We cannot overcome the challenges presented by workforce shortages without better digital health: How do we build a structure that actually succeeds?

In a time of increasing shortages of healthcare personnel, with hospital wards closing and waiting lists growing, it is crucial that Denmark succeeds in realizing the potentials of digital health.

The potentials are significant, but require the seamless integration of digital health into the healthcare system and its use as a means to improve and coordinate citizen- and patient journeys. We can alleviate the strain on overburdened staff, bind the healthcare system together, and mitigate geographical inequality. In the recommendations of the Danish Resilience Commission, 3 out of 20 recommendations directly address digital health, including a "digital and technological first" principle.

Denmark is heavily investing in technology development, but too little is being implemented and disseminated for the benefit of citizens and healthcare professionals nationwide. This is well-known.

Since the beginning of the year, Health Tech Hub Copenhagen and Think Tank Mandag Morgen have mapped barriers and structural solutions to create a more coherent and collaborative healthcare system in Denmark using digital health. The mapping involved conversations with 53 skilled and experienced leaders and experts in the field, as well as a review of analyses and reports.

The barriers are plenty

Often, these are structures that hinder our healthcare professionals from harnessing the opportunities in digital health, even though they want to. It involves different configurations of workflows and documentation practices across organizations, varying prioritization of needs and priorities, rivalry among leaders, financing and incentive systems that reward development projects and research publications more than the reuse of others' good solutions. It involves one-year and sector-specific budget planning. It involves different legal interpretations, where "approved" in one place can be "illegal" elsewhere. It involves a fragmented IT landscape where systems are not sufficiently interconnected within sectors or across sector boundaries. It involves healthcare professionals who have inherited a reluctance to digital change because it has almost always been focused on cost savings.

The future healthcare system is not brick-and-mortar

The good news is that we have not found barriers that are insurmountable.

However, it won't be easy. Not all barriers can be overcome with structure and organization, but many can. The Danish Health Structure Commission now has the opportunity of the decade to look at the healthcare system with fresh eyes, which our analysis supports as a compelling need. At the same time, it is important that we build a structure for the future healthcare system and not just for the present, to avoid needing a new commission and reform again in 5 years' time.

The future healthcare system is not built with brick and mortar but with more treatment at home and coherent citizen and patient journeys, where digital health plays a crucial role.

Can geographical inequality be alleviated with telemedicine centers that help citizens in rural areas on par with those in cities, instead of enticing or forcing doctors reluctantly? Can our young people with emerging anxiety be helped with digital self-help health solutions so that their condition does not worsen while on long waiting lists? Could documentation be automated with sensors and voice recognition, allowing healthcare professionals to have eye contact with patients? Can the digital health solution developed at a university hospital today go out and help patients at hospitals with fewer budgetary resources tomorrow?

It requires insight, foresight, and the courage to think fundamentally differently about the structure of the healthcare system and the future of treatment, rather than just rearranging what we already know today. The potential in digital health is not solved with more websites, coordination forums, or strategy documents. It is not enough this time. We need to rethink the healthcare system and its tasks and take advantage of the benefits of good digitization. Digital health must be integrated directly into structures, including organization, education, and financing.

There are many models for creating a more coherent and collaborative healthcare system when it comes to digital health. In our mapping, we have found 62 structural solutions that have been subsequently prioritized.

13 recommendations for better digital health - for the benefit of patients and a challenged healthcare system.

More important than the individual solution models are the principles that should guide the construction of the future healthcare system. The individual solution models can be discussed and weighed in the light of these principles and, from there, be challenged, changed, or replaced. Based on our mapping, we have found that the following principles are important for building the future healthcare system:

1. 1. A common direction for digital health must be created through binding result goals and a more efficient governance structure. The direction and result goals for digital health are set politically and executed by a national board with a mandate and decision-making power.

2. 2. The "digital first" principle must be implemented in selected stages of citizen and patient journeys. Digital health becomes a design requirement in selected citizen and patient journeys. The healthcare system gets one digital entrance for non-acute conditions, with online triage and treatment options.

3. 3. Large hospitals and municipalities must have greater geographical responsibility for the implementation and dissemination of citizen-centered digital health, through 5-10 health clusters. The communities have overall responsibility for creating good citizen and patient journeys for citizens in their geographical areas, including through the implementation of digital health solutions, with large organizations as the main driving force.

4. 4. Telemedical population health responsibility must create geographical equality in access to healthcare services. The binding communities on digital health get telemedical population responsibility for the entire geographical area, ensuring access to health for citizens in both cities and rural areas.

5. 5. Local implementation of digital health must be supported by a national program organization with outgoing implementation teams. The program organization supports locally with expertise in digital health, implementation, and change management, and has outgoing implementation teams.

6. 6. The healthcare system's common support functions (innovation, IT, and law) must be transformed into jointly owned corporations. Central management ensures a common direction nationally, while decentralized presence ensures local support.

7. 7. Local enthusiasts and clinical environments must be better supported in needs assessment and early digital innovation. Enthusiasts and clinical environments should be better supported in needs-driven innovation until the time of product development, after which the solution should be lifted out.

8. 8. Publicly owned, citizen-centric digital health solutions must be placed in companies with a clear focus on development and dissemination. Public digital health solutions are placed in companies (jointly owned, non-profits, or startups) with a clear managerial focus on development and national dissemination.

9. 9. Healthcare professionals' confidence and education must enable "digital first". "Digital first" requires professional confidence and digital skills among healthcare professionals. It requires education, as well as politicians and top leaders in the healthcare system taking responsibility for ethical dilemmas.

10. 10. Capacity-releasing digital health solutions must be prioritized on the political agenda. Thorough digitization, including the reuse of good solutions from abroad, is our best bet to ensure the future of the healthcare system. It requires political focus and determination.

11. 11. Financial and incentive structures must promote the reuse of others' digital health solutions. Digital health realizes benefits only through national implementation, which requires current investments for future gains. It is recommended to establish a fund with a focus on co-financing implementation and dissemination projects and challenge existing incentives.

12. 12. Procurement models must promote shared digital health. The majority of future procurements should be shared and should also include hospitals and municipalities with fewer resources. Procurement rules and their application are modernized to promote the reuse of others' good solutions.

13. 13. The reuse of other countries' digital health solutions should provide more health for the money. Denmark should be a leader in translating, importing, and reusing good digital solutions from abroad, including standards and methods.

Let us lay the foundation for our future healthcare system in 2024

Our report, launched on 28th November 2023 contains 13 recommendations, 39 mapped barriers, and 62 mapped solution models. Our hope is to make the discussion on better digital health very concrete.

It is not an easy task that Denmark is facing. We are entering new territory. But we have no choice if we are to overcome the shortage of labour- and geographical inequality. We hope that the Health Structure Commission and our politicians dare to challenge the status quo and create a structure for the future healthcare system that realizes the potential in digital health.

So that 2024 becomes the year when a structural reform lays the foundation for the future healthcare system.