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The Nordic eHealth group forms the basis for ongoing knowledge sharing across the Nordic countries regarding strategic issues within digitalisation in healthcare. Digitalisation is increasingly becoming a central means for supporting the delivery of healthcare services around the globe. The Nordic region is regarded as a frontrunner when it comes to the implementation and use of digital solutions. As part of the Nordic eHealth group work is being carried out regarding indicators and standardization. This report is the result of the indicator work carried out by the subgroup called the Nordic eHealth Research Network (NeRN). The aim of the work of the group is to provide a foundation for benchmarking across the Nordic countries and support policymaking in the countries, hence the subtitle “towards evidence informed policies”.

In order to realise the potential benefits of eHealth, governments develop eHealth policies to define and prioritise initiatives, the strategic goals and the resulting benefits. During the 23 years with eHealth policies in Denmark only a few status reports with a systematic and transparent evaluation have been made. This paper advocates a more systematic approach to strategic planning of development and implementation of eHealth systems, by encouraging the concept of evidence-based policy making through analysis of how focus of the Danish eHealth policies have evolved. The Danish eHealth policies have very different framings following the different focus points for the policies. Interestingly, strategies for evaluating the devolopment of eHealth and eHealth policies were very sparcely noted in the policies. For the first time the de-emphasising of evaluations of eHealth policies in Denmark has been empirically demonstrated, thus undermining the objective of obtaining evidence-based eHealth policies.

In order to realise the potential benefits of eHealth, governments develop eHealth policies to define and prioritise initiatives, the strategic goals and the resulting benefits. During the 23 years with eHealth policies in Denmark only a few status reports with a systematic and transparent evaluation have been made. This paper advocates a more systematic approach to strategic planning of development and implementation of eHealth systems, by encouraging the concept of evidence-based policy making through analysis of how focus of the Danish eHealth policies have evolved. The Danish eHealth policies have very different framings following the different focus points for the policies. Interestingly, strategies for evaluating the devolopment of eHealth and eHealth policies were very sparcely noted in the policies. For the first time the de-emphasising of evaluations of eHealth policies in Denmark has been empirically demonstrated, thus undermining the objective of obtaining evidence-based eHealth policies. © 2019 International Medical Informatics Association (IMIA) and IOS Press. This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0).

The municipalities and the Regional Health Authorities in Central Norway have been assigned a mandate to implement a shared electronic health record, Helseplattformen, reflecting the visions set out in the national eHealth white paper 'One Citizen - One Record'. This study identifies and describe anticipated benefit streams of clinical decision support in 'One Citizen - One Record' and the user requirement specification documents of Helseplattformen. This study found that the benefit stream of clinical decision support translates from the health policy visions stated in 'One Citizen - One Record' into Helseplattformen. However, business changes, although a critical element of achieving benefits, were not emphasised in either. This calls for the programme of Helseplattformen to pay careful attention to how the information system and information technology requirements must be accompanied by enabling changes as well as business changes in order to achieve the identified benefits of 'One Citizen - One Record' and Helseplattformen.

The municipalities and the Regional Health Authorities in Central Norway have been assigned a mandate to implement a shared electronic health record, Helseplattformen, reflecting the visions set out in the national eHealth white pa-per ‘One Citizen - One Record’. This study identifies and describe the anticipat-ed benefit streams of clinical decision support in ‘One Citizen - One Record’ and the user requirement specification documents of Helseplattformen¬. This study found that the benefit stream of clinical decision support translates from the health policy visions stated in ‘One Citizen - One Record’ into Helseplattformen. However, business changes, although a critical element of achieving benefits, were not emphasised in either. This calls for the programme of Helseplattformen to pay careful attention to how the information system and information technolo-gy requirements must be accompanied by enabling changes as well as business changes in order to achieve the identified benefits of ‘One Citizen - One Record’ and Helseplattformen © 2018. This is the authors' accepted and refereed manuscript to the article. The final authenticated version is available online at: http://dx.doi.org/10.3233/978-1-61499-852-5-885

This report proposes a long-term management of earlier NeRN work to be utilized also in the European and OECD context, and indicators on patients and citizens' use and experiences of eHealth services. An update to prior eHealth policy analysis shows an increase on governance and stakeholder involvement in all countries. The existing NeRN indicators form a good basis for continued monitoring. Common eHealth indicators from citizens’ point of view are needed. Current Nordic citizen surveys offer a good basis for this. Decisions on governance of eHealth benchmarking work and of collaboration between several different reporting organisations are required for long-term maagement on eHealth benchmarking. With very similar eHealth policy goals, the EU, WHO, and OECD should join forces in defining common indicators to be collected nationally and reported internationally (e.g. by Eurostat).

Background: People who undergo weight loss surgery require a comprehensive treatment program to achieve successful outcomes. eHealth solutions, such as secure online portals, create new opportunities for improved health care delivery and care, but depend on the organizational delivery systems and on the health care professionals providing it. So far, these have received limited attention and the overall adoption of eHealth solutions remains low. In this study, a secure eHealth portal was implemented in a bariatric surgery clinic and offered to their patients. During the study period of 6 months, 60 patients and 5 health care professionals had access. The portal included patient information, self-management tools, and communication features for online dialog with peers and health care providers at the bariatric surgery clinic. Objective: The aim of this study was to characterize and assess the impact of an eHealth portal on health care professionals’ interaction with patients in bariatric surgery. Methods: This qualitative case study involved a field study consisting of contextual interviews at the clinic involving observing and speaking with personnel in their actual work environment. Semi-structured in-depth interviews were conducted with health care professionals who interacted with patients through the portal. Analysis of the collected material was done inductively using thematic analysis. Results: The analysis revealed two main dimensions of using an eHealth portal in bariatric surgery: the transparency it represents and the responsibility that follows by providing it. The professionals reported the eHealth portal as (1) a source of information, (2) a gateway to approach and facilitate the patients, (3) a medium for irrevocable postings, (4) a channel that exposes responsibility and competence, and (5) a tool in the clinic. Conclusions: By providing an eHealth portal to patients in a bariatric surgery program, health care professionals can observe patients’ writings and revelations thereby capturing patient challenges and acting and implementing measures. Interacting with patients through the portal can prevent dropouts and deterioration of patients’ health. However, professionals report on organizational challenges and personal constraints related to communicating with patients in writing online. Further development of guidelines and education of health care professionals about how to handle, prioritize, communicate, and facilitate patients online is required in addition to increased attention to the organizational infrastructures and incentives for enabling such solutions in health care. Published article - CC BY

Development of multinational variables for monitoring eHealth policy implementations is a complex task and requires multidisciplinary, knowledgebasedinternational collaboration. Experts in an interdisciplinary workshop identified useful data and pitfalls for comparative variable development. The results are presented and discussed in this paper.

The Nordic eHealth Research Network was established in 2012 as a forum for policy makers and researchers to jointly work towards measurable policy goals and data that can be exploited to steer decision making related to goals and their implementation. This report describes first results of the Network: eHealth policy analysis and first common Nordic eHealth indicators. The results show similarities and also some differences in the eHealth policies, priorities and implementation. Interesting similarities and differences in availability and use of eHealth services in the Nordic countries were found with the first comparable eHealth indicators. The results create a basis for Evidence-based policy making as well as benchmarking and learning best practices from each other.

Background The research presented in this thesis explores whether the emerging technology of blockchain can provide value in the health domain. The research project is, in essence, interdisciplinary, migrating across health science, health informatics, computer science to cryptography. Challenges around trust, access control, data transparency and data provenance are present in health information systems and e-health applications. The emerging blockchain technology encapsulates inherited characteristics that provide data transparency, tamper-proof, integrity, and provenance. Exploring whether blockchain technology can provide any value to these challenges and the health system as a whole, is therefore of interest. The research project aimed to explore the topic of blockchain applications in health information systems. The aim extended to the design and development of an e-health related service that utilizes blockchain properties and evaluates that service. Methods This research work has adopted a problem-driven approach and is based on design science and user-centered design theory. Three studies were undertaken in the scope of the research: a systematic literature review, a proof-of-concept study and a feasibility study. Results Systematic literature review: 39 publications were included in the review after screening based on strict inclusion criteria. The result indicates that Electronic Health Records and Personal Health Records are the areas most targeted by blockchain technology. Access control, interoperability, provenance and data integrity are all issues blockchain technology should be able to improve in this field. Ethereum and Hyperledger fabric seem to be the most used platforms/frameworks in this domain. Proof-of-concept: This study determined and defined the crucial functional and non-functional requirements and principles for enhancing trust between caregivers and patients within a virtualized health care environment. The cornerstone of the architecture was a blockchain technology utilization approach. The proposed decentralized system provides an innovative governance structure for a novel trust model, and the presented theoretical design principles are supported by a concrete implementation of an Ethereum-based platform named VerifyMed. Feasibility study: Five themes were identified from the interviews and focus groups held with real users of the system, after they were exposed to a mock-up of VerifyMed: (1) the need for aggregated storage of work and study-related verification, (2) trust in a virtual health care environment, (3) the potential use of patient feedback, (4) trust in blockchain technology, and (5) improvements of the VerifyMed concept. The System Usability Score questionnaire gave a score of 69.7. Discussion It is essential to systematically explore the digital transformation that is stimulated by new technologies, and their potential impact on health systems. Following a development cycle founded in design science, increases the development of a high-quality and fit-for-purpose system. The results from the feasibility study indicate that VerifyMed has a high degree of fit-for-purpose. System users expressed that a decentralized system for the storage of work-related verifiable credentials could increase trust in the health system, particularly where there are fewer trusted institutions as a result of an increase in the number of health care providers in a digitally transformed healthcare system. An advantage of this research project is the interdisciplinary approach to the multi-leveled topic of blockchain in health information systems. The VerifyMed project should advance to the next steps in the development cycle applied to this project, these being the development of an updated prototype based on the feasibility study’s input and testing the effect with real users. It is likely, where health services are provided in a virtual environment, that blockchain will provide value in digital transformed health systems. A decentralized technology that can guarantee data provenance and integrity could provide significant value to the maintenance of trust in a future in which physical interaction decrease.

Bakgrunn Det er en høy forekomst av hjertesvikt over hele verden. Til tross for avansert medisinsk, farmakologisk og kirurgisk behandling, er pasientresultatene dårlige og sykehusinnleggelsene høye. Pasientrollen har endret seg, og i dagens samfunn er vi mer delaktige og involverte i egen helse og behandling. Digitale løsninger og tjenester kan være en tilnærming for å kunne følge opp og støtte pasienter med kroniske lidelser mens de bor hjemme. Dette kan potensielt bidra til økt livskvalitet, økt mestring av helsetilstand og sykdomsforebygging for den enkelte, og i et samfunnsmessig perspektiv vil det kunne bidra til økt kvalitet, bedret ressursutnyttelse og styrket produktivitet. Hensikt Hensikten med oppgaven er å beskrive, designe og gjøre en validering av et konsept for digital tvilling for oppfølging av hjemmeboende pasienter med hjertesvikt. Målet er å finne løsninger på utfordringene man ser i dagens behandling og oppfølging av hjertesviktpasienter, samtidig som man øker egenomsorgen til denne pasientgruppen. Metode Det er brukt litteraturstudie som metode i første del av studien, dette for å skaffe en oversikt over eksisterende kunnskap. Det er også utviklet en prototype av en applikasjon for hvordan et produkt er tenkt til kommunikasjon mellom pasient og dens digitale tvilling. I tillegg er det brukt kvalitativ metode, her intervju og observasjon, for innsikt, forståelse og meninger fra informanter etter utprøvelse av prototype. Resultater Det er store variasjoner i norsk hjertesviktbehandling. Det er flere utfordringer knyttet til oppfølging av pasienter, kostnader og det er mange reinnleggelser. Rapporter viser at det i løpet av de siste tre årene ikke har vært den bedringen man helst skulle ha sett med tanke på et tilbud med høy kvalitet, og et likt tilbud til alle pasientene. Samtidig ser man en økning i antall eldre og en reduksjon i antall helsepersonell. Løsningen her kan være bruk av digital tvilling-teknologi, dette har aldri vært gjort før med tanke på pasienter med hjertesykdommer, og er nyskapende teknologisk løsning på dagens utfordringer. Konklusjon Studien viser at digital tvilling-teknologiske løsninger kan bidra til å øke egenomsorgen hos hjemmeboende hjertesviktpasienter. I tillegg kan det virke sykdomsforebyggende for den enkelte pasienten, og redusere antallet reinleggelser, som igjen fører til lavere kostnader, bedre ressursutnyttelse, og styrket produktivitet i helsevesenet. Introduction There is a high incidence of heart failure worldwide. Despite advanced medical, pharmacological and surgical treatment, patient outcomes are poor. The patient role has changed, and in today's society, we are more involved and involved in our own health and treatment. Digital solutions and services can be an approach to follow up and support patients with chronic disorders while living at home. This can potentially contribute to increased quality of life, increased coping with the state of health and disease prevention for the individual, and from a societal perspective it can contribute to increased quality, improved resource utilization and strengthened productivity. Purpose The purpose of the thesis is to describe, design and validate a concept for digital twin for follow-up of patients living at home with heart failure. The goal is to find solutions to the challenges seen in the current treatment and follow-up of heart failure patients, while at the same time increasing the self-care of this patient group. Methods As a method, there has been used literature study in order to obtain an overview of existing knowledge. A prototype of an application has also been developed for how a product is intended for communication between the user and its digital twin. In addition, a qualitative method has been used, here interview and observation, for insight, understanding and opinions from informants after testing the prototype. Results There are large variations in Norwegian heart failure treatment. There are several challenges associated with follow-up of patients, costs and there are many readmissions. Reports show that during the last three years there has not been the improvement one would have preferred to see in terms of a high-quality service and an equal service to all patients. At the same time, there is an increase in the number of elderly people and a decrease in the number of health personnel. The solution here can be the use of digital twin technology. This has never been done before with patients with heart disease, and is an innovative technological solution to today's challenges. Conclusion The study shows that digital twin technology solutions can help increase self-care in home-based heart failure patients. In addition, it can have a disease-preventing effect on the individual patient, and reduce the number of readmissions, which in turn leads to lower costs, better resource utilization, and increased productivity in the health care system.

Background Telemedicine is the use of telecommunication technologies, to provide health-related services and -information over a distance. Evaluation and treatment are some areas telemedicine can be used for. This allows the care seeker and healthcare providers (HCP) to communicate without the need of physically meeting. For this communication to be profitable, trust is needed between the two parties. Trust is an important factor in both in face-to-face as in telemedical meetings. It has been shown that patients with increased trust in the HCP report increased satisfaction in care, less symptoms, higher quality of life and more. Aim, objective and method Due to the rise of telemedicine use, especially during the Covid-19 pandemic, there is a need for a closer look of the current scientific literature in order to better understand how trust is perceived by patients in telemedical settings. The aim is to review the current knowledge in trust between a care seeker and a caregiver who use telemedical tools to communicate. The study focuses on the interpersonal trust between the two people. A qualitative content analysis was used for this study. 5 online databases were systematically searched using relevant search terms. Strict inclusion and exclusion criteria were established before the searches. Results The searches generated 1974 relevant hits. 45 articles were found through snowball method. From these articles, 52 were chosen for further inspection based on title, abstract and/or subject. 19 were chosen from the snowball group. From the 71 articles, 9 were chosen after a thorough read through, for the final analysis based on the inclusion and exclusion criteria. 8 main themes and 1 sub theme were identified. Conclusion Trust can play an important role in satisfaction, the outcome and the patient-HCP relationship. A prior face-to-face meeting is beneficial for both parties, as it lays the basis for trust building. Telemedicine can be used as a means to enhance this trust. Continuity and regularity were also found to be important for building and maintaining trust. Telemedicine tools can be both a barrier for establishing trust, as well as a facilitator for it. More time, less hassle around, and the option to choose as well as a caring and focused HCPs are some of the positive facilitators. Studies included had limited age and demographics inclusion. The research done in this area is also limited. Further research is still needed in order to gain comprehensive knowledge of patients trust in HCP in telemedical environments.