National eHealth Research Articles

Maturity Assessment of the Health Information System Using Stages of Continuous Improvement Methodology: Results From Serbia.

Since the health information system (HIS) in public health care services in Serbia was introduced in 2009, it has gradually expanded. However, it is unclear how well the HIS components have developed and the whole system's stage of maturity. In June-September 2021, a maturity assessment of the Serbian HIS was conducted for the first time using the HIS Stages of Continuous Improvement (SOCI) toolkit. The toolkit measures HIS status across 5 HIS domains: leadership and governance, management and workforce, information and communication technology (ICT), standards and interoperability, and data quality and use. The domains were further divided into 13 components and 39 subcomponents whose maturity stage was assessed on a 5-point Likert scale, indicating the level of development: (1) emerging/ad hoc; (2) repeatable; (3) defined; (4) managed; and (5) optimized. The toolkit was applied in a working group of 32 professionals and experts who were engaged in developing the new national eHealth strategy and action plan. The overall maturity score of the Serbian HIS was 1.6, which indicates a low level. The highest baseline score (2) was given to the standards and interoperability domain, and the lowest (1.1) was given to ICT infrastructure. The remaining 3 domains (leadership and governance, Management and Workforce, and Data Quality and Use) were similarly rated (1.7, 1.7, and 1.6, respectively). A baseline assessment of the maturity level of Serbian HIS indicates that the majority of components are between the emerging/ad hoc stage and repeatable, which represent isolated, ad hoc efforts, with some basic processes in place and existing and accessible policies. This exercise provided an opportunity to address identified weaknesses in the upcoming national eHealth strategy.

Shared patient information and trust: a qualitative study of a national eHealth system

BackgroundIn Norway, as in other countries, national eHealth systems, such as the Summary Care Record (SCR), have been implemented to improve the collaboration around patients by sharing patient information between health professionals across healthcare institutions and administrative levels. Although widely implemented across the health and care services in Norway, evaluations of the SCR indicate less use than expected. There is a need for analysis that lays out the visions and expectations of the SCR and contrasts these with detailed observations of use in everyday health professional work. This study adds to the eHealth research field by exploring this reality.MethodThis paper has a qualitative design with an ethnographic approach, including participant observation, qualitative interviews, and a document review. Qualitative individual interviews with 22 health professionals and six weeks of participant observation were conducted, and eight documents were reviewed. The field notes and the interview-transcriptions were analyzed following a stepwise-deductive induction analysis.ResultsThe document review identified the expectations and visions of the SCR, including an underlying assumption of trust in shared patient information. However, this assumption is implicit and not recognized as a crucial element for success in the documents. In our observation and interview data, we found that health professionals do not necessarily trust information in the SCR. In fact, several procedures and routines to assess the trustworthiness of SCR information were identified that complicate and disturb the expected use. In our analysis, two main themes characterize the health professionals' handling of the SCR: adapting to workflow and dealing with uncertainty.ConclusionOur study illustrates that unconditional trust in shared patient information is an implicit assumption in SCR policy documents, but in their everyday work health professionals do not necessarily unconditionally trust shared patient information. Rather, sharing patient information through technology, such as the SCR, requires of health professionals to critically assess the digital information. The information in the SCR, as all sources of information presented to health professionals, becomes an item for their constant trust-work. Our study is of value to policymakers, health information systems developers, and the field of practice both nationally and internationally.

Acceptance of electronic referrals across the Kingdom of Saudi Arabia: results from a national e-health database.

An effective referral system is necessary to ensure quality and an optimum continuum of care. In the Kingdom of Saudi Arabia, an e-referral system known as the Saudi Medical Appointments and Referrals Centre (SMARC), has been fully functioning since 2019. This study aims to explore the rate of medical e-referral request acceptance in the KSA, and to study the factors associated with acceptance. This period cross-sectional study utilised secondary collected data from the SMARC e-referral system. The data spans both 2020 and 2021 and covers the entirety of the KSA. Bivariate analyses and binary logistic regression analyses were performed to compute adjusted Odds Ratios (aORs) and 95% confidence intervals. Of the total 632,763 referral requests across the 2 years, 469,073 requests (74.13%) were accepted. Absence of available machinery was a significant predictor for referral acceptance compared to other reasons. Acceptance was highest for children under 14 with 28,956 (75.48%) and 63,979 (75.48%) accepted referrals, respectively. Patients requiring critical care from all age groups also had the highest acceptance including 6,237 referrals for paediatric intensive care unit (83.54%) and 34,126 referrals for intensive care unit (79.65%). All lifesaving referrals, 42,087 referrals, were accepted (100.00%). Psychiatric patients were observed to have the highest proportion for accepted referrals with 8,170 requests (82.50%) followed by organ transplantations with 1,005 requests (80.92%). Sex was seen to be a significant predictor for referrals, where the odds of acceptances for females increased by 2% compared to their male counterparts (95% CI = 1.01-1.04). Also, proportion of acceptance was highest for the Eastern business unit compared to all other units. External referrals were 32% less likely to be accepted than internal referrals (95% CI = 0.67-0.69). The current findings indicate that the e-referral system is mostly able to cater to the health services of the most vulnerable of patients. However, there remains areas for health policy improvement, especially in terms of resource allocation.

Disparities and outcomes of immune checkpoint inhibitor therapies in LMICs: Retrospective study on current state, efficacy, and challenges in Armenia.

e23315 Background: The escalating incidence of cancer in Armenia is a global trend, underscoring the urgency for innovative treatments, including immune checkpoint inhibitors (ICIs). This study, a first in the region, investigates ICIs' real-world impact, emphasizing the current state and critical gaps in access to care. Methods: We conducted a retrospective review of 224 patients, excluding 32, resulting in 192 patients treated with ICIs between 2017 and 2023 across four major oncology centres. The review covered demographic and clinical data, genetic testing, treatment regimens, and survival outcomes, analyzed using the STATA 18 BE. Results: The mean age of the patients was 61.4 years, with 69.27% being male. Lung cancer was the most common diagnosis (42.19%, n = 81), followed by melanoma (11.98%, n = 23) and gastric cancer (10.94%, n = 21). Survival outcomes varied, with melanoma patients exhibiting a mean overall survival (OS) of 33.26 months, lung cancer patients 19.69 months, and gastric cancer patients 20.50 months; the survival difference between patients with metastases and without was not statistically significant. Patients receiving ICIs in the second or later lines of treatment had a 2.12-fold lower chance of survival compared to those receiving them as first-line treatment (95% CI 1.16-3.88, p = 0.014). 78% of patients received ICIs in the metastatic setting and only 22% in curative. In two centres, among 185 patients with metastatic lung cancer, only 23.2% (43 patients) received ICIs, and of these, about 50% underwent mutation testing, with only 4 assessed via broad panel NGS. A significant 76.8% (142 patients) did not receive immunotherapy. Furthermore, 34% of those starting ICI treatment were forced to discontinue due to financial hardships. Pembrolizumab and Nivolumab were the most widely used agents, but the choice varies significantly between centres. Conclusions: The financial barrier is substantial: the cost of one pembro cycle on the black market, at $3,000, is 3.8 times the annual income of those at the national poverty line, more than twice the income of the lower middle-income class, and represents over 60% of the country's GDP per capita. Median cycle lengths for ICIs, such as 6.5 for Ipil+Nivo and 5.61 for Pembro, are below the NCCN's standard recommendations, highlighting the profound impact of financial constraints on treatment adherence and duration. This study reveals the stark reality of ICI accessibility and affordability in Armenia, where a significant portion of cancer patients are unable to benefit from these potentially life-extending treatments. Additionally, a preference bias towards selecting treatments without nationwide guidelines was observed, alongside the absence of a national E-health database, underscoring the need for policymaker attention, insurance adjustments, and more precise, prospective data collection.

Connecting the Electronic Medical Records in the European Union – Where Do We Stand and Where Does It Go?

The editorial discusses the integration of eHealth systems in the European Union (EU) through the eHealth Digital Service Infrastructure (eHDSI) project. The EU's unique approach to integration involves overcoming language and system differences among its 27 member states. The European Directive 2011/24/EU emphasizes patients' rights in cross-border healthcare, pushing for interoperability in national eHealth systems. The eHDSI project aims to facilitate emergency cross-border healthcare. It involves National Contact Points for eHealth (NCPeH) in each country, connecting through standardized interfaces. The project covers Patient Summary (PS) exchange, electronic prescription (eP), dispensation (eD), and Original Clinical Documents (OrCD) exchange. Despite its progress, the eHDSI faces challenges, including language diversity and differences in national healthcare systems. Key performance indicators (KPIs) reveal operational details, with 11 NCPeHs established by 2023. While eP/eD services are more developed, PS exchange and OrCD usage remain limited. Although eHDSI seems to be a viable project, its real-world usage is currently low. This can be attributed to technical complexities and incomplete implementation. Broader use should be pursued instead of expanding the system's capabilities. The complexity of the eHDSI and its implementation could pose additional challenges, and widespread use may not be achieved before 2030.

Significant differences in the length and weight measurements of Jordanian infants compared to the World Health Organization 2006 growth standards.

In 2006, the World Health Organization (WHO) introduced new growth standards based on data derived globally from optimally nourished breastfed infants. The aim of this study was to assess the effects of implementing WHO growth standards on the growth patterns of Jordanian infants. In addition, it was to ascertain the necessity of establishing country-specific growth standards and charts tailored to Jordanian infants. The data of 102,846 infants (50.1% boys, 49.9% girls) aged 0-24 months, from 115 primary healthcare centers across the country were retrieved from a National E-health Program. Weight and length measurements were analyzed, and age- and sex-specific z-scores were calculated relative to the WHO growth standards. Data was analyzed using SPSS version 26. Mann-Whitney U test was performed to determine significant differences between the measurements for boys and girls in terms of age, length, and weight. Jordanian infants exhibited significantly shorter length-for-age measurements than WHO standards with mean z-scores of -0.56 and -0.38, for boys and girls, respectively. Weight-for-age measurements showed a good fit and were comparable to the WHO growth standards for boys (mean z score = -0.05) and girls (mean z score = 0.04). Notably, Jordanian infants displayed higher weight-for-length measurements, with mean z-scores of 0.51 for boys and 0.47 for girls. The availability of Jordanian-specific growth standards will improve the accuracy of assessing infant growth and enhance the monitoring and evaluation of their health and development.

Tanzania's and Germany's Digital Health Strategies and Their Consistency With the World Health Organization's Global Strategy on Digital Health 2020-2025: Comparative Policy Analysis.

In recent years, the fast-paced adoption of digital health (DH) technologies has transformed health care delivery. However, this rapid evolution has also led to challenges such as uncoordinated development and information silos, impeding effective health care integration. Recognizing these challenges, nations have developed digital health strategies (DHSs), aligning with their national health priorities and guidance from global frameworks. The World Health Organization (WHO)'s Global Strategy on Digital Health 2020-2025 (GSDH) guides national DHSs. This study analyzes the DHSs of Tanzania and Germany as case studies and assesses their alignment with the GSDH and identifies strengths, shortcomings, and areas for improvement. A comparative policy analysis was conducted, focusing on the DHSs of Tanzania and Germany as case studies, selected for their contrasting health care systems and cooperative history. The analysis involved a three-step process: (1) assessing consistency with the GSDH, (2) comparing similarities and differences, and (3) evaluating the incorporation of emergent technologies. Primary data sources included national eHealth policy documents and related legislation. Both Germany's and Tanzania's DHSs align significantly with the WHO's GSDH, incorporating most of its 35 elements, but each missing 5 distinct elements. Specifically, Tanzania's DHS lacks in areas such as knowledge management and capacity building for leaders, while Germany's strategy falls short in engaging health care service providers and beneficiaries in development phases and promoting health equity. Both countries, however, excel in other aspects like collaboration, knowledge transfer, and advancing national DHSs, reflecting their commitment to enhancing DH infrastructures. The high ratings of both countries on the Global Digital Health Monitor underscore their substantial progress in DH, although challenges persist in adopting the rapidly advancing technologies and in the need for more inclusive and comprehensive strategies. This study reveals that both Tanzania and Germany have made significant strides in aligning their DHSs with the WHO's GSDH. However, the rapid evolution of technologies like artificial intelligence and machine learning presents challenges in keeping strategies up-to-date. This study recommends the development of more comprehensive, inclusive strategies and regular revisions to align with emerging technologies and needs. The research underscores the importance of context-specific adaptations in DHSs and highlights the need for broader, strategic guidelines to direct the future development of the DH ecosystem. The WHO's GSDH serves as a crucial blueprint for national DHSs. This comparative analysis demonstrates the value and challenges of aligning national strategies with global guidelines. Both Tanzania and Germany offer valuable insights into developing and implementing effective DHSs, highlighting the importance of continuous adaptation and context-specific considerations. Future policy assessments require in-depth knowledge of the country's health care needs and structure, supplemented by stakeholder input for a comprehensive evaluation.

Digital assistance to support integrated healthcare.

This abstract is devoted to digital assistance as a supportive tool of integrated healthcare. According to the World Health Organization, developing more integrated people-centred care systems has the potential to generate significant benefits to health and healthcare of all people, including improved access to care, improved health and clinical outcomes, better health literacy and self-care, increased satisfaction with care, improved job satisfaction, improved efficiency of services, and reduced overall costs [1]. At the same time, the concept of Digital Health supports the implementation of a person-centred integrative approach in healthcare. The European Commission published a Communication on the digital transformation of health and care, which identified the priorities, including personalised medicine through shared European data infrastructure, allowing researchers and other professionals to pool resources, and citizen empowerment with digital tools for user feedback and person-centred care using digital tools to empower people to look after their health, stimulate prevention and enable feedback and interaction between users and healthcare providers [2].
 A project to develop a digital assistance platform for long-COVID and associated myalgic encephalomyelitis/ chronic fatigue syndrome (ME/CFS) patient healthcare is planned in Latvia. The current main challenge is diagnosis, stratification and monitoring of long-COVID and associated ME/CFS at the point of care, as well as patients’ self-awareness and proper practical navigation within the health system. A technology-grounded solution for m-Health based screening and self-management of ME/CFS will be developed within the patient-centred App model. The objectives of this model are: 1) Patient-centred, societally-oriented, real-time decision-support using an innovative App; 2) Using artificial intelligence to support decision-making on patients and treatment options; 3) Learning opportunities for patients, caregivers and health professionals about the illness. Sustainability of project activities will be supported by integrating of the new databases with the national e-Health and Electronic Health Records (EHRs) systems and national research institutions’ IT systems with the future option to become a base for further developing a common long-COVID and ME/CFS Patients’ Registry.
 The project intends to actively involve patients and clinicians in the development of a fully-fledged digital assistance platform that will support the development of digital health literacy and the implementation of integrated healthcare principles.
 
 
 

Association between hyponatremia, inflammation, and mortality in patients undergoing peritoneal dialysis: A nationwide observations.

Hyponatremia is the most common electrolyte disorder often present in peritoneal dialysis (PD) patients. The aim of this retrospective study was to investigate the effect of hyponatremia on mortality in patients undergoing PD. The health records of adult individuals with an inserted PD catheter identified via the centralized national e-health database were used. The mean age of the 846 patients included in the study was 52.48 years (±14.6). The mean sodium level was 136.51 mEq/L. Sodium levels <137 mEq/L were associated with higher death risk independent of comorbidities. There was a 0.821 times less reduction in mortality for each mEq /L increase in serum sodium. Our study provides evidence that monitoring and adjusting serum sodium levels is crucial in managing PD patients with hyponatremia, as low serum sodium level was found to be a significant and independent predictor of mortality.

Insight into the Digital Health System of Ukraine (eHealth): Trends, Definitions, Standards, and Legislative Revisions.

This article aims to provide an in-depth examination of the digital health system of Ukraine, focusing on the emerging trends, precise definitions, established standards, and recent legislative revisions that shape the practice and implementation of eHealth solutions within the country. The digital health landscape in Ukraine has witnessed significant transformations, especially in the wake of the COVID-19 pandemic and subsequent military conflicts. These events have catalyzed the expansion of telemedicine services, leading to innovative approaches in healthcare delivery. The national strategy underscores the necessity for human-centric and accessible telemedicine, reinforced by technological neutrality, and harmonization with global standards. A review of the current literature, national strategies, and legal documents was conducted, alongside an analysis of data usage and service provision patterns in various Ukrainian regions. Participation in the "Science for Safety and Sustainable Development of Ukraine" competition facilitated project initiatives like the development of a cloud-based platform for patient-centered telerehabilitation for oncology patients. The utilization of telemedicine has significantly increased in conflict-affected regions, demonstrating the need for, and the effective deployment of, digital health strategies under crisis conditions. Private health facilities and entrepreneurs have been pivotal in the provision of telemedicine services. Legislative efforts have been geared toward framing telemedicine as an integral component of the national eHealth system, ensuring interoperability, and aligning with international standards and the Internet of Medical Things (IoMT). The findings underscore the resilience and adaptability of the Ukrainian healthcare system in the face of adversity. There is a clear trend towards a more integrated, patient-focused, and technologically advanced healthcare model, aligning with international trends and prioritizing public health goals over private profits. This progress, however, is contingent upon continuous development, investment in technological infrastructure, and legislative support to sustain and advance digital health initiatives.

Holistically assessing digital public health systems: The Digital Public Health Maturity Index

Abstract Background In their toolkit on national eHealth strategies, the WHO lists core areas for a holistic approach to digital public health (DiPH) systems: governance, investment, services, infrastructure, interoperability, workforce, legislation, policy, and compliance. However, addressing all of them is challenging, time-consuming, and expensive. Therefore, countries must first assess their DiPH system's maturity to identify gaps or improvement areas and prioritise investments. This ensures that policies align with the system's current state and guide future policy and regulation development. Assessing the system also has international advantages, as global benchmarking and policy learning are possible when multiple countries use the same tool for evaluating their DiPH system's maturity. However, until now, no index asses DiPH systems as comprehensively as the WHO proposes. This is where our research seeks to support public health policymakers by proposing the Digital Public Health Maturity Index (DiPHMI) to holistically assess the maturity of national DiPH systems following the WHO toolkit. Methods We developed the DiPHMI through systematic literature research on the characteristics and requirements of DiPH interventions. Indicators were collected through a Delphi process and compared with validated indicators by the EU, the World Bank, and the ITU. Results Our composite index consists of four main topics: 1. The required ICT infrastructure 2. The legal framework and political support 3. The attitudes of the population and public health workforce toward DiPH 4. The level of national DiPH intervention rollout Each area includes thematic subgroups to measure various aspects of national maturity. It will allow experts and policymakers to systematically assess their DiPH system's strengths, weaknesses, and opportunities. Conclusions We are confident that using the DiPHMI to evaluate and compare European countries will enable the continent to move forward in unprecedented ways. Key messages • The digitalisation of national health systems increases their complexity and needs to be evaluated accordingly. One can only identify its potential and barriers by applying a holistic approach. • The DiPHMI is currently the only tool that follows the holistic approach suggested by the WHO: Supporting ICT infrastructure and legislative, tool-application level, and social interest in tool use.

Recommendations for Developing a Telemedicine Strategy for Botswana: A Meta-Synthesis.

Botswana is developing its eHealth capacity using a National eHealth Strategy. However, that strategy overlooks telemedicine, a potential solution for many healthcare challenges. For telemedicine to benefit Botswana, a telemedicine-specific strategy is required. While establishing a national strategy is a sovereign responsibility, guidance and recommendations can be provided. Using published resources specific to Botswana, key health-related issues were identified. These issues were matched with suitable telemedicine activities and delivery approaches. Recommendations were then derived from these for use in an effective telemedicine-specific strategy for Botswana. From 28 health-related issues, 6 were prioritised. Three telemedicine activities were identified (clinical services, education, and behaviour change), and one delivery approach was chosen (store-and-forward) because they align well with current needs, infrastructure, and mobile phone user capabilities. Since telemedicine has been proven to be effective, efficient, and cost-effective when implemented correctly, this knowledge and experience, plus a recognised strategy development framework, has led to evidence-based recommendations. Specific telemedicine options were identified as examples. As confidence grows, telemedicine options can be expanded to address additional clinical needs and explore alternative activities and delivery options. The recommendations can help the government develop a telemedicine-specific strategy that aligns with the National eHealth Strategy while actively promoting and supporting the adoption and system integration of straightforward telemedicine interventions. This foundation will facilitate the future expansion of telemedicine initiatives for the benefit of all Batswana.

National digital strategies and innovative eHealth policies concerning older adults’ dignity: a document analysis in three Scandinavian countries

BackgroundScandinavian countries are internationally recognised for leading the way in older adult care and in digitally transforming healthcare. Dignity has become a central value in care for older adults in all three Scandinavian countries. Investigating documents about digitalisation in these countries can offer insights into how the dignity of older adults is impacted by digitally transforming healthcare. This study aims to provide knowledge about digital strategies and eHealth policies concerning older adults’ dignity in three Scandinavian countries: Norway, Sweden and Denmark.MethodsNational-level documents by the Norwegian Directorate of eHealth, the Norwegian Directorate of Health, the Swedish Ministry of Health and Social Affairs and the Danish Ministry of Health concerning older adults were used as data sources. In addition, a systematic search of databases, informed by the Joanna Briggs Institute framework for systematic reviews of text and opinion papers, was undertaken to find relevant papers. All extracts concerning national digital strategies or innovative eHealth policies were deductively coded. Thereafter, extracts concerning older adults were inductively coded using a thematic analytic approach.ResultsA total of 26 sources satisfied the inclusion criteria, 14 governmental papers and 12 other papers. The three countries’ national digital strategies focused on access to digital technologies and continuous learning for digital skills. The included papers describing national eHealth policies underlined the importance of placing the patient at the centre of healthcare and how digital systems can increase feelings of safety. Both types of documents concerned access to data, digital device security and the human dimension of care.ConclusionThe findings present evidence on Scandinavian countries’ national digital strategies and innovative eHealth policies concerning older adults’ dignity. The documents describe a lack of digital competence among older adults, resulting disengagement may put their well-being and human dignity at risk. Findings also underline the importance of security and at the same time the human dimension of care: Use of new digital systems must be meaningfully integrated into digital strategies and eHealth policies. All three Scandinavian countries strategies and policies underline the importance of equal access to healthcare services, as thus they promote a stance of dignified care.

Validation of an Interoperability Framework for Linking mHealth Apps to Electronic Record Systems in Botswana: Expert Survey Study.

Electronic record (eRecord) systems and mobile health (mHealth) apps have documented potential to improve health service delivery, resulting in increased global uptake. However, their interoperability remains a global challenge hindering diagnosis, monitoring of health conditions, and data access irrespective of geographic location. Given the widespread use of mobile devices by patients and health care providers, linking mHealth apps and eRecord systems could result in a comprehensive and seamless data exchange within a health care community. The Botswana National eHealth Strategy recognizes interoperability as an issue and mHealth as a potential solution for some health care needs but is silent on how to make mHealth apps interoperable with existing eRecord systems. A literature review and analysis of existing mHealth interoperability frameworks found none suitable for Botswana. As such, it was critical to conceptualize, design, and develop an mHealth-eRecord Interoperability Framework (mHeRIF) to enhance the interoperability pillar of the Botswana National eHealth Strategy and leverage the full benefits of linking mHealth apps with other health information systems. This study aimed to validate the developed mHeRIF and determine whether it requires further refinement before consideration towards enhancing the National eHealth Strategy. Published framework validation approaches guided the development of a survey administered to 12 purposively selected local and international eHealth experts. In total, 25% (3/12) of the experts were drawn from Botswana, 25% (3/12) were drawn from low- and middle-income countries in sub-Saharan Africa, 25% (3/12) were drawn from low- and middle-income countries outside Africa, and 25% (3/12) were drawn from high-income countries. Quantitative responses were collated in a Microsoft Excel (Microsoft Corp) spreadsheet for descriptive analysis, and the NVivo software (version 11; QSR International) was used to aid the thematic analysis of the qualitative open-ended questions. The analysis of responses showed overall support for the content and format of the proposed mHeRIF. However, some experts' suggestions led to 4 modest revisions of the mHeRIF. Overall, the experts' reviews showed that the mHeRIF could contribute to the National eHealth Strategy by guiding the linking of mHealth apps to existing eRecord systems in Botswana. Similarly, the experts validated an architectural model derived from the mHeRIF in support of the first mobile telemedicine initiative considered for national rollout in Botswana. The mHeRIF helps identify key components to consider before and after linking mHealth apps to eRecord systems and is being considered for use as the foundation of such interoperability in Botswana.

Perceptions and attitudes of patients and healthcare workers towards the use of telemedicine in Botswana: An exploratory study.

In March 2020, the Botswana Ministry of Health and Wellness approved a National eHealth Strategy. Although a milestone, the strategy does not mention telemedicine. There is need to address this by developing an evidence-based adjunct strategy for telemedicine to facilitate its introduction and adoption. To do so, several stages of a published eHealth Strategy Development Framework were mimicked. This allowed situational awareness to be created through exploring behavioural factors and perceptions that might influence the adoption of telemedicine in Botswana. The study aim was to explore current issues, concerns, perceptions, attitudes, views, and knowledge of patients and healthcare professionals regarding health-related issues and telemedicine that might influence implementation of telemedicine in Botswana and thereby inform future development of a telemedicine strategy. An exploratory survey study was conducted using different survey questionnaires for patients and healthcare professionals, each using a mix of open- and closed-ended questions. These questionnaires were administered to convenience samples of healthcare professionals and patients at 12 public healthcare facilities in Botswana; seven clinics (three rural; four urban), and five hospitals (two primary, two district, and one tertiary), selected to align with the country's decentralised healthcare structure. Fifty-three healthcare professionals and 89 patients participated. Few healthcare professionals had actively used telemedicine for clinical consults and self-education using telephone calls, cell phone apps, or video conferencing (doctors 42%, nurses 10%). Only a few health facilities had telemedicine installations. Healthcare professional preference for future telemedicine uses were e-learning (98%), clinical services (92%), and health informatics (electronic records (87%). All healthcare professionals (100%) and most patients (94%) were willing to use and participate in telemedicine programmes. Open-ended responses showed additional perspective. Resource shortages (health human resources and infrastructure) were key to both groups. Convenience, cost effectiveness, and increased remote patient access to specialists were identified as enablers to telemedicine use. However inhibitors were cultural and traditional beliefs, although privacy, security and confidentiality were also identified. Results were consistent with findings from other developing countries. Although use, knowledge, and awareness of telemedicine are low, general acceptance, willingness to use, and understanding of benefits are high. These findings bode well for development of a telemedicine-specific strategy for Botswana, complementary to the National eHealth Strategy, to guide more systematic adoption and application of telemedicine in the future.

FAIR Equivalency with Regulatory Framework for Digital Health in Uganda

Abstract This study explores the possibility of opening a policy window for the adoption of the FAIR Guidelines— that data be Findable, Accessible, Interoperable, and Reusable (FAIR)—in Uganda's eHealth sector. Although the FAIR Guidelines were not mentioned in any of the policy documents relevant to Uganda's eHealth sector, the study found that 83% of the documents mentioned FAIR Equivalent efforts, such as the adoption of the National Identification Number (NIN) as a unique identifier in Uganda's national Electronic Health Management Information System (eHMIS) (findability), the planned/ongoing integration of various information systems (interoperability), and the alignment of various projects with international best practices/standards (reusability). A FAIR Equivalency Score (FE-Score), devised in this study as an aggregate score of the mention of the equivalent of FAIR facets in the policy documents, showed that the documents at the core of Uganda's digital health/eHealth policy have the highest score of all the documents analysed, indicating that there is a degree of alignment between Uganda's National eHealth Vision and the FAIR Guidelines. Therefore, it can be concluded that favourable conditions exist for the adoption and implementation of the FAIR Guidelines in Uganda's eHealth sector. Hence, it is recommended that the FAIR community adopt a capacity building strategy through organisations with a worldwide mandate, such as the World Health Organization, to promote the adoption of the FAIR Guidelines as part of international best practices.

National Development and Regional Differences in eHealth Maturity in Finnish Public Health Care: Survey Study.

BackgroundeHealth increasingly affects the delivery of health care around the world and the quest for more efficient health systems. In Finland, the development of eHealth maturity has been systematically studied since 2003, through surveys conducted every 3 years. It has also been monitored in several international studies. The indicators used in these studies examined the availability of the electronic patient record, picture archiving and communication system, health information exchange, and other key eHealth functionalities.ObjectiveThe first aim is to study the national development in the maturity level of eHealth in primary health care and specialized care between 2011 and 2020 in Finland. The second aim is to clarify the regional differences in the maturity level of eHealth among Finnish hospital districts in 2020.MethodsData for this study were collected in 2011, 2014, 2017, and 2020, using web-based questionnaires from the Use of information and communication technology surveys in Finnish health care project. In total, 16 indicators were selected to describe the status of eHealth, and they were based on international eHealth studies and Finnish eHealth surveys in 3 areas: applications, regional integration, and data security and information and communications technology skills. The indicators remain the same in all the study years; therefore, the results are comparable.ResultsAll the specialized care organizations (21/21, 100%) in 2011, 2014, 2017, and 2020 participated in the study. The response rate among primary health care organizations was 86.3% (139/161) in 2011, 88.2% (135/153) in 2014, 85.8% (121/141) in 2017, and 95.6% (130/136) in 2020. At the national level, the biggest developments in eHealth maturity occurred between 2011 and 2014. The development has since continued, and some indicators have been saturated. Primary health care lags behind specialized care organizations, as measured by all the indicators and throughout the period under review. Regionally, there are differences among different types of organizations.ConclusionseHealth maturity has steadily progressed in Finland nationally, and its implementation has also been promoted through various national strategies and legislative changes. Some eHealth indicators have already been saturated and achieved an intensity of use rate of 100%. However, the scope for development remains, especially in primary health care. As Finland has long been a pioneer in the digitalization of health care, the results of this study show that the functionalities of eHealth will be adopted in stages, and deployment will take time; therefore, national eHealth strategies and legislative changes need to be implemented in a timely manner. The comprehensive sample size used in this study allows a regional comparison in the country, compared with previous country-specific international studies.

Commoning Semantic Interoperability in Healthcare

Commons traditionally refer to shared natural resources that are at risk of being depleted or even destroyed. The rules established by commoners offer a way to manage such scarce resources. Through a series of projects on national eHealth patient health records, we have identified another type of shared resources – semantic resources – that would benefit from commons-based governance. Semantic resources are standardised definitions of data that ensure a common understanding of data during processes of data sharing between different actors and systems. In this paper, we first use commons as a lens to explore shared semantic resources and the governance challenges associated with them (e.g. lack of cross-cutting support across many projects). This leads to a better understanding of (1) shared semantic resources as global commons, (2) the relationship between the global and local levels of semantic resource governance and, by observing traces of commoning at the local level, (3) the role of commoning as a crucial concept in the context of semantic interoperability. Second, we introduce the notion of semantic commons to address the governance problems of semantic resources that needs to be continuous and sustainable. In addition, we also contribute to the commons literature by proposing a new area of research for commons scholars. We identify semantic resources in healthcare as an interesting and important type of resource that offers a new perspective on the dynamics of the relationship between global and local commons. We also identify a central role for commoning in healthcare in general as well as in the governance of semantic resources there.

New era in healthcare marketing through digital transformation and CRM

Customer Relationship Management has drastically evolved as a new marketing domain and has already been implemented in all major industries. The technological innovations through CRM systems has already proven successful in the financial and manufacturing domains. And the past one year has seen the drastic technological implementations in the healthcare sector. The purpose of this research is to evaluate the impact of CRM implementations in the hospitals and also to through light how the national e-health card mission of Govt. of India will open the doors to new era of healthcare marketing. The research discusses the benefits and factors that contribute to an increase in adoption of CRM in the hospitals. The research will be based on secondary data analysis integrated with initial primary data collection to determine the impact of CRM and national digital health mission. The study propose adoption procedure of CRM and its key benefits to the healthcare industry. The research will add significantly to the literature of technological innovations for the healthcare industry.

Patients' Access to Their Psychiatric Records - A Comparison of Four Countries.

Several Nordic and Baltic countries are forerunners in the digitalization of patient ehealth services and have since long implemented psychiatric records as parts of the ehealth services. There are country-specific differences in what clinical information is offered to patients concerning their online patient accessible psychiatric records. This study explores national differences in Sweden, Norway, Finland, and Estonia in patient access to their psychiatric records. Data was collected through a socio-technical data collection template developed during a workshop series and then analyzed in a cross-country comparison focusing on items related to psychiatry records online. The results show that psychiatric records online are offered to patients in all four countries, and provide the same functionality and similar psychiatry information. Overall, the conclusion is that experiences of various functionalities should be scrutinized to promote transparency of psychiatric records as part of the national eHealth services to increase equality of care and patient empowerment.