Factors determining the success and failure of eHealth in low SES regions: opinions of healthcare professionals

Factors determining the success and failure of eHealth in low

SES regions: opinions of healthcare professionals

A qualitative research

Laurie de Lange, S2185962

Master’s Thesis, MSc Supply Chain Management

University of Groningen

Supervisor: Dr. E.I. Metting

Co-assessor: Prof. Dr. D.P. van Donk

Date: 24-01-2021 Word count: 14131

Abstract

Aim

As people live longer and multimorbidity is common, the workload for healthcare professionals is increasing. eHealth services might help to increase work efficiency and decrease workload. In addition, eHealth can facilitate cross-border cooperation to release pressure on national healthcare systems. However, the adoption of eHealth technologies has progressed far more slowly than initially expected. Especially in low SES regions, eHealth initiatives have the potential to offer great benefits. Therefore, it is important to examine why eHealth fails to achieve its expected benefits in low SES border regions, including cross-border cooperation in specific.

Methods

Semi-structured interviews were conducted with thirteen Dutch healthcare professionals in East Groningen. Thematic analysis using Atlas.Ti was done.

Results

The current adoption of eHealth in East Groningen is low, but healthcare professionals are open towards more eHealth in the future. The main advantages of eHealth are improved communication and efficiency. The main barriers identified are: lack of interoperability, poor Internet connections, disruption of workflow, and lack of eHealth literacy. Regional aspects are important to consider in order to let eHealth initiatives succeed. Healthcare professionals are generally not open towards cross-border collaboration with Germany because of the distance, and the difference in language and systems. Therefore, it is important to address regional and national issues first.

Conclusions

Table of contents

1. Introduction………...1

2. Theoretical background………...4

2.1 What is eHealth……….4

2.2 Factors that influence the implementation of eHealth……….5

2.2.1 Technological factors…...………6

2.2.2 Economic/organizational factors….………...6

2.2.3 Social factors……….7

2.3 Cross-border eHealth………...9

2.3.1 The Dutch and German healthcare systems………..10

2.3.2 Digitization and eHealth in the Netherlands & Germany………..10

3. Methodology………...13

3.1 Research design……….13

3.2 Setting and participants……….13

3.3 Data collection……….14

3.4 Data analysis………...…15

3.5 Ethical considerations………15

4. Results……….15

4.1 eHealth in general………..15

4.2 Main advantages of eHealth for end-users.………...16

4.3 Factors that influence eHealth adoption and implementation………..17

4.3.1 Social factors………..………19

4.3.2 Economic/organizational factors….……….…20

4.3.3 Technological factors……….21

4.4 Cross-border………...23

4.4.1 Contact with patients and colleagues……….…23

4.4.2 Future cooperation with Germany………23

5. Discussion………..24

5.1 Main findings………...24

5.2 Practical and theoretical implications………..29

5.3 Limitations and future research………30

6. Conclusion………...31

Appendix I Dutch invitation for study participation……….38

Appendix II Interview guideline in Dutch……….……….39

Appendix III Overview of barriers & advantages found in the literature………42

Appendix IV Coding scheme……….43

List of figures

2.2 A conceptual framework for sustainable eHealth implementation………..6

2.3 Hospital digitization scores per country……….11

2.4 Digital progress in the Netherlands………11

2.5 Digital progress in Germany………12

List of Tables

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1. Introduction

The essence of healthcare is to provide the best possible care that meets the needs of both patients and healthcare professionals. Due to a decline in birth rates and longer life expectancies, the number and proportion of older people is growing (van Gemert-Pijnen et al., 2018). This implies that there will be more age-related chronic illnesses like diabetes, cancer, heart diseases, and/or lung diseases. These illnesses cannot be cured, but they can be self-managed (World Health Organization, 2018). These longer life expectancies and multimorbidity increases the economic burden of society and workload for healthcare professionals (de Wilt et al., 2020; Reiners et al., 2019). eHealth services, like online diagnostic testing, might help to increase work efficiency and therefore decrease the workload of healthcare professionals. With the introduction of the Internet, eHealth became a popular tool for communication between healthcare professionals and their patients. In addition, eHealth allows for easier cross-border communication between healthcare professionals of different nations. eHealth aims to improve health and well-being using technologies, and is increasing rapidly (van Gemert-Pijnen et al., 2018). It refers to forms of prevention and education, diagnostics, therapy and care delivered through digital technology, independently of time and place (Ossebaard & Van Gemert-Pijnen, 2016). Most frequently offered eHealth services are: making appointments online, patient portals, e-consults, and online medication service (de Wilt et al., 2020).

However, the adoption of eHealth technologies by both patients and healthcare professionals have progressed far more slowly than initially expected (Wind et al., 2020; Huygens 2018). With the outbreak of the COVID-19 pandemic, eHealth tools such as online therapy had to be implemented overnight and forced healthcare professionals to overcome any doubts or barriers (Wind et al., 2020). Predictions about COVID-19 are still unclear, but the literature stresses the importance to create longer-term eHealth solutions that are more than just a temporary emergency increase in online work (Wind et al., 2020; Blumenstyk, 2020), especially now that unforeseen disruptive viruses and events driven by climate change are likely to be increasingly common (Blumenstyk, 2020).

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unhealthy lifestyles including heavy smoking, drinking and being overweight (RIVM 2016; ZorgInnovatieForum, 2009), which are conditions where eHealth initiatives could especially be beneficial. This highlights the need to make eHealth more accessible to this demographic group, since so far eHealth is least used by people who can benefit most from it (Reiners et al., 2019; Huygens, 2018).

There is quite some differentiation between European countries with respect to the implementation of eHealth and (hospital) digitization. The Netherlands scores high above European average regarding integration of digital technology and digital public services, whereas Germany lags behind (European Commission, 2020a). It is important to get more insight into reasons for this difference, since policymakers stimulate cross-border healthcare use and digitization is essential to enable this. To support cross-border cooperation between countries, the EU has created programs aiming to increase innovative capacity and reduce the barrier effect of borders (Interreg, 2020). Sharing experiences from practice with colleagues and developers cross-border can contribute to better eHealth implementation and healthcare professionals can learn from each other and develop best practices (European Commission, 2018b; Huygens, 2018). In addition, the most accessible or appropriate care for patients, especially in border regions, might be available in other countries. Although there have been many eHealth initiatives in the EU, it is often not implemented in practice (Huygens, 2018). Therefore, it is important to evaluate what the opportunities are for cross-border eHealth initiatives in these border regions.

Since the COVID-19 pandemic, the need for good eHealth solutions becomes even more accurate. Though the advantages of eHealth are known and well described in previous literature, there is still a gap between expected benefits and actual outcomes. To improve the overall success of eHealth it is important to identify factors that can influence, positively or negatively, the outcomes of eHealth in low SES regions. Therefore, the research questions this paper aims to answer is:

Why does eHealth fail to achieve the expected benefits in low SES border regions? Specifically, (1) What are the main advantages of eHealth according to end-users? (2)

Which factors affect the adoption and implementation of eHealth? (3) What are the opportunities for cross-border eHealth initiatives?

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2. Theoretical background

2.1 What is eHealth

The most cited definition of eHealth is the one by Eysenbach in 2001: “eHealth is an emerging field in the intersection of medical information, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve healthcare locally, regionally and worldwide by using information and communication technology.”

This definition is very broad and a clear, comprehensive definition is still missing. Besides the need for a uniform definition, there is the usage of many umbrella concepts, such as: telemedicine, mHealth, tele-care, ePublic health, eMental health or tele-health (Ossebaard & Van Gemert-Pijnen, 2016), and these terms are used interchangeably throughout the literature (Boogerd et al., 2015). The term eHealth refers to all kinds of information and communication technology used for supporting healthcare. These technologies include: 1) Electronic Health Records (EHR): the collections of a patient’s health information in digital format; 2) Tele-monitoring Solutions: Tele-monitoring patients that are not at the same location as the healthcare provider; 3) Mobile Health (mHealth) applications: the use of mobile devices as a support; 4) Coordinated care: organized patient care activities and sharing information among all the participants concerned (Staffa et al., 2019). Figure 2.1 shows a more elaborate classification of eHealth and services that can be offered by healthcare professionals to their patients.

Figure 2.1. Classification of eHealth. Adapted from De Wilt et al., 2020.

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information, health discussion forums & e-consultation, smartwatches that trace and trigger behaviour, and online (self-help) treatments. Supportive care involves healthcare professionals and is more characterized by information exchange between professionals and/or their patients, chronic disease management, and personal health records. Supportive care does not stop at the national border, but also includes cross-border communication. Societal health refers to more broad health-related issues, such as COVID-19, and includes policies and regulations that influence individuals, but looks at a higher, societal level. For the purpose of this study, eHealth will be defined as: “All information and communication technology used for supporting and/or improving health and healthcare”, which is based on definitions used in previous well-known literature (de Wilt et al., 2020; Staffa et al., 2019; van Gemert-Pijnen et al., 2018). This broad definition includes the classifications of different eHealth services as displayed in figure 2.1. An example of e-public health is giving general information about healthy lifestyles or medicines. e-Care concerns the diagnosis, therapy and care of individual patients and consists of for example video consults, disease management, and monitoring, but also intercollegiate contacts. e-Support includes all administrative and quality aspects such as online appointment systems, decision support systems, or keeping track of electronic patient records.

2.2 Factors that influence the implementation of eHealth

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Figure 2.2. A conceptual framework for sustainable eHealth implementation. Adopted from Fanta & Pretorius (2018).

Since literature shows that eHealth implementation is rather complex, it is important to get a view on the different factors that influence eHealth adoption and implementation.

2.2.1 Technological factors

The complex medical environment poses a major obstacle to the translation of integrated diagnostics into clinical research and routine and therefore here is a high need to address aspects like interoperability standards, data integration & privacy, appropriate IT infrastructures (Bukowski et al., 2020). Since eHealth needs to integrate various information from different domains such as medical research laboratories, hospitals and insurance firms, there is a need for a cloud-based environment, which makes collaborative sharing of information easier (Azeez & Van der Vyver, 2019). This is made more complicated by the high diversity of approaches across Europe, especially in cross-border healthcare use. Despite advantages such as cost effectiveness and collaborative sharing of resources, the security and privacy challenges are high. In 2016, the EU established the General Data Protection Regulation (GDPR) with rules concerning the protection of personal data, which should make Europe ready for digitization (European Commission, 2020c). Regarding privacy and security issues, Azeez & Van der Vyver (2019) propose the following: 1) Governments and policy makers in all countries of the world should develop a comprehensive eHealth document framework to motivate and enable its acceptance; 2) Governments should develop research institutes where security experts come together to brainstorm on secured eHealth solutions; 3) There should be a detailed privacy regulations on the services and practices of eHealth so that people can feel highly protected while disclosing their health-related information.

2.2.2 Economic & organizational factors

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Factors that directly or indirectly influence the organizational implementation of eHealth are: organizational structure, procedures, culture, rules, values and practices, resources, management support, supervision, and leadership (Fanta & Pretorius, 2018). For hospitals specifically, organizational factors that influence eHealth implementation are size of the hospital, top management support, organizational readiness, centralization in decision-making, and absorptive capacity (Faber et al., 2017). Differences between healthcare organizations can hinder the uptake of eHealth, especially when it includes cross-border cooperation, since national healthcare structures might differ a lot from each other (Nalin et al., 2019). In addition, new eHealth opportunities require tricky political, regulatory, or legal challenges (Greenhalgh et al., 2018). For example: who is going to be the owner of the health data? Policymakers and the industry might also have different views on what counts as high-quality, or there might be issues such as barriers to inter-organizational networking and knowledge-sharing. Many studies described that an absence or inadequacy of legislation, policies and liability concerns can make it harder to implement eHealth systems and they recognize the need for eHealth system standards (Ross et al., 2016).

Besides organizational and legal issues, the costs of eHealth systems and costs associated with their implementation was found to be a key barrier of implementation by many previous studies (Ross et al., 2019). There are costs associated with the initial investment, change management, human resources, training, and maintenance of the systems (Parv et al., 2012). Another cost mentioned was costs related to a loss of revenue and potential savings (Ross et al., 2019). In general, eHealth is associated with improved cost-effectiveness (Schreiweis et al., 2019) and cost reduction (Ossebaard & Van Gemert-Pijnen, 2016). However, the high initial costs of eHealth services still hinder the adoption of these services (de Wilt et al., 2020). The most important economic factors towards eHealth are the availability of funding, affordability of technology, cost-effectiveness, and return on investment (Fanta & Pretorius, 2018). However, self-care and informative websites and eHealth apps are available to everyone and there are usually no costs for using the applications for patients, so often care providers have to pay the development or purchase of a care program (Hallensleben et al., 2019).

2.2.3 Social factors

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implement eHealth technologies, because benefits can only be achieved from effective implementation and interaction with end-users (Sheikh et al., 2011). Peeters et al. (2016) found that, despite the limited evidence of the effectiveness of eHealth in primary care, a large proportion of GPs in the Netherlands offer or intend to offer eHealth services. A survey carried out in 31 European countries showed that 93 percent of GPs reported having an electronic health record system. However, doubts on privacy and confidentiality of this eHealth information prevents some GPs from utilizing such systems (Melchiorre et al., 2020). ICT has been identified as a crucial enabler for supporting information sharing across healthcare professionals (Winthereik & Bansler, 2007). However, research has shown that healthcare professionals often have difficulties to master the complexity of the new technologies that were implemented (Ross et al., 2016).

The implementation of eHealth systems is complex, because it requires healthcare professionals to take on new roles, it can put them under pressure, threaten their professional identity, or pose a risk of job loss; because it requires patients to undertake certain tasks themselves such as initiate changes in therapy or make judgements about what is an emergency (Greenhalgh et al., 2018). Studies reported that healthcare professionals’ resistance to eHealth implementation are related to fear of, dissatisfaction with, and uncertainty over these new roles and responsibilities created by the eHealth systems (Ross et al., 2016). An example of taking on new roles is a GP who can more easily contact a medical specialist through online communication technologies, but may miss real life contact. From the perspective of the medical specialists, this teleconsultation shifts his/her role from personal action to the provision of advice (Houwink et al., 2020). Other barriers often mentioned in the literature are: fears over a loss of autonomy, concerns about liability, and perceived threats to patient and healthcare professional relationships (Ross et al., 2016).

Greenhalgh et al. (2018) argue that the implementation of eHealth should have a user-centered approach, with focus on the people involved, including the deeply held professional identities, norms and values that underpin the resistance to new technologies. Suggested strategies to reduce barriers are: additional training, the adaptability of technologies to fit with roles, tasks and workflows, dedicated technical support staff, careful study of the downstream effects of implementation on workflow, and the quality of project management during the implementation period (Ross et al., 2016). The uptake of eHealth could be encouraged by incorporating more eHealth educational programs into medical education (Ross et al., 2016). However, eHealth education has been largely absent in medical curricula in Europe so far (Houwink et al., 2020). They propose that healthcare professionals should be supported, educated, and involved in all processes, from the development of effective eHealth solutions to their implementation in regular care.

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Furthermore, chronic diseases, like cardiovascular disease, diabetes, cancer, and chronic respiratory diseases, represent the main cause of functional impairment and mortality in many countries, with 85 percent of related deaths in Europe (Melchiorre et al., 2020). These chronic diseases can be related to behavioral factors such as unhealthy diet, lack of physical activity, and use of tobacco and/or alcohol (World Health Organization, 2018). People can take their own responsibility for lifestyle change through self-management to manage their behaviour and their chronic illnesses (Talboom-Kamp et al., 2018). It was found that people with chronic diseases who are living alone are less likely to use eHealth, because family members often help with difficulties experienced while using eHealth (Reiners et al., 2019). Since these people are less likely to benefit from eHealth, this can lead to a digital divide between those who use eHealth technology and those who do not. The digital divide can be defined as: "The gap between individuals, households, businesses, and geographic areas at different socio-economic levels with regard to both their opportunities to access information and communication technologies (ICTs) and to their use of the Internet for a wide variety of activities" (OECD, 2001, p.5). Previous literature found that there is indeed a digital divide between people with high and low SES (Yoon et al., 2020). There are various stages of digital divide (Reiners et al., 2019): First, there is an economic divide, since not everyone can afford to buy the hardware needed to access eHealth. Second, there is the usability divide, meaning that not everybody is able to use the technologies because it is too difficult. This can especially be the case for older and lower educated people. Third, there is the empowerment divide, where people are just not willing to use the opportunities since they do not think they will personally benefit from it. The empowerment divide is much more complicated to overcome and most articles only address the economic and usability divide.

So, it is important to further investigate the opportunities of eHealth, especially in lower SES regions with a faster ageing population, since these people could benefit a lot from eHealth opportunities (Reiners et al., 2019) and a digital divide between those who use eHealth and those who do not should be prevented.

2.3 Cross-border eHealth

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2.3.1 The Dutch and German healthcare systems

In the Netherlands health insurance is mandatory and covers a standard benefit package including primary care delivered by GPs. All Dutch residents are registered with a local general practice of their own choice and their GP is gatekeeper to hospital- and specialist care. In the Netherlands, the government promotes hospital digitization and patient health record exchange. Many Dutch hospitals already have a system in place called Cross-enterprise Document Sharing that enables standardized and secure data exchange at a National level (ICT&health, 2020). Research by Philips and Enovation showed that 80 percent of the Dutch hospitals have invested in digitized patient health record exchange in the last couple of years. In Germany, healthcare is divided into public or private health insurance (gesetzliche Krankenkasse or Krankenversicherung respectively) (Internations, 2020). It is a legal requirement to have health coverage, whether it is public or private, and the contributions are based on a percentage of income. However, an employer will usually take care of registration with a German health insurance company and then employer and employee share the costs. Another difference from the Dutch system is that people do not need a GPs referral to see other specialists, such as a psychologist. Even though the German government is encouraging the use of eHealth, the implementation in German hospitals remains low (TFHC, 2019). The main challenges are the availability of digitization budgets and the lack of a digitization strategy. However, since 2018 patients do have an electronic health insurance card, where data concerning medical findings, diagnoses, treatment measures and medication are gathered. Medical practices are obliged to have the necessary technical equipment to be able to validate and update a patients’ electronic health insurance card.

2.3.2 Digitization and eHealth in the Netherlands & Germany

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Figure 2.3. Hospital digitization scores per country, adopted from Bukowski et al., (2020).

The European Commission has also been monitoring Member States’ digital progress through the Digital Economy and Society Index (DESI). The DESI includes analysis of broadband connectivity, digital skills, use of the internet, digitization of businesses, digital public services, emerging technologies, cyber security, the ICT sector and its R&D spending (European Commission, 2020a). Figure 2.4 and figure 2.5 show respectively the digital performance of the Netherlands and Germany. As can be seen in figure 2.4, the Netherlands is one of the top performing EU countries with a solid and steady digital growth. Germany on the other hand does perform well on most dimensions, except for integration of digital technology and digital public services. Even though only 5 percent of Germans have never used the internet and 84 percent shops online, the use of e-government services is only 49 percent of all internet users, which is currently Germany’s greatest digital challenge (European Commission, 2020a).

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Figure 2.5. Digital progress in Germany (European Commission, 2020a).

A first reason for Germany to lack behind could be that Germany is known to have very strong demands and regulations surrounding anything involving personal data and privacy, which could be a result of their history (TFHC, 2019). Germany has namely given rise to political systems in which the surveillance of its own people played a fundamental part of control, manipulation, and oppression. Second, their large private hospitals are already investing in eHealth services to set them apart from the public hospitals where IT budgets are low, there is no clear digitization strategy and where investments are not allowed unless it is proven that a digital solution can save costs while maintaining or increasing quality (TFHC, 2019). This can lead to a digital divide between people that use public care and those who have private care. Third, the decision-making processes in German hospitals vary greatly from hospital to hospital, which makes the systems very complex (TFHC, 2019). Fourth, Germans tend to only deal with what they know and require long-term commitment. If an application is for example not in German, or the longer term benefits are unknown or uncertain, they might prefer not to invest at all.

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3. Methodology

The research questions this paper aims to answer is: Why does eHealth fail to achieve the expected benefits in low SES border regions? Specifically, (1) What are the main advantages of eHealth according to end-users? (2) Which factors affect the adoption and implementation of eHealth? (3) What are the opportunities for cross-border eHealth initiatives?

For this research a qualitative study is the most suitable approach, because currently the literature does not give enough insights why eHealth fails to achieve the expected benefits in low SES regions. Therefore, a qualitative, explorative approach was found to be the appropriate way to conduct this research (Churchill, 1992). Also, individual perspectives and experiences may differ, which makes a qualitative research approach in this case most appropriate (Castle, 2017). To further guide this research, the consolidated criteria for reporting qualitative research checklist (COREQ) was used to lay out the important aspects of the study design and analysis and findings of this qualitative research (Tong, 2007).

3.2 Setting and participants

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Participant Profession Age Gender Job

experience Interview form

i1 Manual therapist 51-60 F >20 Video call

i2 Hospital specialist 51-60 F >20 Video call

i3 Manual therapist 51-60 M >20 Video call

i4 Nurse 21-30 F 0-5 Phone call

i5 Physiotherapist 21-30 F 0-5 Video call

i6 GP 51-60 M >20 Video call

i7 Hospital specialist 41-50 F >20 Phone call

i8 GP 31-40 F 10-20 Phone call

i9 GP 51-60 M >20 Phone call

i10 Hospital specialist/ Chief Medical Information Officer

41-50 F 10-20 Video call

i11 GP 41-50 F 10-20 Phone call

i12 Psychologist 51-60 F 10-20 Video call

i13 Ambulatory doctor psychiatry

21-30 M 0-5 Video call

Table 3.1. Demographic characteristics of the participants. 3.3 Data collection

Data was collected via semi-structured interviews following a pre-defined topic list. This method gives the opportunity to ask follow-up questions and allows for hitching into interesting topics that emerge during the interviews and will lead to more open and detailed answers. The interviews were guided by an interview guide that was constructed with mainly open questions (see Appendix II). The interview questions have been constructed around the following topics: experiences with eHealth, barriers & advantages of eHealth for healthcare professionals, barriers & advantages for patients, cross-border eHealth opportunities, and the view on eHealth in the future. The interview guideline was based on the model of Fanta & Pretorius (see figure 2.2), an overview of factors influencing eHealth as described in the literature section (see Appendix III), the eHealth classification by de Wilt et al. (2020), and on a study by Klitzke (2020), who conducted a similar research for his Master’s thesis in Germany. Since we currently deal with the COVID-19 pandemic, interviews could not be held live. Therefore, participants were invited for a video call to better interpret the answers, but this was not always possible because of poor connections or simply because the participant requested a phone call.

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collaboration with Germany was discussed. Sixth and final topic was how participants view the future of eHealth, including plans, main barriers, and suggestions. Finally, the participants got the opportunity to discuss anything regarding eHealth they thought was not discussed in the interview.

The interviews were all held in Dutch and then transcribed in Dutch. The interviews were held between November 5 and December 17 of 2020 and lasted between 28 and 63 minutes. 3.4 Data analysis

The interviews were audio-recorded using a mobile phone and transcribed verbatim. None of the participants requested the transcribed interview to check for correctness. To answer the research question, the most interesting or often occurring aspects of the interviews had to be identified. Therefore, all transcripts were uploaded into Atlas.Ti version 8.4 and made anonymous by removing any names or information that could be directly linked to the participant. The initial coding process had a deductive approach, building upon the main themes from the interviews. Line-by-line coding was carried out, followed by categorization of the codes and identifying the main themes. Also, an inductive approach was used after it became apparent that there were interesting data parts that could not be categorized using a deductive approach. In qualitative research it is common that both deductive and inductive approaches are used (Bowling, 2014). The complete coding scheme can be found in Appendix IV.

3.5 Ethical considerations

This study was approved by the METc, UMCG, and the University of Groningen. To address privacy and security issues for safeguarding medical information, the data collection, analysis, and data storing is compliant with the UMCG policy and Standard Operating Procedures in the UMCG Research Toolbox. All participation was voluntary and data was anonymized. Direct identifiable information will be stored separately from the pseudonymized data in a secure environment. Before the start of the interview, participants signed an informed consent form that explained the purpose of the interview and the data collection procedure.

4. Results

4.1 eHealth in general

Before providing a definition of eHealth for this research, participants were asked to give their own definition of eHealth. Most participants mentioned that eHealth is a broad concept of digital care supporting patients and/or healthcare professionals (i1, i2, i4, i5, i6, i7, i10, i11, i12, i13). After providing the definition of eHealth that is used for this research there was one participant that expressed strong feelings of disagreement: “According to your definition this is eHealth, but I do not see that as eHealth, that is just service” (i3). Participants agreed that eHealth, according to the definition of this research, plays an active role in their daily work, but they disagree on the size and shape of this role. Where some participants argue that this role is currently very modest (i6, i10, i11), others say eHealth already has a big role (i1, i4, i5, i7, i9, i13). Participants do agree that eHealth is still upcoming and will have a bigger role in the future.

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aspect was that eHealth implementation varies significantly between different healthcare professionals and between the different medical professions. One example is making online appointments: while some already have an online appointment system in place (i1, i6), others say they want to introduce such a system in the near future (i2, i8, i11), for some it’s not really applicable (i4, i10, i13) and others deliberately chose not to introduce it (i3, i5): “I prefer to control my own schedule” (i5).

Current implementation of eHealth varies most among GPs. Some GPs (i6, i9) already have eHealth opportunities in place such as e-consultations, insight into patient files, and home measurement options: “I offer everything that is possible to that extent” (i9). For others (i8, i11), eHealth is still very upcoming and there are not that many options yet: “It is still really in its infancy, [...] I just haven’t been able to pay attention to it” (i8). Even though i8 and i11 do not offer much yet, they are currently working on more eHealth opportunities in the near future. One project that the GPs are involved in and explained about is the OPEN-project. This project recently started and is a nationwide four year acceleration program to help GPs with safely sharing of medical information with their patients: “I am a bit cynical about it, but I’ll join anyway” (i11). Overall, all GPs are open and positive towards new eHealth implementations. In physiotherapy and mental healthcare, the use of eHealth is more common. All participants offer options like apps for home exercises or the possibility of video calls, especially during the COVID-19 lockdown when patients were not allowed to go to the practice. They invest their own money into eHealth implementation, because they see it as a service to their patients: “We’ve bought tablets and put some sort of app on it so we can get in contact with the patient. [...] We give the tablet to a patient and that tablet only contains what they need, you can click on it and it is very easy” (i5). A participant explained that the use of these tablets is not very common yet, but the reactions so far are very positive. Even though in physiotherapy and mental healthcare eHealth options are more common, all participants agree that eHealth is just a service to patients and it is impossible to replace all parts of treatment. The hospital in East Groningen does not have many eHealth options yet: “We do have a patient portal, so patients can have insight into their data, but they cannot change anything and are also not able to plan their own appointments. [...] We also have very little telemonitoring, which is a pity, [...] so for the most part it’s in its infancy, but there are further development wishes” (i10).

4.2 Main advantages of eHealth for end-users

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of online consultation, in practice healthcare professionals still seem to use the phone too often: “At the moment internal medicine gets around 40 phone calls from GPs every day. [...] Sometimes that is about urgent matters, but sometimes it is also about supplementary medical questions, let me put it like that, but that constantly interrupts your work. [...] It is possible in this region, but not all GPs embrace that yet, so I think that would be an absolute gain for our daily workflow” (i10). The main reason GPs give for not fully embracing the digital possibilities is that they prefer direct results: “We, GPs, are activists, so it should be direct, we are not like the government: ’next week is also okay.’ We are very impatient and we want direct results” (i11). Furthermore, participants argue that current communication is not as easy between all medical professions, contact with the hospital is more rigid, and not every healthcare professional is yet connected to the digital network. There were also some other critical notes about eHealth leading to more efficiency for healthcare professionals: “I would say it is more responsibility for the same amount of money, [...] it could make healthcare a bit more efficient, [...] but macro budgetary it does not matter” (i9). One physiotherapist argued that in their profession eHealth does not lead to efficiency at all: “The added value of eHealth as the insurance companies see it, that it leads to efficiency and cost effectiveness, that is just not true for our profession” (i3).

Participants see self-management and not having to travel as the main advantages of eHealth for patients. Participants (i8, i10, i11, i12, i13) mentioned that eHealth could save travel time, which is especially beneficial for patients with physical disabilities or for example small children at home. In addition, participants argued that people sometimes barely have money for a bus ticket and are very dependent on others for transport. Reasons why most participants (i1, i2, i4, i5, i7, i8, i11, i12) mention self-management as a great advantage for patients are: (1) people become more familiar with their illness and it makes them more responsible, (2) people can get more confidence in themselves when they notice they are self-reliant, (3) patients like being more involved in their own treatments, (4) after treatment stops people can still continue on their own, and (5) both patients and healthcare professionals can do things in their own time.

4.3 Factors that influence eHealth adoption and implementation

18 Category Sub-factor Interesting quotes

Social

Motivation

“The implementation, well we are going to do it [...], but I think there is more resistance with the healthcare professionals themselves, because most patients do not care” (i3).

“I had a few times that they were unable to do it, so then people are not very motivated to try again next time” (i7).

“Nobody wants to be ill. Nobody wants to swallow pills every day. The concept of self-management implies that a patient wants to work on his illness, that a patient wants to put time and effort in it and wants to think about it every day. Nobody wants that!” (i9).

Workflow

“The main barrier is always: it is different from what I’m used to [...], so they only see the difficulties instead of the advantages. [...] healthcare professionals are very conservative and scared of every change that comes with it.” (i10).

“You will miss a part of what it’s like to be a doctor: your clinical view. People will not really encounter that, but healthcare professionals do” (i11).

“I can tell you that our work satisfaction decreases as well, because we are not educated to communicate this way” (i3). eHealth

literacy

“It is educational level, it is the age, it is experience with the digital world, [...] also socioeconomic status that causes inability to purchase digital equipment, [...] so I think it is a combination of all these factors” (i1).

“It doesn’t matter how simple it’s been set up, it is often still too difficult for them” (i12).

Economic & organizational

Financing

“You often hear that people think it’s a pity to use a session when you only spoke digitally. So that is a thing, how are you going to earn that time?” (i1).

“What you see is that, because of all care purchasing processes, they look in an accounting way at tariffs and that hinders innovation and investments” (i3).

“When we work with a tablet it costs time, but we don’t get paid for that time, so that is a problem” (i5). Policies/laws

“Even if you can only manage to help a small part of the people, I think you should put effort and money into it, [...] but that is a task for our government” (i11).

“Who is right? On the one hand we have transmural standards [...] with all kinds of things you should do, but on the other hand we try to catch everything electronically so we have to see patients as little as possible” (i9).

Health outcomes

“When it is harder for people to reach their own GP, they will save it and the problem can get bigger, [...] so accessibility is very important” (i6).

“You can give patients a lot more guidance when it's automated instead of manually or over the phone” (i10).

Technological

Interoperability “It is not connected to our system, [...] you want that data from such apps transfers automatically to your electronic patient portal, so it is no added value to us” (i7). “I lose so much time entering everything in the systems, which is a pity, I think that can go so much faster” (i5).

Internet connections

“It is very useful that we can quickly share things, but I’m also not a great supporter because you are dependent on Internet signals and when the Internet doesn’t work you are not able to reach anything you need” (i4).

“We can make sure the possibilities are there, but we cannot fix problems outside of our doorstep. [...] We cannot solve the fact that there is only one bar of reception. [...] Then you notice we are not so interesting there in the middle of nowhere” (i10).

Usability “It is not one clear format [...] like we all use Whatsapp. There are so many different entrances [...], that makes it difficult” (i11). Privacy &

security

“I really don’t believe it is safe for larger organizations, those data is worth so much money, I don’t believe it is very well secured and not anonymously resold, but still retraceable to people” (i11).

“When patients email something to me it is their responsibility whether it is privacy sensitive information or not” (i9).

“I think privacy is very important, but sometimes it gets extremely complicated. [...] We have to keep it pragmatic, otherwise it is not workable” (i10).

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4.3.1 Social factors

4.3.1.1 Motivation

The main reason for healthcare professionals to offer eHealth services is patient satisfaction. Participants mentioned that the region East Groningen is different from other, wealthier and more educated parts of the country. A difference is the culture in East Groningen, which is very down-to-earth, sober, and conservative, which makes people less motivated to try new things (i1, i2, i4, i5). Participants mentioned that many patients have no interest in eHealth because of skeptical attitudes, the preference for face to face contact, and getting anxious (with the thought of) using electronic devices. In addition, people in East Groningen tend to be more submissive: they prefer a more paternalistic way of care where a doctor tells them exactly what to do so they do not have to indicate anything themselves: “That’s in their system: ‘The doctor measured it, so then it’s alright’” (i8). Moreover, one participant (i9) argued that self-management and other supportive tools could not work efficiently, because nobody wants to be reminded about his or her illness every day. This participant explained that patients do not want to put time and effort in self-management, and would make up certain measurements, just because they do not feel like measuring them. However, many participants (i3, i4, i5, i6, i7, i10, i12) stated that patients do like and are motivated to use eHealth. One participant explained that healthcare professionals often unjustified think that people in East Groningen are not willing to use eHealth technologies: “We often make a fuss about living in a low educational region with a lot of older people, but our whole patient panel mainly consists of retired people and they are all super enthusiastic and think developments are going way too slow, so they would prefer to see more eHealth implementation” (i10).

Participants (i6, i7, i9, i11, i12, i13) mention that if you want to accomplish certain eHealth goals, healthcare professionals should motivate and stimulate their patients. Therefore, they argue that it could be especially important to motivate healthcare professionals by providing them with better information and educating them about eHealth opportunities. Participants (i2, i6, i7, i10) also argue that the right way to make people more aware of the existence and possibilities of eHealth is with more publicity and advertising: “Advertising, just letting people know it is available and easy and where they can go if they would like to apply it, [...] facilitating and seducing” (i6). Concrete suggestions include using social media, and providing patients with promotion- and instruction movies. It was said that especially patients in low SES regions with reading difficulties or lower educational levels could benefit from these movies.

4.3.1.2 Workflow

An often mentioned issue was that eHealth affects the way healthcare professionals are used to work. A first reason is that eHealth can change the relationship between patient and healthcare professional. Almost every participant mentioned the preference of face to face contact with their patients. Reasons for this are the interpretation of non-verbal communication, being able to keep a better view on a patient’s wellbeing, the psychological role they have for their patients that could not be established online, and the personal factor of missing a part of what it is like to be a doctor.

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A final issue is (the fear of) added workload: “They think it is just a hassle, just like I have: it costs time and energy. [...] You only experience the positive side after the implementation” (i8). This added workload also includes the visibility of electronic patient portals. Now that patients can get insight into their own files, these files should be clear and understandable for the patient. Therefore, healthcare professionals cannot wright down technical jargon or only three medical abbreviations anymore.

4.3.1.3 eHealth literacy

Most participants only mention eHealth literacy as a barrier for patients: “The bottleneck really is the digital skills of patients” (i6), but one participant (i4) also mentioned that digital skills of healthcare professionals can play a role. Most participants argue that older people usually have more difficulties with technology. With patients getting more visibility into their health records, participants mention difficulties with processing that medical information. Some patients are not able to understand what is written down in their files and/or get restless or anxious when they are constantly able to read about their illnesses. When patients read for example certain results they do not understand, but the healthcare professional is not available, they have to deal with it themselves, positive or negative.

Participants agree that treatments should be well-adjusted to the people, because people in low SES regions need a lot more guidance and are less able to self-manage their illnesses because they are less able to comprehend things (i1, i6, i8, i9, i10, i11). Participants (i6, i7, i11, i12) mention that the lack of user-friendliness of systems and devices can be a barrier for people, especially those with hearing, visual, and movement impairments.

Participants mention some other factors that influence eHealth literacy: there is a lot of dementia (i5), people do not own suitable digital devices (i6, i9), and there are quite some refugees who generally already have difficulties with the current ways and the language (i2, i3, i4).

4.3.2 Environmental & organizational factors

Opinions regarding financing differ between medical professions. Especially physiotherapists strongly agree that financing is a problem. They argue that insurance companies make it difficult to finance treatments, innovations, and investments. Insurance companies seem to think that certain solutions are generally applicable in more medical professions when that is not the case: “From some stakeholders you get the idea that they structurally see it as something new to save costs. They usually think of something behind a desk because they’ve read it works for X, so it should work for the rest of the alphabet, but that is not the case” (i3). Where physiotherapy practices mostly have to pay for eHealth services themselves, GPs usually get financial support from different, separate subsidies and therefore they can be dependent on others: “It is usually financed by irregular money flows that are available when you apply certain eHealth developments in your practice. That is usually initiated by a larger organization, I’m not going to implement something on my own” (i6).

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Regarding governmental regulations there were two main issues discussed: who should be responsible for educating people about eHealth, and who is going to be responsible for eHealth data. For the first issue most participants thought that if you want to educate people about eHealth, the responsibility should lay with the government, because they are too busy and/or expensive (i2, i3, i4, i6, i8, i9, i11). Participants also provided some other options for these responsibilities: townships, libraries, medical students, social workers, or as part of reintegration processes. However, some participants did mention that they would be willing to spend some of their own time on educating their patients (i1, i5, i7).

The second issue concerns data responsibility: who is responsible when people are able to take all kinds of measurements at home and send them to a healthcare professional when he/she did not ask for it: “When there is a deviation and I haven’t seen it, am I going to be responsible for a bad ending? Or when we’re talking about blood pressure, heart rhythms at the cardiologist, is he expected to look at 80.000 results? And that is not really clear and crystallized in the Netherlands, that is very complicated” (i10). Moreover, i10 explained that expectation management and legal consequences should be very clear before introducing eHealth options.

4.3.2.3 Health outcomes

Participants explain that working in a low SES region contributes to a patient’s health status: “A lot of people that are overweight, a lot of impotence, relatively much COPD, asthma, smokers, which is percentage wise way too high compared to the national average. [...] So it is a difficult population that is a bit disadvantaged, but that is a familiar image” (i6).

Most participants agreed that eHealth could somewhat contribute to more accessible healthcare because healthcare professionals are more easily reachable and accessible, and there is the possibility for better communication and shorter lines between the patient and healthcare professional, and between different healthcare professionals. Therefore, patients can also get their results faster and can be easier referred to a specialist or other healthcare professional. This accessibility can also have a positive influence on illness prevention, which can unburden doctor’s service on weekends and can save money. However, there was a critical note about prevention: “I think what we, healthcare professionals, forget is that prevention does not have added value for people. Their only burden is what happens now. The concept that you won’t get a stroke is in the far future” (i9).

Participants (i1, i5, i6, i8, i9, i10, i12) also mentioned that eHealth could provide opportunities for more efficient treatments. Reasons given are: (1) home measurements are more reliable, (2) there is the possibility to give more guidance to patients before, during, and after treatments, and (3) there is the possibility to have more contact with patients and keep a better eye on people that might need it such as lonely elderly: “I think loneliness amongst the elderly might decrease if you’re able to regularly have a short video call with some people you want to keep a little extra eye on” (i6).

4.3.3 Technological factors

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my information system, I won’t do it. I’m not looking for added workload, it has to make my job easier as well. I think most developers do not pay attention to that. [...] It’s about the translation process” (i6). Several participants mentioned that a downside of lack of interoperability is that it adds to the workload of administration. Some participants argue that part of this administrative burden could be reduced when current systems become easier invisible for different medical professionals at different levels. Moreover, all participants explain how beneficial it would be to work with one single system that connects everything. However, it is generally recognized that this is a complicated task: “They keep introducing new developments, but they can’t manage to connect the systems, [...] I don’t work in ICT, but it seems that that is quite a complicated task” (i2). A thing often mentioned by participants (i5, i7, i10, i13) to be reachable in the near future and being very beneficial and efficient for patients, healthcare professionals and insurance companies is having paperless questionnaires: “Not having questionnaires on paper, that is very important. [...] I see so many benefits of that” (i10). Having answers in the right form at the right place in the electronic patient portal so it is reusable could save preparation time and administrative burden for healthcare professionals, costs for insurance companies and a lot of repeating for patients. 4.3.3.2 Internet connections

Many participants mention that poor Internet connections in East Groningen are negatively influencing the adoption of eHealth: “Our information system is often very slow or completely shuts down, but the problem is not the program or the supplier, it’s the Internet connection. There is for example no fiber optic network” (i8). Participants mention for that they do not like being dependent on Internet signals and poor Internet connections have a negative influence on their daily work because they are not able to reach certain people or documents. Participants argue that the poor Internet connections could even be the main barrier for eHealth implementation, which make it essential to do something about that: “The ICT infrastructure does not make eHealth implementation easier, [...] we need 5G and fast Internet as soon as possible, that is essential for whatever you want to let succeed here” (i9).

4.3.3.3 Usability

Usability of the current systems was mentioned a few times in the interviews. This can be split into systems that do not work the way they are supposed to and systems that are too complex to work with. The first was mentioned most often regarding hospital systems: “I like it, but only when the technique cooperates, because that’s the problem, [...] systems that do not work, sometimes that’s quite difficult” (i7). The latter has more to do with personal user-friendliness, because systems are unhandy or too complicated. One participant also explained how suppliers of systems can counteract the user-friendliness for healthcare professionals: “The supplier of the information system, super complicated, I had to collect signatures from every patient [...], so I thought: you’ve got to be kidding me” (i8).

4.3.3.4 Privacy & security

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for this third issue was logging: “It would be a good thing if you always have to log what happens to your data, that way you can see who looked into your files” (i11). Logging is already being applied in the hospital, but not in other medical professions. Participants argued that privacy is not an issue for their patients at all (i1, i4, i8, i9, i11, i12, i13), who just send sensitive information via unsecured ways and barely ask questions about eHealth initiatives: “They have no idea!” (i11). Two participants expressed opposite opinions about the responsibility of privacy sensitive information. Whereas one participant (i9) argued that it is a patients’ own responsibility, a second participant (i11) strongly argued that healthcare professionals and the rest of society should protect these patients.

4.4 Cross-border

4.4.1 Current cross-border contact with patients and colleagues

Most participants said that they barely treat patients from Germany (i2, i3, i6, i8, i9, i11, i12. i13) and when they do, it concerns Dutch people with Dutch insurance who live in Germany, or German people living in the Netherlands. Exceptions are two physiotherapists (i1, i5) who mentioned that they do treat some German patients because their practice is very specialized in certain treatments. Also, specialists from the hospital (i7, i10) said that they treat German patients with some regularity because they get a referral from a German GP. Contacts with healthcare professionals in Germany are for all participants minimal. When they do have to share information or data it is usually very basic and old-fashioned via letters or DVDs. Since contacts are so minimal, participants also do not see the added value of eHealth by for example changing letters into digital contact. Also, most participants (i2, i3, i6, i7, i8, i9, i11, i12) do not see the added value of having more contact with colleagues in Germany: “There are always worldwide congresses where you can get new insights into treatments, so I don’t think contacts with Germany specifically would add much value” (i7).

4.4.2 Future cooperation with Germany

Participants mentioned three barriers towards contacts with Germany. The first barrier is the distance (i8, i12), because even though East Groningen is a border region, it is still too far to reach patients on a home visit. The second barrier is the different language. Participants (i1, i4, i7, i10) mention difficulties with respect to the actual language, the inability and unwillingness of German colleagues to communicate in English, but also the differences in medical language such as the meaning of certain abbreviations. The third and most mentioned barrier is the difference in healthcare systems. All GPs (i6, i8, i9, i11) and Physiotherapists (i1, i3, i5) argue that you are unable to compare their medical professions with those in Germany, because the differences are too great. Also, organizational differences in hospitals and ways of insurance were discussed: “You still have public and private health insurance, that is so strange. [...] When you wave with your expensive insurance card you get priority over other people. Here we can’t even imagine that!” (i11). One participant (i8) had quite some negative experiences with healthcare practices in Germany and explained about cultural differences, long legal procedures for patients when certain things go wrong, and the hierarchical way the hospitals are organized which does not promote communication and safety.

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only get more complicated when integrating Germany” (i9). However, after fixing national problems first, the hospital might be open towards future possibilities: “In the end I don’t care what the residence of the patient is, but exchanging information with foreign healthcare providers remains challenging. [...] However, for the future I do see possibilities, but it is a very distant dot on the horizon. It would be great if we got everything straight here” (i10).

5. Discussion

This study is, to my knowledge, the first to explore why eHealth fails to achieve its expected benefits in low SES border regions, and specifically towards cross-border cooperation. This study indicates that the use and acceptance of administrational technology is greater than treatment technology such as telemonitoring, which is almost absent. In case of hospitals, it was found that size and financial situation influence eHealth implementation (Greenhalgh et al., 2018; Faber et al., 2017), which can explain the limited availability of eHealth in the hospital in East Groningen, since it is a small hospital and currently in a bad financial position. There is a difference in eHealth offers between different medical professions. This study found that physiotherapists and mental health practitioners offer more eHealth solutions than GPs or the hospital. Physiotherapists and mental health practitioners argue that they offer it as an extra service for their patients. The main reason for this could be that they need to differentiate more, because people can choose between more practices. Overall, availability of eHealth in East Groningen is still in its infancy. However, this study shows that healthcare professionals are very open towards more eHealth in the future. This is in line with research by Peeters et al. (2016), who found that healthcare professionals in primary care in the Netherlands offer or intend to offer eHealth services. Individual aspects such as motivation and workflow were found to be important for healthcare professionals, but the majority of barriers concern external factors like lack of interoperability, poor internet connections and user-friendliness of the systems. This study indicates that in the adoption and implementation of eHealth initiatives and most important roles lie with healthcare professionals and the government. Healthcare professionals are the ones that should motivate and stimulate their patients and therefore it is important to carefully consider all doubts, barriers and suggestions they have in order to reach successful eHealth implementations in the future.

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This study found that healthcare professionals experience different levels of work pressure, but the majority states that work pressure is quite high, which is in line with research by Boekee & Hoekstra, (2018). Because of the ageing population and multimorbidity, work pressure is expected to rise (de Wilt et al., 2020) and eHealth could make work more efficient (Ossebaard & Van Gemert-Pijnen, 2016). Administrational technology is the most attractive amongst the participants of this study, because it concerns patients less and it is felt that this has a great potential to lead to more efficiency. Whereas participants do feel that eHealth can lead to more efficiency, the feeling that it can save costs was barely expressed, which contradicts the research of Schreiweis et al. (2019), who argued that improved cost-effectiveness is one of the main benefits of eHealth. This might indicate that healthcare professionals can see efficiency gains in the short run, but find it harder to see cost-effectiveness in the long run. Self-management was found to be a third advantage, because people like being more involved in their treatments, people can get more familiar with and responsible for their illness, and confidence will increase when people notice they are reliant. In literature, self-management was also found to be the most frequently occurring factor contributing to the success of eHealth (Granja et al., 2018).

The final advantage is that patients do not have to travel to their healthcare professional, which is specifically important in these low SES regions. Distances to the nearest hospital for example could be quite long and many people are dependent on others for transport. In addition, transport costs money, and people in low SES regions might have more difficulties paying for this, so for these people eHealth is very beneficial.

Sub question 2: Which factors affect the adoption and implementation of eHealth? The results of this study are quite similar to the study of Schreiweis et al. (2019), who mapped all barriers and facilitators towards eHealth implementation. All factors that this study found, influencing adoption and implementation of eHealth, were also represented in the research of Schreiweis et al. (2019), with the exception of Internet connections. The results of this study are also in line with previous studies that also found that the main barriers for patients to adopt eHealth are user-friendliness (de Wilt et al., 2020; Kruse et al., 2015), eHealth literacy (Griebel et al., 2017), and the feeling that eHealth frequently reminds them about their disease (Huygens, 2018). Other barriers previously found in the literature that were not found in this study include: risk of job loss (Greenhalgh et al., 2018), loss over autonomy (Ross et al., 2016), fear of loss of information (Griebel et al., 2017), lack of confidence in technology (van Gemert-Pijnen et al., 2018), and system language (Schreiweis et al., 2019).

Furthermore, there is disagreement in the literature about the importance of factors influencing eHealth implementation, which is where regional differences might play a role. This research found that the main factors that influence eHealth implementation in a low SES region are: system interoperability, Internet connections, disruption of workflow, and lack of eHealth literacy.

System interoperability & Internet connections

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administrative burden for healthcare professionals, costs for insurance companies and a lot of repeating for patients. Healthcare professionals in East Groningen see this as one of the most important and reachable first steps in the near future. Even though the literature shows that system interoperability is an international problem, East Groningen seems to be lagging behind other higher SES regions in the Netherlands such as Utrecht, where for example paperless documentation is already more common (de Wilt et al., 2020).

Research shows that low SES regions generally have worse Internet connections than high SES regions (Harris et al., 2017). Nevertheless, the influence of poor Internet connections on eHealth implementation has not been getting much attention in the literature. This could be due to the fact that previous research was conducted in high SES regions with good Internet connections where this is not an issue (de Wilt et al., 2020). However, this study shows how influential poor Internet connections can be on attitudes towards eHealth implementation. Currently, the use of simple eHealth solutions such as video calling is often not possible in low SES region. Therefore, participants of this study argue that they are willing to implement more eHealth solutions, but the ICT infrastructure needs to be improved first.

Workflow

A widely discussed topic in the literature is that the implementation of eHealth can disturb workflow and working routines (van Gemert-Pijnen et al., 2018; Topooco et al., 2017). In this study, the disruption of workflow mainly concerns the relationship healthcare professionals have with their patients. This study confirms that disruption of workflow is seen as a major barrier, mainly because healthcare professionals and patients prefer face to face contact over some form of digital contact. Participants mention different disadvantages and negative impacts on their relationship with and treatment of patients: the interpretation of non-verbal contact, the psychological role they have for their patients, and personal factors like a clinical view. This negative impact on the relationship between healthcare practitioner and patient was also stressed in the literature (van Gemert-Pijnen et al., 2018; Granja et al., 2018). Despite research showing the opposite (Berger, 2017), the view that a therapeutic relationship can only be established face to face is still dominating the field (Wind et al., 2020).

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regions is to slowly adapt them into the pre-established workflow without creating stand-alone solutions. The main reason being healthcare professionals' resistance to change too drastically and too fast because their working routines are rooted. A large factor is this resistance to change is their patients, since healthcare practitioners seem to have the perception that patients are the ones unwilling and/or unable to change.

Motivation & eHealth literacy