Translational Medicine @ UniSa-ISSN 2239-9747
2019, 19(18): 124-128
DIGITAL SERVICES LANDSCAPE IN PRIMARY CARE SETTING IN CITY OF ZAGREB;
AN EIP-AHA REFERENCE SITE CASE STUDY
Lazic V1, Pjevac N1, Masic A1, Milutinovic L1, Sijak D1, Balenovic A1
Health center Zagreb – Center, Zagreb, Croatia
(Corresponding author: Vanja Lazic, vanja.lazic@dzz-centar.hr)
1
Abstract - European Innovation Partnership on Active
and Healthy Ageing (EIP on AHA) brings together
partners to create innovative solutions to the challenges of
aging. Reference Sites (RS) of the Partnership act as hubs
of innovation and assist the scale-up of identified
solutions. “Blueprint on Digital Transformation of Health
and Care for the Ageing Society” (The Blueprint) is
guiding the shift towards ICT enabled patient-centered
care. To further inform its development, a tool has been
created and piloted across RS, to explore the digital
services landscape and find services that address the needs
of the personas developed for this tool, that represent the
needs of the populations. The aim of this case study was
to explore the digital services ecosystem in primary care
in Zagreb from the services availability and accessibility
perspective, using the personas needs tool. The total of 23
digital services was identified out of which 21 matched at
least one persona need. Each service-need match was
scored against usefulness and accessibility criteria and the
resulting matrix was evaluated using original methods.
The results point to several underperforming services and
provide insight into possible improvement strategies.
Several “workhorse” services were identified that are
heavily dependent on the health workforce. The services
adopted through EIP on AHA twinning schemes
performed well against set criteria. The persona based
tool, along with the original service assessment
methodology based on the tool’s framework provides a
new perspective to the digital services landscape, useful
for planning the areas for improvement and detecting
underperforming services on a system level.
Keywords: EIP on AHA, digital services, case study,
eHealth, mHealth, telemedicine
I. INTRODUCTION
European Innovation Partnership on Active and
Healthy Ageing (EIP on AHA) is an initiative of the
European Commission (EC) which has been designed to
bring together relevant stakeholders from national and
regional levels and from different policy areas to create
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innovative solutions to the societal challenges that arise
from the demographic development of the European
population [1,2]
The aim of the partnership is to improve health
and quality of life of the aging European citizens, increase
the sustainability of the health and social care systems and
stimulate economic growth based on the principles of the
silver economy [3].
The operational framework of the partnership
includes the formation of Reference Sites (RS)- regional
partnerships that include stakeholders from healthcare,
industry, academia and government on regional level, to
act as hubs of innovation, and assist the scale-up of
identified solutions, based on the new paradigm of health
and care [4]. In December 2016, 74 European regions
were awarded the status of RS. The actions of RS should
be guided by the shared policy vision, the “Blueprint on
Digital Transformation of Health and Care for the Ageing
Society”(The Blueprint) [5], which has been endorsed by
the EC.
In order to inform the further development of
The Blueprint, a new tool has been developed by
WE4AHA project [6], based on personas representing
different age groups and different levels of complexity of
health needs, which reflect the needs of the population
(Persona’s needs survey). 12 different personas were
invented and divided into 3 groups. A young girl's Rose,
working woman Leila, and elderly Randolph and Theresa
belong to ‘’Generally well’’ group. In the second group,
‘’Chronic conditions & social needs,’’ the users of the tool
are introduced to Millie, a young adult, Nikos, a middleaged man, and elderly Eleni and Maria. Members of the
third group ‘’Complex needs’’, are: Ben, a boy with
Down’s syndrome, Antonio, paralyzed young adult, and
elderly Procolo and Jacqueline. The tool is intended for
use “on the ground” to assist the development of
innovative patient-centered solutions, identify digital
services already in place and screen for potential gaps in
the digital services ecosystem.
Health center Zagreb – Center (HCZC) is a
public health care provider in the City of Zagreb, Croatia.
HCZC provides services of primary care and secondary
care level to the population of about 350 000 inhabitants
of City of Zagreb and neighboring regions and is the
largest health center in Croatia. HCZC has been a lead
partner of the City of Zagreb RS (Zagreb RS) of the EIP
on AHA since the region was awarded this status in
December 2016. Zagreb RS was a beneficiary of the 2017
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“Transfer of Innovation Twinning Support Scheme [7],” a
part of the ScaleAHA project supported by the EC. RS
Zagreb participated in the twinning activities as adopting
region for the elements of the Andalusian eHealth
Strategy “Diraya.” and the Galician “IANUS” regional
EHR system and ePrescription solution. The transferred
service elements have been integrated into the existing
primary care digital service ecosystem of HCZC in form
of new services “Zdravlje.net: Health diary”,
“Zdravlje.net: Group messages” and “Zdravlje.net PRO”.
The aim of this study is to explore the digital
services ecosystem in primary care in Zagreb from the
availability of the services and accessibility perspective,
using the Persona’s needs survey, in order to evaluate the
existing services, provide insight into potential areas of
improvement of existing services, and inform the
development of new digital services in primary care,
better suited to the needs of the patients.
2019, 19(18): 124-128
concerns,” “Health tests,” “Treatment: medications,
therapies etc.,” “Health professional concerns.” Needs
section contains 3-5 listed needs of the persona. These
needs are again listed in “needs summary sheet” and
appear on the x-axis of the recording spreadsheet.
Figure 1: Example persona poster with highlighted
sections
II. METHODOLOGY
For this case study, a persona based tool [5]
developed by WE4AHA project was used to map the
digital services ecosystem in primary care in HCZC.
Original methods, based on the framework of the persona
tool, were used to further assess the services of the digital
landscape in HCZC.
The tool consists of:
● An overview poster with 12 personas grouped
according to their needs (generally well/good
wellbeing, chronic conditions and/or social needs
and complex needs) and to their life course
(children/young people, working-age adults,
retired people, people aged 80+) in a way that
each needs group is represented in one life course
stage
● 12 individual persona posters
● Instructions sheet
● Needs summary sheet
● Recording spreadsheet.
Each persona poster consists of 5 major sections
for this purpose contextualized by the authors as
“Introduction,” “Digital skills,” “Personal story,”
”Overview,” and “Needs.” Introduction section contains
the cartoon image of the persona face, name, age, life
course (stage), needs (complexity level), connectivity (use
of the internet, mobile devices etc.), country and area
(urban, suburban, rural). Digital skills section shows the
following skills of the persona on a visual scale low to
high: Internet usage, Mobile device skills, Affinity to new
tech, Digital Health Literacy, Assistance (ICT use).
Context section containing a brief “background” story
about persona, including personal details, feelings,
responsibilities, needs, problems. Overview section
contains 8 subsections: What’s important to name of
persona,” “Daily living,” “Own resources & assets /
support,” “Events, issues & personal concerns,” “Health
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* This persona was developed by Esteban de Manuel
Keenoy, Kronikgune/ Basque Country and Javier Urraca
Madinabeitia, Basque Country, with the support of the
WE4AHA Blueprint and expert team, as part of the EU
project WE4AHA (H2020 RIA Grant Agreement
No.769705)
A three-step protocol was developed and used to
complete the recording spreadsheet:
In step 1, a team of 4 reviewers from HCZC listed the
available digital services in HCZC on the y-axis of the
spreadsheet. Some services were grouped reflecting their
similarities in the way they are accessed or used.
Reviewers then matched the services with the persona
needs in the x-axis. For each match, an explanation was
recorded in the predetermined field of the spreadsheet.
In step 2, two independent reviewers, each blind to result
of the other, scored each match against two criteriausefulness to the persona (three-point Likert scale 1 being
“barely addresses the patient needs” 2 being “partially
addresses the patient needs” 3 being “fully addresses the
patient need”) and accessibility to the persona (three-point
Likert scale 1 being “barely accessible to the patient”, 2
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being “partially accessible to the patient” and 3 being
“fully accessible to the patient”).
In step 3, a reviewer consensus was reached on all
unequally scored items.
A number of needs (out of 49 total persona needs) that
each service matched (service matches, SM) and the sum
of usefulness scores of those matches across one service
(usefulness score, US) was calculated. Figure 2.
Figure 2: Calculation of SM and US values
Alignment measure (AM) of the service towards
complexity groups is US value split into three parts,
according to the scores obtained from each complexity
group.
Average of accessibility scores (accessibility average,
AA) was calculated for each service.
III. RESULTS
Digital Services availability
performance measures
and
digital
service
Reviewers identified 23 digital services available in
HCZC. Table 1.
On average, services in ‘’Panel’’ group matched 3 needs
overall (avgSM=3, min=0, max=6). The patient panel
dedicated to chronic management of dermatitis failed to
meet any of the described persona needs and COPD, OAT
and NRS panels (#6,8 and 10) met only a single need. In
this group, the highest scoring (US=8) was the diabetes
panel (#4) and the pharmacotherapy management chronic
patient panel (#11). None of the services from this group
scored a “3” on usefulness scale for any of the persona
needs.
The #12 Medicus.net- Field nursing. (SM=21, US=42,
AM=18/14/10, AA=2) was the highest scoring service,
with both SM and US as the highest (example, persona
Leila, need 2- eAppointment for a field nurse visit to
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2019, 19(18): 124-128
conduct insulin administration training). The service was
more aligned to the needs of the generally well population
with AM 18/14/10 spread across complexity groups. AA
was 2 for this service.
Palliative care as a service, providing a structured
communication channel between GP and Palliative care
team, aimed at improving the coordination of care of
palliative and end-of-life patients did not match to any of
the persona needs.
Zdravlje.net group, consisting of services numbered 14 to
19, was the highest scoring group overall, with high SM,
US and AA values across service range (SM=5, US=8,
AM=2/4/2, AA=3)
The highest scoring was #15 Patient-GP messaging and
#19 Appointment scheduling services. The lowest
scorings were #14 Patient group messaging and #18
Health Diary: Hypertension. The AM differed across the
group. AA of Zdravlje.net group was the highest overall.
Zdravlje.net PRO group, enabling GP consultation with
other specialists and counseling services, showed an
average SM with the high US, and AM towards chronic
and complex needs. AA was 2 for both services.
eAppointment showed above average SM and relatively
high US. AM of this service was “U” shaped (10/5/14),
similar to the shape of that of service #15. AA was 2.
ePrescription showed low SM and US. AM was aligned
towards more complex needs. AA was 3.
IV. DISCUSSION
Based on the used methodology, new insight was
created into the complexity of the existing digital services
in HCZC. The persona based tool, along with the original
service assessment methodology based on the tool’s
framework provides a crude overview of the performance
of services.
Field nursing (#12), GP-patient messaging (#15),
and GP appointment scheduling (#19) scored the highest
both in SM and in the US with the latter two also having a
high AA (3 and 2,8). These are conceptualized by the
authors as “workhorse” services, providing a starting point
in the further development of the digital service based
system. The newest additions in the digital service
repertoire of HCZC, the services adopted from the
ScaleAHA twinning, “Zdravlje.net: Health diary”
(#17,18), “Zdravlje.net: Group messages” (#14) and
“Zdravlje.net
PRO” (#20,21) blended exceptionally well into the service
matrix with Zdravlje.net PRO group services being among
the highest scoring overall.
The “Panel” group of services (#1-11),
underperformed on all measures indicating a need to
change the concept of physician-based chronic condition
monitoring. As the performance of these services has
never been evaluated in a formal way and taking into
account the reported increase in chronic disease morbidity
and mortality in Croatia, these results could point to an
important gap in healthcare provision. In order to increase
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2019, 19(18): 124-128
the SM of these services, they would need to be
view and edit various panel values was extended from GP
redesigned to a more patient-based form. If the right to
to the patients,
Table 1: Digital services of HCZC list with an example of addressed persona need together with selected
performance measures of HCZC digital services
*General practitioner
**Solutions 2 and 13 did not match any of the persona needs
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2019, 19(18): 124-128
***SM-service matches, US- usefulness score, AM1/2/3- alignment measure for groups 1(generally well), 2(chronic
conditions & social needs) and 3 (complex needs). AA-average accessibility score. Color range code- red 1st percentile,
yellow 50th percentile, the green 99th percentile
this could create an interesting platform for exchange,
similar to the much higher scored “Health diary”.
Additional improvements could also include integrated
message and image sharing, task and goal setting and
progress tracking.
The high scoring Field nursing and GP-patient
messaging services (#12 and 15) point to a problem of
high dependency of newly developed digital services on
the health workforce. Thus, the lack of patient- and
community-based services leads to an increasing burden
on already stretched-out healthcare workforce, all in the
context of population aging and increasing medical and
social needs. The abundance of services with little
usefulness in terms of not addressing any of the patients
needs to the problem of lack of strategic planning of
digital service development, underdevelopment of the
digital service market and poor innovation management,
lacking real co-development and patient involvement
elements.
Due to the largely qualitative nature of this case
study potential sources of bias include, non exclusively:
inherent design bias of the used tool (e.g. overrepresentation of a certain type of persona need could
have influenced the downstream process and reasoning
leading to faulty conclusions), procedural bias in the step
2 reviewer group leading to over-matching and low
service usefulness scores, confirmation and culture bias
might have led the authors to misinterpret the findings.
Potential pitfalls in the results interpretation (e.g. low SM
and US scores could indicate both low performance and
high focus of service) should be avoided through careful
evaluation.
V. CONCLUSION
The persona based tool, along with the original
service assessment methodology based on the tool’s
framework, although lacking in finesse, can provide a new
perspective of the digital services landscape, useful for
planning the areas for improvement and detecting
underperforming services on a system level. Shifting
focus to individual needs instead of individual services
might produce more interesting insights into the
functioning of the services matrix, as this would allow the
analysis of multiple service synergies.
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ACKNOWLEDGMENT
All persons named among Authors have given
contributions in the manuscript. Authors wish to express
special thanks to the partner organizations of HCZC
within the EIP on AHA City of Zagreb RS.
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