Telemedicine and mHealth are an opportunity for citizens and a driver of great economic impact, although the market is not yet developed on a large scale. The European Commission has been funding several projects and is developing a number of initiatives to foster a massive utilization of these tools by 2020.
Mobile technologies are spreading. According to the Gartner Hype Cycle 2014  mHealth monitoring is currently in the trough of disillusionment and the plateau of productivity can be expected in 5 – 10 years.
Telemedicine was not specifically highlighted in the Cycle, but some aspects of it such as wearable users interface and data science, were in different stages. At the same time, the Ericsson Mobility Report of November 2014  predicts that 90% of people aged six years and over will have mobile phones by 2020, when the number of smartphone subscriptions is set to reach 6.1 billion.
This trend is reflected on mHealth use in Europe and the world. Every day, different websites and journals publish scientific articles on the use of mobile devices for preventing, diagnosing, treating or monitoring a disease.
State of play – Globally…
According to a World Health Organisation 2011 survey on mHealth , there was already at the time at least one mHealth initiative in 100 of the 112 Member States surveyed; in three quarters four or more types of mHealth initiatives were reported.
The types of mHealth initiatives most frequently reported globally were health call centres/health-care telephone help lines (59%), emergency toll-free telephone services (55%), emergencies (54%), and mobile telemedicine (49%).
According to another WHO survey on telemedicine , teleradiology is currently the most developed telemedicine service area globally, with just over 60% of 114 responding countries offering some form of service, and over 30% of respondents having an established service.
Other more widely used services are teledermatology, telepathology, and telepsychiatry. Services were listed in 16 different healthcare areas – cardiology, mammography, surgery, ophthalmology, diabetes management, paediatrics, stroke treatment, urology, otorynology etc.
… and in Europe
Technological solutions and research data already exist, patients are curious in using new, effective methods for different steps in managing their health and disease, doctors actively participate in research or introduce their own solutions for providing better service. More importantly, EU Member States have realized the potential of telemedicine and are supportive of its beneficial deployment.
Some Member States have already adopted legislation on telemedicine or have started discussions on making it a regular healthcare service. However, today telemedicine and mobile health are still not part of mainstream healthcare in Europe.
The European Hospital Survey: Benchmarking deployment of eHealth services (2012–2013)  and the survey among General Practitioners (2013)  demonstrated that only 9% of hospitals offer patients the opportunity to be remotely monitored and fewer than 10% of general practitioners conduct online consultations with patients and fewer than 16% with other medical specialists online.
From these surveys we also see that 39% of general practitioners are able electronically to exchange patient medical data with other health professionals/organizations.
However, regular exchange occurs mainly for simple features, such as laboratory reports, referral and discharge letters, sick leave and disability certification.
When it comes to hospitals, 48% share some medical information with external general practitioners electronically and 70% of EU hospitals with external care providers. At the same time, less than 8% of EU hospitals share medical information electronically with healthcare providers located in other EU countries.
A 2014 European eHealth Stakeholder Group report  assesses telemedicine services in the EU from the user’s and the stakeholder’s perspective and offers advice on how to make telemedicine services available to all Europeans by 2020 at the latest.
According to the report, tele-radiology has reached the status of routine use but is well ahead of other fields of telemedicine: while tele-radiology is currently used by 65 % of 368 radiology professionals who participated in the recent survey of the European Society of Radiology, tele-neurology (Telestroke) is in regular practice only in some regions in Europe for example in Catalonia and Scotland, tele-dermatology is in use in Scotland, but relies much on a limited number of enthusiasts and is not yet systematically organised on a National level.
Only few examples are available about the regular use of telemedicine for managing diabetes (Denmark, Finland) or Chronic Heart Failure (Germany).
Working towards legal clarity
In 2012, the Commission tried to assess the existing EU legal framework applying on telemedicine services in a dedicated Staff Working Document on Telemedicine, published along with the eHealth Action Plan 2012-2020.
The document covered legal questions such as licensing, data protection, reimbursement, and liability as regards the telemedicine in cross-border healthcare in the EU.
Moreover, in April 2014, the European Commission launched a public consultation to identify the right way forward to unlock the potential of mobile health in the EU. The consultation demonstrated that strong privacy and security tools (such as data encryption and authentication mechanisms) are needed to build users’ trust.
Half of the respondents called for a strengthened enforcement of data protection and the rules applicable to mHealth devices and nearly half of the respondents ask for more patient safety and transparency of information, by means of certification schemes or quality labeling of lifestyle and wellbeing apps.
The European Commission is currently analyzing options for addressing the issues highlighted by the public consultation. This is also in line with the Commission overall strategy on establishing Digital Single Market.
Addressing the need for evidence
Many countries participating in the WHO survey on telemedicine  reported high costs as a barrier to the implementation of telemedicine solutions. One possible reason for this is that telemedicine has not yet proven its value in cost-effectiveness and better quality compared to traditional services.
The European Commission through its Framework Programs on Research and Innovation has founded several projects  that address either telemedicine and mobile health.
Some of these projects are setting up more general principles for implementation, e.g. the project “Momentum” prepared a European telemedicine “Blueprint” to mainstream telemedicine into daily practice and make it sustainable  and the project “MovingLife” (“MObile eHealth for the VINdication of Global LIFEstyle change and disease management solutions”) has delivered a set of mHealth roadmaps, which should accelerate the establishment, acceptance and wide use of mHealth solutions globally .
Other projects are looking into more specific areas of healthcare that could benefit from the use of telemedicine services both in terms of better health outcomes as well as being cost-effective.
An examples could be here the CommonWell project that delivered integrated telecare and telehealth services among social care providers and hospitals on open platforms.
The developed services were targeted mainly for patients suffering from chronic diseases and professionals dealing with these conditions. The project ended in early 2012 and integrated services are now in real-life operation at the four pilot sites established in Spain, Germany, England and the Netherlands.
The project Renewing Health  implemented large scale real-life pilots to validate and evaluate innovative patient-centred personal health systems and telemedicine services for people suffering from Chronic Obstructive Pulmonary Diseases, diabetes and cardiovascular diseases.
The United4Health project  aims to exploit and further deploy innovative telemedicine services implemented and trialled under the RenewingHealth project. UNWIRED Health  deals with mHealth procurement for the transformation of healthcare services.
In this case, the Pre-Commercial Procurement (PCP) focuses on apps offering services to improve vaccination coverage and adherence and to coach patients with heart failures enabling education, motivation, remote monitoring and other functionalities, integrating and coordinating care provided by a hospital and the primary care physician.
The European Innovation Partnership on Active and Healthy Ageing (EIP AHA)  has formed a community across many EU regions of a critical mass of over 3000 stakeholders with considerable expertise in innovative digital solutions (including mHealth and telemedicine) for citizens, care systems and industry.In six Action Groups they tackle health and ageing related challenges at European scale, involving approximately two million patients. The EIP AHA Reference Sites and other regions have already deployed a range of innovative practices which are available for sharing, transferring to other regions and scaling up.
Global activities to learn from
Small-scale projects that look into the effectiveness of both telemedicine and mobile health are carried out all over the world.
For example, a study conducted by Irvine et al. on the use of mobile-web app to self-manage low back pain demonstrated that a theoretically based stand-alone mobile-Web intervention that tailors content to users’ preferences and interests can be an effective tool in self-management of low back pain .
Furthermore, new online communities have been set up for collecting and sharing information and learning from each other. The first well-known site was PatientsLikeMe.com  which motto is “Making healthcare better for everyone through sharing, support and research”.
The site has now more than 300.000 members, looks into more than 300 conditions and has published more than 50 research studies based on data available to them.
Let’s not forget about another exiting area of using mobile health – gamification. BrainGames from Anti-Aging Games  are based on 17.000 published scientific articles based on which brain stimulation games, relaxation games, best brain tips and games for stroke recovery were developed. Each of the games is linked to the PubMed study.
Some technological solutions may become beneficial rather quickly for example in organizing more effectively the use of operating theaters or contributing to patient movement within a hospital so that it would cause a little discomfort as possible.
Global Lab for Health  is a good example of collecting, sharing as well as analysing information about innovative approaches in healthcare, also those that support organizational changes.
Any innovator can submit on this Internet platform their innovative ideas giving also information about the existing users of the tool. Small group in the University of Southern California will then contact reference customers for their feedback which contains also information about savings.
Based on all gathered information a report about the efficiency of the innovation will be made.
“75% of what he does today he never learned in residency”, says Dr Atul Gawande in his book “Complications” while talking about his father, also a doctor.In the same book, Dr Gawande also says: “To fail adopting new techniques would mean denying patients meaningful medical advances.”
I believe the latter applies both to e.g. a new technology/ technique used in surgery and to home monitoring of patients with chronic heart failure.
The above-mentioned survey among general practitioners of 2013 indicated that main barriers for using eHealth are:
(1) lack of remuneration for additional work answering patients’ emails (79%);
(2) lack of sufficient IT training for healthcare professionals (75%);
(3) lack of interoperability of IT systems (73%);
(4) lack of sufficient IT skills on the side of healthcare professionals (72%);
(5) lack of a regulatory framework on confidentiality and privacy for email doctor-patient communication (71%). None of these barriers is impassable and are also addressed in the European Commission eHealth Action Plan 2012-2020 .
Tele-monitoring of a patient does not mean a doctor should keep an eye on all data 24/7; nor does it mean that all face-to-face patient-doctor meetings will be replaced by the exchange of information using e-mails, sms and Skype sessions. Telemedicine and mHealth are tools that may help doctors react to the worsening of a condition (smart systems call attention only to changes that need intervention) in an early stage and thus help avoid complications and unnecessary hospitalization.
In addition, regular daily collection of data gives much better overview of a condition than a single review of a patient’s condition during a face-to-face meeting once month (or less). A patient’s active participation in managing their long-term condition supports patient empowerment. This is a fundamental principle for healthcare of 21st century.
 Irvine AB, Russell H, Manocchia M, Mino DE, Cox Glassen T, Morgan R, Gau JM, Birney AJ, Ary DV Mobile-Web App to Self-Manage Low Back Pain: Randomized Controlled Trial. J Med Internet Res 2015;17(1):e1. DOI