EU*US eHealth Work Project’s Global Case Studies

EU*US eHealth Work Project H2020-SC1-HCO13-2016

EU*US eHealth Work ProjectMapping Skills and Competencies; Providing Access to Knowledge, Tools and Platforms; and Strengthening, Disseminating and Exploiting Success Outcomes for a Skilled Transatlantic eHealth Workforce

Authors:

Ursula Hübner, University of Applied Sciences Osnabrück Germany
Toria Shaw, Beth Elias and Sarah Bell, HIMSS Foundation on behalf of the TIGER Initiative
Rachelle Blake, Omni Micro Systems/Omni Med Solutions

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under Grant Agreement No. 727552 EUUSEHEALTHWORK.

Executive Summary

The EU*US eHealth Work Project has been a 21-month project designed to measure, educate, inform and advance eHealth skills, training and workforce development through creation of tools and resources, stakeholder engagement, and contribution to policy evolution regarding digital skills enhancement for healthcare professionals. 

Within the first few months, the Project conducted a comprehensive Survey of Current State and Needs of the eHealth Workforce in order to document real world issues, challenges, and gaps that may be present within the eHealth field. The survey evaluated the impact of education, skills, training and other conditions on the successful development and sustainment of a proficient, digitally-skilled workforce.  In addition to the Survey, the Project also conducted an extensive Gap Analysis on the Survey results, with findings demonstrating 10 major gaps in skills, training, funding and other areas of eHealth workforce preparation, development and advancement.  As a next step, 22 Global Case Studies were compiled to capture examples from institutions and organizations with strategies that showcase and demonstrate real-world issues, challenges and/or gaps that further underscore the findings of both the Survey and the Gap Analysis, as defined below.

The 22 Global Case Studies highlight and enrich the Survey and Gap Analysis results, while concurrently bringing current states and future needs to life in practical ways. They also reveal real-world examples and powerful insights that can be learned from and built upon. In many instances, the Case Studies propose remedies and identify concepts or solutions to help bridge gaps and overcome challenges in key areas within the eHealth infrastructure or provide further access to education. 

Being a European-funded project, the Project made it a priority to include studies from the major areas throughout the European Union (EU); however, being a transatlantic and in fact globally oriented project, the Project also strived to include examples that reflect on-the-ground realities and challenges in the United States (US), as well as in developing countries and regions around the world. All Case Studies are unique and very diverse in nature, but their overall findings and recommendations are also highly comparable in many instances.

In all, the reader will find examples of successes and best practices as well as deficiencies and needs when it comes to eHealth education and training, skills preparation, competency assessment and workforce development.

Survey of Current State and Needs

The Survey of Current States and Needs of the eHealth Workforce gathered information about the current status of skills, skills assessment tools, available formal/informal curriculum and training programs, workplace needs, trends and the future state of eHealth throughout the EU, the US and globally.

The survey assisted with identification of global health IT/eHealth workforce development needs, trends and gaps to help create a bigger picture of how to achieve a highly skilled workforce regionally, across borders and on a global scale. The survey also sought to capture information about health IT skillsets; available curriculum and/or workplace training programs and skills assessment tools; and educational needs, trends and future state mapping.

The survey addressed a variety of actors in eHealth, including participants from the ministerial/political realm, academia, and scientific areas as well as those with healthcare backgrounds. Based on the respondent’s role or sector, the survey led the respondents to role-based questions such as a ministry official, professor, scientist, clinical educator, healthcare worker, etc. The Project Consortium chose a role-based approach and used role-specific questions in a branching manner that led to a customized questionnaire stream tailored to fit respondents from specific sectors.

The survey covered the following topics:

  • Demographics
  • Politics and Government
  • eHealth Training and Education
  • eHealth Skills
  • Gaps
  • eHealth Workforce Status and Interactions
  • Relevance of Competencies for Different Health Professions
  • Additional eHealth Training, Skills and Assessment Questions
  • Additional Online Training Tools / Courses Questions

Overall, the survey goals focused on: 

  • Enabling new workforce members to advance in their organizations
  • Helping incumbent professionals to sustain success in their roles
  • Sharing of personal insights to shape health IT and informatics, enabling a skilled workforce
  • Performing analysis of the results, including analyzing any gaps found
  • Using the published results to measure, inform, educate and benchmark relevant data, such as case study findings, against

The survey represented the flagship deliverable of the project. Survey findings have informed all project deliverables that followed, such as the Gap Analysis, development of global Case Studies and the Foundational Curricula.

Gap Analysis

A Gap Analysis was generated from the Survey of Current State of Needs data. This analysis used descriptive statistics (frequencies and percentages), which followed the logic and structure of the survey. Ten major gaps were identified in the analysis. 

Those gap areas are as follows:

  • GAP 1: eHealth knowledge and skills of healthcare professionals:  The majority of healthcare managers and healthcare workers do not have sufficient digital skills.
  • GAP 2: eHealth knowledge and skills of informal care givers:  There is inadequate training for informal caregivers globally.
  • GAP 3: Knowledge and skills of teachers and trainers: The experience of educators in health informatics and ICT needs to be improved.
  • GAP 4: Availability of courses and programmes at various levels and for various professions: The number of eHealth courses and programmes is limited throughout Europe (and globally).
  • GAP 5: Quality and quantity of eHealth training material: Training material and tools are not available online and/or need to be better designed.
  • GAP 6: Adaptation of job descriptions, training on the job, staff development: There are deficiencies in preparing and training staff, and adjusting job descriptions due to system changes, new tools and methods.
  • GAP 7: eHealth infrastructure: Many countries in Europe (and globally) do not have an appropriate eHealth infrastructure.
  • GAP 8: eHealth usage:  Healthcare professionals are not encouraged to use eHealth, and are not in a position to utilize eHealth to ensure continuity of care.
  • GAP 9: Acceptance and usability of systems: Users are not involved in their organisations to participate in systems engineering and IT life cycle management.
  • GAP 10: Shortage of health professionals and gender disparities: There is a shortage of health care professionals in all countries; there are still gender disparities, particularly in the technology-oriented field.

Finally, based on the results of the gap analysis, EU-US eHealth Work Project Consortium devised the following twelve recommendations as guidelines for “Best Practices” in eHealth workforce development education, training and skills:

  1. Raise the awareness of healthcare decision makers at all levels in terms of eHealth opportunities and applications, job requirements and continuous education needs.
  2. Bridge the gap between ICT and clinicians by providing digital skills to clinicians, by offering clinical workflow insights to information systems specialists, and by sharing informatics methods with all members of the extended healthcare team.
  3. Ensure all healthcare staff are given enough time and training to adjust to implementations, changes and optimizations required by eHealth systems.
  4. Integrate core eHealth competencies into traditional healthcare training, curricula and courseware, including for the standard healthcare professions (e.g., nursing, physicians, pharmacists, allied health, etc.), at all educational levels (from secondary through post-graduate levels), and encourage recognition of eHealth competence through certification.
  5. Equip all those who work with eHealth systems and healthcare technology, including informal caregivers and nonprofessional workers, with the necessary training and skills to use such systems.
  6. Teach the teachers, as they are the gatekeepers at an early stage of education and multipliers at all stages of education and training.
  7. Actively engage and integrate women in eHealth workforce development.
  8. Design eHealth training, including instructor-led, online and blended learning courses, with up-to-date, real-world clinical, informatics and technology scenarios, in modular format when possible, preparing learners to be successful in their roles, from their first day of work throughout their career progression and advancement.
  9. Update and evaluate eHealth courseware and training materials frequently for improved outcomes.
  10. Align eHealth roles with skills and competencies required for success and future growth, along with the required training and education needed to achieve competence in the roles, learning and adapting from occupational standards on local, regional, national and international levels.
  11. Enable healthcare providers to better integrate information technology into clinical workflows by providing them with digital skills, and engaging them in system selection, design and development, testing and training, deployment and optimization.
  12. Promote the industry of eHealth by encouraging, advancing, and strengthening the integration of clinical practice, informatics and technology in the healthcare workforce, especially where the opportunity exists to enhance interoperability, care coordination, and active and healthy ageing.

Additionally, in order to achieve these goals, recommendations for investments were suggested. As the gap analysis showed a that large majority of respondents favoured an increase in research with regard to acceptance, integration and advancement of eHealth, these measures were recommended:

  • To foster research in usability and other human factors
  • To push initiatives at national level to select IT standards and to make these standards mandatory
  • To support activities of:
    • awareness raising of existing eHealth solutions
    • education and training of how to use these systems to solve clinical, care and patient-related problems, and
    • evaluation of innovative eHealth systems.

Case Studies Introduction

With the increasing implementation and use of health information technology (IT) in complex environments, new opportunities as well as new risks have emerged. While electronic access to patient information has become less cumbersome due to the adoption of electronic health record (EHR) systems, unintended consequences of using health IT have been reported1. Exploiting the opportunities and avoiding the risks is not simply a matter of hardware and software but strongly includes the individual professionals involved. All types of healthcare professionals (e.g., nurses and physicians), engineers and systems developers, as well as health informatics (HI) specialists – who are bridging the gap between healthcare providers and technical specialists – are involved. Furthermore, board members, executives and other high-level decision makers are also involved and belong to the group of key stakeholders and decision makers who contribute to the success or failure of a system. All these groups require competencies to use, manage or leverage health IT in their particular role.

New informatics challenges also arise when different disciplines and professions form a team to care for a patient. There can be a lack of communication and coordination between different groups, which can negatively affect the care delivered 2. Much of this inter-professional effort also requires the collaborative use of eHealth and the cooperative development of new electronic systems and applications to ensure high-quality patient care.

Although the HI knowledge base is global, education is local and particularly benefits from case studies that reflect local realities as blueprints. Due to the global nature of eHealth knowledge, there are great opportunities for synergy in cross-country learning. While HI recommendations on competencies and education – particularly international recommendations – serve as highly valuable guides for designing curricula and courses, they cannot show how the content should be situated in a specific and local context due to their generic nature. For this purpose, the case study is a more suitable format.

Case studies usually describe a complex phenomenon from multiple perspectives within a unit or environment where the study takes place. Case studies tell the story of this unit with regard to key questions about this phenomenon and illustrate it so that it becomes clearer, more tangible and more understandable 3,4,5. Case studies also lend themselves as stimulation for discussions and are ideal material from which to learn.

The TIGER (Technology Informatics Guiding Education Reform) Initiative has been addressing educational issues for more than a decade worldwide 6,7. During this time, TIGER has brought many instrumental stakeholders together, with a focus on nursing in the early days and with a wide scope integrating all health professional groups today. The results of TIGER activities have been published as various recommendations on HI education 8. In the last three years, the TIGER International Competencies Synthesis Project (ICSP) compiled learning priorities and core competencies from a global perspective. Most recently, the TIGER ICSP has been presented at global scientific conferences and thus combines global expert views about core competency areas with local case studies 9. It is important to note that findings from the ICSP were leveraged to serve as a foundation upon which the EU*US eHealth Work Project was built.    

This body of work also integrates approaches and findings from other project deliverables, particularly from the Survey of Current States of Needs and Gap Analysis. Thus, our main questions were:

  1. Are the core competency areas identified and investigated in D2.1, the survey of current needs, reflected in the curricula and approaches that are described in selected case studies?
  2. What in-depth information do these case studies provide concerning the gaps in eHealth education as described in D2.3, the gap analysis?
  3. Do the case studies support, enhance or underscore the Best Practice recommendations postulated by the EU*US eHealth Work Project Consortium?

Methodology

In order to answer the three questions stated previously, we needed to develop a methodology that would allow different stakeholders to describe their cases in comparable manners. To this end, we designed a case study template that was structured according to sections and provided guidance on which topics belonged to each section.

Results

In total, 22 groups of case study authors were recruited and 22 case studies were completed. Out of the 22 case studies, there are 15 from Europe, representing 10 European states. There are three from the UK (England, Scotland); two from Norway; and two from Finland – of which one is a multi-national study focused on the central Baltic Region (Estonia, Finland, Latvia). Northern (Denmark, Finland, Norway, Sweden); western (UK); southern (Portugal); central (Austria, Germany, Slovenia); and eastern (Estonia, Latvia) parts of Europe are also represented. In addition to the case studies from Europe, contributions from Asia (China, India, Israel, Saudi Arabia); North America (Canada, US); and Africa (Nigeria) were included.

All authors who volunteered their time to develop case studies are affiliated with major leading institutions in their field and hold a high reputation in their country as experts in the field.

Case studies represent the micro (university), meso (hospital/health system) and macro (country) levels. They are inclusive of courses for different professions and inter-professional courses, different academic levels and training/continuing education, and various approaches of technology-supported learning.

Two micro-level case studies describe IT tools and approaches for learning medical and nursing topics that contribute to building experience with technology. One is a clinical decision support system (CDSS) for nurses that is often used for informal learning, training and continuing on-the-job education in hospitals with installations in Denmark, Germany and Norway. The other is a Massive Open Online Course (MOOC) for an inter-professional audience to acquire competencies to use the necessary eHealth tools and perform high-quality collaborative care.

The meso level is represented by case studies that describe the integration of informatics education and training in healthcare organisations. For example, a case study from the US describes progress on work to integrate a nursing informatics team into the culture of a large health system. A similar macro-level study from Portugal describes informatics aspects integrated in nursing graduate programs, as well as continuing education programs across the country, including the development of national-level competencies.

Many case studies, in particular those from academia, describe the curriculum in full detail and/or show the underlying principles and pedagogic rationale. There are macro-level case studies that look at education from the perspective of an entire country and refer to developed or adapted recommendations or to research and development (R&D) projects in which the educational activities are embedded. For example, a case study from India focuses on building a standardized and competency-based eHealth curriculum and training for various allied health professionals to address an expected acute skill gap of 12.7 million in the healthcare sector by 2022.

1 Karsh, B.-T., Weinger, M. B., Abbott, P. A., & Wears, R. L. (2010). Health information technology: fallacies and sober realities. Journal of the American Medical Informatics Association, 17(6), 617-623. doi: 10.1136/jamia.2010.005637.

2Renfro, C. P., Ferreri, S., Barber, T. G., & Foley, S. (2018). Development of a Communication Strategy to Increase Interprofessional Collaboration in the Outpatient Setting. Pharmacy (Basel), 6(1). doi: 10.3390/pharmacy6010004.

3Baxter P, Jack S. Qualitative Case Study Methodology: StudyDesign and Implementation for Novice Researchers. The Qualitative Report 2008; 13(4). Available from: http://nsuworks.nova.edu/cgi/viewcontent.cgi?article=1573&context=tqr.

4 Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Med Res Methodol. 2011 Jun 27;11:100. doi: 10.1186/1471-2288-11-100.

5Tellis W. Application of a Case Study Methodology. The Qualitative Report 1997; 3(3). Available from: http://nsuworks.nova.edu/cgi/viewcontent.cgi?article=2015 &context=tqr.

6 J. Sensmeier, C. Anderson, T. Shaw, International Evolution of TIGER Informatics Competencies. Stud Health Technol Inform. 2017;232:69-76.

7 M.J. Ball, J.V. Douglas, P Hinton Walker, et.al., Nursing Informatics: Where Technology and Caring Meet. 4th Edition. Springer, London, 2011.

8 B. Gugerty, C.W. Delaney, TIGER Informatics Competencies Collaborative (TICC). Final Report. 2009. http://tigercompetencies.pbworks.com/f/TICC_Final.pdf.

9U.H. Hübner, M.J. Ball, H.F. Marin, et al. Towards Implementing a Global Competency-Based Nursing and Clinical Informatics Curriculum: Applying the TIGER Initiative. Stud Health Technol Inf 225 (2016), 762-4.

Discussion and Conclusion

This robust Case Study compilation is unique, as it is the first to cover such a large number of comparably described educational approaches from around the globe, offering great diversity and indicating the differences among educational activities. It is a continuation of the TIGER case studies within the ICSP, which embraced a smaller number of case studies and was therefore not fully comprehensive. Interestingly, when looking at the individual descriptions, there are many commonalities concerning competencies. All competencies that had been addressed in the survey were found, in one way or another, within the case study descriptions. This also validates the set of competencies that had been addressed in the questionnaire. The differences in the case studies result from the national healthcare system in which they are embedded, and from their focus on either a student’s course or programme or a training for health professionals. National healthcare systems can affect eHealth in many ways; they can be supportive, neutral or full of barriers on the path to implementation. The educational programmes reflect this. It is not by chance that there are many case studies in this compilation from Scandinavian and Baltic states, where eHealth flourishes.

Further, these case studies both illustrate the importance of eHealth education and support many of the Best Practice recommendations made by the Consortium.  They also demonstrate real-world scenarios where eHealth infrastructure is lacking.

However, the case studies are not intended to be representative of an entire country or region. This is not what the case study methodology is meant to achieve. A word of caution needs to be issued regarding how representative these case studies are for a country: they highlight cases from which one can learn much, but the ‘typical case study’ for a country does not exist. Case studies are not meant to be representative but to ask questions about why and how. This is showcased by the rich material within this project and the breadth it mirrors.

Pursuant to this understanding, these case studies should be used as stimulating exemplars that others can either emulate, adapt or modify to begin or continue their own work and initiatives in the field. To this end, all studies are now available to the public, given the consent of the authors, so that they will be able to reach a larger audience.

In addition, these case studies will form the basis for further scientific analyses and publications. In detail, the competencies, gaps and deficiencies addressed will be analysed and further interpreted against the background of the survey findings in due course.

These case studies are excellent learning exemplars that provide a rich resource for those who wish to develop a new curriculum or programme from scratch or to redesign and reshape their materials and approaches. Many of these case studies share common topics across the globe and address similar competencies. The differences occur due to the context of the national healthcare system, which is reflected in examples of eHealth applications, legal restrictions and national programs that foster eHealth use and infrastructure.

Many of the teaching and learning activities employ technology as a supportive medium. The strategies range from fully online programmes to blended learning methods using electronic platforms or integrating webinars.

 

Copyright Notice

©2018 EU*US eHealth Work Consortium Partners. All rights reserved. EUUSEHEALTHWORK is a HORIZON 2020 Project supported by the European Commission under contract No. 727552. For more information of the project, its partners, and contributors please see http://ehealthwork.org. You are permitted to copy and distribute verbatim copies of this document, containing this copyright notice, but modifying this document is not allowed. All trademarks and other rights on third party products mentioned in this document are acknowledged and owned by the respective holders. The information contained in this document represents the views of EU*US eHealth Work Consortium members as of the date they are published. The EU*US eHealth Work Consortium does not guarantee that any information contained herein is error-free, or up to date, nor makes warranties, express, implied, or statutory, by publishing this document.