Re iew o Economic Pe spec i es – Ná odohospodářský obzo
Vol. 20, Issue 3, 2020, pp. 337–359, DOI: 10.2478/ e ecp-2020-0016
© 2020 by he au ho s; licensee Re iew o Economic Pe spec i es / Ná odohospodářský obzo , Masa yk Uni e si y,
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E alua ion o eHeal h Deploymen a P ima y Ca e
in he EU Membe S a es by Usage o Selec ed
MCDM Me hods
E a A dielli
1
Abs ac : In o ma ion and Communica ion Technologies ha e become a e olu iona y
pa o Eu opean heal hca e in ecen yea s. The Eu opean Commission conside s
eHeal h as an impo an and app op ia e ool ha can con ibu e o cope wi h he chal-
lenges ha a e cu en ly a ec ing he heal hca e sys ems in Eu ope. The de elopmen o
eHeal h is he e o e embedded in many EU s a egies and is being e alua ed on an on-
going basis. In he pas , se e al s udies ha e been ca ied ou ocusing on he e alua ion
o indi idual a eas o eHeal h - especially on he a ea o p ima y ca e secu ed by Gen-
e al P ac i ione s and Acu e Hospi als. Howe e , no syn hesis o hese wo ks was made.
This pape is ocused on he
p oposing o an assessmen o bo h men ioned a eas o
eHeal h. The aim is o e alua e he eHeal h deploymen in he Eu opean Union Membe
S a es by he syn hesis o Composi e Indica o s in exis ing s udies in o he e alua ion
model based on he applica ion o Mul iple-C i e ia Decision-Making echniques. The
e alua ion is pe o med by he usage o TOPSIS, WSA, and MAPPAC me hod. The
esul o he esea ch is he design o an e alua ion amewo k o eHeal h ha enables
he compa ison o eHeal h indica o s in he in e na ional con ex and e alua ion o
eHeal h deploymen in Eu opean Union Membe S a es
in he o m o a anking. In his
anking, he No dic coun ies a e among he bes - a ed coun ies, while he wo s - a ed
coun ies a e in Eas e n Eu ope.
Keywo ds: eHeal h; Eu opean Union; EU coun ies; E alua ion; MCDM
JEL Classi ica ion: C38, H11, I11
Recei ed: 15 Feb ua y 2020 / Accep ed: 17 July 2020 / Sen o Publica ion: 9 Sep embe 2020
In oduc ion
Elec onic heal hca e, eHeal h, o commonly used e m “Heal h In o ma ion Technolo-
gy” (HIT) is one o he cu en global mode n ends in in o ma ics, medicine, and poli-
ics (WHO, 2016a; Oh e al., 2005). I is a b oad e m ha e e s o he elec oniza ion
o heal hca e and heal h se ices and mainly desc ibes he use o In o ma ion and
1
VSB – Technical Uni e si y o Os a a, Depa men o Public Economics, Sokolská 33, Os a-
a, Czech Republic, e a.a dielli@ sb.cz
Re iew o Economic Pe spec i es
338
Communica ions Technologies (ICT) in heal hca e (Eu opean Commission, 2004; Ey-
senbach, 2001; Adebesin, 2013). eHeal h is p ac iced and deal wi h in mos de eloped
coun ies and, o cou se, also in Eu opean Union Membe S a es. I is conside ed as an
oppo uni y o mee he challenges caused by an aging socie y and he d ama ically
ising cos s o heal hca e (Chaudh y e al., 2006). As s a ed by Ross e al. (2015) o
Chaudh y e al. (2006), he e is a g ea po en ial o eHeal h o deli e cos -e ec i e and
quali y heal hca e. The impo ance is also demons a ed by spending on eHeal h by
go e nmen s and heal hca e sys ems, which is inc easing wo ldwide (T u e , 2010 and
Eu opean Commission, 2012a).
eHeal h includes heal h se ices such as elec onic heal h eco ds, elec onic d ugs p e-
sc ibing, o heal h in o ma ion sys ems, see Ahad e al. (2019) o Ben-Assuli (2015). As
s a ed by many au ho s, i b ings clea bene i s o pa ien s, doc o s, and he en i e
heal h sys ems (Codagnone and Lupianez Villanue a, 2011; Cu ie and Seddon, 2014).
eHeal h is also a c ucial issue wi hin he Eu opean Union (EU) policy nowadays. The
EU policy in ends o link indi idual na ional eHeal h p ojec s and o coo dina e hem
(Eu opean Commission, 2018). This e o is one pa o he eEu ope ac ion plan ap-
p o ed in 2000, see (Eu opean Commission, 2012b). As s a ed by Bujnowska-Fedak
(2015), he coo dina ion o eHeal h p ojec s in ol es abo e all he apid access o
sha ed emo e medical expe assessmen s h ough ICT;
he e o e, hese solu ions a e o
in e es cu en ly.
The p esen ed a icle is ocused on he e alua ion o eHeal h in p ima y ca e in he EU.
The aim is a design o eHeal h deploymen assessmen model o he EU Membe S a es
using he mul i-c i e ia decision making (MCDM) me hods (TOPSIS, WSA, and MAP-
PAC). In his esea ch, eHeal h was e alua ed based on he syn hesis o Composi e
Indica o s o eHeal h p ocessed by he Eu opean Commission in he ield o Gene al
P ac i ione s and Acu e Hospi als. The inpu da a comp ised he esul s o “Benchma k-
ing Deploymen o eHeal h among Gene al P ac i ione s”, see Eu opean Commission
(2013) and Eu opean Commission (2018), and “Eu opean Hospi al Su ey: Benchma k-
ing Deploymen o eHeal h Se ices ”; see Eu opean Commission (2014). The empi ical
pa o his a icle was p ocessed by he usage o he SANNA so wa e (Sys em o
Analysis o Al e na i es), see mo e in Jablonský (2009).
MCDM me hods we e used because hey ep esen a sui able ool o he selec ion and
c ea ion o he anking o he la ge numbe o a ian s, see Fiala (2008). The pu pose
o he p esen ed esea ch is o syn hesize he esul s o eHeal h e alua ions o he Eu o-
pean Commission p esen ed in indi idual s udies ocusing on selec ed eHeal h a eas in
p ima y ca e. The esul s a e p esen ed in he o m o Composi e Indica o s, which we e
used as a base o he assessmen p ocesses in his esea ch. The ou pu is a comp ehen-
si e e alua ion o eHeal h deploymen a p ima y ca e in he EU Membe S a es and he
design o an e alua ion model using MCDM me hods. This syn hesis has no been ca -
ied ou ye by o he au ho s o Eu opean Commission, al hough i has been p oposed
by he Eu opean Commission, see (Eu opean Commission, 2013).
In p ac ice is he e alua ion o eHeal h an impo an ma e because i leads o he selec-
ion o app op ia e measu es o u he p og ess in he ield o elec onic heal hca e and
o p opose ecommenda ions o he de elopmen o eHeal h in he EU coun ies (Eu o-
pean Commission, 2019; OECD, 2019 o Ragha an e a., 2015).
Volume 20, Issue 3, 2020
339
Implemen a ion o eHeal h in he Con ex o eGo e nmen De elopmen
eHeal h is he subjec o in e es o majo global in e na ional o ganiza ions (Eu opean
Commission, 2012a). The e idence base o he bene i s o eHeal h has been es ablished
by Wo ld Heal h O ganisa ion (WHO), ha in 1998 ecognised he impo ance o egu-
la ing c oss-bo de ad e ising and he p omo ion o medical p oduc s h ough he in e -
ne (WHO, 1998). In 2005 WHO adop ed a esolu ion on eHeal h (WHO, 2005), ha
in i ed he WHO Membe S a es o concei e and implemen heal h in o ma ion sys ems,
o e alua e eHeal h ac i i ies and o sha e knowledge on cos -e ec i eness, hus ensu -
ing quali y, sa e y, e hical s anda ds, da a con iden iali y, p i acy, equi y and equali y
(Eu opean Commission, 2013). Acco ding o he WHO epo , see WHO (2016b), mo e
han hal o WHO Membe S a es ha e an eHeal h s a egy. Ac ual ecommenda ions o
WHO on digi al in e en ions o heal h sys em s eng hening a e se down by ecom-
menda ions on digi al in e en ions o heal h sys em s eng hening, see (WHO, 2019).
eHeal h is also highly suppo ed in Eu opean coun ies. Eu opean Commission is con-
side ing eHeal h as an app op ia e ool o cope wi h he ac ual challenges o Eu opean
heal h sys ems, including he sys em sus ainabili y ensu ing and quali y p ese ing in
he con ex o he ageing popula ion (Eu opean Commission, 2013). The quali y o he
heal h sys em is oge he wi h he good heal h o he ci izens he p io i y in all EU
Membe S a es (Gulli o d and Mo gan, 2003). The impo ance o his economic sec o
is demons a ed by he spending on heal h se ices ha a e explici ly ising wo ldwide
in he las decades (OECD, 2012). The main eason o his end is connec ed wi h he
consequence o demog aphic change and imp o emen s in medical ea men in Eu ope.
Public expendi u e on heal h and long- e m ca e has been inc easing o e he las dec-
ades in all EU coun ies and is expec ed o ise e en u he as a consequence o an
aging popula ion (Eu opean Commission, 2013; Lau and Kuziemsky, 2016). In 2015, i
accoun ed o 8.7 % o GDP in he EU and could each up o 12.6 % o GDP in 2060,
acco ding o he Eu opean Commission's “Join Repo on Heal h Ca e and Long- e m
Ca e Sys ems and Fiscal Sus ainabili y” (Eu opean Commission, 2019). Howe e , an-
o he ac o in luencing he g ow h o expendi u es in heal hca e is he in ol emen o
ICT. ICT implemen a ion in his a ea is a apidly e ol ing and expensi e eso , which
is why he inancial demand o heal hca e is inc easing (Heal h ICT Indus y G oup,
2009).
eHeal h De ini ion
eHeal h is he collec i e e m used o e e o ools and se ices ha use mode n ICT
ha can imp o e p e en ion, diagnosis, ea men , moni o ing, and managemen o
heal h in heal h ca e (Eysenbach, 2001). As s a ed by Lau and Kuziemsky (2016), i is
impo an o no e ha he e m eHeal h is used sligh ly di e en ly ac oss coun ies.
Acco ding o Eu opean Commission, eHeal h is de ined as he use o ICT in heal h
p oduc s, se ices and p ocesses combined wi h o ganisa ional change in heal hca e
sys ems and new skills, o imp o e he heal h o ci izens, e iciency and p oduc i i y in
heal hca e deli e y, and he economic and social alue o heal h (Eu opean Commission,
2012b).
eHeal h is also he ques ion o li es yle. I comp ises he acquisi ion, managemen , s o -
age, and usage o heal h in o ma ion in connec ed ne wo ks, see Bujnowska-Fedak
(2015). Acco ding o Jung and Loi a (2010) and Eu opean Commission (2013 and 2018)
Re iew o Economic Pe spec i es
340
is conside ed as po en ial ool o imp o e access o ca e and quali y o ca e. I is he way
how o suppo in o ma ion exchange, educe cos s, imp o e he quali y o pa ien ca e,
and inc ease he e iciency o he heal h sec o , see Eu opean Commission (2012b).
eHeal h co e s a eas such as in o ma ion and da a sha ing (be ween pa ien s and heal h
se ice p o ide s, hospi als, heal h p o essionals and heal h in o ma ion ne wo ks),
elec onic heal h eco ds, elemedicine se ices, po able pa ien -moni o ing de ices,
ope a ing oom scheduling so wa e o obo ised su ge y (Eu opa, 2018, Dob e e al.
(2008).
Acco ding o Eu opean Commission (Eu opa, 2018 o WHO, 2016a), digi al echnology
can imp o e heal h and ca e p o ision, allowing ci izens o li e longe and mo e heal hy
li e yea s, and i can help inno a ing he way we deli e and ecei e heal h and ca e
se ices. Digi al echnologies such as 4G/5G mobile communica ion, a i icial in elli-
gence, o supe compu ing o e new oppo uni ies o ans o m heal hca e sys ems, see
Ahad e al. (2019). They enable new app oaches o pe sonalized medicine, independen
li ing o in eg a ed heal h and social ca e, accele a ing scien i ic p og ess, ea ly diagno-
sis o diseases, and mo e e ec i e ea men s (Eu opean Commission, 2019).
Challenges and Ba ie s o eHeal h De elopmen
The eal implemen a ion o eHeal h in Eu opean coun ies is, o a la ge ex en , linked o
he le el o eGo e nmen in indi idual coun ies (WHO, 2016b). In he a ea o commu-
nica ion be ween ci izens and go e nmen a e widely used elec onic communica ion
echnologies in ecen decades (Abu-Shanab and Ba aineh, 2014). The compu e iza ion
o go e nmen is called "eGo e nmen ", see Heeks (2001) o OECD (2003). In e ne
and he usage o ICT caused and enabled he de elopmen o many sphe es o li e as
well as se ices; see Walczak and Pólkowski (2013). Also, he ield o medical se ices
is no excep ion. So, eGo e nmen cu en ly includes in e alia also he compu e iza ion
o heal h ca e (OECD/EU, 2016). eHeal h g adually came ou o a wide ield o eGo -
e nmen . Howe e , he success ac o s and implemen a ion p oblems a e la gely simila
(S oe man e al., 2011). Recognising and unde s anding success ac o s and ba ie s is
c ucial o he implemen a ion o s a egies and in e en ions o imp o e he use o
eHeal h and add essing blockages o implemen a ion (Ross e al., 2015).
The basic ac o s o success ul implemen a ion o eGo e nmen acco ding o Heeks
(2001) a e buil on h ee pilla s:
 echnology a chi ec u e, in e ope abili y, and s anda diza ion,
 ha moniza ion o da a and sys ems,
 in o ma ion managemen and secu i y
Abu-Shanab and Ba aineh (2014) desc ibe he key success ac o s o eGo e nmen
p ojec s. They a e classi ied in o h ee main dimensions: in as uc u e- ela ed, human-
ela ed, and go e nmen - ela ed. Acco ding o Alsheh i and D ew (2010), he common
challenges o eGo e nmen implemen a ion comp ise:
 echnical ba ie s – ICT in as uc u e and p i acy and secu i y (OECD, 2003)
 social ba ie s – digi al di ide and cul u e and a i ude
 o ganiza ional ba ie s – managemen suppo , esis ance o change, collabo a-
ion, lack o echnical suppo
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341
 inancial ba ie s – high implemen a ion and main enance cos (Gil-Ga cia and
Pa do, 2005; Al-Wohaibi e al., 2002)
eGo e nmen o De elopmen In o ma ion Exchange p ojec coo dina ed by he Uni-
e si y o Manches e 's Ins i u e o De elopmen Policy and Managemen , see
(ego 4de , 2008) s a es, ha eHeal h success and ailu e mainly depends on he size o
he gap ha exis s be ween “cu en eali ies” and “design o he eHeal h p ojec ”. The
la ge his design- eali y gap, he g ea e he isk o eHeal h ailu e. Equally, he smalle
he gap, he g ea e he chance o success. Analysis o eHeal h p ojec s indica es ha
se en dimensions a e necessa y and su icien o p o ide an unde s anding o design-
eali y gaps: in o ma ion, echnology, p ocesses, objec i es and alues, s a ing and
skills, managemen sys ems and s uc u es, and o he esou ces ( ime and money).
Huang and Bwoma (2003) deal wi h he success ul implemen a ion o eGo e nmen and
ecommenda ions. C ucial pa s a e s a egic planning o go e nmen when de eloping
go e nmen al websi es. IT p ojec s a e cumbe some, con o e sial, and expensi e. Fo
his eason, o p ojec s o su i e and succeed, he e mus be poli ical will and leade -
ship suppo o ensu e smoo h implemen a ion. The same is ue o eHeal h p ojec s.
The main condi ions o success deal by Adebesin e al. (2013) comp ise: unde s and-
ing o he signi icance o eHeal h, ini ializa ion o ICT in as uc u es, in ol emen in
eHeal h s anda ds de elopmen and human esou ce capaci y o eHeal h s anda d de-
elopmen (Adebesin e al., 2013; T u e e al., 2010).
The e a e ini ialized a la ge numbe o na ional ini ia i es designed o eHeal h imple-
men a ion wo ldwide, and his end is inc easing, see Wa e son (2014). He desc ibes
he mos equen ly used examples o eHeal h echnologies: managemen sys ems, com-
pu e ised decision suppo sys ems, communica ion sys ems, and in o ma ion esou ces.
Acco ding o Ross e al. (2015), despi e he po en ial bene i s o eHeal h, implemen a-
ion o hese sys ems is o en epo ed as p oblema ic. Fo example, he implemen a ion
o elec onic heal h eco ds and elec onic p esc ibing sys ems has lagged in mos Eu o-
pean na ions as well as in he USA un il 2013 (Ben-Assuli, 2015).
As main eHeal h implemen a ion obs acles a e desc ibed inancial, legal, social and
e hical ba ie s as well as secu i y conce ns (Cu ie and Seddon, 2014 and Mai e al,
2012). Acco ding o Eu opean Commission, he mos impo an ba ie s in p ima y
heal hca e include he lack o inancial incen i es, lack o ime o aining, lack o ech-
nical suppo , lack o amewo k on con iden iali y and p i acy and lack o su icien
ICT skills o mo i a ion (Alsheh i and D ew, 2010; Eu opean Commission, 2018).
Howe e , as s a ed by Heal hca e In o ma ion and Managemen Sys ems Socie y
(HIMSS) i is also impo an o ealize, ha he de elopmen o eHeal h is no d i en
only by he go e nmen s o indi idual coun ies o in e na ional o ganiza ions, bu also
by he companies in he echnology sec o s because hey a e esponsible o he ans-
o ma ion o heal h ca e sys ems and o sha ing knowledge (HIMSS Eu ope, 2020 o
Abu-Ahanab and Ba aineh (2014).
eHeal h Tools o he Eu opean Union
ICT has become an essen ial pa o Eu opean heal hca e in ecen yea s (Eu opean
Commission, 2019). Al hough eHeal h ools and se ices ha e been well es ablished in
many EU coun ies, hey a e commonly used oday, bu e y o en, indi idual

Re iew o Economic Pe spec i es
342
heal hca e acili ies, hospi als, o physicians chose he bes , indi idual sys em o hem-
sel es wi hou any coo dina ion (Eu opean Commission, 2018; Heal h ICT Indus y
G oup, 2009). So, he implemen a ion o eHeal h in indi idual Eu opean membe s a es
is g ea ly agmen ed and dispa a e nowadays, see Lau and Kuziemsky (2016). eHeal h
concep in he indi idual EU Membe S a es is mainly in luenced by he concep o
eHeal h in he EU legisla ion and he ecommenda ions o he Wo ld Heal h O ganiza-
ion (WHO, 2016a o WHO 2016b).
The e o e, he po en ial c oss-sys em communica ion is he e ye one o he main s eps
ha can encou age and enhance he bene i s o compu e iza ion (Eu opean Commission,
2019). Fo his eason, he aim o he Eu opean Union heal h policy is o link and coo -
dina e indi idual na ional eHeal h p ojec s. This e o is also a pa o he “Eu opean
eHeal h Ac ion Plan” ha co e s he pe iod om 2012 o 2020, see (Eu opean Commis-
sion, 2012b). This is an o e iew o EU ac ions con ibu ing o he c ea ion o a Eu o-
pean eHeal h a ea (Eu opa, 2018). I was launched in Ma ch 2011 as he second s a egy
(a e 2004 - 2010 s a egy) dedica ed o he issue o heal hca e elec onisa ion in he
EU. I p o ides a long- e m ision o Eu opean eHeal h in syne gy wi h o he docu-
men s as “Eu ope 2020”, he “Digi al Agenda o Eu ope” o he “Digi al Single Ma ke
s a egy”. Coo dina ion includes as access o sha ed and emo e medical expe ise
h ough elecommunica ion and in o ma ion echnology, no ma e whe e he pa ien o
ele an in o ma ion is loca ed (S oe man e al., 2011). Also, he “Ho izon 2020 p o-
g amme” con ibu es signi ican ly o he a ea o digi al echnology o heal h and aging.
In his con ex , he “Eu opean Inno a ion Pa ne ship on Ac i e and Heal hy Ageing”
p o ides a pla o m o link he e o s o many egions and ecosys ems ac oss Eu ope,
some o which a e ecognized as e e ence si es on digi al inno a ion o heal h and ca e
(Eu opa, 2018).
In he Eu opean Union, whe e people a e absolu ely ee o mo e o he o he EU Mem-
be S a es, he e is a need o engage in mu ual communica ion ha should ensu e he
highes s anda ds o heal h ca e, whe he pa ien s a e anywhe e (Wa e son, 2014;
S oe mann e al., 2011). The main aim is o build a common Eu opean eHeal h space
ha will success ully sol e his p oblem and hus become one o he main objec i es o
he Eu opean Commission's wo k. In 2012, he eHeal h- ocused wo king g oup o Eu-
opean Commission p oduced a epo on “Redesign o Heal h in Eu ope by 2020”, see
Eu opean Commission (2012a), highligh ing he majo challenges ha p e en he eo -
ganiza ion o Eu opean heal hca e wi h he use o exis ing in o ma ion echnology (Eu-
opean Commission, 2004). The goals o he Eu opean Commission a e mainly o im-
p o e ci izens' heal h by making heal h in o ma ion a ailable using digi al heal h and
ca e ools, including ac oss bo de , o inc ease heal hca e quali y and access by making
digi al heal h and ca e a pa o heal h policy and coo dina ing EU membe s a es' poli -
ical, inancial and echnical s a egies and o make digi al heal h and ca e ools mo e
e ec i e, use - iendly and widely accep ed by in ol ing p o essionals and pa ien s in
s a egy, design and implemen a ion (Eu opean Commission, 2011; Eu opa, 2018).
Impo ance o eHeal h in P ima y Ca e
The widesp ead and e ec i e use o eHeal h in p ima y ca e is conside ed by he Eu o-
pean Commission as pi o al (Eu opean Commission, 2019). P ima y ca e is a key p o-
cess in he heal h sys em (Eu opean Commission, 2018). I is i s -con ac , accessible,
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343
con inuous, comp ehensi e, and coo dina ed ca e gi en by a heal h ca e p o ide . Fi s -
con ac ca e is accessible a he ime o need (Eu opean Commission, 2013). Pa ien s
commonly ecei e p ima y ca e om p o essionals such as a p ima y ca e physician
(gene al p ac i ione o amily physician), a nu se p ac i ione (adul -ge on ology nu se
p ac i ione , amily nu se p ac i ione , o pedia ic nu se p ac i ione ), o a physician
assis an (WHO, 2018). The Wo ld Heal h O ganiza ion a ibu es he p o ision o es-
sen ial p ima y ca e as an in eg al componen o an inclusi e p ima y heal hca e s a e-
gy (WHO, 2019).
Adop ion o eHeal h ools and applica ions in p ima y ca e is mainly essen ial o
s eng hening Eu opean heal hca e sys ems, see G eß e al. (2009). Abo e all, he gen-
e al p ac i ione s play an impo an ole in acili a ing access o, and deli e y o ca e,
see A un (2004). They ep esen he i s poin o con ac and ga he impo an in o -
ma ion needed ac oss he whole o he heal h and social ca e sys ems (Eu opean Com-
mission, 2019). Good quali y o he coun y’s p ima y ca e is posi i ely associa ed wi h
heal h ou comes, o example dec easing all-cause mo ali y, p ema u e mo ali y as
well as less equen hospi aliza ion and declining use o specialis and eme gency ca e,
see Macinko, e al. (2003) and WHO (2018).
E alua ion o eHeal h in he Eu opean Union
eHeal h deploymen in Eu ope is he subjec o e alua ion o in e na ional o ganiza ions
as he EU o OECD (OECD/EU, 2016). eHeal h e alua ion is desc ibed as an ac o
assess whe he an eHeal h sys em is unc ioning and p oducing he e ec s as expec ed
(Lau and Kuziemsky, 2016). Fos e ing he de elopmen and implemen a ion o na ional
eHeal h policies and s a egies has been a key goal o he Eu opean Union eHeal h Ac-
ion Plan (Eu opean Commission, 2004). In 2011 he Eu opean Commission p epa ed
an o e iew and syn hesis epo on eHeal h in Eu ope "Eu opean coun ies on hei
jou ney owa ds na ional eHeal h in as uc u es - e idence o p og ess and ecommen-
da ions o coope a i e ac ions" analysing Ac ion Plan p io i ies, see Eu opean Com-
mission (2011). In 2016 in he coope a ion wi h OECD was de eloped he join Com-
mission and OECD epo “Heal h a a Glance: Eu ope 2016” (OECD/EU, 2016). New
edi ion o “Heal h a a Glance” p esen s he mos ecen compa able da a on he heal h
sys em pe o mance in OECD coun ies (OECD, 2019). The e was no ed ha imp o e-
men in he adop ion o digi al echnology in he p ima y ca e and hospi als is needed
ac oss Eu ope. Howe e , he e a e moni o ed only a ew compa able eHeal h indica o s.
In 2017 he Eu opean Commission also published a Eu oba ome e su ey (TNS opin-
ion & social, 2017) p esen ing Eu opean ci izens' opinions on he impac o digi alisa-
ion and au oma ion o heal h ca e. The eHeal h s udy om 2017 “T ans o ming
eHeal h in o a poli ical and economic ad an age”, see (A ak and Wójcik, 2017), e alu-
a ed hen he le el o eHeal h implemen a ion in EU membe s a es. The esul s demon-
s a e a lack o ha monisa ion o eHeal h implemen a ion wi hin he EU and unsa is ac-
o y access o c oss-bo de heal hca e.
E alua ion o eHeal h in Acu e Hospi als and among Gene al P ac i ione s
The Eu opean Commission moni o s in de ail wo a eas o eHeal h adop ion. Adop ion
o eHeal h in p ima y ca e by Gene al P ac i ione s and by Acu e Hospi als. Gene al
P ac i ione s and Hospi als wi h acu e ea men play a c ucial ole in p o iding heal h
Re iew o Economic Pe spec i es
344
ca e, see Eu opean Commission (2013). The e we e ca ied ou h ee measu emen s o
eHeal h adop ion among Gene al P ac i ione s in he Eu opean Union in 2007, see Do-
b e e al. (2008), 2013, see Eu opean Commission (2013) and 2019 see Eu opean
Commission (2019). The s udies ha e he objec i e o measu e he adop ion o eHeal h
applica ions and unc ionali ies among Gene al P ac i ione s in he EU Membe S a es,
while a he same ime explaining wha d i es o hampe s i (Eu opean Commission,
2013). The da a we e ga he ed by he usage o in e iews wi h Gene al P ac i ione s and
p ocessed by he usage o mul i a ia e s a is ical ools, see mo e in Eu opean Commis-
sion (2013 and 2019). The e a e used he ou measu emen indica o s ha eme ged
om he combined e o s o he Eu opean Commission, OECD, and WHO:
 Elec onic Heal h Reco ds (EHR) - sys ems ha a e used by heal hca e p o es-
sionals (doc o s and nu ses) o en e , s o e, iew, and manage pa ien heal h
and adminis a i e in o ma ion and da a.
 Heal h In o ma ion Exchange (HIE) - is he p ocess o elec onically ans e -
ing / sha ing / enabling access o pa ien heal h in o ma ion and da a.
 Teleheal h - is he use o b oadband-based echnological pla o ms o p o ide
heal h se ices, medical aining, and heal h educa ion o e a dis ance.
 Pe sonal Heal h Reco ds (PHR) - a e elec onic sys ems allowing pa ien s o
ha e secu e access o, and manage, hei heal h in o ma ion.
In ela ion o eHeal h in Acu e Hospi als, wo su eys ha e been ca ied ou wi h he
aim o ga he ing da a o benchma king eHeal h. The i s one was ca ied ou in 2010,
see esul s in Codagnone and Lupiañez-Villanue a (2011), and he second one in 2013,
see esul s in Sabes-Figue a and Maghi os (2013).
The o e all objec i e o he Eu ope-
an Hospi al Su ey was assessing he le el o eHeal h usage in acu e ca e hospi als in
he EU Membe S a es. To p o ile eHeal h capabili ies in he coun ies, he e we e se-
lec ed 13 indica o s, see Eu opean Commission (2014).
Ne e heless, he way how eHeal h is e alua ed and he ac ual implemen a ion o he
benchma king exe cises ha e no been as sys ema ic as in o he a eas o he In o ma ion
socie y (Codagnone and Lupiañez-Villanue a, 2011). This was caused by he mul i-
dimensional complexi ies o he ield and by he highe cos and di icul y o ge ing he
equi ed da a in compa ison wi h o he ields whe e web-based measu emen is easible
and alid (e.g., eGo e nmen ), see (Sabes-Figue a and Maghi os, 2013).
Ma e ial and Me hods
The p esen ed esea ch is based on da a se ac oss mul iple da a sou ces, see Eu opean
Commission (2014), Codagnone and Lupiañez-Villanue a (2011) and Eu opean Com-
mission (2013). The inpu da a o med Composi e Indica o s pe a ea o Acu e Hospi-
als and pe a ea o Gene al P ac i ione s, summa ized in Tab. 1 and 2. Composi e Indi-
ca o s CI1 – CI4 desc ibe he le el o eHeal h use in Acu e Hospi als in he EU Membe
S a es. They co e he a ea o : In as uc u e, Medical Applica ions, In eg a ion, and
Secu i y. Composi e Indica o s CI5 – CI8 desc ibe he le el o eHeal h use among Gen-
e al P ac i ione s in EU Membe S a es. They co e he a ea o : Elec onic Heal h Rec-
o d, Heal h In o ma ion Exchange, Teleheal h, and Pe sonal Heal h Reco d.
Volume 20, Issue 3, 2020
345
Resul s p esen ed in he s udies o Eu opean Commission conce n only doc o s wo king
in p ima y ca e and hospi als wi h acu e ca e. The esul s a e p esen ed in sepa a e s ud-
ies, and he esul s o bo h a eas a e no syn hesized o ela ed. So, i is no possible o
d aw om hem conclusi e gene alisa ions on he s a us o eHeal h adop ion a p ima y
ca e in gene al. Fo his eason, he p esen ed esea ch is ocused on he syn hesis o he
esul s o he 2012 su ey o eHeal h Deploymen in Acu e Hospi als and he 2013
su ey o he Gene al P ac i ione s. Th
e e alua ion is pe o med by usage o a e ag-
ing and by he usage o MCDM me hods.
In he case o a e aging, he p ocedu e was
based on he cons uc ion o he Agg ega ed eHeal h Deploymen Index and was he
same as o he cons uc ion o he O e all Composi e Index o Eu opean Commission,
see Codagnone and Lupiañez-Villanue a (2011) and Sabes-Figue a and Maghi os
(2013). The Composi e Indica o s I1- I8 we e assessed wi h equal weigh s (0.125) and
a e aged. I was necessa y o con e he alues o he same scale because he e we e
used di e en scales in he o iginal s udies. Then he calcula ion was pe o med using
MCDM me hods (WSA, TOPSIS, and MAPPAC). MCDM me hods we e used because
he e is no need o con e da a. They a e objec i e and e lec he a iabili y; o
example, he ange o alues among coun ies, and hey a e designed o c ea ing ank-
ings.
Da a and Composi e Indica o s
The o iginal da a we e ob ained using benchma king me hods by he Eu opean Com-
mission su eys aimed a Gene al P ac i ione s and Acu e Hospi als. Benchma king
plays a c ucial and undamen al ole in enabling he Membe S a es o moni o ac ual
pe o mance, enhance policy lea ning, and he on-going policy p ocesses (Sabes-
Figue a and Maghi os, 2013). The e we e iden i ied he indi idual indica o s, which
we e desc ibing he selec ed a eas o he su ey. Then, ac o analysis was pe o med on
he indi idual a iables, o mo e de ails see Codagnone and Lupiañez-Villanue a
(2011). Weigh s o indi idual indica o s we e ob ained om ac o analysis. Then
Composi e Indica o s we e o med, on he bases, ha indi idual indica o s we e com-
piled in o a single index on he basis o an unde lying concep ual model wi h he sup-
po o he empi ical explo a ion o he da ase , see Sabes-Figue a and Maghi os (2013).
To de elop he O e all Composi e Index, Eu opean Commission ollowed he s eps
desc ibed in he OECD-JRC Handbook on cons uc ing composi e indica o s me hodol-
ogy and use guide, see OECD-JRC (2008).
In he a ea o Acu e Hospi als, he indica o s we e g ouped in o ou Composi e Indica-
o s o eHeal h, see Table 1.
The O e all Composi e Index o he a ea o Acu e Hospi als was ob ained by assessing
equal weigh s (0.25) o ou Composi e Indica o s. The p ocedu e was simila in he
case o Gene al P ac i ione s s udy. The indica o s we e also g ouped in o ou ca ego-
ies (Composi e Indica o s), see Table 2. Then he O e all Composi e Index o he a ea
o Gene al P ac i ione s was de e mined.
Re iew o Economic Pe spec i es
352
Based on he esul s o selec ed MCDM me hods, i was possible o de e mine he o de
o he EU Membe S a es in e ms o he eHeal h deploymen , om he bes o he wo s .
The esul s o all me hods we e compa ed and syn hesized in Tab. 5. The o e all a -
angemen o a ian s was eached by a e aging o he se ial numbe s o a ian s. As
he bes e alua ed is he op ion ha has he lowes o e all se ial numbe . The o e all
anking is displayed in he able as an O e all Sco e. Some coun ies ha e he same
O e all Sco e.
Table 5 E alua ion o eHeal h in EU membe s a es by MAPPAC me hod
Va ian
TOPSIS
WSA
MAP-
PAC
OVERALL
SCORE
Va ian
TOPSIS
WSA
MAP-
PAC
OVERALL
SCORE
Denma k
1
1
1
1
F ance
16
14
12
14
Es onia
2
3
3
2
Cyp us
11
17
15
15
Finland
5
2
2
3
Hunga y
19
16
13
16
Sweden
3
4
5
4
Ge many
17
19
14
17
Ne he -
lands
6
5
4
5
Po ugal
18
18
14
17
Uni ed
Kingdom
7
6
5
6
Romania
20
20
16
18
Mal a
4
8
7
7
C oa ia
21
21
16
19
Spain
10
7
6
8
Bulga ia
22
22
17
20
Aus ia
9
9
8
9
Slo akia
24
23
19
21
Belgium
8
11
9
10
G eece
26
24
18
22
I aly
13
10
8
11
Slo enia
25
25
18
22
Luxem-
bou g
12
12
11
12
La ia
23
27
21
23
I eland
14
13
10
13
Poland
27
26
20
24
Czech
Republic
15
15
12
14
Li huania
28
28
22
25
Sou ce: Own esea ch
Assessmen o he s a e o eHeal h in he EU membe s a es based on MCDM me hod
e ined he esul s ob ained by assessmen wi h he usage o Agg ega ed Indica o , by
he design o he anking o EU coun ies. All used me hods showed simila esul s. On
he bes i e places by O e all Sco e anked Denma k, Es onia, Finland, Sweden, and
he Ne he lands. The wo s s a e o eHeal h was ound ou in G eece, Slo enia, La ia,
Poland, and Li huania. F om he alues o he o al ela i e dis ance indica o ci in he
TOPSIS me hod, i is ob ious ha he di e ences be ween he EU coun ies a e signi i-
can . While he alue o he bes esul (Denma k) eaches alues o 0.77877, he wo s
esul alue (Li huania) is 0.14555.
I is clea om he esul s ha he eHeal h deploymen a p ima y ca e a ies among EU
coun ies. The implemen a ion o EHR is o en conside ed as a necessa y condi ion o
he u he de elopmen o eHeal h in p ima y and seconda y ca e (Eu opean Commis-

Volume 20, Issue 3, 2020
353
sion, 2014). In 2013 EHR was he mos widesp ead unc ionali y o eHeal h among
Gene al P ac i ione s – Composi e Indica o CI5 ( alue 0.678 o Agg ega ed Indica o ).
The adop ion le el o o he unc ionali ies (CI6, CI7, and CI8) was much lowe (HIE –
0.442, Teleheal h – 0.343, and PHR – 0.319). The implemen a ion o EHR, Teleheal h,
and PHR in Acu e Hospi als was a e aged (CI2 - Applica ions), wi h a alue o 0.558 o
Agg ega ed Indica o . Elec onic exchange o medical in o ma ion in he case o hospi-
als (CI3 - In eg a ion), was he lowes alue (0.252), which p o es ha he sha ing o
medical in o ma ion elec onically in hospi als was e y limi ed. On he con a y, in he
a ea o In as uc u e (CI1), which includes he in e -connec i i y, ans e o da a, and
mobile access, he alue is abo e-a e age (0.637). The below-a e age alue also
eached he a ea o Secu i y (CI4), including he p i acy o da a (0.355).
The implemen a ion di e ences be ween coun ies a e also conside ably. No dic coun-
ies (Denma k, Finland, and Sweden) end Es onia a e he o e all leade s acco ding o
he assessmen o eHeal h indica o s ac oss he EU Membe S a es. Con e sely, he
lesse pe o ming a e Eas e n and Sou he n Coun ies.
Discussion
Based on he e alua ion o eHeal h in he EU Membe S a es in he yea 2013, i was
ound ha Denma k, Finland, Es onia, Sweden, and he Ne he lands a e on he op
among EU membe s a es when e alua ing he p ac ical usage o eHeal h. These coun-
ies a e he coun ies wi h well-de eloped in e ne usage and ad anced implemen a ion
o eGo e nemn (WHO, 2016a; OECD, 2019). Es onia is conside ed o be he leade
among he Eas e n Eu opean coun ies in eGo e nmen (Eu opean Commission, 2019).
The ci izens he e a e gene ally keen on he usage o in e ne , eGo e nmen and eHeal h
applica ions. In Denma k, o example, using he heal h and ca e se ices p o ided on-
line a leas once in he yea 42 % o ci izens (in Finland 49 % and in Es onia 49 %), see
TNS opinion & social (2017). As s a ed by Ragha an e al (2015), he in e ne usage
and li e acy le els o a egion a e also o en associa ed, o example, wi h highe le els
o EHR adop ion.
Acco ding o he s udy “T ans o ming eHeal h in o a poli ical and economic ad an age”,
see (A ak and Wójcik, 2017), he implemen a ion o elec onic heal h eco ds, eP e-
sc ip ions, and na ional eHeal h p og ammes a ies signi ican ly ac oss EU membe
s a es. The bes e alua ed a e Denma k, Finland, Spain, and Sweden ha ha e he mos
de eloped eHeal h solu ions. The esul is simila o he esea ch p esen ed in his a icle.
A highly unsa is ac o y s a e o eHeal h was ound in he case o La ia, Poland, and
Li huania. Acco ding o A ak and Wójcik (2017), eHeal h is he leas de eloped in
Bulga ia, Poland, and Cyp us. Fo example, in Poland, al hough he e has been imple-
men ed a ious inno a i e p ojec s o compu e izing o he heal h sys em, he e is a lack
o p incipal ules necessa y in he ield o compu e izing and incomple e coo dina ion o
IT ac ions be ween he heal h ca e uni s and go e nmen al ones. Also, he on-line se -
ices lack he basic elemen s signi ican when i comes o con ac wi h he pa ien s; see
Walczak and Pólkowski (2013). Howe e , he e a e also coun ies anked nea he a e -
age among he EU Membe S a es. In hese coun ies, he e a e mainly se ious sho -
comings, pa icula ly on he side o public digi al se ices p o ide s. Changing he
a i ude o go e nmen o icials in he a ea o eHeal h p omo ion is he e o e equi ed
(Czech Republic, Hunga y).
Re iew o Economic Pe spec i es
354
While EHR was he mos ad anced eHeal h unc ionali y ac oss EU Membe S a es
(CI5), he g ea es sho comings we e moni o ed in he a ea o elec onic sha ing medi-
cal in o ma ion (CI3). Sabes-Figue a and Maghi os (2013) s a e also ha only abou hal
o he moni o ed hospi als sha e medical in o ma ion elec onically wi h o he ca e
p o ide s (gene al p ac i ione s, ex e nal specialis s). Eu opean Commission (2014)
s a e, ha abo e all, he sha ing o medical in o ma ion wi h heal h ca e p o ide s loca -
ed in o he EU coun ies emains a challenge because less han 8 % o he hospi als
epo ed he sha ing o some medical in o ma ion wi h o he EU coun ies.
In 2018 he Eu opean Commission pe o med benchma king in he a ea o Gene al
P ac i ione s, see Eu opean Commission (2018). As a esul , he Composi e Index o EU
coun ies was compa ed. I was ound ou ha he s a e o eHeal h in he a ea o Gene al
P ac i ione s has imp o ed since 2013. The EU coun ies a e age sco e inc eased om
1.876 in 2013 o 2.131 in 2018 (max alue is 4). The coun ies wi h he highes le el o
eHeal h adop ion we e Denma k, Es onia, Finland, Sweden, and he Uni ed Kingdom
(sco es be ween 2.517 and 2.862), while Li huania, Mal a, Slo akia, Luxembou g, and
G eece had he lowes le el o adop ion (sco es be ween 1.647 and 1.785). The e we e
ound inc eases in he adop ion o EHR since 2013 ac oss all EU coun ies (Eu opean
Commission, 2018). The implemen a ion in he o he eHeal h ields – HIE, Teleheal h,
and PHR has also inc eased since 2013, howe e emains much lowe han he adop ion
o EHR.
Fo he u u e implemen a ion o eHeal h in he EU, i is expec ed he highe e o o
he Eu opean Commission in he ield o eHeal h ha monisa ion and s anda disa ion
(Eu opean Commission, 2011). I is expec ed he c ea ion o common Eu opean egis-
e s o ch onic diseases and ac ions o imp o e esea ch da a exchange be ween EU
membe s a es (Mai e al. 2012). The Commission is wo king wi h he membe s a es o
s a exchanging e-p esc ip ions ac oss bo de s in 2018 (Eu opean Commission, 2019).
C oss-bo de elemedicine is a co ne s one o he “Eu opean Re e ence Ne wo ks”
which will connec close o 1.000 clinics in Eu ope o diagnose and ea complex and
a e diseases. Bo h schemes a e suppo ed by he “Connec ing Eu ope Facili y” and he
sys em o he exchange o p esc ip ions is based on a success ul CIP p ojec “epSOS”
(Eu opa, 2018).
Limi a ions o he Resea ch
In connec ion wi h his esea ch, he e a e se e al limi s. The eHeal h Deploymen e al-
ua ion is ca ied ou o 2013, as i is based on he a ailable benchma king ac i i ies in
he ield o eHeal h o he Eu opean Commission. The esea ch esul s, he e o e, co e-
spond o his ime. Cu en ly, esul s may a y. In 2018, a ollow-up s udy was ca ied
ou in he ield o Gene al P ac i ione s, whe e i is possible o compa e pa ial esul s.
Howe e , a ollow-up s udy in he ield o hospi als has no been ca ied ou ye , and
ele an da a a e a ailable only o 2013. The conduc ing o up- o-da e eHeal h De-
ploymen esea ch, as p oposed in he p esen ed a icle, is limi ed now o his eason.
In he p esen ed esea ch, an Agg ega ed Index is cons uc ed, which is he subjec o
o he limi s. The e a e numbe o ad an ages and disad an ages associa ed wi h c ea ing
composi e indexes. In he case o complex policy issues, as eHeal h deploymen , he e
exis a la ge numbe o indica o s. The summa iza ion o hem in he o m o a compo-
Volume 20, Issue 3, 2020
355
si e index is a con enien ool o ecei e a mo e uni ied and compac policy message.
The disad an age is ha hei use can dis o eali y in ce ain espec s.
Conclusion
The adop ion o eHeal h in p ima y ca e is a c ucial ask on bo h na ional and in e na-
ional le els. The in e es o he EU and EU Membe S a es policy is o measu e p o-
g ess and assess he ex en o he implemen a ion so ha sho comings can be explained
and educed. In he p esen ed a icle, a p ocedu e o e alua ing eHeal h deploymen a
p ima y ca e using an Agg ega e Indica o was p oposed. The esul s we e e i ied and
imp o ed by he usage o MCDM me hods. The anking o EU coun ies was speci ied
on he basis o he applica ion o TOPSIS, WSA, and MAPPAC me hods.
The bene i is ha in he p esen ed s udy, bo h a eas o eHeal h a e e alua ed wi hin one
e alua ion model, and he anking o EU coun ies assessing he posi ion o eHeal h
deploymen is speci ied by he applica ion o MCDM me hods, so i is no jus an a i h-
me ic a e age o a ian s.
I was acknowledged ha he bes anking in his a ea ob ained Denma k, Finland,
Es onia, and Sweden. The wo s s a e o eHeal h was epo ed in Slo enia, Poland, and
Li huania. The esea ch showed ha access o and use o ICT become almos uni e sal
in p ima y ca e in all EU coun ies. Howe e , in he case o mo e ad anced unc ionali-
ies as EHR, HIE, Teleheal h, and PHR, mo e p og ess ac oss EU coun ies is needed.
Also, he a ea o sha ing elec onic medical in o ma ion and p i acy and secu i y o da a
should be imp o ed. The esul s o eHeal h deploymen e alua ion in EU coun ies
poin ed ou ha he eaching o he a ge and objec i es de ined o eHeal h bo h in he
Digi al Agenda o Eu ope and in he 2012 eHeal h Ac ion Plan hey emain a challenge
o u u e and ha mo e policy e o s a e needed o enable mo e imp o emen s.
Funding: This pape was c ea ed wi hin he p ojec SGS No. SP2020/32: Economic
e alua ion o o ganiza ions p o iding public se ices ela ed o he alloca ion unc ion
o public budge s.
Disclosu e s a emen : No po en ial con lic o in e es was epo ed by he au ho .
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