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A Framework for Digital Health Policy: Insights from Virtual Primary Care Systems Across Five Nations [1]

['Divya Srivastava', 'Department Of Health Policy', 'London School Of Economics', 'Political Science', 'Lse', 'London', 'United Kingdom', 'Lse Health', 'Robin Van Kessel', 'Department Of International Health']

Date: 2024-02

Abstract Digital health technologies used in primary care, referred to as, virtual primary care, allow patients to interact with primary healthcare professionals remotely though the current iteration of virtual primary care may also come with several unintended consequences, such as accessibility barriers and cream skimming. The World Health Organization (WHO) has a well-established framework to understand the functional components of health systems. However, the existing building blocks framework does not sufficiently account for the disruptive and multi-modal impact of digital transformations. In this review, we aimed to develop the first iteration of this updated framework by reviewing the deployment of virtual primary care systems in five leading countries: Canada, Finland, Germany and Sweden and the United Kingdom (England). We found that all five countries have taken different approaches with the deployment of virtual primary care, yet seven common themes were highlighted across countries: (1) stated policy objectives, (2) regulation and governance, (3) financing and reimbursement, (4) delivery and integration, (5) workforce training and support, (6) IT systems and data sharing, and (7) the extent of patient involvement in the virtual primary care system. The conceptual framework that was derived from these findings offers a set of guiding principles that can facilitate the assessment of virtual primary care in health system settings.

Author summary Remote consultations in primary care feature in some health systems for several years. With the arrival of Covid-19, there was a concerted widespread effort to move towards remote consultations. But there may be negative impacts on patient care when consultations are not in person. To better understand the impact of remote consultations in primary care we conducted a narrative review and map the findings against the World Health Organization framework of the functional features of health systems. We develop the first iteration of this updated framework that accounts for the heterogenous nature of digital transformations and review the deployment of virtual primary care systems in five leading nations: Canada, Finland, Germany and Sweden and the United Kingdom (England). Seven common themes emerge: the stated policy objectives, regulation and governance, financing and reimbursement, delivery and integration, workforce training and support, IT systems and data sharing, and the extent of patient involvement in the virtual primary care system.

Citation: Srivastava D, Van Kessel R, Delgrange M, Cherla A, Sood H, Mossialos E (2023) A Framework for Digital Health Policy: Insights from Virtual Primary Care Systems Across Five Nations. PLOS Digit Health 2(11): e0000382. https://doi.org/10.1371/journal.pdig.0000382 Editor: Haleh Ayatollahi, Iran University of Medical Sciences, IRAN (ISLAMIC REPUBLIC OF) Received: June 22, 2023; Accepted: October 4, 2023; Published: November 8, 2023 Copyright: © 2023 Srivastava et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the manuscript and its Supporting Information files. Funding: The authors received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist.

Introduction Digital health technologies represent a growing market share due in part to rapid advances in wireless technology and computing power as well as increasing interest in the application of artificial intelligence (AI) in health systems and service delivery, but also patient interest in having faster and easier access to medical care [1]. Digital health technologies used in primary care (also termed virtual primary care [VPC]) allow patients to interact with primary healthcare professionals remotely and through various modes of communication such as email, text, online chat, video or phone calls [2]. With the COVID-19 pandemic reducing or removing the possibility face-to-face appointments, VPC options such as online consultations have become an important element of primary care service delivery [3], which are also actively sought out by their populations [4,5]. Since the start of the COVID-19 pandemic, two-thirds of European Union healthcare providers reported an increase in the adoption of digital technologies to engage with and support patients within their organisation [6]. A survey from the US reported that 80% of patients would like virtual consultations to continue post-pandemic and in Canada, up to one third would like virtual care to be the first point of contact after the pandemic [7,8]. However, the current iteration of VPC may also come with unintended consequences, such as accessibility barriers among patients with lower levels of digital literacy or complex conditions, adverse selection (relatively healthy patients opting out of the public system for virtual care), or cream-skimming [9,10]. The World Health Organization (WHO) has a well-established framework to understand the functional components of health systems, comprised of six building blocks (i.e., leadership and governance; health care financing; health workforce; medical products and technologies; information and research; and service delivery) [11], which are linked to four key health system functions (i.e., delivering services, creating resources, financing, and stewardship [12]. However, the existing framework does not sufficiently account for the disruptive and multi-modal impact of digital transformations across the various building blocks. Therefore, there is a distinct need to reinterpret and update this framework in the context of digital transformations and develop a novel framework with accompanying guiding principles to support a strengthened VPC system. In this article, we aimed to develop the first iteration of this updated framework by reviewing the deployment of VPC systems in five leading countries: Canada, Finland, Germany, Sweden, United Kingdom (UK) with a focus on England [9,13–16]. The five countries were selected based on the extent of integration of the VPC system with the health system and the study team’s areas of expertise. They also reflect a mix of models of delivery, including different levels of decentralisation, financing, implementation, and user uptake [17–22].

Methods We performed a narrative review to identify gaps in the existing WHO building blocks framework and develop the conceptual framework. Five databases (PubMed, CINAHL, EBSCO, Web of Science, Cochrane Review) and Google Scholar were searched. Articles were included if they comprised empirical research, systematic reviews and review articles and were published between 2011 to the first quarter of 2022. Grey literature was identified through Google (Scholar) searches, websites of national institutions, and institutions that conduct health policy analyses (Table 1). Two authors (DS and MD) undertook the primary literature review and cross-checked each other’s findings. PPT PowerPoint slide

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TIFF original image Download: Table 1. Literature search of the narrative review. https://doi.org/10.1371/journal.pdig.0000382.t001 Findings of the review were first clustered in seven overarching categories, which were derived from the original WHO building blocks framework: (1) stated policy objectives, (2) regulation and governance, (3) financing and reimbursement, (4) delivery and integration, (5) workforce training and support, (6) IT systems and data sharing, and (7) the extent of patient involvement in the VPC system.

Discussion This article aimed to advance the WHO building blocks framework to be better fit for purpose in the context of digital transformations in health, in particular VPC. Various implementation issues were identified through the updated framework and narrative review for all five countries. First, for-profit telemedicine has been difficult to regulate in some of the countries reviewed, with new arrangements (often temporary) having to be found with the private sector. Second, difficulties with regards to the coordination and continuation of care remain, particularly due to the lack of integration and data sharing between the public and private VPC systems. Third, disparities and inequalities of access remain a key issue, especially with regards to access to reliable internet and digital literacy [42], [43], particularly for older patients, patients with complex conditions, patients living in rural areas, and lower-income individuals. Fourth, current policies are inadequate to address issues like isolation among GPs who provide remote consultation, the need to develop eHealth competencies in education curricula and ongoing workforce training and support. Fifth, reimbursement has not been sufficiently addressed: fee-for-service is not optimal but remains a widely used payment method for telemedicine. Alternative methods of payment exist but there is less evidence available of how well they work in practice. Finally, reports of inadequate and insufficient infrastructure and lengthy bureaucratic and procurement processes hindered rapid roll-out. These findings align with previous research on digital health in other parts of the healthcare sector [44,45], indicating that these barriers are not specific to the field of primary care and instead may need to be addressed through a more holistic health policy lens [46]. There are opportunities for each country to improve the current use of VPC within the national health system. For example, learning from the large volumes of data being generated both at the national and international level on real-world data and real-world evidence [47]. Country findings Canada. In Canada, there is a need for greater focus on streamlining requirements for VPC systems across the country, strengthening interoperability, putting a greater emphasis on user-centred approaches, and increasing support for health professionals in their training [8,20]. The provincial remit in health presents a challenge in differing approaches to implementation but also an opportunity to learn from varying practices [8]. Strong monitoring and evaluation plans are needed to help inform financial and reimbursement policies. User feedback is used by the private sector to continuously shape digital services, but patients are insufficiently involved in co-creating digital solutions. Finland. In Finland, the government has prioritised the digital health infrastructure over several years [14,27]. For example, the prioritisation in the national repositories of data in primary care has laid the groundwork to understand the impact of VPC systems at an aggregate level. At the same time, a decentralised approach has led to varying degrees of uptake. In particular, further work is needed to support population sub-groups in accessing the VPC system to mitigate inequities in access. For example, on the type of technology used in the VPC and differential impact among population sub-groups. Germany. In Germany, the federal push towards remote consultations has contributed to its widespread availability. For example, over 25,000 practices offer a virtual consultation; but there is a need for more training and support of healthcare professionals in using these platforms [15]. Integrating video consultations with the national Gematik platform (which hosts patient electronic health records) would further facilitate coordination of care for patients and improve interoperability and data sharing where appropriate. The monitoring and evaluation of private and public platforms would support regulation of VPC systems and inform financing and reimbursement policies. Sweden. In Sweden, further policy work is needed to ensure better coordination of care by integrating services, including coordinating IT systems and improving data sharing for better regulatory oversight of the private platform providers of VPC systems, as well as evaluating the current modes of payment and reimbursement of virtual consultations [18]. Building and fostering cooperation between providers, and increasing learning and development opportunities with proper peer support for health care workers is needed. A focus in improving inclusion and strengthening a user-centred approach would inform the monitoring of VPC system but also identify areas to improve access to population sub-groups. United Kingdom (England). In England, the multiplicity of decision-making bodies poses a real challenge with coordination and communication, making it difficult to provide a clear national steer to facilitate the implementation of a robust VPC system [36]. For example, a more focussed approach to collect information on the use of VPC system in both private and public settings including user feedback would inform the regulatory response and inform pricing and reimbursement policies. There is a need for greater policy focus to address the bureaucratic, procurement processes, inadequate infrastructure and insufficient workforce training and support. Limitations There are limitations in our analysis that should be noted. Our study focussed on five countries to capture differences in the policy development, implementation and delivery of VPC systems. The narrative review was not systematic in design. The analysis is based on published available information and did not capture policy changes beyond 2022. We are unable to verify the published information with corroboration from field experts, though we did draw on expertise of the study team to compliment the narrative review. We note that the referenced publications are predominantly in English and so is not exhaustive of publications in each country’s native language, which may be especially relevant for our collection of grey literature. This framework has implications to understand secondary and tertiary care services, particularly around coordination of care involving electronic health records for example and is an important policy area worthy of future work but was outside the scope of this analysis [44].

Conclusion In conclusion, the implementation of VPC within a health system is a complex challenge that is contingent on many stakeholders. Our proposed digital health policy framework and guiding principles can be a useful starting point to assess how VPC systems are working in practice. The growing interest in VPC suggests that decision-makers should consider a flexible VPC offer; one that is more appropriate at identifying patients and draws on user experience to inform the design of its delivery, the health impacts and particularly for underserved populations including affordability of digital devices, and connectivity. A policy to expand VPC policies at scale requires consideration of the financial sustainability including pricing and reimbursement of VPC, the cost of putting in place the required infrastructure, data needs and a well-trained workforce to support its delivery. Ultimately, a well-designed primary care system forms the cornerstone of an effective health system. In the face of rising healthcare costs and health workforce shortages worldwide, it is vital that VPC can be mobilised effectively without the risk of exacerbating existing inequalities or further skyrocketing healthcare costs.

Acknowledgments Martin Brunninger and the Austrian Insurance of Health & Social Care provided valuable feedback on earlier drafts.

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[1] Url: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000382

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