The influence of Covid-19 on eHealth and cross-border cooperation from the perspective of German and Dutch medical professionals

The influence of Covid-19 on eHealth and cross-border

cooperation from the perspective of German and Dutch

The influence of Covid-19 on eHealth and cross-border

cooperation from the perspective of German and Dutch

medical professionals

MASTER’S THESIS

by

Moritz Klitzke

S4162242 / 190548180

15639 words (excluding tables and references)

Abstract

eHealth is an often-treated topic in the literature as well in politics for more than 20 years now,

but the implementation in health care systems is developing slowly. However, during the

current Covid-19 pandemic, eHealth is getting a considerable amount of attention as essential

support to manage the pandemic. Also, cross-border cooperation appears to play a role in the

pandemic management. Therefore, the present study aims to investigate the influence of

Covid-19 on eHealth and cross-border cooperation in German and Dutch health care systems. For this

purpose, eleven stakeholders of the health care system from each country have been

interviewed. The findings show that eHealth has been used more, implementation processes

sped-up and different influencing factors on eHealth acceptance have been identified.

Cross-border cooperation has been determined not to be influenced by Covid-19. Afterwards, the

discussion points out whether this is a long-term opportunity or not and put the findings in

context from an operation- and supply chain management perspective.

1

Supervisor:

Dr. Esther Metting

Faculty of Economics and Business at

University of Groningen

EBM028A30

2

Supervisor:

Dr. Rebecca Casey

Newcastle University Business School at

Newcastle University

Acknowledgement

I would like to express my sincere appreciation to my first supervisor Esther Metting. She

supported me through my research project from the very beginning on with her great expertise.

Without her guidance and her constant feedback for my work, this project would not have been

possible. I am grateful for her extraordinary support.

I wish to extend my special thanks to my second supervisor Rebecca Casey, who showed great

interest in my project. She was always willing to answer my questions. Her insightful feedback

gave me the opportunity to improve my work.

I thank all my interviewees for the valuable insights and information they contributed to this

study. I am thankful that, despite their very stressful day, they still found the time to answer my

questions

Table of Contents

1.

Introduction ... 1

2.

Theoretical Background ... 3

2.1.

Definition ... 3

2.1.1.

eHealth ... 3

2.1.2.

mHealth ... 3

2.1.3.

Wearables ... 4

2.2.

Development of eHealth ... 4

2.3.

The German and Dutch HCS ... 5

2.3.1.

The HCSs of Germany and the Netherlands ... 5

2.3.2.

Progress of eHealth in the HCSs ... 6

2.3.3.

Cross-border cooperation between Germany and the Netherlands ... 7

2.4.

Drivers and barriers of eHealth implementation ... 8

2.5.

eHealth during pandemics ... 9

2.6.

Research objectives ... 10

2.6.1.

The impact of Covid-19 in different countries ... 12

2.7.

Research Questions ... 13

3.

Methodology ... 14

3.1.

Case selection ... 14

3.2.

Data collection ... 15

3.3.

Data analysis method ... 16

3.4.

Validity and reliability ... 18

4.

Findings ... 20

4.1.

eHealth ... 20

4.1.1.

eHealth being offered by MPs ... 20

4.1.1.1.

Experienced change during Covid-19 ... 20

4.1.1.2.

Barriers and improvement potential for eHealth... 21

4.1.3.

Acceptance of eHealth ... 23

4.1.3.1.

Acceptance among patients ... 24

4.1.3.2.

Acceptance among MPs ... 24

4.1.3.3.

Factors influencing the acceptance of eHealth ... 25

4.1.4.

Implementation process of eHealth ... 27

4.1.4.1.

Influence of Covid-19 on the implementation process ... 27

4.1.4.2.

External help received during the implementation ... 28

4.1.4.3.

Barriers and process improvement for implementations ... 28

4.2.

Cross-border cooperation ... 29

4.2.1.

Cross-border cases ... 29

4.2.2.

Cross-border learnings ... 30

4.3.

Meaning of eHealth in HCSs and motivation for the use of eHealth ... 31

5.

Discussion ... 33

5.1.

Main results ... 33

5.2.

Sustainability of eHealth offers ... 33

5.3.

Acceptance of eHealth ... 35

5.3.1.

The role of acceptance factors regarding sustainable use of eHealth ... 36

5.3.2.

The role of different technologies ... 37

5.3.3.

Other barriers for sustainable use ... 38

5.4.

Interpretation of Covid-19’s influence on the implementation process ... 39

5.5.

Interpretation of the cross-border findings ... 40

5.6.

eHealth in the context of operations and supply chain management ... 41

5.7.

Limitations and Implications ... 43

vi

List of Figures

Figure 1: Derivation of the research objectives ... 11

Figure 2: eHealth categorized into the framework of De Vries and Huijsman, 2011 ... 42

List of Tables

Table 1: Overview of eHealth implementation barriers in literature ... 8

Table 2: Overview of interviewees ... 15

Table 3: Explanation of the coding tree ... 18

Table 4: Validity & reliability criteria ... 19

Table 5: Overview of influencing factors on eHealth acceptance... 25

Table 6: Application areas of eHealth of Ohannessian, 2015 and this study findings ... 34

Table 7: Factors for a sustainable eHealth implementation of Bradford et al., 2016 ... 35

Table 8: Overview of the Covid-19 influence on implementation barriers ... 40

List of Abbreviations

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1. Introduction

The current Covid-19 pandemic is challenging different industries around the world. Closed

restaurants have meant that the gastronomy industry is struggling. Commercial flights have

been lowered to a minimum and the oil price went below zero. In these exceptional times,

personal contact has been limited as much as possible. In multiple countries it is forbidden to

leave the house and “social distancing” has been introduced, which includes 1,5m between

individuals to avoid further infections. Reduced personal contact has led to changes in the

business world.

Especially, the health care systems (HCS) around the globe have been pushed to their limits.

With worldwide over 64 million infected people and 1.5 million deaths due to Covid-19

(03.12.2020), the whole medical sector is focusing on the control and treatment of the new virus

(Johns Hopkins University & Medicine, 2020). Multiple countries have extended their expenses

into their HCS. Germany, for example, has spent an extra €30,000 more per bed to provide

increased capacity of intensive care beds (ICB) (Geinitz, 2020). The risk of infection for health

care professionals is extremely high since many are in close contact with Covid-19 patients

daily. Technology could be beneficial in the health sector by reducing the need for face-to-face

contact and consequently lowering the infection risk for professionals (Bashshur et al., 2020).

The digitalization of health care (HC) has been regarded as a promising tool for more than two

decades (Tensen et al., 2016). eHealth technology is considered an efficient way to improve

issues including the increasing costs and long waiting lists seen in many HCSs (Kierkegaard,

2013). The World Health Organization (WHO) considers eHealth to be a mechanism to provide

universal HC coverage, and encourages its member states to implement digital infrastructure

(WHO, 2017). The EU claims that eHealth infrastructure is “one of the European Commission's

main priorities” (European Commission, 2020, p. 1). They developed an action plan to

implement Europe-wide infrastructure which would ensure secure access and exchange of

health data. Although, the concept of eHealth is generally supported, it has received some

criticism. Experts of the European Society of Cardiology have requested for more large-scale

evidence (Cowie et al., 2016).

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of eHealth a success or a failure (Ross et al., 2016). Among the most commonly identified

barriers to eHealth implementation were the governmental regulations which bring about

innovation inhibition, and data protection concerns were also identified as barrier to overcome

(Anaya et al., 2018).

Interestingly, since the beginning of the Covid-19 pandemic, digitalization seems has sped-up.

Many people have been forced to work from home to avoid contact with others, and as a result

digital communication has increased (PwC Strategy&, 2020). One region in Norway registered

a rise of video-consultancy by 350% in March (Rolf, 2020) and in some HSCs the regulations

have changed. In Germany, it was possible to request sick leave via phone from February until

May, and this is also possible during the current second wave from October to at least the end

of 2020 (Bundesregierung, 2020). In addition, the German government enacted a law to force

hospitals to share daily updates about their free ICB on a platform for a better coordination of

infected people (dpa, 2020). Different countries have shared their free capacities with those

countries in need. For example, Germany treated Dutch patients in their hospitals (von Dewitz,

2020). The need for cross-border communication seems to be an increasingly important topic

in HC, and for politicians. The Covid-19 pandemic could influence the speed of eHealth

implementation. This is also indicated by the increasing call for more eHealth to aid the fight

against Covid-19 in the newest literature (Ohannessian et al., 2020).

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2. Theoretical Background

2.1. Definition

2.1.1. eHealth

According to the WHO, electronic health (eHealth) is the “use of information and

communication technologies […] for health” (WHO, 2020). This definition has been adopted

by others, for example by Blaya et al. (2010). In a highly respected review to define “eHealth”,

Oh et al. (2005) found that most definitions include the words “health” and “technology”, or

more explicitly the word “internet”. eHealth has often been identified as a tool to overcome

barriers, such as long distance. Eysenbach (2001) regards eHealth as “a state of mind, a way of

thinking”. In his definition “e” not only stands for “electronic”, but also for numerous other

words, which is why his definition is broad. Nevertheless, in most publications eHealth implies

the use of technology in healthcare.

This technology can be categorized into two different categories. Firstly, the technology needed

for a patient’s treatment, for example video-consultancy. This is the wireless treatment of

patients via a video-tool. Secondly, the technology that is being used within an organization to

improve the administrational work. For example, a software to save files electronically in order

to operate paperless. The usage and benefits of eHealth were noted in the early work from Ball

and Lillis (2001), who stated that costs could be reduced via electronic communication. As a

result, money could be saved and the outcome could be increased. More recent publications

also highlight the benefits of the use of eHealth in HC. In particular, the area of psychology has

received the attention of eHealth studies (Bennett et al., 2020).

2.1.2. mHealth

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Kumar et al. (2013) found benefits such as reduced costs and improved well-being when

investigating the use of mobile and wearable technology. Catalani et al. (2013) published a

study about mHealth for HIV treatment and prevention and found evidence for a link between

mHealth and improved care.

2.1.3. Wearables

A new trend within the mHealth sector are wearables, such as smartwatches, as “non-invasive

alternatives for continuous 24-h monitoring of health, activity, mobility, and mental status”

(Chan et al., 2012, p. 138). The constant monitoring of a patient can assist a patient or a MP

with (self-) diagnosis and can enable changes in behavior (Piwek et al., 2016). Wearables often

have a wireless connection to a smartphone, which can be via Bluetooth or the internet. When

it comes to monitoring patients in HC, wearables have proved to be useful for long-term

tracking and they have the potential to detect diseases at an early stage. This is evident in a

publication by Arora et al. (2014) regarding Parkinson’s disease. They used smartphones as

inexpensive tools to measure the movement behavior of individuals diagnosed with Parkinson’s

disease in order to identify key indicators for early detection of Parkinson’s symptoms.

Wearables can also provide the opportunity to self-monitor human vital signs, for example

blood pressure (Dias and Paulo Silva Cunha, 2018). As a result, wearables can increase the

availability of treatment and reduce the associated cost, while improving hypertension rate

(Shimbo et al., 2015).

2.2. Development of eHealth

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Smartphone applications have various features for example, counting daily steps, tracking

sleep, planning personalized workouts, or reminding patients to take medication.

In recent years, modern wearables have attracted significant interest from private consumers.

Supported by the connection to the smartphone, GPS tracking, and the new possibility to

monitor heartrate at the wrist, wearable sales increased from 28,8 million units sold in 2015 to

336,5 million in 2019 (IDC, 2020). The size of the wearables market is expected to be worth

$18.9 billion in 2020, which would be an increase of 30% due to the recent Covid-19 pandemic

(Statista, 2020a). In their review about the reliability of commercial wearables, Fuller et al.

(2020) found that the devices can accurately measure steps and heart rate, but this varies by

brand and manufacturer. However, the accuracy has been demonstrated in laboratory

conditions, and Fuller et al. (2020) consequently call for further research as the devices are

developing rapidly. This reliability issue is one example of a barrier in adopting eHealth in the

HCSs (Harrison and Lee, 2006; Dundon et al., 2020). The next chapter will review this situation

in more detail.

2.3. The German and Dutch HCS

2.3.1. The HCSs of Germany and the Netherlands

While the consumer sector has rapidly increasing demand for digital health products, the

demand in the HCS has developed more slowly. Only 73 of the WHO member states had an

eHealth strategy in place in 2017 (WHO, 2017). This is despite the WHO’s existing resolution

to implement an eHealth strategy, in which they acknowledged the potential positive impact of

communication technology on HC (WHO, 2005). The following chapter will briefly introduce

and compare the German and the Dutch health systems, followed by a presentation of the

current progress regarding eHealth in both HCSs.

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In comparison, in the German HCS the decision power is divided between the federal and state

governments, making the process and reform more complicated (Blümel and Busse, 2020). The

interests of not only the federal government, but also of the 16 states have to be considered in

the process and a compromise, acceptable for all parties, must be agreed upon. Unlike the Dutch

system, Germany does not have a gatekeeper system. In Germany, it is possible to directly visit

a specialist, which leads to longer waiting times for an appointment. In the German HCS two

different kind of health insurances exist: the statutory health insurance and private health

insurance. The latter can only be chosen when a person’s income surpasses a certain boundary

(€56,250) (Blümel and Busse, 2020). Dutch citizens do not have priority over other patients

when having an additional private insurance. In contrast, German citizens with private health

insurance are often prioritized, leading to increased waiting times for statutory insured patients.

Even though the insurance is different, the providers are the same for both (Kornelius and

Langner, 2020).

When it comes to insurances and the coverage of costs, the Dutch have more freedom to choose

their degree of coverage. The costs for basic insurance in the Netherlands are relatively low and

roughly the same for everyone. Citizens with low income receive government support to pay

their medical insurance. In Germany, the costs are related to a person’s income, but basic

insurance in Germany covers more treatments and additional insurance is often not needed.

For treatments not covered by their own IC, people will want to keep the costs as low as

possible. Since eHealth is associated with more efficiency and lower costs, the adoption of

eHealth might be influenced by the degree of insurance coverage of a person, or a countries

population. In this case, the Dutch would have more flexibility about how much to spend on

insurance and what to cover (Blümel and Busse, 2020; Wammes et al., 2020).

2.3.2. Progress of eHealth in the HCSs

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the first plans to implement it (Fricke, 2020). According to the Future Health Index, only 64%

of MPs in Germany use any digital health technology (Koninklijke Philips N.V., 2019). While

only 53% of young MPs see an advantage in the usage of eHealth, while the average of 15

countries is 74% (Koninklijke Philips N.V., 2020).

The Dutch government is currently pursuing similar goals. Dutch MPs keep electronic patient

files which are accessible to the patient (Netherlands Enterprise Agency, 2020). In addition,

they try to support instruments for self-measurement and further promote the video-consultancy

(Government of the Netherlands, 2015). Similar to the German government, the Dutch

government is struggling with the implementation process due to concerns over privacy and the

fragmentation of HC stakeholders (Eerste Kamer der Staten-Generaal, 2011). However, in an

international context, the digitalization of the Dutch HCS is highly developed. For example, on

average, a Dutch GP has twelve video-consultations per day (Daley et al., 2013).

2.3.3. Cross-border cooperation between Germany and the Netherlands

The HC cooperation between Germany and the Netherlands is supported by the EU through the

Interreg program, which spent €9.0 billion between 2014 and 2020 on cross-border cooperation

in Europe (Interreg, 2020a). Among the supported projects are multiple in the field of HC. The

IZOM (Integratie Zorg Op Maat) project, for example, aimed to ease patient movement between

Belgium, Germany, and the Netherlands, and was supported with €2.7 billion. Telemedicine

implementation was supported in the border area between Germany and Poland in order to

move data, but not patients, between 2007 and 2013. To encourage the cooperation between

hospitals, €500,000 were used for the collaboration between a German and a French hospital

between 2007 and 2013 (Delecosse et al., 2017). The EU is currently supporting projects and

studies in the German-Dutch border area with “Interreg Deutschland Nederland”. The volume

is estimated to be €400 million for the time between 2014 and 2020 (Interreg, 2020a). The

self-claimed program objective is “to increase the innovative capacity of the border region and to

reduce the barrier effect of the boundary” (Interreg, 2020a, p. 1), while the goals with highest

priority are innovation in SME, and energy and low carbon economy.

8

transport patients at the end of October (Behrendt, 2020; Meissner, 2020). To improve patient

movement and information flow between different countries, projects such as those supported

by Interreg are now even more valuable for the EU.

2.4. Drivers and barriers of eHealth implementation

A large amount of research exists regarding the drivers and barriers of eHealth implementation

(Niknejad et al., 2020). No single factor is responsible for the failure or success of eHealth

adaption (Ross et al., 2016). Some factors are more obvious, such as the reliability of

technology (Harrison and Lee, 2006; Tison et al., 2018; Dundon et al., 2020), the training of

staff to handle eHealth equipment (Harrison and Lee, 2006; Ross et al., 2016; Morilla et al.,

2017) and the digital divide caused by different accessibility of technology such as the internet

(Yamin et al., 2011). To overcome the first-mentioned barrier is a question of time and the

second one comparably easy to tackle when identified. The need for structural change of an

organization and the lack of infrastructure for adequate technology usage is more difficult to

successfully overcome (Gleason, 2015; Nohl-Deryk et al., 2018; Dundon et al., 2020).

Overcoming these barriers requires immense effort and is especially difficult when the

infrastructure also includes individuals from outside a company. A part of this barrier is the

challenge to manage big data for efficient use of valuable information (Krey, 2020).

Barrier

Explanation

Identified by

Lack of policy

support

Clear regulations are missing,

which inhibits the

implementation

Akter and Ray (2010); Kaye et al.

(2010); Ross et al. (2016); Morilla et

al. (2017)

Data protection

MPs and patients are concerned

about the security of patient

data

Gleason (2015); Ross et al. (2016);

Anaya et al. (2018)

Lack of digital

infrastructure

The infrastructure and

connectivity between system is

insufficient

Gleason (2015); Nohl-Deryk et al.

(2018); Dundon et al. (2020)

Reliability of

technology

eHealth devices are not ready

for the market

Harrison and Lee (2006); Tison et al.

(2018); Dundon et al. (2020)

Big data

management

The amount of data needs to be

handled in an efficient way

Krey (2020)

Training of MPs

MPs need training to adapt

oneself to new technology

Harrison and Lee (2006); Ross et al.

(2016); Morilla et al. (2017)

9

The barriers which are identified most often are arguably, the lack of policy support and data

protection concerns related to health information (Akter and Ray, 2010; Kaye et al., 2010;

Gleason, 2015; Ross et al., 2016; Morilla et al., 2017; Anaya et al., 2018). The lack of policy

support relates to the enacting of laws to facilitate implementations, the financial funding for

eHealth projects and the management of different stakeholders of the HCS. The data protection

concerns are mainly driven by the patients and MPs.

2.5. eHealth during pandemics

For HCSs around the world, eHealth has proven to be valuable for the management of HC

during different pandemics. During the outbreak of SARS-CoV as well as Zika Virus in Africa

technology proved itself to be useful (Ahmadi et al., 2018; Ohannessian et al., 2020). Also, in

Africa the tracking of confirmed Ebola cases via mobile apps, helped to reduce the spreading

of Ebola, since it was faster than paper-based solutions (Keshvardoost et al., 2020).

Initial Covid-19 studies regarding the use of internet hospital in China, where the Covid-19

virus originated and began to spread, have demonstrated the usefulness of eHealth during this

pandemic. Patients were consulted remotely at home, which prevented overcrowding in the

hospitals and minimized the risk of further infection (Gong et al., 2020; Rockwell and Gilroy,

2020). In another publication, the vital signs of patients in a hospital in Switzerland were

monitored with a smartphone app and it has been evaluated as “an effective and time-saving

communication channel within our institution” (Zamberg et al., 2020, p. 6). The latter two

findings are initial and brief results, which are limited to a short time period and a limited

method or literature base. Nevertheless, findings do indicate the potential benefits of eHealth

in the Covid-19 pandemic. Timmers et al. (2020) evaluated the implementation of an app for

self-monitoring of Covid-19 in the Netherlands over a short period of three weeks. They

successfully linked the data to an interactive map with the aim to gain further insights about the

virus via this eHealth tool.

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authors strongly recommended “to apply telehealth tools as an appropriate option to prevent

and contain COVID-19 infection” (p. 8). The indication for improvement in HC delivery also

has been stated by Tebeje and Klein (2020), and these authors call for more research about that

topic in the future. So do Smith et al. (2020) in their paper about eHealth in a Covid-19 context.

Even though they state that “Telehealth does have a critical role in emergency responses” (p.

311), they also mention the importance to highlight is limitations and how important it is to

communicate those.

The potential role of eHealth during the Covid-19 pandemic has also been evaluated in a more

specific context of different medical areas. For example, Neubeck et al. (2020) reviewed nine

articles about people living with cardiovascular disease during Covid-19 and found that eHealth

improved the HC for those people. Furthermore, a systematic literature review by Rauschenberg

et al. (2020) identified mHealth as an important tool to provide HC, and Novara et al. (2020)

established eHealth as helpful in the context of urology.

According to Hollander and Carr (2020), the use of technology is not a complete solution but

is well suited for the Covid-19 pandemic. They state that “health systems that have already

invested in telemedicine are well positioned to ensure that patients with Covid-19 receive the

care they need” (Hollander and Carr, 2020, p. 1681). This statement would indicate that the

Netherlands are better prepared than other countries, such as Germany, when taking the Future

Health Index as benchmark. Keesara et al. (2020, p. 1) also suggest the need for more

digitalization in the HCS against Covid-19 when appealing for “unleashing the power of digital

technologies”.

2.6. Research objectives

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government passed an investment program to digitize hospitals and launched an online platform

to provide serious health information to the population (BMG, 2020b; BMG, 2020a).

The Dutch government provided a grant for GPs to invest in the digital infrastructure of their

practices (RVO, 2020). Furthermore, ICs were allowed to cover additional digital treatments.

The first contact between a patient and a GP, for example, no longer must be face-to-face (NZa,

2020). This might help MPs to overcome their documented lack of willingness to adopt eHealth

in their daily practice (Nohl-Deryk et al., 2018). In addition, the general population may have

overcome their concerns regarding data protection. The German corona app has been

downloaded more than 20 million times by the end of October 2020 (BMG_Bund, 2020). The

pandemic is undeniably a major challenge for the HCS, but it could accelerate change in HC

and lead to improvement in efficiency and quality of care. Wind et al. (2020) stated in their

publication that in multiple countries, the threat of Covid-19 has forced managers to address all

eHealth implementation barriers. Or as Ting et al. (2020, p. 461) wrote in their article: “As the

saying goes, ‘a crisis provides an opportunity’; this first great crisis of 2020 provides a great

opportunity for digital technology.”.

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The literature regarding Covid-19 is increasing rapidly. A large amount of literature is from a

biological or a medical perspective, such as the influence of the virus on different diseases

(Fang et al., 2020; Zheng et al., 2020), the treatment of Covid-19 (Cascella et al., 2020) and

the containment of further dissemination (Hellewell et al., 2020). Another significant literature

focus is the economic influence of Covid-19 (Fernandes, 2020; Ivanov, 2020). However, many

studies conducted on Covid-19 and eHealth only review previous literature, without collecting

additional data. Sust et al. (2020) take North Spain as a case to illustrate the faster

implementation of eHealth due to Covid-19 using only previous literature. Consequently, the

following master thesis aims to investigate the influence of Covid-19 on the digitalization of

public HCS with a qualitative study and expert interviews to determine whether the pandemic

provides an opportunity for eHealth.

2.6.1. The impact of Covid-19 in different countries

The Covid-19 pandemic has impacted each country in different ways, the actions and further

development of the HCS will differ from country to country. Consequently, this study aims to

measure the impact in two countries – Germany and the Netherlands. These countries are

comparable for various reasons. Firstly, they are neighboring countries, and it is sensible to

compare two areas which are geographically close to each other. Secondly, Germany and the

Netherlands are highly interconnected due the free trade area of the EU. Thirdly, both countries

are among the wealthiest in the world, and they have a similar culture. Germany and the

Netherlands do, however, differ when it comes to HCS. As mentioned previously, the

Netherlands are considered to be a forerunner in the HCS, while Germany is less effective and

less developed in the eHealth area. However, Germany appears to have performed slightly

better than the Netherlands, particularly during the first wave of the Covid-19 pandemic.

According to the Johns Hopkins University & Medicine (2020), Germany had 1,117,953

infected people, of which 17,718 died. This equates to a death rate of 1.6% (03.12.2020). For

the Netherlands it is known that there are 9,645 deaths (03.12.2020), but the actual number of

infected people is difficult to determine since the Netherlands did not test as extensively as

Germany in the beginning (Stafford, 2020). It can be assumed that the actual death rate of the

Netherlands is similar to the German rate.

13

countries. It is plausible that these differences may also influence the further development of

the actions of these countries during and after the Covid-19 pandemic. For this reason, it is

necessary to compare Germany and the Netherlands in the present study. Also the cooperation

of both countries appears to be relevant to successfully manage the Covid-19 pandemic. Since

the start of the pandemic, Germany used its high capacity of ICB to support other countries and

treated over 200 foreign patients (Auswärtiges Amt, 2020a). This kind of support may be crucial

in the near future.

2.7. Research Questions

In order to determine whether the Covid-19 pandemic provides an opportunity for eHealth and

the cooperation between Germany and the Netherlands, the research question will be the

following:

“How do German and Dutch medical professionals see the influence of Covid-19 on

eHealth and cross-border cooperation?”

There are supportive questions which are formulated to help answering the main questions of

the research. The first question aims to identify changes in the daily operation of the stakeholder

and tries to identify if these changes were faced with eHealth. Secondly, the thesis question

asks for influencing factors in the opinion of the interviewees. In this way, the research aims to

identify factors having an impact on the acceptance of eHealth. The third supportive question

aims to analyze the implementation process and find out whether or not the implementations

took place faster. Finally, the cooperation between the two introduced countries is treated in

order to identify cooperation, the role of eHealth and the future plans of the stakeholders.

I.

What change did the MP’s experience in their operation during Covid-19 and how

was it related to eHealth?

II.

What factors are relevant for stakeholders of the HSCs regarding the acceptance of

eHealth?

III.

How did Covid-19 influence the implementation processes of eHealth?

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3. Methodology

3.1. Case selection

This study follows an inductive approach, since the master thesis will build a theory from

observed phenomena, such as the increased call for eHealth implementation, and politicians

being forced to act. To conduct this cross-border case study, MPs have been interviewed to

gather qualitative data. Interviews with eleven MPs have been conducted to ensure a sufficient

amount of data.

Inclusion criteria were used to select interviewees. Firstly, participants must operate within the

border area defined by Interreg project (Interreg, 2020b). A total number of seven interviewees

are from Germany, while four are from the Netherlands. According to Gläser and Laudel

(2009), an expert has to have a special standing in the research context. To ensure more than

one point of view was covered in the context of HCSs, and that valuable information was not

missed, the experts are represented by different stakeholders of the HCS (see Table 2). Every

interviewee has at least 10 years of working experience in their profession.

The GPs have been chosen because they are in the center of the HCS and can experience rapid

change in the way they work. Therefore, their input has created valuable information about

eHealth in their practice. Other experts with a special standing in the system and who experience

change in HCS are ICs. ICs can have a huge influence with their policies. For example, tools

and technology that are supported or paid by ICs are more likely to be used by patients and

prescribed by a doctor. Therefore, ICs can encourage eHealth implementation when

recommending eHealth products. Changes of policies and set-up of programs during the

Covid-19 pandemic suggest the need for an increased digital HSC.

15

Name Profession

Job

experience

Country

Interview

form

Age

I1

Insurance manager

11 years

Netherlands

Video-call

31-40 years

I2

GP

12 years

Germany

Video-call

31-40 years

I3

Hospital manager

30 years

Germany

Telephone

51-60 years

I4

GP

19 years

Netherlands

Video-call

41-50 years

I5

Physiotherapist

16 years

Germany

Telephone

31-40 years

I6

Insurance manager

>30 years

Germany

Video-call

51-60 years

I8

Insurance manager

30 years

Germany

Video-call

51-60 years

I9

GP

30 years

Germany

Video-call

51-60 years

I10

Insurance manager

20 years

Netherlands

Video-call

41-50 years

I11

GP

-

Netherlands

Telephone

-

I12

Head of psychology 12 years

Germany

Video-call

41-50 years

Table 2: Overview of interviewees

3.2. Data collection

Interviews were used to collect data based on a semi-structured interview guide (see Appendix

A). This interview type is flexible and gives the interviewer the opportunity to ask follow-up

question to gain further details. It also gives the interviewer the chance to explain unclear

questions (Gläser and Laudel, 2009). The interviews focused on experts in order to gain

knowledge about their experience with eHealth during the Covid-19 pandemic. The interview

guides were very similar, however, for the interviewees from ICs, the questions were adjusted

slightly to provide an optimal fit to the interviewees. The interviews were mostly performed via

video-call. Compared to other options, video-calls provided the opportunity to see the other

person which allowed the interviewer to have more control over the conversation, and interpret

the body language of the interviewee (Gläser and Laudel, 2009). Due to the Covid-19 pandemic,

personal contact in face-to-face interviews, as well as travelling across borders, was not an

option. Three interviews were conducted via telephone due to a lack of appropriate technology.

In all interviews, only the interviewee and the interviewer were present. Interviews with

German participants were held in the German language, while interviews with Dutch

respondents were held in English.

The interviews took place between the 18

_{of September and the 21}

_{of October. All interviews}

16

The form contained how the confidentiality and anonymity has been ensured (see Appendix B).

The interviewees were given the opportunity to read the consent form and ask questions before

signing the document. Audio recordings of the interviews were taped for multiple reasons.

Firstly, it ensured highly detailed and accurate reconstruction of the interviews. Secondly,

during the interview the interviewer was able to focus on the interview itself and analyze the

situation to ask follow-up questions, and the flow of the interview was not disturbed by taking

notes (Gläser and Laudel, 2009).

At the end of each interview, interviewees had the opportunity to ask for a copy of the transcript

of the recording. This gave the experts the opportunity to check and evaluate their responses,

and it also meant that the interviewer might gain additional knowledge (Gläser and Laudel,

2009). For example, after one interview, the questions regarding cross-border treatment were

sent to a colleague of the interviewee. This made it possible to gain more valuable and additional

information since the interviewee could not provide the needed information.

3.3. Data analysis method

The interviews were transcribed from the recorded audio file to save the data in a reasonable

format (Kaiser, 2014). The coding of the material followed the approach of Gläser and Laudel

(2009) which has the advantage of being flexible to work with. A search grid with different

categories based on theoretical knowledge was created to categorize the data from the

extraction. Then, the text was separated into different phrases and sentences which include

statements with valuable information. The text parts were assigned to the categories from the

search grid. While the extraction process took place, the categories have been further developed.

Definitions of existing categories were developed, and categories were created. This ensured

the flexibility of the search grid and made it open to include unexpected information.

17

searching for words and phrases can make it easier to locate connections in the structured data.

There are, however, limitations to the use of NVivo 12. The researcher must learn how to

properly use the software, as a consequence timesaving decreases slightly. Furthermore, the

software cannot interpret the data for the researcher, it can only be used to facilitate the work.

“The general processes of generating categories or taxonomies, assigning meaning,

synthesizing or theorizing […] still rests on the researcher’s shoulders.” (García‐Horta and

Guerra‐Ramos, 2009, p. 163).

Main

category

First level of

sub-category

Second level

of

sub-category

Description of what the

statements/comments of that category

refer to

eHealth

Offers

Since

Covid-19

The different eHealth services offered to

patients and customers since the Covid-19

pandemic started

Barriers

The barriers that impede to offer more

eHealth

Improvement

potential

Areas and ideas of improvement to offer

more eHealth

Acceptance

Since

Covid-19

The acceptance of eHealth since the

beginning of the pandemic and the

development of eHealth acceptance

Factors

Factors that influence the acceptance of

eHealth

Implementation

process

Since

Covid-19

The implementation processes that took

place since the start of the pandemic and

changes in those processes

Improvement

potential

Areas and ideas of improvement to offer

more eHealth

Barriers

Barriers that appeared during

implementation processes

External help External help that had been received

during the implementation processes

Future

Projects

eHealth projects/plans with concrete steps

been taken to realize them

Plans

Intended plans for future eHealth use with

no step taken yet

Predictions

Predictions about the eHealth development

in the HCS

18

eHealth

Motivation

-

The stakeholder’s motivation to implement

and use eHealth

Meaning

-

The meaning of eHealth for the HCS and

the future development of eHealth

Definition

-

What would be defined as eHealth

according to the interviewees

Cross-border

Cases

-

Cross-border patients that the interviewees

have contact with in their work-life

Learnings

-

Things that the own country/HCS can

learn from the other country/HCS

Cooperation &

communication

-

Cross-border cooperation that the

interviewees have or how the

communication takes places

Treatment

- The process of treatment and follow-up

treatment if necessary

Future

- The plans about the management of

cross-border cases and cooperation

Difficulties

- The difficulties that emerge when treating

patients from another country

Operational

Change

since

Covid-19

-

- The changes in the organizations since the

Covid-19 pandemic began

Job

-

- The description about the interviewees,

their positions and their organizations

Table 3: Explanation of the coding tree

3.4. Validity and reliability

19

the interviews ensured that the analysis was not biased, and the opportunity for interviewees to

review their transcript increased the quality and reliability of the statements.

Criteria

Description

Internal validity

▪ Recording of the interviews

▪ Inclusion criteria to verify stakeholders

▪ Multiple sources – e.g. literature, interviews

External validity

▪ Variety of different stakeholders

▪ Familiar environment for interview setting

Reliability

▪ Semi-structured interview guide

▪ Transcription of interviews

▪ Conduction of interviews in similar settings and period

20

4. Findings

4.1. eHealth

4.1.1. eHealth being offered by MPs

The following chapter will show the change experienced by the interviews, with a focus on

eHealth, and consequently answer the first sub question of this study.

4.1.1.1. Experienced change during Covid-19

The number of eHealth products offered and used since the Covid-19 pandemic has increased.

There is technology that has been used more and also technology which usage decreased again

after the first wave. Most often mentioned by GPs, ICs and hospitals was the video-consultancy

for patients. Interviewee I8 (IC) says that customers had the opportunity to “conduct a free

video-call with a doctor”, while I4 states that Covid-19 gave the final push to implement the

planed a video-system. For the GPs, the number of consultancies decreased early due to

difficulties with usability (I2 & I9) or soon after it was possible to see patients face-to-face

again (I11). Hospitals made use of video-consultancy for a longer period. Contactless treatment

seems to be a good alternative, particularly in mental health sector. Next to digitalizing lectures

and tools for their patients, I12 says they also offered other digital ways to deliver care:

„We have offered telephone pastoral care for staff and patients, and also for other external

persons who are burdened. We have offered video conferencing and video support, individual

therapy or group therapy". (I12)

In contrast, the physiotherapist I5 had neither used phone nor video-consultancy. Not only I12

used the telephone to reach out to their patients. The GPs see it as less complicated to

communicate using telephone as opposed to video-consultancy and so I2, I4, I9 and I11

predominantly used a telephone during the Covid-19 pandemic.

“We started to call them active[ly], asking how they were doing if and if they were socially

[…] in isolation or anything.” (I4)

One IC provided customers and employees with a Covid-19 telephone-hotline, while another

IC implemented a chat-bot which could “answer 24/7 a lot of customer questions with relation

to the pandemic”. In general, eHealth has often been used to transfer information. GPs from

21

also referred them to patients (I4) and updated their own website to inform their patients (I11).

Employees in hospitals had their compulsory training digitally.

"We do have a certain number of compulsory training courses so that the employees could be

trained on the subject, on data protection, but also on medical device technology, hygiene,

and fire protection. We tried to train them electronically as far as possible.“ (I3)

4.1.1.2. Barriers and improvement potential for eHealth

The interviewees gave multiple reasons as to why the offered technology is still limited. Both

Dutch ICs claims that one reason is how doctors are paid. The payment is higher when seeing

patients in person compared to remote consultancy.

“So [..] the system works […] sometimes the other way around, that you want to see as many

patients as possible and then you get, well, all the money for all these patients.” (I1)

On the German side financial barriers are also mentioned (I5). Investment costs for appropriate

equipment are too high and the management is not convinced by its advantages. High

investment costs slow down the process of digitalization in the hospital of I3 since multiple

buildings must be included in the process. However, I3 points out there is no resistance within

the company anymore, just “financial reasons and procedural reason”.

Interviewees from both countries mentions the data protection laws as inhibiting to offer more

digital services. Specifically, interviewees from ICs (I6 & I8) and a hospital (I3) criticizes the

lack of digital infrastructure for information transfer. For both factors the interviewees believe

it is the government’ duty to improve it.

“And finally, I would say that a complete infrastructure, i.e. a data highway, is still missing.

So that's what they are working on...in the Federal Ministry to create a data highway. That in

principle every medical service provider can transfer data using the same format.” (I6)

The German GPs believe that not all technology is marketable. In particular, smart watches are

not seen as practical. According to I9 “they unfortunately always recognize [diseases] wrong“

(I9). interviewee I12 would like a universal standard to ensure quality.

22

4.1.2. Future eHealth use & strategies

The following section about the future will consist of three sections. Firstly, the projects, which

are already in the making. The second category is the plans and strategies the interviewees have

for the future, plans they intend to act on but have not yet taken steps to do so. Thirdly, there

are predictions about their companies, and the HCS, concerning eHealth in the future. Most of

the time the interviewees do not have a direct influence on that outcome.

Most interviewees have concrete projects to offer new eHealth. They differ in whether they are

driven by 19 or not. The following projects are directly or indirectly driven by

Covid-19. Both German hospitals (I3 & I12) want to further digitalize the compulsory training for

their MPs to be more flexible. I12s hospital currently digitalizes its offers to patients, while I3

says their hospital has a budget for digitalization in their investment plan for the next year.

“Now in the investment plan it is planned for next year to connect the intensive care unit, or I

must say the intensive care units, for the newborns to the overall house system, hospital

information systems.” (I3)

One German IC (I6) intents to further extend its new chat-bot. When it comes to

video-consultancy systems, GP I9 and I11 want to increase the usage of this system since “it is better

than phoning” (I9). GP I4 has no such system, but the installment is in progress and the system

will be available from November onwards. GP I11 states she will update her website with

relevant information more frequently, something she started during the Covid-19 pandemic.

Less driven by Covid-19 are the projects of GP I2 who began implementing projects before the

pandemic, such as monitoring the heart rate of patients via smartphone. ICs in Germany and

the Netherlands state that their current projects, and their support for eHealth are unrelated to

Covid-19.

IC’s strategies are one of the main differences between Germany and the Netherlands. German

ICs try to increase the eHealth usage by directly approaching the patients and making the offer

attractive to them, for example, by offering free usage in the beginning. According to I6, the

company wants to be accepted “even more as a partner” by their customers.

23

Dutch ICs follow a different strategy. They support the MPs and try to convince them of the

benefits of technology use. I10 mentions multiple strategies, for example, they invest in pilot

which are extended if successful. Moreover, they use scientific approaches such as the

quadruple aim model to verify effective implementation of technology (Bodenheimer and

Sinsky, 2014). I1 and I10 say they consult MPs during the implementation to increase the

sustainability of change (I1). I1 mentions that they try to highlight that eHealth is supposed to

be the new way to deliver care. MPs should be completely convinced of the necessity of eHealth

implementation.

“So, we […] described it as a no regret move. And for us, that was the most important part.”

(I1)

Of all the GPs only I4 formulate a strategy, she states that she tries to convince patients of

eHealth by letting them know that “it is different, but it will be just as good.” Moreover, I4

plans to have one doctor in the practice specifically for video-consultancy. I9 intends to install

a tool which will allow people to make appointments online and I12 prepares the hospital to

have a reasonable mix of digital and face-to-face treatment in the future.

“Well, [it] would have to go surely around that one can freely select the relationship from

interhuman operation offers and really well functioning, respectably, thus technically

respectably, ideal application and also in such a way that also everyone can afford that.”

(I12)

When asked about eHealth in the HCS and their company in three years, almost all interviewees

see a further development. Only the physiotherapist I5 believes that not much will change in

the company since a progress until now was barely existing. GPs are mainly focus on

digitalizing administration tasks or digitalizing processes, such as monitoring and diagnostic.

Many German interviewees predict a breakthrough in the infrastructure for the health card, and

wish to have easier communication between different MPs.

4.1.3. Acceptance of eHealth

24

4.1.3.1. Acceptance among patients

The acceptance and usage among patients has been different over the last months. According

to a Dutch IC, the use of eHealth tools, especially video-consultancy, behaved the following

way:

“So when Covid-19 started […] it was sky high […] and when it got better with Covid, well,

we saw that things got normal like before and now we see again a big increase in attention.”

(I10)

The other Dutch IC (I1) observed a similar course from February to August. Both interviewees

still see an increase in the usage and acceptance among patients when the situation began to

normalize.

The German ICs have different opinions on eHealth usage. While interviewee I8 states that the

usage of video-consultancy has been five-times as high in April 2020 compared to 2019,

interviewee I6 reflects an increase in the use of eHealth:

„So, as I said, the bottom line is that the demand was not so exorbitant that it would have

overwhelmed us. Online doctor more? – Yes. Chat more? - Yes. The telemedicine offers and

apps have also been used more, but everything is still within a manageable range.“ (I6)

GPs from both countries observed that patients are using the phone and information websites

more often. While video-consultations are not that widely accepted among patients, the phone

received an increased amount of attention. All GPs from Germany and the Netherlands report

it as the preferred method of communication due to its ease of use.

[…] as before Covid, I would have like four or two or three telephone calls and now I have

about ten telephone calls instead of seeing people live. (I11)

4.1.3.2. Acceptance among MPs

When it comes to the acceptance of eHealth on the side MPs, the ICs in both countries are in

favor of more usage and see the advantages of technology. Interviewee I10 says: “we as a health

insurer would like to see it's developments to go a little bit quicker.” ICs think that the

25

“But when the lockdown was [...] there that was completely over. So, they were very

motivated […] to start with this new way of […] seeing their patients.” (I1)

I10 calls the pandemic situation an “eyeopener” for MPs, interviewee I6 thinks it “lead[s] to a

positive effect” for some MPs. The MPs themselves have different opinions on different kinds

of technology. They are often in favor of technology which makes administrational work easier.

A Dutch GP (I4) says that referring to information websites can make her work “much easier”.

In Germany, the health card is seen as advantage by the interviewees. When asked about the

health card project, I9 says: “I see big advantages.” Whilst I3 mentions the positive feedback

on the digitalized compulsory training for hospital staff, the other hospital in Germany (I12)

says that they definitely see added value through the digitization process during Covid-19.

When it comes to the actual treatment of patients, however, the GPs are more skeptical about

eHealth. I2 is not convinced by the existing video-consultancy technology, while I9 is also

undecided about its use in the future. A Dutch GP (I11) says the advantages and disadvantages

“even each other out” and explained further:

„It was an eye opener that I thought: Okay even after Covid we could do much more

telephone calls. That's possible. Medically it's possible. I don't like it because I rather see

somebody live.” (I11)

4.1.3.3. Factors influencing the acceptance of eHealth

Four factors have been identified in the interviews which influence the likelihood to accept

eHealth (see Table 5).

Factor

Explanation

Discipline of MP

The discipline that the MP is exercising (e.g. GP, mental health,

IC) found to have influence the acceptance of eHealth

Age of eHealth user

The age of the person who is using eHealth as well as the MP’s

age influences the likelihood to accept eHealth

Level of education of

eHealth user

The higher the level of education, the higher the familiarity with

eHealth according to the interviewees

Disease

The type of disease is influencing the acceptance of eHealth. It is

better applicable for mental health e.g.

26

Most of the interviewees think that elderly people are more hesitant to use technology.

Interviewee I5 mentions that there is “definitely” a difference concerning the user’s age and that

“younger people like it more to get in touch with it”. I11 mentions that elderly people “are not

very used to using this kind of technology.” And I9 counts herself as part of a generation that is

not very familiar with technology. On the other hand, interviewee I8 states that society “often

underestimates the seniors”, because they are more conscientious when providing data.

Both interviewees from Dutch ICs see the medical discipline as a factor when it comes to the

acceptance of eHealth. In the experience of interviewee I1 in mental HC “it's […], more

common that it's a […] blended version to receive their care” and “the implementation of

eHealth […] in the GP practices, that's going very, very slow”. Additionally, I10 believes it is

easier to implement technology in hospitals.

“The hospitals, they are better organized than the GP [practices] because […] the hospital

they've got like a big ICT department and GP [practices] don't.” (I10)

Both interviewees are supported by statements from two Dutch GPs and one of the German

GPs (I9), who regard GPs as more skeptical than MPs from other disciplines.

“GPs, […] they're more hesitant to […] use it because, […] that's really against the whole

[…] soul of being a GP. It’s not to be digital, but to be live. (I11)

The third factor mentioned multiple times is that the acceptance of eHealth depends on the

diseases. Mental health applications are common and are often offered by ICs (I6). Also,

chronical diseases, for example lung-& heart illnesses and high blood pressure, are more often

connected to eHealth. Patients can either monitor or educate themselves via the internet.

“Ah, many people do that anyway, almost everyone who has high blood pressure gets such a

device and measures their blood pressure at home. (I9)

“If there sometimes are such rare diseases, then sometimes they know more than we do.” (I9)

27

The final factor is the patient’s level of education. Interviewee I5 thinks that “people who

studied, simply get more comfortable with computers during student time“. While interviewee

I10 even sees educational background as “a bigger problem” then age.

“So when people have higher education and a higher age, then it's not a problem. With the

right tools, […] they can get around with eHealth. That's […] okay .But people with lower

education, that's a bigger problem to take care of themselves with […] eHealth devices.”

(I10)

4.1.4. Implementation process of eHealth

The third supporting questions aims to identify the influence the of the Covid-19 pandemic on

the implementation process. The following chapters will present the findings related to that

question.

4.1.4.1. Influence of Covid-19 on the implementation process

The implementation process of eHealth technology experienced change during Covid-19. The

administrational point has been brought forward. The hospitals offered their employees a fast

and smooth implementation of home office (I3). According to I8 (German IC), home office has

been possible for the first time. Before data protection concerns made it difficult, but “in the

context of Covid-19 you could do it faster”.

I6 reports that the implementation of a chat-bot for FAQs took place much quicker than usual

due to the encouragement to act during the first Covid-19 wave:

„That was an [...] ideal picture now. Normally it's not so easy, because we wanted to be fast

and cost drivers […]is what we waived at this point.“ (I6)

However, I2 reports that the implementation of eHealth projects have been delayed by a few

months. The field test for the infrastructure of the German health card was a struggle “because

no patient came” to the practice in March. I10 describes a similar situation:

“They were enthusiastic and they said we will start in 2020 and then Covid came and they

said, okay well, we have to pass it because we don't have the time for that now and we have

28

The same interviewee reveales that every implementation related to video conferencing “went

a lot faster” compared to before the Covid-19 pandemic. In summary, projects without an

Covid-19 focus were delayed while the Covid-19 related implementations were boosted. After

the first wave of Covid-19 ended, the focus on eHealth implementations increased according to

I10.

4.1.4.2. External help received during the implementation

All interviewed ICs work with companies which develop eHealth and practically buy the whole

digital service without big own involvement.

„[…]we don't always have to invent everything ourselves, do everything ourselves, and that is

where we got into business, so to speak, with a small Leipzig start-up, who offered something

like a chatbot.” (I6)

The Dutch ICs specifically mention the grant offered by the government for digitalization and

state that many GPs use the money. Interviewee I4 says that her head company used the money

but not them directly. In Germany, interviewee I3 is positive about the future investment

program from the government, which he thinks was accelerated by Covid-19. Financial support

has also been reported by I9 from the head association for using video-consultancy. Other than

that, the external support was limited and the support from the software provider in case of

interviewee I9 has even been insufficient.

4.1.4.3. Barriers and process improvement for implementations

The interviewees mention different problems in the implementation process. For example, one

of the most common barriers is the incompatibility between IT system. German and Dutch

professionals from hospitals, ICs and physiotherapist mentions this issue (I1, I3, I5, 16, I12).

“And then our company has the particular problem that we work with two different systems.

This means that the doctors have a completely different system than the therapists and these

two systems are not compatible.” (I5)