of Health, London, 2002.
• Da Costa, O., Boden, M., Punie, Y., and Zappacosta, M., Science and Technology Roadmapping: from Industry to Public Policy, IPTS Report Vol. 73, 2003.
• Ducatel, K., Bogdanowicz, M., Scapolo, F., Leijten, J. & Burgelman, J-C., ISTAG - Scenarios of Ambient Intelligence in 2010, European Commission Community Research, 2001, http://www.cordis.lu/ist/istag
• Eucomed http://www.eucomed.org
• European Commission, DG Employment and Social Affairs, Communication from The Commission To The Council, The European Parliament, The European Economic And Social Committee and The Committee of The Regions. Proposal For a Joint Report: Health Care And Care For The Elderly: Supporting National Strategies For Ensuring a High level of Social Protection COM(2002) 774 final, 2003.
• Friedewald, M., Da Costa, O., (eds), AmI@Life - Science and Technology Roadmapping Ambient Intelligence in Everyday Life, Working Document, 2003, http://esto.jrc.es/docs/AmIReportFinal.pdf
• Official Journal L 271/1 of 9/10/2002, Decision 1786/EC.
• Richardson, R., Schug, S., Bywater, M., and Williams, D., Position paper for the development of eHealth Europe, European Health Telematics Association, 2002.
• Tang, P., Gann, D., Curry, R. Telecare New ideas for care @ home. Bristol: Policy Press, 2000.

We are grateful to our roadmapping partners who contributed to the project.

For HCTRM: Anette Braun (VDI), James Barlow (SPRU), Kristian Borch (RISØ), James Ryan (CIRCA), Niilo Saranummi (VTT), Hindrik Vondeling (SDU), Fernando Gil Alonso (European Commission, Employment and Social Affairs Directorate-General), David Rickerby (Advisory Cell for Science and Technology, JRC), Marianne Takki, (European Commission, Health and Consumer Protection Directorate-General), Mario Zappacosta (ex IPTS).

For AmI@Life: Yves Punie from IPTS, Michael Friedewald from Fraunhofer-ISI, Pieter Ballon, Lucien Dantuma and Desiree Hoving from TNO STB.

Mark Boden, IPTS

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Olivier Da Costa, IPTS

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About the authors

• Mark Boden is currently a visiting scientist in the IPTS. He is on extended leave of absence from Policy Research in Engineering Science and Technology (PREST) at the University of Manchester, UK, where he has worked since 1986, after completing his doctoral studies.
• Olivier Da Costa has been a research fellow at the IPTS since 2002. Before joining the IPTS he coordinated the first phase of the French national foresight exercise on Research, Innovation and Society. He has a background as a consultant in innovative technologies, strategy and foresight and as a physicist. He has a PhD and is a graduate of the Ecole Polytechnique.