From: Subject: ICT3E816 Date: Thu, 19 Feb 2004 10:34:41 -0500 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0000_01C3F6D3.FB5B41A0"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1165 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C3F6D3.FB5B41A0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.jrc.es/home/report/iptsreport/vol81/english/ICT3E816.htm ICT3E816

Electronic Health Records: a key enabler for eHealth
Andreas=20 Ligtvoet, RAND Europe

Issue: Electronic health = records open=20 up new options for healthcare delivery: better access to relevant = information,=20 consultation and cooperation between healthcare providers, and = monitoring and=20 care delivery at the patient=92s home. However, issues of = confidentiality and=20 privacy need to be balanced with the requirements for increased = communication=20 between medical practitioners.

Relevance: If the health=20 applications enabled by electronic health records are to be taken up, = they will=20 need widespread consensus among all stakeholders (public authorities, = medical=20 professionals and patients). This will require focused and coordinated = action at=20 both national and EU-level.

Introduction

Over the last few = years, the=20 Lisbon objectives and the eEurope policy actions have painted a = strategic vision=20 of the direction that Europe is heading regarding competition and = services in=20 the information society. The use of eHealth has a role in the constant = challenge=20 of balancing the requirements of reducing the cost of healthcare (due to = budgetary constraints), while at the same time aiming to increase access = and=20 quality.

eHealth offers the potential to = enhance the=20 capacity to monitor and protect public health through better health=20 surveillance

eHealth offers the potential to enhance the capacity = to monitor=20 and protect public health through better health surveillance. Having a=20 comprehensive system for monitoring chronic non-communicable diseases - = based on=20 small monitoring devices - will provide medical researchers and public = health=20 officials with comprehensive health data on the population, thus = enabling them=20 to identify opportunities for improving the health system. Furthermore, = citizens=20 can be better informed by high quality health-related information = services. They=20 will provide online access to health information, support communities,=20 pharmacies, decision aids, and tools to handle administrative tasks. = Patients=20 can test specific conditions, such as blood glucose levels, respiratory = rates,=20 etc. or produce an ECG using e-devices at their own home (referred to as = patient=20 self-management or telemedicine). Many senior citizens will = become=20 housebound but will still need services, training, and reinforcement of = medical=20 self-management, as well as continued connection to clinicians and = contact with=20 other patients. And finally, integrated patient management aims = to=20 provide mechanisms for client case management and efficient sharing of=20 information between care professionals, such as the exchange of data = (medical,=20 administrative or financial) which today remain a cause of problems in=20 healthcare.

These developments can have a number of advantages: = specialized=20 clinical expertise may be made available in rural settings and it may = become=20 possible to obtain a second opinion in medical specialty areas; medical=20 facilities within the EU are to be interlinked and accessible to all,=20 particularly when patients seek treatment in other EU member states = (improving=20 access). These changes transform the traditional organizational model = into a=20 network organizational approach where the user is the focal point of = health and=20 social care: instead of the doctor acting as sole manager of patient = care,=20 patients are becoming partners in managing their own care; new = technologies will=20 enable safer independent living and increased social inclusion = (improving=20 quality of life).

eHealth-related developments are = transforming the=20 traditional organizational model into a network organizational approach = where=20 the user is the focal point of health and social = care

The basis = for these=20 developments is an electronic health record (EHR; the central role of = EHR in the=20 services described is depicted in Figure=20 1). All developments in eHealth rely on the transfer and storage = of=20 medical data. On the one hand this enables the foreseen applications, = but on the=20 other hand it opens up a whole range of discussions on organizational = change,=20 technical implementation and security & privacy. Before the records = can be=20 used ubiquitously, however, there should be more clarity on these=20 issues.

eHealth requires the storage and = transfer of=20 medical data; thus the development of the electronic health record is a = key=20 enabler of progress in the field

Figure 1. Different e-health services enabled = by=20 electronic health records

Electronic health records

In their simplest form, electronic health records are = hospital=20 records for a single inpatient stay or social insurance account records. = However, in the future they could also contain the record of the = individual=92s=20 genome, or the entire history of an individual=92s interactions with the = healthcare system. The electronic health record is widely cited as a = critical=20 key to modernizing healthcare in the EU. It may save resources and = effort by=20 eliminating duplicate testing and the need for doctors to take down = notes on a=20 patient=92s history repeatedly. The added advantage - since the advent = of mobile=20 communications - is that the data can be stored in one place (helping = ensure=20 data integrity) but accessed via wireless networks (GPRS, 3G, WIFI) at = another=20 and thus cater to the needs of mobile carers (nurses and doctors making = house=20 calls) or telemedicine applications. Ideally these EHRs will be easy to = use by=20 different specialists, easily accessible (for example, via mobile = devices and=20 terminals) and ensure secure transmission of personal = data.

In the future electronic health = records could=20 progress from being a simple record of a hospital stay to containing the = individual=92s genome or an entire history of interactions with the = healthcare=20 system

The data collected can make a major contribution to = health=20 monitoring, medical research, and the measurement of system = effectiveness by=20 providing aggregate health information. Health information systems have = the=20 capacity to exchange information electronically with private providers = of=20 medical services such as clinics and laboratories. Standardized = definitions and=20 access to databases will permit more useful analysis of information on = incidence=20 and prevalence of chronic diseases and injuries, risk factors and = conditions,=20 services, programmes, and outcomes. When linked with clinical = decision-support=20 systems, the electronic health record can facilitate evidence-based = diagnosis=20 and treatment. Through the use of the Internet, smart cards, and other=20 information technology, patients will be able to access their own = electronic=20 health record and take on the role of =91partner=92 in managing their = own health=20 (although this may lead to opposition from health professionals who = disapprove=20 of laypeople interfering with their job or self-medicating). =

Technology could empower patients, = enabling them=20 to take greater control over their electronic health record and take on = the role=20 of =91partner=92 in managing their own health

The storage of large amounts of personal data in one = central=20 EHR database has advantages, as we have seen. However, it also raises = concerns=20 about the accessibility of these data: medical information is = information of the=20 most private nature. More than with other data, care should be taken to = restrict=20 access and anonymize where possible. Here we see that the interests of = the=20 different stakeholders in the process may come into conflict.

Stakeholder requirements

It is today very clear that technology is only part = of the=20 story: successful implementation of EHR also depends on the acceptance = of the=20 stakeholders involved and their willingness to alter their traditional = way of=20 working.

Arguably, as end-user of many of the services, the = most=20 important stakeholder is the patient. Present and future patients expect = specific information to be available about their condition so as to = allow them=20 to have an informed discussion with their care provider. Furthermore, = they=20 expect all assessment, treatment and care to happen at a time and place = of their=20 choosing and to be protected from unsafe and poor quality products and = services=20 ordered via the Internet. But most importantly, they expect privacy and=20 confidentiality; i.e. that patients themselves should be in charge of = their own=20 medical records.

Electronic health records (EHRs) = could be=20 implemented so as to be provided on-line over a secured network or = embedded on a=20 smartcard

EHRs could be implemented so as to be provided = on-line over a=20 (secured) network or embedded on a smartcard. Smartcards can provide = persistent=20 and portable information storage as well as identification, digital = signature,=20 security and payment functions. It is also clear that that Privacy = Enhancing=20 Technologies, such as data scrambling and biometric or other forms of=20 identification are required when handling personal data, on both the = citizen=92s=20 as well as the professional=92s side. For example, pharmacists would = only need to=20 access a limited subset of the individual=92s complete record.

However, health- and social-care providers, hospitals = or any=20 wider consortia of service providers in public and private sectors = expect=20 services to support (and not hinder) them in their routine tasks. = Medical=20 records and other health applications will have to be accessible from = mobile=20 devices in order for healthcare professionals to be able to work = effectively. As=20 health records need to be accessed from different locations using = different=20 devices, the information provided should be scalable so that it will = also be=20 usable over connections with less bandwidth or without full audio/video=20 capabilities.

As health records need to be accessed = from=20 different locations using different devices, the information provided = should be=20 scalable so that it can also be used over connections with less = bandwidth or=20 without full audio/video capabilities

As with many other ICT = applications, the=20 service stands or falls with the standardization that is applied to both = the=20 data-format and the software and equipment handling the data. If the = exchange of=20 health records both nationally and internationally is to take place in = an=20 effective and efficient manner, interoperable standards will have to be = laid=20 down at a transnational level. To avoid vendor lock-in and to facilitate = uptake,=20 the standards used should be open and accessible to scrutiny.

Analysis

Like in many fields of IT, the technical theoretical = vision has=20 given rise to considerable expectations, but the realization of these=20 expectations is taking longer than anticipated. It is therefore crucial = to=20 analyse the strengths, weaknesses, opportunities and threats (so-called=20 SWOT-analysis) of the present situation to be able to come up with = policy=20 recommendations that build on what is available while trying to target = the=20 stakeholders=92 requirements. For EHR, an analysis of the kind alluded = to=20 highlights the following points for attention.
StrengthsWeaknesses
There are many international and EU = projects=20 that aim to implement electronic health records.

There is = consent=20 among European Health ministries that this is a high priority = issue.=20

Healthcare professionals understand the benefits =96 that = an=20 interchangeable patient health record could facilitate cooperation = among=20 professionals, while preventing repetitive tasks and costs. = 		There are relatively few = examples of=20 so-called =91transmural care=921.=20

Cooperation between different care institutions remains = difficult.=20

The implementation of the required systems is often seen = as an=20 activity falling outside an institution=92s normal budget. =

The=20 willingness and ability of healthcare staff to accept and manage = change is=20 seen as a major obstacle to implementing EHR. =
Opportunities Threats
As =91managers=92 of their personal = information,=20 citizens will be empowered to manage their own = healthcare.

Not=20 duplicating data when a patient moves from one care institution to = another=20 reduces the risk of data errors and enables institutions to focus = on their=20 primary task of caring. 

Information brokers and = middleware=20 solutions will become an important area of development. =

The=20 diversity of solutions already available presents a rich learning=20 opportunity.

There is an opportunity for close cooperation = on=20 standards setting.

Continuing proliferation of eHealth=20 applications is likely to provoke moves towards providing shared = access=20 infrastructures.		 A shift in professionals=92 = attitude is=20 required: it should become a client-oriented process. This = requires people=20 to cooperate beyond the boundaries of their institutions, to = describe the=20 medical history of patients so that it suits all users of the = information.=20

Clearly, this requires large coordination efforts. =

If the=20 question of data protection and certification is not addressed, = the=20 take-up of services might encounter resistance.=20

Synthesis

When combining the strengths, weaknesses, = opportunities and=20 threats above, we can arrive at the following synthesis, reasoning from = the=20 patient outward to the healthcare system:

  • Patients will need to feel comfortable about having their data = stored on=20 electronic media. Although it is often said that a patient will accept = anything in order to improve his/her quality of life, a far stronger = position=20 would be to provide adequate protection of data by using privacy = enhancing=20 technologies. User interfaces will need to be simple so that the = patients feel=20 in control of their data. Also, care should be given to explain the = process of=20 data capture and retention.
  • Secondly, obstacles may need to be overcome in order to encourage = adoption=20 of new technologies by practitioners. Getting the primary care = physician, who=20 is often the patients=92 first contact with the healthcare system, to = =91buy in=92=20 is critical. But achieving this will take more than just money and = clever=20 software. If widespread use of EHR is to become a reality, physicians = will=20 need to be motivated to adopt new work practices and tools. They will = need to=20 see a strong business case outlining the tangible benefits as well as=20 assurances about the reliability of the technology, the = appropriateness of the=20 user-interface, available training, and technical platforms. = Standardization=20 of the exchange of electronic health records and adoption of national=20 standards for entering data is needed in order to avoid = misinterpretation of=20 information.
  • Thirdly, there are the technical challenges related to developing = the=20 hardware, software, and technical support to operate and maintain the = EHR=20 network. Interoperability of EHRs is critical and will hinge on the=20 development of consistent standards for data collection, storage, and=20 retrieval across organizations and jurisdictions. For the development = of a=20 user interface, key content elements such as the patient=92s problem = list, and=20 the management strategies (including diagnostic testing, medications, = and=20 progress notes), will need to be captured. A structured problem list = could be=20 the means of helping the provider to navigate easily and intuitively = through=20 the relevant summary of patient information. Data entry must be = designed to=20 help the users keep the data accurate and meaningful.
  • Fourthly, and finally, there are the = challenges faced=20 by the healthcare system and policy-makers. Confidentiality and = protection of=20 patient data is something that needs to be emphasized in any European=20 regulations that are adopted relating to e-health system security. In = this=20 field, in particular, a well-coordinated approach between the = authorities at=20 European, national and regional level is needed in order to foster the = exchange of experience and information.

Apart from overcoming the technical = challenges,=20 both patients and medical practitioners need to be convinced of the = benefits of=20 EHRs if they are to be motivated to adopt them

Conclusions

It has become clear that implementation of ICTs in = healthcare=20 can and will only succeed if the services are adapted to the = specificities of=20 the existing healthcare system. Nevertheless, the system itself will = need to=20 evolve in order to facilitate better health services. The crux of EHR as = an=20 enabler of services lies not only in the "e" of electronic, but also in = the=20 organizations, budgets, stakeholders, communication and cooperation that = provide=20 the context of the services.

The implementation of an electronic = health record=20 crosses the boundaries between healthcare and ICTs, as well as invoking=20 organizational, political and economic issues

The implementation of an electronic health record = crosses the=20 boundaries between healthcare and ICTs, as well as invoking = organizational,=20 political and economic issues. If the development of EHR is to progress = on any=20 level (local, regional or EU-wide), there should be close cooperation = between=20 the responsible administrative authorities; including those at European = level if=20 feasible.

However, a number of other issues need to be tackled, = in=20 particular, legal and regulatory issues concerning the ownership of = data, safety=20 and confidentiality of data and minimal requirements to ensure this. In=20 addition, liability in the case of data-loss, corruption or accidental=20 disclosure will need to be addressed. Citizens need to trust that their = data is=20 in safe hands; professionals need to be free to use optimal technology = that=20 suits their needs. Although it remains a challenge, finding the correct = balance=20 between these needs seems solvable.

  • The knowledge in the shape of experience and existing pilots in = Europe=20 will need to be collected and monitored.
  • On-the-ground experience can be benchmarked and tested in = different=20 healthcare contexts: one solution might be more appropriate in one = country=20 than another.
  • More effort is needed to resolve the mentioned legal issues and to = harmonize the regulatory and legal frameworks in the different member=20 states.
  • In some countries efforts to raise awareness will be needed, = either=20 because of lack of information or because of bad examples in the = past.

This will facilitate the role of eHealth initiatives = in=20 balancing the quality, cost and accessibility of healthcare systems in=20 Europe.

Keywords

electronic=20 health record, EHR,=20 patient=20 dossier, ICT,=20 e-health,=20 privacy

Note

1. Transmural care is the care that goes beyond the walls of one = single=20 institution. It is care tailored to the needs of a patient and provided = on the=20 basis of collaboration agreements between generalist and specialist care = providers of different organizations such as hospitals, revalidation = homes, and=20 home care organizations.

References

  • Braun, A. et al. Prospecting e-health in the context of a = European=20 ageing society: quantifying and qualifying needs. ESTO/IPTS,=20 (forthcoming).
  • Huynen, M. and P. Martens. Future health: the health dimension = in=20 global scenarios. ICIS, Maastricht, October 2002.
  • Ligtvoet, A. Prisma Strategic Guideline 2 =96 Health. = Leiden, April=20 2003.
  • PRISMA. Report on changes and trends in service delivery. = January=20 2001. (available on http://www.prisma-eu.net).=20
  • PRISMA. Pan-European changes and trends in e-health services=20 delivery. August 2002. (available on http://www.prisma-eu.net).=20
  • Silber, D. The case for e-health, presentation at the European=20 Commission=92s first high-level conference on e-health. Brussels, May = 2003.=20

Contacts

Andreas Ligtvoet, RAND Europe

Tel.: +31 71 524 51 83, fax: +31 71 524 51 91, e-mail: ligtvoet@rand.org

Marcelino Cabrera, IPTS

Tel.: +34 95 448 83 62, fax: +34 95 448 83 39, e-mail: marcelino.cabrera@jrc.es<= /A>

About the author

  • Andreas Ligtvoet works as policy analyst at = RAND=20 Europe, focusing on (technology) foresight and future studies. One of = his=20 interests is in the effect of new technologies, such as eHealth, on = societal=20 change. He received his Master=92s degree in Science & Policy from = the=20 University of Utrecht, where his research focused on technology = transfer.=20

Contents=20 Report 81

About The=20 IPTS Report

Subscriptio= ns

E-Mail: ipts_secr@jrc.es

= ------=_NextPart_000_0000_01C3F6D3.FB5B41A0 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: http://www.jrc.es/home/report/iptsreport/vol81/english/images/ICT3E810_Fig1.gif R0lGODlhggHrALMAAP///5262Hd5fO7z+EyCuTs8PsXW6HSeyLK2ugAAAAAAAAAAAAAAAAAAAAAA AAAAACH5BAkMAAAALAAAAACCAesAAAT/kMhJq7046827/2AojmRpnmiqrtngvnAsz3Rt33iu73zv /8CgcEgsGo8yCXLJbDqf0Kh0Sg0qq9isdsvterfXr3hMLpvPzjB6zW6731o1fE6v2+8xOX7P7/ur en+Cg4SFOYGGiYqLe4iMj5CRZI6SlZaXT5SYm5ydPJqeoaKioKOmp5KlqKushKqtsLF2r7K1tmi0 t7q7XLm8v8BQvsHExUTDxsnKOsjLzs8wzdBTBgEBBx7WAdNw0txM1dgE2jnV1xLW37gE6l8G4ulC 4ejtY971P9X04NgH2/hg2AGkhi2AASnn/g2kcm/hjQDjsrw7cNBhlIYWZUCkyGVjxYxM/zCCHOBR TMmRR0RanPhxDESFKIeoXPhyDcuYMgXi7HGAYxuILXd+0ik0R885BggELYpjZrukB+pAZbrD6bek S+EcpdqUKFcYWPls/UrDKjSgfrCRLev1a1IgCBIIWCL3x7W1SdpSDVuj7oy5CIoImDtAQOAfY/EO MLtM6Q2/MQQUOAJZiD/FLhgnu/x4boICAuoWqIugAOjCCeIO+Pw57uQBCEIDbr0asOm5sk0fLpuV quZiift6xp0ANeziq2N/9jxZblzCxmu7cI48dejp0GfwXfs72DsddeteH199MHLp4QlLLo/9em33 lbVHxdv91/bO0slHl+se/fABoMFHGP9/5QmIQ3C+6YWTY+D9p19ypUXnn38GoodAhBXewNlX9e0S jw6GFRZYbLBBN5gLJLoQ4oojGhZibIGFWBhhKcrYFHcKopSjIh8mSFWPqZDV4S07ThFfFEAKNWQt SWZhI0McFumQlIs0GdOSsWxYRGyvrReYXKCZ5kJztoV2oWldFrDbMb2NhGUr3yGR2ojFSbaac+MN F9eIAHrGJWxHxFnUm6xYGcRok+VWHGRgtnfeaqBRlxoSVC5E6CqV9iBbf9KNedp7j1ZW2qNEGJrR pacIekSiX/IJmZnYQQqonSUG9poRqi6YqTqmAjHYbr+KCIOJhwVbImAnLrFrPaiasiz/I71a+iw0 uXpSrZvTPhOtJdlO06woPpkS7pXdNrbKtvh86wm63CpZbjLsVvJuY/MWw442Hvhj0Bra9OuvNW3G +426m1gjgb5twoAvAf4kjBBEB/8r8QQNKwwTthZB7M+7BjPs8BLnVOxDx/sKzA3BkIRckck1QLyv E/NoKY/L9RqDcpUMX8yyDfqMW4TLFweq8cfq3GzITRoFbURNP3s8xb1On1rzKu9ERMPO5RQkT09E G6ET01NObUrVSlscBdk+oI0FUWoPZLQfYNuANQ9IG2V1Fm1V3XUyb+9R90NlNxE3DVP1QjjDAPV9 R1KBzzB32gjCgM3eTew4ObNic3Jf/w6PIzafDJHjfcPm0ChOx+U9dI4Ygy5MZA8OjBed+SWh46B6 PgzG/jrstds8eyW9A94FVqR3kWnwwZjuBuJB3A5EUqzvrgPqzijPhswjN44Q9dLr8NYz1qOB/CHD s1P8FibfVf3v0H4uExd8fW+S9jSMTyT7ish/DBfjqv/Fzj4jRvjIcD670I8JCLKfMIJQwF0McAwB FILzpuc+yVGucvKIXvLwVwgFVgUL12qdBrHwuBA6kIOD8B8SItiEBuovCyzkgQdZ8UAvsG+CNojh C3D4wSLosBY17MgB81FBmBWxLFswYQ+UCEQU/oGDThzAD3c4RCQ4b4qwCKIWeGg2KP8wMQ9xQMIX sxhFPqBwjJahHBdrgMYdYJGGZcTDGqMBBRUyg4RV9F4cXbFHqURxjtOy4wKZMMdFaLEKbxxCG1OX RwsSJA3AOCSUqIC9InSrkC8Y4dIaSYo+zgGTYAQZJ+mIpFH28ISwSOTPTFkDVYLugj5AoStDIUkp eDJzHGMl53S5S17Uso68NGCgjtgDKEphkZ1sxSwteYTOLbOXtvSlJ98wTZIEMzOrhOQUQDmIXxrR eLCUATIJR8whVLKF5YRjoa75PE3y4Hazm+H7dOFNDHphnDF4ZtLEmM4m6PMS9QyJGORJymziyp04 4NQOuPnEavKrkfFJDxDOaTt2YtP/a0vJza1eEKES5SBZmaSnQ9EAJI3OIKK4WVMxw5mkhXEAYYsx QiUzpCJS4SA+I6VDQK14MZrGCgZHShtCW/aPjsG0ohAbRzglR0wBSUZNABJPcUojJo1eiDYhvR+m ZCAgqUIKVhMqDVj16IOeRGypLzBr1FJXztxAx6vGOY112BOff8orp2Zoi1vzsyjcvCY9ewIUW7um smYWFR17g4gNOKUc4tT0qwSKVXwY2oedpoSroXIsXNOj0NQNlSQ5y1yPevYxri32PKqB63VeRdfs WFOrqNBrZo2z2eF0donuRJpolTa4fPZTQqt1rHFopRzJupayZsRrGWQL1MmMRlaf/5LoZwSLuwq2 LaYyWI5w9xOp3VjpuiL8rUdf8Cv1IAtFJ6pRi9aE3EYodxIySBF5XQQbGJE3RsV6kudap7VQxoC1 5GVPf0zVtgZmob14sKzX3tCT3l70vyY6j4Fo9drRcQ0tZUDwHRTMTDdUzZ160S5qBrOe6YSpi10R bxNUimJZcHh/EN6BQoOKu21AZSkhjnCAsZOAR0XLIwQdAo0r3MStxhhEU/2ra9vZkpM8GKg6fiyo oGMqJ3sQRudFb3ntKyPXsNgFGp7Fe7v304/WiT3m1CTYcrxjKYvmPN81bT4/G2A0hWYye7JTjxV1 mCGHuQ4vnmdzRzMiNKlIN3ENj/9pJrVfNmpNLyTO8nhfJKMkgRcsdB7umTU9Ib/42aKMCLQQ2jLd 58p1N16Fj3NtyjvxfvhlBrXmPnh2txroxz1h+tJ/PL1kKsL2FD7z6nJIIxtO8xW3jRwHYolAkZDB utU3uDVyNirdAdlmn7YQdfMuJmzopNaxE2Z1DmGZDn2MY5TmpuiBEibtMfVYTdX21JmSINJzcRvc ryluqgUs7vqpOAajPQc6JOYvcSibCAaeAYmeY4V6o6KkLdKyiuhbo5SOl3P/BnjgzEHwfhU0gz5I Vr/J9+tT4PWFxTTs0jI+JmMJs+TiQmsREm6DqdmVqVsEdajH7BKdr3QI8FyCuu3/CfNR4FOmwTx6 DJReg0zjiuWe0PaoOwJ1JJbK5yh/wp/F3AoN21zmT+YpJcHOLZ6PgelAcF4Jq37Hp0kzi2GkFNB9 7utSvl2ZZH+nzv9585pLoe93hQVlsz73qdeR7ad0eCviCHj/Zu/veb8a3XceC26ivZVLjeLlMf8L qcM4Co1feiAn/0rBIb4Tngf66bMGTNxWYfP0jqTZzRB6bGeCJ5Fvu9hlXwvYW7313lv94+W+QVvU /uO3n17udTDBrSfXFr7X+DYPGP3Ef573xl9+WrXfdKNw3/ubtNfsz0DzlFNBkL4V4szHP4fUP12U WKhd9c2fwe8HXhdBljwMs1J+/22mkW/sJz7Cl1UgpEH95wRzk38mF4Dik3fzVw5ecXyQ0zwDmEy8 cID6hz6fo4DEJ1TrAwyEp3ddcBToZzhCZX+Y4H6EtHpbZ1Z59QNOV3T4F4OxN4LMQwbx8g6ktwkq 2EI0iHwwRBEcuHsQuIM8yIAeVmvW93pjMYThB4EoiHpI6GHyNE26k1Y/KDgHxD3gM4UMxnKeVDwY SEj044Rk5Axc6Hfxh1BXiD6N4zrt0IPHdIM8U4EQ+Ft/g0cto4Qn44Wnw4c16EVpuIdGmIFLJ2eY ww2XBoRLsIgWBojA9wKO2IfqkIcEKDiQGHyZSIaS2F/SUg9OdolWtFZbI4HY5v9g6eKHfAA0oqhI hTWKQ1cqG2OKRTYQMaNYCMeKWtcP3+cyUViLGdMPz7ZQvkhCZzV3B5OF3qKKhXANSaUvHdcxOfOL gBMxwyh5GvMyzKgIcmgGPRKN/UKNBpRUG3BUjCg1KOF8uOAuV7JO7IgStIgH8ah4IKGOyzUo20gI D+g3dug7C/JwhSiDDmGPYpCP3GiQg7CPdqCQnYeQ3WQKBGmBMRGRJoiPO8GQcICRd/ePoUCRtOSQ KdSPCwmShtCN1yOODcgVJmkTIokULQmATDGPKamSJJmQL9kGGol9RSGTZcCTDbkXN9lm7hCU/kgV dmUeoKFSt6UFPvmTe6GMRxb/GSNHSURZlE9JBH7hJcZBVfnWXY2FGqqhlWlXlVb5I6tHGnWSKMVx aoEFLGeWlGnZTpixklpxelJVYqsVKeYRGc/lHoqCOygpQDWpCPoEV48FYC8QIJsmIYgRmIKJF2P4 U5MSI3EJKNOlaw+SHNTlRmSpDHSJFMpoI8GSIrFhIpQGI/I1I1+WQ53pmYO5CDl5Nq3pmpghRVAJ QbeJjrUZmQM1m/RSmyIUkMPkm78JnAMAhxm5ifTxmpJghl6Um+RinJIDnVAwiMb5mX1QOGagndKZ B8xJO8rJhNS5E9j5B5NIEOF5nd+5CXqzBZ7YnU23nppDikhCh/AZn/cpN8uGlIC8mJ9d4Z88sxHX uG05A6CHIJ8QmY0spaAGygwIam8UA47SKDINWhUPWnkSOqAV6qAb2qHLdaEeqpshOqIBQaImijcg eqKpqKIsehEp2qID86IwuowzWqMpIaM2Wpw5uqMwiKM8Kn4/GqQWKqREegPlWaSxcKRIung+uqQC 6aRBygJSOqVUWqVWeqVYmqVauqUoEAEAOw== ------=_NextPart_000_0000_01C3F6D3.FB5B41A0 Content-Type: image/jpeg Content-Transfer-Encoding: base64 Content-Location: http://www.jrc.es/home/report/iptsreport/vol81/english/images/h1.jpg /9j/4AAQSkZJRgABAgAAZABkAAD/7AARRHVja3kAAQAEAAAANwAA/+4ADkFkb2JlAGTAAAAAAf/b AIQABwUFBQUFBwUFBwoHBgcKDAkHBwkMDgsLDAsLDhEMDAwMDAwRDhAREREQDhUVFxcVFR8eHh4f IyMjIyMjIyMjIwEICAgODQ4bEhIbHhcUFx4jIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMjIyMj IyMjIyMjIyMjIyMjIyMjIyMj/8AAEQgAFQJYAwERAAIRAQMRAf/EAGMAAQEBAQAAAAAAAAAAAAAA AAABAggBAQEAAAAAAAAAAAAAAAAAAAABEAABAgcAAAYCAwAAAAAAAAAAARECEgNTk9MFQVGR0ZIE ItIh4VIRAQEAAAAAAAAAAAAAAAAAAAAh/9oADAMBAAIRAxEAPwDo8IAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAANMgUZADIAZAD IAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADI AZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIAZADIA ZADIAZADIAZADIAZADIAZADIBPz809AI1TzT0X3AjVfCKH4r7gRU+x4RwfBf2KjKw/b8KlPHF+4h Uk+94VaWKLYIVJPv3qOKLYIVJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIU k6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOhe o4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGL aIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJ Oheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXq OGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2 iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohST oXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6jhi2iFJOheo4YtohSToXqOGLaIUk6F6j hi2iFJOheo4YtohSToXqOGLaIVZOheo4otohST796jii2CFWX7vjVpY4tghVSH7fjUp/CL9xCtIn 2PGOD4r+xBWq/wCofivuFVqnnD6L7gPz809P7Av8gf/Z ------=_NextPart_000_0000_01C3F6D3.FB5B41A0 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.jrc.es/home/report/iptsreport/vol81/english/interior.css A:link { FONT-WEIGHT: bold; COLOR: #4583c0; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-DECORATION: none } A:visited { FONT-WEIGHT: bold; COLOR: #0396dc; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-DECORATION: none } A:hover { FONT-WEIGHT: bold; COLOR: #3366cc; TEXT-DECORATION: none } A.location { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.location:link { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #333366; TEXT-DECORATION: none } A.location:visited { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #003366; TEXT-DECORATION: none } A.location:hover { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #ffffff; TEXT-DECORATION: none } A.location:active { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #003366; TEXT-DECORATION: none } .head1tables { PADDING-RIGHT: 3px; BACKGROUND-POSITION: 5px 50%; PADDING-LEFT: 3px; = BACKGROUND-IMAGE: url(../images/h1.jpg); PADDING-BOTTOM: 3px; FONT: 17px = Verdana, Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; COLOR: = #336699; TEXT-INDENT: 20pt; PADDING-TOP: 3px; BACKGROUND-REPEAT: = no-repeat; LIST-STYLE-TYPE: circle; TEXT-ALIGN: left } .head2tables { BORDER-RIGHT: #a6c4e1 1pt solid; PADDING-RIGHT: 3px; BORDER-TOP: = #a6c4e1 1pt solid; PADDING-LEFT: 3px; PADDING-BOTTOM: 3px; MARGIN: 2px; = FONT: bold 11px Verdana, Arial, Helvetica, sans-serif; TEXT-TRANSFORM: = none; BORDER-LEFT: #a6c4e1 1pt solid; COLOR: #3366cc; TEXT-INDENT: 0px; = PADDING-TOP: 3px; BORDER-BOTTOM: #a6c4e1 1pt solid; TEXT-ALIGN: center } .head3tables { PADDING-RIGHT: 5px; PADDING-LEFT: 20px; LIST-STYLE-POSITION: outside; = BACKGROUND-IMAGE: url(../images/h3.jpg); LIST-STYLE-IMAGE: = url(../images/bullet0.jpg); PADDING-BOTTOM: 3px; MARGIN: 2px; FONT: = bolder 12px Verdana, Arial, Helvetica, sans-serif; VERTICAL-ALIGN: = middle; COLOR: #d28048; BACKGROUND-REPEAT: no-repeat; WHITE-SPACE: = nowrap; TEXT-ALIGN: left; TEXT-DECORATION: none } .head4tables { PADDING-RIGHT: 5px; LIST-STYLE-POSITION: outside; LIST-STYLE-IMAGE: = url(../images/bullet0.jpg); PADDING-BOTTOM: 3px; MARGIN: 2px; FONT: = bolder 12px Verdana, Arial, Helvetica, sans-serif; VERTICAL-ALIGN: = middle; COLOR: #336699; BORDER-BOTTOM: #cccccc 1px solid; = BACKGROUND-REPEAT: no-repeat; WHITE-SPACE: nowrap; TEXT-ALIGN: left; = TEXT-DECORATION: none } .head5tables { BORDER-RIGHT: #a6c4e1 1pt solid; PADDING-RIGHT: 3px; BORDER-TOP: = #a6c4e1 1pt solid; PADDING-LEFT: 3px; PADDING-BOTTOM: 3px; MARGIN: 2px; = FONT: bold 11px Verdana, Arial, Helvetica, sans-serif; TEXT-TRANSFORM: = none; BORDER-LEFT: #a6c4e1 1pt solid; COLOR: #3366cc; TEXT-INDENT: 0px; = PADDING-TOP: 3px; BORDER-BOTTOM: #a6c4e1 1pt solid; BACKGROUND-COLOR: = #e9f1f5; TEXT-ALIGN: center } .listanormTablas { BACKGROUND-POSITION: 5px center; PADDING-LEFT: 25px; BACKGROUND-IMAGE: = url(../images/bullet2.jpg); FONT: 11px Verdana, Arial, Helvetica, = sans-serif; MARGIN-LEFT: 7px; TEXT-TRANSFORM: none; CLIP: rect(auto auto = auto auto); COLOR: #336699; BACKGROUND-REPEAT: no-repeat; TEXT-ALIGN: = left } H1 { BACKGROUND-POSITION: -4px -2px; MARGIN-TOP: 9px; PADDING-LEFT: 5px; = FONT-WEIGHT: bold; FONT-SIZE: 15px; BACKGROUND-IMAGE: = url(./images/h1.jpg); TEXT-TRANSFORM: none; WIDTH: 650px; COLOR: = #336699; BACKGROUND-REPEAT: no-repeat; FONT-STYLE: normal; FONT-FAMILY: = Verdana; FONT-VARIANT: normal; TEXT-DECORATION: none } H2 { FONT-WEIGHT: normal; FONT-SIZE: 13px; WIDTH: 550px; COLOR: #336699; = FONT-FAMILY: Verdana; TEXT-DECORATION: none } H3 { BACKGROUND-POSITION: 2px 0px; PADDING-LEFT: 20px; FONT-WEIGHT: bold; = FONT-SIZE: 13px; BACKGROUND-IMAGE: url(./images/h3.jpg); WIDTH: 550px; = COLOR: #336699; TEXT-INDENT: 0px; BACKGROUND-REPEAT: no-repeat; = FONT-FAMILY: Verdana; TEXT-DECORATION: none } H5 { BACKGROUND-POSITION: 1px 50%; FONT-WEIGHT: bold; FONT-SIZE: 10px; = BACKGROUND-IMAGE: url(./images/bullet2.jpg); MARGIN: 10px; WIDTH: 650px; = COLOR: #006699; TEXT-INDENT: 9pt; BACKGROUND-REPEAT: no-repeat; = FONT-FAMILY: Verdana; TEXT-DECORATION: none } H6 { PADDING-LEFT: 5px; FONT-WEIGHT: bold; FONT-SIZE: 12px; FONT-FAMILY: = Verdana, Arial, Helvetica, sans-serif } BODY { SCROLLBAR-FACE-COLOR: #eff7ff; FONT-WEIGHT: normal; FONT-SIZE: 11px; = SCROLLBAR-HIGHLIGHT-COLOR: #c7eaf6; COLOR: #336699; = SCROLLBAR-3DLIGHT-COLOR: #c7eaf6; SCROLLBAR-ARROW-COLOR: #1e5870; = FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = SCROLLBAR-DARKSHADOW-COLOR: #d1d1d1; SCROLLBAR-BASE-COLOR: #eff7ff; = BACKGROUND-COLOR: #ffffff; TEXT-DECORATION: none; Verdana:=20 } P { PADDING-LEFT: 5px; FONT-WEIGHT: normal; FONT-SIZE: 11px; MARGIN-LEFT: = 5px; WIDTH: 550px; COLOR: #336699; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-ALIGN: justify; TEXT-DECORATION: none } INPUT { BORDER-RIGHT: #a3c6e9 1pt solid; BORDER-TOP: #a3c6e9 1pt solid; = FONT-WEIGHT: bold; FONT-SIZE: 11px; BORDER-LEFT: #a3c6e9 1pt solid; = COLOR: #006699; BORDER-BOTTOM: #a3c6e9 1pt solid; FONT-FAMILY: Verdana, = Arial, Helvetica, sans-serif; BACKGROUND-COLOR: #e0ebf5; = TEXT-DECORATION: none } SELECT { BORDER-RIGHT: #006699; BORDER-TOP: #006699 1pt solid; FONT-WEIGHT: = bold; FONT-SIZE: 11px; RIGHT: 1px; LEFT: 1px; BORDER-LEFT: #006699; = CLIP: rect(1px 1px 1px 1px); COLOR: #006699; BOTTOM: 1px; BORDER-BOTTOM: = #006699; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; TOP: 1px; = BACKGROUND-COLOR: #d9e1f0; TEXT-DECORATION: none } TD { FONT-WEIGHT: normal; FONT-SIZE: 11px; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; TEXT-DECORATION: none } .darktable { FONT-WEIGHT: normal; FONT-SIZE: 10px; COLOR: #336699; FONT-FAMILY: = Verdana, Arial, Helvetica, sans-serif; BACKGROUND-COLOR: #e1e9f0; = TEXT-ALIGN: center; TEXT-DECORATION: none } .darktable2 { FONT-SIZE: 10px; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = BACKGROUND-COLOR: #e9f1f5; TEXT-DECORATION: none } .darktable3 { FONT-WEIGHT: bold; FONT-SIZE: 11px; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #ffffff; TEXT-ALIGN: center; = TEXT-DECORATION: none } .darktable4 { FONT-SIZE: 10px; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = BACKGROUND-COLOR: #f8fbfc; TEXT-DECORATION: none } .darktable5 { FONT-WEIGHT: bold; FONT-SIZE: 12px; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #e1e9f0; TEXT-ALIGN: center; = TEXT-DECORATION: none } .bordetablacontenido { VERTICAL-ALIGN: middle; BORDER-LEFT: 1pt; LINE-HEIGHT: 13px; = LETTER-SPACING: 1px; BACKGROUND-COLOR: #dddfca; TEXT-ALIGN: left } .bordetablatop { BORDER-BOTTOM: #b1ceeb 1pt solid } .menubody { FONT-WEIGHT: bold; FONT-SIZE: 11px; BORDER-LEFT: #b1ceeb 1px solid; = COLOR: #004986; FONT-FAMILY: Arial, Helvetica, sans-serif; = BACKGROUND-COLOR: #eff7ff } A.menu { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu:link { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986; TEXT-DECORATION: none } A.menu:visited { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu:hover { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #cc9900; TEXT-DECORATION: none } A.menu:active { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986; TEXT-DECORATION: none } A.menu2 { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu2:link { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #1379c9; TEXT-DECORATION: none } A.menu2:visited { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986 } A.menu2:hover { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #cc9900; TEXT-DECORATION: none } A.menu2:active { FONT: bold 11px Arial, Helvetica, sans-serif; TEXT-TRANSFORM: none; = COLOR: #004986; TEXT-DECORATION: none } .menuele { PADDING-LEFT: 10px; MARGIN-LEFT: 15px; BORDER-BOTTOM: #b1ceeb 2px solid } UL { PADDING-LEFT: 27px; MARGIN-LEFT: 20px; WIDTH: 545px; COLOR: #336699; = LIST-STYLE-TYPE: square; TEXT-ALIGN: justify } LI { PADDING-LEFT: 5px; FONT-WEIGHT: normal; FONT-SIZE: 11px; MARGIN-BOTTOM: = 5px; MARGIN-LEFT: 5px; VERTICAL-ALIGN: top; WIDTH: 450px; COLOR: = #336699; FONT-FAMILY: Verdana, Arial, Helvetica, sans-serif; = LIST-STYLE-TYPE: square; TEXT-ALIGN: justify; TEXT-DECORATION: none } .boxalineado { BORDER-RIGHT: #e1e9d9 2pt solid; PADDING-LEFT: 5px; FONT-WEIGHT: = normal; FONT-SIZE: 11px; MARGIN-LEFT: 5px; COLOR: #336699; = BORDER-BOTTOM: #e1e9d9 2pt solid; FONT-FAMILY: Verdana, Arial, = Helvetica, sans-serif; BACKGROUND-COLOR: #e1e9f0; TEXT-ALIGN: justify; = TEXT-DECORATION: none } .centrado { PADDING-LEFT: 5px; FONT-WEIGHT: normal; FONT-SIZE: 11px; MARGIN-LEFT: = 40px; WIDTH: 450px; COLOR: #336699; FONT-STYLE: italic; FONT-FAMILY: = Verdana, Arial, Helvetica, sans-serif; TEXT-ALIGN: center; = TEXT-DECORATION: none } H4 { BACKGROUND-POSITION: 2px 0px; PADDING-LEFT: 20px; FONT-WEIGHT: bold; = FONT-SIZE: 11px; BACKGROUND-IMAGE: url(./images/h3.jpg); WIDTH: 550px; = COLOR: #336699; TEXT-INDENT: 0px; BACKGROUND-REPEAT: no-repeat; = FONT-FAMILY: Verdana; TEXT-DECORATION: none } ------=_NextPart_000_0000_01C3F6D3.FB5B41A0--