Telemedicine in Europe-Current Status and Future Perspectives

1 Private Medical Practice „Dr. Grajdeanu Ioana Veronica”, Bucharest, Romania 2 „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3 Ilfov County Clinical Emergency Hospital, Bucharest, Romania 4 „Carol Davila” University Emergency Central Military Hospital, Academy of Romanian Scientists, Bucharest, Romania 5 Clinical Emergency Hospital of Bucharest, Bucharest, Romania Corresponding author: Ana Maria Alexandra STANESCU, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania. E-mail: alexandrazotta@yahoo.com Abstract


REVIEW
or for the patients who may be in a poor health or financial state. Th us, most of the times, patients are often deprived of the adequate healthcare they need 2,3 .
In recent years, the technological development that allows rapid data analysis, artifi cial intelligence and Internet use in the health fi eld have brought changes in traditional medicine, transforming the medical services. Th e increasing number of wearable and health-

INTRODUCTION
Telemedicine may be a solution for cases in which the geographical distance impaires access to specialized healthcare, such as rural areas or developing countries with poor health infrastructure 1 . Medical treatment in these conditions would require long distance travel, both energy and time-consuming -either for doctors

TELEMEDICINE IN EUROPE
Internet use among Europeans is constantly increasing, over 85% of EU households had access to the Internet in 2016, and more and more citizens are going online in order to obtain health information, medical services or to make appointments. More than half of European citizens searched online for health information in 2017, twice as many as in 2008 13,14 .
Th e electronic medical record, which contains a detailed history of the patient and which can be accessed by specialists in the medical fi eld in hospitals or medical offi ces, was used in 2016 in over 15 Member States of the EU. In most of these countries, patients have access to data from their personal medical records, and in countries such as Denmark, Estonia, France, Greece, Latvia, Luxembourg, Spain and Sweden, patients can add or modify certain information 15 .
Th e European Commission has adopted a recommendation about the format for the exchange of electronic medical records between the Member States of the European Union, allowing access to patient data outside country borders. Th e fi rst such exchange took place between Estonia and Finland in January 2019. By 2021, 22 Member States are expected to exchange electronic medical records 16 .
Th e prescription of electronic medical prescriptions without the need for a hard copy is successfully used in Finland, Estonia, Sweden, Denmark, Portugal and Spain, where in 2018, over 90% of medical prescriptions have been prescribed electronically 17 . Prescriptions can be issued electronically for patients with chronic illnesses or following a teleconsultation without having to travel to the doctor's offi ce.
Teleradiology is the most widespread tele-health program in the European Region, 38 Member States use it according to a study by WHO in 2016.
Remote patient monitoring is the second most widespread tele-health program, being used by 33 of the Member States 18,19 . Th ere are telemonitoring services for diabetic patients, those with cardiovascular disease or COPD in countries such as Finland, Norway, Denmark, Germany, etc 7 .
Teledermatology is used in Estonia and Sweden, where general practitioners can contact a specialist dermatologist, when they discover a suspicious skin lesion, in order to detect early skin cancer. In Switzerland, patients can send photos of the lesions in specialized centers on dermatology 7 .
Th e teleneurology networks help the diagnosis process of ischemic strokes by means of teleconsult and related devices helps implement large-scale telemedicine solutions 3 . In 2016, 79% of EU residents aged 16 to 74 years have accessed the Internet using either their mobile phone or smartphone and the degree of digital literacy is on the rise 4 .
Telemedicine provides specifi c medical services, including teleconsultation, telemonitoring, teleeducation, telesurgery, teleconference, etc 5 . Telemedicine allows remote monitoring and reassessment, ensuring continuity of day to day care at signifi cantly lower costs than hospitalization. Transmission of vital signs and other medical data, by devices that the patients use, to a remote control center helps create a broader information base for clinical decision making 3 . Telemonitoring has the potential to bring improvements to the management of patients suff ering from chronic diseases. Th is ensures access to health care services for patients that are located far from hospitals or clinics, simplifying the process of prevention, patient management, monitoring and reassessment 6 . Furthermore, in addition to monitoring certain parameters, it may contain an educational component that encourages the patient to adopt changes in behavior and lifestyle 7 .
Th e teleconsu lt involves the real-time communication between the doctor and the patient by video conference or by telephone 8 . Th is method can be applied in almost all medical specialties, even those that require eff ective physical examination, as long as the patient is accompanied by another health professional able to perform the examination and report the results back to the doctor. Additional information can be transmitted during consultation, such as heart auscultation using a digital stethoscope or ultrasound-generated images during ultrasound, pulse oximetry, ECG monitoring 9,10 .
Teleconsultation, another aspect of telemedicine, refers to the communication between two or more health professionals about a certain medical problem or a complicated medical case, in order to obtain a second expert medical opinion and to develop a correct diagnosis and therapeutic plan 11 .
Th rough telehealth, with the help of advances in robotics and communication technology, safe and precise surgical interventions are performed, making possible the collaboration between surgeons from diff erent medical centers in real time 11 .
Tele-education refers to the provision of general medical information, accessible to the general population, and also with the purpose of training medical personnel who can take online courses in order to ensure a continuous medical education 12 . evaluation of the CT scan by the neurology specialists, thereby allowing initiation of the rapid treatment by thrombolysis with signifi cat improvement of the patient's prognosis 20,21 . Such programs exist in Germany, Scotland, Spain, Italy, etc., but they need to be extended to cover rural areas in European states [21][22][23] .
With the help of EU funding projects, the infrastructure of digital health services and trans-European networks have been developed. Th e fi rst European Reference Networks (ERNs) were launched in March 2017, including over 900 highly specialized medical units in over 300 hospitals in 26 EU Member States. Th ere are 24 ERNs designed to help patients with rare or complex diseases, they address a specifi c area of intervention, such as bone disease, cancer in children, autoimmune diseases, immunodefi ciency, disorders and complications related to transplantation in children 24,25 . European reference networks are based on cross-border teleconsultation between several specialists in order to develop the optimal treatment plan for patients with rare or complex diseases 26,27 .
Th e number of downloads of health-related applications for smart devices (mobile Health or mHealth) increased dramatically between 2013 and 2017, from 1.7 billion to 3.7 billion, and the trend is still rising. A study showed that most mHealth applications were downloaded in the UK and Germany during this period, followed by Scandinavian countries. In Sweden, 23% of the population used mHealth applications on smart devices in 2017, in Denmark 16% and in Finland 15% 3 . It is estimated that the global market for mHealth applications will reach over 38 billion euros by 2020 28 .

CONCLUSIONS
Telemedicine could be one of the solutions that can help address the challenges that EU Member States are facing, including the aging population, and an increasing number of chronic patients. In the future, more and more people will need medical care or support. Th e permanent development of new technologies that help patients and the decrease of the workforce in the health fi eld are additional arguments for the implementation and use of telemedicine. It is important to note that telemedicine should be considered complementary to conventional medicine, rather than a substitute and that in some cases it cannot replace face to face interaction.
Compliance with ethics requirements: Th e authors declare no confl ict of interest regarding this article. Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law. Informed consent was obtained from all the patients included in the study.