Urbani izziv, thematic issue, 2015, no. 1 21 Michel AMIEL Lionel BRUNIE André FLORY Tobias Rene MAYER Mazen SAID Digital care in the Alpine area The article analyses the role that new digital technologies (NDTs) can play for improving healthcare. In particular, we identify trends, challenges and success factors. In the near future, NDTs should play a profound and transformative role in healthcare by improving patient healthcare and follow-up, by enhancing health professionals’ (HPs) coordination and pa- tient record exchange, by empowering patients to upload and access their medical records and, finally, by providing person- alised, timely and secure access to medical information. This ongoing revolution is dramatically changing the way HPs and patients interact and how healthcare services are organised. It supports the emergence of the concepts of territorial health- care organisation and a healthcare local community, which propose novel healthcare organisational plans. In this context, this article outlines the multidimensional nature of e-health solutions. In addition to technical and organisational issues, a number of other dimensions must be considered; for example, sociological and financial dimensions. Keywords: e-health, digital health, telemedicine, territorial health- care organisation, healthcare local community 1 Introduction This article summarises the SPHERA regional seminar “Dig- ital care in the Alpine space”, which was conducted at the National Institute of Applied Sciences of Lyon (Institut Na- tional des Sciences Appliquées; INSA de Lyon, Lyon, France) in June  2014 (see Internet  1). Funded by the Alpine Space Programme’s cooperation program, the SPHERA project aims to enhance territorial governance in the Alpine area, focusing specifically on the policy areas of health and spatial planning. The capitalisation approach of SPHERA builds on current and finalised Alpine Space Programme projects within the themat- ic field of “inclusive growth”. Learning from the results of these projects, SPHERA will also help prepare the ground for the new generation of projects in the  2014–2020 programming period by identifying gaps and supporting synergies. The Lyon SPHERA seminar, which is considered in this article, specifi- cally focused on e-health, leveraging the extensive experience of the Rhône-Alpes Region in implementing e-health and tele- medicine solutions. Urbani izziv, thematic issue, 2015, no. 1 22 2 Status of e-health systems in the Rhône-Alpes region 2.1 Rhône-Alpes systems Many e-health systems have been designed and implemented in recent years in the Rhône-Alpes region. The most impor- tant are: • DPPR (Dossier Patient Partagé Régional): the Regional Shared Patient Record; • PEPS: middleware support for healthcare networks; • Trajectoire: A tool for tracking and organising patient healthcare; for example, the transfer from hospital to home care; • Visage: a shared diary used by healthcare professionals involved in patient follow-up; • OSCARS: Support for cancer follow-up and care coor- dination; • ZEPRA (Zéro Echange Papier en Rhône-Alpes): a paper- less document exchange system (see Internet 2); • ASALEE: a cooperation protocol between health pro- fessionals (HPs) involved in patient follow-up; • ROR (Répertoire Opérationnel des Ressources): a directory of all healthcare operational resources. These tools have demonstrated their potential and effective- ness. They allow the Rhône-Alpes region to be a key player in e-health in Europe in  2014. Considered as a whole, they provide a good illustration of current trends in e-health. 2.2 Regional healthcare project The Rhône-Alpes healthcare authorities aim to create an area of excellence in digital health services, serving all health actors for one purpose: to ensure better health and support patients throughout their treatment. In this context, the first regional healthcare project (Projet Regional de la Santé, PRS), which establishes key priorities for the coming years, was released. A synthesis of the plan is available online (see Internet 3). This plan covers a period of five years (2012–2017) and is organised along three strategic priorities, which cover eighteen activities: • Strategic Priority 1: Developing prevention, in particular towards environmental risks; • Strategic Priority 2: Improving healthcare services; • Strategic Priority  3: Facilitating care plan implementa- tion. Strategic Priority  3 concerns improving the prevention and treatment of chronic diseases (diabetes, heart or kidney fail- ure, etc.), notably through better healthcare coordination with special attention to be paid to the disabled and elderly. Key aspects of this priority include: • Access to healthcare services; • Patient follow-up: care plan design and personalisation; • Patient follow-up: coordination of healthcare services; • Interoperable information systems; • Care flow management; • Inclusion of both social and care dimensions. 2.3 The PASCALINE project Submitted to the “Digital Healthcare Territories” (TSN) na- tional call, the Rhône-Alpes PASCALINE project is one of only five proposals that were selected by the French authorities for financing. The keywords of this project are available online (see Internet 4). The TSN national call focuses on e-health and territory planning. It is an opportunity to experiment with high-scale digital healthcare services planned in the Regional PRS (see Section 2.2). TSN targets accessibility to healthcare services, new healthcare models (e.g., a virtual hospital for ter- ritorial governance) and better healthcare service quality. The PASCALINE project consists of twelve work packages with a global budget of EUR  25.5  million. Two use cases will be considered during the project: breast cancer (in which general practitioners are the main actors) and severely disabled chil- dren (in which families are the main actors). PASCALINE addresses three main dimensions: sanitary, medical/social and prevention. They have in common the fact that several actors, information and needs must be coordinated, which raises tech- nical challenges for NDTs. PASCALINE targets five points that were identified as major challenges and needs: • Defining a patient-centred care plan and implementing seamless care flow; • A digital (regional) medical record that will serve as a common base of patient-related information. Note that over 60% of the patients are already registered in the re- gional e-health platform; • Secure communication service between HPs (hospitals, practitioners in cities, etc.) to enable fast exchange of knowledge; • A selection of tele-assistance and prevention services of- fered to patients suffering from chronic diseases; • Innovative projects (e.g., quantified self- and sensor-based systems) PASCALINE offers very good insight into the most promising trends in e-health. It also illustrates the need to design holistic solutions that consider all the dimensions of healthcare and integrate all stakeholders. M. AMIEL, L. BRUNIE, A. FLORY, T. R. MAYER, M. SAID Urbani izziv, thematic issue, 2015, no. 1 23Digital care in the Alpine area 3 Trends and challenges Two crucial issues can be identified that must be considered when designing e-health solutions: • Management of patient and information flows (also re- ferred to as the patient trajectory). Patients often move from their homes to a hospital or from a hospital to another one. The management of patients and their healthcare information is a key element in such multi- party follow-up. This seamless information exchange flow includes patients’ access to their treatment history or health-related information; • Management of the patient care plan. When multiple HPs are involved in patient care (especially when a trans-disciplinary approach is required; e.g.,  in cancer treatment), new coordination models are needed. Who decides what? Who is responsible for what? These ques- tions must be answered before the care process is started. Addressing these two issues requires solving technical, psy- chological, social and organisational challenges, which are addressed below. 3.1 Technical challenges Some technical challenges can be addressed: • Typically, current tools support only one disease, but pa- tients may have multiple diseases or may follow multiple treatments at the same time. Tools should be adapted to cover this aspect; • The new vision for NDTs is not one of specialised (soft- ware) tools, but transverse polyvalent tools able to adapt to the individual needs of hospital professionals, patients, and so on; • A secured messaging service is an essential functionality for HPs. Messaging and document transfer is an efficient first step in accustoming HPs to new digital technology; • New digital technology must be simple, easy-to-use, ef- ficient and affordable. 3.2 Psychological challenges An important problem is changing work habits. Training and support must be provided for several years. The length of the learning curve that has to be followed to fully implement a new way of working is about ten years. The bubble of responsibility refers to the fact that HPs may not want to be integrated into a larger (virtual) team but may prefer to stay in their own area of responsibility. For the success of NDTs, one needs to consider individual competences, needs and best working practices. A crucial factor for success is remuneration for NDT activities, and HPs should be paid appropriately for the time they spend. 3.3 Social challenges Social aspects are not reduced by NDTs. Interestingly, based on prior experience, the need for social contact increases with NDTs. Consequently, integrating the social dimension is in- dispensable for the success of any e-health solution. A social network should be created around the patient. Social work- ers, patient associations and relatives must become involved in the healthcare “environment”. Social media and internet-based social networks should also be considered to support patient’s social integration and the exchange with and among patients. 3.4 Territorial hospital organisations and healthcare local communities New patient follow-up approaches call for a dramatic health- care territorial organisation change in which hospitals should play a key role in coordinating healthcare actors and super- vising care flow. The notions of territorial hospital organi- sations (THOs) and healthcare local communities (HLCs) have recently emerged and suggest organising all healthcare stakeholders (including HPS, paramedics, patients, families, associations, social workers, etc.) into a network of interac- tions supported by NDTs (see Sections 2.1 and 2.3). As noted, such a change requires designing coordination support and information sharing tools/systems, designing a relevant legal framework, and political and financial support. In this context, a bottom-up approach should definitely be privileged; that is, the local coordination model should be designed and imple- mented according to local healthcare actors’ needs and context. 3.5 Success factors Some key factors for the success of THOs/HLCs, as well as all e-health solutions, can be identified: • A pragmatic approach: utility and pertinence must be always clear; • Bottom-up approaches: start from the needs of users (HP, paramedics and patients); • User-centric design of NDT tools to optimise their er- gonomics and their usability; • Integrating patient associations within development strategies; • User support and training strategy; • Integrating the social dimension; • A clear and relevant remuneration framework; • A clear and relevant legal framework. Urbani izziv, thematic issue, 2015, no. 1 24 4 Conclusion This article addressed current trends and challenges in develop- ing and implementing e-health solutions. A key feature that must be considered is the multidimensional nature of such solutions. In addition to technical and operational issues, designers of e-health solutions must consider psychological, sociological, training, legal, financial and organisational issues. NDTs provide tools, not solutions, and, for the success and the sustainability of e-health applications, all of these dimen- sions must be addressed at design time in a holistic approach. Furthermore, in the context of healthcare and spatial planning, emphasis has been placed on the emerging concepts of territo- rial healthcare organisations and healthcare local communities, which propose novel healthcare organisational plans. Finally, success factors have been identified that should be considered when designing and implementing e-health solutions. Michel Amiel ASTRHA (Association pour la Télémédecine en Rhône-Alpes; Rhône- Alpes Telemedicine Association), Lyon, France E-mail: michel.amiel@creatis.insa-lyon.fr Lionel Brunie LIRIS (Laboratoire d’InfoRmatique en Image et Systèmes d’information), National Institute of Applied Sciences (INSA de Lyon), Lyon, France E-mail: lionel.brunie@insa-lyon.fr André Flory LIRIS (Laboratoire d’InfoRmatique en Image et Systèmes d’information), National Institute of Applied Sciences (INSA de Lyon), Lyon, France E-mail: andre.flory@insa-lyon.fr Tobias René Mayer LIRIS (Laboratoire d’InfoRmatique en Image et Systèmes d’information), National Institute of Applied Sciences (INSA de Lyon), Lyon, France E-mail: tobias-rene.mayer@insa-lyon.fr Mazen Said LIRIS (Laboratoire d’InfoRmatique en Image et Systèmes d’information), National Institute of Applied Sciences (INSA de Lyon), Lyon, France E-mail: mazen.said@insa-lyon.fr References Internet 1: http://sphera.g2hp.net/sphera-national-seminar-lyon-rhone- -alpes-17th-june-2014-digital-healthcare-in-the-alpine-space (accessed 12 Dec. 2014). Internet 2: http://www.ars.rhonealpes.sante.fr/Zero-echange-de-papier- -en-Rhon.170391.0.html (accessed 12 Dec. 2014). Internet 3: http://www.ars.rhonealpes.sante.fr/fileadmin/RHONE- ALPES/RA/Direc_strategie_projets/PRS_Programmes_CNP/prs_ maj_072013/20131001_Synthese_PRS.pdf (accessed 12 Dec. 2014). Internet 4: http://www.ars.rhonealpes.sante.fr/fileadmin/RHONE-ALPES/ RA/Direc_strategie_projets/TSN/20140422_DSPro_TSN__PointsFortsRA. pdf (accessed 12 Dec. 2014). M. AMIEL, L. BRUNIE, A. FLORY, T. R. MAYER, M. SAID