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July/August 2024 - Volume 69 - Issue 4

• Editor-in-Chief: Eric Ford, PhD, MPH
• ISSN: 1096-9012
• Online ISSN: 1944-7396
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The search for meaning in health care inquiries: introducing qualitative meaning analysis

• H. Dahlberg , Karin Dahlberg , Christopher Holmberg
• Published in International Journal of… 25 July 2024
• Philosophy, Medicine, Education

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• Systematic Review
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• Published: 25 July 2024

Efficacy of educational interventions on improving medical emergency readiness of rural healthcare providers: a scoping review

• Anju Sreeram   ORCID: orcid.org/0000-0003-1368-5291 1 ,
• Ram Nair 2 &
• Muhammad Aziz Rahman   ORCID: orcid.org/0000-0003-1665-7966 3  

BMC Health Services Research volume  24 , Article number:  843 ( 2024 ) Cite this article

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Medical emergencies are the leading cause of high mortality and morbidity rates in rural areas of higher and lower-income countries than in urban areas. Medical emergency readiness is healthcare providers’ knowledge, skills, and confidence to meet patients’ emergency needs. Rural healthcare professionals’ medical emergency readiness is imperative to prevent or reduce casualties due to medical emergencies. Evidence shows that rural healthcare providers’ emergency readiness needs enhancement. Education and training are the effective ways to improve them. However, there has yet to be a scoping review to understand the efficacy of educational intervention regarding rural healthcare providers’ medical emergency readiness.

This scoping review aimed to identify and understand the effectiveness of educational interventions in improving rural healthcare providers’ medical emergency readiness globally.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews were used to select the papers for this scoping review. This scoping review was conducted using MEDLINE, CINHAL, SCOPUS, PUBMED and OVID databases. The Population, Intervention, Comparison and Outcome [PICO] strategies were used to select the papers from the database. The selected papers were limited to English, peer-reviewed journals and published from 2013 to 2023. A total of 536 studies were retrieved, and ten studies that met the selection criteria were included in the review. Three reviewers appraised the selected papers individually using the Joanna Briggs Institute [JBI] critical appraisal tool. A descriptive method was used to analyse the data.

From the identified 536 papers, the ten papers which met the PICO strategies were selected for the scoping review. Results show that rural healthcare providers’ emergency readiness remains the same globally. All interventions were effective in enhancing rural health care providers’ medical emergency readiness, though the interventions were implemented at various durations of time and in different foci of medical emergencies. Results showed that the low-fidelity simulated manikins were the most cost-effective intervention to train rural healthcare professionals globally.

The review concluded that rural healthcare providers’ medical emergency readiness improved after the interventions. However, the limitations associated with the studies caution readers to read the results sensibly. Moreover, future research should focus on understanding the interventions’ behavioural outcomes, especially among rural healthcare providers in low to middle-income countries.

Peer Review reports

A medical emergency constitutes a severe injury or any acute illness that requires immediate attention to save a life or to reduce a permanent disability of an individual [ 1 , 2 ].WHO highlighted that cardiovascular disorders, respiratory disorders and injuries are the major emergency medical causes of death worldwide [ 2 ]. A study on global medical emergency disease and burden from 1990 to 2015 shows that 28.3 million deaths globally happened due to emergency medical diseases. Among that emergency medical disease contributed to 25% of deaths in higher-income countries, 35% in upper-middle-income countries, 48% in middle-income countries and 53% in low-income countries [ 3 ]. A higher mortality rate related to medical emergencies was observed more in rural areas of low-middle-income countries than in higher-income countries [ 3 , 4 ].

Worldwide, rural populations are more harmfully affected by medical emergencies than urban populations. It might be related to the geographic density of the rural population. A survey on the global distribution of rural population estimated that 19% of the total population of higher-income countries are living in rural areas of those countries [ 5 ]. While the distribution of rural population in low-and-middle-income countries, lower-income countries, lower-middle-income countries, middle-income countries and upper-middle-income countries were 48%, 66%, 57%, and 32%, respectively [ 5 ]. Though there is a disparity in the distribution of rural populations between higher-income and middle- to lower-income countries, evidence suggests that rural or remote populations in all countries experience poor availability, accessibility, affordability, and poor-quality health care [ 4 , 6 ]. Evidence also shows that the occurrence of medical emergency-related morbidity and mortality is higher in rural areas of high-income countries and low to middle-income countries than in urban areas. The identified reasons for the inequitable distribution of healthcare and high mortality rate among the rural populations are the lack of skilled and knowledgeable workforce, equipment and funding [ 6 ], lack of effective tools to identify the gaps in medical emergency and provision of care in rural areas health care provision [ 7 ] or lack of policies and guidelines regarding emergency care [ 8 , 9 , 10 , 11 , 12 ].

World Health Assembly emphasises the importance of strengthening the emergency health care system to provide timely care for people diagnosed with an acute medical emergency to reduce the ill health or death caused by such emergency conditions. One prerequisite for creating such a system is developing a skilled and knowledgeable workforce who can meet patient needs in an emergency [ 4 , 13 , 14 ]. Educational interventions play an important role in developing a capable rural workforce. Such interventions can enhance rural healthcare providers’ medical emergency readiness [ 6 , 8 , 13 , 14 , 15 , 16 ]. Medical emergency readiness is actualising emergency preparedness in an acute emergency [ 17 ]. Therefore, rural healthcare providers’ medical emergency readiness constitutes the effective implementation of medical emergency-related knowledge and skills in an acute emergency to save an individual’s life [ 15 ].

Rural healthcare providers provide first-line emergency care for emergency patients [ 18 ]. However, rural healthcare providers are only partially equipped to provide quality care in low-income and high-income settings. In low to middle-income countries, most of the population lives in rural areas [ 19 ]. At the same time, the rural population is increasing in high-income countries with ageing and complexities of medical conditions [ 20 ]. However, in both settings, the readiness of healthcare providers for medical emergencies is limited concerning knowledge, skills, and competencies [ 21 , 22 ]. Many rural healthcare providers have not undergone formal emergency training [ 22 ], which will prevent the healthcare providers from providing effective care coupled with emergencies. Therefore, it is essential to train rural healthcare providers to enhance their skills, knowledge and attitudes to provide quality care.

Evidence suggests that rural healthcare professionals’ medical emergency readiness needs an urgent call for attention. For example, one study reported that rural Asian physicians’ cardiac and pulmonary rehabilitation skills and knowledge are limited despite having positive attitudes towards managing medical emergencies [ 23 ]. Australian and Chinese studies identified that rural healthcare professionals need more knowledge and skills to manage respiratory medical emergencies [ 24 , 25 ]. An African study highlighted that the high antenatal and post-natal maternal mortality rate was associated with healthcare providers’ poor knowledge and skill to manage such emergencies [ 26 ]. A US study identified that an inadequately prepared workforce could not provide support during emergencies and emphasised the importance of education and training [ 27 ]. An Australian study showed that rural health nurses need a greater understanding of trauma-informed principles and practices [ 28 ]. Another study shows that rural healthcare professionals need more knowledge and skills to manage prehospital psychiatric emergencies [ 29 ]. Rural healthcare professionals had limited theoretical knowledge and practical skills to manage life-threatening emergencies in rural areas compared to urban healthcare professionals [ 30 ]. The above evidence indicates the importance of strengthening the rural health carers’ medical emergency readiness.

Rural populations worldwide are affected by high mortality and morbidity with medical emergencies. One of the reasons for this incidence is the need for more medical emergency readiness among rural healthcare professionals. Evidence shows educational interventions will effectively improve rural healthcare professionals’ medical emergency readiness. Despite those findings, research on rural healthcare providers’ medical emergency readiness is limited. Therefore, this review aims to explore rural healthcare providers’ medical emergency readiness and identify the effect of educational interventions to enhance rural healthcare professionals’ knowledge, skills and competency to provide timely care in acute medical emergencies in rural health settings. Systematic reviews on prehospital emergency readiness of healthcare professionals show that they were not effectively prepared to provide efficient care during medical emergencies and emphasise the importance of training needs for rural healthcare providers [ 14 , 18 ]. So far, a review has yet to be reported about the effectiveness of educational training to enhance rural healthcare providers’ medical emergency readiness. Therefore, a scoping review is conducted to understand the effectiveness of educational intervention in improving the medical emergency readiness of rural healthcare providers.

The scoping review aimed to understand the efficacy of educational interventions in improving rural healthcare providers’ medical emergency readiness. The methodology used for this scoping review is Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews [PRISMA] [ 19 ]. The scoping review helps to map and summarise the available literature about the selected study, explore gaps in the selected research areas and direct to future research. Moreover, scoping reviews are helpful when the literature is complex and heterogeneous [ 19 , 20 , 21 ]. This review followed Joanna Briggs Institute’s [JBI] scoping review methodology, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews [PRISMA] [ 19 ]. The JBI scoping review provides contemporary guidance to researchers regarding scoping review based on the topic, analysis, presentation, implication for practices and reduction of bias [ 22 ]. Simultaneously, it mirrors with PISMA-ScR [ 19 , 22 ]. This scoping review aims to identify and analyse the peer-reviewed scientific literature focusing on rural healthcare providers’ medical emergency readiness and the effectiveness of educational interventions to enhance medical emergency readiness.

Search strategy

A qualified librarian assisted in identifying the selected studies from the database. The database was MEDLINE, CINHAL, SCOPUS, PUBMED and OVID. We searched the database from January to September 2023. The selected studies were limited to English and published between 2013 and 2023 in peer-reviewed journals with full-text articles. A comprehensive search using the database will reduce the selection bias and to understand the current drift in rural healthcare providers’ medical emergency readiness. Evidence shows that a sufficient number of databases will minimise the selection bias and improve the validity and generalisability of the review results [ 31 ]. Therefore, the search strategies used in this review may reduce the selection bias and to understand the current drift in rural healthcare providers’ medical emergency readiness. The selected studies were identified using Population, Intervention, Comparison, and Outcome [PICO] strategies. Search terms were rural OR remote “health care providers “OR “health care clinicians” OR “doctors” OR “nurses” AND “educational intervention” OR “training” OR “basic life support training” OR “Evidence-based practices” AND medical emergency readiness OR competence OR skill OR knowledge or confidence AND effect of intervention OR training OR education OR evidence-based practice OR basic life support*. See Appendix 1 for PICO strategies.

Eligibility criteria and study selection

This review included all identified original articles focused on medical emergency readiness-related interventions based on PICO strategies. Therefore, the paper included Randomised Controlled Trials [RCT] and quasi-experimental designs. At the same time, we excluded abstracts, qualitative studies, protocols, pilot studies, grey literature, narrative, and systematic reviews, which did not follow PICO strategies in this review. All identified studies were uploaded to Endnote, and duplicates were removed. Finally, ten studies were included in the final review. The selected studies were appraised using the Joanna Briggs Institute [JBI] critical appraisal tool for randomised controlled and quasi-experimental trials to rule out the risk of bias [ 32 ]. Those studies were appraised by three individual appraisers using the JBI tool to assess methodology, study design, interventions, analysis, and bias in the selected documents. See appendices 2 & 3 . The selected ten papers were sent to the research team. Three team members independently appraised each of them using JBI tool. Individual critical appraisal helps to understand the quality of the selected paper, design, research process, analysis and bias in the selected studies. All team members appraised eight selected papers using the quasi-experimental critical appraisal tool [ 9 , 33 , 23 , 32 , 33 , 34 , 35 ], and the other two papers were reviewed using the randomised controlled critical appraisal tool [ 36 , 37 ]. Subsequently, the team came together and discussed the reasons for including those papers in the review. After resolving the discrepancies, ten studies were unanimously selected for review.

Data extraction and synthesis

We included randomised and non-randomised experimental studies regarding rural healthcare providers’ medical emergency readiness. Our search considered all interventions focusing on improving adult, paediatric, obstetric, and gynaecological as well as psychiatric emergency readiness and outcomes of those interventions of the readiness of rural health care providers.

The review used a descriptive approach to synthesise the data from the selected studies. Narration and tabulation are used for data extraction and analysis in a descriptive approach [ 38 ]. The narrative synthesis and tabulation help organise the selected studies’ findings and understand the interventions’ effect [ 39 , 40 ]. The analysis of selected studies showed that population, emergency context, outcome measures, interventions, and analysis methods varied in nature. Therefore, this review used a descriptive approach instead of a meta-analysis [ 41 ].

The search yielded 536 studies. After removing the duplicate, 501 studies were selected for screening. Those 501 studies were screened based on the PICO strategies and 42 articles were reviewed completely. Finally, ten studies were included in the final review. Figure  1 PRISMA flow chart shows the inclusion and exclusion criteria of the selected emergency studies.

Prisma flow chart

Characteristics of studies

The selected eight studies used a quasi-experimental design [ 33 , 23 , 32 , 33 , 34 , 35 , 42 , 43 ]. Two studies used RCT design [ 36 , 37 ]. Most published studies were from higher-income countries [ 9 , 32 , 35 , 37 , 42 , 43 ]. One study was from an upper-income country, and the rest were from lower-income countries [ 23 , 33 , 34 , 36 ]. Among the ten selected studies, four were entirely focused on adult medical emergency readiness [ 23 , 32 , 33 , 34 ], and three were about the paediatric medical emergency readiness of rural healthcare providers [ 9 , 37 , 43 ]. The remaining studies dealt with psychiatric and obstetric emergency readiness [ 35 , 36 , 42 ].

Five studies conducted follow-up studies to understand the sustainability of educational intervention [ 32 , 35 , 36 , 42 , 43 ]. Whilst remaining engrossed in the immediate effect of the interventions [ 9 , 23 , 33 , 34 , 37 ], four studies reported improvement in teamwork with the training [ 9 , 32 , 33 , 42 ]. One study pointed out that years of experience in managing emergencies could enhance knowledge levels [ 33 ]. Table  1 summarises the review results.

Medical emergency readiness of rural health care providers

Emergency readiness of the healthcare providers was identified based on their knowledge, attitudes, skills, and confidence. Nine studies explored rural healthcare providers’ knowledge about managing various medical emergency readiness [ 9 , 23 , 32 , 33 , 34 , 36 , 37 , 42 , 43 ]. One study addressed attitudes towards managing psychiatric emergencies [ 35 ]. Six studies tried to understand rural healthcare providers’ skills in managing medical emergencies [ 9 , 33 , 34 , 36 , 38 , 39 ]. Six studies explored rural healthcare providers’ confidence levels to facilitate emergency management [ 9 , 31 , 32 , 35 , 37 , 39 ]. All selected studies’ pre-test results identified room for knowledge, skills, attitudes and confidence improvement among healthcare professionals globally.

The effect of educational interventions regarding medical emergency readiness of rural healthcare providers

In this review, four studies addressed healthcare professionals’ adult medical emergency readiness. One study used the Rural Interprofessional Simulation Course [RiSC] training to enhance knowledge and skills in managing emergency trauma. They also noted that such training effectively improved interprofessional relationships, provided safe learning experiences, and reduced the gap between emergency readiness of rural and urban healthcare providers. RiCS training positively impacted rural healthcare providers’ confidence and competency to manage trauma care in rural healthcare settings [ 38 ]. The second study explored the World Health Organization-International Committee of the Red Cross Basic Emergency Care Course [WHO-ICRC-BECC] training and found it effective in managing medical emergencies in rural settings using a train-the-trainer model. The training enhanced rural healthcare providers’ knowledge and confidence in emergency management. While participants informed that it is essential to have such training on emergency obstetric management, training the local trainers is the cost-effective way to reduce expenses in low- to middle-income countries. The result also shows that all rural healthcare staff, including security, cleaners, and administrative office staff, should undergo such training [ 39 ]. The third study implemented an interprofessional simulation and lecture-based teaching to assess knowledge and skills regarding medical emergencies. The results showed there was an improvement in knowledge and skill after the training regarding trauma management, Cardiac emergencies, medical emergencies, sexual assault, unconscious patients, toxicology, paediatrics, HIV emergencies and radiology. Nurses’ pre-and post-knowledge level of emergency management was higher due to many years of exposure to emergencies than doctors. The result also emphasised the importance of having regular emergency training in rural settings to sustain the knowledge and skill. Similarly, the study shows the importance of integrating subcutaneous pacing and dermatological emergencies in the training and education of rural healthcare providers. They also reported that the training improved teamwork and interprofessional relationships [ 40 ]. The last study focused on the effectiveness of Cardiac Arrest Resuscitation Short [CARS] courses for physicians. The intervention was effective in enhancing Asian rural physicians’ knowledge and skills in cardiac arrest management. The result also showed that cardiac arrest resuscitation short courses were cost-effective. Such interventions will be effective in low-resource settings [ 33 ].

Three studies focused on paediatric emergency management [ 9 , 41 , 42 ]. The training programs used in those studies were instructor-led paediatric emergency management program [ 9 ], paediatrics office medical emergency preparedness program [ 41 ] and Paediatric Advanced Life Support [PALS] Courses with low-fidelity manikins (control group) and high-fidelity manikins (experimental group) [ 42 ]. Those interventions effectively enhanced paediatric healthcare providers’ knowledge, skills, competence, and teamwork. However, two studies reported that the training program, which was developed based on the scope of practice of specific healthcare professionals, yielded more positive outcomes than generally trained healthcare providers [ 9 , 41 ]. The study compared the effect of high-fidelity and low-fidelity manikins in managing paediatric emergencies [ 42 ]. The results showed no difference in acquired knowledge and skills between the control and experimental groups immediately after the intervention. However, the study identified that PAL with high-fidelity manikins was more effective than PAL with low-fidelity manikins in sustaining rural healthcare providers’ knowledge and skills in paediatric emergency management and core case scenario time to task recognition was significantly improved among the experimental group [ 42 ]. Two selected studies were focused on the effect of interventions in maternal emergency management [ 35 , 36 ]. One study focused on rural healthcare providers’ knowledge and skills in maternal emergency management using the Safe Delivery App [SDA]. The result showed that the intervention group acquired more skill and knowledge than the control group during each interval [ 35 ]. The second study was focused on implementing and evaluating the Maternal and Neonatal Emergency [MANE] program. The results showed that there was an improvement in various components of knowledge, such as knowledge of teamwork principles and how to communicate effectively, knowledge of clinical governance and risk management, knowledge of eclampsia management, knowing how to escalate and access help, knowledge of situational awareness and access to resources, knowledge of post-partum haemorrhage management, knowing how to take leadership and when to delegate and knowledge and understanding of performing newborn resuscitation. The results also showed that the MANE program was effective in enhancing confidence in managing eclampsia, post-partum haemorrhage and newborn resuscitation. However, the results showed no change in managing the stress level of those conditions after the MANE program. The result also showed positive participant behavioural outcomes [ 36 ].

One study focused on psychiatric emergencies and explored the effectiveness of education involving lived experience to manage such emergencies [ 37 ]. The result shows that attitudes and confidence of rural health care providers in emergency psychiatric management had been improved immediately after the intervention. However, attitudes and confidence levels remained the same four months later. They highlighted that improved attitudes and confidence may be related to consumer involvement [ 37 ].

Few studies focused on the sustainability of acquired medical emergency knowledge, skill, and confidence among rural healthcare providers, and the observational period varied from three months to three years. All follow-up studies results show that the associated intervention based on the emergency was effective in maintaining the sustainability of medical emergency readiness among rural healthcare providers [ 35 , 36 , 37 , 38 , 41 ].

Another interesting aspect identified through this review was the duration of the training. All interventions were implemented in varying periods, from one hour to five intensive days. Three studies conducted one-hour training [ 35 , 36 , 41 ]. Two studies reported two to three hours of training [ 9 , 33 ]. While other selected studies conducted training for days [ 37 , 38 , 39 , 40 , 42 ]. The results show that despite the variation in time and foci, all interventions effectively improved healthcare providers’ medical emergency readiness.

Another distinct element identified in the educational interventions was the effective use of simulation techniques to enhance healthcare providers’ medical emergency readiness. In which six studies incorporated low-fidelity manikins [ 33 , 36 , 38 , 39 , 40 , 41 ] One used a high-fidelity manikin [ 9 ]. One study compared the effect of high- and low-fidelity manikins [ 42 ]. Maternal emergency training uses a Safe Delivery App [SDA] and low-fidelity manikins to manage maternal emergencies [ 35 ]. Mental health emergency training incorporated lived experience [ 37 ].

Regarding the application of manikins, one study found that there was no difference in the acquired emergency knowledge and skills by using high and low-fidelity simulation training immediately after the intervention. However, the sustainability of acquired knowledge and skill was higher among those who used high-fidelity manikins than the low-fidelity manikins [ 42 ]. Despite variations in the interventions in the selected studies, the results show that all distinct elements identified in the interventions effectively enhanced rural healthcare providers’ medical emergency readiness. All identified studies used statistical methods to analyse the effectiveness of the interventions.

Overall, all interventions were effective in improving rural healthcare providers’ medical emergency readiness. Such interventions not only improved the readiness but also enhanced teamwork and collaborative practices. The worldwide utility of low-fidelity manikins was commendable. However, the interventions designed based on specific healthcare professionals’ scope of practice will be more beneficial.

Medical emergency readiness of rural health care providers in higher-income and lower to middle-income countries are providers

The identified studies were from different parts of the world. Three studies were from African backgrounds. In which an Ethiopian study explored rural healthcare providers’ obstetric emergency readiness [ 35 ]. A South African study focused on the medical emergency readiness of healthcare providers [ 40 ]. Another study tried to understand the medical emergency readiness of rural healthcare providers from Uganda and Tanzania [ 39 ]. Indian study explored Asian Physicians’ knowledge and skill in cardiac arrest [ 33 ]. Two studies from Australia focused on rural healthcare providers’ psychiatric emergency readiness and maternal and neonatal emergency management readiness [ 36 , 37 ]. The remaining studies were from American backgrounds and explored rural healthcare providers’ paediatric emergency preparedness [ 9 , 41 , 42 ].

Comparing the pre-test results of rural healthcare providers’ medical emergency readiness has shown that there was room for improvement in the medical emergency readiness among healthcare providers from higher and lower-income countries. Nevertheless, all interventions were effective in filling the identified gap in readiness. Therefore, the result concluded that rural healthcare providers’ medical emergency readiness was the same globally.

Barriers identified for medical emergency readiness and the effect of educational interventions among rural healthcare providers of higher-income and lower to middle-income countries

The review results also illuminated the barriers that can erode rural healthcare providers’ medical emergency readiness. At the same time, there were variations in the barriers identified by the higher and low-middle-income countries’ rural healthcare providers’ medical emergency readiness and the effectiveness of the interventions. The studies from the higher income countries reported that inadequate staffing in rural areas, availability of equipment, attitudes towards medical emergency training and the rare occurrence of medical emergencies in rural areas limited rural healthcare medical emergency readiness [ 9 , 32 , 37 , 43 ]. Moreover, studies from higher-income countries reported that such training was not mandatory for the staff to participate. Therefore, healthcare providers never show interest in participating in the training [ 9 , 32 ]. Meanwhile, low-middle income countries reported a lack of qualified staff, lack of equipment and transport facilities, lack of trainers to train the staff, lack of training and financial burden. These barriers prevent medical emergency readiness of low to middle-income countries’ rural healthcare providers [ 23 , 33 , 36 ].

This scoping review shed light on rural healthcare providers’ medical emergency readiness. The review results showed that rural healthcare providers need more knowledge, skill, and confidence to meet medical emergencies in rural healthcare settings. There was a similarity in the identified gap globally. A previous study focusing on the training needs of Australian rural physicians to manage medical emergencies showed that their medical emergency readiness needed to be improved and emphasised the importance of training needs [ 30 ]. Another study conducted in the US also showed that emergency clinicians have knowledge and skill gaps to manage medical emergencies [ 26 ]. A Chinese study reported that rural healthcare providers need more knowledge, skill and competency to meet medical emergencies [ 24 ]. Another African study reported that the availability of knowledgeable and skilled healthcare professionals is a requisite to manage medical emergencies, and preparing such a workforce for the future in Africa is essential [ 43 ].

The review’s focus was understanding the intervention’s effect on the medical emergency readiness of rural healthcare providers globally. The review results showed that all interventions were effective in enhancing rural healthcare providers’ medical emergency readiness [ 9 , 33 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. These studies explored various emergency knowledge, skills and confidence levels of rural healthcare providers. However, nine out of ten studies’ distinct feature was the application of simulation techniques that might be the reason for improving rural healthcare providers’ emergency readiness. Simulation-based education integrates simulation scenarios, reflections and implementation of learned behaviour. Such educational intervention enables the learners to acquire knowledge, skills, and competence levels more effectively than classroom teaching. Evidence suggested that the simulation-based competency-focused paradigm positively impacted healthcare providers’ knowledge and skills in consumer care [ 44 ]. Simulation-based training helps healthcare providers to provide the best patient care [ 45 , 46 ]. This review also pointed out that training and years of experience in managing medical emergencies are other factors in improving skills and knowledge among healthcare providers [ 40 ]. A study on practising nurses’ professional competency aligns with current findings [ 47 ]. Moreover, training helped to improve teamwork among healthcare providers [ 36 , 38 , 40 ]. A previous study on interprofessional teamwork in comprehensive primary healthcare services supports the current findings [ 48 ].

Another area identified in this review was the usefulness of low-fidelity simulation techniques in rural areas. Seven studies used low-fidelity simulation training and were effective [ 33 , 35 , 36 , 38 , 39 , 40 , 41 ]. The reasons for implementing low-fidelity simulation in rural healthcare settings may be related to effective budgeting. A previous study on factors affecting the implementation of simulation-based training aligns with the current findings [ 49 ]. The review shows that psychiatric emergency readiness of rural health care providers improved with lived experience involvement. A previous study also pointed out that lived experience involvement in the education and training of health professionals is an effective way to enhance mental health knowledge skills and attitudes towards the care of people with mental illness [ 50 ].

The period of implementation of educational training was different in each selected study. In this review, training implementation varied from one-hour to five days intensive program [ 39 , 41 ]. The difference in the duration of training may be related to the number of emergency components they have covered during the training. Nevertheless, the differences in training duration effectively enhanced medical emergency readiness. The reason could be that the programs are designed clearly and concisely to address medical emergencies with simulation. A previous study suggested that disease-specific and evidence-based training will effectively improve healthcare providers’ knowledge and attitudes to care for patients [ 51 ]. However, one study in this review identified that paediatric emergency training was more effective for doctors than nurses because the training modules were precisely designed for doctors [ 41 ]. Therefore, creating an educational intervention based on the needs of each healthcare provider’s scope of practice would be beneficial. A systematic review of effective training methods to improve patient care aligns with current findings [ 44 ].

This review provides information about the medical emergency readiness of rural healthcare providers in higher- and lower-middle-income countries. This review identified ten studies, among which six studies were from higher-income countries [ 9 , 36 , 38 , 41 , 42 ]; one was from an upper-middle-income country [ 40 ], and three were from lower-middle-income countries [ 33 , 35 , 39 ]. The results show that rural healthcare providers’ medical emergency readiness needed to be improved in higher- and lower- to middle-income countries. Another study also pointed out the existing discrepancy in knowledge, skills, and competence levels of rural and urban healthcare providers worldwide [ 52 ]. In this review, one study pointed out that educational interventions effectively reduce the gap between the readiness of rural and urban healthcare professionals [ 38 ]. Evidence also identified that trauma-related morbidity and mortality rates are higher in rural areas of both higher-income and lower-income countries [ 4 ]. Therefore, it is imperative to have knowledgeable and skilled healthcare workers to reduce such occurrences in rural areas, especially in middle- and lower-income countries. Ninety per cent of the people live in rural areas of developing countries. India and China contribute 45% of that population [ 4 ]. Evidence shows that the emergency-related mortality rate is high in the Indian subcontinent, and India is accountable for 22% of trauma-related deaths [ 53 , 54 ], and this may be related to a lack of resources and skilled professionals to meet emergency care [ 18 , 53 ]. Therefore, it is crucial to identify rural healthcare providers’ medical emergency readiness from these provinces and the development and implementation of intervention-related medical emergency readiness. Future research should focus on these areas.

Finally, this review explored the barriers associated with rural healthcare providers’ medical emergency readiness. Both higher and lower-income countries reported that severe shortage of rural health care providers, lack of qualified staff and trainers, cost associated with training, and limitation of other resources are the main barriers related to rural health care development [ 9 , 35 , 38 , 39 , 42 ]. Global evidence shows that the inequities in rural health protection are due to staff shortages, unqualified staff and unequal budgeting between rural and urban health care [ 4 ]. Two studies reported that the non-occurrence of such emergencies, staff attitudes, and the gap in policies and their implementation related to rural healthcare were the barriers to implementing training for rural healthcare providers [ 9 , 41 ]. Previous studies on hurdles associated with providing effective emergency medical care align with the current findings. They reported that lack of skilled and knowledgeable staff in rural areas, unavailability of equipment, poor transport facilities, limited funding for rural healthcare and overlooking rural healthcare systems were the main reasons for rural healthcare providers’ medical emergency readiness [ 6 , 8 , 9 , 10 , 11 , 12 ].

Strengths and limitations

This is the first scoping review of rural healthcare professionals’ medical emergency readiness and the effect of education. This review methodology enabled us to explore the emergency medical readiness of rural healthcare professionals and the impact of various interventional programs to enhance rural healthcare professionals’ knowledge, skills, and confidence globally. This review identified that rural healthcare providers’ global medical emergency readiness needed improvement. The identified educational interventions to strengthen rural healthcare providers’ medical emergency readiness were promising.

A competent healthcare team in rural health services can reduce those population’s mortality and morbidity levels. At the same time, educational interventions are effective strategies to improve healthcare providers’ knowledge, skills, attitudes and teamwork. The usefulness of low-fidelity manikins is commendable due to their global, cost-effective utility. Public trust can be improved with a competent healthcare team. Rural healthcare providers’ medical emergency readiness may reduce the gap between providing urban and rural health care.

Moreover, the stakeholders can direct their outlook towards rural healthcare development to develop a safe community. Such intervention should make it mandatory for rural healthcare providers to maintain acquired readiness. It is also recommended that undergraduate and postgraduate curricula integrate emergency training programs to develop a strong workforce for the future. This review identified the global variations in rural healthcare providers’ emergency readiness. Most of the published studies are from higher-income countries. Despite the understanding that quality care is essential to reduce emergency-related ill health in low to middle-income countries, limited studies have focused on medical emergency readiness from those countries [ 16 ]. One of the reasons behind this situation is the lack of research priorities and interest in medical emergency readiness among low to middle-income countries. The identified research challenges are diagnostic uncertainties in medical emergencies, lack of interventions, lack of study design and data collection, lack of understanding of ethical considerations and inadequate research capacity [ 16 ]. However, evidence suggests that collaborative emergency care research support from high-income countries can strengthen emergency care research in low to middle-income countries [ 16 ]. Therefore, future research should focus on that direction.

However, there were several limitations associated with selected studies. The selected studies were limited to pre- and post-quantitative interventional studies, with full text published in the English Language, between 2013 and 2023 that followed PICO strategies within the selected databases. There could be studies about emergency medical readiness in other languages. Grey literature was also excluded from the review, although that could have contributed to rural healthcare providers’ emergency readiness. Two studies were RCT, and one study reported failure to maintain randomisation at the end of the study, while both studies did not address blinding the case and control in RCT. Other studies were quasi-experimental and did not explain the randomisation procedures. Furthermore, most studies did not report the behavioural outcomes, and most have not explained the psychometric properties of the outcome measures. Therefore, the methodological limitations associated with the selected studies remind the readers to interpret the result with a sensible conclusion.

Other limitations were the inclusion of heterogeneous participants from varying disciplines and attrition bias. The participants’ background knowledge, scope of practices and clinical expertise varied. So, the results could have been different if the training had been designed for a particular group of healthcare providers, such as nurses, doctors, or clinical assistants. Education is essential; however, if it is tailored to the unique needs of healthcare providers, it will be more effective in providing the best possible care for patients than conducting a general education [ 55 ].

The review identified a global knowledge, skills, and competency gap in rural healthcare providers’ medical emergency readiness. At the same time, all interventions effectively enhanced rural healthcare providers’ medical emergency readiness. The acquired skills, knowledge, and competencies need to be maintained after the training. A regular in-service emergency training program should integrate with mandatory training for healthcare providers to achieve the above aims. There needs to be more research focused on educational intervention in rural healthcare providers’ medical emergency readiness despite trauma-related high mortality rates from low to middle-income countries; future research should be focused on the effectiveness of the educational interventions among those countries. Collaborative research development will be an effective strategy. Future research should focus on this direction.

Moreover, the selected studies did not evaluate the behavioural outcome in clinical settings. Therefore, future research should also be directed to understanding the clinical outcome of the interventions in rural settings. Most of the identified papers used a quasi-experimental design to assess the effectiveness of the intervention. A randomised controlled trial on medical emergency training can yield the most robust research findings. Therefore, we recommend randomised control trials with large samples to understand the outcome of medical emergency training and associated retention of the medical emergency readiness of rural healthcare providers. The review results identified that the interventions positively impacted medical emergency readiness globally. Furthermore, educational intervention with low-fidelity simulation was cost-effective in higher and low-middle-income countries. However, the results should be interpreted cautiously due to the limitations of the selected studies.

Data availability

No datasets were generated or analysed during the current study.

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Sreeram, A., Nair, R. & Rahman, M.A. Efficacy of educational interventions on improving medical emergency readiness of rural healthcare providers: a scoping review. BMC Health Serv Res 24 , 843 (2024). https://doi.org/10.1186/s12913-024-11116-7

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Co-creating and hosting PxP: a conference about patient engagement in research for and by patient partners

• Dawn P. Richards 1 , 2 , 3 ,
• Hetty Mulhall 1 ,
• Joletta Belton 4 ,
• Savia de Souza 5 ,
• Trudy Flynn 6 ,
• Alex Haagaard 7 ,
• Linda Hunter 8 ,
• Amy Price 9 , 10 , 11 ,
• Sara Riggare 12 , 13 ,
• Janice Tufte 14 , 15 ,
• Rosie Twomey 1 &
• Karim M. Khan 1  

Research Involvement and Engagement volume  10 , Article number:  77 ( 2024 ) Cite this article

Metrics details

Research projects, initiatives and conferences that include patients as partners rather than as participants are becoming more common. Including patients as partners (what we will call ‘patient partners’) is an approach called patient engagement or involvement in research, and we will call it patient engagement throughout this paper. Patient engagement moves traditional health research conferences and events to include a broader audience for their knowledge exchange and community building efforts, beyond academics and healthcare professionals. However, there are few examples of conferences where patients are given the opportunity to fully lead. Our conference went beyond patient engagement – it was patient-led. Patient partners conceived, planned, and decided on all aspects of a virtual conference.

We present the work and processes we undertook throughout 2023 to create and produce a free conference called “PxP: For patients, by patients” or PxP for short, with a tagline of “Partnering to make research stronger.” PxP was patient-led and about patient engagement in research rather than a specific disease or condition. PxP was supported by the Canadian Institutes of Health Research Institute of Musculoskeletal Health and Arthritis. The PxP website, known as the PxP Hub, now houses the conference recordings along with resources about patient engagement in research. These resources were recommended by the PxP Steering Committee members, speakers, and others who attended the 2023 conference. Here we lead you through how the idea for PxP was generated; how the international patient partner Steering Committee was convened and supported; how PxP was brought to life over nine months; the PxP 3-day event and feedback collected to improve future efforts; trade-offs, challenges and learnings; and resources required to support this type of event. We close with what the future holds for PxP in 2024 and beyond.

It’s time to elevate patients into leadership roles for conferences and events, and we encourage you to adopt the PxP ethos by using or adapting our approach and resources to support your opportunity.

Plain English summary

Patients are often included in health research as study participants. Involving patients as partners in research projects or conferences is becoming more common. This approach is called patient engagement or involvement. Traditional health research conferences are by and for academic researchers or healthcare professionals. These events rarely include patients as the main attendees or in the planning. While some research conferences are starting to use patient engagement, few are designed and led by patients. We share our work on a conference led and designed by patients. In 2023, our team co-created a free conference called “PxP.” PxP is short for “For patients, by patients.” The conference tagline was “Partnering to make research stronger.” PxP was focused on patient engagement in research rather than any one health problem. PxP was supported by the Institute of Musculoskeletal Health and Arthritis. This is one of 13 Canadian Institutes of Health Research. A free online PxP Hub now hosts all of the conference recordings and many resources. We share how the idea for PxP came about, how the international patient partner Steering Committee came together and was supported to plan and bring PxP to life, the PxP conference and feedback, challenges and what we learned, and resources needed. It’s time for patients to have a leadership role for conferences and events. Through sharing this example, we encourage others to adopt the PxP ethos.

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While there are increasingly more research projects, initiatives and conferences that include patients as partners and not just participants, examples where patients fully lead are rare in these settings [ 1 , 2 ]. To date, most of the focus in these spaces has been on co-creation or co-production aspects. The approach of including patients as partners (which we call ‘patient partners’) is referred to as patient engagement (in North America) [ 1 ], patient involvement (in Europe) [ 3 ], or consumer involvement (in Australia) [ 4 ]. Here we use the term patient engagement as a ‘catch all’ for these phrases.

Health research conferences and events provide an opportunity for knowledge exchange and community building, though have traditionally been restricted to a narrow audience of academics and health professionals. While some conferences are patient-led through conception, design, delivery and dissemination, these tend to be patient organization-run conferences that offer support and education to their specific communities (e.g., arthritis, pain, cancer, etc.) [ 5 , 6 ]. To our knowledge, there is little in the academic literature about patient-led health research conferences [ 7 , 8 ] and we were unable to locate any literature about patient-led conferences on the topic of patient engagement in research.

Here we describe the processes to plan and organize a free conference all about patient engagement in research called “PxP: For Patients, by Patients” and share the outputs of the conference [ 9 ]. The conference’s tagline was “Partnering to Make Research Stronger.” The free PxP conference was virtually hosted in September 2023, and was fully designed and driven by an international Steering Committee of individuals who identify as patient partners [ 1 ]. PxP was supported by the Canadian Institutes of Health Research (CIHR) Institute of Musculoskeletal Health and Arthritis (IMHA) [ 10 ]. IMHA’s mandate includes supporting research related to: active living, mobility and the wide range of conditions related to bones, joints, muscles, connective tissue, skin as well as the mouth, teeth and craniofacial region. IMHA has a history of engaging patients as partners for over 20 years [ 11 ]. Recently, IMHA and its Patient Engagement Research Ambassadors (PERA) fully co-created and launched free, online learning modules as a How-To Guide for Patient Engagement in Research which is ‘disease agnostic,’ meaning that it is not specific to any one disease area [ 12 , 13 ]. PxP is another example of work that IMHA is supporting in the patient engagement in research space that is also disease agnostic.

This paper aims to describe what we did and learned following a planning and executing timeline so that people who are interested in elements of PxP may benefit when planning their own patient-led conferences or events. We detail the processes, provide templates and resources, and share our learnings by highlighting the expertise, time and other resources that were necessary to make PxP a success. In the spirit of PxP, this paper was co-written with many of its patient partner Steering Committee members (JB, SdS, TF, AH, LH, AP, SR, JT).

Below we outline the PxP conference process, including its inputs and outputs, in a manner that is linear to PxP’s overall planning and executing timeline.

Generating the idea for the PxP

The idea for the PxP conference came from conversations in 2022 with IMHA’s PERA members [ 12 ]. PERA is composed of individuals who live with conditions that fall under IMHA’s research mandate. PERA meets every 1–2 months virtually to provide bidirectional insights and lived experiences to help IMHA achieve its goals and priorities while also carrying out its own mandate. PERA’s mandate is to inform IMHA and CIHR of patient priorities in research; inform their respective communities about IMHA, CIHR, and their work with PERA; advocate to benchmark best practice in patient-oriented research (POR) across IMHA’s activities (including priority setting); curate quality POR assets (for example, videos, websites etc.) for IMHA and the broader CIHR community, and create new POR assets to fill gaps; and, evaluate progress of PERA [ 11 ]. PERA members who wished to contribute to the conference were invited to be part of the conference’s 2023 Steering Committee (SC; noting there were 6 PERA members at the time).

An initial discussion with interested PERA members (TF, LH, plus one other) was hosted in November 2022 to gain further insights. This initial conference discussion was supported by IMHA’s Scientific Director, a staff member, and a patient engagement consultant (DPR, who also identifies as a patient partner). Terms of reference for the SC were drafted (see Additional File 1 ) and a timeline of SC meetings with high-level agenda topics was created for internal IMHA purposes. The decision about the conference name was reserved for the patient-led SC. The only pre-determined parameters around the conference were that it would be: free, virtual, led by patient partners, about patient engagement in research, disease agnostic, and for patients (as a primary audience), though anyone would be welcome to attend (and those in academic roles heard about it through IMHA’s regular newsletter and other targeted newsletters). Patients being the primary audience was a decision purposefully made so that patients could explore topics about patient engagement that were most important to them in a safe space. After this meeting, in late 2022 and in early 2023, additional patient partners from across the globe were invited to be part of the SC (based on the diversity of their locations, experiences, etc.), with an aim to have a total of 10 members. SC members who were invited beyond PERA members were known to IMHA through various research and personal networks and social media interactions. One SC member left for personal reasons in spring 2023.

Bringing the PxP conference to life

An overview of the inputs and outputs of PxP 2023 (see Fig.  1 ) are described in more detail in the following sections.

PxP Inputs and Outputs. An overview is provided of the human, financial and operational resources as well as the expertise, insights and skills that went in to PxP 2023. The various outputs include the 3-day conference, a community, and learning and resources

Championing the patient-led ethos

The international SC first met virtually in February 2023 and then monthly (except August and September) until October 2023 [ 14 ]. Two hours were reserved for each virtual meeting. The initial conference concept and parameters were brought to the SC during the February meeting so they could develop their collective vision. The development of the conference was guided by the five PatientsIncluded™ criteria [ 15 ], and went beyond patient co-creation to patient leadership. As outlined below, all elements of the conference were decided by the SC and facilitated through IMHA resources (time, financial, and skills).

The SC meetings were facilitated by the IMHA patient engagement consultant (DPR) and were attended by additional members of the IMHA team as needed to capture relevant action points to fulfill the logistical needs of the conference. DPR developed draft agendas for each meeting (which were open to changes made by SC members), took meeting notes (finalized upon review at each subsequent meeting) and facilitated meetings to ensure meetings supported psychological safety, respect, transparency and collaboration [ 16 ]. If SC members could not attend meetings, they were invited to provide their ideas separately via email or to meet one on one with DPR who incorporated their ideas in to planning. Meetings were kept to a minimum to be respectful of SC members’ time and other commitments. SC members were provided regular updates via email about operational progress between meetings. Email updates also included communication assets (such as social media graphics) so that the SC could share news about PxP with their own networks and on social media; with the opportunity to request additional assets, information or communication support at any point.

All SC members were offered honoraria aligned with the IMHA Patient Engagement Compensation Guidelines, which were developed after this work started [ 17 ]. Honoraria covered all aspects of SC members’ work and contributions for conference planning, and additional honoraria were offered for their time to participate in and attend the conference even if they chose not to be part of the program. Offering honoraria to SC members aligns with principles of equity, diversity and inclusion, and with best practices related to patient engagement in research [ 18 ].

Determining the path of PxP

Launching a new conference and an associated community required a significant amount of work and a focus on both the big picture and the more detailed elements (more on resources required is provided near the end of the paper). The patient-led and operations elements throughout the course of the PxP are detailed in Table  1 . Over the course of conference planning, the SC decided on the following for the conference:

its name (For Patients, By Patients) which was shortened to PxP;

its goal of partnering to make research stronger;

its mission to bring resources, mentorship and community to other patient partners in any kind of health research, no matter their experiences as a patient partner;

its logo design and colours;

the dates, format and length;

its agenda, including each day’s themes, sub-themes and speakers;

the platform (Zoom Webinars);

the preferred communications channels (X/Twitter, LinkedIn, Instagram and newsletter); and,

the post-conference survey questions for attendees, hosts, moderators, and speakers.

Additionally, the SC advised on the PxP website (also called the PxP Hub) [ 19 ] by providing thoughts on: user journey, functionality, content and accessibility features. Each member also provided up to 3 resources about patient engagement in research that are posted on the site. The PxP website was created by an agency and is updated by an IMHA staff member.

Co-developing the program

The themes for each day of the conference and for the sessions themselves were selected based on several SC conversations at the monthly meetings. The conference agenda including each day’s theme and sessions is provided in Table  2 , with the full conference agenda that includes dates, times, hosts, moderators, and speakers/panelists in Additional File 2 . Day 1 was considered to be introductory to help equip attendees with the language and baseline knowledge necessary to get involved in patient and public engagement in research, as well as to get the most out of the program [ 20 ]. Day 2 was designed to highlight self-research (where speakers shared doing their own research on themselves as part of their own healthcare journeys), patient-led research, and researcher perspectives on the how and why of their patient engaged research [ 20 ]. On Day 3, the SC wanted to tackle difficult conversations around real-world challenges for patient partners and those who have historically been excluded from health research in the safe space of this patient-led conference, and finished with a session providing practical tips around knowledge dissemination and amplifying the impact of health research [ 20 ]. The themes and session topics were of importance to the SC as patient partners rather than those researchers thought would be important to them.

All SC members had multiple opportunities to suggest specific people or organizations as speakers. They also had the opportunity to be as involved or uninvolved as they wished with the program itself, including as hosts (opened and closed each day and handed each session over to the session moderator), moderators (facilitated sessions by introducing the topic, speakers, and asking audience questions), and speakers, or, if time-zones permitted, as attendees who contributed to the live chats and encouraged discussion amongst attendees. SC members also contributed to how each conference session would be structured, being purposeful about having different approaches to each session (some included presentations, most were moderated discussions). DPR collected, compiled and reviewed all suggestions, and then proposed a draft agenda with a number of options for speakers, which took in to account equity, diversity, and inclusion (EDI) principles [ 16 ]. This agenda was subject to additional discussion, changes, and then approval by the SC before speakers were invited.

Conference supports

SC members who participated as hosts, moderators, and speakers/panelists were supported by the IMHA staff and DPR, as were all other moderators and speakers/panelists. All hosts, moderators and speakers/panelists were offered monetary compensation for their time in preparing for and being involved in the conference, with the exception of those who had an academic appointment and whose involvement in such a conference was considered part of their role in academia. For each session of the conference, a meeting was set up and facilitated by DPR so the moderator and speakers/panelists of that session could meet and get to know one another in the month leading up to PxP. At these virtual meetings, logistics about the conference were reviewed and notes were taken that were provided back to attendees. In most cases, the participants worked together to co-create the session content (often with suggestions from SC members).

A ‘run of show’ was created in Google Docs and was shared with all SC members for comment. The ‘run of show’ included each day’s schedule, logistics comments for daily hosts to share with all PxP attendees at the start and close of each day, transitions to breaks, and notes for each session about how it would run, who the moderator and speakers were, etc. The daily hosts were encouraged to make the logistics comments and all commentary their own by copying and pasting content out of the Google Doc. The ‘run of show’ for each session was shared with each session’s moderator, speakers or panelists. Two drop-in sessions on different times and days (to accommodate a variety of time-zones) were offered to all session speakers or panelists and hosts the week before the conference as an opportunity to gain familiarity with the platform, ask logistical questions, and test out slide sharing functionality. Communications to moderators and speakers and panelists were intentionally minimized, but carefully crafted to ensure language was clear and support was available if needed. Formal and informal feedback indicated that hosts, moderators and speakers felt well-prepared for and supported at the conference.

Being purposeful about accessibility

The SC was clear about the importance of accessibility, that is removing barriers to attend and fully participate, being mindful that the conference audience would include people with a wide range of disabilities and access needs, including energy-limiting chronic illness and neurodivergence. Registrants were invited to contact the IMHA team to make it aware of any access or accommodation needs that were not being provided so that it could do its best to support them. The conference was free and the program was purposefully designed with 30-min breaks between sessions. The timings of the program were intended to suit people joining from different time-zones around the world, with Day 3 run during different hours to better include attendees and speakers in Oceania and parts of Asia. To help reduce the burden of converting between time-zones, a table was provided on the PxP website [ 21 ].

As an ongoing consideration to accessibility and inclusivity, all sessions were recorded (with consent) and are available to view directly on the PxP YouTube Channel [ 22 ] or via the PxP Hub [ 9 ]. Asynchronous viewing was considered important for those who could not join live (for example, due to time-zone, medical needs, or other responsibilities) or who would like to re-watch the sessions. The entire transcript was manually edited with Adobe Premiere Pro to help improve accuracy of closed captions. The Adobe software was available through an institutional subscription and there may be alternative options for those who do have access to this product. Anonymized chat summaries from the live sessions are also available for each day on the PxP Hub resource page.

Accessibility for all participants was a priority with the logo and website design, and highlighted in the logo brief and website scope of work. The logo and website have sufficient colour contrast to meet Web-Content Accessibility Guidelines and the colour palette was chosen to not be visually overwhelming for people with visual processing challenges [ 23 ]. The decision to exclude icons was purposeful; different images may not translate well between patient communities and across different cultures. An easy-to-read font was chosen. The premium version of UserWay was added to the site which includes a range of tools for users such as the ability to adjust font, line height or contrast; to pause animations; and to utilise a screen reader, reading mask or reading guide [ 24 ]. There can be limitations and problems that may arise from using automated accessibility overlays which should be investigated and understood before using one. A web page to explain these features and signpost to contact details for additional support is featured prominently on the main menu of the website [ 25 ]. The website is bilingual, offered in both of Canada’s official languages, English and French. Speaker biographies were provided in three different options, in recognition of different preferences or needs for content format: html, PDF with selectable text, and digital flipbook optimized for mobile devices [ 26 ].

The SC chose Zoom Webinars as the conference platform to help promote inclusivity given the familiarity that many people have with it. To keep things simple with the first PxP, a conscious decision was made to use Webinar without any breakout rooms or networking sessions. Attendee and speaker/panelist versions of a PxP 2023 Zoom Webinars guide were created with images to help people get set up at the conference [ 27 ]. See Additional File 3 for the attendee Zoom Webinar guide. A member of the IMHA logistics team was available throughout the conference as technical support for attendees, and a second Zoom room was set up for speaker/panelist questions. At the start of each day of the conference, the daily host provided information to attendees about supports provided and how to access them (e.g., closed captions for sessions, etc.). A Zoom Webinars background was automatically provided for speakers/panelists when they logged in to the webinar, and the colour was chosen to reduce brightness for those with visual processing needs. The logistics team ensured the Zoom platform had the live translated captions as an add-on in over 30 languages. While the addition of live interpreters in other languages including sign-language is preferred, this was not viable due to the number of countries and languages represented in the audience, the conference budget, and other resource considerations.

PxP live and feedback

PxP 2023 took place virtually on September 12, 13 and 14/15, 2023 UTC over a total of 4 h (including breaks) on each day (see Additional File 2 for the full agenda). There were a number of powerful quotes as takeaways from the sessions, some of which are provided in Table  3 . PxP 2023 had 617 registrants from 34 countries, with 310 live attendees self-identifying that they were from 18 countries (note SC members and IMHA staff are included in this number). Attendees were from around the globe including from North America (Canada, United States), South America (Brazil, Colombia), Europe (Denmark, France, Ireland, Italy, Portugal, Romania, Spain, Sweden, United Kingdom), Asia (India, Israel), Africa (Nigeria), and Oceania (Australia, New Zealand). The majority of attendees were from Canada (57%), United States (18%), United Kingdom (11%) and Australia (7%), respectively. Attendees were provided the option at the start of each day to identify the perspective they brought in a Zoom poll (they were allowed to select more than one option), and in these polls (data are summarized across all 3 days), attendees identified themselves as a patient partner/person with lived experience (59%), a researcher (35%), a caregiver or relative (20%), a clinician (9%), or a trainee or student (6%).

One member of the IMHA team hosted Zoom Webinars and DPR was also on the ‘back-end’ of Zoom Webinars to support each session’s participants if/as required. SC members took on a variety of roles including as hosts, moderators, presenters, or active participants watching and participating in the Zoom chats. In addition to housekeeping, a Land Acknowledgement [ 28 ], and a bit of information about the day, daily hosts encouraged engagement from the start by asking the audience to respond to the Zoom poll mentioned above.

A graphic artist sketched each speaker/panelist in each day’s first session along with one of their quotes from the session. Once these sketches were signed off by the sketched speakers/panelists, they were shared on social media. There are plans to build on this idea for the 2024 conference by engaging an artist who identifies as a patient to do this for all sessions of the conference.

Attendee interactions and social media

Before the conference, all individuals who registered were provided with a link to a guide to make the most of Zoom Webinars and encouraged to share anything they wished in the chat and on social media with the hashtag #PxP23. At the start of each day, hosts provided introductory comments that included a short overview on using Zoom’s chat, question and answer (Q&A), and emoji functions, the latter to provide live feedback to hosts, speakers and moderators. These appeared to be successful tactics for audience participation as there was a great deal of commenting and sharing of resources in the chat, of emojis during presentations and conversations, and efforts made to include questions from the audience into each session (at the end for a dedicated question and answer session or throughout if the session was a moderated discussion). Since permission was not sought of attendees to copy and share the chats verbatim, two IMHA staff created anonymous summaries of each session’s chat comments and resources that were shared in the chat, which are available on PxP Hub in its resources section. [ 29 ].

Leading up to PxP, a newsletter and social media handles were created on Twitter/X (@PxPHub), Instagram (PxPHub), Threads (PxPHub), and LinkedIn (PxPHub). On the days of the event, PxP live updates and threads were shared primarily on X, in addition to Instagram Stories and LinkedIn. A social media graphic was prepared in advance to be used for event quotes and all images were shared with Alt text. In September 2023 (the month of the conference), the PxP X account gained 94.5 k organic (i.e., not paid for) impressions with a 2.4% engagement rate; on PxP LinkedIn, organic impressions were 3,859 with a 12.2% average engagement rate (which is the engagement rate for each post divided by the total number of posts). The newsletter has over 700 subscribers with an average open rate of 57% and an average click rate of 10%.

Between its launch on July 19, 2023, and December 31, 2023, the PxP website had 5.9 k unique visitors, 16.3 k page views, and an average visit duration of over 2 min. The top four countries for website views were Canada (46%), United States (20.9%), United Kingdom (12.3%) and Australia (9.5%), which mirrors the geographic makeup of PxP attendees. Most people were accessing the site directly (for example, through email share), followed by through X, Google, LinkedIn and Facebook. Other than the homepage, the most frequently accessed pages related to the event tickets and program and the PxP resource page, which is a collation of PxP and external resources.

All PxP 2023 session recordings were made available to view on the PxP YouTube Channel [ 22 ] following manual editing of the closed captions. Day 1 recordings were shared in September 2023, Day 2 recordings in October 2023, and Day 3 recordings in November 2023. As of December 31, 2023, the recordings have already garnered 546 views from over 200 unique viewers, with a combined watch time of 90.5 hours; the videos also have 2 k impressions (which is the times the video thumbnails were shown on YouTube) and an impressions click-through rate of 4.8%, this includes people who have been shown the content in their suggested videos, or Browse features (for example).

Conference feedback

A Project Ethics Community Consensus Initiative (ARECCI) framework was used to assess for and mitigate ethical risks for a survey of PxP participants (hosts, speakers, moderators, and attendees), including the four-step ARECCI Ethics Screening Tool and the ARECCI Ethics Guidelines [ 30 , 31 ]. The survey was deemed as minimal risk to participants and did not require review from a Research Ethics Board. All PxP participants (hosts, speakers/panelists, moderators and attendees) were provided a link to an online, voluntary, self-reported anonymous survey to complete. The survey included a consent statement at the beginning about the potential use of their results and open-ended responses for learning purposes or for publication purposes. Respondents could opt-out of their survey responses being used for publication purposes if they wished. The survey was issued using a modified Dillman’s method to achieve a better response rate [ 32 ].

All 310 attendees were invited to respond to a survey about the conference. One-hundred and thirty-seven (137) attendees voluntarily submitted survey responses (response rate of 44%). Of these respondents, 136 respondents consented to their responses being used for publication purposes and 1 respondent agreed for their responses only to be used for learning purposes, not for publication purposes. The survey results from the 136 attendees were overwhelmingly positive:

96% (130) of respondents agreed or strongly agreed that the themes and topics discussed were relevant to them;

96% (130) of respondents agreed or strongly agreed the question and discussion periods were well-organized and helpful in their learning;

74% (100) agreed or strongly agreed that there were opportunities to interact, engage and network with other attendees during the conference;

88% (120) of respondents agreed or strongly agreed they learned something new that will be useful in their future approach in patient partnership/engagement;

95% (129) of respondents agreed or strongly agreed that the conference environment was inclusive and safe;

95% (129) of respondents agreed or strongly agreed that they would recommend the PxP conference to a friend or colleague;

95% (129) of respondents agreed or strongly agreed that they were satisfied with Zoom Webinars as the conference platform; and,

94% (128) of respondents agreed or strongly agreed that they were satisfied with the sessions they attended.

In response to 5 comments on main areas for improvement, increased diversity (gender, ethnicity, geography) for SC members and speakers will be a focus for PxP2024.

SC members were also issued a separate online survey based on the validated Patient and Public Engagement Evaluation Tool to respond to anonymously about their experiences of being a SC member between February to September 2023 [ 33 ]. This survey also had a consent statement at the start about potential uses of the survey data and from which respondents could opt-out. All 9 SC members responded anonymously to this survey. The results indicated that their experiences were positive overall with respect to planning and carrying out the conference. Overall, they indicated that the SC was a safe environment where they could express their views, they felt supported by IMHA in a number of ways (e.g., through being offered one on one meetings if they were unable to attend scheduled meetings), they felt that their feedback was taken into account by IMHA, and that they were proud of the conference. Like conference attendees, they felt that the SC’s diversity of experiences, ethnicity, gender, geography, etc., should be expanded in future years.

Trade-offs, challenges and learnings

The SC aimed to minimize the burden of registering for and attending the conference. The SC decided a conference platform was not necessary, and instead opted to use Zoom alone given familiarity with Zoom due to the COVID-19 pandemic. Further, the SC considered the options of separate registrations and links for each session vs. each day of the conference, and opted to have each day run as one long Zoom Webinar. It was thought that this registration/link approach would minimize potential for confusion around different time-zones for an international event. With this approach, each attendee registered for each day and was provided with a personalized link for that day. Using Zoom Webinar meant that for the starting session of each day, session hosts and speakers/panelists were in a private Zoom Webinar room before the event went live and could prepare without the audience seeing or hearing them. However, after that first session and during breaks, new session speakers/panelists joined and if audience members kept their Zoom Webinar open, they were privy to these preparations. Using Zoom Webinar also meant that attendees could not direct message each other, rather only had the option to post to everyone in the chat. Visual messaging on the screen and in the chats was used during the breaks to let attendees know when sessions would start again. Even with these trade-offs, evaluation results and comments indicated that Zoom Webinar was an appropriate platform for PxP 2023.

Some audience members found the action in the Zoom Webinar chat during the sessions to be distracting and struggled to keep up with the amount of participation in the chat. Part of this may have had to do with how their chat settings were set up (some participants indicated that the chat kept ‘popping up’). For PxP 2024, some suggestions will be offered to deal with the chat and how it can be minimized, and attendees will be informed that the chats will be summarized (including the resources shared in the chats) and posted on the PxP resource hub after the conference.

Future conferences will see an increased diversity (gender, ethnicity, etc.) of the SC members and the invited speakers. Four survey comments indicated gender diversity is an area for improvement given they observed few who appeared to identify as men presenting in the sessions (note that organizers did not ask hosts, moderators or speakers/panelists to disclose their gender). A study of the demographics of patient partners in Canada indicates that this gender uniformity is fairly reflective of the patient partner demographic in many initiatives [ 34 ].

Even though this event was all about patient engagement in research and aimed to execute well on best practices, we experienced process challenges at IMHA’s home institution with respect to issuing honoraria for international participants. The IMHA team has developed an approach to minimize these process issues by working with its home institution for subsequent events.

Resource requirements

The conference required certain resources from IMHA. In addition to a financial budget, a conference platform, communication tools (e.g., a website, social media accounts, a newsletter, etc.), and human resources were required. Without these resources, it would have been difficult to host the same quality of PxP.

It is estimated that in addition to IMHA human resource costs (see below for information on time of various roles), the cost for the first PxP was approximately $27,500 CDN (all figures here in Canadian dollars). This amount includes honoraria offered to SC members (to attend meetings and for various roles in the conference) and all speakers/panelists ($20,000), building the website ($6,000, excluding an annual maintenance fee of $900), and the Zoom platform (~ $1,500). For PxP2024, the only item that will come off the budget is the cost to build the website.

While time commitment varied and especially ramped up closer to the conference itself, a number of IMHA team members contributed to the conference. The financial cost of these human resources is not provided as a dollar amount as this will vary for organizations. Balancing other IMHA-related work within her one-day a week commitment to IMHA (that is, less than 0.2 full time equivalents), DPR prepared materials for and hosted all SC meetings, met with SC members individually if they could not attend scheduled meetings, invited speakers and panelists, hosted 9 conference planning sessions/introductory meetings for sessions, attended the 2 pre-conference drop-ins for all speakers, hosts, and panelists, led developing the ‘run of show,’ shared information about the conference on social media and in her networks, and supported speakers, hosts and panelists on the back-end of Zoom Webinars each day of the conference. RT worked closely with DPR and attended all SC meetings and provided technical support for speakers, hosts and panelists at the conference. HM worked closely with DPR, attending most SC meetings, co-designed all communications and social media assets for the conference, coordinated all IMHA communications about the conference, coordinated PxP logo and website development, created all conference agendas and guides for using Zoom Webinar, etc., and hosted Zoom Webinar for the conference. HM’s time commitment was between 0.25–0.5 full time equivalents in the 6 months leading up to the conference. Another member of the IMHA team supported compensation processes for all SC members, speakers and panelists, through setting up individuals with a finance system and ensuring payments were received. And one other member of the IMHA team co-created the evaluation materials and uploaded them in to an online survey software (Qualtrics), and helped with analyzing all survey results. KK supported the entire project by attending SC meetings, the conference itself, and allowing IMHA resources to be used to support the PxP.

Next steps for PxP and beyond

Planning for PxP 2024 has already started, and PxP will continue until at least 2025 with IMHA support. Beyond 2025, a new Scientific Director will be appointed to IMHA (Scientific Directors’ terms are for a maximum of 8 years, with the current Scientific Director completing his term in 2025), and their support for PxP is not guaranteed. With a commitment to provide new patient partners the opportunity to plan and participate in the conference, a new SC is being formed for 2024 with efforts to expand its diversity (patient partner experience, gender, ethnicity, geography, etc.), and based on suggestions made by 2023’s SC members. The 2023 SC has become an Alumnus Committee and their interaction with the 2024 SC and involvement in PxP 2024 will be decided by the incoming SC. As was the case with the 2023 event, the 2024 SC will decide on all aspects of the conference, building on the successes and learning from the challenges of PxP 2023.

As individuals who were involved in designing and executing PxP, we encourage others to use the PxP template and build on it to find ways to support and create conferences and events for patients and by patients. Support may take the form of any of a number of resources, such as people, funding, and skills. One of the main challenges for patients planning and carrying out their own conferences is funding, and we urge organizations to consider how they can provide this type of financial support. There may also be more innovative partnership models waiting to be created and learned from.

Conclusions

We present work we undertook throughout 2023 to co-create and produce PxP, a conference for patients and by patients, all about patient engagement in research, and its associated PxP Hub. We share how the conference prioritized the patient partner community and accessibility, and provided an opportunity for knowledge exchange and nuanced discussions on all aspects of patient engagement in research. The conference has convened an active community of over 700 people that we hope will grow. We aim to engage in future events, with a deeper focus on equity, diversity and inclusion. In addition to working with knowledgeable patients who have their own networks, having support (funding, project management and communications skills and expertise, people, etc.) is required to carry out such an event. The time is now to elevate patients into leadership roles for conferences and events. We encourage you to adopt the PxP ethos by using or adapting our approach and resources to support this model.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Canadian Institutes of Health Research

Institute of Musculoskeletal Health and Arthritis

Patient Engagement in Research Ambassadors

Patient-Oriented Research

For Patients, by Patients

Steering Committee

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Acknowledgements

The authors thank Eileen Davidson as a Steering Committee member of PxP 2023, Eunice Lui for her work related to the conference evaluation, and Mike Brennan for his speaker sketches.

All SC members who are authors were offered an honorarium for their involvement in developing and writing this paper.

Author information

Authors and affiliations.

Canadian Institutes of Health Research Institute of Musculoskeletal Health and Arthritis, University of British Columbia, Vancouver, BC, Canada

Dawn P. Richards, Hetty Mulhall, Rosie Twomey & Karim M. Khan

Five02 Labs Inc., Toronto, ON, Canada

Dawn P. Richards

Patient Partner and Patient Author, Toronto, ON, Canada

Patient Partner and Patient Author, Fraser, CO, USA

Joletta Belton

Patient Partner and Patient Author, London, UK

Savia de Souza

Patient Partner and Patient Author, Halifax, NS, Canada

Trudy Flynn

Patient Partner and Patient Author, Kingston, ON, Canada

Alex Haagaard

Patient Partner and Patient Author, Ottawa, ON, Canada

Linda Hunter

Patient Author, London, UK

Dartmouth Institute for Health Policy and Clinical Practice (TDI), Geisel School of Medicine, Dartmouth College, Hanover, NH, USA

Patient Editor BMJ, London, UK

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Sara Riggare

Participatory eHealth and Health Data, Uppsala University, Uppsala, Sweden

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Contributions

DPR, HM and RT led conception of the work, DPR convened the writing group and discussions (JB, SdS, TF, AH, LH, KK, HM, AP, SR, JT, RT). DPR led writing of the manuscript. All authors contributed to the design, analysis of the work and in writing and revising the manuscript. All authors read and approved the final manuscript.

Authors’ information

We have not filled in the GRIPP2 for this commentary as a number of the authors identify as patient partners. All author contributions are noted above. The following authors can be found and tagged on X: DPR (@TO_dpr), TF (@trudyflynn_), AH (@alexhaagaard), LH (@lhunter1310), HM (@HettyMulhall), AP (@AmyPricePhD), JT (@Hassanah2017).

Corresponding author

Correspondence to Dawn P. Richards .

Ethics declarations

Ethics approval and consent to participate.

A Project Ethics Community Consensus Initiative (ARECCI) framework was used to assess for and mitigate ethical risks for a survey of PxP participants (attendees, hosts, session participants) as well as SC members, including the four-step ARECCI Ethics Screening Tool and the ARECCI Ethics Guidelines. The surveys were deemed as minimal risk to participants, and did not require review from a Research Ethics Board. The surveys were answered anonymously (no identifying information was collected) and voluntary, and there was a consent statement before the survey start so they could opt out of if they wished.

Consent for publication

Individuals who chose to complete the survey (see above) were consented for their results to be part of a discussion in a publication. One person did not consent to their survey results being used for this purpose, and their results were removed from those discussed in this paper.

Competing interests

DPR is a full-time employee of Five02 Labs, Inc., and is under contract to the Canadian Institutes of Health Research Institute of Musculoskeletal Health and Arthritis to support its patient engagement efforts.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1. steering committee terms of reference., 40900_2024_603_moesm2_esm.pdf.

Additional file 2. Full version of the conference agenda which includes dates, times, hosts, session names and their respective moderators and speakers.

40900_2024_603_MOESM3_ESM.pdf

Additional file 3. Zoom Webinar Guide that was created for conference attendees to make the most of attending the conference on the Zoom Webinar platform.

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Richards, D.P., Mulhall, H., Belton, J. et al. Co-creating and hosting PxP: a conference about patient engagement in research for and by patient partners. Res Involv Engagem 10 , 77 (2024). https://doi.org/10.1186/s40900-024-00603-0

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• The NHS founding...

The NHS founding principles are still appropriate today and provide a strong foundation for the future

Read the full series: the bmj commission on the future of the nhs.

• Related content
• Peer review
• Nigel Crisp , independent member of the House of Lords 1 ,
• JS Bamrah , consultant psychiatrist 2 ,
• Jessica Morley , postdoctoral researcher 3 ,
• Charlotte Augst , executive director for policy, campaigns and improvement 4 ,
• Kiran Patel , consultant cardiologist and chief medical officer 5 6
• 1 House of Lords, London, UK
• 2 Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
• 3 Yale Digital Ethics Center, Yale University, CT, USA
• 4 Diabetes UK, London, UK
• 5 University Hospitals Coventry and Warwickshire, Coventry, UK
• 6 Medical School, University of Warwick
• Correspondence to N Crisp crisp{at}parliament.uk

The vision of a comprehensive health service is as relevant today as in the 1940s, but new and different societal challenges require a rethink on how to deliver the NHS as it faces a national health and care emergency

The NHS is currently experiencing the gravest crisis in its history. While much excellent treatment and care is being delivered, too many people are not receiving the care they or their relatives need. Staff, patients, and the public are experiencing a loss of hope, confidence, and trust which must be reversed. 1 Austerity, the covid-19 pandemic, and major financial and staffing problems, have left the NHS in a weakened state. 2 3

Radical change is needed in the way services are designed to make better use of the technologies available and to provide more services in homes and communities. These changes should be led by the professionals and communities directly involved. They can build on the UK’s world class biomedical science and professional education, 4 the skills and passion of NHS staff, and new contributions to improve health and wellbeing from all sectors. They can be modelled on best practice in the UK and other countries. These changes must be supported by an engaging vision for the future and by adequate levels of funding and staffing.

This article addresses the question of whether, given the problems and scale of change needed, the NHS founding principles are still appropriate now and for the future. The article is the first in a series of papers from the BMJ Commission; others will deal with equity, finance, workforce, wider health determinants, redesigning the health and care systems, and sustainability and the physical environment.

We begin with the founding principles, review how science and the wider environment have changed since 1948, and describe the current problems before returning to the principles. We identify three areas for development to help the NHS deliver—policies on wider health and wellbeing, the roles of patients and citizens, and use of technology and data—before presenting a final section on implementation and a recommendation.

A national health and care emergency

The NHS’s problems require urgent and speedy action. The NHS was founded through a major act of political will against opposition from the BMA and other powerful interests. The next government should be similarly bold and declare a national health and care emergency, calling on all parts of society to help improve health, care, and wellbeing. It should, in effect, relaunch the NHS with the active participation of all sectors.

Government needs to be honest about the scale of the problems, the financial, staffing, and other constraints, and the length of time and effort that will be required. It should establish an Office for NHS Policy and Budgetary Responsibility to provide an independent and expert assessment of NHS plans and policies, which would help protect the NHS from short term political pressures and policies that are poorly thought out.

Equally, the NHS should prioritise tackling inequalities in access and outcomes and give particular attention to the disadvantage and racism experienced by different ethnic groups both as patients and staff of the NHS.

These developments should be supported by embedding NHS policy within a cross-government and cross-sectoral health and wellbeing strategy, and by developing better ways to involve patients, the public, and community groups alongside other stakeholders in policy, planning, and improvement.

The founding principles

The 1946 NHS Act ( fig 1 ) made the minister of health responsible for establishing “a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness […] and to provide or secure the effective provision of services. […] The services so provided shall be free of charge, except where any provision of the Act expressly provides for the making and recovery of charges.” 5 Parallel legislation was enacted for Northern Ireland and Scotland.

The NHS Act 1946

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The Act explicitly refers to the NHS as being comprehensive, free of charge, and, by implication, available to everyone equally. Neither the legislation nor health minister Aneurin Bevan’s speeches mention founding principles, but review of extensive discussion at the time suggests it is reasonable to identify five founding principles: the NHS as a comprehensive service, universally available, based on clinical need, free at the point of need, and funded through collective contributions.

The principles have since been defined more clearly by the policies adopted to implement them. These policies have changed over the years in response to changes in the wider environment. Since the outset, tension has existed between national and local decision making, with practice changing from one administration to another.

Additions and modifications have also taken place. The most important for England are the seven principles in the 2013 NHS Constitution for England. 6 The first two are rewritten versions of the founding principles, with the addition of a wider duty to promote equality. The other five relate to achieving the highest standards of excellence and professionalism, putting patients at the heart of everything, working across organisational boundaries in partnership, providing best value for taxpayers’ money, and accountability. These principles were reconfirmed in 2023.

No other UK country has published a constitution, but each has broadly similar statements of values or principles.

Our discussions produced other suggestions for principles, including recognising the importance of supporting staff and ensuring their welfare. This is the topic of another BMJ Commission article, and we will limit ourselves to discussing the five founding principles.

The changing environment

Enormous changes have occurred since the 1940s. Some of the most obvious affecting the NHS are: demography, where an aging and more diverse population requires a wider range of services; epidemiology, where the greatest burden of disease is now longer term conditions and disability; science and technology, where options for diagnosis and treatment have expanded enormously and personalised medicine is becoming reality; and in the economy, where cheap alcohol, processed food, high stress working conditions, and growing inequalities increase risks to health.

The aging population and changing disease patterns have resulted in more comorbidities, with patients needing support from several services. The increase in longer term conditions, together with a move to a more personalised service, mean that much healthcare needs to be long term and relational, not transactional and episodic. Despite this, the NHS (like other industrialised health systems) still uses service models based on hospitals and episodes of care, which were designed for the different needs of a younger population in the 1940s (more infectious disease, trauma, and acute illnesses). This is a major source of inefficiency in the NHS. In effect it is using a 20th century model to address 21st century problems.

In addition, we now know that most ill health can be linked to external causes (poverty, housing, education, nutrition, and others) and this requires a new focus by wider society and the NHS on preventing disease and creating health.

The current position

Box 1 describes the problems one clinician describes in delivering a comprehensive health service. We expect that most health workers will recognise these problems. In recent years, the decades-long improvements in life expectancy in England have slowed dramatically, 7 waiting lists are at their highest levels ever, 8 and confidence in the NHS has fallen. Austerity and covid-19 have played major roles in this. As a result, more people in England who can afford it are using the private sector. 9 As the UK champions policy for universal health coverage globally—so that everyone everywhere has access to healthcare—the UK’s own system is in crisis, as are others in western Europe. 10

A clinician’s view of the barriers to providing a comprehensive healthcare system

Funding and resource allocation.

Funding constraints affect the range of services, the availability and quality of care, and the consistency with which services can be offered. Personalised medicine and advances in healthcare make it increasingly costly to offer and make available all healthcare opportunities. The effective and efficient allocation of resources is variable across the NHS, resulting in health outcomes that range from excellent to inadequate.

Fragmented care

Integration and coordination of care across primary, secondary, and specialised care services is often lacking, leading to a disjointed patient experience.

Health inequalities

Health inequalities arising from socioeconomic, ethnic, cultural, and environmental factors are significant causative factors for poor life expectancy, morbidity, disease prevention, access to services, and measures of life quality.

Technological advances

Providing a comprehensive service requires that technology can be exploited safely and effectively across the whole range of services, particularly in electronic care records, digital consultations, health applications, and other digital solutions, enhanced with the closely governed use of artificial intelligence. This requires significant investment, training, and infrastructure support.

Workforce shortages

The NHS, like other health systems globally, faces severe shortages of doctors, nurses, and other allied healthcare professionals. Adequate staffing levels are crucial for providing comprehensive care, addressing the needs of the population, tackling health inequalities, and meeting demand.

Appropriateness of the founding principles

The key test for whether the founding principles are still appropriate is whether they can (in the words of the 1946 Act) “secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness.”

The five founding principles are connected, and work together to provide an overarching framework for the system, although they can sometimes be in conflict (as seen below). Bevan said that a comprehensive service would “ensure that every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health.” 11 What constitutes a comprehensive service is not simple, however. Services can be provided in a variety of ways: in the community or hospital, for example, or through prevention rather than treatment. Opinions differ on what constitutes effective and necessary treatment and care, and different parts of the community have different needs.

Moreover, the financial implications are significant. In the first year of its existence, the NHS spent £32m on optometry against a budget of £1m, prompting the government to introduce charges for dentistry, prescription, and optometry.

Successive governments have introduced policies to manage the tensions between providing a comprehensive service and it being free at the point of need. These include:

Exemptions from dentistry, optometry, and prescription charges for children, people drawing a pension, those with disabilities or long term sickness, pregnant women, new mothers, and those in receipt of certain benefits. Only the English NHS still charges for prescriptions. The Scottish NHS provides eye tests and dental examinations free of charge.

National and local arrangements for priority setting, which are sometimes in conflict, and permitting the development of waiting lists to ration and delay access.

Managing resources through evidence based practice and protocols, and introducing new technologies largely through professional education and the National Institute for Health and Care Excellence (NICE) and its equivalents in the four countries.

These provide a policy framework. However, the NHS and its clinicians and managers need constantly to adapt to the situation on the ground, make judgments, and manage politics and their patients’ expectations.

Alternatives to a comprehensive service

The alternative to a comprehensive service is to limit the services either to a particular range available to everyone and/or to limit them to a part of the population. This would be typical, for example, of an insurance policy which had a defined set of benefits provided only to its policy holders. People would then have to pay for any additional services either directly or through an insurance system if they could afford to, or go without them.

Defined benefits

A defined benefits system has several drawbacks. The benefits package may be eroded over time to become a minimum safety net of services. Cash strapped governments might exert pressure to reduce benefits (austerity is a recent example) and commercial interests are likely to promote more expensive options as alternatives to the basic package. A safety net service is likely to lead to stagnation and poor services as innovation, development, and investment move into other areas with higher profitability. Inequality is likely to increase because poorer people can’t pay for additional services, and service quality and health outcomes may suffer if only some needs are met.

A comprehensive system, in contrast, promotes innovation in the services available to everyone. We argue that a comprehensive service should remain as a vital aspiration that will constantly force planners and commissioners to consider how best to achieve it. It is a spur to progress, but it will only work when there is transparency and trust.

Today’s NHS can best be described as a comprehensive service with some limited exceptions where resources are managed through waiting lists and other practical means such as NICE guidance and protocols. This needs to be publicly acknowledged together with a public commitment to making it as comprehensive as possible, adding new services as evidence of their effectiveness and value is demonstrated and resources permit. Priority setting will remain essential and must be conducted through public, visible, and accountable processes with everyone—patients, staff, and the public—having good information about what can or cannot be provided at any given time.

Trust and transparency are essential. Health workers, who have to make decisions about treatment, as well as patients, will benefit from greater transparency in decision making.

Defining benefits might be perceived as bringing certainty, but this is not entirely true. Difficult and disputed decisions will still need to be made. Defined benefits need to change as practice advances and, for example, insurance based systems that take a defined benefits approach spend a great deal of time and money on disputes about contracts and coverage.

The greatest anomaly in the English system is that social care, on which a lot of healthcare depends, is the responsibility of local authorities, is mostly means tested, and varies enormously between areas. Shared health and care management, as occurs in Scotland, Northern Ireland, and Manchester, offers a partial solution, but this approach is not widespread. The problem is beyond the scope of this paper.

On the subject of clinical need, practice has become more sophisticated with, for example, patients and their advocates increasingly involved in clinical decisions through co-creation and informed choice. What matters to patients can be as important as what is the matter clinically. Similarly, assessing the health needs of populations and communities has become more comprehensive and needs to involve patients and citizens who can identify issues not recognised by professionals.

Charging patients at the point of care

Another alternative would be to provide a comprehensive service by charging patients for using some or all services through co-payments. This takes us to discussion of the NHS being free at the point of need. Aneurin Bevan, in his book In Place of Fear , argued that “no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means,” and describes the difficulties people had without a free health service. 12 The establishment of the NHS eliminated the catastrophic economic impacts that illness often had on an individual and their family. In contrast, two thirds of bankruptcies in the US (where services are largely insurance based) result from medical costs, and medical debt affects enormous numbers of people. 13

Charging for care might be expected to reduce unnecessary health service usage, affecting poorer people more acutely. The RAND Health Insurance Experiment, a randomised controlled trial conducted in the US between 1974 and 1982, was designed to assess the impact of cost sharing between the insurer and the patient, or co-payments, on people’s use of health services. 14 It showed that cost sharing reduced “appropriate or needed” medical care as well as “inappropriate or unnecessary” medical care. This had minimal impact on health status, except in people who were poor and sick, where the reduction was on average harmful: “The projected effect (from having no charges) was about a 10% reduction in mortality for those with hypertension.” 14

A recent report that considered these issues concludes that user charges are not an effective way of directing people to use health services more efficiently. It finds that people do not value interventions more highly when they have to pay for them out of pocket, and that even relatively small user charges can deter people from using needed healthcare. Such charges can reduce adherence to essential medicines and other forms of treatment, increase the use of other health services, lead to financial hardship, increase the use of social assistance, and adversely affect health, particularly in people with low incomes or chronic conditions. 15

One option would be to give exemptions to charging, as currently happens with prescribing, optometry, and dentistry. About 40% of the English population has exemptions, but almost 90% of items prescribed are exempt. 16 This is unsurprising given that older, younger, sicker, and poorer people, who are largely exempt, are more likely to need prescriptions and services. If the same exemptions were agreed, charges would be paid only by a small part of the population and would need to be high to make a material difference to the NHS budget. 17

With the UK’s current approach, financial risks are shared across a large population, and general taxation is the cheapest way to raise funding without the large overheads of insurance or patient payment systems. Proponents of alternative ways of funding will need to demonstrate how the benefits of change will outweigh the increase in overheads and the costs of changing to a system of insurance, private payments, or co-payments.

The principle of collective contribution is about solidarity and sharing risks. It is a natural accompaniment to a system free at the point of need and is a unifying factor at a time when society is becoming less cohesive.

Financial issues are discussed in more depth in a later article from the BMJ Commission.

Universality, equality, and equity

The NHS Constitution states: “[the NHS] is available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy, and maternity or marital or civil partnership status.” However, major inequalities in access and in health outcomes exist between different groups of service users. In 2022, the difference in healthy life expectancy between the highest and lowest local authority areas in the UK was 19.8 years for women and 17.8 for men. 18

The NHS also needs to consider equity. This means recognising that people do not all start from the same place, and acknowledging and adjusting for imbalances. Allocation of resources and opportunities should therefore be based on what is needed by different groups to access appropriate services equally and to achieve equal outcomes. Against this background, it is important to make equity more explicit in operational policy and to stress the importance of measuring and achieving equality of outcomes.

People from black and Asian backgrounds, as well as recent migrants, make up a higher proportion of NHS staff than their representation in the wider population. They also suffer worse access to services and poorer health outcomes, from maternal services to surgery and mental health. Given their numbers, tackling the disadvantage and inequalities affecting these groups will make a major contribution to reducing inequalities overall. 19

Some asylum seekers, undocumented migrants, and many recent migrants do not always have full access to services, and many have to pay a fee for them (even those who work for the NHS). These issues must be addressed, but are beyond the scope of this paper.

The NHS performs well on equity in international comparisons of health systems, such as the Commonwealth Fund, but this is not the whole story. The NHS was designed to meet the needs of everyone, including the poorest. Today, however, inequity in access to services and health, and the ability of people with higher incomes to express needs, claim rights (often described as the inverse care law), and to opt for private care, leaves the poorest at greatest disadvantage. Covid-19 starkly revealed these inequalities.

Were Bevan redesigning the NHS today he would surely ask why the service was failing those most in need.

These issues are also discussed more fully in a later article from the BMJ Commission.

We have argued that the NHS is a comprehensive service with some limited exceptions, where resources are managed through waiting lists and other practical means, and that the aspiration to being comprehensive needs to be retained as a spur to innovation and development.

We have also argued that being (very largely) free at the point of need promotes equity and is a practical and appropriate approach to improving the health of the population. Any movement away from it is likely to be expensive and without certainty of improvement.

The other founding principles of universality, decisions based on clinical need, and collective contributions follow from the first two, and are relatively uncontentious.

In summary, we believe that the NHS founding principles are still appropriate today and provide a strong foundation for the future. We recommend that the government in place after the next election re-commits to these principles as part of a wider set of actions. These include giving immediate priority to tackling inequalities in access and outcomes and paying particular attention to the disadvantage and racism suffered by different ethnic groups both as patients and staff of the NHS.

Much can be learned from other health systems in both high and low income countries. 20 21 The NHS is not unique; most western European systems are based on comprehensiveness and universality and have different ways of managing the issues raised here. All have some exceptions and/or charges. Private and insurance based systems, as in the US, ration by the ability to pay and often do not cover vital areas such as mental health. Other systems combine public and private health approaches and have many exclusions and co-payments. Meanwhile, the lowest income countries have predominantly out-of-pocket payment systems.

The NHS has a serious financial problem to resolve, but the central issue is a health problem, which can only be dealt with through changing the approach to health and healthcare. Financial solutions need to follow health ones.

The next section briefly discusses three areas for development which will help the NHS perform its role. These are wider policies on health and wellbeing, the roles of patients and the public, and technology and data. We conclude with recommendations.

Future developments

Policies on health and wellbeing.

It is well understood that social, economic, commercial, and environmental determinants shape a large proportion of an individual’s health status. 22 The NHS can only directly affect these as an employer and anchor institution in local communities. We therefore recommend the creation of a cross-government and cross-sectoral health and wellbeing policy where wellbeing is, as described by the World Health Organization, “a state of mind” encompassing “quality of life and the ability of people and societies to contribute to the world with a sense of meaning and purpose.” 23

We argue for the development of such a policy and the introduction of a UK version of the “health for all policies” approach pioneered in other countries, and placing new emphasis on the importance of communities, social structures, wellbeing and health creation. 24 This would be characterised by:

Strengthening the roles of all parts of society—government, families, businesses, communities, schools, and more—in promoting health and wellbeing, protecting the public, and preventing disease. An example would be the recent Healthy Homes Bill, which, if passed, would have laid a duty on the secretary of state to ensure that all new housing promoted health, safety, and wellbeing. 25

Understanding that the health of an individual is intimately linked to the health of their family, community, the health of wider society, and the health of the planet, and introducing measures to promote health and wellbeing at all these levels.

Recognising the importance of promoting and creating health and wellbeing, as well as tackling the causes of disease and preventing disease and injury. Health is not simply the absence of disease. 26 Factors that promote health include having a social network, meaning and purpose in life, an increased degree of autonomy, and access to nature and green spaces, as well as the more familiar factors such as exercise, good diet, and good conditions of employment and living.

Treating improved health and wellbeing as a positive contributor to the country’s economy and not, as too often happens, a cost. This involves a recognition that human development and “human capital” are central to the wellbeing and prosperity of the country.

Patients and the public

The 2002 Wanless report, commissioned by the Treasury to look at the long term sustainability of the NHS, recommended that this could only be achieved through the full engagement of patients in their own health and healthcare. 27 Relatively little progress has been made since, with a focus on immediate service provision rather than upstream on human behaviours, illness and injury prevention, and health creation. This needs to be reversed, with patients and the public (as voters and future patients) engaged not only in maintaining and improving their own health but also in maintaining and improving the system.

Patients and the public can play a greater role in the design and evaluation of NHS services. Patients are experts in what it is like to experience NHS care, to live with specific conditions, or to care for loved ones experiencing ill health. They often know better than researchers and analysts the most important research questions, the most vital services needed, the right outcomes to measure, and the best ways to ensure that the NHS delivers on its ultimate goal of patient and public benefit.

Patients and the public also have important roles in improving and creating health, and make an important contribution to the future success of the NHS. Organisations within local communities and in every sector are already dealing with some of the most difficult health issues and creating health for themselves and others, with or without the assistance of the health system and health professionals. 28 We therefore recommend that the government develops better ways to connect patients, the public, and community groups with the NHS, particularly at local level.

We propose that the NHS needs to embrace these roles by:

Placing community assets and efforts at the centre of health creation and long term conditions management.

Recognising that measures that strengthen community connection, voluntary sector activity, citizen voice, and health democracy strengthen the NHS’s ability to do its job properly and create the conditions for people to be healthy.

Learning from community health improvement in environments where resources are more constrained: focusing on the essentials, looking upstream, majoring on inclusion, and advocating for rights.

This approach will help rebuild confidence and trust in the NHS. We are not proposing structural changes or going back to structures such as regional health authorities, but looking for behavioural change and new approaches such as citizens’ assemblies, where patients and the public can better engage in governance and decision making, alongside other stakeholders. 29 Local services and planners need to think about how patients, the public, and community groups can be connected at the most local level and feel part of the efforts to care for themselves, their fellow citizens, and communities.

Some of the loss of trust in the NHS appears to be about the role of politics in its management. This is why we recommend a method for independent scrutiny of plans and policies.

Technology and data

The importance of advances in technology can be exaggerated, but it is clear that increasingly “Science, technology, and data will determine much of the framing and the language of health, shaping how health workers think about health problems and possible solutions, and how they act.” 30

Technology and data are themes running through all the BMJ Commission’s articles and have so much to contribute to improving health, healthcare, and wellbeing in the future. NHS data on tens of millions of patients over many years, for example, are extraordinarily valuable for research and development.

However, artificial intelligence could also be used for private gain or disruptive purposes, and this relates directly to issues of trust and confidence in the NHS. Poor performance of the English 111 service has already led to criticism of diagnosis by algorithm, and suspicion of motives will make this worse where private companies are involved, as in the Post Office scandal.

Mitigating these risks requires the NHS to adopt a principle of values based innovation and to put in place robust governance arrangements to protect the core principles and values from trade-offs and dilution. One of the authors (JM) has published recommendations for how to secure appropriate governance. These cover use of NHS data for training AI algorithms, accountability, technical validation, prevention of vendor lock-in, economic evaluation, and the potential for AI screening of the population. 31 This would support development of the NHS as a Learning Health system driven significantly by data, as well as digital and predictive AI. 32

Recommendations

We have argued that the NHS founding principles are, with the qualifications noted, still appropriate now and provide a strong foundation for the future. But we need to make major changes to how these principles are put into practice. These include updating service models to make them fit for the 21st century, greater use of technology and data, developing an approach that encompasses all of society in creating health and preventing disease, and a focus on people—trust, engagement of patients, citizens, and staff, the development of human and social capital—and changes to professional education.

Implementing change at this scale is difficult and it is useful to look back at the major reforms introduced in 2000, which the King’s Fund reported as leading to the most significant sustained improvements in the history of the NHS. 33 Lessons can be learnt about what worked and what didn’t. 34

Three key actions enabled those reforms. They involved people from across the NHS and its partners in developing a 10 year plan. 35 This was supported by a major programme of “investment for reform” and by the Wanless report, which produced a long term financial plan and brought in the Treasury. 27 These actions created buy-in and momentum which carried the NHS through the next few years when controversial policies were introduced about use of the private sector and patient choice. This momentum was maintained by success in achieving targets from 2002 onwards—with waiting lists and waiting times down significantly, 36 substantial improvements in cardiac and cancer care, and public satisfaction doubling over a 10 year period. The private sector, which had gained patients from the NHS in the 1990s began to lose business from 2003 onwards as people came back to the NHS.

Despite this, problems arose because of over-focus on numbers and targets rather than quality. Too many reorganisations took place, and there was political infighting over the direction of policy, too great a political involvement in operational issues and, ultimately, a failure to pivot towards health and away from a focus only on health services.

This discussion illustrates how important politics are to the NHS. Political will drove its foundation and the NHS Plan, but political engagement in operational policy and planning can be influenced by short term political objectives, and therefore should be subject to independent public scrutiny. The NHS needs long term thinking and stable, consistent policies. We therefore recommend the establishment of an Office for NHS Policy and Budgetary Responsibility for England. This would be based on the role of the Office for Budget Responsibility. 37 It would review national NHS plans and policies and publish its conclusions, thereby helping to ensure that they are well based on evidence and properly costed. It should not, however, duplicate the roles of any existing bodies. The BMJ Commission group on finance will develop this idea further.

Given the extreme seriousness of the situation and the lessons learnt, we recommend that the government in post after the election should declare a national health and care emergency calling on all parts of society to help improve health, care, and wellbeing. The government should, in effect, relaunch the NHS with the active participation of communities, employers, businesses, housing providers, local authorities, food producers, schools and the public, as well as patients, health and care workers, carers, and others in preventing disease, providing care, and creating health.

This would involve:

Making a clear statement of commitment to the NHS and its founding principles, and engaging all parts of society in a renewed vision and plan for health, care, and wellbeing that will generate the buy-in and momentum to implement the necessary reform.

Creating a cross-government and cross-sector health, care, and wellbeing strategy, of which NHS strategy would be an integral part, to show how the whole population and all sectors can contribute, and supporting this with legislation as necessary.

Developing better ways to connect patients, the public, and community groups with activities and planning for the NHS, particularly at local level.

Giving immediate priority to tackling inequalities in access and outcomes and paying particular attention to the disadvantage and racism suffered by different ethnic groups both as patients and staff of the NHS.

Establishing an Office for NHS Policy and Budgetary Responsibility to provide an independent and expert assessment of NHS plans and policies, which would help protect the NHS from short term political pressures and policies that have not been sufficiently thought out.

Providing some additional funding to support early improvements and commissioning a review of future sustainability similar to the 2021 Wanless review.

This recommendation is summarised in box 2 .

The government in post after the election should declare a national health and care emergency, calling on all parts of society to help improve health, care, and wellbeing and, in effect, relaunch the NHS with the active participation of the whole of society. This would involve:

A commitment to the NHS and its founding principles and engaging all parts of society in a renewed vision and plan for health, care, and wellbeing

Creating a cross-government and cross-sector strategy for health, care, and wellbeing

Developing better ways to connect patients, the public, and community groups with the NHS, particularly at local level

Giving immediate priority to tackling inequalities in access and outcomes, with particular attention on the disadvantage and racism suffered by ethnic groups both as patients and staff of the NHS

Establishing an Office for NHS Policy and Budgetary Responsibility to provide an independent and expert assessment of NHS plans and policies

Providing some additional funding to support early improvements and commissioning a review of future sustainability

This article is part of The BMJ Commission on the Future of the NHS. The purpose of our NHS Commission is to identify key areas for analysis, lay out a vision for a future NHS, and make recommendations as to how we get there

Competing interests: We have read and understood The BMJ policy on declaration of interests and declare that we have no competing interests.

Contributors and guarantor: All authors contributed to the research, writing, review, and editing of this manuscript. NC is the guarantor. All authors were members of the BMJ commission.

Provenance and peer review: commissioned; externally peer reviewed.

The BMA, which owns The BMJ , grants editorial freedom to the editor in chief of The BMJ . The views expressed in the papers of the BMJ Commission on the Future of the NHS, are those of the authors and may not necessarily comply with BMA policy. The BMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. The BMJ was responsible for the peer review, editing, and publication of the papers of the commission.

All of the articles in this commission are available at https://www.bmj.com/nhs-commission .

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Large language models don’t behave like people, even though we may expect them to

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One thing that makes large language models (LLMs) so powerful is the diversity of tasks to which they can be applied. The same machine-learning model that can help a graduate student draft an email could also aid a clinician in diagnosing cancer.

However, the wide applicability of these models also makes them challenging to evaluate in a systematic way. It would be impossible to create a benchmark dataset to test a model on every type of question it can be asked.

In a new paper , MIT researchers took a different approach. They argue that, because humans decide when to deploy large language models, evaluating a model requires an understanding of how people form beliefs about its capabilities.

For example, the graduate student must decide whether the model could be helpful in drafting a particular email, and the clinician must determine which cases would be best to consult the model on.

Building off this idea, the researchers created a framework to evaluate an LLM based on its alignment with a human’s beliefs about how it will perform on a certain task.

They introduce a human generalization function — a model of how people update their beliefs about an LLM’s capabilities after interacting with it. Then, they evaluate how aligned LLMs are with this human generalization function.

Their results indicate that when models are misaligned with the human generalization function, a user could be overconfident or underconfident about where to deploy it, which might cause the model to fail unexpectedly. Furthermore, due to this misalignment, more capable models tend to perform worse than smaller models in high-stakes situations.

“These tools are exciting because they are general-purpose, but because they are general-purpose, they will be collaborating with people, so we have to take the human in the loop into account,” says study co-author Ashesh Rambachan, assistant professor of economics and a principal investigator in the Laboratory for Information and Decision Systems (LIDS).

Rambachan is joined on the paper by lead author Keyon Vafa, a postdoc at Harvard University; and Sendhil Mullainathan, an MIT professor in the departments of Electrical Engineering and Computer Science and of Economics, and a member of LIDS. The research will be presented at the International Conference on Machine Learning.

Human generalization

As we interact with other people, we form beliefs about what we think they do and do not know. For instance, if your friend is finicky about correcting people’s grammar, you might generalize and think they would also excel at sentence construction, even though you’ve never asked them questions about sentence construction.

“Language models often seem so human. We wanted to illustrate that this force of human generalization is also present in how people form beliefs about language models,” Rambachan says.

As a starting point, the researchers formally defined the human generalization function, which involves asking questions, observing how a person or LLM responds, and then making inferences about how that person or model would respond to related questions.

If someone sees that an LLM can correctly answer questions about matrix inversion, they might also assume it can ace questions about simple arithmetic. A model that is misaligned with this function — one that doesn’t perform well on questions a human expects it to answer correctly — could fail when deployed.

With that formal definition in hand, the researchers designed a survey to measure how people generalize when they interact with LLMs and other people.

They showed survey participants questions that a person or LLM got right or wrong and then asked if they thought that person or LLM would answer a related question correctly. Through the survey, they generated a dataset of nearly 19,000 examples of how humans generalize about LLM performance across 79 diverse tasks.

Measuring misalignment

They found that participants did quite well when asked whether a human who got one question right would answer a related question right, but they were much worse at generalizing about the performance of LLMs.

“Human generalization gets applied to language models, but that breaks down because these language models don’t actually show patterns of expertise like people would,” Rambachan says.

People were also more likely to update their beliefs about an LLM when it answered questions incorrectly than when it got questions right. They also tended to believe that LLM performance on simple questions would have little bearing on its performance on more complex questions.

In situations where people put more weight on incorrect responses, simpler models outperformed very large models like GPT-4.

“Language models that get better can almost trick people into thinking they will perform well on related questions when, in actuality, they don’t,” he says.

One possible explanation for why humans are worse at generalizing for LLMs could come from their novelty — people have far less experience interacting with LLMs than with other people.

“Moving forward, it is possible that we may get better just by virtue of interacting with language models more,” he says.

To this end, the researchers want to conduct additional studies of how people’s beliefs about LLMs evolve over time as they interact with a model. They also want to explore how human generalization could be incorporated into the development of LLMs.

“When we are training these algorithms in the first place, or trying to update them with human feedback, we need to account for the human generalization function in how we think about measuring performance,” he says.

In the meanwhile, the researchers hope their dataset could be used a benchmark to compare how LLMs perform related to the human generalization function, which could help improve the performance of models deployed in real-world situations.

“To me, the contribution of the paper is twofold. The first is practical: The paper uncovers a critical issue with deploying LLMs for general consumer use. If people don’t have the right understanding of when LLMs will be accurate and when they will fail, then they will be more likely to see mistakes and perhaps be discouraged from further use. This highlights the issue of aligning the models with people's understanding of generalization,” says Alex Imas, professor of behavioral science and economics at the University of Chicago’s Booth School of Business, who was not involved with this work. “The second contribution is more fundamental: The lack of generalization to expected problems and domains helps in getting a better picture of what the models are doing when they get a problem ‘correct.’ It provides a test of whether LLMs ‘understand’ the problem they are solving.”

This research was funded, in part, by the Harvard Data Science Initiative and the Center for Applied AI at the University of Chicago Booth School of Business.

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Digital Transformation in Healthcare: Technology Acceptance and Its Applications

Angelos i. stoumpos.

1 Healthcare Management Postgraduate Program, Open University Cyprus, P.O. Box 12794, Nicosia 2252, Cyprus

Fotis Kitsios

2 Department of Applied Informatics, University of Macedonia, 156 Egnatia Street, GR54636 Thessaloniki, Greece

Michael A. Talias

Associated data.

Not applicable.

Technological innovation has become an integral aspect of our daily life, such as wearable and information technology, virtual reality and the Internet of Things which have contributed to transforming healthcare business and operations. Patients will now have a broader range and more mindful healthcare choices and experience a new era of healthcare with a patient-centric culture. Digital transformation determines personal and institutional health care. This paper aims to analyse the changes taking place in the field of healthcare due to digital transformation. For this purpose, a systematic bibliographic review is performed, utilising Scopus, Science Direct and PubMed databases from 2008 to 2021. Our methodology is based on the approach by Wester and Watson, which classify the related articles based on a concept-centric method and an ad hoc classification system which identify the categories used to describe areas of literature. The search was made during August 2022 and identified 5847 papers, of which 321 fulfilled the inclusion criteria for further process. Finally, by removing and adding additional studies, we ended with 287 articles grouped into five themes: information technology in health, the educational impact of e-health, the acceptance of e-health, telemedicine and security issues.

1. Introduction

Digital transformation refers to the digital technology changes used to benefit society and the healthcare industry. Healthcare systems need to use digital technology for innovative solutions to improve healthcare delivery and to achieve improvement in medical problems. The digital transformation of healthcare includes changes related to the internet, digital technologies, and their relation to new therapies and best practices for better health management procedures. The quality control of massive data collected can help improve patients’ well-being and reduce the cost of services. Digital technologies will also impact medical education, and experts will deceive new ways to train people. Now in this way, practitioners will face new opportunities.

Digital transformation is an ongoing process that can create opportunities in the health sector, provided the necessary infrastructure and training are available. Under Regulation (EU) 2021/694 of the European Parliament and of the Council of 29 April 2021, establishing the Digital Europe Program and repealing Decision (EU) 2015/2240, digital transformation is defined as the use of digital technologies for the transformation of businesses and services. Some technologies that contribute to digital transformation are the digital platform of the Internet of Things, cloud computing and artificial intelligence. At the same time, the sectors of society that are almost affected are telecommunications, financial services and healthcare.

Digital health can play a role in innovation in health, as it facilitates the participation of patients in the process of providing health care [ 1 ]. The patient can overcome his poor state of health when they are no longer in a state of well-being. In this case, the patient is given the to participate in the decision-making regarding their health care. Searching for information through the patient’s internet or using digital health applications (e.g., via mobile phone) is essential for the patient to make the right decision about their health.

In the coming years, health change is expected to focus primarily on the patient, who will take on the “health service consumer” role as the patient seeks control over their health management. The healthcare industry will be shaped based on the needs and expectations of this new “consumer of health services”, which will require upgraded experiences with the main characteristics of personalisation, comfort, speed and immediacy in the provision of services. Gjellebaek C. et al. argue that new digital technologies will shift healthcare towards digitalisation, bringing significant benefits to patients and healthcare infrastructure [ 2 ]. Some of the benefits listed by Gjellebaek C. are the increase in employee productivity, the improvement of the efficiency and effectiveness of the operation of the health units, and the reduction of their operating costs.

On the other hand, in terms of health infrastructure, a typical example is the United States, where 75% of hospitals use electronic health record systems, according to Rebekah E. et al. [ 3 ]. However, clinicians often report side effects using digital technologies, which can be attributed to their misuse [ 3 ]. In addition, some health professionals oppose using these systems and develop solutions that jeopardise patient care. In some countries, such as the United States, the government provides incentives for the “effective use” of e-health technologies, but their results remain uncertain [ 3 ].

Rebekah E. et al. focus more specifically on U.S. hospitals, observing that the remaining countries are relatively in the early stages of transformation [ 4 ]. The United Kingdom, for example, has recently pursued troubled e-health initiatives, and Australian hospitals have only recently participated in investments in the digitalisation of their hospital services [ 4 ]. At the European Union level, digital health is a critical key strategic priority, in line with the European Strategic Plan 2019–2024 (European Commission).

Today, digital transformation in health is spreading and consolidating rapidly [ 5 ]. The purpose of this paper is to provide an assessment of the current literature on digital health transformation, as well as to identify potential vulnerabilities that make its implementation impossible. The ultimate goal is to see how digital technologies facilitate patients’ participation in health and their health.

Due to the rapid development of e-health and digitalisation, data from previous studies are becoming potentially irrelevant. Most studies evaluating digitalisation have relied heavily on quantitative research-based methods. Although quantitative evaluations are required, some of their effects could be omitted.

According to Gopal G. et al., healthcare has the lowest level of digital innovation compared to other industries, such as media, finance, insurance and retail, contributing to limited labour productivity growth [ 6 ]. With this article, we seek to reverse this picture and contribute to the emergence of digitalisation as a factor of health innovation while optimising patient outcomes and the cost of services provided. However, to achieve this innovation, systemic changes are needed in healthcare finances, the education of healthcare staff and healthcare infrastructure.

The following section analyses the methodology and its steps, which then contributed to the emergence of our results.

2. Material and Methods

2.1. search strategy and bibliography reviews.

Our research approach is based on the methodology of Webster and Watson, who developed a concept-centric method and an ad hoc classification system in which categories are used to describe areas of literature [ 7 ]. Initially, the existing bibliographic reviews were searched to select the databases based on keywords. A retrospective search was then performed to examine the reports of the selected works. Finally, the references of selected works were investigated to increase the search sample through the future search. After selecting the articles, they were grouped according to their content.

Systematic reviews were conducted to place this paper on existing knowledge of digital health, as well as to review prior knowledge in this area and to discuss recognised research questions based on the results of previous studies. A comprehensive review of the published literature was reported by Marques, I. C., & Ferreira, J. J. [ 8 ]. The authors explored the potential of existing digital solutions to improve healthcare quality and analysed the emerging trend in digital medicine to evaluate the research question of how stakeholders apply and manage digital technologies for business purposes [ 9 ]. The main question is: How and what could be done sustainably and inclusively through innovation to achieve sustainable development goals by taking advantage of Information and Communication Technologies? Recently, researchers have expressed concern about secure communication and user authentication within providing information to patients. In contrast with data storage, information exchange, and system integration, new approaches and uses of patient care processes are envisaged with the prospect of monitoring not only diagnostic statistics but also in-depth analysis of signs and symptoms before and after treatment, essential sources for new research. Table 1 presents the previous bibliographic reviews on which our study was based.

Previous Bibliographic Reviews.

2.2. Network Analysis

Network analysis is considered a branch of graph theory. Our network analysis is based on the similarity of keywords found in identifying the eligible papers. We used visualisation of similarities (VOS) software, version 1.6.18, to construct graphical networks to understand the clustering of the keywords and their degree of dissimilarity. Our network analysis is based on the similarity of keywords found in identifying the eligible papers.

Initial Search

The search was performed on the following databases: Scopus, Science Direct, and PubMed, using the keywords “digital transformation”, “digitalisation”, “Ehealth or e-health”, “mhealth or m-health”, “healthcare” and “health economics”. We selected publications from the search of international journals and conference proceedings. We collected papers from 2008 until 2021. The documents sought belonged to strategy, management, computer science, medicine, and health professions. Finally, the published works were in English only. The total number of articles collected using the keywords as shown in Table 2 was 5847.

Search Strategy.

We systematically checked the total number of papers 5847 by reading their titles, abstracts, and, whenever necessary, the article’s first page to conclude if each document was relevant as a first step as shown in the Figure 1 .

The diagram for the first phase of the selection process.

Then, we looked at the titles of the 378 articles, and after reading their summary, we accepted 321 articles. Further studies were rejected because their full text was not accessible. As a result, there were 255 articles in our last search. Of the selected 255 articles, 32 more were added based on backward and forward research. The investigation was completed by collecting common standards from all databases using different keyword combinations. According to the systematic literature review, we follow the standards of Webster and Watson (2002) to reject an article. Since then, we have collected the critical mass of the relevant publications, as shown in Figure 2 .

The diagram of the article selection process.

3.1. Chronological Development of the Publications

The categorisation of the articles was based on their content and the concepts discussed within them. As a result, we classify articles into the following categories: information technology in health, the educational impact on e-health, the acceptance of e-health, telemedicine, and e-health security.

Although researchers in Information and Communication Technology and digitalisation conducted studies almost two decades ago, most publications have been published in the last eight years. This exciting finding highlights the importance of this field and its continuous development. Figure 3 shows a clear upward trend in recent years. More specifically, the research field of Information and Communication Technology, in combination with digital transformation, appeared in 2008. However, the most significant number of articles was found in 2019, 2020 and 2021. The number of articles decreased to the lowest in 2009–2011 and 2013–2014. Due to the expansion of the field to new technologies, the researchers studied whether the existing technological solutions are sufficient for implementing digital transformation and what problems they may face.

Number of articles and citations per publication by year.

Figure 3 shows a combination of the articles per year and the number of citations per publication per year.

3.2. Document Type

Of the document types, 59.51 per cent of the articles were categorised as “survey”, while a smaller percentage were in: “case study” (32.53%), “literature review” (5.88%) and “report” (2.08%). However, these documents focused on specific concepts: “information technology in health” (45%), “education impact of e-health” (11%), “acceptance of e-health” (19%), “telemedicine” (7%), “security of e-health” (18%).

As we can see from the following Figure 4 , we used network analysis, where the keywords related to digitalisation and digital transformation were identified in the research study. Network analysis, using keywords, came with VOSviewer software to find more breadth and information on healthcare digitalisation and transformation exploration. It was created by analysing the coexistence of keywords author and index. This analysis’s importance lies in the structure of the specific research field is highlighted. In addition, it helped map the intellectual structure of scientific literature. Keywords were obtained from the title and summary of a document. However, there was a limit to the number of individual words. The figure represents a grid focused on reproducing keywords in the literature on the general dimensions of digitalisation. The digitalisation network analysis showed that e-health, telemedicine, telehealth, mobile health, electronic health/medical record, and information systems were the main relevant backgrounds in the literature we perceived. In the healthcare literature, keywords such as “empowerment” and “multicenter study” usually do not lead to a bibliographic search on digitalisation. Figure 4 shows how e-health and telemedicine have gone beyond the essential and most crucial research framework on how they can affect hospitals and the health sector. The potentially small gaps in network analysis can be filled by utilising data in our research study, contributing to future research.

Bibliometric map of the digital transformation and healthcare.

Figure 5 shows the network analysis with the keywords concerning time publication. The yellow colour indicates keywords for most recent years.

Network visualisation of keywords per year.

Figure 6 presents the density visualisation of keywords.

Heat map of keywords.

Figure 7 shows the number of articles per each method (survey, literature review etc.) for each year.

The map of number of articles per method for each year.

It is evident from Figure 7 that the most used method paper is the survey type and that in the year 2021, we have a high number of surveys compared to previous years.

3.3. Summary of the Included Articles

In Figure 2 , we have explained how we collected the critical mass of the 255 relevant publications. We added another 32 articles based on further research with the backward and research methods, which resulted in a total number of 287 articles.

Then, the articles were categorised according to their content. The concepts discussed in the papers are related to information technology in health, the educational impact of e-health, the acceptance of e-health, telemedicine, and e-health security. For this purpose, the following table was created, called the concept matrix table.

4. Concept Matrix

In this section, we provide the Concept matrix table. Academic resources are classified according to if each article belongs or not to any of the five concepts shown in Table 3 .

Concept Matrix Table.

5. Analysis of Concepts

From the articles included in the present study between 2008 and 2021, they were grouped into five categories identified: (i) information technology in health, (ii) acceptance of e-health, (iii) telemedicine, (iv) security of e-health, and (v) education impact of e-health.

5.1. Information Technology in Health

Researchers have studied several factors to maximise the effectiveness and success of adopting new technology to benefit patients. Hospitals can benefit from information technology when designing or modifying new service procedures. Health units can use information and communication technology applications to analyse and identify patients’ needs and preferences, enhancing their service innovation processes. Previous findings conclude that technological capability positively influences patient service and innovation in the service process [ 301 ]. These results have significant management implications as managers seek to increase technology resources’ efficiency to achieve patient-centred care as the cornerstone of medical practice [ 207 ].

Informatics facilitates the exchange of knowledge necessary for creating ideas and the development process. The internet supports health organisations in developing and distributing their services more efficiently [ 206 ]. Also, Information Technology improves the quality of services, reduces costs, and helps increase patient satisfaction. As new technologies have created opportunities for companies developing high-tech services, healthcare units can increase customer value, personalise services and adapt to their patient’s needs [ 209 ]. To this end, the “smart hospitals” should represent the latest investment frontiers impacting healthcare. Their technological characteristics are so advanced that the public authorities need know-how for their conception, construction, and operation [ 228 ].

A new example is reshaping global healthcare services in their infancy, emphasising the transition from sporadic acute healthcare to continuous and comprehensive healthcare. This approach is further refined by “anytime and everywhere access to safe eHealth services.” Recent developments in eHealth, digital transformation and remote data interchange, mobile communication, and medical technology are driving this new paradigm. Follow-up and timely intervention, comprehensive care, self-care, and social support are four added features in providing health care anywhere and anytime [ 289 ]. However, the healthcare sector’s already precarious security and privacy conditions are expected to be exacerbated in this new example due to the much greater monitoring, collection, storage, exchange, and retrieval of patient information and the cooperation required between different users, institutions, and systems.

The use of mobile telephony technologies to support health goals contributes to the transformation of healthcare benefits worldwide. The same goes for small and medium-sized healthcare companies, such as pharmacies. A potent combination of factors between companies and customers is the reason for creating new relationships. In particular, mobile technology applications represent new opportunities for integrating mobile health into existing services, facilitating the continued growth of quality service management. Service-based, service-focused strategies have changed distribution patterns and the relationship between resellers and consumers in the healthcare industry, resulting in mobile health and significant pharmacy opportunities. It has been an important research topic in the last decade because it has influenced and changed traditional communication between professionals and patients [ 211 ]. An example of a mobile healthcare platform is “Thymun”, designed and developed by Salamah et al. aiming to create intelligent health communities to improve the health and well-being of autoimmune people in Indonesia [ 225 ].

5.2. Acceptance of E-Health

In a long-term project and a population study (1999–2002), Hsu et al. evaluated e-health usage patterns [ 302 ]. The authors conclude that access to and use of e-health services are rapidly increasing. These services are more significant in people with more medical needs. Fang (2015) shows that scientific techniques can be an essential tool for revealing patterns in medical research that could not be apparent with traditional methods of reviewing the medical literature [ 303 ]. Teleradiology and telediagnosis, electronic health records, and Computer-Aided Diagnosis (CAD) are examples of digital medical technology. France is an example of a country that invests and leads in electronic health records, based on what is written by Manard S. et al. [ 243 ]. However, the impact of technological innovation is reflected in the availability of equipment and new technical services in different or specialised healthcare sectors.

On the other hand, Mariusz Duplaga (2013) argues that the expansion of e-health solutions is related to the growing demand for flexible, integrated and cost-effective models of chronic care [ 304 ]. The scope of applications that can support patients with chronic diseases is broad. In addition to accessing educational resources, patients with chronic diseases can use various electronic diaries and systems for long-term disease monitoring. Depending on the disease and the symptoms, the devices used to assess the patient’s condition vary. However, the need to report symptoms and measurements remains the same. According to Duplaga, the success of treatments depends on the patient’s involvement in monitoring and managing the disease. The emphasis on the role of the patient is parallel to the general tendency of people and patients to participate in decisions made about their health. Involving patients in monitoring their symptoms leads to improved awareness and ability to manage diseases. Duplaga argues that the widespread use of e-health systems depends on several factors, including the acceptance and ability to use information technology tools, combined with an understanding of disease and treatment.

Sumedha Chauhan & Mahadeo Jaiswal (2017) are on the same wavelength. They claim that e-health applications provide tools, processes and communication systems to support e-health practices [ 305 ]. These applications enable the transmission and management of information related to health care and thus contribute to improving patient’s health and physicians’ performance. The human element plays a critical role in the use of e-health, according to the authors. In addition, researchers have studied the acceptance of e-health applications among patients and the general public, as they use services such as home care and search for information online. The meta-analysis they use combines and analyzes quantitative findings of multiple empirical studies providing essential knowledge. However, the reason for their research was the study of Holden and Karsh (2010) [ 306 ].

To provide a comprehensive view of the literature acceptance of e-health applications, Holden and Karsh reviewed 16 studies based on healthcare technology acceptance models [ 306 ]. Findings show them that the use and acceptance of technological medical solutions bring improvements but can be adopted by those involved in the medical field.

5.3. Telemedicine

On the other hand, telemedicine is considered one of the most important innovations in health services, not only from a technological but also from a cultural and social point of view. It benefits the accessibility of healthcare services and organisational efficiency [ 215 ]. Its role is to meet the challenges posed by the socio-economic change in the 21st century (higher demands for health care, ageing population, increased mobility of citizens, need to manage large volumes of information, global competitiveness, and improved health care provision) in an environment with limited budgets and costs. Nevertheless, there are significant obstacles to its standardisation and complete consolidation and expansion [ 300 ].

At present, there are Telemedicine centres that mediate between the patient and the hospital or doctor. However, many factors make this communication impossible [ 300 ]. Such factors include equipment costs, connectivity problems, the patient’s trust or belief in the system or centre that applies telemedicine, and resistance to new and modern diagnostics, especially in rural and island areas. Therefore, telemedicine would make it easier to provide healthcare systems in remote areas than having a specialist in all the country’s remote regions [ 300 ]. Analysing the concept further, one can easily argue that the pros outweigh the disadvantages. Therefore, telemedicine must be adopted in a concerted effort to resolve all the obstacles we are currently facing. Telemedicine centres and services such as teleradiology, teledermatology, teleneurology, and telemonitoring will soon be included. This means that a few years from now, the patient will not have to go to a central hospital and can benefit remotely from the increased quality of health services. This will save valuable time, make good use of available resources, save patient costs, and adequately develop existing and new infrastructure.

In 2007, the World Health Organisation adopted the following broad description of telemedicine: “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities ” [ 307 ]

According to the Wayback Machine, Canadian Telehealth Forum, other terms similar to telemedicine are telehealth and e-health, which are used as broader concepts of remote medical therapy. It is appropriate to clarify that telemedicine refers to providing clinical services. In contrast, telehealth refers to clinical and non-clinical services, including education, management and research in medical science. On the other hand, the term eHealth, most commonly used in the Americas and Europe, consists of telehealth and other elements of medicine that use information technology, according to the American Telemedicine Association [ 308 ].

The American Telemedicine Association divides telemedicine into three categories: storage-promotion, remote monitoring, and interactive services. The first category includes medical data, such as medical photographs, cardiograms, etc., which are transferred through new technologies to the specialist doctor to assess the patient’s condition and suggest the appropriate medication. Remote monitoring allows remote observation of the patient. This method is used mainly for chronic diseases like heart disease, asthma, diabetes, etc. Its interactive services enable direct communication between the patient and the treating doctor [ 309 ].

Telemedicine is a valuable and efficient tool for people living or working in remote areas. Its usefulness lies in the health access it provides to patients. In addition, it can be used as an educational tool for learning students and medical staff [ 310 ].

Telemedicine is an open and constantly evolving science, as it incorporates new technological developments and responds to and adapts to the necessary health changes within societies.

According to J.J. Moffatt, the most common obstacles to the spread of telemedicine are found in the high cost of equipment, the required technical training of staff and the estimated time of a meeting with the doctor, which can often be longer than the use of a standard doctor [ 311 ]. On the other hand, the World Health Organisation states that telemedicine offers excellent potential for reducing the variability of diagnoses and improving clinical management and the provision of health care services worldwide. The World Health Organisation claims, according to Craig et al. and Heinzelmann PJ, that telemedicine improves access, quality, efficiency and cost-effectiveness [ 312 , 313 ]. In particular, telemedicine can help traditionally under-served communities by overcoming barriers to the distance between healthcare providers and patients [ 314 ]. In addition, Jennett PA et al. highlight significant socio-economic benefits for patients, families, health professionals and the health system, including improved patient-provider communication and educational opportunities [ 315 ].

On the other hand, Wootton R. argues that telemedicine applications have achieved different levels of success. In both industrial and developing countries, telemedicine has yet to be used consistently in the healthcare system, and few pilot projects have been able to be maintained after the end of their initial funding [ 316 ].

However, many challenges are regularly mentioned and responsible for the need for more longevity in many efforts to adopt telemedicine. One such challenge is the complexity of human and cultural factors. Some patients and healthcare workers resist adopting healthcare models that differ from traditional approaches or home practices. In contrast, others need to have the appropriate educational background in Information and Communication Technologies to make effective use of telemedicine approaches [ 314 ]. The need for studies documenting telemedicine applications’ economic benefits and cost-effectiveness is also a challenge. Strong business acumen to persuade policymakers to embrace and invest in telemedicine has contributed to a need for more infrastructure and program funding [ 312 ]. Legal issues are also significant obstacles to the adoption of telemedicine. These include the need for an international legal framework that allows health professionals to provide services in different jurisdictions and countries. Furthermore, the lack of policies governing data confidentiality, authentication and the risk of medical liability for health professionals providing telemedicine services [ 314 ]. In any case, the technological challenges are related to legal issues. In addition, the systems used are complex, and there is a possibility of malfunction, which could cause software or hardware failure. The result is an increase in patient morbidity or mortality as well as the liability of healthcare providers [ 317 ].

According to Stanberry B., to overcome these challenges, telemedicine must be regulated by definitive and comprehensive guidelines, which are ideally and widely applied worldwide [ 318 ]. At the same time, legislation must be enacted governing health confidentiality, data access, and providers’ responsibility [ 314 ].

5.4. Security of eHealth

The possibility of the patients looking at the electronic patient folder in a cloud environment, through mobile devices anytime and anywhere, is significant. On the one hand, the advantages of cloud computing are essential, and on the other hand, a security mechanism is critical to ensure the confidentiality of this environment. Five methods are used to protect data in such environments: (1) users must encrypt the information before storing it; (2) users must transmit information through secure channels; (3) the user ID must be verified before accessing data; (4) the information is divided into small portions for handling and storage, retrieved when necessary; (5) digital signatures are added to verify that a suitable person has created the file to which a user has access. On the other hand, users of these environments will implement self-encryption to protect data and reduce over-reliance on providers [ 210 ].

At the same time, Maliha S. et al. [ 227 ] proposed the blockchain to preserve sensitive medical information. This technology ensures data integrity by maintaining a trace of control over each transaction. At the same time, zero trusts provide that medical data is encrypted and that only certified users and devices interact with the network. In this way, this model solves many vulnerabilities related to data security [ 227 ]. Another alternative approach is the KONFIDO project, which aims at the safe cross-border exchange of health data. A European H2020 project aims to address security issues through a holistic example at the system level. The project combines various cutting-edge technologies in its toolbox (such as blockchain, photonic Physical Unclonable Functions, homomorphic encryption, and trusted execution) [ 234 ]. Finally, Coppolino L. et al. [ 271 ] proposed using a SIEM framework for an e-healthcare portal developed under the Italian National eHealth Net Program. This framework allows real-time monitoring of access to the portal to identify potential threats and anomalies that could cause significant security issues [ 271 ].

5.5. Education Impact of E-Health

But all this would only be feasible with the necessary education of both users and patients [ 11 ]. As the volume and quality of evidence in medical education continue to expand, the need for evidence synthesis will increase [ 295 ]. On the other hand, Brockers C. et al. argued that digitalisation changes jobs and significantly impacts medical work. The quality of medical data provided for support depends on telemedicine’s medical specialisation and knowledge. Adjustments to primary and further education are inevitable because physicians are well trained to support their patients satisfactorily and confidently in the increasingly complex digitalisation of healthcare. The ultimate goal of the educational community is the closest approach of students to the issues of telemedicine and e-health, the creation of a spirit of trust, and the acceptance and transmission of essential knowledge [ 268 ].

Noor also moved in this direction, seeking to discover the gaps in Saudi education for digital transformation in health [ 248 ]. The growing complexity of healthcare systems worldwide and the growing reliance of the medical profession on information technology for precise practices and treatments require specific standardised training in Information Technology (IT) health planning. Accreditation of core Information Technology (IT) is advancing internationally. Noor A. examined the state of Information Technology health programmes in the Kingdom of Saudi Arabia (KSA) to determine (1) how well international standards are met and (2) what further development is required in the light of recent initiatives of the Kingdom of Saudi Arabia on e-health [ 248 ]. Of the 109 institutions that participated in his research, only a few offered programmes specifically in Health Information Technology. As part of Saudi Vision 2030, Saudi digital transformation was deemed an urgent need. This initiative calls for applying internationally accepted Information Technology skills in education programmes and healthcare practices, which can only happen through greater collaboration between medical and technology educators and strategic partnerships with companies, medical centres and government agencies.

Another study by Diviani N. et al. adds to the knowledge of e-health education, demonstrating how online health information affects a person’s overall behaviour and enhances patients’ ability to understand, live and prepare for various health challenges. The increasing digitalisation of communication and healthcare requires further research into the digital divide and patients’ relationships with health professionals. Healthcare professionals must recognise the online information they seek and engage with patients to evaluate online health information and support joint healthcare-making [ 235 ].

6. Discussion

The selected studies comprise a conceptual model based on bibliographic research. Using an open-ended technique, we analyse the selected 287 articles, which are grouped into categories based on their context. This methodology provides readers with a good indication of issues concerning the timeliness of health digitalisation. A limitation of the methodology is that selected criteria of the method might be subjective in terms of the search terms and how the papers are selected. The articles indicate that this field is initial, and further research is needed. Although several articles have created a theoretical basis for corporate sustainability and strategic digital management, only limited studies provided guidelines on the strategic digital transformation process and its health implementation stages. However, studies have also developed sustainable models, software or applications in this area. This is also the reason for creating opportunities for future researchers, who will be closed to investigate this gap and improve the viability of digital health strategies. In addition, any work carried out in case studies provides fruitful results by facilitating researchers through deep penetration into sustainable digitalisation. No generalised frameworks are available to guide the wording and implementation of digital action plans. Thus, the need for quantitative or qualitative research is created, providing conclusions on the impact of internal or external factors in the sustainability process, implementation, adoption, planning, and challenges of digital health solutions in general, as well as the impact of digital transformation. Most existing studies explore the issue of digitalisation in a particular part of a nursing institution or a disease rather than the management strategy perspective. In this way, researchers ignore a debate on obstacles and problems that often face in practice during integration. Such an analysis could lead to more profound knowledge.

7. Conclusions

In conclusion, our research observed a timeless analysis of systematised studies focusing on digital health developments. These studies broaden the researchers’ vision and provide vital information for further investigation. This article focuses on understanding digitalisation in healthcare, including, for the most part, the digitalisation of information and adopting appropriate parameters for further development. To build a more holistic view of digital health transformation, there is a great need for research on the management implications of digitalisation by different stakeholders. Finally, the development of telemedicine, the further enhancement of digital security and the strengthening of technological information systems will contribute to the universal acceptance of the digital health transformation by all involved.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualisation, A.I.S., F.K. and M.A.T.; methodology, F.K. and M.A.T.; software, A.I.S.; validation, A.I.S.; data curation, A.I.S.; writing—original draft preparation, A.I.S. and M.A.T.; writing—review and editing, A.I.S. and M.A.T.; visualisation, A.I.S.; supervision, M.A.T.; project administration, M.A.T. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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