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A common development observed during the COVID-19 pandemic is the renewed reliance on digital health technologies. Prior to the pandemic, the uptake of digital health technologies to directly strengthen public health systems had been unsatisfactory; however, a relentless acceleration took place within health care systems during the COVID-19 pandemic. Therefore, digital health technologies could not be prescinded from the organizational and institutional merits of the systems in which they were introduced. The Italian National Health Service is strongly decentralized, with the national government exercising general stewardship and regions responsible for the delivery of health care services. Together with the substantial lack of digital efforts previously, these institutional characteristics resulted in delays in the uptake of appropriate solutions, territorial differences, and issues in engaging the appropriate health care professionals during the pandemic. An in-depth analysis of the organizational context is instrumental in fully interpreting the contribution of digital health during the pandemic and providing the foundation for the digital reconstruction of what is to come after.
The COVID-19 pandemic has presented governments, managers, and professionals worldwide with unprecedented challenges, highlighting the limitations of analog health care systems that have long reinforced face-to-face models of care and congregation of individuals [
Rapid implementation of social distancing measures and rescheduling of elective procedures have led health care providers to resort to digital health applications for granting access to virtual consultations and remote visits and monitoring [
As a result, during the first 3 months of the pandemic, an unparalleled surge in digital health adoption was observed, with a general scale-up of telemedicine [
The fact that these technologies were available and ready for use should not have come as a surprise. However, before the COVID-19 outbreak, the uptake of digital health technologies to strengthen public health systems had been unsatisfactory, and the scholarly debate had rather focused on the barriers to adoption of digital health solutions [
Italy was among the first and most significantly hit countries by SARS-CoV-2. As of July 21, 2020, Italy reported a total of 244,708 confirmed cases, over 34,000 COVID-19–related deaths, and the highest deaths per million inhabitants and case fatality rates worldwide [
In terms of institutional composition, the Italian National Health Service (SSN) is strongly decentralized and based on universal access to care. The central government exercises general stewardship, whereas 21 regions—each considerably different in size and economic development and autonomous in their health care management decisions—are responsible for the organization and delivery of primary, secondary, tertiary, and preventive health care services through local health authorities (LHAs) [
Before the COVID-19 emergency, adoption of digital health was a challenge in Italy, as elsewhere. By analyzing the distinctive digital health experiences during the first wave of the pandemic in Italy—a country that was on the front line of the pandemic [
Appropriate reimbursement schemes are essential to expanding the role of digital technologies. During the current public health crisis, telemedicine services promptly seemed to be vital to support remote monitoring of less severe cases and ensure continuity of care for vulnerable, typically chronic patients, whose needs were overshadowed by the surge in patients with COVID-19 seeking assistance. However, telemedicine services in Italy have traditionally been scattered across a number of different applications, with poor interconnection and inconsistent local and regional reimbursement practices, since they are not specifically covered by the guaranteed health basket of the Italian SSN [
Use of contact tracing techniques and apps during the pandemic exposed the challenges of safeguarding privacy in the development of prompt digital responses to address current and future needs. National contact tracing apps were identified as a key tool to tackle the epidemic and facilitate reopening of the economy. However, unsurprisingly, the design and adoption of these applications, along with associated evaluation timelines, have raised significant privacy and security concerns and resulted in considerable delays in their deployment during the pandemic. Like most European countries, Italy initially backed the adoption of centralized management and maintenance of contact tracing data, including the “social graph” of individuals a person has physically met over a given period [
Collectively, lengthy negotiations on privacy standards and relatively scarce previous attempts to evaluate these technologies have delayed the widespread roll-out of functional contact-tracing apps.
Immuni, an app selected by an adhoc task force of the Italian Ministry of Health [
Leveraging local experiences with digital health projects in response to the crisis must be balanced with the national governments’ global policy-setting responsibilities. Highly regionalized health systems, such as the Italian SSN, can generate both significant opportunities for innovation as well as threats to national public health initiatives. Moreover, territorial differences in digital response to the COVID-19 crisis that have emerged could provide a basis for mutual learning. For instance, some regional health care systems were better prepared than others, not just in terms of telemedicine policies. In addition, in territories where large-scale digital health projects were ongoing, LHAs were able to rapidly apply them to the needs of the COVID-19 pandemic. For example, in 2015, the LHA of the Autonomous Province of Trento adopted TreC, a patient monitoring system that includes a mobile diary app and a web-based dashboard to facilitate patient-physician interaction and reduce direct access to hospitals. This system was designed to be interoperable with various electronic health records and was tested in several chronic populations [
In the Puglia region in Southern Italy, similar work was being carried out for years on remote follow-up management of chronic patients through several pilot projects. This enabled the implementation of a remote monitoring system based on a web-based application for citizens, a web portal for health care professionals, and a telemedicine kit. The platform, called #Accasa, was implemented on April 22, 2020, for individuals under quarantine or those who have tested positive for COVID-19 [
Designing a successful digital health solution requires advanced alignment of the interests of all health care professionals and stakeholders involved. Management of the COVID-19 pandemic is challenging for the health care systems in many ways, including maintaining a balance and relative responsibilities of hospital vis-à-vis community care. It has become clear over time that primary care professionals should play a central role in managing less severe COVID-19 cases via home-based monitoring, possibly by using digital solutions. However, in Italy, general practitioners are contracted professionals. Therefore, it has been much more complex to extend institutionally sponsored digital tools to these third parties and guarantee the necessary system interoperability between services deployed in primary care clinics and all others provided by LHAs. Elsewhere, however, this has been pivotal in implementing a successful digital strategy during the pandemic [
The analog approach is not going away any time soon, so analog and digital health systems will need to coexist. Although digital health applications have spread in parallel to the virus, they have rarely been proposed as the only available option. None of the digital solutions implemented in the Italian SSN have been imposed as a mandatory alternative; rather, they have been added to the mix of traditional in-person and telephone-based services to maximize coverage for the entire population. Despite the increased adoption of smartphone use, Italy’s overall population and health care workforce are among the “oldest” in the world [
Despite the unprecedented expansion in the utilization of digital health tools during the COVID-19 pandemic, Italy, like many other countries worldwide, was not sufficiently equipped to harness the full potential of these tools. The urgency of the current public health emergency may have set the grounds for making exceptions [
If we intend to maintain the momentum in expanding the digital health services that have resulted from the COVID-19 pandemic, now is the time to effectively plan for the future and to follow a new path, distinct from the pre-pandemic models [
No single best recipe exists, but a list of ingredients may help Italy, and other health care systems worldwide, focus their proposals to achieve sustained benefits (
Ingredients to achieve sustained benefits through digital health.
The COVID-19 crisis has reinforced the need to define and uphold appropriate policy standards. Long-standing digital health issues (reimbursement, regulatory framework, evidence generation, privacy, and security concerns) will still be unresolved by the end of this pandemic. Decisive and comprehensive action is thus needed from a policy standpoint, and several extensive proposals have been suggested in other contributions [
The combination of the widespread availability of digital health solutions, their poor uptake before the pandemic, and the confidence gained during the recent expansion may push countries to aim too high. Governments should act promptly, but pragmatically, in adopting a stepped-wedge approach based on their health care system needs and organizational characteristics.
Digital transformation is bringing in new players with different backgrounds, expertise, and logic compared to the players that have typically populated the health care industry. Public institutions need to welcome innovation and be open to interorganizational relationships and trust. During a public health emergency, occasional, hastily generated partnerships may proliferate. Governments must adopt a strategic approach to partnerships and actively pursue the necessary competencies to harness these opportunities.
The pre-pandemic digital health environment was characterized by a predominance of scattered experiences and the inability to adequately value existing best practices. Higher interinstitutional coordination should be assured by stewardship at the central level to take charge of streamlining the process, identifying parameters and conditions conducive to transferability, and ensuring no one is left behind—all without stifling local innovation.
Digital health introduction should be complemented by an in-depth service redesign. The organizational implications of digital health have been largely neglected to date, but they need to be addressed now to exploit the complete potential of digital tools, integrate solutions in current care pathways, and pave the way for new models of care. Any digital technology is only as good as the response it gets from its end-users in terms of acceptability, continuity, and engagement. Hence, new, digitally enriched organizational processes should be planned and designed by all relevant stakeholders, directing patient-provider interactions to the channels generating the most value [
Unprecedented times call for unprecedented decisions. It is time for policymakers to step up and make timely valiant choices about the use of telemedicine and digital health to permanently integrate them into the health care systems for the good of the public health and, ultimately, of the people. This will be extremely helpful now, during the COVID-19 crisis, and even more as we head toward the post-pandemic world.
local health authority
Italian National Health Service
We would like to warmly thank Ettore Turra for his contribution regarding the digital health solutions implemented in APSS Trento before and during the COVID-19 outbreak. The authors received no specific funding for this work.
FP, OC, MC, and RT all reported grants from the European Union’s Horizon 2020 research and innovation program under grant agreement no. 779306. FP, OC, MC, and RT are also involved in an RCT to evaluate a mobile supportive care app for patients with metastatic lung cancer.
Horizon 2020 research and innovation program under grant agreement no. 779306.