# Summary - Three technological solutions need to be taken into account: a monitoring and alarm handling system which covers the local system and cross-border ones, a data monitoring system, and a video conferencing system - Final diagnosis and treatment must lie with the doctor and thus, liability issue is still with doctor while technology allow improvement of decision-making support using a richer data-pool. Thus, to allow cross-border telemedicine, need a legal framework for data security and liability issues. - Factors that support/hinder cross-border telemedicine implementation: legal, sustainability, cultural, and contextual factors. - In sustainability, financial sustainability is one of the most important, and thus, budgets for technical start-ups and maintenance, plus reworking the incentive system to spur the shift are imperative. Other factors, such as integration into national health information system is noted as a problem. # Abstract Telemedicine is expected to improve quality of life in home settings, while enabling timely medical intervention. Similarly, crossborder care arrangements could improve quality and patient experience of health care services and also drive innovation. Yet, there are only a few cross-border telemedicine solutions that link professionals directly to patients. The EU-funded international DREAMING project piloted services in six countries using telemedicine to support the independent living of older people with chronic diseases. Analysis shows that the service could benefit from centrally organised monitoring and datamanagement subject to developing sustainable payment models and a legal framework for data security and liability issues. # Project on telemedicine across borders The DREAMING (elDeRly-friEndly Alarm handling and MonitorING) project piloted services using information and communication technology to support the independent living of older people with three chronic diseases: diabetes, chronic obstructive pulmonary disease (COPD) and heart failure. Semi-structured interviews with project participants were carried out to evaluate their experience with the pilot and qualitative analysis was used to address mainly evaluative and strategic questions. A conceptual framework developed by Saliba et al.2 was used for the data analysis [[Insights]] Culturally it doesn't work in Indonesia—or at least, must be tailored—because in Indonesia multigenerations live in one household. The technological solution consisted of three components: 1. A monitoring and alarm handling system that included a health monitoring subsystem, an environmental monitoring subsystem, and a mobile alarm and localisation subsystem 2. A data management tool to collect, organise, analyse, and store data collected by the subsystems 3. A video conferencing technology # Potential for cross-border service Interested to move into formal cross-border provision of a monitoring service facilitated by intelligent software. The key is transferable technology. Thus, monitoring and data-management could be organised centrally, which allows for the improvement of decision-support algorithms using a richer data-pool. A recent systematic review2 identified factors that hinder or support cross-border telemedicine implementation: legal, sustainability, cultural, and contextual factors. ## Legal factors Crucial to ensure trustworthiness and quality of the service. For example, final diagnosis and treatment on the basis of the information by the monitoring data and algorithm (i.e. this function should not be delegated to a technological solution). Thus, liabilit should also lie with the doctor, whether the service is provided in a single country or across borders. Patient data is moved across borders and thus requires patients' informed consent to data sharing and storage. Data security concerns were felt to be relevant especially where legal clarity was lacking at national level. ## Sustainability factors Financial sustainability: start-up costs for setting up the technical infrastructure, costs for technical maintenance, personnel and management costs. In Estonia, costs for maintenance accounted for around 30%, while personnel and management costs absorbed 70%. In general, telemonitoring was integrated into the everyday practice of the service provider involved in the pilot. However, ==challenges remained due to the limited involvement of staff members in the project as well as non-integration of the IT (Information Technology) platform into national health information systems==. In addition, integration into national health systems in terms of reimbursement continues to be a challenge, particularly when the telemonitoring service includes ==elements of health and social care that rely on different financing mechanisms==. Currently, such mechanisms do not provide incentives to enable patients to live at home, but reward health care providers for curative service provision, such as hospital stays. Thus, ==a rethinking of reimbursement and the financing of telemedicine is necessary in order to deploy telemedicine on a larger scale==. ## Cultural, language and contextual factors Different langauges needed to be addressed through common standards, definitions and guidelines. Cultural differences such as patterns of communication and perception of privacy across countries need to be addressed. Trust and acceptance between health professionals and in relation to patients was pursued through training of health professionals and running support schemes for patients in order to overcome resistance to change and fear of technology. Moreover, infrastructure has to be suitable for the given service and user preferences, which means adequate and forwardlooking planning of investments, as the cost of technology is dropping fast. # Conclusion Review by Saliba et al.2 identified that most cross-border telemedicine services link professionals, but only a few link professionals directly to patients. It also revealed that the main motivation for developing cross-border telemedicine is to compensate for the lack of specialist health care workers, improve access to care in LMICs and enable cost containment in HICs. > The internationally piloted telemonitoring service described here responded to a need for such services in local health care systems. In Estonia, the participating hospital had a large ambulatory patient base, but significant space constraints in acute care, creating an incentive to find alternative means to service the high number of patients. This could be achieved by timely medical intervention and keeping patients in home settings. Whether it be space constraints, lack of health professionals or more efficient use of resources, these are quite universal factors and indicate that there might be potential for moving from loose projectbased collaboration to formal cross-border service provision with this type of service. Issues of liability, clinical governance, patient consent, and data security were seen as important barriers where no national or EU-wide guidance on telemedicine services existed, and therefore special agreements between providers are requested to facilitate implementation. Financial sustainability is a critical issue for long-term service provision. # References 1. DREAMING Project website. Available at: www.dreaming-project.org/ 2. Saliba V, Legido-Quigley H, Hallik R, et al. Telemedicine across borders: a systematic review of factors that hinder or support implementation. International Journal of Medical Informatics 2012; 81: 793–809. 3. Fitzgerald R. Medical regulation in the telemedicine era. The Lancet 2008; 372: 1795–96.