Digital health (eHealth) tools have been proposed to improve access to health care services, enhance care co-ordination and integration, enable self-management, support decision-making, enable monitoring, perform risk analysis, and facilitate proactive interventions [1]. It is within this context that the European Commission has defined eHealth as follows:

The implementation of digital health tools has constituted an area of major research and innovation in the past years [1,4-7]. For example, the impact of electronic health records on health care quality has been explored by Campanella et al who showed improvement in health care quality in terms of guideline adherence and time efficiency while reducing medication errors [8]. In parallel, most countries have recognized the value of patient portals [9-11]. The use of health monitoring devices in the general population is also increasing, with a broad spectrum of sophistication, including examples like integration between artificial intelligence and monitoring in a single device (ie, cardiac rhythm analysis) [12]. Moreover, the use of open-source algorithms for subject-specific as well as population-based risk prediction has been reported [13,14]. Some of these technologies are already in use for the management of chronic multimorbid patients [15-20].

It is currently accepted that eHealth tools can be particularly useful to support Integrated Chronic Care (ICC) programs for patients with multimorbidity, that is, co-occurrence of 2 or more chronic disorders within 1 individual [21]. Insights from the ICARE4EU project [6] concluded that eHealth improves care integration and management processes, but the project identified that inadequate funding mechanisms, poor interoperability, and inadequate technological support represent major barriers for adoption of technologically supported ICC. In fact, it is acknowledged that the takeoff of digital health tools to support ICC is progressing rather slowly. Also, regulatory aspects are still a concern [22-24] to achieve a proper balance between preservation of individual privacy and the need for health data sharing [25], as well as the increasing demand for health data analytics.

The Sustainable intEgrated care modeLs for multimorbidity: delivery, Financing, and performancE (SELFIE) Horizon 2020 project [26] aims to produce evidence and applicable policy advice on ICC programs for people with multimorbidity. Within the project aims, the SELFIE conceptual framework [27] was developed. It comprises 6 core components of integrated care systems adapted from the World Health Organization, namely: (1) Service delivery, (2) Leadership and governance, (3) Workforce, (4) Financing, (5) Technologies and medical products, and (6) Information and research.

This paper focuses on 2 elements out of the 6 components of the SELFIE conceptual framework [27], which refer to the enabling role of digital health tools (Technologies and medical products) and assessment of ICC programs (Information and research). For each of these 2 components, the 3 levels of the SELFIE conceptual framework (micro, meso, and macro) were taken into account. The micro level is where the individual with multimorbidity interacts with care professionals and informal caregivers. The meso level relates to the organizational level and the institutional setup of providers. Finally, the macro level includes legislations, governance, policies, and system-wide changes at the national and international level.

For Technologies and medical products, the SELFIE framework stresses the need for digital health tools to be widely available and user-friendly to provide robust support to the care processes. At a micro level, the use of technology (eg, electronic medical records [EMR) and patient portals) can be a facilitator of collaborative care if tailored to the needs of the patient with multimorbidity. At a meso level, a shared information system (eg, EMR including shared care plans) among multiple providers and care settings can greatly facilitate communication, person-centeredness, personalized care, and care co-ordination. Finally, at a macro level, nationwide and international policies that foster technological development and innovation most likely would benefit from both implementation and continuous assessment of ICC programs for multimorbidity.

For Information and research, the project stresses the successful use of collected data from digital health tools for a 3-fold objective, namely: (1) Population health management; (2) Enhanced subject-specific health care delivery; and (3) Comprehensive assessment of ICC programs. At a micro level, currently collected individual-level data (eg, patient journey record) can effectively be used in the care process for individual risk prediction. At a meso level, shared information systems may further be used for service selection both at individual and group level (eg, triage systems and clinical predictive modelling) to strengthen the evidence base of complex integrated care interventions, as well as to develop indicators particularly relevant for the care of patients with multimorbidity. Alongside data ownership at a meso level, privacy and data protection legislation is an important consideration at macro level.

It is well accepted that the existence of an important gap between the way in which the role of digital tools is understood and the effective uptake of digital transformation by the different stakeholders in the health care systems at European level. To enable the real implementation and scale-up of the digital health tools with all their potential, we undertook this overarching analysis. Our study aims to synthesize the experiences, views, and opinions (including barriers and enabling factors) of the stakeholders and their impact on the care process, as well as the role and desirable future developments of digital health tools, to foster transformation of health care systems toward sustainability by enhancing management of patients with multimorbidity. A second aim is to characterize the different programs with respect to maturity of their supporting digital health tools and the level of assessment of the ICC program.

Here, we present the results of an overarching analysis of the Thick Descriptions [28] of 17 promising ICC programs selected by the SELFIE project across 8 European countries: Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom. Within the overarching analysis, we focus on the different aspects of implementation of digital health tools supporting services and facilitating assessment strategies. This will lead to future directions defining how digital support can contribute to scale-up and evaluation of integrated care services. These services should focus on patient-centered health care provision with dynamic evaluation of technology-enabled integrated care programs, without compromising patient privacy.

To select the 17 ICC programs, each country participating in the SELFIE project [29] applied a search strategy using the findings from an international scoping review, national publications on previous and on-going programs and projects, and consultation with national experts and networks. Details on the process of selection of the programs, as well as the list of the 17 selected programs per country, are reported in Multimedia Appendix 1. The 17 programs were grouped into 4 categories: (1) population health management programs (n=5); (2) frail elderly programs (n=6); (3) programs for individuals at the end-of-life and oncology patients (n=3); and (4) programs for vulnerable individuals who face problems in multiple life domains, like health, housing, and financial problems (n=3).

The Thick Description, a qualitative empirical research method, was used in SELFIE to gain a deep understanding of the ICC programs from the different stakeholders’ point of view [28,30]. The method undertaken included two different approaches: (1) Study of a variety of documents about each of the 17 ICC programs (ie, official and contractual documents, documents related to past evaluations, and factsheets from each ICC); and (2) interviews conducted with all relevant stakeholders (ie, program managers, initiators, representative of sponsor or payer organizations, health care professionals, informal caregivers, and patients or patient representatives). As described earlier, we concentrate on the two information technology-related dimensions in this paper.

Each partner-country interviewers underwent specific training on how to conduct and analyze the semistructured interviews to ensure uniform procedures. A total of 233 stakeholders were interviewed from November 2014 to September 2016 (see Multimedia Appendix 2 for more detailed information on stakeholder composition per country). The interviews were audio recorded and transcribed verbatim from the audio file by either the interviewer or an independent research transcriber. The resulting transcripts were analyzed by members of the local SELFIE teams using Mayring qualitative content analysis [31]. The quotations which were used in the thick descriptions were edited into readable forms and translated into English. The transcripts were not returned to participants for correction.

When writing this manuscript, we adhered to the COnsolidated criteria for REporting Qualitative research [32]. All information retrieved from the document analysis (including the stakeholders´ interviews) was processed according to the country-specific ethics statement listed under the subheading: Ethics Approval and Consent to Participate. The Thick Descriptions of the 17 ICC programs studied can be found on the SELFIE website [33].

The first author did a thematic analysis [34] on the Thick Descriptions of the 2 components of the SELFIE conceptual framework referring to the enabling role of digital health tools (Technologies and medical products) and assessment strategies of the ICC programs (Information and research). He then discussed findings with all other coauthors. For each of these 2 components, this secondary analysis of the Thick Descriptions considered the 3 levels of the SELFIE conceptual framework: micro, meso, and macro. As detailed in Table 1, a 3-level grading system (+ to +++) was developed and used, under the criteria of the coauthors (JR and IC), to score maturity of the 17 ICC programs for each of the 2 components assessed in this research. Finally, the maturity of each of the 2 components of the SELFIE conceptual framework is summarized as the average of the maturity at micro, meso, and macro level.

Letters of Medical Ethics Approval of study protocols, questionnaires, and informed consent forms were sent and approved by the European Commission as a Deliverable of the SELFIE project.

Austria: Letter from Institute for Advanced Studies (IHS) declaring that ethical approval is not necessary for the evaluation of the two Austrian Integrated Care programs, October 3, 2017.

Croatia: Statement from the Agency for Quality and Accreditation in Health Care and Social Welfare declaring that the two evaluation studies are not within the scope of work of Croatian Central Ethics Committee, August 28, 2017, with reference to Official Gazette No 121/07 and No 25/15.

Germany, Gesundes Kinzigtal: Letter from the Ethical Committee, Technische Universität Berlin, declaring that the research is ethically acceptable (Ref: ST_02_20170620, August 15, 2017).

Germany, Casaplus: Letter from the Ethical Committee, Technische Universität Berlin, declaring that the research is ethically acceptable (Ref: ST_01_20170428, August 4, 2017).

Hungary, OnkoNetwork: The research plan has been authorized under approval No IG/03092–000/2016 by the Director General of Moritz Kaposi General Hospital, based on the positive opinion of the Institutional Research Committee and the responsible person of the Hospital for data protection. The Institutional Ethics Committee of the hospital double-checked the research and publication plan and confirmed that no ethical concerns were emerging related to this research and to the publication of findings (October 10, 2018, Ref: IKEB_IG_04125-000_2018).

Hungary, Palliative Care Consult Service: Letter from the Medical Research Council (Tudomanyos es Kutatasetikai Bizottsag, ETT TUKEB) declaring that the research is granted with Professional-Ethical Approval (Ref: 18632–4/2017/EKU, 24–4-2017).

The Netherlands, Proactive Primary Care Approach for Frail Elderly (U-PROFIT): Letter from the Medical Ethical Committee (MEC) Erasmus Medical Center Rotterdam declaring that the research is exempt from the Medical Research Involving Human Subjects Act (Dutch acronym: WMO; Ref: MEC-2017-402, July 25, 2017).

The Netherlands, Care Chain Frail Elderly (CCFE): Letter from the Medical Ethical Committee (MEC) Erasmus Medical Center Rotterdam declaring that the research is exempt from the Medical Research Involving Human Subjects Act (Dutch acronym: WMO; Ref: MEC-2014.558, December 18, 2014).

The Netherlands, Better Together in Amsterdam North (BSiN): Letter from the Medical Ethical Committee (MEC) of the Free University Medical Centre declaring that the research is exempt from the Medical Research Involving Human Subjects Act (Dutch acronym: WMO; Ref: MEC-2017-121, March 10, 2017).

Norway, Learning Network for Whole, Co-ordinated and Safe Pathways: Letter from the Regional Committees for Medical and Health Research Ethics-West (Komité for medisinsk og helsefaglig forskningsetikk -REK vest) declaring that the research is ethically approved (Ref: 2017/632/REK vest, March 28, 2017).

Norway, Medically Assisted Rehabilitation Bergen: Letter from The Regional Committees for Medical and Health Research Ethics-West (Komité formedisinsk og helsefaglig forskningsetikk -REK vest) declaring that the research is ethically approved (2017/944/REK vest, June 21, 2017).

Spain, Barcelona-Esquerra (AISBE): Letter from Clinic Research Ethical Committee (Comitè Ètic d’Investigació Clinica—CEIC) of the Clinic Hospital of Barcelona (Ref: CIF-G-08431173, Reg. HCB 2017/0451, June 14, 2017).

Spain, Badalona Serveis Assistencials (BSA): Letter from Clinic Research Ethical Committee (Comitè Ètic d’Investigació Clinica—CEIC) of the Clinic Hospital of Barcelona (Ref: CIF-G-08431173, Reg. HCB 2017/0453, June 14, 2017).

United Kingdom: Approval was granted by the National Health Service (NHS) Health Research Authority Research Ethics Committee (SELFIE REF: 16/WM/0295; CLASSIC REF: 14/NW/0206, June 23, 2016).

All participants provided written informed consent before participation.

Multimedia Appendix 3 provides a high-level description of results for the 2 components of the SELFIE conceptual framework considered in this study. In this table, main features of each ICC program (third and fourth columns) are provided per type of ICC program (first column) and country (second column). Extended results for the 17 ICC programs are reported in the text below. As a summary of the results, Table 2 displays an average of the 3-level maturity grading criteria stated in Table 1 for each of the 17 ICC programs, according to the micro, meso, and macro levels of the SELFIE conceptual framework.

The overarching analysis provided the following valuable insights on the implementation and exploitation of digital health tools to support ICC.

As summarized in the Multimedia Appendix 3, the overarching analysis provided the following valuable insights on the assessment strategies of the 17 technology-enabled ICC programs.

The overarching analysis allowed us to assess the use of digital health tools to support the care process in the 17 ICC programs on the 2 specific aspects analyzed: Technologies & Medical products and Information & Research. As most of the ICC programs are pilot experiences in terms of nation and region wide rollout of digital health tools, this analysis was useful to learn from them regarding requirements for a successful large-scale implementation elsewhere.

Acknowledging that the 17 ICC programs are highly heterogeneous regarding the use and impact of digital health tools, the main findings are summarized below.

A recent report by the European Union on Integrated Care maturity [62], including the evaluation of Information and eHealth tools, concluded that the level of maturity in Germany, Denmark, Belgium, Italy, Spain, Greece, Sweden, and Iceland scored higher in comparison to their peers in Estonia, the Netherlands, Poland, and Bulgaria. The most mature countries are Denmark, followed by Spain, Germany, and Iceland at the same level. Finally, Sweden, Belgium, Italy, and Greece were in intermediate level. This is line with our findings, except for the 3 case studies in the Netherlands, which in our study were more mature than Dates et al [62] suggests. It is of note that differences between the study by Dates et al [62] and this study might be explained by using different tools as well as the selection of 3 promising cases in the Netherlands which actually use eHealth tools. The European Union on Integrated Care maturity report applies an interactive tool developed by SIROCCO (Scaling Integrated Care in Context) to assess the maturity of ICC programs on a global level using different aspects (one of them being eHealth); whereas in our study, we explicitly focus on different aspects of digital health tools and assessment strategies solely. Also, the previous report is based on a review of the literature on integrated care policies and strategies, whereas our study adds the point of view from the different stakeholders directly involved in generation and implementation of these policies and strategies.

Integrated care programs for chronic patients involve complex interventions for heterogeneous populations; therefore, proper articulation of digital health tools and the different components of the evaluation process are still unmet needs that markedly hinder comparability and scale-up. The overarching analysis of the 17 ICC programs conducted in this study allowed us to identify the following potential areas for future developments:

Refinement of assessment methodologies of large-scale deployment and adoption of ICC programs, likely based on implementation research approaches [63-65], are needed. We understand that assessment should adopt the classical three-dimensional approach including outcomes, processes, and structures [66]. Moreover, usual health outcome variables (ie, mortality, hospital readmissions, etc.) should be ideally expanded [67] considering the Quadruple Aim approach [60,61]. The approach requires the collection of patient-reported outcomes and experience data (PROMS and PREMS) on a regular basis.

The concept of adaptive case management explored in AISBE [36,68] should be made operational. Conventional health information systems rely on the management of clinical episodes with a disease-oriented approach and only very rarely incorporate the required process logics to support continuity of care with a patient-centered approach.

Dynamic health-risk assessment taking into consideration both service commissioning (population-based health-risk predictive modelling) and subject-specific service selection involving optimal patient allocation in the health system (individual health-risk predictive modelling supporting decision support) should be addressed to improve outcomes [69-71]. Ultimately, the application of holistic strategies for subject-specific risk prediction and stratification that incorporates multilevel determinants of health (eg, socioeconomic, lifestyle, behavioral, clinical, physiological, cellular, and omics information) emerges as a high priority goal to properly pave the way toward personalized medicine for complex chronic patients [72]. Enhanced clinical predictive modelling, personalized diagnostic and treatment tools can contribute to the acceleration of transfer of scientific evidence to practice.

Development of pragmatic trials that incorporate real-life evidence from multilevel determinants of health may require implementation strategies, ideally using cloud computing environments, tackling privacy and regulatory constraints [23,72]. Currently, the articulation of the main technical building blocks, that is, multilevel biomedical data integration, tools for clinical predictive modelling in the cloud and High-Performance Computing, as one integrated system is yet a largely unmet potential.

This overarching analysis informs the current implementation status of digital health tools for management of multimorbidity in the 17 promising ICC programs selected in SELFIE. Notwithstanding the heterogeneity of the results, most studied programs are progressively evolving their supporting digital health tools from pilot prototypes to full scale-up at regional and national level. However, the majority of programs have not yet undergone full evaluation and assessment strategies. Future directions which can enable of digital transformation are based on innovation at micro and meso level with full support from the macro level. Some strategic areas that can help toward this end are the following: (1) implementation of research strategies; (2) explore an adaptive case management approach; (3) further developments of health risk assessment; and (4) holistic implementation strategies using future, regulatory compliant, cloud computing environments.