Digital health services and rural healthcare access: Evidence from China

BackgroundPrevious research suggests that the COVID-19 pandemic caused significant disruption to the lives and mental health of Australians. In response, health services adapted rapidly to digital modes of treatment, prevention and care. Although a large amount of research emerged in the first year of the pandemic, the longer-term mental health impacts, contributing factors, and population-level utilization of digital health services are unknown.MethodsA population-based online survey of 5,100 Australians adults was conducted in October 2021. Psychological distress was assessed with the Kessler 6-item Psychological Distress Scale. Additional survey questions included use and satisfaction with digital health services. Where available, data were compared with our previous survey conducted in 2018, permitting an examination of pre- and post-pandemic digital health service utilization.ResultsIn 2021, almost a quarter (n = 1203, 23.6%) of respondents reported serious levels of psychological distress; participants with pre-existing health related conditions, of younger age, lower educational attainment, those who lost their job or were paid fewer hours, or living in states with lockdown policies in place were at highest risk of serious psychological distress. Almost half of all respondents (n = 2177, 42.7%) reported using digital health technologies in 2021, in contrast to just 10.0% in 2018. In 2021, respondents with serious psychological distress were significantly more likely to consult with a healthcare professional via telephone/videoconferencing (P < 0.001), access healthcare via a telephone advice line (P < 0.001), or via an email or webchat advice service (P < 0.001) than those with no serious psychological distress. Those with and without psychological distress were highly satisfied with the care they received via digital health technologies in 2021.ConclusionRates of serious psychological distress during the second year of the pandemic remained high, providing further evidence for the serious impact of COVID-19 on the mental health of the general population. Those with psychological distress accessed digital mental health services and were satisfied with the care they received. The results highlight the continued need for mental health support and digital health services, particularly for people living with chronic conditions, younger adults and people most impacted by the COVID-19 pandemic, both in the short term and beyond.

With the aging of the population in our country, healthy aging becomes an important strategic objective to improve the quality of life. Digital health services, as an emerging model, use the Internet, big data, artificial intelligence, and other technical means to provide innovative solutions for the health management of the elderly. However, older people have special characteristics in terms of digital skills and health service needs, which lead to many challenges for digital health services in promoting healthy aging. In recent years, the state has issued a series of policies to promote the development of healthy aging, such as the "14th Five-Year Plan for Healthy Aging" and "Opinions on Promoting the construction of Basic Elderly Care Service System", which have provided policy support for the development of digital health servicesexposed problems such as weak infrastructure, supply-demand imbalance, and digital divide. This study adopts literature, logical analysis, expert interviews, and other research methods to the logical path of digital health services to promote healthy aging, analyze the barriers it faces, and propose a corresponding breakthrough path. The study found that the logical path of digital health services to promote healthy aging includes implementing policy requirements, meeting the increasing demand for elderly health services, empowering the elderly health service system, and innovating management models. However, its development faces challenges such as weak infrastructure, insufficient matching of supply and demand, deepening digital divide, coordination of multiple entities, and lack of institutional norms. Digital health services have great potential to promote healthy aging, but they also face many challenges. Measures such as strengthening infrastructure construction, optimizing supply and demand matching, narrowing the digital divide, establishing collaborative mechanisms, and improving institutional norms can effectively improve the quality and accessibility of digital health services for the elderly and promote the development of healthy aging. From the perspective of theory and practice innovation, this study provides theoretical reference and practical reference for China's digital health services to promote healthy aging.

BackgroundThe COVID-19 pandemic has given an unprecedented boost to already increased digital health services, which can place many vulnerable groups at risk of digital exclusion. To improve the likelihood of achieving digital health equity, it is necessary to identify and address the elements that may prevent vulnerable groups from benefiting from digital health services. This study examined the challenges experienced by vulnerable groups in using digital health services during the COVID-19 pandemic.MethodsQualitative descriptive design was utilized. Semi-structured interviews were conducted between October 2020 and May 2021. The participants (N = 74) were older adults, migrants, mental health service users, high users of health services, and the unemployed. Qualitative content analysis with both inductive and deductive approach was used to analyze the data. Challenges related to the use of digital health services were interpreted through digital determinants of health from the Digital Health Equity Framework.ResultsFor most of the participants the access to digital health services was hampered by insufficient digital, and / or local language skills. The lack of support and training, poor health, as well as the lack of strong e-identification or suitable devices also prevented the access. Digital services were not perceived to be applicable for all situations or capable of replacing face-to-face services due to the poor communication in the digital environment. Fears and the lack of trust regarding digital platforms were expressed as well as concerns related to the security of the services. Contact with a health care professional was also considered less personal and more prone to misunderstandings in the digital environment than in face-to-face services. Finally, digital alternatives were not always available as desired by participants, or participants were unaware of existing digital services and their value.ConclusionSeveral development needs in the implementation of digital health services were identified that could improve equal access to and benefits gained from digital services in the future. While digital health services are increasing, traditional face-to-face services will still need to be offered alongside the digital ones to ensure equal access to services.

It is understandable that digital health services are now being developed in the context of a global emergency. However, it is crucial that standards are in place for these services to support their operation in a way that accommodates common interests and objectives and recognises the level of their importance for all stakeholders involved (including service recipients or users). We believe that it is necessary to establish and maintain quality standards for digital health products and services in these conditions. Furthermore, even after the pandemic, the need to integrate digital health services into traditional health and social services will remain a priority. Therefore we consider whether multi-criteria, self assessment tools, supported with artificial intelligence, can raise standards of digital health services that are rapidly developing as a consequence of the COVID-19 pandemic. We believe that such digital services are no longer just an alternative form of health care. It follows that frameworks for the development of standards, accreditation and regulation must also be included as national (or supra-national) priorities. These will help ensure not only technological but also service quality.

Shared decision making (SDM) is based on the clinical expertise of healthcare professionals and patients' preferences and values. Digital health services may offer new possibilities for patient-generated data e.g. in SDM. This study aimed to assess older adults' experiences of decision making in healthcare and attitudes toward digital health and social services. Data were collected via an online survey of 629 respondents. Results showed that digital services are considered beneficial, yet half of respondents needed guidance in their use. Many factors affect SDM and the perceived benefits of digital services. Based on our findings digital services are expected to provide guidance and individualised user experience. More research is needed to provide services with equitable access for people with special needs.

Sophisticated methodological approaches and measures for scaling up are key elements of effective evaluation Digital health technologies and services are significant contributors to the transformation of health care delivery. It has been estimated that 80% of technology projects fail1 due to uncertainty, abandonment and lack of organisational willingness to adopt.2 In response to the high failure rate, the discipline of benefits management has emerged, with the aim of measuring and optimising the value of digital health initiatives. The development and application of benefits management has received some attention,3 but owing to the infancy of the discipline there has been limited assessment of methodological frameworks and their application. In this article, we describe the framework that is being used to measure and quantify the benefits of the My Health Record system in Australia. We consider the strengths and limitations of this framework in the context of existing frameworks, and its ability to demonstrate digital health system benefits. We also identify priority areas for further development of digital health benefit evaluation frameworks. Further, we provide an overview of the approach to digital health system benefits evaluation in Australia, in the context of the My Health Record system. A role of the Australian Digital Health Agency has been to lead the development of the National Digital Health Strategy, to lay the foundations for a safe, seamless and secure health system.4 This strategy comprises seven priority areas to be achieved by 2022. A key strategic priority is to provide health information whenever and wherever it is needed, and this is underpinned by the My Health Record system. My Health Record is a secure online summary of health information which can be accessed by people and their health care providers, and is patient-controlled. It is a personal health record, enabling people to access, manage and share their health information with their clinicians using a range of privacy controls. This functionality includes the ability to decline access to specific documents, set a control to restrict access to the entire record, see an audit trail of any organisations that have accessed the record, and block organisations from viewing the record. The record can contain summary information from general practice, hospital, pharmacy and other health care settings. It may also contain results of investigations, plus documents that patients create themselves (such as advance care plans and personal notes). In addition, it can provide access to Medicare documents such as Medicare Benefits Schedule and Pharmaceutical Benefits Scheme information, the Australian Immunisation Register and the Australian Organ Donor Register. A multimethod evaluation framework has been developed to comprehensively evaluate the benefits of the My Health Record system. It draws on approaches that have been used overseas and assesses the range of clinical contexts in which the system is used. Connecting people to their own health information has been shown to produce a range of benefits relating to patient engagement and a 60–80% improvement in their adherence to treatment regimens.5 In addition, enabling self-management has been associated with significant financial savings in terms of health care costs and avoided hospital admissions.6 It is also theorised that enabling clinicians across different health care settings to share information will result in improved patient safety (eg, fewer medication errors), improved care coordination, a reduction in unnecessarily duplicated investigations, and efficiency gains for clinicians in terms of time savings. In Australia, 2–3% of hospital admissions each year relate to medication misadventure, costing an estimated $1.2 billion annually.7 Improved access to medication information from a range of settings through the medicines information view in My Health Record should provide clinicians with more comprehensive information, and it is hoped that this will result in a reduction of medication misadventure events. Moreover, the use of digital health records to enable test results to be shared has been shown to reduce duplicated pathology tests by 18% per week,8 and in primary care settings it has been found that 13.6% of visits were missing important clinical information.9 Several lessons relating to the application of digital health research and evaluation frameworks have been learned. Many different "key measures" have been described, and there is an overall lack of consensus as to the "who, why, how, when and what" that should apply to an evaluation.10 The impact of this has been a failure to capture the complete range of players involved in the successful delivery of a system — players who do not necessarily share identical perspectives. A recent systematic review recommends that future frameworks present better methods for stakeholder identification and have a greater focus on understanding the context in which the system is delivered. From a systems perspective, this includes usability and organisational impact.10 The foundations of Australia's digital health system benefits evaluation framework are based on applying a range of measurement methods to capture a broad variety of outcome measures, reflecting a multistakeholder National Digital Health Strategy which offers different types of benefits to its different stakeholders. Five benefit workstreams have been introduced to evaluate the My Health Record system using qualitative, quantitative and mixed-method designs, as well as behavioural economic and health economic evaluation methods (Box). These workstreams are: Perceived improvement in access to patients' information and reduction in the need to order pathology tests and diagnostic imaging Self-reported experience of being able to view information that was previously unknown, and saving time requesting information Reduction in adverse medicine-related events through having access to a patient's medicines information Reduction in unnecessary duplication of pathology tests and diagnostic imaging The workstreams have been designed with data sources in mind to assist with planning and prioritising evaluation measures. These have been ranked by feasibility11 and impact, taking into account the relative importance of each measure to different stakeholders.10 To support two of these workstreams — customer and market insights, and impact evaluations — we have taken a similar approach to Canada's Clinical Adoption Framework.3 The impact evaluations workstream in particular focuses on outcomes and how these are being realised. For example, it focuses on measuring usability and adoption of digital tools from clinicians and consumers from their inception and throughout their development. The behavioural economics workstream refers to the evaluation methods which aim to measure change in the behaviour of system users (eg, clinicians and patients), organisational issues which can affect adoption, and indicators that would inform change management requirements to improve usability and adoption of digital health services.12 The data analytics workstream enables monitoring of trends in adoption and usage. For example, this workstream is investigating, through data modelling, whether My Health Record use is associated with fewer medication errors and reduced unnecessary duplication of pathology tests, to provide comprehensive results from a range of settings. The health economics evaluations workstream evaluates and forecasts indirect population health outcomes and downstream economic benefits using health economics modelling. For example, it is developing a health economics model to inform the ongoing business case for the My Health Record system, and conducting modelling that will support measurement of current and future benefits. To support an iterative process in product and service design, the Australian Digital Health Agency also undertakes user experience research and agile project management methods.13 The advantage of this approach is that it can deliver user insights which inform continual design and development of new features. Further, conducting field research to observe a range of digital system users in their environment is a way of identifying attributes that can influence the methods and measures used more broadly in our benefits evaluation framework. Current approaches and frameworks that have been developed overseas to support evaluation and benefits measurement of digital health services are at various stages of maturity. An increasing range of methods to evaluate digital health technologies is being supported by publications, which recognise that they are being deployed in complex health systems that require a contextual understanding of users, clinical settings and the policy environment in which they operate. We must not underestimate the challenges of evaluating benefits of digital health system delivery, and new methods to support evaluations continue to be developed and validated.2 Benefits evaluation frameworks offer a platform that can guide researchers and policy makers in generating and translating evidence to support future directions and ongoing investment in digital health services. Recent debates highlight the importance of fostering evaluation designs which combine different research methods, using qualitative, quantitative and co-design principles, as well as process measures1 that we have embedded into our benefits framework. To strengthen our current benefits evaluation framework and overall approach to digital health service evaluation, we are actively introducing methods that ascertain how services can be scaled up, to identify enablers and barriers to implementation across a range of settings.1 In this context, we define scalability as "the ability … to be expanded under real-world conditions to reach a greater proportion of the eligible population, while retaining effectiveness".14 Measuring scalability is not a commonly undertaken process and has been described as poorly understood.15 But the Australian Digital Health Agency is working towards applying these methods to build an understanding of impact. These findings form a picture of how, where and for whom the intervention could have the greatest impact and, conversely, what adaptations are needed for interventions to work across different population groups. A practical example of how this is being undertaken through the Agency is the introduction of and investment in a range of "test bed" studies. Test beds are projects assessing new digital-enabled models of care that are instigated and delivered cooperatively through sustainable and viable partnerships between industry, government and other organisations. Their purpose is to promote innovation to address Australia's highest priority health challenges and generate evidence on how the new approaches improve health outcomes. Currently, there are 15 test beds across Australia which are testing digital infrastructure and integration of digital health into clinical workflows.16 Despite ongoing interest in digital health benefits evaluation frameworks, few examples of their use in evaluation of digital health services have been published. The Australian Digital Health Agency's benefits evaluation framework will be used to justify future funding of digital health and to inform community and clinical education material. Moreover, the findings will be used to inform enhancements of the My Health Record system, ensuring that its progress is relevant and appropriate for clinicians and consumers. We are grateful to Darian Eckersley, from the Australian Digital Health Agency, for advice on product design methods. Many thanks to the broader Research Programs team at the Agency for reviewing parts of this manuscript and commenting on an earlier version. We are all employed by the Australian Digital Health Agency. Commissioned; externally peer reviewed.

Background In line with insights whereby digital health services (DHS) can increase the accessibility and availability of health services, health maintenance organizations (HMO) have developed various DHS, with the aim of improving services and reducing disparities in health. Specifically, the COVID-19 crisis forced HMO to accelerate the use of DHS, to allow for remote health services. Yet, the implementation of technology-based services in healthcare is complex, due to a range of obstacles related to technological, ethical, and human aspects. This study aimed at identifying and comparing the predicting factors of DHS use, including digital health literacy and attitudes towards DHS, to understand its implementation among the four HMO in Israel. Methods The study included a correlative cross-sectional design. Data was gathered via a closed-end questionnaire, distributed through an online panel to 609 Israeli respondents, aged ≥20, regarding demographics and attitudes towards DHS, digital health literacy, and the extent of DHS use. Hierarchical regression was performed to examine whether the research variables predict DHS use. One-way ANOVA was conducted to compare between HMO. Results Higher use of DHS was found to be predicted by ethnicity (Jews), income (average and above), belonging to a certain HMO (Maccabi and Leumit Health Services), positive attitudes towards DHS, and higher digital health literacy (R2=.26). In addition, significant differences were seen between HMO in the degree of use (moderate effect) and attitudes towards DHS (weak effect): members of Maccabi and Leumit Health Services held more positive attitudes towards DHS, and made greater use of them, compared to members of Clalit and Meuhedet Health Services. Conclusions As use of DHS differs across HMO, the latter should act to adapt DHS to meet the characteristics and needs of certain target groups among their members, as a means for increasing the use of digital services. Key messages • HMO should adapt their DHS to meet members’ demographic characteristics and needs. • Adjusting DHS may improve members’ attitudes towards such services and increase their involvement in using them.

BackgroundThe development of digital health services reflects not only the technical development of services but also a change in attitude and the way of thinking. It has become a cornerstone for engaging and activating patients and citizens in health management while living at home. Digital health services are also aimed at enhancing the efficiency and quality of services, while simultaneously providing services more cost-effectively. In 2020, the COVID-19 pandemic accelerated worldwide the development and use of digital services in response to requirements for social distancing and other regulations.ObjectiveThe aim of this review is to identify and summarize how digital health services are being used among patients and citizens while living at home.MethodsThe Joanna Briggs Institute (JBI) methodology for scoping reviews was used as guidance. A search conducted in 3 databases (CINAHL, PubMed, Scopus) resulted in 419 papers. The reporting was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR), and the analysis of the included papers was performed using a framework consisting of 5 clusters describing the use of digital health services. After screening and excluding papers that did not match the inclusion criteria, 88 (21%) papers from 2010 to 2022 were included in the final analysis.ResultsResults indicated that digital health services are used in different situations and among different kinds of populations. In most studies, digital health services were used in the form of video visits or consultations. The telephone was also used regularly for consultations. Other services, such as remote monitoring and transmitting of recorded information and the use the of internet or portals for searching information, were observed as well. Alerts, emergency systems, and reminders were observed to offer possibilities of use, for example, among older people. The digital health services also showed to have potential for use in patient education.ConclusionsThe development of digital services reflects a shift toward the provision of care regardless of time and place. It also reflects a shift toward emphasis on patient-centered care, meaning activating and engaging patients in their own care as they use digital services for various health-related purposes. Despite the development of digital services, many challenges (eg, adequate infrastructure) still prevail worldwide.

The digitalization of public and health sectors worldwide is fundamentally changing health systems. With the implementation of digital health services in health institutions, a focus on digital health literacy and the use of digital health services have become more evident. In Denmark, public institutions use digital tools for different purposes, aiming to create a universal public digital sector for everyone. However, this digitalization risks reducing equity in health and further marginalizing citizens who are disadvantaged. Therefore, more knowledge is needed regarding patients' digital practices and experiences with digital health services. This study aims to examine digital practices and experiences with public digital health services and digital tools from the perspective of patients in the neurology field and address the following research questions: (1) How do patients use digital services and digital tools? (2) How do they experience them? We used a qualitative design with a hermeneutic approach. We conducted 31 semistructured interviews with patients who were hospitalized or formerly hospitalized at the department of neurology in a hospital in Denmark. The interviews were audio recorded and subsequently transcribed. The text from each transcribed interview was analyzed using manifest content analysis. The analysis provided insights into 4 different categories regarding digital practices and experiences of using digital tools and services in health care systems: social resources as a digital lifeline, possessing the necessary capabilities, big feelings as facilitators or barriers, and life without digital tools. Our findings show that digital tools were experienced differently, and specific conditions were important for the possibility of engaging in digital practices, including having access to social resources; possessing physical, cognitive, and communicative capabilities; and feeling motivated, secure, and comfortable. These prerequisites were necessary for participants to have positive experiences using digital tools in the health care system. Those who did not have these prerequisites experienced challenges and, in some cases, felt left out. Experiences with digital practices and digital health services are complex and multifaceted. Engagement in digital practices for the examined population requires access to continuous assistance from their social network. If patients do not meet requirements, digital health services can be experienced as exclusionary and a source of concern. Physical, cognitive, and communicative difficulties might make it impossible to use digital tools or create more challenges. To ensure that digitalization does not create inequities in health, it is necessary for developers and institutions to be aware of the differences in digital health literacy, focus on simplifying communication with patients and next of kin, and find flexible solutions for citizens who are disadvantaged.

Utilising digital health services in the treatment of patients who frequently attend outpatient care could be beneficial for patients' health and the sustainability of health systems but carries the risk of digital exclusion. This study aimed to explore the patterns of acceptance and use of digital health services among frequent attenders (FAs), which may help in the assessment of patients' digital suitability. Persistent FAs (N = 30) were recruited by random sampling from one Finnish municipality. The semistructured interviews were conducted in February-May 2021. We analysed the data with qualitative content analysis using the Unified Theory of Acceptance and Use of Technology (UTAUT) model. Additionally, we quantified the data for two-step cluster analyses to create separate cluster models that grouped FAs based on acceptance and use of (a) digital services for self-management of health and (b) telemedicine services. Based on digital self-management, FAs were defined as Self-Managers, Supported Self-Managers, and Non-Self-Managers. Based on telemedicine use, they were grouped into Telemedicine Users, Doubtful Telemedicine Users, and Telemedicine Refusers. The clusters described different opportunities, awareness, and interest in using digital health services. Referral from professionals seemed to promote digital service use. For some, digital services were not accessible. Our findings emphasise the importance of assessing the suitability of FAs to digital health services, as their readiness to use may vary. Professionals should recommend digital services that support individual health to suitable patients. More accessible digital services could promote digital suitability despite functional limitations.

Effectiveness of interactive digital health services in non-communicable diseases: An umbrella review and evidence synthesis from 26 meta-analyses.

Background Lack of access and use of health services may widen health inequalities, but less is known about the impact of new digitally mediated health services. This study aims to analyse 1) trends in the adoption and use of digital health services across gender, age, and different socio-economic groups and 2) if the digital health services have substituted traditional services. Methods This register-based study included annually 32 000 full-time public sector employees of the City of Helsinki aged 20-59 years 2017-2022. Occupational position was used as an indicator of socio-economic position. Medically certified long-term sickness absence of more than 11 days was used to measure health. The use of digital health services per 100 person-years and the use of traditional health services were analysed using regression analysis. Results In 2017 the use of digital health services was very low but increased yearly until it peaked in 2020 during the Covid 19 -pandemic. Women used digital health services on average 46% more than men. Manual workers used digital health services less than professionals, and the difference was highest in 2019 (estimate -52.35 [95% CI -60.47--44.24] among women and -44.16 [95% CI -48.84--35.48] among men). The effect remained after adjusting for long-term sickness absence (estimate -50.02 [95% CI -58.09--41.96] among women and -44.58 [95% CI -51.28--37.84] among men). Adjusting for health status widened the difference among men from 2020 onwards. Conclusions The results show that socio-economic gradient in the adoption and use of new digital health services are steep and consistent. The difference was higher among men, after adjusting for health services need. New digital health services have partly replaced traditional services. The design of digital health services needs to make sure that lower socio-economic groups can better use these services according to their health needs. Also, traditional health services must remain an option. Key messages • Socio-economic inequalities in the adoption and use of new digital health services are steep. • The design of digital health services needs to make sure that lower socio-economic groups can better use these services according to their health needs.

Towards an improved understanding of the antecedents of digital health service loyalty during a pandemic: An fsQCA approach

Digital mental health interventions are effective and can greatly enhance access to mental health care. They can reach people in remote and low-income areas and reduce the stigma of seeking mental health help by offering anonymity. Despite these benefits, they have not been fully integrated into mental health service delivery. The aim of this study was to understand consumers’ experiences and perceptions of accessing care through digital mental health services. Consumers of three key Australian Digital Mental Health Services completed an online survey about their experience receiving mental health care through digital mental health services. Some consumers were also invited to elaborate on their responses by taking part in a phone interview. A total of 351 participants completed an online survey (overall response rate of 11% of all those invited to take part), and 23 participants of whom also completed a phone interview. Most consumers were female and under the age of 50 years. Overall, consumers were very positive about their experience of using digital mental health services. They appreciated the accessibility, convenience, self-paced nature, therapeutic support, and guidance. Most found the services user-friendly, easy to use and navigate and were satisfied with their experience. A small number of consumers experienced difficulties with technology and internet connections. Most consumers would recommend services to their peers and recommend that digital mental health services be better promoted to improve awareness. Digital mental health services have a vital role in mental health care provision. Further research is needed to examine how digital mental health services can cater to the specific needs of disadvantaged sub-populations and diverse cultural populations and be seamlessly implemented in mental health care systems.

The role of leadership in how digital health services are managed has not been extensively covered. Most of the research concerning leadership in digital services has concentrated on digital service implementation, which represents only one element of leadership. Thus, further research is needed to provide a comprehensive description of leadership in digital services. This study aimed to describe primary care leaders' perceptions of leadership in digital health services. A descriptive qualitative study involving 21 semi-structured interviews was conducted with Finnish primary care leaders in different leadership positions. Inductive content analysis was used to analyse the collected data. The following six main categories were formed: strategic leadership; operative leadership; transformational leadership; competence leadership; remote leadership; and leading collaboration and co-creation. The present research has shown that healthcare leaders require education that will provide adequate digital health capability to face today's complex, and constantly changing, digital healthcare environment.