In the context of the 7th annual EuroCloud Forum, which takes place from 5-6 October in Bucharest, Romania, Elena Zvarici, executive board member of EuroCloud Europe, talks about how Europe can take advantage of cloud computing and the data economy.
In order for Europe to take full advantage of cloud computing and the data economy, we need to strike the right balance between regulation and innovation
In the digital world the balancing act between business and regulation is a delicate one. In the past year we have seen the adoption of the new European General Data Protection Regulation, the invalidation of the Safe Harbour agreement for transatlantic data transfers and problematic discussions around its replacement the Privacy Shield.
Setting these developments into the context of the many ongoing initiatives at EU level aimed at encouraging innovation and the data economy, it is clear that getting the balance right is no easy task.
Europe is leading the way in data privacy and advocates a high level of data protection worldwide. The newly adopted General Data Protection Regulation introduces a new concept of responsibility towards data ownership, as well as new legal obligations for businesses to comply. For cloud SMEs and start-ups, getting up to speed can be problematic and they will need help.
A coordinated approach is needed between data protection authorities, policy makers and industry, in order to help organizations in this transition, by providing adequate data breach reporting tools, compliance toolkits and publicising the key issues. Let’s make sure that European SMEs and start-ups, so often the drivers of growth in Europe, are well placed to comply.
While the GDPR provides a high level of data protection we must remember that we are ever more connected through digital means and cannot think solely in terms of Europe. We are global users and exporters of digital services and need to have a strong cloud computing and data economy to be competitive. International data flows will play a key part in this. To avoid regulation clashes and to create international data-driven markets, in the future we should strive towards the creation of uniform, accepted standards of personal data protection on a global basis.
The recent agreement on the Privacy Shield for EU-US data transfers did not come a moment too soon and will hopefully bring the much needed legal certainty for the approximately 4,000 businesses who made use of the safe harbour mechanism. This legal assurance is vital. Many of these companies will rely on global information exchanges. Let’s hope that the provisions in the Privacy Shield can provide a robust enough framework to encourage data flows while providing high standards of data protection.
Global data flows are vital to international trade and economic growth and the European Commission Initiative on the free flow of data, expected at the end of 2016, should aim to enable European companies, particularly in the growing cloud computing sector, to be in the forefront of the global innovation race.
The Initiative should aim to reinforce the European cloud sector, so that companies are encouraged to develop new innovative services in the cloud, sell their services cross-border and enter the global market as exporters of technology.
This can be done by providing clarity on issues such as data ownership, liability arising from data use and data localisation across Europe.
If we really want to position Europe as a global leader in the data economy we need to ensure that we get the balance right. This means ensuring high levels of privacy while fostering new business innovation in sectors that rely on data and developing trust and confidence among users, from the individual consumer to the public and private sector.
Now is the time to move forward and encourage Europe to reap the benefits of data and the cloud.
Picture credits: Roberto Sartori
In order to boost to the creation of smart cities across the EU, we need a clearly defined European ‘smart city model’. The creation of such a model should be the next step in claiming our own European ‘smart city identity’.
In the past decade, the Internet has grown exponentially. And the best is yet to come: gradually, the Internet is evolving into a true ‘Internet of Things’ in which nearly all objects that surround us (cars, household appliances, light bulbs, etc.) will be connected.
As such, the foundation is laid for the creation of ‘smart cities’ in which tens of thousands of sensors and connected devices will optimize the way in which we live and work.
Smart cities are emerging all over the world. In Asia and the Middle East, some are even built from scratch. Noteworthy examples are the South Korean city of Songdo (a prestigious $35 billion project of which the first phase has been delivered last year) and the planned Masdar City in the United Arab Emirates.
At the other side of the world, smart cities such as San Francisco are seeing a boost in ‘bottom-up’ smart city developments – with private companies such as Uber (smart mobility), Airbnb (smart tourism) and Google’s Sidewalk Labs (city Wi-Fi hubs) pushing the uptake of smart service platforms.
At both ends of this spectrum (from greenfield projects in Asia to commercial initiatives in the US) quite some buzz is created – which leads many people to believe that not much is happening in Europe.
In order to correct that perception and to give a boost to the creation of smart cities in Europe, we need a clearly defined European ‘smart city model’ as well as the proper research methodologies and financial incentives to help mitigate part of the implementation risks.
Smart cities go beyond ‘top-down’ or ‘bottom-up’ platforms
While ambitious initiatives such as the Songdo project generate lots of interest and are perfect marketing vehicles to attract investments and expertise, they tend to ignore what smart cities are really about: a smart city is not just a prefab machine crammed with the latest technologies; it is a city that lifts quality of life to a totally new dimension by responding to people’s actual needs.
Also, initiatives such as Songdo tend to contract with one major technology consortium which is then responsible for the city’s backbone, its operations center and the definition of the major end-user services. It is clear, though, that one corporate provider can never provide the variety of services needed in a vibrant, dynamic city.
At the other side of the world, in the US, ‘bottom-up’ developments lead to commercial smart city offerings that are well-received by end-users. Yet, the emergence of such powerful corporate platforms that disrupt and replace public services, but that are not accountable to citizens, has also raised a number of concerns.
Already, objections against the ‘exploitation’ of public resources by these new smart city platforms have been voiced.
The European smart city model: putting users’ needs and creativity at the center stage
European cities such as Amsterdam, Barcelona, Helsinki and Vienna have clearly understood this, and are successfully reinventing themselves – in collaboration with their citizens. They have embraced a model that could be referred to as the ‘City as a Platform’ (CAAP).
In this model, the public authority remains in the lead of smart city developments, gathering around itself a whole ecosystem of start-ups, SMEs, large firms, non-profits and citizens to jointly create smart cities.
Yet, in spite of those efforts, a formally-defined European smart city model that could easily be picked up by other European stakeholders does not yet exist. The creation of such a model should be the next step in claiming our own European ‘smart city identity’.
At the basis of the European smart city model should be the so-called ‘quadruple helix’ – bringing together government, citizens, academia and industry to build smart cities in a way that combines the advantages of the top-down approach (safeguarding public interests) with bottom-up steered creativity.
For public organizations to remain a central stakeholder in this process – all while putting citizens’ needs center stage – they need to implement an actual Research, Development and Innovation (RDI) role for cities. The European model of Living Labs, where users and producers are brought together on a neutral platform to co-create and test innovations, is ideal for this.
The European model could thus overcome some important shortcomings of the American and Asian initiatives, securing the upfront buy-in from the people that will actually have to live, work and have fun in tomorrow’s smart cities.
At the same time, living lab research also allows us to tap directly into citizens’ own creative and valuable ideas, once again securing their buy-in and enthusiasm as they actually become smart city co-creators. Such an approach would make the European smart city model really stand out; all elements are there, we just need to formalize, operationalize and upscale them!
European incentives to help mitigate smart city implementation risks
Obviously, next to the central role of the users, financial considerations come into play too when building a smart city. Today, innovation support to mitigate risk is mainly granted to very immature technologies.
Yet, in a smart city context, risk not only resides in technology development, but also in its implementation. While the European Commission has started to acknowledge this, national innovation agencies are still often clinging to old techno-push frameworks.
In order to make the European CAAP model work, it is critically important that we continue to adapt our innovation programs to this new reality.
On the one hand, we need to help smart city partners leverage Europe’s experience in living lab research methodologies (through the European Network of Living Labs, for instance) to make sure implementation of new technologies is done first time right; and on the other hand, new measures are required to helping them mitigate the financial risk of smart city deployments too.
Photo credit: Guy Mayer
Despite what many people may think, there is no real lack in capital supply for Europeans interested in launching their own start-ups in the digital domain.
The rise of (digital) technology start-ups is a global phenomenon, with extensive start-up ecosystems – such as the one in Silicon Valley – being replicated all over the world. Like any other region, Europe is highly interested in reaping the economic and societal benefits of a flourishing start-up economy.
In a recent speech, Neelie Kroes (the former Commissioner for Europe’s Digital Agenda) stated for instance that two out of three (!) new jobs in Ireland are created by start-ups in the first five years of existence.
Not all is rosy, though. Critics often say that it remains hard for European start-ups to get access to the proper financial means to kickstart their businesses.
But is that really the case?
It’s definitely not their biggest problem. Despite what many people may think, there is no real lack in capital supply for Europeans interested in launching their own start-ups in the digital domain.
Virtually each region has done a good job in developing the appropriate funding mechanisms to support start-ups’ launch activities. In other words: it’s not (all) about the money. As a matter of fact, three bigger threats to European start-ups’ longer-term growth can be discerned – culture, regulation and mindset.
A first issue is Europe’s fragmented market – not so much from a geographical perspective, but rather from a cultural one. Indeed, in spite of all good intentions, it remains difficult for European start-ups to sell their products across ‘cultural’ borders. The use of different languages is one obstacle, of course, but divergent social aspirations and cultural values are equally important barriers.
For example, selling a solution for personalized online advertising might be perfectly acceptable in one region because of the advantages it brings (instead of being spammed, one only gets to see those ads that are in line with his/her interests), but it may fail completely in cultures where this is perceived as a direct assault on people’s privacy.
Intra-European legal and regulatory barriers present additional obstacles. A concrete example is the burden that accompanies the launch of pan-European digital health solutions, with each European country having issued its own regulations related to the development, sale, usage and reimbursement of products and services in the digital health realm.
And finally, there’s mindset. Contrary to the US, where everything is big and aimed towards rapid international expansion, European start-ups typically have a more ‘provincial’ mindset. In today’s global, digital economy, though, that’s a major shortcoming. In order to really succeed, start-ups should have international ambitions right from the start.
As we observed already, none of those barriers exist in the US – making this geographical and cultural region a single, big ‘unified’ market with more than 320 million consumers.
Both its scale and transparency make it an easier target to introduce products and grow. A bit ironically perhaps, even conquering the rest of the European market is typically easier if done from the US…
So, how can we address those challenges? I see three important lines of action, in which European policy makers have a major role to play:
– From a regulatory perspective, measures should be taken to further unify the European market – so that its full potential of more than 500 million consumers and potential investors can be tapped.
Streamlining regulation in domains such as digital health, for instance, would already open up a wide range of growth opportunities for potentially hundreds of European start-ups.
Obviously, this would not help us overcome the cultural boundaries overnight; but to that end, instruments are already in place, such as the European Network of Living Labs (ENoLL), to help companies investigate how people will respond to new products and features – before the actual market launch.
– To foster the pan-European growth of start-ups and overcome the provincial mindset, a number of good initiatives have already been taken as well.
One concrete example is the creation of EIT Digital, which helps European start-ups accelerate their growth – o.a. by finding European and worldwide customers for their products and solutions, or by helping them raise funds.
– And finally, when it boils down to securing first customers, Europe should investigate the concept of ‘innovative procurement’– a best practice that has already been widely adopted by the UK and US administrations. It requires government bodies and local branches of big multinationals to allocate a certain percentage of their public procurement activities to innovative start-ups.
As such, start-ups can more easily get the necessary credentials and references to continue growing their businesses. According to certain estimates, public procurement is worth €2,000 billion to the EU economy – so dedicating even 1% of that amount to innovative procurement still equals €20 billion per year to support the European start-up ecosystem.
But also for that, a cultural and regulatory shift is required…
photo credit: Shumona Sharna
In the overflow of ongoing debates about security and privacy in Europe, the discussion over an EU wide passenger name record system (PNR) is most telling of Europeans’ data-schizophrenia. But interestingly enough, going beyond the PNR controversy, could also propel Europe into a new era of security, prosperity and privacy.
It’s always a strange feeling, and it happens more often than not within the EU. From the moment you walk into the airport to the moment you exit your arrival terminal, it may happen that no one has asked you at a single time during your journey to show an ID.
You scanned your QR code to access the departure gates, you scanned it again to go through security and then to board, you flew and crossed one or multiple borders, you exited the plane, walked through baggage claim without stopping, and then customs, and you are in another country.No one ever asked you for an ID, and when flying, it is always a strange thought to have that the passenger sitting next to you might not be the person whose name is on the ticket.
Reality, though, is much different. Passenger information collected by airlines is accessible to law enforcement authorities who can ‘pull’ names of suspected terrorists or criminals. But suspects need to already be on a list for the system to work impermeably.
With rising concerns throughout Europe that terror attacks may be the act of EU citizens radicalized and trained abroad, many argue for a system that would allow drawing patterns and pre-empting the worse from happening.
It was in this spirit that an EU-U.S. PNR agreement was adopted as soon as 2007, providing a framework for the transfer of EU air passengers’ personal data to the US authorities. With such a system, airlines ‘push’ passenger information to law enforcement authorities, who are then able to identify ‘unknown’ suspects.
Put bluntly: after analysis of their data (travel dates, itinerary, baggage and payment information, etc.) passengers can become suspects; they get on the list.
Understandably, for security purposes, such a tool can be very useful. It makes sense between allies, and the EU has signed such agreements with Canada and Australia too. It makes even more sense between EU countries; something that has yet to be achieved.
But understandably as well, such tool raises a number of questions when it comes to the type of data collected, the authorities who will have access to it, the duration of retention of the data, and the risks such profiling could present to individual fundamental rights.
In the aftermaths of the Paris terror attacks of January 2015, it made renewed sense in Europe to push for a single EU wide PNR. While member states can perfectly design their own systems – and some already have – such fragmentation defeats the purpose of ensuring the same high level of security and privacy to all EU citizens in all EU countries.
In a resolution that put an end to a long standing stalemate between EU institutions, members of the European Parliament called in February for progress to be made by the Commission and member states on issues related to data retention and data protection, with a view to adopt an EU PNR legislation by the end of the year.
Reform of data protection rules and adoption of a necessary and proportionate PNR system should therefore be done in parallel. Such conditionality is risky on many levels. But it could also give a much awaited boost to discussions in Europe on data retention and data privacy.
In addition, finding the right balance in the EU PNR legislation could prove valuable for negotiations with partner countries. On April 1st, Mexico could have started imposing fines of up to $30,000 per flight to European airlines if it was not given sufficient guarantees that an EU-Mexico PNR agreement would soon see the light of day.
The EU agreed to do so, and the deadline was pushed back to July 1st. Mexico’s muscle flex is not surprising in the current global security context. Other countries, such as Japan and Korea, have asked for the same in past, and could potentially resort to the Mexican precedent.
As it now stands, the debate over PNR in Europe reaches far beyond the borders of the EU. It reaches to the core fundamentals of both individuals and nations: liberty and security. “They who can give up essential liberty to obtain a little temporary safety deserve neither liberty nor safety”, cautioned Benjamin Franklin.
Perhaps, but when it comes to personal information, the assumption of an inevitable trade-off between security and privacy should not be the norm.
The mere idea of such a trade-off makes it virtually impossible for policymakers or citizens to move forward constructively.The EU should on the contrary work towards increasing collective security by raising the standards in the protection of privacy. And the parallel discussions over PNR provide an ideal framework to do so before the end of the year.
We still may not know who is really sitting next to us on the plane after that, but someone definitely will.
photo credits: Jessica Keating Photography
The big question is this: do administrators and politicians understand what the consequences of the “smartness” they are injecting into public infrastructures?
Recommendation 1: Focus on peer-to-peer technology.
In its infancy, the Internet’s designers opted for an architecture of distributed communication. This means that, within the network, each node is equal to any other node without the intervention of a central source. Such networks are often called “peer-to-peer” (P2P)—equal to equal. Within these networks, everyone has access to the same tools without having to ask for permission.
This distributed, horizontal architecture of the Internet has been the determining factor for its disruptive nature. It undermines traditional hierarchies, and provides opportunities for newcomers to upset antiquated business models in no time.
This leads to an on-going struggle between old and new powers. To keep the Internet open to new entrants and provide everyone the same opportunities, net neutrality remains crucial. Unfortunately, net neutrality often comes under pressure politically, and must be defended from those with ulterior motives.
The “open” Internet has also been the basis for the explosion of digital social innovation in our modern society. Its structure offers people opportunities to create things of real value through self-organization, sharing, and the production of knowledge and goods.
Not as isolated individuals, but as networked innovators in contact with peers around the world. Through international cooperation, digital tools have become sophisticated enough to create sustainable and scalable economic models. P2P Foundation keeps track of all these developments on their blog, which I highly recommend.
The term “sharing economy” often crops up when discussing these new models. But, beware, it is a treacherous term. “Sharing economy” is often used to describe the business model of companies like Facebook, Google, Airbnb, and Uber.
These companies subscribe to values that are fundamentally different from a “sharing economy”— values that make the term “capitalism platform” seem more appropriate. In the hands of companies like these, Internet users’ data is centrally stored and exploited.
To assess whether a new service is truly social and reciprocal in nature, you first must analyze its business model. Who is the owner? Is the technology open or closed? What is their policy on data? Is production process a fair one?
For sustainable economic transformation, it is better to avoid companies driven by shareholder-value, and back organizations driven by social values. That means that procurement processes should favor open and fair technologies and in this way you can maximize the power of social entrepreneurs, citizens, and p2p initiatives.
Care should always be taken when making policy, and in the development of innovative tools that not only large companies and research institutions are allowed to sit at the table. Small and medium sized companies should be actively involved in these processes.
In addition to economic development, digital social innovation has the potential to enhance technological literacy. A good example of this potential is The Smart Citizen Kit project.
The project allows people to measure environmental variables (e.g. air quality, noise levels, etc.) themselves, and to share the information they’ve gathered with others. This produces data (and visualizations of that data) that policymakers and scientists might find interesting.
More than that, participation in this project helps to increase awareness and understanding of measurement. By being involved in the generation of data, and by using open source hardware and software, people begin to understand that measurement is not an objective process. Such an insight is of great importance in an era where salvation is expected to appear in the form of big data.
To give meaning to data, we need algorithms to analyze it. And, the results of these analyses often provide arguments for policy.
But, what are algorithms? Who designs these models? And what is their worldview? Instead of simply focusing on opening up data, we must also focus on opening the computer models and algorithms used to analyze the data that informs the policies upholding our democracy.
Recommendation 2: Be open. Be fair.
The credo of the “Maker Movement” is: “If you can not open it, you do not own it” (Maker’s Bill of Rights). Yet, while products are becoming smarter, we seem to be getting dumber.
We can barely open up our smart devices without the risk of destroying them. The concept of “self repair” no longer exists. Take the car, for example. Until recently, a car was something you could repair yourself. All right, maybe not yourself, but surely the neighbor or the garage around the corner could take care of it for you.
These days, cars house mobile computers that rarely disclose their secrets.
Starting in 2016, all cars in Europe will be equipped with a black box, called an “e-call,” which will be able to independently contact emergency services. Europe has decided that the car is no longer private property by including a component that you can neither open nor remove, and that constantly keeps watch over you.
Unfortunately, this applies to many smart city solutions: you can not open them. Before governments make such technologies law in our society, they must be the subject of civil debate.
New technologies should abide by the values you uphold as a society. Providers should be assessed on questions like: Is the technology based on open hardware, open source, and open data? Is the idea of “Privacy by Design” taken into account? Do they make use of a distributed peer-to-peer model? And, last but not least: Is the production process fair and sustainable?
It should be a fundamental principle that a government only invests in open technology. Currently, when municipalities have to choose between two administrative systems, there is no semblance of an open market.
There are usually only two players in the game. You either choose this one, or the other; and—whatever you choose—you’re stuck with it for decades to come. We’d be much better off using systems based on open technology.
Additionally, we must ensure that publicly purchased technologies are fair technologies. We must realize the suffering that often hides behind many gadgets and technologies.
Think about the exploitation of children in the mines of the Congo, or the miserable working conditions in China. Not to mention the toll manufacturing process takes on the environment, and the gigantic mountain of e-waste it generates. It is our task to strive for fair technology and build on an economy that puts human rights in the center.
Recommendation 3: Work within the “Quadruple Helix” model with the citizen as a full partner.
In one of its reports, the OECD called for better cooperation between government, industry, and academia by bringing all three together in a so-called “Triple Helix.” Since then, all economic advisory bodies are based on the interactions of these three entities.
The main problem with this model is that society gets completely pushed aside. Here and there, one hears murmurs of the “Quadruple Helix”: the idea that citizens should be central to these decisions.
Yet, idle thoughts and whispers rarely result in substantial change. Social actors belong at the table, and should be involved in policy and decision making processes.
Another problem with this model is that innovation does not necessarily originate in large companies and universities. Digital social innovation also comes from the broad, inventive ecosystem of creators, hackers, and social entrepreneurs. In the search for disruptive solutions, we need innovative strategies based on those outside the “Triple Helix”.
Recommendation 4: I’m smart, too.
Not a day goes by without some sort of Smart City initiative cropping up. The Smart City movement is convinced that technology is the answer to big city problems. But technology is not neutral, and must always be questioned.
Without technological literacy, we can only consume, and never produce. Only read, never write. If systems are smart, but we remain “stupid,” can we really say that we’ve progressed?
The major goal of our time is to become smarter and more tech-savvy. This is true not only for the youth, but also for those who currently hold the controls: the people responsible for making policies.
Smart City technologies introduce a huge dependence on suppliers, and IT departments within the public sector often struggle with the vendor lock-in that can accompany administrative systems. Only the suppliers can read and update their proprietary software.
So, who will hold the key to the smart city? Administrators, politicians, IT departments? Or the shareholders of companies? The companies that would just as soon sell their SmartCity software to North Korea as they would sell it to the Netherlands?
The big question is this: do administrators and politicians understand what the consequences of the “smartness” they are injecting into public infrastructures? Take the great promise of “smart lighting,” a showpiece for the energy saving, sustainability agenda. With smart lighting, the light only turns on when someone walks past a sensor. For some people, this provides a sense of security.
Others find it a sinister thought that someone with bad intentions could be waiting for them in the darkness. Depending on the context, light can mean the difference between life or death.
At the border between Mexico and America, for instance, simply walking with a flashlight can mean being shot on sight. Smart lighting might save energy, but it introduces a social dilemma. Will we sacrifice safety for the sake of efficiency?
Let us ask ourselves these questions before we inject technology into the bloodstream of the city, and consider carefully the models and algorithms that will affect our reality.
Let’s make sure that those who are making decisions about the future of our cities have a real understanding of what technology means. Learn what code is, and the standards and values inherent to it. Only then can you make the right choices.
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