DELIBERAZIONE DEL DIRETTORE GENERALE - Regione FVG

transcript

SERVIZIO SANITARIO REGIONALEA Z I E N D A P E R I S E R V I Z I S A N I T A R I N . 1 “ T R I E S T I N A ”

TRIESTE

DELIBERAZIONE DEL DIRETTORE GENERALE

n. 193 del 24/05/2013

OGGETTO

CUP E95J13000030006 - Partecipazione al Progetto triennale (2013-2016) della Commissione Europea CIP-ICT-PSP-2012-6 denominato "SMARTCARE" per la sperimentazione dell'uso di nuove tecnologie nell'assistenza integrata domiciliare agli anziani. Sottoscrizione del Grant Agreement.

L'anno duemilatredici, il giorno ventiquattro del mese di maggio nella sede legale,

IL DIRETTORE GENERALE

Dott. Fabio SAMANI, nominato con Decreto del Presidente della Giunta Regionale n. 056/PRES dd. 23.03.2010, coadiuvato dal Direttore Amministrativo e dal

Direttore Sanitario, ha adottato la deliberazione che segue:

OGGETTO: CUP E95J13000030006 - Partecipazione al Progetto triennale (2013-2016) della Commissione Europea CIP-ICT-PSP-2012-6 denominato "SMARTCARE" per la sperimentazione dell'uso di nuove tecnologie nell'assistenza integrata domiciliare agli anziani. Sottoscrizione del Grant Agreement.

Premesso che rientra tra i compiti istituzionali dell’Azienda sviluppare innovazione e condurre ricerche atte ad ampliare la gamma e la qualità dei propri servizi istituzionali;

atteso che, tra i molteplici ambiti di attività, questa Azienda attribuisce all’assistenza integrata domiciliare agli anziani una valenza strategica e che in essa fin dall’avvio sono state inseriti elementi di innovazione anche con il ricorso a nuove tecnologie (ad es. il telesoccorso-telecontrollo), o a sperimentazioni allargate (ad es. il Progetto Europeo “Dreaming”) allo scopo di offrire crescente sicurezza e/o comfort agli assistiti e progresso nella qualità globale dei percorsi di cura;

rilevato che con decisione n. 1639/2006/CE del Parlamento e del Consiglio Europeo dd 24.10.2006 è stato istituito, per il periodo 1.1.2007 - 31.12.2013, un programma quadro di azione comunitaria nel settore della competitività e dell’innovazione, tra i cui obiettivi (art. 2, c. 2, lett. b) figura “il programma di sostegno alle politiche in materia di tecnologie dell’informazione e della comunicazione (TIC, in inglese ICT), all’interno del quale è stato previsto per il 2012 uno stanziamento comunitario pari a 24 milioni di euro per il tema del “ICT for health, ageing well and inclusion”;

che in data 3 febbraio 2012 è stata pubblicata in GUCE C 2012/C 30/03 la call for proposal relativa al programma “ICT PSP sixth call for proposals 2012 - Pilot Type A – Objective 3.1: Wide deployment of integrated care services” e che i temi progettuali proposti nella suindicata call for proposal sono risultati di particolare interesse per la A.S.S.1 in quanto pienamente coerenti con le positive esperienze maturate nell’ambito del progetto triennale “DREAMING”, recentemente concluso, di cui la A.S.S. 1 è stata partner con successo (delibera n. 208/2008);

richiamata la delibera n. 284/2012, da cui si evince che

a. la DCSISPS della Regione FVG con nota prot. 0006587/P del 04/04/2012 ha espresso parere favorevole alla partecipazione al Progetto SmartCare indicando l’Azienda Sanitaria n. 1 quale ente titolato a rappresentare la Regione, individuata quale soggetto capofila del Consorzio Europeo di partnership tra Enti pubblici e privati;

b. sono state avviate le attività propedeutiche alla preparazione dei documenti da inoltrare alla Commissione Europea per l’approvazione del progetto, avvalendosi della collaborazione del dott. Giulio Antonini della ASS 5 Bassa Friulana-Area Welfare quale Coordinatore del Progetto e del supporto della ditta HIM sa di Bruxelles la cui competenza e capacità collaborativa è stata ampiamente validata nel corso del Progetto Dreaming;

osservato che in forza di quanto sopra ed a seguito della pubblicazione della scheda di invito a presentare proposte e delle attività sopraccitate, la ASS 1 ha presentato alla Commissione Europea (CE) sulla materia sopraccitata la proposta di progetto denominato “SmartCare”, nell’ambito dei Progetti “Joining up ICT and service processes for quality integrated care in Europe” (trad : Combinare ICT e innovazione di processo per un’assistenza integrata di qualità in Europa), del valore complessivo di euro 16.000.000,00, cofinanziato al 50% da parte della CE ;

riassunti qui sinteticamente per pronta evidenza alcuni suoi elementi costitutivi fondamentali:

a) la composizione del Consorzio di Progetto, costituito da 42 partners:

N. Denominazione soggetto partecipante Nome breve Paese Costi totaliContributo

CE1 Azienda per i Servizi Sanitari n. 1 Triestina FVG – ASS1 Italia 3.177.209 1.588.6042 Land Kärnten KÄRNTEN Austria 84.350 42.1753 Gesundes Kinzigtal GmbH BAD-WÜR Germania 78.500 39.2504 Region Syddanmark RSD Danimarca 1.873.749 936.8745 Ida-Tallinna Keskhaigla AS ETCH Estonia 725.616 362.8086 Tallinna Linnavalitsus Sotsiaal- ja Tervishoiuamet TALLINN Estonia 200.328 100.1647 Fundació Ticsalut CATALONIA Spagna 92.540 46.2708 Servicio Aragonés de la Salud ARAGON Spagna 1.314.250 657.1259 Cruz Roja Española CRUZROJA Spagna 77.800 38.900

10 Asociación Centro de Excelencia Internacional en Investigación sobre Cronicidad EUSKADI Spagna 78.500 39.25011 Consejeria de Salud y Politica Social - Junta de Extremadura EXTREMADURA Spagna 31.450 15.72512 Fundación para el Desarrollo de la Ciencia y la Tecnología en Extremadura FUNDECYT Spagna 31.450 15.72513 Fundación para la Formación e Investigación Sanitarias de la Región de Murcia MURCIA Spagna 78.500 39.25014 Fundación de la Comunidad Valenciana Centro de Investigación Principe Felipe VALENCIA Spagna 79.122 39.56115 Etela-Karjalan Sosiaali-Ja Terveydenhuollon Kuntayhtyma EKSOTE Finlandia 1.193.273 596.63716 Anaptyxiaki Etaireia Dimou Trikkaion Anaptyxiaki Anonymi Etaireia Ota - E-Tikala AE CEN-GREECE Grecia 62.881 31.44017 Municipality of Palaio Faliro PALFALIRO Grecia 299.451 149.72618 Dimos Alimou - Municipality of Alimos ALIMOS Grecia 105.500 52.75019 Dimos Agios Dimitrios AGDIMITRIOS Grecia 184.225 92.11320 Anonimi Etairia Erevnas, Kainotomias kai Anaptiksis Tilematikis Texnologias - VIDAVO A.E. VIDAVO Grecia 260.350 130.17521 Hrvatska Udruga za Farmakoekonomiku Ekonomiku Zdravstva CROATIA Croazia 78.500 39.25022 Unità Locale Socio-Sanitaria N.2 Feltre VENETO Italia 84.350 42.17523 Stichting Smart Homes SMARTHOMES Olanda 294.279 147.14024 Gemeente Rotterdam ROTTERDAM Olanda 101.713 50.85625 Municipio da Amadora - CMA AMADORA Portogallo 38.250 19.12526 PT Comunicaçoes SA PTELECOM Portogallo 31.750 15.87527 Irmandade da Santa Casa da Misericordia da Amadora IPSS MISERICORDIA Portogallo 22.000 11.00028 Uppsala Läns Landsting CCU Svezia 1.054.724 527.36229 Preduzece za Informacione Tehnologije i Elektronsko Trgovanje Belit d.o.o. BELIT Serbia 805.334 402.66730 Zdravstveni centar "Studenica" Kraljevo STUDENICA Serbia 30.740 15.37031 Centar za socijalni rad Kraljevo KRALJEVO Serbia 30.740 15.37032 Regional Health and Social Care Board N-IRELAND UK 91.756 45.87833 NHS 24 (Scotland) SCOTLAND UK 1.714.279 857.14034 AGE Platform Europe AISBL AGE Belgio 78.500 39.25035 Assemblée des Régions d'Europe ARE Francia 104.500 52.25036 Continua Health Alliance Private Stichting CHA Belgio 76.885 38.44337 Eurocarers - Association Européenne travaillant pour les aidants non professionnels ASBL EUROCARERS Lussemburgo 20.000 10.00038 Stichting International Foundation for Integrated Care IFIC Olanda 173.140 86.57039 édération européenne des associations infirmières AISBL EFN Belgio 245.794 122.89740 Forum des Patiens Europeens ASBL - European Patients' Forum - FPE/EPF EPF Lussemburgo 77.824 38.91241 Empirica Gesellschaft Fuer Kommunikations - und Technologie Forschung MBH EMPIRICA Germania 707.500 353.75042 AOK Rheinland/Hamburg - Die Gesundheitskasse AOK Germania 108.400 54.200

16.000.000 8.000.000TOTALE

b) il contenuto del progetto: trattasi di ricerca sperimentale di durata triennale, con inclusione, in 10 Paesi, di oltre 8.500 soggetti anziani assistiti a domicilio, che andranno a costituire gruppi o aree di confronto, di “usual care” (assistenza usuale), e di intervento con dotazioni tecnologiche (collegamento in video conferenza, dispositivi per il monitoraggio al proprio domicilio in via telematica di parametri vitali - funzioni cardio-respiratorie e metaboliche- , di sicurezza - telefono cellulare salvavita dotato di sensori di caduta e di assenza prolungata di movimento- , di caratteristiche ambientali -sensori di fumo, acqua, ecc.); dal confronto tra i due gruppi si trarranno conclusioni metodologicamente corrette di impatto operativo;

constatato che l’impegno per la ASS 1 consiste pertanto in:

1. attività di coordinamento globale del Consorzio Europeo dei partner e gestione del budget globale di progetto (“funzione internazionale”), con redistribuzione dei contributi della CE pervenuti in ASS 1 a favore dei molteplici partner pubblici e privati dei vari Paesi Europei; la ASS 1 Triestina eserciterà pertanto attività di coordinamento con gestione dell’intero finanziamento, versando agli Enti beneficiari le quote di rispettiva pertinenza, come indicato nella documentazione di progetto;

2. attività di coordinamento di livello regionale (“funzione regionale”) tra le ASS/distretti del FVG, chiamate a contribuire – come da Progetto approvato dalle CE - con un proprio gruppo di partecipanti, da seguire secondo il protocollo concordato di studio, in maniera integrata con i Servizi Sociali Comunali ed Organizzazioni del terzo settore; alcune indicazioni a riguardo sono contenute nelle Linee di Gestione regionali e nei Piani Aziendali; allo stato è previsto che

dovranno essere seguite a domicilio per 24 mesi 200 persone fragili, prevalentemente (ma non esclusivamente) anziane, affette da patologie croniche cardiovascolari, respiratorie, diabete, mediante prestazioni integrate mediche (generaliste e specialistiche), infermieristiche e/o riabilitative, in integrazione con i servizi resi dai Servizi sociali, secondo profili/percorsi di assistenza personalizzati che, in un sottogruppo, saranno arricchiti delle nuove tecnologie e strumenti informatici specifici del Progetto SmartCare;

3. interventi locali diretti, in un proprio campione di residenti dei 4 distretti (ca 50-60 soggetti), in cui realizzare quanto indicato dal protocollo di studio (“funzione locale”);

considerato che la finalità generale esplicitata nel progetto si colloca in piena coerenza con l’attuale strategia aziendale, come illustrato nei documenti custoditi presso la Direzione Sanitaria, e riguarda tra i risultati attesi la riduzione dei ricoveri in ospedale ed in casa di riposo, il contrasto all’esclusione sociale e all’isolamento, oltre che il miglioramento della qualità di vita degli assistiti;

atteso che il personale della ASS 1 sarà impegnato ad ottimizzare le proprie risorse professionali, già disponibili o di nuova acquisizione, eventualmente acquisite per la sua realizzazione, quelle strumentali, i propri beni e servizi, le apparecchiature e le tecnologie, incluse quelle aggiuntive consentite dai contributi europei;

preso atto dell’avvenuta sottoscrizione in data 08.05.2013 del Grant Agreement, come risultante dalla nota Ares (2013)1044715 dd. 14.05.2013, e della conseguente erogazione da parte della Commissione Europea dell’acconto di pre-finanziamento pari ad € 4.266.666,00, da redistribuire tra i beneficiari aderenti al Progetto individuati nel Grant Agreement;

rilevato che le attività progettuali, nelle more della formalizzazione del relativo riconoscimento ed in considerazione della complessa organizzazione richiesta per il coordinamento dei 42 partners, hanno comunque avuto inizio in data 01.03.2013, come peraltro comunicato alla Commissione Europea con nota prot. 9935 dd. 27.02.2013, e che pertanto nei giorni dal 04.03.2013 al 08.03.2013 si è tenuto a Trieste il “Kick-off Meeting”,

ravvisata la necessità di procedere con il presente atto deliberativo alla formalizzazione del riconoscimento delle attività progettuali sopraccitate, che - come comunicato alla Commissione europea con nota prot. - hanno avuto inizio in data 01.03.2013, ed alle funzioni connesse attraverso la firma del Grant Agreement, a conclusione delle fasi negoziali con la CE;

rilevato altresì che gli oneri derivanti dalla conduzione del Progetto graveranno solo parzialmente sull’esercizio aziendale del corrente anno (2013), in quanto le attività di natura assistenziale avranno inizio (ad es. la centrale di gestione allarmi) negli ultimi mesi del corrente anno, per esplicarsi poi pienamente nei due anni successivi (come da protocollo di studio) e ritenuto pertanto di rinviare a successivi appositi provvedimenti gli adempimenti connessi all’esecuzione del Progetto;

constatata altresì, al fine di garantire l’efficacia delle azioni progettuali, la necessità di attribuire al dott. Andrea Di Lenarda, Responsabile della SC Centro Cardiovascolare, il ruolo di Responsabile del Progetto, in considerazione dell’esperienza e professionalità in materia di telemedicina e di assicurare continuità al ruolo di Coordinatore del Progetto fin qui svolto con successo dal dott. Giulio Antonini della ASS 5-Area Welfare di Comunità, nonché di riconoscere come appropriate e di valenza strategica aziendale le attività per lo sviluppo del progetto da parte del personale aziendale all’interno del proprio orario ordinario e straordinario di lavoro, ovvero sotto forma di missione, in via preliminare ed indicativa attualmente così catalogabili:

1. attività sanitarie dei professionisti dei 4 distretti, inclusi i MMG ed i Medici specialisti convenzionati, dei Dipartimenti e delle altre Strutture sanitarie sovradistrettuali, volte all’erogazione delle cure appropriate agli assistiti inseriti nella sperimentazione;

2. attività tecnico-amministrative di supporto svolte da responsabili/tecnici ed operatori delle varie articolazioni aziendali coinvolte, a vario titolo, nella conduzione della sperimentazione, indispensabili per soddisfare gli adempimenti richiesti dalla CE, tra cui la tenuta della contabilità e la puntuale emissione degli ordinativi di pagamento, la ricognizione delle risorse utilizzate (umane, strumentali, logistiche, ecc.), l’acquisizione ed il funzionamento delle apparecchiature e

degli strumenti informatici e di servizi quali quelli del Contact center-centrale gestione allarmi (attività attualmente in corso e pertanto estendibile ai nuovi soggetti utenti), ecc.;

atteso che è necessario autorizzare gli Uffici competenti aziendali, a seguito della firma del Grant Agreement, ad attivare le procedure appropriate per acquisire le figure professionali aggiuntive di supporto alla realizzazione del progetto, attualmente non disponibili nella forza organica aziendale, indicativamente per funzioni e competenze tecnico-amministrative (al fine di rispettare gli obblighi di rendicontazione sia ai Centri Europei partner che alla Commissione) e di monitoraggio delle attività sperimentali locali e regionali, che verranno più precisamente definiti in atti successivi;

preso atto che detto progetto è stato illustrato e condiviso in Collegio di Direzione nonché all’interno dell’Azienda con riunioni tra operatori e dirigenti dell’Azienda (iniziate in concomitanza del corso di formazione sull’ADI in data 11 ottobre 2012), così da porre le premesse per un suo compiuto esplicarsi grazie all’integrale ed integrato coinvolgimento di tutte le componenti aziendali, sia di parte sanitaria che tecnico-gestionale;

preso atto che il provvedimento è presentato dalla Direzione amministrativa, che ne attesta la regolarità tecnica, amministrativa e la legittimità e i cui uffici ne hanno curato l’istruzione e la redazione;

inteso il parere favorevole del Direttore Sanitario e del Direttore Amministrativo;

I l D i r e t t o r e G e n e r a l e

D e l i b e r a

per quanto esposto in narrativa:

a) di approvare la partecipazione dell’Azienda al Consorzio Europeo per la realizzazione del progetto sperimentale di ricerca multinazionale denominato SmartCare, come illustrato in narrativa e negli allegati, della durata di tre anni (2013-2016), del valore globale di € 16.000.000 nel triennio, co-finanziato al 50% dalla Commissione Europea per un importo pari ad euro 8.000.000, da impiegare in base alla modalità e con le finalità analiticamente descritte negli allegati alla presente deliberazione quali parti integranti e sostanziali (“Grant Agreement n. 325158” e Annex I – II – III – IV);

b) di prendere atto dell’avvenuta sottoscrizione, in data 08.05.2013 del Grant Agreement n. 325158, come risultante dalla nota Ares (2013)1044715 dd. 14.05.2013, e della conseguente approvazione della proposta progettuale da parte della Commissione Europea per l’intero Progetto, per un valore complessivo pari ed € 16.000.000,00, di cui il 50% pari ed € 8.000.000,00 finanziato dalla CE;

c) di prendere altresì atto dell’avvenuta erogazione da parte della Comunità europea dell’acconto di pre-finanziamento pari ad € 4.266.666,00, da redistribuire tra i beneficiari aderenti al Progetto individuati nel Grant Agreement;

d) di autorizzare l’avvio delle procedure tecnico-amministrative appropriate per dotare l’Azienda delle risorse umane e strumentali, dei beni e servizi necessari alla realizzazione del Progetto, da acquisire mediante l’adozione di appositi provvedimenti separati;

e) di individuare il Responsabile della SC Centro Cardiovascolare aziendale, dott. Andrea Di Lenarda, quale Responsabile del Progetto, in considerazione dell’esperienza e professionalità in materia di telemedicina ed al fine di garantire l’efficacia delle azioni progettuali;

f) di confermare il dott. Giulio Antonini quale Coordinatore di Progetto, dando atto che risultano già formalizzati tra ASS 1 e ASS 5, gli appositi provvedimenti per consentirgli il regolare svolgimento delle attività connesse alla funzione, inclusi viaggi e missioni, anche all’estero, ed ogni iniziativa richiesta dall’agenda dei lavori;

g) di autorizzare in coerenza l’avvio delle attività sociosanitarie, l’uso delle risorse aziendali e le

spese di spettanza aziendale ricomprese nel progetto, facendo salve le attività progettuali già svolte per l’organizzazione del “Kick-off Meeting”, tenutosi a Trieste nel periodo 04-08.03.2013, nelle more della formalizzazione del relativo riconoscimento ed in considerazione della complessa organizzazione richiesta per il coordinamento dei 42 partners, come peraltro comunicato alla Commissione Europea con nota prot. 9935 dd. 27.02.2013.

Il contributo del co-finanziamento, pari a € 8.000.000,00, sarà introitato al conto 610.290 “Contributi da altri enti” del bilancio aziendale in correlazione ai costi annualmente sostenuti.

Gli oneri derivanti dalla realizzazione del progetto graveranno secondo il principio di competenza economica sui competenti conti del bilancio in relazione alla tipologia dei costi sostenuti.

Il presente provvedimento diviene esecutivo, ai sensi dell’art. 4 della L.R. 21/92 come sostituito dall’art. 50 della L.R. 49/96, dalla data di pubblicazione all’Albo aziendale.

**************

Il Direttore Sanitario

dott.ssa Adele Maggiore

(Firmato elettronicamente)

Il Direttore Amministrativo

dott.ssa Cinzia Contento

Il Direttore Generale

dott. Fabio Samani

Allegati: 2

Grant agreement for: CIP-Pilot actions

Annex I - "Description of Work"Project acronym: SmartCareProject full title: " Joining up ICT and service processes for quality integrated care inEurope "Grant agreement no: 325158Version date: 2013-03-25

Table of Contents

Part A

A.1 Project summary ......................................................................................................................................3

A.2 List of beneficiaries ..................................................................................................................................4

A.3 Overall budget breakdown for the project ............................................................................................... 7

Workplan Tables

WT1 List of work packages ............................................................................................................................1

WT2 List of deliverables .................................................................................................................................2

WT3 Work package descriptions ................................................................................................................... 5

Work package 1......................................................................................................................................5

Work package 2......................................................................................................................................9

Work package 3....................................................................................................................................12

Work package 4....................................................................................................................................15

Work package 5....................................................................................................................................18

Work package 6....................................................................................................................................21

Work package 7....................................................................................................................................23

Work package 8....................................................................................................................................25

Work package 9....................................................................................................................................29

Work package 10..................................................................................................................................34

WT4 List of milestones .................................................................................................................................39

WT5 Tentative schedule of project reviews ................................................................................................. 40

WT6 Project effort by beneficiaries and work package ................................................................................41

A1:Project summary

325158 SmartCare - Part A - Page 3 of 8

Project Number 1 325158 Project Acronym 2 SmartCare

One form per project

General information

Project title 3 Joining up ICT and service processes for quality integrated care in Europe

Starting date 4 01/03/2013

Duration in months 5 36

Call (part) identifier 6 CIP-ICT-PSP-2012-6

Objective most relevant toyour topic 7

Free keywords 8Elderly people, European Regions, Social and HealthServices, monitoring, health, ehealth, chronic diseases

Abstract 9

Against the background of the European Innovation Partnership on Active & Healthy Ageing, SmartCare aimsto define a common set of standard functional specifications for an open ICT platform enabling the deliveryof integrated care to older European citizens. A total of 24 regions and their key stakeholders will define acomprehensive set of integration building blocks around the challenges of data-sharing, coordination andcommunication. Ten regions will then pilot integrated health & social services to combat a range of threats toindependent living commonly faced by older people while the other will prepare for early adoption. In a rigorousevaluation approach, the pilot will produce and document much needed evidence on the impact of integratedcare, developing a common framework suitable for other regions in Europe. Guidelines and specifications forprocuring, organising and implementing the service building blocks will be produced. The organisational andlegal ramifications of integrated care will be analysed to support long term sustainability and upscaling of theservices.SmartCare services will provide full support to cooperative delivery of care, integrated with self-care and acrossorganisational silos, including essential coordination tools such as shared data access, care pathway designand execution as well as real time communication support to care teams and multi-organisation access to homeplatforms. The services build on advanced ICT already deployed in the pilot regions including high penetrationsof telecare and telemonitoring home platforms. System integration will be based, whenever possible, on openstandards and multivendor interoperability will be strongly encouraged. The common services will allow efficientcooperative care delivery and empower all older people according to their mental faculties to take part ineffective management of their health, wellness, and chronic conditions and maintain their independence despiteincreasing frailty

A2:List of Beneficiaries

List of Beneficiaries

No Name Short name CountryProject entrymonth10

Project exitmonth

Nationaladministrationor a certifiedrepresentativeof a nationaladministration

1 AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA FVG - ASS1 Italy 1 36 YES

2 Land Kärnten KÄRNTEN Austria 1 36 YES

3 GESUNDES KINZIGTAL GMBH BAD-WÜR Germany 1 36 NO

4 REGION SYDDANMARK RSD Denmark 1 36 YES

5 IDA-TALLINNA KESKHAIGLA AS ETCH Estonia 1 36 YES

6 TALLINA SOTSIAAL-JA TERVISHOIUAMET-TALLINN SOCIALWELFARE AND HEALTH CARE BOARD TSTA TALLINN Estonia 1 36 NO

7 FUNDACIO TICSALUT CATALONIA Spain 1 36 NO

8 SERVICIO ARAGONES DE LA SALUD ARAGON Spain 1 36 YES

9 CRUZ ROJA ESPANOLA FUNDACION CRUZROJA Spain 1 36 NO

10 ASOCIACION CENTRO DE EXCELENCIA INTERNACIONAL ENINVESTIGACION SOBRE CRONICIDAD EUSKADI Spain 1 36 YES

11 CONSEJERIA DE SALUD Y POLITICA SOCIAL - JUNTA DEEXTREMADURA EXTREMADURA Spain 1 36 NO

12 FUNDACION FUNDECYT - PARQUE CIENTIFICO YTECNOLOGICO DE EXTREMADURA-FUNDECYT PCTEX FUNDECYT Spain 1 36 NO

13 FUNDACION PARA LA FORMACION E INVESTIGACIONSANITARIAS DE LA REGION DE MURCIA MURCIA Spain 1 36 NO

14 FUNDACION DE LA COMUNIDAD VALENCIANA CENTRO DEINVESTIGACION PRINCIPE FELIPE VALENCIA Spain 1 36 YES

15 ETELA-KARJALAN SOSIAALI- JA TERVEYDENHUOLLONKUNTAYHTYMA EKSOTE Finland 1 36 YES

Project exitmonth

16 ANAPTYXIAKI ETAIREIA DIMOU TRIKKAION ANAPTYXIAKIANONYMI ETAIREIA OTA - E-TRIKALA AE CEN-GREECE Greece 1 36 YES

17 MUNICIPALITY OF PALAIO FALIRO PALFALIRO Greece 1 36 YES

18 DIMOS ALIMOU-MUNICIPALITY OF ALIMOS ALIMOS Greece 1 36 NO

19 DIMOS AGIOS DIMITRIOS AGDIMITRIOS Greece 1 36 NO

20 Anonimi Etairia Erevnas, Kainotomias kai Anaptiksis TilematikisTexnologias - VIDAVO A.E. VIDAVO Greece 1 36 NO

21 HRVATSKA UDRUGA ZA FARMAKOEKONOMIKUI EKONOMIKUZDRAVSTVA CROATIA Croatia 1 36 NO

22 UNITA LOCALE SOCIO-SANITARIA N. 2 FELTRE VENETO Italy 1 36 NO

23 STICHTING SMART HOMES SMARTHOMES Netherlands 1 36 NO

24 GEMEENTE ROTTERDAM ROTTERDAM Netherlands 1 36 NO

25 MUNICIPIO DA AMADORA-CMA AMADORA Portugal 1 36 YES

26 PT COMUNICACOES SA PTELECOM Portugal 1 36 NO

27 IRMANDADE DA SANTA CASA DA MISERICORDIA DAAMADORA IPSS MISERICORDIA Portugal 1 36 NO

28 UPPSALA LANS LANDSTING CCU Sweden 1 36 YES

29 PREDUZECE ZA INFORMACIONE TEHNOLOGIJE IELEKTRONSKO TRGOVANJE BELIT DOO BELIT Serbia 1 36 NO

30 Zdravstveni centar "Studenica" Kraljevo STUDENICA Serbia 1 36 NO

31 CENTAR ZA SOCIJALNI RAD KRALJEVO-SOCIAL WORKCENTRE IN KRALJEVO CSRKV KRALJEVO Serbia 1 36 NO

32 REGIONAL HEALTH AND SOCIAL CARE BOARD N-IRELAND United Kingdom 1 36 YES

33 NHS 24 (SCOTLAND) SCOTLAND United Kingdom 1 36 YES

34 AGE PLATFORM EUROPE AISBL AGE Belgium 1 36 NO

Project exitmonth

35 ASSEMBLEE DES REGIONS D'EUROPE ASSOCIATION ARE France 1 36 NO

36 CONTINUA HEALTH ALLIANCE PRIVATE STICHTING CHA Belgium 1 36 NO

37 EUROCARERS ASSOCIATION EUROPEENE TRAVAILLANTPOUR LES AIDANTS NON PROFESSIONELS ASBL EUROCARERS Luxembourg 1 36 NO

38 STICHTING INTERNATIONAL FOUNDATION FOR INTEGRATEDCARE IFIC Netherlands 1 36 NO

39 FEDERATION EUROPEENNE DES ASSOCIATIONSINFIRMIERES AISBL EFN Belgium 1 36 NO

40 FORUM DES PATIENS EUROPEENS ASBL EUROPEANPATIENTS FORUM FPE EPF EPF Luxembourg 1 36 NO

41 EMPIRICA GESELLSCHAFT FUER KOMMUNIKATIONS- UNDTECHNOLOGIE FORSCHUNG MBH EMPIRICA Germany 1 36 NO

42 AOK RHEINLAND/HAMBURG - DIE GESUNDHEITSKASSE AOK Germany 1 36 NO

A3:Budget breakdown

One Form per Project

Indirect CostsParticipantnumber in

this project

Participantshort name

Personnelcosts

Subcontracting

Otherdirect costs Cost

model (a)Value

Total costsMax EU

ContributionRequested EUcontribution

1 FVG - ASS1 738,635.00 1,684,074.00 532,912.00 AIC 221,590.00 3,177,211.00 1,588,605.00 1,588,605.00

2 KÄRNTEN 49,500.00 0.00 20,000.00 SFR 14,850.00 84,350.00 42,175.00 42,175.00

3 BAD-WÜR 45,000.00 0.00 20,000.00 AIC 13,500.00 78,500.00 39,250.00 39,250.00

4 RSD 939,730.00 454,300.00 197,800.00 281,919.00 1,873,749.00 936,874.00 936,874.00

5 ETCH 363,875.00 24,445.00 228,133.00 AIC 109,163.00 725,616.00 362,808.00 362,808.00

6 TALLINN 101,175.00 48,800.00 20,000.00 SFR 30,352.00 200,327.00 100,163.00 100,163.00

7 CATALONIA 55,800.00 0.00 20,000.00 AIC 16,740.00 92,540.00 46,270.00 46,270.00

8 ARAGON 526,500.00 253,000.00 376,800.00 AIC 157,950.00 1,314,250.00 657,125.00 657,125.00

9 CRUZROJA 56,000.00 0.00 5,000.00 SFR 16,800.00 77,800.00 38,900.00 38,900.00

10 EUSKADI 45,000.00 0.00 20,000.00 13,500.00 78,500.00 39,250.00 39,250.00

11 EXTREMADURA 16,500.00 0.00 10,000.00 SFR 4,950.00 31,450.00 15,725.00 15,725.00

12 FUNDECYT 16,500.00 0.00 10,000.00 SFR 4,950.00 31,450.00 15,725.00 15,725.00

13 MURCIA 45,000.00 0.00 20,000.00 SFR 13,500.00 78,500.00 39,250.00 39,250.00

14 VALENCIA 35,234.00 27,000.00 6,318.00 SFR 10,570.00 79,122.00 39,561.00 39,561.00

15 EKSOTE 547,800.00 253,000.00 228,133.00 SFR 164,340.00 1,193,273.00 596,636.00 596,636.00

16 CEN-GREECE 32,985.00 0.00 20,000.00 SFR 9,895.00 62,880.00 31,440.00 31,440.00

17 PALFALIRO 110,250.00 0.00 156,127.00 33,075.00 299,452.00 149,726.00 149,726.00

18 ALIMOS 70,000.00 10,000.00 4,500.00 SFR 21,000.00 105,500.00 52,750.00 52,750.00

19 AGDIMITRIOS 110,250.00 36,400.00 4,501.00 SFR 33,075.00 184,226.00 92,113.00 92,113.00

20 VIDAVO 187,500.00 3,100.00 13,500.00 AIC 56,250.00 260,350.00 130,175.00 130,175.00

21 CROATIA 45,000.00 0.00 20,000.00 AIC 13,500.00 78,500.00 39,250.00 39,250.00

A3:Budget breakdown

Indirect CostsParticipantnumber in

this project

Participantshort name

Personnelcosts

Subcontracting

Otherdirect costs Cost

model (a)Value

Total costsMax EU

ContributionRequested EUcontribution

22 VENETO 49,500.00 0.00 20,000.00 14,850.00 84,350.00 42,175.00 42,175.00

23 SMARTHOMES 214,830.00 0.00 15,000.00 64,451.00 294,281.00 147,140.00 147,140.00

24 ROTTERDAM 62,856.00 0.00 20,000.00 18,857.00 101,713.00 50,856.00 50,856.00

25 AMADORA 22,500.00 0.00 9,000.00 SFR 6,750.00 38,250.00 19,125.00 19,125.00

26 PTELECOM 17,500.00 0.00 9,000.00 SFR 5,250.00 31,750.00 15,875.00 15,875.00

27 MISERICORDIA 10,000.00 0.00 9,000.00 SFR 3,000.00 22,000.00 11,000.00 11,000.00

28 CCU 216,381.00 649,362.00 124,067.00 64,914.00 1,054,724.00 527,362.00 527,362.00

29 BELIT 232,088.00 295,572.00 208,048.00 69,626.00 805,334.00 402,667.00 402,667.00

30 STUDENICA 19,800.00 0.00 5,000.00 AIC 5,940.00 30,740.00 15,370.00 15,370.00

31 KRALJEVO 19,800.00 0.00 5,000.00 AIC 5,940.00 30,740.00 15,370.00 15,370.00

32 N-IRELAND 55,197.00 0.00 20,000.00 SFR 16,559.00 91,756.00 45,878.00 45,878.00

33 SCOTLAND 840,488.00 244,845.00 376,800.00 AIC 252,146.00 1,714,279.00 857,139.00 857,139.00

34 AGE 58,500.00 0.00 20,000.00 AIC 0.00 78,500.00 39,250.00 39,250.00

35 ARE 65,000.00 0.00 20,000.00 SFR 19,500.00 104,500.00 52,250.00 52,250.00

36 CHA 51,450.00 0.00 10,001.00 AIC 15,435.00 76,886.00 38,443.00 38,443.00

37 EUROCARERS 0.00 0.00 20,000.00 SFR 0.00 20,000.00 10,000.00 10,000.00

38 IFIC 117,800.00 0.00 20,000.00 35,340.00 173,140.00 86,570.00 86,570.00

39 EFN 173,688.00 0.00 20,000.00 SFR 52,106.00 245,794.00 122,897.00 122,897.00

40 EPF 44,480.00 0.00 20,000.00 SFR 13,344.00 77,824.00 38,912.00 38,912.00

41 EMPIRICA 510,000.00 4,500.00 40,000.00 153,000.00 707,500.00 353,750.00 353,750.00

42 AOK 68,000.00 0.00 20,000.00 20,400.00 108,400.00 54,200.00 54,200.00

TOTAL 6,988,092.00 3,988,398.00 2,944,640.00 2,078,877.00 16,000,007.00 8,000,000.00 8,000,000.00(a) AIC : Actual indirect costs , SFR : Standard flat rate

1. Project number

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2. Project acronym

Use the project acronym as indicated in the submitted proposal. It cannot be changed, unless agreed during the negotiations.The same acronym should appear on each page of the grant agreement preparation documents to prevent errors duringits handling.

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10. The month at which the participant joined the consortium, month 1 marking the start date of the project, and allother start dates being relative to this start date.

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WorkplanTables

Project number

325158

Project title

SmartCare—Joining up ICT and service processes for quality integrated carein Europe

Call (part) identifier

CIP-ICT-PSP-2012-6

Funding scheme

CIP-Pilot actions

WT1List of work packages

325158 SmartCare - Workplan table - Page 1 of 42

LIST OF WORK PACKAGES (WP)

WPNumber 53 WP Title

Leadbeneficiarynumber 55

Person-months 56

Startmonth 57

Endmonth 58

WP 1 Requirements and use case definition 41 79.80 1 9

WP 2 Service Process Model 41 83.70 3 11

WP 3 Integration Infrastructure Architecture and ServiceSpecification 38 91.00 1 12

WP 4 System implementation and test 8 70.50 5 20

WP 5 Pilot Site Preparation 4 105.00 5 22

WP 6 Operation of 1st Wave Pilots 33 288.25 15 36

WP 7 Operation of 2nd Wave Pilots 28 299.25 23 36

WP 8 Pilot Evalution 4 119.40 1 36

WP 9 Exploitation support and dissemination 41 152.10 1 36

WP 10 Project management and performance monitoring 1 55.25 1 36

Total 1,344.25

WT2:List of Deliverables

List of Deliverables - to be submitted for review to EC

Delive-rableNumber61

Deliverable TitleWPnumber53

Lead benefi-ciary number

Estimatedindicativeperson-months

Nature 62

Dissemi-nation level63

Delivery date64

Requirementsfor SmartCarePathways andIntegrationInfrastructure

1 41 40.00 R PU 3

SmartCare Pilotlevel Pathwaysand IntegrationInfrastructure

1 41 39.80 R PU 9

D2.1 SmartCareService Model 2 41 83.70 O PU 11

D3.1Pilot levelServiceSpecification

3 38 43.00 D PU 5

D3.2The SmartCareServiceSpecification

3 38 48.00 O PU 12

D4.1SmartCareprototype testreport

4 1 25.00 O PU 8

D4.2The SmartCarePrototypeSystem

4 1 45.50 P PU 20

D5.1SmartCareOperationalPilots

5 1 105.00 O PU 22

D6.1SmartCareCommonSpecifications

6 1 144.00 R PU 30

D6.2Report onOperation of 1stWave Pilots

6 1 144.25 R PU 36

D7.1Report onOperation of 2ndWave Pilots

7 5 299.25 R PU 36

D8.1Evaluationframework forSmartCare

8 4 28.00 R PU 7

D8.2First interimprocessevaluation report

8 4 28.00 R PU 22

Nature 62

Delivery date64

D8.3Second interimprocessevaluation report

8 4 35.40 R PU 28

D8.4 SmartCare PilotOutcomes 8 4 28.00 R PU 36

First report ondisseminationand exploitationactivities

9 41 37.10 R PU 12

Interim report ondisseminationand exploitationactivities

9 41 39.00 R PU 24

D9.3 Guidelines fordeployment 9 41 38.00 R PU 36

Deploymentplans forSmartCarePathways andIntegrationInfrastructure

9 41 38.00 R PU 36

D10.1 SmartCareQuality Plan 10 1 7.00 R RE 2

D10.2TEthics andData ProtectionFramework

10 1 7.00 R PU 6

D10.3 Interim periodicprogress report 10 1 6.00 R PU 6

D10.4Project periodicprogress reportfor RP1

10 1 7.25 R PU 12

D10.6Project periodicprogress reportfor RP2

10 1 7.00 R PU 24

Project finalreport incl. PRfor RP3 andreport on thedistribution ofthe financialcontribution

10 1 7.00 R PU 36

Nature 62

Delivery date64

Total 1,344.25

WT3:Work package description

One form per Work Package

Work package number 53 WP1

Work package title Requirements and use case definition

Start month 1

End month 9

Lead beneficiary number 55 41

Objectives

- to ensure all relevant requirements relating to the specific characteristics of key user groups (older peopleand care professionals) are met to the fullest feasible extent in data sharing, coordination, real-time and patientcommunication building blocks- to capture, systematise and document for design the requirements of each service delivery organisation- to document legal and regulatory factors in pilot regions- to draw up use cases for HealthCare-Centred Pathways (V.1) (HCCP)- to draw up use cases for Social Care Centred Pathways (V.1) (SCCP)- to draw up use cases for HealthCare-Centred Pathways (V.2) (HCCP)- to draw up use cases for Social Care Centred Pathways (V.2) (SCCP)

Description of work and role of partners

Task T1.1 Requirements of SmartCare users (M1 - M2) - Lead: empiricaLiterature and partner data on non-functional user requirements are reviewed for completeness and synthesisedto support design. The approach is to identify requirements prevalent among key subgroups of users (olderpeople and care professionals)Information on requirements for SCCP and HCCP is collated and reviewed. User groups include older people,informal and voluntary carers, social service and healthcare staff. Samples of users are drawn and requirementsinvestigated using appropriate techniques.An appropriate number of interviews (n >14) will be carried out. Up to 3 focus groups will be organised at eachpilot site with older people, informal and voluntary carers, social service and healthcare staff.

Task T1.2 Organisational, staff and business requirements (M1 - M2) - Lead: empiricaThe business-related, organisational and technical requirements at each site are collected and analysed tosupport the use case development and work on Service Specification.2-3 fact finding interviews with decision makers and professionals are carried out at each site. Non-coretechnical components are assessed for their suitability and selected for inclusion into the service concept.A joint meeting of site partners and technical partners for each site is organized and outcomes of theassessment documented.

Task T1.3 Legal and regulatory requirements for SmartCare (M1 - M2) - Lead: RSDThe primary domains of legal and regulatory relevance to the planned services are determined. A commonresearch template for site / national level investigation is drawn up.Desk research is used to identify the principle source of information in the pilot regions / MS. This iscomplemented by fact-finding interviews with key knowledge-holders e.g. in national and local governmentbased on the common research template.

Task T1.4 Use cases for HealthCare-Centred Pathways (V.1) (M2 - M3) - Lead: RSDBased on service-related requirements, use cases for HealthCare-Centred Pathways (V.1) are drawn up. Theprocess of use case generation is creative, requiring the participation of experts with good knowledge of thespecific service domain.

User involvement is also often necessary and appropriate, as use case development focuses strongly onservice value output. Nevertheless the use case team also liaises with technical partners to ensure feasibility ismaintained.

Task T1.5 Use cases for Social Care Centred Pathways (V.1) (M2 - M3) - Lead: empiricaBased on service-related requirements, use cases for Social Care Centred Pathways (V.1) are drawn up. Theprocess of use case generation is creative, requiring the participation of experts with good knowledge of thespecific service domain.User involvement is also often necessary and appropriate, as use case development focuses strongly onservice value output. Nevertheless the use case team also liaises with technical partners to ensure feasibility ismaintained.

Task T1.6 Use cases for HealthCare-Centred Pathways (V.2) (M8 - M9) - Lead: RSDBased on service-related requirements, experience in service model creation and results of version oneprototype testing, the version one use case set for HealthCare-Centred Pathways (V.2) is reviewed forcompleteness and adequacy.Existing use cases revised where appropriate, new use cases added as needed and the full set finalised. Ameeting or a virtual meeting is arranged with the members of the Project Advisory Boards in which current pilotplans, in particular selected use cases, are presented and feedback sought

Task T1.7 Use cases for Social Care Centred Pathways (V.2) (M8 - M9) - Lead: empiricaBased on service-related requirements, experience in service model creation and results of version oneprototype testing, the version one use case set for Social Care Centred Pathways (V.2) is reviewed forcompleteness and adequacy.Existing use cases revised where appropriate, new use cases added as needed and the full set finalised. Ameeting or a virtual meeting is arranged with the members of the Project Advisory Boards in which current pilotplans, in particular selected use cases, are presented and feedback sought

Person-Months per Participant

Participant number 10 Participant short name 11 Person-months per participant

1 FVG - ASS1 4.00

2 KÄRNTEN 2.00

3 BAD-WÜR 2.00

4 RSD 5.00

5 ETCH 1.50

6 TALLINN 2.00

7 CATALONIA 2.00

8 ARAGON 4.00

9 CRUZROJA 1.00

10 EUSKADI 2.00

11 EXTREMADURA 1.00

12 FUNDECYT 1.00

13 MURCIA 2.00

14 VALENCIA 1.90

15 EKSOTE 3.00

16 CEN-GREECE 2.00

17 PALFALIRO 1.00

18 ALIMOS 0.50

19 AGDIMITRIOS 1.00

20 VIDAVO 1.50

21 CROATIA 2.00

22 VENETO 2.00

23 SMARTHOMES 1.00

24 ROTTERDAM 2.00

25 AMADORA 0.50

26 PTELECOM 0.50

27 MISERICORDIA 0.50

28 CCU 1.50

29 BELIT 1.00

30 STUDENICA 1.00

31 KRALJEVO 1.00

32 N-IRELAND 2.00

33 SCOTLAND 4.00

34 AGE 2.00

35 ARE 2.00

36 CHA 1.00

38 IFIC 2.00

39 EFN 2.00

40 EPF 1.00

41 EMPIRICA 8.40

42 AOK 2.00

Total 79.80

List of deliverables

Deliverable Title

Leadbenefi-ciarynumber

Nature 62

Dissemi-nationlevel 63

Delivery date 64

D1.1Requirements for SmartCarePathways and IntegrationInfrastructure

41 40.00 R PU 3

D1.2 SmartCare Pilot level Pathways andIntegration Infrastructure 41 39.80 R PU 9

Deliverable Title

Nature 62

Delivery date 64

Total 79.80

Description of deliverables

D1.1) Requirements for SmartCare Pathways and Integration Infrastructure: The document comprises a frozenversion of the Evolving Document SmartCare Guidelines with new section on Requirements for SmartCarePathways and Integration Infrastructure. The deliverable incorporates results from: Task 1.1, Task 1.2, Task 1.3,Task 1.4, Task 1.5 [month 3]

D1.2) SmartCare Pilot level Pathways and Integration Infrastructure: The document comprises a frozen versionof the Evolving Document SmartCare Guidelines with new section on SmartCare Pilot level Pathways andIntegration Infrastructure. The deliverable incorporates results from: Task 1.6, Task 1.7 [month 9]

Schedule of relevant Milestones

Milestonenumber 59 Milestone name

Deliverydate fromAnnex I 60

Comments

MS1 Issuing of the SmartCare pathways 41 3

Work package title Service Process Model

Start month 3

End month 11

Objectives

Objectives .o to develop Service Process Models for HealthCare-Centred Pathways (V.1)o to develop Service Process Models for Social Care Centred Pathways (V.1)o to develop Service Process Models for HealthCare-Centred Pathways (V.2)o to develop Service Process Models for Social Care Centred Pathways (V.2)o to develop an integrated set of service process definitionsApproach .The approach is to use an appropriate tool to define and model service processes in terms of actors, tasks anddocuments (data). This work is carried out in two iterations, followed by the integration of the approaches (SCCPand HCCP) provided there is confirmation that significant benefit can be achieved with further integration.The tool will be oriented to the capabilities of Map of Medicine and similar workflow "case builder" tools.The tool selected may be a dedicated process design environment but the choice is more likely to be of aflexible, open charting tool such as MS Visio.

Task T2.1 Service Process Models for HealthCare-Centred Pathways (V.1) (M3 - M4) - Lead: empiricaExisting services for HealthCare-Centred Pathways are investigated and process models built using anappropriate tool. Process models may cover activity in one or more of the types of organisation involved (health& social care, informal / voluntary).Service modelling may lead gaps to be identified between service provision and user needs. Any such gapsare addressed and processes modified as appropriate. Issues to be taken into user testing of v1 prototypes arenoted.

Task T2.2 Service Process Models for Social Care Centred Pathways (V.1) (M3 - M4) - Lead: IFICExisting services for Social Care Centred Pathways are investigated and process models built using anappropriate tool. Process models may cover activity in one or more of the types of organisation involved (health& social care, informal / voluntary).Service modelling may lead gaps to be identified between service provision and user needs. Any such gapsare addressed and processes modified as appropriate. Issues to be taken into user testing of v1 prototypes arenoted.

Task T2.3 Service Process Models for HealthCare-Centred Pathways (V.2) (M9 - M10) - Lead: empiricaBased on results from V1 prototype testing, process models built in V1 are reviewed for completeness andrevised as appropriate to create service models for HealthCare-Centred Pathways (V.2).V2 process models are to cover the full V2 set of use cases and activity in all the organisations involved inservice provision (health & social care, informal / voluntary). Feedback is sought from the Project AdvisoryBoards

Task T2.4 Service Process Models for Social Care Centred Pathways (V.2) (M9 - M10) - Lead: empiricaBased on results from V1 prototype testing, process models built in V1 are reviewed for completeness andrevised as appropriate to create service models for Social Care Centred Pathways (V.2).

V2 process models are to cover the full V2 set of use cases and activity in all the organisations involved inservice provision (health & social care, informal / voluntary). Feedback is sought from the Project AdvisoryBoards

Task T2.5 Definition of Service Model (M10 - M11) - Lead: empiricaThe process models from the service domains (SCCP and HCCP) are combined into a single Service ProcessModel. The full set of processes is reviewed for common and complementary information flows.Requirements for inter-organisational services to coordinate activity of informal and voluntary carers, socialservice staff and healthcare professionals etc. are identified.

1 FVG - ASS1 4.00

2 KÄRNTEN 2.00

3 BAD-WÜR 2.00

4 RSD 6.00

5 ETCH 1.50

6 TALLINN 2.00

7 CATALONIA 2.00

8 ARAGON 4.00

9 CRUZROJA 2.00

10 EUSKADI 2.00

11 EXTREMADURA 1.00

12 FUNDECYT 1.00

13 MURCIA 2.00

14 VALENCIA 1.90

15 EKSOTE 3.00

16 CEN-GREECE 2.00

17 PALFALIRO 1.00

18 ALIMOS 0.50

19 AGDIMITRIOS 1.00

20 VIDAVO 1.50

21 CROATIA 2.00

22 VENETO 2.00

23 SMARTHOMES 1.00

24 ROTTERDAM 2.00

25 AMADORA 1.00

26 PTELECOM 1.00

28 CCU 1.50

29 BELIT 1.00

30 STUDENICA 1.00

31 KRALJEVO 1.00

32 N-IRELAND 2.00

33 SCOTLAND 4.00

34 AGE 2.00

35 ARE 2.00

36 CHA 0.90

38 IFIC 2.00

39 EFN 2.00

40 EPF 1.00

41 EMPIRICA 8.90

42 AOK 2.00

Total 83.70

Deliverable Title

Nature 62

Delivery date 64

D2.1 SmartCare Service Model 41 83.70 O PU 11

Total 83.70

D2.1) SmartCare Service Model: The document comprises a frozen version of the Evolving DocumentSmartCare Guidelines with new section on SmartCare Service Model. The deliverable incorporates results from:Task 2.1, Task 2.2, Task 2.3, Task 2.4, Task 2.5 [month 11]

Comments

Work package title Integration Infrastructure Architecture and Service Specification

Start month 1

End month 12

Objectives

Objectives .o to catalogue legacy applications relevant to the provision of SmartCare serviceso to draft the SmartCare Architectureo to draw up specifications for Home Linked Services (V.1)o to draw up specifications for Organisational Cooperation Services (V.1)o to elaborate the SmartCare Architectureo to draw up specifications for Home Linked Services (V.2)o to draw up specifications for Organisational Cooperation Services (V.2)Approach .Specification is based on a dedicated architecture which is drafted in two iterations. Based on the architecture,specifications are drawn up for SCCP and HCCP, also in two iteration steps.

Task T3.1 Initial starting points in legacy technology (M1 - M2) - Lead: IFICOrganisations which are to participate in pilots are investigated and all relevant ICT applications and datastructures catalogued, including their interoperability characteristics.

Task T3.2 Initial SmartCare Integration Infrastructure Architecture (M3 - M4) - Lead: IFICBased on SOA techniques, an overall architecture is drafted to incorporate web-services, service platforms anddevice interconnection.The appropriate set of standards are identified for interfaces between components (esp. Continua).

Task T3.3 Home Linked Services (V.1) specification (M4 - M5) - Lead: empiricaBased on the set of Service Process Models, Home Linked Services (V.1) are specified using real-time andpatient communication building blocks. Depending on the issues identified for testing, a prototype or mock-upstrategy is selected for V.1 implementation.Home Linked Services (V.1) take into account messaging and information sharing requirements from the set ofService Process Models

Task T3.4 Organisational Cooperation Services (V.1) specification (M4 - M5) - Lead: IFICBased on the set of Service Process Models, Organisational Cooperation Services (V.1) are specified using datasharing and coordination building blocks. Depending on the issues identified for testing, a prototype or mock-upstrategy is selected for V.1 implementation.Organisational Cooperation Services (V.1) take into account messaging and information sharing requirementsfrom the set of Service Process Models

Task T3.5 Final SmartCare Integration Infrastructure Architecture (M10 - M11) - Lead: IFICThe overall architecture is extended and refined on the basis of results from V.1 work.The approach is reviewed for compatibility with the relevant standards to be applied (esp. Continua)

Task T3.6 Specification of Home Linked Services (V.2) (M11 - M12) - Lead: IFICBased on V.1 specifications and V.2 Service Process Models, Home Linked Services are specified to run onreal-time and patient communication building blocks.

Task T3.7 Specification of Organisational Cooperation Services (V.2) (M11 - M12) - Lead: IFICBased on V.1 specifications and V.2 Service Process Models, Organisational Cooperation Services are specifiedto run on data sharing and coordination building blocks.

1 FVG - ASS1 6.00

2 KÄRNTEN 2.00

3 BAD-WÜR 2.00

4 RSD 6.00

5 ETCH 2.00

6 TALLINN 3.00

7 CATALONIA 2.00

8 ARAGON 6.00

9 CRUZROJA 1.00

10 EUSKADI 2.00

11 EXTREMADURA 1.00

12 FUNDECYT 1.00

13 MURCIA 2.00

14 VALENCIA 1.80

15 EKSOTE 4.00

16 CEN-GREECE 2.00

17 PALFALIRO 1.00

18 ALIMOS 0.50

19 AGDIMITRIOS 1.00

20 VIDAVO 2.00

21 CROATIA 2.00

22 VENETO 2.00

23 SMARTHOMES 1.50

24 ROTTERDAM 2.00

25 AMADORA 1.50

26 PTELECOM 1.00

28 CCU 2.00

29 BELIT 2.00

30 STUDENICA 1.00

31 KRALJEVO 1.00

32 N-IRELAND 2.00

33 SCOTLAND 6.00

34 AGE 2.00

38 IFIC 8.00

39 EFN 2.00

41 EMPIRICA 4.20

42 AOK 2.00

Total 91.00

Deliverable Title

Nature 62

Delivery date 64

D3.1 Pilot level Service Specification 38 43.00 D PU 5

D3.2 The SmartCare Service Specification 38 48.00 O PU 12

Total 91.00

D3.1) Pilot level Service Specification: The document comprises a frozen version of the Evolving DocumentSmartCare Guidelines with new section on Pilot level Service Specification. The deliverable incorporates resultsfrom: Task 3.1, Task 3.2, Task 3.3, Task [month 5]

D3.2) The SmartCare Service Specification: The document comprises a frozen version of the EvolvingDocument SmartCare Guidelines with new section on The SmartCare Service Specification. The deliverableincorporates results from: Task 3.5, Task 3.6, Task 3.7 [month 12]

Comments

Work package title System implementation and test

Start month 5

End month 20

Objectives

Objectives .o to implement Home Linked Services (V.1)o to implement Organisational Cooperation Services (V.1)o to implement Prototype (V.1) ready for testing services and component interfaceso to subject the Prototype (V.1) to thorough testingo to acquire and deliver all hardware and software for 1st Wave Pilotso to test full system on 1st Wave Pilots siteso to implement Home Linked Services (V.2)o to implement Organisational Cooperation Services (V.2)o to implement Prototype (V.2) ready for testing services and component interfaceso to subject the Prototype (V.2) to thorough testingo to acquire and deliver all hardware and software for 2nd Wave Pilotso to test full system on 2nd Wave Pilots sitesApproachThe approach is to implement SCCP and HCCP in two iterations, followed by testing of services and componentinterfaces before delivery of the v.2 prototype to on-site testing ready for pilot operation.

Task T4.1 Implementation of Home Linked Services (V.1) (M5 - M6) - Lead: FVGASS1Based on the Service Specification, software modules and protocols for Home Linked Services (V.1) areimplemented to run on real-time and patient communication building blocks.Where the approach to prototyping is to simulate user dialogue, appropriate tools are used to create a userexperience around the issues to be tested.

Task T4.2 Implementation of Organisational Cooperation Services (V.1) (M5 - M6) - Lead: FVGASS1Based on the Service Specification, software modules and protocols for Organisational Cooperation Services(V.1) are implemented to run on data sharing and coordination building blocks.Where the approach to prototyping is to simulate user dialogue, appropriate tools are used to create a userexperience around the issues to be tested.

Task T4.3 Implementation of pilot prototype (V.1) (M6 - M7) - Lead: FVGASS1A set of platforms, devices and ICT components required are acquired against the procurement specification.Acquired and existing legacy components are modified as required to create a prototype system with thefunctionality required by the test plan.Implemented service components and protocols are installed on the prototype platform. Where the test planspecifies a simulation approach, the simulation environment is completed ready for testing with users.

Task T4.4 Testing of pilot prototype (V.1) (M7 - M8) - Lead: FVGASS1The implemented test prototype is subject to testing with users from the target groups and service provider staffwhere appropriate. Test protocols based on the defined use cases are drawn up. Sets of data are created foruse in testing.

Depending on the test plan and issues under test, tests may take place in the laboratory or in locations withfeatures similar to future use situations, and use cases are visualised, simulated or enacted in an implementedservice delivery environment.

Task T4.5 Implementation of building blocks for 1st Wave Pilots (M8 - M9) - Lead: FVGASS1All hardware required for the pilots according to the site plan is acquired, including platforms and devices to thespecified numbersThis task provides any dedicated systems required for a particular service. Network access and otherpreparatory work are located in the pilot site preparation task detailed below.

Task T4.6 Full on-site testing, 1st Wave Pilots (M9 - M12) - Lead: FVGASS1Home Linked and Organisational Cooperation Services are tested under realistic conditions. Test protocols aredrawn up based on service use cases. Tests are carried out with the help of selected users from each test pilotsiteOn-site testing is designed to reveal problems arising from the particular situation of equipment, the networksused and the organisational environment in which staff work to eliminate problems in the full pilot.

Task T4.7 Home Linked Services (V.2) implementation (M12 - M14) - Lead: FVGASS1Based on the Service Specification, all software modules and protocols for Home Linked Services (V.2) areimplemented to run on real-time and patient communication building blocks.Technical testing is carried out to ensure reliable operation prior to testing with users. Quality and reliabilityissues are addressed as they arise.

Task T4.8 Organisational Cooperation Services (V.2) implementation (M12 - M14) - Lead: FVGASS1Based on the Service Specification, all software modules and protocols for Organisational Cooperation Services(V.2) are implemented to run on data sharing and coordination building blocks.Technical testing is carried out to ensure reliable operation prior to testing with users. Quality and reliabilityissues are addressed as they arise.

Task T4.9 Implementation of final pilot prototype (test version) (M14 - M15) - Lead: FVGASS1Additional or alternative platforms, devices and other ICT components required are acquired and modified asrequired to create a fully functional prototype system conformant to V.2 specifications.Where V.1 testing was based on simulation techniques, all platforms etc. must be acquired at this point.

Task T4.10 Test of final test pilot prototype (M15 - M16) - Lead: FVGASS1Test protocols based on the defined use cases are drawn up. Sets of data are created for use in testing.The implemented test prototype is subject to laboratory based testing with users from the target groups andparticipation of service provider staff.Testing is organised around the final set of use cases for all services. The full use case is run through. End-userand staff input is simulated or generated automatically as appropriate. A report is prepared on test results

Task T4.11 Implementation of building blocks for 2nd Wave Pilots (M16 - M17) - Lead: FVGASS1All hardware required for the pilots according to the site plan is acquired, including platforms and devices to thespecified numbersThis task provides any dedicated systems required for a particular service. Network access and otherpreparatory work are located in the pilot site preparation task detailed below.

Task T4.12 Full on-site testing, 2nd Wave Pilots (M17 - M20) - Lead: FVGASS1Home Linked and Organisational Cooperation Services are tested under realistic conditions. Test protocols aredrawn up based on service use cases. Tests are carried out with the help of selected users from each test pilotsiteOn-site testing is designed to reveal problems arising from the particular situation of equipment, the networksused and the organisational environment in which staff work to eliminate problems in the full pilot.

1 FVG - ASS1 8.00

4 RSD 8.00

5 ETCH 21.00

6 TALLINN 2.00

8 ARAGON 8.00

15 EKSOTE 4.00

17 PALFALIRO 1.00

18 ALIMOS 0.50

19 AGDIMITRIOS 1.00

20 VIDAVO 3.00

23 SMARTHOMES 2.00

28 CCU 2.00

29 BELIT 2.00

33 SCOTLAND 8.00

Total 70.50

Deliverable Title

Nature 62

Delivery date 64

D4.1 SmartCare prototype test report 1 25.00 O PU 8

D4.2 The SmartCare Prototype System 1 45.50 P PU 20

Total 70.50

D4.1) SmartCare prototype test report: The document comprises a frozen version of the Evolving DocumentSmartCare Guidelines with new section on SmartCare prototype test report. The deliverable incorporates resultsfrom: Task 4.1, Task 4.2, Task 4.3, Task 4.4 [month 8]

D4.2) The SmartCare Prototype System: The deliverable consists of the SmartCare Prototype System iscomplete and ready for use. The deliverable incorporates results from: Task 4.5, Task 4.6, Task 4.7, Task 4.8,Task 4.9, Task 4.10, Task 4.11, Task 4.12 [month 20]

Comments

Work package title Pilot Site Preparation

Start month 5

End month 22

Objectives

Objectives .o to confirm the selection of 1st Wave Pilots and plan system and service introductiono to recruit the planned number and type of users to participate at 1st Wave Pilotso to ensure staff are empowered to carry out service provision operations at 1st Wave Pilotso to set up services at 1st Wave Pilotso to confirm the selection of 2nd Wave Pilots and plan system and service introductiono to recruit the planned number and type of users to participate at 2nd Wave Pilotso to ensure staff are empowered to carry out service provision operations at 2nd Wave Pilotso to set up services at 2nd Wave PilotsApproach .The selection of sites is confirmed and system and service introduction planned. Users are recruited toparticipate in the pilot at each site, staff are empowered to carry out service provision operations and servicesare set up at all pilots sites

Task T5.1 Operational planning of 1st Wave Pilots (M5 - M7) - Lead: FVGASS1The pilot plan is reviewed and the selection of services and number of users per service adjusted to currentrequirements and site circumstances. One site is selected for initial on-site testing.The introduction of services at each site is planned and a joint plan set up with all site contributor organisationsled by the pilot management organisation.

Task T5.2 Recruitment of patients and older persons for 1st Wave Pilots (M7 - M14) - Lead: FVGASS1The planned number of users with the specified demand for services is recruited to participate in the pilotWork on user recruitment must often begin well in advance of pilot operation. This is particularly the case ifthe evaluation plan specifies that users are to have specific characteristics in addition to simple willingness toparticipate in the pilot.

Task T5.3 Training of health service, social service and voluntary sector staff for 1st Wave Pilots (M10 - M12) -Lead: FVGASS1Staff users (informal and voluntary carers, social service staff and healthcare professionals) are instructed howto operate the new services and respond to events arising. For complex service procedures, instruction mayextend to a short training course.In the case of services or service components which are automatic in day to day provision, only IT staff need beinstructed in service / data maintenance issues and user support.

Task T5.4 Introduction of systems and services at 1st Wave Pilots (M13 - M14) - Lead: FVGASS1An installation team at each site schedules and carries out installations at the premises identified in the planningtask above.Users are instructed in how to use interfaces for client-facing services

Task T5.5 Operational planning of 2nd Wave Pilots (M13 - M15) - Lead: FVGASS1The pilot plan is reviewed and the selection of services and number of users per service adjusted to currentrequirements and site circumstances. One site is selected for initial on-site testing.

The introduction of services at each site is planned and a joint plan set up with all site contributor organisationsled by the pilot management organisation.

Task T5.6 Recruitment of patients and older persons for 2nd Wave Pilots (M15 - M22) - Lead: FVGASS1The planned number of users with the specified demand for services is recruited to participate in the pilotWork on user recruitment must often begin well in advance of pilot operation. This is particularly the case ifthe evaluation plan specifies that users are to have specific characteristics in addition to simple willingness toparticipate in the pilot.

Task T5.7 Training of health service, social service and voluntary sector staff for 2nd Wave Pilots (M18 - M20) -Lead: FVGASS1Staff users (informal and voluntary carers, social service staff and healthcare professionals) are instructed howto operate the new services and respond to events arising. For complex service procedures, instruction mayextend to a short training course.In the case of services or service components which are automatic in day to day provision, only IT staff need beinstructed in service / data maintenance issues and user support.

Task T5.8 Introduction of systems and services at 2nd Wave Pilots (M21 - M22) - Lead: FVGASS1An installation team at each site schedules and carries out installations at the premises identified in the planningtask above.Users are instructed in how to use interfaces for client-facing services

1 FVG - ASS1 8.00

4 RSD 8.00

5 ETCH 20.00

6 TALLINN 3.00

8 ARAGON 8.00

15 EKSOTE 8.00

17 PALFALIRO 2.50

18 ALIMOS 1.00

19 AGDIMITRIOS 2.50

20 VIDAVO 8.00

23 SMARTHOMES 4.00

28 CCU 4.00

29 BELIT 20.00

33 SCOTLAND 8.00

Total 105.00

Deliverable Title

Nature 62

Delivery date 64

D5.1 SmartCare Operational Pilots 1 105.00 O PU 22

Deliverable Title

Nature 62

Delivery date 64

Total 105.00

D5.1) SmartCare Operational Pilots: The SmartCare Pilots are complete and ready for test/operation. Thedeliverable incorporates results from: Task 5.1, Task 5.2, Task 5.3, Task 5.4, Task 5.5, Task 5.6, Task 5.7, Task5.8 [month 22]

Comments

Work package title Operation of 1st Wave Pilots

Start month 15

End month 36

Objectives

Objectives .o to maintain the operation of systems and services throughout the pilot at 1st Wave Pilotso to set up and provide help services to pilot users at 1st Wave Pilotso to provide rich and timely feedback from issues dealt with by 1st Wave Pilots to the following wave ofpilots/adoptersApproach .The operation of systems and services throughout the pilot is maintained. Help services to pilot users are set upand provided.

Description of WorkTask T6.1 Operation of 1st Wave Pilots (M15 - M36) - Lead: FVGASS1Operation of all services at each site is to be maintained at full quality.A team is set up by the pilot manager toprovide support and address maintenance and system operation problems which may occur during operation.The pilot operation team is led by the pilot site management organisation and supported by core team staff. Thistask is carried out at pilot site level only (except for coordination / overall report)

Task T6.2 Help desk provision for 1st Wave Pilots (M15 - M36) - Lead: FVGASS1A help service is set up and run to respond to problems faced by staff users and by clientsThis team is operational at each site, supported by the core team.

Task T6.3 Pioneer broadcasting of lessons learned (M15 - M36) - Lead: FVGASS11st Wave Pilots hold regular webinars and workshops to provide a forum for next-wave pilot / early adopterorganisations to learn from their pioneer peers.Between broadcast sessions, pilot managers of 1st Wave Pilots collate reports of issues met and addressedin pilot implementation and operational maintenance. The issue list is used as a basis for informing thoseresponsible for following waves of pilots in the project / early adopters.

1 FVG - ASS1 70.00

4 RSD 70.00

8 ARAGON 70.00

9 CRUZROJA 9.00

33 SCOTLAND 69.25

Total 288.25

Deliverable Title

Nature 62

Delivery date 64

D6.1 SmartCare Common Specifications 1 144.00 R PU 30

D6.2 Report on Operation of 1st WavePilots 1 144.25 R PU 36

Total 288.25

D6.1) SmartCare Common Specifications: The report builds on input from WP3-5 as well as WP7-9. [month 30]

D6.2) Report on Operation of 1st Wave Pilots: [month 36]

Comments

MS4 Installation of the 1st wave pilot sitescompleted 1 12

MS5 1st wave pilots fully operational 1 15

Work package title Operation of 2nd Wave Pilots

Start month 23

End month 36

Objectives

Objectives .o to maintain the operation of systems and services throughout the pilot at 2nd Wave Pilotso to set up and provide help services to pilot users at 2nd Wave Pilotso to provide rich and timely feedback from issues dealt with by 2nd Wave Pilots to the following wave ofpilots/adoptersApproach .The operation of systems and services throughout the pilot is maintained. Help services to pilot users are set upand provided.

Task T7.1 Operation of 2nd Wave Pilots (M23 - M36) - Lead: ETCHOperation of all services at each site is to be maintained at full quality.A team is set up by the pilot manager toprovide support and address maintenance and system operation problems which may occur during operation.The pilot operation team is led by the pilot site management organisation and supported by core team staff. Thistask is carried out at pilot site level only (except for coordination / overall report)

Task T7.2 Help desk provision for 2nd Wave Pilots (M23 - M36) - Lead: ETCHA help service is set up and run to respond to problems faced by staff users and by clientsThis team is operational at each site, supported by the core team.

Task T7.3 Pioneer broadcasting of lessons learned (M23 - M36) - Lead: ETCH2nd Wave Pilots hold regular webinars and workshops to provide a forum for next-wave pilot / early adopterorganisations to learn from their pioneer peers.Between broadcast sessions, pilot managers of 2nd Wave Pilots collate reports of issues met and addressedin pilot implementation and operational maintenance. The issue list is used as a basis for informing thoseresponsible for following waves of pilots in the project / early adopters.

5 ETCH 50.00

6 TALLINN 10.00

15 EKSOTE 50.00

17 PALFALIRO 20.00

18 ALIMOS 16.00

19 AGDIMITRIOS 20.00

20 VIDAVO 16.50

23 SMARTHOMES 22.15

28 CCU 25.00

29 BELIT 49.60

30 STUDENICA 10.00

31 KRALJEVO 10.00

Total 299.25

Deliverable Title

Nature 62

Delivery date 64

D7.1 Report on Operation of 2nd WavePilots 5 299.25 R PU 36

Total 299.25

D7.1) Report on Operation of 2nd Wave Pilots: The report covers the activities carried out during the operation of2nd Wave Pilots. The deliverable incorporates results from: Task 7.1, Task 7.2, Task 7.3 [month 36]

Comments

MS6 Installation of the 2nd wave pilot sitescompleted 5 17

MS7 2nd wave pilots fully operational 5 23

Work package title Pilot Evalution

Start month 1

End month 36

Objectives

Objectives .o to detail and finalise the methodology for pilot evaluation, to improve the current evidence base onimplementation barriers/facilitators and outcomes for/of integrated SmartCare services, to ensure that evaluationdata collection is carried out according to the common methodology across all pilot sites.o to carry out the evaluation baseline for 1st Wave Pilotso to carry out follow-up evaluation for 1st Wave Pilotso to carry out 2nd follow-up evaluation for 1st Wave Pilotso to carry out final evaluation for 1st Wave Pilotso to carry out the evaluation baseline for 2nd Wave Pilotso to carry out follow-up evaluation for 2nd Wave Pilotso to carry out final evaluation for 2nd Wave Pilotso to report on the results of all pilots according to common scientific standards and to feed evaluation results intoexploitation support activitiesApproach .Evaluation work will be organised in three main phases: (a) start-up scoping and preparatory work, (b) detailedevaluation specification, planning and methods development and (c) implementation and reporting.Initial planning will start early to align with and as appropriate, influence work on user requirements and ServiceSpecification. Based on MAST, the methodology will be finalised once details of the services and the needs ofimportant stakeholders/roles have emerged.Data collection across 1st wave pilots and 2nd wave pilots will be organised according to a stepped wedgedesign involving multiple measurement points. Functioning and impacts of the services will be evaluated fromthe point of view of all important stakeholders, for which appropriate methods and indicators will be defined.For key user groups, a three-stage data collection approach (baseline, interim and final) will be consideredwhere this is appropriate to the service logic that is being piloted.

Task T8.1 Evaluation framework and planning (M1 - M7) - Lead: RSDThe evaluation will start with the elaboration of a minimum dataset and a baseline measure prior to anyimplementation (as a part of the stepped wedge design).The detailed evaluation approach is developed on the basis of the outline in the proposal. Effectiveness andoptions for realising experimental designs are reviewed taking into account project timing, resources andemerging Pathways and Integration Infrastructure.The catalogue of intended and possible unintended pilot outcomes is completed and measures developed orselected from available metrics.Criteria and procedures are defined for building control groups where required e.g. based on individual orcluster randomisation. Requirements for baseline data are further clarified. A minimum data set to be collatedacross all sites is defined as well as additional data to be collated at particular sites to reflect particular localcircumstances.The status quo is described in terms of maturity of services/technology and country readiness assessmentcorresponding to the contents of the minimum data set. A scientific protocol is defined.Instruments are drafted or selected from available instruments, including questionnaires and loggingspecifications as appropriate, and made ready for use in baseline, mid-term and/or final data collection. The final

methodology is confirmed by the ISB and members are trained in its application. A central evaluation data baseis set up.

Task T8.2 Evaluation baseline for 1st Wave Pilots (M15 - M16) - Lead: empiricaPrior to commencement of operation of each pilot, and in particular prior to introduction of the Pathways andIntegration Infrastructure, the defined baseline data are gathered by the appropriate means.Appropriate means are those defined in the evaluation plan and may be standardised instruments,questionnaires, interviews, observations, data from logging software, etc. Local evaluation databases are set upand maintained

Task T8.3 Follow-up evaluation for 1st Wave Pilots (M21 - M22) - Lead: RSDAt a point in time after commencement of operation defined in the evaluation methodology, data on earlyoutcomes and intermediate effects are gathered by the means, metrics and instruments defined in the evaluationmethodology.Feedback from users and staff is used to inform pilot maintenance activity. Where the experimental designpermits, services may be improved in a formative process. In other cases it is required that interventioncharacteristics stay stable for a valid summative result.

Task T8.4 2nd follow-up evaluation for 1st Wave Pilots (M27 - M28) - Lead: RSDAt a point in time after commencement of operation defined in the evaluation methodology, data on intermediateoutcomes and effects are gathered by the means, metrics and instruments defined in the evaluationmethodologyFeedback from users and staff is used to inform pilot maintenance activity. Where the experimental designpermits, services may be improved in a formative process. In other cases it is required that interventioncharacteristics stay stable for a valid summative result.

Task T8.5 Final evaluation for 1st Wave Pilots (M33 - M34) - Lead: RSDAt a defined point in time towards the end of pilot operation, data are gathered by the appropriate means -questionnaire, interview, observation or data from logging software - as defined in the evaluation methodologyQualitative feedback from users and staff is documented ready for compilation of the evaluation report.

Task T8.6 Evaluation baseline for 2nd Wave Pilots (M23 - M24) - Lead: empiricaPrior to commencement of operation of each pilot, and in particular prior to introduction of the Pathways andIntegration Infrastructure, the defined baseline data are gathered by the appropriate means.Appropriate means are those defined in the evaluation plan and may be standardised instruments,questionnaires, interviews, observations, data from logging software, etc. Local evaluation databases are set upand maintained

Task T8.7 Follow-up evaluation for 2nd Wave Pilots (M27 - M28) - Lead: RSDAt a point in time after commencement of operation defined in the evaluation methodology, data on earlyoutcomes and intermediate effects are gathered by the means, metrics and instruments defined in the evaluationmethodology.Feedback from users and staff is used to inform pilot maintenance activity. Where the experimental designpermits, services may be improved in a formative process. In other cases it is required that interventioncharacteristics stay stable for a valid summative result.

Task T8.8 Final evaluation for 2nd Wave Pilots (M33 - M34) - Lead: RSDAt a defined point in time towards the end of pilot operation, data are gathered by the appropriate means -questionnaire, interview, observation or data from logging software - as defined in the evaluation methodologyQualitative feedback from users and staff is documented ready for compilation of the evaluation report.

Task T8.9 Analysis and reporting (M35 - M36) - Lead: RSDThe results from each data collection phase are combined to analyse impact on outcomes as defined in theevaluation criteria for the project. A transferability assessment will be carried out. All results are compiled into areport.The report details which criteria were met, and outlines further improvements to service provision to take intoaccount in further uptake / roll-out. A scientific dissemination plan is agreed by the ISB and fed into WP9. Jointscientific papers are produced respectively.

1 FVG - ASS1 7.30

4 RSD 42.00

5 ETCH 2.50

6 TALLINN 2.50

8 ARAGON 8.00

9 CRUZROJA 1.00

15 EKSOTE 5.00

17 PALFALIRO 2.00

18 ALIMOS 1.00

19 AGDIMITRIOS 2.00

20 VIDAVO 5.00

23 SMARTHOMES 1.00

28 CCU 2.50

29 BELIT 5.00

30 STUDENICA 2.00

31 KRALJEVO 2.00

33 SCOTLAND 8.00

34 AGE 1.00

39 EFN 5.00

41 EMPIRICA 12.60

42 AOK 2.00

Total 119.40

Deliverable Title

Nature 62

Delivery date 64

D8.1 Evaluation framework for SmartCare 4 28.00 R PU 7

D8.2 First interim process evaluation report 4 28.00 R PU 22

D8.3 Second interim process evaluationreport 4 35.40 R PU 28

D8.4 SmartCare Pilot Outcomes 4 28.00 R PU 36

Total 119.40

D8.1) Evaluation framework for SmartCare: The document comprises a frozen version of the Evolving DocumentSmartCare Guidelines with new section on Evaluation framework for SmartCare. The deliverable incorporatesresults from: Task 8.1. A preliminary draft will be produced in M3 including a minimum dataset and a baselinemeasurement. [month 7]

D8.2) First interim process evaluation report: The report includes first interim results from the respective pilots.The deliverable incorporates results from: Task 8.2, Task 8.3, Task 8.6 [month 22]

D8.3) Second interim process evaluation report: The report includes further interim results from the respectivepilots. The deliverable incorporates results from: Task 8.4, Task 8.7 [month 28]

D8.4) SmartCare Pilot Outcomes: Report on the evaluation results covering the outcomes of the SmartCarepilots. The deliverable incorporates results from: Task 8.5, Task 8.8, Task 8.9 [month 36]

Comments

MS3 Evaluation framework agreed 4 7

MS10 Final trial evaluation 4 36

Work package title Exploitation support and dissemination

Start month 1

End month 36

Objectives

to guide the project towards successful joint exploitation of resultsto define appropriate viability or business models for socal care, healthcare, integration and componentprovidersto set up networking activities between the pilot sitesto constitute the Project Advisory Boards for the project.to organise meetings of the Project Advisory Boardsto prepare materials to support external disseminationto inform public authorities, healthcare and social care providers, local and regional government about theprojectto establish and maintain an attractive and informative web presence for the project and to engage with leadingonline mediato finalise guidelines for Pathways and Integration Infrastructure procurement and uptaketo set up regional / national deployment plans for ?SystemsAndServicesto organise and carry out a conference covering the domain of the projectApproach .Exploitation plans for the services are generated using information on the legal, financial and policy environmentin European regions other than the pilot regions. An attractive and informative web presence for the project isestablished and maintained.Guidelines for SmartCare Service Systems are drawn up, and business models defined for each type of marketplayer involved.

Task T9.1 Exploitation planning (M5 - M36) - Lead: empiricaThe methodology for exploitation planning, extended uptake and business case modelling is further detailed andagreed with all partners covering both expanded use of project outcomes by partners, engagement of furtherproviders and exploitation into further regions and countries.Deployment and explotation plans cover needs, conditions for service provision, market structure (bothend-users and intermediaries), investment, provision schemes and revenue sources.Cost-benefit analysis is used to model business cases and to estimate ROI and overall socio-economic return.

Task T9.2 Service viability assessment for socal care, healthcare, integration and component providers (M5 -M12) - Lead: empiricaInitial service configurations are reviewed for completeness in terms of economic parameters and assessedfor economic and service viability from the point of view of socal care, healthcare, integration and componentproviders. As appropriate, configurations may be ranked along criteria such as value delivered, service quality orefficiency.Demand is elaborated, revenues identified, costs and benefits listed and a case made for investment inSmartCare Service provision. Viability information is delivered early to impact on use cases and service models.Detailed analysis is focussed on top ranked services, where appropriate.

Task T9.3 Pilot Site networking (M1 - M36) - Lead: empirica

Pilot site managers exchange proposals for dissemination and exploitation at local and regional level. An actionplan is developed.Actions for dissemination in line with the networking action plan are carried out and the impact reported. Actionsaimed at exploitation are also carried out in line with the plan.

Task T9.4 Project Advisory Boards constitution (M1 - M3) - Lead: empiricaThe Project Advisory Boards are formally constituted including review of representation of all necessary areas ofexpertise / interests. A briefing document is developed setting out a detailed work schedule for the entire projectduration.The briefing specifies work tasks and co-operation modes. Board members are expected to comment on projectplans and interim project results. Special responsibilities make be taken on for particular areas of project work,as appropriate.

Task T9.5 Project Advisory Boards meetings (M4 - M36) - Lead: empiricaA series of meetings is scheduled well in advance of the first intended meeting. For each meeting, an agenda isdrafted and provided to members for comment.A chair for the meeting is selected. The project participants nominated to take part in the Project AdvisoryBoards meetings ensure that minutes are drafted for participants.

Task T9.6 External dissemination preparation (M1 - M3) - Lead: empiricaA project communication plan is developed and jointly agreed by all consortium members in line with ConsortiumAgreement provisions, as appropriate. Materials are prepared to support dissemination activities including PPTpresentation and project brochure.A list of target organisations and individuals is drawn up at national level. Groups of target organisations aredefined and it is ensured that each group is properly reflected in the communication plan.

Task T9.7 External dissemination activities (M4 - M36) - Lead: empiricaProject outcomes are communicated to the wider public, public authorities, healthcare and social care providers,local and regional government. Alongside the website, measures include production of project videos, informinginterested parties, writing of publications and presentation at relevant conferences.public authorities, healthcare and social care providers, local and regional government are contacted at nationallevel and informed about the project. In year 2, a series of workshops are organised at regional or national level.At European level, external dissemination activities will target the work of the Action group B3 on “IntegratedCare”, set up in the framework of the European Innovation Partnership. The project will disseminate its outcomesand lessons learnt as well as learn from discussions in this working group.

Task T9.8 Project web presence and online media management (M5 - M36) - Lead: FVGASS1A URL is reserved and a layout agreed including PI, content structure and navigation. Key documentsare provided for download with project summary and partner profiles. Good usability is to be ensured andaccessibility to meet W3C WAI WCAG2.0 (Level AA).Publication policy for the website includes that public deliverables, publications, presentations and pressreleases are uploaded immediately on release. Project summary and other documents on the project and itsactivities are kept up to date.A subdomain is established private to the project on the same or an appropriate, different server. The privatedomain is maintained by WP leaders supported by all participants.Operational procedures for ongoing project communication though selected social online media such as Twitter,Facebook, LinkedIn and others are agreed and maintained.

Task T9.9 Guidelines for Pathways and Integration Infrastructure procurement and uptake (M35 - M36) - Lead:FVGASS1Outcomes of work tasks already extensively documented in the Evolving Document SmartCare Guidelines arereviewed , synthesised into a coherent single source of operational information and edited for use by externalparties.The draft table of contents is reviewed within the consortium. Service models and results from the pilot arereviewed for requirements to guide service providers through service introduction.Initial content is checked for scope with 3-4 representatives of the target group. Taking comments into account,content for the Guidelines is completed, subject to quality control and published

Task T9.10 Deployment planning (M2 - M36) - Lead: FVGASS1

Results from exploitation planning and from evaluation are taken into account in reviewing uptake anddeployment plans, covering both expanded use of project outcomes by partners, engagement of furtherproviders and exploitation into further regions and countries.Deployment and explotation plans cover needs, conditions for service provision, market structure (bothend-users and intermediaries), investment, provision schemes and revenue sources.The cost-benefit analysis is reviewed in which business cases are modelled as are the estimates of ROI andoverall socio-economic return.

Task T9.11 SmartCare conference (M35 - M36) - Lead: FVGASS1A list of contents is drawn up. Speakers are identified and approached. The date and general location is fixed.The conference is announced with title on the project web-site.A conference venue is identified. A press announcement is made. The conference is described on the projectweb-site.The conference is carried out. Proceedings are published.

1 FVG - ASS1 13.00

2 KÄRNTEN 2.00

3 BAD-WÜR 2.00

4 RSD 8.00

5 ETCH 2.00

6 TALLINN 2.00

7 CATALONIA 2.00

8 ARAGON 6.00

9 CRUZROJA 1.00

10 EUSKADI 2.00

11 EXTREMADURA 1.00

12 FUNDECYT 1.00

13 MURCIA 2.00

14 VALENCIA 1.00

15 EKSOTE 4.00

16 CEN-GREECE 2.00

17 PALFALIRO 2.00

19 AGDIMITRIOS 2.00

21 CROATIA 2.00

22 VENETO 2.00

23 SMARTHOMES 0.50

24 ROTTERDAM 2.00

25 AMADORA 1.00

26 PTELECOM 1.00

28 CCU 2.00

29 BELIT 4.00

30 STUDENICA 0.50

31 KRALJEVO 0.50

32 N-IRELAND 2.00

33 SCOTLAND 6.00

34 AGE 3.70

35 ARE 8.00

36 CHA 2.00

38 IFIC 6.00

39 EFN 6.00

40 EPF 5.00

41 EMPIRICA 40.90

42 AOK 2.00

Total 152.10

Deliverable Title

Nature 62

Delivery date 64

D9.1 First report on dissemination andexploitation activities 41 37.10 R PU 12

D9.2 Interim report on dissemination andexploitation activities 41 39.00 R PU 24

D9.3 Guidelines for deployment 41 38.00 R PU 36

D9.4Deployment plans for SmartCarePathways and IntegrationInfrastructure

41 38.00 R PU 36

Total 152.10

D9.1) First report on dissemination and exploitation activities: The report covers progress in dissemination andexploitation activities over the first period. The deliverable incorporates results from: Task 9.1, Task 9.6, Task 9.8[month 12]

D9.2) Interim report on dissemination and exploitation activities: The report covers progress in disseminationand exploitation activities over the second period. The deliverable incorporates results from: Task 9.3, Task 9.7[month 24]

D9.3) Guidelines for deployment: Final version of Evolving Document SmartCare Guidelines for Pathways andIntegration Infrastructure procurement and uptake. The deliverable incorporates results from: Task 9.2, Task 9.4,Task 9.5, Task 9.9 [month 36]

D9.4) Deployment plans for SmartCare Pathways and Integration Infrastructure: The report presents the finalversion of plans for deployment of SmartCare Pathways and Integration Infrastructure as well as reporting ondissemination activities in the final period of the project. The deliverable incorporates results from: Task 9.10,Task 9.11 [month 36]

Comments

MS8 Publication of the procurement guidelines 41 36

MS9 Completion of the deployment plans forparticipating regions 41 36

MS11 Final Conference 1 36

Work package title Project management and performance monitoring

Start month 1

End month 36

Objectives

o to ensure smooth operation of all aspects of the project and proper implementation of the ConsortiumAgreemento to finalise management plans including quality planso to comply with provisions of the Contract and Consortium Agreement in respect of reporting including financialreportingo to set up internal communications and ensure timely organisation and performance of consortium and PCCmeetingso to perform planning, internal progress control and technical evaluation of project progresso to ensure project activities and service content conform to ethics and data protection principleso to ensure project work achieves the highest quality measured against defined objectiveso to report performance indicators for Year 1o to report performance indicators for Year 2o to report performance indicators for Year 3Approach .Proper operation of all aspects of the project is to be assured by the management, as is compliance withprovisions of the Contract and Consortium Agreement. Internal communications including meetings, belongs tomanagement.Management also covers planning, internal progress control and technical evaluation of project progress.

Task T10.1 Consortium coordination (M1 - M36) - Lead: FVGASS1All duties imposed by the EC Contract and by the Consortium Agreement are to be fulfilled with support by othermanagers and WPL. from timely quality-assured deliverable submission to proper distribution of payment.The Consortium Agreement is finalised and brought into force prior to Contract signature. Throughout theproject, the Project Coordinator is to assure adherence to agreed upon rules for decision-making and conflictresolution processes.

Task T10.2 Management planning (M1 - M2) - Lead: FVGASS1The project plan is reviewed and adapted to emerging information from initial project work. Timing of first yearactivities are reviewed in detail and adjustments made where necessary. Project planning documents are madeavailable on the project cloud repository for all partners.The project management team updates the preliminary quality management plan, in close consultation with theparticipating pilot regions. The project quality plan is to identify critical project deliverables requiring particularquality considerations and formalize the quality management responsibilities and procedures (review templates,list of reviewers, quality indicators) in the project.

Task T10.3 Administrative management (M1 - M36) - Lead: FVGASS1Resource planning is to be kept up to date. Financial data is to be collected from partners and financialstatements forwarded to the Commission. Progress reports are drawn up with input from partners.Payments due to participants are calculated based on Contract and Consortium Agreement. EC queries onfinancial statements are passed on to participants in line with the provisions of the Consortium Agreement

Task T10.4 Internal communication incl. infrastructure (M1 - M36) - Lead: FVGASS1

Document formats are agreed and internal web site set up. A meeting schedule is drawn up with WP leadersand locations / mode defined.Appropriate tools for collaboration over and above web-site, email and telephone conferencing are identified,selected and implemented.

Task T10.5 Technical Management (M1 - M36) - Lead: FVGASS1Overall project risk management is put into place and execution supervised. Should a risk situation be detected,appropriate steps are undertaken in mitigation, if necessary involving the PCC and informing the EC POEnsuring tasks have the necessary input in due time and rescheduling timing as necessary are essential tasks.In this, technical management works with the leaders of work-packages to ensure the project continues toachieve objectives and milestones. A subtask within this task will be dedicated to the check of the compliance ofthe platform that the pilot sites intend to procure with the common functional specifications and the adoption bypilot sites of open rather than proprietary systems

Task T10.6 Ethics & data protection management (M1 - M36) - Lead: FVGASS1This task is to oversee conformance with ethical principles and DP legislation. A framework is drawn up to coverboth domains, covering issues such as consent forms, submissions to the respective ethics committee at eachsite etc.The ethics & DP manager reports regularly to consortium meetings on the status of the work and on activitiesthat need to be undertaken by the partners. Outcomes of ethics management are reported in the framework ofexploitation deliverables.

Task T10.7 Quality assurance (M1 - M36) - Lead: FVGASS1Defined project deliverables are the central focus of quality assurance within the project. The measurableoutcomes as specified in the project plan serve as key benchmarks for this task.Deliverables are submitted for review and feedback to selected participants not involved in the deliverableconcerned, or where appropriate, to an advisory board or external expert.

Task T10.8 Performance monitoring (Year 1 ) (M11 - M12) - Lead: FVGASS1Data on each performance indicator are gathered through formalised reporting by pilot managers. This reportingis based on a template developed as part of the evaluation toolkit.Depending on the indicator concerned, the means of measurement may include survey or other technique,integrated in the evaluation approach. Results are reported to the EC.

1 FVG - ASS1 11.25

2 KÄRNTEN 1.00

3 BAD-WÜR 1.00

4 RSD 3.00

5 ETCH 2.00

6 TALLINN 2.00

7 CATALONIA 1.00

8 ARAGON 3.00

9 CRUZROJA 1.00

10 EUSKADI 1.00

11 EXTREMADURA 1.00

12 FUNDECYT 1.00

13 MURCIA 1.00

14 VALENCIA 1.00

15 EKSOTE 2.00

16 CEN-GREECE 1.00

17 PALFALIRO 1.00

19 AGDIMITRIOS 1.00

21 CROATIA 1.00

22 VENETO 1.00

23 SMARTHOMES 1.50

24 ROTTERDAM 1.00

25 AMADORA 0.50

28 CCU 1.00

29 BELIT 2.00

30 STUDENICA 1.00

31 KRALJEVO 1.00

32 N-IRELAND 1.00

33 SCOTLAND 3.00

34 AGE 1.00

35 ARE 1.00

36 CHA 1.00

38 IFIC 1.00

39 EFN 1.00

40 EPF 1.00

Total 55.25

Deliverable Title

Nature 62

Delivery date 64

D10.1 SmartCare Quality Plan 1 7.00 R RE 2

D10.2 TEthics and Data ProtectionFramework 1 7.00 R PU 6

D10.3 Interim periodic progress report 1 6.00 R PU 6

D10.4 Project periodic progress report forRP1 1 7.25 R PU 12

D10.6 Project periodic progress report forRP2 1 7.00 R PU 24

D10.8Project final report incl. PR for RP3and report on the distribution of thefinancial contribution

1 7.00 R PU 36

Total 55.25

D10.1) SmartCare Quality Plan: The document presents the quality plan, criteria and processes for the projectduration. The deliverable incorporates results from: Task 10.2 [month 2]

D10.2) TEthics and Data Protection Framework: The document comprises a frozen version of the EvolvingDocument SmartCare Guidelines with new section on Ethics and Data Protection Framework. The deliverableincorporates results from: Task 10.6 [month 6]

D10.3) Interim periodic progress report: The report covers project progress and activities including managementfor the first six months. The interim report does not include cost statements. [month 6]

D10.4) Project periodic progress report for RP1: The report covers project progress and activities includingmanagement for the first reporting period. The deliverable incorporates results from: Task 10.1, Task 10.8[month 12]

D10.5) Interim periodic progress report: Interim periodic progress report [month 18]

D10.6) Project periodic progress report for RP2: The report covers project progress and activities includingmanagement for the second reporting period. It incorporates results from: Task 10.3, Task 10.4, Task 10.9[month 24]

D10.7) Interim periodic progress report: Interim periodic progress report [month 30]

D10.8) Project final report incl. PR for RP3 and report on the distribution of the financial contribution: Project finalreport incl. Progress report for RP3 and report on the distribution of the financial contribution [month 36]

Comments

MS2 Go/no go decision 1 6 This milestone is linkedto the 1st Interim Review

MS12 Successful completion of the Project 1 36

WT4:List of Milestones

List and Schedule of Milestones

Milestonenumber 59 Milestone name WP number 53 Lead benefi-

ciary numberDelivery datefrom Annex I 60 Comments

MS1 Issuing of theSmartCare pathways WP1 41 3

MS2 Go/no go decision WP10 1 6 This milestone is linked tothe 1st Interim Review

MS3 Evaluationframework agreed WP8 4 7

MS4Installation of the1st wave pilot sitescompleted

WP6 1 12

MS5 1st wave pilots fullyoperational WP6 1 15

MS6Installation of the2nd wave pilot sitescompleted

WP7 5 17

MS7 2nd wave pilots fullyoperational WP7 5 23

MS8Publication ofthe procurementguidelines

WP9 41 36

MS9Completion of thedeployment plans forparticipating regions

WP9 41 36

MS10 Final trial evaluation WP8 4 36

MS11 Final Conference WP9 1 36

MS12Successfulcompletion of theProject

WP10 1 36

WT5:Tentative schedule of Project Reviews

Tentative schedule of Project Reviews

Reviewnumber 65

Tentativetiming

Planned venueof review Comments, if any

RV 1 6 BrusselsInterim Review - No Financial Statement submissionbut go/no go decision on the basis of the progressachieved

RV 2 12 Scotland

RV 3 18 South Denmark Interim Review - No Financial Statement submission

RV 4 24 Friuli-Venezia Giulia

RV 5 30 Uppsala Interim Review - No Financial Statement submission

RV 6 36 Tallinn

WT6:Project Effort by Beneficiary and Work Package

Indicative efforts (man-months) per Beneficiary per Work Package

Beneficiary numberand short-name WP 1 WP 2 WP 3 WP 4 WP 5 WP 6 WP 7 WP 8 WP 9 WP 10 Total per Beneficiary

1 - FVG - ASS1 4.00 4.00 6.00 8.00 8.00 70.00 0.00 7.30 13.00 11.25 131.55

2 - KÄRNTEN 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

3 - BAD-WÜR 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

4 - RSD 5.00 6.00 6.00 8.00 8.00 70.00 0.00 42.00 8.00 3.00 156.00

5 - ETCH 1.50 1.50 2.00 21.00 20.00 0.00 50.00 2.50 2.00 2.00 102.50

6 - TALLINN 2.00 2.00 3.00 2.00 3.00 0.00 10.00 2.50 2.00 2.00 28.50

7 - CATALONIA 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

8 - ARAGON 4.00 4.00 6.00 8.00 8.00 70.00 0.00 8.00 6.00 3.00 117.00

9 - CRUZROJA 1.00 2.00 1.00 0.00 0.00 9.00 0.00 1.00 1.00 1.00 16.00

10 - EUSKADI 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

11 - EXTREMADURA 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 1.00 1.00 5.00

12 - FUNDECYT 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 1.00 1.00 5.00

13 - MURCIA 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

14 - VALENCIA 1.90 1.90 1.80 0.00 0.00 0.00 0.00 0.00 1.00 1.00 7.60

15 - EKSOTE 3.00 3.00 4.00 4.00 8.00 0.00 50.00 5.00 4.00 2.00 83.00

16 - CEN-GREECE 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

17 - PALFALIRO 1.00 1.00 1.00 1.00 2.50 0.00 20.00 2.00 2.00 1.00 31.50

18 - ALIMOS 0.50 0.50 0.50 0.50 1.00 0.00 16.00 1.00 0.00 0.00 20.00

19 - AGDIMITRIOS 1.00 1.00 1.00 1.00 2.50 0.00 20.00 2.00 2.00 1.00 31.50

20 - VIDAVO 1.50 1.50 2.00 3.00 8.00 0.00 16.50 5.00 0.00 0.00 37.50

21 - CROATIA 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

22 - VENETO 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

WT6:Project Effort by Beneficiary and Work Package

Beneficiary numberand short-name WP 1 WP 2 WP 3 WP 4 WP 5 WP 6 WP 7 WP 8 WP 9 WP 10 Total per Beneficiary

23 - SMARTHOMES 1.00 1.00 1.50 2.00 4.00 0.00 22.15 1.00 0.50 1.50 34.65

24 - ROTTERDAM 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

25 - AMADORA 0.50 1.00 1.50 0.00 0.00 0.00 0.00 0.00 1.00 0.50 4.50

26 - PTELECOM 0.50 1.00 1.00 0.00 0.00 0.00 0.00 0.00 1.00 0.00 3.50

27 - MISERICORDIA 0.50 1.00 0.50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00

28 - CCU 1.50 1.50 2.00 2.00 4.00 0.00 25.00 2.50 2.00 1.00 41.50

29 - BELIT 1.00 1.00 2.00 2.00 20.00 0.00 49.60 5.00 4.00 2.00 86.60

30 - STUDENICA 1.00 1.00 1.00 0.00 0.00 0.00 10.00 2.00 0.50 1.00 16.50

31 - KRALJEVO 1.00 1.00 1.00 0.00 0.00 0.00 10.00 2.00 0.50 1.00 16.50

32 - N-IRELAND 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 9.00

33 - SCOTLAND 4.00 4.00 6.00 8.00 8.00 69.25 0.00 8.00 6.00 3.00 116.25

34 - AGE 2.00 2.00 2.00 0.00 0.00 0.00 0.00 1.00 3.70 1.00 11.70

35 - ARE 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 1.00 13.00

36 - CHA 1.00 0.90 0.00 0.00 0.00 0.00 0.00 0.00 2.00 1.00 4.90

37 - EUROCARERS 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

38 - IFIC 2.00 2.00 8.00 0.00 0.00 0.00 0.00 0.00 6.00 1.00 19.00

39 - EFN 2.00 2.00 2.00 0.00 0.00 0.00 0.00 5.00 6.00 1.00 18.00

40 - EPF 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 1.00 8.00

41 - EMPIRICA 8.40 8.90 4.20 0.00 0.00 0.00 0.00 12.60 40.90 0.00 75.00

42 - AOK 2.00 2.00 2.00 0.00 0.00 0.00 0.00 2.00 2.00 0.00 10.00

Total 79.80 83.70 91.00 70.50 105.00 288.25 299.25 119.40 152.10 55.25 1,344.25

1. Project number

The project number has been assigned by the Commission as the unique identifier for your project. It cannot be changed.The project number should appear on each page of the grant agreement preparation documents (part A and part B) toprevent errors during its handling.

2. Project acronym

Use the project acronym as given in the submitted proposal. It cannot be changed unless agreed so during the negotiations.The same acronym should appear on each page of the grant agreement preparation documents (part A and part B) toprevent errors during its handling.

53. Work Package number

Work package number: WP1, WP2, WP3, ..., WPn

55. Lead beneficiary number

Number of the beneficiary leading the work in this work package.

56. Person-months per work package

The total number of person-months allocated to each work package.

57. Start month

Relative start date for the work in the specific work packages, month 1 marking the start date of the project, and all other startdates being relative to this start date.

58. End month

Relative end date, month 1 marking the start date of the project, and all end dates being relative to this start date.

59. Milestone number

Milestone number:MS1, MS2, …, MSn

60. Delivery date for Milestone

Month in which the milestone will be achieved. Month 1 marking the start date of the project, and all delivery dates beingrelative to this start date.

61. Deliverable number

Deliverable numbers in order of delivery dates: D1 – Dn

62. Nature

Please indicate the nature of the deliverable using one of the following codes

R = Report, P = Prototype, D = Demonstrator, O = Other

63. Dissemination level

Please indicate the dissemination level using one of the following codes:

• PU = Public

• PP = Restricted to other programme participants (including the Commission Services)

• RE = Restricted to a group specified by the consortium (including the Commission Services)

• CO = Confidential, only for members of the consortium (including the Commission Services)

• Restreint UE = Classified with the classification level "Restreint UE" according to Commission Decision 2001/844 andamendments

• Confidentiel UE = Classified with the mention of the classification level "Confidentiel UE" according to Commission Decision2001/844 and amendments

• Secret UE = Classified with the mention of the classification level "Secret UE" according to Commission Decision 2001/844and amendments

64. Delivery date for Deliverable

Month in which the deliverables will be available. Month 1 marking the start date of the project, and all delivery dates beingrelative to this start date

65. Review number

Review number: RV1, RV2, ..., RVn

66. Tentative timing of reviews

Month after which the review will take place. Month 1 marking the start date of the project, and all delivery dates being relativeto this start date.

67. Person-months per Deliverable

The total number of person-month allocated to each deliverable.

CIP-ICT-PSP-2012-6 Pilot A SmartCare

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COMPETITIVENESS AND INNOVATION FRAMEWORK PROGRAMME

ICT Policy Support Programme (ICT PSP)

ICT for Health, Ageing well and Inclusion

Pilot Type A

ICT PSP Objective (and sub-objective) identifier: Objective 3.1: Wide deployment of integrated care services

Proposal acronym: SmartCare Proposal full title: Joining up ICT and service processes for quality integrated care in Europe Grant agreement no.: 325158 Version number: 24 Date of preparation of Annex I (latest version): 15 March 2013

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Project Profile

Proposal acronym: SmartCare

Proposal title: Joining up ICT and service processes for quality integrated care in Europe

Information on the service

Service solution Describe the common interoperable service solution that the Pilot aims to implement and demonstrate (maximum 10 lines).

SmartCare will enable the delivery of integrated care to older European citizens to support them to live independent lives within the community by providing the ICT tools necessary to integrate care pathways across organisations and locations, in particlar between social and health service providers. A key area of integration is to provide common access to home platforms, which already povide monitoring of physiological parameters, environmental and behavioural monitoring and functions for self-care such daily schedulers, medication management, falls prevention, exercises for cognitive faculties training and coaching. In SmartCare these platforms are to be opened to cross-sectoral care teams, improving the ability of older people to better manage their chronic conditions at home and deal with their increasing frailty. The ICT platform will enable regionally customised integrated care models and care pathways (the SmartCare Pathways). The latter will be supported by workflow tools which will activate the most appropriate resources across the entire spectrum of services available for older people both for scheduled and emergency care. The ICT platform will be based, whenever possible, on open standards and multivendor interoperability and collaboration will be strongly encouraged.

Existing services Describe the existing services related to the Pilot for each of the countries involved. Indicate the extent to which these services are already operational at national, regional or local level and the national

initiatives/strategies to which they belong (maximum 1 page)

SmartCare can build on existing ICT services in all pilot regions supporting the delivery of care and already to some extent adapted to meeting the pressing need for coordination across care-givers. Existing platforms will be adapted in the direction of supporting coordination of the entire spectrum of care services offered to older people to improve their quality of life and extend their independent living in a way which remains financially sustainable in view of the evolution of demographic indices and restrictions in public spending.

The following regions, which have already moved furthest in this direction, make up the 1st wave of SmartCare pilots.

Friuli-Venezia Giulia Friuli-Venezia Giulia has been one of the pilot sites of the ICT PSP DREAMING project. The trials were based on a comprehensive set of services: health and environment monitoring, alarm handling, videoconferencing, etc. The results of the trials will be published shorty, but there is a widespread conviction that older people can derive major benefits from AAL in terms of quality of life and independence, even without considering the peace of mind that remote monitoring provides to relatives. On the basis of this conviction, ASS 1 of Trieste, the Local Health Authority responsible for the trials, has decided to maintain the service operational for the existing user population (30 older citizens). However, the size of the sample turned out to be insufficient to measure the economic impact of the services which is important for a wider deployment given the current squeeze on social and health care budget. This is the goal set for SmartCare.

Scotland Scotland, with a population of just over 5 million people, has experience of delivering health and wellbeing services in innovative ways and at a large scale. The investment of around £20million in telecare services over the period 2006-2011 has evidenced health benefits and economic efficiencies worth more than three times that amount for nearly 44.000 people, however as this was dispersed across many communities it diluted the potential for disinvestment from traditional care models.

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Scotland has an integrated healthcare system with all hospital and community health services delivered by 14 single regional Health Boards, and we have also embarked on the integration of health and social care services to deliver safer, more effective and person centred care. This will be supported through policy and legislative change. Scotland has a national provider of Telehealth Services, NHS 24 and through the Scottish Centre for Telehealth and Telecare, an organisation that supports the development and delivery of evidence based ICT supported healthcare services across Scotland, delivering our national Telehealth and Telecare Strategies. SmartCare provides Scotland with the opportunity to draw all of these components together within a defined geographic area to ‘add value’ as part of a whole systems approach, and enable significant change in our healthcare investment models. SmartCare will also provide the opportunity to learn from the experiences of other Member States and partners to help design sustainable solutions.

Aragon Aragon has put in place a very comprehensive ICT infrastructure in support of healthcare services and several telemedicine services, initially trialled in the framework of previous EU funded projects, are now in routine use in the Region which is characterised by a very sparse and ageing population (Aragon is 1 ½ times as big as Belgium for a population of just 1.4 million more than 50% is concentrated in the capital city of Saragossa). All the healthcare outlets are connected to a broadband secure network which has greatly facilitated the development of teamwork services. Citizens in Aragon have a single EHR which is accessible throughput the Region to all authorised users collaborating in the care of the citizen. The social service department on the other hand has not developed any major information system. This justifies the decision taken after the merger of the health and social care responsibility under a same Minister to develop the new information services using the infrastructure built for the healthcare services. This will ensure a native integration between the health and social sector over a shared ICT infrastructure. Already today the social care records form part of the EHR for any citizen followed by the Aragon Social Service Department. Aragon has also been one of the pilot sites of the ICT PSP DREAMING project. Further deployment of the DREAMING services is already taking place and coverage has been extended to elderly homes and dependent older people (excluded from the DREAMING trials) in close collaboration with Cruz Roja Española, which is part of the Aragon Regional Partnership for SmartCare.

Southern Denmark The building blocks of the infrastructure currently in place in Southern Denmark include the Danish Health Data Network, electronic health and care records, and the online health portal (sundhed.dk). The healthcare IT infrastructure is supported by several organisations and strategies on national, regional, and municipal level. Figures from 2010 show that 88% of the population have access to a computer and 86% of the population have access to the internet in their own homes. This indicates that the Danish population have a high degree of IT and computer literacy. To ensure that the already well-established healthcare IT infrastructure is further developed, the region makes considerable investments in new eHealth related projects; regional, national, as well as international. The ultimate aim is to improve the quality of life for older people and allow for more flexible and efficient home care services in the rural areas. Additionally, RSD works towards a higher degree of interoperability of health information systems and also interoperability of electronic health records. South Denmark (RSD) will deploy its first integrated care internet portal in late 2012 for heart failure care and will extend deployment of the cooperative portal to care for COPD, diabetes or cancer rehabilitation in SmartCare. To this end, integrated care service delivery processes between GPs, hospitals and municipal care organisations will be supported by a common integrated ICT infrastructure to be implemented within the project, partly building upon components which have been put in place already (e.g. an integrated care record system). Southern Denmark, together with the Municipality of Langeland, which is also part of the Southern Denmark Regional Partnership for SmartCare, has been yet another of the pilot sites of the DREAMING project. Based on the positive perception of the service provided in the context of the EU Project, further deployment of the service has just started using an up-date platform.

Methodology Describe the methodology and the roadmap of main milestones and tasks to be carried out during the Pilot (maximum 10 lines)

The workplan incorporates a carefully structured, two-interation approach for optimal customisation of

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ICT services to user, organisational and local requirements, to ensure deployed services fully meet needs of social and healthcare professionals and the older people they care for. The evaluation of the various trials will be conducted using the MAST multidimensional evaluation methodology, developed under contract with the European Commission (MethoTelemed project) and based on HTA (Health Technology Assessment). MAST has been successfully validated in the ICT PSP Type A project RENEWING HEALTH and is encountering an increasing level of success among organisations involved in trials of complex interventions such as those piloted in SmartCare. MAST was developed by a multinational team led by the Odense University Hospital which participates in SmartCare as part of the South Denmark Regional Partnership. The same team which developed and validated MAST will be in charge of the evaluation of SmartCare. The design of the trials will be elaborated taking into consideration the kind of evidence that the various stakeholders needs to engage in the roll-out of ICT-supported integrated care services for older people and the statistical validity of the outcomes measured. Consortium Describe briefly the composition of the consortium and the extent to which it includes the whole service value chain (maximum 10 lines)

The Consortium comprises the whole value chain of older people care. The core of it is constituted by Regional Partnerships which comprise all the local older care stakeholders, mainly but not exclusively Regional Authorities and Municipalities which, in most EU regions, are, together, responsible for and manage the expenditure budget for older people care. 15 of these Regional Authorities and Municipalities have been mandated by their respective National Administrations to represent the Member State they belong to. In many cases, these public entities are also the providers of care to older people. In cases where this task is outsourced, the outsourcer is or will be equally included in the Regional Partnerships as a beneficiary or a subcontractor. At this stage the Regional Partnerships are not legal entities but there is a commitment by the SmartCare partners, if the proposal is retained, to explore the possibility of creating legal entities, named Local SmartCare Alliances in the form of consortia or similar to both simply the administrative management of the Grant Agreement and show long-term commitment to the roll-out of the SmartCare services in the territory.

The SmartCare Consortium comprises the following Regional Partnerships: • Friuli-Venezia Giulia (IT) • Carinthia (AT) • Baden Württemberg (DE) • South Denmark (DK) • Tallin (EE) • Catalonia (ES) • Aragon (ES) • Basque Country (ES) • Extremadura (ES) • Murcia (ES) • Valencia (ES) • South Karelia (FI) • Central Greece (GR) • Attica (GR) • Northwest Croatia (HR) • Veneto (IT) • Noord-Brabant (NL) • Rotterdam (NL) • Uppsala (SE) • Amadora (PT) • Serbia (SR) • Northern Ireland (UK) • Scotland (UK)

The other stakeholders will be represented through their federations at European level and through their local branches in each of the pilot sites. The associations/federations which form part of the Consortium are:

• ARE - Assembly of European Regions • AGE Platform Europe – Older People's Platform.

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• EFN - European Federation on Nurses Associations. • Eurocarers - Informal caregivers. • IFIC - International Foundation for Integrated Care – Medical association.

The ICT industry on the other hand, will be represented by the following associations: • CHA – Continua Health Alliance.

Finally, the Consortium comprises a leading consultancy specialised in the eHealth and eInclusion fields, namely Empirica, which will support the Consortium through their expertise in Change Management, Process Re-engineering, Project Management, Quality Assurance and Medical Co-ordination.

Openness Describe the mechanisms that will be put in place during the project to ensure the openness of the work and the involvement of other states and stakeholders not participating directly in the Pilot. (maximum 10 lines)

For manageability reasons, the Consortium has decided not to exceed the number of 10 regional trials, but it is evident that interest in the matter addressed by SmartCare spans well beyond this number. The Consortium has therefore decided to accept the applications of all the regions which have expressed an interest in joining SmartCare. Those which will not host a trial will form part of an Committed Regions Board. Through their participation in the Board, these regions will have access to all the material produced in the Project and will be able to provide input into the implementation process. The will be also able to elaborate their own deployment plans for the SmartCare services thanks to the transferability model.

New members can join the Committed Regions Board even after the start of the project. A budget has been set aside to cover the travelling costs of representative of regions which are not included among the beneficiaries of the Project to allow them to participate in physical meetings of the Board. Pilots have been split in two waves. The sites for the 1st wave (4 pilots) will act as trailblazers for the 2nd wave (6 pilots). This second wave of pilots, will start during the second year of the Project and will benefit from the experience acquired by the trailblazers that the latter will share with all the other participating regions. Regions not retained for the 1st or 2nd wave of pilots could join the project at a later stage; those participating in the Committed Regions Board will have priority over other regions.

Impact Describe the expected impact of the Pilot at EU level (maximum 10 lines)

Although there is a general perception that ICT could facilitate the integration of social and health services, and that this would greatly improve the efficiency and effectiveness of care for older people, actual deployment of ICT in support of such an integration has been scattered throughout the EU; the cases in which the scale has gone beyond that of a pilot are rare. SmartCare intends to move the yardstick a long way further by aggregating data about the outcome of ICT-enabled integrated care across several pilots in different region and EU countries. This will provide an unprecedented base of evidence, and will distil lessons from practical experiences in different organisational and cultural settings. This will allow in turn to “develop guidelines for procuring, organising and implementing integrated care building upon innovative eHealth and active ageing services”

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Table of Contents Page

B.1 Project description and Objectives .............................................. 17

B.1.1 Project objectives ........................................................................................ 17

B.1.1.1 Objectives ...................................................................................................... 17 B.1.1.1.1 Background ......................................................................................................... 17 B.1.1.1.2 Mission ................................................................................................................ 18 B.1.1.1.3 Objectives ........................................................................................................... 19

B.1.1.2 Interoperability issue tackled in the Project .................................................... 20

B.1.1.3 Existing national infrastructures it will base itself on (i.e. the existing national, regional, local initiatives) ................................................................. 21

B.1.1.3.1 Austria ................................................................................................................. 21 B.1.1.3.1.1 Carinthia ................................................................................................................... 22

B.1.1.3.2 Germany ............................................................................................................. 24 B.1.1.3.2.1 Baden Württemberg................................................................................................... 24

B.1.1.3.3 Denmark ............................................................................................................. 25 B.1.1.3.4 Estonia ................................................................................................................ 27 B.1.1.3.5 Spain................................................................................................................... 28

B.1.1.3.5.1 Catalonia ................................................................................................................... 29 B.1.1.3.5.2 Aragon ...................................................................................................................... 30 B.1.1.3.5.3 Basque Country ......................................................................................................... 34 B.1.1.3.5.4 Extremadura.............................................................................................................. 36 B.1.1.3.5.5 Valencia .................................................................................................................... 37

B.1.1.3.6 Finland ................................................................................................................ 39 B.1.1.3.6.1 The South Karelia Social and Health Care District, Etelä-Karjalan sosiaali- ja

terveydenhuollon kuntayhtymä ................................................................................... 40 B.1.1.3.7 Greece ................................................................................................................ 41

B.1.1.3.7.1 Central Greece .......................................................................................................... 41 B.1.1.3.7.2 Palaio Faliro .............................................................................................................. 43

B.1.1.3.8 Italy ..................................................................................................................... 44 B.1.1.3.8.1 Friuli-Venezia-Giulia .................................................................................................. 47 B.1.1.3.8.2 Veneto ...................................................................................................................... 48

B.1.1.3.9 The Netherlands .................................................................................................. 50 B.1.1.3.9.1 Noord-Brabant ........................................................................................................... 50

B.1.1.3.10 Sweden ............................................................................................................... 52 B.1.1.3.10.1 County of Uppsala ..................................................................................................... 53

B.1.1.3.11 Serbia ................................................................................................................. 53 B.1.1.3.12 Northern Ireland .................................................................................................. 54 B.1.1.3.13 Scotland .............................................................................................................. 55

B.1.1.4 Way to connect national initiatives together ................................................... 58

B.1.1.5 Expected measurable final result of the project .............................................. 59

B.1.2 EU and national dimension ......................................................................... 61

B.1.2.1 Relevance of the project to EU directives ...................................................... 61

B.1.2.2 Relevance of the proposed solution to political objectives.............................. 63 B.1.2.2.1 European policy level .......................................................................................... 63 B.1.2.2.2 National/regional policy level ............................................................................... 65

B.1.2.3 EU relevance of the solution to be demonstrated ........................................... 79

B.1.3 Consensus building..................................................................................... 82

B.1.3.1 Consensus building in the telehealth and telecare industrial arena ................ 82

B.1.3.2 Elderly associations ....................................................................................... 82

B.1.3.3 Nurses and informal carers associations ....................................................... 82

B.1.3.4 Other relevant stakeholders ........................................................................... 83

B.2 Impact ........................................................................................... 84

B.2.1 Target outcome and expected impact ......................................................... 84

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B.2.1.1 Final outcome of the project ........................................................................... 84 B.2.1.1.1 Focus and outcomes ........................................................................................... 84 B.2.1.1.2 Characteristics..................................................................................................... 84 B.2.1.1.3 Expected impact .................................................................................................. 86

B.2.1.2 Building blocks ............................................................................................... 88 B.2.1.2.1 Components of home-linked ICT support services ............................................... 91 B.2.1.2.2 Components of ICT support services for organisational cooperation .................... 93

B.2.1.3 Common specifications .................................................................................. 94

B.2.1.4 Scalability ...................................................................................................... 94

B.2.2 Long term impact, viability .......................................................................... 95

B.2.3 Availability of results ................................................................................... 99

B.2.3.1 Spreading results and disseminating knowledge ........................................... 99

B.2.3.2 Exploitation planning .................................................................................... 104

B.2.3.3 Management of knowledge, IPR .................................................................. 105

B.2.3.4 Respecting public procurement rules ........................................................... 106

B.2.3.5 Results of the project made freely available ................................................. 106

B.3 Implementation ............................................................................. 108

B.3.1 Capability and commitment of the partnership ........................................... 108

B.3.1.1 Overall description ....................................................................................... 108

B.3.1.2 Partner details and function ......................................................................... 110 B.3.1.2.1 Regional Partnerships ....................................................................................... 110

B.3.1.2.1.1 Friuli-Venezia Giulia - Italy ....................................................................................... 110 B.3.1.2.1.1.1 Azienda per i Servizi Sanitari n. 1 - Regione Friuli-Venezia Giulia 110

B.3.1.2.1.2 Carinthia - Austria .................................................................................................... 111 B.3.1.2.1.3 Baden Württemberg................................................................................................. 113

B.3.1.2.1.3.1 Kinzigtal 113 B.3.1.2.1.4 South Denmark ....................................................................................................... 114

B.3.1.2.1.4.1 Odense University Hospital 116 B.3.1.2.1.5 Tallinn - Estonia ....................................................................................................... 117

B.3.1.2.1.5.1 City of Tallinn 117 B.3.1.2.1.5.2 East Tallinn Central Hospital 118

B.3.1.2.1.6 Catalonia – Spain .................................................................................................... 120 B.3.1.2.1.6.1 Fundació Privada Centre TIC i Salut 120

B.3.1.2.1.7 Comunidad Autónoma de Aragón – Spain ................................................................ 121 B.3.1.2.1.7.1 SALUD 121 B.3.1.2.1.7.2 Cruz Roja Española 123

B.3.1.2.1.8 Basque Country - Spain ........................................................................................... 125 B.3.1.2.1.8.1 OSAKIDETZA- Servicio Vasco de Salud (it will enter the Consortium in case the

Basque Country hosts a pilot) 125 B.3.1.2.1.8.2 Kronikgune 127 B.3.1.2.1.8.3 OSATEK (it will enter the Consortium in case the Basque Country hosts a pilot) 127

B.3.1.2.1.9 Extremadura - Spain ................................................................................................ 128 B.3.1.2.1.9.1 Consejería de Salud y Política de Extremadura - Social Department of Autonomy

and Promotion of Care (SEPAD) 128 B.3.1.2.1.9.2 FUNDECYT 129

B.3.1.2.1.10 Murcia - Spain ......................................................................................................... 131 B.3.1.2.1.11 Valencia - Spain ...................................................................................................... 132

B.3.1.2.1.11.1 Prince Felipe Research Centre (CIPF) 132 B.3.1.2.1.11.2 Universitat Politècnica de València - UPVLC (Subcontractor) 133

B.3.1.2.1.12 South Karelia Finland .............................................................................................. 134 B.3.1.2.1.12.1 South Karelia Social and Health Care District 134

B.3.1.2.1.13 Central Greece ........................................................................................................ 136 B.3.1.2.1.13.1 e-Trikala SA 136

B.3.1.2.1.14 Attica....................................................................................................................... 138 B.3.1.2.1.14.1 Municipality of Palaio Faliro - Greece 138 B.3.1.2.1.14.2 The Municipality of Alimos, Greece 140 B.3.1.2.1.14.3 Municipality of Agios Dimitrios, Attica – Greece 140 B.3.1.2.1.14.4 Vidavo - Greece 141

B.3.1.2.1.15 Northwestern Croatia ............................................................................................... 142

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B.3.1.2.1.15.1 Croatian National Institute of Public Health (it will participate as an informal observer) 143

B.3.1.2.1.15.2 Croatian Society for Pharmacoeconomics and Health Economics (http://www.farmakoekonomika.hr/) 143

B.3.1.2.1.16 Regione Veneto - Italy ............................................................................................. 144 B.3.1.2.1.16.1 Local Health Authority nr. 2 of Feltre 145

B.3.1.2.1.17 Noord-Brabant - The Netherlands............................................................................. 146 B.3.1.2.1.17.1 Stichting Smart Homes 146 B.3.1.2.1.17.2 TweeSteden Ziekenhuis (candidate organisation to become the second partner for

Noord Brabant – still under validation by REA) 148 B.3.1.2.1.18 Rotterdam-Rijnmond – The Netherlands ................................................................... 149

B.3.1.2.1.18.1 Municipality of Rotterdam 149 B.3.1.2.1.19 Amadora - Portugal.................................................................................................. 151

B.3.1.2.1.19.1 Câmara Municipal da Amadora (Amadora City Hall) 152 B.3.1.2.1.19.2 Santa Casa da Misericórdia da Amadora - SCMA 153 B.3.1.2.1.19.3 Portugal Telecom Comunicações 154

B.3.1.2.1.20 Uppland .................................................................................................................. 155 B.3.1.2.1.20.1 Uppsala Läns Landsting 155 B.3.1.2.1.20.2 Center for eHealth in Sweden (Subcontractor) 156

B.3.1.2.1.21 Serbia ..................................................................................................................... 157 B.3.1.2.1.21.1 Kraljevo 157 B.3.1.2.1.21.2 Studenica Health Center – Kraljevo 157 B.3.1.2.1.21.3 Centre for Social Work – Kraljevo 160 B.3.1.2.1.21.4 Belit ltd 162 B.3.1.2.1.21.5 Fonlider Ltd (Subcontractor) 163

B.3.1.2.1.22 Northern Ireland - UK ............................................................................................... 166 B.3.1.2.1.22.1 Health & Social Care Board (HSCB) 166 B.3.1.2.1.22.2 Third Party associated to the Health & Social Care BoardError! Bookmark not defined. B.3.1.2.1.22.2.1 Southern Health & Social Care Trust and Southern LCG CommissionError! Bookmark not defined.

B.3.1.2.1.23 Scotland - UK .......................................................................................................... 168 B.3.1.2.1.23.1 NHS24 168 B.3.1.2.1.23.2 Third Party associated to NHS24 171 B.3.1.2.1.23.2.1 NHS Lanarkshire 171 B.3.1.2.1.23.2.2 NHS Greater Glasgow and Clyde 172 B.3.1.2.1.23.2.3 NHS Ayrshire and Arran 172

B.3.1.2.1.24 AGE Platform Europe - Belgium ............................................................................... 173 B.3.1.2.2 Health Insurers .................................................................................................. 175

B.3.1.2.2.1 AOK Reinhland/Hamburg ......................................................................................... 175 B.3.1.2.3 Regions associations ......................................................................................... 176

B.3.1.2.3.1 Assembly of European Regions - France .................................................................. 176 B.3.1.2.4 Industry associations ......................................................................................... 178

B.3.1.2.4.1 Continua Health Alliance - Belgium .......................................................................... 178 B.3.1.2.5 Professional associations .................................................................................. 180

B.3.1.2.5.1 Eurocarers - Luxembourg ........................................................................................ 180 B.3.1.2.5.2 International Foundation for Integrated Care – The Netherlands ................................ 181 B.3.1.2.5.3 European Federation of Nurses Associations - Belgium ............................................ 182

B.3.1.2.6 Patients associations ......................................................................................... 183 B.3.1.2.6.1 European Patients' Forum - Luxembourg .................................................................. 183

B.3.1.2.7 Business consultants ......................................................................................... 184 B.3.1.2.7.1 empirica Gesellschaft für Kommunikations- und Technologieforschung mbH -

Germany ................................................................................................................. 184 B.3.1.3 Partners roles in the project implementation ................................................ 186

B.3.1.4 Relationships between project participants .................................................. 191

B.3.2a Chosen approach ..................................................................................... 194

B.3.2a.1 Key conceptional elements .......................................................................... 195

B.3.2a.2 Work-plan overview ..................................................................................... 197

B.3.2a.3 Workplan implementation and monitoring .................................................... 201

B.3.2a.4 Evolving Document SmartCare Guidelines .................................................. 202

B.3.2a.5 Work package methodology ........................................................................ 203

B.3.2a.6 Pilot site plans ............................................................................................. 212

B.3.2a.7 Criteria for selecting users ........................................................................... 217

B.3.2a.8 Sample of users involved including justification ........................................... 217

B.3.2a.9 Description of tests to be performed ............................................................ 217

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B.3.2b Work plan .................................................................................................. 218

B.3.2b.1 GANTT chart ............................................................................................... 218

B.3.2b.2 Key Performance Indicators (KPI) ................................................................ 220

B.3.2b.3 Risk assessment.......................................................................................... 223

B.3.3 Project management ................................................................................. 226

B.3.3.1 Project Steering Committee ......................................................................... 227

B.3.3.2 Advisory Boards .......................................................................................... 228 B.3.3.2.1 Users’ Advisory Board (UAB) ............................................................................. 228 B.3.3.2.2 Industry Advisory Board (IAB) ............................................................................ 229 B.3.3.2.3 Internal Scientific Board (ISB) ............................................................................ 229 B.3.3.2.4 The Committed Regions Board (CRB) ............................................................... 230

B.3.3.3 Project Roles ............................................................................................... 231 B.3.3.3.1 Project Co-ordinator .......................................................................................... 231 B.3.3.3.2 Administrative Co-ordinator ............................................................................... 231 B.3.3.3.3 Co-ordinator Support Team ............................................................................... 232 B.3.3.3.4 Work Package Leaders ..................................................................................... 232

B.3.3.4 Management Team ...................................................................................... 233 B.3.3.4.1 Project Co-ordinator .......................................................................................... 233 B.3.3.4.2 Operational Co-ordination .................................................................................. 233 B.3.3.4.3 Scientific Co-ordination ...................................................................................... 233 B.3.3.4.4 Quality Assurance ............................................................................................. 234 B.3.3.4.5 Work Package Leaders ..................................................................................... 234

B.3.3.5 Conflict resolution ........................................................................................ 235 B.3.3.6 Handling of the results ................................................................................. 235

B.3.3.7 Quality Control and Assurance .................................................................... 235

B.3.3.8 Ethics and Data Protection Manager............................................................ 235

B.3.3.9 Approach to Change Management .............................................................. 235

B.3.3.10 Approach to Risk Management .................................................................... 241

B.3.4 Security, privacy, inclusiveness, interoperability, standards and open-source ....................................................................................................... 242

B.3.4.1 Security ....................................................................................................... 243

B.3.4.2 Privacy ......................................................................................................... 246

B.3.4.3 Inclusiveness ............................................................................................... 246

B.3.4.4 Interoperability ............................................................................................. 247

B.3.4.5 Standards .................................................................................................... 249 B.3.4.5.1 Web based communication ................................................................................ 249 B.3.4.5.2 Continua guidelines ........................................................................................... 249 B.3.4.5.3 Cross-border operability .................................................................................... 252 B.3.4.5.4 Standards and tools to create care pathways ..................................................... 254 B.3.4.5.5 ISO 13940 Health Informatics - a system of concepts for the continuity of

care ................................................................................................................... 254

B.3.4.6 Open-source ................................................................................................ 255

B.3.5 Resources to be committed ...................................................................... 256

B.3.6 Dissemination/Use of results .................................................................... 271

APPENDIX I Example of SmartCare pathway .................................. 272

A.I.1 Integrated care pathway components ....................................................... 273

A.I.2 Integrated care pathway for hospital discharge – an example .................. 273

A.I.2.1 Components of the integrated care hospital discharge pathway .................. 273

A.I.2.2 Modelling the ICT-supported discharge process in Bielefeld, CommonWell ............................................................................................... 274

A.I.3 Examples of current pathways in pilot regions .......................................... 278

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A.I.3.1 Controlled hospital discharge in Triest, Italy ................................................. 278

A.I.3.2 Patient Pathway for the Patient with a chronic condition (COPD) in Region South Denmark................................................................................ 281

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Glossary Abbreviation Full name

ACG-pm Ambulatory Care groups

ADI Integrated In-home Care

ADSL Asymmetric Digital Subscriber Line

AAL Ambient Assisted Living

AG Access Gateway

AHA Active and Healthy Ageing

A/P Already in Place

ATNA Audit Trail and Node Authentication

AWBZ Exceptional Medical Expenses

BPMN Business Process Modelling Notation

BPPC Basic Patient Privacy Consents

CA Consortium Agreement

CBA Cost-benefit analysis

CCD Clinical Care Document

CDA Clinical Data Architecture

CETEC Consumer Electronics Testing and Engineering Centre

CHI Community Health Index

CIP Competitiveness and Innovation Programme

CMAT Change Management Advisory Team

CNIPA Centro Nazionale per l’Informatica nella Pubblica Amministrazione

COPD Chronic Obstructive Pulmonary Disease

CRB Committed Regions Board

CVD Cardiovascular Diseases

DALLAS Demonstrating Assisted Living Lifestyles At Scale

DHDN Danish Healthcare Data Network

DHSSPS Health, Social Services and Public Safety

DMS Disease Management Service

DNS Directory Network Service

DPD Data Protection Directive

DREAMING elDeRly-friEndly Alarm handling and MonitorING

DTT Digital Terrestrial Television

ebXML Electronic Business using eXtensible Markup Language

ECG Electrocardiogram

ECR Electronic Care Records

ECS Electronic Care Summary

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Abbreviation Full name

EFMI European Federation for Medical Informatics

eHealth Transfer of health resources and health care by electronic means1

EHR Electronic Healthcare Record

EIP European Innovation Partnership

EIP AHA European Innovation Partnership for Active and Healthy Ageing

ELGA Austrian Patient Record System

EMC Electronic Medical Record

ENSA European Network of Social Authorities

ePCS Palliative Care Summary

EPD Electrophoretic Display

EPR Electronic Patient Records

epSOS European Patients - Smart Open Services

ESA European Space Agency

eTEN Electronic Trans-European Network

EU European Union

FTP File Transfer Protocol

GP General Practitioner

GPRS General Packet Radio Service

GSM Global System for Mobile Communication

GUI Graphical User Interface.

HCB Hospital Clinic Barcelona

HCCP Health Care Centred Pathways

HCDSNS Historia Clínica Digital del Sistema Nacional de Salud - The digital medical record project of the National Health System in Spain

HCP Healthcare Provider,

HIS Hospital Information System

HL7 Health Level 7

HLYs Healthy Life Years

HLS Home-linked Services

HR Health Reporting

HRN Health Reporting Network

HTA Health Technology Assessment

HTML HyperText Markup Language

HTTP Hypertext Transfer Protocol

HTTPS Hypertext Transfer Protocol over Secure Socket Layer

IASS Instituto Aragonés de Servicios Sociales

IAB Industry Advisory Board

1 Definition by WHO. See http://www.who.int/trade/glossary/story021/en/index.html

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IC Integrated Circuit

ICD9 International Classification of Disease, 9th edition,

ICP PSP ICT Policy Support Programme

ICPs Integrated Care Partnerships

ICR Integrated Care Record

ICT Information Communication Technology

ID Identity Document

IEEE Institute of Electrical and Electronics Engineers

IFIC International Foundation for Integrated Care

IHE Integrating the Healthcare Enterprise

IMIA International Medical Informatics Association

MIE International Conference(s) of the European Federation for Medical Informatics

IPR Intellectual property Right

IR InfraRed

ISB Internal Scientific Board

ISO International Organization for Standardization

IT Information Technology

ITIL IT Infrastructure Library

JCA Java Connector Architecture

JMS Java Message Service

KIS Key Information Summary

KRONET Patients Associations Web Services

LAN Local Area Network

LHAs Local Health Authorities

LHS Local Healthcare Systems

LGDK Local Government Denmark

LiU Living it UP

LOINC Logical Observation Identifiers Names and Codes

LSP Large Scale Pilot

MAST Model for ASsessment of Telemedicine applications

Mb Megabyte

MHSC Multi-channel Health Service Centre

MoSA Estonian Ministry of Social Affairs

MWC Mobile World Capital

N3 NHS Scotland Single Virtual Private Network

NGO Non-Governmental Organisation

NPfIT NHS National Programme for IT in the U.K.

NPO National Patient Overview

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NSI National Board of e-Health in Denmark

NSRF National Strategic Reference Framework

OCS Organisational Cooperation Services

OMG Object Management Group

OMI AP Primary Care electronic health record in use in Spain

P2P Peer-to-peer

PAN Personal Area Network

PACS Picture Archiving and Communication System

PBIP Population Based Intervention Plans

PC Personal Computer

PCC Patient Care Coordination

PCD Patient Care Device

PGP Pretty Good Privacy

PGS Pflege- und Gesundheitsservice (Care and health services)

PHC Primary Healthcare

PhD Academic Degree of Doctor of Philosophy

PHR Personal Health Records

PHM Personal Health Monitoring

PMS Patient Management System

PSC Project Steering Committee

PSTN Public Switched Telephone Network

RDSI Red Digital de Servicios Integrados (Integrated Service Digital Network)

RENEWING HEALTH

REgioNs of Europe WorkINg toGether for HEALTH

RIS Radiology Information System

R&D Research and Development

RfC Request for Change

RTC Rádio e Televisão de Cabo (Radio and Cable Television)

RTD Research Technology Development

RTF Regional Telemedicine Forum

RTMP Real Time Messaging Protocol

SALPB Scottish Assisted Living Programme Board

SAML Security Assertion Markup Language,

SCCP Social Care Centred Pathways

SCI Scottish Care Information

SCPs Social Care Professionals

SCP Social Care Provider

SG Steering Group

SHSCT Southern Health and Social Care Trust

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SOA Service Oriented Architecture

SSL Secure Socket Layer

SIP Session Initiation Protocol

SME Small-Medium Enterprise

SMS Short Message Service

SMTP Simple Mail Transfer Protocol

SNOMED Systematized Nomenclature of Medicine

SNS Spanish National Health Service

SOA Service-Oriented Architecture

SOAP Simple Object Access Protocol

SSO Single Sign On

STS Socio-Technical System

TAS Technical application system

TB Terabyte

TC Telecare

TCP/IP Transmission Control Protocol/Internet Protocol

TLS Transport Layer Security

TSE Tavolo permanente per la Sanità Elettronica – Permanent roundtable for eHealth

TM Telemonitoring

TV Television

TYC Transforming Your Care

UAB Users’ Advisory Board

UDDI Universal Description, Discovery and Integration

UMTS Universal Mobile Telecommunications System

URL Uniform Resource Locator

VC Videoconferencing

VPN Virtual Private Network

WAN Wide Area Network

WG Work Group

WHO World Health Organisation

WiFi Wireless Fidelity

WMO Social Support Act

WP Work Package

WSDL Web Services Description Language

WS-Security Web Services Security

XCA Cross-Community Access

XDR Cross-Enterprise Document Reliable Interchange

XDS Cross-Enterprise Document Sharing

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XHUP the public utility network of healthcare providers

XML eXtensible Markup Language

X-Road Estonian e-solutions infrastructure

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B.1 Project description and Objectives

B.1.1 Project objectives

B.1.1.1 Objectives

B.1.1.1.1 Background

As Europe's population ages, the way we support older people has to change. It is socially and economically unsustainable to have the same proportion of older people being looked after in institutional care as today.. Healthcare and social care are important elements in supporting older people to live safely and well at home, and there is evidence that care service provision is enabled and improved by ICT solutions. The potential of ICT-enabled forms of support such as telecare and telehealth can be exploited in a radically more effective way if they were more systematically embedded within a ‘whole systems’ approach to health and social care. Up until quite recently, national welfare and health systems and regional/local support practices were developing more and more specialisation and clear boundaries closed them to cooperation.2

It may thus not come as a surprise that today’s reality is characterised by fragmentation and bureaucracy in current provision systems resulting in disjointed and patchy support services. Only recently the dangers of closed silo service provision have been widely recognised at the policy level and steps taken to spread responsibility more widely and introduce cooperative structures, including third sector and citizens groups. Some governments are now beginning to seek to improve collaborative support of older people living in the community. Evidence points into the direction that “models of integrated health and social care for the elderly can result in improved outcomes, client satisfaction and/or cost savings”3. ICT suppliers are beginning to respond to this trend and make interoperable components available to care providers.

SmartCare unites leading regions in Europe sharing a common vision of taking key steps towards establishment of a comprehensive ICT integration infrastructure to support efficient delivery of highly effective integrated care at levels required and desired by their citizens.

These regions have already taken organisational and policy steps necessary to integrate care provision across healthcare and social care, including bringing together budgets for clinical and social care, setting up decision bodies across the main agencies for social and health care to enable joint commissioning, deploying multidisciplinary teams in operation incorporating social care staff and addressing both clinical and non-clinical independence-threatening conditions.

The regions also have advanced ICT infrastructure within their healthcare and social care "silos", comprising in particular widespread telemonitoring and telecare, and therefore present ideal conditions for proving the advantages of innovative ICT support to integrated inter-agency/inter-sectoral care delivery.

They believe that more progress could be made towards state-of-the-art ICT support to their integrated care delivery processes and organisations. They are aware that ICT based services and data and system integration, an ICT integration infrastructure, can support integrated care delivery in multiple ways, saving staff time, reducing bureaucratic work steps and delivering coherent, joined-up care to their older citizens in the way they wish to receive it.

2 KELLY, D. (2005): Touching People’s Lives with Technology. Presentation at the Silver Economy in Europe Conference on

16./17. February 2005 in Bonn, Germany. 3 Margaret MacAdam (2008): Frameworks of Integrated Care for the Elderly: A Systematic Review.

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B.1.1.1.2 Mission

The overarching mission of the SmartCare project is to promote a more integrated and effective approach to the health and care of older people across Europe, by embedding an open, multifunctional ICT platform in support of joined up service processes and providers. This will effectively prevent or at least slow the otherwise inexorable progress towards the edges of health, wellness, safety and independent living.

To this end, the project sets out to define and pilot a comprehensive set of integration building blocks supporting services to combat a range of threats to independent living commonly faced by older people, incorporating interoperable components to enable cooperative delivery of healthcare, social care and independence-enhancing support by healthcare and social care organisations, family and informal carers and voluntary sector personnel.

To achieve its mission and to effectively manage changing demography and lifestyles in Europe, the SmartCare Consortium will adopt both a preventative and cure approach. The Consortium will utilise technology to enable effective care pathways for older people (aged 65+) to support their chronic conditions and frailties at a large scale. However, one of the SmartCare partners will also engage with a younger population (aged 50+) to effect change on a preventative care basis and share experience with the wider collaboration. This is because the 50+ age group are much larger in number than our existing ‘older’ population, they are anticipated to live longer and are expected to create a significant challenge to our existing health and care services if their behaviours and health do not improve. They are also higher adopters of technology, are significant providers of informal care, and may better engage with self management and preventative care approaches. Scotland will include a population of 50+ (including a significant number of people aged 65+) as part of its contribution to SmartCare.

The following table lists the main components of a comprehensive digital infrastructure supporting integrated delivery of care by care providers in different agencies including voluntary organisations, informal carers and self-care action.

ICT based core integration

building blocks Main components

1) Integrated data access for care providers in different agencies and informal carers

Integrated Care Record

Sharing clinical, scheduling, monitoring information

Shared EHR / Access to subsets of EHR

Input from health and social care actors / interfaces to different ICT tools

Web-based portal

Integration of vital sign / health monitoring data into care planning and management processes

2) Design and execution of pre-planned care pathways enabling temporal coordination between provision steps taken by care providers in different agencies, informal carers and cared for people

Workflow engines Charting tools for IC pathways design

Joint/shared scheduling, daily schedulers Shared care plans Team coordination support

Training delivery/learning pathways / plans for professional and/or patient self-care training support tools

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3) Access to the home: home-based systems (Telemonitoring and/or Telecare TM/TC) by care providers in different agencies and informal carers

Vital parameter monitoring

Patient’s daily symptom questions

Alerts, prompts, reminders configuration and handling/ protocols and escalation procedures

Reports, protocols

Passive and/or active alarms

Automated self-care and (older people wellness and informal carers) promotional/ educational/ training/ planning tools

Life-style/behaviour monitoring

Physical training & coaching programmes/tools

Access to other services to address social isolation, information sources, connections to community activities

Development of Service Standards, e.g. response times

Integration of data into care planning and management processes

Home safety monitoring (gas, temperature, light, doors, windows, etc.)

Device administration; remote device tracking, maintenance and updates

4) Real-time communication between care providers in different agencies and informal carers, e.g. support to case conferences, and older people

IP-based screen sharing

Videoconferencing (VC)

Telecare service communication with informal or formal carers for care coordination and management

5) Joint response to ad hoc requests by care providers in different agencies and informal carers

Call / Contact Centre, Triage

Web-based portal

Centralised and flexible role-, patient- and user- administration

Links with emergency services e.g. ambulance SmartCare regions are among the most advanced in Europe and committed to taking steps towards deploying many components of the full infrastructure. The payoff of implementing the infrastructure is to be demonstrated in SmartCare, by evaluating specific steps pilot regions plan to take next towards the full scenario. Ultimately, by demonstrating in what way such a digital support infrastructure can be exploited in a sustainable manner the project aims at:

• Contributing to wider deployment of integrated care for improved health and wellness

• Implementing and validating new (care pathways and organisational) models for integrated care

• Contributing to a replicable plan for sustainable deployment of integrated care services across Europe.

B.1.1.1.3 Objectives

Guided by this mission, SmartCare aims to achieve the following objectives:

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1. Implement and validate in 10 European pilot regions SmartCare services (ICT-based support to integrating healthcare, social care and self-care for different health/living conditions, along integrated care pathways) including the underlying organisational models

2. Generate multidimensional evidence on impacts of integrated care on all stakeholders concerned through common evaluation approach transferable to follower-regions across Europe

3. Develop guidelines and specifications for procuring, organising and implementing ICT building blocks supporting integrated care

4. Elaborate plans for sustainable mainstream operation of SmartCare services in participating regions based on the evidence elicited through the pilots and taking into account the entire value chain0

5. Ensure large scale communication and dissemination of project approach and achievements through networks and communication channels of participating stakeholder associations and public authorities

An overview of the objectives of SmartCare, overall approach and main outcomes is presented in Figure 1 below. The expected measurable final results are described in detail in Section B.1.1.5.

Figure 1: SmartCare – an overview

Health care

Socialcare

Cared for person

Informal/family carer

Self-care

SmartCare integrated service models

SmartCare integrated pathways

SmartCare ICT integration infrastructure

building blocks

Integrated data access

Coordi-nation

Real-time communication

Access to home-based systems: Telemonitoring/Telecare

Joint response

� Large scale commitment in 24 regions� Pilot & validation in 2 waves in 10 European regions� Multidimensional evidence on impacts� Common evaluation approach � Transferable to follower-regions across Europe� Guidelines, specifications for procurement &

implementation� Plans for sustainable mainstream operation� Large scale dissemination� Links to EIP AHA & other EU/nat./regional initiatives

� collaborative

� inclusive

� safety enhancing

� responsive

� efficient

�empowering

B.1.1.2 Interoperability issue tackled in the Project

The SmartCare Consortium in the implementation of the pilots will pay particular attention to the issue of interoperability among the large number of ICT applications, both newly

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developed and legacy, which will need to communicate with another to support the SmartCare Pathways. This, in addition to being a prerequisite for successfully run pilots, will promote open competition among solution suppliers; this will benefit both the suppliers and the procurers of ICT in support of integrated care, by boosting the market and lowering prices.

The SmartCare Consortium will closely follow the most significant initiatives at European level which address this problem by introducing new methods of work, namely:

• LSP project epSOS (www.epsos.eu) that is addressing the areas of EHRs and ePrescription.

• Thematic Network Calliope (www.calliope-network.eu) that has created two WGs (WG5 on eHealth Interoperability and WG6 on eHealth standards) that also address this issue.

The SmartCare Consortium will also take into consideration the recommendations contained in the following documents recently issued by the European Commission in this area:

• The Recommendation on cross-border interoperability of electronic health record systems (COM(2008)3282 final).

• The communication on telemedicine for the benefit of patients, healthcare systems and society (COM(2008) 689), which is of particular importance to SmartCare.

The commitment of the SmartCare Consortium to interoperability is confirmed by the fact that one of the most important industrial cooperative initiatives in the area of interoperability, Continua Health Alliance, is directly involved in the Project as a full beneficiary and as a bridge between the pilot sites and the industrial partners active in the field of telehealth, telecare and service integration.

In the past, attempts to try to produce new interoperability implementation guidelines within a project have proven not to contribute towards the solution, but rather to increase the confusion and dispersion. Therefore, the SmartCare Consortium will liaise with standardisation initiatives already underway in this area, as identified above.

To sum up, SmartCare will address the interoperability issue from many angles, as it will: • encourage the use of Continua compliant devices in the pilots where appropriate;

• closely follow up IEEE X73 series developments;

• promote through the regional pilots interoperability guidelines, and try to influence adoption at national level (at least) in the Member States represented in the Consortium;

• provide input to the EC for any follow-up relevant to the Telemedicine Communication (COM(2008) 689).

B.1.1.3 Existing national infrastructures it will base itself on (i.e. the existing national, regional, local initiatives)

B.1.1.3.1 Austria

The Austrian government published the “Austrian National eHealth Strategy”4, following the “eHealth Action Plan” of the European Commission. Based on the fact that Austria has a federal health system which gives a high level of responsibilities to the nine regional governments, and finances different treatments in different settings (inpatient, outpatient, home care etc.) through different channels, the decision was made to improve health ICTs in

http://www.bmg.gv.at/cms/site/attachments/8/5/3/CH0708/CMS1156950437801/entwurf_fuer_eine_oesterreichische_ehealth_strategie.pdf [2009/10/08]

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order to optimise the processes and to reduce the information gaps between the different level of care – and, as a consequence of these, possibly gap in the continuity of care too.

On the basis of a national patient record – based on standards and architectures chosen by IHE – the Austrian Patient Record System (ELGA) should yield a secure system that provides authorised healthcare professionals with standardised health CDA-documents during the treatment, if a patient gives his/her consent to this exchange of data.

Until now, the essential document types have been defined, and many organisations are starting to adopt these types and provide their documents in an electronic and standardised form. Besides this technical part, a major effort has been made to reach a closer coordination of the different levels of care in their planning and their operating strategies. So, there are regional health boards closely cooperating especially in the in- and out-patient treatment, but also in the home care. The different health providers are also preparing their organisations and their staff to deal with new information networks and paths.

B.1.1.3.1.1 Carinthia

Carinthia, a (partly) mountainous region in the south of Austria with some 560.000 inhabitants, has about 1.000 physicians in the outpatient area and some 950 hospital physicians. There are 11 hospitals with different sizes and specialisations, 12 homecare organisations and nearly 60 care units for citizens needing care who are often elderly too.

The Carinthian Department of Health is currently preparing the implementation of an IHE Affinity Domain, Carinthia, using the existing patient index in an evolutionary way.

In 2000, the Regional Health Board started a telemedicine project aimed to establish coordinated telemedicine in Carinthia. The main goals are:

• teleradiology between different hospitals in acute (1.100 cases a year) and routine cases;

• pictures of former treatments (about 1.400 a year), available from radiological institutes;

• a Carinthian (in-)patient record (>800.000 patients with 3.8 million hospital stays); and

• secure clinical records for the outpatient area (more than 50.000 a year, increasing strongly).

KABEG (Carinthian public hospital holding) was the leading and coordinating organisation in this telemedicine project. In 2002, the Regional Health Board established a KABEG-based coordinating unit for all Carinthian e-health and telemedicine activities supported by the Board. Physicians, public insurances, social service departments and delegates from different healthcare organisations are involved.

KABEG is the holding company of five public hospitals with some 2.700 beds; (additionally, the Carinthian government has outsourced four care units for chronically ill patients with 266 beds). 6.350 employees provide 70 to 80% of the Carinthian inpatient treatments (about 130.000 inpatients and 550.000 outpatients a year).

The following diagram shows the present healthcare infrastructure in Carinthia:

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Additionally, the regional Ministry of Social Affairs has implemented a GPRS/UMTS based mobile documentation system for homecare treatment, using centralised storage and communication between the providers involved. These are 12 nursing organisations with about 1.500 employees providing about 880.000 hours of assistance for thousands of patients, many of whom are chronically ill. These organisations are co-financed by the Carinthian Government. The staff of all these organisations currently use the same mobile multitenancy system for collecting data when at patients’ home and then transmit them.

Social Services

The Carinthian Department of Social Affairs is responsible for the social services.

About 35,000 Carinthians are currently dependent on nursing care; this is approximately 6.4% of the total population. This percentage is expected to increase dramatically. Currently, there are about 8.000 persons consuming mobile care, provided by 12 mobile care organisations with 1.400 employees. 4.500 persons are looked after in care homes. 22.000 persons are cared for on an informal basis by relatives.

At the same time Carinthia is implementing the so called PGS (Pflege- und Gesundheitsservice). The “PGS” service sees itself as the central contact partner in questions concerning health, social concerns and the provision of care. Citizens are provided with a central regional telephone number. A “health and care provision adviser” works at the Centre, who can provide citizens with information concerning all relevant issues relating to health, social concerns and the provision of care.

In order to connect existing ICT structures, Carinthia is aiming to implement technical solutions. SeniorPad Entwicklungs-KG is developing, and has developed a prototype for a “SeniorPad” (“a small computer with specific software and new kinds of information and communications technology”), which will improve the quality of mobile care. The model project covers the application areas home monitoring, social integration, care provision and safety. With the prototype, it is intended that the potential should be identified for further development of existing services, as well as new, appropriate and effective measures and services in the mobile care sector, and for new measures and services to be devised. It is the

St. Veit PI, TR, TK TK-Bild Waier

Klagenfurt TR,(TP),PI, TK-Bild, RK

Wolfsberg

TR,TK,RK,PI, TK-

Villach

(TR),PI, TK,

RK, TK-Bild

Hermagor

TR, PI,

TK, TK-

Laas TR,PI, TK,

TK-Bild

Spittal TR, TK, PI, TK-Bild

Friesach TR,TK,(TP), (PI),

TK-Bild

KABEG hospitals Hospital of Spittal consort. conf. hosp. Sanatoriums

WAN – Corporate Network KABEG WAN Communication with 250 practitioners (increasing) in the outpatient sector (TK)

DL KAGES

H Lienz

KAV Tilak

Picture- (& Indexkom-munikation)

PI … Patient index; RK … Ordering Red Cross; TK … Communication with practitioners; TP … Telepathology; TR … Teleradiology; ( ) … some limitations; TK-Bild … Teleconsulting (Neurosurgery,…) with pictures

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first model project aimed at supporting longer independent life at home, and thus offers a possibility to avoid or at least defer (expensive) residence in a nursing home.

Another innovative technical solution is going to be developed for to ensure that medicines that have been prescribed by a doctor are handed out to the customer at his or her home, promptly and in the right quantity, and individually packed. This project is also particularly important for safety reasons. It is estimated that a large number of hospital admissions are due to elderly people at home forgetting to take their medication, or taking the wrong medication. The intention is to evaluate the level of cost saving to be achieved as a result of saving working hours spent by qualified nurses who are currently responsible for the preparation of medications in the context of the mobile services.

As well as the structures of Renewing Health already implemented, we want to combine the above mentioned piloted projects in the context of SmartCare.

B.1.1.3.2 Germany

B.1.1.3.2.1 Baden Württemberg

A key problem of the German health service system is its institutional fragmentation: Public health services, primary and secondary ambulatory (outpatient) care, and hospital (inpatient) care are organised and financed largely independently from each other. The separation between clinic-based (ambulatory) and hospital-based (inpatient) physicians is stricter than in other countries. This historical division of health services is connected to a reimbursement system without incentives for outcome-oriented healthcare, or prevention, so that quality and value-based incentives have been virtually non-existent [Schlette, 2009].

The shortcomings of such a fragmentation into health care sectors have often been noticed. Probably the most obvious problems are insufficient follow-up care after patients’ discharge from hospitals or rehabilitation clinics: Very often, medication diverges prior, during, and post hospitalisation, which irritates the patients and reduces their adherence. As a rule, it takes more than two weeks for German primary care physicians to “receive a full report from a hospital once their patient has been discharged” (ibid.). Insufficient communication leads many providers to perform redundant services and, therefore, to unnecessary cost. For the concerned patients, these redundant services imply not only a waste of time but also – at least in some cases such as X-rays– unnecessary risks. The idea of implementing mutually compatible electronic means of communication and data processing between cooperating providers has remained a utopia for German normal care, with 68% of primary care physicians working in solo practice and another 31% in small group practice (ibid.). The same holds for the idea of creating a system of electronic patient files accessible to all providers treating a given patient (patients’ informed consent provided). Sometimes the shortcomings of a fragmented healt care system are exacerbated by specific reimbursement schemes, leading to blatant inefficiency. In hospital care, where fee-for-service reimbursement in the DRG-mode prevails, unfortunately it makes economic sense for a hospital to render more operations than necessary by itself – regardless of whether other providers are possibly better qualified or may render a given service at a much lower cost or whether the operation could have been prevented by conservative medicine. On the other hand, in a reimbursement system with budgets – this applies more or less to the outpatient care - it may be economically sensible for a primary care provider to transfer services to another sector (for instance hospitals or secondary care provider) despite a considerably higher overall cost. [Hildebrandt, 2009, p. 154].

One of the most severe problems of most current health service systems is that there are no effective incentives for health promotion and prevention: Health care providers are rewarded for their efforts in treating diseases, but not for preventing them successfully. In general, many current health service systems lack an effective system of incentives that would lead providers to consider a kind of “systemic” or “macro-rationality” in their actions.

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Considering such inefficiencies, healthcare legislation in Germany initiated some innovations with healthcare reforms from 2000, implying more favourable conditions for integrated care solutions (see Schlette, 2009). According to the Statutory Health Insurance Modernisation Act (“GKV-Modernisierungsgesetz”, abbrev. GMG) adopted in 2004, Germany’s health insurance companies were allowed to spend 1% of their total expenditure on integrated care programmes. This act was in effect from 2004-08. Contrary to the expectations of responsible health politicians, however, the overwhelming majority of integrated care projects which have come into being since 2004 have focused only on a few specific indications (e.g. hip or knee surgery) and have usually integrated two sectors (e.g. inpatient care and rehabilitation) and occasionally three sectors (e.g. inpatient care, rehabilitation, and pre- and post-surgery ambulatory care).

One of the most advanced integrated care contracts realises a population-based integrated care system, covering all sectors and indications of care for a given population. This population-based integrated care system is located in the Kinzig valley in the Southwest of Germany; it is called “Integrierte Versorgung Gesundes Kinzigtal” (“Healthy Kinzigtal Integrated Care”). Gesundes Kinzigtal has a population of approximately 70.000 inhabitants.

B.1.1.3.3 Denmark

Denmark has a population of approximately 5.5m inhabitants, and the Danish health service is nationalised. Administratively, the country is divided into five regions, which are responsible among other things for healthcare and for running 60 public hospitals with a total of 21,000 beds. Furthermore, the regions have agreements with 3,500 GPs. 98 municipalities also have tasks regarding healthcare, including home care and rehabilitation.

Approximately 3,500 GPs constitute the primary interface with citizens, and act as gatekeepers in relation to the healthcare sector. The health service also has approximately 1,000 specialist doctors and 250 pharmacists. All players in the health sector use IT as a tool of their trade; a large proportion communicate electronically via the health service data network: 98% of laboratory orders and resorts are electronic; 89% of all prescriptions are electronic. The five Danish regions are responsible for regional IT solutions. A number of public-sector IT organisations develop joint solutions nationally, which the decentralised players undertake to implement.

eHealth is very commonly used throughout all branches of the Danish health service, and today IT supports a great many work processes, including processes that reach across organisations and sectors. This has also helped to make a large number of services available for citizens and healthcare professionals alike. Alongside personal contact with the GP, the web portal sundhed.dk is the citizen’s most important interface with the healthcare sector. Here, citizens have direct access to knowledge and advice about their own condition and treatment, and about illnesses and health in general. Digital services to citizens are based on the fact that a considerable amount of communication between healthcare professionals – hospital wards, GPs, specialist doctors, laboratories, pharmacies, and physiotherapists – has become digital over the past 15 years. It began with electronic exchange of messages between healthcare professionals via MedCom standards. Communications such as prescriptions, referrals, laboratory orders and responses, etc., are exchanged daily. In January 2010, more than 5 million communications were exchanged. Over the years, the repertoire of communications has expanded considerably, and the infrastructure has been extended to include more and more aspects of the health service. Concurrent with this, Internet technology has been adopted, so now communications also include web services, and telemedical solutions are rapidly being developed. Throughout the development process, efforts have remained focused on giving healthcare professionals access to flexible knowledge searches and internal communications, and, at the same time, enhancing the quality of the services that the healthcare sector is able to offer to citizens.

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The history of MedCom - the Danish Healthcare Data Network (DHDN) - goes back to the late 1980s, when interest in electronic communication among healthcare providers grew. It is a long-term project that enables effective data transfer between several actors of the health service, including stakeholders of the community-based social care system. This national network allows fast information flow in the form of reliable data exchange of EDIFACT or XML-based messages among the respective software systems of the participating healthcare providers. Agreements on interface specifications as well as certification of software compliance with agreed upon standards and syntax allow for optimal interoperability. Data transfer begins at the point of care for patients and GPs. From there, services that citizens may need access to include pharmacists, diagnostic services and specialist consultation at hospitals, referral to and discharge from a hospital, and transfer to home care and residential care services. Effective access to these by citizens depends on the efficient exchange of messages between health and social care providers and other actors.

The Region of Southern Denmark is in the midst of the process of developing a so-called SharedCare platform supporting the Danish ‘programmes for the continuity of care’ and

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thereby also supporting the cross sectorial collaboration (communication and sharing of data) for patients with chronic illnesses. The process involves the primary care sector, the regional hospital sector, the municipal social care sector and the patients themselves. The SharedCare platform is developed generically to include future technologies and types of illnesses, therefore SmartCare is welcomed as a project in which further deployment and exploration is possible. The SharedCare project supports the recent Danish trends on integrated care and adopts the common dataset standard for chronically ill patients whenever ready. This dataset standard is developed in other large scale projects by the non-profit organisation MedCom. The Danish pilots in the SmartCare project will utilize the existing national as well as international infrastructure, workflows, and care service delivery processes to ensure a consistency between the current status and the project developments. Through SmartCare, the Danish pilots will share experiences from the Danish health and social care system as well as further explore and deploy care service delivery in Denmark through the set of services defined as part of the project.

The Danish pilots will therefore aim to support care service delivery processes between GPs, hospitals and municipal care organisations through existing and new infrastructural and technical products and services as offered on the one side through SmartCare and on the other through existing initiatives.

The diagram above shows the SharedCare platform and its infrastructural relations to the GP electronic health care records and their data capture, to the hospital EHRs, to the local and municipal electronic care records and health systems, and finally its relations to the patients in their own home with home monitoring and various eHealth applications.

B.1.1.3.4 Estonia

Estonia has a population of 1.31 million. Due to demographic changes, population ageing in Estonia was delayed for 40 years, but accelerated rapidly at the end of the 20th century.

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People 65 years and older accounted for 17% of the total population in 2010. By 2050 it will be 24% of the total population. The average life expectancy in Estonia is 73,2, while the average of European Union (EU) is 78 years.

Estonia has vigorously and quite successfully reformed its health system over the last decades. The current system is built on solidarity based health financing; a modern provider network based on family-medicine centred primary healthcare (PHC); modern hospital services and more attention for public health. This has resulted in a steadily increasing life expectancy and continuously high satisfaction rates with access and quality.

In Estonia, the main political document in the field of health is “National Health Development Plan 2009-2020” that reflects the issue of e-health or usage of IT solutions: to assure a quality health service to all people through optimal usage of resources; contemporary ICT tools (including telemedicine) have to be taken into use.

ICT solutions are seen as one of the possibilities to improve the situation in the healthcare sector. By maintaining a healthy population and increasing the ability to work, human well-being and life expectancy will increase. ICT is seen also as a tool to facilitate taking care of the elderly.

Since 2000, the eHealth strategy of the Estonian Ministry of Social Affairs (MoSA) was based on three pillars: establishment of a nationwide integrated electronic health record system, also known as the "Electronic Health Record Project of Estonia (2005 – 2008)”, strong focus on standardisation and in particular on a interoperability, and the use of the existing ICT infrastructure. The cornerstone for successful Estonian e-solutions is a modern e-state infrastructure, commonly known as “X-Road”. Digital signatures and ID cards are the basic elements which enable the creation of new, high quality e-services.

The strategy foresees a comprehensive central register of the health information for all 1.35 million Estonians from birth to death. The register is intended to facilitate the exchange of all types of health data between healthcare providers. It is also meant to support centralised healthcare management and strategic planning through better quality and accuracy of the necessary data for organising healthcare.

The Electronic Health Record Project initiative will also support the provision and usage of eHealth services for and by the public in Estonia. All patients will be able to securely access and review their medical data, and make it available to the healthcare professionals they are dealing with. This also includes the ability– via the Internet – to obtain appointments online, submit prescription renewal requests, and exchange test results such as blood pressure readings.

B.1.1.3.5 Spain

Healthcare in Spain is highly decentralised. Responsibility for providing healthcare was officially transferred to Spain’s 17 Regional Governments in 2002. Regions vary considerably in size, the largest ones being Andalusia, Catalonia and Madrid with a population comprised between 6 and 8 million, while La Rioja has just 300.000 inhabitants.

Because of the high level of decentralisation, initiatives in the area of eHealth in Span are mostly taken by Regions rather than by the National Government. Nevertheless the National Government has an important role in terms of providing guidelines and recommending technical and organisational standards, and a framework for the exchange of data between regions. A fundamental right that it is recognised for all Spanish residents is the conditional access to their own EHR.

The National Government equally provides a backbone for the electronic exchange of clinical data which ensure the required level of security at national level. Access to the backbone is based on digital certificates; data travelling across the backbone are encrypted and digitally

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signed. Each Region in turn has its own health network. These vary very much in size and number of access points because of the huge difference in size between regions.

Web services were introduced a few years ago at the national level. They enable not only an exchange of administrative data between Regions, but also the exchange of e-prescriptions and EPRs, and this helps dealing with the increasing mobility of patients. These services also cater for financial compensation between Regions. The national web service system consists of a central Control Centre which handles the message traffic and provides a number of additional functions. The Control Centre does not store data, but makes available services and applications which enable to access data stored within a Region from another Region.

These web services enable the exchange of information from the database of information of users of the electronic health card. They permit the exchange of information of electronic recipe and electronic health record.

There is a common health card database for the whole of the SNS (National Health Service) which allows the unequivocal identification of each individual patient. In addition, a healthcare intranet has been put in place allowing the exchange of information among the different communities through the central node housed in the Ministry. At the same time, an agreement has been reached about what is the relevant clinical data the HCDSNS has to include to ensure good healthcare.

The digital medical record project of the SNS (HCDSNS) has completed its final phase of development. The system was applied all over Spain in 2010.

Currently, 97% of family doctors and paediatricians have the possibility of using the HCDSNS.

The information on electronic prescriptions will flow through the NHS communications network.

B.1.1.3.5.1 Catalonia

Although communication networks are a factor limiting the expansion and development of new telemedicine projects, advanced solutions can be found in a good number of centres, based on open platforms and integration of different services.

Currently, the Autonomous government is promoting a new model of care, based on the integration of services and defining new programmes for the attention of the elderly and chronic patients, having patient oriented telemedicine services as an essential element. This policy, running for the last 7 years, has promoted alliances between the main players in the healthcare arena, and originated a number of initiatives to promote the integration of different systems.

Today, tele-radiology, tele-diagnosis and tele-consultation, as well as web-based resources, are widely available, offering a new provision of competitive and cost efficient services.

On the other hand, the organizational, cultural and legal aspects related to telemedicine are still an obstacle to deployment. In order to develop global telemedicine projects, the Ministry of Health is tackling a number of issues and working with the different stakeholders. Some of the most relevant challenges are:

• The significant fragmentation of the providers of the Catalan System.

• The lack of multidisciplinary work culture.

• The implications that a new channel for supplying services can have from a legal aspect.

• The resistance to change that professionals may have when faced with new ways of working, new tools and new technology.

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Faced with this scenario, the Ministry is investing on two fronts: 1) developing communication infrastructures; and 2) promoting interoperability as a key factor for the deployment of projects, ensuring communication and integration with existing applications.

In this context, telemedicine is one more channel to supply services, and its integration with current information systems and with EHR is of the utmost importance.

The current most relevant telemedicine services in Catalonia include COPD, Tele-ictus, diabetes, and renal transplanted patients monitoring programmes, covering radiology, tele-consultation, tele-diagnosis and videoconference.

The COPD programme

The integrated care programme (ICP) for chronic patients is a mainstream programme at Hospital Clinic Barcelona (HCB) since early 2006. It represents a natural evolution from previous successful pilots carried out to validate innovative integrated care strategies, mainly in patients in whom the predominant disorder was chronic obstructive pulmonary disease (COPD).

The Tele-ictus program

Based on 13 reference hospitals, covering 10 territorial areas, each of the 48 hospitals prepared for admitting ictus patients were within the range of at least one of the reference hospitals.

In each of the territorial areas, the different levels of the health system were organised so that patients with acute ictus entered the “ictus code” and were taken as quickly as possible to the suitable reference centre.

For The Tele-ictus programme, telemedicine has been the tool to interconnect reference centres and their regional hospitals, facilitating the ictus specialists to visualize in real-time the radiology image of the patient, providing tele-consultation and tele-diagnosis.

The diabetes telemedicine project

The project meets the need for implementing a monitoring system for diabetic patients that optimizes the control of visits and avoids unnecessary journeys, while maintaining the correct metabolic control of patients.

Data capture is made either via mobile phone, able to handle a glucometer and the data transfer, or using the web service via Internet. In all cases, the patient is given a glucometer and/or a microinfuser Accu-Chek, which by means of infrared allows transmission via cell phone or Internet. Health professionals revise the data and send their recommendations via SMS.

The renal transplanted patients monitoring programme

The Hospital Universitari de Bellvitge in Barcelona is the reference centre for transplantations in Catalonia, and the leader of the initiative. It covers the most populated area of Catalonia. Most of these patients live quite far from the hospital, and greatly benefit from the telemedicine service the hospital has put in place: the renal transplanted patients monitoring programme, based on videoconference facilities to monitor patients who have undergone a kidney transplant and are living far from the health centre. The videoconference substitutes some of the needed consultations planned for kidney transplanted patients.

B.1.1.3.5.2 Aragon

Aragón is a region located in north-east Spain where 1.204.215 citizens live in an area of about 50.000 km². Aragon comprises three provinces: Huesca in the north, Zaragoza in the middle, and Teruel in the south.

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The SALUD (Aragón’s health service) is a public provider of all healthcare services in Aragón. These include primary, secondary, mental and geriatric care. SALUD is subdivided into eight Health Sectors; two of them participate in the pilot in Aragón.

The Huesca Health Area comprises the Barbastro and Huesca Health Sectors. It is in the north-east of Aragón, and shares its borders with France, Catalonia, Navarre and the rest of Aragón. It has distinct geographic areas: The mountainous northern area has some of the roughest peaks of the Pyrenees, the centre is crossed by Guara Sierra, marked by canyons and ravines, and the south is flat. The Huesca Health Area looks after 220.000 inhabitants and its population is older than in the rest of Aragón and Spain.

Social and home care are provided by Instituto Aragonés de Servicios Sociales (IASS); an autonomous organisation reporting to the Department of Social and Family services of the Government of Aragón. Its main objective is providing services to citizens so as to maintain and possibly improve their quality of life. Via the IASS, the Regional Government offers to the older people the following services: grants for social care in elderly homes, elderly homes, day-care centres, respite stays at elderly homes, cyber classes, spas, classes for elderly, etc. Towns and counties also contribute to improve the quality of life of elderly citizens, and provide resources for homecare services and maintenance and management of elderly homes and social clubs.

Available elderly care resources in Aragon (2003)

• homecare service: 7.695 users (2,9 for every 100 65+ elders);

• day-care centres: 46 with 1.478 places (0,6 for every 100 65+ elders);

• social clubs: 313;

• protected homes: 5;

• elderly homes for assisted elders: 65 homes with 4.985 places (5,48 for every 100 dependent 65+ citizens);

• other homes for elders: 202 with a total of about 9.000 beds.

The figure and the table below give the distribution of dependent people inside Aragón and the comparative figures between the Huesca Health Area and the whole of Aragón.

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Year 2005 Total Population aged 65+ Dependent people with major dependence

Figure 2 - Distribution of general population and dependent people in Aragón

Year 2005 Total population Population

aged 65+ Dependent people

People with major dependence

Aragón 1.269.027 267.453 40.677 7.294

Huesca H.A. 223.761 51.896 7.893 1.454

Table 1 - Summary of total and elderly population for Aragón and Huesca Health Area

SALUD Healthcare Area infrastructure and services

SALUD owns 10 nodes (one for each area plus emergencies and the central node – CETEC) and 12 data centres that host patient’s clinical information, one for each node, with a total capacity of 137TB and 468 servers. These nodes host all departmental and corporate applications and databases for each sector. A fibre optic cable links nodes, with a bit rate of 1 GB-100Mb between hospitals. 124 centres and 718 consultations have ADSL lines.

SALUD provides multiple systems and services to their patients and professionals, the most important being:

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• The users database (BDU), that identify all users in the region.

• Primary care electronic health record (OMI AP) in all centres and medical offices.

• Clinic Intranets: Every hospital has a corporate intranet for professional use integrated with the primary care clinical record (OMI-AP).

• Salud Informa: A web page oriented to citizens where among other services, users have free GP choice.

• Hospital management system (HIS): Application that hosts all clinical activity at the centres and provision units of Aragón’s healthcare system.

• Emergencies services information system (PCH) deployed in all sectors.

• Radiology images digitisation: an images storage and managment system (PACS) and an radiology information system (RIS) deployed in 7 out of 8 sectors.

• And others such as the e-prescription in pilot phase, telemedicine solutions, nursing care information systems, data warehouse and business intelligence, patients manager (to help in the clinical management and coordination of all health agents - under development), knowledge portal, online training tool, user’s call centre, management and support to systems centre.

Barbastro’s Healthcare Area Infrastructure

Barbastro’s Healthcare Area (SALUD – Sector Sanitario Barbastro) has worked in a very active manner in the last decade in the deployment of several telemedicine solutions in the sector.

Firstly, and thanks to several European projects, the sector was provided with devices and systems creating a niche of technology, communications and information systems needed to deploy telemedicine solutions across the rea. Barbastro’s Healthcare Area was provided with a wide band communication network connecting all centres in the territory. Radio-frequency antennas were installed at Barbastro’s hospital, an image storage system for Aragón’s area (PACS), telemonitoring devices and videoconference systems were set up for the whole organisation.

Once the territory had been provisioned with technology, Barbastro’s Healthcare Area worked on the deployment of basic telemedicine services, such as teleadvise, that allows a two-way communication between specialists to offer healthcare assistance across the whole territory. More services such as teleconsultations, teleradiology, telelaboratory, tele-ophthalmology and teleictus were created. All these services assist the total population of Aragón. Dermatoscopes for 3 out of 8 sectors in the territory were bought, and currently telederma is being included in the set of services available.

One of the main tools provided is the clinic intranet, a portal available to all staff in the healthcare sector. This web portal gives access to the applications of each service enhancing the professionals’ daily tasks, avoiding waiting times and the need for sending documents. The intranet supports looking up patient data, health records and tests done. It also provides access to other tools, statistics, and files selection.

Beside these basic services, nowadays the healthcare area has been working on the tele monitoring of patients in the rural environment, especially older people with chronic pathologies. The aim was to provide a service to track vital signs to prevent health problems. This service makes it possible to control patients in an easy way, unblocking waiting lists, clearing healthcare centres, and preventing health problems as patients feel much more controlled due to the continuous checkups. This service was provided under the DREAMING European project, (7th programme Framework project).This pilot has 80 (40+40) patients on the monitoring programme.

This service was enhanced with more services to embrace other ranges of population, such as chronic dependent elders, which includes social organisations in vital signs collection –

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33+33 patients on trial, and patients living it homes for the elderly, which defines a telemedicine network for rural areas together with France and Portugal

All services were evaluated with both clinical indicators and economical indicators, and assure patients’ privacy and security following the guidelines described by the ethical evaluation team.

Another important working area was to train the population in health topics through encouraging participation in e-learning programmes. Several courses have been made and promoted on themes such as nutritional advice to avoid/prevent chronic diseases (based on the genetic load and user habits), guides of best practices, pregnancy and birth, anticoagulant treatments, etc. Those courses were integrated on open free communications such as television and DTT.

Nowadays, Barbastro Healthcare area is working on policies of patient empowerment. SALUD provides a web page (www.saludinforma.es) where users have access to several resources and services, such as booking a consultation with a primary care doctor. This set of services will be broadened with a subset that permits users to have a more active role in the management of their own health through a platform to have access to their EHR and clinical results.

The sector is working on creating a technological platform with global access to provide health services and tele-assistance throughout the world, based on advances in video collaboration solutions. This environment will be able to integrate units from different centres with the aim to integrate virtual specialised assistance services, including home hospitalisation.

B.1.1.3.5.3 Basque Country

Administrative and economic management is supported by a SAP system. The current technical infrastructure has different applications related to electronic clinical records, radiology imaging, laboratory, pathology, prescriptions and others. A system integration approach has been developed in the last few years. It has allowed, via a BUS integration package, to create a Personal Health Folder that allows citizens to access their own clinical data and other administrative services via the web.

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The Department of Health and Consumer Affairs of the Basque Government, through the Basque Health Service (Osakidetza), is supporting the setting up of a Multi-channel Health Service Centre (MHSC) which will increase the number of ways in which the public can interact with the health system. OSAREAN is the ICT strategic project of Osakidetza for e-health and telemedicine in the Basque Country. This project is critical from the point of view of chronic care, as it serves as a tool with which to maintain the level of low intensity constant contact which is required by chronic patients, in contrast to the sporadic high intensity contact which acute patients receive from traditional face-to-face care. The aim of the project is to use all the available channels of interaction (web, telephone, SMS, digital TV, etc.) between the citizen and the health system in order to facilitate the care procedures. It will provide them with greater flexibility and more decision making capacity, in such a way that interactions between the public and the health system interfere less with their personal life and work. Furthermore, it adds value to the medical work, offloading administrative procedures, monitoring activities and routine check-ups, with the aim of focusing on higher value activities. Last but not least, it promotes the involvement of citizens with their own health, and patients with their illnesses, using channels complementary to face-to-face, as a key strategy to improve health results throughout the health system, converting citizens into agents of the health system.

The final objective of the MHSC is to help the Basque Health System to fulfil its objectives and to contribute actively to the transformation of the current health system, providing Basque society with remote multi-channel mechanisms of healthcare provision through the application of ICT and telemedicine. It will bring public services closer to citizens making use of new technologies, improving efficiency in the use of resources, and by introducing demand management mechanisms which will contribute at the same time to an improvement in the quality of services provided.

As far as the principal services to be provided are concerned, the MHSC enables administrative procedures to be carried out (primary care appointment management, reminders and/or confirmation of appointments, medical certificate reports, TIS (personal health card management, etc.), and makes general health service information available to the users (range of services, health centre directory, night clinics and duty pharmacies). Moreover, it fosters health promotion, information and education, through patients’ forums for the promotion of healthy lifestyles, vaccination reminders and information regarding public health programmes. Chronic patients will also receive training in the management of their illness; remote monitoring will be promoted in order to carry out precautionary action during phases of medical destabilisation; coordination between health services will be fostered (e.g. with emergency services, access to medical data and guidelines and online corporate protocols). There will also be a telemedicine home care service (remote assessment systems and telemetric monitoring) for domiciliary chronic patients, multipathology patients, and those with advanced or unstable pathologies.

Finally, the MHSC will provide medical advice and will enable the citizen to access information regarding his or her health (personal health file).

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Beti-On is the telecare services that are publicly financed by the Regional Government and provided on a contract basis by a single private provider. People on telecare services are those persons over 65 with a demonstrated dependency, over 75 living alone, dependent mentally or physically handicapped people, and at-risk isolated persons. Telecare services provide phone care 24/7, immediate response to emergencies (health, fire, theft, etc.), and periodic follow up contact by visits or phone. By the end of February 2012, 24.754 people were covered (6% of all those over 65 years and 16% of the over 80´s). The average number of phone calls per month is 25.000, only 6% of them actual emergency calls. Since December 2011, Beti-On users can get access to the health counselling on-line service of OSAREAN. It includes an appointment with the GP if needed. In the first three months, 2.751 consultations have been made, 30% have been solved just by phone.

B.1.1.3.5.4 Extremadura

In the Autonomous Region of Extremadura, care services for the elderly and people in situation of dependency is delivered by different factors, mostly from public sector or private-public partnerships, which are providing them independently and in many cases, uncoordinated :

• Municipalities: providing home care services and basic social services;

• NGOs through agreements with the regional administration: providing telecare services;

• Public health services providing primary care services;

• Private firms: managing day centres and old people's homes.

The system in the region is coordinated by the Service for the Promotion of Personal Autonomy and Care for Dependence (hereinafter SEPAD) under the Ministry of Health, in the Government of Extremadura. The other participating actors will be involved in the range of this regional department, the only one with complete competences in the attendance of elderly people in the region.

These integral competences for SEPAD are the consequence of the Personal Autonomy and Dependent Care Law (39/2006). It guarantees public support for people who cannot lead independent lives for reasons of illness, disability or age. The diversity of care arrangements covered by the bill will lead to the creation of formal employment and to a regularisation of previously undeclared employment, which is rather common in the field of domestic care.

Other key factor of the region is the service of Home Telecare that it is already provided in the rural areas of Extremadura.

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This technological infrastructure involves the installation of a terminal in telephone line of the house and a “medallion” that serves as a remote switch, connects older people with a call centre available 24 hours a day.

Nowadays, 8,900 people from Extremadura benefit from telecare service that was implemented in 1993 and has been awarded the Certificate N (Quality in Services) by the Spanish Association for Standardisation and Certification (AENOR).

B.1.1.3.5.5 Valencia

Health Data Network

The Ministry of Health of the Region of Valencia has developed a data network that named ARTERIAS that connects more than 450 health and administrative centres across the whole region.

Originally created as a network for transferring basic alpha-numeric data and emails, in the last years it has evolved to accomplish three major milestones:

1. Development of new applications with a central architecture based on data repositories.

2. The evolution of internet and the addition of web based GUI and multimedia applications, extremely useful in the health domain (telehealth, telerehab, teleimaging)

3. Meeting the increase in the requirements of legislation on personal data protection and the classification of healthcare data as Level 3 data, according to the National Real Decreto 994/1999.

In order to face those challenges, the network infrastructure has been adapted to increase connectivity with the addition of new centres, the overall bandwidth, and line and device redundancy. Thus, the network assures high quality access to healthcare information systems for any health professional anywhere in the region.

In line with this, and in order to comply with the current needs of voice and video/image traffic, the network has evolved into a multi-service network with the capability to manage voice, data and video traffic. The network supports the following functionalities:

• Quality of service.

• Bandwidth optimisation.

• Security, with a single Internet entry point to centrally manage security policies.

This network transports health data; it is thus subject to very strict security measures. On the other hand, there is an increasing demand for remote access to the network, from different entry points and organisations: tele-workers, maintenance companies, public bodies (e.g. National Health Ministry), non-public health organisations (e.g. private hospitals), etc. These connections are often carried out through different technologies such as RDSI, RTC, ADSL, GSM, GPRS, UMTS and other telecommunication operators. To provide support for all these needs, the network provides the following services:

• Remote access server allowing connections from outside the network.

• VPN service enabling encrypted traffic.

• Authentication server to validate users and enable security reporting.

• Management Centre: hardware and software centre providing monitoring, maintenance, quality and security control and technical support to the network.

This health data network is deployed across the whole of the region of Valencia, and provides connection to the corporate integrated applications to all health stakeholders of the region.

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Health Information Systems

The Department of Health has developed the Information Systems Plan 2009-2011. Within this plan, the regional government states that, assuming that information is essential for appropriate decision making, ICT is an essential tool for assuring health system performance, and to improve equity, quality of care, safety, productivity and efficiency.

Conscious of its strategic importance, the Valencia Health Agency (AVS) made a strong commitment to improving information systems, with a significant investment of effort in this area. Within this plan, a new Health Information System (SISAN) of the Generalitat Valenciana has been under development in the last few years with a strongly integrative approach that considers homogeneously all aspects of the organisation. The SISAN system includes four main domains:

• Primary care (ABUCASIS).

• Hospital care (ORION).

• Extra-hospital emergency care (CORDES).

• Central Services (SSCC) and Public Health.

There are three blocks of information systems that cover the areas of care, logistics and business intelligence, as well as all activities that enable the management of each project: development of applications, channels of access to systems, ICT infrastructure, support for the activity, quality and continuity of services, and finally those aimed at coordination of investigation and innovation as the evolution of healthcare.

SISAN Modules

1. ABUCASIS: This is a complex system for the support of primary care, and combines both former and new developments. Its main modules are:

• MOS: management counters and appointments for both primary and specialised primary (e.g. paediatrics).

• GIP: comprehensive management of patients.

• GAIA: pharmaceutical benefits and electronic prescription.

• RVN: nominal immunization registry.

2. ORION: Integrated information system for hospitals and specialised care. This hospital management system provides a comprehensive approach, both in the clinical aspects and in management, administration and financial control; additionally, it is fully connected with the daily patient care system (ABUCASIS).

The main components of this system are:

• ORION-Clinic: ○ ORION-HIS: clinical management system for basic hospital care (admission,

consultations, surgery, appointment management, referrals, etc.). ○ ORION-FARMA: assisted prescription and management of hospital

pharmaceutics department. ○ ORION-RIS: management of the medical images services, including data

exchange and remote referral.

• ORION-Gestion: ○ ORION-LOGIS: information system for logistics management (recruitment,

procurement, storage and maintenance). ○ ORION-PERSO: information system for managing human resources.

3. CORDES: Information system for emergency coordination and hospital emergencies.

4. Central Services and Public Health: The SSCC and Public Health are fully integrated with all the rest of applications and provide the overall network with the following functions:

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• SIP: Population information system, providing unique identification of patients linked to the national identity card (obligatory in Spain) and the Social Security number.

• CRC: Corporate Resource Catalogue, providing a series of common data tables that are used in the different systems to ensure integrity and uniqueness.

Additionally, the SSCC and Public Health module includes the following functionality and subsystems:

• Data Warehouse: enterprise data warehouse.

• CIRO: comprehensive and centralised system for managing personal health.

• COBRA: information system to manage processes and exploit the information in the field of healthcare addressed by the Department of Health but that should be covered by other funding schemes.

• COMPAS: Billing centre.

• SIE: economic information system.

• Legionella portal.

• Microbiological monitoring network.

• SISGEREN: Centralised management.

• Traffic Accidents Prevention Programme.

• Health Portal.

B.1.1.3.6 Finland

National eHealth infrastructure

Despite of being a sparsely populated country with 5.3 million inhabitants and the surface area of 338.000 km², the healthcare system in Finland is working well according to common indicators5. Health expenditure is 8.2% of GDP, which is below the OECD average, and the inhabitants are relatively content with the services. However, the waiting times for public health services are long in many healthcare sectors, and there are also remarkable inequalities in access to services. Furthermore, the population aging rate in Finland is one of the highest in the world. The ageing of the Finnish population will start to affect the social and health service systems in the next few years; demand for services will increase in both the social services and the healthcare sector. Regardless of the development of the public economy, addressing this challenge requires that the service system is revised radically in order to ensure adequate services for the elderly in particular.

A major structural challenge for efficiency is the fact that provision of care is distributed to several organisations. Primary care services are provided by 229 health centres owned by the municipalities. Specialised health care services are provided in central and regional hospitals organised in 20 hospital districts. Private healthcare services are available in large cities - mainly providing out-patient care, and in particular occupational health services. It is typical for a patient to use both public and private healthcare services.

Efficient usage of ICT has been recognised as an important enabler for the provision of high-quality and cost-effective healthcare throughout the nation. Remarkable improvement has taken place during the recent years in the adoption of electronic healthcare records (EHR), which are currently used by all public and private healthcare providers. Also, the infrastructure for exchanging laboratory and imaging results within the hospital districts largely exists. However, the availability of patient information across organisational boundaries is still limited. In particular, this is the case when information should be transferred between hospital districts. In order to provide nationwide availability of patient information, a centralised EHR archive (eArchive) is currently being implemented. All public 5 eHealth in Finland, Social Insurance Institute of Finland

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and private health providers are obligated to connect with the archive. The eArchive will be operated by the Social Insurance Institute of Finland as part of the so-called KanTa services, which also include national services for ePrescription and online citizen access to the EHR. The KanTa services will be gradually available by 2012. HL7 standards are used in order to facilitate integration of existing health information systems with KanTa.

Concerning telemedicine services, consultation between professionals is widely doen by using electronic referral systems, videoconferencing, electronic mail and specific applications such as systems for transmitting ECGs (electrocardiograms) from ambulances to emergency clinics. The usage of telemedicine applications targeted to citizens at home is gradually increasing. Electronic appointment booking and online forms for providing patient information are most promising applications in the short term. Self-care of chronic diseases is considered extremely attractive due to the potential savings implied by avoiding unnecessary visits to health centre or hospital. ICT based systems targeted for home monitoring of chronic diseases, such as diabetes, are largely available.

The importance of interoperability related to telemedicine has been recognised by all stake holders. The importance of interoperability has also been identified as the key success factor for Personal Health Records (PHR), which are increasingly offered to the individual as a tool for managing personal health.

B.1.1.3.6.1 The South Karelia Social and Health Care District, Etelä-Karjalan sosiaali- ja terveydenhuollon kuntayhtymä

The South Karelian Social and Health Care District (Eksote) is responsible for the care of approximately 135.000 inhabitants, and in 2010 covered nine separate municipalities. Primary healthcare, specialist healthcare and social care were merged in 2010 for all the municipalities in the District with the only exception of one municipality which will still retain responsibility for primary health and social care. This reorganisation makes it possible in the future to develop really integrated care processes.

The aim is patient-oriented healthcare. Patients are planned to get as much as possible of the care they need at their homes. Technology (telemonitoring, phone calls etc.) must be developed to help this aim.

In order to improve information access across organisational boundaries, the same electronic patient record system (Effica) is used in healthcare centres and hospitals of all eight communities. Nurses can send messages to GPs, and GPs to specialists. This enables achieving continuity in the care process, and saves time for both patients and healthcare personnel.

Eksote has represented both the public community and the end-users in several international development projects, such as ISISEMD (Intelligent System for Independent living and Self-care of seniors with cognitive problems or Mild Dementia). In this project a system enabling video calls using a computer was utilised, enhancing the communication between home and care environments. Safety alarms and access control technologies were used to assist people with dementia to live at their homes. Additionally, intelligent medicine dosing systems and intelligent packaging methods were developed in South Karelia under this project.

South Karelia health and social services is also one of the main participants in KEKSI project (2010 – 2013), which enables the development of multi-channel electronic services for social welfare and healthcare. The project involves four hospital districts in the provinces of South Karelia, Etelä-Savo and Kymenlaakso. The project area covers nearly 10% of the population in Finland and employs over 10.000 social welfare and healthcare professionals. The project has enabled the region to develop a new form of cooperation, which has resulted in an agreement on providing a uniform implementation of policies and electronic well-being services to serve citizens, public healthcare as well as social and civic services. As a result, the project produces services such as risk tests, health history forms, a secure dialogue

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between a professional and a patient, electronic self-announcement and various SMS services. Digital services, health information acquisition, self-health monitoring and online services will be presented to citizen’s through a common and shared health portal (Hyvis.fi).

The SUSTAINS is the most recent EU project (ongoing 2012-2014) where Eksote is one of the participants. SUSTAINS continues the work of KEKSI project, and will expand the multi-channel electronic services develop by giving citizens online access to their EHR.

RENEWING HEALTH is also an ongoing EU project (2011 – 2012) where Eksote is one of the participants. The primary goal of Renewing Health project is to study how electronic based remote monitoring of basic measurements (weight, blood pressure, steps taken, blood sugar) could impact the care model of chronicle diseases such as diabetes type-2 (diabetes mellitus 2) or hearth failure (insufficientia cordis). Besides the remote monitoring of the basic measurements of patients, each patient is supported by a personal health coach who interacts with the patient and guides them in the control of their own health.

B.1.1.3.7 Greece

National Telemedicine Centre for remote areas of Greece

In the context of national health system, there is the telemedicine programme funded by the Ministry of Health and Social Affairs that connects health centres in remote areas of Greece, with a tele-central system in the Sismanoglio Hospital in Athens. The aim of the programme is to provide support and enhancement of the medical and nursing services in remote areas of Greece, provided via telemedicine from specialised health centres. According to the data of eInclusion@EU 2004-2006, in 2005 the telemedicine network comprised 40 telemedicine units spread all around Greece connected centrally with Sismanglio Health Centre.

eHealth Unit of Sotiria Chest Diseases Hospital in Athens

A project for the provision of e-health home-based rehabilitation, follow up and home hospitalisation services for patients with advanced stages of chronic diseases is run by the eHealth Unit of Sotiria Hospital, Athens. The project concerns chronic patients suffering mainly from advanced stage COPD, with a past history of multiple hospital admissions. Services are offered in two stages: first, as an outpatient rehabilitation programme and then as home-based rehabilitation and follow-up, combined with home hospitalisation when needed. An electronic health record is created for each patient, based on a specially designed multimedia software system. The purpose of the first phase is to create the patients’ EHR, to train both patients and their relatives in the optimal, holistic rehabilitative treatment of their disease, and to prepare them for the innovative services of the programme. The home care phase is accomplished through nurse home visits on a scheduled or emergency basis. The nurses use a laptop equipped with the system supporting the patient's EHR, peripheral medical devices for patient examination at home, and a digital video-camera.

Various other minor public and private telemedicine services exist at local level in several areas of Greece.

B.1.1.3.7.1 Central Greece

Telecare Project of Central Greece

10 Municipalities of central Greece, representing more than 1.000.000 citizens, have recently joined forces to formulate a Digital Community, in order to establish a telecare service for patients with chronic diseases. The project will be based on the experience of the telecare centre of the Municipality of Trikala, which will be the coordination centre, on the basis of a framework agreement signed by the 10 Municipalities of central Greece.

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The infrastructure and services for the Region of Central Greece are provided by the Municipality of Trikala (www.trikalacity.gr); they were funded partly by the 3rd Community Support Framework (CSF), while any additional equipment required for the Renewing Health trials were procured by the Municipality of Trikala in 2010. In 2012, the telehealth services will be expanded to cover more patients and additional chronic conditions. These additional infrastructures and services are funded by the National Strategic Reference Framework (NSRF) of Greece 2007-2013. In particular, the Municipal of Katerini (www.katerini.gr) will invest 246.850€ in a new telehealth / telecare service, while the Municipality of Veria (www.veria.gr) will invest 263.000€ in a similar service.

Digital Cities SA (www.citiesnet.gr), a company owned by the 11 Municipalities of the Digital Community of Central Greece (DCCG) in cooperation with the municipal company of the Municipality of Trikala, e-Trikala SA (www.e-trikala.gr), runs the telehealth / telecare services under a framework agreement with the respective Municipalities.

In particular, the telehealth / telecare centre provides telemonitoring services to chronic patients and the elderly, and social services to all citizens. Novel microtelemedicine devices are being utilised, for the wireless transmission of vital signs to a web-based platform. Individual citizens are equipped with light-weight handheld devices and record their vital signs at home which will then be transferred (via the telecare centre) to the municipality hospital over internet or GPRS for review and feedback by specialists. Through these Personal Health Systems and innovative types of telemedicine services, medical staff can monitor the health status of patients anywhere and anytime. The telehealth / telecare centre is located in the Municipality of Trikala, which has run a local telehealth service already for three years. Therefore the e-Trikala is the competence centre for DCCG.

Telemonitoring services will be provided to individual citizens with chronic heart failure, chronic asthma, diabetes, arrhythmias, dementia and hypertension.

The equipment includes tele-electrocardiographs, tele-spirometers, tele-GPS trackers, tele-scales, tele glucometers and blood pressure meters.

The infrastructure of the telehealth / telecare project of DCCGis therefore expected to focus on the major chronic diseases (such as cardiovascular diseases (CVD), COPD, diabetes, dementia) and it will cover the needs of a statistically significant size of patient population per disease of Central Greece.

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B.1.1.3.7.2 Palaio Faliro

Existing national, regional, local initiatives and infrastrcture – Municipality of Palaio Faliro and associated Municipalities

“Kallikratis”, one of the two famous architects who designed and built the Parthenon, has lent his name to the major national plan of local administration restructuring that has come into effect since May 2010. This plan is of paramount importance for the future of primary health care, public health and prevention, as their control will gradually pass from centralised structure to the local authorities.

The Municipality of Palaio Faliro, keeping abreast of recent trends in healthcare delivery, has made a strategic decision to invest in ICT infrastructure in order to offer innovative integrated health and social care services to citizens.

The focus is mainly on prevention of chronic conditions, but the strategy envisaged is multi-pronged, as it includes regular checkups for a variety of socially vulnerable groups (elderly frequenting the open day care centres, adolescents who attend the schools of the municipality, employees of the municipality, and finally athletes of the local sport clubs). The tools for implementing the strategy are ICT enabled, and more specifically belong to the m-health domain as they are facilitated by the ubiquity of mobile communications. This system consists of specially designed light weight hand held telemedicine devices used to capture and transfer the citizens’ vital signs to an electronic health record infrastructure where they are stored and further assessed for an evidence-based diagnosis by involved physicians. The data stored in the electronic health record are not restricted to clinical metrics, and also include demographics as well as information derived from the social care sector, hence providing for an integrated care model. The following picture represents the system’s flow of information.

Another important application targeting once again prevention at an early stage is focusing on monitoring obesity and metabolic syndrome within the adolescents who attend the three municipality schools. The technical base is similar to the one described above (m-health), but the devices in use are somewhat limited corresponding to the physical and physiological parameters under scrutiny (waist circumference, weight, blood glucose levels etc). An example of the devices is shown in the following diagram:

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Another important aspect of the municipality’s infrastructure is the dedicated web portal for health prevention and awareness for adolescents, but not limited only to them.

One of the fulfilled objectives of this application is the creation of a complete electronic health record for adolescents that continuously evolves and enriches itself with a plethora of data, again contributing to the establishment of an integrated care model that could gradually be adopted at a regional and finally national level.

B.1.1.3.8 Italy

Historically, very different processes and systems govern the public administration – these characterise the 20 regions of Italy.

A few national institutions have been established, allowing these different organisations to communicate with each other without losing their autonomy; the objective is to transform, in a positive way, the relationships between citizens and Public Administration.

The main entities are:

• Rete Unitaria della Pubblica Amministrazione (RUPA) e Sistema Pubblico di Connettività (SPC): o RUPA was created by the law “Directive of the Prime Minister of 5th September

1995”. o SPC was established by Legislative Decree 28th February 2005, n. 42 (published

in Official Gazette No. 73 dated 30th March 2005), subsequently brought into line with the Legislative Decree 7th March 2005, n. 82

Both entities provide indications and tools to enable the interoperability of information systems of Public Administration. The goal is to make possible the cooperation between the different systems, which have independently developed information and organisational systems often without interoperability. There are two main areas of intervention: o Telematic interconnections (physical and transport structures): the

interconnecting structure comprises a virtual private network (VPN) between the institutions of Public Administration. The network can be connected directly or through an Internet access provider, regional and local governments.

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o Interoperability (communication protocols): the interoperability of services are enabled primarily by standard protocols for communication - email, file transfer (FTP), virtual terminal (telnet), retrieval of information (news and www services), management services and transport (DNS, Directory Service, Call Centre, Training), and security services (generation, distribution and certification of cryptographic keys for digital signature).

• Centro Nazionale per l’Informatica nella Pubblica Amministrazione (CNIPA) CNIPA works in the Ministry for Reforms and Innovation in Public Administration. The mission of CNIPA is to provide support to public administration in innovative information technology and, more generally, in ICT. The main activities that CNIPA plays in achieving this goal are: o giving advice regarding strategies and actions to public authorities and operators

in the sector; o issuing technical regulations as guidelines and technical guides, or supporting the

drafting and issuance of guidelines issued directly by the government. o evaluation - ex ante (for consistency with national strategies for innovation in the

government), while travelling (during the implementation of projects planned), and ex post (on the results achieved) - the ICT activities of the Public Administration.

• Tavolo di lavoro permanente per la Sanità Elettronica (TSE) – Permanent Rountable for eHealth Tavolo permanente per la Sanità Elettronica (TSE) was formed to co-ordinate and support the implementation of Electronic Health Plan in October 2004. TSE was established as a forum for institutional comparison and consultation between the regions, autonomous provinces and central government, to harmonise the policies of eHealth and implementation of national and regional action plans. TSE is composed of representatives of the Minister for Innovation and Technology, the Ministry of Health and the Regional Governments and Autonomous Provinces. TSE has drafted guidelines for the establishment of Infrastruttura di Base della Sanità Elettronica (IBSE) that is the National Interoperability Infrastructure of eHealthcare. The architectural vision has been addressed to meet the following requirements: o shall allow the availability of clinical information from everywhere; o must, at the same time, respect the architecture of the federal National Health

System; o using it as a resource, (every Region in Italy is completely autonomous about

healthcare policy); o must have a high degree of security and comply with privacy regulations; o must have a high level of reliability / availability (24/7); o must have a modular structure that allows an implementation to cover the

national territory progressively (in Italy there are different levels of technology infrastructures);

o must be minimally invasive as far as possible compared to existing systems in order to safeguard the investments made;

o shall use open standards.

The figure below shows the architecture of the system. Without going into detail, IBSE can be defined as a Service Oriented Architecture (SOA) based on P2P. Every institution, whether Region, ASL, AO or otherwise, provides an entry point to the network of the National Health System through the Access Gateway (AG).

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Telemedicine has a long history in Italy. Since the early days, exploration of the opportunities provided by remote consultations with technological support was performed spontaneously by a number of pioneers.

Three initiatives of national interest are regularly running:

• CIRM, Centro Internazionale Radio-Medico (International Radio Medical Centre) is the oldest existing organisation providing radio-medical assistance in the world, having been founded in 1935, recognising the importance of healthcare for seamen and of giving them the possibility and comfort of access to the professional advice of a doctor at all times. CIRM is headquartered in Rome, where specially trained physicians and radio operators are on 24/7 continuous duty. In addition, highly qualified specialists in all medical branches can be consulted. The duty doctor, by means of consecutive calls, maintains regular contact with the ship requiring radio-medical assistance until their arrival in a port with adequate medical facilities, or until the complete recovery or evacuation of the patient.

• The IPOCM Project - Integrazione e Promozione degli Ospedali e dei Centri Sanitari Italiani nel Mondo (Integration and Promotion of Italian Hospitals and Health Care Centres Worldwide) promotes the quality improvement of healthcare delivery through the supply of tele-consultation and e-learning services to doctors, health personnel and, eventually, to local populations. The Italian Hospitals in the World, located in 24 countries abroad, and the excellence hospitals in Italy, which are Health Care and Research Institutes and important public and private hospitals in Italy, participate in the project, through the Secretariat for Technical Assistance of the Association “Alleanza degli Ospedali Italiani nel Mondo”.

• The EOLIANET project, is a model to cope with the healthcare needs in small islands (in particular, the Eolian Islands) through telemedicine services. The deployment includes (1) the assessment of the appropriateness of the transfer of patients to the mainland for emergencies, (2) telemedicine support to frail subjects; (3) e-learning and educational services (4) support to tele-diagnostics and tele-laboratory services.

A query to the “Osservatorio Nazionale per la valutazione ed il monitoraggio delle reti e-care (e-care National Observatory, http://www.onecare.cup2000.it/losservatorio, which collects the

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descriptions of eHealth initiatives in Italy) produces 117 descriptions of local and regional projects with a tag on “telemedicine”. However, only a few initiatives were able to become a permanent service within the National Healthcare System. Most initiatives are set up spontaneously according to a perceived need, but are not included in the local strategy for healthcare provision as a permanent structural service.

The “Structural Telemedicine” initiatives, in fact, would require a precise and explicit managerial policy about the reorganisation of service provision, with the assistance of the telemedicine services as a secondary issue.

Often, the innovation process is instead centred on the technological aspects while the aspects related to healthcare policies on the organisation of services are considered as a consequence of the technological innovation.

A new approach is gradually emerging in various Italian Regions (e.g. Veneto, Lombardia, Piemonte, Emilia Romagna), based on the analysis of the healthcare requirements (mainly for remote areas) and on the usage of the longitudinal EHR infrastructure under deployment.

B.1.1.3.8.1 Friuli-Venezia-Giulia

Home Telehealth Services

FVG Region outsources a telehelp-telemonitoring service integrated with Keys safe-keeping and First Aid for elderly and vulnerable beneficiaries to a private provider lead by TesanTelevita-Trieste. Some 4,250 persons are assisted under this service.

“Telehelp” is an alarm service created to cope with possible emergencies arising at home and putting at risk assisted elderly people. It is active 24/7 thanks to the presence of regional Operations Centres aimed at the reception of alarms triggered by a device connected to the landline of the user’s home. The telephone is equipped with a portable button that works as remote control allowing calls to the Centres from a distance.

“Telemonitoring” service was created mainly to keep the beneficiary company and support actions for social and health prevention and psycho-physical monitoring. Its purpose is also to verify the correct use of the Telehelp device. One of the main tasks of the Telemonitoring Centre operators is to telephone the beneficiaries at least once a week to interact with htem and to ask for testing of the Telehelp alarm device. Lastly, telemonitoring is also a useful instrument for informing the beneficiaries about healthy behaviours, good habits, and targeted initiatives.

These services are funded by the FVG Region; they are for free for low income users and partially free for medium income users.

Smart homes and Ambient Assisted Living regional initiatives

Below are briefly described the main projects and initiatives developed in the Regional territory under the Regional Law 6/2005 Art. 22 “Innovation in social-health services” in order to promote the quality of life at home for older people and people with disabilities.

“Presto A Casa” / “Back Home”

This is an experimental project committed to develop innovative models for temporary domiciles devoted to users with sub-acute physical and sensory disabilities.

The use of a “training” house is mainly aimed at young and adult people with physical and/or sensory disabilities (usually after serious trauma), who will experiment with tools, devices and facilities that can help them, managing and monitoring their activities, house functions and interactions with the outside world while fully complying with their requirements in terms of personal safety, environment and home comfort.

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Help Key TV

Help Key TV was created to encourage communication between older people through the use of simplified and more understandable technologies. This is possible thanks to the use of a new generation platform, which allows even those without a computer to access the services provided by internet.

Telemedicina - Telemed

To provide support to a healthcare service sensitive to the users’ needs, to be delivered according to current protocols but able to go back to the clinical data. This allows for an improvement of the services perceived by the citizen who will benefit from appropriate care with intensive monitoring comparable to hospital service.

Re-Freedom

This is a project based on networking of two apartments in the town of Udine, structured to host new technologies research and validation. It includes also testing an organisational model for the provision of innovative services using advanced technologies. The project’s aim is to develop guidelines and tools for planning the refurbishment of housing units and also at the level of district city.

Lak-Living For All Kitchen

A kitchen integrating domotic technologies and innovative remote controlled services to improve quality of life in terms of safety, comfort and energy savings.

Regional network on ICT for the quality of life

A regional lab on accessibility, domotics and innovation has entered the regional social and health planning through a provision included in the outline for the management of the regional health system 2011/12. This lab is dedicated to the development of home living, domotics, accessibility and it impacts on:

• Housing and living environments.

• ICT role for active and healthy ageing.

• Social innovation: public private partnership – and community development.

The main purpose is to increase efficacy of regional policies for the non-autonomous elderly and of interventions for the development of the international dimensions of health policies.

B.1.1.3.8.2 Veneto

Agenzia regionale socio sanitaria del Veneto (ARSS)

ARSS was established by Regional Law No 32, 29th November 2001. ARSS is an instrumental institution in the Veneto Region that gives Local Health Authorities technical support in health and social services, for example in the fields below:

• assistance to Local Health Authorities on methods for the control of management;

• processing, identification and definition of tools to verify the quality of services and social care services;

• quality control of services and benefits provided under the Regional Health Service.

Given the huge use of devices used for monitoring patients at home, the knowledge and experience developed by ARSS on topics such as Health Technology Assessment (HTA) of devices can bring a great added value to the project.

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The systematic assessment of the properties, effects and other possible impacts of health technologies can be a great help to achieve shared guidelines for choosing the most efficient instruments for achieving the objectives of the project.

Telemedicine Platform of Veneto Region

Telemedicine applications in Veneto Region health service are in some cases fragmented and scarcely interoperable among the 23 Local Health Authorities (LHAs) spread across the region.

With help of Arsenàl.IT, the Veneto Region has released implementation and integration guidelines to set up a tele-counselling service for neurosurgery, tele-laboratory, oral anticoagulant therapy and stroke management in the context of HEALTH OPTIMUM project initiative. The realisation of integration guidelines in the first phase of this project were restricted only to the provincial area, where each province embraces typically from 2 to 5 different LHAs. The second step was making these services work also at the cross-provincial level, increasing significantly the continuity of care assistance and the sharing of clinical documents and diagnostic images. The third step was realising a Governance System of Telemedicine Services. The key purposes of this platform are to avoid useless patient transfers, tearing down the corresponding economic and organisational costs and supporting, when possible, patients with chronic diseases in their own home.

All 23 LHAs were made interoperable using IHE profiles. For the intra-provincial level, within same province, XDS Integration Profile (Cross Enterprise Document Sharing) was used, and for the cross-provincial level the new IHE profile was used, called XCA Integration Profile (Cross Community Access), where each province is considered an independent community. The IHE XCA Profile allows the seven communities to talk with each other, sharing documents and images thanks to standardised transactions and ad-hoc gateways that manage all in-coming and out-going messages.

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This interoperability platform will be supervised by the Governance System: the adopted methodological approach to define its capabilities is based on the detailed study of all necessary and possible services supported by the introduction of telemedicine applications. The main functionalities of the Governance System deduced from this study concern both technical and management control aspects, and statistical analysis of data.

The greatest challenge taken up by Arsenàl.IT was to create a regional telemedicine platform composed of seven heterogeneous domains that have adopted both open standards and legacy solutions. The XDS-I and XCA IHE Integration Profiles adopted in the planning phase provide the necessary flexibility that allows extending, to other use cases, the functionalities of the software upon which the telemedicine applications are based.

B.1.1.3.9 The Netherlands

B.1.1.3.9.1 Noord-Brabant

Netherlands, care professional side

PoZoB, in the South East of the province Noord Brabant, employs practice nurses who coordinate the care for patients with chronic diseases in primary care of 200 GPs connected to PoZoB. Since the Dutch healthcare system is not centrally organised by the government (top-down), there is no national health care network. This has resulted in the development of different systems to support (chronic) medical care in primary care. To support the practice nurses in providing care for patients with chronic illnesses, a chronic care ICT system has been developed by the organisation Care2U in close collaboration with PoZoB.

Care2U is a secured web based ICT system which contains medical information on patients who are treated for a chronic illness in primary care (e.g. diabetes, cardiovascular risk factors, etc.), and allows the practice nurse, in a user-friendly way, to follow their patients closely. In addition, flexibility of the system results in the possibility to add different chronic diseases as requested by the care group. For example, the system started with diabetes; in later stages, asthma and COPD, cardiovascular risk management, mental illness and care for frail elderly have been incorporated. In addition, the system allows for connection (e.g.

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requesting consultations) with systems of other care professionals involved in chronic care (e.g. hospitals, laboratory, physical therapists and dieticians).

Healthcare data and medical records at a GP office are stored in a GP information system. These systems contain electronic patient records of all patients in a GP practice. GPs in the Netherlands can chose from eleven different GP information systems to work with in their practice. To allow for sharing of medical and clinical patient data between the GP and the practice nurse, a link (two-way) has been established between Care2U and the GP information systems. In addition to use for chronic care, Care2U can also be used as a dashboard for the GP to get an overview of patients with chronic illnesses and associated parameters (e.g. blood pressure, cholesterol levels, etc.) in their own practice.

Since 2011, Care2U has been implemented in several other primary care organisations in the south of the Netherlands. The goal of Care2U is to implement the system in other regions of the Netherlands as well, and to realise further expansion.

Netherlands, client side

Whereas Care2U is the communication and information portal for care professionals, it lacks a suitable and intelligent interface for citizens and patients. In Smart Homes (Netcarity, FP6) an open service platform is developed that as a feature that offers secure communication and information exchange between clients and between citizens and carers. The combination and integration of Care2U and the Netcarity platform offers a wide variety of new opportunities and added value. The interface modality of Netcarity is completely based on HTML5; using either a large-size touch screen PC, tablet or smart phone, various services can be offered to citizens, including video-communication services, data exchange and information provision. Through the Netcarity, new services can also be developed whenever there is an interest for a specific topic. Citizens also benefit from other projects in which the Netcarity platform is used, since services developed for the platform in other projects can also be made available to users of SmartCare and vice versa.

Within the SmartCare project, medical and social services will be offered to the arthritis patients through the Netcarity service platform. On weekdays, patients can take part in a 60-minute online video-based training programme, including EPD-linked activity monitors (Independent project). Depending on the specific joint that is affected, arthritis is a serious handicap. Besides intense pain, advanced arthritis causes loss of joint functionality, which leads to mobility limitations for the patient. This directly increases the risk for a large number of other diseases and problems often mediated by obesity, such as cardiac problems, diabetes and osteoporosis. Therefore, the houses of the patients will be equipped with vital parameter monitoring devices in order to closely follow up the patient’s health condition and to detect critical health changes at an early stage. (CommonWell project) The Netcarity service platform offers protocols to exchange telemonitoring data with high levels of security. This data can be automatically transferred to the EPD in Care2U. In addition, immobility is often an important cause of social isolation and loneliness, which are in turn risk factors for depression. The Netcarity service

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platform currently offers different services to enable social (video) communication with a contact centre and friends and family using the SIP protocol, services to minimise boredom (e.g. games, cognitive training) and services to motivate clients to go out and take part in society. The Netcarity service platform additionally supports alert and reminder generating, either pop-ups, mails or SMS. In this way, both the users themselves and (formal or informal) carers can be notified in a comprehensive way. Another useful feature of the Netcarity platform is the developed integration with several well established home automation systems, supporting environmental parameter monitoring, fall detection and other smart home functionality.

Telemonitoring (CommonWell) Video-based physical training (Independent)

Internet networks

The Netherlands take the lead in Europe with 94% of households having Internet access, according to statistics from the European Union (2011). Additionally, the Akamai State of the Internet Report (2011) reports that the Netherlands is the country with the highest percentage of broadband users. More than two thirds (68%) of Dutch Internet users browse the Internet with 5Mbps or more.

Broadband Manifest Brabant

In the province Noord-Brabant there is an initiative, the Broadband Manifest Brabant, to equip the entire province with fibre optic Internet, and to provide all inhabitants with ultra high-speed Internet accessibility. The goal is to provide fibre optic Internet in all urban, rural and industrial areas of the province within a few years, and to empower initiatives and projects such as SmartCare in the region. In this way, the ambitions of the Broadband Manifest Brabant go way beyond the digital agenda of the European Commission.

B.1.1.3.10 Sweden

Sjunet is the Swedish Health Care Network comprising an infrastructure for communication between hospitals, primary care centres and home care. It also hosts a wide range of services from national authorities, healthcare service providers and selected vendors. Sjunet allows secure transmission of healthcare data and applications on an IP-network separate from the Internet. The network is used for telemedicine, videoconferences, teleradiology, remote access to applications, ePrescriptions, database access, secure email, EDI messages, IP telephony, etc. It is also useful for e-learning in medical education and further training for health personnel. CeHis is responsible for Sjunet in close cooperation with the county councils and other actors within Sjunet. Hence, Sjunet is as much a co-operative network as it is a technical communication platform for Swedish healthcare.

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Practically all Sweden’s 80 public hospitals, 800 primary care centres and 950 pharmacies as well as some national authorities and vendors are connected to Sjunet, and use it both for telemedicine and administrative communication. The network infrastructure allows secure communication and distribution of patient data, pictures, medical applications and services for which the Internet is not acceptable. The idea from the beginning was to form a layered infrastructure consisting of a secure network, a set of common services, and telemedicine applications. Sjunet is continuously under development, especially with regards to establishment of new services and connecting other branches of healthcare and more service providers. Telemedicine has been tested and/or used in over 100 applications; more than 85% of hospitals have tested or are already using telemedicine applications.

B.1.1.3.10.1 County of Uppsala

The county of Uppsala has one common EPR system for both primary care and hospital care. This even includes about ten private caregivers. The municipality has a different system. The county and municipalities can communicate electronically through NPÖ.

The common EPR system for the county includes various modules such as:

• Documentation.

• Patient administration.

• Electronic communication with X-ray and laboratory systems.

• Electronic referrals within the system.

• Emergency care.

• Theatre module.

• Electronic prescribing.

• Dictation.

• The system even is the base for billing both patients and other counties.

There are also systems for X-ray, laboratories, picture archive, and telemedicine.

The strategy for the county is to have one system for all care givers. That will increase the possibilities to communicate electronically. But to share information with care givers in the municipalities and other counties in Sweden, we will use NPÖ.

B.1.1.3.11 Serbia

In accordance with the strategic objective of the Serbian Ministry of Health and the implementation of the document “e-health 2015” (Program for Operation, Development and Organisation of Integrated Health Information System), development of the health information system for primary healthcare is being actively performed. Large numbers of

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healthcare institutions have already implemented electronic medical records, and in other medical centres process activities are underway. The software will enable the application of electronic health records in all 158 primary health care centres.

Today, in the Republic of Serbia there are 158 health centres (primary healthcare) and 172 social welfare institutions established by the municipality.

Kraljevo Health Centre (primary healthcare centre) has over 7 years’ active use of a health information system which has healthcare data for about 130,000 inhabitants. Given that the software meets all technical and functional requirements that are defined by the Ministry of Health, this software is suitable for the establishment of integration with the information system of the social work of Kraljevo.

The ultimate objective is forming of an integrated health information system of the Republic of Serbia, which will enable access to medical information to all participants in the health system according to their roles and responsibilities. Patients will have significant benefits from availability of information because appropriate healthcare and treatment can be provided only on the basis of a comprehensive picture of a person’s health. Use of electronic documents instead of traditional hard copy documents ensures huge savings in terms of time and money.

Development of primary healthcare IT systems will enable replacement of classic medical records, medical histories and medical reports by electronic medical data, which applies all necessary measures in connection with the security, safety of data, and privacy of patients.

B.1.1.3.12 Northern Ireland

The 60,000 health and social care workers in Northern Ireland are supported by a regional secure network which enables access to a range of IT applications including:

• Patient administration system.

• Digital X-ray recording and archive.

• Electronic referrals.

• Emergency care summary.

• Patient registration database.

• Electronic prescribing.

• Community information systems.

• Remote telemonitoring.

• Video conferencing.

• Theatre management.

• Laboratory systems.

• Secure email.

• As well as a range of specialist clinical systems, e.g. diabetic, maternity, emergency department, oncology.

This network links to a central data centre (and its failover contingency site), and connects all 50 hospitals (of varying sizes) together with the 353 primary care practices, all of which are computerised using one of four commercially supplied systems.

The current Regional ICT Strategy has two major interlocking themes for ICT development: Electronic Care Records (ECR) and Electronic Care Communications. Appropriate ICT service delivery platforms are viewed as key enablers for change and business improvement. This includes improving the technical infrastructure and the need to ensure that staff are appropriately trained to use the ICT services and have ready access to these services. The ECR would be viewable from multiple settings by GPs, pharmacists, community nurses, allied health professionals, hospital specialists and social workers. It has been piloted by two

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GP practices and one HSC Trust, and will be rolled out regionally in January 2013. A contract for telemedicine services has also been established recently to deliver remote telemonitoring of patients with long-term conditions.

The Strategy is independent of organisational boundaries, in that it recognises that while the organisation of the health service is subject to change, the services that users expect and need must be provided seamlessly regardless of which organisation or combination of organisations are involved in the delivery of the services. The changing demography of the population of Northern Ireland coupled with unprecedented constraints on the HSC budget will inevitably lead to significant changes in how and where services are delivered, and indeed in what services are delivered. ICT continues to have a key role to play in this transformation, and must be tightly integrated with service modernisation and reorganisation planning in order to effectively assist the service. A key plank in this strategy over the next three years will be the implementation of a full integrated ECR.

B.1.1.3.13 Scotland

Scotland has moved significantly towards an integrated ICT architecture for health. Information on the main ICT systems in place is noted below. There are also a limited number of systems in place for social care, telecare and telehealth. Scotland has a current population of 5.2 million. Our population projections reveal that there will be a significant and sustained rise in the number of older people in Scotland during the decade ahead and beyond. The potential impact of these changes have been extrapolated to the use of healthcare and hospital beds (assuming current demand rates and response remains the same) and show a 24% rise in beds occupied by older people admitted as emergencies by 2016 – that’s around 1800 more beds, equivalent to three additional District General Hospitals for Scotland. These examples underscore the need for appropriate investment in new forms of care and support to meet the requirements of our future generations. Scotland’s input to SmartCare will focus on 7 local health & social care partnership areas, which provide a continuous geographical spread across the west-central part of the country. This area has a combined population of around 1.2 million – nearly one 25% of Scotland. In terms of age structure and other key factors the participating areas are broadly similar to Scotland as a whole, enabling it to be used as a ‘testbed’ for the wider population.

All the available evidence suggests that an integrated care model approach provides greater benefits for people with care needs which are a consequence of chronic conditions, frailty or deteriorating health at the end of life. Scotland has an integrated healthcare system with all hospital and community health services delivered by 14 single regional Health Boards. Scotland has also embarked on the integration of health and social care services across the country to deliver safer, more effective and person centred care.

Scotland has a track record for delivering services in innovative ways. Examples of current services:

• The investment of around £20million in telecare services in the period 2006-2011 has evidenced health benefits and economic efficiencies worth more than three times that amount for nearly 44,000 people, for example almost 9,000 unplanned hospital admissions, and 4,000 care home admissions were avoided between 2006 and March 2011.

• A risk prediction algorithm, which includes prescribing data, is being used across Scotland to identify a cohort of people with multimorbidity, polypharmacy and high risk of adverse events and / or emergency admissions. Targeting anticipatory care planning and medication reviews has reduced emergency admissions and bed days e.g. a 40% reduction in rate of polypharmacy. We are developing options to deliver these interventions at scale.

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• Falls and fractures, in people aged 65 and over, account for over 18,000 unscheduled admissions and 390,500 bed days each year in Scotland. A national falls programme is in place, with a recent re-port showing good progress.The potential role and benefits of using telecare within the programme has been explored within parts of Scotland, with over 60% of Community Health Partnerships now accessing telecare data to inform prevention and management.

• In August 2010, the NHS Inform service was launched to provide the people of Scotland with access to a single source of quality assured health information (www.nhsinform.co.uk) via internet. Recognising that a significant proportion of the population are not digitally literate, Scotland now offers access to health and care information through digital television.

• The Telescot programme is a programme of academic research investigating telemetric supported self monitoring of long term health conditions (hypertension, COPD, congestive heart failure and dia-betes. This activity is now being moved to a full and mainstream home monitoring ‘service’ for people with COPD or congestive heart failure.

• Many areas of Scotland are using videoconferencing to support access to pulmonary rehabilitation for people with COPD, linking classes in different locations (many remote and rural).

• As part of its participation in the Regional Telemedicine Forum (an Interreg IVC programme) Scotland produced the Good Practice Guidelines for telemedicine services for chronic Cardiovascular disease, based on Scotland’s own telestroke service, and on telemedicine services in four other European regions.

• Working in partnership with the UK’s Technology Strategy Board, there is a commitment to £10m of investment (€12m) over 2012-15 to deliver the Scottish Assisted Living Programme to at least 10,000 people across the country. This is the first phase of an at scale transformational change programme, which will enable improved independence, health and wellness for individuals and their carers living with long term health and care issues in Scotland through service redesign supported by ICT. There will also be an associated creation of new business and employment opportunities in Scotland in the public and private sectors.

All of the services outlined above have been supported by a national and integrated Education and Train-ing programme for health and care staff, and for carers, along with the development of a national coordi-nated videoconferencing platform for Scotland. This builds on the existing multi million pound investment made by Scottish Government on the national ICT infrastructure supporting health and care services and the future committed funding for the role out of superfast broadband for Scotland. Scotland has moved significantly towards an integrated ICT architecture for health. Information on the main ICT systems in place is noted below.

The N3 Network

All of Scotland's Health Boards are connected in a single virtual private network (N3). This network provides the security, capacity and availability that is required in order to exchange information in the health sector. N3 supports all national applications, and provides the networking infrastructure which allows all NHSScotland organisations to communicate electronically via data, voice, video, messaging and other ICT application services.

CHI (Community Health Index)

The CHI number is a unique ten-digit number that identifies patients in NHS Scotland and is the only consistent way of positively identifying patients across the service. Anyone born in Scotland or registered with a Scottish GP practice will have a CHI number. Use of CHI on

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clinical communications is mandated across NHS Scotland, with few exceptions. The CHI number is a fundamental building block to future Scottish Government health initiatives.

Patient Management System (PMS)

Five Health Boards, supported by the Scottish Government, undertook a joint procurement and selected the TrakCare PMS. The benefits of this collaborative approach are considerable; driving the convergence and standardisation of IT systems at substantially lower cost than could be achieved if Boards were working locally and individually, while maintaining the local ownership that is vital to the successful implementation of these complex changes.

Ensuring Boards are able to use the same system improves clinical and administrative management of patient information and frees up staff to spend more time in frontline services. This is releasing time for frontline care and reducing the burden of bureaucracy across NHSScotland. Collaborative working amongst these Boards is also leading to standardisation and has helped create a version of TrakCare that is known as the Scottish Foundation System. Six Boards now have the opportunity to share support, expertise and experience (TrakCare was already in use in one Board before the procurement), and when fully implemented this system will cover some 75% of NHSS by population.

General Practitioners

There are over 1000 GPs practices in Scotland, with all using electronic patient records. There are two different EPR systems in use. The decision as to which system of the two to select and install locally is made by the individual health boards rather than by GPs who then utilise the specific system being adopted by their own local health board.

Electronic Care Summary /Palliative Care Summary/Key Information Summary

The Electronic Care Summary (ECS) provides a summary of demographic, allergy and medication information for 5.5 million patients in Scotland. It enables Out of Hours, Accident and Emergency, NHS 24, the Scottish Ambulance Service and Acute Receiving Unit clinicians access to important patient information in emergency and unscheduled care situations. ECS also holds and shares Palliative Care Summary (ePCS) information on resuscitation, patients’ wishes and place of care with the aim of reducing the number of end-of-life patients taken to hospital unnecessarily. The Key Information Summary (KIS) provides support for electronic Anticipatory Care Plans, Long Term Conditions, and Mental Health

Electronic Messages

Through the Scottish Care Information (SCI) system, a wide range of processes are managed electronically between Primary and Secondary Care. These include the entire outpatient process from referral to discharge, the sharing of information between clinicians including patient demographics, laboratory investigation reports, Radiology reports, Treatment logs, Clinical documents, and details of admissions, discharges, and transfers

NHS 24's Unscheduled Care Service

NHS 24's Unscheduled Care Service is the first point of access for patients during the out of hours period whose concerns cannot wait until their GP is next open. NHS 24 receives daily electronic updates from all GP practices across Scotland, containing basic patient data. For all patients requiring onward referral to other parts of the NHS (e.g. Accident and Emergency Departments; Emergency Dental Services; the Ambulance Service; Primary Care Emergency Centres etc), NHS 24 provides electronic information detailing the patient's most recent contact with the organisation.

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Social Care Systems

There are 32 local authorities in Scotland who have responsibility for the provision of social care, housing support services and telecare. There are a limited number of IT systems in place for social care (Carefirst, SWIFT/SWIS), and an eCare programme which seeks to support data sharing and partnership working.

B.1.1.4 Way to connect national initiatives together

The preceding sections provided a detailed overview of the numerous existing national and regional initiatives in the participating regions. It became obvious, that in all partnering countries the integration of health and social care is high on the policy agenda and various activities ranging from strategy development to piloting and implementation are taking place. This provides a solid basis for joint action to enforce good practice exchange, common planning and piloting of integrated care supported by ICT. SmartCare will pursue a programme of systematic service process innovation complemented by adaptation of technology.

As graphically summarised by Figure 3 overleaf, the participating initative will be connected through the SmartCare work programme guided by a shared vision and underpinned by a dedeicated coordination and support structure. This common approach will enable generating numerous shared outputs adding value to European-level consensus building towards large scale implementation of integrated care solutions in mainsream settings. The overall mechanism for joining-up the participating regions included various operational elements such as:

• Joint definition of common building blocks of the SmartCare solution at the start of the project

• Based on that, common features shared across the pilot sites will be identified

• A dedicated programme for mutual learning and efficient coaching of regional actors will be pursued to allow participants to optimise the learning process and team up with actors in other regions with a similar profile where experience exchange and targeted coaching will have the greatest impact

• Establishment of a common evaluation framework and common impact assessment framework (user impacts, socio-economic impact, business models)

• Development of the concept and joint production of the living document – “Evolving Document SmartCare Guidelines”. These Guidelines will comprise sections on: ○ Requirements for SmartCare Pathways and Integration Infrastructure ○ SmartCare Service Model ○ Pilot level Service Specifications (incl. standards based, interoperable

architecture) ○ SmartCare prototype test reports ○ Evaluation framework Ethics and Data Protection Framework ○ Publication of SmartCare Guidelines for Pathways and Integration Infrastructure

procurement and uptake

• As a result, also synthesised guidance on service transferability beyond the pilot regions – SmartCare transferability model, will be delivered towards the end of the project.

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Figure 3: SmartCare connecting activities

• Common ICT integration

infrastructure architecture

• Generic care pathways, service

models & value chains

• Guidelines for procurement,

implementation & up scaling

• Synthesised evidence on

impact

• Sustainable business models &

transferability assessment

• Consensus building on further

organisational & policy

development for care

integration

• Contribution to EIP by critical

mass for large scale uptake

• SmartCare coordination & management structure

• Expert advise & support (User Advisory Board, Industry Board, Committed Regions

Board, Internal Scientific Board

• Local SmartCare Alliances / Stake Holder Partnerships

SmartCare Support structure

SmartCare work programme• Requirements elicitation, use cases & integrated care pathways development

• Pilot service specification & process model development

• Joint definition of common building blocks for ICT integration infrastructure

• Pilot site preparation & operation in two waves

• Pilot evaluation & exploitation support

Shared outputs

Common SmartCare approach

Through creating a critical mass for mainstreaming of integrated care solutions SmartCare will provide a valuable contribution to the European Innovation Partnership on Active and Healthy Ageing, and in particular to the Action Group on Integrated Care, which in turn will further disseminate the lessons learnt and final results to further European countries and regions not participating in the project.

B.1.1.5 Expected measurable final result of the project The project will deliver a multitude of results and outcomes as described in greater detail in the work plan, particularly within the respective work packages. Here we will only outline and summarise major results and outcomes, which will also serve as key indicators of the project’s measurable and verifiable success. Of course, all of these results are expected to be attainable with the available resources, and it is estimated that reaching their achievement is fully realistic within the time span of the project. There follows a Table of these key results, their timing, and their means of verification and measurement:

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Table 2: Key project results, their timing, and means of verification and measurement

Result Timing Verification measure Note

SmartCare pathways available to all partners

05 Well defined pathways available to all partners

Timely publication on the project’s website is foreseen as well

Evaluation framework finalised

07 A comprehensive, detailed framework has been prepared, agreed upon by project partners and relevant stakeholders, and delivered to the EC.

A concise summary may be published on the project’s website

Establishment of 1st wave of pilot sites

7 At least 3 of the 4 1st wave pilot sites a comprehensive planning and deployment document has been issued, based on formal agreement by regional authorities and stakeholders as may be appropriate

Due to the risks identified, we may not expect all sites to have prepared such documents in time.

Establishment of 2nd wave of pilot sites

15 At least 4 of the 6 2nd wave pilot sites a comprehensive planning and deployment document has been issued, based on formal agreement by regional authorities and stakeholders as may be appropriate

Due to the risks identified, we may not expect all sites to have prepared such documents in time.

1st wave pilots fully operational

14 At least 3 of the 4 1st wave pilot sites are up and running

Due to the risks identified, we may not expect all sites to be fully running at his point in time.

2nd wave pilots fully operational

23 At least 4 of the 6 2nd wave pilot sites are up and running

Due to the risks identified, we may not expect all sites to be fully running at his point in time.

Publication of procurement guidelines

36 Procurement guide published on project website

Completion of deployment plans for participating regions

36 For at least 7 of the 10 so-called participating regions a comprehensive planning and deployment document has been issued, based on formal agreement by regional authorities and stakeholders as may be appropriate.

These documents will be collected and delivered to the EC as a project deliverable. Publication to a wider audience may depend on confidentiality restrictions.

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Result Timing Verification measure Note

Final trial evaluation report

36 Report available; key Impact Indicators (KII) for at least ¾ of all pilot sites (waves 1 and 2) reported upon.

These measureable outcomes concern those sites which successfully implemented and routinely apply the developed pathways

B.1.2 EU and national dimension

B.1.2.1 Relevance of the project to EU directives

Developing and piloting integrated care services is at the heart of the SmartCare initiative. In general, the EU has no mandate for regulating how the Member Sates organise their own healthcare and social care systems. Nevertheless, there are various European Directives that have relevance to SmartCare. In the following it is briefly described how project activities will be aligned with these.

Protection of personal data privacy

The European Data Protection Directive 95/46/EC (DPD) complement fundamental rights in the area of personal data protection. Personal data are defined as "any information relating to an identified or identifiable natural person ("data subject"); an identifiable person is one who can be identified, directly or indirectly, in particular by reference to an identification number or to one or more factors specific to his physical, physiological, mental, economic, cultural or social identity;" (art. 2 a).

By adopting the Data Protection Directive of 1995 (Directive 95/46/EC) the European Union set legally binding rules for the protection of individuals with regard to the processing of personal data. Through this regulation basic principles for processing personal data have been stipulated which have to be followed in all Member States:

• Transparency: The data subject has the right to be informed when his or her personal data are being processed. The controller must provide his or her name and address, the purpose of processing, the recipients of the data and all other information required to ensure the processing is fair. (art. 10 and 11). The data subject has the right to access all data processed about him or her. The data subject even has the right to demand the rectification, deletion or blocking of data that is incomplete, inaccurate or isn't being processed in compliance with the data protection rules. (art. 12)

• Legitimate purpose: Personal data can only be processed for specified explicit and legitimate purposes and may not be processed further in a way incompatible with those purposes. (art. 6 b)

• Proportionality: Personal data may be processed only insofar as it is adequate, relevant and not excessive in relation to the purposes for which they are collected and/or further processed. The data must be accurate and, where necessary, kept up to date; every reasonable step must be taken to ensure that data which are inaccurate or incomplete, having regard to the purposes for which they were collected or for which they are further processed, are erased or rectified. The data should not be kept in a form which permits identification of data subjects for longer than is necessary for the purposes for which the data were collected or for which they are further processed. Member States shall lay down appropriate safeguards for personal data stored for longer periods for historical, statistical or scientific use. (art. 6) When sensitive personal data (including religious beliefs, political opinions, health, sexual

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orientation, race, membership of past organisations) are being processed, extra restrictions apply. (art. 8)

By now, the European data Protection Directive has been transposed into national regulation/legislation across the entire EU. Today all European Member States have put some kind of legislation in place which sets out specific rules covering the handling of electronic data. This may include a general law that governs the collection, use and dissemination of personal information by both the public and private sectors. It may also include sectoral laws governing data protection in relation to specific domains such as health care, employment and so on.

In line with the European Data Protection Directive, SmartCare will adhere to national and sectoral data protection legislation/regulation across its entire life cycle and at every operational step from collection to storage and dissemination. As the project aims at cross-sectoral service delivery, different legislative/regulative data protection frameworks may deserve attention in this context. A review of national data protection regulation/legislation will be conducted across all pilot sites during the start-up phase and project activities at each pilot site will comply with identified requirements respectively.

Safety of medical devices

The Council Directive 93/42/EEC covers the placing on the market and putting into service of Medical Devices (MHRA, 2008). The directive covers any instrument, apparatus, appliance, material or other article, whether used alone or in combination, including the software necessary for its proper application intended by the manufacturer to be used for human beings for the purpose of:

• diagnosis, prevention, monitoring, treatment or alleviation of disease,

• diagnosis, monitoring, treatment, alleviation of or compensation for an injury or handicap,

• investigation, replacement or modification of the anatomy or of a physiological process,

• control of conception,

From the 1st of January 2008 a new safety standard, the European Harmonised Standard (ETSI EN 300 220-2 V2.1.2) came into effect. Amongst others, the standard affects for instance telecare/social alarm equipment that receives radio transmissions from telecare devices. This kind of equipment needs to carry a CE marking to be legally sold in the European Union.

Again all equipment items used in the framework of SmartCare which fall under the ambit of the EU’s Directive and national regulation/legislation enacted in the pilot site countries respectively will be fully compliant with relevant requirements.

Patient rights in cross-border healthcare

The EU Directive on the application of patients’ rights in cross-border healthcare (2011/24/EU) provides clarity about the rights of patients who seek healthcare in another Member State and supplements the rights that patients already have at EU level through the legislation on the coordination of social security schemes (regulation 883/04). The Directive represents a common legislative framework to be transposed into national legislation/regulation by all Member States that fully respects the case law of the European Court of Justice on patients' rights in cross-border healthcare while preserving member states' rights to organise their own healthcare systems. Beyond specifying requirements for cross-border health care provision, cooperation between Member States in the field of healthcare has been strengthened more generally, for example, in the field of e-health and through the development of a European network which will bring together, on a voluntary basis, the national authorities responsible for e-health.

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Although cross-border delivery of integrated care is not envisaged to be piloted within the duration of the SmartCare project itself, the general thrust of the EU Directive will be reinforced by various project activities and outcomes. In particular, the establishment of a shared basis of sound and robust evidence on well proven integrated care practices is to facilitate the emergence of common European standards in this field, at least in an indirect manner. This will not at least be facilitated by a dedicated programme of project dissemination and targeted support of interested parties in exploiting outcomes beyond the immediate project duration.

B.1.2.2 Relevance of the proposed solution to political objectives

B.1.2.2.1 European policy level

Beyond European-level legislation and regulation, Smart Care will support key European policy objectives in a number of ways. This is summarised in the following subsections.

Reinforcing common European values Although, the European Commission has no mandate to regulate health/social services in the Member States, the health systems of the European Union are considered as a “fundamental part of Europe's social infrastructure”6. In a very succinct way the "Council Conclusions on Common values and principles in European Union Health Systems"7 summarise the goals and priorities of Member States in the field of healthcare. Universality, access to good quality care, equity, and solidarity constitute a set of overarching values that are shared across Europe. Universality refers to the universal, i.e. for everyone, access to healthcare; solidarity relates to the financial dimension of ensuring accessibility to all; equity emphasises that access should be according to needs, regardless of ethnicity, gender, age, social status or ability to pay.8 When it comes to social policy in a wider sense, the so called renewed social agenda represents a commonly agreed European value framework. It was adopted by the European Commission on 2nd July 2008 with a view to ensuring that European Union policies respond effectively to today's economic and social challenges.9 By the adoption of the renewed social agenda the European Union intends to respond to technological change, globalisation and an ageing population. It aims to create more opportunities for EU citizens, improve access to quality services and demonstrate solidarity with those who are affected negatively by change.

The SmartCare initiative will reinforce the European social model and common European values by better harnessing ICT for enabling equal access to high quality support services by older people living in the community. Beyond this, the project will contribute to the sustainability of universal and solidarity-based welfare / health systems at the level of the Member States by harnessing ICT for delivering relevant support services to those who need them in a more effective and cost-efficient way. Finally, common European values will be reinforced by adopting a comprehensive approach towards ethics in the independent living domain.

Reinforcing the European growth and innovation strategy Through the Europe 2020 strategy framework and its "Innovation Union" flagship initiative, the European Commission has committed to overcome the barriers to innovation, especially for addressing the major societal challenges. It put forward the novel concept of European Innovation Partnerships (EIPs). Active and Healthy Ageing (AHA) was chosen as the pilot area. In the conclusions of its meeting of 4 February 2011, the European Council endorsed

6 Document (2006/C 146/01), published in the Official Journal of the European Union on 22 June 2006, pp. 1 - 5

7 ibid. 8 ibid. 9 Communication from the Commission to the European Parliament, the Council, the European Economic and Social

Committee and the Committee of the Regions, Renewed social agenda: Opportunities, access and solidarity in 21st century Europe, COM(2008) 412 final.

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the Commission's proposal for an Innovation Union, and in particular the launch of a European Innovation Partnership on Active and Healthy Ageing ((SEC(2010) 1161)). With its Strategic Implementation Plan, the Steering Group (the SG) of the EIP on AHA delivers its rationale, its vision and suggestions for addressing the challenge of active and healthy ageing. It is highlighted that innovation, in all its forms – spanning across technology, process and social innovation – can be a crucial contributing factor to improving the health and well-being of citizens as well as the sustainability of care systems, and to enhancing Europe's global competitiveness and growth. Further it is emphasised that it is also important to ensure the continuity across the innovation chain, starting from research, to pilot projects, to the diffusion and scaling up of innovation into mainstream care.

As an overarching operational objective, the Partnership aims to increase by 2 the average number of healthy life years (HLYs) in the European Union by 2020, by securing a triple win for Europe:

• Improving the health status and quality of life of European citizens, with a particular focus on older people.

• Supporting the long-term sustainability and efficiency of health and social care systems.

• Enhancing the competitiveness of EU industry through an improved business environment providing the foundations for growth.

In order to determine the best way forward and focus on those innovative actions which deliver the highest impact, the Steering Group has structured the work needed in three pillars reflecting the 'life stages' of the older individual in relation to care processes:

• Pillar A: Prevention, screening and early diagnosis as an integral part of life-event approaches to keeping people healthy and postponing the onset of the illnesses;

• Pillar B: Care and cure as integral pathways of integrated care, aiming to develop a more holistic and personalised approach to multi-dimensional health needs;

• Pillar C: Active ageing and independent living as a felt need and a future reality for many older Europeans.

Through its action plan the Steering Group has recognised the importance of innovation within each of the three “pillars”. It is highlighted that - while priorities and actions are defined within each pillar - one should however view these in a broader perspective as several priorities and actions proposed in the Action Plan are relevant to more than one pillar, hence synergies and complementarities are expected to develop. In addition, horizontal issues are identified that address framework conditions and are enablers for all other priorities and actions. These include the mapping of research, funding schemes, compiling an evidence base, monitoring and evaluating actions, as well as working on the regulatory framework and (public) procurement.

The SmartCare initiative will contribute to meeting the objectives of the EIP on AHA as set out in the Strategic Implementation Plan in a number of ways. To begin with, the project will make a direct contribution to Pillar B (care and cure) by implementing and piloting new integrated care models cutting across health care, social care and self-care in terms of collaboration, alignment, training and connectivity. Through an iterative programme of organisational innovation and technology innovation - complemented by targeted exploitation support measures – current key barriers towards delivering integrated and more personalised care to older people will be addressed in a systematic manner. The latter will include technology related issues such as interoperability of ICT systems and devices as well as non-technological issues such cross-sectoral care pathways, governance structures, incentive systems and financing/reimbursement models. In relation to Pillar A (prevention, screening and early diagnosis), the SmartCare services to be developed, piloted and evaluated will strengthen the preventative nature of care delivered to older people living in the community, e.g. by facilitating compliance through better joined-up long-term care

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processes aiming at stimulating the care recipient’s capacity to act as co-producers of their own health. Moreover, SmartCare will make a contribution to the objectives set out under Pillar III (active ageing and independent living), in particular when it comes to better harnessing ICT for supporting formal and informal carers in providing assistance to older people - and empowering older people themselves - in living independently in the home environment despite multiple needs for health/social support they may develop over time.

In a horizontal manner, SmartCare will contribute to the establishment of a shared basis of sound and robust evidence on well proven practices through a dedicated programme of pilot evaluation and outcome monitoring. To this end, a project design and methodological approach will be adopted that is capable of reflecting current realities in terms of different stages of progress individual regions have already reached when it comes to preparing successful implementation of integrated care models, both technology wise and organisationally. Not at least, by developing evidence-based guidance materials and cross-regional coaching measures the project will effectively support up-scaling and transferability of integrated care models across the participating pilot regions and beyond. Thus, SmartCare will help in making a major leap towards a shift in the focus from acute, reactive, and hospital-based care to long term, proactive and home-based care, integrating both health and social settings. Demonstrable added value is expected to be created through better outcomes for older people and increased work satisfaction of health professionals and care personnel, better quality of life of informal/family carers, as well as improved efficiency and increased productivity of health and social care systems. Finally, by addressing the entire value chain the business environment for key EU industry players will be improved, which again provides the foundations for growth and competitiveness..

B.1.2.2.2 National/regional policy level

At the national and regional policy level Smart Care will support key policy objectives in a number of ways, as summarised in the followingsections.

Carinthia (Austria)

In the period up to 2020, the population structure in Carinthia will change in the following ways: the number of people under 15 will fall from 79,022 (2010) to 73,508 (2020), the number in the 15-60 age group will fall from 340,202 (2010) to 320,131 (2020), and the over 60s group will increase from 139,731 (2010) to 164,815 (2020) (from 25% of the population to 29.5 %). This means that already more than one fifth of the Carinthian population is over 60. According to some estimates, the proportion of over 60s will have increased to as much as 36% by 2050. This represents a clear call to those in the political sphere to make increased efforts to improve the living conditions of older people. The services currently provided by the Province of Carinthia in this field are something we can be proud of, but there are many future goals still to be addressed. The payment of the nursing allowance or Pflegegeld has existed in Austria since 1993. Persons requiring nursing care receive an allowance which is independent of their income and which is paid out monthly at 7 levels according to the need for care as determined in the individual case (ranging from € 148.30 at level 1 for more than 50 hours of nursing care per month and rising to € 1562.10 at level 7, where there is an average need for more than 180 hours of nursing care, or in cases of immobility or where technical equipment is used to maintain life). This is intended to enable people to remain in their familiar surroundings leading an independent life for as long as possible. Anyone who needs care should also be able to make their own decisions. The Provincial Government endeavours as far as possible to provide services on a low-threshold basis, where this is possible and expedient.

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Baden Württemberg (Germany)

In the year 2012 Germany is confronted with a wide spread care reform. The number of high maintenance people will increase more and more because of the demographic change. From the year 1989 till the year 2009 the number increased up to 16%. The government plans on raising the premium rate from 1,95 % to 2,05 % by the 1th of January 2013 to cover care costs in the future and expand the benefits for patients with dementia. The higher incomes of 1,1 billion euro refinance the bigger expenses. Especially the aim to reduce care costs in nursing homes and to bring forward the outpatient care sector is in focus of the government. For example the launching of care assistance services to relieve the relatives. These services are planned to be piloted first in addition to the established professional care services. The introduced pilot project Smart Care Kinzigtal in this paper supports the development of new resources, their more efficient and higher use of outpatient services by the availability of this service platform. Beyond that government is working out a draft law for the financial support of well managed regional networks with certain quality standards. At the same time some of the responsibility for medical care is transferred to these networks and offer the opportunity to create care structures in a new and more optimal way. The pilot project Smart Care Kinzigtal is an important chance to develop new care processes, to proof and review them.

South Denmark (Denmark)

All local, regional, and national levels’ plans and policies complement and contribute to the envisaged pilot service. This pilot service is completely in line with strategies and investment strategies in Denmark. The three most important influences are described in the following.

A number of new initiatives form the strategic foundation for the future implementation of integrated personal health systems and remote patient monitoring and treatment in Denmark. The first to be mentioned is Regional Health IT or RSI (Regional Sundheds-it), which was initiated in February 2010. The challenges described call for a strengthening of inter-sectorial collaboration in the Danish healthcare system. From a citizen perspective, it is expected that the healthcare system is open and includes citizens in the care for their own health at the same time as delivering high quality treatment. The regions regard the use of health IT as crucial in relation to the pressure put on the healthcare system. Thus, health IT is an integrate part of the regions’ work towards continuously being able to treat more patients with fewer staff and fewer means while maintaining high-level quality. In order to meet these challenges, the regions have established 24 indicators to be reached within different deadlines before the end of 2013.

The second initiative is the National Board of E-Health or NSI (National Sundheds-it). This is a new board under the Ministry of Interior and Health. NSI has two main tasks:

• Managing the national administration of IT in the healthcare sector, including the collaboration with regions and municipalities

• Managing operation and development of the Ministry’s health related IT systems in agreement with the individual boards, etc.

As part of these tasks, NSI establishes national standards, implements prioritised cross-disciplinary initiatives, and ensures that the development of IT in the healthcare sector takes place in line with the IT strategy for the healthcare system.

During the writing of this project proposal, NSI is finishing its National Strategy for Telemedicine. The strategy is expected to be published on their website and consists at this stage of 22 recommendations (un-official recommendations at this stage).

The third initiative comes from Local Government Denmark or LGDK (Kommunernes Landsforening or KL), which is behind a number of initiatives targeted at strengthening integrated care and the use of IT on a municipal level. One of these initiatives is the “Municipal Digitalisation Strategy 2010-2015” in which LGDK encourages all municipalities to

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collaborate for the digitalisation, standardisation, and efficiency improvement of the public services offered by the municipalities. Strategies for the following four areas have been prepared: employment, social services and healthcare, technical and environmental services, and children and culture.

Tallin (Estonia)

All local, regional, and national level plans and policies in Estonia complement and contribute to the envisaged pilot service. The main policy document in this field is “National Health Development Plan”2009-2020. It reflects the issue of e-health or usage of IT solutions (including telemedicine) which are seen as one of the possibilities to improve the situation in the health sector. By maintaining a healthy population and increasing the ability to work, the human well-being and life expectancy will increase. ICT is seen also as a tool to facilitate taking care of the elderly. Since 2000, the eHealth strategy of the Estonian Ministry of Social Affairs (MoSA) is based on three pillars: establishment of a nationwide integrated electronic health record system, also known as the "Electronic Health Record Project of Estonia (2005 – 2008)”, strong focus on standardisation and in particular on interoperability, and the use of the existing IT infrastructure. The cornerstone for successful Estonian E-solutions is a modern E-state infrastructure, commonly known as “X-Road”. Digital signatures and ID cards are the basic elements which enable the creation of new, high quality E-services. The strategy foresees a comprehensive central register of the health information for all 1.35 million Estonians from birth to death. The register is intended to facilitate the exchange of all types of health data between health care providers. It is also meant to support centralised healthcare management and strategic planning through better quality and accuracy of the necessary data for organising healthcare. All patients will be able to securely access and review their medical data and make it available to the health care professionals they are dealing with. This also includes the ability to – via the Internet – obtain appointments online, submit prescription renewal requests, and exchange test results such as blood pressure readings.

Regarding integration with social care, the following plans should be mentioned:

• Competiveness plan Eesti 2020“ which aims to increase active living years of elderly by decreasing accidents through developing medical and social infrastructure. Also to support sustainable development of social expenses in environment where percentage of elderly is increasing.

• Development plan of Social ministry 2012-2015 which supports development of services meant for home living (electronic alarms, GPS devices, etc.). Local municipality will provide preventive home visits, which helps elderly people staying at home independently. There is a nationwide health development plan which supports e-nation ideas and innovative solutions to be included in health infrastructure. To improve cooperation between service providers and information exchange between different stakeholders. Take into use up to date ICT solutions and communication devices (including telemedicine).

Aragon (Spain)

At national level there is a common framework that sets the strategies in terms of health that all Spanish regions must follow. We can enumerate several policies as the “Dependence Law” (“LEY 39/2006 Promotion of the Personal Autonomy and Attention to people and families in dependency situation Law“) that establishes the bases to build the future Dependency Attention National System that will finance the services required by dependent people either due to illness, invalidate accident or aging. Other programs are the “Attention to chronics Programme” and the “Attention to elders Programme”.

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At a regional level, the Aragon’s Health, Welfare and Family Department is the body that defines the acting policies in terms of health, consumption, welfare, immigrants’ integration, women, youth and family. This body defines the region sanitary resources offer with the aim to guarantee a sufficient sanitary offer being equal and of quality assessing the efficiency of centres and services, and pushes forwards the sanitary service portfolio, along with the design, control and evaluation of projects and programs oriented to enhance the offer of care assistance available for risky groups, oriented to certain groups of population and with the objective to adapt and enhance these services to the age and gender of the target population.

Some of the key objectives for the region are regulated under different laws, as the Aragon’s Social Services which are regulated under the Aragon Social Services Law, “LEY 5/2009, 30 de Junio, de Servicios Sociales de Aragón” that names the public bodies responsible for analyzing the social reality with the aim to detect necessity situations of the population and to define policies that favours welfare and enhance the quality of live, promoting personal and family autonomy and of those of groups through the development of their capacities. This law defines, among others, on its 53 article the need to create an information system unified of social services that include all resources provided by public administrations and private social services managing entities.

Other policies that contribute to the social and health services are the “Information Systems and Telemedicine Plan” of Aragon’s Government, the “Strategic Plan for Aragon Social Services 2012_2015”, the “Aragon Social Law”, and “the Strategy of Attention to chronics”.

The Aragon’s Healthcare Area is the body of the Aragon’s Health, Welfare and Family Department that takes care of the health services of the region and has the following functions and responsibilities:

• overall management and co-ordination of the existing healthcare resources in the territory of Aragón;

• Primary Care and Secondary Care management, including homecare

• promotion and protection of individual and collective health.

Aragon’s Healthcare Area has introduced innovation on the professionals’ regular practice through the integration of telemedicine solutions thanks to the collaboration on several strategic projects. It has been actively working in telemedicine solutions and e-health programs and projects, promoting active aging, helping to chronic dependent and autonomous patients at home and elder houses, home telemonitorization and empowerment of patients. Our core fields are telemedicine innovation as teleadvice, teleconsultations and telemonitoring of chronic elder patients, prevention and promotion of healthcare practices, security of patients, e-learning programs, use of expert tools as support in the decision-making.

The importance of searching new mechanisms to ensure the health services in Aragon territory is shown as the Aragones’ Health and Welfare Department is currently working on creating a Centre of Excellence in Telemedicine and e-Health that will provide of a niche of technological companies and industries with local, regional, national and international scope and that will be available to cooperate on the project thorough collaboration frameworks contributing with added value and high quality ICT solutions.

Basque Country (Spain)

A Regional Government Strategy entitled ‘Kronikbasque’ (http://cronicidad.blog.euskadi.net/ descargas/plan/ChronicityBasqueCountry.pdf) aiming to address the challenge and opportunities that Healthy ageing provides has been adopted. It involves the different departments in the government, mainly, Health, Employment and Social Affairs, Education and Science and Industry. The social-health service is framed within the objective of providing social-health care, as stated in the Social Service Act 12/2008, 5th December, and

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defined as “all care offered to people who, due to serious health problems or functional limitations and /or being at risk of social exclusion, need coordinated and stable simultaneous social and health care”. The objectives are as follows:

• To develop the social health services, enhancing socio-health coordination at Primary Care level through interdisciplinary teams, as a guarantee of integrated care throughout the period of care, considering the home as the principal provider of care, as well as promoting and standardizing the development of socio-health resources in the three Provinces.

• To improve the coordination of systems and structures at socio-health level, promoting the existence of a common legal framework which specifies the catalogues of social and health care, as well as drawing up a new model for the financing agreement for socio-health services.

• To enhance system management to bring about an improvement in the levels of care, by means of training and increasing the awareness of everyone involved in socio-health coordination, as well as the implementation of a shared information system.

Under this strategy, new developments have started to be designed. In the forthcoming two decades 26% of all Basques, the baby boomers, will belong to the over 65 age group. For the first time our society must prepare itself for a situation in which those who, today, are aged 50 will have to care for their parents for longer than they have looked after their children. Chronic illnesses represent the dominant epidemiological situation of the country. It is estimated that they currently represent 80% of the interactions with the Basque Health System and account for more than 77% of health expenditure. Cardiovascular disease and COPD, cause 16.4% and 6% respectively of all deaths. In the case of women, cardiovascular illnesses were also the major cause of deaths (17.3%), while diabetes was the second most dangerous (3%).In the Basque Country there is a public NHS type of health care system. All health care professionals are salaried in both primary health care and hospital care. The important lesson of the past years is that despite this apparently tidy vertically integrated system in management terms, at the provider level this system has not achieved integrated clinical care and continuity of care. Management integration at all levels does not guarantee clinical integration where we need it at the provider level, ensuring we are developing local systems of care which offer continuity of care. Investment is required in an information strategy and the technology to make it possible, it is necessary to use new approaches to educate patients to manage their illness, to continue to promote evidenced-based medicine, and also to integrate primary care, hospital care and social care and to develop new professions which integrate care. The whole Basque population is stratified by severity and levels of health service use according to their clinical risk. It is based on previous Hospital Admission data, Prescription data and morbidity in Primary Care using Ambulatory Care groups (ACG-pm). The approach seeks the provision of personalized services tailored to the needs of each group of users of the health and social care system: patients, informal carers, health and social-care professionals and citizens. It aims to implementing a new model of health care focused on prevention, monitoring and new forms of non-face to face attention, including health counseling, then shifting the care model from acute care to chronic care. Primary care doctors and nurses will include in their “screening” protocols questions trying to assess social risk and needs. People under social care either at home or in nursing homes will have their health care more integrated with their social care processes. The Associations of Chronic Patients, has set up a Network of Activated and Connected Patients using Web 2.0 technologies. There is already a Basque Council for Social and Health Care (Consejo Vasco de Atencion Sociosanitaria) as a coordinating body of all involved actors: the Basque Government, the County Councils and the Town Halls. What is being sought is not just coordination, but a synergy resulting from the joint action of all the involved parties.

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Catalonia (Spain)

In Catalonia several policies have been designed and implemented to improve the healthcare provision model, and special attention to integrated care models has been taken and is one of the main benefits the healthcare system could take from the policies in place.

One of the strengths of the Catalan public health system is the continued care between primary and specialised attention. 69 Hospitals , 400 primary care centres , 39 mental health centres and 100 social/health centres, are part of the XHUP (the public utility network of healthcare providers), with more than 65.000 professionals, properly aligned to the health strategies from the Health Department and the public insurer (CatSalut).

At the technological level, the first stage of the Health ICT plan (2008-2011) has permitted the deployment of the infrastructure required for eHealth services and the core of them have been designed, implemented and deployed. ePrescription and Shared Clinical Record are fully operable and all the public health care providers use them; also the digitalised image plan has permitted that 94% of providers do not print any kind of radiological image; the Personal Health Record has raised its fully operational phase and more services have been deployed under the Telemedicine plan. The new Health ICT plan (2012-2015) ensures the continued effort on the evolution of the core systems to ensure future service development. The key areas that will be reinforced during the plan will be the redesign of the regional shared clinical record to a network to integrate information and services, the provision of a multichannel network to interact with the citizens, and the deployment of the required infrastructure, fully standard compliant, to support the services.

At organisational level, the new governance system has created territorial areas where all healthcare providers and public administration (regional, territorial and local) define the priorities and coordinate healthcare services.

At clinical level, the Primary Healthcare and Community Health Innovation Plan, initiated in 2010, establishes the integrated care model as the new paradigm to pursue in the assistance provided to citizens. And the Program for Prevention and attention to Chronicity, created in 2011, and now in territorial deployment sets the bases, the processes and the guidelines for the attention to chronic patients where health and social care professionals manage the patient in close cooperation ensuring the continuity of care.

Finally the new Healthcare Plan for 2012 has defined some specific strategic lines in the areas of chronic patient attention, quality in highly specialised services (opening to remotely provided services), and a restructure of the governance and reimbursement model for the healthcare providers that will promote a more result oriented procedure enhancing the integration between levels of care.

In all this progress TicSalut Foundation has been, in the name of the Health Department, a key player in developing actions and enhancing the coordination from the administration with healthcare services, health professionals, vendors and universities.

Just recently the Social Policy Department has joint TicSalut Foundation in order to coordinate the implementation of ICT in both areas healthcare and social policy. At the same time TicSalut as a consequence of the designation of Barcelona as MWC (Mobile World Capital) has been asked to lead the development of the mHealth Competence Centre.

Extremadura (Spain)

At regional level, a dedicated Programme for Promoting Active Ageing, 2012 has been adopted. It coordinates the development of a set of programs, resources and services. The actions carried out under this programme are aimed at preventing situations of dependency, promoting health care, skills development, knowledge transfer, the participation of disabled people into the social, economic and cultural life as well as stable social networking and strengthening support groups, intergenerational relationships and volunteering. In this

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context so called ‘Senior Centres’ play an important role, together with other actions including collaboration with external entities. Senior Centers are public facilities offering services to older citizens directed towards facilitating training, empowerment and social participation. Moreover, a comprehensive plan for health and social care of Extremadura has been adopted, prioritising utilisation of ICT for the provision of quality services to the elderly. Further to this a quality plan for Spanish health system has been adopted, in order to respond to key challenges faced by the NHS, thereby increasing the cohesion of the system and ensuring equality in health care provision to all citizens, regardless of where they reside, and ensuring highest quality of quality.

Valencia (Spain)

At Spanish level, it exists a common framework defines the strategies in terms of health and social services that all Spanish regions must follow. From the Spanish Ministry of Health, Social Affairs and Equity, there is a common portfolio of health services that are guaranteed to be provided and from the point of view of social services, there is the “Dependence Law” (“LEY 39/2006 Promotion of the Personal Autonomy and Attention to people and families in dependency situation Law“)

Additionally, it has been sucessfully developed the Information Systems Plan 2009-201111. Within this plan, the regional government stated that assuming that information is essential for appropriate decision making; Information and Communication Technologies (ICT) are an essential tool for assuring health system performance, and to improve equity, quality of care, safety, productivity and efficiency.

Conscious of its strategic importance, the Valencia Health Agency (AVS) made a strong commitment to improving information systems, with a significant investment effort in this area. Within this plan, a new Health Information System (SISAN) of the Generalitat Valenciana has been into development in the last years with a strongly integrative approach that considers homogeneously all aspects of an organization as complex.

The SISAN system includes four main domains:

• Primary care (Abucasis)

• Hospital care (ORION)

• Extra-hospital emergency care (CORDES)

• Central Services (SSCC) and Public Health

There are 3 blocks of information systems to cover the areas of care, logistics and business intelligence as well as all activities that enable the management of each project: development of applications, channels of access to systems, ICT infrastructure, support the activity, quality and continuity of services, and finally those aimed at coordination of investigation and innovation as the evolution of health care.

Based on that and existing European initiatives, the Valencia Health Region is deploying a new strategical framework fully aligned with the three pillars of EIP-AHA initiative. Following that approach, the Valencia Health Region has already applied to be a reference site with EIP-AHA initiative.

Further to that strategy, a number of existing running initiatives in the region are expected to sum added value to the proposed pilot:

• GeChronic – Public-private partnership established to create a pilot for integrated chronic disease management of chronic conditions in the La Fe Health Department.

• Palliative care programme – funded by Obra Social La Caixa, includes the involvement of a full time psychologist and a ICT based programme for supporting and providing education and monitoring of caregivers of these patients.

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• ChronicSalud – funded by ESTEVE Pharma Company, aiming at providing web-based support and monitoring for low-complex chronic patients focusing in mild respiratory conditions and hypertension.

• Electronic Health Care Record initiative (ORION, ABUCASIS)– public initiative that allows the integration of both primary and hospital health records, making results also public and available to the patient through different channels.

• EPSOS pilot – It focuses on improving medical treatment of citizens while abroad by providing health professionals with the necessary patient data. Fully aligned with Valencia Health region strategies, all the EHRs (+5.000.000) are available for exchange.

• Telemedicine Strategic Plan – Valencia Health agency, that is being developed by Universidad Politécnica de Valencia

South Karelia (Finland)

The greatest challenges relating to the ageing of the Finnish population will start to affect the social and health services systems in the next few years. Demand for services will increase in both the social services and the health care sector. Regardless of the development of the public economy, addressing this challenge requires that the service system is revised radically in order to ensure adequate services for the elderly in particular. The objectives provided in this strategy represent the four viewpoints included in the strategy map of the South Karelia Social and Health Care District (Eksote). They aim to tackle these challenges by moving from municipal-level thinking and organization of operations towards regional integration.

One of the four viewpoints is utilization of technology. The increasing service needs require that information and service logistics are enhanced with technology. Technology will be utilized in enhancing the efficiency of processes, lightening of administrative procedures, and supporting home care and service housing.

The welfare strategy of South Karelia 2011-2015 was launched in 2010. Also the welfare strategy supports new innovative technological solutions. Strategy has been made together with all municipalities in South Karelia who are responsible for public services, other organizations who are responsible for many voluntary tasks, private sector and Eksote as a public sector. Welfare strategy emphasizes comfortable and safe environment and living conditions for elderly people, old people recourses and involvement and taking care of each other.

At the national level, the project plan is in line with the strategy of Finland Ministry of Social Affairs and Health which supports independent living at home as long as possible (http://www.stm.fi/c/document_library/get_file?folderId=3320152&name=DLFE-17207.pdf).

Central Greece (Greece)

The planned regional action will in particular reinforce an ambitious regional development strategy directed towards already IT mature municipalities of Central Greece into so called “Digital Communities” with integrated health and care services. The Municipality of Trikala has been playing a leading role in creating a network of 11 municipalities that are jointly working towards this goal, together representing more than Greek 1.000.000 citizens. Hence, a framework agreement has been concluded on the basis of a shared vision. As a response to this strategy Central Greece is spearheading the deployment of innovative ICT solution in variouse fields. In geographic terms, the city is located in the north of Greece. It is the capital of the prefecture of Trikala, a rather peripheral region. Trikala has been defined as the first Greek digital city, e-Trikala, as it has started since 2003 within the Program of Information Society to orient towards digital solutions to improve its citizens’ quality of life. A range of services are offered, from health and care to transportation services. On the other, the

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already deployed and running services have been to efficiently integrated and keep up with the state of the art in this fundamental field.

Furthermore, e-Trikala SA is a competence center of Central Greece and actions that are going to be deployed within the pilot will then be implemented in a larger scale through the Greek National Administration system.

General purpose: The main objective is to reinforce national, regional and local policy strategies with relevance to integrating existing services along with the corresponding objectives and approach that aims to substantially contribute to the reliability and sustainability of the ICT solutions.

Attica (Greece)

At the local level there is strong commitment for the pilot service as three municipalities (Palaio Faliro, Alimos and Agios Dimitrios) are in the process of signing an MoU towards an Alliance for Healthy and Active Ageing using Innovative Technologies. As already mentioned, there is strong commitment at the municipality level regarding a systemic change in the mode of planning and delivering health and social care with the use of innovative technologies. Possible mainstreaming will enforce implementation of the new legal framework for primary health care, social care and public health through municipalities. Mainstreaming will require capacity building of involved stakeholders in terms of care pathways, clinical protocols, self - support management, use of IT technologies etc. The National Strategic Reference Framework (NSFR) with its Sectoral Operational Programme “Digital Convergence” supports the implementation of actions related to e-health by providing financing to selected projects as well as the Sectoral Operational Programme “EPANAD”. The first is coordinated and managed by the Ministry of Development and the second one by the Ministry of Health.

Northwest Croatia (Croatia)

The Croatian Ministry of Health and Social Welfare considers eHealth as an enabler to higher quality of healthcare delivery, health services made available to all citizens and better utilization of resources. The introduced Healthcare Networking Information System in Croatia represents a comprehensive solution designed for the integration of healthcare processes, information management and business workflows for healthcare organizations, enterprises and delivery systems. It is developed as a modular, secure, and open communication platform that efficiently synergizes common enterprise integration services with healthcare specific application components. To date some 2.400 primary healthcare teams in all 20 counties and in the City of Zagreb have been networked. Northwest Croatia’s priority is an advanced IT nursing system, which integrates hospital care and post-hospital patronage activities as well as home care of the patients. The IT nursing system follows all the aspects of the hospital care of the patient, as well as it integrates the communication between the primary care doctor, patronage nurse and home care teams. This is achieved by following the highly structured process of nurse care monitoring the patient in the hospital, informing all relevant health care subjects upon his dismissal from the hospital, and creating all the necessary conditions for the follow-up care by using patronage and home care teams.

By standardizing nursing procedures on the regional level through workshops and pilot programs, existing IT nursing system could be significantly improved to the level of providing standardized healthcare in all EU countries participating in the pilot program. After translating the software through its existing multilingual support already built in the system, evaluation could be performed and this improved IT system could be installed in the hospital systems for further evaluation of all improvements resulting from its usage. Implementation of such advanced IT systems based on "cloud" technology, significantly decreases total costs of investment for the healthcare institution, since the only crucial asset is internet bandwidth.

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Veneto (Italy)

The Veneto Region is the public authority governing health and social policies and decisions. The policies are developed and implemented by the 21 Local Health Units; these entities all together form the Regional Health System of Veneto Region. All the Units as one or more structure dedicated to primary health care, elderly care and social care called “Social and health District”. One of the main features of Veneto Region Health Model is the integration of health and social care guaranteed through a close cooperation between municipalities and the Local Health Units.

In the Resolution n.2082/2010 the Regional Committee set the guidelines for the new local plan of action in the field of social and health care. The general objectives of those plans are the support and the further development of an integrated system of public social and health care. Amongst the other objectives it is emphasized the role of the home care for elderly people, chronic patients and moreover for all those people who need assistance. Veneto Region, through the Local Health Authorities is already implementing and delivering a complex set of cares called Integrated In-home Care (ADI). The ADI involves health and social care for chronic disease patients and for weaker and disadvantaged categories.

Friuli-Venezia-Giulia (Italy)

Smart Care allows the Regione Autonoma Friuli Venezia Giulia to better support the national key policy objective, in the field of “information and Communication Technology”, as expressed in the National Health Plan 2011-2013: “to enhance the health service and to invest in strategic areas such as prevention, new technologies, information systems and information, the clinical governance and safety of care, research and medical innovations”.

At a regional level Smart Care is fully supporting the “regional health and social care and services integrated plan” giving a very useful contribution to the “Technical development and reorganization of Information Systems mainly through the realisation of the Electronic Medical Record (EMC) of people with disabilities in order to collect information about the different life stages, on the preventive/curative/rehabilitative interventions”.

The EMC's construction and his implementation over time, together with the use of information and their traceability pose a great challenge of technological innovation and citizen's cultural change towards their health, as well as of the health/social operators on decision, treatment and care processes.

Smart Care will also permit to exploit regional resources and projects of social housing solutions for the elderly and people with disabilities.

In order to better support the implementation of regional policies and services, Friuli Venezia Giulia Region has recently adopted, with a specific provision included in the “Outline for the management of the regional health system 2011/12” a “Regional network on ICT for the quality of life” intended as a Regional lab dedicated to the development of home living, domotics, accessibility and it intervening on:

• Housing and living environments;

• ICT role for active and healthy ageing;

• Social innovation (Public Private Partnership –and community development)

Friuli Venezia Giulia has adopted a Regional Law n.26/05 on Innovation (area: “innovation in social-health services”)with the specific aim to promote home care for dependent people through community development actions, the use of technologies for home care and the adoption of services management models with particular reference to developing ICT systems.

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Noord-Brabant (Netherlands)

In the Netherlands, a vision document is written by an independent health and care advisory board for the Dutch government and parliament. Goal of this advisory board is to achieve a higher quality and accessibility of care. The document reports that the care sector will have to undergo a radical change: from “care and disease” to “health and behaviour”. This implies prevention and care efficiency. This important focus shift not only accounts for care professionals, but also for the clients. The two have to work together as so-called co-producers of the client’s health. Citizens are no longer passive consumers of care, but will become active citizens in search of health and opportunities to participate in society. In all phases of the care process, one has to act sooner, faster and more focussed.

According to the Dutch Minister of Health Edith Schippers (2012), the combination of digitization and care is seen as one of the spearheads of the current health policy: “eHealth is necessary as an aid to ensure accessible future care”. Besides, also local governments frequently launch innovative care-related initiatives. The Province of Noord-Brabant started the project “Slimme Zorg”, a collection of local projects on sustainable social innovation. On a municipal level, a broad range of organisations in different sectors started the “Slimmer Leven 2020” project, intended to work closely together and develop more efficiënt care delivery in the region.

Recently, the National Health Care Authority (NZA) has published that – in case a patient is involved in eHealth care – annually a grant of 400 Euro / patient will be supplied to fully licensed organisations (like POZOB) who support the chronic diseased patient. In addition, it is decided that up to 4 hours video-communication in terms of remote care delivery can be reimbursed.

Rotterdam (Netherlands)

The Social Support Act (WMO) of 2004 is meant to manage the integration of people with limitations in society. It makes municipalities responsible for home care, supporting and activating care, as well as the regulations for transport, client support and various subsidies.

The implementation of the provisions of the law on social assistance (WMO in Dutch) is a responsibility of the municipalities (here: of Rotterdam). The main goal is to enforce the independence of the citizens. The policies are segmented towards social and physical activities thorough programs and projects where regional and national programs are linked.

At its core, the WMO act should ensure people’s participation in society. Its starting point is to organise social care in such a manner that people may live and participate in society at the highest level of independence, possibly supported by friends or family. When this should be deemed insufficient, support is provided by the local authorities. This support includes contributing to voluntary work or organising help in managing the service users’ households. The WMO also focuses on the accessibility of services as it aims to ensure the availability of good quality information about the support.

The Act for Social Support – WMO – stipulates:

• Local Authorities supporting people in their daily life with aid in housekeeping, wheel chairs or accessibility renovations and special transport for people with disabilities;

• Supporting voluntary work for the neighbourhood or for specific service users;

• Stimulating activities to promote cohesion and participation in neighbourhoods and city districts;

• Supporting efforts to prevent the decline into situations that may require additional support. E.g. support in upbringing or activities to counter desolation.

With this act there is more coherence in the support delivered. Care providers will be able to negotiate contracts with the municipality to formulate a proactive and community driven

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intervention program and by that providers will strengthen the relation with the client. Local authorities are to improve social cohesion and the quality of life in their villages, city districts and neighbourhoods. Every Dutch citizen will have easy access to the WMO services with advice provided at their respective municipal WMO-desk. Furthermore, the inhabitants are involved in the Municipal WMO policy, they can monitor progress and they can express dissatisfaction to the city council.

The WMO is a general law with services for everybody. Under this law a specific target audience are people in need of social support. The WMO also coordinates part of the implementation of the National Act on Exceptional Medical Expenses (AWBZ) to local authorities. The AWBZ is a mandatory national collective health insurance for those healthcare risks that are not individually insurable. Inhabitants and those that generate income in the Netherlands are automatically insured for those expenses, by the AWBZ. On the basis of this act expenses are paid for extended stays in hospitals or institutions. These expenses are not covered by regular insurance.

The biggest change the WMO constitutes is the consolidation of previously existing acts and the change in control philosophy. The bundling of laws facilitates integrated policy, while the change in control philosophy results in local authorities being held accountable by its inhabitants instead of by national government.

Uppsala (Sweden)

On national level there have been a number of initiatives that affects the area of SmartCare. The Center for eHealth in Sweden (CeHis) has been established to coordinate and push these efforts forward. The Center shall create the long-term conditions necessary for developing and introducing nationwide use of IT in the decentralised health and social care system Sweden.

The Center for eHealth in Sweden is governed by representatives of county councils and regions, the Swedish Association of Local Authorities and Regions (SALAR), municipalities and private care providers.

One of the most important initatives in this area is the National Patient Overview (NPO). The NPO makes it possible for qualified nursing staff to the patient's consent to take part of the medical records filed with other caregivers as well as municipalities and the social care. Coordination of care measures and to provide a comprehensive picture of the patient gives a better basis for diagnosis, treatment and monitoring. The NPO is now rolled out in both municipalities as well as County Councils. This will be the base for information exchange between the actors.

Just recently the Government launched a work for changed legislation concerning a smoother and more transparent information exchange between Health Care and Social Care. That work estimate to be finished at the end of 2013.

Kraljevo (Serbia)

Since 2005. to the present Government of the Republic of Serbia produced a number of strategic documents related to the improvement of social and health care, and strategic development on society and recommendations for building portals eGoverment in all state and local departments of governments.

All documents are highlighted for vulnerable population groups, as well as main directions of activities aimed at improving health and quality of life. In connection with the appearance of ageing, health care and quality of life for people over 65 has a special place in National Health Policy.

Effects of good practice in health and social care for older people can be present through several important principles of treatment, in appropriate areas of activity:

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• involvement of older person in all forms of decision-making about their illness and future health care

• promote good health and healthy living habits in elderly

• take action to prevent disease

• reducing functional ability

• promoting independence of living

• support the elderly in their homes

• the introduction and use of new ICT technologies to improve Health care of elderly and more efficient of health and social services

• general purpose: maintaining and improving health and quality of life for older citizen by providing health and social care services and quality

To preserve and improve the health status and, in general, the position of older citizen, it is essential to the health and social services sector - both in the state and the non-profit and private sector – to be better integrated and coordinated.

Amadora (Portugal)

In the last years the economic and social situation in Portugal has shown remarkable progress. The sustained and systematic improvement of health and social services in this period has been recognized internationally. In addition, Portuguese population is increasingly aware of its rights, increasingly demanding, and alert to the defence of its health. Nevertheless, there is much to do regarding the provision of integrated care services in Portugal, including long-term care, day centres and social services for the chronically ill, older people and other groups with special needs, such the mentally and physically disabled. There is a traditional reliance on the family as the first line of care in Portugal, particularly in rural areas. However, demographic changes, such as an increase in female employment and a breakdown in the extended family due to migration to urban centres, mean that many people are no longer able to rely on such informal care. As in many other European countries, Portugal faces a growing older population and the pressure to provide social as well as medical care is increasing.

The National Network for Integrated Long-term Care was created in 2006 within the scope of the Ministry of Health and the Ministry of Labour and Social Solidarity (the Integrated Support Plan for the Elderly) due to evidence of a clear lack of resources in long-term and palliative care as a result of an increase in the number of people with incapacitating chronic diseases. This network combines teams providing long-term care, social support and palliative activity with its origins in communitarian services, covering hospitals, local and district social security services, the Solidarity Network and municipalities.

Northern Ireland (UK)

The pilot would have the potential to accelerate the regional rollout of Northern Ireland’s integrated care strategy Transforming Your Care (TYC): (http://www.dhsspsni.gov.uk/ transforming-your-care-review-of-hsc-ni-final-report.pdf). TYC was published in December 2011 following a comprehensive and strategic assessment of all aspects of health and social care services in Northern Ireland, which was requested by the Minister for the Department of Health, Social Services and Public Safety (DHSSPS). Themes identified by the Review included the provision of care as close to home as possible and the transfer of resources from hospitals to be reinvested in primary, community and social care services.

The case for change identified within TYC clearly documented the impact of changing demographics. Northern Ireland has an increasing and ageing population. It is expected that

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by 2020 the number of people aged over 75 years will increase by 40% from that in 2009, and the number of people over 85 years of age will increase by 68%.

One of the key recommendations of TYC is the creation of 17 Integrated Care Partnerships (ICPs) across Northern Ireland to enable closer working between and within hospital and community services. The pilot to be implemented in the Southern Health and Social Care Trust would support integrated working between GPs, Pharmacists, nurses, social workers, allied health professionals and hospital specialists across a specific care pathway, focusing on patients over 75 years of age. It is important to note that the over 75 care pathway is the first step on a journey to integration of care (hospital, community and social care) across many other pathways, particularly those relating to long-term conditions. The pace of change will depend on the availability of additional resources.

TYC has been endorsed by the Minister for DHSSPS, is aligned with worldwide developments towards more integrated care and its implementation has begun. The SmartCare proposal to pilot an ICP is strategically aligned with the themes of care closer to home and the transfer of resources to primary care, whilst taking into consideration the ageing population of NI and the necessity for more cohesive, integrated working between professionals, as identified within TYC.

Scotland (UK)

The Scottish Government’s Health & Social Care Directorate has identified further support to enable successful ICT based European initiatives. This involves funding along with facilitation/implementation support via JIT and SCTT. In addition, local health and social care partnerships have indicated a willingness to commit Change Fund resources to contribute to match funding and implementation resources. NHS24/SCTT facilitate a national telehealth and telecare network where developments are shared on a monthly basis via virtual meetings, and at two national events over the year (May and November). This includes representation from all geographic areas in Scotland. Input is also provided to many other national network events, strategies to share learning and develop best practice. In additional SALPB report progress to the Scottish Government on key developments which may inform policy and resourcing priorities. The SmartCare programme will also be supported by a 3 year national strategy for telehealth & telecare in Scotland, which is due to be published in Spring 2012.

Our two Scottish Enterprise companies have been progressing business opportunities around digital health and assisted living for the past two years. Scotland has now established a strong partnership pool of potential industry partners (inward investors, companies and SME’s) to support innovation and collaborative working around life sciences, digital health and enabling technologies. We are also progressing an innovation programme in partnership with the Technology Strategy Board, which is anticipated to result in a £10 million DALLAS (demonstrating assisted living lifestyles at scale) initiative in Scotland – our ‘Living it UP’ programme. ICT industry partners involved within LiU include Philips, O2/Telefonica, Vodafone, Andago, Looking Local, Atos, Intersystems, Intrelate, Ernst & Young, Maverick TV, Scottish Television, Illumina and Sitekit, evidencing a wealth of global, European and Scottish SME’s already active collaboration partners. Our relationship with the above, our enterprise companies, our industry pool and additional ICT providers working within health and social care will ensure Scotland is well placed to support the transfer process by sharing learning, engaging in and encouraging innovation opportunities and expanding good practice.

As detailed above, the envisaged pilot service is regarded as a phased implementation of the national Telehealth & Telecare Strategy in Scotland and an important contribution to our Reshaping Care for Older People Programme. It is also intended to complement and share learning with the DALLAS programme. Scotland has significant expertise and experience in technology supported service redesign within health and social care services, and has in

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place a wealth of supporting materials, resources and networks to ensure a successful implementation of SmartCare. We are also members of European thematic networks established to further support this agenda e.g. the Regional Telemedicine Forum, CASA and MOMENTUM.

B.1.2.3 EU relevance of the solution to be demonstrated European (national) health systems – be they of the Bismarck System type, which is based on payments for health insurance by both employers and employees, or the Beveridge System type, tax-based National Health Services -, have become highly complex, adaptive systems which are awkward to manage. Already 60 years ago in Europe and globally public health visionaries discussed priorities for health policy which sound acutely modern and similar to today’s statements by European policy makers and medical experts:

• 1950: “While it is not strictly correct to link the aged with those who are chronically ill in any discussion on the provision of a health service for the community, they may be grouped together because of the fact that special provision has to be made for them. The rising cost of the upkeep of hospital beds is one of the factors which make discussion necessary... We should realise that prevention of chronic illness is no less important in the community than prevention of the acute variety... The most important of the chronic diseases have been named as heart disease, arterio-sclerosis, arterial hypertension, nervous and mental disease, arthritis, kidney disease, tuberculosis, cancer, diabetes and asthma.”10

• 1954: “Comprehensive programs, such as those directed to bring maximum benefit to persons with chronic diseases ..., require the coordination of the efforts of many individuals and agencies... The home care program clearly demonstrates the importance of the close integration of clinical, public health, and other services if the needs of chronic disease patients are to be met to a reasonable degree.”11

It seems that some health policy and health system discussions have been turning in circles without much progress for more than half of a century. This serves to underpin for Europe the urgency of the need for a new health services paradigm both to cope with these still unsolved issues and to meet new challenges from the ageing of our societies, chronic diseases, environmental threats, and others as outlined and discussed in great detail in European policy documents, recommendations etc. as discussed above in Section 1.2.1. It is exactly here were the key EU relevance lies of the solutions to be demonstrated by this Pilot Action.

To assure the sustainability of our health systems and improve the quality of care, various national governments, the European Commission, WHO Europe and many others are recommending the implementation of integrated wellness, health and social care service models. But to become successful, they will need the enabling power of Health ICT facilitated systems and applications. Such solutions support the efficient coordination of service provision across provider and jurisdictional boundaries, the sharing of data, information and knowledge, and the streamlining as well as individualisation of care. Achieving such change in health systems with limited resources requires refocusing the trend of medico-technical progress. Health and long term care ICT innovations must be scrutinised for their potential to indeed contribute not only to decreasing costs, but – at the same time - improving the quality of life and ability to cope with challenges like the increasing prevalence of certain chronic diseases or new expectations from healthy people and patients alike. It is focusing on these generic, overriding goals of Europe and its Member States that this project will be concerned with.

Editorial The aged and the “chronics”. Medical Journal of Australia 1950;1:601-602. Reprinted in Medical Journal of Australia 2003;179(5):246

11 Burney LE. Community Organization - An Effective Tool. American Journal of Public Health 1954;44(1):1–6

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All of this will be achieved by the wide deployment of integrated care services, thereby supporting “Pillar 2: Care and Cure” and particularly the Priority Action Area B3 of the Strategic Implementation Plan for the European Innovation Partnership on Active and Healthy Ageing. Through implementing in 10 European regions “SmartCare services” facilitated by highly innovative ICT-based applications and systems supporting these integrating healthcare, social care and self-care services for different health/living conditions, the Pilot will strongly contribute to capacity building and showcasing European good practice, which provides leading exemplars of successful integrated care systems, replicable across European health and social care systems. Although focusing primarily on horizontal integration, i.e. the collaboration within health care services and among social, health, community and family carers/care providers, some pilots will also involve some aspects of vertical integration, i.e. the coordination of care between primary and secondary healthcare. The European relevance is also underlined by being squarely aware of and taking into account European diversity and the specificities of national health and social care systems and their different ways to organise such services depending on the respective local, regional or national healthcare system, fully reflecting individual persons preferences and needs. Thus European relevance is also underlined by, on the one hand, assuring that these developments will identify the way forward to benefit all Europeans (and in particular older and chronically ill people), and on the other hand, helping to address resource efficiency and sustainability of national systems.

By basing its overall approach and procedure on several already well-established regional integrated (health)care schemes, and piloting and implementing in 10 European regions SmartCare services, this project is able to generate not only a critical mass at EU level – which is a key for successful implementation – but also to assure the later scaling-up in participating regions and the scaling out towards other regions across Europe. We fully expect that in the participating regions a wide convergence of visions and commitments to learn together, implement and act can be assured from multiple stakeholders. Also in this way this project will deliver great European relevance and unique European added value.

As the pilots will be concerned with and explore new modalities for establishing multi-morbidity case management, with new models of care for a range of chronic conditions, including protocols and individualised care plans, it will become a showcase and lighthouse project for the rest of Europe in the field of integrated care, supported by ICT for health systems and solutions. This will also involve deploying and validating new care pathways and organisational models for integrated care, thereby strongly contributing to replicable models and exemplars for sustainable deployment of integrated care services across Europe.

Based on the prior experience and achievements of a number of pioneer sites, the remaining follower sites will be tutored by the pioneers and replicate – in the context of their respective local or regional health system - adaptable integrated care models for chronic diseases, including remote monitoring.

This also underlines the European dimension and relevance, because by thus promoting innovative chronic conditions/case management, which includes remote management and /monitoring approaches, it can be expected that it will become possible to reduce the hospitalisation of older people with chronic conditions – a fact that will be closely monitored by the evaluation process to improve the evidence base for such models of care.

Such evidence will help to define a business case, based on which to scale up and replicate integrated care models across European regional and national levels. This will furthermore be supported by adequately disseminating all relevant project procedures, results and outcomes, and publishing, as appropriate, experience, identified success factors and lessons learned, care and pathway protocols, education and training materials etc. – all in support of raising the European visibility, relevance and furthermore concrete implementation of such beneficial healthcare models and processes.

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Of further European relevance and importance is that the project will validate and pilot promising solutions coming from the RTD phases of earlier eTEN, eHealth, AAL and CIP supported projects – various regions and other partners participating in this proposal have sometimes long-term experience in this respect and were involved in highly successful projects, the results of which will inform this Pilot and thereby becoming (commercially) explored.

The project will also develop European guidelines and recommendations for the organisation and implementation of integrated care, based on the experience of the wide diversity of the European settings in the regions participating in this Pilot. This will allow other European regions to experience a steeper learning curve when implementing similar, new models of integrated care, and thereby reap the resulting benefits faster for the good of European citizens.

Harnessing the power and benefits expected from the wide application and diffusion of ICT-based solutions across the European Union is an additional factor which needs to be mentioned here. The regional pilots will test, validate, and scale up new generations of innovative tools and services for more effective chronic conditions management, telemonitoring, and/or assisted self-management for home and integrated care – aspects which are high on the policy agenda across the Union and its regions.

A core challenge all European countries have to cope with relates to developing, implementing and gaining evidence on the effectiveness of new methods of reimbursement and providing the right incentives for the diverse actors to cooperate and integrate their services into a single offering for our chronically ill, frail older persons. Clearly, inadequate incentive mechanisms in support of innovative applications in the field of integrated care are a major barrier to progress in this field. Only if Europe becomes successful in unlocking and diffusing new value systems in active and healthy ageing, based on incentives and pricing mechanisms which assure solid business cases for all actors involved, will these new models of care become sustainable, successful businesses for old and new actors. This requires European-wide evidence which can inform policy makers across the Union, and which can only be gathered in such a European Pilot as proposed here.

To summarise: the core and overriding European relevance of the solutions to be demonstrated by this Pilot results from the achievements to be realised during the 36 month period this project will run, namely that it will

• Develop and operationally deploy new integrated care pathways and organisational models, supported by ICT, which cut across health- and social care in the participating European pilot regions

• Contribute thereby also to the long-term sustainability of a replicable plan for the pan-European deployment of integrated care services

• Generate generalisable evidence to probably confirm an improvement in the quality and accessibility of care as well as in cost-effectiveness (leading to containment and even reduction of associated costs) through the chosen common evaluation approach

• Demonstrate that integrated care models as piloted in the participating European regions provide real life exemplars of important future vehicles of improved healthcare delivery; that they “work”, and provide new evidence on their benefits and sustainable business cases

• Help creating a critical mass for the large scale, European-wide deployment of ICT-enabled integrated service models, thereby relying on the support of public entities and their capabilities to achive EU-wide operation of a commonly defined ICT integration infrastructure

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• Provide practical guidelines and solutions to address organisational, legal, regulatory, and reimbursement issues for integrated care across EU health and social care systems

B.1.3 Consensus building SmartCare is a unprecedented case of Pilot A project because never before such a large number of European regions have joined forces to break the traditional barriers between health and social care using ICT as the trigger to take them down. Removing these barriers means providing older people with a continuum of care eliminating the current gaps and the duplication of efforts particularly unacceptable in the current climate of public spending cuts.

B.1.3.1 Consensus building in the telehealth and telecare industrial arena

The SmartCare Consortium has consciously decided not to invite any industrial partner to be part of it but rather to invite the most influential association of industrial partners active in the area addressed by the Project, i.e. Continua Health Alliance (CHA). The latter has in its mission the building of consensus in the telehealth and telecare industrial arena. Their work is aimed at offering customers real freedom of choice in the future and to force potential suppliers to compete with one another on the sheer quality/price and price/performance ratios of their products/solutions rather than dwelling on proprietary solutions. Technical specifications for the procurement of the technological platform due to support the SmartCare services will be elaborated in collaboration with the Industry Advisory Board which is chaired by CHA but which will comprise also members from outside the Alliance. The collaboration with the telehealth and telecare industry could be even broadened during the lifecycle of the Project through the co-opting of other major industrial associations.

B.1.3.2 Elderly associations The Regional Partnerships which compose the core of the SmartCare Consortium are the rightful representative of citizens of any age resident in their territory and have channels of communications already in place to convey the relevant messages concerning the Project and win their support for the initiative. Older people are represented in the Consortium by AGE Platform Europe and by the European Patients’ Forum which, together cover both the social and the health needs of this growing layer of the European population. These two associations will disseminate through its membership information about SmartCare to the relevant local stakeholders. In addition to this, the individual partners will establish contacts with the local associations of older people to have them supporting the initiative locally on the ground of the potential benefits that SmartCare could release to older patients.

B.1.3.3 Nurses and informal carers associations The European Federation of Nurses Association and Eurocarers represent the professional side of the SmartCare Consortium and will be responsible for transmitting to the Project team the point of view of the categories they represent. This will ensure on one hand that the needs of these categories are properly taken into consideration and will help creating consensus in their constituencies because they have been part of the design of the SmartCare solution. In parallel, EWMA will facilitate meetings with local user representatives to facilitate interactions of the Project Team with them.

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B.1.3.4 Other relevant stakeholders The members of the SmartCare Consortium are conscious that the success of a Project as ambitious as this require consensus across a very broad spectrum of stakeholders. Time and efforts will be dedicated to gain support from this vast universe of stakeholders which can influence at higher or lower degree the long term success of SmartCare. A provisional list of these stakeholders, which will be refined during the implementation phase, comprises:

• Regional Health and National Social Affairs Ministries

• Pharmacists and their associations;

• General Practitioners and their associations

• Gerontologists and geriatricians and their associations

• Social service Managers

• Health Managers

• Insurance companies (represented in SmartCare by AOK)

• Telehealth and telecare standardisation bodies

• other EU funded projects with similar or complementary goals to SmartCare.

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B.2 Impact

B.2.1 Target outcome and expected impact In the following section, the way in which SmartCare will address the final outcome of the project, the building blocks, the common specifications, and the scalability, as listed in the Work Programme in relation to objective 3.1, is explained item by item.

B.2.1.1 Final outcome of the project

B.2.1.1.1 Focus and outcomes

Projects qualifying for funding under Objective 3.1 of the ICT-PSP Work Programme 2012 “Wide deployment of integrated care services” should:

• Validate the “role ICT services and applications can play in integrated care (i.e. the integration of healthcare, social care and self-care) for any kind of health/living conditions, including issues such as dementia and mobility with impairment”12. In SmartCare, ICT plays the role of enabler for the full implementation of the SmartCare Pathways which will be defined during the early phases of the Project. These Pathways will support the co-ordination of the interventions of the numerous carers who should collaborate with one another to provide the full range of care required to support older people in their wish to continue living independently. Co-ordination among the various actors is aimed to fill gaps in the continuum of care and avoid duplications which would negatively affect the sustainability of the older care services with the current demographic scenario and in a general climate of public budget cuts. Although inclusion and exclusion criteria in the sample of older population have not yet been set, all reasonable endeavours will be made to include subsets of the older population with specific needs such as dementia and mobility impairment.

• “Unlock new services and value chains in active and healthy ageing including the involvement of new actors (such as reimbursement scheme providers, insurers, regional development planners), leading to operational deployment of new care pathways and organisational models for integrated care”. In each of the pilot sites, the Regional Partnerships (see § B.3.1.3) comprise the entire value chain of stakeholders and players which contribute to the planning, provision, financing and evaluation of older care. Because the entire value chain is committed, and has the power, to implement the SmartCare Pathways, there are no doubts that the latter will find their way into the market as soon as their benefits and their sustainability has been, hopefully, demonstrated through the trials.

B.2.1.1.2 Characteristics • “Involve public authorities, providers of tele-care and tele-health services,

associations of care professionals and informal care givers, patient and elderly organisations, reimbursement scheme providers, insurers, procurers, regional development planners.” As explained above, all the categories of stakeholders listed in the Work Plan are represented in the SmartCare Consortium, both at European level through their associations, and in the Regional Partnerships through their local representatives. They will all play a role in elaborating the specifications of the SmartCare Pathways and in defining the trial evaluation framework. This involvement in such critical areas of the Project will ensure that both the vision and the outcomes of the Project meet the needs and the expectations of all the stakeholders. This is particularly important in the definition of the indicators in such a

Text in bold italic is extracted from the ICT-PSP Work Plan 2009

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way that the evidence produced in SmartCare can unlock the obstacles which have hampered until now the widespread deployment of integrated care services.

• “Validate the necessary organisational changes to support integrated care for improved health and wellness. This will include: patient care pathways; training of care teams, informal care givers and patients; reimbursement models and synergies between social care and healthcare budgets”. The SmartCare trials will be conducted in real life conditions. The required changes in the organisational set-up to take full advantages of the potential of the ICT-supported SmartCare Pathways will be implemented. All the aspects related to the overall sustainability of the services, and the mechanisms to be put in place for funding them through savings released in any part of the older care system, will be identified and recommended to care procurers.

• “The pilot shall contribute to the implementation and integration of actions as outlined in the Strategic Implementation Plan of the EIP on Active and Healthy Ageing”. SmartCare is designed to address the core of the EIP AHA, and moves it from concept to reality. It therefore de facto contributes to the implementation and integration of these actions.

• “Ensure the deployment of integrated care models in several Member States or associated countries to result in a convincing case for large-scale deployment. The expectation is to involve 8 or more Member States or associated countries; targeting in particular a significant number of national and/or regional authorities responsible for health and social care. To facilitate exchange of good practice and coaching of the regions involved, the pilot shall reflect a good balance between early adopter and follower regions.” SmartCare largely exceeds the target of countries set in the Work Plan by bringing together Regional Partnerships from a total of 14 among Member States or associated countries. Practically all the Regional Partnerships include national and/or regional authorities responsible for health and social care, except in those countries where the latter do not play a role in the provision / procurement of such services (i.e. in the Netherlands or Germany). Regional Partnerships have been split into three groups, 1st and 2nd wave of pilots, and members of Committed Region Board, to take into account the different level of readiness of the regions.

• “Develop guidelines for procuring, organising and implementing integrated care building upon innovative eHealth and active ageing services”. A specific deliverable of SmartCare is dedicated to the guidelines for procuring, organising and implementing integrated care, building on the SmartCare services.

• “Gather, and make available, evidence on remote patient monitoring and tele-care and evaluation of their impact in line with widely recognised methodologies in the field of health and social care”. SmartCare has decided to adopt the MAST evaluation methodology which has been developed by the Danish partners of the SmartCare Consortium under contract with the European Commission (MethoTelemed project); this has been validated in the RENEWING HEALTH Type A project, and it is rapidly spreading as the most suitable methodology to evaluate complex tele-health and tele-care interventions.

• “Deliver a credible and ambitious exploitation plan (dealing with both the sustainability and the expansion of services)”. SmartCare will produce credible exploitation plans based on the evidence produced by the regionally conducted trials. Thanks to the transferability model used in SmartCare, even regions within and outside the Consortium which have not conducted trials will be enabled to elaborate rather accurate deployment plans which take into consideration their specific context.

• “Ensure dissemination and communication activities constitute an integral part of the proposed work, addressing not only experts, but also public authorities

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and relevant stakeholders)”. SmartCare foresees a very comprehensive set of dissemination activities which are fully detailed in § B.2.3.

• “Proposals should include specific and realistic quantitative indicators to monitor progress at different stages in the project's lifetime”. The full set of indicators together with the value expected at the end of each year is detailed in § B.3.2b.2.

B.2.1.1.3 Expected impact • “Through its guidelines and support to Member States or associated countries

and regions, contribution towards a long-term sustainability of a replicable plan for pan-European deployment of integrated care services”. SmartCare will take the deployment of ICT-supported integrated care to older people to an unprecedented level both in terms of scale of population reached, and quantity and quality of evidence collected. This, coupled with the use of the guidelines produced in the framework of the project and of the transferability model, will foster the roll-out of integrated care services throughout Europe.

• “Contribution to improved communication and co-operation between health, social and informal care institutions”. The primary goal of SmartCare is the sharing of essential information among all the players that collaborate in providing care to older people. This, coupled with tools such as videoconferencing for communication among carers anytime and anywhere, and with the SmartCare Pathways, should remove the well-known barriers which have so far hampered the efficient use of the entire spectrum of resources dedicated to older care.

• “Provision of practical guidelines and solutions to address organisational, legal, regulatory and reimbursement issues for integrated care.” Due to the variety of settings for older care throughout Europe, the guidelines elaborated in the framework of SmartCare will provide general recommendations, together with specific ones which relate to the national / regional context. This is particularly true when dealing with reimbursement issues, which cannot be addressed in the same way in the Bismarck and Beveridge models for health and social care.

• “Encourage deployment of innovative organisational and business models and new operational practices, based on new communication protocols and procedures, multidisciplinary teams and a multi-stakeholders approach”. This is the very essence of SmartCare and of the SmartCare Pathways.

• “Enhance the body of evidence on sustainable and optimised management and on cost-effectiveness linked to integrated healthcare solutions, including efficient and holistic care at home”. SmartCare is the largest ever multicentre pilot of ICT-supported integrated care. Thanks to the adoption of a rigorous and wellproven methodology, SmartCare will provide multidimensional evidence of the possible benefits provided by ICT supported integrated care. Due to the stepped wedge design, as many patients as possible will be included, thus serving as a basis for reaching statistically significant differences between groups (before and after implementation cohorts) on the primary outcome measure.

• “Raise awareness and knowledge of patients and the elderly population of the benefits of integrated care”. The dissemination strategy of SmartCare will include older people and their families using tools such as the social networks to reach the general public. This will ensure that the people who can benefit the most from ICT-supported integrated care will be well informed about what it can deliver.

• “Contribute to the competitiveness of the European ICT industry”. SmartCare is without any doubts a trailblazer project; as such, it will offer the European ICT industry a prime window to show what it is capable of doing. Individual pilot sites will be allowed to choose their providers, and, whenever possible, to continue working

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with their existing ones, provided that they are able to implement the functionalities required to support the SmartCare Pathways in all their different aspects including the monitoring of older people in their homes. The ICT providers, most of which are expected to be European, will increase their competitiveness thanks to their ability to show what they are able to do in the area of support for integrated care. Moreover, SmartCare will offer the large test bed ever for European industry to show what it is able to do in the area of support to the independence of elderly people and to the integration of the care services which contribute to such independence. European industry active in the home monitoring (telehealth and telecare), system integration, workflow management, etc. fields will have access to business intelligence on the state of play and future plans by health and social care authorities in diverse European markets and their respective needs. Piloting experience will in addition provide insights into aspects such as usability, user satisfaction etc. which are valuable inputs into further product development. Through the local pilot implementation and further deployment of telehealth and telecare services, European industry in this sector will be able to participate in calls for procurement and thus showcase the value of their products and services to European and international clients worldwide. Finally, through the boost that SmartCare will provide to the base of evidence of the benefits released by ICT in support of integrated care and of its economic sustainability, it will provide the European industry with the essential elements to put together convincing business cases for potential customers.

The expected long term impact on the pilot sites will be felt at different levels, with different degrees of importance by individual pilot site. An internal survey allowed, among others, .

At the level of care delivery to the patient, the patient’s well-being, satisfaction and independ-ency, a number of pilot sites expect measurable changes to items such as:

• Increase in the personalization of care, leading to an improvement of the elder’s percep-tion of the received services and a more cost-effective usage of the available resources at all levels (e.g., Valencia, etc.)

• Greater autonomy and tranquility of the patient and elder people (Amadora)

• Help to combat loneliness (Amadora)

• Longer user independence (Kinzigtal)

• Patient well-being and happiness (“mood”) improved through case managers (Nord Brabant)

• Better supported with evidence-based guidelines, specialty expertise, and information systems (Murcia)

• Integration of social needs assessment questions in the work of nurses and doctors with elderly patients (Basque country)

• Reduce unnecessary and inappropriate emergency admissions of elderly patients (Tallin)

At the level of resource expenditure for health and social care the following impact is expected:

• Costs reduction through integrated intervention, supervision and evaluation (Amadora)

• Per capita weighted cost of accumulated bed days lost to delayed discharge (Scotland)

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• Cost of emergency inpatient bed days for people over 75 per 1000 population over 75 (Scotland)

• A measure of the balance of care (e.g., split between spend on institutional and commu-nity based care) (Scotland)

• Reduction in the number of bed days (South Denmark, etc.)

• Reduction in the number of readmissions (e.g., South Denmark, etc.)

• A reduction in unnecessary and inappropriate emergency admissions of elderly patients which is often a source of distress to elderly people and places enormous pressure on the healthcare system (Northern Ireland)

• Number of nursing home admissions and their duration will be reduced (Friuli-Venezia Giulia)

• Slowing down the increase of per capita healthcare expenditure for patients in the pilot environment (Gesundes Kinzigtal)

• Enhanced communication between different caregivers could lead to time savings e.g. by using one agenda to schedule the care of a patient via an eHealth tool (Noord-Brabant)

At the policy/health system level, the following impacts were mentioned:

• Transfer of low-value specialized care to primary care (Aragon)

• Competence and capability of professionals will increase (Friuli-Venezia Giulia)

• Transnational good practices replication & mainstream (Amadora)

B.2.1.2 Building blocks

SmartCare services will provide full support to cooperative delivery of care, integrated with self-care and across organisational silos, including essential coordination tools such as shared data access, care pathway design and execution as well as real time communication support to care teams and multi-organisation access to home platforms. The services build on advanced ICT already deployed in the pilot regions including high penetrations of telecare and telemonitoring home platforms. System integration will be based, whenever possible, on open standards and multivendor interoperability will be strongly encouraged.

To this end, a comprehensive set of integration building blocks will be defined, tested and piloted, incorporating interoperable components to enable cooperative delivery of healthcare, social care and independence-enhancing support by healthcare and social care organisations, family and informal carers and voluntary sector personnel. The following table presents an initial view of key components of the SmartCare ICT integration support indfrastructure. During the start-up phase of the project, the initial set of components will be assessed - if required revised or amended – and finally confirmed.

ICT support services to be delivered through this infratsructure along commonly defined integrated care pathways will, on then one hand, include services that directly link into cared-for person’s homes. Such services have been coined “home-linked services” for the purpose of the project. On then other hand, ICT-enabled services supporting inter-organisational cooperation at the “back office” level – so called “organisational cooperation services” - will also be adressed. In the following subsections and initial set of ICT services is sketched for for ullustrating each of these service categories. Being combined along integrated care pathways, both types of ICT support services will enable efficient cooperative care delivery and empower all older people according to their mental faculties to take part in effective management of their chronic conditions and maintain their independence despite increasing frailty.

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Table 3: Initial set of building blocks and components of the SmartCare ICT integration infrastructure

building blocks

Main components FVG RSD TALLIN

ARAGON

EKSOTE S.Karelia

ATTICA

N-BRABANT

CCU Uppsal

SERBIA

SCOTLAND

A=Available; P=Planned for Pilot A P A P A P A P A P A P A P A P A P A P

Integrated data access for care providers in different agencies and informal carers

Integrated Care Record X X X X X X X X X X X

Sharing clinical, scheduling, monitoring information

X X X X X X X X X X X X

Shared EHR / Access to subsets of EHR

Input from health and social care actors / interfaces to different ICT tools

X X X X X X X X X X X X X

Web-based portal X X X X X X X X X X

Design and execution of pre-planned care pathways enabling temporal coordination between provision steps taken by care providers in different agencies and informal carers

Workflow engines X X X X X X X X X X X

Charting tools for Integrated Care pathways design

X X X X X X X X X X X

Joint/shared scheduling, daily schedulers

X X X X X X X X X X

Training/learning pathways/ plans and/or patient self-care support tools

Access to home-based Monitoring (TeleMonitoring and/or Telecare, TM/TC) by care providers in different agencies and informal carers

Vital parameter monitoring X X X X X X X X X X X X

Patient survey X X X X X X X X X

Alerts, prompts, reminders configuration and handling/ protocols and escalation procedures

Reports, protocols X X X X X X X X X X X X

Passive / active alarms X X X X X X X X X X X X X

Automated self-care, promotional/educational/training

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building blocks

Main components FVG RSD TALLIN

ARAGON

EKSOTE S.Karelia

ATTICA

N-BRABANT

CCU Uppsal

SERBIA

SCOTLAND

A=Available; P=Planned for Pilot A P A P A P A P A P A P A P A P A P A P tools

Home safety monitoring (gas, temperature, light, doors, windows)

X X X X X X X X

Device administration; remote device tracking, maintenance and updates

X X X X X X X X X X

Real-time communication between care providers in different agencies and informal carers, e.g. support to case conferences

IP-based screen sharing X X X X X X

Videoconferencing (VC) X X X X X X X X X X X X

Telecare communication between care providers and informal or formal carers

X X X X X

Joint response to ad hoc requests by care providers in different agencies and informal carers

Call / Contact Centre, Triage X X X X X X X X X X X X X

Portal X X X X X X X X X X

Centralised and flexible role-, patient- and user- administration

Self management, including links into all above cooperation mechanisms

Self-care and (older people wellness and informal carers) promotional/ educational/ physical/lifestyle training tools

Daily schedulers X X X X X X X X X X Note: “A” stands for component(s) “Already in place”; “P” means these components will be implemented as part of the pilot

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B.2.1.2.1 Components of home-linked ICT support services In the following some illsutrative examples of components of home-linked ICT support servicves are presented.

Vital Parameter Monitoring

The solution provides the means of collecting clinical data directly from the older person’s house/flat, and sending them to specialised back-office applications for further processing (alarm handling and further integration into the SmartCare Integrated Care Records). Measurements taking has to be extremely simple (one-touch activation or similar) for the older person to be able to take them without external help, although support by informal carers is equally envisaged. Connection with the home gateway needs to be wireless to avoid manipulations (e.g. inserting a plug into a medical device) which can be very difficult or impossible for older people (e.g. trembling hands, vision impairments, etc.). It is expected that a minimum set of medical devices (weight scale, blood pressure, thermometer) will be always present, because they are relevant to check the health and the well-being of older people whatever their health conditions are, while the presence of other medical devices (peak-flow meter, glucometer, pulse-oximeter, ECG, etc.) will depend on the existence of chronic conditions.

Environmental Parameter Monitoring

The house/flat in which the older person lives needs to be monitored to avoid the common domestic accidents of which older people are often the victims. Smoke, gas and water leaks, temperature, humidity, movement etc. should be monitored to ensure the safety of the people at home ,and avoid catastrophic accidents (fires, explosions, etc.).

Videoconferencing

We can expect several older people to have serious problems of mobility even if they are not confined to a wheelchair. Equally, some of them could have no family members living nearby or visiting them regularly. Although virtual presence cannot and should not replace physical presence, it is an important element for socialisation, and can complement visits by relatives, informal and formal carers. Based on previous experience, videoconferencing, to be effective, needs to be supported by a pro-active service which makes outbound calls to the older people. This role can of course also be played by volunteers and relatives, but it is unrealistic to expect elderly people to be proactive, at least initially, in the use of videoconferencing.

Reminders

It is well known that compliance with prescribed treatments is essential to keep chronic conditions under control. A reminder system helping older people to comply with the dosage and timing of the drugs they should take would greatly help to increase compliance, especially when there are changes in the prescribed drugs. However, reminders could additionally cover a broader range in circumstances such as appointments with physicians, visits by carers, etc.

Fall prevention and automatic detection

It is well known that falls can have a devastating effect on quality of life, health and even medium-term survival chances of older people, and that the time between a fall and the intervention of a rescue person/team has an effect on the prognosis for recovery. Of course, prevention is better than cure, and fall prevention is far more advisable that just automatic fall detection. This service has been labelled as optional not because of doubts about its utility, but just because of doubts about the sensitivity and reliability of the solutions available on the

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market. It can well be promoted to core after further investigation of the solutions that the market offers.

Smart home functionality

The liveability of a house/flat by older people, and the ability for the latter to extend their independent life, can be vastly extended by smart home functionalities which enable the older person to literally manage the house/flat from an armchair, even without considering that the management of it can be progressively taken over by a contact centre operator. The most common smart home functionalities are listed below:

Temperature and energy management

Temperature and energy consumption in the house can be controlled in such a way that temperature can be centrally controlled at the level of each individual radiator, and that heating can be cut or switched on depending whether the windows are open or closed to avoid energy waste.

Door and windows opening/closing

Door and windows can be opened or closed centrally by the older person, but also automatically by the system if e.g. the temperature in the flat/house exceeds a certain threshold and the external temperature is lower than that inside the flat/house.

Light management

Lights can be automatically switched on and off when, through the movement detectors, the system realises that the older person is entering a room or leaving it. Automatic light management provides increased safety, because a certain number of falls in the house/flat are caused by poor lighting, or people just walking in the dark at night. At the same time, the automatic switching off of the lights avoids energy waste.

Daily Scheduler

The Daily Scheduler is a piece of software which helps the older person to organise his/her own daily activities by showing what type of activity is scheduled for when. The Daily Scheduler is managed by the formal or informal caregiver who has responsibility for the older person, and interacts with the diaries of the various caregivers and professionals who look after the elderly person. Changes in e.g. the time of a home visit by a nurse using an electronic diary are reflected in the schedule of the elderly person.

Reminders are generated to help the person to organise his/her routine (e.g. getting dressed to go out, take medications, etc.).

The main purpose of the Daily Scheduler is to relieve the older people of the anxiety that is typical of their age, when they know that they have to do something and are afraid to forget about it.

Cognitive training services

The cognitive training services make use of interactive games, aimed at preserving older people’s abilities by stimulating their brain and feelings. These games are designed to train both basic cognitive processes (vigilant, selective and focused attention, auditory, visual and tactile perception, short-term and long-term memory, etc.) and high-order cognitive abilities (executive functions, space and time orientation, language, mathematical calculation, imagination and creativity, etc.).

The games should be designed keeping in mind the need for simplicity of instructions; they should offer self-regulation of the level of difficulty to avoid boredom or the feeling of frustration.

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B.2.1.2.2 Components of ICT support services for organisational cooperation In the following some illsutrative examples of of ICT support services for orgnaisational cooperation are presented.

Contact Centre

The Contact Centre can be a physical location or a distributed function and has to make sure that alarms which cannot be directly routed to the final recipient through a hard-coded handling protocol are handled. In addition to the handling of alarms, the Contact Centre has also to provide the function of first-level helpdesk to receive calls from older people having troubles with the use of technology and first contact for older people for any other type of problems they have.

To break isolation of older people living alone and not necessarily visited by friends, relatives of carers, the Contact Centre should also plan to make outbound video-calls to older people which, according to previous experiences, are highly appreciated by this layer of the population.

Behavioural Pattern Monitoring

Sudden changes in behaviour can provide indications about conditions of the older person which are not immediately reflected in the clinical parameters measured through the medical devices (e.g. depression, weakening of the muscular tone, etc.). Behavioural patterns can be established on the basis of the observation of information collected by the different kind of environmental sensors and by the use of the other services and major shifts from the standard pattern of an individual can be automatically detected.

Integrated data access

Data from the monitoring and input of any kind from Social and Health Information Systems have to be integrated in a single SmartCare Integrated Care Record which contain all the information relevant for ensuring proper exchange of information between the older person, his/her informal caregivers and the social and healthcare professionals looking after him/her. Access to data will be dependent on the role of the person requesting access and any access of data will be recorded for audit purposes (e.g. authorisation to access data needs to be coupled with need to do it for valid reasons). The SmartCare Integrated Care Record is of course a concept and it does not need to correspond to a single physical location for the data concerning a certain individual provided it can be dynamically reconstructed in real-time13.

Report configuration

Reports for the older person, his/her informal and formal caregivers will be configured in terms of content, frequency of production and channel of transmission depending on the specific needs of each of these roles.

Alert configuration

For each older person or homogeneous group of older persons alerts can be configured by people having the appropriate role in the system. Alarms can be based on any combination of data from the monitoring or from other sources of information relevant to detect situation of risks for the older person (e.g. heat wave from the weather forecast with precedent of hyperthermia from the Electronic Health records of the individual).

In some countries as e.g. Spain the permanent storage of personal medical data outside the healthcare institution where they have been originated is not permitted by the law

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Alert handling protocols and escalation procedures

Alerts can be linked to “hard coded” protocols which indicates the steps to be taken, the workflow to activate, the escalation procedure to adopt for handling the alerts. Alternatively and/temporarily while the handling procedures are tested and validated, alerts can be handled by the same Case Managers who are responsible for the specifications and the management of the care pathways that the Project is aimed at establishing. As soon as a handling protocol is validated and “frozen”, it can be “hard coded” in the system to improve the efficiency of the care system.

Care pathways (core service)

The system supports Care pathways. These are planning tools which define which care resources should act, at which point in time and for doing what, to provide optimum care to the older people depending on the analysis of their individual needs. The resources included in the care pathways cut across the boundaries of health and social care and include informal carers in the case these agree to take specific responsibilities in the older person’s care.

B.2.1.3 Common specifications

Individual pilot sites have been left freedom of choice concerning the kind of technological platform they are going to use to implement the services described above provided the platform is open and therefore allows mixing and matching devices and applications from different sources. Although today’s world of telehealth and telecare is far from reaching the level of “plug and play” solutions which has become more familiar to PC users, the Consortium is convinced that SmartCare will foster the evolution of the market towards “de jure” and “de facto” standards and contribute to open competition on the market which, in turn, will convert into affordability of the solutions.

B.2.1.4 Scalability

SmartCare is deploying large-scale pilotss which, by definition, require solutions adapted to manage large (>100) numbers of users in real life conditions. Moreover these solutions must be designed having upscaling in mind in such a way that moving from trials to roll-out in the future will not imply redesigning the solutions from scratch.

An initial set of aspects of scalability that SmartCare solutions are envisaged to address is described in the following. Again, these will be reveiwved and finally agreed during the start-up phase of the project.

Device administration

When dealing with large numbers of devices (each house/flat can contain a dozen of individual devices or more depending on the needs of the older person living in it) the centralised administration of the devices becomes absolutely indispensable. This means that the System Administrator must be able to assign devices to users and manage them centrally and dynamically because the needs of older people might and will change over time and the system needs to be reconfigured and extended accordingly.

Remote device tracking, maintenance and updates

The management of large numbers of devices is likely to become a real nightmare if not supported by an efficient and centralised tracking system which is able, at any point in time, to know to whom they have been assigned.

Maintenance and updates are particularly critical when systems are physically installed in premises (older people’s houses/flats) which are accessible by appointment with the

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owners/tenants only even without considering the reluctance of older people to let strangers, especially young technicians, enter their houses/flats.

Maintenance has to be planned as much as possible by checking remotely the status of the different devices including the level of batteries for battery-powered devices (often older people are unable to change the batteries by themselves) and schedule interventions well in advance.

Software updates of the front-office component of the solutions should be done over the network to reduce even more the need for on-site interventions and guarantee that all the home systems are updated at once.

Centralised and flexible role-, client- and user- administration

The solutions deployed in the different pilot sites have, as one of their main goals, that of facilitating the communication among all the actors playing a role in the older people’s care. Sharing of information however has to be done keeping in mind the need to comply with data protection regulations and the principle that even authorised users should access personal data only when they need to do so for justifiable reasons. The solutions must allow for the definition of roles within the system and each role is characterised by specific access rights which might be further limited by the relationship between the user and the individual older person.

B.2.2 Long term impact, viability The expected long term impact of SmartCare is twofold:

• A substantial and lasting improvement in the quality of life of older European citizens, and an extension of their independent and active life in line with the objectives of the European Innovation Partnership for Active and Healthy Ageing.

• A more sustainable older care system obtained through a coherent mobilisation of all the care resources available: older people and their families, volunteers, formal social and health professionals.

This improvement is expected to come from a combination of factors:

• The SmartCare Pathways, supported by workflow systems, will activate the most appropriate care resources at any point in time for both scheduled and emergency care interventions.

• Seamless and timely access by all the carers to relevant information about the older people, through the integration of the various information systems that hold data about them. Information will include not only data entered by professionals through the more traditional information systems, but also data provided by the informal carers or the older people themselves, through Personal Care Systems which until now have not been widely used for this purpose. This comprehensive set of data will provide carers with enhanced decision making support.

• Comprehensive and minimally invasive tele-monitoring of older people both in- and outdoors to ensure their safety 24/7 wherever they are. Tele-monitoring will not be limited to health conditions, but will be extended to the environment where older people live. Tele-monitoring in turn is supposed to enable: o prevention and early detection of domestic accidents (e.g. falls, fires, water

flood, etc.); o earlier detection of worsening health conditions, leading to mitigation measures

to avoid hospitalisation; o early discharge from hospital as soon as older people do not anymore require

the specialised treatment that only the hospital can offer, but simply need to be monitored to follow their recovery;

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o increased feeling of safety for older people and their relatives, leading to better quality of life and extension of independent living for as long as the physical and mental conditions of the older people allow it.

• Effective involvement of the older people and their informal carers in the management of safe and independent living through better education and access to data about the evolution of older people’s conditions.

• Better interaction among older people, their informal and formal carers, and healthcare professionals, which is triggered by SmartCare Pathways and the facilities for dialogue that the technology platform will offer.

For concrete examples of expected long-term impact at the individual pilot sites, please see section B.2.1.1.3 above.

While there is a widespread expectation among the older care stakeholders that really integrated care supported by the adequate ICT tools can really release the benefits mentioned above, this remains to be demonstrated through a rigorous assessment of the impact of these services on a number of indicators related to: quality of life of older people and their caregivers; satisfaction of the various users with the service; and clinical and economic outcomes. To demonstrate that this is the case, SmartCare has chosen to adopt the MAST assessment model developed by some of the partners of the Consortium.

The economic sustainability of the SmartCare services cannot be taken for granted at this stage, but needs to be demonstrated through the evidence that the pilots will provide, because they are going to implement the services in real life and with a sample of older people which lends statistical value to the results obtained.

In the present economic climate, nothing requiring substantial investment such as integrated care services can be introduced into the care delivery routine unless there is a demonstrable return on investment. This can be represented either by a marked improvement of the outcome obtained (e.g. in the health condition or quality of life of the older people) without increasing the cost of care, or by a reduction in the cost of care through better efficiency without compromising the outcome obtained, or by both. Any other combination is not likely to be accepted by Governments because of the current pressure on public spending.

If the return on investment is demonstrated by the real life trials, the funding of the service has to come from the savings in the current care budget of the participating municipalities, regions and countries. This will require bold steps by politicians or novel business models, possibly including partnerships between procurers and suppliers, because the investment has to be done upfront, while the most substantial savings are likely to appear only years after the introduction of the services.

There is an extra complication that SmartCare will have to analyse and provide recommendations on how to overcome it: this is the fact that in many cases, because of the fragmentation of the care systems, which is not just limited to the traditional separation between healthcare and social services, savings are released in areas different from those where the biggest investment has to be made. The possibility of using savings to repay the initial investment is likely to require profound changes in the way budgets are allocated to the various components of the older care system in each country, together with modifications in the objectives given to care managers and professionals.

All these aspects will be analysed in the lifecycle of the Project, capitalising on the fact that the National, Regional and Local Authorities responsible for the organisation and the budget for older care are part of the Consortium. Country or region-specific recommendations will be issued to overcome these obstacles. Every care will be made to ensure that recommendations will be generally applicable to other National, Regional and Local Authorities through interaction with other Regions throughout the entire lifecycle of the Project and leveraging the transferability model (see § B.1.1.4).

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The services piloted in SmartCare should be easily scalable to the entire population of older people within the participating regions, because the pilots already address a critical mass of people in each of them. Moreover, the technology platforms adopted in the various pilots to support the SmartCare Pathways are either already of production quality, or will be reengineered and strengthened during the lifecycle of the Project.

EU-wide interoperability of the services implemented in SmartCare is not envisaged at this stage, because the specific case of older people management rarely has a cross-border dimension. This is due to both the fact that the population addressed in SmartCare (frail older people) tend to have a limited mobility, and the fact that integrated care for older people requires a close life-long collaboration among older people, their informal carers and the health and social care professionals. Informal and formal carers engaged in older people care are normally part of the local or regional care delivery network of the place where the older person lives. What matters in this specific case is the effective integration of the local care services through ICT, rather than communication between one regional system and another.

However, this situation could evolve in the future, and measures for enabling the future interoperability of regional older care information systems will be looked at.

The Consortium has already started to discuss how the sustainability of SmartCare services could be ensured after the end of the project at each pilot site. Pilot site sustainability should be understood as continued operation of the service or services tested and piloted during the project in the care environment of the pilot site with political, financial and organizational support. This implies that pilot site activity continues to respond to health and social care needs which are financed on a permanent basis as part of a political strategy for health and social care services.

It should be noted that the envisaged pilot activities resonate well with existing policy priorities in the pilot site regions. This is a key success factor for sustainability beyond the piloting stage.

Practically all the pilot sites are joined in the project by the authority that also provides funding for health and/or social care services. This ensures from the outset that the relevant organisations for sustainability are involved in the pilot design.

Sources of funding for providing the SmartCare services in the long run also depend on where savings are released and what’s the perceived value of the services to the end users and their families. The workplan therefore includes various dedicated tasks directed towards supporting evidence-based decision making on service mainstreaming/up scaling at pilot site level (WP9), such as T9.2 (“service viability assessment”) and T9.10 (“deployment planning”).

With regard to the financial and organizational aspects of sustained operation, a number of pilot sites have already sketched out their approach as the following examples indicate:

In Scotland, the pilot will operate in the framework of the “Reshaping Care for Older People programme”, which is supported by a Scottish Government Change Fund of £300 million over a 4 year period (2011-2015). Following the end of the SmartCare pilot experience, formal change plans will be agreed by local authorities, NHS Boards, third and independent sector representatives, and funding should leverage genuine shifts in the totality of partnership health and care spend. Through the use of the Change Fund the Scottish Government expects to see an increase in the proportion of monies allocated to ‘preventative and anticipatory care’ and ‘proactive care and support in the home’. Currently, Scottish Ministers are progressing a legislative programme to support integration and self care including full consultation processes and primary legislation. This will:

• support local partnerships to bring together health and care resources, both financial and operational for the benefit of people and local communities

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• impose duties on local authorities to offer the individual as much choice and control as they want to have over the support provided to them and to give effect to the individuals decision

In Denmark, the participation in SmartCare is expected to push the Danish DRG reimbursement rates for telemedicine even more in the direction of reimbursing treatment and rehabilitation efforts outside the traditional scope of hospital care delivery. This represents a key pillar in the long run sustainability of the SmartCare pilot. A political commitment is in place between the Region of Southern Denmark and the 22 municipalities in which the region is subdivided to ensure that no administrative or reimbursement issues block the implementation of services that benefit the patients and are expected to make better and more efficient the services provided by the healthcare system. This means that any problems that might occur due to the current national acre reimbursement scheme will be solved at regional level. The region of Southern Denmark also intends to use the experience acquired and the evidence generated in the SmartCare project, through a rigorous scientific evaluation process, to ensure that national reimbursement systems such as e.g. the DRG one will adapt to the new models of care delivery. However, based on previous experiences, this is a very long process that can take years to be completed. This is why the political support at regional level is essential to achieve the large scale deployment of the services.

An important policy change in the Veneto region ensures through the new local plan of action in the field of social and health care that future support is channeled even more towards activities to support and to further deploy the integration between health and social care. In June 2012 the Regional Council approved the new Regional Social and Health Care Plan that strongly address the integration between the social and health care.

Facilitating widespread rollout of the pilot services in Northern Ireland will involve a new training approach for new health and social care professionals joining the service. Training to support those professionals already within the service to make the transition from the current arrangements to the future model is also envisaged. The process for funding Integrated Care Partnerships (ICPs) and managing the reimbursement of GPs and Trusts for delivering the work of the ICP will require clear guidelines. Appropriate audit arrangements will be developed and utilized on a regular basis.

Similar trends are reported from the Basque Country, where the government is proposing a overall change modifying policy, planning, funding and regulation of health, social and industry issues related to ageing and chronicity. It will require local integrated organizations network and redesigned commissioning and funding contracts. This means that 2% of the funding will be linked with the compliance with the objectives of the Population Based Intervention Plans (PBIP) towards frail and chronic patients, including care coordination. A SmartCare pilot in the Basque country would seize this opportunity to make the pilot sustainable.

The region of Noord-Brabant intends to investigate with health insurers future reimbursement opportunities as well as the willingness of patients and (possibly) informal carers to (partly) pay for eHealth solutions themselves.

Being requested to provide examples from the 1st wave pilot sites illustrating their approach to the aspects related to financial and reimbursement issues, Aragon reported that they are actually facing the financial responsibility and reimbursement for integrated care services through the optimization of the Health and Socialcare public providers, the liaison with private socialcare organizations and the transfer of competences from healthcare professionals to patients:

“Since end 2011, the Aragon Government has unified the ancient departments of Welfare and Health into an only Social Welfare, Family and Health Ministry. The organization is suffering from a deep change that positively affects to the optimization of the care pathways

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and also to the operation and coordination of health and social services. This is an opportunity to search for budget synergies to optimize the Government’s care costs. At the same time National Laws (as the Dependecy Law) and regional policies that affect to the provisioning of social assistance to citizens are currently under consideration. The reorganization of the public social services institutions are on the way pushing forward to the inclusion of social organizations, as the Red Cross, to work together with the aim of preventing overlaps.

SALUD has been working in the last years on chronic care policies promoting and training citizens on managing their own health and maintain their independency and wellbeing (with the help on social organizations and its volunteer-based caring model for frail dependent patients). Recent projects have demonstrated the success of these policies that have transferred responsibilities to patients, more willing to assume this new role thanks to their technology literacy and cultural competence. This joint health care responsibility (among healthcare professionals and patients) has been demonstrated as the more successful solution to transfer competences and sustain public health services (versus shared-financing). Investment in integrated care is reimbursed by the reduction of the consumption of social and health services thanks to users that act on a more responsible manner and are more proactive in managing their own health. Some examples are the decrease on the number of the emergencies visits, the reorganization of the demand from specialized care to primary care or the elimination of low-value tasks to healthcare professionals, etc.”

As already mentioned, the Consortium will facilitate all these developments through the work in WP9, in particular by generating supportive evidence throughout various work tasks such as “service viability assessment”, “legal and regulatory analysis” and “deployment planning.” Moderated workshops will be organised at the pilot sites with a view to engaging all relevant stake holders in an evidence based discussion on synergies that can be realised through better joined-up care delivery, e.g. social care and health care agencies. Evidence from the project will be fed into this debate in a systematic manner and brought to bear on pilot service mainstreaming

However, the operational responsibility for pilot sites will remain with the local decision-makers, pilot-coordinators.

B.2.3 Availability of results This section will outline how SmartCare will spread the overall results of the project and disseminate knowledge of the benefits achievable from integrated care. It outlines how exploitation activities will be undertaken, how IPR (intellectual property rights) will be managed, and how public procurement rules will be respected beyond the project phase for the full deployment of services.

B.2.3.1 Spreading results and disseminating knowledge

Spreading SmartCare results, and disseminating information and knowledge of the numerous benefits from integrated care – and in particular the lessons learned and guidelines developed on how to realise these benefits in an optimal manner - will be a major objective of the dissemination activities. Due to the importance we attach to them, these tasks have been allocated to a separate WP within the project structure. Furthermore, numerous workshops with KEY stakeholders will be organised in the context of several other work packages.

At this stage, it is anticipated that the dissemination strategy of SmartCare will combine local and regional, national and international activities. A preliminary list of these activities is given below:

• Local and Regional activities:

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o Frequent coverage by local and regional media: newspapers, radio and television. In the case of the latter, at least one reportage or interview every six months will be targeted;

o Organisation or participation in seminars dedicated to integrated care, home monitoring, active and healthy ageing, silver economy, services to citizens, universal access, etc.;

o Preparation of a promotional video in each of the participating regions for local promotion of the initiative.

• National o Organisation of seminars and workshops dedicated to the SmartCare trials with

the participation of industrial partners, health and social care professionals and managers, patients’, caregivers’ and professionals’ associations;

o Participation in national events and fairs dedicated to integrated care, home monitoring, active and healthy ageing, silver economy, services to citizens, universal access, etc.;

o Articles in national newspapers and magazines for both the general public and the healthcare professionals and managers;

o Possible participation in national TV programs and TV debates whenever this is possible.

• International o Appealing, commercially-oriented and user-friendly project website; o High-profile Interim Workshop and Final Conference, potentially with TV

coverage and simultaneous interpretation in several languages, to address a large audience. The participation of a panel of international experts and opinion leaders from outside the Consortium is foreseen in both events.

o Participation in international events and fairs dedicated to integrated care, home monitoring, active and healthy ageing, silver economy, services to citizens, universal access, etc.

Dissemination channels

Key dissemination channels to be employed by this project will include a comprehensive and up-to-date web presence (using modern electronic communications media [website, Google Wave, Facebook, Twitter, other social media as appropriate]) and more conventional types like email newsletters and printed material, publications in journals and at conferences and the delivery of customised presentations, workshops and via other media to the scientific, medical and political communities.

Project Website:

In the framework of general dissemination and networking activities, a concrete objective is to establish a web presence as dissemination tool.

The vast majority of the deliverables of SmartCare will be put in the public domain. The SmartCare website will play a major role in making them available to a large audience of interested parties. In particular, all the deliverables concerning standards, care pathways, service design and organisational approach to the deployment of ICT supported integrated care will be public (see Table 2 – Deliverables List).

The interlinkage of the website with other relevant web portals guarantees a high impact and relevance on Google and other search-engines. RSS feeds and sharing functionalities with personalised web portals will allow website users to stay informed and embed new information in their personal web environment.

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Other dissemination media include:

Press releases and articles

We will seek to provide contributions to eHealth newsletter editors, such as

• eHealth Newsletter by the European Commission;

• eHealth Insider eNewsletter;

• HealthNews.EU Portal & eHealth Directory

• Med-e-Tel eNewsletter;

• Health ICT Headlines eNewsletter

Presentations, workshops, tutorials, and seminars:

To address the wider communities, present and discuss results, and drive future exploitation, the participants will submit and contribute to various events respectively to the annual conferences organised by societies listed below:

• World of Health IT (annual conference in conjunction with the eHealth high level Ministerial conference usually hosted by the EU Presidency)

• International Medical Informatics Association (IMIA)

• International Conference(s) of the European Federation for Medical Informatics - MIE

• European Federation for Medical Informatics (EFMI) STC Special Topic Conferences

• Arctic Light E-health Conference ALEC - a joint initiative of Norrbotten County Council, the Assembly of European Regions (AER), the Regional Telemedicine Forum (RTF) and the E-health Innovation Centre at Luleå University of Technology (EIC)

• Continua Health Alliance Summits

Articles in scientific journals will also be aimed for, in journals like these and others

• Journal of Medical Informatics

• Journal of the American Medical Informatics Association

• The Open Medical Informatics Journal

• European Journal of Heart Failure

• International Journal of Integrated Care

Dedicated events: SmartCare workshops and final conference

In year 2 of the project, 1-2 workshops will be organised at national level to enable interactive contact with stakeholders and potential replicators. A final project conference will round off dissemination and exploitation support activities, thereby targeting a European and global audience. The SmartCare Advisory Boards will be particularly supportive to this activity. Relevant EU-level initiatives will be approached well in advance to discuss synergies and potentially cooperate in event dissemination and organisation, e.g. European Innovation Partnership on Active and Healthy Ageing, the future Thematic Network on community building for active and healthy ageing (Objective 3.7), etc.

Targeted dissemination at European, national/regional level

Targeted dissemination will be done by using well established channels for dissemination to which the participants have direct access.

Partner IFIC has offered support in dissemination through:

• dedicated project page for SmartCare on the IFIC website

• a special issue of the International Journal of Integrated Care (a peer-reviewed open access electronic journal - www.ijic.org with over 1,500 registered readers and 10,000

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unique visitors each month) focused on SmartCare findings / eHealth and integrated care

• dedicated space/special sessions at our international congresses, e.g. specifically at the telehealth/telecare congress in London, but also at our other events worldwide

• knowledge-centre, connecting with other projects internationally developing similar approaches to ICT and integrated care

All participating regions have established strong relations with local associations of care professionals and informal care givers, patients and elderly organisations, which will be utilised for dissemination purposes. Each of these associations will reach out to their members and further larger networks. For example, the Danish participant will link to the Dane Age Association which has 610,000 members organised in 16 regional committees and 211 local committees as well as to Danish Patients, an umbrella organization for 16 patient associations representing 850,000 members. In Scotland, cooperation is ensured with the Association of Directors of Social Work, Association of Community Health Partnerships, Long Term Conditions Alliance Scotland, Cosla (Convention of Scottish Local Authorities), etc.

In the Netherlands, meetings with the Dutch Government, insurance companies, care organizations (AAFJE en LAURENS Care Groups), welfare (Dock), and citizens organisations are planned to inform all about the progress and benefits of the project. Reports in national health journals (Medisch Contact, Nederlands Tijdschrift Geneeskunde) will be written by knowledge organisations (TNO, TU Delft, Veldaca-demie.nl) to promote and facilitate future SmartCare implementation. In Kinzigtal, Baden-Würtemberg, the Caritas, Seniorenhilfe as well as several local associations, even sport clubs will be informed.

In Extramadura, besides the Red Cross and local association of older people, clusters of health, knowledge, ICT providers will be involved in an enlarged partnership for dissemination and networking; Valencia has access to a large list of formal and informal caregiver, patient, elderly and social associations. Specialist societies and professional bodies will be involved as appropriate, e.g. in South Karelia: the Alzheimer Society of Finland.

Reaching out to multipliers

The Advisory Boards members will play an active role in dissemination activities to external communities:

• The Assembly of European Regions (AER), being the largest independent network of regions in wider Europe, will ensure communication to 250 regions from 35 countries and 16 interregional organisations.

• The AGE Platform Europe will disseminate the project results to 165 organisations of and for people aged 50+ - ca. 150 million senior citizens in the European Union.

• Continua’s quarterly summits offer great opportunities to network with peers from across the global personal telehealth industry. Held across the world, these summits give Continua members the possibility to network with approximately 200 members during face-to-face working group meetings. Continua will use its web site and regular newsletters to disseminate important project milestones and events such as the final SmartCare conference. Furthermore, Continua is regularly co-organising with other partners relevant events. Together with AIM, EHMA, EPF, COCIR, and EHTEL, Continua is engaged in a Telehealth Campaign, a series of initiatives whose objectives are to increase the collaboration and awareness about Telehealth in support of integrated care in Europe amongst all the relevant stakeholders. This is another opportunity for promotion of SmartCare.

• The International Foundation for Integrated Care (IFIC) will support learning exchanges through its website and also through specific events. Several of the participants have been previously involved as delegates and presenters within the

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Annual International Congresses on Telehealth and Telecare that IFIC hosted in partnership with The King’s Fund, London, in February 2011 and 2012. These congresses have attracted more than 1,500 delegates (actual and virtual) from nearly 60 different countries.

• EFN will work with its EFN members from 34 EU Member States (representing 6 million nurses throughout the European Union and Europe) on using and implementing the outcomes into the national health systems. Furthermore, EFN’s 34 knowledge brokers will encourage the uptake at national level. This will ultimately lead to the further mainstream of project results, as through EFN connections, the wide availability and adoption of results will be supported. The evidence to be gathered on improved economy, efficiency of health services by using chronic conditions management, improved satisfaction and health outcomes will be translated to those responsible for telehealth policy in Europe (EFN has influence in the European Parliament) and at national level through the EFN membership. EFN will be able to engage in workshops aimed at health professionals and policy makers to make them aware of the project results.

• The European Patients’ Forum (EPF) will reach out to its 54 member patient organisations operating at European and national level.

• Eurocarers will use its website, and newsletter as well as its regular meetings with members to disseminate SmartCare good practice and stimulate the exchange with its 65 members in all corners of Europe paying special attention to the effects of ICT on informal carers.

• Furthermore, the participation of the head of the healthcare politics and health economics department of the Allgemeine Ortskrankenkasse (AOK) Rheinland/Hamburg, Christoph J. Rupprecht, offers unique opportunity to reach out to the key stakeholder group of insurers and disseminate good practice from European SmartCare regions/pilots. (The AOK Rheinland/Hamburg is a large regional German statutory health insurance company – 2.9 million people insured).

Networking activities between the pilot sites will be a key instrument in exchanging experience and good practice.

Linking up with other key initiatives and consortia

Over the last months, several SmartCare participants have actively engaged in the European Innovation Partnership on Active and Healthy Ageing, contribution in particular to Specific Action B3: Replicating and tutoring integrated care for chronic diseases, including remote monitoring at regional level.

For instance, AER is cooperating with other European organisations to bring to its member regions examples of innovative solutions and support them in identifying funding sources and partners to adapt and implement these in their regional/local systems.

Continua, among others, will actively participate in the EIP Action Group on Integrated Care (full name: Capacity building and replicability of successful integrated care systems based on innovative tools and services; an Action Group is an assembly of partners contributing towards a common objective and committing to run a number of actions within the framework of the EIP on AHA). A list of partners can be found at the web site of “Workspace on Care and cure” (https://webgate.ec.europa.eu/eipaha/theme/index/pa/23).

Special attention will be paid to the Marketplace of the EIP - a platform for cooperation and help to further developing innovative ideas and projects within the EIP on AHA by enabling access to information, discussion fora, relevant partners, etc. A comprehensive list of events endorsed by the EIP is available at https://webgate.ec.europa.eu/eipaha/events

SmartCare will link to the future Thematic Network on community building for active and healthy ageing (Objective 3.7), the future Pilot A under Objective 3.5: Large scale

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deployment of telehealth services for chronic conditions management, both funded by the CIP PSP, under the same call for proposal.

Links to relevant projects exist such as RENEWINGHEALTH (co-financed under the ICT PSP), which brings together 7 regions from across Europe, to pilot telemedicine tools and create evidence for their quality and cost-efficiency, INDEPENDENT (Pilot B), Interreg-funded projects as well as AAL projects.

Figure 4: Dissemination of SmartCare results – an overview

� Publications in / special issue of the

� Early adopter regions� Local/regional/national-level service providers & funders� User organisations (older people, informal/voluntary carers) � Relevant research / policy actors � Relevant technology providers/ integrators

� Project leaflet, brochure, newsletter

� Rationale � Objectives� Approach� Partner regions

� Useful integrated care pathways� Fit-for purpose service

specifications/design� Preliminary expectations on benef its &

economic validity

� Evidence on user acceptance under real life conditions� Technical infrastructure & integrated service model fit

for routine use� SmartCare guidelines and specifications� Benefits & economic viability, business models

Project Phase I: Integrated care pathways

development

Project Phase II: Organisational & ICT related pilot preparation

Project Phase III: Experiencesfrom pilots & transferability

Dispersed audience:� Interested expert

circles � Public at large

� EIP AHA Action Groups (B3)

Project website SmartCare: http://www.SmartCare.eu (tentative)

Social media sitesrepresentations

Prevention, sc reening

& ea rly dia gnos is

Ca re & Cure Ac tive ag eing &

independent liv ing

•Health lite rac y, p atien t

empowe rment, e thic s and a dhere nce

•Pe rsona l hea lth

ma na gement

•P re ventio n, e arly

d ia gnos is o f functio na l a nd cog nitive de cline

•Guidelines fo r car e,

work for ce (mu ltim orb idity,

po lypha rmac y, fra ilty

and co llab ora tive c are )

•Mu ltim orb idity a nd R&D

•Capac ity bu ild ing and rep lic ab ility of su cc essfu l

in te gra ted car e sy stem s

•Assiste d d aily livin g for old er p eo p le with

co gn itiv e impairm en t

•F lex ib le a nd

inte ro pe rab le ICT so lu tion s for a ctiv e and

independen t liv in g

•In no va tio n imp ro vin g

so cial inc lu sion of o lde r pe op le

Visio n / F o unda tion

• Fo cu s on ho listic and mu ltidisc ip lina ry app roa ch

• Deve lopment o f dy na mic and s usta ina ble c are

s ystems o f t omo rrow

•New p ara dig m of ag ein g

•Innov atio n in se rvic e o f the e lde rly p eo ple

• Re gu lato ry a nd standa rd is ation co nd ition s

• Effe ctiv e fund in g

• Ev ide nc e b ase , refe re nc e ex am ple s, repos ito ry fo r ag e-frie nd ly

inno va tion

• Mark et plac e to fa cilitate co opera tion among va riou s stak ehold er s

Ho rizo n tal iss ue s

� Presentations� Workshops� Special events,

supported by:

� Presence in the media in participating regions

SmartCare

Confe-

� Links to otherprojects, initiatives

Marketplace

B.2.3.2 Exploitation planning

SmartCare will develop a sound exploitation programme to guide the project towards successful joint exploitation of results. The project will pursue a programme of systematic service process innovation complemented by adaptation of technology. This approach will be flanked by a robust evaluation programme which, together with targeted exploitation support, will finally lead to the generation of evidence-based information and decision-support data to facilitate planning for further service mainstreaming in the pilot regions. Business plans are formulated in a targeted manner for social care, healthcare, integration and component providers. The evaluation work will also report on the results of all pilots according to common scientific standards in order to feed evaluation results into exploitation support activities Synthesised guidance on service transferability beyond the pilot regions will be developed which is to serve as an operationally useful source of information for external parties.

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The mainstream deployment planning will be based on extensive viability analysis from multiple stakeholder perspectives. This will include investigation of wider EU markets, analysis of EU legal and regulatory conditions, liaison with stakeholders for the purposes of cost/benefits analyses and business modelling as well as preparation of guidelines to enable other regions to emulate the achievements. Particular attention will be paid to the interaction of national and European rules on public procurement and how these affect the longer term deployment and sustainability of the services. These activities will be actively supported by three Advisory Boards which will be providing regular input throughout the project’s life cycle.

The approach includes also dissemination of project results to stakeholders in regions and organisations beyond the project Consortium interested in early adoption of SmartCare services. The approach is rounded off by the production of guidelines for service adopters, primarily for social and healthcare providers. An assessment of economic and service viability from the point of view of the particular sector actors concerned will be conducted already during the 1st phase of the project, to enable relevant issues to be taken into account in final use case and service model developments. Legal, financial and policy environment issues in European regions other than the pilot regions will be considered. As a key output to be utilised for further exploitation and thereby mainstreaming and replication beyond the pilot regions, guidelines for pathways and integration infrastructure procurement and uptake will be derived from the experiences gained throughout the project’s lifecycle by means of an “evolving document” approach.

B.2.3.3 Management of knowledge, IPR

As a general principle regarding the management of IPRs, results of SmartCare will be owned by the participating Regional Authorities which will have co-invested with the Community in the implementation of ICT supported integrated care services in their territory – assuming they will, in the end, indeed formally register such IPRs. It will be assured through the Consortium Agreement (CA) that these Authorities are prepared to licence these results for free to other Regions wanting to implement similar services. The possibility that they will be converted into freeware will be discussed by the Consortium in the initial stages of Project implementation. The Consortium Agreement agreed by participants lists detailed rules regarding access rights to intellectual property and provides a list of the background that project beneficiaries bring into the project.

Technological partners will be selected locally by each of the participating Regional Authorities complying with the rules of public procurement. The former will be contracted on normal commercial terms. Contracts with suppliers will be structured in such a way that the Regional Authorities will be allowed to sublicense to other Regional Authorities the products developed (e.g. nationalisation of existing software, bridging software for integrating existing applications with one another, etc.) paying royalties to the technological partners at preferential rates.

Because of their nature as public non-profit oriented organisations, the Regional Authorities will apply an open approach to the sharing of the results of the project with other Public Authorities whenever they own the IPRs on specific products.

It is equally envisaged that results from the Project may be licensed to commercial companies to take advantage of the interest of the latter to expand their business by offering telemedicine and tele(home)care solutions to other Regional and Local Authorities.

It is however important to notice that the transferability model which is mentioned later in the proposal represents background knowledge of empirica and HIM SA because it will be developed in parallel with the implementation of SmartCare and will not be funded through the ICT PSP grant.

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B.2.3.4 Respecting public procurement rules

It is anticipated that all Regional Authorities and similar Agencies will fully subscribe to European, national and, if they exist, regional public procurement rules full heartedly. We also foresee that the consortium agreement will cover a clause assuring that all partners will respect such public procurement rules beyond the project phase for the full deployment of their respective services. Furthermore, it should be noted that this declaration of intent is part of this project description which will, if this proposal is successful, become part and parcel of the contract with the EC, a contract to be signed by all the relevant actors involved in this project.

B.2.3.5 Results of the project made freely available

In principle all the results of the Project will be freely available to interested parties with the only exception of:

• the contractual reporting towards the Commission which, by its very nature, is confidential;

• the commercial product procured by the individual partners for implementing their pilots;

• the ad hoc developments which will be subcontracted by individual partners for integrating the existing information systems which need to communicate with one another to provide integrated care and the specifications of which are tailored to each individual ICT context. However, even in this case, as explained in § B.2.3.3 above, contracts with suppliers will be structured in such a way that the Regional Authorities will be allowed to sublicense to other Regional Authorities the products developed paying royalties to the technological partners at preferential rates;

• the “transferability model” which is “background knowledge” and has been developed outside the framework of SmartCare.

This is in line with both the requirements of Pilot A and the spirit of SmartCare which is an initiative open to all interested parties, irrespective of the fact that they are part of the current Consortium.

In particular the following deliverables will be in the public domain:

• D1.1 - Requirements for SmartCare Pathways and Integration Infrastructure

• D1.2 - SmartCare Pilot level Pathways and Integration Infrastructure

• D2.1 - SmartCare Service Model

• D3.1 - Pilot level Service Specification

• D3.2 - The SmartCare Service Specification

• D4.2 - The SmartCare Prototype System

• D5.1 SmartCare Operational Pilots

• D8.1 - Evaluation framework for SmartCare

• D8.2 - First interim process evaluation report

• D8.3 - Second interim process evaluation report

• D8.4 - SmartCare Pilot Outcomes

• D9.1 - First report on dissemination and exploitation activities

• D9.2 - Interim report on dissemination and exploitation activities

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• D9.3 - Guidelines for Pathways and Integration Infrastructure procurement and uptake

• D9.4 - Deployment plans for SmartCare Pathways and Integration Infrastructure (incorporating reports on dissemination)

• D10.2 - Ethics and Data Protection Framework

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B.3 Implementation

B.3.1 Capability and commitment of the partnership

B.3.1.1 Overall description

The SmartCare Consortium comprises the entire value chain of integrated elderly care namely:

• National, Regional and Local Authorities

• Elderly Associations

• Health Insurers Associations

• Regions Associations

• Industry Associations

• Caregivers Associations

• Patients Associations

• Professional Associations

• Business Consultants

Each element of the value chain is present in the Consortium at the highest possible level, with a selection of the most representative members of each group at European or International level.

The members of the Consortium involved in the delivery of integrated care and the organisation supporting them have been grouped by region; for each region, at proposal level, a main beneficiary was selected. In order to speed up the negotiation of the Grant Agreement, the Consortium has accepted to structure the local partnerships according to the traditional structure of beneficiary-subcontractors but it considers that this solution does not respect the kind of close relationship which exists among the members of such local partnerships. As anticipated in the proposal, the Consortium will pursue the goal of creating, in due course and wherever this is possible, a legal entity, the Local SmartCare Alliance, which can rightfully represent all the local players and which can claim costs for all its members. These entities could progressively replace the initial beneficiaries taking advantage of the contract amendments required for any other reason. The third party special condition recently introduced for Pilots A could well be the instrument of choice for achiving this goal in the evolution of the Consortium set-up.

Close contact concerning these contractual aspects will be maintained with the Consortium selected for Objective 4.1 of the ICT Call 6 which, because of its nature of “pilot of pilots”, will face the same issue concerning the size of the Consortium.

No less than 23 regional partnerships representing 14 Member States or associated countries are part of the SmartCare Consortium. They cover the whole of Europe from North to South and from East to West. This will guarantee that the variety of situations and cultures which are found in Europe will be properly represented.

No changes have taken place in the Consortium between the proposal and the Grant Agreement as far as regional partnerships are concerned with the only exception of the Brussels Region which has withdrawn from the Consortium during the negotiation phase but has agreed to remain as an informal observer of the Project evolution.

In the case of most of the regional partnerships and mainly those currently earmarked for hosting a pilot, the local partners have moved from the role of subcontractors to that of beneficiaries, substantially reducing the number of subcontractors and the amount of budget allocated to them.

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The regional partnerships represent the following regions or metropolitan areas:

• Friuli-Venezia Giulia (IT).

• Carinthia (AT)

• Baden Württemberg (DE)

• South Denmark (DK)

• Tallin (EE)

• Aragon (ES)

• Basque Country (ES)

• Extremadura (ES)

• Murcia (ES)

• Valencia (ES)

• South Karelia (FI)

• Central Greece (GR)

• Attica (GR).

• Northwest Croatia (HR)

• Veneto (IT)

• Noord-Brabant (NL).

• Rotterdam (NL).

• Uppsala (SE).

• Amadora (PT).

• Serbia (SR).

• Northern Ireland (UK).

• Scotland (UK).

Older people associations

• AGE Platform Europe

Health Insurers

• AOK

Regions associations

• Assembly of European Regions (ARE)

Industry associations

• Continua Health Alliance

Caregivers associations

• Eurocarers

• European Federation of Nurses Associations

Patients associations

• European Patients' Forum

Professional associations

• International Foundation for Integrated Care (IFIC)

Business consultants

• empirica.

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B.3.1.2 Partner details and function

B.3.1.2.1 Regional Partnerships

B.3.1.2.1.1 Friuli-Venezia Giulia - Italy

B.3.1.2.1.1.1 Azienda per i Servizi Sanitari n. 1 - Regione Friuli-Venezia Giulia

The Friuli Venezia Giulia Region is fully competent and autonomous in public care sectors. In order to guarantee a consistent welfare policy and homogeneous care standards, the Region establishes the preconditions for planning in the social and health sectors and steers, coordinates and checks the activities of actors within the social and health system. The regional law dated 19th May 1998, No. 10, regulates the protection of the health and social promotion of the elderly, aiming at preventing the risk of losing one’s autonomy and self-sufficiency; encouraging the elderly to remain within their family and social context; adjusting the supply of services and structures, in particular for dependent persons; carrying out interventions to guarantee that, within adequate relations with the institutions, the elderly and their families are fully involved in care services, while respecting their right to freedom of choice. The Region has adopted specific service planning provisions governing the local integration between health and social services.

The FVG Region actively participates in the ARE - Assembly of European Regions, ERRIN, EUREGHA and ELISAN EU networks, and it is also member of CORAL - Community of Regions for Assisted Living. Previous experience in healthy and active ageing programmes as Lead Partner:

• HELPS, Housing and Home-care for the Elderly and vulnerable people and Local Partnership Strategies in Central European, 2011-14 - Central Europe Programme, Strategic Projects

• Evaluation Guidelines on disability based on ICF, 2007-10 (National Centre for the prevention and control of diseases, Italian Ministry for Health and Social Policies) for a new assessment procedure consistent with the provisions of the Convention on the Rights of Persons with Disabilities.

• Regional Network on Accessibility, Domotics, Innovation - Regional law 26/05, art.22 Welfare Innovation for the promotion of quality of life at home for elderly and dependent, adaptation of apartments with technologies, teleassistance and telemedicine.

• Project FReNeSys 2002-2003, ERDF- innovative actions, “e-Welfare action” – Integrated networks to manage the protection system for the elderly

Previous experience as Partner:

• Collaborative Research on Ageing, FP7, 2009-12, a study on population ageing quality

• Measuring Health and Disability, FP6 CA,2005-08, and Multidisciplinary Research Network on Health and Disability-FP6 MCA-2007-10, research and management capable of integrating different know-how.

The Local Health Authority n.1 of Trieste (Azienda per i Servizi Sanitari n.1 Triestina) - acting in SmartCare on behalf of Regione Friuli Venezia Giulia - is one of the six entities of the Regional Health System. Its primary objectives can be summarised in the following corporate projects:

• Community care for frail people: the present project intends to structure and experiment with “integrated community support” for frail people, with a strong focus on prevention, taking into consideration the risk of evolution towards dependence.

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• Development of the emergency intervention at home with rehabilitation: this project is aimed at improving and developing an existing function, which is part of the global set of homecare services of the Municipality and of the Health Authority.

• Improvement and strengthening of the integrated services for elderly people, which are not autonomous. These activities are meant to cope with the loss of autonomy and offer the elderly persons and their family a concrete alternative to residential or nursing homes, guaranteeing continuity of care within the health and social care system.

• Revision of the modalities to support the families of caregivers: “Not alone anymore: supporting without fear”. The objective of the project is that caregivers feel more integrated and sustained within the network of institutional and informal services.

• Overcoming standardisation of treatment through good practices in the residential structures for older people: in order to improve the quality of life in institutions through the revision of the workflow of acceptance, with the introduction of personalised planning, development of good practice among the actors in the provision of services, and opening towards the field.

• Promoting the permanence of the older person at home, fighting against the institutionalisation. Some actions are of fundamental importance in this context: o promote the centrality of the person; o develop teamwork through the activation of a personalised integrated

support plans aimed at implementing real care budgets; o improve the quality of life at all levels, at home and in residential and

nursing homes.

Previous European projects: The Local Health Authority n.1 of Trieste is partner in the consortium implementing the DREAMING Project which brings together a set of services which, packaged together, allows to extend the independent life of older people while providing them with a level of safety equivalent to that which they would enjoy in a protected environment such as an elderly home, and offering them a way of staying in touch with their loved ones even when the latter are away.

Key People

Paolo Da Col, MD Director of the Health District n. 1 in Trieste.

In 1977 Paolo Da Col graduated in Medicine in Trieste, where he has remained, dedicating the following 20 years to internal medicine, geriatric medicine and cardiology hospital practice, research (with a large number of publications) and teaching. Presently, he acts in turn as Co-ordinator of the four Districts and holds also the position of General Health Director of the Local Health Authority. Moreover, Paolo Da Col is in charge of the elderly care area and chairs the local Diabetic Centre.

B.3.1.2.1.2 Carinthia - Austria

The Provincial Government endeavours as far as possible to provide services on a low-threshold basis, where this is possible and expedient.

In spite of this there are currently 4.415 persons in Carinthia’s 66 elderly persons’ and nursing homes (780 at care levels 0-II and 3.635 at care levels III-VII). At the present time there are 1.696,47 full-time equivalent (FTE) nursing and care staff employed in elderly persons’ and nursing homes in Carinthia (actual number of employees: 1,977).

Additional important provision options in the inpatient/residential sector are offered by centres for psychosocial rehabilitation, which offer support and living accommodation for people with chronic psychological conditions and people who need nursing care up to level 3

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(approx. 650 places), and the offer of care and support in family-type small units, known as alternative living spaces or “Alternative Lebensräume” (approx. 63 places).

As at 2011 there were also around 170 persons in psychiatric institutions for the elderly. These are fully inpatient facilities for people with psychiatric disorders requiring a particularly high level of care.

Budget

In the care sector (which covers residential homes and nursing homes for the elderly, centres for psychosocial rehabilitation, the nursing care allowance paid by the Provincial Government, and mobile nursing services), the budget for the Social Welfare Office is currently around € 197 million. As a result of the introduction of nursing case management, which I would like to present to you shortly, there has been a significant reduction in the increase curve for people going into inpatient nursing facilities.

In particular the intention is to keep the inpatient care option as a last resort. To make this possible, the Social Welfare Office of Carinthia has set up numerous options:

The Mobile Social Services division in Carinthia covers:

a) Home nursing care: The primary objective of nursing care in the home is to provide need-based support and professionally qualified nursing for sick people, those in need of nursing care, and the disabled, in their home environment.

The provision of support to people requiring nursing care in their home environment is primarily intended to fulfil the following functions:

• It accords with the desire of the affected persons to be cared for in their familiar living environment, providing a stabilising and health-promoting effect

• It avoids or defers inpatient admission to hospitals, nursing homes, nursing wards and residential homes

• It provides the possibility of earlier discharge from inpatient care as a result of the guarantee of care at home

• It provides support and relief for relatives

b) Home nursing assistance: Home nursing assistance is dedicated to providing support to elderly people requiring assistance and nursing care, irrespective of whether or not they are actually ill. The mobile home nursing assistance service is understood as integrated assistance or comprehensive provision of care for these people, directed not only towards their physical condition but also towards their psychological and social wellbeing. Home nursing assistance is intended to complement the work of qualified home nurses, not to replace it.

Home nursing assistance is intended to fulfil the following functions:

• It enables clients to remain in their familiar home environment

• It avoids or defers inpatient admission

• It provides the possibility of earlier discharge from inpatient care as a result of the guarantee of care at home

• It assists in maintaining social contacts in order to prevent isolation and loneliness

c) Assistance in continuing to manage the household: The aim of home help is to provide support to people needing assistance or nursing care, in particular those who have been assessed as needing nursing care at one of the defined levels, who are having problems with keeping their home clean, with shopping and with other activities of daily life.

The functions of home help essentially accord with those of home nursing and home nursing assistance:

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• It enables clients who have been assessed as needing nursing care to remain in their familiar home environment

• It avoids or defers inpatient admission

• It assists in maintaining social contacts in order to prevent isolation and loneliness

Contracts have been concluded with 12 service providers in Carinthia who undertake the tasks described.

In Carinthia at the present time around 7.800 clients are receiving ongoing mobile support from around 1.900 employees (trained nurses; nursing assistants, home helps).

In 2011, 127.100 hours of service were provided in the field of home nursing, 396.200 hours in the field of home nursing assistance and 371.000 hours in the field of assistance in continuing household management; the amount billed to the Province of Carinthia being around € 23 million (provisional budget volume for 2012: around € 25 million).

Key People

Philipp Hermann

Philipp Hermann was born in Wolfsberg, Austria in 1972, and had been employed as a project manager in the corporate sector for several years prior to changing to the public sector. After successfully finishing his studies in Corporate Communications at the University of Applied Sciences, Vienna, he added a postgraduate degree of Integrated Marketing Communications/Public Relations at the University of Stirling, UK, to his academic record.

Philipp Hermann is currently employed at the ”Verein Kärnten Sozial“ – Competence Centre of Social Affairs of the regional government of Carinthia as an ENSA/ELISAN contact person, and embedded in the team responsible for EU project coordination concerning social topics.

B.3.1.2.1.3 Baden Württemberg

B.3.1.2.1.3.1 Kinzigtal

Gesundes Kinzigtal Integrated Care is coordinated and managed by Gesundes Kinzigtal GmbH (“Healthy Kinzigtal Ltd.”), a regional integrated care management company. The company was founded in September 2005 by two organisations: the local physicians’ network MQNK (“Medizinisches Qualitätsnetz – Ärzteinitiative Kinzigtal e.V.) and OptiMedis AG, a German health care management company with a background in medical sociology and integrated care management. MQNK provides medical expertise and its members, being familiar with the region and its people, are aware of the strengths and shortcomings of the region’s health care system. OptiMedis AG brings into this partnership prevention and health economic as well as management know-how and the ability to provide monetary investment. 66.6% of Gesundes Kinzigtal GmbH’s shares are owned by MQNK members; thus it is ensured that the interests of local physicians remain dominant. The remaining shares are held by OptiMedis AG. According to its mission statement, Gesundes Kinzigtal GmbH aims to establish a more efficient and better-organised healthcare for the residents of the Kinzigtal area “in cooperation with patients, health professionals and health insurers”. At the same time, Gesundes Kinzigtal Integrated Care aims to provide state-of-the-art, i.e. best-practice health care to all its patients [Hermann, 2006].

The total population within the western and central Kinzigtal region – the service area of the Gesundes Kinzigtal Integrated Care system – amount to about 69.000 inhabitants. Nearly half of these (31.000) are insured by AOK Baden-Württemberg (about 29.300 assureds) and by LKK Baden-Württemberg (about 1.700 assureds). Both are statutory health insurers

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(sickness funds); AOK BW is open to anyone whereas LKK BW is open only to farmers and their dependents. Gesundes Kinzigtal GmbH is in economically accountable of the total healthcare budget of all these 31.000 assured people, regardless whether they are treated by physicians who take part in the project or not and regardless where they are treated.

The regional management company Gesundes Kinzigtal GmbH and the statutory health insurers AOK BW and LKK BW have set up one of the first large-scale population-based integrated care systems in Germany. Without replacing the previous reimbursement schemes and financial flows between health insurers and individual health care providers, Gesundes Kinzigtal GmbH takes charge of the whole (i.e. trans-sector) healthcare service budget for all AOK BW and LKK BW assureds living in the Kinzigtal region. Cooperating closely with the two health insurers and the contracting healthcare providers (who are at the same time shareholders of Gesundes Kinzigtal GmbH), the management company has implemented a series of preventive and care management programmes such as active health promotion for the elderly, an intervention programme for patients who are at risk of osteoporosis or with chronic heart failure or back pain, as well as other trans-sector measures to realise a substantial population health gain in the mid to long term.

The expected health gain is to lead in turn to a substantial comparative reduction of health care costs in the Kinzigtal region (compared with the German standard). Some other measures such as e.g. a more rational pharmacotherapy and a better trans-sector coordination of health care services are to lead to comparative efficiency gains even in the short term, thus compensating for initial investment cost in the above-mentioned care management and preventive programmes.

Key People

Monika Roth, Dr. sc. hum. Public Health

She is currently working as a mainprojectmanager in the department of healthcare management. She has managerial functions in the development and distribution of the healthcare programmes. Monika Roth is the first contact person for the health insurances which have a contract with Gesundes Kinzigtal and to all partners of the model.

Monika Roth graduated in Public Health in Hall in Tyrol, Austria. She is a nurse with many years of experience within the area of health promotion. Since 2000 she works in managing healthcare and developing healthcare programmes.

Christian Melle

Christian Melle is currently working for Gesundes Kinzigtal as a project manager in the department of healthcare management. Since then Christian has gained valuable knowledge in the development and management of healthcare programmes such as backpain or rheumatismat a local level. He also contributes to calls for proposals by the Ministry of Health on issues such as ambient assisted living.

With a Masters degree in business administration with focus on healthcare management from Nuremberg university in 2007, Christian also has years of experience in implementing telemedicine structures in the impatient, outpatient and home care sector by working for a telemedicine provider company in Nuremberg.

B.3.1.2.1.4 South Denmark

The Region of Southern Denmark (RSD) consists of 22 Danish municipalities. With a population of approximately 1.19 m inhabitants, RSD has the third largest regional population after the Capital Region and the Central Region. RSD spans over 12,191 km², i.e. 28% of

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Denmark, and is the second largest region only surpassed in size by the Central Region. The region has a population density of 98 inhabitants / km². Many of them live in cities or large towns; the region therefore has rural areas which are sparsely populated. The region’s main task is healthcare; it has direct responsibility for the running of the region’s five hospitals.

For the inhabitants of the rural areas, who are often elderly people with a frail state of health, distances to both primary care clinics and hospitals are long. This is reinforced both by the current tendency in the Danish healthcare system to centralise treatment in large urban hospitals, as well as by the current demographic challenge (a growing number of older citizens combined with a labour force decreasing in size). Aside from the demand for a healthcare system with high patient safety, availability, quality of care, and productivity that this situation creates, demands are now surfacing for a higher degree of innovation, flexibility, and efficiency. This calls for the further development of ICT solutions for healthcare, which takes high priority in the region.

By turning the abovementioned challenges into opportunities, RSD has become a centre for innovation in healthcare and has a strong IT infrastructure. The healthcare IT infrastructure is based on programmes for continuity of care and health agreements between the different parties in the Danish healthcare system. The requirement for regions and municipalities to form health agreements was introduced with the Health Act of 2007, as a tool for ensuring a coherent course of treatment for all patients across hospitals, municipalities, and private practices. The goal is for patients to receive coherent and high quality treatment no matter how many healthcare actors are involved in their treatment or what kind of treatment they need.

The building blocks of this infrastructure include the Danish Health Data Network, electronic health and care records, and the online health portal (sundhed.dk). The healthcare IT infrastructure is supported by several organisations and strategies at national, regional, and municipal level. Figures from 2010 show that 88% of the population have access to a computer and 86% of the population have access to the internet in their own homes. This indicates that the Danish population have a high degree of IT and computer literacy.

To ensure that the already well-established healthcare IT infrastructure is further developed, the region makes considerable investments in new eHealth related projects; regional, national, as well as international. The ultimate aim is to improve the quality of life for older people, and allow for more flexible and efficient home care services in the rural areas. Additionally, RSD works towards a higher degree of interoperability of health information systems and also interoperability of electronic health records.

Key People

Tove Lehrmann

Tove Lehrmann is Chief Consultant at Region of Southern Denmark. She is currently heading the innovative department focusing on cross-sectoral communication between hospital, GPs and municipalities with special emphasis on the digital communication between the sectors. Tove has worked in the field of telemedicine and ICT since 1981, and her experience and expertise will be put into full effect in the project. She will be assisted by a competent team of innovative specialists and consultants in development and implementation. Tove is heading the process of procuring and implementing the Shared Care Platform.

Christina E. Wanscher

Christina is currently Chief Consultant and Head of the International Unit at MedCom where she has worked since 2004. CEW holds a masters degree (MA) from the University of Southern Denmark in English and Cultural Studies, specifically focussing on linguistic issues.

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CEW has more than five years of experience in the field of eHealth, TeleHealth and eInclusion. She has been involved in several European projects either focusing on research, validating or implementation.

B.3.1.2.1.4.1 Odense University Hospital

OUH (Odense University Hospital and Svendborg Hospital) comprises one of three main centres in the Danish hospital service, and is the largest of four hospital areas in the Region of Southern Denmark. Approximately 105,000 patients are hospitalised at OUH every year. Furthermore 900,000 ambulant patients are treated every year. OUH comprise a total of 50 clinical departments in Odense and Svendborg. The annual operational costs is c. 5 billion DKK.

OUH treats almost all physical illnesses and disorders, and is furthermore so highly specialised in a wide variety of areas that some of the types of treatment provided at OUH are available at only a few other places in Denmark.

OUH is highly specialised in a number of fields – such as the treatment of cardiovascular disorders, cancer, the replantation of fingers, hands, etc., allergy treatment, complicated sores, diabetes, paediatrics, the treatment of oesophageal afflictions, infectious diseases, as well as rheumatic and connective tissue disorders. The specialisation includes doctors, nurses and other healthcare professionals, and their knowledge and abilities are constantly being further developed – in ways that include closely cooperating with colleagues in Denmark and abroad, and through high calibre supplementary training and further education.

Key People

Claus Duedal Pedersen

Claus Duedal Pedersen is currently a Consultant in Odense University Hospital (OUH). With a Masters degree in economics and with his extensive experience within telemedicine and infrastructure, Claus has valuable knowledge within implementation of electronic communication in the healthcare sector and the management of eHealth projects from his time in the Development Section at the County of Funen and afterwards as the international manager at MedCom before he joined OUH.

Kristian Kidholm

Kristian Kidholm is currently a Health Technology Assessment (HTA) Consultant in the Odense University Hospital. Kristian has a PhD in Health Economics, and is responsible for the National mini-HTA database in Denmark. His key expertise is in production of HTA in co-operation with clinical staff at the hospital. Kristian has wide experience with multidisciplinary co-operation in HTA and research projects, together with clinical staff, researchers and hospital management.

Anne-Kirstine Dyrvig

Anne-Kirstine Dyrvig is MSc. in Public Health from the University of Southern Denmark. She is recently enrolled as ph.d. student at Odense University Hospital and University of Southern Denmark within the field of HTA and telemedicine with special focus on transferability of results across countries.

Since 2008, Ms Dyrvig has been employed in the Quality & Research/Health Technology Assessment department at Odense University Hospital & Svendborg Hospital (OUH), where she is part of the Health Technology Assessment (HTA) team. The HTA team supports the clinical departments in writing and completing mini-HTAs that are a standard tool at OUH

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prior to the purchase and implementation of new devices etc. The HTA team and their services are also in high demand from external organisations, which means that the team holds a leading position in not just the Region of Southern Denmark, which is the regional health authority, but also at a national level. Ms Dyrvig is a central part of the team and has worked extensively with completion of full HTA reports as well as teaching and support for the hospital departments in their work with mini-HTAs. Also, she is frequently used as a teacher in courses on systematic literature review, HTA and mini-HTA by many other organisations than OUH.

Her work not only extends to Denmark, but given her broad HTA experience, Ms Dyrvig competences are sought internationally as well. Ms Dyrvig teaches mini-HTA to other European health organisations and she plays a main role in the evaluation of telemedicine services in an ongoing EU project called RENEWING HEALTH (CIP PSP Pilot A), which involves 9 European regions and 26 different telemedicine services, where Ms Dyrvig tasks involve evaluating the effectiveness of the different telemedicine solutions in a telemedicine-adapted HTA framework based on prospective data collection.

B.3.1.2.1.5 Tallinn - Estonia

B.3.1.2.1.5.1 City of Tallinn

Tallinn is the city with the highest population in Estonia; 30% of the population of Estonia lives in Tallinn. It occupies an area of 159.2 km² (61.5 m²). Tallinn is divided into eight administrative districts: Põhja-Tallinn (Northern Tallinn), Kesklinn (City Centre), Pirita, Lasnamäe, Kristiine, Mustamäe, Nõmme, Haabersti.

The significance of Tallinn as the capital and the largest centre of the country for the population of other regions of Estonia has been increasing. Tallinn’s area of influence includes the entire Estonia; 90% of the population of the nearby regions of Tallinn have connections with Tallinn.

Tallinn has become one of the largest centres of passenger and cargo transportation in the Baltic Sea region; the key factor in the development of harbours and the entire transportation and logistics sector is transit, which makes up 2/3 of the turnover of Tallinn’s harbours.

Tallinn is rich with sights and cultural heritage, the most important among them being the Old Town of Tallinn which is entered into the UNESCO World Heritage list; it is one of the best-preserved and most complete medieval towns of Europe.

In addition to its long time function as seaport and capital city, Tallinn has seen development of the ICT sector; in its 13th December 2005 edition, the New York Times characterised Estonia as "a sort of Silicon Valley on the Baltic Sea". Skype is one of the best-known of several Estonian start-ups originating from Tallinn.

Tallinn City Government organises social welfare via the Social Welfare and Health Care Board and via the District Governments.

Large healthcare institutions such as Foundation North Estonia Medical Centre, East Tallinn Central Hospital, West Tallinn Central Hospital, Foundation Tallinn Children’s Hospital (total of 7.400 employees) are located in Tallinn and treat residents of Tallinn, Harju County and other areas and countries.

The entities that Tallinn supervises are listed below:

• 3 hospitals.

• 1 municipal primary care physician centres

• 10 social care centres

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Access to welfare services for people with disabilities and older people are being improved and optimised.

Tallinn city has implemented an alarm button service for older people. The objective of the service is to increase the feeling of security of older and disabled people by using the mobile alarm button service. The objective of the use of the service includes summoning help above all in situations where the user is unable to move and independently open the door to helpers, for example: 1) unexpected need of medical help to which inability to move is added; 2) unexpected need for so-called personal help (falling, temporary immobility, getting trapped in interior rooms, etc); 3) situations requiring rescue service (fire, explosion, etc).

Tallinn City is making preparations for joining the International Safe Community Network.

Tallinn City has an advanced ICT structure. Nine out of ten inhabitants have access to Internet through broadband connections. Computers and ICT are commonly used in education, and are introduced as early as pre-school. As a result, Tallinn citizens have a high degree of ICT awareness and a willingness not only to use existing state-of-the-art technology, but to test new technologies, which provides a breeding ground for new ideas to be tested.

To further develop the healthcare systems and boost regional economic growth, considerable investment has to be made in new eHealth projects. The region of Tallinn has realised that eHealth projects including interoperability of health information systems are very important to improve the quality of life for older people and allow more flexible and effective home care services in a rural environment.

Key People

Dr Ene Tomberg

Ene Tomberg is a Deputy Head of Social Welfare and Health Care Board of Tallinn City Government from year 2007. Also a member of the Supervisory Board of Estonian Health Insurance Fund and head of the Estonian Cancer Screening Foundation. As the Head of the Department of Healthcare Ene is involved in various city government projects such as organising health care for citizens and cooperation between healthcare and social care providers in city. She was involved in eHealth of schoolchildren project. Ene has a diploma as GP from Tartu University and Magister Artium (social work) from Tallinn University. She is fluent in English, Russian and Finnish.

Raivo Allev - Manager of development and administrative department of Tallinn City Social welfare and health care board

As manager of development and administrative department, Raivo Allev is responsible for various projects in Tallinn City social department. He has work experience since 1995 with healthcare and related social welfare project. He is also lecturer in Tallinn University social faculty for social work students.

B.3.1.2.1.5.2 East Tallinn Central Hospital

East Tallinn Central Hospital (ETCH) is the third largest hospital in Estonia, with 626 beds and 532.932 outpatient consultations. It is located in Tallinn, the capital of Estonia. ETCH has been a municipality owned legal entity since 2001. It was established by merging seven of Tallinn's healthcare institutions: four hospitals, two policlinics and one diagnostic centre.

Today ETHC encompasses seven clinics: Internal Medicine Clinic, Long Term Nursing Clinic, Surgery Clinic, Diagnostic Clinic, Women’s Clinic, Eye Clinic and Medical Rehabilitation Clinic.

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Since its creation in 2001, the ETCH has gone through important changes and restructuring. ETCH is presently one of the fastest growing hospitals in Estonia; there are approximately 2.295 employees, including 371 doctors and 900 nurses. ETCH’s turnover was 64M€ in 2011. ETCH provides a large spectrum of healthcare services. There is active care for inpatient and outpatient as well as rehabilitation and long-term care. The hospital also provides a day surgery service. For emergency patients, an emergency department is open 24 hours/day. The hospital covers the most specialties lacking only neurosurgery, cardiac surgery, nephrology, haematology, child diseases and psychiatry.

In the academic field, ETCH has close cooperation with the Medical Faculty of Tartu University and the Faculty of Science of Tallinn Technical University. The hospital is the official partner for Tartu University in training of residents and postgraduate training of doctors.

The research in ETCH is organised in three different research modules – hospital initiated clinical research (HICR), collaborative basic research (CBR) and sponsored clinical research (SCR). Researchers within HICR have experience in the design of clinical protocols; they carry out studies in compliance with the Good Clinical Practice (GCP), database management, and patient care. This activity is focused on innovation, drugs development and integration of the research knowledge, as well as discoveries in patient care. Researchers within CBR have experience in bench work and cooperation with basic scientists. This activity’s main purpose is preparation of physicians, researchers and innovation. Researchers within SCR actively cooperate with industry, clinical research organisation public bodies and regulatory agencies. The key aspect of this activity is integration into clinical practice of new drugs and therapeutic modalities.

To a certain extent, ETCH is active also in international cooperation: it has been partner in two EU Baltic Sea Region Interreg projects. ETCH participated as a partner in the Baltic Sea Region Interreg IIIB program Baltic eHealth (concluded in September 2007) and in the partially EU funded eTEN project R-Bay (concluded in May 2009). ETCH also participated in the DREAMING project from 2008 to 2012.

Key People

Marko Parve Head of Medical Engineering Department

As the Head of Department,Marko Parve provides medical engineering support for the whole hospital. He is involved in various hospital IT projects, such as medical imaging and e-health projects.

Marko is a fully qualified medical engineering specialist (diploma biomedical engineer V level) and has worked for ETCH for 8 years. He also holds an Msc in biomedical engineering, and in 2010 started PhD ICT studies at Tallinn Technical University.

He is fluent in several languages: English, German and Russian.

Mikk Jürisson – Development Director

As the head of development centre in ETCH, he is a supervisor of five departments – medical engineering, infotechnology, training and science.

Mikk holds a medical doctor degree in Tartu University in 1988. His speciality is paediatric neurology. Mikk has worked 16 years in Merck Sharp and Dohme as an area director. Since 2011, Mikk started a PhD in public health studies at Tartu University. He is fluent in English.

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B.3.1.2.1.6 Catalonia – Spain

B.3.1.2.1.6.1 Fundació Privada Centre TIC i Salut

The Tic Salut Foundation was created in 2006 by the Government’s Ministry of Health and its main specific objectives are:

• To elaborate criteria, strategic orientation and useful information for the decision-making on Information and Communication Technologies in the health area.

• To offer technical support to the Administration, users and providers of technological solutions.

• To introduce the newest technological applications in the health area which make the transfer of knowledge easier for health centres and professionals, thus improving the health services devoted to citizens.

• To promote the movement of information before the movement of people, getting the highest degree of efficiency in the diagnosis.

• Disseminate and implement the standards that allow interoperability between all systems.

• To become a reference centre in Catalonia, networking with other entities in Spain, Europe and around the world.

Among the Foundation main initiatives are the following:

• Observatory to evaluate the evolution of ICT in the health area,

• Telemedicine and tele-assistance plan

• Showroom (E-showroom of ICT-Health Centres, Exhibitions and fairs promoting ICT, E-Health events)

• Innovation (sponsorship of pilot projects, sponsorship of pure and applied research)

• Industry clusters (dossiers to attract IT industries to Catalonia, fostering relationships between health centre, research and financing companies, generation of spinoffs companies and international alliances)

• Office of Standards and Interoperability (aiming to implement the standards in Catalonia, being the representative of DSGC agencies in standards development and currently the chairman of HL7 in Spain, board member of IHE in Spain, Member of Continuing Alliance, Member of CTN 139 AENOR).

Key People

Joan Cornet

Executive Chairman of the TicSalut Foundation, was appointed General Secretary of the Department of Health of the Government of the Generalitat de Catalunya in 2004 and from 2007 he is also Member of the Directors Board of EHTEL (European Health Telematics Association). He has also worked for the Health and Social Services Commission (FMC), and the World Health Organisation. He has also served as civil servant in the European Commission.

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Josep Mañach

Director of the TicSalut Foundation. He holds a degree in Law (University of Barcelona), a Bachelor’s degree in judicial practice (EPJ Roda Ventura) and in Clinical Psychology (UB). He has occupied several public offices in the Catalan Government. He was responsible for the Health area at the Centre of Telecommunications and Information Technologies and Coordinator of the ICT Programme in the Ministry of Health of the Catalan Government.

Ignasi Garcia-Milà

Ignasi Garcia-Milà. EU Project Manager. He holds a degree in Computer Cience (Universitat Politècnica de Catalunya). He is currently responsible for the management of TicSalut’s participation in EC project for eHealth RENEWING HEALTH. He works at the international projects department in technical and administrative management of mainly EU funded projects.

B.3.1.2.1.7 Comunidad Autónoma de Aragón – Spain

The Autonomous Region of Aragón comprises three provinces: Zaragoza, Huesca and Teruel, and 729 municipalities. 50% of the population lives in the regional capital city of Zaragoza while the remaining 50% is sparsely spread among the rest of the municipalities.

Healthcare, together with education, is the most essential service that the Regional Authorities offer to the resident population and one in need of permanent attention because it is necessary to strike a balance between the demand for quality healthcare (more and better services) and the need to contain the growth in the resources (human and financial) dedicated to healthcare.

The Health Department of the Autonomous Government of Aragón is an autonomous body within the Government of Aragón. It has the following functions and responsibilities:

• Overall management and co-ordination of the existing healthcare resources in the territory of Aragón.

• Primary care, secondary care, mental care and geriatric care management, including homecare.

• Promotion and protection of individual and public health.

B.3.1.2.1.7.1 SALUD

SALUD is the public provider of healthcare care in Aragón and has a network composed of: 12 general hospitals, 110 primary health centres and 5 geriatric hospitals.

Vision

SALUD heads towards a scenario where an outstanding healthcare service is provided through the optimum management of the public resources allocated, whilst reaching a high level of customer satisfaction, fully backed by the citizens. Each and every professional working for SALUD is motivated and highly involved in achieving this objective.

Mission

To provide an “end to end” healthcare service to the citizens and residents within Aragon’s geographical area, by ensuring easy and quick access to the service, understood as: promotion of healthy ways of life; prevention and protection against physical, environmental and biologic factors; provision of any care required in an illness situation; whilst keeping the highest degree of autonomy for patients in their environment and in society in order to meet all of their needs and expectations in terms of personal health.

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Values:

• Equity, solidarity and universality.

• Community oriented.

• Results oriented.

• Continuous improvement, learning and innovation.

• Responsibility of the top management.

• Social responsibility.

Key People

Juan Ignacio Coll Clavero–responsible for innovation and new technologies at Barbastro Hospital, Barbastro Health Care Sector (SALUD)

Juan Coll holds a Degree in Medicine and Surgery granted by the University of Zaragoza in 1983. From 1990-2002, he was the Computer and Information Systems Manager at Barbastro Hospital;since 2002 he has been responsible forInnovation and New Technologies Department at Barbastro Hospital.

Juan Coll has participated in several projects in the fields of telemedicine, telecare and new technologies. Some of the most representative are the national project PITES T-Ayuda, EU projects such as eTEN HEALTH OPTIMUM and HEALTH OPTIMUM ID, DREAMING and SUSTAINS in the field of telemonitoring elder chronic patients.

He participates in a very active manner in congresses, conferences, forum and scientific days through discussions, oral communications and posters, being very active in the dissemination of the projects.

Juan and the Innovation and New Technologies Department has been awarded several prizes, such as the “Sanitaria 2000” Prize 2011 for his technological contribution to the Aragones Public Health System, or recently the “National Prize of Informatics and Health” 2011 by the Health Informatics Spanish Society (SEIS) recognising “his contribution to the development of telehealth at a National and European level, thanks to the leadership of the unit in new technologies and health innovation”.

Juan Antonio Vallés Noguero

Juan Antonio holds a Degree in Medicine and Surgery and a Doctorate Degree in Medicine with honourable “Cum Laude” mention. His doctorate was awarded in the biomedical area in 1995.

Dr. Vallés’ speciality is geriatrics since the beginning of his career; he has a long experience working as such in several Aragón hospitals. He was responsible for the quality enhancement groups of the Huesca’s and Barbastro‘s health sectors, member of the enhancement group focused on chronic dependent patients, and member of 14 clinic committees.

He has a wide experience in dissemination, acting as speaker in 16 training courses, 41 participations in events, and 12 publications in several journals and books. From 2004 to 2009, he was director of the “Cuadernos de Geriatria” magazine, a journal from the Aragón’s Geriatrics Society Dissemination Entity.

Dr Alfredo Zamora Mur

Alfredo holds a Degree in Medicine and Surgery from the Zaragoza University, with a specialisation in geriatrics and gerontology. He is currently working in the geriatrics service at Barbastro Hospital as doctor of Barbastro’s Home Care Support Team which combines as a doctor in an elderly home.

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Alfredo has investigated nutritional care for hospitalised patients, and home hospitalisation of patients with terminal pathologies.

Alfredo has a wide dissemination activity, primarily as associate professor for the Zaragoza University’s Anatomy and Human Embryology Department;he is member of the national and regional Gerontology and Geriatrics and Palliative Care Societies and several hospital committees.

Maricela Lopez

Maricela Lopez holds a Degree in Medicine and Surgery officially recognised in Spain since 2003. She holds the speciality in Family and Community Medicine by the UDMFYC Huesca, and is certified in Emergencies and Urgencies Medicine since 2011. She works since 2009 at the Emergencies Unit at Barbastro Hospital, where she has provided services since 2005.

She has been working as doctor in the DREAMING European project, a project to telemonitoring chronic elder patients. She was wide experience in older patients and in oral communications on telemonitoring, older people, and cardiovascular pathologies.

Dionisia Romero Marco

Dionisia holds a Nursing University Degree (DUE) and works since 1984 at Barbastro Hospital. She is specialist in radiology and electrology and medical-surgery care. Due to her wide experience in emergencies, she has participated as the reference nurse for the European and National telemonitoring projects DREAMING and PITES on monitoring chronic older patients at home and with the support of social organisations.

Dionisia has a wide experience in dissemination and has participated in several events on medicine at emergencies, catheterisation, healthcare innovation, telemonitoringforolder people, and ethics in the treatment of patients’ data.

Rosana Angles Barbastro

Rosana holds a degree on Computer Engineering from the Polytechnic University of Cataluña (UPC) in 1999. She has a tenyear experience as project leader in the multinational Vodafone Group, researching and innovating on telecommunications technologies. Currently she is working as a consultant at Barbastro Hospital managing National and European projects in health areas and telemedicine innovation.

B.3.1.2.1.7.2 Cruz Roja Española

The humanitarian objectives of the Spanish Red Cross (SRC) are centred, among others, in the improvement of the situation of the most vulnerable people.

SRC address its activities and programs to different population sectors (elderly people, people with disabilities, immigrants and refugees, childhood at risk, mistreated women, prisoners and former-prisoners, people affected by HIV-AIDS, unemployed ,drug addicts, ...), specially to those most unprotected . SRC works for their social integration, trying to eliminate social exclusion risks. Addressed to general population, there are programs of sanitary assistance, transport, emergencies, public sensitization and awareness, non-formal education, environmental protection, services for elderly people based in ICTs, etc.

The healthcare services provided by Red Cross are currently running in two ways: home tele-assistance and mobile tele-care (indoor and outdoor). The target beneficiaries of such a service are elderly and victims of gender-violence:

• Home tele-assistance: The home tele-assistance was developed in 1998 and the first provider that offered it in Spain to the society was the Spanish Red Cross. This service provides elderly people and people with disabilities, the possibility to contact a

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Call Centre rapidly through an alarm pendant (which enables the user to trigger an alarm in case of fall) and a home unit which makes the call to the Attention Centre. The service works 24 hours a day, 365 days a year, and depending on the case, the CRE employs different resources to solve the various urgent situations. Nowadays, Spanish Red Cross manages 13 call centers, in which tele-assistance service is attended. One of the most important characteristics of the Red Cross’ home tele-assistance service is the support offered by volunteers at users’ home. However, elderly people not only need to feel safe in their homes, but outside them. The elderly demand the possibility of improving their quality of life, staying healthy, living independently for longer, and counteract reduced physical and cognitive capabilities, and then, claim the necessity of a tele-assistance to enable mobility: Mobile telecare.

• Mobile tele-care: The objective of the mobile tele-assistance (MTA) service is to extend the benefits outside tele-assistance users’ homes. The service was set up in 2002, using a mobile device for tele-assistance services, giving excellent results in terms of suitability of the technology, user satisfaction and efficiency of the services. Thanks to this experience, at the end of 2004, Red Cross and Vodafone won a public contest for the provision of Tele-assistance services for victims of domestic violence in the northern part of Spain. More than 11.000 women have benefited from it. At the beginning the devices used were very specific and had several drawbacks that burden the service provision, most of them dealing with costs, but also with logistic problems and user attention difficulties. For this reason, TECSOS Foundation developed an “SOS application” that can now be installed in a standard mobile phone, and thanks to the benefits of using a standard device, mobile tele-assistance service is being offered to the elderly too.

Key People

Fernando Pérez Valle

Fernando Pérez Valle holds a Degree in Social Work granted by the University of Zaragoza From 1998 to 2001. He organized several courses and seminars related to Health an social welfare areas, such as “Tuiton for Nursery aide in geriatrics”, “Home care assistant”, both for the National Employment Institute or “Health promotion and prevention on Drug dependency in Communal Collectives”, conference prepared for the III Aragonian Health education meeting. From 2001 to 2002 he worked as Social worker for National Health Department on the IV Area.

During the last ten years he has been working on several social and Health projects and providing services related to this area as General Manager of the Spanish Red Cross in Aragon. He is currently developing a national study on domotics applied to aging, related to telecare. He participates in a very active manner in congresses and conferences, being very active in the dissemination of the projects.

Sigfrido González Pardo

Sigfrido holds a Degree in Social Work granted in 1991 by the University of Zaragoza, with a specialization in drug addictions and AIDS and Human Resources Direction.

He has a long experience in Volunteering and local Development Department in Red Cross in Huesca and various non-governmental organizations. He has collaborated in different programs related to health and technological training of the voluntary work. With experience in European programs like creations and occupational training in services for the women community and campaigns and activities in Health programs -programming and evolution-. Nowadays he develops his labor as Red Cross Provincial Coordinator and collaborates in different projects of technology applied to elderly people and health in the headquarters that supports Red Cross in the technological center of Walqa (Huesca).

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B.3.1.2.1.8 Basque Country - Spain

The Basque Country is a region located in the north of Spain, with a population of 2.2 million inhabitants. The average population density is around 300 inhabitants / km², higher than the European Union average; but the distribution of the population is fairly unequal, concentrated around the main cities. This leads to two different situations: in the northern area, a high population density and high concentration of primary care clinics and hospitals, and in the southern area, a greater distance to healthcare services.

The situation creates a different demand of services for a healthcare system with a high quality of care and productivity. In any of the different situations, the systems enable the care provider to deliver the same care no matter where the patient lives. Healthcare in the region is managed by the Basque Government through the Basque Health Service (Osakidetza), the regional public body providing healthcare to the whole Basque population. Today Osakidetza provides healthcare in 14 Hospitals, more than 100 Primary Care clinics organized through four different geographical areas, apart from the Mental Health Centres, Emergencies and Basque Transfusions and Human Tissue Centre.

Osakidetza has been pioneering the use of ICT technologies since the early 90’s when Osakidetza launched the CLINIC project that allowed consulting the clinical information of one patient across the whole network of hospitals and centres, independently of the architecture of each system in the network. Since then, Osakidetza has been focusing on the development and implementation of ICT-based technologies to improve the quality of the services as well as to rationalise resource consumption. The investment in new technologies has increased from 9m€ in 2007 to 24m€ in 2010.

Osakidetza was designed and structured in the early 80’s to comply with an epidemiological model focused mainly on acute interventions, which does not correspond to today’s needs. The basic characteristic of this care model is reactive, in which the patients have an episodic relationship with the health system. Taking into account that chronic illnesses represent the dominant epidemiological situation of the country (it is estimated that they currently represent 80% of the interactions with Osakidetza and account for more than 77% of health expenditure) this model is not what chronic patients need. This is why in 2010 the “Strategy to Tackle the Challenge of Chronicity in the Basque Country” was drawn up in order to adapt Osakidetza to both current demands and those of the future in areas of prevention and care for chronic illnesses, which offers a framework for ultimately transforming Osakidetza in the mid-term.

As a response to the challenges that the healthcare system is facing, the Basque Country has set the objective of further developing and implementing technologies that facilitate clinical practice and self-care. This objective includes several strategic actions such as Electronic Clinical Record, added value services for professionals, ePrescription, multi-channel centre for contacts and health services, digitalisation of the radiology images, telemedicine, etc. The “Strategy for facing the Chronicity Challenge in the Basque Country” identifies 14 strategic projects, among them the creation of the research centre Kronikgune, which takes care of innovative practices and the structured generation of scientific evidence regarding chronicity and health services sustainability, to enable evaluation and demonstration of innovative pilot activities in order to assess their efficiency and their capacity to be scaled up throughout the Health System.

B.3.1.2.1.8.1 OSAKIDETZA- Servicio Vasco de Salud (it will enter the Consortium in case the Basque Country hosts a pilot)

OSAKIDETZA- Servicio Vasco de Salud is the public health care system of the Basque Country a region located in the North of Spain. Osakidetza was created by the Health

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Department of the Basque Government in 1983. All the public Hospitals and Primary Care of the Basque Region are under this organization.

The Basque Health System includes 14 Hospitals, more than 100 Primary Care clinics organized through 4 different geographical areas, apart from the Mental Health Centres, Emergencies and Basque Transfusions and Human Tissue Centre. More than 30.000 professionals work for Osakidetza, which could be considered the biggest organization of the Basque Country.

Osakidetza has a target population of more than 2 million inhabitants. It is estimated that in twenty years the 26% of the Basque Population will be older than 65 years old, so this epidemiological pattern requires the improvement of the management of chronic diseases. In the last 15 years the prevalence of chronic patients has increased remarkably all over the region, so actions related to the patient empowerment through e-Health tools are considered a big challenge for the region.

Key People

Igor Zabala Rementeria

Mr. Igor Zabala Rementeria. Since January 2010 to present he is Staff member of the Office for the Strategy of Chronicity in Basque Health Service. Previously, from 1993 to 2010 he has been working as manager in the training department in Osakidetza (Basque Country),

He has a Psychology Degree from the Basque Country University. Master in Human Resources. Postgraduate in training programs from National Distance University (UNED)

His expertise goes with human resources development and knowledge management in health services as on the design of training programs especially for clinicians

Nekane Murga

Mrs. Nekane Murga is a cardiologist at University Hospital of Basurto in Bilbao. Doctor of medicine and surgery with the degree of fit CUM LAUDE (special prize health sciences at the UPV / EHU).

During her career highlight her interest and dedication to clinical care of patients with heart failure (acute, chronic monitoring and rehabilitation), ischemic heart disease and ventricular dysfunction.

She has taken part in courses / seminars / meetings / workshops / conferences and symposiums clinical issues, research and clinical management. She has been author or editor in 4 books, co-author of 12 book chapters and multiple scientific articles on peer reviewed journals.

Currently Dr. Murga is a member of the editorial board of the Spanish Cardiology Journal and reviewer of articles. She is a member of the Research Ethics Committee of Hospital de Basurto and Euskadi.

She has been President of the Section of Cardiology outpatient clinic and the Spanish Cardiology Society from 2006 to 2011 and currently collaborating with the Spanish Foundation of the Heart in the dissemination of Cardiology through a website, preparing material for dissemination among the population at large.

Apart from this people, other clinicians of different Hospitals and Primary care settings of the Basque Health System will be involved in this project.

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B.3.1.2.1.8.2 Kronikgune

Kronikgune is the research centre created by the Department of Health and Consumers Affairs of the Basque Country (Spain) as part of the regional Strategy to Tackle the Challenge of Chronicity in this region. This regional government is strongly committed to the transformation of Health Systems for the treatment of chronic patients, with a strong focus on prevention and promotion, on the role and autonomy of the patient, and on assuring continuity of care; hence promoting Aging Well and the independent living of older people.

Kronikgune is an international excellence centre in research on chronicity, entrusted with institutional representation on international projects and actions aimed at developing products and services and their deployment for the whole Basque population (2,2m inhabitants). The aim of this research centre is to enable innovative practices and the structured generation of scientific evidence regarding chronicity and health services sustainability. Kronikgune will evaluate and demonstrate innovative pilot activities in order to assess their efficiency and their capacity to be scaled up throughout Osakidetza.

Kronikgune has a clear international vocation aiming to establish interregional partnerships with other European regions, emphasising that knowledge oriented to the implementation and extension of products and services in any health system. Kronikgune is one of the specialised regional entities in the design, implementation and assessment of the regional policies and strategies in chronic care.

Kronikgune's mission is focused on generating new knowledge, to facilitate, enhance or accelerate the implementation and innovation of strategies to address the chronic strategy in the Basque Country and other health networks. One important part of Kronikgune’s work plan is to participate in international reference projects, action research methodologies, and health services’ research of high scientific quality. Thus becoming a "space" to meet and share experiences amongst researchers in health services.

Key People

Mr. Esteban de Manuel Keenoy

MD University of Navarra, holds a Master degree in Community Health, University of London (LSHTM) and a specialist degree in Family Medicine, Autonomous University of Madrid. He has a career in management in health and scientific institutions. He has been Regional Director in Andalucia (Spain) of Primary Health Care and Health Promotion and later, Academic Director of the Andalucian School of Public Health. From 2003 he has been CEO of the Institute of Health Sciences of Aragón (Spain), responsible for Health R&D and knowledge management in that Region. Since July 2011, he has been in charge of Kronikgune, the Basque Centre for Health Services Research and Chronicity set up by the Basque Government within the R&D strategy to study ageing, chronic diseases and healthy living. He has been involved in national and international projects advising on public health and health systems development. His main expertise is on strategic management, human resources development, and knowledge management in health services and research.

B.3.1.2.1.8.3 OSATEK (it will enter the Consortium in case the Basque Country hosts a pilot)

OSATEK is a public company of the Basque Government attached to the Department of Health and Consumer Affairs. OSATEK was created in 1992 to become a national reference in the medical imaging sector and an organizational model in the health sector. OSATEK has contributed to more than 600,000 patients being diagnosed using magnetic resonance imaging. Diagnostics has made us leaders in this sector in the Basque Country. OSATEK

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has been a pioneer in the deployment of new applications of MRI as proven 3D angiography, Cholangiopancreatography and cerebral perfusion among others.

On the other hand, Osatek was committed by the Basque Department of Health, to launch for the whole Basque Country, the Osarean Project. The main objective of this project is to develop a technological and organizational platform in order to allow a multichannel interaction of all citizens of the Basque Country with the health system, complementary to current face to face healthcare services, facilitating all processes, simplifying the procedures for the citizens, providing excellence to the clinical work and above all, paying a special attention to the treatment and monitoring of chronic diseases.

One of the main objectives of the OSAREAN project is to promote the patients involvement on their health, providing all the tools to introduce a culture of shared responsibility with their diseases. This is in total alignment with the main objective of this initiative, which is the provision of a set of services around online access by the citizens to their EHRs (electronic health records) so that the patients are empowered. The main benefit of this strategy is that citizens will be better informed about their health and will be able to make more conscious decisions about treatment and lifestyles in collaboration with the healthcare professionals looking after them. The approach to achieve this strategy in the OSAREAN project is the provision of personalized services tailored to the needs of each group of users of the health-care system: patients, health professionals and citizens.

Some of the services offered or to be offered in the near future by OSATEK are as follows:

• Patient expert program so that the patient is co-responsible of his health and he/she receives continuous system support.

• Personal health folder, that is, the patient decides which health information wants to share with other professionals. This personal health folder is the health data that can be accessed from other health-care systems outside the patient’s own health system, for example when going abroad, when travelling or when having consultations with private health insurance companies.

• Getting online access to the Electronic Health Records so that the Patient can access all his/her medical information.

• Providing professional advice, pharmacologic or psychological advice to the citizens.

• Attending a non-emergency consultation for a patient based on the analysis of his/her EHR. This consultation can be made following different channels: the traditional face-to-face, by email, by SMS, by phone, by Internet or either by post mail.

• Providing different health services for people suffering from chronic diseases when travelling abroad.

B.3.1.2.1.9 Extremadura - Spain

B.3.1.2.1.9.1 Consejería de Salud y Política de Extremadura - Social Department of Autonomy and Promotion of Care (SEPAD)

The Department of Autonomy and Promotion of Care (SEPAD) is a state body submitted to the administrative law, set up by means of the Spanish Law 1/2008, (22nd May), with a limited budget, and attached to the competent Ministry in dependence matters. Its aim is to manage and administer services, benefits and geriatric problems from the Administration of the Autonomous Regions according to the objectives and principles of the Law 39/2006 (14th December) of Promotion of Personal Autonomy and Support for Dependant People; and development and coordination of social policies for support of disable and elderly people.

Main products and services:

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• Centres and services net (hospitals, residential homes, telecare, occupational centre service, assisted living, family unit, cognitive rehabilitation service, and dementia centres.

• Personal autonomy promotion programmes.

• Education and investigation.

• Dependant people care programme.

• Residential support and work-and-social integration for people with severe mental disorder programmes.

• Adult tutelary committee.

• Social integration of disabled people.

• Support for people with severe mental disorders.

• Preparation of quality guidelines and guidelines for action, and putting them into practice.

• Early intervention.

The reference for all the services rendered by SEPAD to Extremaduran citizens can be found on the corporate web site: www.sepad.es.

Key People

Cristina Gallardo Rey

BA in Political Science and Public Administration from the University of Granada and a Master Degree in Health and Safety at Work, University of Extremadura. Professionally she has focused her activities in the area of social action innovation, coordinating E-Tradis Association (in the field of social integration of people with disabilities) to lead FUNDECYT where she works as Project Assistant in the Knowledge Society Area, being responsible for projects, studies and research, as well as participating in international networks, in the following areas: e-learning, e-health, health promotion and active aging and initiatives of new technologies to citizens, eliminating the digital divide and promoting open source software.

B.3.1.2.1.9.2 FUNDECYT

Established in 1995, FUNDECYT is a non-profit organisation that has a fundamental role in economic development, structural and innovation strategy of Extremadura, encouraging, likewise, technology transfer and technological development. As stated in Article 1 of the Statutes of the Foundation, its main purpose is to promote projects to foster development of Science and Technology in the system "Science-Business Administration."

This main objective is divided into the following, which constitute the main purpose of the activities and projects developed by FUNDECYT:

• Promote the implementation of the culture of innovation and knowledge in business, government and research centres.

• Promote synergies and interactions between the university, research centres, business organisations and the Public Administration.

• Provide assistance to institutions, private enterprises and research centres with the aim to obtain international, European or national finance for R+D+i projects.

• Identify the technology needs of companies and research centres, and promote technology transfer through sectorial studies, or compile and disseminate the available knowledge to improve scientific and technological development at the University, in R+D centres, and regional SMEs.

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• Participate in national and international events to know the latest trends in management policy of innovation and knowledge, to transfer the results to the business.

It is important to note that FUNDECYT has its own Office for Transfer of Investigation Results (OTRI).

Board of Directors

The Foundation has among its board of directors the University of Extremadura, as evidenced by the presence of the Rector of the University and two Vice-Chancellors, including Vice President for Research, as well as prominent members of the Regional Government and the two major regional financial institutions.

Human Resources

The Foundation currently has over 60 employees, 23 of which are directly involved in project management and R & D.

The current team has extensive experience in project management, experience of over ten years, detailed through an extensive list of many projects, which include more than 30 carried out successfully.

FUNDECYT´s Working Areas

The projects developed at FUNDECYT are carried out within the following areas:

• Knowledge society New economy, globalisation, innovation, knowledge management, etc. are concepts that have recently joined the reality of corporate governance and society in general. In fact, what lies behind these terms is the constant search for solutions for the management of organisations, aimed at value creation and sustained competitiveness in a changing environment. Topics: ICT, knowledge, talent and organisation management and new business models.

• Research, technological development and innovation Innovation is one of the essential skills of strategy and business practices for success in today's global marketplace. An economy grows largely by the development and exploitation of new investment opportunities. The technical innovations are precisely those to open up new forms of production, improving costs, offer new products and increased demand for them. Topics: Office for Transfer of Investigation Results (OTRI), transfer of technology, building technology-based business, management and financing of innovation, cooperation with Latin America.

• Free Software Equal opportunities for a fairer world. Software available to everyone, without barriers and without obstacles for growth and development. Topics: GNU/LinEx in Public Administration, GNU/LinEx in business, GNU/LinEx in society, and GNU/LinEx in research.

• Training Professionals’ training and qualification in social skills, techniques and policies. Profiles’ and curricula adaptation to the new economy’s demands, employability abroad and diverse roles. New scenarios and technologies that pose new learning methodologies geared to current organisational models and work performance. This is a cross-sectoral area to other areas of the foundation.

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Topics: Training needs, design of training activities, training proposals presentations, courses, seminars, conferences, and collaboration with other training centres.

Key People

Kety Cáceres Falcón

Education

• Bachelor of Economics from the University of Extremadura – 1996 (last year in the London University, UK).

Experience

• At the present, Coordinator of the European Affairs Area in FUNDECYT (Foundation for the Development of Science and Technology in Extremadura) for assistance to submission of proposals and European projects management within the organisation.

• Experience in preparation of proposals to European calls and project management in programmes such as Seventh Framework, CIP (ICT, Intelligent Energy), Territorial Cooperation (Interreg, POPTEC,…).

• Experience in R&D proposals submission and project management with SMEs from Extremadura at regional and national level (PID, Fondo Tecnológico and NEOTEC), in the themes of technological innovation and technology transfer.

• Technical assistance to enterprises and organisatons of Extremadura for submission, participation and monitoring in R&D programmes at regional, national and European level.

• Experience in the implementation, management and certification of R&D and innovation management systems by Spanish rule UNE 166002:2006.

• Speaker in workshops and conferences related to European Projects (Regional Capacities and European Innovation Projects, Extremadura, Spain, 2011), to funding opportunities for research groups (Spain – Portugal Transnational Session, Extremadura, Spain 2010), with R&D “Technical and financial documents for R&D projects” and “R&D and innovation aids for enterprises in Extremadura” (Extremadura, Spain, 2010), and with R&D European Programmes “Negotiation, management and execution of R&D European Programmes (Universidade de Beira Interior, Portugal, 2004).

B.3.1.2.1.10 Murcia - Spain

Located on the southern Mediterranean coast of the Iberian Peninsula, the region of Murcia has a total area of 11.314 km² and a population of 1,47m inhabitants

The regional Ministry of Healthcare is also a member of the cluster. With a budget in 2011 of 2.085m€, it employs about 19.000 professionals and manages a network of 11 hospitals, and 508 facilities of primary care. These resources are managed by the Servicio Murciano de Salud (SMS), directly reporting to the Ministry. Murcia was the first Spanish regions to implement their own Electronic Health Record solution (SELENE) after decentralisation in 2002. This purchase motivated Siemens Healthcare to locate their RTD facilities in a regional technology park, and explains the maturity of regional eHealth solutions. Private healthcare providers are grouped under the Unión Murciana de Hospitales, and some of its organisations also belong to the cluster.

The three regional Universities participate in the cluster both at institutional and research group levels. The most numerous are the ICT groups at the University of Murcia and at the Polytechnic University of Cartagena. 15 of these groups have recently created an academic

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network, Infinite Salud, to promote technical development and education in eHealth. One of them is leading the initiative ‘cloud incubator’ that trains graduate students in the development of apps for mobile devices; and another is specialised in Semantic Web Services applied to biomedical domains.

Other research members are the Technological Centre for Information Technology and Communications (CENTIC); the Scientific Park with its super-computer Ben-Arabi (the 4th most powerful in Spain); and IBIME, a research group specialised in semantic interoperability at the Polytechnic University of Valencia.

Key People

Asensio López, MD, Bioresearch strategic plan coordinator.

Directorate-General for Planning, Health and Pharmaceutical Management and Research. Regional Ministry of Health Región de Murcia. Vice President of the Spanish Society of Family and Community Medicine (semFYC).

Pilar Fernández, MD

Medical specialist in family medicine and public health. Actually working in methodology, ethic and quality investigating unit of health research in the FFIS coordinated with Regional Ministry of Health. Stage as a researcher at the Italian Cochrane center and OSTEBA (center of health technology assessment of Basque Country), with experience in systematic reviews.

B.3.1.2.1.11 Valencia - Spain

B.3.1.2.1.11.1 Prince Felipe Research Centre (CIPF)

Prince Felipe Research Centre (CIPF) is dedicated to multidisciplinary research in biomedicine and health in a global approach, with the aim of taking on new challenges in the field of basic and applied research and encouraging excellence in health-related disciplines.

CIPF’s financing comes mainly from the investment made by the Generalitat Valenciana (Valencian Regional Government) through its Ministry of Health.

CIPF’s mission includes: (i) generating innovative technologies and scientific results that improve citizen’s quality of life; (ii) being an international reference for research and innovation; and (iii) encouraging the creation and consolidation of a competitive business ecosystem in the health and social sectors.

The CIPF scientific project was structured around basic and applied research in biomedicine, with particular emphasis on the characterisation of molecular and cellular basis of diseases, identification of biomarkers and therapeutic targets, development of potential therapeutic agents, quantitative modelling of biology systems, development of biochemical and genetic methods for deciphering complex signalling networks, and development of new cell therapies.

However, since early 2012, CIPF is acting as platform for strategic projects carried out or boosted by the Valencian Ministry of Health, assuming the competences needed to deploy and integrate solutions for health and social demands. Therefore, CIPF is now coordinating all the key initiatives related to the use of ICT for improvement of quality of life towards an active and health ageing in the Valencia region, not only from the public perspective but also with the support of other related private stakeholders suchas SMEs and multinational companies.

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Key People

Óscar David Sánchez

Óscar David Sánchez holds a Telecommunications Engineering degree and a Master of Advanced Studies in Computer Science. He is appointed as Director of Strategic Projects and Valorisation at the Prince Felipe Research Center (CIPF), where he is charge of its Technology Transfer Office since 2009.In his current position, he manages the participation of the CIPF in strategic projects and alliances with the pharma, biotech and healthcare sectors, providing strategic advice on public and private funding opportunities for R&D, mainly international and European (Framework Programme, Innovative Medicines Initiative…) and coordinating the project management team. Moreover, he is responsible of the management of the CIPF’s intellectual property and know-how portfolio, including the valorisation and marketing of R&D results, and the negotiation of licence and research contracts with industrial partners.He shows an in-depth understanding of the R&D needs of SMEs, large companies and academia, and knowledge of the technology transfer processes and cooperative project management, to build fruitful partnerships in the health and biotech sectors.

B.3.1.2.1.11.2 Universitat Politècnica de València - UPVLC (Subcontractor)

The organisation: The Polytechnic University of Valencia (UPVLC) is a 45 year old institution with over 42.000 people, comprising 10 technical schools, 3 faculties and 2 higher polytechnic schools in three campuses, one in the city of Valencia and two external. With a strong international experience in ICT technologies applied to different domains, one of the main areas of work of the UPVLC is the application of ICT to the fields of health and social services in three primary action lines (eHealth, eInclusion, and Quality of Life). As a result of its long history of research and academic work in this line, the university has recently been awarded, in a joint initiative with the second university of the city and the CSIC (Spanish High Council for Scientific Research), recognition as Campus of International Excellence14 in the competitive call of 2010. The main focus of this joint initiative will be the generation of high quality scientific-technological production in health, ICT and sustainability.

UPVLC-ITACA is the major research group in eInclusion and eHealth of the UPVLC, and one of the most relevant ones at the national level, with a research record of more than 10 years. UPVLC-ITACA has extensive expertise in the application of ICT to the social and healthcare systems, in Ambient Intelligence (AmI) and in Ambient Assisted Living technologies (AAL). The team also has demonstrated experience in the management of complex cooperative international projects, as it has been project coordinator or technical coordinator of more than 10 European projects, WP leader on more than 20 occasions, and has been involved in the coordination other major events such as the organization of the phealth15 conference on 2008. The group is also active in standardisation and technology support bodies such as the International Telecommunications Union (ITU), the AALOA16 open association, and the platform eVIA17 (Spanish National technology Platform for Health, Well-being and Social Inclusion).

Relevant skills/experience/technologies: The research team of UPVLC has a wide experience in collaborative international projects focused in the eInclusion and eHealth domains since the 4th Framework Programme, having participated in more than 20

http://www.vlc-campus.com/ 15

http://www.phealth2008.com/Default.aspx?lang=en 16

http://aaloa.org/ 17

http://www.idi.aetic.es/evia/

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European projects in these fields, such as: HEALTHY-MARKET (IST-2001-33204), HEALTH-MATE (IST- 2000-26154), CONFIDENT (IST-2000-27600), IDEAS in e-Health (IST 2001- 34614), BABEL (TE2002), TEN-CARE (TEN-Telecom), ATTRACT (HC4002), EPICUROS (Leonardo), METABO (FP7-ICT), NUADU (ITEA2), eTUMOUR (FP6-ICT), HEALTHAGENTS (FP6-ICT), Help4Mood (FP7-ICT), PREVE (FP7-ICT), epSOS18 (CIP), universAAL (FP7-ICT), MANAGED OUTCOMES (FP7-HEALTH) and M-INCLUSION (FP7-ICT).

Key People

Dr Vicente Traver

Bachelor in Telecommunications Engineering (1998) and PhD (2004) from UPVLC. His activities in R&D and innovation are focused on telemedicine and e-health, having the responsibility of managing the Health & Wellbeing Technologies Group of the ITACA Institute. Senior Lecturer at UPVLC, since 2001, he is member of the Academic Committee of the Inter-university Master of Biomedical Engineering. He has participated in more than 20 EU and national funded research projects, and taken part in multiple research agreements with companies, dealing mostly with healthcare and social services making use of ICT. He has published more than 30 technical papers in national and international journals, and has participated in several seminars and conferences as invited speaker. His research is focused on the provision of home healthcare services through telematic media. Member of the Editorial Board of IET Networks, Expert for e-health Technological Prospective Study. Organiser and/or member of scientific commitees of different international congresses in the ehealth and wellbeing sector. Coordinator of the microcluster for HealthyLiving at the Valencia region.

Teresa Meneu

Degree in Telecommunications Engineering (2001- UPVLC), Master’s Degree in Business Administration, MBA (2004-Instituto Universitario de Posgrado), and is currently in the research phase of her PhD studies in Business Organisations at UPVLC, focusingon the impact of ICT in the reengineering the healthcare delivery chain and the empowerment of the effective adoption of ICT solutions by citizens & professionals including technological, social, organisational and economic considerations. She is responsible for the eHealth Strategic Programme of UPVLC-ITACA and Member of the Board of the Telecommunications Engineer Professional Association of the region of Valencia. Since 2001, she has actively participated in more than 10 national and international projects, working in all the project phases, being specialist in the definition of the project proposal, the acquisition of the user requirements, the definition of business models, the evaluation and assessment of the impact of the solution, and project management. She has been involved in several technical audits under the e-TEN programme, as an expert for project evaluation for health related business models and evaluation outcomes, and as peer reviewer in several European projects and in the Scientific Committee of several international congresses and conferences.

B.3.1.2.1.12 South Karelia Finland

B.3.1.2.1.12.1 South Karelia Social and Health Care District

Lappeenranta was founded in 1649 and has today a population of 70.500. The town covers an area of 1.347 km². Lappeenranta is the centre of the South Karelia region in south-east

As technical support to the Ministry of Health of Spain

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Finland. The economic development of the city has been favourable, especially in the service sector. Lappeenranta counts among the main training and education centres in Finland.

Lappeenranta City social and health services promote citizens’ independent and equal social life and good health by arranging good quality and versatile basic services for inhabitants. The services emphasise preventive care and also direct people to ask for special services.

In South Karelia, health and social services are closely integrated together. The South Karelia District of Social and Health Services (EKSOTE), established in 2009, combines primary and secondary healthcare, elderly care and social care in a totally new way. The goal of this new organisation is to ensure equal access to social and health care services to all citizens in the region, across the boundaries of municipalities. The effectiveness of service delivery will be enhanced thanks to better co-operation of different social and health care organisations. One of the goals in South Karelia is to emphasise the importance of preventive healthcare and to empower citizens to take more responsibility for their own health and well-being.

Municipality of Lappeenranta has represented both the public community and the end-users in several international development projects, such as ISISEMD (Intelligent System for Independent living and SElf-care of seniors with cognitive problems or Mild Dementia). In this project, a system enabling video calls using a mobile phone was utilised, enhancing the communication between home and care environments. Safety alarms and access control technologies were used to assist people with dementia to live in their homes. Additionally, intelligent medicine dosing systems and intelligent packaging methods were developed in South Karelia under this project.

Another project example is a national HyLa project (Quality to Nursing Care with New Welfare Technology), which was implemented in 2004-07. The objective of this project was to support older people and people with chronic diseases in continuing to live in their homes. A new operational model for nursing home care was developed in this project. The quality of care was improved by using new technology enabling near patient testing (e.g. CRP, Hb, INR, HbAlc, Kol, PLV, urine albumin/creatinine), remote ECG monitoring as well as a remote doctor solution using a web camera, broadband or videophone. As an outcome, more time could be dedicated to nursing work thanks to the improved co-operation between nursing home care personnel, clients and their relatives, as well as the third sector.

InnoELLI Senior programme was prepared and carried out by the South Finland Regional Alliance, which acts as the regional co-operative agency among seven counties including South Karelia. The programme was carried out during 2006-08, and was based on the regional strategy, aiming at supporting the development of new, innovative procedures for developing cost-effective and high-quality wellness services for the elderly. True progress in the social and health sectors can only be achieved by renewing the intertwined entities of technology and services. InnoELLI Senior’s strength has been its ability to focus on the development and implementation of service concepts and operation models. The programme also contributed to transferring know-how and best practices across the region.

Key People

Tuula Karhula, MD,PhD, is a MD from the University of Helsinki. She has specialised in general medicine, and has worked as a licensed doctor since 1991, first in Savitaipale Health Centre and Anttolanhovi Rehabilitation and Research Centre, after that in South Karelian Main Hospital and Lappeenranta Health Centre. Since 1999, Tuula has worked in Luumäki Health Centre, at last as the Head Doctor of Luumäki, Lemi and Taipalsaari until the 2010. Currently she is Acting Director of the South Karelia Social and Health Care District Elderly Services. She also teaches about academic work in Health Centres in the University of Helsinki where she still participates in scientific work. During the past three years, she has worked as part of the EU projects in the field of telemedicine and eHealth.

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Merja Tepponen,PhD, currently holdsthe position of Development Director at South Karelia Social and Health Care District. She has MSc at Kuopio University. Postgraduate studies in the field (PhD) social- and health care management from Kuopio University, doctoral thesis from Integration and quality of elderly home care. During the past six years she has worked on several development projects in the field of healthcare and telemedicine.

Katja Rääpysjärvi is a medical engineer, graduated from Oulu University in applied sciences in 2005. She has also studied medical technology at the University of Oulu. During the past four years, Katja has worked as a project manager and project engineer at South Karelia Social and Health Care District (Eksote) on European projects in the field of eHealth (ISISEMD, RENEWING HEALTH, SUSTAINS) and local e-health projects in the city of Lappeenranta and Eksote.

Mika Mitikka work as aWelfare Technology Coordinator at the South Karelia Social and Health District, Elderly Services. He graduated as a registered nurse, Saimaa University of Applied Sciences, 2007. Since then has been worked in different projects with all kinds of technical solutions and eHealth. He is now studying for Master’s Degree Programme (Welfare Technology) at Tampere’s University of Applied Sciences.

B.3.1.2.1.13 Central Greece

B.3.1.2.1.13.1 e-Trikala SA

e-trikala SA is an SME, formed within the Municipality of Trikala. The Municipality is the basic stakeholder, owning 99%, while the remaining 1% is owned by the local Chambers of Commerce. By creating infrastructure and by providing services, e-Trikala continuously aims to develop ICT based applications, oriented to the improvement of all citizens’ everyday life, in a medium sized city, delivering new services related to the local way of life.

As we are moving through the 21st century, and as we deploy technology and its advantages, every citizen has the opportunity to enjoy useful applications for their everyday transactions, long distance services as well as local and tourist information services. The e-Trikala team operates under the new broadband reality, while it creates and provides digital projects, integrated broadband applications and e-services for citizens.

e-Trikala has participated in the following European Projects; i) INTERREG IVC Digital Cities (http://www.digital-cities.eu/). ii) PSP-ICT Pilot B 2008 Project ISISEMD “Intelligent System for independent living and

self-care of seniors with cognitive problems or mild dementia” (http://www.isisemd.eu/).

iii) PSP-ICT Pilot B 2009 Project INDEPENDENT “ICT Enabled Service Integration for Independent Living” (http://www.independent-project.eu/index.php).

iv) PSP-ICT Pilot A 2009 Project RENEWING HEALTH “Regions of Europe Working Together for HEALTH” (http://www.renewinghealth.eu/).

v) CIP Pilot SUSTAINS “Support USers To Access INformation and Services”. vi) AAL 2 2009 Project ELDER-SPACES “Managing Older People Social Relationships

for better Communication, Activation and Interaction” (http://www.elderspaces.eu/). vii) CIP Thematic Network MOMENTUM, viii) CIP Thematic Network NET-EUCEN.

The company’s main areas of expertise are19:

• e-transportation;

19 www.e-trikala.gr

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• e-education;

• e-health;

• e-government & e-democracy;

• geographical information systems;

• networks (Wi-Fi, fibre optic, Wi-Max pilot application & operation);

• event planning & organising (exhibitions, conferences, galas).

Previous relevant experience and roles.

The enterprise is quite experienced in the field of e-Health, as it participates in a number of e-Health EU-funded projects, either alone or in cooperation with the Municipality of Trikala.

We briefly present some of these projects and their characteristics:

• CIP-ICT-PSP-2008-2 / ISISEMD / 238914 (http://www.isisemd.eu/): equipment sensors, GPS devices, touch screens, cameras, etc. for smart homes installed in the homes of 10 elderly users with mild dementia.

• CIP-ICT PSP-2009-3 / INDEPENDENT / 250521 (http://www.independent-project.eu/home/): equipment for conducting videoconferencing tele-counsels between elderly users with dementia and psychologists from home or from special social centres, Electronic Health Record integration, a total of 150 users.

• ICT PSP 2009 3 / RENEWING HEALTH / 250487 (http://www.renewinghealth.eu/): equipment for patients with chronic diseases COPD, CVD and diabetes, to conduct home bio-medical measurements, a total of 510 users.

• CIP-ICT-PSP-2011-5 / SUSTAINS / 297206: Electronic Health record integration.

• AAL2 / ELDER-SPACES / aal-2009-2-116: introducing users aged over 55 to social networking.

The telehealth platform in the Municipality of Trikala has already been up and running for the last decade. We participate in a number of e-Health networks (e.g. EHTEL) and other e-Health projects (e.g. Thematic Network - CIP-ICT-PSP-TN (CIP-ICT-PSP-2011-5) / MOMENTUM / 297320).

Furthermore, e-Trikala SA has been officially granted a license to handle sensitive personal medical data by the Hellenic Data Protection Authority.

Key People

Dr George Dafoulas MD

George Dafoulas received his Medical Degree from Aristotle University of Thessaloniki, Greece. He has an extensive working and research experience profile in the field of telehealth and telecare, as well as in the management of international projects. Since 2007 he is the e-health services administrator of the Telehealth Project of the Municipality of Trikala, and a trainer on the subject of telemedicine in the 2008 Training Programme for the Greek Emergency Medical Services (EMS) Academy. He has participated in studies in the field of e-health, including the study of the Prefecture of Thessaly, for the establishment of EMR for the ROM communities, and the study for the establishment of a tele-medicine service for the remote rural health centres in the Prefecture of Trikala. In 2008 he was a Research Assistant of the Project "e-Hrofilos: a strategy for improvement of quality and reliability of Telecardiology" - Biomedical Research Foundation, Academy of Athens. Since March 2009 he has been a project team member of the ISISEMD (Intelligent System for independent living and self-care of seniors with cognitive problems or mild dementia) – PSP-ICT 2008 Pilot B project.

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He has participated in training courses on Health Management by the University of Macedonia-Greece, Faculty of Management, and he was a member of the 2002-2003 Supervising Council of IFMSA (NGO), working on the coordination of health projects worldwide in cooperation with WHO, UN and EU.

B.3.1.2.1.14 Attica

B.3.1.2.1.14.1 Municipality of Palaio Faliro - Greece

The Municipality of Palaio Faliro is one of the most historic municipalities in Athens. It is situated in the southern sector of the Region of Attica and has a population of around 100.000. It is a densely populated urban centre and relies mainly on tourism and recreational activities for development, since it has a well-developed seafront. Together with the neighbouring Municipalities of Alimos and Agios Dimitrios, a population of about 250.000 citizens is covered.

Since 2010, a new legislative framework (KALLIKRATIS) sets out the boundaries for health and social services at regional and municipality level. Primary care, public health, prevention, health promotion, health education and social services will gradually be planned, provided, financed and monitored by Municipalities, having as a start point the beginning of 2013.

Due to serious fiscal constraints, municipalities face the dilemma of either cutting back services or excluding certain categories of citizens from social and healthcare services. This is, however, unacceptable according to the philosophy of local authorities; as a result, a strategic decision has been made to support the introduction of innovative technologies (m-health and p–health) into everyday healthcare and social care delivery. Organisational changes aiming to integrate care to cut down costs and improve continuity of care are also put in place. The strategic inclusion of ICT services in the newly introduced integrated care services result in care provision schemes that follow the current state of the art citizen-centred health and social care.

In accordance with the above, in November 2011 a pilot project commenced where early diagnosis services and health monitoring indicators in the community are provided through telecare to all citizens in the municipality.

The model relies on multidisciplinary teams of community healthcare professionals recording basic health indicators in the PHR using mobile health devices. The pathologists or GP, situated in the municipality care centre, overview the data; according to the results, a decision is made for referral, monitoring of citizens in local Social Care Units (KAPI) or monitoring at home. The telehealth model is also used to educate patients and healthcare professionals in health promotion and health prevention activities.

An association with the Municipalities of Ag. Dimitrios and Alimos was created in late December 2011 with a common goal of enhancing the quality and prolonging the life of citizens in a very stringent financial environment. By the end of March 2012, ESF funding was allocated from the Ministry of Health to the association of Municipalities in order to implement a programme including prevention, health promotion and health education activities for diabetes in the local population, supported by the use of e-health services.

The above mentioned programme is expected to start by the end of September 2012. It will involve 7 doctors, 13 nurses / case managers, 1 psychologist, 2 dieticians, 1 physical education expert, 1 health services manager. More than 10.000 citizens are expected to benefit from these activities.

The Association of Municipalities aspires to become a reliable partner within national and international settings for future actions in m-health and p-health; it regards ICT as the necessary tool to improve the quality and prolong the life of Greek citizens.

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Key People

Ioannis Fostiropoulos – Deputy Mayor

Ioannis Fostiropoulos is the Deputy Mayor of Palaio Faliro, responsible for Education and Social Solidarity issues.

He graduated from the Technical University of Athens with a BSc in Health Services Management, but as a professional he owns and manages an SME specialising in the textiles industry.

Since 1996, Ioannis has been actively involved in policy making at the local level. He has held many significant political positions within the Municipality, such as president of the local public sports centre, General Secretary to the Municipality Council etc.

Ioannis is politically responsible for the pilot telemedicine project targeting healthy adults for early diagnosis and monitoring of basic health indicators in the community that takes place in Palaio Faliro. Starting September 2010 and for 15 months, he supervised the ESF funded telemedicine project targeting diabetics in three neighbouring municipalities of Athens, i.e. Palaio Faliro, Alimos and Agios Dimitrios, covering a population of 250.000 people.

Ioannis in cooperation with Anastasios plans the Strategy for Health and Social Solidarity in the Municipality of Palaio Faliro; he regards telemedicine as an invaluable tool in order to achieve cost-effectiveness, efficiency, quality of care and satisfaction within community settings.

Eleni Papadopoulou – Head of Health and Social Services

Eleni Papadopoulou is a qualified nurse and a graduate of the University of Athens School of Nursing. She is specialised in primary care nursing and currently she is the head of the Health and Social Solidarity Department at the Municipality of Palaio Faliro.

Mrs Papadopoulou supervises health and social care professionals such as social workers, doctors, psychologists and nurses, and coordinates the delivery of integrated care services to all citizens irrespective of age, sex or socio-economic status.

Mrs Papadopoulou is scientifically responsible for the pilot telemedicine project targeting healthy adults for early diagnosis and monitoring of basic health indicators in the community that takes place in Palaio Faliro; she will be scientifically responsible for the ESF funded telemedicine project targeting diabetics in three neighbouring municipalities of Athens, i.e. Palaio Faliro, Alimos and Agios Dimitrios, covering a population of 250.000 people.

Anastasios Rentoumis – Advisor

Anastasios Rentoumis is an experienced freelance consultant specialising in Health Policy and Health Services Management.

He graduated from the University of Coventry (UK) with a BSc in Biochemistry. His postgraduate qualifications include an MSc in Medical Biochemistry from the University of Brunel (UK) and an MSc in Health Services Management from the Royal School of Hygiene and Tropical Medicine and the London School of Economics (UK).

Anastasios has an outstanding professional track record, with 13 years of experience in the public and private healthcare sector. Between 1999 and 2003, Anastasios worked in healthcare consulting with many Greek consulting firms such as ZeinCRO, Planet, Ernst & Young and EEO group. He was an advisor to the Ministry of Health in Greece (2004) and for five years (2005 – 2010) was appointed as a Managing Director and CEO at the State Mental Health Hospital of Chania, Crete, where he was responsible for very important projects regarding deinstitutionalisation and social inclusion of mental healthcare users. In 2008, he

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implemented a pilot tele-psychiatry project for the Prefecture of Chania, connecting the hospital with three rural primary health centres and one mental health centre.

Since 2010 he has been working as an independent consultant in Romania for two ESF funded projects, PROACTIVE (From Marginal to Inclusive( and INTEGRAT (Resources for women and Roma socially excluded groups) with CATALACTICA Association and BOLT International Consulting respectively. He is also a team member of the Greek Consortium CECL (DIADIKASIA SA), offering technical assistance to the Greek Ministry of Health towards implementation of the National Mental Health Reform Plan, PSYCHARGOS.

From October 2010 onwards, Anastasios is a Business Development Manager for VIDAVO SA, a telemedicine services firm in Greece.

In addition to the above, Anastasios as of October 2011 is an advisor to the Mayor’s office at the Municipality of Palaio Faliro, in Athens, Greece, where he is managing a pilot telemedicine project targeting healthy adults for early diagnosis and monitoring of basic health indicators in the community. Starting September 2010 and for 15 months, he managed an ESF funded telemedicine project targeting diabetics in three neighbouring municipalities of Athens, i.e. Palaio Faliro, Alimos and Agios Dimitrios, covering a population of 250.000 people.

B.3.1.2.1.14.2 The Municipality of Alimos, Greece

The Municipality of Alimos is situated in the southern sector of the Region of Attica and has a population of around 50,000. It is a densely populated urban centre and relies mainly on tourism and recreational activities for development, since it has a well-developed seafront. Together with the neighbouring Municipalities of Alimos and Palaio Faliro, a population of about 250.000 citizens is covered.

Key people

Andreas Kondylis - Deputy Mayor

Andreas Kondylis is responsible for Administration and Social issues. He graduated from the University of Athens with a BSc in Law, and also holds an MSc in Civil Law from the University of Athens and beside his political activities, he is a Lawyer.

Since 2002, Andreas Kondylis has been actively involved in policy making at the local level with a specific responsibility for:

• Development of Social Services

• Reorganisation of Administration Services

Andreas Kondylis, in cooperation with the Mayor, plans the Strategy for Health and Social Solidarity Projects in the Municipality of Alimos; he regards telemedicine as an invaluable tool in order to achieve cost-effectiveness, efficiency, quality of care and satisfaction within community settings.

B.3.1.2.1.14.3 Municipality of Agios Dimitrios, Attica – Greece

The Municipality of Agios Dimitrios is situated in the southern eastern sector of the Region of Attica and has a permanent population of around 70.970, though it is estimated that the real population of the city is more than 85.000.

Agios Dimitrios is a densely populated urban centre which relies mainly on commerce and local entrepreneurship.

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Key people

Christos Belias - Scientific Associate to the Mayor

Christos Belias is a Chemical Engineer by academic training. He is Scientific Associate of the University of Athens and of the Technical Educational Institute of Chalkida.

He is also Certified Trainer by the National Organisation for Accreditation of Qualifications & Vocational Guidance and Project Certified Professional by Computing Technology Industry Association (CompTIA) and Microsoft Corporation.

During his career, he has been active in Project Management and Quality Management Systems, Environmental Research, Energy Savings & Planning and Continuous Vocational Training.

He has published scientific papers in several international journals and has been invited speaker in numerous conferences.

B.3.1.2.1.14.4 Vidavo - Greece

VIDAVO is a health telematics company, highly specialised in the eHealth domain. The company provides telematics products and services (mainly focusing on the healthcare sector), envisaging the elevation of the quality of life of all citizens and is particularly involved in standardisation/ strategy issues. The company has experience in the implementation of R&D projects and in the development of sound business cases concerning the provision of novel services, based on ICT advances and focused research outcomes. Its human capital includes specialised professionals in telemedicine applications implementation, business development and commercialisation of innovative products, assessment of innovative personalised health (pHealth) systems with emphasis on chronic disease management

implementation. The company maintains a consultancy unit that focuses on eHealth business models assessment and feasibility reviews, as well as strategic and planning studies for large scale adoption and implementation of eHealth installations. VIDAVO has participated in several policy and strategy working groups, national and European and is an active member of the eHealth Forum of the Greek Ministry of Health, member of the EFMI HealthCards Group and member of the CEN eHealth Standardisation Focus Group. In addition, it has participated in several national and pan-European research projects. To this end, it brings forward experience in project management and most importantly experience in telemedicine implementations, in terms of business potential and user satisfaction and acceptance, with particular expertise on chronic disease management.

Key People

Eleftheria Vellidou

Eleftheria Vellidou is an Electrical Engineer (NTUA, GR), and holds an MSc in Digital Signal Processing (UMIST, UK) and an MSc in Management of Business Innovation and Technology (AIT, GR). She spent more than 15 years in the telecom industry and her professional experience ranges from product research and development to management of large scale telecom projects implementation. She has participated in numerous European and National research projects mainly of the e-health and biotechnology domains. Her current research interests include medical informatics, telemedicine, vital signal processing and diagnostic support systems. She leads the company’s European collaboration activities. She is a member of the Technical Chamber of Greece.

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Athanasia Karanasiou

Athanasia Karanasiou received her diploma in Information and Communication Sciences, from the Technological Educational Institute of Serres. The subject of her thesis was the Development of a web-based application of an Electronic Health Record (EHR), which enabled the systematic collection of electronic health information and vital signs of medical wireless devices about individual patients.

She is currently working for Vidavo where she is in charge of the IT department; she plans and coordinates all activities regarding the development, customization, installation and technical support of medical applications/devices. She has participated in several ehealth projects both national and European, as the person in charge of the development, installation and technical support. She also publishes in relevant conferences and journals.

Dr. Pantelis Angelidis

Dr. Pantelis Angelidis received his diploma in Electrical Engineering and his Ph.D. in Telecommunications Engineering from the School of Electrical Engineering, Aristotle University of Thessaloniki in 1989 and 1993 respectively. In June 2002 he founded VIDAVO. He has worked as a technology expert in the area of Telecommunications for the past 15 years. He has served as a project manager in more than thirty international projects. He has published over forty papers in international journals. He is a member of the permanent consulting committee of the Technical Chamber of Greece on telecommunications, a certified consultant on telecommunications of the Technical Chamber of Greece (Central Macedonia chapter and of the Greek Courts (Thessaloniki), and a member of the CEN TC224/WG6 technical committee.

Panagiotis C. Stafylas MD, MSc, PhDc - Cardiologist - Clinical/HTA Consultant for e-Health Services

Dr. Stafylas is Cardiologist and Clinical/HTA Consultant for eHealth services. After his training in Internal Medicine and Cardiology, he specialized in hypertension. He obtained his Master of Science degree (MSc) in Management of Health Services and now he works on his PhD Thesis. He has been actively involved as primary or associate investigator in more than 20 research projects with special interest in eHealth/Telemonitoring, Hypertension and Pharmacoeconomics/HTA. He has more than 20 publications, 20 lectures and 100 presentations in Greek and international medical journals and conferences. He has received 3 scientific awards and he is a reviewer in 6 international medical journals.

From 2007 he has been a Clinical/HTA Consultant in Telecardiology and e-Health research projects and services, designing clinical protocols for eHealth services, managing telemonitoring services, performing cost-effectiveness analyses in this field etc. He has been the scientific coordinator of the first municipal telecare service in Greece and currently he is the Scientific Co-Ordinator of the “RENEWING HEALTH” (REgioNs of Europe WorkINg toGether for HEALTH, http://www.renewinghealth.eu/) project as part of the HIM SA’s team supporting the Co-ordinating partner.

B.3.1.2.1.15 Northwestern Croatia

The region includes 7 out of 21 Croatian counties at the utmost western part of the country namely: Međimurje, Varaždin, Krapina-Zagorje, Zagrebačka, Karlovac, Primorje-Gorani and Istria. The region is relatively more involved in EU pre-accessional projects and initiatives, particularly in cross-border health care and patient’s rights projects, mostly due to their position at the border with the neighbouring Slovenia and good professional relationships and partnerships with the adjoining region.

Every county has its general hospital, public health institute and primary health care network. The County of Međimurje with 126.500 inhabitants has around 1.000 health workers out of

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which around 250 doctors and 650 nurses. Varaždin County with 185.000 inhabitants has around 2.200 health workers out of which 500 doctors and 1.500 nurses. Krapina-Zagorje County with 142.500 inhabitants has around 1.600 health workers out of which 400 doctors and 1.100 nurses. Zagrebačka County with 310.000 inhabitants has around 1.550 health workers out of which 350 doctors and 900 nurses, but for tertiary health care completely oriented to the adjoining capital, the city of Zagreb, which is separated administrative unit, but with greatest concentration of sophisticated tertiary health services accessible to patients from all around the country. Primorje-Gorani County with 305.500 inhabitants has around 5.100 health workers out of which 1.450 doctors and 3.400 nurses. This county has a clinical centre as well covering around 20% of patients from surrounding counties. Istra County with 206.000 inhabitants has around 2.200 health workers out of which 300 doctors and 550 nurses.

B.3.1.2.1.15.1 Croatian National Institute of Public Health (it will participate as an informal observer)

Croatian National Institute of Public Health (HZJZ) is a governmental, central public health institution that through coordinating the network of county institutes of public health covers all major public health activities including: epidemiology of infectious diseases and chronic diseases, public health with health statistics, health education, promotion and disease prevention, health ecology, microbiology, school health, mental health and addiction prevention. Regarding the eHealth, HZJZ, according to the Health Care Act, plans, recommends and implements processes on the establishment, development and management of the national central health information system.

HZJZ is an associated partner and WP4 leader in a Joint Action 2nd Community Programmes project PARENT (Cross-Borders Patient Registries Initiative) that officially started on 2nd May 2012. Project has a pilot solution of Register of all Registries as an e-Health component that will provide an overview of existing national patient registries with the emphasis on methodology, availability, comparability (time and space), ownership and potential contexts of use of the data.

HZJZ in collaboration with the Ministry of Health and National Insurance Fund is managing Procurement of Geographical Information Software and Related Services project (CHBIS) co-financed by WB as a part of DEMSIPP-B1-G-17: Development of Emergency Medical Services and Investment Planning Projects. CHBIS should assist Croatian authorities in health care planning by integrating available data sources, enabling advanced data analysis and geographic presentation of information. The information system is to be continuously used to assist in decision making related to planning capacities, investments and human resources development in primary health care, acute and special hospitals, nursing homes, procurement of medical services and procurement of high cost health technologies; as well as in better understanding the health of the Croatian population through analysis of mortality and morbidity indicators on local, regional and national levels. In addition, it should have a limited online component accessible to the public for research and information purposes.

B.3.1.2.1.15.2 Croatian Society for Pharmacoeconomics and Health Economics (http://www.farmakoekonomika.hr/)

CSPHE is a civil non government association, which was an active participant of Croatian health reform, introducing pharmacoeconomics and principles of health economics to Croatian health care regulatory. The society promotes innovative approach based on evidence and science in many areas of its work including health economics, health care digitalization, public health projects based on equity and availability. More than 120 members, doctors, pharmacists, sociologists, economists and researchers from correlated

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areas work in teams on projects based in this region (Croatia, Bosnia and Herzegovina, Serbia, Macedonia and Slovenia).

The aim of the Society is promoting pharmacoeconomics and health economics in this region in processes of decision making in health care policies, to enable equal and effective health care for societies.

CSPHE, leading institution for performing pharmacoeconomic and health economics studies (cost benefit, budget impact, cost of illness), tests ist own models and adapts already created ones. Moreover, the CSPHE performs several public health monitoring of compliance and indirect costs trends for patients with chronic diseases.

Our cooperating institutions are: Ministry of health Croatia, Ministry of Health BiH, Corvinus HTA Centre Budapest, London School of Economics, clinical hospitals and public health institutions from region.

Key People

Ranko Stevanovic

MD, PhD, Research Associate, President of Croatian Society for Pharmacoeconomics and Health Economics (CSPHE), Coordinator and lecturer on Telemedicine PhD Education course in Biomedicine and Health Sciences Zagreb School of Medicine http://phd.mef.hr/predmeti.asp?jezik=en&id=M10, Member of Croatian Telemedicine Society, Member of Telemedicine Expert Group and Member of Telemedicine Project Management Unit of Croatian Ministry of Health from 1998. Author of numerous books, Book chapters, Textbooks and scripts, Journal articles in CC journals and other paper in different publications: http://bib.irb.hr/lista-radova?autor=191232&lang=EN.

B.3.1.2.1.16 Regione Veneto - Italy

Regione Veneto is situated in the North-Eastern part of Italy and is divided into seven provinces. It covers an area of 18.391 km² and has about 4,9 million inhabitants that live in 581 municipalities. About 72% of the population lives in small towns with less than 30.000 inhabitants and the average population density is 267 per km². The demographic component is characterized by a strong ageing phenomenon with an increase of elderly people living alone. In 2009, the 20% of Veneto population was over 65 years old, while that component considered “frail” and with a major risk of chronic diseases is usually over 75 years old, that covers the 9,4% of Veneto population.

The Veneto Region’s priorities, as the public authority governing health policies and decisions, in the period 2012-2014– as settled in the draft of the Regional Plan for Health and Social Services 2012-2014, that is currently under discussion for approval by the Regional Council – can be defined as:

• Integrated management of the patient and continuity of care;

• Organizational redefining of hospital supply, according to qualitative and quantitative criteria of homogeneity;

• Redefining of expertise and implementation of synergy between hospital and territory;

• development of policies for Professional integration and interventions among the different sectors with sustainable and qualified organizational models;

• Investment on clinical and organizational appropriateness, with active and responsible involvement of professionals and citizens;

• Need to ensure the economic and financial government in order to guaranteed the balanced budget to the Regional social and health system

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In particular from an organizational perspective:

• Strengthen the Regional Administration’s decision processes on long-, medium- and short-term investments for innovation in ICT, by means of systematic adoption of HTA procedures.

• Set up a reference structure about ICT standards for eHealth applications at regional level.

• Build up a knowledge management infrastructure on ICT for Health at regional level.

• Boost the existing capabilities of Veneto’s healthcare organization in designing and deploying successful eHealth initiatives by fostering the aggregation of local capabilities into a single regional Centre of Excellence for ICT for Health.

And from a technical perspective:

• Enable the interoperability of Telemedicine services at regional level.

• Build up standardised Electronic Health Record systems at local level in view of the realization of a single digital Patient Health Folder system at regional level.

• Develop eHealth-based Disease Management models for the treatment of outpatients.

• Foster the interoperability of the above systems/services at National level.

• Foster the interoperability of the above systems/services at European level.

With reference to the health and social care system, the Veneto Regional Government provides health and social services to the resident population through the Regional Health System, which is composed by 21 Local Health Authorities (LHAs) and 2 Hospital Trusts (HTs).

B.3.1.2.1.16.1 Local Health Authority nr. 2 of Feltre

The Local Health Authority nr. 2 of Feltre covers an area of approximately 90.000 inhabitants that live in 18 municipalities and it has has an area of 934.47 km². The whole territory is mountainous and it is characterized by difficult road and transportation network. It has one hospital, one rehabilitation centre and a structure dedicated to primary health care, elderly care and social care called “Social and Health District”. Furthermore the Local Health Authority nr.2 coordinates the activities of 15 nursing and care homes (both public and private), with a total of over 1000 residents.

One of the main features of Veneto Region Health Model is the strong integration of health and social care guaranteed through a close cooperation between municipalities and the Local Health Authority.

Due to this complex framework it has been necessary to develop and to implement an information management system in order to deliver a complex set of cares called Integrated In-home Care (ADI). The ADI involves health and social care for chronic disease patients, elderly people and weaker and disadvantaged categories. At an upper level, the ADI data converge to the SISTE, a data warehouse that collect all the data coming from all the different department of the district, such as the mental illness service, the social work services, the childhood, adolescent and family counselling service, the GPs service and the drug addictions support service.

In addition to this, Veneto Region together with the LHAs and the Municipalities has implemented a 24/7 Telemonitoring and Telecare integrated service. At anytime, in case of parameters over of range or call from the user, the operation center verify the signal and provide immediately to contact the competent center, both for medical, nursing, domestic or social assistance.

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All these services are governed by the local plan of action, that is draft every five years by a joint commission of representatives from the municipalities and the board of directors of the LHA, following the Regional Government guidelines that set the general objectves of action.

In this care system, a crucial role is played by the partnership between the LHA and over 50 voluntary and charity associations that work actively on the territory.

The Local Health Authority nr.2 has experience in European projects. Amongst the other projects, LHA nr. 2 has been lead partner of several INTERREG ITALIA – AUSTRIA funded projects and it is currently participating to RENEWINGH HEALTH, an ICT-PSP CIP Pilot A project co-funded by the DG INFSO.

Key People

Alessandro Pigatto, MD

Dr. Pigatto, L.Psy., is the Director of Social Services of the Local Health Authority nr. 2 of Feltre since 2008. He is also the Coordinator of the Social Services Directors of the Veneto Region’s LHAs and member of the Steering Committee of ELISAN, the European and Local Inclusion and Social Action Network.

Dr. Pigatto is also specialized in clinical neuropsychology and in emergency psychology. From 1999 Dr. Pigatto has been Director of the Department for Drug Addictions and then, from 2001 to 2008 Director for Social Service at LHA nr.3 of Bassano.

Domenico Scibetta, M.D

Dr. Domenico Scibetta is the Medical Director of the Local Health Authority nr. 2 of Feltre since 2008. Dr. Scibetta holds a degree in Medicine and Surgery (1982) and he specialised in General Surgery, Odontostomatology and Community Medicine. From 2005 and 2008 he has been Director of the Health and Social Care District of the same LHA nr. 2. previously he has been responsible for the “Epidemiologic evaluation and quality system implementation” unit at the LHA nr 12 of Venice. Dr. Scibetta has also experience in European projects.

B.3.1.2.1.17 Noord-Brabant - The Netherlands

Many small scale eHealth-projects have been succesfully realized in Noord-Brabant over the last years. In 2011 the region is proclaimed “the most intelligent community on health in the world” (ICF). Whereas the Netherlands plays a pioneer role in the development of telehealth and telecare, eHealth is only implemented sporadically in regular care yet. To overcome this discrepancy, the Netherlands is motivated to take part in large scale pilots.

Since the Dutch healthcare system is not centrally organised by the government (top-down), there is no national health care network. This has resulted in the development of different systems, and lack of integration and interoperability. In close collaboration with PoZoB, a chronic care ICT system for primary care is developed to monitor chronic disease patients in Noord-Brabant. Since 2011, Care2U has been implemented in several other primary care organisations in the South of the Netherlands. The goal of Care2U is to implement the system in other regions of the Netherlands as well and to realize further expansion and further integration opportunities, resulting in better care.

B.3.1.2.1.17.1 Stichting Smart Homes

Smart Homes is an independent expert centre for smart houses and smart living. Smart Homes was established in 1998. Smart Homes has extensive knowledge in the area of smart houses, smart living, home networking and its use by residents. Its founder has particular experience of smart houses in the care sector, from 1992 up to the present time. From the beginning up to the present time, a lot of experience has been built up around acceptance by

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older people, problems with user system interaction, marketing of assistive technology, maintenance problems, cost calculations, ROI for investors, and business models. The centre carries out applied research projects in its demonstration house, the Smartest House of the Netherlands. This home was built by Smart Homes in 2001 and completely renewed in 2009. It has state of the art technology not just in home automation, home networking and various applications, but also in the use of sustainable energy and energy saving, as well as flexibility and accessibility for all. This house permanently serves as a tool for testing and trying out of new products and services.

Smart Homes carries out dissemination activities by continuously developing courses, seminars, congresses and exhibitions. It is also publisher of a bi-monthly magazine on smart living and smart home technology for various professionals (housing associations, installers, etc.). In 2000, consulting housing associations, project developers and building companies about how to implement smart houses became part of its activities. Activities are funded by projects, subsidies from regional and national government, grants and partnerships with industry. Via the partnerships with approximately 150 individual companies, belonging to the Smart Homes Partner Community, Smart Homes has close links with industry.

Smart Homes has expertise in the area of user needs analyses and requirements, system integration of different technologies, testing, validation, evaluation, dissemination and exploitation activities. Smart Homes can be considered as an intermediary organisation in the difficult market of technology for the ageing, bridging the worlds of technology development and those of end-users and service/care providers. Competences: User centred design, use case development, training of stakeholders, exploitation plans within the care market, system integration in demo environment and home environment, field trials specification, and evaluation of system with relevant stakeholders.

Smart Homes has been involved in two IP projects on ambient assisted living called NETCARITY and SOPRANO (FP6) and is still working on one IP project called CompanionAble (FP7). In addition, Smart Homes is involved in projects funded under the Competitiveness and Innovation Framework Programme (CIP) named CommonWell, Independent and Caalyx-MV. Finally, Smart Homes is involved in one STREP (Specific Targeted Research Projects) project named MobiServ, one KA3 Multilateral project called Leage and one Coordination Actions (CA) project called CARDIAC. These projects deal with context aware software based services, built around many different sensors and smart technology in the house.

Key People

Ilse Bierhoff (M.Sc.)

Ilse Bierhoff is a research project leader at Smart Homes. She studied at Eindhoven University of Technology at the faculty of Technical Innovation Science, department of Human Computer Interaction. Her expertise is applying knowledge from social sciences on problems related to the introduction of new technologies. After acquiring the MSc, she was part of the research group on Human Computer Interaction at the Eindhoven University of Technology for one year.

In 2002 she joined the team of Smart Homes. Her main activities are in the field of the use of smart home technology in the care and cure sector. Research activities can be divided into three main areas. The first area is the implementation of the user centred design approach with a focus on the gathering of user requirements with innovative methods that allow an equal and creative interaction between user and experts. This design approach has been applied in the European funded (FP6) research project SOPRANO and NETCARITY. Working in these project resulted in a deeper understanding of the role that users can play in the design process and the importance of involving a wide variety of stakeholders.

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The second area is on a more practical level, and focuses on giving guidance to the process of actually installing smart home technology and the evaluation of those projects with all the stakeholders. This work has been carried out at both national and international level. At a national level, the work is done in close cooperation with care organisations and housing associations and consisted of guiding the process of using smart home technology from the conceptual phase up to the evaluation phase. Within international research project, the focus was on leading the pilot and demonstration phase and taking responsibility for the evaluation reports.

The third area focuses on the development of educational material on ambient assisted living for multidisciplinary teams of students. Work consisted of giving lectures, performing market analysis for new studies, and the development of educational material for minors and majors in cooperation with teachers.

Ilse Bierhoff has been author and co-author of publications in the area of ambient assisted living in books and journals and has presented several papers and workshops at international and national conferences.

Wil Rijnen

Currently, Wil Rijnen works as a project leader for Smart Homes, the Dutch expert centre for house automation and smart living. Since 2010 he is involved in various European research projects in the field of Ambient Assisted Living, eHealth and Integrated Care, funded under the European Programmes AAL, CIP and FP6. Collaborating in these projects broadened his understanding of Europe’s care delivery, his expertise in care-related user research, and his insight into various user groups, including vulnerable elderly, COPDpatients, chronic heart failure patients, etc.

Previously he obtained a post-Master degree in User-System Interaction (2009). During this two years post-graduate training, Wil was employed at the Technical University of Eindhoven, and at Philips Research, performing user research, user-centred design, and usability evaluations. Whereas many different technologies were investigated and applied, a wide variety of user groups were approached and studied, ranging from website technology and graphical user interfaces for vulnerable elderly, to mobile applications for nomadic workers, and tangible interfaces to support toddlers.

Graduated as a Master in Product Development in Belgium, he has the expertise of solving problems by developing innovative products and solutions, based on a firm ground of technical, economical and human aspects. (2007).

B.3.1.2.1.17.2 TweeSteden Ziekenhuis (candidate organisation to become the second partner for Noord Brabant – still under validation by REA)

The TweeSteden Hospital is a mid-size (2.000 employee, 135 specialists, 576 beds) general, regional hospital in Tilburg, the Netherlands. The hospital offers a wide range of high-quality care in a patient-centered way. The hospitals mission is to deliver care in an extra-ordinary good manner, just around the corner. For certain specialties, TweeSteden hospital is a market leader, and fulfils a regionwide function. The hospital is used to take the initiative for regional collaborative projects. Care is organised in well-shaped care pathways, efficient and clear for the patient.

The hospital is affiliated with the academic hospital St. Radboud in Nijmegen, the Netherlands. TweeSteden is involved in education for multiple specialties, such as cardiology, neurology, psychiatry, and many more.

One of the spearheads of the hospital is taking better care of patients with cardiovascular diseases. Due to the greying society and an unhealthy lifestyle, the number of patients with cardiac problems will increase in the coming decades. By working in interdisciplinary teams,

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the TweeSteden hospital focuses on prevention, cure and care. In addition, a second spearhead is the care for older people. In this context, the hospital is involved in research with vulnerable elderly.

Key People

Jos Widdershoven

Jos Widdershoven is a cardiologist and a Professor of Cardiology. He studied medical science in Amsterdam (1987). He has worked as a medical doctor in Great Britain. Since 1988 he started his fellowship cardiology, he completed his fellowship and PhD dissertation at University Hospital Maastricht.

Since 1998 he has been working as a cardiologist at the TweeSteden Hospital in Tilburg. Since 2004 he also works as a teacher of cardiology-fellows in collaboration with the Catharina hospital in Eindhoven.

Jos Widdershoven is involved in scientific research in collaboration with Tilburg University for some years. Since 2012 he has been appointed as full professor ‘Integrative Cardiology’ at Tilburg University for 0.2 FTE. He is involved in several research projects focusing on cardiac patients.

B.3.1.2.1.18 Rotterdam-Rijnmond – The Netherlands

The Region Rotterdam-Rijnmond has the biggest harbour of Europe. The harbour of Rotterdam with the ‘Eurogate’ is almost 50 km long. The Region Rotterdam-Rijnmond is governed by the Stadsregio with a board of 27 cities in the region that collaborate in matters that concerns the harbour, mobility, industry and jobs, housing and climate developments. The region has more than 1.2 million inhabitants.

B.3.1.2.1.18.1 Municipality of Rotterdam

The municipality of Rotterdam is responsible for many matters concerning the 600.000 inhabitants of the city. In this case, Rotterdam is responsible for matters of participation of all people including older and disabled people. The local government of Kralingen Crooswijk is responsible for welfare and activities for these groups. Central city and local government work closely together. There are several projects related to the consortium:

The municipality trusts its own strength of the citizens of Rotterdam and of the Rotterdam institutions. Everyone is supported for the maximum to obtain their own care and welfare infrastructure. Within the framework of the law of social support, it means that it is expected of Rotterdam citizens that as much as possible they participate in own support, using informal care (collective networks).

With the urban partners in the city, we want arrange an efficient support that offers better answers through innovative technical support, and sees what is possible and usable for older people themselves. The municipality considers as its task that the urban policy frameworks with care and well-being institutions and corporations create effective results.

Since setting-up the new innovative policies in Rotterdam, with a budget of 300m€, a lot experience and knowledge has already been gained, and successes made. More important still is that cooperation has increased between organisations and citizens, more than a few years ago. There are also technical instruments to achieve a new way of exploring and looking at the integral questions of a citizen, more targeted on what someone needs in their district or street, and less on what a care provider has to offer.

Living Labs: Within the borders of Rotterdam, a second phase of the project living Labs started in 2012. It stimulates e-Health applications and secures domotica (house automation) and ICT applications in the Rotterdam care and well-being sector. Last year there were several meetings and workshops organised to stimulate innovation in the ICT sector. The

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project group has given priority to an increase in the commitment to innovation; the living Labs in Rotterdam are in close collaboration with Leiden University.

Several studies are also taking place with different institutions to explore new ways of thinking, and offer students methods for the future, for example studies about mobility in the local environment and neighbourhood20.

Key People

Sikko Bakker (MHA,BA)

Sikko bakker is programme manager for assisted living for the municipality Rotterdam. He recently studied a MBA programme at the Tias Nimbas School in Tilburg and graduated for the Master of Health Administration (MHA) programme. After his study in 1996 as a highly educated integral coodinating nurse, he studied several management programmes. His expertise is focused on elderly care and expertise in changing organisations, real estate projects, and area orientated health policies. With success he managed several institutes in the sector of care and living toward stable and service orientated organisations. The urban environment is the complex habitat where strategic projects and scientific research are taking place through his interventions over the last three years. He is responsible for creating 16 assisted living areas as a urban and regional example for 53 the other areas (600.000 people). These areas have integrated care, innovation, e-Health anddomotica instruments to create the environment where elderly and handicapped people can live as long as possible in their own environment.

The municipality of Rotterdam is developing the ambition for a long term strategy which stimulates collaborations between living, care and welfare. In the end, these connections and intensive collaboration between organisations must increase the autonomy and self-reliance of citizens. The programme for assisted living focuses on a wide range of instruments and methods. Throughout the programme, various areas of technical innovation must become more accessible, both physically and socially, for seniors and people with disabilities.

The assisted living area is enlarging the network with the participating partners and looking for common objectives and strategic opportunities to activate technical projects between living, care and welfare. The current urban policies must create strategic consensus for the partners in a stable long-term cooperation. The challenge is to develop an innovative network of public and private partners for the future in order to find distinctive choices and a focus for a joint network of innovative products.

An important strategic success factor is the main role for the municipality in a mandated network organisation. Such a network organisation is managing the responsibility, independence and expertise of each stakeholder. The size of the data exchange, where quality is paramount, turned out to be a second success factor in monitoringseveral assisted living areas in development. Joined marketing and information campaigns stimulated strong messages and accessibility of services.

For all partners and stakeholders, a jointly composed organisational vision for assisted living areas contributes to future expectations for collaboration. Finally, a joint measuring geographic instrument is to be developed to manage and inform partners about changes in the environment, and redevelop the strategic focus for the future.

Louis van Ditshuizen

Louis van Ditshuizen is the advisor of integrated care services for the local government in the county of Kralingen-Crooswijk in Rotterdam. He will be responsible for the development and the implementation of four Assisted Living Areas in Kralingen-Crooswijk in the coming years. 20 http://www.veldacademie.nl/news_items/display/resultaten_assisted_living_studio/31/

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His primary role is to stimulate and to take initiatives for integrated care, ICT development, welfare and living structures for older and disabled people.

In the years before, he was the manager of Social Sector for the county Kralingen-Crooswijk. In that position he was responsible for the implementation of the new social and health care law (WMO). Furthermore, Louis studied at the Social Academy for higher professions in Rotterdam.

Anthony Polychronakis (MA)

Anthony Polychronakis is a European Programme Manager for the City of Rotterdam.

He studied Public Administration, European Studies at the Erasmus University of Rotterdam, the Rijksuniversiteit of Leiden, and the Panepistimio Kritis of Crete, Rethymnon.

He worked for many years as a senior policy advisor for elderly care in the city of Rotterdam.He is also responsible for the Rotterdam approach to elder abuse.

Nowadays his main responsibility is to get the city of Rotterdam involved in the broader European network and participate in European projects in order to learn and stimulate innovation.

He is also an elected member of the City Council in the municipality of Alphen aan den Rijn.

B.3.1.2.1.19 Amadora - Portugal

Amadora is one of the largest cities in Portugal by population (despite the geographic area is only 23.8 km2 has a population of 175,558 inhabitants, according to the preliminary results of the Census of 2011, which reflects its high population density). It forms a conurbation with the Portuguese capital Lisbon, and both cities share the same subway, bus and train network. It is also a major residential suburb of the capital, and the landscape is dominated by large apartment blocks and some industry. Accessibility and proximity to Lisbon are factors of attraction, which has contributed to the great social and cultural diversity that characterizes the Municipality of Amadora.

According to the "Social Diagnosis 2011 Amadora", elaborated by the Social Network of Amadora “the demographic context of the Municipality reflects, in the last years, the loss of resident population and its gradual aging, consequence the combination of socio-economic factors”. Also according to this document, 19% aged over 65 years, of which 42% had more than 75 years; in parallel the expressiveness of the young population in the total population is around 15%.

In recent years has become an effort to improve health care response, in particular at the reorganization of the Health Centres, however still an insufficiency of medical resources - 42% of population registered at the Units that provide primary health care of the County - National Health Service - does not have a family doctor.

In terms of employment, and taking into account the economic social situation, was recorded increase in unemployed registered in the Job Centers (Amadora: in January 2012 there were 11.714 people registered – 7.135 < 1 year; 4.579 with 1 year and +).

The degraded areas declined with the encouragement of housing programs, but there remain some. If on one hand they do not provide decent living conditions, enhance the stigmatization of its inhabitants, on other hand these neighborhoods are associated with issues of addiction and crime, plus the issues of poor education, unemployment or precarious positions of employment, commonly unskilled and poorly renumbered.

The key social issues in this area concern mainly with:

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• Ageing population (often associated with situations of social vulnerability, a consequence of their economic precariousness, social isolation and loneliness);

• Existence of deprived neighbourhoods (degraded housing);

• Vulnerable population groups such as elderly, migrants, women and people with disabilities;

• Failure of medical resources.

B.3.1.2.1.19.1 Câmara Municipal da Amadora (Amadora City Hall)

Câmara Municipal da Amadora is a local authority (municipality) whose powers are statutory, highlighting the support activities of local interest such as: Decide on the forms of support to entities and legally existing bodies, including in pursuit of works or events municipal interest, and the information and rights of citizens; Support or reimbursed, by appropriate means support the activities of municipal interest, social, cultural, sporting, recreational or other; to participate in providing services to strata socially disadvantaged or dependent, in partnership with the relevant authorities of the administration central, and provide support for those social strata, by appropriate means and in conditions in the municipal regulation;

Decide on school social particularly with regard to food, accommodation and allocation of economic aid students; Ensure adequate support to the exercise of jurisdiction of the State under defined by law; To decide on the participation of the municipality in projects and decentralized cooperation operations, particularly within the European Union and the Community of Portuguese-speaking countries.

The three major strategic objectives of the Municipality for 2011 are: promoting social and urban cohesion of the city; strengthening the competitiveness of the city within the region; modernizing municipal management, promoting the quality of services provided and the approach of the city council to citizens.

It is in this framework have been designed and developed the sectorial policies in urban areas and the urban environment, education, housing, vocational training and qualifications for young people and adults and creating new social responses, applying, where necessary, measures of positive differentiation in order to optimize the results at the level of social and territorial cohesion of the city.

The political and administrative level of the Municipality of Amadora: the City Council is composed by a Mayor and ten Deputy Mayor; the Municipal Assembly is composed by a President and 33 municipal members.

There are eight main Departments: General Administration; Urban Administration; Environment and Urban Services; Education and Sociocultural Development; Financial; Housing and Urban Requalification; Modernization and Technologies of Information and Communication; Municipal Works.

The municipality chairs the Social Network of Amadora (Rede social da Amadora). The municipality chairs this network that is a forum for coordination and pooling of efforts based on the adherence by local authorities and public or private entities for the eradication or alleviation of poverty and exclusion and promoting social development. The Social Network appears in the context of affirmation of a new generation of active social policies, based on accountability and mobilizes all of society and every individual in the effort to eradicate poverty and social exclusion in Portugal.

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Key People

Ana Moreno – Coordinator of the Social Work Office

Degree in Social Work, Coordinator of the Social Work Office since 2000, managing all the activities developed by the office, managing human resources, representing the Amadora City Council in all external activities, responsible for the creation of several project applications (DAPHNE, Equal, Progride, Social Network, QREN). Coordinator of the Executive Nucleous of the Local Council for Social Action (CLAS) – Measure ’Social Network’ – responsable for creating the social diagnosis and other work tools, creation of annual work plans, partners managing ans interaction with financial programs managing offices.

Rute Gonçalves - Coordinator of Projects Area

Social Worker in the City Hall of Amadora since 1999, with a degree in Social Policy, Coordinator of the Projects Area, responsible for the development and implementation of the Social Local Network (based on local partnership) and the functioning of the Local Council for Social Action (CLAS) and for research and project management in areas such as Domestic Violence, Qualification of the Social Services, Equality of Opportunities, Entrepreneurship and elderly population.

B.3.1.2.1.19.2 Santa Casa da Misericórdia da Amadora - SCMA

Misericordia of Amadora (SCMA) is a Non Profit Organisation, founded in 1987, that pursues the mission statement To be Mercy is to provide good Service, oriented to Human dignity in a sustainable and organized way. The Organisation has grown exponentially, during the last years, due to Community and Organisations recognition of the Quality of the Services delivered in the Social, Elderly and Health areas.

Nowadays, the Organisation delivers daily support to 6000 Beneficiaries, in Amadora Council, and delivers Services in Geriatric; Health Cares, Social Support Education and After-School Activities, through a holistic and systemic Intervention: Gerontology and a quality support to elderly persons, it’s one of the core businesses of SCMA. Since 1987, the Organisation provides Services to elderly persons through Formal Carers. Nowadays, Misericordia of Amadora manages 2 Day Care Centers, supporting daily 100 seniors; 2 Nursing Homes, supporting daily 140 seniors; Home Support Services, supporting 139 seniors, 7 days a week; and a Long Term Care Facilities Unit supporting daily 140 seniors and vulnerable people; Meal Home Deliver Service providing 30 meals daily to the Community.

Along with the importance of providing ergonomic facilities to the Senior Population, SCMA has the Vision of providing the best responses in terms of the Human Resources that have been supporting that population. The Organisation has a very high skilled Team in the Nursery Area, Physiotherapy and Social and Mental Area. In addition, SCMA has been working, in Partnership with the Town Council (Câmara Municipal da Amadora) an Informal Carers Network, so called the tertiary Informal Carers, based on Proximity Volunteering, namely constituted by vulnerable people depending on State Benefits. These Volunteers, after a very structured and fulfilled Training Programme and intensive Supervision, provide cares to those elderly persons that live isolated. They visit them, make company, take and outside walk (if it is possible), shop for them and, mainly, deliver affect and attention.

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Key People

Manuel Girão

Manuel Girão is the General Director of. He has an MBA degree on Executive Social and Health Equipment Management. In addition, he belongs to Board Member in Santa Casa da Misericórdia da Amadora; Member of Amadora Town Council Educational School Committee (presently); Member of the Commission for Education in the União das Misericórdias Portuguesas (presently); Member of Lisbon Regional Secretary in the União das Misericórdias Portuguesas (presently); Member of the Amadora Child and Youth Protection Committee and Board Member in UPAJE Association. Manuel Girão vision of the Social Intervention is based on an innovative view, through a holistic dimension focused on Partnerships between Public Sector, Private Sector and 3rd Sector.

Adriano Fernandes

Adriano Fernandes earned his degree on Sociology from Universidade Moderna in 1999. Adriano Fernandes employment record includes Case Mangement and Teams Coordination on Organisations of the 3rd Sector in the area of childhood and vulnerable people, namely on 3rd Sectors Organisations and since 2007, in Santa Casa da Misericórdia da Amadora. Adriano Fernandes has 13 years of Social Intervention experience and Team Management, based on the devolopement of Inovative Methodologies and Tools to faster increase vulnerable people empowerment. Adriano Fernandes role in the Project will be in the domain of the Informal Carers, namely Volunteers depending on State Benefits

B.3.1.2.1.19.3 Portugal Telecom Comunicações

Portugal Telecom is the leading telecommunication and multimedia group in Portugal. The company's activity covers all segments of the telecommunications sector: wireline, mobile, multimedia, data and corporate solutions, strongly focused on the convergence of telecommunications with media and information technology areas. Portugal Telecom’s international footprint spreads to countries like Brazil, Cape Verde, Mozambique, Timor, Angola, Kenya, S. Tomé and Príncipe and Namibia.

During the last two decades, PT has been an active participant in EU-funded projects and international telecommunications standards bodies (CEPT, ETSI, CCITT, ITU). The commitment to the promotion of co-operation with national and international R&D institutions has enabled PT to play a decisive role as an agent for the technological knowledge transfer between the market and the industry environments.

Portugal Telecom has been involved in several FP7 projects. The most recent ones are: VCONECT, COGEU, BRAVEHEALTH, IOT.EST, VOICES, SOCIETIES, SAIL, CLOUD4SOA, FIVER, C2POWER, MEDIEVAL and ALICANTE.

Key People

Ana Dias

Ana Dias is currently head of Innovation Management and Business Development at Portugal Telecom. Ana joined PT in 2003, with the responsibility for business process definition and quality improvement in the wireline business. She was then involved in the re-organization of the back office area and in the implementation of new commercial channels in the Corporate segment. Afterwards, she led the human resources development and leadership department, being responsible for the definition of PT’s career model, evaluation and reward policies, recruitment and training, talent management and retention. Before

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joining PT, Ana worked as a consultant for McKinsey & Company, in different industries such as telecommunications, finance, insurance, multimedia and energy. Ana graduated in Physics and Engineering from Instituto Superior Técnico (Lisbon), and has an MBA from Insead (Fontainebleau).

João Dolores

João Dolores is an executive at Portugal Telecom’s Innovation Management Division, having the responsibility of ensuring the involvement of all PT employees in the innovation processes of the company, coordinating the definition of medium term innovation roadmaps for the different business segments and managing innovation funding programmes at a group level. Previously, between 2005 and 2011, João was a consultant at McKinsey & Company in the areas of telecommunications, banking, energy, raw materials and aviation. Up to 2005, he was country manager for JW Burmester, having been responsible for the introduction and growth of the brand’s wines in the U.S. market. João has an Economics degree from the University of Porto and holds an MBA from London Business School.

B.3.1.2.1.20 Uppland

B.3.1.2.1.20.1 Uppsala Läns Landsting

The Uppsala Läns Landsting is an organisation responsible for healthcare in the area of the county. It is an organisation managed by politicians. The County Council has about 11.000 employees. Most of them work within healthcare. The population of County of Uppsala is about 336.000 inhabitants.

• Primary healthcare: Primary healthcare can be described as front line healthcare, and the organisation serves the whole area. Care is provided by 150 GPs, 100 district nurses, midwives, physiotherapists etc. About 40% of the organisation consists of private contractors and the rest is run by the public body CCU.

• Hospitals: There are two hospitals in the area, one hospital with care for the residents of Enköping and Håbo municipalities, and one hospital - Akademiska sjukhuset (University Hospital of Uppsala) - serves the whole area with general care, specialist care, and specialist care for a larger area in Sweden. o The University Hospital of Uppsala: Today this hospital is one of Sweden’s

biggest, and a full-scale university hospital with 8.000 employees and 1.100 beds. Each year there are 58.000 admissions, 330.000 physician encounters and 420.000 out-patient treatments. The University Hospital has several different roles: county hospital, specialist hospital, training hospital and research hospital. Teaching and research, under the auspices of the Uppsala University’s faculty of medicine, are an integrated part of hospital activity. The hospital has inpatient clinics for somatic, geriatric and psychiatric care, as well as outpatient clinics, which serve two million people in central Sweden. For residents of Uppsala County, the university hospital functions as a normal county hospital, but it also has highly specialised units which draw patients from all over Sweden and abroad. Uppsala University hospital is one of Sweden’s most complete hospitals, with some fifty different specialities. 70% of treatment and care is given to residents in the County, and 30% is given to patients from other parts in Sweden, and also from other countries.

o Enköping General Hospital: This is the county hospital for the residents of Enköping and Håbo municipalities. At the hospital there is one medical and one surgical centre.

Today and tomorrow, financing health care and social services and the supply of appropriately qualified personnel are main issues relating to the present and future of caring and other services for the elderly. The problems of financing care is a kind of welfare

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paradox, i.e. due to general living conditions in Sweden, Swedes are living longer and reaching the age when service and care needs are mounting. This development stresses a tax –based system of financing the welfare of the elderly.

Year 2005 Total Population Population Age

>65 Dependent

People People with major

dependence

Uppsala 319.925 47.662 7149 1.429

Table: Summary of general figures for Uppsala County

Three percent of the population aged 65-84 answered that they didn’t carry on their daily activities. 15 Three percent of the population aged 65-84 answered that they have some problems to carry on their daily activities. To ensure that services for elderly will increase in both status and interest on the job market, project like “SmartCare” will strengthens efforts national and regional investments in this area. This is necessary if sufficient staffing should be possible in the future.

Key People

Benny Eklund

Currently Benny Eklund is the acting CIO of CCU (County Council of Uppsala). He earned his degree in Microelectronics and Computer Science from Uppsala University in 1976. Since then he has also studied Medical Engineering and Software Technology.

Benny’s employment record includes Telecommunications and Medical Engineering as well as conducting field trials for Swedish Combat Aircrafts. Furthermore, he has been employed by University Hospital in Uppsala, Sweden. From 1989 onwards, Benny worked at County Council as Manager of Strategic Systems and e-Government. He is also responsible for security and legal aspects of ICT in the whole County Council.Benny has been involved in several European projects. He has been the Chairman of the Swedish national organisation Carelinks’ Working Group for Patient Portals.

Leif Lyttkens

Dr. Leif Lyttkens is employed as Chief Medical Officer in the County of Uppsala, and is responsible for strategic medical issues of the County. He is responsible for a project for introducing electronic medical record in the county, a project for building a new hospital in the county, and other projects that concern the whole county.

Leif is a medical doctor with specialisation in ear, nose and throat as well as audiology. He has a PhD and is associate professor in ENT at University of Uppsala.

His earlier positions include, at University Hospital of Uppsala, chief for department of audiology, chief for division of ENT, Audiology, Foniatrics, Plastic surgery and Hand surgery, chief for Children’s Hospital. He has also been the chief medical officer of the University Hospital of Uppsala as well as deputy CEO of the hospital.

B.3.1.2.1.20.2 Center for eHealth in Sweden (Subcontractor)

Coordinated development for safer, more effective health and social care

To meet the great challenges the Swedish care system is facing today, an intensive effort is being undertaken on many fronts to develop and make all aspects of health and social care more effective. All levels are included – from individual patient care to changes in the entire organisation. One important element in the creation of modern, safe and accessible health

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and social care based on the population's needs is to better exploit the potential of IT and eServices. The Swedish Strategy for eHealth forms the foundation for our efforts.

In order for county councils' and regions' eHealth collaboration to be run effectively with clear goals and continuity, consensus is needed on the focus and scope of the work. Joint efforts must be able to be controlled, prioritised and budgeted in a coordinated manner. The Center for eHealth in Sweden has been formed to coordinate and push these efforts forward. The Center shall create the long-term conditions necessary for developing and introducing nationwide use of IT in the decentralised health and social care system that the Swedish model is.

The work comprises new citizens' services and support for health and social care provision, a national technical infrastructure and common regulatory frameworks and standards. These joint eHealth solutions will improve accessibility of information, quality and patient safety.

The Center for eHealth in Sweden is governed by representatives of county councils and regions, the Swedish Association of Local Authorities and Regions (SALAR), municipalities and private care providers.

B.3.1.2.1.21 Serbia

B.3.1.2.1.21.1 Kraljevo

Kraljevo is a relatively young city, with several models of urban construction. During its development, it has passed all stages, from rural to the urban settlements of today.

In the fifteenth century, there are mentions of the village Rudo Polje; this was later given the name Karanovac. By decree of King Milan Obrenovic of 19th April 1882, Karanovac city was renamed in Kraljevo, in memory of the establishment of the Kingdom of Serbia, and the arrival of the first crowned king after the Kosovo tragedy in this small town.

Kraljevo is now an economic, cultural and administrative centre, not only this municipality, but also Raska and Vrnjačke Banje. It is the seat of the Raska district. The city lies in the middle part of Serbia, east of Kraljevo valley, between the Western Morava and Ibar River, not far from the mountains - Goc, Željina, Kopaonik and Kotlenik. It is a great intersection for road and railway transport, with tourist centres (Vrnjacka Banja, Kopaonik, Goc, Mataruška Banja, Kotlenika), and a cultural heritage (monasteries Žiča, Studenica Maglič etc.). It had a significant positive influence on the development and dynamics of this region in the post-war period. All this was inevitably followed by the development of health services.

B.3.1.2.1.21.2 Studenica Health Center – Kraljevo

The health centre is a unique medical institution that provides primary care at the Kraljevo Health, and secondary healthcare services in the General Hospital Kraljevo.

Kraljevo Health provides primary care for approximately 140,000 residents living in the city of Kraljevo. The Health Department of General Medicine has 60 teams in 25 clinics in Kraljevo and one health station in Ušće. In addition, our health centre is working very successfully with other departments:

• The Health of children.

• Office of Women's Health.

• Department of Home Treatment.

• Occupational Medicine,

• Preventive and counselling centre for young people.

Since we particularly recognise the importance of primary care, we are in cooperation with the International Committee of Red Cross and the Ministry of Health. In the period since 2002 to 2005, we developed the model "selected doctor" which was later expanded and

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applied to all health centres in Serbia. The “selected doctor” is the basis for fundamental reform of primary healthcare, especially in terms of financing known as capitation. Capitation means equal opportunity for the public and private health facilities in the primary sector. This model introduces competition, contributing to efficiency and quality in healthcare. Capitation is a far fairer and more rational system of financing. Application of capitation requires sufficient knowledge and experience and a serious professional team and change in legislation.

There are many other programmes in which our Health Centre actively participates in order to improve primary healthcare. In our Health Centre, most users are generally satisfying their need for improving health, and those users who need services at secondary level can get this through the specialist-consultative and outpatient departments of the General Hospital. Among other things, this is because Health Centre and General Hospital operate under the same roof as the Health Centre "Studenica".

The Health Centre was elected twice as the best Centre in the continuous improvement of health care quality in 2005 and 2009. It is an accredited medical institution and leader in the reform of primary healthcare in Serbia. The Centre also successfully completed several projects organised by the European Union, World Bank and the Canadian International Development Agency.

General data Name and address: HC “Studenica” – Health Center, Jug Bogdanova bb. Founded: 1950 Director: Msc. Dr Mirjana Krčevinac Number of health departments: 10 Total area: 5.000 m2 Region: Kraljevo Municipality (1.500 km2) Population served: 135.000

Specific data

Number of medical staff employed: 510

Medical services: general medicine, stomatology, gynaecology, paediatrics, emergency service, home care, polyvalent patronage, work medicine, medical shipments and transportation.

Number of non-medical staff employed: 64

Non-Medical services: shared services: legal, financial, technical, central sterilisation, hygiene.

Projects:

• “Reform of Primary Health Care Policy in the Balkans” (CIDA)

• “Upgrade of Primary Health Care software” (WB)

• “Capitation” (EU)

• “Shining smile 2” (Decade of Roma)

• “Protection of reproductive health of the Roma population”

• “Life Impulse project”

• “Third age with us”

• “Following the growth and development of children under the age of 18”

• “You are my heart”

• “Chosen doctor”

• “Individual nicotine addiction therapy”

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• “Shining smile 1” (Decade of Roma)

Mission and Vision: Vision: Modern, rational, efficient HEALTH CARE institution, aligned with the new concept

and the international standards. Mission: Efficient health care institution, directed at realisation of planned performances

with the maximum appreciation of patients’ demands and providing the satisfactory level of quality of services.

Key People

Mirjana Krcevinac - General Manager of Health Centre - Department of GP

She has worked in Health Centre "Studenica" since 1989. She is one of the organisers of the successful pilot project of the "Chosen Doctor" (2001 - 2004).

She was a member of:

• Working Group of the Ministry of Health for quality improvement in primary health care.

• Working Group of the Ministry of Health for the accreditation of health centres.

• Working group to develop guides for good practice – dyspepsia.

• Expert Commission of the Ministry of Health for National Programme for the prevention of colon cancer.

• Working Group of the Ministry of Health to develop a strategy for quality improvement.

• Member of the RSK to determine compliance with the technology and software functional requirements for the establishment of an Integrated Health Information System.

As a consultant, she participated in the implementation and training for an International Classification for Primary Health Care (ICPC-2) as adopted by WONCA.

Also, she was a member of the team that participated in the preparation of old and new versions of software for the PHC, which is used in Kraljevo Medical Centre, which was done in the organisation of the Ministry of Health of the Republic of Serbia and the World Bank.

As representative of the Health Centre she was selected in the project Reform Primary Health Care in Balkan (CIDA) and was a member of the leadership of the Working Group. She has written many papers and publications.

Rada Novakovic - Health Centre "Studenica" - Head of Preventive Centre and Chief of Home Medical Treatment

Rada Novakovic worked in Health Centre "Studenica" since 1978 as GP. She is now Head of Preventive Centre and Chief of Home Medical Treatment.

Rada was creator and leader of project “Helping old and helpless persons in their natural environment”. The project was financed by Ministry of Economy and regional development, and represents a good example of successful practice.The goal of the project is to improve the service of primary healthcare in local and good care of old people.

She worked on a project for preventive health including Roms.She participated in project 484 which is related to Roms, named “Keep your health and join with us”.

Vladimir Cibukovac - Health Centre "Studenica" Kraljevo

He is expert in making and maintaining complex information systems, as well as the use of electronic and telecommunications equipment in order to automate system.

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He has experience in designing and making software for end users in order to facilitate operations, and training users to work with a computer and special computer software.

The last seven years he was the person responsible for administration and maintenance of computer networks and equipment in the Health Centre in Kraljevo. The Health Centre consists of about 60 computers in the central building, and 70 computers that are in the extended ambulances. Also he worked on installing and maintaining servers with MSSQL and Oracle database to support user’s applications.

In the past he was involved in several projects as IT trainer and consultant for implementation to other Health Centres in Serbia. Tasks included preparation and analysis of data with the aim of research in the field of medicine, development and improvement of the user application to meet needs, and practical implementation reports (financial management, quality control, etc.).

He participated as IT consultant in a project for improvement and upgrade of primary health care software supported by the World Bank (2007).

He participated in the pilot projects "My doctor" (funded by ICRC), on the implementation of software for working in medical institutions, along with installation and maintenance of the entire information and computer infrastructure. In addition, he trained end users to work on this software

B.3.1.2.1.21.3 Centre for Social Work – Kraljevo

Centre for Social Work in Kraljevo was established in 1960, and the work began in 1961. The Centre employs 49 workers. The Republic funds 38 workers, of which 35 are full time and 3 part time. 11 employees are finance by Local Government. Most of employees performing technical and specialised tasks of social work have higher education. Therefore, some of them have additional courses, training or specialisation to work in social care area. Centre for Social Work occupies an area of 964.80 m² with a total of 37 offices.

Some of the most significant preventative projects that the Centre has undertaken in the past three years are:

• "Rebels with a cause" - a project relating to the prevention of antisocial behaviour and juvenile delinquency.

• "Discover and protect ourselves and others" - prevention of AIDS and other sexually transmitted diseases, etc.

The Centre has also implemented numerous projects related to improving the situation of some of the most vulnerable groups in our society. The project related to empowerment and independence of people with disabilities, called "The Word is Hope, Hope is Life", was realised with the help of the British Government.

The "Step-up for the new century" also refers to the empowerment of people with disabilities to acquire new knowledge and skills that are important for their functioning in everyday life.

Refugees and internally displaced persons also constitute one of the most vulnerable groups in our city. The Centre has implemented the project "Working with Refugees who Leave Collective Centres" in order to empower these families.

To strengthen and empower our older citizens, we have undertaken projects "Third time with us" and "Pulse of Life" which had as a result the formulation of the service for home help and services for medical care in order to reduce the number of requests for accommodation in social care.

As a partner in the project, the Centre with Kraljevo and UNHABITAT carried out construction of 76 apartments for social housing, with HELP 58 more, and with SDC 30 apartments for social housing in a supportive environment.

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Key People

Svetlana Stanić - General Manager of Centre for Social Care Kraljevo

She is in charge of Social Care since 1997. During her professional career she participated in several programmes/projects in social and health care. The most important projects are: "Social Policy Reform of Kraljevo", funded by DFID, Social Innovation Fund of the Ministry of Labour, Employment and Social Policy RS for Projects; "An innovative approach to solving the problems of the elderly"; "An innovative approach to solving the problems of youth and youth with behavioural problems"; "Grow up together", toimprove support for orphans and foster families; "Always The Family",the development of family housing for the elderly and adults.

She was participant in consultancy in the SCTM Committee on Social Policy for the formulation of Poverty Reduction Strategy (2002) supported by DFIF and World Bank.As part of comprehensive reforms in social care in the period 2001 to 2004, she participated in many projects, Development of Foster Care, Development of Social Housing in supportive environment.

Other work included:

• Cooperation on several projects with Roma organisations and associations of persons with disabilities in the municipality of Kraljevo.

• She was mentor for implementation of rules on internal organisation and labour standards in Social Care Centre in Valjevo, Cacak Sopot, Lazarevac, and Mladenovac.

• Coordinator of internal monitoring and evaluation of local projects implemented under the Strategic Plan for Social Policy in the municipality of Kraljevo (2006-2007).

• Member of the Committee for the selection of local projects in the municipalities of Bor, Zemun and Uzice Project of Social Policy Reform (2005).

• Coordinator of projects implemented under the FSI programme (2003 - 2005).

She is accredited trainer for the Programme of Case Management in Social Care.

In the past, she worked in Counselling Services for youth in Health Centre "Studenica" - Kraljevo.

Svetlana Dražović - Psychologist

She works at the Centre for Social Care in Kraljevo as Psychologist since 1985. First five years she worked with clients with different social issues and needs. She has 15 years’ experience on issues of disordered family relationships and on different family issues. For the last 15 years she is a Team Leader and Coordinator for Social Care of Children and Youth.

She worked as a Psychologist on various projects in the ICRC, UNHCR and DFID, related to families and individuals issues, as well as various projects from the Ministry of Social Affairs. In many project she was Consultant for Therapeutic Work and Planning.

She is a Head Counselling for premarital, marital and family relations, and she participated in a project to develop and equip counselling offices with monitoring, complete accessories and audio and video surveillance.

She is co-author several projects to assist single mothers funded by DFID and municipality of Kraljevo.

For many years she was a contributor and author of the ICRC and the creator of numerous programmes related to incomplete displaced families and families who suffer a lost. She participated in the segment of the strategic plan for social care for the municipality of Kraljevo, which was related to children and young people.

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Dragana Nešović

During her work experience (since 1986) she has worked with children, youth and adults and older persons on social issues. She is now assigned to the Service Manager Jobs.

She is BA in Social Work (1984) further educate on different professional courses and training (course in systemic family therapy (2000), Family Therapy of Alcoholism Seminar, prevention of substance abuse / UNICEF 2003, full participation and equality-awareness of disabled people,etc.).

She participated in several projects approved by the Ministry of Labour and Social Policy, Department for Persons with Disabilities.

She worked with children without parental care through the SOS Kinderdorf.

B.3.1.2.1.21.4 Belit ltd

Belit ICT company was founded in Belgrade in 2000. By stressing the high quality of its products, Belit‟s professional reputation has grown over the years. The company has been able to establish close collaboration with financial institutions, governmental agencies and ministries. The realisation of many projects, financed by the European Union to improve the functionality of the state sector, has significantly contributed to the modernisation and standardisation of business in the country.

Belit’s team of experts and professionals covers all segments of the development of information systems, namely design, development, implementation and all aspects of customer support. Through the use of the latest technologies, the creative group of engineers and programmers create highly functional, expandable, easy to use and maximum secure software solutions. Also, teams of experts deliver training, system maintenance, industrial design, and consultancy services to its clients.

Key People

Vladimir Urošević

Vladimir Urošević has an MA degree in Industrial Design from Belgrade University of Arts, and over 10 years of industry experience in all stages of software development, from requirements and system analysis, to software architecture, programming, optimisation and team management.

Vladimir has worked on the development of major IT infrastructure systems at national level in Serbia, in finance, public administration and e-health (Credit Bureau, National Public Procurement Portal, National EHR, Unified registry of taxpayers), and has been involved, since 2004, in EU funded R&D projects (CIP-ICT-PSP, IPA, EuropeAid).

He is MCDBA for Microsoft SQL Server since 2003, and has completed database optimisation and Oracle ADF (Java) programming courses at Oracle University.

Armin Zeljković

Armin Zeljković has an MScEE degree in Information Systems and Computer Science from the Faculty of Electrical Engineering, University of Belgrade. He started as junior short term expert, IT trainer, on EU funded IT infrastructure projects, in tax administration and statistical office continuing his professional career in software solutions design and development, project management and team leading.

Since 2006, Armin has been involved in the entire lifespan of key IT infrastructure projects at national level, collaborating with various public institutions such as Tax Administration, Public

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Procurement Office and Serbian Chamber of Commerce, extending his primary software engineering qualifications to planning, leadership and presentational skills.

Marija Zeljković

Marija Zeljković has an MScEE degree in Information Systems and Computer Science from the Faculty of Electrical Engineering, University of Belgrade. Starting as a software developer, Marija is now working as software architect, and has worked on several national and EU funded IT infrastructure projects, mainly in Tax Administration and Statistical office, as junior short term expert. She was involved in the whole project lifecycle, requirements management, service definition and specification, system architecture, project development and implementation, and subsequent customer support process, and as IT trainer.

B.3.1.2.1.21.5 Fonlider Ltd (Subcontractor)

Since it was established in 1998, Fonlider has built a leading regional position in modern voice machines and complex solutions for contact centres alongside the mobile and internet solutions.

Careful recruitment and selection of only the most talented and dedicated professionals made Fonlider a successful company with more than 200 employees in Serbia, Bosnia and Herzegovina, Montenegro, Macedonia and Germany. We created a working environment where innovation, monitoring trends and setting new and higher quality standards of service are always present.

Reliability, correctness and commitment to clients are the basic principles of our business policy. Our business is based on a motto: “Satisfied customer is the best advertisement!” Today, we can proudly say that we cooperate with over 400 partners and customers across Europe.

To satisfy clients’ needs, we developed our own telecommunication solutions such as Soft-switch and Media platform, together with contact centre solutions and outsourcing as well. Furthermore, we are able to provide solutions for mobile payments, internet and mobile business and all sorts of supporting applications. Our solutions are recognised by the highest performances of outbound oriented contact centres and effectiveness and usability we called One-Click-Solution.

Within the One-Click-Solution concept, we can offer services that rely on our solutions and technologies as well as services we are offering in cooperation with leading European companies such as Sytelltd, DTAG, MINDMATICS, TELEFORTE and others.

Services provided:

Production of websites: production of all sorts of websites, from small static presentations to more complex ones with their own CMS (Content Management System):

• Web design.

• Audio & video streaming.

• SEO optimisation.

• Internet marketing.

• Website hosting.

• Production of web applications.

• Facebook fan pages and custom applications.

Proprietary e-shop solution: Our complex proprietary e-commerce solutions provide all the key features needed to run and maintain both small and large Internet stores. The advanced administration system allows you to create multiple stores hosted on a single server which

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can all have different layouts, categories, products and users registered, and can all be administered individually. The system is customisable, intuitive and very easy to use.

Internet solutions payment: We enable all possible ways of payment of your Internet solutions for the market in Serbia and the countries in the region, as well as worldwide payments. You make a choice of how you will pay: it is possible to make a choice of SMS payments, or through Interactive Voice Response (IVR) (0900), or through Money Booker or credit card payments.

Android Application Development: Our Android development team has significant expertise in development, design and complete assistance for Android applications. Our Android programmers have the ability to build applications for a wide variety of client's requirements. We act ahead of the curve to deal in the latest Android application development.

Video stream: If you need live video stream for your website or mobile application – we can offer you our “ready2go” solutions. Our live video stream provides high-performance solutions for Flash Player compatible browsers, as well as Android applications. The service is offered globally and delivered over the 100mbps optic link via Telecom Serbia, or any other ISP located worldwide.

Carrier Grade Soft Switch (CGSW): This is an ideal solution for internal communication, not just for middle size companies, but for the large telecommunication operators and providers of telecommunication services as well. Integrated and proven in practice, open source components make this solution very competitive. Optional billing system enables a variety of services such as service to residents, transit termination, calling cards service mission covering and many others.

Carrier Grade Media Platform (CGMP): In addition to CGSW platform, or independent of it, our media platform is an open platform with a large capacity that can create simple or very complex applications. This platform supports communication channels such as voice, video, fax, SMS, chat and e-mail. It is the easiest way to integrate other popular channels such as Facebook, Skype and others, and also to create any type of IVR or IVVR services,

Contact Centre Solutions: Our Contact Centre Solution is safe and flexible software for IP phoning and media management that provides quality work in the field of telemarketing, customer service, market research, data collection and others. A central component of managing and dialling (as well as other components including scripting, call recording, IVR, and others) can be placed on-site or can be delivered as services over the web.

OneClick Help: It is a solution that offers real-time or offline technical support to end users. Over all ways of communication (chat, audio, video...), with just one click, users are able to access the personalised help service directly over web browser or Smartphone application. Application allows changing the way of communication at any time.

SMSC solution for SMS aggregators: The OneClick SMSC enables operators to fulfil today’s demand for messaging services offering them highly available, efficient and cost- effective solution. It is a feature-rich, high performance platform that offers high capacity traffic and ensures good quality services.

Mobile payments:

• Credit card (Mobile portals, Smartphone applications).

• Premium SMS (M-Parking, M-Ticket, M-Voucher, M-VoIP, M-Add).

• Wap payment.

Mobile Applications: Depending on a target or internal needs, our team can create customised solutions that can satisfy all your needs. (m–shop, m– portal, m–health, m–business, m–ticketing, m–sales and retail, m–invent management, m–government, m–education).

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Key People

Genadij Simic – CTO of Fonlider

He began in 1997 in Monting company as a programmer, working on an application which calculates and prints salaries of workers as well as other financial documentation, using Delphi, Excel and OLE). He also trained secretaries and other company personnel.

In 2001 until November 2002, he began working in the company “GVS” which produces public telephone exchanges, as C/C++ programmer for telephone exchange line software and some similar devices.From September 2002 to December 2003 he had an additional job as instructor for various programming languages in Micronet computer school.

After that he was Development and Support Officer in Itineris, a Belgium company, and had a chance to be involved in reconstruction of Serbian financial treasury system on municipality level through USAID project.He was in charge offive people.

Later he was involved in several big, state level projects in Bosnia and Herzegovina and Serbia, working for Bearing Point and Deloitte with multi-language and multi-cultural teams.

He has 10 years of experience in IT industry, software development, and complex systems integration in the Balkan region using various technologies, and has five years of managerial experience as project leader, technical/IT manager, and project manager.

At present he is responsible for ITstrategies, current development and creating of future systems.He is in charge of 20 people.

A mathematician by academic education with two post-graduate course in mathematics and economics.

Djordje Pavlovic – Technical Manager – Contact Center Solutions and Telecommunications

Djordje Pavlovic started in development and maintenance of complex, hybrid telecommunication system at Fonlider d.o.o. In this position, Djordje performed: development of IVR and IVVR services; agi scripts for Asterisk platform; installation, integration and maintenance of Asterisk servers;development and core modification of existing Dialogic platform (C++); migration to Dialogic HMP platform;managing interconnections. Also, he was in charge of design and implementation of a new communication platform with: scalability, high availability, fail-over, extensibility and performance.

He now manages department and projects regarding Contact Centre Solutions and Telecommunications. Djordje is a certified integrator for Sytel's CallGem Contact Centre Solution. During this period, Djordje mastered technologies such as VoIP, SQL, MySQL clustering, perl, C++, bash, linux, VMware, XEN, and many others.

Previously, he was engaged on a short term R&D project “Simulation of energy consumption in dynamic tariff system”, financed by Ministry of Science at Faculty of Electronic engineering, Nis. The goal was to research and develop three classes of household electrical appliance models, for use in multi-agent simulation, using object oriented programming, C++ and event-driven techniques.

More than two years before he was engaged on a large project for a new ISP provider in Krusevac, “Krusevac Open”. The goal was to design and implement infrastructure of WLAN network “Krusevac Open” in the territory of Krusevac. He installed and configured Mikrotik OS based routers;installed and configured services for ISP (billing info system, radius, MySQL, Apache, Linux and Windows servers...); resolved security issues and QoS. Also, he conducted training of future staff for administering the system.

Djordje is Master Engineer of Electrical Engineering and Computer Science, graduated at Faculty of Electronic engineering, Nis 2008.

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B.3.1.2.1.22 Northern Ireland - UK

Health & Social Care in Northern Ireland

Northern Ireland has an increasing population of citizens over 75 years of age – approximately 117,000.

An Electronic Care Record (ECR) which would be viewable from multiple settings by GPs, pharmacists, community nurses, allied health professionals, hospital specialists and social workers has been developed and piloted by two GP practices and one HSCT. This will be rolled out regionally in January 2013. The HSCT continually engages with a range of community and voluntary organisations and other relevant stakeholders.

Recently, the PHA established a contract for telemedicine services to deliver remote telemonitoring of patients with long-term conditions. The PHA is currently working with the European Connected Health Alliance (ECHA) on the delivery of telemedicine, eHealth and mobile health (m-Health) solutions with colleagues in the Republic of Ireland, partner regions in Europe and the Northern Ireland Massachussets Connection (NIMAC) in North America. The ECHA was established in January 2012 as an initiative to facilitate leadership for the development of Connected and m-Health across Europe.

B.3.1.2.1.22.1 Health & Social Care Board (HSCB)

The regional Health & Social Care Board (HSCB) is the statutory commissioning organisation responsible for the purchase of health and social care services for the population of Northern Ireland, circa 1.8 million. The organisational structure of the Board is shown below:

The HSCB is funded through central government taxes and holds a budget of £3.8 billion. The HSCB performances manages Health and Social Care Trusts within NI and contracts with primary care providers (GPs, pharmacists, dentists and optometrists) which directly

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provide services, in order to ensure that optimal quality and value for money is achieved, in line with government targets. HSCB has five committees – Local Commissioning Groups (LCGs) – which are coterminous with the Health and Social Care Trusts and are responsible for commissioning health and social care which addresses the needs of their local population. LCGs are not stand alone public bodies but committees of Health & Social Care Boards and are governed by the Health & Social Care Board’s Standing Orders. One of these LCGs, the Southern Local Commissioning Group, will be involved in the SmartCare implementation. The Southern Local Commissioning Group commissions services on behalf of the regional Health & Social Care Board for the population of the southern LCG area (approximately 350.000 people).

The Public Health Agency (PHA) is tasked with delivering health improvement and disease prevention across NI. The HSCB, PHA and HSCTs are accountable to the Department of Health, Social Services & Public Safety.

Key People

Eddie Ritson - Director of European Centre for Connected Health

Eddie has been Director of the European Centre for Connected Health (part of the Northern Ireland Public Health Agency) since April 2008. He is responsible for leading the Centre’s work to improve the quality and responsiveness of the NI health & social care system by assisting the faster adoption of technological innovation. Eddie has recently led the design, procurement and implementation of a remote telemonitoring ‘end-to-end’ managed service which aims to provide telemonitoring services across the region of Northern Ireland to over 3,500 people per year.

Eddie’s career in health care stretches back to 1985; previous posts include Director of Primary Care in the Southern Health & Social Services Board, and Chief Executive of a Primary Care Group in the south of England. He has extensive experience in health & social care, both in the operational management of services and in leading change from a commissioning perspective.

Dr Sloan Harper - MB BCh BAO MRCGP MPA DRCOG DCH

Dr Harper qualified in Medicine from the Queen’s University, Belfast, 1983. After working as a GP in Belfast for 15 years, he was appointed Medical Adviser to the Northern Health & Social Services Board (pop 450,000) in 2001. In 2005 he was appointed as the Board’s Director of Primary Care, responsible for the commissioning of GP, dental and optometry services. Since March 2009 he has worked for periods as Primary Care Pandemic Flu Lead for Northern Ireland and as Deputy Chief Medical Officer at the Department of Health, Social Services and Public Safety (DHSSPS).

In April 2010 he was appointed to the post of Director of Integrated Care at the regional Health and Social Care Board (pop. 1.78m) and carries executive director responsibility for the Board’s commissioning of GP, dental, pharmaceutical and optometric services as well as the development of integrated care. This includes oversight of clinical, financial and organisational governance for these essential public services, including an annual budget of £830m. During his tenure he has delivered on annual financial efficiencies in the regional pharmaceutical budget of 12%.

In the past he has been part of regional and national study visits by the UK health service to Kaiser Permanente in Colorado, to the John F Kennedy School of Government, Harvard University, and the Department of Public Health, State of Massachusetts.

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B.3.1.2.1.23 Scotland - UK

NHS Scotland under the direction of the Scottish Government is responsible for ensuring that all 5 million citizens in Scotland receive the health services that they need. Local delivery is devolved to the 14 regional health boards where hospital, community and primary care services are organised.

The strategic agenda for healthcare services is focused around three quality ambitions.

• Effective: The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit; wasteful or harmful variation will be eradicated.

• Person centred: Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, clear communications and shared decision making.

• Safe: There will be no avoidable injury or harm to people from healthcare, advice or support they receive; an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.

There are five specific eHealth aims for the use of ICT in health services:

• To maximise efficient working practices, minimise wasteful variation, bring about savings, and ensure value for money.

• Support people to manage their own health and well-being and to become more active participants in the care and services they receive.

• Contribute to shifting the balance of care and support for people to self-manage and to provide appropriate information for people with long term conditions and mental health problems.

• Improve the availability of appropriate information for healthcare workers and the tools to use and communicate that information effectively to improve quality.

• Improve medication management as an essential part of peoples’ care.

B.3.1.2.1.23.1 NHS24

Scotland has a population of approximately 5 million people, with a mix of urban and remote and rural locations. The health and social care system in Scotland is a devolved responsibility which is overseen directly by the Scottish Government.

Faced with geographic challenges, and a rapidly growing older population (the fastest growing in Europe, but still dying younger), with an increasing dependence on health and social care, the Scottish Government view the development of telehealth and telecare as critical to help address the demography, aspirations and choices of our population.

The Scottish Government has recently published its "2020 vision" below:

Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting.

We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and

safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with

minimal risk of re-admission.

NHS 24 and the Scottish Centre for Telehealth & Telecare (SCTT) have been positioned to assist deliver this vision, and establish telehealth and telecare as an integral part of service

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delivery in order to help the people of Scotland live longer healthier lives at home, or in a homely setting.

NHS 24 is a Special Health Board providing and facilitating the development of national telehealth and telecare services across Scotland, and is directly accountable to Scottish Ministers.

The Scottish Centre for Telehealth and Telecare (SCTT) is part of NHS 24, and has been established by the Scottish Government to provide practical advice and support to Health Boards, Local Authorities and other key stakeholders across Scotland as they seek to realise the potential of digital health and assistive living technologies in the redesign of health and care services.

To date, the SCTT has supported the implementation of four national telehealth programmes (Stroke, Paediatrics, Mental Health, and Long Term Conditions, focusing on COPD), and overseen the implementation of Scotland’s Telecare Action Plan. In addition, the team is managing the technical implementation of a national videoconferencing solution, and our national telehealthcare education & training programme. NHS 24/SCTT are also leading the Scottish Assisted Living Programme on behalf of the Scottish Government, which aims to:

• roll out assisted living solutions to at least 10,000 people across Scotland;

• develop a Centre for Excellence in Digital Health & Assisted Living; and

• embed telehealth & telecare within the £300m Reshaping Care for Older People Programme.

SCTT is committed to collaborative working with colleagues from key stakeholder groups to ensure improved health and care services for the people of Scotland. This includes harnessing the skills and expertise from medicine, academia, design, carer organisations, operational management and telehealth/telecare technology suppliers.

By 2020 we intend to see….

• The use of telehealth and telecare as the first consideration for Health Boards, Local Authorities and independent sector providers when introducing or redesigning services.

• Health Boards, Local Authorities and independent sector providers using familiar, everyday technologies like the telephone, television and internet to improve access to person centred care, tailored to individuals’ preferences.

• Health Boards, Local Authorities and independent sector providers exploiting evolving digital technologies in order to support people to stay at home / in the community as long as appropriate and avoid the need for unplanned emergency admission to hospital where possible.

• Where people are admitted to hospital, Health Boards, Local Authorities and independent sector providers with established and sustainable telehealth and telecare services safely supporting individuals to be discharged back to their home / community as early as possible.

Health Boards, Local Authorities and third sector providers using telehealth and telecare in order to achieve more integrated working between health and social care services.

Key People

Professor George Crooks OBE MBChB MRCGP

Professor George Crooks is currently the Medical Director for NHS 24 and Director of the Scottish Centre for Telehealth & Telecare. He is also Medical Director for the Scottish Ambulance Service where he is responsible for the quality, safety and effectiveness of all

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clinical services and the development of new services in partnership with other NHS organisations. George was elected to President of the European Health Telematics Association in February 2012. NHS 24 is the national provider of telehealth services for the whole of Scotland currently providing the majority of its services via telephony, the web and digital television. The Scottish Ambulance Service provides accident and emergency and patient transport services for the whole of Scotland, covering a population of circa 5.2 million people.

George was a GP in Aberdeen for 22 years, and his past appointments have included Director of Primary Care with NHS Grampian with responsibility for all community-based independent contractor services. George has a particular interest in the appropriate use of technology to support the delivery of high quality patient care, using it as a vehicle to empower patients to actively participate in their care. He also is involved in the development of common assessment and triage processes across the NHS in Scotland as a better way to manage unscheduled and emergency care provision.

He was awarded an OBE in the Queen's New Year Honours List 2011 for services to healthcare. He is a Member of the Royal College of General Practitioners having led the development of a number of key developments in primary care including the evolution of new contracting models for service delivery, the development of salaried GPs in Scotland, and a new career framework for newly trained GPs. He pioneered the provision of rapid community response services, and community hospitals in city environments delivering nurse led and GP supported care for patients.

Justine Westwood

Justine has worked within NHS 24 since 2006, and is currently Head of Planning and Performance with responsibilities including Strategic Development, Corporate Planning and Performance and Programme Delivery.

She managed the transition of the Scottish Centre for Telehealth and Telecare into NHS 24 and since June 2010, has been responsible for the team who are currently delivering the national and supporting clinical programmes as detailed in the SCT Strategic Framework (Stroke, Paediatrics, Mental Health, Long Term Conditions, National Infrastructure, and Education and Training).

Justine is a member of the NHS 24 Executive Team, and is part of the senior management team of the Scottish Centre for Telehealth and Telecare.

Justine is a graduate in Music from Edinburgh University, and has extensive experience in both the public and private sectors, with a background in delivering IT and digital solutions. Prior to joining NHS 24, Justine worked in a number of IT and e-business roles within Britannic Asset Management, developing and delivering financial services to private and institutional investors.

Moira Mackenzie MA, Hsg Dip

Moira joined the Scottish Centre for Telehealth and Telecare (SCTT) in April 2012 as its Telecare Development Manager. Previous to this she was the Scottish Government’s National Programme Manager for Telecare where she was directly responsible for the implementation of its five year innovative and ground breaking programme. There are now over 180,000 telecare connections across all 32 local partnership areas in Scotland, and telecare is increasing being regarded as an important element within community based care services.

Moira is part of the senior management team within SCTT, and has been responsible for implementing Scotland’s Telecare Action Plan (2010-12), Home Health Monitoring Services, the national Telehealthcare Education and Training Strategy, and oversees the national Telehealth & Telecare Learning Networks.

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Moira has successfully worked in collaboration with a wide range of strategic partners from industry, academia, health care and housing policy and practice, and is a member of the Scottish Assisted Living Programme Board. She has over 20 years experience within public sector service development and delivery, where she was a manager for care, support and homelessness services for the West Lothian Community Health & social Care Partnership. She has successfully implemented significant service redesign within health, housing and care services, where she often provided a strategic programme leadership role. Moira was also chair of the Convention of Scottish Local Authorities Supporting People Lead Officers.

B.3.1.2.1.23.2 Third Party associated to NHS24

Scotland has an integrated healthcare system with all hospital and community health services delivered by fourteen geographical Health Boards. The provision of integrated health and social care in the primary and community settings is carried out by Community Health and Care Partnerships, which are subdivisions of Health Boards in Scotland. These Health and Care Partnerships are co-terminus with Local Authority areas.

NHS 24, through the SCTT, will manage the implementation of SmartCare into seven Community Health and Care partnerships from three geographical Health Board regions in Scotland (NHS Lanarkshire, NHS Greater Glasgow and Clyde, and NHS Ayrshire and Arran) as highlighted in the map below:

B.3.1.2.1.23.2.1 NHS Lanarkshire

NHS Lanarkshire is responsible for improving the health of more than 562,477 people living within the North and South Lanarkshire local authority areas. In 2012 NHS Lanarkshire developed a strategic health planning framework to support future strategic health planning and to gain a shared understanding of the actions required to achieve the Scottish Government’s 2020 Vision.

NHS Lanarkshire has identified four strategic aims to achieve this vision, which are set in the context of delivering a healthier future for all from cradle to grave. These are:

• To reduce health inequalities and improve health and healthy life expectancy

• To support people to live independently at home through integrated health and social care working

• For hospital day case treatment to be the norm, avoiding admissions where possible

• To improve palliative care and supported end of life services

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NHS Lanarkshire has two Health and Care Partnerships – North Lanarkshire and South Lanarkshire. Both will participate in SmartCare.

B.3.1.2.1.23.2.2 NHS Greater Glasgow and Clyde

NHS Greater Glasgow and Clyde is the largest Health Board in the United Kingdom, providing health care to over 1.2m people. NHS Greater Glasgow and Clyde is currently planning the future shape of clinical services to deliver the 2020 vision, and has set up eight clinical working groups, each led by a medical expert, to examine how these services should be delivered in the future.

Chronic Disease Management is one of the areas under review. The scope of this review will cover the current pathways of care for patients with chronic diseases, including:

• heart disease

• diabetes

• respiratory disease (COPD)

• rheumatology

The group will focus on:

• balance of care between primary and community care and hospital care,

• anticipatory care,

• palliative care,

• supporting patients at home.

NHS Greater Glasgow –and Clyde has ten Health and Care Partnerships. Two of them will participate in SmartCare - East Renfrewshire Health and Social Care Partnership and Renfrewshire Health and Social Care Partnership.

B.3.1.2.1.23.2.3 NHS Ayrshire and Arran

NHS Ayrshire and Arran is responsible for the health of almost 400,000 people and has three Health and Care Partnerships ––East Ayrshire,–South Ayrshire and North Ayrshire.

In 2009 the review of primary care services ‘Your health - we're in it together' - put the public at the heart of healthcare. 'Your health' focuses on getting the balance right between caring for people close to their homes, and looking after people who come into hospital as an emergency, or because they need specialist treatment. NHS Ayrshire and Arran have already introduced a number of initiatives to support this shift including:

• Telehealth systems that harness the power of technology to enable people with long term and complex conditions to be monitored and even treated in their own homes.

• Health and wellbeing advisors working alongside general practice staff to offer people support with health issues related to alcohol, tobacco, obesity and mental health.

• Better communication between hospitals and general practice, including more effective planning for discharge.

• Transforming relationships between clinicians and patients to give patients the information and support they need to take more control of their conditions and to live safely but independently

The actions are being delivered through a number of workstreams, including the Long Term Condition Management and Telehealth/Telecare workstream, with planned activities including:

• Each Health and Care partnership is currently developing its own local telehealthcare action plan and is contributing to the development of the NHS Ayrshire & Arran telehealth and care strategy;

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• Managed Clinical Networks (MCNs) and the Long Term Conditions working closely to pursue a variety of service developments such as early Supported Discharge for respiratory disease, telehealth monitoring for heart failure patients, specific disease patient self-management plans, and other treatment in reserve for patients with COPD.

All three partnership areas will participate in SmartCare.

Key Activities

These three Health Boards will be responsible for the recruitment of the older people and the implementation of the pilot interventions within their areas, under the overall project management of NHS 24.

Key people

Craig Cunningham

Craig was previously a General Manager prior to moving into his most recent post as Head of Planning and Performance for South Lanarkshire Community Health Partnership (CHP). Craig is currently the Interim Head of the CHP.

Craig is leading the Reshaping Care for Older People process on behalf of NHS Lanarkshire within South Lanarkshire CHP. In addition, Craig is also a member of the Community Planning Partnership Board, developing shared health and care services across the South Lanarkshire Partnership in its widest sense.

In seeking to develop the agenda in supporting the shift in the balance of care, both North and South Lanarkshire Partnerships are seeking to explore opportunities afforded by new technologies and the sharing of electronic information in delivering more proactive care in keeping with the wishes of individuals.

Kevin Beverage

Kevin is the Acting Commissioning Manager at East Renfrewshire Council and is responsible for developing strategic commissioning and contract management across the integrated health and social care partnership.

Lorna Muir

Lorna is currently Renfrewshire’s Care at Home Services Manager .Lorna has worked in social work services for over 20 years and is responsible for the management, strategy and development of community based services including extra care housing, care at home, reablement services, community meals, community alarms and telecare services. She was Chair of the Telecare Services Association during 2011/12 and is presently vice Chair. Telecare Services Association is a member based organisation and the UK representative body for telecare and telehealth and Lorna represents its Scottish members on the Board of Directors

Mandy Yule

Mandy is currently the Health care Director -Integrated Care and Partner Services at NHS Ayrshire and Arran and is responsible for exploring the opportunities that telelehealth and telecare can offer across the Health and Social Care Partnership, with a particular focus on supporting integrated care.Older people associations

B.3.1.2.1.24 AGE Platform Europe - Belgium

AGE, the European Older People’s Platform, aims to voice and promote the interests of older people in the European Union and to raise awareness of the issues that concern them most.

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Everyone in the European Union is increasingly affected by decisions taken by its institutions: the Council of Ministers, the Commission, the European Parliament and the Court of Justice. Decisions affect the daily lives of all its inhabitants - including older people.

AGE Platform Europe is involved in a range of policy and information activities to put older people’s issues on the EU agenda and to support networking among older people’s groups. Among our guiding principles is that a change of attitudes is needed to achieve a society for all ages, seeking solidarity between generations in a way that recognises older people’s contributions to society. AGE Platform Europe is committed to combating all forms of age discrimination in all areas of life, and aims to monitor and influence the implementation of the various EU initiatives in this area.

AGE Platform Europe was set up in January 2001 following a process of discussion on how to improve and strengthen cooperation between older people’s organisations at EU level. Membership of AGE Platform Europe is open to European, national and regional organisations, and to organisations both of older people and for older people. Organisations of older people will have the majority of votes in AGE’s decision-making bodies. Membership is open only to non-profit-making organisations. AGE Platform Europe is co-financed by its members and by the European Commission.

Key People

Anne-Sophie Parent, Secretary General of AGE Platform Europe

Anne-Sophie has more than 18 years of experience in dealing with policy and project development at EU level, having been Director of Autism Europe for six years and President of the Social Platform for two mandates. She sits on various advisory committees set up by the European Commission (European Pensions Forum, e-Inclusion programme, European Health Policy Forum, Ad Hoc Expert Group on Desinstitutionalisation, Expert group for the interim evaluation of the Assisted Ambient Living Programme, Dialogue Group on Insurance, Financial Services Users’ Group, Steering Group of the European Innovation Partnership on Active and Healthy Ageing). She is also a member of the Advisory Group of the United Nations – Economic Commission for Europe (UN-ECE) Generations and Gender Programme and sits on the Steering Committee of the Social Justice Programme of the King Baudouin Foundation (Belgium).

Ilenia Gheno, Research Project Coordinator at AGE Platform Europe

Ilenia holds a BA in European Integration; MA in Policies and Politics of the European Union.

Since 2009 she follows the participation of AGE experts and members on projects related to UNIVERSAL Design, health and eHealth, accessibility and ICT. Her expertise is related to accessibility, acceptance of technology, access to services, safety and security of applications and services and independent living issues. She has managed the End User Platform (EUP) within the Mediate project and is working towards the long-term engagement of the EUP in project and policy activities. She has been working on the needs of older people in the realm of new technologies and web accessibility thanks to her involvement in the Thematic Networks eAccess+ and Atis4All, plus coordinating the User Fora organised within the 7PF projects OASIS and VERITAS. She is also involved in projects dealing with mobility (AENEAS) and CIP-PSP projects (Dreaming, Home Sweet Home). She is currently working on practical guidance for the involvement of older people in research activities and policy making, and keeps on monitoring the engagement of seniors in different Members States thanks to the support of AGE members.

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Nena Georgantzi, Legal and Research officer at AGE Platform Europe

Nena is a qualified lawyer, specialised in human rights and social protection, with wide experience in the NGO sector. Since January 2010 she works for bridging AGE research activities with its policy action, drafting policy recommendations for each project pinpointing the implications for older users and coordinating AGE experts’ input in the projects. Her legal background allows her to follow some specific dossiers related to ethics, fundamental rights, anti-discrimination, privacy and data protection. She is involved in a number of projects in the areas of ICT, health, accessibility and design for all, identifying user needs and promoting user involvement.

Maude Luherne, Projects officer for AGE Platform Europe

Masters in Political Sciences and European and International projects management.

She is working for AGE since October 2009.Specialised on gender issues with experience in structural funds and in not-for-profit organisations, she coordinated the EUSTaCEA project (2008-2010) which developed a European Charter on the rights and responsibilities for older people in need of care and assistance, with a specific focus on older women. She is at the moment coordinating the WeDO project (2010-2012) on the improvement of the quality of life of older people in need of care and assistance. In addition to this, she is working on research projects regarding AAL and assistive technologies. She also developed a great knowledge of the European Parliament activities and processes as she also worked until Dec. 2011 as European Parliament Liaison officer for AGE. She is working at a distance from Rennes, France.

B.3.1.2.2 Health Insurers

B.3.1.2.2.1 AOK Reinhland/Hamburg

The Allgemeine Ortskrankenkasse (AOK) Rheinland/Hamburg is a large regional German statutory health insurance company. Around 2,9 million people are insured under the AOK Rheinland/Hamburg - close to a third of the market share. The annual expenditure for health services is more then 8,4 billion €. A broad range of preventive programmes rounds off the AOK's portfolio of services. AOK has developed its own structured treatment programmes for people with chronic diseases. These programmes benefit from scientific monitoring and evaluation, and an integrated quality management system to ensure their constant improvement. The AOK sets standards in other fields, too. Integrated care is a good example. Different stages in treatment - doctor's surgeries, hospital, nursing homes or rehabilitation - are coordinated for maximum efficiency. Patients are spared duplicate procedures and therapy is more effective.

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Key People

Christoph J. Rupprecht

Christoph J. Rupprecht heads the healthcare politics and health economics department of the AOK Rheinland/Hamburg (SHI). He is visiting lecturer in the department of Cormparative Health Systems Research at the Cologne Rheinische Fachhochschule. He has an extensive experience in cross-border healthcare project management in collaboration with different political and scientific partners and hands-on experience in data analysis and evaluation of morbidity and mortality rates, strategies for integrated care models, and disease management programs. He has also been closely involved in the development of supplementary health insurance packages, clinical guidelines and standards, and clinical improvement models.

B.3.1.2.3 Regions associations

B.3.1.2.3.1 Assembly of European Regions - France

With more than 250 regional authorities from 35 countries as members, the Assembly of European Regions (ARE) is the largest independent interregional organisation in Europe, with over 265 million citizens living in its member regions. Established in 1985, ARE is a forum for regional politicians to engage in interregional co-operation and to voice regional interests on the European stage. Since its inception, one of ARE's key priorities has been to raise awareness and understanding of the relevance of European policies for regions and their citizens, basing its activities on the principle that sharing information, offering platforms for exchange of views and experiences and creating opportunities to debate issues of general European concern all contributes to creating a sense of ownership of the European project among the citizens. ARE and its members also contribute to the development and implementation of European policies, by contributing the regional perspective at the early decision making stages and making sure that EU level decisions can later be successfully implemented on the ground, in the regions.

ARE is active in all policy areas where regions have competences. The ARE Social Policy and Public Health Committee leads ARE’s work in the field of active and healthy ageing. Member regions active in this Committee have selected the following political priorities for ARE actions for the period 2012-2013:

• Active and healthy ageing;

• Innovation in health and social services (with a network dedicated to e-health issues);

• Building inclusive societies (with a network focusing on equal opportunities for people with disabilities).

Created in 2006, the ARE e-he@lth network supports regions to embrace innovation and the potential offered by ICT in health and social care. The network adopts a multi-stakeholder approach and encourages regional politicians from ARE member regions to cooperate with their local stakeholders (local industry and SMEs, local universities, associations of patients and health professionals) in order to further develop and successfully deploy ICT for health.

The aim of the ARE e-he@lth network is to accompany regions in the deployment of e-health policies and tools. To this end, ARE monitors developments at EU level and regularly collects feedback from ARE members currently deploying e-health, to detect obstacles and new trends and contribute to setting priorities at European level. ARE organises capacity-building workshops where member regions can learn from others’ experiences, adapt existing models to their specificities and implement ICT in their services.

Over the past year, ARE has actively engaged in the European Innovation Partnership on active and healthy ageing. ARE is cooperating with other European organisations to bring to

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member regions examples of innovative processes and support them in identifying funding sources and partners to adapt and implement these in their systems.

ARE often participates to EU co-financed projects. In the field of e-health, ARE is a member of the Users’ Advisory Board of the RENEWING HEALTH project (co-financed under the ICT PSP), which brings together 7 regions from across Europe, to pilot telemedicine tools and create evidence for their quality and cost-efficiency. ARE has lead Interreg-funded projects in the past, and is currently a partner to 2 Interreg-funded projects and 2 LLP-funded projects.

Key People

Camille Bullot – Policy Coordinator

As a Policy Coordinator at the Assembly of European Regions, Camille Bullot has supported the coordination of the different networks of the Social Policy and Public Health Committee for over three years. The working areas covered by this Committee range from innovation and sustainability in health and social policy to active and healthy ageing, addressing health inequalities and implementing cross-border healthcare.

Since August 2010, she leads the work of the AER e-he@lth network, a network that supports the deployment of e-health in the regions by promoting the exchange of knowledge and experience in the field. The network also builds capacity at political level by raising awareness on the opportunities offered by ICT in health and social care.

Her role is to liaise with elected politicians from AER member regions to define the strategic vision of the network and to contribute to its implementation. Her tasks include monitoring related policy developments; maintaining daily contacts with regional politicians and experts working in the field; organising network events; representing AER at external events in this area and identifying new potential partners for AER member regions. As a result, Camille has developed a sound knowledge of e-health and a good understanding of regions’ priorities and concerns in this area.

Previously she held other positions in different non-governmental organisations, notably as a Policy Assistant at World Economy, Ecology and Development, where she collaborated in the development and management of a project on decent work.

In the past three years, she has contributed to the organisation of over 10 international thematic conferences and capacity-building seminars throughout Europe, and has proven her excellent sense of organisation as well as ability to communicate in cross-cultural environments. She is fluent in French, English, German and Italian.

Ourania Georgoutskaou - Senior Policy Coordinator

Ourania Georgoutsakou has held the post of Senior Policy Coordinator in the Assembly of European regions (AER) since 2003, where she first managed the AER Committee on Institutional Affairs and since 2004 runs the AER Social Policy and Public Health Committee. Her role consists of liaising with members and external stakeholders, developing and implementing the strategic vision of AER member regions in the fields of health and social policy and voicing regions’ needs and demands at European level.

Her tasks include managing the Secretariat of the AER Social Policy and Public Health Committee, formulating AER policy positions, overseeing the organisation of events tailored to suit member regions’ needs and regularly liaising with elected politicians from member regions to understand members’ needs and interests, build consensus and support interregional and multi-stakeholder networking. She is active in the fields of e-health, innovation in health and social systems (integrated care, change management), using European Cohesion policy funds for health and social policy, equal opportunities for people with disabilities, cross-border healthcare, and services of general interest.

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Ourania has been project coordinator on behalf of AER in two ECfunding projects, on preventing alcohol-related harm (European Public Health Programme) and on preventing natural disasters (EU Civil Protection Programme), and has also represented AER in projects on e-health (Renewing Health-co-financed by CIP-ICT PSP) and financing healthcare (Euregio III co-financed by the European Public Health Programme).

Ourania is an experienced speaker and regularly contributes AER’s perspective to external events. She is also invited to moderate workshops and conferences organised by AER member regions. She is accustomed to living and working in an international multi-cultural environment and speaks English, French and German, as well as her native Greek. Her academic background is in European law and European policy-making processes.

B.3.1.2.4 Industry associations

B.3.1.2.4.1 Continua Health Alliance - Belgium

The Continua Health Alliance is an industry initiative of almost 200 organisations that was established three years ago with the explicit goal of promoting and accelerating interoperability between PHS and devices.

Continua’s objectives include:

• Developing design guidelines that will enable organisations to build interoperable sensors, home networks, telehealth platforms and offer innovative health and wellness services.

• Establishing a product certification programme with a consumer-recognisable logo signifying the promise of interoperability across certified telehealth products.

• Collaborating with government regulatory agencies, industry associations and provider organisations to provide methods for safe and effective management of diverse solutions.

• Working with leaders in the healthcare and technology industries to develop new ways to improve the costs of providing personal telehealth systems.

Its recently published “Version One Design Guidelines” are an initial key result of three years of global efforts to progress on this challenge. They contain references to standards and specifications that Continua’s membership selected − through an open and transparent voting process − to ensure interoperability of personal health devices. The Design Guidelines also contain additional interoperability design guidelines that further clarify these standards and specifications by reducing options or adding a feature missing in the underlying standard or specification. Continua works closely with many industry groups to build upon existing standards, thereby removing barriers to global implementation and mass adoption.

Connecting people and technology makes a meaningful difference:

• Improved Chronic Disease Management Providing chronic disease patients with interoperable, unobtrusive devices that can be conveniently used at home, at work, or on the move allows them to regularly track and share their health status. Improved information systems also empower care teams to make necessary interventions more quickly. These systems also allow family members – such as parents of children with chronic diseases or relatives of the elderly – to play a greater role in their loved one’s care. With these tools, it is possible to manage chronic diseases more efficiently and cut down on physician office visits and hospital stays.

• Enhanced Lifestyle Independence There is comfort and dignity in being able to grow old in familiar surroundings. Thanks to devices like in-home sensors that can keep an eye on daily activities and alert

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loved ones and care teams in case of an emergency, more individuals can continue to live independently. By offering a viable alternative to institutional living, Continua helps alleviate some of the burden on social and healthcare systems while improving quality of life for our aging population.

• Maximised Wellness Programmes With compatible devices and information systems, individuals can optimise the effectiveness of their fitness and healthy lifestyles programmes. They can track their progress and share workout results with a trainer, who can provide feedback, or with a friend who can help them stay motivated. Trainers and gyms can build customer loyalty by offering products with the Continua Certified™ logo that can help clients reach their goals.

To build trust and confidence among consumers, Continua recently announced a product certification programme featuring a recognisable logo signifying interoperability with other certified products. By connecting people with their trainers, care teams and family members through integrated information technology, Continua helps them meet their fitness goals, better manage their chronic diseases and live independently as they age. Following a year of strong momentum and continued progress, Continua welcomed the first Continua Certified device to the marketplace in 2009. Continua expects more than a dozen products to be certified in the first half of the year, with a goal of June 2009 for a fully automated certification programme.

Driving this ambitious schedule are Continua’s Version One Design Guidelines. Leveraging the work of more than 1,400 individuals from more than 180 member companies, these guidelines provide member companies with the necessary technical information to build and design Continua certified products.

The Continua Health Alliance (CHA) places interoperability of Personal Health Systems (PHS) at its core. CHA has developed the first ever guidelines for PHS interoperability This makes CHA the world’s most prominent organisation targeting the development and promotion of PHS, one of the cornerstones of the telemedicine services trialled in RENEWING HEALTH.

Key People

Petra Wilson is the Secretary Generalof Continua Health Alliance Europe,a daughter organisationof Continua HealthAlliance which isoverseen bythe Continua Health Alliance Board of Directors;she is also co-chair of Continua Health Alliance EU Policy Working Group. Petra isa Director inthe Healthcare teamof the Cisco’s Internet Business Solutions Group (IBSG), focusing on helping customers to develop strategies and implementation plans for“Connected Health” information managementand technology. Originallytrained in law, Petra specialised inhealthcare lawand European lawandhasa PhDinpublic health law from Oxford University.

MarioRomao is co-chairof theContinua HealthAlliance EU Policy Working Group. He is senior manager for eHealth policy at Intel Corporation where he oversees Intel Digital Health’s Grouppolicyand standardsactivities inEMEA(Europe,MiddleEastand Africa). He is a former European Commissionagentdealing witheHealthprojects withabackground in Computer EngineeringandaMaster in Business Administration;hisexperiencebridges from technical systemsimplementationtopolicy making in ICTand eHealth.

Charles(Chuck)Parker is Executive Director of the Continua Health Alliance. This membership-driven company focuses on developing an eco-system of interoperable personal health devices. Through working with standards bodies and industry experts, Continuapublishes certification standardsbuilt upon international criteria from IEEE, HL7,

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Bluetooth, USB,andothers. Chuck leads the many workgroupsandday-to-dayoperations of the Alliance.

Emily Stearns is theDirector of Business Relations for Continua Health Alliance. Over the pasttwo years, Emily hasapplied intimate knowledge andbestpractices intheareas of boardgovernance,membership management,technology marketing,and corporate communications to the Continua programmes andprojects underher direction. Emily has alsoheld theelectedpositions of Executive Director of CP-TAand HANA. She participates withpeers inthe membership activities of the American Societyof Association Executives andthe Centre for Association Leadership.

B.3.1.2.5 Professional associations

B.3.1.2.5.1 Eurocarers - Luxembourg

Eurocarers is a European association bringing together national organisations representing carers and those involved in research and development concerning carers’ issues. The organisation was formally established in Luxembourg in December 2006 and emanated from two European projects: “Carmen”, a networking project on integrated care, and “Eurofamcare”, a large research project on family carers of older persons.

Eurocarers aims at being the carers’ voice in Europe, promoting the social inclusion of carers, the recognition of their interests, and the development of services that can support them. It contributes to policy development at the European level and supports national and/or regional organisations when desirable.

It stimulates and carries out research that is relevant for carers and can contribute to enhance their position. Eurocarers has currently 65 members in all corners of Europe, including and beyond the 27 EU Member States.

It uses its website and newsletter as well as its regular meetings with members to disseminate good practices and stimulate the exchange of information and experiences. In the last few years, it has been increasingly involved in research projects, including the EU-funded project “CARICT”, aimed at formulating an Impact Assessment Methodology to evaluate the effects of ICT-based solutions for informal carers.

Key People

Giovanni Lamura – Vice-President for Research of Eurocarers

Giovanni Lamura is a social gerontologist with an international and interdisciplinary background, working at INRCA (Italy’s National Institute of Health and Science on Ageing) since 1992, and Eurocarers’ Vice-President for Research since 2009. He graduated in economics in Italy in 1990; obtained a PhD in "Life course and social policy" at Bremen University (Germany) in 1995; was visiting fellow in 2006-07 at the University of Hamburg-Eppendorf (Germany); and research director of the pillar “health and care” of the European Centre for Social Welfare Policy and Research in Vienna (Austria) in 2010-11. He has gained experience in international research projects mainly focused on family and long-term care of dependent older people (including the use of ICT-based solutions to support informal carers); work-life balance; migrant care work; prevention of elder abuse and neglect. In 2011 he coordinated the four-country research project CARICT (Assessing the impact of ICT-based solutions for informal caregivers). In the last five years he has participated, among others, in the following European projects: “EUROFAMCARE: Support services for family carers of older people”; “ABUEL: A multinational prevalence study on elder abuse”; “ASPA: Activating senior potential in an ageing Europe”; “Care@work: reconciliation of employment and elder

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care”; “EURHOMAP: mapping home care services in Europe”; and “Futurage: outlining a “road-map” for future ageing research in Europe”.

Marja Pijl – Advisor of the Executive Board of Eurocarers

Marja Pijl, sociologist, is an Advisor to the Board of Eurocarers. She has been involved in this organisation right from the beginning as she was one of its co-founders. She is also actively involved in AGE, the European Platform of Older Persons, ANBO, a Dutch Seniors’ Organisation and OVN, the Dutch Older Women’s Network.

Until recently she worked as an independent researcher on social policy issues, doing comparative studies mostly on long-term care and the support of carers.

Before that she was employed by the Netherlands’ Institute for Social Work Research, by the Netherlands’ Youth Council and the European Bureau of Adult Education.

B.3.1.2.5.2 International Foundation for Integrated Care – The Netherlands

The International Foundation for Integrated Care (IFIC) is a network that crosses organisational and professional boundaries to bring people together to advance the science, knowledge and adoption of integrated care policy and practice. The Foundation seeks to achieve this through the development and exchange of ideas among academics, researchers, managers, clinicians, policy makers and users and carers of services throughout the World.

IFIC was instituted in October 2011 and is registered as a Stichting with the Dutch Chamber of Commerce. The new organisation builds on a 12-year history of activities including, since 2000, the publishing of a peer-reviewed open access electronic journal (www.ijic.org) with over 1,500 registered readers and 10,000 unique visitors each month. It also runs a flagship annual congress each year at a location in Europe (our 12th Edition was hosted in the Republic of San Marino on 29th-30th March 2012) as well as co-organising the annual International Congress on Telehealth and Telecare held in London that has attracted more than 1,500 delegates (actual and virtual) from nearly 60 different countries.

IFIC is now developing itself as a membership-based organisation and is currently represented by an IFIC Board drawn from Europe, North America, Latin America, Asia and Australasia. It is developing its range of activities to undertake and partner research activities, develop educational programmes, and create a new website (www.integratedcare foundation.org) with a member’s forum and an integrated care observatory with the aim of bringing together international expertise and knowledge on integrated care.

The International Foundation for Integrated Care (IFIC) will support learning exchanges between the SmartCare participants throughout the project through its website and also through specific events. Several of the participants have been previously involved as delegates and presenters within the Annual International Congresses on Telehealth and Telecare that IFIC hosted in partnership with The King’s Fund, London, in February 2011 and 2012.

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Key People

Albert Alonso, MD, PhD, Innovation Directorate, Hospital Clinic Barcelona and Vice-Chair of IFIC.

Albert Alonso is responsible for clinical efficiency through ICT integration at the Innovation Directorate of Hospital Clinic, Barcelona. His main lines of work include the definition, evaluation and deployment of new models of health care provision with a special emphasis in integrated care models that use ICT. He has participated in numerous research and development projects since 1997, often as a member of large co-ordinating teams. He has been involved as a local principal investigator for the Homecare project, and deputy coordinator for the Nexus project (at scale deployment and validation of eHealth programs for chronic patients with different pathologies). He is a regular lecturer on graduate and postgraduate teaching programs, founder and scientific advisor to Linkcare Health Services SL, Secretary of the Catalan Society for Clinical Documentation, and vice chair of IFIC.

Lourdes Ferrer, MD, MSc, Secretary and Research Co-ordinator, IFIC and Managing Editor, IJIC

Lourdes Ferrer is a medical doctor with an MSc in International Health Management and Development. Her areas of work focus on health, development and change. She supported programmes in her country of origin, El Salvador, to strengthen capacities for managing change in health workers at different levels; providing and evaluating health services for hard to reach poor communities, and investing in early child development. She also supported intra- and inter-organisational policy mainstreaming in working towards the achievement of the Millennium Development Goals with the Pan-American Health Organisation (PAHO/WHO); and processes of health sector reform with the World Bank (WB) and Inter-American Development Bank (IDB). She is managing Editor of the International Journal for Integrated Care (IJIC) and Secretary and Research Co-ordinator at IFIC

Nick Goodwin, PhD, Senior Fellow, The King’s Fund, London and Co-Founder and Treasurer, IFIC

Nick Goodwin works as a Senior Fellow at The King’s Fund, London. A social scientist, academic and policy analyst, he has a specialist interest in investigating the organisation and management of primary and integrated healthcare.Nick leads the King’s Fund’s programme of work on integrated care for older people and those with complex health and social care needs. He was also the project director of a three year Department of Health-funded project in England examining the evidence for the application of telehealth and telecaretechnologies in LTC management. Nick is co-Founder and Treasurer of IFIC and the Editor in Chief of the International Journal of Integrated Care.

B.3.1.2.5.3 European Federation of Nurses Associations - Belgium

The EFN is the independent voice of the nursing profession. The EFN consists of National Nurses Associations from 34 EU Member States, working for the benefit of 6 million nurses throughout the European Union and Europe. The EFN is in the position to provide the national nursing associations of 34 European countries with the information necessary to create awareness among the current developments on eHealth. Through EFN connections, the national, regional and local nursing experiences on eHealth will be brought up to the EU sphere to enrich the process and the further implementation of results.

The EFN is a member of the Steering Group of the “European Innovation Partnership on Active and Healthy Ageing”, member of the “eHealth Stakeholders Group” and partner of the “eHealth Governance Initiative”. Together with EPF, the EFN participates in “Chain of Trust” looking at assessing and raising awareness of user perspective of telehealth.

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Having a proactive approach to setting the EU health policy agenda by influencing the major policy initiatives from the European Commission, which in turn impacts on nurses and the nursing profession, is the core business of the EFN. Translating this political journey into the ‘language’ of the EFN members, bridges the distance between Brussels and the governmental capitals of the Member States where national policies are developed.

Key People

Dr. Paul De Raeve, EFN Secretary General, is an expert of European policy developments in the field of nursing education, workforce for health and healthcare quality and patient safety, and eHealth, holding positive outcomes and success in the lobby process to the EU institutions. He is a nurse and has a vast experience with an active and productive team being part of prior EU projects such as CALLIOPE and EUNetPas, as well as on-going projects such as the eHGI, Chain of Trust, the Joint Action on Quality and Safety and the one on EU Workforce for Health. He is in a unique position to provide crucial expert advice on the design of the project; as the Secretary General of EFN he became member of the Steering Committee of the EIP and Active and Health Ageing, particularly with regards to the content and political implications of the deliverables.

Silvia Gómez Recio, EFN Policy Advisor, joined EFN in September 2010 after she joined in 2008 the Regional Ministry of Health’s Education for Health department before moving to the Health Strategic Planning department, where she was appointed representative for the coordination of the Spanish regions in the EU Council (EPSCO) during the Spanish EU Presidency, attending the working parties on Food, Public Health and Pharmaceutical Package. Silvia has followed the EIP Active and Healthy Ageing as Sherpa of the EFN Secretary General. She is responsible for the follow up of the eHealth Governance Initiative and other eHealth related projects in which the EFN participates.

B.3.1.2.6 Patients associations

B.3.1.2.6.1 European Patients' Forum - Luxembourg

The European Patients’ Forum (EPF) currently represents 54 member patient organisations operating at European and national level, and is the key interlocutor with the European Institutions to integrate a patient perspective in the healthcare debate. Through its EU wide membership, its secretariat and its effective governance structure, EPF is capable of very efficient programme management, knowledge building and dissemination.

EPF has a strong expertise in ensuring that patient needs, concerns and expectations are effectively reflected in policy and projects which have an impact on the patient community, particularly through the transparent and meaningful involvement of patients in health-related policy making and projects. Since its establishment, EPF has been promoting the early involvement of patients as “experts” in the design, implementation and evaluation of health-related projects, particularly in areas such as Health Technology Assessment, eHealth and telehealth.

eHealth and integrated care are key operational priorities for EPF, as reflected in EPF Annual Workplan 2012. EPF contributes to the eHealth Stakeholders Group, liaises with OECD on eHealth issues, and has actively participated in the last 3 Annual eHealth Ministerial Conferences. EPF provided consistent input to EC for the Telemedicine Communication and wrote an editorial for the EU Health Portal Newsletter.

EPF has extensive experience in projects: it was the leader of the project VALUE+ (PHP - Public Health Programme 2008/2009) where an effective co-operation was established thanks to EPF's capacity to guide the work of the Steering Group and maintain good internal

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communication. EPF is currently leading the telehealth project “Chain of Trust” (PHP 2011/2012) looking at assessing and raising awareness of user perspective of telehealth. Moreover EPF is/has been an associate partner in RESPECT (FP7), Interquality (FP7), CALLIOPE (ICT PSP) ), EUnetHTA (PHP), and EuNetPas (PHP), RENEWING HEALTH (ICT PSP), eHealth Governance Initiative, SUSTAINS, Joint Action on Patient Safety and Quality of Care, and leads on specific work in these projects. With a view to promoting patient involvement primarily, albeit not exclusively, in health-related project, EPF has developed the so-called “Value+ Model of Meaningful Patient Involvement” and produced a number of key publications targeting three groups, i.e. patients/patient organisations, project leaders/coordinators/promoters, and policy makers on how to apply effectively involve patients in health projects, including research projects, as well as in policy making process21.

Key People

Liuska Sanna, Programme Manager

Liuskahas soundexpertise inprojectand programme coordination- in particular managing multi-partnerregionalprojects, in projectdevelopment, monitoringandevaluation, capacity building, gender mainstreaming, training, citizens' participation in democratic processes, patients' involvement and interest ineHealth solutions,andprovision oftechnical assistance. She has workedforten years in this capacity in various European NGOs. At EPF,Liuska is responsible for the management and implementation of EPF programme activities and is, among other things, in charge of eHealth and HTA policy portfolio and leader of the EPF-led Chain of TRUST project (www.chainoftrust.eu) investigating patient and health professional perspective on telehealth. Liuska also represents EPF in the eHealth Governance Initiative and eHealth Stakeholder Group recently set up by DG INFSO.

Walter Atzori

Walter Atzori, Programme Officer, has been working for four years on developing, implementing, monitoring and evaluating EU projects in various sectors including e-health. Having worked for a major European network of regions before joining EPF, he has extensive knowledge of regional issues. At EPF he is currently involved in various EU projects and initiatives in the area of eHealth and health research, and responsible for EPF involvement in the RENEWING HeALTH telemedicine and SUSTAINS projects deploying a wide range of administrative and clinical services based on patient’s access to Electronic Health Records. He is also involved in policy and advocacy strategies and campaigns in areas such as cohesion policy, health inequalities, eHealth and youth policies.

B.3.1.2.7 Business consultants

B.3.1.2.7.1 empirica Gesellschaft für Kommunikations- und Technologieforschung mbH - Germany

empirica GmbH, founded in 1988 in Bonn, Germany, has established itself as a leading European institute with a broad understanding of political, business and socio-economic issues surrounding eServices and telematics applications. The group has a permanent staff from a range of disciplines, including medicine / health, social care, IT engineering, (medical) informatics, economics, social, political, management and public administration sciences. This mix of qualifications combined with a well-established network of international partners allows easy formation of interdisciplinary and international teams well-tuned to the demands of newly developing markets or for new strategic and policy directions. Concerning eHealth

21 http://www.eupatient.eu/Initatives-Policy/Projects/EPF-led-EU-Projects/ValuePlus/Resources/Value-Resources/

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and ICT for Ageing related work, empirica’s key asset is a team with a distinguished track-record of advanced research, ranging from road mapping new RTD fields to concrete solutions for ICT-based new models of health and social care services. It has provided services to EC, OECD, WHO, global industrial players, various national governments as well as health service providers, based on a broad understanding of policy, strategic, clinical, business and socio-economic issues surrounding well-being and health services, and helping bridge the widening gap between new developments in technology and their application in ways fully meeting user needs. A further focus is contributing to European as well as global long-term research endeavours, where empirica has managed several projects developing services supporting and empowering patients to better manage their own health, e.g. supporting the management of chronic diseases.

Selected projects and studies: epSOS, INDEPENDENT; PALANTE, eCareBench; ProeHealth, CommonWell; ASSIST; Cross-border ePrescription, HeartCycle, SmartPersonalHealth; eHealth Strategies; EHR-IMPACT, eHealthInnovation TN, SemanticHealthNet, MobilAlarm, eInclusion@EU, Trusted@Work4Homes, SeniorWatch.

Key People

Simon Robinson B.A. M.A. is director of empirica. He read Engineering and Management at the University of Cambridge, and subsequently worked on empirical social research techniques at the Universities of Essen and Bielefeld. A major area of continuing research is the use of ICT developments to further the independence and improve the quality of life of elderly and disabled people. He was responsible for setting up a world first application of broadband interactive video-telephony to support older people at home in Frankfurt, Main, a service which has since expanded to many other sites in Europe. He has initiated, managed, coordinated and/or contributed to many of the above mentioned studies and projects including responsibility for administrative project management in epSOS, the European large scale pilot of cross-border patient summary, and ePrescription.

Lutz Kubitschke received his degree in Social Research (interdisciplinary degree in social research, economics and law) from Goettingen University. The particular focus of his research was on technology and market-related studies on opportunities and threats of new telematic applications for people with special needs. In this context, he acted as evaluator of the TIDE programme. He was project coordinator for the SeniorWatch project (cf above) and participates actively in INDEPENDENT. Evaluation and validation approaches and methods are further specialisation areas.

Dr. Veli Stroetmann, MD PhD, is a Senior Research Fellow with empirica. She obtained an MD degree from the Academy for Medical Sciences in Sofia, Bulgaria, as well as a PhD in Medical Informatics. She was/is project coordinator or principal investigator for European Commission initiated studies on eHealth policies, strategies, market research, validation of eHealth / telemedicine applications, interoperability, and patient safety. She coordinated the ECfunded Support Action SemanticHEALTH and is Editor of the report Semantic Interoperability for Better Health and Safer Healthcare, a Roadmap for Europe. Dr. Stroetmann actively participated in the EU CIP-PSP-supported TN CALLIOPE as part of the authoring team of the Interoperability Roadmap. She is the main author of the SmartPersonalHealth report “Enabling smart integrated care: Recommendations for fostering greater interoperability of personal health systems”.

Reinhard Hammerschmidt, MA, is research consultant at empirica specialising in studies on the impact of ICT-related change in healthcare. He studied Geography and Sociology and obtained his masters degree (Dipl.Geogr.) in 2003. He obtained medical expertise from training as a paramedic and worked in that area for several years. He was involved in eHealth impact and EHR impact developing and applying an economic impact assessment method based on cost-benefit analysis. He led the Good eHealth study and is WP leader for

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socio-economic impact assessment and business development in the Philips led HeartCycle project, developing a third generation home telemonitoring service for heart failure and CAD patients, and in PALANTE, piloting patient access to EHRs in eight countries. He leads ASSIST for the European Space Agency - an impact assessment framework and tool for telemedicine projects aiming to become sustained services. He also leads ProeHealth, an EC study analysing how procurement practices can facilitate the success of investments in EHR and telemonitoring systems.

Sonja Müller is research consultant at empirica. She holds a degree in geography, urban development, and economic sociology from Bonn University. Main fields of her research activity are ICT applications and their usage patterns amongst older people and people with special needs, and the way ICTs impact on societal participation and inclusion of disadvantaged population groups. Since joining empirica in 2001 she has been involved in a number of projects focusing on opportunities and threats of new ICT applications for older people and people with disabilities. She participates actively in CommonWell and INDEPENDENT.

Joerg Artmann is eHealth research consultant with more than five years experience in managing eHealth policy and piloting projects. He has been involved in the European large scale pilot epSOS for interoperable patient summary and ePrescription services since its beginning in 2008. He is leading the study on guidelines for interoperable ePrescription services, commissioned by DG SANCO and has previously led the eHealth strategies study on policy and implementation progress of eHealth in the EU and EEA Member States. In parallel, Joerg is involved in empirica’s projects surrounding the European Innovation Partnership on active and healthy ageing. He holds a degree in International Relations from the Institut d’Etudes Politiques (Paris) and the London School of Economics.

B.3.1.3 Partners roles in the project implementation

The role of each of the groups above are explained below:

Regional partnerships

These are the “spine” of SmartCare because, in most cases, they comprise both the procurers and the providers of care to older people; they will play the leading role both in defining the specifications of the integrated care pathways, and in trialling them in the field when they are released.

The Consortium has adopted an open attitude towards accepting all the regional partnerships which have expressed an interest in participating in SmartCare. Of course, their current number, 24, is such that it is not possible to run a pilot in each of them within the budget foreseen for this Pilot Type A project.

The first wave of pilots comprises four regions (Friuli-Venezia Giulia, Aragón, South Denmark and Scotland). These regions appear to be more advanced than the others in the implementation of ICT-supported integrated care and will have the role of trailblazers.

The second wave comprises six pilots (Tallinn, Noord Brabant, Attica, South Karelia, Uppsala, Serbia).

These have been selected according to the following criteria:

• Geographical balance, common to all the EU funded projects: the different areas of the Union should be represented: Northern, Southern, Eastern, Western and Central Europe.

• The criteria specifically indicated in the Objective 3.1 text, namely balance between: o Pioneers, i.e. regions already advanced in the deployment of ICT to support

integrated care; and

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o early adopters, i.e. regions which have decided strategically to move towards the integration of health and social care with the participation of all their care actors, but have no experience yet in deploying ICT in support of the process.

Regional partnerships which do not host pilots will form the Committed Regions Board, a body which will have close cooperation with the project implementation team, and which will remain permanently in contact with the pilot sites to exchange ideas and to receive feedback from the people experimenting on the ground.

Regional partnerships belonging to the Committed Regions Board will be the first to which the transferability model will be applied to give them a realistic deployment plan for the SmartCare services in their specific context.

Older people Associations

They will ensure that the point of view of the older people is always taken into proper consideration in all the phases of the Project. To this end, AGE Platform Europe will organise and chair a Users’ Advisory Board22 which, in addition to AGE’s own members, will draw on the expertise and constituency of Caregivers and Patients’ Associations to provide a consolidated view of what the users of the SmartCare services are looking for. AGE Platform Europe will also mobilise its membership to disseminate the SmartCare results to the dense network of contacts that its members have; AGE will also promote SmartCare in the numerous events that AGE organises or in which it participates.

Health Insurers

The Health Insurers, represented in the Project by AOK, will contribute to the Project by bringing to the party the point of view of Health Insurers which are called on to play a major role in the roll-out of ICT-supported integrated care. In particular, AOK, possibly in collaboration with other insurers, will spell out the kind of evidence that its members need to change the way they finance healthcare to enable integrated care to be deployed on a large scale in countries with an insurance-based healthcare system.

Regions’ Associations

The Regions’ Associations, represented in the Project by ARE, will collect input from the European Regional community at large, to orient the choices made in the Project and disseminate the results of SmartCare to the most representative selection of potential adopters of ICT-supported integrated care. They will also organise and chair the Committed Regions Board23 which will have privileged contact with the regions hosting the SmartCare pilots throughout the lifecycle of the Project.

Industry Associations

Industry Associations, represented in the Project by CHA, will provide advice to the SmartCare Consortium about the technologies and standards which are most likely to ensure the openness of the solutions which are implemented in the various pilot sites and, consequently, an open competition among potential service platform suppliers for the benefit of the users.

Caregivers’ Associations

They represent all the different categories of caregivers, informal caregivers (Eurocarers) and nurses (EFN). Their role in the Project is that of transferring to the team in charge of the Project implementation the specific requirements of the constituencies that they represent. The Caregivers’ Associations will also mobilise their memberships to disseminate the

For more information about the Users’ Advisory Board see Section B.3.1c.2 23

For more information about the Committed Regions Board see Section B.3.1c.2

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SmartCare results to the dense network of contacts that its members have, and will promote SmartCare in the numerous events that they organise or in which they participate. Together with AGE Platform Europe, they will form the core membership of the Users’ Advisory Board.

Patients’ Associations

They are represented in the Consortium by EPF. They will ensure that the point of view of older patients is always taken into proper consideration in all the phases of the Project. EPF will also mobilise its membership to disseminate the SmartCare results to the dense network of contacts that its members have, and will promote SmartCare in the numerous events that it organises or in which it participates. Together with AGE Platform Europe, it will form the core membership of the Users’ Advisory Board.

Professional Associations

These represent professionals from across health and social care who take on strategic and operational responsibilities to lead, manage, purchase, provide and evaluate ICT-enabled integrated care innovations. These different stakeholder groups will be mobilised for SmartCare by the International Foundation for Integrated Care (IFIC) through dissemination to and beyond its membership, via its website, academic journals, and international conferences. Together with the caregivers’ and patients’ associations outlined above, IFIC will be a core member of the Users’ Advisory Board. IFIC will also lead WP3.

Business Consultants The role of the business consultant in the project is taken by empirica. Based on extensive experiences gained in internaional large-scale pilots on ICT-based services in the health care and social care domains, they will provide the necessary expertise, methods and techniques for effectively and efficiently guiding project participants’s activities in several respects. To begin with, they will assure optimal identification of usere/stakeholder requirements and the the development of the project’s use cases based on viable and sustainable value propositions for key stakeholders. This will enable operationally useful formulation of service specifications in line with integrated care practice and policies, and formulating an effective exploitation approach reaching out to Europe's regions and other actors responsible for health and social care provision. In line with this, the business consultants will ensure that SmartCare uses available evidence and expertise on the deployment of integrated care solutions in Europe to maximum advantage, and that it enlarges the current evidence base in this domain in an operationally useful manner and at commonly accepted qulity standards. They will also ensure that a particular focus is placed on synchronisation with relevant international standardisation activities. With particular regard to exploitation activities, the consultancy services will ensure efficient analysis of eHealth and eCare markets in Europe, specification of business case perspectives and developments of viable business models based on a sound cost-benefit perspective. The table below show how the full stakeholders value chain is mapped in each of the pilot sites.

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Table 4 – Stakeholder mapping by pilot site

Stakeholder type 1st wave pilots Friuli-Venezia Giulia Aragon Scotland Region Syddanmark

Healtcare providers A.S.S.1 Triestina, other Local Health Care Units

SALUD NHS Scotland Region Syddanmark

Social care providers Municipalities Cruz Roja

Renfrewshire Council, East Renfrewshire Council, South Ayrshire Council, East Ayrshire Council, North Ayrshire Council, South Lanarkshire Council, North Lanarkshire Council

The 22 Municipalities in which the Region is subdivided

Informal carers Families, NGOs, caregivers

None Families, NGOs Families, NGOs

Professionals

A.S.S.1 Triestina, Municipalities,, other Local Health Care Units, GPs

SALUD NHS Scotland, GPs, Local Authorities

Region Syddanmark, GPs, The 22 Municipalities in which the Region is subdivided

ICT product/service providers Outsourced Outsourced Outsourced IBM, Logica

Patners and associated third parties are in bold font Subcontractors are in normal font Stakeholders having no contractual relationship with partners are in italic

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Stakeholder type 2nd wave pilots Uppsala County24 Tallinn Noord-Brabant25 Kraljevo (Serbia) Palaio Faliro (Attica) South Karelia

Healtcare providers County Council, GPs

East Tallinn Central Hospital

TweeSteden Ziekenhuis

26 Studenica Health Center

Palaio Faliro, Ag. Dimitrios and Alimos Health Care Units

EKSOTE

Social care providers Municipalities City of Tallinn

Municipalities, home care organisations and social care organisations which are part of the KOMPLEET network

Centre for Social Work

Palaio Faliro, Ag. Dimitrios and Alimos Social Care Units - KAPI

EKSOTE

Informal carers Families, NGOs Families, NGOs Families, NGOs Families, NGOs Families, ELODI Families, NGOs

Professionals County Council, GPs

East Tallinn Central Hospital, City of Tallinn

TweeSteden Ziekenhuis

Studenica Health Center, Centre for Social Work

Palaio Faliro, Ag. Dimitrios and Alimos Municipality GPs and Specialists

EKSOTE

ICT product/service providers

Outsourced Outsourced Smart-House Foundation and partially outsourced

Belit, Fonlider, MNO Vidavo Medi-IT Oy, Saita Oy

In case the County of Uppsala is eventually unable to secure the participation of one of the municipalities present in the County, the responsibility and the budget for the pilot will be transferred to one of the regions which are currently part of the Committed Regions Board

25 In case the Smart House Foundation is eventually unable to secure the participation of a care provider from Noord Brabant, the responsibility and the budget for the pilot will be transferred to one

of the regions which are currently part of the Committed Regions Board 26

The TweeSteden Hospital could be replaced by another care providers from Noord Brabant should their validation by REA fail for any reason

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B.3.1.4 Relationships between project participants

The members of the SmartCare Consortium have a long tradition of collaboration among themselves.

Flanders is represented in the ENSA network, the European Network of Social Authorities. For Flanders, Kenniscentrum Sociaal Europa and vleva (Liaison agency Flanders-Europe) are taking part in the different working groups of ENSA (elderly and disability care, youth, …) The aim of the network is developing and supporting solid partnerships between a wide range of European Regions. The co-operation between partners brings about the opportunity to carry out several projects financed by the European Commission. Due to this sustainable co-operation, Flanders got the opportunity to become partner in the SmartCare project. ‘Kenniscentrum Sociaal Europa’, as an intermediary and supporting actor for non-profit organizations and service providers to apply for European funding and projects, proposed to ‘Kenniscentrum Woonzorg Brussel’ and ‘Mederi’ to step into SmartCare.

Region of Aragon, Sydanmark, Region Veneto and HIM SA have worked together on the CIP project DREAMING, monitoring vital constants of chronics.

Region Syddanmark, Gobierno de Aragon, Regione Veneto and HIM SA have all worked together in the Market Validation and in the Initial Deployment phases of the eTEN HEALTH OPTIMUM initiative (eTEN Project of the Year for 2005).

Region Syddanmark and Regione Veneto have also worked together in the Regional Telemedicine Forum (RTF).

Region Syddanmark and the East-Tallinn Central Hospital were both partners in Baltic eHealth funded under the Baltic Sea Region Interreg IIIB Programme which ended in September 2007 as well as in the eTen Market Validation project R-Bay. They are currently working together in the ICT for Health project.

Region Syddanmark and HIM SA have also worked together in Better Breathing and in DREAMING they were partners together with Langeland Municipality. In RENEWING HEALTH, they both worked together with Carinthia and Regione Veneto.

This dense network of relations existing among the Consortium members, the profound knowledge of each other, and the experience of working together is the best guarantee for the successful implementation of SmartCare.

County of Norrbotten, Region Veneto, Catalonia, Spain, North Norway Region, Region Syddanmark and their eHealth competence centres are all partners of the Regional Telemedicine Forum (RTF) proposal which has been recently submitted to the InterReg IVC Secretaria.

AGE Platform Europe is partner in the DREAMING project

AGE Platform Europe leads the EY2012 coalition of European organisations, whose members are among others the Assembly of European Regions, Eurocarers, Regione Veneto, AIM. AGE, Eurocarers and AIM are also used to work together in several common projects, like the WeDO project (www.wedo-partnership.eu).

The South Karelia Social and Health Care District (Eksote) is part of the RENEWING HEALTH consortium and has experience for cooperation with all the participants. Eksote has also participated ISISEMD project (2009-2011) where Eksote worked together with Trikala, Greece.

The Health and Social Care Board (HSCB) is responsible for the commissioning of health and social care services for the entire population of Northern Ireland (1.78 million). The Southern LCG (a committee of HSCB) has devolved authority from the HSCB to plan and

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commission health and social care services to meet the needs of their local population. Southern LCG is coterminous with the Southern Health and Social Care Trust (SHSCT).

SHSCT provides services for a population of approximately 358,000 within the council areas of Armagh, Banbridge, Craigavon, Dungannon, and Newry and Mourne. The HSCB performance manages the SHSCT in its delivery of services and monitors the Trust’s progress in achieving the targets and standards set by the Minister for the Department of Health, Social Services and Public Safety.

GPs are independently contracted to the HSCB and within the SHSCT area, there are 213 GPs (77 practices). The budget for these GPs is approximately £45 million and this is managed by the HSCB.

Friuli Venezia Giulia Region has a very strong institutional agreements with the Land of Carinthia and Regione Veneto supporting the deployment of INTERREG cross-border projects promoting health and social inclusion. Friuli Venezia Giulia, Carinthia and Veneto have already adopted the constitution of a EGTC also dealing with cooperation in the health sector.

In the field of ICT Friuli Venezia Giulia is also member of CORAL - Community of Regions for Assisted Living together with South Denmark, Extremadura, Veneto, Noord Brabant and, through CORAL, is partner of the Interreg IVC project CASA – Consortium for Assistive Solutions Adoption actually in the starting phase.

In the Dreaming Project ASS 1 is the only pilot site in Italy. During the trial acquired intense relationships with colleagues of other Institutions in many countries: HIM SA and HIS (Bruxelles, Munich), the Health Authority of Barbastro (Spain), the Municipality of Hebi (Sweden) and Langeland (Denmark), the Hospital Trust of Tallinn (Estonia), the German Health Co. Pflegewerk. ASS 1 has organized the kick off meeting and will organize also the final conference (14 June, in Trieste). ASS 1 is inserted in the national network of Public Health Authority (FIASO) and Municipalities (Federsanità ANCI); his Mental Health Dept. is a collaborating Centre of WHO.

Smart Homes has a long tradition of European collaboration. Together with various partners from the SmartCare Consortium, Smart Homes worked before on several projects, focussing on Ambient Assisted Living and Integrated Care. In SOPRANO (FP6-045212), COMMONWELL (CIP-225005) and INDEPENDENT (CIP-250521) Smart Homes has built up relationships with The Andalusian Social Services and Dependence Agency, E-trikala, and Empirica.

Smart Homes and PoZoB have jointly organised the Dutch pilot site for CommonWell, integrating social and health care for chronic heart failure patients. This succesfull collaboration will be prolongued and expanded in the SmartCare project.

The members of the SmartCare consortium represent a combination of long established relationships, project associations and new partners. This will enable SmartCare to build on strong foundations of experience, whilst embracing innovation and fresh thinking.

Noord Brabant, South Denmark, Scotland are part of the Consortium for Assistive Solutions Adoption (CASA). This is a 36 month regional initiative project funded via Intereg IVC which aims to mainstream the learning of the exchange of experiences for the deployment of assistive living solutions into the regional strategies of its 14 participating regions.

County of Norrbotten, Region Veneto, Catalonia, Spain, North Norway Region, Region Syddanmark, Scotland are all partners of the Regional Telemedicine Forum (RTF) which has been funded via InterReg IVC Programme.

The European Federation on Nurses Associations (EFN) has been collaborating with AGE Platform Europe, Assembly of the European Regions, Eurocarers and European Patients’ Forum within the European Innovation Partnership on Active and Healhty Ageing. In

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addition and specific to the latest partner, the EFN participates in Chain of Trust, a EU project under the Public Health Programme, due to finish in 2013. The EFN has participated, together with Continua Health Alliance, in the CALLIOPE Thematic Network and is currently a member of the eHealth Governance Initiative.

The Basque Country Health System is already collaborating with other regions involved in this proposal in the CIP programme (PALANTE and SUSTAINS) from the last European call of the CIP ICT-PSP programme targeted at empowering patients and supporting widespread deployment of telemedicine services.

The Basque Country is one on the core group regions of the CORAL Community of Regions for Assisted Living (CORAL) together with other regions in Smartcare proposal

Kraljevo (Serbia): BELIT as ICT Company have had good cooperation with Empirica in few CIP-ICT-PSP projects in past few years. Together we developed a lot of services used to increase user’s quality of life. Our development team participated in development of Health software for Ministry of Health. This software is in use in Primary Health Care Kraljevo last 5 years and we are maintaining it. Also, we will upgrade PHC with more functionality during DILS project funded by Ministry of Health.

Assembly of European Regions’s (ARE) membership includes Friuli Venezia Giulia, Norrbotten and Uppsala County Council, Catalonia, South Denmark, Communitat Valenciana, Province of Noord Brabant, Land Baden-Württemberg and Land Kärnten. ARE is a member of the Users Advisory Board of the Renewing Health Project. ARE is part of the Stakeholders' Coalition for the European Year 2012, led by AGE Platform Europe. ARE cooperates with EFN in implementing the objectives of the European Innovation Partnership on Active and Healthy Ageing as regards transferring models of integrated care across regions with the financial support of European Cohesion Policy.

The European Patients’ Forum (EPF) is currently cooperating with the regions of Carinthia, South Denmark, South Karelia, Central Greece, and Veneto, as well as with Continua Health Alliance in the RENEWING HeALTH project and Aragon, Basque Country, South Denmark, Central Greece, Veneto, Scotland, and Uppsala County in the SUSTAINS project. EPF has established closed relationships with European-level organisations representing health stakeholders that are involved in the SmartCare Consortium, especially the European Federation of Nurses Associations, Eurocarers, AGE Platform Europe, Continua Health Alliance, and the Assembly of European Regions.

The different partners involved in the Valencia region site, headed by CIPF, have significant expertise in European projects, with a wide set of relationships with other project participants. The following shows some, but not all, of these working relationships:

• UPV – Polytechnical University of Valencia – They have been involved in different projects with EMPIRICA since 1998 (ATTRACT, project that was finally coordinated by UPV; TEN-CARE or epSOS project, being subcontracted by the Spanish Ministry of Health, and HEARTCYLE), MedCom (@HEALTH, PERSONA).

• TSB – SME – They have cooperated with MedCom (UNIVERSAAL) and with EMPIRICA and the Social Services and Dependence Agency in INDEPENDENT.

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Eurocarers contributes to the RENEWING HEALTH project by sending a representative to participate in the project’s User Advisory Board.

Continua Health Alliance is a member of the RENEWING HEALTH consortium / project, and is also participating in the United4Health project which is currently in the negotiation phase.

Noord Brabant

Smart Homes has a long tradition of European collaboration. Together with various partners from the SmartCare Consortium, Smart Homes worked before on several projects, focussing on Ambient Assisted Living and Integrated Care. In SOPRANO (FP6-045212), COMMONWELL (CIP-225005) and INDEPENDENT (CIP-250521) Smart Homes has built up relationships with The Andalusian Social Services and Dependence Agency, E-trikala, and Empirica.

Smart Homes and PoZoB have jointly organised the Dutch pilot site for CommonWell, integrating social and health care for chronic heart failure patients. This succesfull collaboration will be prolongued and expanded in the SmartCare project.

B.3.2a Chosen approach The SmartCare project strives for overcoming today’s health care and social care silos by defining, delivering and piloting a multifunctional comprehensive integrated ICT infrastructure, with a view to enabling coordinated cross-sector delivery of support to older people in need of care. This is graphically summarised in Figure 5 below and further described in the following subsections. Based on this infrastructure, SmartCare services - ICT-based support to integrating healthcare, social care and self-care for different health/living conditions, along integrated care pathways - including the underlying organisational models will be piloted in 10 European regions. To achieve this goal, the project will pursue a programme of systematic service process innovation complemented by adaptation of technology. This approach will be flanked by a robust evaluation programme which – together with targeted exploitation support including cost benefit analyses and business modelling - will finally lead to the generation of evidence-based plans for further service mainstreaming in the pilot regions. Synthesised guidance on service transferability beyond the pilot regions will be developed which is to serve as an operationally useful source of information for external parties.

Figure 5: The SmartCare approach

Social

care silo

Care plans / protocol

ICT / telecare infrastructure

Health

care silo

Care protocols / pathways

ICT / telehealth infrastructure

ConventionalCare SmartCare

� inclusive

� collaborative

�safety enhancing

�responsive

�disempowered care recipient

�misinformation & patient risk

�suboptimal task distribution

Service Models

SmartCare ICT Integration Infrastructure

Real-time

communication

Access to home-

based Systems

Integrated

data access Joint response to

ad hoc requestsCoordination

between

provision steps

Integrated Support Services (ICT)

Building

�efficient

� empowering

SmartCare Services

Health care centred pathways SmartCare

integrated

pathwaysSocial care centred pathways

Cared-for person

Cared-for &self-caring person

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B.3.2a.1 Key conceptional elements The SmartCare approach relies on different key connectional elements- Smart care pathways and services - to overcome conventional, disjointed care and support practices as follows.

SmartCare pathways

Despite initial developments towards a better integration health care and social care practices in the SmartCare regions, today’s health care and social care systems are still far away from being fully integrated. To adequately reflect systemic silo structures that – to greater or lesser extent - still exist across the pilot sites, integrated care pathways can be grouped into two classes according to main care system entry points to service delivery:

• HelathCare-centred Pathways include pathways or protocols for consistent delivery of care for a particular circumstance that are typically addressed by health care actors at a given pilot site, albeit process interfaces may exist to actors addressing any additional social care needs that may evolve at the part of the care recipient.

• SocialCare-centred Pathways include pathways or protocols for consistent delivery of care for a particular circumstance that are typically addressed by social care actors in a give pilot site, albeit process interfaces may exists to actors addressing any health care needs may evolve in a particular case at the part of the care recipient.

Current pathways are to be systematically adapted with view a to achieving integrated care delivery in terms of a cross-scrotal outline of anticipated care for older people with a similar needs profile or set of symptoms. Achieving this is not an end in itself but intended to reduce unnecessary variations in care and outcomes, supporting the development of efficient care partnerships and empower older people and their carers. In this regard, recent evidence clearly suggests that a merely technology-driven integration approach is most likely to fail. For instance a recent review of a 16 pilots of integrated care in the UK revealed that “values and professional attitudes were of great importance to the success of pilots, with shared values, a collective communicated vision, and efforts to achieve widespread staff engagement cited as strong facilitating factors. Where key staff groups were not engaged (e.g., GPs), it was difficult to make progress. It was much easier to make progress where staff could see clear benefits that would result from the changes proposed and where they felt involved in the development of new services”.27 In view of the diversity of current care systems across the EU Member States and specific circumstance prevailing at the pilot sites - in relation to organisational settings, roles, responsibilities and so on - sufficient attention needs to be given by the workplan to thoroughly understanding key requirements for ICT-supported care pathway integration.

SmartCare services

In the services to be implemented in the proposed pilot, value will be delivered to service users in new (business) processes. In the extreme, value can be delivered by ICT systems interacting directly with the user. However, in this domain, ICT systems are usually more effectively deployed when access is provided to service provider staff and their requirements met. Overall value is delivered by a combination of ICT systems and professionally competent staff - people. This combination, capable of supporting delivery of enhanced people-based service, is referred to here as a socio-technical system (STS). Though the approach is based on the notion of a “people” service operating as a STS, it does not exclude cases where service automation can be - or for cost reasons must be - virtually complete, with no personnel roles in day to day service provision. Here overall services and ICT services are close to identical. However, for sustainable delivery, even of fully automated services, the wider socio-technical system is never completely absent. Where there is an organisation with responsibility for the automated service, organisational processes are

See for instance RAND Europe, Ernst & Young LLP (2012): National Evaluation of the Department of Health’s Integrated Care Pilots, Prepared for the Department of Health, p. IX

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always necessary, if not for acquiring data then for maintaining and updating software. The approach described here is designed to be substantially independent of the degree of automation of the new services.

In line with the STS concept and relying upon a set of SmartCare pathways identified during the start-up phase of the project, SmartCare services will be defined in terms of both roles that are to be performed by different actors - let them be professional staff, informal carers or care recipients themselves - and ICT components used for performing and/or supporting these roles. In this sense, two types of ICT-enabled services will - in combination - constitute the overall SmartCare service (Figure 6). Beyond services that are directly delivered into older people’s homes - which have been coined Home-linked Services (HLS) for the purposes of this project – ICT-enabled cooperation services at the “back-office” level will also be addressed, e.g. when it comes to shared access to client information by social and healthcare provider organisations. The term Organisational Cooperation Services (OCS) is used throughout the remainder of this proposal when such services are concerned.

Figure 6: Home-linked Services & Organisational Cooperation Services

Health professional

Socialcarer

Informal carer

Health care centred pathwaysSmartCare

integrated

pathways Social care centred pathways

SmartCare ICT Integration Infrastructure

Real time

communication

Access to home-

based Systems

Joint response to

ad hoc requests

Coordination

between

provision steps

SmartCare

service

models

Home linked services &

self-care

Organisational Cooperation Services

Integrated

data access

Delivery HLS and OCS will be supported by integrated ICT services implemented through a common ICT integration infrastructure, thereby relying a number of building blocks including tools/applications enabling:

• Integrated data access for care providers in different agencies, informal carers and care recipients

• Design and execution of pre-planned care pathways enabling temporal coordination between provision steps taken by care providers in different agencies, informal carers and care recipients

• Real-time communication between care providers in different agencies and informal carers, e.g. support to case conferences, care recipients

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• Access to home-based support and monitoring (TeleMonitoring and/or Telecare TM/TC) by care providers in different agencies, informal carers and care recipients

• Joint response to ad hoc requests by care providers in different agencies and informal carers

Experiences gained by the Consortium in earlier projects suggests that successful implementation of ICT-enabled care tends to be more complex than often assumed, and the introduction of integrated care practices adds even more complexity to this process: “The scale and complexity of delivering integrated care activities can easily overwhelm even strong leadership and competent project management. While it may seem obvious in theory that integrating activities should be scaled to match local capacity, this was not always the case in practice. In some cases, enthusiastic local leadership produced expectations that were difficult to realise in practice. Changes to practice often took much longer to achieve than anticipated”.28 Therefore, proper testing of SmartCare solutions and operational planning of pilot implementations deserve sufficient attention in the workplan.

B.3.2a.2 Work-plan overview

In line with the overall conceptual approach, the workplan contains ten work-packages, each focussing on a particular area of specialist activity and each comprising multiple tasks. Overall, work is organised along three subsequent project phases as graphically represented by Figure 7 overleaf.

• The first phase focuses on properly defining the SmartCare services to be piloted at a later stage, process wise and technology wise. This starts with a thorough analysis and documentation of key requirements on ICT-supported integrated care pathways (WP1). Here, the perspectives of different stake holders are taken into account which concern according to the MAST model clinical, user-related, organisational, economic, technology-related, legal and ethical requirements, each deserving appropriate attention right from the beginning if pilot services are to be set up that are both fit for purpose and technologically/economically sustainable. Outcomes of this work step then inform the development of a set of contextualised use cases reflecting concrete instances of integrated service delivery in an exemplary manner. This strand of work involves relevant actor groupings such as care recipients, care staff, administrative staff and ICT experts together with methodological exerts. This ensures that the definition of SmartCare services is primarily driven by the needs and requirements of relevant actors and mere technology-push is avoided, which again facilitates long-term sustainability of the solutions to be piloted. In a next step (WP2), outcomes are synthesised with a view to specifying generic model service processes (in terms of actors, tasks and data) meeting the requirements of all relevant stake holders.

• The second phase of the work plan focuses on properly preparing the piloting of the SmartCare integrated care models in organisational and technological regard. This starts with a thorough analysis and documentation of any ICT applications and data structures that constitute the initial starting point for service integration at each of the pilot sites, and any needs for adapting and/or extending these within project (WP3). Outcomes of this work step form the basis for specifying a common SmartCare Integration Infrastructure Architecture to incorporate all relevant web services, service platforms and device interconnections. The architecture enables specification of standards based service components directly linking into care recipients’ homes and of services that support cooperation across different agencies involved in joined-up care delivery. Required components of the specified solutions are then procured. Thorough testing of prototype versions involving a confined no. of users ensures optimal functioning and reliability of the Smart Care integration infrastructure before entering into the pilot phase with a large

RAND Europe, Ernst & Young LLP (2012): National Evaluation of the Department of Health’s Integrated Care Pilots, Prepared for the Department of Health. FINAL REPORT: SUMMARY VERSION, p. V

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number of users under day to day condition. At the same time, operational planning of the pilot starts with a final review of initial pilot plans, e.g. in relation to services selected for piloting and types/no. of users to be involved (WP5). If required the initial plan is adjusted to current requirements and circumstances and documented at required detail. Based on the final pilot plan, user recruitment starts well in advance to the beginning of the pilot phase. Staff users are instructed and trained how to operate the new integrated services and to respond to any events arising. Finally, a team at each pilot site schedules and carries out installations of equipment at the premises identified in the pilot plan.

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Figure 7: Work plan overview

WP5 Pilot site preparation(2nd wave pilots)

Integrated care pathway definition

(2nd wave pilots)

ICT system implementation & test

(2nd wave pilots)

ICT architecture & service specification

(2nd wave pilots) WP1

Requirements & use case definition

(2nd wave pilots)

Requirements Elicitation & Care Pathway Development

Organisational & ICT-related pilot preparation

Pilot operation &evaluation

WP1Requirements

& use case definition

(1st wave pilots)

WP2Integrated care pathway

definition (1st wave pilots)

WP3Project architecture & service specification

(1st wave pilots)

WP4System

implementation & test(1st wave pilots)

WP5Pilot site preparation

(1st wave pilots)

WP7 Pilot operation (2nd wave)

WP6 Pilot operation (1st wave)

WP8 Pilot evaluation

WP9 Exploitation support & project dissemination

WP10 Consortium management & performance monitoring

• The third phase of the workplan focuses on operation of SmartCare services at each pilot site which are maintained at full quality under day to day conditions (WPs 6 & 7). A team at each pilot site ensures infrastructure, platforms and applications run smoothly during the pilot and providing help services to users. A dedicated help desk service is set up to respond to problems faced by staff users and clients. The evaluation team defines and executes the evaluation methodology centring on pre-defined data capture points (WP8). Execution therefore includes carrying out baseline data gathering, data gathering at mid-term and end of the pilots and reporting of results.

All participating regions are committed to implement ICT-supported integrated care practices, but have reached different stages in preparing for this – both, technology wise and organisationally – already today. Therefore, two subsequent waves of service piloting are scheduled in the workplan. A group of four pioneer regions is expected to pass through the first two phases of the work plan within the first project years (1st wave pilots), while the remaining six pilot regions will need more time until they are ready for starting pilot operation during the second project year (2nd wave pilots). Furthermore 14 participating regions will not at all pilot the SmartCare solutions but actively participate in the 1st phase of the workplan and follow all subsequent phases, with a view to operationally preparing rapid adoption of SmartCare solutions after the ending of the project duration, the so called early adopter regions. Through this approach, common results of the SmartCare initative will be made directly and freely available to a wide range of European regions (e.g. in terms of integrated care pathways definitions and related service models as well as definitions of SmartCare ICT integration infrastructure building blocks and architecture). All participating regions’ deployment capabilities will be sustainably strengthened through a dedeicated programme of “exploitation support” to be implemented as part of the workplan. Availability of SmartCare outcomes at an even wider scale will moreover be supported through a dedeicated dissemination programme.

Beyond this, the early adopter regions will join a dedicated project advisory board – the so called SmartCare Committed Regions Board (CRB). This will strongly facilitate long term viability of SmartCare solutions by ensuring that their requirements and needs will be effectively fed into the project right from the beginning and throughout all phases of the

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overall workplan, e.g. when it comes to viability, sustainability and scalability of solutions to be piloted within SmartCare.

Also, through a dedicated coaching approach the workplan systematically caters for a mutual exchange between the pioneer regions (1st wave pilots) and the other regions. To this end, pioneer regions will broadcast lessons learnerd to other regions, e.g. by means of dedeicated webinars (T6.3).

Table 5 below gives an overview of the three groups of regions participating in the project. Towards the end of the 1st project year, the current assignment of regions to the three groups will be reviewed in relation to progress achieved in each of the regions and the final grouping confirmed accordingly.

Table 5: Grouping of regions participating in the SmartCare project

1st wave pilot regions 2nd wave pilot regions Early adopter regions

(CBR members) South Denmark Tallin Carinthia Friuli-Venezia-Giulia South Karelia Aragon Attica Baden Württemberg Scotland North Brabant Basque Country Kraljevo (Serbia) Catalonia Uppsala Extremadura Murcia Valencia Central Greece Northwest Croatia Veneto Rotterdam Amadora Northern Ireland

As a horizontal strand of work, dissemination of project results (WP9) is via a project web-site and through various other means, all guided by a dedicated project communication plant to be developed during the project’s start-up phase. Exploitation support is provided in terms of mainstream deployment planning based on extensive viability analysis from multiple stakeholder perspectives. The workpackage therefore includes investigation of wider EU markets, liaison with stakeholders for the purposes of cost/benefits analyses and business modelling as well as preparation of guidelines to enable other regions to emulate the achievements. A dedicated action plan for further deployment of SmartCare services beyond the project duration will be developed and carried out.

As part of this workpackage various Advisory Boards are constituted and run. Finally, WP10 covers project management – technical, clinical and administrative management and quality assurance for the entire project period. Coordination of the project comprises key tasks from quality management and the management of ethics issues to administrative procedures, conflict resolution and the implementation of the Consortium Agreement.

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B.3.2a.3 Workplan implementation and monitoring Iteration at task level

During the 1st phase of the workplan, a proven iterative approach to service design is the basis for the proposed work plan.29 A classic “waterfall” design process from requirements to final service is not seen as fit for purpose in a domain where a considerable amount of knowledge is still lacking on how best to further integrate locally available care services with a view to optimising usability, viability and scalability of SmartCare solutions. Accordingly, the work plan for the proposed pilot is based on an agile, iterative, use case based service design approach specially developed for medium to large scale pilots of innovative ICT-based services and successfully deployed in innovative service piloting in a range of settings where it is proving to be extremely successful.

The process of service development in the proposed pilots is based on the principle of iterative design. This approach enables an appropriate level of control to be taken by users and their representatives, as well as enabling service design specialists to learn how best to meet all key user requirements and ensure all service responses are attractive and acceptable.

A minimum of one iteration of design is seen as essential to ensure the innovative new services are fit for purpose, and usability and role issues all appropriately clarified, before delivering them to hundreds of users over many months. In particular, there must be an opportunity to review and assess use cases, service design and IT system functionality and dialogue on the basis of appropriate testing with users. A two stage iterative approach has been integrated into the work plan for this project.

The first design cycle sets out from an analysis of the requirements of users - non-functional and service related requirements - and of any requirements imposed by service providers. This is used in a creative process of envisioning the new services, captured in a first version of service use cases. The use cases incorporate key functional requirements the services will be required to meet. Use cases are validated with users and providers before generalised service models are built in which use case responses can be delivered. Following this, a complete specification of the service to be delivered, the ICT system and its architecture are drawn up, the information needed to implement overall ongoing service delivery to users.

Tools have been developed to support the approach. These have already been used in planning and will be used for managing the project.

Task level planning

Workplan information at the level of a work-package (WP) is based on a complete plan at task level. Each task has defined start and end point (as specified in the work-package tables, see B3.2b.4), partner resources are allocated at task level and task leadership has been allocated (also specified in WP tables).

As part of operational management, partners will receive lists of tasks they are responsible for or will contribute to - objectives, approach, timing, resources. Each task in the list has a description identical to the proposal. To enable this approach to be fully effective, even task descriptions which are very similar are nevertheless reproduced in full in documents such as work-package tables.

Clear responsibility is allocated for all intermediate outputs by assignment of a lead organisation for each task. A detailed distribution of personnel resources across pilot teams and core team has been prepared at task level to ensure that each task output can be

Meyer, I., S. Müller, et al. (2011). AAL markets – knowing them, reaching them. Evidence from European research. Handbook of Ambient Assisted Living. Technology for Healthcare, Rehabilitation and Well-being. J. C. Augusto, M. Huch, A. Kameaset al, IOS Press. 11.

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achieved at the required level of quality. Effort per task for each contributing partner has been carefully and systematically estimated on the basis of role, task objectives, expected outcome and scale. The estimation is based on considerable experience from estimating effort for comparable projects.

Most tasks are carried out in collaboration between two or more participants, and roles per work task have been designed to minimise duplication of effort. The result is a lean distribution of resources nevertheless adequate to cope with the very significant breadth of the work and scope of pilots.

The aggregation of task level resource distributions is reflected in resource figures at WP level. Workpackage leaders and project management support task leaders in achieving the assigned output.

B.3.2a.4 Evolving Document SmartCare Guidelines

The SmartCare work programme supports efficient service optimisation in which all the specification domains critical to full interoperable, sustainable, usable and acceptable service implementation - service models, ICT component specifications, architecture, viability assessments etc. etc. - are each refined in two iterations. For external experts to monitor this process, and for project participants to maintain overview of all parts of specifications, it is essential that all changes are clearly locatable and visible. Where the output of a task consists at least in part of copied information from previous documents, e.g. where that particular area of specification has stood the test of intervening work, this should both be in the same "place" and changes to the previous version distinguishable from unchanged areas - the "evolution" should be visible. At least as important as these transparency considerations is the fact that service specification information domains are strongly interrelated and must make up a consistent whole, in terms of terminology, facts, references etc.

The SmartCare work plan therefore introduces a document, SmartCare Guidelines, which is to evolve over the lifetime of the project. It has the primary purpose of capturing plans and specifications which guide further work in the project and may also be modified by project results.

The evolving document may actually consist of multiple documents, without compromise with the principle of a living document. The final use to which this material is put is as coherent body of information to support uptake and replication in other regions and organisations, hence the title throughout: "Guidelines".

The evolving document is created early in the project (from Phase 1 results) and maintained throughout the project. Specific versions of the ED are defined as deliverables in the workplan. Towards the end of the project (M 35-36), the outcomes of previous work tasks documented in the evolving document will be reviewed and synthesised into a coherent single source of operational information and edited for use by external parties (D9.3 Guidelines for pathways and integration infrastructure procurement and uptake).

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B.3.2a.5 Work package methodology

WP 1: Requirements and integrated care pathway development

Work will start with a thorough investigation of requirements for integrated care service provision, and based on this identification of SmartCare pathways. This will include a thorough analysis of requirements of envisaged SmartCare end users and care staff as well as organisational and legal/regulatory requirements when it comes to pathway integration. In relation to the latter, existing national and supra-national legislation / regulation with a potential bearing on the services to be piloted will be identified in a systematic manner, e.g. when it comes to data protection and liability issues. Beyond this, any sectoral and/or occupational codes of practice that may exist in the participating regions and/or service provider organisations will be identified as well. A subsequent analysis of the identified legal/regulatory requirements will then feed into the development of a comprehensive requirements catalogue for subsequent work on service/system design and implementation (see also B3.4).

Different methods will be applied to this end including a literature review and primary data collection by means key informant interviews and moderated group discussions.

To enable generation of SmartCare pathways in a systematic and operationally useful manner a use case approach will be applied which has proved highly effective and efficient in comparable context. Generally, the use case concept has been applied differently in different context. For the purposes of SmartCare a use case is understood as a structured textual description of a specific example of care service use following a dedicated pathway, thereby focussing in particular on activities by all actors involved (clients, categories of staff, other users) and outputs to each user not only of the ICT system but of any part of the socio-technical system. Each use case is documented according to a number of dimensions:

• Roles: A description of persons active in the use case - name and relevant characteristics.

• Clients: description of end-users (receivers of service) involved in the use case - names and characteristics relevant to the use case.

• Socio-technical system (STS): Description of the ICT components and applications and use / staff roles in the system.

• Use case body: a) description of the outset / problem situation b) STS response focussing on outcomes of the response visible to each user type (end-user, professional etc.) c) autonomous events changing the situation d) STS response (etc.)

• Technical application system (TAS): A detailed description of the functional requirements the use case presents to the ICT applications which are to support it.

• Service integration: Features of the use case illustrating integration with other services / application usage.

• Possible variants and improvements: Options use case authors have discussed in terms of the content and the TAS requirements both as alternatives and as improvements to the case described.

• Assessment: Advantages and disadvantages in comparison to alternative systems/services, a concise summary of the relative improvements presented by the services in the use case, not hiding possible disadvantages such as greater costs; an initial assessment of anticipated requirements of mainstream implementation (e.g. technology-related, organisationally, ethically).

Use cases are chosen to illustrate key benefits provided by the integrated care pathways in a contextualised and examplary manner, including where appropriate how service delivery is adapted to special requirements of users. For any but the simplest of services, two or three use cases will be needed to properly illustrate all key service responses which must be

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present in the final implementation. In cases of fully automated services, the description of the socio-technical system is empty and the set of roles includes the end-user only. Guideline documents will be applied by expert staff for guiding pilot sites on use case development. WP 2: Service process model

Based on a set of exemplary pathways described and assessed by means of the use cases approach; SmartCare service processes are modelled and formally documented. Here, a key step will be to model the socio-technical system (STS), in which services are to be delivered. As discussed earlier in a STS, service delivery incorporates a number of elements in addition to ICT, in particular, specific roles played by a range of staff with appropriate qualifications. Service models are set up based on use-case generation and validation. Service models describe the operation of the complete STS, along with the roles to be played by different categories of staff. In each case, appropriateness and feasibility of tasks will be tested against competence profiles and validated with those who are in future to play the role in question, who ideally participate directly in the modelling process. In order to use the ICT system effectively, staff will be helped to impose appropriate requirements on the functionality, availability, data structures etc. of the ICT system and its services. This will take place in group settings and in individual interviews and envisioning sessions, usually using the use-cases at hand.

A key component of the service model is a schematic description of how the service operates in response to any service request i.e. in all cases of service use. This generalisation of the flow of a use case typically requires a process modelling language of some kind. Coding and visual presentation of the service model has been found to be well- supported both by specialist process design packages such as that developed by IDS Prof. Scheer, now Software AG, but also by simple flowcharting tools, including the ubiquitous Microsoft Visio. The more specialist business process design tools are most appropriate, if not essential, if a service is to be implemented by using workflow engine technology.

Service models are constructed from generalised roles including particular staff qualifications and specialisms and may also differentiate between different user roles. Checklists will be made available for project partners to assemble the information needed to create a service model. The result can be as simply presented as the following example (Figure 8), which nevertheless is part of a complete description of service responses in the case concerned. The example is presented for illustrative purposes only and concerns a service model for a web-based energy management and awareness service.

In a first step, such model service processes will be separately specified for health care centred pathways (HCCP) and social care centred pathways (SCCP). The service models from both domains are then combined into a single service model. As an outcome, this strand of work will deliver a valid and operationally useful basis for specifying a common SmartCare Integration Infrastructure Architecture to incorporate all relevant service platforms and device interconnections.

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Figure 8: Example of graphical representation of a service models

WP 3: Project architecture and service specification

This WP focuses on defining the ICT infrastructure supporting all services delivery processes modelled earlier. All in all, there is considerable diversity across the individual SmartCare pilot sites when it comes to existing ICT-infrastructures to build upon for the purposes of service integration. Also, the health and social care sectors across the pilot sites (and elsewhere) tend to work to differing work practices. Given these complexities, a controlled migration from existing work practices and technologies is to be considered. Almost by definition, this means that the project encounters a great deal of legacy technology along the way, which was created to support a range of processes and pathways, and prior to the SmartCare concept of better joined-up support provision. Therefore, adequate attention needs to be paid to understanding not only the organisational, legal and regulatory environments in which ICT-enabled services integration is to be realised (WP1), but existing "legacy" ICT infrastructure as well. SmartCare service specification work therefore begins with a thorough investigation of any relevant legacy technology across all pilot sites. All relevant legacy ICT applications and data structures to be considered for the purposes of SmartCare will be catalogues at pilot site level. Based on outcomes, an appropriate SOA-based architecture will be drawn up in which ICT-based services are located and providing orientation for ICT service specification. SOA is a set of design principles used to define systems with a high level of integration. Systems based on SOA package functionalities as interoperable services which can be used by multiple different systems from several business domains. The SmartCare architecture and service specifications will be made freely available and support interoperability across the pilot sites and beyond. WP 4: System implementation and test

This WP focuses on implementing the properly defined SmartCare services. This includes user testing of an appropriate prototype implementation in a laboratory or where appropriate in focus group setting. Prototypes of services and their testing with users play a pivotal role in the overall iterative service design approach. A service prototype is in general a partial implementation or representation of the new service with the purpose of serving to test key features of the service in advance of full implementation. The prototype is thus to help clarify outstanding issues in service design with users and service providers.

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Component implementation or even implementation of a full prototype is advisable where there is a range of technical options to be explored, interoperability or specific interface usability issues to be addressed.

Where issues of user dialogue including user acceptance of service use are key to service implementation, technical implementation of functionalities is seldom appropriate. Instead, service operation will be simulated in such a way that potential users can easily understand what they will receive. This simulation is likely to be a clearer experience for users than an early implementation, which often presents a range of faults, disturbing users. Such a visualisation will be oriented to existing use cases - without implementation of the service model, the sequence of events which can be simulated is typically constrained to user choices and actions specified in advance.

A use case can be taken forward into user testing by visualising the process in any of a number of ways. Simple presentation graphics or animation techniques will be used, and where appropriate video sequences will be created. WP 5: Pilot site preparation Following successful specification of SmartCare service process models and complementary to system implementation, this WP will focus on operational planning and preparation of pilot service roll out. Initial pilot plans are reviewed and if required adapted to given circumstances. At the same time operational pilot preparation is started at site level, guided by the WP leader with a view to ensure adoption of a coherent approach across all pilot sites, including:

• Setting-up the SmartCare ICT infrastructure for piloting purposes o Selecting ICT equipment/devices to be installed in the pilot users’ homes and

defining responsibilities for installation, de-installation and maintenance o Selecting ICT platforms/devices to be installed at the “back office” level and

defining responsibilities for installation, de-installation and maintenance o Procuring ICT equipment/system components

• Setting-up of the SmartCare service delivery processes for piloting purposes o Agreeing on roles and responsibilities of organisations which will be involved

in service delivery o Agreeing on roles and responsibilities of people/staff who will be involved in

service delivery o Training measures to be conducted o Concluding any contractual arrangements that may be required o Identifying service end users and planning/starting their recruitment

• Planning / setting-up a help desk at pilot site level o Defining services to be offered by the help desk o Implementation of the help desk

• Planning/implementing ethics and data protection management procedures o Formal ethics approval potentially required o Compliance with basic ethical principles o Informed consent o Data privacy

• Planning / setting-up risk management procedures o ICT related risk management o Service process related risk management o User participation related risk management o Identifying any other risks of potential relevance to the pilot and options for

remedial action

• Planning / setting-up evaluation procedures at pilot site level

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o Defining responsibilities for information gathering o Training of local staff in applying evaluation techniques / instruments o Managing the evaluation/data gathering process at site level

WP 6: Operation of all 1st wave pilots

After having successful passed the previous work steps and having concluded pilot preparation work, a 1st wave of pilots will become operational. Here, SmartCare services at all pioneer sites are to be maintained at full quality, including implementation of a dedicated Ethics and Data Protection Framework to be developed in xxxLK WP10 during the start-up phase of the project. A team led by the pilot site manager provides support and addresses maintenance and system operation problems which may occur during pilot operation. A help service is maintained to respond to problems faced by staff users and by clients. A dedicated mechanism will be put in place to enable systematic knowledge transfer and mutual exchange between pioneer regions (1st wave pilots) and all other regions involved in the project (2nd wave pilots, early adopter regions). To this end, regular webinars and workshops are held to provide a forum not only for jointly capitalising on experiences gained in pilot implementation and operational maintenance, but for supporting the participating regions in view of reaching consensus on an challenges potentially faced and solutions to be pursued respectively. WP 7: Operation of all 2nd wave pilots

In a deferred manner, the 2nd wave pilots will follow the same process when compared with the pioneer regions (1st wave pilots) WP 8: Pilot evaluation

A dedicated work package will be donated to pilot evaluation activities. Functions and impacts of the SmartCare pilot services from the point of view of the different roles/stakeholders of importance will be evaluated, such as end users (care recipients), voluntary and non-voluntary informal carers, formal care staff/professionals, managers and fund-holders. Evaluation of integrated care service delivery processes (process evaluation) will improve the current scientifically based knowledge base on barriers and facilitators towards integrated care delivery. Beyond this, scientific knowledge will be generated on outcomes of integrated care service delivery from the perspective of all actors involved. Apart from generating a number of self-standing deliverables, this workpackge will directly feed into WP9 with a view to support further exploitation of project outcomes beyond the project duration by relevant stakeholders and wider dissemination within the project duration.

The overall evaluation approach and individual methods to be employed will be consolidated in a dedicated evaluation framework (D8.1) to be generated throughout the start-up phase of the project including the elaboration of a minimum dataset and a baseline measurement (as a part of the stepped wedge design). The current view is that the evaluation framework will build upon the Model for the Assessment of Telemedicine (MAST) developed by the Metho-Telemed project. Here, evaluation work is seen as a multi-disciplinary process that summarises and evaluates information about the medical, social, economic and ethical issues related to the use of telemedicine in a systematic, unbiased, robust manner. As SmartCare sets out to pilot integrated care services rather than telemedicine, the MAST approach will specifically be tailored to the requirements of the project.

Evaluation design A stepped wedge evaluation design will be adopted for the purposes of SmartCare to take appropriate account of the given situation, that pilots have different starting points in terms of SmartCare service implementation. Briefly, the stepped wedge approach means that interventions are implemented stepwise in a population, with the population itself serving as control group. The figure below shows the design (Mdege et al. 2011).

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Thus each row in the diagram represents one pilot or one aspect of the SmartCare service. This means, it is essential that all pilots make their measurements simultaneously in same time intervals with first measurement at kick-off and the following at other pre-defined times. This is regardless of whether or not the interventions are implemented. The variables to be measured will consist of some common, mandatory variables provided centrally in a minimum dataset and if necessary, additional local voluntary variables. The scientific arguments for choosing this particular design are: 1) there is an a priori belief that the intervention will do more good than harm, and 2) phased implementation is preferable due to practical or other limitations (Brown & Lilford 2006; Mdege et al. 2011). The design will be non-randomised, since the waves are determined by maturity of technology and setting as opposed to randomization.

Outcome evaluation As already mentioned, the current view is that the evaluation of outcomes will address dimensions set out in MAST in order to facilitate a comprehensive, multidisciplinary evidence suitable to support decision making on service implementation/mainstreaming. This will include assessments of: 1) Health problem and characteristics of the application, 2) Safety, 3) Clinical effectiveness, 4) Patient perspectives, 5) Economic aspects, 6) Organisational aspects, and 7) Socio-cultural, ethical and legal aspects. Also, the MAST model ensures that the evaluation will cover all services and all stakeholders’ perceptions. Examples of potentially useful outcome measures include :

• Number of hospital admissions • Number of access to emergency rooms • Number of duplication of tasks among care organizations • Patient-rated and staff-rated continuity and comprehensiveness of care • Patient-rated quality of life (e.g. reduction in loneliness feeling, anxiety, depression,

carers overburden) • Self-rated informal carers’ contribution towards care needs • Self-rated older people’s safety including reduction in home accidents, wandering of

people suffering from dementia • Measure of timeliness and appropriateness of interventions • Potential reduction in overall travelling time for non-essential face to face intervention

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Process evaluation When it comes to process evaluation, the evaluation design to be adopted for the purposes of SmartCare, will reveal new knowledge on implementation aspects. The assumption behind the figure below representing the programme theory is that resources available will lead to activities, which again lead to performance. The process evaluation approach, then, aims at creating knowledge on the assumed process, i.e. answer the question: do available resources lead to implementation of SmartCare solutions? (Daponte 2008)

Activities (developing

the platforms,

implementing

platforms)

Performance

(improved

communication,

improved patient-,

carer-, and staff

satisfaction)

Programme theory, evaluated

by process evaluation

Resources available

(ICT technology, staff)

Adding a process evaluation to the SmarCare project then implies the project leading to added knowledge on implementation aspects, which are still to a high degree unanswered through the outcome evaluation. Operational implementation of the evaluation approach In operational regard, the evaluation process follows the design summarised in the figure above, i.e. measurements will be carried out at baseline, implementation time points and at the end. The final interventions should be similar in terms of objectives and service delivered, although technical solutions are allowed to differ. Evaluation work will be organised as follows: • An Internal Scientific Board (ISB) constitutes an overall decision body, with

responsibilities of discussing and deciding on overall project evaluation issues, and developing a scientific dissemination strategy.

• The ISB is expected to consist of one research expert representing each pilot, preferably experienced within clinical, economic or public health sciences

• The ISB will produce and register a scientific protocol • A central database will be developed and contain all data from all pilots • ISB members will locally be responsible for collecting data and submitting data to

RSD/the central database • Data analyses for scientific papers and EC reports are the responsibility of the ISB

members for their respective pilots. • Overall summaries and data analyses for scientific papers and EC reports are the

responsibility of RSD

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WP 9: Exploitation support and dissemination

As a horizontal strand of work, this WP aims at guiding the Consortium towards successful joint exploitation of results. To this end a dedicated programme of preparing wider deployment and wider use of SmartCare services will be pursued, thereby focusing on two strands of work, namely dissemination and exploitation support:

• Dissemination work will begin as soon as the EC contract is signed, including setting up and maintaining a project web site, dissemination through social and healthcare provider organisations and multiple further vehicles such as brochure, presentation, publication etc. Project aims, plans and interim results will be disseminated to all interested parties from kick-off (contract signature) onward. Work on dissemination will include informing all stakeholders from public authorities, healthcare and social care providers and voluntary sector organisations to older people, their families and the general public about the project and its results. A communication plan will be developed for external dissemination early in the project, involving all pilot site managers though a dedeicated networking task. Dissemination materials including a general project presentation (PowerPoint slides) and a 2-6 page project brochure will be made available. A list of target organisations and individuals for promoting the project is then drawn up, initially at national level. During the project, outcomes are communicated to the wider public and to policy makers. Alongside the website, measures include the regular publication of a project newsletter, writing of scientific papers and presentation at relevant conferences. In coordination with the SmartCare advisory boards, policy and public authorities are contacted at national level and informed about the project. In year 2, 1-2 workshops are organised at national level to enable interactive contact with stakeholders and potential replicators. A key vehicle for dissemination is to establish and maintain an attractive and informative web presence for the project. To ensure global visibility and full accessibility to the project, the web-site is set up early in the project and maintained throughout. An URL is reserved and a layout agreed including Corporate (Project) Image components (logo, colours etc.), content structure and navigation. Key documents are provided for download with project summary and partner profiles. Good usability is to be ensured and accessibility to meet W3C WAI WCAG2.0 (Level AA). Public deliverables, publications, presentations and press releases are to be uploaded as they are released. All documents including summary are to be kept up to date throughout. Furthermore, online channels such as LinkedIn, Facebook, Google plus, Twitter and Youtube will be used to disseminate project findings and offer forums for discussion. Communication through these channels will be thoroughly planned and included in the project communication plan to be developed early in the project.

• The approach to exploitation support is directed towards optimally supporting public authorities and other types of actors at regional level in reaching consensus on further mainstreaming of SmartCare solutions. It will be guided by methodological and business experts to ensure maximum effectiveness. Core elements of the approach are the development of a deployment action plan and a dedicated strand of business case modelling and business plan formulation activities. The approach also involves assessment of service viability (already guiding service definition) and the analysis of legal and regulatory conditions at European and national governance levels. The deployment action plan will be developed at local and regional level in cooperation between all pilot site managers, in order to guide all relevant activities throughout the lifetime of the project. It will focus on supporting successful implementation of the SmartCare pilot service under legal and regulatory conditions which currently exist at the various pilot sites. However, recommendations for any regulatory and/or legal changes that may facilitate further mainstreaming beyond the immediate project duration will be developed and presented in the deployment action plan as well. Beyond this, all pilot site related legal/regulatory recommendations presented in the action plan will be synthesised and presented as part of the SmartCare Guidelines (D

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9.3) with a view to providing more generic legal/regulatory guidance to potential follower regions as part of the project’s dissemination work strand (e.g. by means of presentations, publications and workshops). To this end, a dedicated networking task will cater for an exchange of proposals for dissemination and exploitation between all partners. The approach to business case modelling is based on the analysis of service costs and benefits to different actors, the due consideration of financing means and the modelling of the service concept to ensure economic viability30. Based on an analysis of the service framework conditions, costs and benefits to the different stakeholders in the service are identified, suitable indicators are developed, data on the indicators is collected and a cost-benefit analysis (CBA) is carried out. The analysis will be done using the ASSIST tool for CBA of eCare services31. ASSIST was originally developed by empirica for the European Space Agency (ESA) for use in the assessment of telemedicine projects, and was adapted to the purposes of integrated eCare in CIP projects CommonWell and INDEPENDENT. After analysis, ASSIST shows for each stakeholder in the service the different costs and benefits (such as equipment cost, setup cost, costs for service provision, efficiency of service benefits, quality of service benefits, quality of life benefits). Further to this, key aggregate measures such as overall socio-economic return, cumulative net outcomes or return on investment are calculated for the whole service. Calculating these measures for alternative models of service provision allows both to find the model that best fits the service and also to identify adaptations to the service that may be necessary from a business point of view. Data to be fed into the Assit tool will be gateherd directly from the pilot regions, and augmented by a transferability assessment to be carried out as part of WP8 (pilot evaluation). In close alignment with the business case modelling, operational business plans are developed covering needs addressed, conditions for service provision (including the legal and regulatory framework), market structure (both end-users and intermediaries) and competition, costs and benefits (from CBA), provision schemes and revenue sources. All exploitation activities will be closely linked to project dissemination with a view to spreading the word on economic impacts of integrated eCare among relevant stakeholders, in particular regions and organisations interested in early adoption. To this effect, use will also be made of the expertise and connections of the project’s Advisory Boards. The approach is rounded off by the production of “Guidelines for Pathways and Integration Infrastructure Procurement and Uptake (Task 9.9), primarily addressing public administrations and other social and healthcare providers, but also reimbursers and political decision makers. The guidelines will present, in a concise and easy-to-understand manner, the lessons learned from SmartCare’s exploitation activities.

Different Advisory Boards will be established to provide continuous input throughout the project’s life cycle (for details see section B.3.1.4). Each Board is to be informed about project results and invited to meet, at least once a year over the duration of the project. Further meetings may be scheduled if agreed by Advisory Board members. During the project’s start-up phase, a briefing document will be elaborated and tailrored to each AdvisoryBoard’s expertise. Each briefing document will set out a detailed work schedule for the entire project duration, specific work tasks to be achieved as well as appropriate co-operation modes and techniques to be applied in this context. The briefing documents will be distributed in advance to the inaugural Board meetings to take place within 3 months from the beginning of the project. A key outcome of these meetings will be a commonly agreed Roadmap document datiling commonly agreed worksteps and expected contributions along an agreed time line. A draft version will be prepared and circulated in advance to the inaugural Board meetings and largely build on the indicative list of tasks provided below. The

For details, see Meyer, I., S. Müller, et al. (2011). AAL markets – knowing them, reaching them. Evidence from European research. Handbook of Ambient Assisted Living. Technology for Healthcare, Rehabilitation and Well-being. J. C. Augusto, M. Huch, A. Kameaset al, IOS Press. 11.

31 See ASSIST – Assessment and evaluation tools for Telemedicine, http://iap.esa.int/projects/health/assist.

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final version will consider input received from the panellists prior to the inaugural meeting and at the event itself. In parallel, the project web site will be used be used for communication, planning and information exchange. It is envisaged that the Advisory Boards will provide continuous support to most work packages throughout the project’s life cycle. At a generic level, three different types of involvement are envisaged as follows:

• Advise: Board members will actively provide input and advice to certain work packages or tasks, e.g. in the form of dedicated contributions to be elaborated for the purposes of the project and by provision of existing knowledge in terms of research reports and the like

• Inform: Board members will be informed about work progress and achievements. The information provided will either be for their own use or for dissemination among their own and related organisations

• Comment: Board members will react on input provided by the project partners and make comments on them (e.g. key project deliverables, specifications, internal working documents), either during personal meetings or remotely by means of electronic communication

A final project conference will round off dissemination and exploitation support activities, thereby targeting a European audience. Relevant EU-level initiatives will be approached well in advance to discuss synergies that could potentially be realised by cooperating in one form or another, e.g. European Innovation Partnership on Active and Healthy Ageing and a Thematic Network on community building for active and healthy ageing to be set up with the support of the European Commission in the near future (Objective 3.7). SmartCare will target in particular the work of the Action group B3 on “Integrated Care”, set up in the framework of the European Innovation Partnership. SmartCare will disseminate its outcomes and lessons learnt as well as learn from discussions in this working group.

WP 10: Project management and performance monitoring Finally, a dedicated WP covers project management - technical and administrative management and quality assurance for the entire project period. Coordination and management of the project comprises key tasks from quality management and the management of ethics issues to administrative procedures, conflict resolution and the implementation of the Consortium Agreement. Performance of the project will be monitored throughout its entire life cycle according to pre-defined and quantifiable indicators. A specific subtask within this work package will be dedicated to the check of the compliance of the platform that the pilot sites intend to procure with the common functional specifications and the adoption by these of open rather than proprietary systems.

B.3.2a.6 Pilot site plans

Most regions of Europe are facing similar issues in maintaining the independence of its older citizens, and there is convergence in the responding policy approaches. Care and support responsibilities have started being coordinated more closely across all SmartCare regions, albeit yet with differences in focus and speed. Much the same approach to cross-sectoral care pathway and infrastructure integration will be needed across Europe, and in particular at each pilot site. In SmartCare, a European level vision will be commonly shared among all pilot regions, whereby a focused approach will be adopted to take appropriate account of particular national/regional circumstances prevailing across the SmartCare regions. Building upon services already in place, each pilot region will take a broad approach and implement multiple components of a complete integration infrastructure. To apply project resources efficiently and to adequately cater for the particular pre-conditions and circumstance prevailing at each site (e.g. in relation to existing social/health care structures, services processes and responsibilities/actors involved), each of the 10 pilot sites adopts a clear initial focus as a starting point for progressing towards integrated care delivery in line with the

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common SmartCare approach. For example, for the pioneer regions (1st wave pilots) the initial focus can be summarised as follows:

• In South Denmark (RSD) an integrated care internet portal for heart failure care will be implemented in late 2012. Taking the portal as a starting point for SmartCare, extend deployment of the cooperative portal to care for COPD, diabetes or cancer rehabilitation in SmartCare will be achieved. Integrated care service delivery processes between GPs, hospitals and municipal care organisations will be supported by a common integrated ICT infrastructure to be implemented within the project, partly building upon components which have been put in place already (e.g. an integrated care record system). The Danish pilot will not only work across current sector boundaries, but also actively involve patients with chronic diseases as “co-producers” of health care, thereby supporting patient empowerment in the sense of increased patient safety and satisfaction as well as increased competencies for self-care in the patient’s own home, and a stronger attention to their personal health respectively. The patients would benefit from care coordinated between GP, hospital specialist and social carers placed in the community. Older COPD, diabetes or cancer sufferers will be able to utilise the SmartCare integrated care infrastructure to receive better treatment across sector boundaries and to further deploy the Shared Care platform into new areas such as self-monitoring in their own homes. Hospital staff, municipal staff and GPs will use the infrastructure in this cross-sector treatment by sharing central information across systems and by utilizing the suitable components of SmartCare, thereby ensuring a higher quality of care and a more seamless transfer of vital information across typical sector boundaries. If care requirements are more complex, e.g. with patients suffering from several chronic conditions, additional life-style related recommendations might be implemented with the support of the community services. With the deployment of a fully functional integrated care platform, a typical Danish citizen suffering from one or several chronic conditions will benefit from important changes in the encounter with the GP. At the same time, the GP would have access to sophisticated decision-support tools, supporting him in the delivery of evidence-based care. At the start of every encounter, the GP and the patient would together review a digital patient plan, elaborated at the beginning of the treatment relationship. This plan is the common tool for cooperation between patient and GP, containing the treatment goals jointly determined and an overview of all past and upcoming appointments. A GP with a diabetic patient would be in a position to consult patient reported outcomes from a home monitoring or vital sign monitoring system, responses to nurse administered well-being questionnaires etc. Problems such as appropriate foot or eye care could be detected early, target values for the blood glucose level and possibly dietary habits would be managed together. With reference to the patient plan, progress would be visible instantly, as well as deviation from the plan, thus putting the self-care responsibility of the patient in the centre. Combined with decision-support tools and an aggregation of results on the population level of the community in which the GP works, treatment would always be based on official guidelines. The quality of the treatment delivered could be assessed against a larger set of patient data. The envisaged mobile application for the Danish healthcare platform would allow role-based access to the data held on the platform.

• Patients in Scotland will benefit from joined-up care, enabled by ICT to allow staff across agencies to collaborate for integrated care delivery. At the basis of this innovation is an integrated record linking out of hours & emergency care which is being build on and extended. This is supplemented with a wide range of telemonitoring tools such as remote vital sign monitoring and home safety monitoring tools. An elderly patient, living on his own, is thus able to continue living in his familiar environment. Lifestyle and behavior of older people are being monitored and services are provided which allow them to access information on community activities; an

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effective means to prevent social isolation. Staff from health and social services communicate via videoconferencing and screen sharing tools to coordinate a patient’s care. The data collected in these activities is fed back to improve care planning and management processes. Service standards are developed jointly by health and social care professionals to further improve care and reduce response times.

• The autonomous community of Aragon has already established an advanced ICT infrastructure for providing care to chronic patients. Thanks to the SmartCare project this infrastructure will be enhanced to provide an integrated care for chronic patients in tight collaboration with social organizations and patient’s associations. At the core of the infrastructure is a telemonitoring platform linked to a call centre. The telemonitoring platform collects patient status information sent from the home and generates clinical alarms (medium and urgent types) according to the health status of the patient, and the personalized value range registered for each patient. These alarms are flagged to healthcare staff at call centre. The specialized care nurses and doctors evaluate the alarms through the monitoring web portal and if necessary, start the attention processes that the patient may need in collaboration with the health and social providers, either through the visit of the social organizations and volunteers, either transferring him to primary care, the GP or sending an ambulance in the case of emergencies. All these entities coordinate to provide an integrate care to patients. This system will be enhanced with tools that allow the management and coordination of social and healthcare actions provided by each actor, and integrating it with the existing infrastructure that social organizations and health providers have. The overall care provided is adapted to the needs profile of citizens, which may vary. From the point of view of healthcare staff, they have an IT infrastructure that allows the collaboration among professionals. They are provided with an intranet that gives web access to all departmental applications, report repositories and access to data integrated on care health records and also collaboration environments with tools as videoconferences systems. At the same time, social organizations are provided with the so-called “assistance centers” to collect and manage the assistance acts provided by the organizations. The Smartcare platform will enrich the current systems with mechanisms to centralize the social and health care services provided and will deploy new services for social organizations, patients’ associations, sanitary professionals and citizens as the implementation of care pathways that permit to coordinate the actions of every carer.

• Friuli-Venezia-Giulia will build upon the local primary health care service developed since many years by the health care districts, which are responsible for all types of out-of-hospital care, in particular home and residential care for elderly people. Activities of the existing call centre will be connected to the integrated care platform to deliver timely responses to citizens in need of care. Patients suffering from diseases, such as heart failure, COPD and diabetes, coupled with high risk of isolation and social exclusion represent the key target group. The services will be driven by nurses and doctors (GPs and doctors of the districts) with many years of experience in running programs devoted to the improvement of home care services for these patients. The objective of the integrated care platform to be implemented in the course of the pilot is to allow sharing of clinical data and monitoring of clinical conditions of patients through data collected from telemonitoring devices. This would allow to constantly adapt healthcare to changing clinical parameters and to promptly detect emergency situations. Special attention will be paid to emergency cases, and the platform will benefit from the activity of the existing contact centre for prompt intervention. In order to achieve fully integrated care, the home-based social services, which respond to the municipality, will be systematically involved. Thus, besides routine activities to prevent risks, ongoing social assistance will be provided. Finally, volunteers and citizens associations will be involved as users of devices and platform in order to improve the contribution of informal care, thus enhancing the solidarity and

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subsidiarity networks, as continuously looked forward for many years. It seems reasonable that the platform could be introduced also in residential care routine, since in FVG there are 10.500 elderly people living in 191 residential nursing homes. The platform would be useful to support social contact and networking of institutionalized patients

For progressing towards a common SmartCare approach all pilot regions will rely upon a set of ICT based core integration building blocks described earlier (see B.1.1). Each site will address several components out of these building blocks of the overall SmartCare digital support infrastructure. The specific components to be implemented may vary according to the initial focus of the sites. The table below provides an overview of the core ICT functionalities to be utilised for integrated care – the ICT based building blocks as described in Section B.1.1. Coding used in the table is follows: “A” stands for component(s) “Already in place”; “P” means that components will be implemented as part of the pilot; A/P stands for already in place but may need adaptation.

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Table 6: Overview of ICT to be utilised for integrated care delivery

Region

ICT based building blocks

(1) ICT tools / applications for integrated data access – e.g., shared EHR/ integrated care record

(2) ICT tools / applications for real-time communication – e.g., videoconferencing

(3) ) ICT tools / applications for care coordination/ pre-planned care pathways

(4) ICT tools/ applications for home-based monitoring (Telemonitoring and/or Telecare)

(5) ICT tools/ applications for joined response to ad hoc requests – eg Contact Centre

Friuli-Venezia-Giulia P P P A/P P

South Denmark A/P (A)/P A/P A/P

Scotland A/P A/P A/P A/P A/P

Aragon A/P A/P A/P A/P A/P

Tallin A/P P P A/P P

South Karelia A/P P A/P A/P A/P

Attica A/P A/P P A/P P

North Brabant A/P P A/P A/P A/P

Uppsala A/P A/P A/P A/P A/P

Kraljevo P P P P P

The following table provides an overview of the category and number of users to be involved. Overall, more than 15.400 users will be involved in the SmartCare pilots. These include around 8.610 older cared for people, ca. 1.300 health professionals (medical doctors, nurses, physiotherapists / physical training coach, etc.), 1.230 social care professionals, 4.260 informal carers, and other groups, such as community/voluntary groups.

Table 7: Pilot site users – preliminary overview

Region Number of

Older people (care recipients)

Health professionals

Social care professionals

Informal carers

Friuli-Venezia-Giulia

200 80 20 100

South Denmark 400 50 75 400 Scotland 6.000 1.000 1.000 2.000 Aragon 300 50 100 Tallin 100 3 3 South Karelia 100 15 2 10 Attica 800 35 10 1.100 North Brabant 500 30 10 500 Uppsala 100 15 10 50 Kraljevo 110 20 5 100

In the following sections a very preliminary set of criteria for the selection of users the sample of users and the test to be performed are presented. These will be subject to thorough discussion within the Consortium in the initial stages of the Project and consensus will be

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sought among the professionals involved in the pilots. The results of this process will be included in the Interim Progress Report due in month 6 and will be discussed during the 1st Interim Review.

B.3.2a.7 Criteria for selecting users

People • People are considered eligible for inclusion, if they are included in one of the following

groups: o Aged 50+ o Frail (measured clinically by Barthell and/or timed up-and-go test) o Suffer from diabetes mellitus, chronic heart failure or COPD; o Have signed an informed consent form.

Health professionals (HPs)

• HPs are considered eligible for inclusion, if they: o Are in any way involved in providing healthcare to the older people included in

the trials; o Will, under normal circumstances have access to ANY type of electronic

information on the patient.

Social care professionals (SCPs)

• SCPs are considered eligible for inclusion, if they: o Are in any way involved in providing social care for the included patients; o Will, under normal circumstances have access to ANY type of electronic

information on the patient.

Relatives and informal carers

• Relatives and informal carers are considered eligible for inclusion, if they o Are in any way involved with the included older people, AND; o Are willing to participate and share information with the other formal and

informal carers.

B.3.2a.8 Sample of users involved including justification

Any of the previously mentioned users will be enrolled, since they are eligible for the study. There are no restrictions on the number of users and the figures provided in Table 7 have to be considered as just indicative. Thus, any person eligible and willing to participate in order to make the evaluation results generalisable to a broader spectrum of setting will be retained.

B.3.2a.9 Description of tests to be performed

No tests considered additional to usual care will be performed. Introduction of telehealth and telecare is aiming at providing a broader range of patients, health and social care professionals and relatives with information on the disease development of the chronic patient. Thus, the telehealth and telecare solutions will most likely lead to a decrease in number of tests performed in that it is expected that duplication of work between sectors will be avoided.

The tests performed will thus not change from the ones already carried out by HPs or SCPs described in clinical guidelines in relation to the specific diseases the older people live with.

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B.3.2b Work plan

B.3.2b.1 GANTT chart

Figure 9: GANTT chart – task level 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Title Leader

T1.1 Requirements of SmartCare users empirica x x

T1.2 Organisational, staff and business requirements empirica x x

T1.3 Legal and regulatory requirements for SmartCare RSD x x

T3.1 Initial starting points in legacy technology IFIC x x

T1.4 Use cases for HealthCare-Centred Pathways (V.1) RSD x x

T1.5 Use cases for Social Care Centred Pathways (V.1) empirica x x

T2.1 Service Process Models for HealthCare-Centred Pathways (V.1) empirica x x

T2.2 Service Process Models for Social Care Centred Pathways (V.1) IFIC x x

T3.2 Initial SmartCare Integration Infrastructure Architecture IFIC x x

T3.3 Home Linked Services (V.1) specification empirica x x

T3.4 Organisational Cooperation Services (V.1) specification IFIC x x

T4.1 Implementation of Home Linked Services (V.1) FVGASS1 x x

T4.2 Implementation of Organisational Cooperation Services (V.1) FVGASS1 x x

T4.3 Implementation of pilot prototype (V.1) FVGASS1 x x

T4.4 Testing of pilot prototype (V.1) FVGASS1 x x

T4.5 Implementation of building blocks for 1st Wave Pilots FVGASS1 x x

T4.6 Full on-site testing, 1st Wave Pilots FVGASS1 x x x x

T5.1 Operational planning of 1st Wave Pilots FVGASS1 x x x

T5.2 Recruitment of patients and older persons for 1st Wave Pilots FVGASS1 x x x x x x x x

T5.3 Training of health service, social service and voluntary sector staff for 1st Wave PilotsFVGASS1 x x x

T5.4 Introduction of systems and services at 1st Wave Pilots FVGASS1 x x

T6.1 Operation of 1st Wave Pilots FVGASS1 x x x x x x x x x x x x x x x x x x x x x x

T6.2 Help desk provision for 1st Wave Pilots FVGASS1 x x x x x x x x x x x x x x x x x x x x x x

T6.3 Pioneer broadcasting of lessons learned FVGASS1 x x x x x x x x x x x x x x x x x x x x x x

T1.6 Use cases for HealthCare-Centred Pathways (V.2) RSD x x

T1.7 Use cases for Social Care Centred Pathways (V.2) empirica x x

T2.3 Service Process Models for HealthCare-Centred Pathways (V.2) empirica x x

T2.4 Service Process Models for Social Care Centred Pathways (V.2) empirica x x

T2.5 Definition of Service Model empirica x x

T3.5 Final SmartCare Integration Infrastructure Architecture IFIC x x

T3.6 Specification of Home Linked Services (V.2) IFIC x x

T3.7 Specification of Organisational Cooperation Services (V.2) IFIC x x

T4.7 Home Linked Services (V.2) implementation FVGASS1 x x x

T4.8 Organisational Cooperation Services (V.2) implementation FVGASS1 x x x

T4.9 Implementation of final pilot prototype (test version) FVGASS1 x x

T4.10 Test of final test pilot prototype FVGASS1 x x

T4.11 Implementation of building blocks for 2nd Wave Pilots FVGASS1 x x

T4.12 Full on-site testing, 2nd Wave Pilots FVGASS1 x x x x

T5.5 Operational planning of 2nd Wave Pilots FVGASS1 x x x

T5.6 Recruitment of patients and older persons for 2nd Wave Pilots FVGASS1 x x x x x x x x

T5.7 Training of health service, social service and voluntary sector staff for 2nd Wave PilotsFVGASS1 x x x

T5.8 Introduction of systems and services at 2nd Wave Pilots FVGASS1 x x

T7.1 Operation of 2nd Wave Pilots TALLIN x x x x x x x x x x x x x x

T7.2 Help desk provision for 2nd Wave Pilots TALLIN x x x x x x x x x x x x x x

T7.3 Pioneer broadcasting of lessons learned TALLIN x x x x x x x x x x x x x x

T8.1 Evaluation framework and planning RSD x x x x

T8.2 Evaluation baseline for 1st Wave Pilots empirica x x

T8.3 Follow-up evaluation for 1st Wave Pilots RSD x x

T8.4 2nd follow-up evaluation for 1st Wave Pilots RSD x x

T8.5 Final evaluation for 1st Wave Pilots RSD x x

T8.6 Evaluation baseline for 2nd Wave Pilots empirica x x

T8.7 Follow-up evaluation for 2nd Wave Pilots RSD x x

T8.8 Final evaluation for 2nd Wave Pilots RSD x x

T8.9 Analysis and reporting RSD x x

T9.1 Exploitation planning empirica x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T9.2 Service viability assessment for socal care, healthcare, integration and component providersempirica x x x x x x x x

T9.3 Pilot Site networking empirica x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T9.4 Project Advisory Boards constitution empirica x x x

T9.5 Project Advisory Boards meetings empirica x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T9.6 External dissemination preparation empirica x x x

T9.7 External dissemination activit ies empirica x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T9.8 Project web presence and online media management FVGASS1 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T9.9 Guidelines for Pathways and Integration Infrastructure procurement and uptakeFVGASS1 x x

T9.10 Deployment planning FVGASS1 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T9.11 SmartCare conference FVGASS1 x x

T10.1 Consortium coordination FVGASS1 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

T10.2 Management planning FVGASS1 x x

T10.3 Administrative management FVGASS1 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Note:

• At M6, a first review meeting will take place (a Go/No Go decision point for the continuation of the project). By this review, the following requirements must be met for continuation: i) Provide an illustrative sample of the guideline deliverable (D9.4) (delivery media, structure, target, likely content); ii) Select and finalise a core set of care paths including the end users they address. Justify the inclusion of each of these care paths.

• A specific subtask within WP10, as part of T10.5, Technical Management, will be dedicated to the check of the compliance of the platform that the pilot sites intend to

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procure with the common functional specifications and the adoption by the pilot sites of open rather than proprietary systems.

Figure 10: GANTT chart – WP level

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

WP Nr. / Title Leader

WP1 Requirements and use case definition empirica x x x x x x x x x

WP2 Service Process Model empirica x x x x x x x x x

WP3 Integration Infrastructure Architecture and Service SpecificationIFIC x x x x x x x x x x x x

WP4 System implementation and test FVGASS1 x x x x x x x x x x x x x x x x

WP5 Pilot site preparation FVGASS1 x x x x x x x x x x x x x x x x x x

WP6 Operation of 1st Wave Pilots FVGASS1 x x x x x x x x x x x x x x x x x x x x x x

WP7 Operation of 2nd Wave Pilots TALLIN x x x x x x x x x x x x x x

WP8 Pilot evaluation RSD x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

WP9 Exploitation support and dissemination empirica x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

WP10 Project management and performance monitoringFVGASS1 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

Table 8: Key deliverables and task dependencies

Deliverable No

Deliverable name WP No. Task dependencie

Tasks duration

Deliverable due date

D1.1 Requirements for SmartCare Pathways and Integration Infrastructure

WP1 T1.1-T1.5 M1-M3 M03

D3.1 Pilot level Service Specification WP3 T3.1-T3.4 M1-M5 M05 D8.1 Evaluation framework for SmartCare WP8 T8.1 M1-M8 M07 D4.1 SmartCare prototype test report WP4 T4.1-T4.4 M4-M8 M08

D1.2 SmartCare Pilot level Pathways and Integration Infrastructure

WP1 T1.6-11.7 M8-M9 M09

D2.1 SmartCare Service Model WP2 T2.1-T2.5 M3-M11 M11 D3.2 The SmartCare Service Specification WP3 T3.5-T3.7 M10-M12 M12 D4.2 The SmartCare Prototype System WP4 T4.5-T4.12 M9-M12 M20 D5.1 SmartCare Operational Pilots WP5 T5.1-T5.8 M5-M22 M22 D6.1 SmartCare Common Specifications WP6 T3.5-T3.7,

T4.5-T4.12, T8.3-T8.4

M15-M30 M30

D6.2 Report on Operation of 1st Wave Pilots

WP6 T6.1-T6.3 M15-M36 M36

D8.4 SmartCare Pilot Outcomes WP8 T8.5-T8.9 M32-M36 M36 D9.3 Guidelines for SmartCare deployment WP9 T9.2, T9.4,

T9.5, T9.9 M5-M36 M36

D9.4 Deployment plans for SmartCare Pathways and Integration Infrastructure (incorporating reports on dissemination)

WP9 T9.10-T9.11 M2-M36 M36

D7.1 Report on Operation of 2nd Wave Pilots

WP7 T7.1-T7.3 M23-M36 M36

Note (as above: at M6, a first review meeting will take place - a Go/No Go decision point for the continuation of the project) An illustrative sample of D9.4 (delivery media, structure, target, likely content) will be provided prior to the review as well as a core set of care paths (including the end users they address).

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B.3.2b.2 Key Performance Indicators (KPI)

Table 9 - Key Performance Indicators by pilot site (KPI)32

KPI No. Relating to which project objective/expected result?

Indicator Method of measurement Expected Progress

Year 1 Year 2 Year 3

1 Integration of care Number of SmartCare pathways defined

Deliverable D2.1 8 8 8

2 Integration of care Number of SmartCare pathways actually implemented

Deliverable D5.1, D6.1, D7.1 4 4 4

3 European dimension Number of active pilots Progress reports 4 4 4 Number of actual users by

category

4 Large scale Older people Active accounts in the Portal33 700 4.296 10.460

5 Large scale Healthcare professionals Active accounts in the Portal 150 694 1.675 6 Large scale Social care professionals Active accounts in the Portal 160 663 1.647 7 Large scale Informal carers Active accounts in the Portal 313 1.710 4.220 Friuli-Venezia Giulia 8 Large scale Older people Active accounts in the Portal 50 100 200 9 Large scale Healthcare professionals Active accounts in the Portal 20 40 80 10 Large scale Social care professionals Active accounts in the Portal 5 10 20 11 Large scale Informal carers Active accounts in the Portal 20 40 100 Aragon 12 Large scale Older people Active accounts in the Portal 50 200 300 32

The Consortium wants to emphasise that estimates of number of users by site are far less reliable than estimates for the Project as a whole because shortfalls in one pilot cannot be compensated by overperformance in others. Moreover, recruitment of users is not totally under the control of the Consortium because especially older people and informal carers will participate on a voluntary basis and their recruitment and retention is a complex task as widely reported in literature.

33 The number of active users should not be confused with the number of older people included in the trials. For the same ethical reasons which have been recommended for RENEWING HEALTH

by Professor Richard Wootton of NST, the number of older people actually included in the trials will be calculated on the basis of the statistical power that the Project has fixed as a target for SmartCare. Should the number in the table fall short of the number required, they will be increased.

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13 Large scale Healthcare professionals Active accounts in the Portal 10 40 50

14 Large scale Social care professionals

(including social organization volunteers and relatives)

Active accounts in the Portal 30 75 100

15 Large scale Informal carers Active accounts in the Portal This figure does not exist as such in Spain

Region Syddanmark 16 Large scale Older people Active accounts in the Portal 500 2.500 3.000 17 Large scale Healthcare professionals Active accounts in the Portal 100 400 500 18 Large scale Social care professionals Active accounts in the Portal 100 400 500 19 Large scale Informal carers Active accounts in the Portal 250 750 1000 Scotland 20 Large scale Older people Active accounts in the Portal 140 940 6.000 21 Large scale Healthcare professionals Active accounts in the Portal 30 150 1.000 22 Large scale Social care professionals Active accounts in the Portal 30 150 1.000 23 Large scale Informal carers Active accounts in the Portal 60 300 2.000 Tallinn 24 Large scale Older people Active accounts in the Portal 0 34 100 25 Large scale Healthcare professionals Active accounts in the Portal 0 5 15 26 Large scale Social care professionals Active accounts in the Portal 0 4 10 27 Large scale Informal carers Active accounts in the Portal 0 16 50 South Karelia 28 Large scale Older people Active accounts in the Portal 10 50 100 29 Large scale Healthcare professionals Active accounts in the Portal 10 20 30 30 Large scale Social care professionals Active accounts in the Portal 0 1 2 31 Large scale Informal carers Active accounts in the Portal 3 10 10 Attica 32 Large scale Older people Active accounts in the Portal 0 300 500 33 Large scale Healthcare professionals Active accounts in the Portal 0 15 25 34 Large scale Social care professionals Active accounts in the Portal 0 10 10 35 Large scale Informal carers Active accounts in the Portal 0 450 750 Noord Brabant 36 Large scale Older people Active accounts in the Portal 0 100 250

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37 Large scale Healthcare professionals Active accounts in the Portal 0 10 20 38 Large scale Social care professionals Active accounts in the Portal 0 5 10 39 Large scale Informal carers Active accounts in the Portal 0 100 250 Upssala 40 Large scale Older people Active accounts in the Portal 0 50 100 41 Large scale Healthcare professionals Active accounts in the Portal 0 9 15 42 Large scale Social care professionals Active accounts in the Portal 0 6 10 43 Large scale Informal carers Active accounts in the Portal 0 22 50 Serbia 44 Large scale Older people Active accounts in the Portal 0 22 110 45 Large scale Healthcare professionals Active accounts in the Portal 0 5 20 46 Large scale Social care professionals Active accounts in the Portal 0 2 5 47 Large scale Informal carers Active accounts in the Portal 0 22 110 48 User centered solutions Level of user satisfaction Questionnaires N/A 80% 85% The status of the progress indicators will be updated at least every 6 months and will be included in the Interim and in the Annual Progress Reports.

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B.3.2b.3 Risk assessment

The risks identified for the implementation of SmartCare are summarized in the tables below. Additionally the approach adopted by the SmartCare Consortium to the risks management is extensively explained in Section B.3.1.c.

Table 10 – Risk assessment table - Risk during the implementation of the EU funded project

Milestone/task Risk Probability Impact Remedial actions/mitigation plan

Consortium management

Bankruptcy of one of the beneficiaries Low Low

The Consortium Agreement caters to this situation and the corresponding clause will be applied (contract termination with the beneficiary concerned), substitution of the work to be performed by a present or a new Consortium partner

Consortium management

Serious underperformance of one of the beneficiaries

Medium Low

The Consortium Agreement caters for this situation and the corresponding clauses will be applied (warnings, and in case of prolonged underperformance contract termination with the beneficiary concerned and reallocation of tasks and budget to another or a new beneficiary)

Agreement on and issuing of the SmartCare pathways

Failure of partner agencies in agreeing on roles and care responsibilities in one or more pilots sites

Low High

Timely recognition of the problem; mediation attempt. If failed, identify an alternative pilot site and/or discuss with all partners involved in this activity and PO to identify optimal alternative solution.

Evaluation framework agreed

Failure to agree on a common evaluation framework with one or more pilots sites

Low High

Timely recognition of the problem; mediation attempt. If failed, identify an alternative pilot site and/or discuss with all partners involved in this activity and PO to identify optimal alternative solution.

Installation of the 1st wave pilot sites completed

Delay in the procurement of the service components, recruitment of participants, engagement of carers in one or more pilots sites

Medium Medium

Early requirements analysis, timely procurement process etc., and related activities, including tight process control. If unavoidable, small delay in the start of trial at that site. In case of prolonged delay, degrade the pilot from 1st to 2nd wave or move to involve an alternative pilot site.

Installation of the 2nd wave pilot sites completed

Delay in the procurement of the service components, recruitment of participants, engagement of carers in one or more pilots sites

Medium Medium

Timely procurement process etc., and related activities, including tight process control. If unavoidable, small delay in the start of the trials. In case of prolonged delay, degrade the pilot from 2nd wave to Committed Region Board and/or move to involve an alternative pilot site.

1st wave pilots fully operational

Delay in the activation of the pilot in one or more pilots sites Low Medium

Delay in the start of the trials. In case of prolonged delay, degrade the pilot from 1st to 2nd wave and/or move to involve an alternative pilot site.

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Milestone/task Risk Probability Impact Remedial actions/mitigation plan

2nd wave pilots fully operational

Delay in the activation of the pilot in one or more pilots sites Low Medium

Delay in the start of the trials. In case of prolonged delay, degrade the pilot from 2nd wave to Committed Region Board or move to involve an alternative pilot site.

Publication of the procurement guidelines

Not enough commonalities to draw general guidelines form the pilots

Low Medium Separate respectively differentiated guidelines will be produced for subsets of regions with similar health and social care organisations.

Completion of the deployment plans for participating regions

The deployment plan for one specific region cannot be prepared because of too many peculiarities or barriers in the local organisation

Medium Low

The region will be dropped from the list or regions for which deployment plans are produced and the relative budget will be reallocated to other tasks or regions.

Final trial evaluation Too disparate and uneven results to deliver a concise synthesis of overall outcomes to be of value at the European level

Low Medium

Early planning and implementation of a methodology, assessment methods, measures, tools and instruments to assure gathering optimal outcome measures in spite of disparate outcomes at certain sites and/or results the quality of which is too uneven. Application of advanced methods and analytical approaches able to cope with such methodological challenges.

Final conference Insufficient interest in and participation in such a conference, and/or not very stimulating programme

Low High

Advanced, timely planning and PR for the conference; stimulatiing programme, early identification of attractive, well-know speakers, professional support in preparation and execution.

Table 11 - Risk assessment table - Risks for the further deployment of the SmartCare services

Risk nr. Risk Probability Impact Remedial actions/mitigation plan

RD1 The impact of the introduction of SmartCare on the health of the older people under monitoring is negative.

Low High

There is no guarantee that the impact of the introduction of the SmartCare services on the health of the older people will be positive, although this is highly probable. No mitigation plan can be envisaged, and further deployment of the SmartCare services will be seriously hampered if not stopped altogether.

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Risk nr. Risk Probability Impact Remedial actions/mitigation plan

RD2 The impact of the introduction of SmartCare on the quality of life of the users is negative. Low High

There is no guarantee that the impact of the introduction of the SmartCare services on the quality of life of the older people will be positive, although this is highly probable. No mitigation plan can be envisaged, and further deployment of the SmartCare services will be seriously hampered if not stopped altogether.

RD3 The impact of the introduction of SmartCare on the health and social care expenditure is negative.

Medium High

There is no guarantee that the impact of the SmartCare services on health and social care expenditure will be positive because, e.g. temporary health problems which would have go undetected will be now detected thanks to the monitoring devices deployed in the field. The bet is that the likely short-term increase in healthcare costs will tail down rather quickly and will be more than offset by the medium-, long-term gains. If this is not the case, no mitigation plan can be envisaged, and further deployment of the SmartCare services will be seriously hampered if not stopped altogether.

RD4 One or more categories of users are not satisfied with the SmartCare services.

Medium Medium

The satisfaction of the different categories of users is a precondition for the further deployment of sustainable SmartCare services after the end of the EU project. Satisfaction of users is of course a subjective evaluation and it is independent from the objective impact of the service on the quantifiable indicators. All possible endeavours will be used to address the elements of the service which create dissatisfaction within one category of users or the other.

RD5 The market for the SmartCare services is not as promising as all analysis predict

Low High

Although the probability of this risk is low because the Consortium is well acquainted with the demand for these services, the lack of reasonable market for the SmartCare services will stop the further deployment of these. The Consortium comprises already many potential buyers of the services who, through their presence in the Project already show their commitment to deploy the services. The Consortium has put in place an aggressive dissemination strategy which should ensure that procurers are well aware of the benefits of the SmartCare provided the Project demonstrate that they are actually there and that they are measurable.

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B.3.3 Project management This chapter outlines the organisational structure, decision-making bodies and procedures of the project, as well as the overall project management approach to questions regarding document and software life-cycle management, quality management and software development. Also, the change management approach, based on technical and organiational change management techniques, is outlined as well (B.3.1c.9). An overview of the milestones, review and reporting procedures is outlined in section B.3.1b.7.

The guiding principle determining all project management activities is that of decentralised, flexible decision-making. While day to day control of the project is in the hands of the coordinator, the responsibility for the project as a whole lies with the Project Steering Committee (PSC).

The project management structure will be responsible for:

• producing the Project and Quality Plan;

• controlling the execution of the project plan;

• keeping the overall project on schedule, by applying the appropriate corrective actions in case of shift in relation to the project plan;

• guaranteeing that the appropriate standards of project management and quality assurance are applied;

• applying all the regulatory prescriptions in terms of data confidentiality and integrity;

• discussing project objectives and results with the User and Industry Advisory Boards, and take inspiration from their advice for the implementation of the Project.

The need to keep an overall co-ordination, while catering for autonomous work package management and decentralised decision power, implies a two-level management structure, which addresses the need for both consistency at project level and flexibility in the field. In this scheme, the upper level of management is responsible for the overall supervision of the project, while the lower level has the mandate to carry out the individual work packages and the activities in the countries.

The upper level of management is represented by the Project Steering Committee, composed of senior representatives of the Partners, by the Project Co-ordinator, by the Administrative and Financial Co-ordinator, and by the Quality Manager.

The management structure of SmartCare is represented below.

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Figure 7 – Project Management Structure

Project Steering Committee

Project Co-ordinator

WP1 Leader

WP2 Leader

WP3 Leader

WP4 Leader

WP5 Leader

WP 10 Leader

…………….

Industry Advisory Board

Line functions

Staff functions

LOWER LEVEL OF

MANAGEMENT

UPPER LEVEL OF

MANAGEMENT

Hierarchical dependence

Functional dependence/advice

Co-ordinator Support Team

Change Management

Advisory Team Committed Regions Board

Committed

Regions Board

Functional dependence/input into

service vision/deployment planning

Internal Scientific Board

Users’Advisory Board

B.3.3.1 Project Steering Committee

The partners have drafted and agreed to a Consortium Agreement (CA) for the project, which sets up a Steering Committee, referred to in the CA as project coordination committee. Based on this CA, which is expected to be ratified by all concerned parties, the PSC is responsible for:

(a) agreeing tasks and responsibilities of the Parties and the distribution of EC Funding among the Parties through modification to Schedule 6;

(b) proposing amendments to the Contract and authorising the Coordinator to apply to the Commission for such amendment;

(c) approving applications from Parties to make individual documents publicly available and giving other permissions conforming to agreed publication policy;

(d) assisting the Coordinator in preparing reports on the whole Project; (e) agreeing a publication policy specifying procedures for press releases and making

documents publicly available; (f) authorising the Coordinator to serve notices on a Defaulting Party in accordance with

Section 8.7 and to assign the Defaulting Party's tasks to specific entity(ies) (preferably chosen from the remaining Parties);

(g) carrying out calls for proposals for third parties to participate in the Project and accepting Accession Candidates;

(h) agreeing to extend rights of use to a third party; (i) approving withdrawal of a Party pursuant to Section 15.2;

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(j) limiting the power of the PSC by specifying additional cases (cf. Section 20.2) where agreement is to be in writing and signed by an authorised signatory of each of the Parties,

(k) modifying any provision of the Contract where this is possible without amendment of that contract,

(l) agreeing changes in the schedule of rules allowing the Coordinator to withhold all or part of EC Funding to any or all Parties (Schedule 5).

The Steering Committee gives strategic guidelines to the Project Co-ordinator and the Administrative and Financial Co-ordinator, and steers the Project according to the agreed objectives. The Steering Committee is responsible for the approval of the financial budgets, and making decisions which can modify the distribution of funding between beneficiaries. The Consortium Agreement foresees the set-up of a joint activity budget, which allows resourcing of activities with relevance across the project at a funding rate of 100%.

Decisions on managerial and technical issues are made following standard procedures of circulation of agenda items, discussion and agreement at meetings. Virtual meetings through videoconferencing, tele-conferencing and e-mail will be held to improve efficiency and reduce travelling costs.

The Steering Committee will also address legal, confidentiality, security and ethical issues emerging during the lifecycle of the project.

The Steering Committee will evaluate, and approve when appropriate, the candidature of additional regions applying to become part of the SmartCare initiative.

The Steering Committee will meet at the start and completion of the project and at six-monthly intervals during the project duration.

Detailed rules for the functioning of the Steering Committee are laid down in the CA, which will be negotiated and signed by the partners prior to the signature of the Grant Agreement with the European Commission. Decisions are taken by majority and the quorum is a minimum of 2/3 of the Principal Contractors. In voting, each Contractor has one vote.

B.3.3.2 Advisory Boards

The SmartCare Consortium will avail itself of four boards representing the voice of four extremely relevant groups of stakeholders: users, European Regions, European Regions, scientific community and industry.

The advice and recommendations from the various Advisory Boards will not be compelling, but they will be thoroughly considered by the Project Management Team which, in case it does not follow the advice and recommendations, will have to justify the reasons why they have not been followed. The Committed Regions Board is an exception to this rule, because its role will not be that of an adviser, but it will collaborate very closely with the regions hosting the SmartCare pilots.

These bodies are briefly described in the sections below.

B.3.3.2.1 Users’ Advisory Board (UAB)

The various categories of users of the integrated services trialled in the context of SmartCare, older people, informal carers, social and healthcare professionals, will form an Advisory Board which is tasked with ensuring that the interest and needs of all the users are properly taken into consideration in the implementation of the Project.

The Users’ Advisory Board is constituted by AGE Platform Europe, Eurocarers, International Foundation for Integrated Care, European Federation of Nurses Associations, and the European Patients’ Forum

The Users’ Advisory Board is chaired by AGE Platform Europe, which will designate a person from its staff to co-ordinate this Board.

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The Users’ Advisory Board will receive copies of all the documentation which is needed for its members to grasp the various aspects of the Project which are relevant for the constituencies that they represent.

The Users’ Advisory Board will be able to express its advice both in writing at any time during the lifecycle of the Project, and during interactive meetings that will be organised every six months.

During the first three months of the project, nominees for the Users’ Advisory Board are contacted. Additional candidates may be sought to represent specific relevant interests. A briefing document is developed setting out a detailed work schedule for the entire project duration. This briefing specifies work tasks and co-operation modes. Board members are expected to comment on project plans and interim project results; it is expected that this will be from the perspective of the organisation or stakeholder grouping represented.

B.3.3.2.2 Industry Advisory Board (IAB)

The Industry Advisory Board will advise the Project Management Team on all the technical issues which are relevant for the implementation of the large scale pilots and for the further deployment of the services. These issues include, but are not limited to, the technical architecture of the services, and the standards towards which the various regional implementations have to converge to ensure openness and scalability of the solutions and the protection of investment (obsolescence-proof solutions).

The Industry Advisory Board is chaired by Continua Health Alliance which will designate a person from its staff to co-ordinate this Board. Members of the Industry Advisory Board will be mostly drawn from companies which are part of the Alliance, although it is possible that for a specific subject, competence will be sought from other Industry Associations.

The Industry Advisory Board will receive copies of all the non-confidential documentation which is needed for its members to grasp the technical aspects of the Project which are relevant for the industry that they represent.

The Industry Advisory Board will work fundamentally through asynchronous document exchange. Nevertheless, meetings on specific subjects can be organised at the initiative of the Board chair or of the Project Co-ordinator of SmartCare.

The Board will be also used as a channel of communication and dissemination of Project results among the industry players; this has been successfully done in RENEWING HEALTH, a previous Pilot Type A on chronic diseases funded by ICT PSP.

B.3.3.2.3 Internal Scientific Board (ISB)

The main task for the ISB is to monitor the scientific performance of the SmartCare project, based on the project proposal and approved recommendations from any scientific review.

The ISB will be composed of experts collectively covering the work carried out within SmartCare. In addition to the internal experts, two experts from outside the Consortium with compentence in integrated care change management across different organisational cultures will be equally part of the ISB.

The ISB will meet as required, where the Scientific Coordinator reports to the ISB on progress and plans. The ISB reports directly to the PSC after these meetings. In between meetings, the Scientific Coordinator is encouraged to be in dialogue with the ISB on important decisions relating to scientific performance of the SmartCare trials.

The SmartCare Project Steering Committee (PSC) retains decision-making authority and responsibility.

Change Management Advisory Team (CMAT)

In addition, the SmartCare change management activities will be supported by an advisory team, composed of experts outside the consortium, dedicated to integrated care change

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management across different organisational cultures. Three outstanding experts have been invited to join the advisory team:

Marina Teresa Lupari, Assistant Director for Nursing R&D; Executive nursing team; Northern Health & Social Care Trust, Northern Ireland. In her current post she is leading on the design, development and implementation of an integrated care partnership for one of the 5 health economies in Northern Ireland. This involves extensive redesign, transformation of existing services and a culture change to partnership model with patients. Prior to this, she led extensive change management programmes including the Integrated Care of the Elderly project, redesign of community nursing, creation of Case management model.

Michael Rigby, Emeritus Professor of Health Information Strategy at Keele University, United Kingdom; Adjunct Professor at Dublin City University, Ireland; and Faculty Member of the Nordic School of Public Health. His initial career was in the English National Health Service, commencing as a policy researcher in community health services, and progressing through posts in planning, computer systems development, and management to become responsible for planning health services for a population of 2.5 million. He is rapporteur for the OECD in their work on Smart Health Systems, collaborator with the European Science Foundation’s Standing Committee for the Social Sciences on the role of social science in enabling informatics applications in health and social care.

Joan Escarrabill, AIAQS (Health Evaluation Agency, Barcelona, Spain). He studied medicine in Barcelona and worked as Chest Physicien since 1983.Currently, he is Director of the Master Plan for Respiratory Diseases with the Ministry of Health in Catalonia and responsible for the change management in the region for integrated care for chronic diseases.

Apart from participation in a project meeting and/or a dedicated workshop, the advisors will be invited to review relevant parts of deliverables, in particular in WP1-3.

B.3.3.2.4 The Committed Regions Board (CRB)

Regions that have not been selected for hosting a pilot will become part of a Committed Regions Board. Through their participation in the Board, which will be chaired and driven by the Assembly of European Regions, these regions will have access to all the material produced in the Project, and will be able to provide input into the implementation process.

The CRB will contribute to all stages of the Project, including the first part when standards and evaluation criteria etc. are decided upon; it should give feedback on several aspects of this. Its objectives will be:

• Ensuring the compliance of the project with the regions’ needs.

• Providing the Steering Committee and project with constructive feedback.

• Stimulating political leadership.

• Contributing to dissemination of the project outcomes.

• Promoting transferability and sustainability.

The Board will also serve as a bridge between the Consortium and the entire community of the European Regions which are not directly involved in SmartCare. In doing this, it will act both as a collector of input coming from the community of the European Regions, and as a primary instrument of dissemination towards regional decision makers for the uptake of the services trialled in SmartCare.

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B.3.3.3 Project Roles

B.3.3.3.1 Project Co-ordinator

The Project Co-ordinator is the official interface between the Consortium and the European Commission, and has responsibility for the administrative and financial matters as specified in the Consortium Agreement, for example:

• chairs the Project Steering Committee meetings;

• manages budget transfers between project partners;

• carries out the overall legal, contractual, ethical, financial and administrative management;

• collects, if required, audit certificates provided by each contractor in conformity with Article 4.7 of Annex II General Conditions;

• provides to the Commission, after the end of the project, a summary financial report consolidating the claimed costs of all the contractors in an aggregate form covering the entire duration of the project;

• provides to the Commission, after the end of the project, a final management report covering the full duration of the project;

• co-ordinates project-wide workshop meetings;

• keeps the whole project on schedule;

• maintains accurate consolidated records of costs, resources and timescales;

• interfaces with the European Commission with regard to the contractual and financial issues;

• ensures that the project maintains its technical objectives and relevance within ICT-PSP;

• reports regularly to the Steering Committee on the progress of the Project;

• has ultimate Project responsibility towards the European Commission on behalf of the entire Consortium.

B.3.3.3.2 Administrative Co-ordinator

The Administrative Co-ordinator has a mandate from the Project Co-ordinator to deal with administrative tasks related to the financial and administrative coordination of the Project as derived from the Project’s obligation in the Grant Agreement and Consortium Agreement. The daily tasks of the administrative coordinator focus on keeping the resource planning up to date. Important recurring tasks include:

• calculation of budget transfers to project partners on the basis of rules laid down in the Contract and Consortium Agreement;

• preparation of progress reports with input from partners at regular intervals defined in the Grant Agreement;

• collection of audit certificates provided by each contractor in conformity with Article 4.7 of Annex II General Conditions;

• provision to the Commission, after the end of the project, of a summary financial report consolidating the claimed costs of all the contractors in an aggregate form covering the entire duration of the project;

• obtaining financial securities such as bank guarantees when requested by the Commission;

• maintenance of accurate consolidated records of costs and resources;

• preparation and submission to the Commission of the Financial Statements of all partners.

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B.3.3.3.3 Co-ordinator Support Team

The Co-ordinator Support Team assists the Project Co-ordinator in the day-to-day management of the overall project:

• establishes the intra-project communications infrastructure;

• prepares and distributes reports (Management Reports, Progress Reports);

• reports regularly to the Project Co-ordinator on the progress of the Project;

• helps the Project Co-ordinator to manage individual Work Package Leaders;

• supports the Project Co-ordinator in organising project-wide workshop meetings;

• helps the Project Co-ordinator to keep the whole project on schedule;

• helps the Project Co-ordinator to supervise all technical project deliverables;

• defines in close collaboration with the Project Co-ordinator common inclusion and exclusion criteria for older people;

• monitor the compliance of the ICT system and solutions under procurement by the individual pilot sites to make sure that these comply with the specificatsion contained in this Technical Annex;

• supports pilot sites in the preparation of applications for Ethics Committee approval;

• prepares the trial protocol;

• registers the trials;

• takes care of the randomisation of older people if required;

• assists the Project Co-ordinator in defining the reporting structure and the relative reporting procedures;

• produces the Project and Quality Plan;

• monitors the proper production of quality records by individual Work Package Leaders;

• reports regularly to the Project Co-ordinator and Steering Committee on the quality aspects of the project.

The Consortium has agreed that, in the best interets of the Project, the Co-ordinator Support Team function will be subcontracted to a single competent organisation which can provide fully dedicated professional figures to the management of SmartCare. This organisation will have a proven track record of succesfull management of European projects, in particular of those funded under the ICT PSP and possibly of previous Pilots A in the specific field of ICT supported elderly care.

The profile of the professional figures leading each of the three functional areas are specified below in § B.3.3.4.

B.3.3.3.4 Work Package Leaders

Work Package Leaders are responsible for the detailed management of the work package within the budget of expenses and the workload which is allocated to the work package. This will include:

• production of work package-specific addenda to the overall Project and Quality Plan if required;

• monitoring and control of the work package progress;

• production of the deliverables specified for the work package;

• monitoring and control of quality within the standards defined in the Project and Quality Plan and quality procedures;

• co-ordination of work package workshops.

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B.3.3.4 Management Team

B.3.3.4.1 Project Co-ordinator

Giulio Antonini

Public Manager under the Local Health Authority 5 Bassa Friulana, with remit from Friuli Venezia Giulia Autonomous Region, Health and Social Security Head Office. Main tasks are the planning and the management of: Regional and EU projects and activities dealing with technologies for improving the quality of life at home for older and disabled people (under the Central Europe Programme, Interreg IVC project CASA, CORAL – Community of Regions for Ambient Assisted Living). Regional experimentation of public contributions in order to promote the self-sufficiency of dependent older and disabled people. Support to local processes in order to ensure the participation of the different stakeholders in developing mutual assistance organisations and to rebuild social connections. Modalities of involvement of public and private entities able to enhance interventions in favour of the social inclusion of population at risk of marginalisation. The regional PPP/network working on innovation and research in order to promote a better quality of life at home and the self-sufficiency of dependent older and disabled people. The application of accessibility criteria in urban planning and housing design to reduce spatial segregation and to facilitate life at home for all. The empowerment of human resources dedicated to formal and informal homecare.

B.3.3.4.2 Operational Co-ordination

The person appointed for leading this functional area will have a deep knowledge and a proven track record of successfully managing projects of comparable size and ambition to SmartCare with partners from many EU countries and a thorough understanding and the indispensable skills for building successful teams from partners with different cultures and backgrounds in the specific field of health and social care for elderly people.

He/she will have a good knowledge and understanding of the different healthcare and social systems in the European Union, and of the issues at stake when trying to implement integrated care in support of the independence of elderly people.

He/she will have multiyear experience in the specific requirements for running EU funded projects in the health and social care fields under European Programmes such as e.g. RTD Framework Programmes, eTEN and ICT-PSP.

The person will be multilingual in at least English and Italian. The knwoledge of other European languages will be an advantage and will have a solid general management experience.

B.3.3.4.3 Scientific Co-ordination

The person appointed for leading this functional area will be medically qualified, and preferably practising, and have experience in running randomised control trials: defining inclusion and exclusion criteria, clinical protocols associated with the trial, trial registration requirements, preparation of Informed Consent forms, and gaining Ethical Committee approval.

A preferential factor the fact of having already played the role of Scientific Co-ordinator in previous EU funded project. The person will be fluent in English and in at least two other European languages preferably among those of the countries participating in SmartCare.

He/she will have specific knowledge and experience in the area of chronic degenerative diseases typical of the old age.

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B.3.3.4.4 Quality Assurance

The person appointed for leading this functional area will have worked in the health and social care sector, will be familiar with ISO 9001 2008, and have a multiyear experience as Quality Manager for European projects in the health and social care field, and ICT supported elderly care in particular. He/she will have experience in the EC requirements for running EU funded projects in ICT for health and social inclusion under European Programmes, e.g. RTD Framework Programmes, eTEN and or IST-PSP.

The person will be fluent in English and possibly a native English speaker to review project deliverables not only for their contents but also for the language and the style.

He/she will have general management experience and acquaintance with working in a multilingual and multicultural environment.

B.3.3.4.5 Work Package Leaders

WP1 Leader

Lutz Kubitschke (for his CV please see § B.3.1.2.7.1)

WP2 Leader

Dr. Veli Stroetmann (for her CV please see § B.3.1.2.7.1)

WP3 Leader

Nick Goodwin (for his CV please see § B.3.1.2.5.2)

WP4 Leader

Juan Coll (for his CV please see § B.3.1.2.1.7.1)

WP5 Leader

Claus Duedal Pedersen (for his CV please see § B.3.1.2.1.4.1)

WP6 Leader

George Crooks (for his CV please see § B.3.1.2.1.23.1)

WP7 Leader

Benny Eklund (for his CV please see § B.3.1.2.1.20.1)

WP8 Leader

Anne-Kirstine Dyrvig (for his CV please see § B.3.1.2.1.4.1)

WP9 Leader

Lutz Kubitschke (for his CV please see § B.3.1.2.7.1

WP10 Leader

Giulio Antonini (for his CV please see § B.3.3.3.1)

Other key personnel

For the other key personnel’s CV, please see the individual partners’ profiles in § B.3.1.2.

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B.3.3.5 Conflict resolution

Conflict resolution mechanisms will be fully described in the Consortium Agreement. The SmartCare CA will be based on previous agreements which have proven their effectiveness in governing the relationship among the partners of eTEN or CIP projects.

When a conflict cannot be resolved inside the Project Steering Committee nor in any other amicable way in spite of the collaborative spirit that exists within the Consortium, the CA includes arbitration provisions which state that the rules of arbitration of the International Chamber of Commerce will be followed.

B.3.3.6 Handling of the results

The results from the SmartCare project will be managed according to the rules regarding IPR management in the CIP-PSP. The CA will clearly identify:

• The pre-existing know-how brought into the Project by SmartCare Partners;

• The IPR related to results produced inside the Project;

• The ownership of Project results.

B.3.3.7 Quality Control and Assurance

The SmartCare quality assurance system will follow as closely as possible the ISO 9001 2008 “Quality management systems - Requirements” standards, adapting them however to the size and nature of the Project, to keep a reasonable balance between the thoroughness and sophistication of the quality system and the total amount of resources mobilised for the Project.

Particular care will be put when selecting the company to which the Co-ordinator Support Team will be subcontracted to ensure that the selected candidate has acquired experience in the Quality Control and Assurance of previous EU funded projects, in general and in ICT PSP ones in particular, in which it was responsible for setting up the Quality Assurance system.

Details of the quality assurance system will be described in deliverable D1.1 Project Quality Plan which is due in month 2.

Each partner however, in the execution of the tasks it is responsible for, will be allowed to use its internal Quality System provided the external outcome of such system (reporting, quality records, etc.) are coherent and conformant to the prescription of the overall quality system defined in the Project and Quality Plan.

All the official Project deliverables will be peer-reviewed by the Quality Manager who is part of the Co-ordinator Support Team.

B.3.3.8 Ethics and Data Protection Manager

The Ethics and Data Protection Manager, part of the technical management team, oversees conformance with ethical principles and data protection legislation. A framework is drawn up to cover both domains, covering issues such as informed consent forms, submissions to the respective ethics committee at each site, etc.

The Ethics & DP Manager reports regularly to Consortium meetings on the status of the work and on activities that need to be undertaken by the partners. Outcomes of ethics management are reported in the framework of exploitation deliverables.

B.3.3.9 Approach to Change Management

At project management level, SmartCare will pursue a change management approach on both the technical (informatics) level and the business level. With regard to the technical change (request) management, the project will adopt an approach as close as possible to

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the IT Infrastructure Library (ITIL) approach. This consists of a number of steps, which will be formalized at the start of the project:

• a request for change (RfC) is formulated according to a pre-defined structure and with a pre-determined severity level

• a change manager receives this RfC and assess its formal completeness and severity

• in collaboration with advisory boards, the change manager assesses the cost and service availability impacts of the RfC and oversees the implementation of the change The following principles, which shall be observed by all participants, apply:

○ All participants must realize that there are no changes "on acclamation" or "on the quiet".

○ Every change request which leads to a deviation from the ordered, released or accepted characteristics shall be processed by means of a change request within the scope of change management.

Every change request shall be documented and evaluated.

The change management regulates the following:

• required contents of a change request,

• analysis and assessment of change requests, and

• procedures for deciding on changes.

Out of the experience with large scale eHealth and eCare deployment projects, it is advisable and envisaged by the project management team to allow change management for three categories that are strictly kept separate: use-cases, functional design and technical design.

With regard to the organisational change, the project management team will support piloting regions and other participants to adopt the change management approach formulated by Kotter in his Harvard Business Review article of April 1995. Kotter defines eight necessary steps to bring about organisatioanl change. Key among these are the communication of a vision and a focus on quick wins that can be easily consolidated.

The vision of the project is formalised in the workplan and subscribed to by all participants. Change management as a structured approach to shifting/transitioning individuals, teams, and organizations from a current state to a desired future state is at the core of the overall workplan described earlier, e.g. in terms of pursuing an iterative and participatory approach towards user / organisationsl requirements elicitation (WP1) as well as integraton infrastructure and service definition (WPs 2/3). Not the least, the workplan caters for a structured approach towards organisational transition by means of pilot preparatin activities (WP5) and exploitation support (WP9). Also, specific work tasks are directed towards initiating and moderating organisational processes aimed at helping staff to accept and embrace changes in current environments.

With regard to short term wins and the consolidation of improvements, SmartCare will adopt an incremental approach to piloting and uses evolving documents. This allows all project participants to formalise and consolidate progress on specifications and use cases quickly as they are achieved, without jeopardising the possibility of further evolution in the future.

Change management in the piloting regions will be the responsibility of the local piloting organisations. Through regular reports to the project coordinator and where appropriate project boards, requirements for change will be formulated and supporting resources mobilised. The project coordinator and management will be advised by a dedicated change management advisory team.

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The approach to and empowerment of local staff to implement required changes during the SmartCare pilot can be described using the example of the Scottish SmartCare pilot.

Scotland’s approach to delivering the fundamental changes required for SmartCare will not follow a traditional change management model. Instead, Scotland will combine current and leading practice in change management “by design” with a user-centric approach, to achieve the cultural shift required by service providers to enable individuals to be well informed, make choices and live healthy and active lives.

In order to kick-start Scottish involvement in the SmartCare pilot, two workshops will be held. Already on October 30th 2012 to:

• secure stakeholder buy-in to the SmartCare vision and anticipated outcomes;

• set up project management and monitoring / reporting structures;

• secure engagement of different organisations and levels.

This workshop is a follow up to a workshop held already in April 2012.

The high level Scottish Assisted Living Programme Board (SALPB) will set the strategic vision for the Scottish SmartCare pilot, provide governance, policy support and review progress. To involve and empower local managers, SALPB will develop a comprehensive Communication Plan which will see local change agents (Champions) being identified to ensure maximum involvement with stakeholders and effective communication.

During the actual piloting activities, local targets and performance criteria are agreed for SmartCare to ensure that outcomes can be clearly measured. SmartCare will foster a 'shared responsibility' model of health and wellbeing where everyone looks after everyone else. To foster enduring change, the Scottish pilot implementation sites will report and share successes to the SALPB as part of project reporting and communication plan activities.

SmartCare project resources have been identified to plan and deliver change management related activities which will include the planning and delivery of stakeholder engagement, awareness raising, workforce development, knowledge transfer events and resources. Project resources (in terms of staff time) are being drawn from the Scottish Centre for Telehealth and Telecare and the Scottish Government’s Joint Improvement Team (facilitation role), both of which are able to draw in learning from related national strategic work programmes and provide additional change management capacity. A further time contribution is coming from local partnership areas which have identified existing staff to lead on the SmartCare project and act as “Champions”.

An initial survey among participating regions showed that Kotter’s eight steps necessary to bring about organisational changes adapted into six generic steps are well understood and accepted. In the following some examples are provided (including Scotland for completeness as additional information is given to the six steps).

STEP 1: Get the vision right - get the team to establish a simple vision and strategy.

Northern Ireland: The vision of implementing integrated care has been recognised as a necessity for the future of health and social care in Northern Ireland. It will be important to maintain sight of this vision and its key aspects when undertaking the process of implementing integrated care. Directors and other senior management responsible for implementing this process will be required to ensure that this vision remains at the forefront of any work that is being undertaken.

Basque country: A multilevel strategy involving different dimensions is needed (integrative organizational change, patient empowerment, massively deployed ICT tools, new professional roles, healthcare guidelines, research and others). Meetings with healthcare services managers and other heatlh professionals take place several times a year. An Office for Chronicity Strategy at Osakidetza Headquarters that monitors all aspects of the strategy has been set by the Regional Government.

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Palaio Faliro (Attica): Frequent vision and strategy team meetings before the commencement of works till the adequate level of knowledge has been achieved. In all projects related to integratred care, a “strategist” role is assigned to a senior member of the team responsible for the material to be discussed. In addition, regular assessments take place to ensure that the group has the same level of understanding of the objectives.

Veneto: The head of the social department and the director of the health department will coordinate the deployment of the project. They are jointly responsible for formulating and promoting the strategic vision for integrated care delivery.

Region of Southern Denmark: The implementation of the shared care service has been politically decided between the region and the 22 municipalities. The progress of the project will be monitored in the common political steering committee.

NHS Scotland: Scotland will combine current and leading practice in change management “by design” with a user-centric approach, to achieve the cultural shift required by service providers to enable individuals to be well informed, make choices and live healthy and active lives. The high level Scottish Assisted Living Programme Board (SALPB) will set the strategic vision for the Scottish Smartcare pilot, provide governance, policy support and review progress. SALPB contains representation from Scottish Government, Enterprise Company, Users, Carers, Health & Care Practitioners. A Project Steering Board for SmartCare is being established with representation from the local sites, who will each be responsible for developing local strategies which dovetail with overarching strategic priorities and vision.

STEP 2: Communicate for buy-in - Involve as many people as possible, communicate the essentials

Northern Ireland: Transforming Your Care’ (TYC), Northern Ireland’s most recent review of health and social care, has communicated the need for more integrated working between health and social care professionals. The review process incorporated a comprehensive schedule of stakeholder engagement and members of the public and other stakeholders supported the concept of integrated care that was outlined. Currently, the Southern Health and Social Care Trust (SHSCT) is beginning its implementation of an Integrated Care Partnership (ICP) and maintaining this communication process to secure ongoing buy-in from all key stakeholders. It will be critical to ensure that communication and engagement at local level is undertaken throughout the process of implementing the ICP within the SHSCT. SHSCT will ensure Director-level responsibility for the development and implementation of a comprehensive communication plan, to support the process of implementing the ICP.

Palaio Faliro (Attica): The approach is to disseminate the project’s aims, goals and potential benefit to three levels: a) Inside the organisation so as to raise awareness even to the members of staff not directly involved with the project in order to create a sense of joint property; b) Inside the municipality with the organisation of workshops and open days so as all citizens will share the same level of information; c) At national level to stress the need for similar actions and put pressure for solving issues related to central administration e.g. recruitment of personnel. One person should be in charge for each dissemination level with the mayor chairing this informal committee and taking over the national level activities.

Basque country: Buy-in from multiple stakeholders is achieved for example through participatory environments (web 2.0, blogs) such as KRONET (patients associations web services) that seeks to support changes in the role and the care processes for chronic patients. In addition, NGOs and patient associations, local professional colleges and scientific associations are involved. This is supplmeneted by the organisation of seminars and workshops in Health Centres.

Region of Southern Denmark: SmartCare will make use of the “Sam:Bo” collaboration contract between the region and the municipalities regarding admission and discharge when patients/citizens are transferred to/from hospital and home care. The project will use the

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existing and well established communications channels for staff, management and political leaders. The “VisinfoSyd” platform for information to all relevant participants will be utilised.

NHS Scotland: “Smartcare Champions” will engage and connect shared learning and innovative approaches (across the spectrum of stakeholders members e.g. citizens, carers, friends and family, volunteers and professionals) within a design thinking process which will be applied to the redesign of services and care pathways. SALPB will develop a comprehensive Communication Plan which will see local change agents being identified to ensure maximum involvement with stakeholders and effective communication. Local pilot implementation sites will be responsible for delivery of local communication activities.

STEP 3: Empower action - Remove obstacles, enable constructive feedback and lots of support from leaders.

Northern Ireland: The SHSCT is currently in the process of enabling these actions in order to progress its ICP implementation. Throughout the process of implementing the ICP the SHSCT will be required to identify and remove obstacles to ensure progress can be achieved. A key component to assist the implementation process will be securing feedback and support from leaders and clinicians etc. Responsibility will rest at Director level within SHSCT for maintaining an overview and developing a risk register of all the obstacles that could prevent progress from occurring. This should be reviewed on a continual basis throughout the process. The relevant Director will also be the identified contact point for leaders and clinicians to provide feedback to.

Catalonia: Several meetings already took place at high level instances among the municipality, healthcare and social care authorities. The meetings were aimed at reaching consensus on identified local “barriers.” Smartcare specific service blocks were then identified to overcome them. To separate clear responsibilities at the municipality social services in the context of their competencies & to align and complement them with those of the HCservices and third organisations (volunteers) and family carers.

Veneto: One of the main obstacles at this stage is the fragmentation of the different information systems used on daily operations by professionals. Another obstacle is the resistance to change consolidated routines of professionals in the delivery of services and treatments. The action required will focus on the integration of different platforms and technologies used for performing activities and the deployment of new solutions. In the meanwhile it will be also required to push the integration of the professionals’ teams coming from different departments. An activity of teambuilding will help the cooperation between GP, nurses, physiotherapists, social workers and all the other figures involved in the process. Responsible for the coordination of these actions will be the Director of the Social and Health District, supported by the ICT department and the middle management of the District.

Basque country: the change management is based on the work by frontline teams which promote organisational bottom-up innovation, for example by developing; new nursing roles. Training for all professionals. All these activities are carried out under the supervision of the Regional Authorities and Healthcare Managers, Office for Chronicity Strategy at Osakidetza Headquarters and the O Berri Basque Healthcare Innovation Center.

Region of Southern Denmark: a dedicated unit with experts from the regional IT and healthcare departments has been established. The unit is in charge of the implementation of the SmartCare solution and have all necessary funding and management support that is needed, and is also entitled to carry out public procurement processes.

NHS Scotland: A Community Engagement Plan will be developed which will describe how all stakeholders will be involved in the design and delivery process. Local pilot implementation sites will be responsible for delivery of the community engagement activities.

STEP 4: Create short-term wins - Set aims that are achievable - in bite-size chunks. Finish current stages before starting new ones.

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Northern Ireland: Activities to ensure that initial benefits from the process of implementing the ICP are delivered. All those health and social care professionals involved in the ICP will be required to demonstrate the necessary commitment to delivering the benefits of the ICP in order to ensure that the initial short-term wins can be achieved.

Palaio Faliro (Attica): The achievement of quick wins is ensured by an internal tight implementation time schedule taking into consideration the work segmentation in such a way as to allow for the creation of short term wins at the completion of the various distinct phases. An internal auditor is responsible for the follow up of the time schedule. Management ensures that all interested parties are fully aware of their tasks and they are committed to accomplish them.

Region of Southern Denmark: By focusing on one patient group (heart failure) it will be possible to demonstrate effects and improvements on a short term basis. RSD is in charge of creating a forum for GPs, municipalities and patients that can follow the project.

NHS Scotland: Smartcare will attempt to change the culture of focusing on illness by building on existing good practice examples like the Telecare Programme, Telehealth developments, – all examples of change in service design, delivery and evaluation that have been progressed, in partnership with service providers. We will adopt an assets based ethos, focusing on what people can do.The Project Steering Group will develop an Implementation Plan which builds on current good practice with a view to achieving successful delivery of both short term and long term objectives. Pilot implementation sites will be responsible for delivery of local objectives and actions.

STEP 5: Don't let up - Foster and encourage determination and persistence - ongoing change.

Northern Ireland: The benefits that have been achieved (as per the stage above) should be communicated to all staff within the SHSCT. The senior management team will be responsible for disseminating information highlighting the benefits delivered by the ICP and for any learning points identified to be communicated and actioned.

Palaio Faliro (Attica): Momentum of activities is maintained through frequent team meetings with very specific agendas where short term goals will be set following the pilot’s implementation plan, deviations from schedule will be discussed and corrective measures will be decided. Strong team leadership is fostered.

Basque country: the rearrangement of the financing and commissioning contract which is linking a 2% of the funding of the 11 LHS with the compliance of their specific PBIP.

Region of Southern Denmark: The implementation plan has been politically approved in the Region and municipalities. It includes a risk assessment and plan for maintaining the progress in the implementation phase. RDS has more than 20 years of experience with implementations processes with in this area.

Finland: A “Centre” will be built by using multidimensional and multi-professional teams. It will become a smart supporting technology forerunner in Finland.

NHS Scotland: Smartcare will foster a 'shared responsibility' model of health and wellbeing where everyone looks after everyone else. We will aim to shift the balance of care in a way that the citizen is comfortable and confident with. Professionals will 'reposition' themselves within the “circles of care” model, shifting from the 'us and them' relationship to a 'live' social lifestyle model that connects the citizen across their ‘circle of care’ with friends, family, local community and experts/ service providers. SALPB and Project Steering Group will be responsible for developing and supporting implementation.

STEP 6: Make change stick - Reinforce the value of successful change via recruitment, promotion, new change leaders. Weave change into culture.

Northern Ireland: It will be necessary to identify leaders to oversee the ongoing change that widespread implementation of ICPs will require. The benefits of this method of working

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should also be disseminated regionally. The identification of change leaders and regional dissemination of information would have to be overseen at Chief Executive and senior management level within the Health and Social Care Board, the six Health and Social Care Trusts, and the Department of Health, Social Services and Public Safety.

Basque country: Continuous improvement is ensured through the rearrangement of the current care delivery organization and its operation towards integrated Local Healthcare Systems (LHS). Advocacy and networking: Leaders, Professionals, Managers and the Communication team of Osakidetza will be actively involved in dissemination, meetings and engagement of relevant constituencies. Patients and professionals are enabled to act as trainers of their peers. Information is communicated through brochures distributed to service organizations, associations of patients, etc.

Catalonia: Change is made sustainable by the recruitment of volunteers to reinforce the social and family carers for the training phase and adherence phase.

Veneto: Continue activities to create a culture of change, to improve the performance following a common and share pathway with other several countries in the European context (the cooperation itself will be a guarantee of success); and to became a model for best practice in the field of integration between social and health carers.

Region of Southern Denmark: The SmartCare solution has been included in the collaboration agreement between RSD and the municipalities. The project will be monitored by the political board established between RSD and the municipalities (with RSD being in charge of the secretariat).

NHS Scotland: As part of its existing commitment to knowledge transfer, NHS 24 will be responsible for ensuring that Smartcare successes are conveyed and shared with both internal and external stakeholders to embed change. Existing digital platforms and networks will be used to support theses activities. Pilot implementation sites will report and share successes to the SALPB as part of project reporting and communication plan activities.

These activities will be supported by an advisory team, composed of experts outside the consortium, dedicated to integrated care change management across different organisational cultures.

B.3.3.10 Approach to Risk Management

Overall project risk management is put into place and execution supervised. Should a risk situation be detected, appropriate steps are undertaken in mitigation, if necessary involving the PSC and informing the EC PO

The SmartCare risk management approach consists of establishing both an organisational structure and a two-step procedure.

As an element of project management, a risk manager will be identified. Together with workpackage leaders and all participating partners, he/she will assure a regular review of risk management procedures and results, thereby focusing on an early identification of risks and their timely mitigation. At appropriate meetings, a regular agenda item will be concerned with risk issues.

All potential and occurring risks will be managed by a two-step process:

• Risk identification and assessment: o Active and early risk identification, recorded in a list to be updated regularly. o Risk analysis, with respect to their urgency and potential impacts. o Risk classification, by estimating their probability of occurrence.

• Risk mitigation and control:

o Plan for early mitigation actions of risk avoidance or minimisation of impact.

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o Implementation of risk avoidance / reduction actions at the appropriate point in time.

o Tight monitoring of the results of such actions, including timely reporting of outcomes to project management and WP leads, and re-assessment of risks as may become necessary.

From the management point of view, there are a number of risks which can never be totally avoided, but need to be controlled; these potential risks are identified. Risks already identified shall be monitored continuously.

To control for such risks, indicators and metrics are defined and reported in the periodic progress reports. When any such indicators reach an alarm level, the relevant mitigation activity is started.

The following information shall be defined for each risk:

1. Unique identifier and name, location of probable risk occurrence in the context of overall work performance and processes.

2. Probability reflecting the estimated probability level of occurrence of the risk (from low to high, numeric values may be used).

3. Estimate of impact level in case the risk occurs (from low to high, numeric values may be used) and area of highest impact anticipated.

4. Mitigation actions to reduce the probability and/or severity of occurrence of the risk.

5. Status, with possible values: o Identified: the IRS (Identified Risk Sheet) has been filled in and the risk is being

monitored; o Superseded: no longer a (potential) risk; o Active: the risk is currently affecting the project.

Table 5 above exemplifies the above risk analysis and uniquely identifies those risks already known at the time of writing this proposal.

B.3.4 Security, privacy, inclusiveness, interoperability, standards and open-source

In the following sections the issues related to security, privacy, inclusiveness, interoperability; standards and open-source are addressed.

It reading the following sections it has to be kept in mind that the SmartCare system is not a single ICT system which is implemented in all the pilot sites using the same technological platform and that, in most cases, the actual SmartCare system is the result of the integration between existing legacy applications already running in the pilot sites with applications newly procured for realising the full SmartCare environment. As a result, the specifications described below have to be interpreted as the target of fully open and interoperable systems towards which the individual implementations will evolve over the time.

The Co-ordinator Support Team will liaise with the individual pilot sites when these procure the ICT systems and solutions in support of the SmartCare pathways to ensure that these comply with the specifications described in § B.2.1.2 to B.2.1.4 and with the Security, Privacy, Inclusiveness and Interoperability requirements described in the following sections. To this end the Co-ordinator Support Team can avail itself of experts from industry, academia and well reputed telemedicine competence centres. The appropriate provisions for implementing this control function will be included in the Consortium Agreement, the signature of which has to precede the signature of the Grant Agreement with the Commission. The Coordinator will notify to the Commission if he identifies procurements orientations which do not comply with the specifications or are not based on open systems which allows to mix and match components from different manufacturers. In particular cases,

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proprietary solutions can be accepted as short-term, stop gap measures provided there is a clear commitment by the supplier to move towards systems compliant with the specifications contained in this Technical Annex. Recommendations from the Co-ordinator will be binding for the beneficiaries at the time of procuring systems and solutions to be used in the framework of SmartCare.

Adherence to commonly agreed security and ethical requirements will be ensured through a structured management process as graphically presented below.

T 10.6Ethics & data

protection

management

T 1.3Legal &

regulatory

analysis

D1.1 Requirements

for SmartCare

pathways& integration

infrastructure

D10.2 Ethics & data

protection

framework

Requirements catalogue

Common :

• Data security

• Data privacy• Ethics

Site specific:

• National legislation / regulation

• Occupational / organizational

codes of practice

Architecture

& service

definition

System

implementation & test

Pilot site

preparation

operation

Implementation

WP3 Leader

WP4 Leader

WP5 Leader

WP6 Leader

Monitoring

Supervision

Ethics & Data Protection Manager

As can be seen from the schema above, a requirements catalogue will be derived from outcomes that will have been generated in two work packages at an early stage in the overall project, namely WP1 and WP10.

To begin with, an ethics and data protection framework will be developed (D10.2) with a view to systematically identifying any issues around data protection and ethics that have relevance to the project. Guidance will be given to the project participants in terms of general principles on how these are to be addressed, as for instance laid down in European data protection regulation and the Charter of Fundamental Rights of the European Union which all activities supported by FP7 have to respect. Beyond this, the Ethics and Data Protection Framework will include more specific guidelines on how to address particular issues arising in this context, e.g. when it comes to ensuring data privacy and informed consent to be sought from end users to be involved in the project.

In parallel, a dedicated strand of work will focus on identifying any legislation and regulation which may have a bearing on design and implementation of services to be piloted at a later stage (T1.3). Here, a broad perspective will be adopted to enable systematic identification of requirements stemming from national/regional legislation and regulation, e.g. when it comes to data privacy and liability issues, as well as requirements potentially stemming from any sectoral and/or occupational codes of practice that may have been put in place in the participating regions and/or service provider organizations.

Implementation of the requirements catalogue throughout the project’s life cycle will be monitored by the responsible WP leaders in the first sense. These will be supervised by the ethics and data protection manager as set out in the work package description (WP9).

In the following, some key issues to be considered in this context are initially discussed from a technology-related perspective.

B.3.4.1 Security

The SmartCare systems will guarantee the integrity, confidentiality, non-repudiation, authenticity of data and secure communications. The definitions of these various security

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objectives and their specific applicability to the ICT-supported Integrated Care field are given in the following text boxes, while the way these properties will be implemented in SmartCare, when applicable, is given in the main text, e.g. the security, privacy and ethical requirements will be commonly collected. This is the responsibility of WP1 and WP10. This work will be supplemented by national level applicable requirements. Both affected WP leaders and the Ethics and Data Protection Manager will supervise the implementation (see B.3.4 for further details).

Confidentiality: The ethical principle or legal obligation for a social or healthcare professional or for an informal caregiver to hold secret all information related to a person they provide care to, unless the person gives consent permitting disclosure. Confidential information is any record containing private information about an identifiable individual or establishment, when the person providing the data or described in it has not given consent to make that information public and was assured that such data would not be made public when the information was collected.

The Vital Monitoring, Environmental Monitoring and Scheduling Services in the “Front Office” as well as the “Back Office” systems of SmartCare will use encryption techniques to protect the data temporarily or permanently stored on the servers, or those transmitted over an open network. These will techniques can be based on both symmetric cryptographic algorithms (3DES, AES, etc.) or asymmetric cryptographic algorithms (RSA, DSA, EC, etc.). The use of these encryption techniques ensures that sensitive data will not be tapped by unauthorised persons.

Integrity: This security property guarantees that the information is accurate, reliable and suitable for its purpose. The integrity assures protection of information systems against modification of information, whether in storage, processing, or transit, including those measures necessary to detect such threats.

This security requirement is intended to avoid that an unauthorised person can modify or manipulate data. The requirement suggests the use of digital signatures, hash functions as well as restricting (write) access to data so as to guarantee the preservation of sensitive or otherwise security-critical data, and/or to manage who is allowed to change which data under which conditions. Thus, encryption techniques based on message authentication codes (MACs) and cryptographic hash functions (SHA1, SHA256, etc.), along with both symmetric cryptographic algorithms (3DES, AES, etc.) and asymmetric cryptographic algorithms (RSA, DSS, EC, etc.) are used to obtain the digital signatures. As indicated above, these digital signatures apply to the data whose integrity needs to be guaranteed, ensuring that the data cannot be tampered. As in the previous case, digital signatures need to be applied to protect data stored on the machine on which the eHealth application runs or data securely transmitted over an open network.

In the case of SmartCare, access to data is based on the definition of profiles and roles for the authorised user of the system. During the trials, users might be identified and authenticated via user ID and password only. However it is highly probable that digital signatures will be introduced at a later stage, before the SmartCare service starts to be deployed on a larger scale.

Authenticity: Verification of the identity of a user who is logging onto a computer system or confirmation of the origin of a transmitted message. Authentication depends on four classes of data, generally summarised as ”what you know”, ”what you have”, “'what you are”, and ”what you do”. This security property is closely related to the authorised accesses, i.e. the permission granted to individuals to see confidential data that potentially could be identifying or linked to an individual. User can authenticate via their credentials or using their certificates or smartkeys.

SmartCare will use whenever possible an SSO (Single Sign On) method based on SAML, Security Assertion Markup Language, to authenticate users between different security domains. Single Sign On is a mechanism that allows a user to authenticate once and to then

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access other domains. The SSO will greatly improve the ease of use of the applications avoiding the need for the user to authenticate him/herself for each application composing the SmartCare echosystem.

Non-repudiation: This security objective should be in place to enforce the non-repudiation (of both origin and receipt) of sensitive data to be transmitted over an open network, as well as the non-repudiation of previously stored security-critical data.

Source of data is always recorded in the SmartCare databases. Data cannot be deleted, but only invalidated if there are likely to be erroneous readings or if their validity has expired.

Secure communications: This security objective suggests the use of encryption to allow sensitive or otherwise security-critical data to be securely transmitted over an open network. This objective is essential so as to secure personal medical or other sensitive data exchange over public networks.

To secure communications the SmartCare environments will employ protocols such as the Secure Socket Layer or SSL (more often known as TLS - Transport Layer Security). SSL/TLS enforces security using X.509 certificate technology for authentication and encryption, guaranteeing in this way secure web services.

To achieve security for web services, the transport level, as well as the message level will be considered.

At the first level, Transport Layer Security uses existing Internet protocols to secure the traffic between the Web Service and the client application. The SmartCare environments will adopt authentication and encryption systems such as:

• HTTP based authentication (HTTP BASIC, HTTP Digest, HTTP CLIENT-CERT) directly on the web server.

• SSL for encrypting data.

The primary goal of the TLS Protocol is to provide privacy and data integrity between two communicating applications. The protocol is composed of two layers: the TLS Record Protocol and the TLS Handshake Protocol.

One advantage of TLS is that it is application protocol independent, placing no limits to interoperability. It is used to establish a private and reliable connection between two parties, assuring cryptographic security.

In order to provide for an end-to-end security, a model message level security, also called XML level security, will be considered. At this level, the security information and access policies are bundled into the message itself. In this area the SmartCare environments will used basic standard such as WS-Security. WS-Security is a protocol neutral mechanism for securing SOAP messages. It builds upon XML-Signature and XML-Encryption, and also specifies how security tokens can be associated with messages. To enable interoperable authentication and authorisation across systems, security tokens are bundled along with a SOAP message, and these tokens are in X.509 certificates format.

Auditing and logging: This security objective is intended for logging events that are of interest to administrators and other users. If used properly, these logs can help ensure user accountability and provide warnings of possible security violations. Some of the events that occur during the use of an application are of particular interest. Recording specific information about events that have occurred creates records that allow the system to be debugged, monitored for security events, and measured for performance.

Only authenticated users have access to the databases. All accesses to the SmartCare databases will be logged. Information on who has entered, modified or invalidated data is kept in the database for auditing purposes. This is particularly relevant when data are consulted in emergency situations and with the consent previously expressed by the older person, by people other than the usual carers.

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B.3.4.2 Privacy

The SmartCare solution ensures privacy protection at different levels.

Informed consent. During the trials, but also during the provision of the service beyond the end of the European Project, older people will be included in the system only if they have expressed their consent in writing to receive the SmartCare services. For the consent to be expressed in an informed way, the consent form will contain a succinct description of the service and of the consequences for an individual to adhere to the services in terms of access by social and health care professionals or by informal carers to personal data.

Encryption of personal data. Data transmitted from the gateways in the flats or houses to the SmartCare “back office” systems will be encrypted. Moreover no older person identification will ever travel together with the data. Only the “back office” systems and the System Administrator(s) know to which person the data refer.

Closed community for videoconferencing. The videoconferencing systems will be based on the concept of a closed community. Only the older person him/herself or a person designated by him/her is authorised to ask the Contact Centre operators to add or remove contacts from the community of his/her correspondents. The SmartCare environment will stop any unauthorised attempt to contact the users of the videoconferencing system. Access to the videoconferencing servers will be enabled through a user-id and password or stronger authentication methods.

Multilevel access control to data. Data stored in the SmartCare databases are only accessible to authorised users properly authenticated. The access rights of each individual user will be based on the category to which he/she belongs (physician, psychologist, nurse, social worker, informal carer, relative, etc.), his/her relationship with the older person (e.g. a nurse or a social worker will only have access to data concerning older persons he/she looks after) and the need to know at any point in time. Inemergency situation, an authorised user might be allowed to override some of the restrictions above in the superior interest of the older person (provided the latter has given his/her consent to emergency access to his/her data). Overriding of restrictions will be always recorded in the audit trail and the System Administrator will be immediately notified of the event.

These features of the SmartCare solution will be implemented according to the process outlined at the beginning of this chapter (B.3.4), e.g. the requirements collection (fed by WP1 and WP10) will compile a common set of privacy, security and ethics requirements, supplemented by national level requirements.

B.3.4.3 Inclusiveness

The SmartCare systems have been conceived for use by people with no familiarity whatsoever with modern technology. Interfaces between the user and the system will be inspired by the interaction paradigms which are likely to be most familiar to or, at least, of the most intuitive use for the older persons such as:

• TV sets;

• remote IR controls;

• smartphones possibly reconfigured to reduce functionalities and simplify interaction (menu comprising fewer and larger icons compared to the factory set-up);

• intuitive interfaces on touchscreens;

• etc.

In other words, whoever is able to change channels on an ordinary TV set using the remote IR control or use the basic functions of a cellular phone should be able to interact with the SmartCare environments.

Interaction with the “front end” systems in the home will be reduced to a bare minimum.

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The SmartCare environments will be totally configured and controlled by the Contact Centre. The interaction between the older people and the components of the SmartCare environments available in the home will be achieved through, e.g.:

• vocal messages synthesised by gateway devices;

• vocal messages sent through smartphones;

• text messages displayed smartphones, on the TV set, or on the integrated touch screen of gateway devices;

• graphical messages (icons).

All these ways of communicating between the SmartCare environment and the older person are highly intuitive and do not require any previous knowledge of technology.

A majority of older people are expected to be able to make use of the system with a very small amount of training and support from the Contact Centre operators.

B.3.4.4 Interoperability

Two levels of interoperability will be considered:

• Data interchange interoperability: This enables the interchange of data between different modules and applications. In the health environment e.g., the most widespread standards for data interchange are HL7 for interchange of medical data and DICOM for that of radiology images. For the exchange of messages within and outside the system, the SmartCare systems will put forward HL7 standards over a variety of communication protocols (ebXML, SOAP, WSI-Web Services, HTTP). The integration platforms will contain adapters that provide bi-directional, real-time connectivity, and support open standards such as JCA, XML, JMS, Web Services and WSIF. All adapters should conform to the J2EE Connector Architecture (JCA) open standard adopted by all major integration vendors. This is the minimum level of interoperability that all the local SmartCare systems have to ensure.

• Semantic interoperability: In general this is the ability of two or more computer systems to exchange information and have the meaning of that information accurately and automatically interpreted by the receiving system. This is achieved e.g. in eHealth by using coding conventions to express medical concepts such as diseases, problems list, allergies, diagnoses and so on. Examples of commonly used coding systems for eHealth are SNOMED, LOINC, ICD9. Semantic interoperability among the subsystems composing each of the local SmartCare systems will be sought but cannot be guaranteed at this stage.

Interconnectivity of equipment and services

• General The “front office” services of SmartCare foresee in the flat or house of the older person the presence of a number of medical devices (blood pressure meter, scale, pulse-oximeter, etc.), environmental sensors (e.g. smoke detector, temperature and humidity sensor, etc.) and domotic actuators (i.e. window, door opening/closing actuators). These devices will be in principle connected to communication gateways through wireless communications to reduce / eliminate installation costs and avoid manipulation to connect medical devices to gateways for data transmission. The “front office” system in the home enables the transmission of information to “back office” systems and databases that can be securely accessed by Contact Centre personnel and by healthcare and social care professionals, informal caregivers and relatives according to the access rights that each of them has. This enables, among other things, the social worker, the psychologist or the gerontologist in charge of an older person to share information and use the data obtained through

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the system to check the evolution of the person’s behavioural patterns and, hopefully, to prevent more serious problems.

• Communication gateways in the home Communication gateways in the home will incorporate as much as possible wireless receivers (usually BlueTooth receivers for medical devices and RF ones for environmental sensors and domotic actuators) that serve to connect to the various types of medical devices, sensors and actuators. Once the device acquires data, it is able to transmit it over an IP Data connection. The IP Data connection can be either a mobile or land IP Network with Internet connectivity. By using a GPRS modem, compliance is guaranteed with the main ITU-T recommendations for communication within a GSM network (GSM 13.11 version 7.0.1 Release 1998). The modem supports the GPRS class 12 standard for high-speed packet data communication. Support for Multislot Class 12, Full PBCCH support, Mobile Station Class B and Coding Scheme 1 – 4 is also provided. The bit rates range from 300 to 14.400 BPS non-transparent according to V.21, V.22, V.22bis, V.26ter, V.32, V.34, V.110. By using an analogue modem, compliance is guaranteed with the main ITU-T recommendations for communication between two analogue dial-up modems to carry digital data at different bit rates. It can work at 2.400, 1.200 and 300 bps, guaranteeing compatibility with: V.22bis (2.400bps), V.22 - V.23 - Bell 212A (1.200 bps), V.21 - Bell 103 (300 bps). It can be used either with Pulse or Tone Dialling Mode. The communication gateway transfers data from the older person’s location to the Contact Centre where monitoring is performed. The data transfer is based on TCP/IP according to RFC 4614, RFC 793, RFC 1122 and RFC 1323 (Standard Specification for TCP/IP Protocol).

• Location detection system

Data security will be assured by a series of checks during the transmission from the mobile unit to the system. The information about user’s position will be protected through encryption techniques based on both symmetric cryptographic algorithms (3DES, AES, etc.) and asymmetric cryptographic algorithms (RSA, DSA, EC, etc.) to protect the data temporarily or permanently stored in the SmartCare databases or those transmitted over an open network. The use of these encryption techniques ensures that data will not be tapped by unauthorised persons. The location detection system is based on several international standards: o GSM, the most popular standard for mobile devices in the world. o GPS, the Global Positioning System standard.

• Behavioural pattern monitoring In terms of interoperability, almost all messages within the behavioural pattern monitoring system will be transported via XML. The exchanged messages will be all encrypted by using open standard such as Pretty Good Privacy (PGP). Moreover, all the messages to the database will be transported over secured transmission layers such as SSL. Access to Behavioural Pattern Monitoring software as well as to the Vital and Environmental Monitoring systems will be managed according to the Role Model of the Server Application.

• Videoconferencing The system will be based in general on a typical Client-Server architecture. The mobile Clients will be running in environments such as the Adobe Air installed on mobile operation systems like Android open source. The Web Clients will use plug-in such the Adobe Flash for a variety of web-browsers such as Firefox, Chrome, Internet Explorer etc.

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Servers such as the Open Source Red5 Media Server will be used to provide the needed signalling functionality for the streaming based videoconference system. The underlying signalling protocol of choice will be (RTMP) Real Time Messaging Protocol while for real time text messages a Shared Object will be distributed to all Clients with the same chatroom.

B.3.4.5 Standards

B.3.4.5.1 Web based communication

For SmartCare “back office” systems, Internet and World Wide Web standards will be used e.g. for the user interface which is to be realised through a standard Internet browser as well as for interconnection and data integration which are implemented through Web Services and XML.

The “back office” systems will be designed to make information available to external users through browser-based technology. This allows client applications running on all the most widespread computer platforms to access the systems with appropriate authorisation. Internet and World Wide Web standards such as HTTP, HTTPS, X.509 V3, TCP/IP, SOAP, UDDI, WSDL are used.

Communications between any client devices and the databases will be based on open standards and will be encrypted for data protection.

As recommended by institutions such as the Department of Health in the UK, the SmartCare systems will use web services that are based on SOAP and WSDL specifications. Basic messages exchanged in web services will be encoded using, in principle, XML and transported using, in principle, the Simple Object Access Protocol (SOAP). With regards to web-based transactions over SOAP, the Universal Description Discovery and Integration specification (UDDI) will be the specification of choice to publish the Services and the Web Services Description Language (WSDL) will be in principle used to describe the definition of both the abstract functions offered by a given service and the protocol mechanisms used to support these functions.

B.3.4.5.2 Continua guidelines

Guidance from both Continua Health Alliance and IHE (Integrating the Healthcare Enterprise) guidelines will be equally sought for the SmartCare systems.

Continua guidelines make references to standards and specifications for ensuring interoperability of personal health devices. The current design guidelines that build upon Version 1 and 2011 guidelines focus on the following interfaces as depicted in Figure 11 to 15 below:

• PAN/LAN-IF: Interface to Personal Area Network health devices – For the transport level, Continua has selected Bluetooth Health Device Profile and the ZigBee Healthcare Profile for wireless communication, and USB Personal Healthcare Devices for wired communication. Above the transport level is the data level. Continua has selected the ISO/IEEE 11073 Personal Health Device family of standards to enable data format interoperability.

• WAN-IF: Interface between Personal Area Network devices and Disease Management Services – Continua and IHE have defined the PCD (Patient Care Device) 01 standard to define a common approach to deliver near real-time device observations across a wide area network. Underlying this profile the Health Level 7 (HL7) Personal Health Monitoring (PHM) v 2.6 Report document format was chosen to ensure consistent data encoding and interpretation.

• HRN-IF: Interface between Disease Management Service (DMS), WAN devices (HR Senders) and Electronic Health Record (EHR) devices (HR Receivers). Continua has selected the Integrating Healthcare Enterprise (IHE) Cross-Enterprise Document

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Reliable Interchange (XDR) profile as means to establish the communication between WAN devices and xHR systems. This includes The Clinical Data Architecture (CDA) Clinical Care Document (CCD) formatted messaging for EHR connections.

Figure 11 – Current Continua design guidelines Project Management Structure

Figure 12 –Continua Architectural Diagram

Figure 13 – Continua Sensor-LAN Configuration Diagram – Transport is ZigBee Healthcare Profile

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Figure 14 – Continua Architecture Diagram showing Wide Area Network (WAN) Interfaces: WAN Observation Receiver and Health Reporting Network (HRN)

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Figure 15 – Continua Health Reporting Network (HRN) Diagram

Continua Health Alliance provides testing and conformance to their interoperability guidelines. These will be considered during the execution of SmartCare.

B.3.4.5.3 Cross-border operability

Additionally, for cross-border interoperability, reporting will capitalise upon the experience and identified standards of epSOS. Consequently, other standard profiles that, following the IHE guidelines, could be considered in SmartCare are:

• Cross-Enterprise Document Sharing (XDS) Cross-Enterprise Document Sharing enables a number of healthcare providers belonging to an XDS Affinity Domain (e.g. a community of care) to cooperate in the

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care of a patient by sharing clinical records in the form of documents as they proceed with their patients’ care delivery activities. The use of Federated Document Repositories that a single Document Registry points to allows generating a longitudinal record of information about a patient within a given XDS Affinity Domain. This profile is based upon ebXML Registry standards, SOAP, HTTP and SMTP.

• Cross-Community Access (XCA) The Cross-Community Access profile supports the means to query and retrieve patient relevant medical data held by other communities. A community is defined as a group of enterprises that have agreed to work together using a common set of policies for the purpose of sharing clinical information via an established mechanism. Enterprises may host any type of healthcare application such as EHR, PHR, etc. Membership in one community does not preclude an enterprise from being member of another community. Such communities may be XDS Affinity Domains which define document sharing using the XDS profile or any other communities, no matter what their internal sharing structure is.

• Patient Care Device (PCD) The IHE Patient Care Device Technical Framework defines specific implementations of established standards to achieve integration goals for the Patient Care Device domain. Such integration promotes appropriate sharing of medical information to support optimal patient care. The Device Enterprise Communication Integration Profile describes mechanisms to communicate PCD data to enterprise information systems. The scope of PCD includes periodic physiologic data (heart rate, invasive blood pressure, respiration rate, etc.), aperiodic physiologic data (non-invasive blood pressure, patient weight, cardiac output, etc.), CLIA waived (or equivalent international waiver) point-of-care laboratory tests (i.e. home blood glucose, etc.) and can include contextual data such as the patient ID, caregiver identification, and patient care device configuration information and real time alarms and alerts, waveforms (ECG, EEG, etc.), or control operations.

• Patient Care Coordination (PCC) IHE Integration Profiles offer a common language that healthcare professionals and vendors can use to discuss in precise terms integration needs of healthcare enterprises and the integration capabilities of information systems. Integration Profiles specify implementations of standards that are designed to meet identified clinical needs. They enable users and vendors to state which IHE capabilities they require or provide, by reference to the detailed specifications of the IHE Patient Care Coordination Technical Framework.

• Basic Patient Privacy Consents (BPPC) The Basic Patient Privacy Consents profiles provides a mechanism to record the patient privacy consent(s), a method to mark documents published to XDS with the patient privacy consent that was used in the first place to authorise the publication, and a method for XDS Consumers to enforce the privacy consent appropriate to the use.

• Audit Trail and Node Authentication (ATNA) The Audit Trail and Node Authentication (ATNA) Integration Profile establishes security measures which, together with the Security Policy and Procedures, provide patient information confidentiality, data integrity and user accountability. This environment is called Security Domain and its scope can range from a single department, to a whole enterprise or Affinity Domain. The involved systems are also responsible for providing security audit logging to track security events. In healthcare this audit log is often more useful than strict access controls and should be relied upon even in emergencies.

IHE provide testing and conformance to their interoperability guidelines. These will be considered during the execution of SmartCare.

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B.3.4.5.4 Standards and tools to create care pathways

A report in 2005 identified and reviewed a number of tools which could facilitate the development of electronic care pathways34. These are: PROforma, the Map of Medicine, BPMN and the HL7 Version 3 Clinical Statement Pattern.

• PROforma is a guideline specification language, developed by Cancer Research UK (CRUK), which specifies each decision in terms of any number of candidate options and the arguments for and against each candidate. Each candidate is evaluated in terms of the available evidence for and against it. Decisions are contained within plans, which may also specify actions to be done and enquiries, which obtain evidence. PROforma is a declarative language, focusing on what is or is not known about the patient, as opposed to procedural languages that focus on the sequence in which tasks are carried out. In this way PROforma reflects clinical practice. PROforma has been developed over a number of years, and an impressive body of published evidence has been accumulated, which demonstrates its practical value.

• The Map of Medicine is an online clinical knowledge browser that provides desktop access to a wide range of specialist clinical information and evidence-based practice. The Map of Medicine is platform independent and can be localised to meet local needs.

• BPMN (Business Process Modelling Notation) is a new standard for business process modelling. It is now part of the OMG (Object Management Group). It provides facilities for documenting events, such as triggers, and for decomposing processes into sub-processes and tasks.

• The HL7 Version 3 Clinical Statement Pattern is the model used for all clinical messages, including the exchange of patient records, in the NPfIT. Preliminary analysis suggests a fit between the needs of care pathways and the HL7 Clinical Statement Pattern, but this has not been demonstrated in practice and requires further work to identify issues and document recommendations.

The Consortium will investigate the best option for preparing the Pathways it intends to implement. Without pre-judging the final decision, BPMN appears to have developed further than PROforma since the report above wad written.

B.3.4.5.5 ISO 13940 Health Informatics - a system of concepts for the continuity of care

This section contains a brief evaluation of ISO 13940 “Health Informatics - a system of concepts for the continuity of care”. The Consortium will evaluate this in further detail to see if it could assist the Project, since care pathways and continuity of care are two sides of the same coin.

The current draft of ISO 13940 sets out from the notion that “semantic interoperability” is necessary for continuity of care. The problem of “interoperability” apparently arises when the same patient is dealt with by more than one clinician. As the authors write, they hope to solve this problem: “The system of concepts and the terms defined in this International Standard are designed to support the … delivery of care by different health care actors who are working together. … to facilitate clinical cooperation … and to enhance relationships between health care professionals and their patients”.

If semantic interoperability is seen operationally as the effective transfer of information about a patient between clinicians along a care process, then this problem is daily addressed - if not always fully solved - in all today’s healthcare systems. Clinicians write and receive reports, ask for and send diagnostic information, take part in end-of-shift handovers patient by patient, call meetings, re-examine, request diagnostics, phone people and generally

34 Tim Benson (Abies Ltd): Care Pathways, report commissioned by the NHS National Programme for IT (NPfIT), England

(now Connecting for Health), 2005

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communicate to support effective collaboration to the best of their ability. It may be that many such relationships could be better supported by easily transferable clinical records, but it is the clinicians who must understand such records, and understand them unambiguously, and it is they who must enter information into those records, easily, and in doing so ensuring the semantic reference they have is as well transferred into their colleagues’ understanding as if that colleague were listening to them in dialogue. Should they adopt a new language to do this?

ISO 13940 does not appear to have examined the learned mechanisms of ongoing clinical collaboration, choosing instead to take a step back and try to model what is going on from scratch. In doing so they propose terminology (“concepts”) which relate to an idealised “clinical process”, while using words such as “health state” etc. in a restricted way. This may be appropriate for data exchange at clinical record level, but even here a divergence from clinician’s use of language should surely at least be reflected on.

Because of its distance from conventional clinical understanding, anchored in years of dedicated training, the new terminology is likely to make communication in health care less effective and introduce significant new risks of person-to-person-interoperability failure.

Another model which has taken a similar approach is HL7’s RIM; since the aims are similar, it would be helpful if the two were explicitly related.

Nevertheless, the structure of the approach taken – at least to attempt to model what is going on – is certainly useful, and there is no fundamental contradiction between formal modelling and conventional terminology. What has to be done in addition is maintain exactly that mapping.

Also, conventional communication has its limits, barriers and borders. Cross-organisational and cross-disciplinary communication, the collaboration of health and social care providers, is relatively new, and the conventional communication channels are not established, nor is the language to communicate in. Here there may be a unique opportunity to develop a lingua franca for integrated care provision, which may well not be a 1:1 adoption of current clinician-speak.

B.3.4.6 Open-source

It is expected that the various systems that compose the SmartCare local systems will run under either Linux or Microsoft Windows operating systems. It has to be kept in mind that the SmartCare solution is mostly based on existing commercial products, which, in many cases, had been already selected at the time of submitting the proposal because they were considered by the partners “best of the breed” for their functionalities rather than for the underlying technological platform. Having said that, this duality in the approach to the technological platform is not surprising considering the different nature and requirements of the SmartCare solution components and stems from the relative merits of the two environments which both have strengths or weaknesses which make them more suitable for one type of applications or the other. Linux will be logically privileged for the Vital and Environmental Monitoring system because of its stability, flexibility and reduced vulnerability to computer viruses. Moreover, the Monitoring system needs to be, as it were, “closed” and “protected” because of the sensitivity of the data handled. The selection of Microsoft Windows on the other hand seems more logical, even if it is certainly not an open-source product, in environments which makes use of the superior user interface facilities offered by this environment and could benefit from the access that it offers to an immense library of third party software which could be integrated in this environment to extend in the future its scope.

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B.3.5 Resources to be committed SmartCare is an ambitious project, and the Consortium has been particularly attentive to include in the budget all the resources required to secure the attainment of the objectives foreseen in the proposal.

The first and most important resource for any project in the social and health care area is people. The Consortium will commit a total of 1.344,25 person-months to achieve the project objectives.

In addition to personnel, the other resources that the Consortium has committed to the implementation of the Project are:

Travelling and subsistence costs. The travelling budget has been distributed evenly among all the partners, irrespective of their role in the implementation, to allow them to participate in all the plenary Project meetings and in other relevant initiatives which require physical presence. Every partner or regional partnership has been allocated between 2.500 € and 40.000 € for travelling and subsistence. This huge spread in the travelling budget is mainly due to the different role in the Project (active pilot sites or members of the Committed Regions Board), and the amount of work which has been subcontracted to other entities within the same Regional Partnership. The highest amount of travelling budget has been assigned to FVG-ASS 1, RSD and EMPIRICA, respectively Project Coordinator, responsible for the Project evaluation and Business Consultant. Table 13 shows the distribution of the travelling and subsistence budget by partner.

Equipment Costs. The SmartCare services require a substantial amount of equipment to be installed in the older people’s houses, together with a server system to be installed centrally in each pilot site. The simplified assumptions used to calculate the durable equipment depreciation costs at the time of the proposal, i.e.:

• 5.000 € of capital investment per flat/house.

• 100 flats/houses per site.

• 10.000 € of capital investment for the server.

have been checked with the individual partners. In the current budget the depreciation of durable equipment eligible for EU funding in the various 1st sites wave of pilots ranges from 140.000 € to 340.000 € and for the 2nd wave of pilots from 76.660 € to 198.333 €. The spread in both cases is due to the amount of equipment which is has been already procured in the past and which can be reused in SmartCare and by the fact that for some of the pilot sites part of the equipment is actually supplied by a service provider as part of a service package. Table 14 and Table 15 show the durable equipment distribution by partner in quantity and value respectively.

Portal fees. It has been assumed that the monitoring of older people at home requires a subscription to a service provider. A provision of 7 € per month per older person participating in the trials has been allowed. This gives a total budget which ranges from a minimum of 4.900 € (this is the case of Tallinn where the budget for the use of the portal has been split between the East Tallinn Central Hospital and the City of Tallinn) to a maximum of 16.800 €. Table 17 shows the distribution of the Portal fee budget by partner.

Subcontracting. In the case of SmartCare, the activities which it has planned to subcontract are detailed in Table 12. Most of these fall in the following categories:

1. Support to the Project Co-ordinator related to the operational, scientific, financial and administrative coordination of the Project. A provision of 500.000 € has been included in the budget for this.

2. System integration. 3. Installation in the houses.

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4. Certification of Financial Statements: 4.500 €/certification. The number of times the Financial Statements will have to be certified depends on the amounts claimed in each Financial Statement. An estimate has been made of how many times each beneficiary will need its Financial Statements to be certified by an external auditor on the basis of the budget assigned to each of them.

The amount of budget allocated to category 2 and 3 above varies quite substantially from one pilot site to the other due to the ICT strategy adopted by the various pilot sites (in-house ICT department versus outsourcing of ICT) and the presence of a technology partner as a beneficiary within the local Regional Partnership (Attica and Serbia). Subcontractors will be selected in general according to the “best value for money” principle. However it has to be kept in mind that:

• in many cases ICT services are already outsourced by the participating regions and that these have framework contracts in place with their outsourcers;

• in other cases the specificity of the activity to be subcontracted and the competence required are such that there is only one supplier able to provide the service.

In all cases sensible decisions will be taken keeping in mind the rules of public procurement, on one hand, and the need to ensure the respect of the Project schedule, on the other hand.

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The table below describes the main activities which will be subcontracted by the SmartCare partners and specifies the subcontractor when it is already known at this stage.

Partner Subcontractor Value Detailed description of the work

FVG – ASS1 To be identified 500.000 €

• Project management

○ establishes the intra-project communications infrastructure;

○ prepares and distributes reports (Management Reports, Progress Reports);

○ reports regularly to the Project Co-ordinator on the progress of the Project;

○ helps the Project Co-ordinator to manage the individual Work Package Leaders;

○ supports the Project Co-ordinator in organising project-wide workshop meetings;

○ helps the Project Co-ordinator to keep the whole project on schedule;

○ helps the Project Co-ordinator to supervise all technical project deliverables;

• Scientific Coordination

○ defines in close collaboration with the Project Co-ordinator common inclusion and exclusion criteria for elderly people participating in the trials;

○ supports pilot sites for the preparation of the application for Ethics Committee approval;

○ prepares the scientific trial protocol;

○ registers the trials;

○ monitors the compliance of the pilot sites with the scientific trial protocol;

○ chairs the Internal Scientific Board;

○ supervises the scientific dissemination of project results.

• Quality Management

○ assists the Project Co-ordinator in defining the reporting structure and the relative reporting procedures;

○ produces the Project and Quality Plan;

○ monitors the proper production of quality records by individual Work Package Leaders;

○ reports regularly to the Project Co-ordinator and to the Project Steering Committee on the quality aspects of the project

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FVG – ASS1 To be identified 45.000 €

Administrative support for the co-ordination within Regione Friuli-Venezia Giulia. In SmartCare ASS 1 FVG will have two different roles to play: first, as Co-ordinator of the Consortium. For this purpose, as it is explained above, it is necessary to acquire services from a highly qualified subcontractor covering operational co-ordination, scientific co-ordination, and quality management. Second, as one of the 1st wave pilot sites. This will require co-ordinating 20 Healthcare Districts (belonging to the Local Health Authorities) and the associated Social Service Departments (belonging to the Municipalities). These will select and follow up the 200 subjects participating in the trials. For this second role, it will be necessary to acquire a part-time support because of the freeze on statutory personnel, which does not allow public authorities to hire new personnel. It should be kept in mind that SmartCare is a highly demanding project and the subcontracting of this local administrative co-ordination in addition to the subcontracting of some of the overall project management functions will ensure the Commission that the right quality and amount of resources is available for the successful conduct of the Project.

FVG – ASS1 TWEESTEDEN35 881.574 € Provison for the inclusion of a second partner in Noord Brabant FVG – ASS1, ETCH, TALLIN, ARAGON, CCU, SCOTLAND

To be identified 918.545 € Integration of the off-the-shelf components (e.g. telehealth and telecare solution, workflow tools) with the Health and Social Information Systems already in place. Integration of the Health and Social Information Systems with one another, etc.

FVG – ASS1, ETCH, TALLIN, ARAGON, EKSOTE, CCU, SCOTLAND

To be identified 240.045 € Installation of the telehelath and telecare equipment in the houses

FVG, RSD, ARAGON, EKSOTE, BELIT, SCOTLAND, EMPIRICA

To be identified 72.000 € Certification of the Financial Statements

To be confirmed once the organisation has been validated by REA

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RSD IBM

440.800 €

In the Region of Southern Denmark, IBM will be sub-contracted to the delivery of the Shared Care portal. Already in 2010 a tendering process was conducted where IBM won the tender for the provision of the Shared Care Portal. The full tender can be submitted in Danish, if needed. IBM will provide:

• Administrative management that concerns the Region’s pilot and roll-out • Technical design, implementation and testing

Running of the Shared Care Portal

RSD IBM and/or Logica

Since the Shared Care Portal needs to be integrated directly into health and social care systems, the integration will be subcontracted to system suppliers. As Denmark has more than 100 IT systems in health and social care, this will be decided during the Project period. Since Logica is the supplier of the patient administrative system (EPR) at the OUH Odense University Hospital, it is expected that they will be subcontracted to ensure the integration to the hospital systems.

CIPF UPV 27.000 €

UPV will take the lead in the following tasks: • Administrative management • Quality control of the Valencia contributions to deliverables • Alignment with already existing strategy of Valencia region for the EIP-AHA, including

Hospital La Fe reference site.

EKSOTE Medi-IT Oy36 125.000 €

Eksote has outsourced its IT operations partially to Medi-IT Oy that is partially owned by Eksote (45% of shares). Medi-IT Oy is totally owned by public federation of municipalities such as Eksote. Medi-IT Oy provides services only to its owners. Medi-IT Oy is a so called inhouse company that operates on a no-profit base. Medi-IT Oy responsibility areas are:

• Technical design • Technical implementation • Technical testing

Medi-IT is in charge of implementing the Hyvis.fi portal (platform to eServices for citizens), where professionals and relatives will use the SmartCAre system.

36 Medi-IT Oy as well as Saimaan talous ja tieto Oy (Saita Oy) are both in-house companies to Eksote. This means that Medi-IT Oy and Saita Oy are partially owned by Eksote (share of owning

between 27%-45%). Other owners of these companies are also public organizations (municipalities or federation of municipalities). Medi-IT Oy and Saita Oy are delivering services only to their owner-customers. So, as a shareholder, Eksote is member of Medi-IT’s and Saita’s Management Boards. When these companies were founded the incorporation agreement as well as the governance agreement were established. These documents state that Eksote is a partial owner of these two companies. Besides these documents Eksote and Medi-IT as well Saita have established framework agreements in place.

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EKSOTE Saita Oy36 35.000 € Eksote has outsourced its IT operations partially to Saita Oy that is partially owned by Eksote. Saita Oy will support project implementation by providing basic IT infrastructure.

EKSOTE VTT (Technical Research Centre)

34.000 €

VTT Technical Research Centre of Finland (www.vtt.fi) is an impartial multidisciplinary expert organization. VTT’s special strength is its ability to create new, globally competitive technologies and innovations by combining knowledge and expertise in different fields. In the framework of the RENEWING HEALTH project VTT has been supported the project coordination activities. In particular, VTT will use its competences in telemedicine technologies in supporting the pilot setup in the South Karelia Social and Health Care District. VTT responsibility is also economical calculations and statistic.

EKSOTE To be confirmed 50.000 € Eksote definitely needs system provider(s) who provide sustainable supporting technology to the elderly homes. Provider(s) will be tendered beginning of the project.

ALIMOS To be identified 10.000 € Medical Co-ordination and Quality Assurance of the local pilot.

AGDIMITRIOS To be identified 36.400 € Evaluation of the local pilot.

VIDAVO Elodi 3.100 €

ELODI, the Hellenic Diabetes Federation, is by far the largest advocacy group for Diabetes type II patients and their carers in Greece. It is a member of IDF (International Diabetes Federation) and of the Greek Committee for Diabetes Management established wothin the Ministry of Health and Social Solidarity. ELODI is expected to contribute to the design of Health and Social Care – Centred Pathways (WP1), the development of Service Process Models for Health and Social Care – Centred Pathways (WP2), the preparation of the pilot site for the implementation of the 2nd wave pilot in Attica (especially the recruitment and training of users) (WP5), the operation of the pilot in general and especially the provision of Helpdesk services to endusers and carers (WP7) and the exploitation and dissemination of the Project results (WP9)

CCU A municipality of the County of Uppsala

487.362 € Provison for the inclusion of a municipalities from the County of Uppsala

CCU Center for eHealth in Sweden

40.000 € Coordination between the SmartCare implementation in Uppsala and the parallel activities going at nation level in Sweden for developing and deploying nationwide use of IT in the health and social care system.

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SERBIA FONLIDER d.o.o. 105.500 €

Fonlider make available its know-how to: • create joint 24/7 Contact Centre with all necessary features; • create videoconferencing between healthcare, social care and patients and old people with

all necessary features; • create various SMS and Audio services as reminders, SOS, etc.; • integrate everything with social care existing database and medical centre database • support the testing of adopted solutions to ensure compliance with the identified standards; • support the definition of hardware and network resources to ensure the proper roll-out of

the envisaged integrated care services; • support the identification of software features to ensure compliance of the integrated care

services with the requirements of the Project; • support the training of end users and system administrators; • support the elaboration of collected data;

SERBIA MNO d.o.o. 181.072 €

In cooperation with Belit, MNO as company which is responsible for maintenance of the Health Information System (HIS) of the Health Centre of Kraljevo and support for the HIS users, will further develop necessary functionalities of existing HIS in order to achieve the goals defined in SmartCare. Besides this, they will also be included in the development process of application for mobile devices (tablets, mobile phones etc.) which will increase interaction between health and social care professionals, on the one side, and selected group of users, on the other side. They will also be responsible for

• support for the training of the medical staff and of the end-users • data migration • implementation of new business processes in the existing Health Information System

Table 12 – Nature of the activities subcontracted

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Other costs. A number of other items of cost have been identified which do not fall into any of the previous categories. They are listed below:

• Project leaflets and other printed material: 10.000 €.

• Project posters: 5.500 €.

• Midterm Workshop: 10.000 €.

• Final Conference: 20.000 €.

• Participation in trade fairs: 24.500 €.

• Videos: 20.000 €.

• Travelling and subsistence for Advisory Board members: 50.000 €.

These are presented in Table 19 broken down, as for the other categories, by type and by partner.

Finally, Table 20, shows the average monthly personnel cost by partner used for the calculation of the budget and the total personnel costs

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Table 13 - Travelling and subsistence costs

40.000 € 20.000 € 20.000 € 41.000 € 20.000 € 20.000 € 20.000 € 20.000 € 5.000 € 20.000 € 10.000 € 10.000 €

20.000 € 6.318 € 20.000 € 20.000 € 11.000 € 4.500 € 4.500 € 9.000 € 20.000 € 20.000 € 15.000 € 20.000 €

9.000 € 9.000 € 9.000 € 20.000 € 19.887 € 5.000 € 5.000 € 20.000 € 20.000 € 20.000 € 20.000 € 10.000 €

20.000 € 20.000 € 20.000 € 20.000 € 40.000 € 20.000 € 723.205 €

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Table 14 – Durable equipment by quantity (total number of months on which depreciation is calculated)37

Type of equipment/partner

House equipment 2.400 960 700 700 2.400 1.400 524 700 1.265 2.400 13.449 Server 24 24 7 7 24 14 14 14 13 24 158

Table 15 – Durable equipment by value (only depreciation over the duration of the trials has been taken into consideration)

House equipment 333.333 € 133.333 € 97.222 € 97.222 € 333.333 € 194.444 € 72.771 € 72.771 € 175.694 € 333.333 € 1.867.910 € Server 6.667 € 6.667 € 1.944 € 1.944 € 6.667 € 3.889 € 3.889 € 1.944 € 3.611 € 6.667 € 43.889 €

Total 340.000 € 140.000 € 99.167 € 99.167 € 340.000 € 198.333 € 76.660 € 99.167 € 179.306 € 340.000 € 1.911.799 €

Table 16 – Consumables by value

Type of consumable /partner

Database licence 58.666 € 58.666 €€

Total 58.666 € 58.666 €€

For example, the figure 2.400 for FVG – ASS1 means that 100 users will use the durable equipment for 24 months, i.e. 100x24 = 2.400

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Table 17 – Portal fees38

Fee/partner F

Portal fees 16.800 € 16.800 € 4.900 € 4.900 € 16.800 € 9.800 € 9.800 € 4.900 € 8.855 € 16.800 € 110.355 €

Table 18 – Subcontracting costs39

Project Management, Medical Co-ordination, Quality Assurance

500.000 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 €

Administrative Management 45.000 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € Provison for the inclusion of a second partner in Noord Brabant

881.574 € 0 € 0 € 0 € 0 € 0 € 0 € 0 €

Provison for the inclusion of a municipalities from the County of Uppsala

0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 €

System integration 194.000 € 0 € 19.400 € 38.800 € 194.000 € 0 € 194.000 € 0 € 0 € House installation 5.000 € 0 € 5.045 € 10.000 € 50.000 € 0 € 50.000 € 0 € 0 € Evaluation of the local pilot 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 36.400 € Medical Co-ordination and Quality Assurance of the local pilot.

0 € 0 € 0 € 0 € 0 € 0 € 0 € 10.000 € 0 €

We have assumed that the price model for the telehealth and telecare software will be a fee per older person/month. The amount of the fee (7,00 €/month) has been provided by a potential supplier of this type of solution

39 This table provides the total amount of subcontracting per partner which is not provided in table 12

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Audit 13.500 € 13.500 € 0 € 0 € 9.000 € 0 € 9.000 € 0 € 0 € Shared Care Portal Management and integration with the Health and Social Information System

0 € 440.800 € 0 € 0 € 0 € 0 € 0 € 0 € 0 €

Support for the design of clinical telemedicine workflow for the monitoring of patients

0 € 0 € 0 € 0 € 0 € 27.000 € 0 € 0 € 0 €

Support in the design of SmartCare Pathways, the development of Service Process Models ; etc.

0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 €

Provision of Contact Centre services 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € Maintenance and enhancement of the Health Information System

0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 € 0 €

Total 1.684.074 € 454.300 € 24.445 € 48.800 € 253.000 € 27.000 € 253.000 € 10.000 € 36.400 €

Project Management, Medical Co-ordination, Quality Assurance

0 € 0 € 0 € 0 € 0 € 500.000 €

Administrative Management 0 € 0 € 0 € 0 € 0 € 45.000 € Provison for the inclusion of a second partner in Noord Brabant

0 € 0 € 0 € 0 € 0 € 881.574 €

Provison for the inclusion of a municipalities from the County of Uppsala

0 € 527.362 € 0 € 0 € 0 € 527.362 €

System integration 0 € 97.000 € 0 € 181.345 € 0 € 918.545 € House installation 0 € 25.000 € 0 € 50.000 € 0 €

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Evaluation of the local pilot 0 € 0 € 0 € 0 € 0 € 36.400 € Medical Co-ordination and Quality Assurance of the local pilot. 0 € 0 € 0 € 0 € 0 € 10.000 €

Audit 0 € 0 € 9.000 € 13.500 € 4.500 € 72.000 € Shared Care Portal Management and integration with the Health and Social Information System

0 € 0 € 0 € 0 € 0 € 440.800 €

Support for the design of clinical telemedicine workflow for the monitoring of patients

0 € 0 € 0 € 0 € 0 € 27.000 €

Support in the design of SmartCare Pathways, the development of Service Process Models ; etc.

3.100 € 0 € 0 € 0 € 0 € 3.100 €

Provision of Contact Centre services 0 € 0 € 0 € 105.500 € 0 € 105.500 € Maintenance and enhancement of the Health Information System 0 € 0 € 0 € 181.072 € 0 € 181.072 €

Total 3.100 € 649.362 € 295.572 € 244.845 € 4.500 € 3.988.398 €

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Table 19 – Other project costs

Projet leaflets and other printed material 10.000 € 0 € 10.000 € Project posters 6.110 € 0 € 6.110 € Midterm Workshop 10.000 € 0 € 10.000 € Final Conference 20.000 € 0 € 20.000 € Participation in trade fairs 20.000 € 4.500 € 24.500 € Videos 20.000 € 0 € 20.000 € Travelling Advisory Boards 50.000 € 0 € 50.000 € Total 136.110 € 4.500 € 140.610 €

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Table 20 – Average personnel monthly cost

Short name Person-months Average personnel

monthly cost

Total personnel costs

FVG – ASS1 137,71 5.615 € 773.260 € KÄRNTEN 9,00 5.500 € 49.500 € BAD-WÜR 9,00 5.000 € 45.000 €

RSD 156,00 6.024 € 939.730 €

ETCH 102,50 3.550 € 363.875 €

TALLIN 28,50 3.550 € 101.175 €

CATALONIA 9,00 6.200 € 55.800 €

ARAGON 117,00 4.500 € 526.500 €

CRUZROJA 16,00 3.500 € 56.000 €

EUSKADI 9,00 5.000 € 45.000 €

EXTREM 5,00 3.300 € 16.500 €

FUNDECYT 5,00 3.300 € 16.500 €

MURCIA 9,00 5.000 € 45.000 €

VALENCIA 7,60 4.636 € 35.234 €

EKSOTE 83,00 6.600 € 547.800 €

CEN-GREECE 9,00 3.665 € 32.985 €

PALFALIRO 31,50 3.500 € 110.250 €

ALIMOS 20,00 3.500 € 70.000 €

AGDIMITRIOS 31,50 3.500 € 110.250 €

VIDAVO 37,50 5.000 € 187.500 €

CROATIA 9,00 5.000 € 45.000 €

VENETO 9,00 5.500 € 49.500 €

SMARTHOMES 34,65 6.200 € 214.830 €

ROTTERDAM 9,00 6.984 € 62.856 €

AMADORA 4,50 5.000 € 22.500 €

PTTELECOM 3,50 5.000 € 17.500 €

MISERICORDIA 2,00 5.000 € 10.000 €

CCU 41,50 5.214 € 216.381 €

BELIT 86,60 2.680 € 232.088 €

STUDENICA 16,50 1.200 € 19.800 €

KRALJEVO 16,50 1.200 € 19.800 €

N-IRELAND 9,00 6.133 € 55.197 €

SCOTLAND 116,25 7.230 € 840.488 €

AGE 11,70 5.000 € 58.500 €

AER 13,00 5.000 € 65.000 €

CHA 4,90 10.500 € 51.450 €

EUROCARERS € €

IFIC 19,00 6.200 € 117.800 €

EFN 18,00 9.649 € 173.688 €

EPF 8,00 5.560 € 44.480 €

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Short name Person-months Average personnel

monthly cost

Total personnel costs

EMPIRICA 75,00 6.800 € 510.000 €

AOK 10,00 6.800 € 68.000 €

Total 1.344,25 5.199 € 6.988.090 €

The Consortium confirms that the average monthmy rates listed above do not include any profit.

B.3.6 Dissemination/Use of results This issues are already covered in detail in § B.2.3.

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APPENDIX I Example of SmartCare pathway

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This Annex presents an example for an integrated pathway following a process, action-oriented view. These have been taken from existing projects and are not intended to represent the SmartCare pathways. The latter will be devolped in close cooperation with the pilot sites and the other stakeholders during the start up phase of the Project.

Main components including actors / end users are introduced, specified for the concrete example of hospital discharge. Challenges, solutions and benefits are discussed briefly. The aim is not to define or review existing definitions of pathways but to illustrate how SmartCare will approach the challenge of developing process maps as the basis for discussion with all actors involved in integrated care.

A.I.1 Integrated care pathway components The components of an integrated care pathway include:

• Actors o At least one actor from healthcare domain o At least one actor for the social care domain

• Entry point & end point

• Actions to be taken by each actor

• Sequence of actions

• Information to be generated by / shared between actors

• Decision points

• ICT use in the process

A.I.2 Integrated care pathway for hospital discharge – an example An example for an integrated care pathway for hospital discharge is provided based on CommonWell, Johanneswerk Bielefeld.

The issue / problems in unsupported hospital discharge

Patient comes home and no support is available at short notice which can lead to worsening situation, at worst readmission, in any case highly inconvenient, disconcerting for relatives.

To overcome these problems, an ICT-supported discharge process has been implemented at Ev. Johanneswerk e.V. in Bielefeld, in the course of CommonWell.

The main components of the pathway are described followed by a model of the ICT-supported discharge process in Bielefeld.

A.I.2.1 Components of the integrated care hospital discharge pathway

• Actors:

o Hospital (healthcare provider, HCP)

o Social care provider (SCP)

• Entry point: “hospital discharge impending”

o Initiate discharge process in Integrated Care Record (ICR)

� Discharge summary stored in ICR (contains data necessary for discharge process & agreed between HCP and SCP

o Check in admission summary (stored in the ICR) if social care received before admission

� If not, check if social acre is required

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• If yes, initiate pathway needs assessment & SCP organization

• If no, no action or initiate pathway self-care

� If yes, continue with discharge process

o ICR notifies SCP of imminent discharge

• SCP accesses discharge summary in ICR

o SCP confirms receipt of discharge notification

o SCP ensures social care delivery

� SCP informs relatives

� SCP informs other providers, e.g., meals on wheels

• End point: “SCP take-over” – starting point of new pathway “SCP follow up” or other pathways such as telemonitoring, self-care, etc.

In the following, a pathway model based on the ICT-supported discharge process in Bielefeld is presented.

A.I.2.2 Modelling the ICT-supported discharge process in Bielefeld, CommonWell

The handover of a patient from hospital to social care is illustrated in the following hospital discharge pathway. It represents a process view which will be discussed with the pilot sites in the context of WP1 and WP2, further refined, accompanied where appropriate and feasible by additional pathways, e.g., dedicated social care provider pathways, telemonitoring pathway, etc. Responsibilities in the hospital domain are colored in blue; social care provider responsibilities are illustrated in yellow. The pathway intends to illustrate action and information flows without any decision on the technical implementation of such a pathway.

In a given SmartCare pilot environment, a patient faces discharge from hospital following for instance a treatment for a chronic disease. The doctor initiates the discharge process which will lead to takeover of the patient by a social care provider (SCP). As a first step in this process, the prior availability of a social care provider is determined through access to the admission protocol of the patient. Through the Integrated Care Record (ICR), the doctor/healthcare provider can notify any available SCP of imminent discharge of a patient.

If the doctor recognizes the need for a social care provider, which wasn’t previously active for the patient, he initiates a new pathway to contact a social care provider and handover relevant data of the patient.

In case of previous social care provider involvement, a predefined discharge summary is issued and sent to the SCP. It may typically contain information on the day and time of the patient’s discharge from hospital and information on specific social care needs such as meals on wheels or a physiotherapist. The receipt of a discharge summary is confirmed by the SCP who then prepares any necessary steps for takeover and follow-up (e.g. by contacting relatives or special care providers or assembling a case assessment team).

A dedicated social care provider pathway may then begin.

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The following flowchart presents an example for an SCP (Social Care Provider) pathway following hospital discharge.

Adaptation of care plan

SCP follow up after hospital discharge

No action required

Reassessment of current care plan needed?

Social care provider visits patient at home

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The flowchart below shows an example for a pathway for telemonitoring following hospital discharge.

Referred back to Community Matron /

District Nurse

Referral from Community Matron or

District Nurse

Visit to the patient’shome. Property and

person risk assessmentcarried out

Decisionre. Telehealth

Patient carries out vital signs monitoring

Reading /alert receivedat the Control Centre

via CSO or PNC

Patient carries out vital signs monitoring

Reading /alert receivedat the Control Centre

Information provided and Patient Consent Form

signed

Installation goes ahead

Individual patient parameters set and test call sent from the monitor

Call Case Clinician

Re -test required

Readingsacknowledge

YESCall patient, retest

requiredRe-test done

Case Clinician decidescourse of action

Telehealth triaging

completed

Telehealth triaging task

completed

Readingswithin

approvedparameters

No action / Options: read-

mission to hospital / medi-cation change

Adapted from Commonwell

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An initial flowchart illustrating an example of home-based self-care is presented below.

Patient logs into self-care service on home

Direct contact to patient required?

Carer initiates follow up

Follow up required?

No action required

Carer contacts patient

No action required

YES Carer initiates follow up

Benefits from SmartCare pathways Patient receives continuous care/support, negative effects are avoided, relatives are assured, hospital avoids additional costs from “revolving door readmissions” that are in many systems not reimbursed, hospital and SCP can offer better service quality.

Real life challenges such as discharge during weekend or holidays will need to be considered.

A.I.3 Examples of current pathways in pilot regions This section briefly introduces two examples of currently active patient care pathways which involve collaboration between health and social care.

A.I.3.1 Controlled hospital discharge in Triest, Italy The city of Trieste has developed a protocol shared with public and private hospitals for per-forming a protected discharge from hospital of complex frail (elderly) patients, in particular if affected by long-term chronic diseases (heart/respiratory failure, diabetes, skin wounds), termi-nal illnesses (i.e. cancer, SLA) or conditions that require intensive rehabilitation (typically, post stroke, post hip/femur fracture).

The approach runs through the following steps:

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1. An initial dispatch by the hospital dept. (ward) of a request for assessment when the pa-tient does not require a prosecution of the hospital stay

2. A reception by the health District of the resident transfer form including the basic personal data and the description of multiple needs

3. The bed-site multidimensional joint assessment by a specialized nurse or therapist of the District (within 3 days) who with the hospital staff evaluate the person in the three dimensions: clinical, functional, social, with the final scope to point a comprehensive evaluation and to define a personalized program of discharge. The possible subsequent destinations could be: home with/without services; residential/nursing home; rehabilitation centre. This assessment repre-sents a triage to define priority settings

4. Supply by the district of all materials or prosthetic devices required at home by the patient (i.e. hospital bed, pads, etc) and set up of the domestic environment.

5. Discharge of patient; she/he receives always an accompanying letter; handover from hospital to community care.

6. Dispensing of home or residential care within a personalized program (the Health Districts fully take in charge the person). The patient will be followed up for support/care through a prolonged period.

7. Periodic re-assessments in order to re-evaluate the situation and readjust the program.

More than 5.000 of such hospital bed-site assessments are annually performed, the 95% in >75 years old patients (figure to be compared with 30.000 total admission/year in all hospitals). Destinations: approx. 1/3 of cases towards rehabilitation centres; 1/3 included in formal home care programmes; 1/3 return home just with informal care.

Care paths are defined for specific conditions such as heart failure, COPD, diabetes, wound care, ecc. Advanced home care is also provided with telecare-teleassistance (24/7), devoted to high risk subjects with multiple needs who require reinforced protection.

The following Figure illustrates this approach.

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This pathway is quite close to the generic model presented on the basis of the Bielefeld dis-charge process (see section 2.2). The SmartCare contribution in the Trieste case consists in pushing the electronic support of this process.

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A.I.3.2 Patient Pathway for the Patient with a chronic condition (COPD) in Region South Denmark

The vision for the health care system in Denmark is to provide coherent clinical pathways through the various parts of the health care system, focusing on the needs of patients and high quality of treatment. One of the main prerequisites for establishing a coherent and cooperating health care system is to ensure that all health care professionals dealing with a patient have easy access to relevant patient information where and when it is needed. This strengthens the base for decision making and enhances patient safety.

Digitalisation is the key element in giving health care professionals and other stakeholders in-volved in the care process access to data and examination results across the entire health sec-tor. Another key element is empowering patients to manage their own health by providing better access to their own health data and by the use of telemedicine and home-monitoring technolo-gies. Sundhed.dk (”health”.dk) is the official Danish health website providing access to informa-tion for citizens, patients and health care professionals. For the patient Sundhed.dk gives the patient easy access to personal health data on treatments and notes from hospital records, in-formation about medicine and about visits to the GP etc.

The example for an integrated care pathway for a citizen with a chronic disease provided here s based on patient programmes. Patient Programmes supports the Region’s priority of promoting integrated care models for citizens with chronic diseases.

The patient programmes for chronic diseases in the Region of Southern Denmark have been developed in a close collaboration between the region – supplying the hospital services – and the municipalities – supplying the rehabilitation and home care services. These have its starting point in an interdisciplinary and cross-sectorial collaboration, including best practise, quality de-velopment and documentation of the effort for citizens with a chronic disease. The programmes are recommendations for the development of the close corporation between the many parts.

The below illustrates the steps of the Danish care pathway including hand-over points to the municipality.

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Municipality - Homecare General Practitioner Hospital

Symptoms are discovered

Diagnosis and referral to specialist treatment and follow-up

Individual plan of action (basis)

Guidance

Prevention & health promotion (referral)

Control

Possibly Revised Guidance

Hospitals Coordinator of Chronic diseases

Planned diagnosing

Discharge w/ recommenda-tions

Patient Education

Specialised patient education and training

Possibly Specialist Counselling

Coordinator of Chronic diseases

Prevention & health promotion Continued

Possibly Con-trol (Yearly) Revised recommenda-tions

EUROPEAN COMMISSION

COMMUNICATIONS NETWORKS, CONTENT AND TECHNOLOGY DIRECTORATE-GENERAL

Joining up ICT and service processes for quality integrated care in Europe

SmartCare

Grant Agreement No 325158

ICT PSP GRANT AGREEMENT

Printed on 17-Apr-13 01:56 PM SmartCare - 325158

EN 2/81 EN

GRANT AGREEMENT NO 325158

The European Union (“the Union”), represented by the European Commission (“the Commission”),

of the one part

and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1), established in VIA GIOVANNI SAI 1-3, 34127 TRIESTE - ITALY, represented by its legal/statutory representatives, Dr. FABIO SAMANI , DIRECTOR GENERAL , and/or Dr. GIULIO ANTONINI , PUBLIC MANAGER , or their authorised representatives,

(the beneficiary acting as “coordinator”) and the other beneficiaries identified in Article 1(2) below,

of the other part,

HAVE AGREED on the following terms and conditions, including those in the following annexes, which form an integral part of this grant agreement (the “grant agreement”):

Annex I - Description of work and indicative breakdown of the budget and the financial contribution of the Union between beneficiaries

Annex II - General conditions

Annex III - Form A – accession of beneficiaries to the grant agreement

Annex IV - Form B – request for the accession of new legal entities to the grant agreement

Article 1 – Scope 1. The Union has decided to grant a financial contribution for the implementation of the project specified in Annex I, called “Joining up ICT and service processes for quality integrated care in Europe (SmartCare)“ (the “project”), under the Information and Communications Technologies (ICT) Policy Support Programme (the “ICT PSP”) and under the conditions laid down in this grant agreement. The consortium shall carry out the project in accordance with the conditions set out in this grant agreement.

2. The consortium is composed of the beneficiary acting as coordinator and the following legal entities, which shall accede to the grant agreement in accordance with the procedure referred to in Article 2 as beneficiaries, assuming the rights and obligations established by the grant agreement with effect from the date on which it enters into force:

- Land Kärnten (KÄRNTEN), established in Arnulfplatz 1, 9020 Klagenfurt -AUSTRIA, represented by its legal/statutory representative, Mr. Christian Ragger, Councilor, or his authorised representative,

- GESUNDES KINZIGTAL GMBH (BAD-WÜR), established in STRICKERWEG 3D, 77716 HASLACH - GERMANY, represented by its legal/statutory representatives, Mr. Helmut Hildebrandt, CEO, and/or Ms. Monika Roth, head of department of Health Management, Gesundes, or their authorised representatives,

EN 3/81 EN

- REGION SYDDANMARK (RSD), established in DAMHAVEN 12, 7100 VEJLE -DENMARK, represented by its legal/statutory representatives, Ms. Tove Lehrmann, Chief Consultant, and/or Mr. Claus Duedal Pedersen, Chief Consultant, or their authorised representatives,

- IDA-TALLINNA KESKHAIGLA AS (ETCH), established in RAVI 18, 10138 TALLINN - REPUBLIC OF ESTONIA, represented by its legal/statutory representative, Dr. Ralf Allikvee , Chairman of the Board , or his authorised representative,

- TALLINA SOTSIAAL-JA TERVISHOIUAMET-TALLINN SOCIAL WELFARE AND HEALTH CARE BOARD TSTA (TALLINN), established in NARVA MNT 11D, 10151 TALLINN - REPUBLIC OF ESTONIA, represented by its legal/statutory representatives, Dr. Vahur Keldrima, Head, and/or Dr. Raivo Allev, Manager, or their authorised representatives,

- FUNDACIO TICSALUT (CATALONIA), established in C ERNEST LLUCH 32 Planta 6 Porta 4 TECNOCAMPUS MATARO MARESME TORRE TC, 08302 MATARO BARCELONA - SPAIN, represented by its legal/statutory representatives, Mr. Joan Cornet, Executive President, and/or Mr. Francesc Garcia Cuyàs, Director, or their authorised representatives,

- SERVICIO ARAGONES DE LA SALUD (ARAGON), established in VIA UNIVERSITAS 34, 50071 ZARAGOZA - SPAIN, represented by its legal/statutory representative, Mr. Miguel Angel Eguizabal , Managing Director of the SALUD-Barbastro Healthcare Area , or his authorised representative,

- CRUZ ROJA ESPANOLA FUNDACION (CRUZROJA), established in AVENIDA REINA VICTORIA 26, 28003 MADRID - SPAIN, represented by its legal/statutory representative, Mr. FRANCISCO BARREÑA PUIVECINO, PRESIDENTE PROVINCIAL, or his authorised representative,

- ASOCIACION CENTRO DE EXCELENCIA INTERNACIONAL EN INVESTIGACION SOBRE CRONICIDAD (EUSKADI), established in CALLE MARIA DIAZ DE HARO 60, 48010 BILBAO - SPAIN, represented by its legal/statutory representative, Mr. Esteban de Manuel Keenoy , CEO, or his authorised representative,

- CONSEJERIA DE SALUD Y POLITICA SOCIAL - JUNTA DE EXTREMADURA (EXTREMADURA), established in AVENIDA DE LAS AMÉRICAS 4, 06800 MERIDA - SPAIN, represented by its legal/statutory representative, Mrs. Cristina Herrera Santa Cecilia, Director , or her authorised representative,

- FUNDACION FUNDECYT - PARQUE CIENTIFICO Y TECNOLOGICO DE EXTREMADURA-FUNDECYT PCTEX (FUNDECYT), established in AVENIDA DE ELVAS CAMPUS s/n, 06071 BADAJOZ - SPAIN, represented by its

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legal/statutory representative, Mr. Antonio Verde Cordero, Managing Director, or his authorised representative,

- FUNDACION PARA LA FORMACION E INVESTIGACION SANITARIAS DE LA REGION DE MURCIA (MURCIA), established in CALLE LUIS FONTES PAGAN 9, 30003 MURCIA - SPAIN, represented by its legal/statutory representatives, Dr. Serna Marmol Juan Pedro, Director, and/or Mr. Borrachero Guijarro Ignacio, Head of Administration, or their authorised representatives,

- FUNDACION DE LA COMUNIDAD VALENCIANA CENTRO DE INVESTIGACION PRINCIPE FELIPE (VALENCIA), established in CALLE EDUARDO PRIMO YUFERA 3, 46012 VALENCIA - SPAIN, represented by its legal/statutory representative, Mrs. Isabel Muñoz Criado, General manager, or her authorised representative,

- ETELA-KARJALAN SOSIAALI- JA TERVEYDENHUOLLON KUNTAYHTYMA (EKSOTE), established in Raastuvankatu 9, 53100 LAPPEENRANTA - FINLAND, represented by its legal/statutory representatives, Mr. Pentti Itkonen, Chief Executive Officer, and/or Ms. Virpi Kölhi, Director of Administration, or their authorised representatives,

- ANAPTYXIAKI ETAIREIA DIMOU TRIKKAION ANAPTYXIAKI ANONYMI ETAIREIA OTA - E-TRIKALA AE (CEN-GREECE), established in STRATIGOY SARAFI 44, 42100 TRIKALA - GREECE, represented by its legal/statutory representatives, Mr. Christos Lappas, President of the Board, and/or Mr. Odisseas Raptis, CEO, or their authorised representatives,

- MUNICIPALITY OF PALAIO FALIRO (PALFALIRO), established in agiou alexandrou 70, 17561 Palaio Faliro - GREECE, represented by its legal/statutory representatives, Mr. Dionisios Chadtzidakis, Mayor, and/or Mr. Ioannis Fostiropoulos, Deputy Mayor, Education & Social Solidarity, or their authorised representatives,

- DIMOS ALIMOU-MUNICIPALITY OF ALIMOS (ALIMOS), established in ARISTOTELOUS 53, 17455 ALIMOS - GREECE, represented by its legal/statutory representatives, Mr. Athanasios Orfanos, Mayor, and/or Mr. Andreas Kondylis, Deputy Mayor, Administration & Social Solidarity, or their authorised representatives,

- DIMOS AGIOS DIMITRIOS (AGDIMITRIOS), established in ODOS AGIOU DIMITRIU 55, 17343 AGIOS DIMITRIOS - GREECE, represented by its legal/statutory representatives, Mrs. Maria Androutsou, Mayor, and/or Mr. Nikos Dasopoulos , City Councilor, Education & Social Solidarity, or their authorised representatives,

- Anonimi Etairia Erevnas, Kainotomias kai Anaptiksis Tilematikis Texnologias -VIDAVO A.E. (VIDAVO), established in 9TH KM THESSALONIKI THERMI ROAD, 57001 Thessaloniki - GREECE, represented by its legal/statutory representatives, Mrs. Markela Psymarnou, General Manager, and/or Mr. Anastasios

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Papakyriakidis, Vice-President, or their authorised representatives,

- HRVATSKA UDRUGA ZA FARMAKOEKONOMIKUI EKONOMIKU ZDRAVSTVA (CROATIA), established in DRAGE STIPCA 10, 10090 ZAGREB -REPUBLIC OF CROATIA, represented by its legal/statutory representatives, Dr. Ranko Stevanovic, President, and/or Ms. Vanesa Benkovic, Consultant, or their authorised representatives,

- UNITA LOCALE SOCIO-SANITARIA N. 2 FELTRE (VENETO), established in VIA BAGNOLS SUR CEZE 3, 32032 FELTRE - ITALY, represented by its legal/statutory representative, Dr. BORTOLO SIMONI, DIRECTOR GENERAL, or his authorised representative,

- STICHTING SMART HOMES (SMARTHOMES), established in DUIZELSEWEG 4 A, 5521AC EERSEL - THE NETHERLANDS, represented by its legal/statutory representatives, Ms. JCM Deeben - van Berlo, Director, and/or Dr. Ad van Berlo, R&D Manager, or their authorised representatives,

- GEMEENTE ROTTERDAM (ROTTERDAM), established in COOLSINGEL 40, 3011 AD ROTTERDAM - THE NETHERLANDS, represented by its legal/statutory representatives, Ms. Anne Marie Van de Wiel , Director Activation & Welfare , and/or Ms. Ine Wiersma , Head of Policy & Strategy , or their authorised representatives,

- MUNICIPIO DA AMADORA-CMA (AMADORA), established in AVDA MOVIMENTO DAS FORCAS ARMADAS, 2700 AMADORA - PORTUGAL, represented by its legal/statutory representative, Mrs. Carla Tavares, Vice-President, or her authorised representative,

- PT COMUNICACOES SA (PTELECOM), established in RUA ANDRADE CORVO 6, 1050 009 LISBOA - PORTUGAL, represented by its legal/statutory representative, Ms. Ana Dias, Head of Innovation, or her authorised representative,

- IRMANDADE DA SANTA CASA DA MISERICORDIA DA AMADORA IPSS(MISERICORDIA), established in ESTRADA DA PORTELA QUINTA DAS TORRES BURACA CONCELHO DE AMADORA, 2610 143 AMADORA LISBOA -PORTUGAL, represented by its legal/statutory representative, Mr. Manuel Monteiro Girão, General Director, or his authorised representative,

- UPPSALA LANS LANDSTING (CCU), established in SLOTTSGRAND 2A, 751 25 UPPSALA - SWEDEN, represented by its legal/statutory representatives, Ms. Eva Ljung , CEO , and/or Mr. Petter Könberg , CIO , or their authorised representatives,

- PREDUZECE ZA INFORMACIONE TEHNOLOGIJE I ELEKTRONSKO TRGOVANJE BELIT DOO (BELIT), established in OBILICEV VENAC 18-20, 11000 BELGRADE - SERBIA, represented by its legal/statutory representatives, Mr. Dusan Poznanovic, General Manager, and/or Mr. Marko Poznanovic, Business Development Manager, or their authorised representatives,

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- Zdravstveni centar "Studenica" Kraljevo (STUDENICA), established in Jug Bogdanova BB, 36000 Kraljevo - SERBIA, represented by its legal/statutory representatives, Mr. Zvonko Veselinovic, General Manager, and/or Mrs. Mirjana Krcevinac, Director of Primary Health Department, or their authorised representatives,

- CENTAR ZA SOCIJALNI RAD KRALJEVO-SOCIAL WORK CENTRE IN KRALJEVO CSRKV (KRALJEVO), established in NASELJE MOSE PIJADE 26 A, 36000 KRALJEVO - SERBIA, represented by its legal/statutory representatives, Mrs. Svetlana Dražović, Director, and/or Mrs. Svetlana Stanić, Deputy of Director, or their authorised representatives,

- REGIONAL HEALTH AND SOCIAL CARE BOARD (N-IRELAND), established in LINENHALL STREET 12-22, BT2 8BS BELFAST - UNITED KINGDOM, represented by its legal/statutory representative, Dr. Sloan Harper, Director of Integrated Care , or his authorised representative,

- NHS 24 (SCOTLAND) (SCOTLAND), established in FIFTY PITCHES ROAD 140, G51 4EB GLASGOW - UNITED KINGDOM, represented by its legal/statutory representatives, Prof. George Crooks , Medical Director , and/or Mr. John Turner , Chief Executive , or their authorised representatives,

- AGE PLATFORM EUROPE AISBL (AGE), established in Rue Froissart 111, 1040 BRUXELLES - BELGIUM, represented by its legal/statutory representative, Mrs. Anne-Sophie Parent, Secretary General, or her authorised representative,

- ASSEMBLEE DES REGIONS D'EUROPE ASSOCIATION (ARE), established in RUE OBERLIN 6, 6700 STRASBOURG - FRANCE, represented by its legal/statutory representative, Mr. Pascal Goergen, Secretary General of the Assembly of European Regions, or his authorised representative,

- CONTINUA HEALTH ALLIANCE PRIVATE STICHTING (CHA), established in AVENUE ROGER HAINAUT 16, 1160 BRUXELLES - BELGIUM, represented by its legal/statutory representatives, Dr. Petra Wilson , Secretary General , and/or Mr. Charles Parker , Executive Director , or their authorised representatives,

- EUROCARERS ASSOCIATION EUROPEENE TRAVAILLANT POUR LES AIDANTS NON PROFESSIONELS ASBL (EUROCARERS), established in RUE DE THIONVILLE 145, 2611 LUXEMBOURG - LUXEMBOURG, represented by its legal/statutory representative, Mr. Robert Anderson , President, or his authorised representative,

- STICHTING INTERNATIONAL FOUNDATION FOR INTEGRATED CARE(IFIC), established in PROF RITZEMA BOSLAAN 5, 3571CL UTRECHT - THE NETHERLANDS, represented by its legal/statutory representatives, Dr. Nicholas Goodwin, Chief Executive Officer, and/or Dr. Maria de Lourdes Ferrer-Goodwin, Director of Programmes, or their authorised representatives,

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- FEDERATION EUROPEENNE DES ASSOCIATIONS INFIRMIERES AISBL(EFN), established in CLOS DU PARNASSE 11A, 1050 Brussels - BELGIUM, represented by its legal/statutory representative, Dr. Paul De Raeve, Secretary General, or his authorised representative,

- FORUM DES PATIENS EUROPEENS ASBL EUROPEAN PATIENTS FORUM FPE EPF (EPF), established in ROUTE DE THIONVILLE 145, 2611 LUXEMBOURG - LUXEMBOURG, represented by its legal/statutory representative, Mr. Anders Olauson, President, or his authorised representative,

- EMPIRICA GESELLSCHAFT FUER KOMMUNIKATIONS- UND TECHNOLOGIE FORSCHUNG MBH (EMPIRICA), established in OXFORDSTRASSE 2, 53111 BONN - GERMANY, represented by its legal/statutory representatives, Mr. Simon Robinson, Director, and/or Mr. Werner B. Korte, Director, or their authorised representatives,

- AOK RHEINLAND/HAMBURG - DIE GESUNDHEITSKASSE (AOK), established in KASERNENSTRASSE 61, 40213 DUSSELDORF - GERMANY, represented by its legal/statutory representative, Mr. Günter Wältermann, Vorstandsvorsitzender (CEO), or his authorised representative,

3. The beneficiaries are deemed to have concluded a consortium agreement regarding the internal organisation of the consortium.1

Article 2 – Accession to the grant agreement 1. The coordinator shall endeavour to ensure that each legal entity identified in Article 1(2) accedes to this grant agreement as a beneficiary by signing Form A (as set out in Annex III) in three originals, countersigned by the coordinator. Not later than 45 calendar days after the entry into force of the agreement, the coordinator shall send to the Commission one of the three duly completed and signed originals of Form A. The two remaining signed originals shall be kept, one by the coordinator, to be made available for consultation at the request of any other beneficiary, and the other by the beneficiary concerned.

2. Should any legal entity identified in Article 1(2) fail or refuse to accede to the grant agreement by the deadline established in the previous paragraph, the Commission is no longer bound by its offer to the said legal entity(ies). The consortium may propose to the Commission, within a time-limit to be set by the latter, appropriate solutions to ensure the implementation of the project. The procedure established in Annex II for amendments to this grant agreement shall apply.

1 A consortium agreement is compulsory for Pilot A-type projects. For such projects, the consortium agreement

covers, among other things: the internal organisation of the consortium, including the decision-making procedures; rules on intellectual property rights, taking into account the specific requirements for Pilot A projects set out in this grant agreement; the distribution of the financial contribution of Union; the settlement of internal disputes, including cases of abuse of power; and liability, indemnification and confidentiality arrangements between the beneficiaries.

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Article 3 - Entry into force of the grant agreement and duration of the project 1. This grant agreement shall enter into force following its signature by the coordinator and the Commission on the day of the last signature.

2. The duration of the project shall be 36 months from 01/03/2013 (“start date of the project”).

Article 4 – Reporting periods The project is divided into reporting periods of the following duration:

- P1: from month 1 to month 12

- P2: from month 13 to month 24

- P3: from month 25 to the last month of the project.

Article 5 – Maximum financial contribution of the Union 1. The maximum financial contribution of the Union to the project shall be EUR 8.000.000,00 (eight million euros).

The financial contribution of the Union shall be limited to 50% of the eligible costs.

The actual financial contribution of the Union shall be calculated in accordance with the provisions of this grant agreement.

2. Annex I contains an indicative breakdown of the budget and the financial contribution of the Union between beneficiaries.

Beneficiaries are allowed to transfer budget amounts between themselves provided the work is carried out as described in Annex I. The coordinator shall notify any such transfer to the Commission without unjustified delay.

Article 6 – Payment 1. The financial contribution of the Union to the project shall be paid to the coordinator on behalf of the beneficiaries in accordance with the provisions of this grant agreement. The payment of the financial contribution of the Union to the coordinator discharges the Commission from its payment obligation.

2. The financial contribution of the Union shall be paid to the coordinator’s bank account, denominated in euros, identified as follows:

Name of bank: UNICREDIT SPA

Name of account holder: AZIENDA PER I SERVIZI SANITARI NO 1TRIESTINA

Account reference: IT97G0200802205000040467975

3. The financial contribution of the Union shall be paid in accordance with the provisions of this grant agreement and the following schedule:

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(a) pre-financing

An initial pre-financing of EUR 4.266.666,00 (four million two hundred sixty-six thousand six hundred sixty-six euros) shall be paid to the coordinator within 30 days following the entry into force of the grant agreement. The coordinator shall distribute the pre-financing only to the beneficiaries who have acceded to the grant agreement.

(b) After each reporting period, except the last reporting period, the Commission shall make interim payments corresponding to the amounts accepted during the reporting period concerned. The total amount of the pre-financing and interim payments shall not exceed 90% of the maximum financial contribution of the Union.

(c) final payment

The Commission shall make a final payment after the end of the last reporting period.

Article 7 – Language of Project Reports and Deliverables The reports and deliverables required under this grant agreement shall be submitted by the coordinator in English.

Article 8 - Special conditions

The following special conditions apply to this grant agreement :

Pilots Type A - Sub-contracting of coordination tasks

Notwithstanding the provisions of Article II.2(1), second subparagraph, of this grant agreement, the coordinator may subcontract administrative tasks related to the technical, financial and administrative coordination of the project in accordance with the provisions in Article II.6 of this grant agreement.

Pilots Type A - Publication and free accessibility of results

Notwithstanding the provisions of Articles II.12 to II.15, deliverables described in Annex I and any foreground needed for cross-border interoperability, in particular common specifications and common building blocks for interoperability established under the project, shall be publicly available, accessible and usable free of charge, in particular with a view to implementing the pilot solution in Member States or Associated Countries not participating in the project. Beneficiaries shall comply with any specific requirements set out in this respect in Annex I, such as the obligation to publish building blocks under an EU Public License or compatible licenses. The above provision shall continue to apply after the termination of the grant agreement or of the participation of a beneficiary, in accordance with Article II.11(7) of this grant agreement.

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Special provision to be inserted in the event that a beneficiary is an EEIG or - in case of Pilots A - is composed of several legal entities, or has delegated powers to a national administration/public body

The beneficiary NHS 24 (Scotland) is composed by its members who are duly listed in Annex I attached to the present agreement. The costs incurred by the above-mentioned members in carrying out the action as described in Annex I constitute eligible costs of the action in accordance with the provisions of the grant agreement, provided that the beneficiary ensures that the conditions applicable to him under articles II.7, II.12 to II.19, II.20 to II.24, II.28, II.29 and II.32 of the grant agreement are also applicable to its members. The financial statement from the beneficiary referred to in article II.4 shall clearly identify the costs incurred by the beneficiary and by each member. The certificate on the financial statements referred to in article II.4 shall certify that the costs claimed in the financial statements for the beneficiary and its members and the receipts declared meet the conditions of this grant agreement. When submitting the reports referred to in article II.4, the beneficiary shall identify the work performed and the resources deployed by each member. The beneficiary shall retain sole responsibility for carrying out the work described in Annex I and for compliance with the provisions of the grant agreement. The beneficiary shall also undertake to make the necessary arrangements to ensure that its members waive all rights in respect of the Commission under the grant agreement.

Identification of beneficiaries that are public bodies

For the purposes of this grant agreement, the following beneficiaries are considered to be a public body: -Azienda Per I Servizi Sanitari N.1 Triestina -Land Kärnten -Region Syddanmark -Tallina Sotsiaal-Ja Tervishoiuamet-Tallinn Social Welfare and Health Care Board TSTA -Servicio Aragones De La Salud -Consejeria De Salud Y Politica Social - Junta De Extremadura -Etela-Karjalan Sosiaali-Ja Terveydenhuollon Kuntayhtyma -Municipality of Palaio Faliro -Dimos Alimou-Municipality of Alimos -Dimos Agios Dimitrios -Unita Locale Socio-Sanitaria N. 2 Feltre -Gemeente Rotterdam -Municipio Da Amadora-Cma -Uppsala Lans Landsting -Zdravstveni Centar "Studenica" Kraljevo -Regional Health and Social Care Board

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-NHS 24 (Scotland) -AOK Rheinland/Hamburg - Die Gesundheitskasse

Payment of the consortium's pre-financing subject to obtaining a financial guarantee from a beneficiary

The coordinator shall not distribute to the beneficiaries Fundacio Ticsalut or Continua Health Alliance Private Stichting any pre-financing until a financial guarantee of a value of EUR 24 655 for Fundacio Ticsalut and EUR 38 457 for Continua Health Alliance Private Stichting is provided to the Commission by the consortium or the beneficiaries.

Article 9 – Communication 1. Any communication or request concerning this grant agreement shall identify the grant agreement number, the nature and details of the communication or request and be submitted to the address notified by the Commission upon signature of the grant agreement and to the address of the coordinator notified in accordance with Article II.2.

2. Where any notification is sent to the address of the coordinator as referred to in paragraph 1 and/or to the coordinator’s legal representative, in the event of refusal of the notification or absence of the recipient, the beneficiary or the consortium, as the case may be, is deemed to have been notified on the date of the latest delivery.

Article 10 - Applicable law and competent court The financial contribution of the Union is a contribution from the European Union budget with the aim of implementing the ICT PSP under the Competitiveness and Innovation Framework Programme (“CIP”)2 and it is incumbent on the Commission to execute this programme. Accordingly, this grant agreement shall be governed by its terms, the relevant European Union acts related to the CIP, the Financial Regulation applicable to the general budget of the European Union and its Rules of Application, other European Community and European Union law and, on a subsidiary basis, the law of Belgium.

Furthermore, the beneficiary is aware and agrees that the Commission may take decisions to impose pecuniary obligations, which shall be enforceable in accordance with Article 299 of the Treaty on the functioning of the European Union.

Notwithstanding the Commission’s right to directly adopt the decisions referred to in the previous paragraph, the General Court or, on appeal, the Court of Justice of the European Union shall have sole jurisdiction to hear any dispute between the Union and any beneficiary concerning the interpretation, application or validity of this grant agreement and the legality of decisions as referred to in the second paragraph.

Article 11 – Data protection 1. All personal data contained in this grant agreement shall be processed in accordance with Regulation (EC) No 45/2001 of the European Parliament and of the Council on the protection of individuals with regard to the processing of personal data by the European Union institutions and bodies and on the free movement of such data. Such data shall be

2 Established by Decision No 1639/2006/EC of the European Parliament and of the Council of 24

October 2006 (OJ L 310, 9.11.2006, p. 15).

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processed by the controller of the data solely in connection with the implementation and follow-up of this grant agreement and the evaluation and impact assessment of Union activities, without prejudice to the possibility of passing the data to the bodies in charge of monitoring or inspection tasks in accordance with European Union legislation and this grant agreement.

2. Beneficiaries may, on written request, gain access to their personal data and correct any information that is inaccurate or incomplete. They shall address any questions regarding the processing of their personal data to the controller. Beneficiaries may lodge a complaint against the processing of their personal data with the European Data Protection Supervisor at any time.

3. Any queries concerning the processing of the personal data of beneficiaries shall be submitted to the controller, using the address for the Commission as referred to in Article 9(1) of this grant agreement and indicating the reference of the grant agreement. For the purpose of this grant agreement, the controller responsible for processing shall be: Head of the Operations for ICT Research and Innovation Unit.

Article 12 – Application of the provisions of this grant agreement 1. The provisions of this grant agreement shall take precedence over the provisions of any of the Annexes to this grant agreement. The provisions of Annex II shall take precedence over the provisions of Annex I.

2. The special conditions set out in Article 8 of this grant agreement shall take precedence over any other provisions.

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Done in two originals in English,

For the coordinator done at

Name of the legal entity: Name of legal representative: Stamp of the organisation (if applicable): Signature of legal representative: Date:

For the Commission done at Brussels

Name of legal representative: Signature of legal representative: Date:

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ANNEX II

General Conditions

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ANNEX II

GENERAL CONDITIONS

PART A: IMPLEMENTATION OF THE PROJECT Article II.1 - Definitions

Article II.2 - Organisation of the consortium and role of the coordinator

Article II.3 - Specific performance obligations of each beneficiary

Article II.4 - Project reports, deliverables and certificates on financial statements

Article II.5 - Approval of reports and deliverables, time-limit for payments

Article II.6 - Subcontracts

Article II.7 - Assignment

Article II.8 - Suspension of the project

Article II.9 - Amendments

Article II.10 - Termination of the grant agreement or of the participation of a beneficiary

Article II.11 - Financial and other consequences of termination

PART B: RULES RELATING TO INTELLECTUAL AND INDUSTRIAL PROPERTY, PUBLICITY AND CONFIDENTIALITY

Article II.12 - Ownership of foreground

Article II.13 - Protection of foreground

Article II.14 - Use and dissemination of foreground

Article II.15 - Access rights to foreground

Article II.16 - Communication of data for evaluation, impact assessment and standardisation purposes

Article II.17 - Information to be provided to Member States or Associated Countries

Article II.18 - Publicity

Article II.19 - Confidentiality

PART C: FINANCIAL PROVISIONS Article II.20 - Eligible costs - general principles

Article II.21 - Direct costs

Article II.22 - Indirect costs

Article II.23 - Justification of costs

Article II.24 - Receipts of the project

Article II.25 - Financial contribution of the Union

Article II.26 - Payment modalities

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Article II.27 - Interest yielded by the pre-financing provided by the Commission

PART D: CONTROLS, RECOVERIES AND PENALTIES Article II. 28 - Financial audit

Article II.29 - Technical review of the project

Article II.30 - Reimbursement to the Commission and Recovery Orders

Article II.31 - Penalties

Article II.32 - Liability

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PART A: IMPLEMENTATION OF THE PROJECT

Article II.1 – Definitions "Access rights" means licences and user rights to foreground.

“Associated Country” means a country which is party to an international agreement with the European Union under the terms or on the basis of which it makes a financial contribution to the programme under which the present grant agreement is financed.

“Beneficiary” means a legal entity which participates in this grant agreement concluded with the European Union.

“Change of control” means any change in the control exercised over a beneficiary. Such control may result in particular from:

- direct or indirect holding of a majority of the share capital of the beneficiary or a majority of the voting rights of the latter’s shareholders or associates,

- direct or indirect holding in fact or in law of decision-making powers in the beneficiary.

“Commission” means the European Commission.

“Union” means the European Union.

“Consortium” means all the beneficiaries participating in the project covered by this grant agreement.

“Consortium agreement” means an agreement concluded between beneficiaries in order to specify or supplement, between themselves, the provisions of this grant agreement.

“Coordinator” means the beneficiary carrying out the tasks provided for in Article II.2(1).

“Date of entry into force” means the date referred to in Article 3(1) of this grant agreement.

“Deliverables” mean any document, information or other element set out in Annex I to be submitted by the consortium to the Commission in accordance with Article II.4.

“Dissemination” means the disclosure of foreground by any appropriate means other than that resulting from the formalities for protecting it, including the publication of foreground in any medium.

“Duration of the project” means the period of implementation of the project as referred to in Article 3(2) of this grant agreement.

“Eligible costs” means the costs referred to in Articles II.21 and II.22, in compliance with the conditions set out in Articles II.20 and II.23.

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“Financial Regulation and its Rules of Application” means Regulation1 of the European Parliament and the Council on the financial rules applicable to the General Budget of the Union n°966/2012 and Commission Delegated Regulation2 of 29.10.2012 on the rules of application of Regulation (EU, Euratom) N° 966/2012 of the European Parliament and of the Council on the financial rules applicable to the general budget of the Union - and any subsequent amendment thereto in force at the time of the signature of this grant agreement.

“Force majeure” means any unforeseeable and exceptional situation or event beyond the control of the European Union or the beneficiaries which prevents either of them from fulfilling any of their obligations under this grant agreement, was not attributable to error or negligence on their part, and proves insurmountable in spite of all due diligence.

“Foreground” means the results, including information, generated in the course of the project, whether or not they can be protected. Such results include rights related to copyright, design rights, patent rights, plant variety rights, or similar forms of protection.

“Irregularity” means any infringement of a provision of European Union law or a provision of this grant agreement resulting from an act or omission on the part of the beneficiary(ies) which causes or might cause a loss to the Union budget.

“Pre-financing” means any part of the financial contribution of the Union which is paid in order to provide advance funds for the project.

“Project” means the work set out in Annex I to this grant agreement.

“Public body” means any legal entity established as such by national law and international organisations.

“Reports” mean the documents and information mentioned in Article II.4, paragraphs 1 to 3.

“Start date of the project” means the date mentioned in Article 3(2) of this grant agreement.

Article II.2 – Organisation of the consortium and role of the coordinator

1. The coordinator shall be in charge of the technical, financial and administrative coordination of the project. In this respect, the coordinator

(a) shall be the intermediary between the beneficiaries and the Commission. In particular, it shall be responsible for transmitting to the Commission all documents and correspondence relating to the project. To this end the coordinator shall upon signature of the grant agreement inform the Commission of the address to be used in all communication relating to the grant and of the addresses of the beneficiaries communicated to it in accordance with Article II.3;

(b) in its capacity as representative of the beneficiaries, shall make payment requests on behalf of the beneficiaries and receive, subject to the special conditions set out in Article 8 of this grant agreement, all the payments made

1 OJ L298, 26.10.2012, p1 2 C(2012)7507 final

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by the Commission to the account referred to in Article 6(2) of this grant agreement. It shall administer the financial contribution of the Union regarding its allocation between beneficiaries in accordance with this grant agreement, in particular the indicative breakdown of the budget and the financial contribution of the Union in Annex I to this grant agreement, as well as the consortium agreement where applicable. It shall ensure that all the appropriate payments are made to beneficiaries within 45 days of the day on which the bank account under Article 6(2) has been credited;

(c) shall keep records and financial accounts so that it is possible to determine at any time what portion of the financial contribution of the Union has been paid to each beneficiary;

(d) shall inform the Commission of the distribution of the financial contribution of the Union and of the date of transfer to the beneficiaries, when required by Article II.4(3) of this grant agreement or by the Commission;

(e) shall review the reports and deliverables to verify consistency with the project tasks before transmitting them to the Commission;

(f) shall monitor the compliance by beneficiaries with their obligations under this grant agreement;

(g) shall inform the other beneficiaries and the Commission of any event liable to substantially affect the project of which it is aware.

The coordinator may not subcontract the above-mentioned tasks.

Without prejudice to termination of the coordinator’s participation in accordance with Article II.10(3), point (c), should the coordinator fail to meet its obligations, the Commission may, in agreement with the other beneficiaries, designate another coordinator from among the beneficiaries.

2. Beneficiaries shall fulfil the following obligations as a consortium:

(a) provide all detailed data requested by the Commission for the purpose of the proper administration of the project;

(b) carry out the project jointly and severally vis-à-vis the Union, taking all necessary and reasonable measures to ensure that the project is carried out in accordance with the terms and conditions of this grant agreement;

(c) make appropriate internal arrangements, consistent with the provisions of this grant agreement, for the internal operation and management of the project, including where appropriate intellectual property provisions, to ensure the efficient implementation of the project. Where provided for in Article 1(3) of this grant agreement, these internal arrangements shall take the form of a written consortium agreement;

(d) allow the Commission to take part in meetings concerning the project.

Article II.3 - Specific performance obligations of each beneficiary

Each beneficiary shall:

(a) carry out the work described in Annex I correctly and in a timely fashion;

(b) inform the other beneficiaries and the Commission through the coordinator in due time of:

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• its contact address as well as any changes to that information;

• the names and contact details of the person(s) who are to manage and monitor its work and ensure that the tasks assigned are correctly performed, as well as any changes to this information;

• any event that might affect the implementation of the project and the rights of the Union;

• any change in its legal name, address and its legal representatives, and any changes with regard to its legal, financial, organisational or technical situation, including any change of control;

(c) keep duly signed original copies of subcontracts, if any have been concluded;

(d) forward to the coordinator the data needed to draw up the reports and deliverables and forward any corresponding financial statements;

(e) take part in meetings concerning the supervision, monitoring and evaluation of the project which are relevant to them;

(f) provide all detailed information requested by the Commission for the purpose of the proper administration of this grant agreement;

(g) undertake to take all the necessary measures to prevent any risk of conflicts of interest which could affect the impartial and objective performance of the agreement. Such conflicts of interest could arise in particular as a result of economic interest, political or national affinity, family or emotional ties, or any other shared interest;

(h) provide the Commission, including the European Anti-Fraud Office (OLAF) and the Court of Auditors directly with all information requested in connection with controls and audits;

(i) carry out the project in accordance with fundamental ethical principles.

Article II.4 – Project reports, deliverables and certificates on financial statements

1. The consortium shall submit the following reports to the Commission for each reporting period not later than 60 days after the end of the respective period:

(i) a progress report, including a publishable summary, containing information about the progress of work, including achievements and attainment of any milestones and deliverables identified in Annex I. In addition, this report shall contain information on the resources employed and departures from the work schedule;

(ii) for interim and final payments, the financial statements from each beneficiary together with a summary financial report consolidating the Union contribution claimed by all the beneficiaries in an aggregate form. The format and layout shall conform to the rules communicated by the Commission. Beneficiaries who do not receive a financial contribution from the Union are required to submit only a description of the efforts made and the resources used to carry out the project. In the case of Thematic Networks financed by lump sums and flat-rates based on scale-of-unit costs, the Commission may request a simplified financial statement to be submitted only by the coordinator;

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(iii) any other information to be supplied in response to a request by the Commission.

2. The consortium shall submit a final report to the Commission within 60 days after the end of the project. This final report shall comprise a final publishable summary report covering the results, conclusions and socio-economic impact of the project.

3. The coordinator shall submit a report on the distribution of the financial contribution of the Union between beneficiaries. This report shall be submitted not later than 30 days after receipt of the final payment.

4. Reports shall be submitted through the coordinator in one electronic copy. For financial statements and certificates on financial statements one original (paper) copy shall be also be submitted. The data in the original (paper) copy shall be regarded as authentic should there be a difference with the electronic copy. Only the date of receipt of the original (paper) copy by the European Union shall be taken into account for the time limits set out in the agreement. The format and layout of the reports shall conform to the rules communicated by the Commission.

5. The reports submitted to the Commission for publication shall be of a suitable quality to enable direct publication and their submission to the Commission in publishable form shall indicate that no confidential material is included therein.

6. Deliverables identified in Annex I shall be submitted as described therein.

7. A certificate on financial statements shall be submitted for claims of interim payments and final payments where the cumulative amount of requests for payment by a beneficiary is equal to or superior to €325 000.

Without prejudice to the first sub paragraph above, the Commission may request, on the basis of an analysis of risks, the submission of a certificate on the financial statement from any beneficiary at any time until the date of the final payment.

Certificates on financial statements shall certify that the costs claimed in the financial statements and the receipts declared meet the conditions of this grant agreement. They shall be prepared and certified by an external auditor. The format and layout of these certificates shall conform to the rules communicated by the Commission.

Each beneficiary is free to choose any external auditor, including its usual external auditor, provided that they meet both the following professional requirements:

(i) the external auditor must be independent from the beneficiary;

(ii) the external auditor must be qualified to carry out statutory audits of accounting documents in accordance with national legislation implementing the Eighth Council Directive 84/253/EEC3 or Directive 2006/43/EC of the European Parliament and of the Council on statutory audits of annual accounts and consolidated accounts4 replacing the Eighth Council Directive, or, in the case of beneficiaries established in third countries, national regulations in the same field.

Where a beneficiary is a public body, it may opt for a competent public officer to provide its certificate on financial statements, provided that the relevant national authorities have

3 Council Directive of 10 April 1984, OJ L 126, 12.05.1984, p. 20. 4 Directive 2006/43/EC of the European Parliament and of the Council of 17 May 2006, OJ L

157, 9.06.2006, p. 87.

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established this officer’s legal capacity to audit that entity and that the independence of the officer, in particular regarding the preparation of the financial statements, can be ensured.

Certificates by external auditors do not affect the liability of beneficiaries under this grant agreement nor the rights of the Union arising from this grant agreement and in particular Article II.28.

Article II.5 – Approval of reports and deliverables, time-limit for payments 1. At the end of each reporting period, the Commission shall evaluate the project reports and deliverables required by Annex I and disburse the corresponding payments within 90 days of their receipt unless the time-limit, the payment or the project has been suspended. The Commission may be assisted by external experts in the analysis and evaluation of reports and deliverables.

2. Payments shall be made after the Commission’s approval of the reports and/or deliverables. The absence of a response from the Commission within the time-limit shall not imply approval. The Commission may reject reports and deliverables even after the time-limit for payment. Approval of the reports shall not imply recognition of their regularity or of the authenticity of the declarations and information they contain and shall not imply exemption from any audit or review.

3. After reception of the reports and deliverables the Commission may:

(a) approve the reports and deliverables in whole or in part or make the approval subject to certain conditions;

(b) reject the reports and deliverables by giving an appropriate justification and, if appropriate, start the procedure for suspension or termination of the grant agreement;

(c) suspend the time-limit if one or more of the reports or deliverables have not been supplied or are not complete or if some clarification or additional information is needed or there are doubts concerning the eligibility of costs claimed in the financial statement and/or additional checks are being conducted. The suspension shall be lifted from the date when the last report, deliverable or additional information requested is received by the Commission, or where the Commission decides to proceed with an interim payment in part in accordance with paragraph 4.

The Commission shall inform the consortium in writing via the coordinator of any such suspension and the conditions to be met for the lifting of the suspension.

Suspension shall take effect on the date when notice is sent by the Commission;

(d) suspend the payment at any time, in whole or in part, of the amount intended for the beneficiary(ies) concerned:

• if the work carried out does not comply with the provisions of the grant agreement;

• if a beneficiary has to reimburse to its national state an amount unduly received as state aid;

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• if the provisions of the grant agreement have been infringed or if there is a suspicion or presumption thereof, in particular following any audits and checks provided for in Articles II.28 and II.29;

• if there is a suspicion of an irregularity committed by one or more beneficiary(ies) in the performance of the grant agreement;

• if there is a suspected or established irregularity committed by one or more beneficiary(ies) in the performance of another grant agreement funded by the general budget of the European Union or by budgets managed by the latter. In such cases, the payments shall be suspended where the irregularity (or suspected irregularity) is of a serious and systematic nature likely to affect the performance of the current grant agreement.

Where the Commission suspends payment, the consortium shall be duly informed of the reasons why payment in whole or in part will not be made.

4. The Commission may proceed with an interim payment in part if some reports or deliverables are not submitted as required, or are only partially or conditionally approved. Any reports and deliverables due for one reporting period which are submitted late shall be evaluated together with the reports and deliverables of the next reporting period.

5. On expiry of the time-limit for approval of the reports and payments, and without prejudice to suspension by the Commission of this time-limit, the beneficiaries shall be entitled to interest on late payment in accordance with the conditions set out in the Financial Regulation and its Rules of Application, at the rate applied by the European Central Bank for its main refinancing operations in euros plus three and a half points. This reference rate shall be the rate in force on the first day of the month of the final date for payment, as published in the C series of the Official Journal of the European Union.

Interest on late payment shall cover the period from the final date of the period for payment, exclusive, up to the date when the payment is debited to the Commission’s account, inclusive. The interest shall not be treated as a receipt for the project for the purposes of determining the final grant. Any such interest payment is not considered as part of the financial contribution of the Union.

Where the amount of interest calculated in accordance with the subparagraphs above is lower than or equal to €200, it shall be paid only upon a request submitted by the coordinator on behalf of the beneficiaries within two months of receipt of the late payment.

The above provisions shall not apply to beneficiaries that are public bodies of the Member States of the European Union.

6. The suspension of the time-limit, of payment or of the project by the Commission may not be considered as late payment.

7. At the end of the project, the Commission may decide not to make the payment of the corresponding financial contribution of the Union, subject to one month’s written notice of non-receipt of a report, a certificate on financial statements or other project deliverable.

8. The Commission shall inform the coordinator of the amount of the final payment of the financial contribution of the Union and shall justify this amount. The coordinator shall have two months from the date of receipt to communicate reasons for any disagreement. After the end of this period such communications shall no longer be considered and the

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consortium is deemed to have accepted the Commission’s decision. The Commission undertakes to reply in writing within two months following the date of receipt of such communications, giving reasons for its reply. This procedure is without prejudice to the beneficiary’s right to appeal against the Commission’s decision.

Article II.6 - Subcontracts 1. A subcontractor is a third party that has entered into an agreement on business conditions with one or more beneficiaries in order to carry out part of the work of the project without the direct supervision of the beneficiary and without a relationship of subordination.

Beneficiaries shall ensure that the work to be performed, as described in Annex I, can be carried out by them. However, where it is necessary to subcontract certain elements of the work, the following conditions shall be fulfilled:

– recourse to the award of subcontracts must be duly justified in Annex I having regard to the nature of the project and what is necessary for its implementation;

– the tasks concerned and an estimation of the corresponding costs must be indicated in Annex I.

Any subcontract for which the costs are to be claimed as eligible costs shall be awarded according to the principle of best value for money (best price-quality ratio), under conditions of transparency and equal treatment. Beneficiaries shall take care to avoid any conflict of interest in awarding a subcontract. Subcontracting costs shall be in accordance with market prices. Subcontracts concluded on the basis of framework contracts entered into between the beneficiary and a subcontractor prior to the beginning of the project in accordance with the beneficiary’s usual management principles may also be accepted.

2. The beneficiary shall ensure that subcontracts:

− oblige the subcontractor to submit invoices making reference to the project and giving details of the service or supply rendered,

− oblige the subcontractor to abide by the terms of Articles II.7, II.12 to II.19 and II.32 and to submit to the audits and reviews provided for in Articles II.28 and II.29,

− provide that the subcontractor has no rights in respect of the Commission under this grant agreement.

3. The beneficiary shall retain sole responsibility for carrying out the work described in Annex I and for compliance with the provisions of the grant agreement.

4. Beneficiaries may use external support services for ancillary tasks.

Article II.7 Assignment The beneficiaries shall not assign any of the rights and obligations arising from the grant agreement without the prior written authorisation of the Commission and the other beneficiaries.

Article II.8 - Suspension of the project

1. The coordinator shall immediately inform the Commission of any event affecting or delaying the implementation of the project.

2. The coordinator may propose to suspend the project if force majeure or exceptional circumstances render its execution excessively difficult or uneconomic. The coordinator shall inform the Commission without delay of such circumstances, including all justifications and

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information relating to the event, as well as an estimation of the date when the work on the project may begin again. The suspension shall be subject to written approval by the Commission and shall take effect on the date when the coordinator receives notification from the Commission of its approval.

3. The Commission may suspend all of the work under the project where it considers that the consortium is not fulfilling its obligations under this grant agreement, in order to re-negotiate with it and propose the necessary amendments to the grant agreement to redress the situation. It shall notify the coordinator without delay of the justifications for suspension as well as of the conditions necessary for the work to be resumed. This suspension shall take effect on the date when the coordinator receives notification from the Commission.

4. During the period of suspension, no costs may be charged to the project.

5. The suspension of the project may be lifted once both parties have agreed on its continuation and, as appropriate, once any necessary modification, including the extension of the duration, has been made by means of a written amendment.

Article II.9 - Amendments 1. All amendments to the grant agreement shall be made in writing and conform to the rules communicated by the Commission, where applicable.

2. Any request for and any acceptance of an amendment by the consortium shall be submitted by the coordinator. The coordinator shall be deemed to act on behalf of all beneficiaries when submitting a request for an amendment and when accepting or rejecting an amendment requested by the Commission. The coordinator shall ensure that adequate proof exists of the consortium’s agreement to the amendment request or of its acceptance or rejection of an amendment and is made available in the event of an audit.

3. In the case of change of coordinator without its agreement, the request shall be submitted or accepted by all other beneficiaries or by one of them representing the others.

4. The absence of a response to an amendment request shall not constitute approval of the request.

5. Requests for the addition of a new beneficiary shall include a duly completed and signed Form B (set out in Annex IV). Subject to acceptance in writing by the Commission of the request, the new beneficiary shall assume the rights and obligations of beneficiaries as established by this grant agreement with effect from the date of its accession as specified in Form B.

6. Amendments may not have the purpose or the effect of making changes to the agreement which might call into question the decision awarding the grant or result in unequal treatment of the beneficiaries.

Article II.10 - Termination of the grant agreement or of the participation of a beneficiary 1. The consortium may request

(a) the termination of the grant agreement at the written request of the coordinator in agreement with all the other beneficiaries on the following grounds:

for major technical or economic reasons substantially affecting the project (including where the resumption of the performance of the agreement following its suspension on account of force majeure proves impossible),

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if the use potential of the results of the project considerably diminishes.

(b) the termination of the participation of a beneficiary in the project. Any such request of the consortium shall include the consortium's proposal for reallocation of the tasks and budget of that beneficiary, the reasons for requesting the termination and a letter containing the opinion of the beneficiary whose participation is requested to be terminated. The letter containing the opinion of the beneficiary concerned may be substituted by proof that this beneficiary has been requested in writing to express its opinion on the proposed termination of its participation within the time-limit established by that notification. This time-limit shall not be inferior to one month.

In case of the termination of the participation of the coordinator without its agreement, the request shall be submitted by all other beneficiaries or by one of them representing the others.

The termination of the grant agreement or the participation of a beneficiary shall take effect on the date agreed by the parties; where there is no date specified, termination shall take effect on the date of the Commission's approval notified to the coordinator, which receives it on behalf of the consortium. In case of termination of the participation of one or more beneficiaries, the Commission shall send a copy to the beneficiary(ies) concerned.

2. The Commission may terminate this grant agreement or the participation of a beneficiary:

(a) where one or more of the legal entities identified in Article 1(2) do not accede to this grant agreement within the deadline established in Article 2(1),

(b) where the project has not effectively commenced within three months of the start date of the project and the new date proposed is considered unacceptable by the Commission,

(c) where the beneficiary directly concerned or the consortium has not fully performed its contractual obligations despite a written request from the Commission to remedy a failure to comply with these obligations within a period not exceeding one month,

(d) where a legal, financial, organisational or technical change or change of control over a beneficiary is likely to substantially affect the project or the interests of the Union, or calls into question the decision to accept its participation in the grant agreement or to grant the financial contribution of the Union,

(e) on the grounds referred to in paragraph 1, point (a) of this Article,

(f) in the event of bankruptcy, winding up, cessation of trading, winding up by court order or composition, or suspension of activities of a beneficiary or any similar proceedings provided for by national laws or regulations and leading to a similar result,

(g) in the event of an irregularity or fraud on the part of a beneficiary in the performance of any contract or grant agreement with the Commission,

(h) where a beneficiary is guilty of misrepresentation in supplying the information required by the Commission or has deliberately withheld information in order

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to obtain the financial contribution of the Union or any other advantage provided for in the grant agreement.

(i) where further to the termination of the participation of one or more beneficiaries, the consortium does not propose to the Commission an amendment to the grant agreement with the necessary modifications for the continuation of the project including the reallocation of tasks of the beneficiary(ies) whose participation is terminated within the time-limit determined by the Commission, or where the Commission does not accept the proposed modifications.

In the event of termination pursuant to points (a), (b), (c), (d), (f), (g), (h) and (i), the termination shall be effective on the date of receipt of the registered letter with acknowledgement of receipt sent by the Commission.

In the event of termination pursuant to points (e), the Commission shall determine the period of notice for termination in a registered letter with acknowledgement of receipt, whereby this period shall not exceed one month from the date of receipt of the letter.

3. Any letter from the Commission to terminate the participation of a beneficiary shall be addressed to the beneficiary concerned with a copy to the coordinator in accordance with the procedure set out in paragraph 2 of this Article. Any letter to terminate the agreement shall be sent to the coordinator who shall notify all the other beneficiaries.

Article II.11 - Financial and other consequences of termination 1. Beneficiaries shall take appropriate action to cancel or reduce their commitments upon receipt of the letter from the Commission notifying them of the termination of the agreement or of their participation or upon the dispatch of the request for termination of their participation, as the case may be.

2. In the event of termination of the grant agreement or of the participation of a beneficiary, the beneficiaries or the beneficiary whose participation has been terminated shall submit the reports, including the financial statements, and deliverables relating to the work performed until the date of termination of the grant agreement or the date when the beneficiary’s participation ends in conformity with the provisions of Article II.4 within 60 days from the date of termination. If these documents are not received within the above time-limits, the Commission may decide not to consider any further cost claims and not to make any further reimbursement and, where appropriate, require the reimbursement of any pre-financing paid to the beneficiary(ies).

3. In the event of termination, payments by the Commission shall be limited to those eligible costs incurred and accepted up to the effective date of termination and to any legitimate commitments undertaken prior to that date which cannot be cancelled.

4. By derogation from the above paragraph:

– In the event of termination pursuant to Article II.10, paragraph 2, points (b), (c),(g), (h) or (i), the Commission may require repayment of all or part of the financial contribution of the Union, taking into account the nature and results of the work carried out and its usefulness to the Union in the context of the present programme.

– In the event of termination pursuant to Article II.10, paragraph 2, point (a), no costs incurred by the consortium under the project shall be accepted as eligible

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for reimbursement by the Union. Any pre-financing provided to the consortium shall be returned in full to the Commission.

5. Where the Commission makes a payment after the termination of the participation of a beneficiary or after termination of the grant agreement, this payment shall be considered as a final payment in relation to this beneficiary or to the project, respectively, and in any case shall be done through the coordinator.

6. The termination of the grant agreement or of the participation of a beneficiary shall not affect any rights or obligations of the parties which arise before the date of termination.

7. The Commission may exercise all rights under this grant agreement to accept or reject reports and deliverables, to accept, reduce or reject a cost claim and to initiate an audit or a technical review.

8. Notwithstanding the termination of the grant agreement or the participation of a beneficiary, the provisions in Part B and Part D of Annex II continue to apply after the termination of the grant agreement or the termination of a beneficiary’s participation. Any other provisions in this grant agreement which specifically indicate their continued application after the termination shall also apply for the duration specified in those provisions.

PART B: RULES RELATING TO INTELLECTUAL PROPERTY, PUBLICITY AND CONFIDENTIALITY

Article II.12 - Ownership of foreground

1. Foreground shall be the property of the beneficiary carrying out the work generating that foreground.

2. Where several beneficiaries have jointly carried out the work generating the foreground and where their respective shares of the work cannot be ascertained, they shall have joint ownership of the foreground. They shall establish an agreement5 among themselves on the allocation and exercise of that joint ownership.

3. If persons hired by a beneficiary are entitled to claim rights to foreground, the beneficiary shall ensure that these rights are exercised in a manner compatible with its obligations under this grant agreement.

Article II.13 – Protection of foreground Where foreground is capable of industrial or commercial application, its owner shall provide for its adequate and effective protection, having due regard to its own legitimate interests and the legitimate interests, particularly the commercial interests, of the other beneficiaries.

Where a beneficiary which is not the owner of the foreground invokes its legitimate interests, it shall show that it would suffer disproportionately great harm.

Article II.14 – Use and dissemination of foreground 1. The beneficiaries shall use the foreground which they own or ensure that it is used.

5 The joint owners may agree not to continue with joint ownership but decide on an alternative regime

(for example, a single owner with access rights for the other beneficiaries that transferred their ownership share).

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2. Each beneficiary shall ensure that the foreground which it owns is disseminated as swiftly as possible. If it fails to do so, the Commission may disseminate that foreground.

3. Dissemination activities shall be compatible with the protection of intellectual property rights, confidentiality obligations and the legitimate interests of the owner(s) of the foreground.

4. At least 45 days prior notice of any dissemination activity shall be given to the other beneficiaries concerned, including sufficient information concerning the envisaged dissemination activity and the data to be disseminated.

Following notification, any of those beneficiaries may object to the envisaged dissemination activity within 30 days of notification if it considers that its legitimate interests in relation to its foreground could suffer disproportionately great harm. In such cases, the dissemination activity may not take place unless appropriate steps are taken to safeguard these legitimate interests.

The beneficiaries may agree in writing on different time-limits to those set out in this paragraph, which may include a deadline for determining the appropriate steps to be taken, or may waive their right to prior notice for specific or all dissemination activities.

Article II.15 – Access rights to foreground 1. Access rights to foreground shall be granted to the other beneficiaries, if it is needed to enable those beneficiaries to carry out their own work under the project.

2. Beneficiaries shall enjoy access rights to foreground, if it is needed to use their own foreground. A request for such access rights for use may be made up to one year after the end of the project or termination of participation by the owner of the foreground concerned, unless the beneficiaries concerned agree on a different time-limit.

3. Access rights shall be granted on a royalty-free basis, unless the beneficiaries concerned agree otherwise.

Article II.16 – Communication of data for evaluation, impact assessment and standardisation purposes 1. Beneficiaries shall provide, at the request of the Commission, the data necessary for:

- the continuous and systematic review of the ICT PSP as part of the CIP;

- the evaluation and impact assessment of Union activities, including the use and dissemination of foreground.

Such data may be requested throughout the duration of the project and up to five years after the end of the project.

The data collected may be used by the Commission in its own evaluations but shall not be published other than on an anonymous basis.

2. Without prejudice to the provisions regarding protection of foreground and confidentiality, the beneficiaries shall, where appropriate, during the project and for two years following its end, inform the Commission and the European standardisation bodies about foreground that may contribute to the preparation of European or international standards.

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Article II.17 - Information to be provided to Member States or Associated Countries 1. The Commission shall, upon request, make available to any Member State or Associated Country any useful information in its possession on foreground, provided that both the following conditions are met:

– the information concerned is relevant to public policy; – the beneficiaries have not provided sound and sufficient reasons for withholding

the information concerned. 2. The provision of information pursuant to paragraph 1 shall not transfer to the recipient any rights or obligations and the recipient shall be required to treat any such information as confidential until it becomes duly public or unless it was communicated to the Commission without restrictions on its confidentiality.

Article II.18 – Publicity 1. The Commission shall be authorised to publish the following information in any form

and medium, including the Internet:

– the names and contact addresses of the beneficiaries; – the subject and purpose of the grant; – the amount and rate of the financial contribution of the Union foreseen for the

project and the estimated amount and rate for each beneficiary foreseen in the indicative breakdown of the budget and the financial contribution of the Union between beneficiaries in Annex I; after the final payment, the amount and rate of the financial contribution of the Union accepted by the Commission for the project and for each beneficiary;

– any picture or any audiovisual or web material provided to the Commission in connection with the project;

– any publishable report or other publishable deliverable submitted to it. The consortium shall ensure that all necessary authorisations for such publications have been obtained and that the publication of the information by the Commission does not infringe any rights of third parties.

Upon a reasoned and duly substantiated request by the beneficiary, the Commission may agree to forego publication if disclosure of the information indicated above would risk compromising the beneficiary’s security or prejudicing its commercial interests.

2. The beneficiaries shall, throughout the duration of the project, take appropriate measures to engage with the public and the media about the project and to highlight the financial support of the Union. Unless the Commission requests otherwise, any communication or publication by the beneficiary about the project, including at a conference or seminar, or any type of information or promotional material (brochure, leaflet, poster, presentation, etc), shall mention that the project has received funding from the Union’s ICT Policy Support Programme as part of the Competitiveness and Innovation Framework Programme, and shall display the European emblem. When displayed in association with a logo, the European emblem shall be given appropriate prominence. This obligation to use the European emblem in respect of projects to which the Union contributes implies no right of exclusive use. It is subject to general third-party use restrictions that do not permit the appropriation of the emblem, or of any similar trademark or logo, whether by registration or by any other means. Under these conditions, beneficiaries are exempted from the obligation to obtain prior permission from the Commission to use the emblem. Further detailed information on the EU emblem may be found on the Europa web page.

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Any communication or publication by the beneficiary in respect of the project, in any form or medium, including the Internet, shall state that it reflects only the author’s views and that the Union is not liable for any use that might be made of information contained therein.

Article II.19 - Confidentiality 1. The beneficiaries and the Commission undertake to preserve the confidentiality of any data, documents or other material that is identified as confidential in relation to the execution of the project (“confidential information”).

This obligation shall no longer apply where:

– the confidential information becomes publicly available by means other than a breach of confidentiality obligations,

– the confidential information is subsequently communicated to the recipient without any confidentiality restrictions by a third party who is in lawful possession thereof and under no obligation of confidentiality or where the disclosing party subsequently waives its confidentiality;

– the disclosure or communication of the confidential information is provided for by other provisions of this grant agreement.

2. The beneficiaries and the Commission undertake to use such confidential information only in relation to the execution of the project, unless otherwise agreed with the disclosing party.

Part C: FINANCIAL PROVISIONS

Article II.20 - Eligible costs - general principles 1. Eligible costs are the costs defined in Articles II.21 and II.22. They shall fulfil the following conditions:

− be indicated in the indicative breakdown of the budget and the financial contribution of the Union between beneficiaries in Annex I;

− be necessary for the implementation of the project; − be actually incurred by the beneficiary; − be identifiable and verifiable, be recorded in the beneficiary’s accounts and

determined in accordance with the applicable accounting standards of the country where the beneficiary is established and with the usual cost accounting practices of the beneficiary. The beneficiary’s internal accounting and auditing procedures must permit the direct reconciliation of the costs and receipts declared in respect of the project with the corresponding financial statements and supporting documents;

− comply with the requirements of the applicable tax and social legislation; − be reasonable and justified and comply with the requirements of sound

financial management, in particular regarding economy and efficiency, and − be incurred during the duration of the project.

Without prejudice to the provisions of the first subparagraph,

− the costs for drawing up the final report and certificates on financial statements required for the final period and

– the costs of participation in technical reviews pursuant to Article II.29 shall be eligible if they are incurred within not more than 60 days after the end of the duration of the project.

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2. Non-eligible costs are in particular the following:

− costs of capital employed, − provisions for possible future losses or charges, − interest owed, − exchange losses, − provisions for doubtful debts, − resources made available to a beneficiary free of charge, − value of contributions in kind, − unnecessary or ill-considered expenses, − marketing, sales and distribution costs for products and services, − indirect taxes and duties, including VAT (unless the beneficiary can show that

it is unable to recover it), − entertainment or hospitality expenses, except reasonable expenses accepted by

the Commission as being absolutely necessary for carrying out the project, − any cost incurred or reimbursed in respect of, in particular, another Union,

international or national project. 3. No cost may be charged to more than one of the eligible cost categories referred to in Articles II.21 and II.22.

Article II.21 - Direct costs 1. Direct costs are those eligible costs that can be attributed directly to the project and are identified by the beneficiary as such, in accordance with its accounting principles and its usual internal rules.

2. Personnel

With regard to personnel costs,

(a) Only the costs of the actual hours worked by the persons directly carrying out work under the project may be charged to the grant agreement.

Such persons must:

− be directly hired by the beneficiary in accordance with its national legislation,

− work under the sole technical supervision and responsibility of the beneficiary, and

− be remunerated in accordance with the normal practices of the beneficiary, provided that these are regarded as acceptable by the Commission.

(b) Personnel costs shall comprise the actual costs (gross remuneration and related charges).

(c) Costs related to parental leave for persons who are directly carrying out the project are eligible costs, in proportion to the time dedicated to the project, provided that they are mandatory under national law.

(d) The value of the work, considered as eligible direct cost, performed by SME owners who do not receive a salary shall be determined by multiplying the hours worked in the project by the hourly rate to be calculated as follows:

– {Annual living allowance corresponding to the appropriate research category published in the 'People' Work Programme adopted under

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Article 6 of Decision 2006/973/EC6 of the year of the publication of the call to which the proposal has been submitted / standard number of annual productive hours} multiplied by {country correction coefficient published in the 'People' Work programme of the year of the publication of the call /100}

– The standard number of productive hours shall be equal to 1 575

– The reference rate for early-stage researchers shall apply to SME owners of start ups with a professional experience of up to two years.

– The reference rates for experienced researchers shall apply to

(a) SME owners with a professional experience of two to ten years;

(b) SME owners with more than ten years of experience 3. Subcontracting

With the exception of costs charged to the grant agreement pursuant to paragraph 1 of this Article, the actual costs of subcontracts may be charged to the grant agreement if they are incurred in compliance with the conditions set out in Article II.6.

4. Other specific direct costs

These costs include, in particular,

– travel and subsistence allowances for personnel taking part in the project, provided that they are in line with the beneficiary’s usual practices on travel costs;

– the purchase cost of equipment (new or second-hand), provided that it is depreciated in accordance with the tax and accounting rules applicable to the beneficiary and generally accepted for items of the same kind. Only the portion of the equipment’s depreciation corresponding to the duration of the project at the rate of actual use for the project may be taken into account by the Commission, except where the nature and/or the context of its use justifies different treatment by the Commission;

– costs arising directly from requirements imposed by the grant agreement, including for the dissemination of information, or any financial guarantees. Such costs may also include specific costs incurred by the coordinator in fulfilling its responsibilities as the body responsible for the overall management of the project and for the coordination of the beneficiaries.

Article II.22 - Indirect costs

1. Indirect costs are all those eligible costs that cannot be identified by the beneficiary as being directly attributed to the project, but which can be identified and justified by its accounting system as being incurred in direct relationship with the eligible direct costs attributed to the project. They may not include any eligible direct costs.

2. Beneficiaries of Pilot projects may charge indirect costs calculated on a flat-rate basis of 30% of the personnel costs. A beneficiary shall request a lower percentage when this is required, for instance, by its internal rules.

In the case of Thematic Networks, the reimbursement of indirect eligible costs shall for each beneficiary comprise a flat-rate of 7% of the direct eligible costs, excluding the direct eligible 6 OJ L 400, 30.12.2006, p. 272. Corrigendum published in OJ L 54, 22.2.2007, p.91

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costs for subcontracting. This flat-rate for indirect costs shall not apply to Thematic Networks financed in the form of lump sums and flat-rate financing based on scale-of-unit costs.

In the case of Best Practice Networks, no indirect costs shall be eligible.

Article II.23 - Justification of costs Eligible costs shall be reimbursed where they are justified by the beneficiary.

To this end, the beneficiary shall maintain, on a regular basis and in accordance with the normal accounting conventions of the State in which it is established, the accounts for the project and appropriate documentation to support and justify in particular the costs and time reported in its financial statements. These accounts shall be maintained for at least 5 years after the date of the final payment. All the working time charged to the agreement shall be recorded throughout the duration of the project, or not later than 60 days from the end of the duration of the project, and shall be certified by the person in charge of the work as designated by the beneficiary in accordance with Article II.3(b) or by the duly authorised financial officer of the beneficiary.

This documentation shall be precise, complete and effective.

Article II.24 – Receipts of the project 1. Resources made available by third parties to the beneficiary by means of financial

transfers or contributions in kind free of charge

a) shall be considered a receipt of the project for the beneficiary if they have been contributed by the third party specifically to be used in the project;

b) shall not be considered a receipt of the project for the beneficiary if their use is at the discretion of the beneficiary’s management.

2. Income generated by the project

a) shall be considered a receipt of the project for the beneficiary when generated by actions undertaken in carrying out the project and from the sale of assets purchased under the grant agreement up to the value of the cost initially charged to the project by the beneficiary;

b) shall not be considered a receipt of the project for the beneficiary when generated from the use of the foreground resulting from the project.

Article II.25 – Financial contribution of the Union 1. The financial contribution of the Union to the project shall be determined by applying the funding limits indicated in this grant agreement and in the indicative breakdown of the budget and the financial contribution of the Union to the eligible costs and/or to the flat-rates and/or lump sums accepted by the Commission.

2. The financial contribution of the Union shall be paid based on the accepted costs of each beneficiary.

3. The financial contribution of the Union may not give rise to any profit for any beneficiary. For this purpose, at the submission of the last financial statement, the final amount of the financial contribution of the Union shall take into account any receipts of the project received by each beneficiary. For each beneficiary, the financial contribution of the Union may not exceed the total costs minus the receipts of the project.

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4. The total amount paid by the Commission shall not exceed in any circumstances the maximum amount of the financial contribution of the Union referred to in Article 5(1).

5. Without prejudice to the right to terminate the grant agreement under Article II.10 and without prejudice to the right of the Commission to apply penalties as referred to in Article II.31, if the project is not implemented or is implemented poorly, partially or late, the Commission may reduce the grant initially provided in line with the actual implementation of the project on the terms laid down in this grant agreement.

Article II.26 – Payment modalities 1. The Commission shall make the following payments:

− pre-financing in accordance with Article 6; − interim payments of the financial contribution of the Union corresponding to

the amount accepted for a reporting period in accordance with Article 6; − a final payment corresponding to the amount accepted for the last reporting

period, or, if the consortium has received only pre-financing, to the amount accepted for the project, plus any adjustment needed.

Where the amount of the financial contribution of the Union is less than the amount already paid to the consortium, the Commission shall recover the difference.

Where the amount of the financial contribution of the Union is more than the amount already paid to the consortium, the Commission shall pay the difference as the final payment up to the limits defined in Article 5(1).

2. The total amount of the pre-financing and interim payments shall not exceed 90% of the maximum financial contribution of the Union defined in Article 5(1).

3. Payments by the Commission shall be made in euros.

4. Costs incurred shall be reported in euros. Beneficiaries with accounts in a currency other than the euro shall report costs by using the conversion rate published by the European Central Bank and applicable on the first day following the end of the reporting period. Beneficiaries with accounts in euros shall convert costs incurred in other currencies according to their normal accounting practice.

5. The payments by the Commission shall be regarded as having been effected on the date on which the Commission’s account is debited.

6. Any payment may be subject to an audit or review and may be adjusted or recovered based on the results of the audit or review.

Article II.27 – Pre-financing provided by the Commission

1. Pre-financing remains the property of the Union until the final payment.

PART D: CONTROLS, RECOVERIES AND PENALTIES

Article II.28 - Financial audit 1. The Commission may initiate an audit in respect of a beneficiary at any time during the implementation of the project and up to five years after the date of the final payment. The audit procedure in respect of a beneficiary shall be deemed to be initiated on the date of

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receipt by the latter of the relevant registered letter with acknowledgement of receipt sent by the Commission.

The audit procedure may be carried out by external auditors or by the Commission services themselves, including OLAF. The audit procedure shall be carried out on a confidential basis.

2. The beneficiaries shall make available directly to the Commission all detailed information and data that may be requested by the Commission, or any representative authorised by it, with a view to verifying that the grant agreement is properly managed and performed in accordance with its provisions and that costs have been charged in compliance with it.

3. The beneficiaries shall ensure that the Commission, or any external body authorised by it, has on-the-spot access, at any reasonable time, in particular to the beneficiary’s offices, the personnel of the beneficiaries connected with the project, the documentation referred to in Article II.23 needed to carry out the audit, including information on individual salaries of persons involved in the project, accounting data, computer records and equipment. In this connection, the Commission, or any external body authorised by it, may request that data be handed over to it in an appropriate form in order, for instance, to ascertain the eligibility of the costs.

4. On the basis of the findings made during the financial audit of a beneficiary, a provisional report shall be drawn up. It shall be sent by the Commission to the beneficiary concerned, which may make observations regarding the report within one month of receiving it. The Commission may decide not to take into account any observations conveyed after that deadline. The final report shall be sent to the beneficiary concerned.

5. On the basis of the conclusions of the audit, the Commission shall take all appropriate measures which it considers necessary, including the issuing of a recovery order regarding all or part of the payments made by it and the application of any applicable sanction.

6. The Court of Auditors shall have the same right as the Commission, notably the right of access, for the purpose of checks and audits, without prejudice to its own rules.

7. In addition, the Commission may carry out on-the-spot checks and inspections in accordance with Council Regulation (Euratom, EC) No 2185/96 of 11 November 1996 concerning on-the-spot checks and inspections carried out by the Commission in order to protect the European Communities’ financial interests against fraud and other irregularities7, Regulation (EC) No 1073/1999 of the European Parliament and of the Council of 25 May 1999 concerning investigations conducted by the European Anti-Fraud Office (OLAF)8 and Council Regulation (Euratom) No 1074/1999 of 25 May 1999 concerning investigations conducted by the European Anti-Fraud Office (OLAF)9.

Article II.29 - Technical review of the project 1. The Commission may initiate a technical review at any time during the implementation of the project and up to five years after the end of the duration of the project in order to verify that the project is being or has been carried out in accordance with the conditions governing this grant agreement, in particular with respect to the Description of Work (Annex I). The technical review shall assess the work carried out under the project by, among other things, evaluating the project reports and deliverables, the proper use of

7 OJ L 292, 15.11.1996, p. 2. 8 OJ L 136, 31.5.1999. 9 OJ L 136, 31.5.1999.

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resources in particular with respect to efficiency and effectiveness, the management of the project and the expected impact.

The technical review shall be deemed to be initiated on the date of receipt by the coordinator of the relevant notification sent by the Commission.

The technical review procedure shall be carried out on a confidential basis.

2. For the technical review, the Commission may be assisted by independent experts.

The Commission shall take appropriate steps to ensure that such experts treat confidentially the data that are communicated to them. Prior to the technical review, it shall communicate to the coordinator the identity of the experts who are intended to assist it. It shall take account of any objection on the part of beneficiaries based on legitimate interests.

3. Technical reviews may be carried out remotely at the experts’ home or place of work or involve sessions with project representatives either at the Commission premises or at the premises of beneficiaries. The Commission or the external experts may have access to the locations and premises where the work is being carried out and to any document concerning the work.

4. The beneficiaries shall make available to the Commission and any external experts all detailed information and data that may be requested by it or the experts for the technical review.

5. A report on the technical review of the project shall be sent to the coordinator. The latter may communicate observations to the Commission within a month of receiving it. The Commission may decide not to take into account any observations conveyed after that deadline.

6. On the basis of the conclusions of the technical review, the Commission shall take all appropriate measures which it considers necessary, including the rejection of any reports and deliverables, the termination of the agreement pursuant to Article II.10 and II.11 and the reduction of the grant pursuant to Article II.25(5).

Article II.30 - Reimbursement to the Commission and Recovery Orders 1. Where an amount paid by the Commission to the coordinator in its capacity as the recipient of all payments is to be recovered under the terms of this grant agreement, the beneficiary concerned undertakes to repay the Commission the sum in question, on whatever terms and by whatever date it may specify.

2. If the obligation to pay the amount due is not honoured by the date set by the Commission, the sum due shall bear interest at the rate indicated in Article II.5(5). Interest on late payment shall cover the period between the date set for payment, exclusive, and the date when the Commission receives full payment of the amount owed, inclusive.

Any partial payment shall be entered first against charges and interest on late payment and then against the principal.

3. If payment has not been made by the due date, sums owed to the Commission may be recovered by offsetting them against any sums owed to the concerned beneficiary after informing it accordingly or by calling in a financial guarantee. In exceptional circumstances, justified by the need to safeguard the financial interests of the Union, the Commission may recover by offsetting before the due date of the payment. The beneficiary’s prior consent shall not be required.

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Bank charges occasioned by the recovery of the sums owed to the Commission shall be borne solely by the beneficiary.

4. The beneficiaries understand that under Article 299 of the Treaty on the functioning of the European Union, the Commission may adopt an enforceable decision formally establishing an amount as receivable from persons other than States.

Article II.31- Penalties 1. Any beneficiary that has been guilty of making false declarations or has been found to have seriously failed to meet its obligations under this grant agreement shall be liable to financial penalties of between 2% and 10% of the value of the financial contribution of the Union received by that beneficiary. The rate may be increased to between 4% and 20% in the event of a repeated offence within five years following the first infringement.

The Commission is entitled to recover the full amount of any undue payments made to a beneficiary on a lump sum or flat-rate financing, where the generating event has not occurred. Furthermore, in the case of a false declaration regarding the lump sum or flat-rate financing, the Commission may impose financial penalties up to 50% of the total amount of the lump sum or flat rate financing.

2. In the cases specified in paragraph 1, beneficiaries may be excluded from all Union grants for a maximum of two years from the date the infringement has been established.

3. The provisions of this Article shall be without prejudice to any other administrative or financial sanction that may be imposed on any defaulting beneficiary in accordance with the Financial Regulation or to any other civil remedy to which the Union or any other beneficiary may be entitled. Furthermore, these provisions shall not preclude any criminal proceedings which may be initiated by the authorities of the Member States.

Article II.32 - Liability 1. The Union may not be held liable for any acts or omissions of the beneficiaries in relation to this grant agreement. It shall not be liable for any defects in respect of any products, processes or services created on the basis of foreground, including, for instance, anomalies in their functioning or performance.

2. Each beneficiary shall bear sole responsibility for ensuring that their acts in connection with this project do not infringe third party rights, including the use of acronyms of the project.

3. The beneficiaries shall fully guarantee the Union and agree to indemnify it in the case of any action, complaint or proceeding brought by a third party against it as a result of damage caused either by an act or omission in relation to this grant agreement or by any products, processes or services created on the basis of foreground resulting from the project.

In the event of any action brought by a third party against the Union in connection with the performance of this agreement, the beneficiaries who may bear responsibility shall assist the Union upon written request.

4. In the event of any action brought by a third party against a beneficiary in connection with the performance of this agreement, the Commission may, without prejudice to paragraph 1 of this Article, assist the latter upon written request. The costs incurred by the Commission in this connection shall be borne by the beneficiary concerned.

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ANNEX III

Form A – accession of beneficiaries to the grant agreement (to be filled in by each beneficiary identified in Article 1(2) of the grant agreement)

Land Kärnten represented for the purpose hereof by Mr. Christian Ragger, Councilor, or his authorised representative established in Arnulfplatz 1 , 9020 Klagenfurt - AUSTRIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. Land Kärnten confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by Land Kärnten, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

Name of legal entity: (full name of the beneficiary) Name of legally authorised representative:(written out in full) Title of legally authorised representative: Signature of legally authorised representative: Date: Stamp of the organisation:

Name of legal entity: (full name of the coordinator) Name of legally authorised representative: Title of legally authorised representative: Signature of legally authorised representative: Date: Stamp of the organisation:

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ANNEX III

GESUNDES KINZIGTAL GMBH represented for the purpose hereof by Mr. Helmut Hildebrandt, CEO, and/or Ms. Monika Roth , head of department of Health Management, Gesundes, or their authorised representatives established in STRICKERWEG 3D , 77716 HASLACH - GERMANY (person legally authorised to act on behalf of the legal entity)acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. GESUNDES KINZIGTAL GMBH confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by GESUNDES KINZIGTAL GMBH, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

REGION SYDDANMARK represented for the purpose hereof by Ms. Tove Lehrmann, Chief Consultant, and/or Mr. Claus Duedal Pedersen , Chief Consultant, or their authorised representatives established in DAMHAVEN 12 , 7100 VEJLE - DENMARK (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. REGION SYDDANMARK confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by REGION SYDDANMARK, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

IDA-TALLINNA KESKHAIGLA AS represented for the purpose hereof by Dr. Ralf Allikvee , Chairman of the Board , or his authorised representative established in RAVI 18 , 10138 TALLINN - REPUBLIC OF ESTONIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. IDA-TALLINNA KESKHAIGLA AS confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by IDA-TALLINNA KESKHAIGLA AS, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

TALLINA SOTSIAAL-JA TERVISHOIUAMET-TALLINN SOCIAL WELFARE AND HEALTH CARE BOARD TSTA represented for the purpose hereof by Dr. Vahur Keldrima, Head, and/or Dr. Raivo Allev , Manager, or their authorised representatives established in NARVA MNT 11D , 10151 TALLINN - REPUBLIC OF ESTONIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. TALLINA SOTSIAAL-JA TERVISHOIUAMET-TALLINN SOCIAL WELFARE AND HEALTH CARE BOARD TSTAconfirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by TALLINA SOTSIAAL-JA TERVISHOIUAMET-TALLINN SOCIAL WELFARE AND HEALTH CARE BOARD TSTA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

FUNDACIO TICSALUT represented for the purpose hereof by Mr. Joan Cornet, Executive President, and/or Mr. Francesc Garcia Cuyàs , Director, or their authorised representatives established in C ERNEST LLUCH 32 Planta 6 Porta 4 TECNOCAMPUS MATARO MARESME TORRE TC , 08302 MATARO BARCELONA - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. FUNDACIO TICSALUT confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by FUNDACIO TICSALUT, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

SERVICIO ARAGONES DE LA SALUD represented for the purpose hereof by Mr. Miguel Angel Eguizabal , Managing Director of the SALUD-Barbastro Healthcare Area , or his authorised representative established in VIA UNIVERSITAS 34 , 50071 ZARAGOZA -SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. SERVICIO ARAGONES DE LA SALUD confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by SERVICIO ARAGONES DE LA SALUD , the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

CRUZ ROJA ESPANOLA FUNDACION represented for the purpose hereof by Mr. FRANCISCO BARREÑA PUIVECINO, PRESIDENTE PROVINCIAL, or his authorised representative established in AVENIDA REINA VICTORIA 26 , 28003 MADRID - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. CRUZ ROJA ESPANOLA FUNDACION confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by CRUZ ROJA ESPANOLA FUNDACION, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

ASOCIACION CENTRO DE EXCELENCIA INTERNACIONAL EN INVESTIGACION SOBRE CRONICIDAD represented for the purpose hereof by Mr. Esteban de Manuel Keenoy , CEO, or his authorised representative established in CALLE MARIA DIAZ DE HARO 60 , 48010 BILBAO - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the EuropeanCommission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. ASOCIACION CENTRO DE EXCELENCIA INTERNACIONAL EN INVESTIGACION SOBRE CRONICIDAD confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by ASOCIACION CENTRO DE EXCELENCIA INTERNACIONAL EN INVESTIGACION SOBRE CRONICIDAD, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

CONSEJERIA DE SALUD Y POLITICA SOCIAL - JUNTA DE EXTREMADURA represented for the purpose hereof by Mrs. Cristina Herrera Santa Cecilia, Director , or her authorised representative established in AVENIDA DE LAS AMÉRICAS 4 , 06800 MERIDA - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. CONSEJERIA DE SALUD Y POLITICA SOCIAL - JUNTA DE EXTREMADURA confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by CONSEJERIA DE SALUD Y POLITICA SOCIAL - JUNTA DE EXTREMADURA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

FUNDACION FUNDECYT - PARQUE CIENTIFICO Y TECNOLOGICO DE EXTREMADURA-FUNDECYT PCTEX represented for the purpose hereof by Mr. Antonio Verde Cordero, Managing Director, or his authorised representative established in AVENIDA DE ELVAS CAMPUS s/n , 06071 BADAJOZ - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. FUNDACION FUNDECYT - PARQUE CIENTIFICO Y TECNOLOGICO DE EXTREMADURA-FUNDECYT PCTEX confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by FUNDACION FUNDECYT - PARQUE CIENTIFICO Y TECNOLOGICO DE EXTREMADURA-FUNDECYT PCTEX, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

FUNDACION PARA LA FORMACION E INVESTIGACION SANITARIAS DE LA REGION DE MURCIA represented for the purpose hereof by Dr. Serna Marmol Juan Pedro, Director, and/or Mr. Borrachero Guijarro Ignacio , Head of Administration, or their authorised representatives established in CALLE LUIS FONTES PAGAN 9 , 30003 MURCIA - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. FUNDACION PARA LA FORMACION E INVESTIGACION SANITARIAS DE LA REGION DE MURCIA confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by FUNDACION PARA LA FORMACION E INVESTIGACION SANITARIAS DE LA REGION DE MURCIA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

FUNDACION DE LA COMUNIDAD VALENCIANA CENTRO DE INVESTIGACION PRINCIPE FELIPE represented for the purpose hereof by Mrs. Isabel Muñoz Criado, General manager, or her authorised representative established in CALLE EDUARDO PRIMO YUFERA 3 , 46012 VALENCIA - SPAIN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. FUNDACION DE LA COMUNIDAD VALENCIANA CENTRO DE INVESTIGACION PRINCIPE FELIPE confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by FUNDACION DE LA COMUNIDAD VALENCIANA CENTRO DE INVESTIGACION PRINCIPE FELIPE, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

ETELA-KARJALAN SOSIAALI- JA TERVEYDENHUOLLON KUNTAYHTYMA represented for the purpose hereof by Mr. Pentti Itkonen, Chief Executive Officer, and/or Ms. Virpi Kölhi , Director of Administration, or their authorised representatives established in Raastuvankatu 9 , 53100 LAPPEENRANTA - FINLAND (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the EuropeanCommission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. ETELA-KARJALAN SOSIAALI- JA TERVEYDENHUOLLON KUNTAYHTYMA confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by ETELA-KARJALAN SOSIAALI- JA TERVEYDENHUOLLON KUNTAYHTYMA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

ANAPTYXIAKI ETAIREIA DIMOU TRIKKAION ANAPTYXIAKI ANONYMI ETAIREIA OTA - E-TRIKALA AE represented for the purpose hereof by Mr. Christos Lappas, President of the Board, and/or Mr. Odisseas Raptis , CEO, or their authorised representatives established in STRATIGOY SARAFI 44 , 42100 TRIKALA - GREECE (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. ANAPTYXIAKI ETAIREIA DIMOU TRIKKAION ANAPTYXIAKI ANONYMI ETAIREIA OTA - E-TRIKALA AEconfirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by ANAPTYXIAKI ETAIREIA DIMOU TRIKKAION ANAPTYXIAKI ANONYMI ETAIREIA OTA - E-TRIKALA AE, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

MUNICIPALITY OF PALAIO FALIRO represented for the purpose hereof by Mr. Dionisios Chadtzidakis, Mayor, and/or Mr. Ioannis Fostiropoulos , Deputy Mayor, Education & Social Solidarity, or their authorised representatives established in agiou alexandrou 70 , 17561 Palaio Faliro - GREECE (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. MUNICIPALITY OF PALAIO FALIRO confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by MUNICIPALITY OF PALAIO FALIRO, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

DIMOS ALIMOU-MUNICIPALITY OF ALIMOS represented for the purpose hereof by Mr. Athanasios Orfanos, Mayor, and/or Mr. Andreas Kondylis , Deputy Mayor, Administration & Social Solidarity, or their authorised representatives established in ARISTOTELOUS 53 , 17455 ALIMOS - GREECE (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the EuropeanCommission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. DIMOS ALIMOU-MUNICIPALITY OF ALIMOS confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by DIMOS ALIMOU-MUNICIPALITY OF ALIMOS, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

DIMOS AGIOS DIMITRIOS represented for the purpose hereof by Mrs. Maria Androutsou, Mayor, and/or Mr. Nikos Dasopoulos , City Councilor, Education & Social Solidarity, or their authorised representatives established in ODOS AGIOU DIMITRIU 55 , 17343 AGIOS DIMITRIOS - GREECE (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. DIMOS AGIOS DIMITRIOS confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by DIMOS AGIOS DIMITRIOS, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

Anonimi Etairia Erevnas, Kainotomias kai Anaptiksis Tilematikis Texnologias -VIDAVO A.E. represented for the purpose hereof by Mrs. Markela Psymarnou, General Manager, and/or Mr. Anastasios Papakyriakidis , Vice-President, or their authorised representatives established in 9TH KM THESSALONIKI THERMI ROAD , 57001 Thessaloniki - GREECE (person legally authorised to act on behalf of the legal entity)acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. Anonimi Etairia Erevnas, Kainotomias kai Anaptiksis Tilematikis Texnologias -VIDAVO A.E. confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by Anonimi Etairia Erevnas, Kainotomias kai Anaptiksis Tilematikis Texnologias - VIDAVO A.E., the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

HRVATSKA UDRUGA ZA FARMAKOEKONOMIKUI EKONOMIKU ZDRAVSTVA represented for the purpose hereof by Dr. Ranko Stevanovic, President, and/or Ms. Vanesa Benkovic , Consultant, or their authorised representatives established in DRAGE STIPCA 10 , 10090 ZAGREB - REPUBLIC OF CROATIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. HRVATSKA UDRUGA ZA FARMAKOEKONOMIKUI EKONOMIKU ZDRAVSTVA confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by HRVATSKA UDRUGA ZA FARMAKOEKONOMIKUI EKONOMIKU ZDRAVSTVA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

UNITA LOCALE SOCIO-SANITARIA N. 2 FELTRE represented for the purpose hereof by Dr. BORTOLO SIMONI, DIRECTOR GENERAL, or his authorised representative established in VIA BAGNOLS SUR CEZE 3 , 32032 FELTRE - ITALY (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. UNITA LOCALE SOCIO-SANITARIA N. 2 FELTRE confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by UNITA LOCALE SOCIO-SANITARIA N. 2 FELTRE, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

STICHTING SMART HOMES represented for the purpose hereof by Ms. JCM Deeben -van Berlo, Director, and/or Dr. Ad van Berlo , R&D Manager, or their authorised representatives established in DUIZELSEWEG 4 A , 5521AC EERSEL - THE NETHERLANDS (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. STICHTING SMART HOMES confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by STICHTING SMART HOMES, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

GEMEENTE ROTTERDAM represented for the purpose hereof by Ms. Anne Marie Van de Wiel , Director Activation & Welfare , and/or Ms. Ine Wiersma , Head of Policy & Strategy , or their authorised representatives established in COOLSINGEL 40 , 3011 AD ROTTERDAM - THE NETHERLANDS (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. GEMEENTE ROTTERDAM confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by GEMEENTE ROTTERDAM, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

MUNICIPIO DA AMADORA-CMA represented for the purpose hereof by Mrs. Carla Tavares, Vice-President, or her authorised representative established in AVDA MOVIMENTO DAS FORCAS ARMADAS , 2700 AMADORA - PORTUGAL (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. MUNICIPIO DA AMADORA-CMA confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by MUNICIPIO DA AMADORA-CMA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

PT COMUNICACOES SA represented for the purpose hereof by Ms. Ana Dias, Head of Innovation, or her authorised representative established in RUA ANDRADE CORVO 6 , 1050 009 LISBOA - PORTUGAL (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. PT COMUNICACOES SA confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by PT COMUNICACOES SA, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

IRMANDADE DA SANTA CASA DA MISERICORDIA DA AMADORA IPSS represented for the purpose hereof by Mr. Manuel Monteiro Girão, General Director, or his authorised representative established in ESTRADA DA PORTELA QUINTA DAS TORRES BURACA CONCELHO DE AMADORA , 2610 143 AMADORA LISBOA - PORTUGAL (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. IRMANDADE DA SANTA CASA DA MISERICORDIA DA AMADORA IPSS confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by IRMANDADE DA SANTA CASA DA MISERICORDIA DA AMADORA IPSS, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

UPPSALA LANS LANDSTING represented for the purpose hereof by Ms. Eva Ljung , CEO , and/or Mr. Petter Könberg , CIO , or their authorised representatives established in SLOTTSGRAND 2A , 751 25 UPPSALA - SWEDEN (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the EuropeanCommission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. UPPSALA LANS LANDSTING confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by UPPSALA LANS LANDSTING, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

PREDUZECE ZA INFORMACIONE TEHNOLOGIJE I ELEKTRONSKO TRGOVANJE BELIT DOO represented for the purpose hereof by Mr. Dusan Poznanovic,General Manager, and/or Mr. Marko Poznanovic , Business Development Manager, or their authorised representatives established in OBILICEV VENAC 18-20 , 11000 BELGRADE -SERBIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. PREDUZECE ZA INFORMACIONE TEHNOLOGIJE I ELEKTRONSKO TRGOVANJE BELIT DOO confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by PREDUZECE ZA INFORMACIONE TEHNOLOGIJE I ELEKTRONSKO TRGOVANJE BELIT DOO, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

Zdravstveni centar "Studenica" Kraljevo represented for the purpose hereof by Mr. Zvonko Veselinovic, General Manager, and/or Mrs. Mirjana Krcevinac , Director of Primary Health Department, or their authorised representatives established in Jug Bogdanova BB , 36000 Kraljevo - SERBIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. Zdravstveni centar "Studenica" Kraljevo confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by Zdravstveni centar "Studenica" Kraljevo , the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

CENTAR ZA SOCIJALNI RAD KRALJEVO-SOCIAL WORK CENTRE IN KRALJEVO CSRKV represented for the purpose hereof by Mrs. Svetlana Dražović, Director, and/or Mrs. Svetlana Stanić , Deputy of Director, or their authorised representatives established in NASELJE MOSE PIJADE 26 A , 36000 KRALJEVO - SERBIA (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. CENTAR ZA SOCIJALNI RAD KRALJEVO-SOCIAL WORK CENTRE IN KRALJEVO CSRKV confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by CENTAR ZA SOCIJALNI RAD KRALJEVO-SOCIAL WORK CENTRE IN KRALJEVO CSRKV, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

REGIONAL HEALTH AND SOCIAL CARE BOARD represented for the purpose hereof by Dr. Sloan Harper, Director of Integrated Care , or his authorised representative established in LINENHALL STREET 12-22 , BT2 8BS BELFAST - UNITED KINGDOM (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. REGIONAL HEALTH AND SOCIAL CARE BOARD confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by REGIONAL HEALTH AND SOCIAL CARE BOARD, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

NHS 24 (SCOTLAND) represented for the purpose hereof by Prof. George Crooks , Medical Director , and/or Mr. John Turner , Chief Executive , or their authorised representatives established in FIFTY PITCHES ROAD 140 , G51 4EB GLASGOW -UNITED KINGDOM (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. NHS 24 (SCOTLAND) confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by NHS 24 (SCOTLAND), the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

AGE PLATFORM EUROPE AISBL represented for the purpose hereof by Mrs. Anne-Sophie Parent, Secretary General, or her authorised representative established in Rue Froissart 111 , 1040 BRUXELLES - BELGIUM (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. AGE PLATFORM EUROPE AISBL confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by AGE PLATFORM EUROPE AISBL, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

ASSEMBLEE DES REGIONS D'EUROPE ASSOCIATION represented for the purpose hereof by Mr. Pascal Goergen, Secretary General of the Assembly of European Regions, or his authorised representative established in RUE OBERLIN 6 , 6700 STRASBOURG -FRANCE (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. ASSEMBLEE DES REGIONS D'EUROPE ASSOCIATION confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by ASSEMBLEE DES REGIONS D'EUROPE ASSOCIATION, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

CONTINUA HEALTH ALLIANCE PRIVATE STICHTING represented for the purpose hereof by Dr. Petra Wilson , Secretary General , and/or Mr. Charles Parker , Executive Director , or their authorised representatives established in AVENUE ROGER HAINAUT 16 , 1160 BRUXELLES - BELGIUM (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commissionand AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. CONTINUA HEALTH ALLIANCE PRIVATE STICHTING confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by CONTINUA HEALTH ALLIANCE PRIVATE STICHTING, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

EUROCARERS ASSOCIATION EUROPEENE TRAVAILLANT POUR LES AIDANTS NON PROFESSIONELS ASBL represented for the purpose hereof by Mr. Robert Anderson , President, or his authorised representative established in RUE DE THIONVILLE 145 , 2611 LUXEMBOURG - LUXEMBOURG (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. EUROCARERS ASSOCIATION EUROPEENE TRAVAILLANT POUR LES AIDANTS NON PROFESSIONELS ASBL confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by EUROCARERS ASSOCIATION EUROPEENE TRAVAILLANT POUR LES AIDANTS NON PROFESSIONELS ASBL, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

STICHTING INTERNATIONAL FOUNDATION FOR INTEGRATED CARE represented for the purpose hereof by Dr. Nicholas Goodwin, Chief Executive Officer, and/or Dr. Maria de Lourdes Ferrer-Goodwin , Director of Programmes, or their authorised representatives established in PROF RITZEMA BOSLAAN 5 , 3571CL UTRECHT - THE NETHERLANDS (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. STICHTING INTERNATIONAL FOUNDATION FOR INTEGRATED CARE confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by STICHTING INTERNATIONAL FOUNDATION FOR INTEGRATED CARE, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

FEDERATION EUROPEENNE DES ASSOCIATIONS INFIRMIERES AISBL represented for the purpose hereof by Dr. Paul De Raeve, Secretary General, or his authorised representative established in CLOS DU PARNASSE 11A , 1050 Brussels -BELGIUM (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. FEDERATION EUROPEENNE DES ASSOCIATIONS INFIRMIERES AISBL confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by FEDERATION EUROPEENNE DES ASSOCIATIONS INFIRMIERES AISBL, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

FORUM DES PATIENS EUROPEENS ASBL EUROPEAN PATIENTS FORUM FPE EPF represented for the purpose hereof by Mr. Anders Olauson, President, or his authorised representative established in ROUTE DE THIONVILLE 145 , 2611 LUXEMBOURG -LUXEMBOURG (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. FORUM DES PATIENS EUROPEENS ASBL EUROPEAN PATIENTS FORUM FPE EPF confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by FORUM DES PATIENS EUROPEENS ASBL EUROPEAN PATIENTS FORUM FPE EPF, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

EMPIRICA GESELLSCHAFT FUER KOMMUNIKATIONS- UND TECHNOLOGIE FORSCHUNG MBH represented for the purpose hereof by Mr. Simon Robinson, Director, and/or Mr. Werner B. Korte , Director, or their authorised representatives established in OXFORDSTRASSE 2 , 53111 BONN - GERMANY (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. EMPIRICA GESELLSCHAFT FUER KOMMUNIKATIONS- UND TECHNOLOGIE FORSCHUNG MBH confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by EMPIRICA GESELLSCHAFT FUER KOMMUNIKATIONS- UND TECHNOLOGIE FORSCHUNG MBH, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX III

AOK RHEINLAND/HAMBURG - DIE GESUNDHEITSKASSE represented for the purpose hereof by Mr. Günter Wältermann, Vorstandsvorsitzender (CEO), or his authorised representative established in KASERNENSTRASSE 61 , 40213 DUSSELDORF - GERMANY (person legally authorised to act on behalf of the legal entity) acting as its legal authorised representative, hereby consents to become a beneficiary to grant agreement No 325158 (relating to project Joining up ICT and service processes for quality integrated care in Europe) signed between the European Commission and AZIENDA PER I SERVIZI SANITARI N.1TRIESTINA (FVG - ASS1) established in VIA GIOVANNI SAI 1-3 , 34127 TRIESTE - ITALY, and accepts in accordance with the provisions of the aforementioned grant agreement all the rights and obligations of a beneficiary. AOK RHEINLAND/HAMBURG - DIE GESUNDHEITSKASSE confirms to have received a copy of the agreement.

Done in 3 copies, of which one shall be kept by the coordinator and one by AOK RHEINLAND/HAMBURG - DIE GESUNDHEITSKASSE, the third being sent to the Commission by the coordinator in accordance with Article 2(1) of the grant agreement.

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ANNEX IV

Form B –Request for the accession of new legal entities to the agreement

(To be filled in by each new legal entity willing to become a beneficiary)

[full name and legal form of new beneficiary], represented for the purpose hereof by [name of legal representative) (function) [and/or (name of legal representative)(function)] or her/his/their authorised representative established in (full address: city/state/province/country)] acting as its legal authorised representative, hereby requests to become a beneficiary to grant agreement No ….. (relating to project [title]) signed between the European Commission and [name of the coordinator], and accepts, in accordance with the provisions of the aforementioned grant agreement, all the rights and obligations of a beneficiary starting on (date). [full name and legal form of the beneficiary] confirms to have received a copy of the grant agreement.

[name of the coordinator and legal form (acronym) established in (full address: city/state/province/country°)], represented for the purpose hereof by [(name of legal representative) (function) [and/or (name of legal representative)(function)] or her/his/their authorised representative established in (full address: city/state/province/country)] acting as its legal authorised representative, hereby certifies as the representative of the beneficiaries to grant agreement No … (relating to project [title]) that the consortium proposes and agrees to the accession of [full name and legal form of new beneficiary] to the aforementioned grant agreement as beneficiary starting on the above-mentioned date.

Enclosures:

− Grant agreement preparation form duly completed and signed by the new beneficiary. − Modified Annex I to the grant agreement describing the work to be performed by the new

beneficiary. – Done in 3 copies, of which one shall be kept by the coordinator and one by [name of new

beneficiary], the third being sent to the Commission by the coordinator in accordance with Articles 9 and II.9 of the grant agreement.

Name of legal entity: (full name of the new beneficiary (legal entity)) Name of legally authorised representative: (written out in full) Title of legally authorised representative: Signature of legally authorised representative: Date: Stamp of the organisation: Name of legal entity: (full name of the coordinator (legal entity)) Name of legally authorised representative: (written out in full)

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Title of legally authorised representative: Signature of legally authorised representative: Date: Stamp of the organisation:

DELIBERAZIONE DEL DIRETTORE GENERALE - Regione FVG

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