Perception of Digital Health in the Baltic Sea Region: Insights of Experts from Nine Countries

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However, its adoption in the countries of the Baltic Sea Region varies considerably. In order to improve the diffusion and speed of adoption of this innovation, it is necessary to know the barriers and promotors that improve or hinder the implementation of digital health. Methods Based on an international workshop, we conducted guided interviews with 15 experts from 9 countries in the Baltic Sea Region to determine their perceptions of the use of the innovation, barriers to its adoption and promoting factors. Results Structural factors such as national income or population density are perceived as less relevant. Instead, cultural values such as future orientation, risk-taking and trust are described as the most important factors in explaining the different rates of adoption between countries in the Baltic Sea Region. Important barriers to rapid adoption of digital health are also federal structures with a high degree of autonomy for regions, as well as a rather strict interpretation of data protection laws. Some interviewees emphasised the role of individuals who make digital health "their child". Conclusions The implementation of digital health depends less on economic conditions than on the commitment of policy makers to make it happen. Future developments, in particular artificial intelligence in healthcare, will require an even deeper penetration of digital health, which calls for urgent strategies to overcome the barriers to digital health. Baltic Sea Region Data Protection Act Digital Health Federalism Innovation Innovation adoption model Telemedicine Figures Figure 1 Figure 2 1 Introduction ‘Digital health’ is a buzzword in 21st century healthcare, encompassing the entire process of healthcare digitalisation based on information and communication technologies (ICT), with the aim of improving healthcare as a whole (prevention, diagnosis, treatment, management, etc.) (Directorate-General for Health and Food Safety, 2025 ; Fatehi, Samadbeik, & Kazemi, 2020 ). The dissolution of the unity of place and action is a central element of digital healthcare. (Hashiguchi, 2020 ). On the one hand, this could improve patient care by extending it to locations outside the service provider (e.g. hospital, doctor's surgery). On the other hand, digital health could reduce the cost of traditional healthcare, for example by reducing travel expenses and concentrating scarce human and material resources where they are most effective. (Freed et al., 2018 ). This could lead to an increase in the efficiency of care (Coliquio, 2023 ; El-Miedany, 2017 ). Digital health, as a new approach to modernising and improving healthcare, has already found its way into many countries. However, the status quo in the development and implementation of digital health varies. The Scandinavian countries of Denmark, Sweden, Finland, Norway and Estonia are at the top of the comparison. In contrast, Germany is in the lower midfield of several rankings (R. Thiel et al., 2018 ). This raises the question of what factors are driving the differences in digital health diffusion, and what advantages these countries may have over laggards. In the following, we want to analyse which factors influence the diffusion speed of digital health innovations in the Baltic Sea countries. In the next section, we present the methodology of qualitative online interviews with experts from each Baltic Sea country. We then describe the results of the interviews. The paper concludes with a discussion of the findings in light of the literature and some conclusions. 2 Methods This research was conducted under the auspices of the Interdisciplinary Centre for Baltic Sea Region Research (IFZO) with the project "Diffusion of innovations in services of general interest using the example of healthcare". Based on the experiences of an international workshop of “Think Rural in the Baltic Sea Region” in March 2023 [9][13], we conducted guideline-based expert interviews to investigate why the emergence and diffusion of digital health innovations in the healthcare sector is so different in the countries of the Baltic Sea Region. The experts from Germany, Poland, Denmark, Sweden, Norway, Finland, Estonia, Latvia and Lithuania gave their assessment of the digital infrastructure, enablers, barriers and possible reasons for the different diffusion of innovations. In the period from June 2023 to August 2024, the interviews were prepared, experts were identified, interviews were conducted, transcribed, analysed and interpreted. The preparation of the interviews involved several steps. The semi-structured expert interview was chosen as the method to ensure flexibility and openness during the interviews. The questions were based on the theory of innovation adoption with the main elements of innovation, diffusion, barriers and promoters (Flessa & Huebner, 2021 ). The full guide is attached (see Appendix 1, full interview guide). We did not use a strict questionnaire in order to allow for deviations from the guideline based on the experts' knowledge and sub-questions. The main questions (key questions) and variable sub-questions were grouped into three thematic blocks, including introductory questions (personal information, background information), a main block (digital infrastructure, barriers, promoters, diffusion) and concluding questions (comments). Based on the innovation model, we developed a broad set of questions that had to be categorised and condensed. All experts from the different countries were asked the same questions in order to obtain comparable results. The interviews were scheduled to last approximately 45 minutes. The next step was to identify suitable interviewees with expertise in digital health in the healthcare sector in their own country. An international, DFG-funded workshop on "Innovations in the Baltic Sea Region" was held at the University of Greifswald in March 2023, bringing together experts on innovation and healthcare from all the Baltic Sea countries. Some of them - but not all - were also experts in digital health in their countries and a cornerstone of this research. We asked the participants of this conference to identify the respective digital health experts in their countries. We also carried out an online contact search. We also used a snowball system, naming other potential contacts in the interviews or asking them by email. In addition, potential contacts from a previous survey conducted as part of the project were screened and researched for expertise and availability (Nawroth, Sabotka, & Fleßa, 2024 ). Potential interviewees were sent a personalised cover letter by email (see Appendix 2 General Cover Letter), together with an abridged version of the interview guide, which they were asked to read beforehand in order to check that the content matched their own expertise and to prepare themselves. If no response was received, two further requests were made at intervals of approximately 2–4 weeks. After successful agreement to an interview, a possible date was arranged and the consent form was provided for signature. After each interview we discussed whether the response was sufficient to provide an overview of the current situation in the country. If not, we decided to interview a second (or third) interviewee from that country. In this way, a total of 15 interviews were conducted in the countries of the Baltic Sea region (see Table 1 ), out of approximately 60 potential contacts requested. All interviews were conducted digitally using the licensed Zoom platform. Table 1 Interviewees Country Interviewees Profession Position Focus Germany 1 physician CEO hospital chain innovative technologies in emergency medicine Poland 2 economist, physician professors e-Health, mobile health, communications Denmark 2 sociology, engineer professor health informatics, health technology assessment Sweden 1 pharmacist advisor Swedish eHealth Agency coordination of digital health Finland 3 manager, manager, IT specialist management Institute for Health and Welfare; professors implementation, health informatics, usability Norway 1 IT specialist professor health informatics Estonia 2 social scientist, pharmacist professor, senior researcher healthcare-networks and IT; social impact Lithuania 1 public health professor impact of digital health on population Latvia 2 manager, IT specialist management companies business analytics, technology assessment Once the interviews had been conducted, the content of the data collected was analysed. The qualitative content analysis method according to Philipp Mayring was chosen (Mayring, 2021). A codebook with main categories and subcategories was created for the analysis (see Appendix 3 Codebook). In line with the inductive approach, the categories were derived from the interview guide and pre-defined for better categorisation. The codebook contains six main categories (plus 'other' if no categorisation is possible), each with 2–4 subcategories for further subdivision. Once the transcripts had been made from the audio files, the text passages were analysed and classified into the categories using MAXQDA software and colour coding for differentiation. The total duration of the interviews ranged from approximately 27 minutes to 1 hour and 11 minutes. Using the colour coding, the text passages from the different interviews were summarised and listed under the corresponding categories and sub-categories. The content of the text passages was then summarised and analysed by country. 3 Results 3.1 Overview In a first set of interview questions, respondents were asked to describe the digital health situation in their country and to identify strengths and weaknesses. A first dimension of digital health was the homogeneity of diffusion of the innovation across the country and population. Several respondents see a rural-urban divide, with much greater penetration in urban areas, although it is generally felt that digital health is (even more) beneficial to rural areas. This urban-rural divide is closely linked to a regional divide in several countries. Many respondents said that digital health is used differently in different states, provinces or regions. This is partly due to political differences. The more independent these political units are, the more likely it is that there will be differences in the uptake of digital health across these states, regions or provinces. A further differentiation was made in terms of age groups, i.e. that older people have greater difficulties in using and benefiting from digital health systems than younger people. This was seen as a consequence of digital literacy beyond health. Older people have less knowledge to use digital services and need more personal contact, whether they use digital banking or video consultations with their doctor. In addition, interviewees described the digital infrastructure in their countries. This includes different dimensions, such as the availability of general IT, networks and connectivity (e.g. quality of WiFi), but also specific dimensions for the healthcare sector, such as connectivity of mobile services (e.g. telemedicine emergency services), e-prescription, digital patient records, etc. It is clear that digital health was an initiative in some countries 20–25 years ago and has now become a standard, while others are lagging behind. A soft form of infrastructure is the population's knowledge and ability to use digital services. As noted above, there are large differences between and within countries. Figure 1 shows the barriers discussed by respondents. It is clear that poor digital infrastructure and high investment and recurrent costs are barriers to the implementation and uptake of digital health in a country. However, respondents focused more on aspects beyond traditional economics, in particular a country's culture. Individuals, groups and nations differ in their time preference, i.e. short-term thinking, financing and planning will lead to a reduced speed of implementation of digital health, as this macro-innovation cannot be implemented in a short-term project, but requires a long-term commitment at all levels. The more future-oriented an individual or culture is, the more likely it is to develop a propensity for innovation and change. Risk aversion is another cultural dimension that can become a barrier to the uptake of digital health. Changing an existing and functional system to a new and unfamiliar one carries risks. The less people appreciate risk, the less likely they are to support digital health innovation. Some interviewees also said that digital health involves a power game between different levels of government. The more people insist on their power, the less they will delegate and the less they will value digital health that empowers local providers and patients. Power distance, risk aversion and time preference determine the propensity of an individual, group or culture to promote digital health. The interviewees mentioned these barriers, even though none of them were humanities experts. Another cultural dimension is conformity, which is "the tendency for an individual to align their attitudes, beliefs, and behaviours with those of the people around them. Conformity can take the form of overt social pressure or subtler, unconscious influence" (Psychology Today, 2025 ). In our context, this can have two dimensions. Legal conformity means that people tend to follow laws and regulations. For example, if a government decides to make the use of digital health mandatory, conforming cultures will follow this command and support the implementation of digital health. Conformity can also mean that people want to be consistent with the past and not make major changes to processes or traditions. "We do what we have always done" is a major barrier to innovation. Implementing digital health as a new technology also requires trust in healthcare providers, IT services, government and life in general. The less trust people have in institutions, the less likely they are to entrust their data to anonymous processes such as the internet. Countries are trying to increase trust in digital health by building strong institutions (e.g. e-services and innovation department, Estonia 2014) (Bittroff & von Mittelstaedt, 2019 ; Rainer Thiel, 2018 )). The General Data Protection Regulation (GDPR) can be seen as a tool to build trust that all data will be professionally protected. At the same time, several interviewees see the regulation as an obstacle because the strict data protection rules make the transfer and use of data for medical decisions and research very cumbersome. Others argue that the same GDPR is interpreted quite differently in different countries. It is mandatory for all EU member states, as well as Norway as a member of EFTA (European Free Trade Association), but its application depends heavily on national interpretation. In some cases, the GDPR is seen as a driver of trust and thus innovation, while in other countries it is more of an obstacle to the spread of digital health. Finally, federalism is perceived by some interviewees as a barrier to innovation. Smaller countries, such as Estonia, do not have very independent states, while larger countries, such as Germany, are divided into states that act quite independently. In more centralized countries, digital health innovation can be implemented from the top down across the country, but in a federal system, the successful implementation of digital health in one state does not guarantee that other states will follow. In this way, federalism can become a barrier to digital health innovation. 3.2 Country situation In the following section, we analyze the situation in different countries and explain the main features of each country in more detail. Table 2 shows the main barriers for different countries. Table 2 Barriers in different countries. Source: interviews and (Enste & Suling, 2020 ; Hofstede Insights, 2024 ) Country Time- preference Risk Power Trust Federalism Data protection Germany high averse hierarchy relevant middle high barrier Poland high very averse hierarchy important low low barrier Denmark middle risk seeking expert power important - main barrier Sweden high risk seeking less important highly important regional autonomy no barrier Finland low averse less important highly important rather low barrier Norway middle neutral less important highly important - barrier Estonia middle neutral less important important low promotor Lithuania low averse hierarchy relevant important low barrier Latvia low averse hierarchy relevant highly important low promotor Germany The interviewee describes digital health innovation in Germany as a patchwork that varies from region to region and state to state. Similarly, rural and urban areas are very different, with examples of both very good and very poor digital infrastructure. A number of telemedicine applications are regularly used, but digital health is not yet standard and the pace of development is considered slow. A major barrier seems to be the lack of long-term funding, i.e. digital health projects are usually funded for a short period of time (e.g. 2 years), which does not allow them to mature and become the new standard. Even if a project is very successful, German federalism may prevent innovations from being adopted in other states. The GDPR itself is not seen as problematic, the problem is rather the federal implementation with a strong dominance of the state data protection authorities. The GDPR sets the framework within which to operate, but the individual states within Germany interpret the regulation quite differently. Poland The experts point to a weak digital infrastructure, but even more importantly, they highlight a low propensity to adopt digital health innovation, resulting in, among other things, a strong urban-rural divide. There are some "early adopters" in cities, but the majority of the rural population is reluctant to use digital health services due to a general aversion to new technologies and attitudes. Poland has implemented a number of programmes to implement digital health solutions, particularly in suburban areas, many of them funded by EU projects. However, the majority of projects come to an end when their financial support comes to an end. The GDPR is seen as an obstacle by the respondents because it is perceived as too strict. In general, the experts consider their own culture to be comparatively slow to adopt innovations, including a high time preference and strong risk aversion. Conversely, the centralism of the Polish government system could support the spread of digital health across the country once it is centrally decided. But so far there are not enough promoters. Denmark The digital health revolution started quite early in Denmark and has penetrated most areas of digital health. Many standards have now been developed and digital health has become routine throughout the country. In addition to sufficient budgets, respondents see a strong culture of innovation and rapid adoption of change as the main reasons for digital success. This also includes a "general sense of trust" among the majority of the population. Although the Scandinavian countries are generally considered to be more egalitarian, the experts noted "power games" (as they called them). Digital health seems to take power away from an individual doctor and distribute it to a network of doctors and/or IT. This also implies a shift of power from individual doctors to networks or other professions. These two interviewees point out that digital health implies a change in workflow, which requires further training, especially for doctors. At the same time, they also realise a number of digital health projects ("projectitis") without systematic translation into routine care. Thus, they point out that there are still some shortcomings - but at a generally satisfactory level. Sweden Sweden started quite early and now has a good digital infrastructure with a wide range of digital services that enable health data sharing. However, there are some regional disparities and the overall speed of innovation adoption could be better. This is partly due to the relatively high degree of independence of municipalities and regions, which is an obstacle to rapid, nationwide diffusion of digital health innovations. Currently, healthcare in Sweden is decentralised, i.e. the responsibility for implementing the digital health innovation lies with the 21 regional and 290 municipal councils. The interviewee points to the same barrier as the colleagues from Germany and Denmark: short-term planning, funding and projects lead to a multitude of pilots without transfer into routines and standards. He calls this phenomenon "piloticities". The gap between pilot and routine seems difficult to bridge, and the step from successful implementation in one region to another is even more difficult. Finland The three experts from Finland agreed that digital health is quite advanced in the country. Although the country is huge and has areas with very low population density, the distribution of digital health services seems to be quite even. However, there is an age gap, with older people less likely to use digital health services. They also say that Finns are very interested in any kind of innovation. They are forward-looking and have no problem sharing power. Trust is of paramount importance to the Finnish population - one interviewee expressed this with the Finnish "habit" of leaving doors unlocked when leaving the house. They trust their fellow citizens, the government and their health services, including the responsible use of their health data. Mistrust - as expressed in the GDPR - is seen as inappropriate, so the implementation of the GDPR faces some resistance, albeit with different arguments than in countries like Germany. It was mentioned that Finland is perhaps the only country in the Baltic Sea region with two official languages (Swedish, Finnish). This has implications for all software, but it is a common challenge beyond the healthcare system. Norway Norway is the richest country in the region with a well-functioning IT infrastructure throughout the country, including fibre and wireless networks. Norsk Helsenett (Norwegian Health Network) is owned by the government and provides patient portals for every citizen. According to the interviewee, Norwegian culture encourages innovation, i.e. Norwegians tend to be forward-looking, not too afraid of risk and have no problems sharing power. Trust is very important and includes trust in fellow citizens as well as in the government. Compared to Sweden, Norway is a rather centralised country, i.e. the central government has managerial and financial responsibility for the health sector. There are four regional health authorities (out of five regions in Norway) that work closely with the central government. However, the expert considers that there is still room for improvement, especially in the usability of digital tools. Furthermore, the implementation of the GDPR is seen as too strict, although the regulation itself is accepted. The expert is convinced that the regulation would give more freedom than the interpretation of local authorities. The Norwegian interviewee was the only expert to mention digital health as a business case, i.e. Norwegian companies could offer services (e.g. reading radiology images) as a paid service globally. Estonia Estonia is considered to be at the forefront of digitalisation in Europe, and the two experts confirm that digital health is quite advanced. The government "owns" digitalisation, with a long line of prime ministers making digitalisation "their child". Many services such as digital patient records, lifelong ID, e-prescription, etc. are standard and routine in Estonia. According to the experts, the reasons for Estonia's leading position in Europe are similar to those in other countries: a high level of innovation based on a forward-looking attitude, a willingness to take risks and trust. This may not fully explain why Estonia is more advanced than neighbouring countries such as Latvia and Lithuania. However, respondents stressed that Estonia was simply the first country to put all its eggs in the digital basket. They started earlier, based on a very high level of commitment from the country's leadership, including a 'personal data protection law' that is said to be stricter than the GDPR. The Estonian experts said that they see the data protection regulation as an enabler of digital health, not an obstacle, because it increases trust in the system. Lithuania Lithuania has made some progress in digital health, but the pace of innovation seems to be slower than in Scandinavia or Estonia. Internet access and in particular the nationwide eHealth platform with access for the population are seen as encouraging factors. The government seems committed to the development of digital health and people trust that their data is well protected. However, the Lithuanian expert recognises a number of barriers to the implementation of digital health in his country. First, he notes that the development of the e-health system has been done without the participation of providers and patients, resulting in low usability and complaints that its use increases the administrative workload of healthcare providers. Secondly, the propensity to innovate seems to be limited by risk aversion. As in most settings, the likelihood of adopting digital health innovations decreases with age, but the expert points out that this tendency is even stronger in Lithuania. In contrast to risk aversion, time preference is low, which should lead to better adoption of innovations. Thirdly, the Lithuanian expert is one of the few to point out the disparity between urban and rural areas, i.e. digital health is much more advanced in cities and towns than in villages. This, he argues, may be due to the government's greater emphasis on urban development. Fourth, the interpretation of the GDPR seems to be stricter in Lithuania than in other Baltic states. As he notes: "They use data protection mostly to protect themselves", i.e. the GDPR is used as an argument to hinder digital health if it is not desired by certain stakeholders. Latvia Latvia has similar characteristics to Lithuania. However, data protection is not seen as an obstacle by the experts. Both agree that Latvia has a good digital infrastructure, but standardisation of health data could be improved to take advantage of interdependencies between sub-systems. As a small country, even cross-border data exchange is considered relevant, but language and semantic standards are a barrier. They also agree that the majority of people are rather conservative and tend to avoid risks and stick to the "good old standards". One of the experts talks about "a negative attitude towards any change", especially among older people. Although the experts knew that the researchers had an economic background, few mentioned financial constraints as a main problem. Independently, the Latvian experts stressed that the government is not investing enough in the development of eHealth infrastructure. However, there is hope that this will change with a very enthusiastic and innovative new Minister of Health who has a strong focus on digital health. Hosams Abu Meri (born 1974) took office in 2023 and, according to interviewees, has already made important contributions to the penetration of digital health in the health sector. In particular, he has developed a digital health strategy. However, they also state that the existing regulation demotivates the leaders of healthcare institutions to get more involved in digital health because they are afraid of breaking the rules. Latvians seem to follow the regulations very strictly. For example, teleconsultation is rarely used for fear of being seen as unprofessional or violating data confidentiality laws. There were some efforts in this direction during the Covid-19 pandemic, but much was not continued afterwards. 4 Discussion The perception of digital health differs between the countries in the Baltic Sea Region. The results of this survey are consistent with the findings in the literature. For example, the Bertelsmann Foundation calculated a Digital Health Index (DHI) in 2018 with 17 OECD countries, including Estonia, Denmark, Sweden, Germany and Poland (Bertelsmann Stiftung, 2021 ). As Flessa & Hübner demonstrate, “there is hardly any correlation between country statistics and the DHI” (Flessa & Huebner, 2021 ), i.e. wealth, population, population density and health expenditure per capita do not determine the penetration of the health system in the respective countries. Instead, cultural values (Hofstede, 1980 , 2001 ) seem to be more important to understand the perception of digital health and the speed of innovation diffusion. They show that there is a “negative correlation between power distance and DHI, i.e., cultures with a strict and hierarchical leadership style have a lower penetration of the health care system with digital technologies. Likewise, cultures in which dominance, assertiveness or win-lose-thinking are seen as virtues (‘masculine cultures’) also tend to have a low DHI. The more people try to avoid uncertainty (and risks), the lower is the adoption of digital health” (Flessa & Huebner, 2021 ). The results of this survey underline these findings. The experts clearly show that there are differences between the nine countries, and they also indicate that financial resources or population size are not the determining factors. Instead, risk aversion, future orientation and willingness to change are much more important. Some of the interviewees emphasise that trust is an important determinant of perceptions of digital health. The role of trust in the willingness to accept change has been much discussed in the literature, in particular the right mix of trust and control. (Das & Teng, 1998 ; Long & Sitkin, 2006 ). Adoption of the digital health innovation is not possible without confidence that the data will be confidential and properly protected. While individuals cannot assess this protection themselves, trust in government and its administration is a prerequisite for the diffusion of digital health. Trust, as a cultural factor, differs from nation to nation and across historical trajectories. However, even these cultural factors alone cannot explain the differences, which require further analysis. Interviewees highlighted the role of data protection legislation and its implementation. This aspect is also discussed by Sliwa et al. for the uptake of e-health in Germany, Austria and Denmark. They identify complexity and documentation requirements as major barriers (Austria, Germany) and practical government regulations as promoters (Denmark) of e-health (Sliwa, Brem, Agarwal, & Kraus, 2017 ). Respondents to this survey also identified administrative barriers, but these are not necessarily the most significant. Instead, they emphasise the role of data protection regulation and implementation. There is still relatively little literature on the role of data protection laws and individuals' willingness to share data in digital records as a barrier to digital health, but interviewees strongly emphasise that this may be a key to understanding why digital health differs so widely. In summary, the model shown in Fig. 2 can help to understand the adoption of health innovations (Flessa & Huebner, 2021 ). It also allows the identification of barriers and their impact on the adoption process, and the appropriate placement of available tools to overcome them. The functionality of the existing standard of diagnosis and treatment as well as their administration is the starting point (Fleßa & Greiner, 2020 ). A fully functioning and stable system will not be changed, i.e. the digital health innovation will meet more resistance in countries where the health system works very well. However, even if there are perceived shortcomings in the current system, it is more likely that the current system will be improved than that a major innovation with risks and costs will be introduced. These compensatory measures lead to artificial stability or metastability (Ritter, 2001 ). It is only when this stabilization is no longer sufficient that the pressure to find alternative solutions becomes dominant and the likelihood of adopting an innovation increases measurably. As a result, countries that had weak and difficult healthcare systems in the 1990s (especially the post-Soviet Baltic States) had a much higher chance of jumping on the digital health innovation than countries with well-established healthcare systems, such as Germany. Furthermore, the ability and willingness to promote the adoption of an innovation depends on a number of factors, such as the complexity of the decision. The more complex an innovation, the less likely it is to be adopted. Digital health requires a network of different providers, standardized processes and semantics. As such, it is an innovation that will face some resistance. In addition, the propensity of stakeholders to innovate is crucial, depending on their time preference, individual risk preference and management approach. If people are future-oriented and risk-seeking, they are more likely to accept innovation. In addition, the management style within the organization influences the propensity to innovate. The more strict, hierarchical and dominant a leadership style is, the less likely it is that innovations will be developed and adopted (Fleßa, 2014 ; Hauschildt, Salomo, Schultz, & Kock, 2016 ; Vahs & Brem, 2015 ). Thus, countries with a very conservative leadership style are less likely to adopt digital health innovations. There are a number of limitations to the findings presented in this study. Firstly, it is a qualitative study based on 15 interviews. The interviewees clearly point to differences between countries that are in line with the literature. However, with the existing methodology and sample, we cannot be completely sure whether these perceived differences are due to the selection of experts or to real country differences. Thus, our results suggest the need for further research with a broader pool of experts. Secondly, our results are (as always) influenced by the choice of criteria and the respective interview guidelines (see Appendix). We tried to mitigate this limitation by using a semi-structured interview with open questions and sufficient time. The interviewees used this time to elaborate on a wide range of issues. However, we cannot be absolutely certain that there are no arguments beyond the bounded rationality of the researchers. 5 Conclusions The study shows that perceptions of digital health vary across the Baltic Sea Region. The most frequently mentioned barriers are cost, data protection laws, federalism, infrastructure and culture. Based on the interviews, we can say that the GDPR itself is not the main barrier. It is the same for all countries, but its interpretation and implementation in the countries is different. Countries that are facing a slow adoption of digital health could consider relaxing their interpretation of this regulation. However, this must not jeopardise data protection, as this could lead to reduced trust and reservations about digital health. The Scandinavian countries and Estonia show that data can be protected without over-regulating data protection. Federalism is another aspect that should be further analysed. Smaller and centralised countries have the advantage that an innovation can spread to all locations without further barriers. Countries with decentralised systems and more independent federal states find it more difficult to develop universal coverage of digital services across the country. The "here-not-invented" syndrome can block the diffusion of promising innovations from state to state or even region to region. In Germany, for example, it would be helpful to shift some decision-making power on digital health from the states to the federal government. Finally, the pace of innovation in digital health depends on cultural values such as trust, power distance, risk aversion, time preference and compliance. It is difficult to recommend changing cultural values, but government can do a lot to build trust by proving itself trustworthy. Patient data must be strictly protected so that patients can build trust and accept lower risks. Finally, respondents identified a number of individuals as key stakeholders in digital health innovation. It is recommended to support these "champions" who are inclined towards digital health. There is no doubt that future developments, in particular artificial intelligence in healthcare, will require even deeper penetration of digital health. There is an urgent need to overcome the barriers to digital health in some countries (e.g. Germany). Otherwise, they will fall further behind. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Based on the regulation of the German Research Council (DFG: https://www.dfg.de/en/research-funding/proposal-funding-process/faq/humanities-social-sciences#263154) not ethical approval was necessary for the expert interviews. Participation in the study was voluntary. Before participating, all individuals were informed about the study’s objectives and provided written informed consent for both participation and the recording of interviews. Participants were assured of confidentiality, anonymity, and their right to withdraw from the study at any time without any consequences Consent for publication Not Applicable Availability of data and materials The interview data utilized and analyzed in this study can be obtained from the corresponding author upon request. Competing interests none Funding This research was funded as a project of the project “FragTrans” of the Interdisciplinary Research Center of the Baltic Sea Region, Germany. It was funded by the German Federal Ministry of Research (Grant No. 01UC22102) Authors' contributions SF: Funding acquisition, Conceptualization, Methodology, Modeling, Formal analysis, Writing – Original Draft, Writing – Review & Editing NH: literature review, interview recording and transcription MN: Investigation, Interviews, Writing – Original Draft, Writing – Review & Editing, Project administration Acknowledgements The publication was prepared within the framework of “FragTrans” of the Interdisciplinary Research Center of the Baltic Sea Region, Germany. The authors would like to thank all responsible persons, in particular Dr. A. Drost, as well as the interview partners for their support. Authors' information (optional) SF is professor of healthcare management with a focus on innovative healthcare interventions. MN is research assistant at the department of healthcare management in charge of the economic evaluation of FragTrans NH was student assistant References Bertelsmann Stiftung. (2021). SmartHealthSystems. Retrieved from https://www.bertelsmann-stiftung.de/de/unsere-projekte/der-digitale-patient/projektthemen/smarthealthsystems#c1203567 Bittroff, M., & von Mittelstaedt, G. (2019). Digitalisierung im Gesundheitswesen: Was wir von Estland lernen können. kma - Klinik Management aktuell, 24 (09), 54-55. Coliquio. (2023, 11.05.2015). Was bedeuten eHealth, mHealth & Co. Retrieved from https://www.coliquio-insights.de/begriffsklaerung-ehealth-und-co/ Das, T. K., & Teng, B.-S. (1998). Between trust and control: developing confidence in partner cooperation in alliances. Academy of Management Review, 23 (3), 491–512. Directorate-General for Health and Food Safety. (2025, 2023). Elektronische Gesundheitsdienste (eHealth): Digitale Gesundheitsdienste und Pflege. Retrieved from https://health.ec.europa.eu/ehealth-digital-health-and-care/overview_de El-Miedany, Y. (2017). Telehealth and telemedicine: how the digital era is changing standard health care. Smart Homecare Technology and TeleHealth, 4 , 43–51. doi:10.2147/SHTT.S116009 Enste, D., & Suling, L. (2020). Vertrauen in die Wirtschaft, Staat, Gesellschaft 2020 . Institut der Deutschen Wirtschaft. Köln. Fatehi, F., Samadbeik, M., & Kazemi, A. (2020). What is Digital Health? Review of Definitions. Stud Health Technol Inform, 275 , 67–71. doi:10.3233/SHTI200696 Fleßa, S. (2014). Grundzüge der Krankenhausbetriebslehre (2 ed.). München: Oldenbourg. Fleßa, S., & Greiner, W. (2020). Grundlagen der Gesundheitsökonomie: eine Einführung in das wirtschaftliche Denken im Gesundheitswesen (3 ed.). Berlin, Heidelberg: Springer Gabler. Flessa, S., & Huebner, C. (2021). Innovations in Health Care—A Conceptual Framework. International journal of environmental research and public health, 18 (19), 10026. Freed, J., Lowe, C., Flodgren, G., Binks, R., Doughty, K., & Kolsi, J. (2018). Telemedicine: Is it really worth it? A perspective from evidence and experience. Journal of innovation in health informatics, 25 (1), 14–18. doi:10.14236/jhi.v25i1.957 Hashiguchi, O. (2020). Bringing health care to the patient: An overview of the use of telemedicine in OECD countries. OECD Health Working Papers, No. 116. OECD Publishing Paris. Hauschildt, J., Salomo, S., Schultz, C., & Kock, A. (2016). Innovationsmanagement . München: Vahlen. Hofstede, G. (1980). Culture and organizations. International studies of management & organization, 10 (4), 15-41. Hofstede, G. (2001). Culture's recent consequences: Using dimension scores in theory and research. International Journal of cross cultural management, 1 (1), 11-17. Hofstede Insights. (2024). Compare Countries. Retrieved from https://hi.hofstede-insights.com Long, C. P., & Sitkin, S. B. (2006). Trust in the balance: how managers integrate trust-building and task control. In R. Bachmann & A. Zaheer (Eds.), Handbook of trust research (pp. 87–106). Cheltenham: Elgar. Mayring, P. (2021). Qualitative Content Analysis: A Step-by-Step Guide . Los Angeles et al., CA, USA: SAGE. Nawroth, M., Sabotka, & Fleßa, S. (2024). Können die Skandinavier Digital Health wirklich besser? KU Gesundheitsmanagement, 9/2024 , S. 17-19. Psychology Today. (2025). Conformity. Retrieved from https://www.psychologytoday.com/gb/basics/conformity Ritter, W. (2001). Allgemeine Wirtschaftsgeographie. Eine systemtheoretisch orientierte Einführung (3., überarbeitete und erweiterte Auflage ed.). München: Oldenbourg. Sliwa, S.-I., Brem, A., Agarwal, N., & Kraus, S. (2017). E-health, health systems and social innovation: a cross-national study of telecare diffusion. International Journal of Foresight and Innovation Policy, 12 (4), 171-197. Thiel, R. (2018). SmartHealthSystems. Digitalisierungsstrategien im internationalen Vergleich: Bertelsmann Stiftung. Thiel, R., Deimel, L., Schmidtmann, D., Piesche, K., Hüsing, T., Rennoch, J., . . . Stroetmann, K. (2018, 2018). Smart Health Systems: Digitalisierungsstrategien im internationalen Vergleich. Retrieved from https://www.bertelsmann-stiftung.de/fileadmin/files/Projekte/Der_digitale_Patient/VV_SHS-Gesamtstudie_dt.pdf Vahs, D., & Brem, A. (2015). Innovationsmanagement: Von der Idee zur erfolgreichen Vermarktung (4 ed.). Stuttgart: Schäffer-Poeschel Verlag. Additional Declarations No competing interests reported. Supplementary Files Attachments.docx Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2026 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 11 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviews received at journal 30 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviews received at journal 22 Jun, 2025 Reviewers agreed at journal 18 Jun, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers invited by journal 13 Jun, 2025 Editor assigned by journal 11 Jun, 2025 Editor invited by journal 23 May, 2025 Submission checks completed at journal 13 May, 2025 First submitted to journal 13 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6617740","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471914022,"identity":"8d259ef9-083f-4b8e-bc49-c3af85d62871","order_by":0,"name":"Melissa Nawroth","email":"","orcid":"","institution":"Universität Greifswald","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"","lastName":"Nawroth","suffix":""},{"id":471914023,"identity":"6acdd0d5-2c6a-4777-acd4-e1f86958757a","order_by":1,"name":"Nicola Hüttmann","email":"","orcid":"","institution":"Universitätsmedizin Greifswald","correspondingAuthor":false,"prefix":"","firstName":"Nicola","middleName":"","lastName":"Hüttmann","suffix":""},{"id":471914024,"identity":"a84801b2-ad70-4875-89a0-fb8f1dbd305f","order_by":2,"name":"Steffen Fleßa","email":"data:image/png;base64,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","orcid":"","institution":"Universität Greifswald","correspondingAuthor":true,"prefix":"","firstName":"Steffen","middleName":"","lastName":"Fleßa","suffix":""}],"badges":[],"createdAt":"2025-05-08 07:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6617740/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6617740/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-026-14065-5","type":"published","date":"2026-01-30T15:59:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84858519,"identity":"b70e604a-25fa-42d8-b964-c3f2e9825de4","added_by":"auto","created_at":"2025-06-18 06:34:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45290,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers of Digital Health Innovation. Source: own.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6617740/v1/2ea4fb73785073fa38623af6.png"},{"id":84858518,"identity":"b9c0b60b-a5ff-4ad7-a6c2-9c746be61456","added_by":"auto","created_at":"2025-06-18 06:34:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":103189,"visible":true,"origin":"","legend":"\u003cp\u003eModel of Adoption of Healthcare Innovations (Flessa \u0026amp; Huebner, 2021)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6617740/v1/f8215daa7209a5c54c417d0d.png"},{"id":101690995,"identity":"0a7bedd6-c6f7-43ac-804f-86152a2bc044","added_by":"auto","created_at":"2026-02-02 16:11:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":734598,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6617740/v1/f36de880-7d1d-4d93-b915-f1fdf30ed5f4.pdf"},{"id":84858522,"identity":"38f7105e-8b95-467a-b04a-d4b3c3733eed","added_by":"auto","created_at":"2025-06-18 06:34:29","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23689,"visible":true,"origin":"","legend":"","description":"","filename":"Attachments.docx","url":"https://assets-eu.researchsquare.com/files/rs-6617740/v1/b140537a7763088f346f343f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perception of Digital Health in the Baltic Sea Region: Insights of Experts from Nine Countries","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003e\u0026lsquo;Digital health\u0026rsquo; is a buzzword in 21st century healthcare, encompassing the entire process of healthcare digitalisation based on information and communication technologies (ICT), with the aim of improving healthcare as a whole (prevention, diagnosis, treatment, management, etc.) (Directorate-General for Health and Food Safety, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Fatehi, Samadbeik, \u0026amp; Kazemi, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The dissolution of the unity of place and action is a central element of digital healthcare. (Hashiguchi, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). On the one hand, this could improve patient care by extending it to locations outside the service provider (e.g. hospital, doctor's surgery). On the other hand, digital health could reduce the cost of traditional healthcare, for example by reducing travel expenses and concentrating scarce human and material resources where they are most effective. (Freed et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This could lead to an increase in the efficiency of care (Coliquio, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; El-Miedany, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDigital health, as a new approach to modernising and improving healthcare, has already found its way into many countries. However, the status quo in the development and implementation of digital health varies. The Scandinavian countries of Denmark, Sweden, Finland, Norway and Estonia are at the top of the comparison. In contrast, Germany is in the lower midfield of several rankings (R. Thiel et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This raises the question of what factors are driving the differences in digital health diffusion, and what advantages these countries may have over laggards.\u003c/p\u003e \u003cp\u003eIn the following, we want to analyse which factors influence the diffusion speed of digital health innovations in the Baltic Sea countries. In the next section, we present the methodology of qualitative online interviews with experts from each Baltic Sea country. We then describe the results of the interviews. The paper concludes with a discussion of the findings in light of the literature and some conclusions.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eThis research was conducted under the auspices of the Interdisciplinary Centre for Baltic Sea Region Research (IFZO) with the project \"Diffusion of innovations in services of general interest using the example of healthcare\". Based on the experiences of an international workshop of \u0026ldquo;Think Rural in the Baltic Sea Region\u0026rdquo; in March 2023 [9][13], we conducted guideline-based expert interviews to investigate why the emergence and diffusion of digital health innovations in the healthcare sector is so different in the countries of the Baltic Sea Region. The experts from Germany, Poland, Denmark, Sweden, Norway, Finland, Estonia, Latvia and Lithuania gave their assessment of the digital infrastructure, enablers, barriers and possible reasons for the different diffusion of innovations. In the period from June 2023 to August 2024, the interviews were prepared, experts were identified, interviews were conducted, transcribed, analysed and interpreted.\u003c/p\u003e \u003cp\u003eThe preparation of the interviews involved several steps. The semi-structured expert interview was chosen as the method to ensure flexibility and openness during the interviews. The questions were based on the theory of innovation adoption with the main elements of innovation, diffusion, barriers and promoters (Flessa \u0026amp; Huebner, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The full guide is attached (see Appendix 1, full interview guide). We did not use a strict questionnaire in order to allow for deviations from the guideline based on the experts' knowledge and sub-questions. The main questions (key questions) and variable sub-questions were grouped into three thematic blocks, including introductory questions (personal information, background information), a main block (digital infrastructure, barriers, promoters, diffusion) and concluding questions (comments). Based on the innovation model, we developed a broad set of questions that had to be categorised and condensed. All experts from the different countries were asked the same questions in order to obtain comparable results. The interviews were scheduled to last approximately 45 minutes.\u003c/p\u003e \u003cp\u003eThe next step was to identify suitable interviewees with expertise in digital health in the healthcare sector in their own country. An international, DFG-funded workshop on \"Innovations in the Baltic Sea Region\" was held at the University of Greifswald in March 2023, bringing together experts on innovation and healthcare from all the Baltic Sea countries. Some of them - but not all - were also experts in digital health in their countries and a cornerstone of this research. We asked the participants of this conference to identify the respective digital health experts in their countries. We also carried out an online contact search. We also used a snowball system, naming other potential contacts in the interviews or asking them by email.\u003c/p\u003e \u003cp\u003eIn addition, potential contacts from a previous survey conducted as part of the project were screened and researched for expertise and availability (Nawroth, Sabotka, \u0026amp; Fle\u0026szlig;a, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Potential interviewees were sent a personalised cover letter by email (see Appendix 2 General Cover Letter), together with an abridged version of the interview guide, which they were asked to read beforehand in order to check that the content matched their own expertise and to prepare themselves. If no response was received, two further requests were made at intervals of approximately 2\u0026ndash;4 weeks. After successful agreement to an interview, a possible date was arranged and the consent form was provided for signature. After each interview we discussed whether the response was sufficient to provide an overview of the current situation in the country. If not, we decided to interview a second (or third) interviewee from that country. In this way, a total of 15 interviews were conducted in the countries of the Baltic Sea region (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), out of approximately 60 potential contacts requested. All interviews were conducted digitally using the licensed Zoom platform.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterviewees\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterviewees\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePosition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocus\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ephysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCEO hospital chain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003einnovative technologies in emergency medicine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eeconomist, physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprofessors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ee-Health, mobile health, communications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDenmark\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003esociology, engineer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprofessor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehealth informatics, health technology assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003epharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eadvisor Swedish eHealth Agency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecoordination of digital health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emanager, manager, IT specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emanagement Institute for Health and Welfare; professors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eimplementation, health informatics, usability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIT specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprofessor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehealth informatics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003esocial scientist, pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprofessor, senior researcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehealthcare-networks and IT; social impact\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLithuania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003epublic health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eprofessor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eimpact of digital health on population\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatvia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emanager, IT specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emanagement companies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ebusiness analytics, technology assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOnce the interviews had been conducted, the content of the data collected was analysed. The qualitative content analysis method according to Philipp Mayring was chosen (Mayring, 2021). A codebook with main categories and subcategories was created for the analysis (see Appendix 3 Codebook). In line with the inductive approach, the categories were derived from the interview guide and pre-defined for better categorisation. The codebook contains six main categories (plus 'other' if no categorisation is possible), each with 2\u0026ndash;4 subcategories for further subdivision. Once the transcripts had been made from the audio files, the text passages were analysed and classified into the categories using MAXQDA software and colour coding for differentiation. The total duration of the interviews ranged from approximately 27 minutes to 1 hour and 11 minutes. Using the colour coding, the text passages from the different interviews were summarised and listed under the corresponding categories and sub-categories. The content of the text passages was then summarised and analysed by country.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Overview\u003c/h2\u003e \u003cp\u003eIn a first set of interview questions, respondents were asked to describe the digital health situation in their country and to identify strengths and weaknesses. A first dimension of digital health was the homogeneity of diffusion of the innovation across the country and population. Several respondents see a rural-urban divide, with much greater penetration in urban areas, although it is generally felt that digital health is (even more) beneficial to rural areas.\u003c/p\u003e \u003cp\u003eThis urban-rural divide is closely linked to a regional divide in several countries. Many respondents said that digital health is used differently in different states, provinces or regions. This is partly due to political differences. The more independent these political units are, the more likely it is that there will be differences in the uptake of digital health across these states, regions or provinces.\u003c/p\u003e \u003cp\u003eA further differentiation was made in terms of age groups, i.e. that older people have greater difficulties in using and benefiting from digital health systems than younger people. This was seen as a consequence of digital literacy beyond health. Older people have less knowledge to use digital services and need more personal contact, whether they use digital banking or video consultations with their doctor.\u003c/p\u003e \u003cp\u003eIn addition, interviewees described the digital infrastructure in their countries. This includes different dimensions, such as the availability of general IT, networks and connectivity (e.g. quality of WiFi), but also specific dimensions for the healthcare sector, such as connectivity of mobile services (e.g. telemedicine emergency services), e-prescription, digital patient records, etc. It is clear that digital health was an initiative in some countries 20\u0026ndash;25 years ago and has now become a standard, while others are lagging behind. A soft form of infrastructure is the population's knowledge and ability to use digital services. As noted above, there are large differences between and within countries.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the barriers discussed by respondents. It is clear that poor digital infrastructure and high investment and recurrent costs are barriers to the implementation and uptake of digital health in a country. However, respondents focused more on aspects beyond traditional economics, in particular a country's culture. Individuals, groups and nations differ in their time preference, i.e. short-term thinking, financing and planning will lead to a reduced speed of implementation of digital health, as this macro-innovation cannot be implemented in a short-term project, but requires a long-term commitment at all levels. The more future-oriented an individual or culture is, the more likely it is to develop a propensity for innovation and change.\u003c/p\u003e \u003cp\u003eRisk aversion is another cultural dimension that can become a barrier to the uptake of digital health. Changing an existing and functional system to a new and unfamiliar one carries risks. The less people appreciate risk, the less likely they are to support digital health innovation.\u003c/p\u003e \u003cp\u003eSome interviewees also said that digital health involves a power game between different levels of government. The more people insist on their power, the less they will delegate and the less they will value digital health that empowers local providers and patients. Power distance, risk aversion and time preference determine the propensity of an individual, group or culture to promote digital health. The interviewees mentioned these barriers, even though none of them were humanities experts.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnother cultural dimension is conformity, which is \"the tendency for an individual to align their attitudes, beliefs, and behaviours with those of the people around them. Conformity can take the form of overt social pressure or subtler, unconscious influence\" (Psychology Today, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In our context, this can have two dimensions. Legal conformity means that people tend to follow laws and regulations. For example, if a government decides to make the use of digital health mandatory, conforming cultures will follow this command and support the implementation of digital health. Conformity can also mean that people want to be consistent with the past and not make major changes to processes or traditions. \"We do what we have always done\" is a major barrier to innovation.\u003c/p\u003e \u003cp\u003eImplementing digital health as a new technology also requires trust in healthcare providers, IT services, government and life in general. The less trust people have in institutions, the less likely they are to entrust their data to anonymous processes such as the internet. Countries are trying to increase trust in digital health by building strong institutions (e.g. e-services and innovation department, Estonia 2014) (Bittroff \u0026amp; von Mittelstaedt, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Rainer Thiel, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)). The General Data Protection Regulation (GDPR) can be seen as a tool to build trust that all data will be professionally protected. At the same time, several interviewees see the regulation as an obstacle because the strict data protection rules make the transfer and use of data for medical decisions and research very cumbersome. Others argue that the same GDPR is interpreted quite differently in different countries. It is mandatory for all EU member states, as well as Norway as a member of EFTA (European Free Trade Association), but its application depends heavily on national interpretation. In some cases, the GDPR is seen as a driver of trust and thus innovation, while in other countries it is more of an obstacle to the spread of digital health.\u003c/p\u003e \u003cp\u003eFinally, federalism is perceived by some interviewees as a barrier to innovation. Smaller countries, such as Estonia, do not have very independent states, while larger countries, such as Germany, are divided into states that act quite independently. In more centralized countries, digital health innovation can be implemented from the top down across the country, but in a federal system, the successful implementation of digital health in one state does not guarantee that other states will follow. In this way, federalism can become a barrier to digital health innovation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Country situation\u003c/h2\u003e \u003cp\u003eIn the following section, we analyze the situation in different countries and explain the main features of each country in more detail. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the main barriers for different countries.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers in different countries.\u003c/p\u003e \u003cdiv class=\"Credit\"\u003e\u003cp\u003eSource: interviews and (Enste \u0026amp; Suling, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hofstede Insights, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime-\u003c/p\u003e \u003cp\u003epreference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRisk\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTrust\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFederalism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eData\u003c/p\u003e \u003cp\u003eprotection\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ehierarchy relevant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003emiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ehigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ebarrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003every averse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ehierarchy important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ebarrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDenmark\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003erisk seeking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eexpert power\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eimportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emain barrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003erisk seeking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eless important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehighly important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eregional autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eno barrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eless important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehighly important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003erather low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ebarrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eneutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eless important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehighly important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ebarrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eneutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eless important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eimportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003epromotor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLithuania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ehierarchy relevant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eimportant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ebarrier\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatvia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaverse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ehierarchy relevant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehighly important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003elow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003epromotor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eGermany\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe interviewee describes digital health innovation in Germany as a patchwork that varies from region to region and state to state. Similarly, rural and urban areas are very different, with examples of both very good and very poor digital infrastructure. A number of telemedicine applications are regularly used, but digital health is not yet standard and the pace of development is considered slow.\u003c/p\u003e \u003cp\u003eA major barrier seems to be the lack of long-term funding, i.e. digital health projects are usually funded for a short period of time (e.g. 2 years), which does not allow them to mature and become the new standard. Even if a project is very successful, German federalism may prevent innovations from being adopted in other states.\u003c/p\u003e \u003cp\u003eThe GDPR itself is not seen as problematic, the problem is rather the federal implementation with a strong dominance of the state data protection authorities. The GDPR sets the framework within which to operate, but the individual states within Germany interpret the regulation quite differently.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePoland\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe experts point to a weak digital infrastructure, but even more importantly, they highlight a low propensity to adopt digital health innovation, resulting in, among other things, a strong urban-rural divide. There are some \"early adopters\" in cities, but the majority of the rural population is reluctant to use digital health services due to a general aversion to new technologies and attitudes.\u003c/p\u003e \u003cp\u003ePoland has implemented a number of programmes to implement digital health solutions, particularly in suburban areas, many of them funded by EU projects. However, the majority of projects come to an end when their financial support comes to an end. The GDPR is seen as an obstacle by the respondents because it is perceived as too strict. In general, the experts consider their own culture to be comparatively slow to adopt innovations, including a high time preference and strong risk aversion. Conversely, the centralism of the Polish government system could support the spread of digital health across the country once it is centrally decided. But so far there are not enough promoters.\u003c/p\u003e \u003cp\u003e \u003cem\u003eDenmark\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe digital health revolution started quite early in Denmark and has penetrated most areas of digital health. Many standards have now been developed and digital health has become routine throughout the country. In addition to sufficient budgets, respondents see a strong culture of innovation and rapid adoption of change as the main reasons for digital success. This also includes a \"general sense of trust\" among the majority of the population.\u003c/p\u003e \u003cp\u003eAlthough the Scandinavian countries are generally considered to be more egalitarian, the experts noted \"power games\" (as they called them). Digital health seems to take power away from an individual doctor and distribute it to a network of doctors and/or IT. This also implies a shift of power from individual doctors to networks or other professions.\u003c/p\u003e \u003cp\u003eThese two interviewees point out that digital health implies a change in workflow, which requires further training, especially for doctors. At the same time, they also realise a number of digital health projects (\"projectitis\") without systematic translation into routine care. Thus, they point out that there are still some shortcomings - but at a generally satisfactory level.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSweden\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSweden started quite early and now has a good digital infrastructure with a wide range of digital services that enable health data sharing. However, there are some regional disparities and the overall speed of innovation adoption could be better. This is partly due to the relatively high degree of independence of municipalities and regions, which is an obstacle to rapid, nationwide diffusion of digital health innovations. Currently, healthcare in Sweden is decentralised, i.e. the responsibility for implementing the digital health innovation lies with the 21 regional and 290 municipal councils.\u003c/p\u003e \u003cp\u003eThe interviewee points to the same barrier as the colleagues from Germany and Denmark: short-term planning, funding and projects lead to a multitude of pilots without transfer into routines and standards. He calls this phenomenon \"piloticities\". The gap between pilot and routine seems difficult to bridge, and the step from successful implementation in one region to another is even more difficult.\u003c/p\u003e \u003cp\u003e \u003cem\u003eFinland\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe three experts from Finland agreed that digital health is quite advanced in the country. Although the country is huge and has areas with very low population density, the distribution of digital health services seems to be quite even. However, there is an age gap, with older people less likely to use digital health services.\u003c/p\u003e \u003cp\u003eThey also say that Finns are very interested in any kind of innovation. They are forward-looking and have no problem sharing power. Trust is of paramount importance to the Finnish population - one interviewee expressed this with the Finnish \"habit\" of leaving doors unlocked when leaving the house. They trust their fellow citizens, the government and their health services, including the responsible use of their health data. Mistrust - as expressed in the GDPR - is seen as inappropriate, so the implementation of the GDPR faces some resistance, albeit with different arguments than in countries like Germany.\u003c/p\u003e \u003cp\u003eIt was mentioned that Finland is perhaps the only country in the Baltic Sea region with two official languages (Swedish, Finnish). This has implications for all software, but it is a common challenge beyond the healthcare system.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNorway\u003c/em\u003e \u003c/p\u003e \u003cp\u003eNorway is the richest country in the region with a well-functioning IT infrastructure throughout the country, including fibre and wireless networks. Norsk Helsenett (Norwegian Health Network) is owned by the government and provides patient portals for every citizen.\u003c/p\u003e \u003cp\u003eAccording to the interviewee, Norwegian culture encourages innovation, i.e. Norwegians tend to be forward-looking, not too afraid of risk and have no problems sharing power. Trust is very important and includes trust in fellow citizens as well as in the government. Compared to Sweden, Norway is a rather centralised country, i.e. the central government has managerial and financial responsibility for the health sector. There are four regional health authorities (out of five regions in Norway) that work closely with the central government.\u003c/p\u003e \u003cp\u003eHowever, the expert considers that there is still room for improvement, especially in the usability of digital tools. Furthermore, the implementation of the GDPR is seen as too strict, although the regulation itself is accepted. The expert is convinced that the regulation would give more freedom than the interpretation of local authorities.\u003c/p\u003e \u003cp\u003eThe Norwegian interviewee was the only expert to mention digital health as a business case, i.e. Norwegian companies could offer services (e.g. reading radiology images) as a paid service globally.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEstonia\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEstonia is considered to be at the forefront of digitalisation in Europe, and the two experts confirm that digital health is quite advanced. The government \"owns\" digitalisation, with a long line of prime ministers making digitalisation \"their child\". Many services such as digital patient records, lifelong ID, e-prescription, etc. are standard and routine in Estonia.\u003c/p\u003e \u003cp\u003eAccording to the experts, the reasons for Estonia's leading position in Europe are similar to those in other countries: a high level of innovation based on a forward-looking attitude, a willingness to take risks and trust. This may not fully explain why Estonia is more advanced than neighbouring countries such as Latvia and Lithuania. However, respondents stressed that Estonia was simply the first country to put all its eggs in the digital basket. They started earlier, based on a very high level of commitment from the country's leadership, including a 'personal data protection law' that is said to be stricter than the GDPR. The Estonian experts said that they see the data protection regulation as an enabler of digital health, not an obstacle, because it increases trust in the system.\u003c/p\u003e \u003cp\u003e \u003cem\u003eLithuania\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLithuania has made some progress in digital health, but the pace of innovation seems to be slower than in Scandinavia or Estonia. Internet access and in particular the nationwide eHealth platform with access for the population are seen as encouraging factors. The government seems committed to the development of digital health and people trust that their data is well protected. However, the Lithuanian expert recognises a number of barriers to the implementation of digital health in his country. First, he notes that the development of the e-health system has been done without the participation of providers and patients, resulting in low usability and complaints that its use increases the administrative workload of healthcare providers.\u003c/p\u003e \u003cp\u003eSecondly, the propensity to innovate seems to be limited by risk aversion. As in most settings, the likelihood of adopting digital health innovations decreases with age, but the expert points out that this tendency is even stronger in Lithuania. In contrast to risk aversion, time preference is low, which should lead to better adoption of innovations.\u003c/p\u003e \u003cp\u003eThirdly, the Lithuanian expert is one of the few to point out the disparity between urban and rural areas, i.e. digital health is much more advanced in cities and towns than in villages. This, he argues, may be due to the government's greater emphasis on urban development.\u003c/p\u003e \u003cp\u003eFourth, the interpretation of the GDPR seems to be stricter in Lithuania than in other Baltic states. As he notes: \"They use data protection mostly to protect themselves\", i.e. the GDPR is used as an argument to hinder digital health if it is not desired by certain stakeholders.\u003c/p\u003e \u003cp\u003e \u003cem\u003eLatvia\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLatvia has similar characteristics to Lithuania. However, data protection is not seen as an obstacle by the experts. Both agree that Latvia has a good digital infrastructure, but standardisation of health data could be improved to take advantage of interdependencies between sub-systems. As a small country, even cross-border data exchange is considered relevant, but language and semantic standards are a barrier.\u003c/p\u003e \u003cp\u003eThey also agree that the majority of people are rather conservative and tend to avoid risks and stick to the \"good old standards\". One of the experts talks about \"a negative attitude towards any change\", especially among older people.\u003c/p\u003e \u003cp\u003eAlthough the experts knew that the researchers had an economic background, few mentioned financial constraints as a main problem. Independently, the Latvian experts stressed that the government is not investing enough in the development of eHealth infrastructure. However, there is hope that this will change with a very enthusiastic and innovative new Minister of Health who has a strong focus on digital health. Hosams Abu Meri (born 1974) took office in 2023 and, according to interviewees, has already made important contributions to the penetration of digital health in the health sector. In particular, he has developed a digital health strategy. However, they also state that the existing regulation demotivates the leaders of healthcare institutions to get more involved in digital health because they are afraid of breaking the rules. Latvians seem to follow the regulations very strictly. For example, teleconsultation is rarely used for fear of being seen as unprofessional or violating data confidentiality laws. There were some efforts in this direction during the Covid-19 pandemic, but much was not continued afterwards.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe perception of digital health differs between the countries in the Baltic Sea Region. The results of this survey are consistent with the findings in the literature. For example, the Bertelsmann Foundation calculated a Digital Health Index (DHI) in 2018 with 17 OECD countries, including Estonia, Denmark, Sweden, Germany and Poland (Bertelsmann Stiftung, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As Flessa \u0026amp; H\u0026uuml;bner demonstrate, \u0026ldquo;there is hardly any correlation between country statistics and the DHI\u0026rdquo; (Flessa \u0026amp; Huebner, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), i.e. wealth, population, population density and health expenditure per capita do not determine the penetration of the health system in the respective countries. Instead, cultural values (Hofstede, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1980\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) seem to be more important to understand the perception of digital health and the speed of innovation diffusion. They show that there is a \u0026ldquo;negative correlation between power distance and DHI, i.e., cultures with a strict and hierarchical leadership style have a lower penetration of the health care system with digital technologies. Likewise, cultures in which dominance, assertiveness or win-lose-thinking are seen as virtues (\u0026lsquo;masculine cultures\u0026rsquo;) also tend to have a low DHI. The more people try to avoid uncertainty (and risks), the lower is the adoption of digital health\u0026rdquo; (Flessa \u0026amp; Huebner, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results of this survey underline these findings. The experts clearly show that there are differences between the nine countries, and they also indicate that financial resources or population size are not the determining factors. Instead, risk aversion, future orientation and willingness to change are much more important. Some of the interviewees emphasise that trust is an important determinant of perceptions of digital health. The role of trust in the willingness to accept change has been much discussed in the literature, in particular the right mix of trust and control. (Das \u0026amp; Teng, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Long \u0026amp; Sitkin, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Adoption of the digital health innovation is not possible without confidence that the data will be confidential and properly protected. While individuals cannot assess this protection themselves, trust in government and its administration is a prerequisite for the diffusion of digital health. Trust, as a cultural factor, differs from nation to nation and across historical trajectories.\u003c/p\u003e \u003cp\u003eHowever, even these cultural factors alone cannot explain the differences, which require further analysis. Interviewees highlighted the role of data protection legislation and its implementation. This aspect is also discussed by Sliwa et al. for the uptake of e-health in Germany, Austria and Denmark. They identify complexity and documentation requirements as major barriers (Austria, Germany) and practical government regulations as promoters (Denmark) of e-health (Sliwa, Brem, Agarwal, \u0026amp; Kraus, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Respondents to this survey also identified administrative barriers, but these are not necessarily the most significant. Instead, they emphasise the role of data protection regulation and implementation. There is still relatively little literature on the role of data protection laws and individuals' willingness to share data in digital records as a barrier to digital health, but interviewees strongly emphasise that this may be a key to understanding why digital health differs so widely.\u003c/p\u003e \u003cp\u003eIn summary, the model shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e can help to understand the adoption of health innovations (Flessa \u0026amp; Huebner, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It also allows the identification of barriers and their impact on the adoption process, and the appropriate placement of available tools to overcome them.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe functionality of the existing standard of diagnosis and treatment as well as their administration is the starting point (Fle\u0026szlig;a \u0026amp; Greiner, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A fully functioning and stable system will not be changed, i.e. the digital health innovation will meet more resistance in countries where the health system works very well. However, even if there are perceived shortcomings in the current system, it is more likely that the current system will be improved than that a major innovation with risks and costs will be introduced. These compensatory measures lead to artificial stability or metastability (Ritter, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). It is only when this stabilization is no longer sufficient that the pressure to find alternative solutions becomes dominant and the likelihood of adopting an innovation increases measurably. As a result, countries that had weak and difficult healthcare systems in the 1990s (especially the post-Soviet Baltic States) had a much higher chance of jumping on the digital health innovation than countries with well-established healthcare systems, such as Germany.\u003c/p\u003e \u003cp\u003eFurthermore, the ability and willingness to promote the adoption of an innovation depends on a number of factors, such as the complexity of the decision. The more complex an innovation, the less likely it is to be adopted. Digital health requires a network of different providers, standardized processes and semantics. As such, it is an innovation that will face some resistance.\u003c/p\u003e \u003cp\u003eIn addition, the propensity of stakeholders to innovate is crucial, depending on their time preference, individual risk preference and management approach. If people are future-oriented and risk-seeking, they are more likely to accept innovation. In addition, the management style within the organization influences the propensity to innovate. The more strict, hierarchical and dominant a leadership style is, the less likely it is that innovations will be developed and adopted (Fle\u0026szlig;a, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Hauschildt, Salomo, Schultz, \u0026amp; Kock, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Vahs \u0026amp; Brem, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Thus, countries with a very conservative leadership style are less likely to adopt digital health innovations.\u003c/p\u003e \u003cp\u003eThere are a number of limitations to the findings presented in this study. Firstly, it is a qualitative study based on 15 interviews. The interviewees clearly point to differences between countries that are in line with the literature. However, with the existing methodology and sample, we cannot be completely sure whether these perceived differences are due to the selection of experts or to real country differences. Thus, our results suggest the need for further research with a broader pool of experts.\u003c/p\u003e \u003cp\u003eSecondly, our results are (as always) influenced by the choice of criteria and the respective interview guidelines (see Appendix). We tried to mitigate this limitation by using a semi-structured interview with open questions and sufficient time. The interviewees used this time to elaborate on a wide range of issues. However, we cannot be absolutely certain that there are no arguments beyond the bounded rationality of the researchers.\u003c/p\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThe study shows that perceptions of digital health vary across the Baltic Sea Region. The most frequently mentioned barriers are cost, data protection laws, federalism, infrastructure and culture. Based on the interviews, we can say that the GDPR itself is not the main barrier. It is the same for all countries, but its interpretation and implementation in the countries is different. Countries that are facing a slow adoption of digital health could consider relaxing their interpretation of this regulation. However, this must not jeopardise data protection, as this could lead to reduced trust and reservations about digital health. The Scandinavian countries and Estonia show that data can be protected without over-regulating data protection.\u003c/p\u003e \u003cp\u003eFederalism is another aspect that should be further analysed. Smaller and centralised countries have the advantage that an innovation can spread to all locations without further barriers. Countries with decentralised systems and more independent federal states find it more difficult to develop universal coverage of digital services across the country. The \"here-not-invented\" syndrome can block the diffusion of promising innovations from state to state or even region to region. In Germany, for example, it would be helpful to shift some decision-making power on digital health from the states to the federal government.\u003c/p\u003e \u003cp\u003eFinally, the pace of innovation in digital health depends on cultural values such as trust, power distance, risk aversion, time preference and compliance. It is difficult to recommend changing cultural values, but government can do a lot to build trust by proving itself trustworthy. Patient data must be strictly protected so that patients can build trust and accept lower risks.\u003c/p\u003e \u003cp\u003eFinally, respondents identified a number of individuals as key stakeholders in digital health innovation. It is recommended to support these \"champions\" who are inclined towards digital health. There is no doubt that future developments, in particular artificial intelligence in healthcare, will require even deeper penetration of digital health. There is an urgent need to overcome the barriers to digital health in some countries (e.g. Germany). Otherwise, they will fall further behind.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Based on the regulation of the German Research Council (DFG: https://www.dfg.de/en/research-funding/proposal-funding-process/faq/humanities-social-sciences#263154) not ethical approval was necessary for the expert interviews. Participation in the study was voluntary. Before participating, all individuals were informed about the study\u0026rsquo;s objectives and provided written informed consent for both participation and the recording of interviews. Participants were assured of confidentiality, anonymity, and their right to withdraw from the study at any time without any consequences\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe interview data utilized and analyzed in this study can be obtained from the corresponding author upon request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was funded as a project of the project \u0026ldquo;FragTrans\u0026rdquo; of the Interdisciplinary Research Center of the Baltic Sea Region, Germany. It was funded by the German Federal Ministry of Research (Grant No. 01UC22102)\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eSF: Funding acquisition, Conceptualization, Methodology, Modeling, Formal analysis, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eNH: literature review, interview recording and transcription\u003c/p\u003e\n\u003cp\u003eMN: Investigation, Interviews, Writing \u0026ndash; Original Draft, Writing \u0026ndash; Review \u0026amp; Editing, Project administration\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe publication was prepared within the framework of \u0026ldquo;FragTrans\u0026rdquo; of the Interdisciplinary Research Center of the Baltic Sea Region, Germany. The authors would like to thank all responsible persons, in particular Dr. A. Drost, as well as the interview partners for their support.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; information (optional)\u003c/h2\u003e\n\u003cp\u003eSF is professor of healthcare management with a focus on innovative healthcare interventions. MN is research assistant at the department of healthcare management in charge of the economic evaluation of FragTrans\u003c/p\u003e\n\u003cp\u003eNH was student assistant\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBertelsmann Stiftung. (2021). SmartHealthSystems. Retrieved from https://www.bertelsmann-stiftung.de/de/unsere-projekte/der-digitale-patient/projektthemen/smarthealthsystems#c1203567\u003c/li\u003e\n\u003cli\u003eBittroff, M., \u0026amp; von Mittelstaedt, G. (2019). Digitalisierung im Gesundheitswesen: Was wir von Estland lernen k\u0026ouml;nnen. \u003cem\u003ekma - Klinik Management aktuell, 24\u003c/em\u003e(09), 54-55. \u003c/li\u003e\n\u003cli\u003eColiquio. (2023, 11.05.2015). 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Los Angeles et al., CA, USA: SAGE.\u003c/li\u003e\n\u003cli\u003eNawroth, M., Sabotka, \u0026amp; Fle\u0026szlig;a, S. (2024). K\u0026ouml;nnen die Skandinavier Digital Health wirklich besser? \u003cem\u003eKU Gesundheitsmanagement, 9/2024\u003c/em\u003e, S. 17-19.\u003c/li\u003e\n\u003cli\u003ePsychology Today. (2025). Conformity. Retrieved from https://www.psychologytoday.com/gb/basics/conformity\u003c/li\u003e\n\u003cli\u003eRitter, W. (2001). \u003cem\u003eAllgemeine Wirtschaftsgeographie. Eine systemtheoretisch orientierte Einf\u0026uuml;hrung\u003c/em\u003e (3., \u0026uuml;berarbeitete und erweiterte Auflage ed.). M\u0026uuml;nchen: Oldenbourg.\u003c/li\u003e\n\u003cli\u003eSliwa, S.-I., Brem, A., Agarwal, N., \u0026amp; Kraus, S. (2017). E-health, health systems and social innovation: a cross-national study of telecare diffusion. \u003cem\u003eInternational Journal of Foresight and Innovation Policy, 12\u003c/em\u003e(4), 171-197.\u003c/li\u003e\n\u003cli\u003eThiel, R. (2018). SmartHealthSystems. Digitalisierungsstrategien im internationalen Vergleich: Bertelsmann Stiftung.\u003c/li\u003e\n\u003cli\u003eThiel, R., Deimel, L., Schmidtmann, D., Piesche, K., H\u0026uuml;sing, T., Rennoch, J., . . . Stroetmann, K. (2018, 2018). Smart Health Systems: Digitalisierungsstrategien im internationalen Vergleich. Retrieved from https://www.bertelsmann-stiftung.de/fileadmin/files/Projekte/Der_digitale_Patient/VV_SHS-Gesamtstudie_dt.pdf\u003c/li\u003e\n\u003cli\u003eVahs, D., \u0026amp; Brem, A. (2015). \u003cem\u003eInnovationsmanagement: Von der Idee zur erfolgreichen Vermarktung\u003c/em\u003e (4 ed.). Stuttgart: Sch\u0026auml;ffer-Poeschel Verlag.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Baltic Sea Region, Data Protection Act, Digital Health, Federalism, Innovation, Innovation adoption model, Telemedicine","lastPublishedDoi":"10.21203/rs.3.rs-6617740/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6617740/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDigital health has the potential to improve the effectiveness and efficiency of health care. However, its adoption in the countries of the Baltic Sea Region varies considerably. In order to improve the diffusion and speed of adoption of this innovation, it is necessary to know the barriers and promotors that improve or hinder the implementation of digital health.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBased on an international workshop, we conducted guided interviews with 15 experts from 9 countries in the Baltic Sea Region to determine their perceptions of the use of the innovation, barriers to its adoption and promoting factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eStructural factors such as national income or population density are perceived as less relevant. Instead, cultural values such as future orientation, risk-taking and trust are described as the most important factors in explaining the different rates of adoption between countries in the Baltic Sea Region. Important barriers to rapid adoption of digital health are also federal structures with a high degree of autonomy for regions, as well as a rather strict interpretation of data protection laws. Some interviewees emphasised the role of individuals who make digital health \"their child\".\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe implementation of digital health depends less on economic conditions than on the commitment of policy makers to make it happen. Future developments, in particular artificial intelligence in healthcare, will require an even deeper penetration of digital health, which calls for urgent strategies to overcome the barriers to digital health.\u003c/p\u003e","manuscriptTitle":"Perception of Digital Health in the Baltic Sea Region: Insights of Experts from Nine Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 06:34:24","doi":"10.21203/rs.3.rs-6617740/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-11T12:30:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T17:42:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T02:27:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140033333473364227252865364006040150106","date":"2025-06-24T16:57:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-22T09:44:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147933587442564510513709971007238287085","date":"2025-06-18T13:21:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124801368388614716887191940039687744452","date":"2025-06-17T13:09:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309413599478279319394339573324513425704","date":"2025-06-15T12:49:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T12:48:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T09:46:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T06:21:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-13T07:20:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-13T07:19:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c65b4a5d-6c63-47ce-b340-400c347db207","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:06:59+00:00","versionOfRecord":{"articleIdentity":"rs-6617740","link":"https://doi.org/10.1186/s12913-026-14065-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-01-30 15:59:08","publishedOnDateReadable":"January 30th, 2026"},"versionCreatedAt":"2025-06-18 06:34:24","video":"","vorDoi":"10.1186/s12913-026-14065-5","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14065-5","workflowStages":[]},"version":"v1","identity":"rs-6617740","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6617740","identity":"rs-6617740","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}