IN
DEGREE PROJECT COMPUTER SCIENCE AND ENGINEERING, SECOND CYCLE, 30 CREDITS
STOCKHOLM SWEDEN 2020,
Analysis of digital health solutions and the most significant
challenges for rural areas
MARCEL ROTH
KTH ROYAL INSTITUTE OF TECHNOLOGY
ABSTRACT
The problem of insufficient healthcare is particularly noticeable in rural regions. Despite this, there is still little research on the digital transformation of healthcare in rural areas. This thesis aims to bridge the gap between the two research fields of "digital health” and “rural development” to find out the most significant challenges for rural areas when implementing and using digital health solutions. "Rural areas" in this work are referring to areas with low population density and small settlements in the industrialised EU countries.
First of all, a “Digital Health Ecosystem” was developed based on a research review, which served as an overview of the most important factors and stakeholders regarding digital health in general. The “Digital Health Ecosystem” was used as part of the qualitative research method and interview guide to identify the challenges in transferring the overview to rural areas. An interview study was conducted with eight experts from the field of digital health with different backgrounds like technology, economics, social sciences, healthcare systems and smart village.
The results show that digital health in general involves many barriers, which also apply to rural areas. The specific challenges for rural areas could be divided into four main categories: broadband and mobile networks; structural barriers; digital acceptance & competence; rural innovation. The findings reveal that the smart village concept and rural initiatives are still in their early stages and digital strategies and networks will have to spread more widely across the entire countries. Furthermore, services must be better targeted to the specific problems of rural communities. In particular, because the need for digital health solutions is very great in rural areas, where they can counteract problems like lack of healthcare providers and poor healthcare. In this context, all the general and specific challenges should not be considered separately, because the complexity of the ecosystem can only be understood by connecting all the different fields of action.
SAMMANFATTNING
Problemet med otillräcklig sjukvård märks särskilt på landsbygden. Trots detta finns det fortfarande lite forskning om den digitala omvandlingen av sjukvården på landsbygden. Denna rapport syftar till att överbrygga klyftan mellan de två forskningsområdena "digital health" och "rural development" för att ta reda på de viktigaste utmaningarna för landsbygden när de implementerar och använder digitala hälsolösningar. "Landsbygdsområden" avser i detta arbete områden med låg befolkningstäthet och små bosättningar i de industrialiserade EU-länderna.
Till att börja med byggdes ett ramverk, “Digital Health Ecosystem”, baserat på en forskningsöversikt. Detta ramverk fungerade som en översikt över de viktigaste faktorerna och intressenterna beträffande digital hälsa i allmänhet.
”Digital Health Ecosystem” användes som en del av den kvalitativa forskningsmetoden och intervjuguiden för att identifiera utmaningarna i överföringen av översikten till landsbygden. En intervjustudie genomfördes med åtta experter inom området digital hälsa med olika bakgrunder som teknik, ekonomi, samhällsvetenskap, hälsovårdssystem och smart by.
Resultaten visar att det finns många hinder för digital hälsa i allmänhet, som också gäller för landsbygden. De specifika utmaningarna för landsbygden kan delas in i fyra huvudkategorier: bredbands- och mobilnät; strukturella hinder;
digital acceptans & kompetens; landsbygdens innovation. Resultaten visar att det smarta landsbygder och andra typer av liknande initiativ i rurala områden fortfarande befinner sig i sina tidiga stadier och att digitala strategier och nätverk måste spridas mer över hela länderna. Dessutom måste tjänsterna riktas bättre mot de specifika problemen i landsbygdssamhällen. I synnerhet eftersom behovet av digitala sjukvårdslösningar är mycket stort på landsbygden, där de kan motverka problem som brist på vårdgivare och dålig sjukvård. I detta sammanhang bör alla allmänna och specifika utmaningar inte beaktas separat, eftersom ekosystemets komplexitet bara kan förstås genom att koppla samman alla olika handlingsfält.
Analysis of digital health solutions and the most significant challenges for rural areas
Marcel Roth
School of Electrical Engineering and Computer Science KTH Royal Institute of Technology
Stockholm, Sweden marcelro@kth.se
ABSTRACT
The problem of insufficient healthcare is particularly noticeable in rural regions. Despite this, there is still little research on the digital transformation of healthcare in rural areas. This thesis aims to bridge the gap between the two research fields of "digital health” and “rural development” to find out the most significant challenges for rural areas when implementing and using digital health solutions. "Rural areas" in this work are referring to areas with low population density and small settlements in the industrialised EU countries.
First of all, a “Digital Health Ecosystem” was developed based on a research review, which served as an overview of the most important factors and stakeholders regarding digital health in general. The “Digital Health Ecosystem” was used as part of the qualitative research method and interview guide to identify the challenges in transferring the overview to rural areas. An interview study was conducted with eight experts from the field of digital health with different backgrounds like technology, economics, social sciences, healthcare systems and smart village.
The results show that digital health in general involves many barriers, which also apply to rural areas. The specific challenges for rural areas could be divided into four main categories: broadband and mobile networks;
structural barriers; digital acceptance & competence;
rural innovation. The findings reveal that the smart village concept and rural initiatives are still in their early stages and digital strategies and networks will have to spread more widely across the entire countries.
Furthermore, services must be better targeted to the specific problems of rural communities. In particular, because the need for digital health solutions is very great in rural areas, where they can counteract problems like lack of healthcare providers and poor healthcare. In this context, all the general and specific challenges should not be considered separately, because the complexity of the ecosystem can only be understood by connecting all the different fields of action.
AUTHOR KEYWORDS
Digital health solutions in rural areas; rural development; smart village; rural innovation; smart healthcare; digital health ecosystem; ICT in healthcare.
ACM Reference format:
Marcel Roth. 2020. Analysis of digital health solutions and the most significant challenges for rural areas. Master’s thesis. Royal Institute of Technology (KTH), Stockholm, Sweden.
1. INTRODUCTION
One of the most important questions that contemporary societies have to address is how to make people’s communities more liveable and sustainable [1]. An increasing fraction of the value creation in modern society comes from knowledge work using information and communication technology (ICT). As stated in the Digital Agenda for Europe, smart use of technology and exploitation of information will help to address the challenges society is facing like supporting an ageing society, climate change, improving transportation efficiency and mobility, empowering patients and ensuring the inclusion of persons with disabilities [2].
Moreover, social, economic and ecological aspects are inextricably linked to changes brought forward by technological developments [3].
In 2050, the United Nations predicts, almost 70 percent of the world's population will live in an urbanised environment. Besides, cities around the world offer a variety of initiatives on how to make cities more livable and sustainable [4]. But, if the transition to smart infrastructure is important for urban living environments, the transition in rural areas is equally necessary and complex [5].
The World Health Organization (WHO) states that the
“use and scale up of digital health solutions can revolutionize how people worldwide achieve higher standards of health, and access services to promote and protect their health and well-being” [6]. At the same time, health systems are under considerable strain from the
constant ageing of the population and the associated increase in chronic diseases [7]. This development requires frequent visits to healthcare providers and increased demand for hospital stays, which raises the cost of medical treatment [8]. Rural areas in particular are struggling with shortages of sufficient healthcare [9].
Over the past few years, ICT have been increasingly used to make healthcare access and delivery easier and more cost-effective [8]. For example, the rapid spread of COVID-19 is currently posing major challenges for health systems. In this context, innovative digital health ideas show new ways in healthcare that offer sensible options.
But true digital interaction in the treatment process remains a rarity [10]. However, this seems to be changing and the dynamics of the developments are currently enormous and show the potential of digital health solutions, but are associated with a variety of barriers. Moreover, even if new technologies emerge quickly, the implementation of the technologies, the creation of interactions between the technologies, and connections between the human being and technologies are totally different matters [11].
In this context, the field of digital health has attracted wide attention from researchers to address the potential of Internet of Things (IoT) in the healthcare sector by considering various challenges [10]. At the same time, little research is still being carried out in the field of digital health in rural areas, although the problem of insufficient healthcare is particularly noticeable in rural regions [11]. Therefore, it was the goal of this study to provide an overview of the main challenges for rural areas when implementing and using digital health solutions. Because only by addressing critical barriers, solutions can be developed to exploit the full potential of digital health for rural communities in the future.
2. BACKGROUND AND RELATED WORK
This literature study provides a scientific overview of the most important areas and concepts of this study. First of all, the “smart village concept” will be discussed to get a better understanding of the importance of ICT developments in the context of rural communities. The concept and importance of a "digital ecosystem"
regarding digital services will further be explained.
Moreover, general healthcare problems in rural areas are briefly outlined, followed by an insight into the development and character traits of “digital health” and the potential of digital health solutions.
2.1. The Smart Village Concept
“Smart” is often applied as a prefix to technological terms to indicate special capabilities, intelligence and
connectivity [12]. Ho jer and Wangel (2015) argue that it is not so much the individual technological advances but rather the interconnection, synchronization and concerted use of different technologies that constitutes smartness. There is a danger that the increased technical perspective of smart development will neglect sociological and ecological aspects. Although an "ideal"
digital transformation can only be achieved through a balance between the technical-economic and the sociological-ecological view [13]. The concept of smart development has been prominently applied to urban areas and is summarised under the term “smart cities”
[14].
A very broad definition proposed by Cohen states that
“smart cities use ICT to be more intelligent and efficient in the use of resources, resulting in cost and energy savings, improved service delivery and quality of life”
[15]. Given the focus of smart city research, e.g. the role of ICT and its goal for citizen´s well-being and sustainability, makes smart city research scalable.
However, research focused on translating smart city research into the context of rural areas, i.e. smart village research, has just begun [16]. This research on smart villages is meant to address a variety of problems, which inhabitants of villages face in the 21st century [3].
Besides, it is important to state that the concept of smart cities and smart villages are two different cases with variable structures and problems [17].
In the context of the European Union (EU), the smart village concept refers to “rural areas and communities which build on their existing strengths and assets as well as on developing new opportunities. In smart villages, traditional and new networks and services are enhanced by means of digital, telecommunication technologies, innovations and the better use of knowledge for the benefit of inhabitants and business” [18]. In 2017, the EU introduced a new rural development policy concept, the
“EU Action for Smart Villages”. The smart village vision is one where rural communities seize the initiative and drive forward solutions to existing and emerging challenges [19]. Moreover, smart villages are used as a descriptor for communities which have both strong human and social capital, good digital connectivity and whose ability to deliver innovative solutions is high [20].
Recent studies on socio-economic performance in rural European countries show that there are big differences between rural areas when it comes to the risk of social exclusion [21]. In general, socio-economic performance has a strong spatial dimension, with rural regions near wealthy cities being among the higher performing communities [20][21].
2.2. Digital Ecosystem
The world we live in today is becoming increasingly networked and terms such as IoT, data management and digital ecosystems become more established [22]. The term “digital ecosystem” integrates and uses the concepts from natural domain; evolving to the sectors specific ecosystem integrated by digital infrastructures, aimed at creating a digital environment for network services and organisations with common resources and expectations [23]. As part of such ecosystems, stakeholders such as individuals, public and private organisations are increasingly becoming dependent on each other [24]. Moreover, the digital ecosystem is characterised by open, flexible, interactive networked architecture and collaborative environments [25].
Digital ecosystems are therefore focused on interactions between technological agents, such as devices, databases and programs, and respective information flows [12].
On the one hand, connected systems provide enormous opportunities for communities, on the other hand, there are several challenges regarding the development and operation. The development of information systems is often characterized by high complexity, but the integration into increased connected systems raises this complexity even more [22]. For example, the use of municipal data enables mobility services to link various offers of public and private transport with each other or with other services [14]. In addition to the digitisation of the different fields of action, digital services also require horizontal connections via different domains in an open, standardized data platform. While many concepts and implementations of smart development projects end here, the need to shape this technological change from a human and environmental perspective has become more important [26]. In this context, Visvizi et al. recommend a considerate and socially conscious use of ICT and define the village as a community of people, rather than an aggregate, largely de-personalised construct [27][28].
2.3. Healthcare Problems in Rural Areas
The term “rural” evokes many diverse associations, which range from small villages to vast landscapes.
Differentiating between urban and rural is difficult, because the virtual line that must be crossed when leaving a town is continuously blurred [9]. The considerable diversity of taxonomies makes it difficult to generalize and compare scientific findings between countries or regions and hinders the development of an evidence-based understanding of rural healthcare [29].
A study from Weinhold and Gurtner (2014) on shortages of sufficient healthcare in rural areas points out a variety
of problems. Firstly, there is a relative shortage of healthcare professionals in many countries and unavailable healthcare is expressed in regional provider shortfalls, understaffed rural facilities, and consequently in a work overload of local professionals [9].
Another aspect of shortage is the deficient quality of healthcare in rural areas. Quality deficiencies arise from the scope of services that rural providers offer and in the professional level. Quality improvement concepts such as managed and coordinated care are difficult to implement in rural areas. Instead, healthcare is often very fragmented [29]. Rural healthcare frequently implies the management of complex and acute cases that potentially extend beyond a provider’s capacity and competency [11].
Elderly people and patients with multiple or long-lasting chronic conditions have been particularly affected [30].
A lack of integrated care management and support for transitions between different medical facilities can be a serious problem for older people in rural areas [9][31].
Furthermore, there is a lack of sufficient healthcare in terms of geographic access limitations. When the distance that must be overcome to obtain care is longer, inconvenient hours of services, difficulties in making appropriate appointments and long waiting times become a challenge [32].
Although access to healthcare services is critical to good health, rural communities often encounter barriers to healthcare that limit their ability to obtain the care they need. In order to have sufficient access, necessary and appropriate healthcare services must be available in a timely manner. A growing body of literature demonstrates that many of these access barriers to sufficient healthcare can be partly addressed with the use of digital technology and an evolved digital ecosystem [23][31].
2.4. Potential of Digital Health Solutions
Improving the quality of healthcare and improving access to health records while maintaining reasonable costs is a challenge for healthcare organisations [8]. In this context, the introduction of ICT in the health sector is commonly referred to as digital health. The use of ICT has led to the development of, for example, electronic health records (EHR). EHRs contain a complete medical history of the patient and can be exchanged between different providers [8].
Over the years, digital healthcare has expanded from primary maintenance and delivery of electronic patient information to more flexibility and convenience in healthcare management, and is commonly referred to as
connected health [33]. Connected health uses smartphones and mobile applications, as well as wireless technologies such as Bluetooth and Wi-Fi, so that patients can easily connect to their providers without visiting them frequently [8].
Connected health has evolved into smart health, where traditional mobile devices are paired with portable medical devices (e.g. blood pressure monitors, glucometers or smart watches) and IoT devices such as implantable or ingestible sensors [8][34]. IoT systems connect with the internet and exchange information [35].
This enables continuous patient monitoring and treatment even when the patient is at home [8][34]. For example, wearable sensors can act as data collecting units, gathering the physiological signals from the patient’s body. The collected data are then forwarded to a local gateway server via a Wi-Fi network and end- systems can retrieve the data from the gateway server.
This allows physicians access to real-time patient data.
The devices ideally work together to create a unified medical report that can be accessed by various providers. The data is not only useful for the patient, but can be pooled together to study and predict healthcare trends across countries and regions [8][36]. Applying effective analytics to big data can provide physicians with meaningful information that help them make more timely, informed decisions, and take proactive measures to improve health management [8][37]. Community healthcare monitoring is a very useful project in which an IoT-based network is established in a limited area to promote healthcare services remotely to reduce the risks of chronic diseases [10]. This may be a network around a municipal hospital, residential area or rural community.
The linking of several networks can be realised as a cooperative network structure [38].
"Digital health" is used in this thesis as a generic term for all technological applications in the health sector. Apart from the potential of digital health solutions, there are challenges or barriers for rural areas in the implementation and use of such technologies. "Rural areas" in this work are defined as areas with low population density and small settlements in the industrialised EU countries. This thesis aims to bridge the gap between the two research areas of "digital health" and "rural development” to answer the question:
“What are the most significant challenges for rural areas when implementing and using digital health solutions?”.
3. METHODOLOGY
To answer the research question, first of all, a “Digital Health Ecosystem” was built on a research review, based on the resources from the “Background and Related
Work” part and the researcher's own understanding and creativity. During development, the areas to be integrated were first defined and the most important elements of the "digital health" theme were identified and visually structured. The model served as an overview of the most important factors and stakeholders regarding digital health in general and aimed to reduce the complexity of digital health by structuring the most important factors.
Second, the model was used as a guide and reference point for data collection in the form of expert interviews to identify the challenges in transferring the model to rural areas. In this context, a qualitative research method was chosen and data was collected with the help of expert interviews, which were then analysed in terms of content. Expert interviews were chosen for the data collection, because of the lack of sufficient research literature and the many different perspectives considered in the analysis. The heterogeneous composition of eight experts made it possible to cover many different areas of expertise [39][40][41].
3.1. Data Collection
In order to collect qualitative data, experts in the field had to be found and selected. In this context various areas had to be covered – technology, economics, social sciences, healthcare systems or smart village. Expertise in the field of digital health was a major priority for all interviewees, but with different perspectives due to their specific expertise and experience. The overview (Appendix 1.0.) provides an insight into the position at the respective institute or company up to the area of expertise of the experts.
A semi-structured interview was chosen and eight experts were interviewed via video call for approximately 30-40 minutes. The data was collected through video and audio recordings. These interviews did not strictly follow a formalised list of questions, and more open-ended questions were asked, allowing discussions with the interviewees. Nevertheless, there was an interview guide with topics to cover and possible questions that might be asked (Appendix 2.0.). Questions on different predefined topics were planned in advance, but as part of the interview, investigations are continued to follow-up questions in order to gain further insights.
The follow-up questions served to understand the argumentation and causality behind the arguments of the interviewees. The semi-structured interview study made it possible to focus on specific areas during the interview, depending on the expertise of the expert. The flexibility in the interview guide was also important in practice, because this enabled the experts to introduce
topics or find connections that were not included in the interview guide [41].
Besides, a summary of the most important information and explanation of the purpose of the interview was sent to the experts in advance, as well as the interview guide and the "Digital Health Ecosystem" overview. This gave the experts the opportunity to get an understanding for the research question and complexity of the “Digital Health Ecosystem”, and to possibly already identify problems and connections.
3.2. Data Analysis
The central idea of qualitative content analysis is to reduce the material in such a way that the essential content remains, in order to create a comprehensive overview of the most important arguments [39]. In the first step of the data analysis, the most important arguments of the interviews were manually transcribed before the actual coding process could begin. The transcription process served as a first step to filter the content. The goal of the subsequent coding process was to analyse the transcribed material in order to draw conclusions to answer the research question.
An inductive approach was chosen, i.e. categories were derived directly from the material without assigning
them to a predefined category formation. In this process, the transcripts were first divided into individual segments and in the next step labelled with so-called codes. These codes marked each text segment with the main topic or argument. Aspects that related to each other or had the same content were combined and assigned to a newly formed category. After having more details on the codes and categories from the transcribed interviews, the results were summarised by the main categories. In addition, the analysis revealed relationships and connections within the data, which was important in summarising the results [39][41].
4. RESULTS
This part presents the "Digital Health Ecosystem" and the research results of the interviews on the challenges in rural areas regarding digital health.
4.1. Digital Health Ecosystem
The “Digital Health Ecosystem” (Figure 1) is composed of four different layers: society; digital services;
infrastructure; and the cross-cutting layer organisation.
The "society" section provides an overview of the most important stakeholders in the field of digital health. The
“digital services” aim to improve the diagnosis,
Figure 1: Digital Health Ecosystem
treatment and prevention process in healthcare. It is very important that the services address the patient and that the patient is at the center in the development process, as well as in the entire ecosystem model. The problem-solution-fit of services plays a decisive role in ensuring that offers developed or to be developed are seen by the target user as a solution to a relevant problem.
The mentioned services show the most important applications and areas in which they are used: health apps, electronic health records (EHR), telehealth, ambient assisted living (AAL), health wearables, eMedication, data analytics and medical testing. There are more areas of service, but these cover the entire range very well.
The availability of an appropriate digital infrastructure (networks, hardware and software) is a necessary condition for digital health services. Moreover, digital health projects require a significant amount of organisational work. The grey column on the right shows the cross-cutting organisational components in the complex ecosystem of digital health. Five main factors may be necessary, which are strongly linked to stakeholders, as these are the responsible actors who set the organisational framework.
All these layers and components of the digital ecosystem should be combined into a digitisation roadmap that serves as a central vision. Because national or regional digital health initiatives must be guided by a comprehensive strategy that integrates financial, organisational, human and technological resources.
Although this ecosystem tries to reduce the complexity of digital health, there are also connections between the individual factors and stakeholders that are not shown here. For example, in digital platforms, the necessary data is stored and displayed in EHRs through data generation and horizontal linking of all services involved.
The large amounts of data, also known as "big data", are collected using wearables, sensors and medical devices on patients and processed for exchange via networks.
Healthcare providers with access rights under the privacy policy can access the data or simply share EHRs with other physicians or hospitals involved in the patient care process.
4.2. General Challenges
The data analysis has shown that digital health in general involves many barriers, which also apply to rural areas.
For this reason, the most important general factors of the expert interviews were first identified and summarised.
4.2.1. Healthcare system
As part of the public sector, the development of digital health cannot be driven forward without the health system. In this context, E8 said that "developing digital solutions is often not the problem, but rather how they fit into health system governance”. Besides, the countries in the EU have different health systems, but everywhere they set the framework and present barriers. This usually involves the objectives of the organisation, affordability, remuneration or performance of the healthcare system. Most experts mentioned that the health sector is a complex system in itself, in which digital health is not yet profitably and sustainably integrated in most countries. This also makes it difficult to compare digital health across countries, as each health system handles services another way and solutions are integrated differently into existing health systems.
According to E8, “digital health does not behave like other regulatory content that has always existed in the healthcare system”. New approvals are either medications, an instrument or a process. Digital health has the effect of all these three and does not apply to traditional categories of the healthcare system. All health systems have to adapt to that – telehealth is a little bit easier because they make an existing process digital (E8).
4.2.2. Financing of digital health
In the context of the healthcare system, digital health reveals the problem of general underfunding in healthcare and adequate remuneration. According to E2,
"the cost of acquisition is set against the remuneration you get when you consult the patient online. This is one of the main reasons why digital offers are not taken up and why financing plays a major role”. And either “health insurance companies must finance the use of the expensive hardware, make the services billable or it must be subsidised by the state” (E2). E4 stated the problem that “all the listed services and trend topics such as big data and artificial intelligence require large financial resources in order to sustainably roll out solutions throughout the country”. E1 spoke of high development costs in healthcare and mentioned that
“costs of a simple software-based health app until marketability without certification costs are estimated to be at least 150-300.000US$”. In this context, it should first be clarified exactly who pays for the services and how they are remunerated, which is not yet properly regulated in many countries. According to E4, the digital transformation raises the fundamental question of whether digital health should be used to replace or supplement services, which is often not yet sufficiently defined at the political level.
4.2.3. Quality of healthcare (added value versus additional expenditure)
Experts agreed that the time aspect is simply omnipresent in healthcare. E4 added that “healthcare providers and patients will never use digital services if they have to spend more time and money on them, because if the extra effort is not justified, any service, no matter how well developed, has no added value”. Instead of considering technology as a supporting function, professionals are often afraid that with the technological change they will be less independent or responsible and thus be left behind by digitisation. E4 mentioned the problem here that professionals use the aspect of
"dehumanizing medicine" as a political instrument, which was considered as critical by E4. Nevertheless, there is a challenge in profitably incorporating services into healthcare as a supporting element. In this context, E7 saw the problem that “digital health services already exist, but are not being used” and that some stakeholders are sceptical about the potential of digital health.
4.2.4. Digital health innovation
E1 and E8 described very long processes, up to a decade, until innovation projects reach the market entry and standard care. Although more and more initiatives and projects arise, they are not scaled up and used nationwide. Therefore, challenges lie in structuring processes in such a way that they lead faster to the goal of integration in care and legal anchoring in the system.
Because innovation cycles in the healthcare sector are extremely long and need more time than in other sectors.
In this context, E1 added that “clinical trials are often needed to prove that treatments are successful, which run for years to possibly have the services financed by health insurance companies. For some services, millions of dollars are needed to finance these studies”. Due to most experts, people as the actual target group are involved too little and too late in the development process. In this context, E3 recommended "co-design"
and "participatory development" in order to integrate the problems and needs of the target group more strongly in the process. According to E6, the health sector often lacks to build enough trust in providing information to the people, even though sensitive personal data is involved. In addition, “sustainable networks of the stakeholders involved would have to be set up much more intensively – on an interdisciplinary and cross-sectoral basis” (E6).
4.2.5. Digital platforms and networking
E2 regarded the networking of the individual areas in the healthcare system as critical. “At the sector level, there are difficulties in linking doctors' practices, or at the level
of different sectors, in linking hospitals and doctors' practices, so that duplicate examinations could occur”
(E2). But there are also different systems in medical practices or hospitals that cannot be connected with each other. Moreover, if technologies are used, there is the
“problem of creating interfaces in such a way that it brings added value and not additional expenditure, because the different systems must first be connected with each other” (E2). E3 added to the interface problem that the various sectors have a completely different level of digitisation. “Hospitals and university clinics usually have a certain level of digitalisation, but they operate it differently. Although further technical and organisational problems can arise the larger the hospital and the more departments are involved. For example, some specialist departments in hospitals work with different systems, which leads to problems with interfaces and patient records in the hospital itself. At the level of outpatient care services, there are even greater differences in digitisation, as well as on the side of the users of digital health services” (E3). E5 added the challenge to “collect data centrally in a structured data infrastructure and to clearly define access rights and processes for data exchange. And in the case of distributed data storage, to connect the systems accordingly to exploit the potential of big data”. In the best case, such a “digital strategy should then be rolled out nationwide” (E4).
4.2.6. Data protection & IT security
If according to the experts, different data are classified, medical data are the most sensitive. In connection with digital platforms, the question arises on the platform owner and who and how the security of the data is guaranteed. This leads to privacy concerns in countries such as Germany, especially compared to the Scandinavian countries, which are traditionally more open and have more trust in politics (E1). It must also be ensured that data is used for the right purposes. In principle, the data belong to the patient, but they are not stored by us. “This could be seen as a reason why digital health solutions are slowly and poorly accepted” (E1).
According to E7 “especially cloud computing poses privacy and security threats to the health data”. Research on cloud computing showed major problems in real-time patient-centric cloud applications that implement a centralised architecture where patients store health data in the EHR system and have full control over their data.
When patient data is stored in the cloud, there are far- reaching data protection issues, as patients' private health data could be used by third-party servers or unauthorised users [42].
4.3. Specific Challenges for Rural Areas 4.3.1. Broadband and mobile networks
In the discussions, all experts mentioned the major problem of the technical infrastructure regarding the lack of sufficient broadband and mobile networks in rural areas. With regard to broadband expansion, E6 said that “development programs now exist in many countries, but there are still huge gaps, not only in rural areas, but increasingly there”. And digital health services need a certain internet connection to function properly.
Besides, this is “not only a major barrier in the health sector, but in principle and across sectors” (E6). From E2's experience of exchanging information with a wide range of doctors on the use of telehealth, the problem arose that the services were not valuable due to the practice's poor internet connection and they therefore did not use it. E4 added that “all the technical disconnections will completely interfere with the healthcare provider's daily routine and therefore the benefit of the services will be lost”.
Besides, in many regions “there is no 4G network, which is necessary for most mobile applications” (E3). This makes it more difficult for real-time monitoring services in the increasingly important area of IoT applications.
According to E3, there is a “certain dilemma, because services in rural areas could solve many problems (e.g.
lack of doctors). But if this is technically not possible due to the low internet speed, then there is an inhibiting factor that has to be solved”. As one reason for this barrier in rural areas, E6 cited that expansion for network operators is more lucrative in urban than in rural areas. Moreover, E1 pointed out that the technical infrastructure differs greatly between countries, which is a major challenge when thinking at EU level. In this context, E6 mentioned Sweden as an example of the country that is leading the way in network expansion. In the 1990s, they already started to expand their networks nationwide and clearly defined at the political level that this would be a necessary infrastructure for services of general interest. As a counter-example, Germany was mentioned, which still has major problems with broadband expansion and has not recognised the necessity for a long time (E6). Although, according to the experts, it is difficult to compare countries fairly because of structural differences.
4.3.2. Structural barriers
Most of the experts cited structural differences between rural and urban areas, which pose leading rural challenges. Research from Eurostat (2017) on differences between people living in rural and urban areas showed that rural areas are worse off in most
fields. Moreover, the share of people who reported unmet needs for healthcare due to expense, distance to travel, or the length of waiting lists was significantly higher in rural areas [43].
E1 mentioned the problem of “decreasing population in rural areas and strong centralisation to the big cities, especially among younger generations”. According to E1, rural depopulation was not a phenomenon of the last five years, but on the political level not much has changed. In this context, the demographic change tends to reinforce existing differences between urban and rural areas.
In addition, “healthcare providers are gradually being driven out of rural areas (e.g. Germany), because they have the goal of operating profitably” (E1). This means that hospitals and practices in rural areas often cannot survive because of financial difficulties, which raises the question of how digital health projects are financed and supported. E2 added that many small hospitals in rural areas should have been closed, but this is not done because of image damage of local politics. E8 spoke of a
“tendency towards better healthcare and even oversupply in cities compared to rural regions”, which means that the additional costs and time required for digital health in rural areas can cause major problems.
4.3.3. Digital acceptance & competence
Due to the development of demographic change and older people in rural areas, experts see major barriers in digital acceptance and competence. Although this is a problem for most stakeholders, it is particularly noticeable for patients and healthcare providers.
Patient perspective:
The experts agreed on the fact that a major barrier arises from the patient. Because if no one uses the services, good infrastructure and digital health offerings will not add any value (E1). In this context, E2 spoke of a “lower acceptance towards digital health applications among the older population”. Acceptance models always focus on two aspects: "ease of use" and "perceived benefit", which is still a problem for many older people. The benefit is simply not necessarily seen by elderly people and the services are often developed without taking into account the needs of the older generations (E3). In addition, E8 defined the digital health impact group as
"mostly young, non-chronically ill people aged 20-35 years".
The lack of skills in handling technologies also plays a role among older people, i.e. they must either be specially trained or the technologies must be developed to be more user-friendly (E6). “There are also limits, due to people who do not have access to digital technologies,
which should not be forgotten under any circumstances, and possibly create other ways for these people to access their services” (E7). According to the experts, not everyone can be expected to use these technologies and one should be careful that digital services do not completely substitute familiar services. Also, “the human contact (physician-patient relationship) is especially important for elderly people, which digital technologies cannot replace” (E2). E3 added that social inequalities increase with age, and with regard to AAL, mHealth and wearables, this can often only be afforded by wealthy people. There is a danger that this will lead to a rise in social inequalities in health. As a result, more attention needs to be paid to social health inequalities to ensure fair healthcare (E3). Although, according to most experts, the problem of digital acceptance and competence is decreasing more and more and the "new generation” of elderly people are more familiar with the use of technologies.
Healthcare provider perspective:
According to the experts, demographic change is not only taking place from the patient perspective, but also among healthcare providers. This is why most experts agreed with the thesis that acceptance among healthcare professionals is significantly higher in urban than in rural areas. E3 mentioned differences in the level of digitisation between inpatient and outpatient services, and mainly sees problems with specialists and general practitioners in rural areas. According to E3, this has less to do with the location than with the "age" factor, and older doctors tend to reject telematics applications compared to younger doctors, who tend to settle in cities.
“This cannot be generalized, but there is a tendency among older doctors in rural areas to be unwilling to use technology and to undergo further retraining” (E4). In addition, there is a “greater density of specialists in cities, which creates a greater sense of economy and competition for the use of technologies, in order to stand out in the specialist structure, which is not the case in rural areas” (E4).
Besides, “many doctors in rural regions will retire in the next few years, e.g. one third of the general practitioners in Germany will retire in the next five years” (E2). And, general practitioners play a huge role in rural areas, where they have to deal with more or a wider range of patients than doctors in the city. This means that the problems of additional expenditure and time are more noticeable in rural areas (E2). On the other hand, E8 saw the rather sceptical attitude towards digital health among professionals in urban as well as rural areas. “It is rather the need and benefit that drives doctors to acquire and implement digital health solutions” (E8).
4.3.4. Rural innovation
The experts mentioned the centralisation to the cities, where the political decisions are made and a large number of tech-companies and startups are located.
Besides, “companies with their solutions concentrate on reaching the broad mass of the population as quickly as possible, which is not located in rural areas” (E1). E3 stated this as a "market economy effect due to higher demand". The experts agreed that too little is being done in the area of innovation and funding opportunities, and
“too few solutions are developed that explicitly address rural regions” (E7). Also due to the fact that the
“consortia for project funding tend to be concentrated in the cities, because that is where the institutes are located and respond to public tender” (E3). Besides, in “small municipalities there is often too little cooperation in the sense of the network idea” (E6). According to the experts, these areas have fewer resources, which means that stakeholders in rural areas should complement each other even more. The “Corona crisis in particular has shown that rural areas with a strong network, which have equipped and familiarised older people with digital technologies (digital coaching & digital village experts), have benefited greatly from this. But there are still too few incentives and people with self-commitment who are involved in such projects” (E6). According to the experts, the realisation of such projects in rural communities is often questioned by financing problems.
“Even though some initiatives explicitly address rural areas, they mainly work with model regions in the form of best-practice examples and do not make comprehensive use of the lessons learned” (E6). On the other hand, advantages for rural areas were also mentioned, as “these regions often have a structure that does not exist in cities. There, traditional networks work even better and there is a greater human cohesion, which possibly makes it easier to involve people in rural areas in innovation processes” (E3). It is also possible that
“some digital health innovations will arrive faster in rural areas because of the higher need for such solutions”
(E8).
5. DISCUSSION
The primary objective of this study was to find out the most significant challenges for rural areas in the context of digital health. The focus of this study was on EU countries, i.e. industrialised countries with a certain technical and financially strong infrastructure. The development of the "Digital Health Ecosystem" and the data of the expert interviews have shown the complexity of digital health solutions. Digital health generally has to contend with many barriers that are experienced in both urban and rural areas. These key factors were identified
during the data analysis: healthcare system; financing of digital health; quality of healthcare; digital health innovation; digital platforms and networking; data protection & IT security.
The most valuable part of bridging the gap between the two research areas "digital health" and "rural development" were the specific challenges for rural areas (see 4.3.). Valuable, since little research has been done in this field. The barriers were divided into four main categories:
Broadband and mobile networks
Many rural regions do not have sufficient broadband expansion and mobile networks, which means that digital health services cannot be used profitably.
Especially mobile networks, which play an increasingly important role when it comes to IoT applications and real-time monitoring services with their great potential in the future. This is one of the biggest barriers, because digital services could greatly improve healthcare and solve health shortages in these regions.
Structural barriers
The demographic change and centralisation to the big cities among younger generations is particularly noticeable in rural areas. Moreover, the decreasing population and structural differences to urban areas make it difficult for rural regions to operate profitably and sustainably in the health sector. Even if digital health could solve these problems, there is a risk that the different levels of digitisation could widen the social and economic gap between rural areas and high-tech cities, affecting healthcare providers and patients.
Digital acceptance & competence
Due to demographic change and the older population in rural areas, there are major barriers in digital acceptance and competence among patients and healthcare providers. This should not be generalised, but there is a tendency for digital solutions to be less well accepted by rural communities due to a lack of user skills and the lower perceived benefits.
Rural innovation
Insufficient support is given to innovation and funding opportunities, and too few solutions are developed that explicitly address rural areas. Also due to the centralisation of innovators and investors in cities and the market economy effect of the concentration of companies and startups on the broad population mass in metropolitan areas.
The findings show that the "smart village concept" (see 2.1.) and rural initiatives are still in their early stages and are being applied in model regions. In the future, digital strategies and networks will have to spread more widely across the entire countries and the barriers have to be more firmly anchored in politics. In this context, all the general and specific challenges should not be considered separately in theory and practice, because the complexity of the ecosystem can only be understood by connecting all the different fields. This has not made it easy to form categories based on the data, as some statements of the experts could not be clearly assigned.
In summary, it cannot be said that rural areas have to deal with more challenges than cities, but with other problems. As a result, services must be better targeted to the specific problems and needs of rural communities.
Also, because the need for digital health solutions is very great in rural areas, where they can sustainably counteract the problems like lack of healthcare providers and poor healthcare. Discussions with experts have shown that the Corona crisis in particular offers an opportunity for digital health. A number of digital solutions aim to continue treatments despite the crisis and show how digital health can support care. However, it is exciting to see how sustainable this "boom" will be and how this development will be integrated into political decisions and the healthcare system.
Limitations of this work were the country-specific structures and differences in the healthcare system and level of digitisation in the individual EU countries. This made it difficult to create a meaningful picture of all EU countries. The research institute “Bertelsmann Stiftung”
provided an extensive cross-national study of digitisation strategies and the progress made in 17 different national healthcare systems [44]. This could serve as a valuable foundation for assessing the potential impact of the challenges identified based on the digital health index for the different countries. Despite great differences, none of the countries studied has fully implemented digitisation, i.e. achieved a perfect level of digitisation. Although the study provided a general picture of the countries and did not directly focus on rural areas [44].
In retrospect, it would have been easier to examine a specific country directly in order to avoid the problem of country differences. It might therefore be interesting as future work to compare countries based on their differences in the digital health index or healthcare system. In addition, individual challenges identified could be further investigated. Based on the thesis results, I see a need for further research in the survey of patients and healthcare professionals regarding digital
acceptance and competence. Because these are the target groups for whom digital health services are mainly developed and who must be able to benefit from the integration of these technologies.
6. CONCLUSION
The study shows that general challenges in the field of
"digital health" exist in rural areas as well as in cities.
Besides, it is necessary to consider both spaces simultaneously and take their mutual connections into account. Despite the potential of ICT in healthcare, rural areas are at risk of becoming even more disconnected from the ever-growing urban regions if they do not see the development of digital transformation as an opportunity.
It is therefore important that the problems and barriers of rural areas are increasingly addressed and anchored in a national and local digital strategy. In this context, area-wide networks must be established and projects using digital health solutions must be expanded through funding opportunities defined by policy makers. In this way, challenges such as the lack of broadband and mobile network expansion, the lack of innovative strength or structural barriers due to demographic change and population decline can be countered.
Digital health is an interdisciplinary field involving many actors, and it is therefore essential that all stakeholders involved set themselves the goal of improving healthcare, including in rural communities. Because every citizen of a country should have the right to adequate and high-quality healthcare. Thus, it is also the responsibility of each individual to deal with the developments of digital health solutions and to be open to new technologies. As digital health services can only be profitably integrated into the healthcare system if the target groups have a certain degree of acceptance and competence towards digital solutions.
ACKNOWLEDGMENTS
I am greatly appreciative to the experts who have devoted their time and expertise to make this study and report possible. I sincerely hope that the information presented has helped the reader to understand the potential and challenges for rural areas in the context of digital health. I also hope that the research areas "digital health" and "rural development" will be more closely connected in science and practice in the future. Finally, a big thank you to my supervisor Miriam Bo rjesson Rivera for her support throughout the whole process of the master´s thesis.
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