Scaling-up of ICT Solutions in Active and Healthy Ageing through

Twinning Actions

Strahil Birov

, Christianne Lavin

and Veli Stroetmann

empirica Gesellschaft für Kommunikations- und Technologieforschung mbH, Oxfordstr. 2, Bonn, Germany

Keywords: ICT, Active and Healthy Ageing, Scaling-up Strategy, Digital Innovation, Twinnings.

Abstract: Despite an increase in life expectancy in today’s rapidly ageing society, unhealthy life years still make up a

big portion of a person’s life. Digital innovations in health and care services need to be scaled up to enable

more citizens to access and lead healthy, active and independent lives while ageing. Under the EU funded

ScaleAHA study, a twinning scheme was conducted to scale up ICT solutions in active and healthy ageing.

Forty-three organisations from thirteen European countries have successfully participated in financed

twinning actions ranging from knowledge exchange and training to full adoption and acquisition of an

innovative practice. Twinning topics included EHRs, ePrescription solutions, integrated health and social care

ICT service platforms, and homecare and telemonitoring solutions, among others. The twinning scheme was

a new concept that aimed to de-risk investment in innovative ICT solutions by financing small but concrete

ideas with high potential for replicability and scaling up. The twinnings led to benefits for the participating

organisations themselves as well as various stakeholders such as patients and their carers, healthcare providers

and regional authorities. This paper presents the results and lessons learnt from the twinning scheme and

recommendations to further refine future twinning actions.

1 INTRODUCTION

Scaling up digital innovations in health and care

services in Europe enables more EU citizens to lead

healthy, active and independent lives while ageing,

whilst improving the sustainability and efficiency of

health and social care systems and boosting and

improving the competitiveness of the markets for

innovative products and services. By scaling up

digital innovations, the EU Member States are

responding to the ageing challenge at both EU and

global level, while creating new opportunities for

businesses.

In order to successfully scale up digitally-enabled

innovative solutions, a comprehensive scaling-up

strategy at European level is needed. The European

Commission, supported by the European Innovation

Partnership on Active and Healthy Ageing (EIP on

AHA), has defined a five-step scaling-up strategy in

AHA by: building a database of innovative practices,

their viability assessment regarding scaling-up

potential, their classification for replication purposes,

https://orcid.org/0000-0002-4575-0492

https://orcid.org/0000-0001-8348-4642

https://orcid.org/0000-0001-8601-5307

the facilitation of appropriate partnerships, and

implementation of the innovative practices in other

regions and countries (European Commission, 2015).

Since its inception in 2010, the EIP on AHA has

shown considerable progress with regards to the first

three steps of the strategy. A repository of innovative

practices of the EIP on AHA contains more than 400

good practices across Europe. Each practice is

detailed and assessed via key performance indicators

(time for deployment, investment, maturity, available

evidence of outcomes, impact, transferability) in

order to help the more than 1,000 stakeholders of the

EIP on AHA identify collaboration opportunities.

With this foundation in place, the EIP on AHA is

in the process of implementing the good practices

through collaboration and partnership search.

Working together, stakeholders exchange knowledge

and share the experience of successful innovations to

facilitate their scaling up across Europe. One

important instrument promoted by the European

Commission to facilitate this step of the scaling-up

strategy is the use of twinning actions. In this paper,

222

Birov, S., Lavin, C. and Stroetmann, V.

Scaling-up of ICT Solutions in Active and Healthy Ageing through Twinning Actions.

DOI: 10.5220/0007722702220229

In Proceedings of the 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2019), pages 222-229

ISBN: 978-989-758-368-1

a twinning action or “twinning” refers to the transfer

of an innovative Information and Communication

Technology (ICT) solution (also referred to as the

“innovation” or “innovative practice” and can be a

product, service, methodology, or strategy) from one

region to one or more other regions.

The “Transfer of Innovation Twinning Support

Scheme” was a pilot scheme to support twinning

actions by partners of the EIP on AHA through the

reimbursement of expenses incurred in the transfer of

innovative practices. It was part of the EU-funded

“Support to scaling up of innovations in Active and

Healthy Ageing” (ScaleAHA) study (ScaleAHA

Consortium, 2016), which aimed to accelerate the

scaling-up of innovative approaches and practices in

Active and Healthy Ageing by fostering dedicated

mentoring activities and active knowledge exchange

among stakeholders of the EIP on AHA.

Two types of organisations could be involved in

the twinning scheme: an adopter organisation and an

originator organisation. The adopter is the

organisation that received the innovation, i.e.,

benefitted from the experience and know-how

developed by the originator organisation in a

particular field of intervention and aimed to deploy or

implement this innovation in their territory. The

originator is the organisation with the experience and

know-how in a particular field of intervention. It is

the organisation that transferred the innovation to the

adopter.

2 APPROACH

The twinning scheme of the ScaleAHA study limited

participation to organisations holding Reference Site

(RS) status as a result of the 2016 Call for Reference

Sites of the EIP on AHA. These “Reference Sites” are

highly inspirational ecosystems, delivering creative

and workable solutions that improve the lives and

health of older people through the collaboration of

different stakeholders. They are also able to give

evidence and concrete illustrations of the impact of

their approaches.

Applications to the scheme were possible through

a "joint request" submitted through a brief online

application form. It was filled in by the adopter and

originator organisations together, with details on the

requested twinning support, on the content of the

twinning action, (notably on which innovative

practice was planned to be transferred), and on the

level of commitment for implementing the innovative

practice within 2016-2018. The applications were

reviewed by an independent panel based on a set of

pre-defined award criteria.

Overall the twinning actions covered a wide range

of eHealth topics, which are relevant to current health

priorities. These included online health portals; ICT-

supported integration of health and social care

services; health and care needs assessment tools; ICT

tools supporting adherence to care plans; mHealth

systems; falls prevention; regional and national

Electronic Health Record (EHR) systems and

integration; ePrescription solutions; tele-mentoring

and virtual consultations; multi-disciplinary team and

care co-ordination; and age-friendly buildings,

among others. The twinning innovations were also

well-aligned with some topics related to the Digital

Single Market priorities on transforming health and

care (European Commission, 2018) such as health

data analytics (risk stratification tools, mobile

applications), citizen and patient empowerment

(online self-management hub, citizen access to data,

health data exchange and re-use, advanced platforms

and infrastructure, and prevention and patient-centred

care (innovations on telecare, home-monitoring, and

digital skills and staff training solutions, among

others).

The twinning organisations themselves were

responsible for managing and organising any activity

(e.g., study visits, translation work) needed to carry

out their twinning action and goals. The organisations

were also requested to report to the ScaleAHA study

team on the evolution of the innovative solution, the

motivation behind the healthcare problem that the

innovation addressed, any concrete plans on how the

innovation was to be transferred, the progress of the

twinning action, barriers and success factors

experienced, any possible future co-development,

benefits and new opportunities expected from the

twinning action, whether the twinning resulted in

implementation of the innovation in the adopter

region, and any other outcomes that resulted from the

twinning action. These reports were submitted twice

in the form of one interim and one final report.

The twinning scheme provided financial support

to cover the travel and accommodation of experts and

other expenses incurred by hosting meetings (such as

transport within the region). It did not cover fees for

professional services (consulting, advisory services,

moderation services etc.) and did not include the

acquisition of products and services from third

parties. The total maximum amount that could be

claimed was capped at € 5,000 for each twinning

action, irrespective of the number of adopter

organisations involved in the respective twinning.

Scaling-up of ICT Solutions in Active and Healthy Ageing through Twinning Actions

223

3 RESULTS

Twenty twinning proposals were accepted into the

twinning scheme, composed of 43 twinning

organisations from 26 Reference Sites in 13 countries

across Europe (Figure 1).

Figure 1: A total of 43 twinning organisations from 26

Reference Sites in 13 countries were accepted in the

ScaleAHA Twinning Support Scheme.

Table 1: Overview of innovative practices accepted in the

twinning scheme, and their respective originators.

Fourteen innovative practices were accepted in

the twinning scheme (Table 1).

The ScaleAHA study team collected and analysed

the reports on the twinnings submitted by the

originator and adopter organisations. The results of

these analyses are found in the next sub-sections.

3.1 Barriers and Success Factors to

Scaling up Innovation in AHA

The barriers and success factors to scaling up

innovation in AHA were identified and collected

based on the twinning experiences in order to present

the key elements that hampered or enabled a

smoother implementation of the innovative practice.

A lack of cooperative knowledge exchange

between professionals resulted in a delay in the

adoption of new practices, for instance, in Northern

Ireland, where clinicians initially feared that they

would lose their clinical freedom when using a new

system. There were also difficulties in convincing

stakeholders of the effectiveness of the new care

pathways, which thereby slowed down the

organisational change process. In some cases, the

implementation of a new system required clinicians

to first participate in educational programs and

training, leading to time and effort-related barriers. It

has been found to be challenging to address the target

group, i.e., present innovative eHealth systems to

those aged 80 years and above. Poor interoperability

among different health information systems and

fragmentation of software applications among

regions not only caused delays in adopting the

innovation but also caused an increase in costs related

to implementation. Technical barriers were also an

Figure 2: Overview of identified barriers to scaling up

innovation in AHA.

Lack of organisational structure

Lack of interdisciplinary communication and cooperation

Lack of interoperability and system integration

Time and effort related barriers

Financial and reimbursement problems

Resistance to change / Scepticism about effectiveness

Lack of awareness among professionals and patients

Technical barriers (infrastructure, connectivity)

Low digital literacy / Addressing the target group

Barriers to scaling up innovation in AHA

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issue in several regions, in which poor internet

connectivity and multiple system crashes caused

discomfort in the users, which in turn delayed user

acceptance of the innovation.

Identifying and analysing the current state of

research in a particular target topic as well as

developing a clear vision on the use and benefits of a

new product were found to be useful initial steps in

implementing an innovative practice. Some of the

innovations were implemented quickly because they

fell in line with national strategies, guidelines and

health plans. In Andalusia and Scotland, continuous

political support helped overcome challenges in the

implementation of innovative electronic health

practices. Training and education of staff as well as

user experience design and acceptability led to more

efficient and widespread usage of the innovation.

User acceptance was particular important for

successful innovation and deployment and was

achieved by placing a focus on outcomes that were

important to the users. In Twente, the developers of

the Telerevalidatie.nl online portal supporting

rehabilitation at home were closely collaborating with

the target group, thus being able to adopt a user-

friendly and highly accepted digital solution.

Similarly, while developing the Andalusian EHR,

both technicians and the health workforce were

involved in the design and successful implementation

of the system. Financial incentives were identified to

be catalysts for change, for example, in helping

motivate doctors actively participate with other

Figure 3: Overview of identified drivers and success factors

to scaling up innovation in AHA.

stakeholders in introducing new treatment pathways.

Overall, networking, partnerships and collaboration

also played a substantial role.

More specific examples on the identified success

factors and barriers to scaling up innovation in AHA

as experienced by specific twinning organisations are

found in the ScaleAHA Final Study Report (empirica,

2017).

3.2 Twinning Archetypes and

Experiences

In terms of scaling-up scope, the twinnings can be

grouped into five archetypes: Knowledge exchange

and training, Adaptation, Partial adoption, Full

adoption, and Acquisition (described in Table 2).

Table 2: Twinning archetypes and corresponding number of

twinning actions.

The Knowledge exchange phase was usually

achieved within 3 months, and for many cases partial

adoption of the innovative practice was achieved after

6 months. Full acquisition of the innovative practice

took longer than 6 months since a pilot phase of at

least 12 months was usually required in order to study

the usability and adaptability of the ICT tools (e.g.,

assessing potential clinical effect, measuring

adherence to treatment, measuring user’s

satisfaction).

Examples of steps done within 6 months that led

to the implementation of the innovation include:

 Organising various meetings for knowledge

transfer such as analysing the situation of the

Clear vision and strong political commitment

Previous research and piloting

Addressing current healthcare needs and embedding the new

system into present healthcare policies

Public and private partnerships

New business models and innovations

Product development in close collaboration with the end-users

User experience design, user acceptance

Local services, integration of the new solution into

the existing environment

Faster benefit realisation of the innovative practices

Marketing and business communication

Funding, financial incentives and investments

Networking and collaboration

Success factors to scaling up innovation in AHA

Training and education of staff

A mature innovation is being adopted by

adjusting it to local conditions (e.g. translation

into local language)

Elements or aspects of the innovation

(product, service, methodology, strategy) are

being implemented using locally available

infrastructure

The innovation (product, service,

methodology, strategy) is being implemented

in its full scope by using local infrastructure

i.e. the innovation is transferred and managed

fully by the adopter

The innovation is being implemented in its full

scope by using the originator’s infrastructure

(paid for or free of charge), i.e. the originator

still has primary ownership, but a license for

use is granted to and acquired by the adopter

Description

Focus on knowledge (know-how) exchange

and training, a central aspect of the innovation

are the required staff skills

Number

Adaptation

Partial

adoption

Full

adoption

Acquisition

Type

Knowledge

exchange &

training,

digital skills

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225

adopter site and analysing how to improve and

adjust the existing infrastructure;

 Setting up working groups that analyse the

innovative solution and detect what changes or

improvements are necessary;

 Translating content into the language of adopter

site (e.g., in mobile applications or portals);

 Planning and designing future implementation

(e.g., creating roadmaps and study

methodologies on how to involve more citizens

and stakeholders); and

 Finding sponsors for and implementing a small-

scale pilot e.g., at a hospital level.

The twinning organisations that successfully

implemented the innovative practice given the

twinning timeframe were able to do so due to the lack

of political or financial barriers even before the

twinning. In these cases, the organisations were able

to already focus on expanding their reach of potential

users (through publishing in magazines; using social

networks; using colourful, captivating icons in their

health platforms to attract a wider audience; etc.).

One of the success stories is the MASK Allergy

Diary twinning action, which was fully implemented

(full acquisition) initially by 10 adopter regions

during the twinning scheme (empirica, 2017)

followed by altogether 30 adopter regions (Bousquet,

2017). MASK Allergy Diary is a tool that enables

citizens to assess and control allergic rhinitis, and

supports pharmacists, physicians and specialists in

prescribing appropriate treatment and follow-ups.

Through the outreach of the adopter Reference Sites

(who aimed to recruit at least 50 elderly persons ≥65

years and at least 100 adults <65 years in more than

20 countries) the twinning allowed the originator to

study, compare, and analyse the differences in the

characteristics of rhinitis and asthma multimorbidity

among different age groups across different countries

(Bousquet, 2017). This twinning action not only

provided more citizens with access to a proven

allergy management tool, but also gave way to

multiple avenues of future research on rhinitis and

asthma that can be gained from the collected data.

Most of the twinnings led to an adoption of

elements of the innovation using the local

infrastructure (partial adoption). Partial adoption did

not necessarily mean an incomplete adoption. In

some cases, a partial adoption was preferred over a

full adoption since an efficient local infrastructure

was already in place in the adopter region. An

example of a success story of partial adoption is the

Andalusia-Zagreb twinning (empirica, 2017). The

adopter (Zagreb) participated in the twinning to find

digital solutions related to AHA that could be piloted

or implemented in the Zagreb RS. The twinning

enabled the Zagreb RS to co-develop workshops with

primary care physicians and ICT service providers in

order to find the best ways to implement elements of

the Diraya eHealth system (Regional Ministry of

Health Andalucia, 2016) to the Croatian healthcare

ecosystem. As a result, a set of modules was added to

the already existing health service of the adopter,

Zdravlje.net. The e-Consultation module was one of

the notable elements implemented through the

twinning. It fostered collaboration between cure and

care sectors and thus provides a multidimensional

approach to managing patients. Through this module,

each patient can receive recommendations for

managing a specific health issue based on the

multidisciplinary interaction of general practitioners

and hospital specialists. The number of citizens using

Zdravlje.net has been increasing and strongly

indicates possibilities to reach out to all current

inhabitants of Zagreb.

3.3 Benefits and New Opportunities

The adopter organisations have identified a number

of benefits and new opportunities resulting from the

adoption of digital innovations through the twinning

actions. The specific examples below are meant to

provide a better understanding of the benefits

experienced mostly by the adopter region. These

examples are not exhaustive.

Better Healthcare Service – for example, the

Basque Country Risk Stratification Tool (Orueta, et

al., 2013) enables patients with specific diseases to be

identified, selected, and precisely grouped, giving the

patient a more coordinated, proactive, and

personalised level of healthcare. The tool also collects

demographic, socioeconomic and clinical variables

from sources such as the Department of Health into

summarised, relevant information that supports

healthcare providers in their clinical decisions.

Timely Diagnosis and Better Screening – The

Quick Mild Cognitive Impairment (Qmci) screening

application (Collaboration on Ageing, 2016) has been

developed as a computerised application that reduced

paper work and data entry, and generated a more

accessible and flexible screening process. It will be

used to rapidly identify patients with Mild Cognitive

Impairment and dementia who can benefit from early

intervention.

Better Communication between Professional

and Patient/Patient's Family – The Andalusian

Telecare Service (SAT) (ASSDA, 2016) has enabled

easier and more personal communication between

doctor and patient due to its easily accessible setup: a

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bracelet device that can be worn by the patient at

home and is connected to a device in the healthcare

centre that contains all patient information. The

service allowed patients to stay at their own homes,

which has also led to a bigger involvement of family

members in the patients’ care.

Improved Health Literacy – the ALOHA e-

Health platform (Gerontopole Pays de la Loire, 2016)

provides information on vaccination, nutrition, and

controlled use of antibiotics for the senior population.

Improving the patients’ awareness on such health

topics can lead to better participation in their medical

plans.

Better Resource Allocation – adopting a

transparent medicines procurement strategy using the

StepSelect system (Scott, et al., 2010) prevents the

dispensation of unnecessary medicines, which

therefore leads to cost savings that could be used to

further improve the health system.

Collection and Evaluation of Data that is by far

still Unavailable in the adopter site – the FrailSurvey

mobile app (University of Rome, 2016) enables the

collection of data and the subsequent evaluation of

the prevalence of frailty in the region. This was

beneficial for the adopter region (Porto), in which

there had not yet been data on frailty prevalence. The

possibility of including frailty status in the patient

care model was also explored.

Other benefits and new opportunities included

improved national sustainability due to massive cost

savings; reduced healthcare visits; development of

healthcare services for complex patients; new job

opportunities or roles for health professionals; patient

empowerment; the creation of new businesses,

business models and new areas of research and

development; and stronger relationships between the

Reference Sites and the possibility of future impactful

collaborations.

In some cases unforeseen benefits or “spill-over

effects” were observed. These are events that were

“inspired” by the twinning action, although not

initially planned. For example, one twinning action

involving the adoption of a telecare service had such

a positive effect on the adopter organisation’s team

that the adopters were inspired to develop another

type of service - a local call centre directed at solving

issues among the younger population. Some

twinnings also led to calls for developing other

solutions that would support the implementation of

the organisator’s innovation into the adopter region.

One of the twinnings resulted to not only in a transfer

of the innovative practice from the originator to the

adopter site but also from the adopter to the originator

site.

Furthermore, some of the twinning organisations

participated as both originator and adopter in separate

twinning actions. They reported benefits for the

originator as well, such as having an improved

internal communication, local coordination and

networking; receiving external positive feedback as

an incentive; and being able to update knowledge and

documentation of their innovative practice.

4 SUMMARY AND

RECOMMENDATIONS

Overcoming implementation barriers and leveraging

success factors for scaling up drives innovativeness in

active and healthy ageing. ScaleAHA has taken stock

of and analysed key barriers and success factors for

scaling-up of healthcare solutions in Europe. Some

barriers faced during the twinning scheme were

technical differences in infrastructure e.g., internet

access, lack of interoperability and system

integration, low digital literacy of the target group,

financial and reimbursement problems, and lack of

awareness among professionals and patients. Among

the key success factors are strong political

commitment; utilising existing networks,

partnerships and collaborations; putting the user in

the centre of the development and the overall process

to ensure acceptance; leveraging public and private

partnerships and funding mechanisms; disseminating

the benefits of the innovations; and providing

appropriate training and education to staff.

The twinnings have given rise to a number of

benefits and new opportunities resulting from the

adoption or planned implementation of the

innovation, not only for the adopter but also for the

originator. Each twinning has accomplished different

implementation steps regardless of their archetype

within the project timeframe. For many cases, a

partial adoption has been achieved after 6 months,

which generally involved organising various

meetings for knowledge transfer, creating relevant

working groups and multidisciplinary teams,

translation of ICT tools into the language of the

adopter site, and finding sponsors or even beginning

the necessary pilot phase.

Examples of lessons learnt that facilitated the

twinning actions included establishing a clear

twinning plan and identifying adopter prerequisites

early on in the timeframe; creating pilot projects to

address areas of improvement in the adopter region;

and creating more joint activities and training

sessions to enable knowledge acquisition not just for

Scaling-up of ICT Solutions in Active and Healthy Ageing through Twinning Actions

227

the adopter region but also for the originator region.

The different twinning archetypes required different

budget and financing but overall there was an own

budget of 1 million EUR invested by the adopters.

Recommendations provided by the twinning

organisations in order to further refine the

management of future twinning actions include

extending the twinning timeframe, also considering

the schedules of the different staff involved in the

twinning; making all necessary templates for

reporting available well in advance; keeping the

overall process simple (application, reporting, etc.);

increasing the twinning budget in order to extend the

scope of activities; and extending the budget to cover

other expenses such as staff participation,

development and implementation costs.

Furthermore, the following observations should

also be considered for future twinnings:

 The twinning scheme should have a dedicated

online presence, which includes a list of ongoing

twinnings and regular news about their progress,

as well as information about any upcoming calls;

 Provide evidence of impact and communicate the

benefits from twinning actions;

 Launch Calls for Twinnings based on current and

upcoming EC priorities. Upcoming twinning

calls may be used strategically to stimulate areas

which are of priority to the EC or areas which are

underfunded but promise high impact, such as

the priority health areas described in the

Organisation for Economic Co-operation and

Development (OECD) Health at a Glance:

Europe reports (OECD/EU, 2018). Such

selective funding will allow to target digital

innovations more effectively and to close

existing gaps.

 Twinnings should be placed in future European

Union funding programmes. By placing

particular requirements in the calls related to

twinning actions, the EC can further stimulate the

scheme; and

 The impact of the twinnings should be captured

in a uniform way. The described twinning

scheme has delivered evidence of what works

well and can provide high impact. This evidence

was highlighted by the establishment of a clear

commitment between the twinning organisations

backed up by political support and additional

budget that was secured from local funds. The

impact of twinnings can be captured more

efficiently if assessed with a uniform impact

assessment tool.

5 CONCLUSIONS

Overall the twinning scheme carried out by the

ScaleAHA study was a new concept that aimed to de-

risk investment in digital innovative ICT solutions by

financing small but concrete ideas with high potential

for replicability and scaling up. The scheme was an

excellent instrument for targeting barriers in line with

current Digital Single Market health and care

priorities and providing digital solutions that can be

applied across Europe. Twinnings provide

inspirational organisations and ecosystems with

opportunities to learn from each other and deploy and

scale up their solutions to other regions. The twinning

actions also served as a stepping stone for further

commitment among regions to continue working

together and ensure the implementation of the

solution even after the given twinning timeframe. The

recommendations listed above were based on the

twinning experiences in the ScaleAHA study to

further refine possible future twinning actions.

Although the ScaleAHA study focused on ICT

solutions for active and health ageing, the twinning

scheme itself is replicable and can be deployed for

various other settings. Following the ScaleAHA

twinnings, the European Commission has encouraged

their use in other initiatives, including the EU project

WE4AHA (WE4AHA consortium, 2019), as well as

two new EU projects launched in January 2019.

ACKNOWLEDGEMENTS

This paper is based on the ScaleAHA study, which

was commissioned by DG Communications,

Networks Content and Technology of the European

Commission. Their support is gratefully

acknowledged.

We thank all colleagues from the ‘eHealth, Well-

being and Ageing’ Unit for their kind encouragement

and guidance, in particular, to Mr. Bruno Alves and

Mr. Arnaud Senn, for their great contributions,

enthusiasm and support.

We also thank all twinning partners for their

dedication and kind support.

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