Published on in Vol 27 (2025)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/63482, first published .
Facilitators and Barriers to the Implementation of Digital Health Technologies in Hospital Settings in Lower- and Middle-Income Countries Since the Onset of the COVID-19 Pandemic: Scoping Review

Facilitators and Barriers to the Implementation of Digital Health Technologies in Hospital Settings in Lower- and Middle-Income Countries Since the Onset of the COVID-19 Pandemic: Scoping Review

Facilitators and Barriers to the Implementation of Digital Health Technologies in Hospital Settings in Lower- and Middle-Income Countries Since the Onset of the COVID-19 Pandemic: Scoping Review

Review

1Department of Public Health Medicine, Faculty of Medicine, National University of Malaysia, Cheras, Malaysia

2Centre for Research in Public Health and Community Care, University of Hertfordshire, Hertforshire, United Kingdom

3Clinical Research Unit, Hospital Sultan Abdul Aziz Shah, Serdang, Malaysia

4Faculty of Medicine and Health Sciences, Department of Family Medicine, Serdang, Malaysia

Corresponding Author:

Daksha Trivedi, BSc, MSc, MPhil, PhD

Centre for Research in Public Health and Community Care

University of Hertfordshire

College Lane, Hatfield

Hertforshire, AL10 9AB

United Kingdom

Phone: 44 01707286389

Email: d.trivedi@herts.ac.uk


Background: Although the implementation process of digital health technologies (DHTs) has been extensively documented in high-income countries, the factors that facilitate and prevent their implementation in lower- and middle-income countries (LMICs) may differ for various reasons.

Objective: To address this gap in research, this scoping review aims to determine the facilitators and barriers to implementing DHTs in LMIC hospital settings following the onset of the COVID-19 pandemic. Additionally, the review outlined the types of DHTs that have been implemented in LMICs’ hospitals during this pandemic and finally developed a classification framework to categorize the landscape of DHTs.

Methods: Systematic searches were conducted on PubMed, Scopus, Web of Science, and Google Scholar for studies published from March 2020 to December 2023. We extracted data on authors, publication years, study objectives, study countries, disease conditions, types of DHTs, fields of clinical medicine where the DHTs are applied, study designs, sample sizes, characteristics of the study population, study location, and data collection methods of the included studies. Both quantitative and qualitative data were utilized to conduct a thematic analysis, using a deductive method based on the Practical, Robust Implementation and Sustainability Model (PRISM), to identify facilitators and barriers to DHT implementation. Finally, all accessible DHTs were identified and organized to create a novel classification framework.

Results: Twelve studies were included from 292 retrieved articles. Telemedicine (n=5) was the most commonly used DHT in LMICs’ hospitals, followed by hospital information systems (n=4), electronic medical records (n=2), and mobile health (n=1). These 4 DHTs, among the other existing DHTs, allowed us to develop a novel classification framework for DHTs. The included studies used qualitative methods (n=4), which included interviews and focus groups, quantitative methods (n=5), or a combination of both (n=2). Among the 64 facilitators of DHT implementation, the availability of continuous on-the-job training (n=3), the ability of DHTs to prevent cross-infection (n=2), and positive previous experiences using DHTs (n=2) were the top 3 reported facilitators. However, of the 44 barriers to DHT implementation, patients with poor digital literacy and skills in DHTs (n=3), inadequate awareness regarding DHTs among health care professionals and stakeholders (n=2), and concerns regarding the accuracy of disease diagnosis and treatment through DHTs (n=2) were commonly reported.

Conclusions: In the postpandemic era, telemedicine, along with other DHTs, has seen increased implementation in hospitals within LMICs. All facilitators and barriers can be categorized into 6 themes, namely, (1) Aspects of the Health Care System; (2) Perspectives of Patients; (3) External Environment; (4) Implementation of Sustainable Infrastructure; (5) Characteristics of Health Care Organization; and (6) Characteristics of Patients.

J Med Internet Res 2025;27:e63482

doi:10.2196/63482

Keywords



Populations residing in lower- and middle-income countries (LMICs) face numerous unmet health care needs due to various factors [World Health Organization (WHO). Tracking universal health coverage: 2023 global monitoring report. WHO. Geneva, Switzerland. WHO; Sep 18, 2023. URL: https://www.who.int/publications/i/item/9789240080379 [accessed 2024-02-10] 1], including an aging population [Shah SA, Safian N, Ahmad S, Nurumal SR, Mohammad Z, Mansor J, et al. Unmet healthcare needs among elderly Malaysians. JMDH. Oct 2021;Volume 14:2931-2940. [CrossRef]2], escalating health care costs [Njagi P, Arsenijevic J, Groot W. Cost-related unmet need for healthcare services in Kenya. BMC Health Serv Res. Apr 17, 2020;20(1):322. [FREE Full text] [CrossRef] [Medline]3], widening income disparities [Sohn M, Che X, Park H-J. Unmet healthcare needs, catastrophic health expenditure, and health in South Korea's universal healthcare system: progression towards improving equity by NHI type and income level. Healthcare (Basel). Oct 16, 2020;8(4):408. [FREE Full text] [CrossRef] [Medline]4], increased child morbidity and mortality [Baek S, Choi E-H, Lee J. Unmet healthcare needs of children in vulnerable families in South Korea: finding from the Community Child Center Child Panel Survey. Int J Environ Res Public Health. Nov 07, 2020;17(21):8241. [FREE Full text] [CrossRef] [Medline]5], the emergence of new epidemics and pandemics [Kim J, You M, Shon C. Impact of the COVID-19 pandemic on unmet healthcare needs in Seoul, South Korea: a cross-sectional study. BMJ Open. Aug 26, 2021;11(8):e045845. [FREE Full text] [CrossRef] [Medline]6], and growing racial discrimination in health care access [Harris RB, Cormack DM, Stanley J. Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey. Aust N Z J Public Health. Feb 2019;43(1):75-80. [FREE Full text] [CrossRef] [Medline]7]. The COVID-19 pandemic has further exacerbated the existing disparities and limitations of health care systems in LMICs, further exposing the issues of understaffing, underfunding, inadequate infrastructure, limited access to testing and treatment, and vulnerability to health emergencies [Rosenthal A, Waitzberg R. The challenges brought by the COVID-19 pandemic to health systems exposed pre-existing gaps. Health Policy Open. Dec 2023;4:100088. [CrossRef] [Medline]8]. In response to this unprecedented pandemic, many hospitals in LMICs have attempted to leverage digital health technologies (DHTs) as an innovative approach to curb the spread of the SARS-CoV-2, improve health care provision, and strengthen pandemic response efforts [Mitgang EA, Blaya JA, Chopra M. Digital health in response to COVID-19 in low- and middle-income countries: opportunities and challenges. Glob Policy. Jul 2021;12(Suppl 6):107-109. [CrossRef] [Medline]9].

Generally, DHTs are defined as a set of information and communications technologies utilized in medicine and health care to manage illnesses and promote wellness [Ronquillo Y, Meyers A, Korvek S. Digital Health. StatPearls. Treasure Island (FL). StatPearls Publishing; Jan 2025. 10]. These technologies have expanded as a transformative force in health care since the onset of the COVID-19 pandemic era, thereby offering a myriad of benefits that revolutionize health care delivery and improve patient outcomes. These technologies encompass a wide range of digital tools, including mobile health (mHealth) [Istepanian RSH. Mobile health (m-Health) in retrospect: the known unknowns. Int J Environ Res Public Health. Mar 22, 2022;19(7):3747. [FREE Full text] [CrossRef] [Medline]11], telemedicine [Roy J, Levy DR, Senathirajah Y. Defining telehealth for research, implementation, and equity. J Med Internet Res. Apr 13, 2022;24(4):e35037. [FREE Full text] [CrossRef] [Medline]12], wearable technologies [Huhn S, Axt M, Gunga H-C, Maggioni MA, Munga S, Obor D, et al. The impact of wearable technologies in health research: scoping review. JMIR Mhealth Uhealth. Jan 25, 2022;10(1):e34384. [FREE Full text] [CrossRef] [Medline]13], electronic medical records [Ibrahim AA, Ahmad Zamzuri M'I, Ismail R, Ariffin AH, Ismail A, Muhamad Hasani MH, et al. The role of electronic medical records in improving health care quality: a quasi-experimental study. Medicine (Baltimore). Jul 29, 2022;101(30):e29627. [FREE Full text] [CrossRef] [Medline]14], big data analytics [Belle A, Thiagarajan R, Soroushmehr SMR, Navidi F, Beard DA, Najarian K. Big data analytics in healthcare. Biomed Res Int. 2015;2015:370194. [FREE Full text] [CrossRef] [Medline]15], Internet of Medical Things [Dwivedi R, Mehrotra D, Chandra S. Potential of Internet of Medical Things (IoMT) applications in building a smart healthcare system: a systematic review. J Oral Biol Craniofac Res. Mar 2022;12(2):302-318. [FREE Full text] [CrossRef] [Medline]16], blockchain in health care [Yoon H-J. Blockchain technology and healthcare. Healthc Inform Res. Apr 2019;25(2):59-60. [FREE Full text] [CrossRef] [Medline]17], metaverse [Petrigna L, Musumeci G. The metaverse: a new challenge for the healthcare system: a scoping review. J Funct Morphol Kinesiol. Aug 30, 2022;7(3):63. [FREE Full text] [CrossRef] [Medline]18], software as a medical device [Yu J, Zhang J, Sengoku S. Innovation process and industrial system of US Food and Drug Administration–approved software as a medical device: review and content analysis. J Med Internet Res. Nov 24, 2023;25:e47505. [FREE Full text] [CrossRef] [Medline]19], augmented reality [Eckert M, Volmerg JS, Friedrich CM. Augmented reality in medicine: systematic and bibliographic review. JMIR Mhealth Uhealth. Apr 26, 2019;7(4):e10967. [FREE Full text] [CrossRef] [Medline]20], and virtual reality [Halbig  A, Babu  S, Gatter  S, Latoschik  M, Brukamp K, von Mammen  S. Opportunities and challenges of virtual reality in healthcare – a domain experts inquiry. Front Virtual Real. Mar 23, 2022;3:3. [CrossRef]21]. With increasing computing power and appreciation of artificial intelligence [Xu Y, Liu X, Cao X, Huang C, Liu E, Qian S, et al. Artificial intelligence: a powerful paradigm for scientific research. Innovation (Camb). Nov 28, 2021;2(4):100179. [FREE Full text] [CrossRef] [Medline]22] and machine learning [Sarker IH. Machine learning: algorithms, real-world applications and research directions. SN Comput Sci. Mar 2021;2(3):160. [FREE Full text] [CrossRef] [Medline]23] in health and medicine, many such smart tools are an making appearance in different aspects of hospital care [Mehta N, Pandit A, Shukla S. Transforming healthcare with big data analytics and artificial intelligence: a systematic mapping study. J Biomed Inform. Dec 2019;100:103311. [FREE Full text] [CrossRef] [Medline]24,Yin J, Ngiam KY, Teo HH. Role of artificial intelligence applications in real-life clinical practice: systematic review. J Med Internet Res. Apr 22, 2021;23(4):e25759. [FREE Full text] [CrossRef] [Medline]25].

Despite the benefits of DHTs, such as improved access to health care, enhanced patient engagement and empowerment, efficient health care delivery, timely and personalized care, remote monitoring, and data-driven decision-making, the implementation process of DHTs in the hospital settings, including its facilitators and barriers, is mostly described in the context of high-income countries [Iyamu I, Gómez-Ramírez O, Xu AX, Chang H-J, Watt S, Mckee G, et al. Challenges in the development of digital public health interventions and mapped solutions: findings from a scoping review. Digit Health. 2022;8:20552076221102255. [CrossRef] [Medline]26,Whitelaw S, Pellegrini D, Mamas M, Cowie M, Van Spall HGC. Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. Eur Heart J Digit Health. Mar 04, 2021;2(1):62-74. [FREE Full text] [CrossRef] [Medline]27]. Given the differences in resources, infrastructure, health care systems, socioeconomic status, level of digital divide, and regulatory frameworks in the LMICs compared with the high-income countries, the evidence on facilitators and barriers to implementing DHTs reported in previous literature may not apply to the LMICs [Jacob KS. Public health in low- and middle-income countries and the clash of cultures. J Epidemiol Community Health. Jul 2009;63(7):509. [CrossRef] [Medline]28]. To address these research gaps, this scoping review aimed to:

  • Provide an overview of the facilitators and barriers in implementing DHTs within hospital settings in LMICs since the onset of the COVID-19 pandemic.
  • Identify and describe the types of DHTs that have been put into practice in hospitals within LMICs since the onset of the COVID-19 pandemic.
  • Develop a classification framework to better define the landscape of DHTs, providing a more comprehensive and practical understanding.

Design

The scoping review was conducted using the methodological framework developed by Arksey and O’Malley [Arksey H, O'Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. Feb 2005;8(1):19-32. [CrossRef]29]. The protocol has been registered in the Open Science Framework and has been previously published [Yew SQ, Trivedi D, Adanan NIH, Chew BH. Facilitators and barriers of digital health technologies implementation in hospital settings in lower-income and middle-income countries since the COVID-19 pandemic: a scoping review protocol. BMJ Open. Jan 31, 2024;14(1):e078508. [FREE Full text] [CrossRef] [Medline]30]. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) [Whitelaw S, Pellegrini D, Mamas M, Cowie M, Van Spall HGC. Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. Eur Heart J Digit Health. Mar 04, 2021;2(1):62-74. [FREE Full text] [CrossRef] [Medline]27,Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. Oct 02, 2018;169(7):467-473. [FREE Full text] [CrossRef] [Medline]31] was used to conduct and report our findings.

Identifying Relevant Literature

To comprehensively identify the literature relevant to DHTs, a broad, sensitive, and specific search strategy was applied to capture all DHT-related literature. With the assistance of an information technologist, a comprehensive list of literature relevant to DHTs was identified according to the criteria below. Textboxes 1 and Shah SA, Safian N, Ahmad S, Nurumal SR, Mohammad Z, Mansor J, et al. Unmet healthcare needs among elderly Malaysians. JMDH. Oct 2021;Volume 14:2931-2940. [CrossRef]2 describe the inclusion and exclusion criteria adopted for this scoping review. The focus was on the period between March 2020 and December 2023, as the World Health Organization (WHO) officially declared COVID-19 as a pandemic in March 2020.

Textbox 1. Inclusion criteria.
  • Studies that were conducted in lower- and middle-income countries (LMICs). (The World Bank classifies countries by income each year, covering all nations with a population over 30,000. In 2023, countries are divided into 4 income categories based on their gross national income (GNI) per capita. Low-income countries are defined as those with a GNI per capita of US $1145 or less. LMICs have a GNI per capita between US $1146 and US $4515, while upper-middle-income countries fall between US $4516 and US $14,005. High-income countries are those with a GNI per capita exceeding US $14,005. Based on this classification, LMICs in the current review are defined as countries with GNI below US $14,005 per capita.)
  • Studies that reported the implementation of digital health technologies in hospital settings (for both acute and chronic conditions).
  • Studies that were reported between March 2020 and December 2023.
  • Studies that were reported in the English language.
  • Qualitative studies (phenomenology, ethnography, grounded theory, case study, etc), quantitative studies (case-control, cohort study, cross-sectional, randomized controlled trials, etc), mixed methods studies, and reviews (narrative review, scoping review, systematic review, meta-analysis, etc).
  • Relevant gray literature (eg, Google Scholar).
Textbox 2. Exclusion criteria.
  • Studies that were nondigital-based (ie, studies that did not investigate the effectiveness of digital interventions, such as paper-based studies and postage surveys).
  • Studies that implemented digital health technologies (DHTs) in primary care or community settings alone. However, studies that concurrently reported on the implementation of DHTs in hospital settings will still be included.
  • Studies that used DHTs in dentistry and nonclinical medicine area (eg, dentistry, basic sciences, medical education, medical engineering, nutrition, dietetics, veterinary science, laboratory experimentations, and medical anthropology).

Systematic searches were conducted in PubMed, Scopus, and Web of Science databases. Potentially relevant gray literature was searched through targeted searches of Google Scholar. Lateral searching included screening reference lists in identified studies or reviews for relevant publications. Articles published in English between March 2020 and December 2023 were retrieved. Two investigators (SQY and NIHA) independently performed literature searches in the aforementioned electronic databases.

The search strategy was developed based on the “Population-Concept-Context” (PCC) framework as recommended by the Joanna Briggs Institute for Scoping Reviews [Jbi. JBI Manual for Evidence Synthesis. JBI Global Wiki. 2024. URL: https://jbi-global-wiki.refined.site/space/MANUAL [accessed 2024-08-04] 32] (Table 1). It aimed to identify the intersection between the “Population,” “Concept,” and “Context.” Based on the PCC framework, the search strategy was “Population combined” AND “Concept” AND “Context.” The details of the search strategy and search terms are tabulated in

Multimedia Appendix 1

Search strategies.

DOCX File , 16 KBMultimedia Appendix 1.

Table 1. The PCCa framework used to generate search terms.
FrameworkSearch terms
Population
Concept
Context
  • Facilitators, barriers, and implementation.

aPCC: Population-Concept-Context.

bLMICs: lower- and middle-income countries

Study Selection

Records were downloaded in Rayyan software (an artificial intelligence–assisted article screening software) [Mehta N, Pandit A, Shukla S. Transforming healthcare with big data analytics and artificial intelligence: a systematic mapping study. J Biomed Inform. Dec 2019;100:103311. [FREE Full text] [CrossRef] [Medline]24] and after deduplication, all titles and abstracts were screened independently against the inclusion criteria by 2 reviewers (SQY and NIHA). Among all titles and abstracts found, 70 out of 279 (25%) were randomly selected and screened to establish interreviewer reliability. The interreviewer reliability (κ) was 0.63, indicating good reliability. Full-text articles of potentially relevant papers identified were screened independently by SQY and NIHA. Disagreements were resolved via discussion, with consultation from a third reviewer (BHC) if needed to reach a consensus. We included studies that met the review criteria and reported on barriers and facilitators of DHT implementation. For this review, DHTs were defined as a set of information and communications technologies used in medicine and health care to manage illnesses and to promote wellness [Ronquillo Y, Meyers A, Korvek S. Digital Health. StatPearls. Treasure Island (FL). StatPearls Publishing; Jan 2025. 10].

Charting the Data

Two authors (SQY and NIHA) independently extracted the following data from the included papers: authors, publication years, study objectives, study countries, disease conditions, types of DHTs, fields of clinical medicine where the DHTs are applied, study designs, sample sizes, characteristics of the study population, study location, and data collection methods of the intervention or program. We categorized the DHTs according to the types of equipment and method of operation. Any disagreements were resolved by discussion and consultation with a third author (BHC).

Collating, Summarizing, and Reporting the Results

Descriptions of the included studies, such as study countries, types of DHTs, fields of clinical medicine where the DHTs are applied, and study designs were reported using descriptive statistics (eg, frequency distribution). Facilitators and barriers to DHT implementation, which were in the form of quantitative and qualitative data, were thematically analyzed using a deductive approach. To guide the thematic analysis, facilitators and barriers to DHT implementation were organized using the Practical, Robust Implementation, and Sustainability Model (PRISM) [Feldstein AC, Glasgow RE. A Practical, Robust Implementation and Sustainability Model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. Apr 2008;34(4):228-243. [CrossRef] [Medline]33].

During the coding process, 2 authors (SQY and NIHA) identified the key components of the PRISM relevant to DHT implementation. They mapped the facilitators and barriers reported in the included studies to the predefined categories and subsequently grouped similar categories under overarching themes. By organizing the facilitators and barriers into themes and categories, patterns, trends, and relationships among the factors influencing DHT implementation can be identified, providing a structured framework for understanding the complexities of implementing DHTs in LMICs’ hospital settings [Naeem M, Ozuem W, Howell K, Ranfagni S. A step-by-step process of thematic analysis to develop a conceptual model in qualitative research. International Journal of Qualitative Methods. Nov 08, 2023;22:22. [CrossRef]34].

Consultation With Stakeholders

Clinicians and information technology (IT) experts from a local teaching hospital were invited to help interpret and contextualize the findings. Through interactive discussions and collaborative sessions, stakeholders provided valuable input on the categorization of facilitators and barriers as well as the implications of implementation of DHTs in their respective contexts. Moving forward, the authors plan to continue engagement with these stakeholders to disseminate the findings of the scoping review through presentations, policy briefs, and peer-reviewed publications.


Literature Search

A systematic search yielded 295 titles and abstracts. After removing 16 duplicates, 279 unique articles remained. Among these, 157 were excluded based on title or abstract review. We thoroughly evaluated 122 full-text articles, and ultimately, 12 met the eligibility criteria. The PRISMA flow diagram was used to illustrate the search decision process of the scoping review [PRISMA Flow Diagram. PRISMA Statement. 2020. URL: https://www.prisma-statement.org/prisma-2020-flow-diagram [accessed 2024-08-04] 35] (Figure 1 and

Multimedia Appendix 2

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.

PDF File (Adobe PDF File), 115 KBMultimedia Appendix 2).

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart. LMIC: lower- and middle-income country.

Characteristics of the Included Studies

Of the 12 articles, 6 (50%) were conducted in Asia [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36-Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41], 4 (33%) in Africa [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42-Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45], 1 (8%) in the Middle East [Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46], and 1 (8%) in South America [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]. Most of the studies (10/12, 83%) [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36,Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37,Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40-Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47] did not specify the specific field of clinical medicine where DHTs were applied. However, some reported implementation in respiratory medicine (1/12, 8%) [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38] and cancer (1/12, 8%) [Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]. Telemedicine (5/12, 42%) [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37,Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38,Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40,Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41,Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46] was the most commonly reported technology, followed by hospital information systems (4/12, 33%) [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36,Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42,Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47], electronic medical records (2/12, 17%) [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43,Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44], and mHealth (1/12, 8%) [Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]. In terms of study design, there were 5 (42%) cross-sectional studies [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37,Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41,Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42,Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44,Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46], 4 (33%) qualitative studies [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38-Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40,Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43], 2 (17%) mixed method studies [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47], and 1 (8%) case study [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]. The participant numbers ranged from 12 to 3386 individuals (Table 2).

Table 2. Overview of the characteristics of the included studies.
Authors and publication yearsStudy details

Objective(s)CountryDisease conditionTypes of DHTsaField of clinical medicineDesignSample sizes and characteristics of the populationLocationData collection method
Abdulai et al [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]To investigate the attitudes, opportunities, and challenges in using health information system.IndiaGeneralHealth information systemGeneralCase study20 health care providers and managersApollo Hospital and Medanta HospitalSelf-administered questionnaire
Alboraie et al [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]To assess the usefulness of telemedicine and the different barriers hindering its utilization.EgyptGeneralTelemedicineGeneral medicine, surgery, and radiologyCross-sectional study642 health care providersAll hospitals across EgyptOnline self-administered questionnaire
Baradwan and Al-Hanawi [Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46]To gain a holistic understanding of the perceptions and barriers of the end users (participants) toward the utility of telemedicine.Saudi ArabiaGeneralTelemedicineGeneralCross-sectional study1024 individualsNationwideSelf-administered questionnaire
Jiang et al [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]To explore the perceptions and experiences of older patients and health care providers in the application of telehealth and online health information to chronic disease management of chronic obstructive pulmonary disease.ChinaChronic obstructive pulmonary diseaseTelemedicineRespiratory medicineQualitative31 older patients with chronic obstructive pulmonary disease and 23 health care providersA community hospital in Jiangnan, ChinaIn-depth interviews
Mekuria et al [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]To assess the level of health information system utilization among health professionals in public health facilities.EthiopiaGeneralHealth information systemGeneralCross-sectional study378 health care providersDire Dawa Administration in eastern EthiopiaSelf-administered questionnaire
Mussi et al [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]To understand the implementation of a hospital information system in university hospitals.BrazilGeneralHealth information systemGeneralExploratory mixed methods770 health managers (24 in in-depth interviews, 10 in focus group discussions, and 736 in cross-sectional study)5 university hospitals in BrazilInterviews, focus group discussions, questionnaires, and documentary research
Ngugi et al [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]To explore end users’ perceptions and experiences on factors facilitating and hindering electronic medical record use in health care facilities.KenyaGeneralElectronic medical recordGeneralQualitative20 health care providers20 health care facilities in KenyaFocus group discussion
Ning et al [Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]To explore the needs and perceptions of patients with head and neck cancer regarding mobile health–based physical activity programs.ChinaHead and neck cancerMobile healthENTbQualitative17 patients diagnosed with head and neck cancerFirst Hospital of Shanxi Medical University, Taiyuan, ChinaIn-depth interviews
Shardha et al [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]To explore the view of health care professionals regarding the benefits, challenges, and prospects of telemedicine to address the gap that hinders its effective use in the rural areas.PakistanGeneralTelemedicineNonsurgical disciplinesQualitative (narrative)12 health care providersTwo tertiary hospitals in Sindh, PakistanIn-depth interviews
Tesfa et al [Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]To assess the level of electronic health record utilization and associated factors among health care professionals at teaching hospitals.EthiopiaGeneralElectronic medical recordGeneralCross-sectional study383 health care providersUniversity of Gondar Specialized Teaching Hospital and Tibebe Ghion Specialized Teaching HospitalSelf-administered questionnaire
Tilahun et al [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45]To evaluate the outcomes and share experiences of working with universities to strengthen the national health information system.EthiopiaGeneralHealth information systemGeneralMixed methods study23 health care providers47 health care organizations in EthiopiaIn-depth interviews
Yu-Tong et al [Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41]To assess telehealth readiness among clinical nurses and explore the factors that affect their telehealth readiness.ChinaGeneralTelemedicineGeneralCross-sectional study3386 nurses19 hospitals in China Self-administered questionnaire

aDHT: digital health technology.

bENT: ear, nose, and throat.

Facilitators and Barriers to DHT Implementation

Among the 12 studies, 9 explored both the facilitators and barriers to implementing DHTs in hospital settings in LMICs since the onset of COVID-19 [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36-Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40,Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43-Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]. Two studies focused solely on facilitators [Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41,Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42], while 1 solely addressed barriers [Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46]. A total of 63 facilitators and 44 barriers were identified. Subsequently, these facilitators and barriers were systematically organized into 6 themes according to the PRISM, which include the following: (1) Aspects of the Health Care System; (2) Perspectives of Patients; (3) External Environment; (4) Implementation of Sustainable Infrastructure; (5) Characteristics of Health Care Organization; and (6) Characteristics of Patients. These are outlined in Table 3.

Table 3. Facilitators and barriers to DHTa implementation in hospital settings in lower- and middle-income countries after the COVID-19 pandemic.
Themes and categoriesCodes for facilitatorsCodes for barriers
Aspects of the Health Care System (nb=11)


Readiness (nfc=4; nbd=3)
  • Understand the basics of information technology [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • Knowledge in protecting data confidentiality [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • High level of self-efficacy [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • Good attitude toward DHTs [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • High awareness about the implementation of DHTs [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • High personal interest and motivation [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • The high willingness of health care providers to provide DHTs for patients [Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41]
  • Inadequate awareness regarding DHTs [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40,Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
  • Feeling that DHTs are only complementary to traditional health care [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • Preference of some health care providers for printed materials [Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
Strength of the evidence base (nf=1; nb=2)
  • The ability of DHTs to offer statistical analysis and reports for decision-making [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]
  • The ability of DHTs to offer timely and up-to-date patient information [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]
  • Concerns regarding accuracy in disease diagnosis and treatment [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40,Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46]
Addresses barriers to frontline staff (nf=1; nb=2)
  • Easy access to computers in the working area [Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
  • Fear of inappropriate data protection might breach patient’s privacy [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • Inadequate computers at the workplace and service point local area network at the workplace [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
Coordination across departments and specialties (nf=1; nb=1)
  • Use of single information technology policy and standard hospital information system [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Lack of interoperability standards between systems [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
Burden (complexity and cost; nf=4; nb=1)
  • Perceive that operations of DHTs are not complex [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • The availability of information technology budget [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Regular upgrades on DHT hardware [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
  • Funding support focusing on research and learning opportunities on DHTs [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45]
  • The need for retrospective data entry into systems [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
Usability and adaptability (nf=4; nb=3)
  • The ability of DHTs to prevent cross-infection [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38,Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • Ability to provide health care in remote areas [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • The functionalities of DHTs align with hospital’s practices [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • User-friendliness of DHTs [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
  • Difficulty in performing physical examination with DHTs [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • Lack of compliance among health care professionals and patients [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • DHTs might reduce the quality of medical services by increasing the probability of medical mistakes [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • Perceive DHTs as research agenda only [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45]
  • Some DHTs are not user-friendly [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]
Trialability and reversibility (nf=1; nb=0)
  • Conduct beta tests and pilot tests before implementation of DHTs [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • N/Ae
Ability to observe results (nf=3; nb=0)
  • Positive previous experiences using DHTs [Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • The ability of DHTs to increase administrative and health care efficiency [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]
  • The ability of DHTs to reduce medication errors [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]
  • N/A
Perspectives of Patients (n=5)


Patient centeredness (nf=1; nb=1)
  • Using technology gives a superior feeling [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • Repeated motivational or praising words increase patients’ usage of DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • The feeling of the distance between the patient and health care providers during remote interaction [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • The feeling of being forced to use DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
Addresses patient barriers (nf=1; nb=1)
  • Involvement of patients’ children could improve the efficiency and effectiveness of DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • Patients’ resistance to change practice [Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46]
Seamlessness of transition between program elements (nf=1; nb=0)
  • Unification of hospitals in a single network and centralized management [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • N/A
Service and access (nf=1; nb=0)
  • Easy access to online health information and applying the knowledge [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • N/A
Burden (complexity and cost; nf=2; nb=0)
  • The ability of DHTs to reduce stress among patients [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • DHTs are cost-effective [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • N/A
Feedback of results (nf=2; nb=0)
  • DHTs are easy and convenient to use [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38,Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]
  • DHTs are able to improve the comfort level of patients [Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]
  • N/A
External Environment (n=3)


Competition (nf=0; nb=2)
  • N/A
  • Competition for resources between information technology equipment and other health care equipment [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
Regulatory environment (nf=1; nb=2)
  • Good communication process between the regulatory authority and the hospitals [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Political and economic instabilities [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
Community resources (nf=1; nb=0)
  • Good internet access among users of DHTs [Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
  • N/A
Implementation of Sustainable Infrastructure (n=5)


Adopter training and support (nf=1; nb=0)
  • Familiarity with handling DHT tools [Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • N/A
Relationship and communication with adopters (nf=0; nb=1)
  • N/A
  • The communication gap between supervisors and supervisees [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45]
Adaptable protocols and procedures (nf=1; nb=0)
  • Remote health service can be carried out easily among clinicians [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • N/A
Facilitation of sharing of best practices (nf=1; nb=0)
  • Experience sharing between advanced and beginner hospitals [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • N/A
Plan for sustainability (nf=1; nb=1)
  • Health care facilities prioritize the implementation and sustainability of DHTs [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • The end of the COVID-19 pandemic reduced the demand for DHTs [Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46]
Characteristics of the Health Care Organization (n=11)


Organizational health and culture (nf=3; nb=1)
  • The availability of fair-to-good organizational support [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • Commitment from the top management or managers [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Top management mandates the adoption of DHTs [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Promote experience and knowledge sharing among hospital networks [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • A workplace culture that is receptive to change [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Understand the policies made by the government [Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41]
  • Frequent changes in the hospital management team [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Lack of medium- and long-term information technology policy planning [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
Management support and communication (nf=2; nb=1)
  • Presence of supervision at the workplace [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • The availability of fair-to-good technical support [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • Provision of support to groups with little knowledge of technology [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Lack of planning and implementation of system design [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
Shared goals and cooperation (nf=2; nb=1)
  • The information technology department of the hospital is directly linked to local information technology sectors [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Create a multidisciplinary management committee [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Partnership with universities to develop DHTs [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45]
  • Health care providers’ resistance to change practice [Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]46]
Clinical leadership (nf=1; nb=1)
  • High level of decision-making autonomy in the workplace [Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]42]
  • Weak leadership and poor commitment at the hospital level [Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]45]
Systems and training (nf=3; nb=5)
  • The workplace has sufficient facilities [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • The availability of continuous on-the-job training [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37,Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Regular system upgrades [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
  • The availability of prompt technical assistance from desk support [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
  • Lack of training in advanced technologies [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36,Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]40]
  • Delays in system development, implementation, and updates [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Frequent power blackouts [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
  • Poor electrical power and backup facilities [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36]
  • Lack of skill among health care providers in accessing and using DHTs [Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
Data and decision support (nf=2; nb=2)
  • The availability of 24-hour technical support services at the workplace [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • Centralization of system development and technical support [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Lack of contingency plan for DHTs [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Delayed information technology support [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
Staffing and incentives (nf=3; nb=3)
  • Workplace has sufficient trained personnel in DHTs [Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]37]
  • Improved financing of human and material resources [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Sufficient human resource allocation [Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]41]
  • Lack of incentives for health care providers to use DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • High staff turnover rate, work overload, and reduced staffing [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43,Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
  • Health care providers who are old aged [Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]43]
Expectation of sustainability(nf=0; nb=3)
  • N/A
  • Health care providers do not have sufficient time and energy to participate and offer timely feedback while using DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38,Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
  • Unrealistic expectations toward DHTs [Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]47]
Characteristics of patients (n=4)


Demographics (nf=0; nb=2)
  • N/A
  • Older patients contemplated using and have low confidence in DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • Personal inertia and the conservative mentality of the older generation [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • Costs of accessing the internet beyond affordability for patients from lower socioeconomic status [Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]
  • Poor cellular network connectivity and internet access in some geographical areas [Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]
Knowledge and beliefs (nf=2; nb=4)
  • Confidence to learn, engage, and sustainably participate in DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • High eHealth and computer literacy among patients [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38,Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
  • High information-searching skills among patients [Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]44]
  • Patients have poor digital literacy and skills in DHTs [Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]36,Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38,Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]39]
  • Patients have skepticism about the accuracy of remote diagnosis [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]
  • Social prejudice against DHTs [Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]38]

aDHT: digital health technology.

bn: number of studies in general.

cnf: number of studies that reported on facilitators.

dnb: number of studies that reported on barriers.

eN/A: not applicable.

Specifically, the theme of Aspects of the Health Care System included 23 facilitators and 13 barriers (n=11 studies). Among the prominent facilitators were the ability of DHTs to prevent cross-infection (n=2) and positive previous experiences using DHTs (n=2). By contrast, inadequate awareness regarding DHTs (n=2) and concerns regarding accuracy in disease diagnosis and treatment (n=2) were the leading barriers highlighted.

Regarding the theme of Perspectives of Patients, 9 facilitators and 3 barriers were reported (n=5 studies). Among these, the convenience and easiness of using DHTs (n=2) were noted as the primary facilitator. However, the feeling of distance between the patient and health care providers during remote interaction (n=1), the feeling of being forced to use DHTs (n=1), and patients’ resistance to change practice could pose challenges to the implementation of DHTs in hospital settings within LMICs.

The successfulness of implementing DHTs also relies on the theme of External Environment (n=3 studies). Within this context, 2 facilitators are aiding the implementation, which include a good communication process between the regulatory authority and the hospitals (n=1) and good internet access among users of DHTs (n=1). Among the 2 barriers identified in this context, competition for resources between IT equipment and other health care equipment (n=2) stands out as the more prevalent barrier.

The theme of Implementation of Sustainable Infrastructure comprises 4 facilitators and 2 barriers (n=5 studies). Notably, familiarity with handling DHTs tools (n=1), the ease of conducting remote health service among clinicians (n=1), and experience sharing between advanced and beginner hospitals (n=1) emerge as facilitators for DHT implementation. Conversely, barriers in this theme include the communication gap between stakeholders (n=1) and the end of the COVID-19 pandemic reducing the demand for DHTs (n=1).

The Characteristics of Health Care Organization theme consists of 22 facilitators and 17 barriers to DHT implementation (n=11 studies). Previous studies have highlighted the availability of continuous on-the-job training (n=3) as the most frequent facilitator of DHT implementation in the health care organization. Conversely, barriers such as lack of trainings in advanced technologies (n=2); delays in system development, implementation, and updates (n=2); high staff turnover rate, work overload, and reduced staffing (n=2); as well as insufficient time and energy among health care providers to participate and offer timely feedback while using DHTs (n=2) prevent the implementation of DHTs.

The Characteristics of Patients was the final theme that could influence the successfulness of DHT implementation in LMICs’ hospital settings. It comprised 3 facilitators and 7 barriers (n=4 studies). Notably, the most frequently mentioned facilitator in this theme is the high eHealth and computer literacy among patients (n=2). Not surprisingly, the exact opposite, that is, patients with poor digital literacy and skills in DHTs (n=3), is reported as the commonest barrier.

The relationship between codes, categories, and themes of facilitators and barriers to DHT implementation is summarized in Figure 2, in which the codes and categories are arranged from the most frequent (top) to the least frequent (bottom).

Figure 3 illustrates the network analysis of the facilitators of DHT implementation. Of note, facilitators such as “Perspectives of Patients” and “Aspect of the Health Care System” are central to the network. This suggests their broad impact across multiple domains, making them key intervention points for DHT implementation. Although no obvious clusters were observed, the interconnectedness suggests that addressing certain facilitators (eg, “Perspectives of Patients,” “Aspect of the Health Care System,” and “Characteristics of the Health Care Organization”) can have ripple effects on others. Figure 4 illustrates the network analysis of the barriers to DHT implementation. It was noted that some barriers are more central, such as the “Characteristics of Health Care Organizations,” “Aspect of the Health Care System,” “Implementation of Sustainable Infrastructure,” and “Characteristics of Patients” barriers, highlighting their pivotal roles in the network. These central barriers act as key influencers and bridge multiple barriers. Meanwhile, the “External Environment” and “Perspectives of Patients” barriers are more toward the periphery and, hence, have less impact on the network. A cluster was observable in the network analysis, involving the “Characteristics of Health Care Organization” and “Aspect of the Health Care System” barriers. Many barriers are interconnected, which indicate that addressing one (eg, “Characteristics of Health Care Organizations”) may alleviate others. However, it should be noted that some nodes, such as “Readiness” and “Usability and Adaptability,” can be both facilitators of and barriers to DHT implementation, and hence, can appear in both network analyses.

Since the onset of the COVID-19 pandemic, the most commonly utilized DHTs in LMICs’ hospitals were telemedicine, followed by health information systems, electronic medical records, and mHealth, as depicted in Figure 5.

Figure 2. Summary of the codes, categories, and themes of facilitators and barriers of digital health technology (DHT) implementation. IT: information technology; LAN: local area network.
Figure 3. Network analysis to illustrate the relationship between the codes of facilitators of digital health technologies (DHTs) implementation in lower- and middle-income countries' (LMICs) hospital settings since the onset of the COVID-19 pandemic.
Figure 4. Network analysis to illustrate the relationship between the codes of barriers of digital health technologies (DHTs) implementation in lower- and middle-income countries' (LMICs') hospital settings in the post-COVID-19 era. IT: information technology; LAN: local area network.
Figure 5. Digital health technologies (DHTs) in the lower- and middle-income countries (LMICs) since the onset of the COVID-19 pandemic.

Facilitators of and Barriers to DHT Implementation in LMICs

The most common facilitators of DHT implementation include the convenience and easiness of using DHTs, the ability of DHTs to prevent cross-infection, positive previous experiences using DHTs, the availability of continuous on-the-job training, and high eHealth and computer literacy among patients. By contrast, we identified that the most frequently reported barriers are inadequate awareness regarding DHTs; concerns regarding accuracy in disease diagnosis and treatment; competition for resources between IT equipment and other health care equipment; lack of trainings in advanced technologies; delays in system development, implementation, and updates; high staff turnover rate, work overload, and reduced staffing; insufficient time and energy among health care providers to use DHTs; and patients with poor digital literacy and skills in DHTs.

To our knowledge, this scoping review is the first to examine the facilitators and barriers to implementing DHTs in hospitals within LMICs since the onset of the COVID-19 pandemic. It is important to note the scarcity of published literature on this topic in LMICs. Even existing reviews often focused on studies from high-income countries or concentrated on specific diseases [Whitelaw S, Pellegrini D, Mamas M, Cowie M, Van Spall HGC. Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. Eur Heart J Digit Health. Mar 04, 2021;2(1):62-74. [FREE Full text] [CrossRef] [Medline]27,Borges do Nascimento IJ, Abdulazeem H, Vasanthan LT, Martinez EZ, Zucoloto ML, Østengaard L, et al. Barriers and facilitators to utilizing digital health technologies by healthcare professionals. NPJ Digit Med. Sep 18, 2023;6(1):161-128. [FREE Full text] [CrossRef] [Medline]48,Berardi C, Antonini M, Jordan Z, Wechtler H, Paolucci F, Hinwood M. Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework. BMC Health Serv Res. Feb 26, 2024;24(1):243. [FREE Full text] [CrossRef] [Medline]49]. For example, a systematic review by Whitelaw et al [Whitelaw S, Pellegrini D, Mamas M, Cowie M, Van Spall HGC. Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. Eur Heart J Digit Health. Mar 04, 2021;2(1):62-74. [FREE Full text] [CrossRef] [Medline]27], comprising 29 studies, investigated DHT implementation in cardiovascular diseases predominantly in high-income countries. As expected, the facilitators and barriers identified in this review significantly differed from our findings. Whitelaw et al highlighted facilitators such as enhanced communication with clinicians, personalized DHT components, user-friendly interfaces, institutional and organizational support, increased efficiency, and perceived usefulness of DHTs. The reported barriers were complex technology, technological apprehension, increased workload, unreliable technology, and lack of integration with electronic medical records. These discrepancies may stem from various factors such as differences in health care infrastructure [Mumtaz H, Riaz MH, Wajid H, Saqib M, Zeeshan MH, Khan SE, et al. Current challenges and potential solutions to the use of digital health technologies in evidence generation: a narrative review. Front Digit Health. Sep 28, 2023;5:1203945. [FREE Full text] [CrossRef] [Medline]50], socioeconomic contexts [Chidambaram S, Jain B, Jain U, Mwavu R, Baru R, Thomas B, et al. An introduction to digital determinants of health. PLOS Digit Health. Jan 2024;3(1):e0000346. [FREE Full text] [CrossRef] [Medline]51], health care financing [Sambo L, Simões J, do Rosario O, Martins M. Firth JD, Conlon CP, Cox TM, Firth J, Conlon C, Cox T, editors. Financing Health Care In Low-Income Developing Countries: A Challenge For Equity In Health. Oxford, UK. Oxford University Press; Jan 2020:168-176.52], as well as costs of DHT development and implementation [Sureshkumar K, Bindu M, John S, Kamarul IM. Editorialvidence on low-cost technologies for neurological rehabilitation in low and middle-income countries. Frontiers in Neurology. 2023. :14.53] between high-income and LMIC settings. Additionally, the focus on specific diseases in previous literature might not fully capture the diverse facilitators and barriers relevant to DHT implementation across various health care contexts.

DHTs That Have Been Implemented

To our surprise, telemedicine was the most commonly reported technology implemented in hospital settings since the onset of the COVID-19 pandemic, exceeding other DHTs such as hospital information systems, electronic medical records, and mHealth. This can be understood by the fact that telemedicine is well-suited for health care providers and patients who are self-isolating, as it effectively reduces the risk of COVID-19 transmission. It eliminates the need for direct physical contact, ensures ongoing care for the community, and ultimately lowers the rates of illness and death during the COVID-19 pandemic [Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. Aug 01, 2020;20(1):1193. [CrossRef] [Medline]54].

Classification Framework for DHT Implementation in LMICs

Despite the emergence of various innovative technologies such as wearable technologies, metaverse, Internet of Medical Things, blockchain in health care, big data analytics, artificial intelligence, machine learning, software as medical devices, augmented reality, and virtual reality, the implementation of DHTs in hospitals within LMICs remains rudimentary compared with high-income countries. The current utilization of DHTs in LMICs, such as telemedicine, hospital information systems, electronic medical records, and mHealth, has informed the key components of a new classification framework that emphasizes LMICs. Based on recent literature [Huhn S, Axt M, Gunga H-C, Maggioni MA, Munga S, Obor D, et al. The impact of wearable technologies in health research: scoping review. JMIR Mhealth Uhealth. Jan 25, 2022;10(1):e34384. [FREE Full text] [CrossRef] [Medline]13,Belle A, Thiagarajan R, Soroushmehr SMR, Navidi F, Beard DA, Najarian K. Big data analytics in healthcare. Biomed Res Int. 2015;2015:370194. [FREE Full text] [CrossRef] [Medline]15,Yoon H-J. Blockchain technology and healthcare. Healthc Inform Res. Apr 2019;25(2):59-60. [FREE Full text] [CrossRef] [Medline]17-Sarker IH. Machine learning: algorithms, real-world applications and research directions. SN Comput Sci. Mar 2021;2(3):160. [FREE Full text] [CrossRef] [Medline]23,Huang C, Wang J, Wang S, Zhang Y. Internet of medical things: A systematic review. Neurocomputing. 2023. :557. [CrossRef]55] and the specific facilitators and barriers to utilizing these DHTs in LMICs, we propose a classification framework of DHTs, as illustrated in Figure 6.

Figure 6. Classification framework of digital health technologies (DHTs). LMIC: lower- and middle-income country.

This classification framework is justified by the fact that simpler DHTs, such as telemedicine, hospital information systems, electronic medical records, and mHealth, are easier to implement in LMICs due to lower costs and infrastructure requirements, adaptability to limited resources, and minimal training needs. These technologies rely mainly on basic internet connectivity, mobile devices, and computers, making them more accessible and feasible given the broader availability of mobile networks in LMICs. They also integrate easily into existing health care workflows, requiring only short training sessions and basic digital literacy. Furthermore, because LMICs prioritize addressing immediate health care needs such as infectious diseases, these accessible technologies receive more support and funding. By contrast, advanced technologies such as artificial intelligence, virtual reality, and blockchain demand specialized infrastructure, technical expertise, and substantial financial resources, which are often scarce in LMICs.

This proposed classification framework also consists of other DHTs that were implemented in high-income countries. This, hopefully, will aid health care stakeholders in LMICs to delineate the scope of DHTs in LMICs and help them to prioritize the right DHTs that could be implemented in the scarcity of resources. Consequently, policy makers can allocate health care funding (eg, the Ministry of Health can determine the DHT classes that are eligible for subsidies), and insurers can reimburse patients who utilized DHTs (ie, identifying which DHT classes can be covered by insurance policies) [National Institute for Health and Care Excellence (NICE). Evidence standards framework for digital health technologies. NICE. Mar 2019. URL: https:/​/www.​nice.org.uk/​about/​what-we-do/​our-programmes/​evidence-standards-framework-for-digital-health-technologies [accessed 2025-02-11] 56,Functional classification, according to their intended use, of digital solutions used in the context of medical and paramedical care. Haute Autorité de Santé. 2021. URL: https:/​/www.​has-sante.fr/​upload/​docs/​application/​pdf/​2021-03/​dm_eval_270_proposition_classification.​pdf [accessed 2024-08-04] 57]. Moreover, clear and effective communication among the public, health care providers, and technology experts can be facilitated [Functional classification, according to their intended use, of digital solutions used in the context of medical and paramedical care. Haute Autorité de Santé. 2021. URL: https:/​/www.​has-sante.fr/​upload/​docs/​application/​pdf/​2021-03/​dm_eval_270_proposition_classification.​pdf [accessed 2024-08-04] 57,World Health Organization (WHO). Classification of digital health interventions v1. WHO. 2018. URL: https://iris.who.int/bitstream/handle/10665/260480/WHO-RHR-18.06-eng.pdf?sequence=1 [accessed 2024-08-04] 58]. Legally, a defined classification framework enables authorities to regulate and govern DHT usage [World Health Organization (WHO). Classification of digital health interventions v1. WHO. 2018. URL: https://iris.who.int/bitstream/handle/10665/260480/WHO-RHR-18.06-eng.pdf?sequence=1 [accessed 2024-08-04] 58,Food and Drug Administration (FDA). Digital Health Center of Excellence. FDA. 2024. URL: https://www.fda.gov/medical-devices/digital-health-center-excellence [accessed 2024-08-04] 59]. Finally, a clearly outlined classification framework for DHTs may streamline implementation, especially in resource-scarce environments, as stakeholders can prioritize which DHT classes should be implemented [National Institute for Health and Care Excellence (NICE). Evidence standards framework for digital health technologies. NICE. Mar 2019. URL: https:/​/www.​nice.org.uk/​about/​what-we-do/​our-programmes/​evidence-standards-framework-for-digital-health-technologies [accessed 2025-02-11] 56].

Strengths and Limitations

This scoping review possesses several notable strengths. Initially, we comprehensively gathered data from a diverse array of databases, including gray literature sources such as Google Scholar. This deliberate choice was made to ensure the inclusivity and robustness of the studies included. Additionally, during the planning phase of the review, we actively engaged relevant stakeholders, including information technologists, seeking and incorporating their feedback into the review protocol. Furthermore, in structuring and categorizing the identified barriers and facilitators, we utilized a conceptual model developed by Feldstein and Glasgow [Feldstein AC, Glasgow RE. A Practical, Robust Implementation and Sustainability Model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. Apr 2008;34(4):228-243. [CrossRef] [Medline]33], thereby enhancing the analytical rigor of the review. Moreover, our review offers a wealth of qualitative and quantitative insights into the implementation of DHTs, providing comprehensive guidance for stakeholders interested in implementing DHTs within their respective settings.

Despite its strengths, our review does have certain limitations. Specifically, in focusing on identifying barriers and facilitators of DHT implementation in hospital settings within LMICs, we restricted our inclusion criteria to studies conducted solely within hospitals. Consequently, many studies providing insights from primary care and community perspectives were excluded. Additionally, studies that did not explicitly address facilitators and barriers were omitted, potentially overlooking valuable information on other beneficial DHTs for patient care. Furthermore, as our primary aim was to offer an overview of existing literature on DHTs, we did not apply any quality control measures to the included studies. The variation in analytical methods, interview questions, and study populations across the included papers presents a potential inconsistency in the findings and makes quality assessment difficult. Additionally, with 128 LMICs at the time of the literature search, listing each country by name in the search string was impractical, which could result in some LMICs not being captured in the search results.

Implications and Recommendations

Understanding the facilitators and barriers to DHTs in hospital settings of LMICs has profound implications for both clinical practice and research. Identifying facilitators of DHT implementation enables the effective integration of DHTs in hospitals, leading to improved diagnostic accuracy, better patient monitoring, improved patient records management, and the availability of remote health care services. Conversely, recognizing the barriers to DHT implementation can prompt various stakeholders in LMICs to devise strategies that address issues in terms of financial resources, technological infrastructure, and knowledge among health care providers. In terms of research, this review is hoped to promote international collaborations, governmental support, and investment in digital infrastructure, which in turn boost the capacity for data collection, analysis, and sharing. These advancements can enhance research capabilities, allowing for more comprehensive epidemiological studies, real-time disease monitoring, and the development of context-specific health interventions.

To maximize the benefits of DHTs in hospital settings in LMICs, several recommendations can be made to leverage facilitators and mitigate barriers. First, the convenience and ease of using DHTs should be emphasized through user-friendly interfaces and intuitive designs, ensuring that health care providers can quickly and efficiently adopt these technologies in their daily routines. Second, the role of DHTs in preventing cross-infection should be highlighted in training programs and awareness campaigns, particularly in regions where infectious diseases are prevalent. Positive previous experiences with DHTs should be shared widely to build trust and demonstrate the tangible benefits of these technologies. Continuous on-the-job training must be provided to keep health care workers up-to-date with the latest advancements and best practices, while also enhancing their technical proficiency. Promoting high eHealth and computer literacy among patients through community outreach and education programs will further support the effective use of DHTs.

Addressing barriers requires a multifaceted approach. To tackle inadequate awareness and concerns regarding the accuracy of DHTs, it is crucial to implement comprehensive educational initiatives that highlight the reliability and clinical efficacy of these technologies. Clear, evidence-based information should be disseminated to health care providers and patients to build confidence in DHTs. Competition for resources between IT equipment and other health care tools can be mitigated by advocating for balanced budget allocations and seeking external funding or partnerships to supplement resources. Training programs in advanced technologies must be expanded to equip health care providers with the necessary skills to use DHTs effectively. To address delays in system development and implementation, streamlined processes and timelines should be established, with dedicated project management teams overseeing these initiatives. High staff turnover rates and work overload can be managed by improving working conditions, offering competitive salaries, and providing career development opportunities. Finally, enhancing digital literacy among patients through targeted educational programs will ensure that they can engage with DHTs effectively, ultimately leading to better health outcomes. By implementing these recommendations, LMICs can overcome barriers and fully harness the potential of DHTs to improve clinical practice and advance health care research.

Conclusions

The scoping review on DHT implementation in LMICs since the onset of the COVID-19 pandemic underscores significant policy, clinical, and research implications. Policy makers can utilize the insights to craft targeted strategies for DHT adoption, while the developed classification framework aids in prioritizing DHTs. In clinical settings, understanding DHT types, facilitators, and barriers enhances decision-making for improved patient care and resource optimization. Additionally, investing in capacity building and training programs for health care professionals is crucial, with a focus on enhancing digital literacy and technical skills. Moreover, identifying research priorities and aligning funding with key challenges such as improving digital literacy and addressing concerns about DHT accuracy will drive advancements in DHT implementation and health care delivery in LMICs.

In the postpandemic era, telemedicine has been widely used in hospital settings in LMICs, among other DHTs. Our findings also reveal numerous facilitators and barriers to DHT implementation in LMIC hospital settings. These factors can be organized into 6 themes, namely, (1) Aspects of the Health Care System; (2) Perspectives of Patients; (3) External Environment; (4) Implementation of Sustainable Infrastructure; (5) Characteristics of Health Care Organization; and (6) Characteristics of Patients.

Acknowledgments

We acknowledge the contributions of the information technologist at the library of Universiti Putra Malaysia for the provision of technical and intellectual assistance during the literature search.

Data Availability

All data retrieved and analyzed are included in this scoping review.

Authors' Contributions

SQY and BHC developed the concept for the scoping review. SQY and DT were involved in designing the research methodology. NIHA and SQY carried out an extensive literature review to identify relevant frameworks and methodological approaches for the scoping review. SQY prepared the initial draft of the review.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Search strategies.

DOCX File , 16 KB

Multimedia Appendix 2

The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist.

PDF File (Adobe PDF File), 115 KB

  1. World Health Organization (WHO). Tracking universal health coverage: 2023 global monitoring report. WHO. Geneva, Switzerland. WHO; Sep 18, 2023. URL: https://www.who.int/publications/i/item/9789240080379 [accessed 2024-02-10]
  2. Shah SA, Safian N, Ahmad S, Nurumal SR, Mohammad Z, Mansor J, et al. Unmet healthcare needs among elderly Malaysians. JMDH. Oct 2021;Volume 14:2931-2940. [CrossRef]
  3. Njagi P, Arsenijevic J, Groot W. Cost-related unmet need for healthcare services in Kenya. BMC Health Serv Res. Apr 17, 2020;20(1):322. [FREE Full text] [CrossRef] [Medline]
  4. Sohn M, Che X, Park H-J. Unmet healthcare needs, catastrophic health expenditure, and health in South Korea's universal healthcare system: progression towards improving equity by NHI type and income level. Healthcare (Basel). Oct 16, 2020;8(4):408. [FREE Full text] [CrossRef] [Medline]
  5. Baek S, Choi E-H, Lee J. Unmet healthcare needs of children in vulnerable families in South Korea: finding from the Community Child Center Child Panel Survey. Int J Environ Res Public Health. Nov 07, 2020;17(21):8241. [FREE Full text] [CrossRef] [Medline]
  6. Kim J, You M, Shon C. Impact of the COVID-19 pandemic on unmet healthcare needs in Seoul, South Korea: a cross-sectional study. BMJ Open. Aug 26, 2021;11(8):e045845. [FREE Full text] [CrossRef] [Medline]
  7. Harris RB, Cormack DM, Stanley J. Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey. Aust N Z J Public Health. Feb 2019;43(1):75-80. [FREE Full text] [CrossRef] [Medline]
  8. Rosenthal A, Waitzberg R. The challenges brought by the COVID-19 pandemic to health systems exposed pre-existing gaps. Health Policy Open. Dec 2023;4:100088. [CrossRef] [Medline]
  9. Mitgang EA, Blaya JA, Chopra M. Digital health in response to COVID-19 in low- and middle-income countries: opportunities and challenges. Glob Policy. Jul 2021;12(Suppl 6):107-109. [CrossRef] [Medline]
  10. Ronquillo Y, Meyers A, Korvek S. Digital Health. StatPearls. Treasure Island (FL). StatPearls Publishing; Jan 2025.
  11. Istepanian RSH. Mobile health (m-Health) in retrospect: the known unknowns. Int J Environ Res Public Health. Mar 22, 2022;19(7):3747. [FREE Full text] [CrossRef] [Medline]
  12. Roy J, Levy DR, Senathirajah Y. Defining telehealth for research, implementation, and equity. J Med Internet Res. Apr 13, 2022;24(4):e35037. [FREE Full text] [CrossRef] [Medline]
  13. Huhn S, Axt M, Gunga H-C, Maggioni MA, Munga S, Obor D, et al. The impact of wearable technologies in health research: scoping review. JMIR Mhealth Uhealth. Jan 25, 2022;10(1):e34384. [FREE Full text] [CrossRef] [Medline]
  14. Ibrahim AA, Ahmad Zamzuri M'I, Ismail R, Ariffin AH, Ismail A, Muhamad Hasani MH, et al. The role of electronic medical records in improving health care quality: a quasi-experimental study. Medicine (Baltimore). Jul 29, 2022;101(30):e29627. [FREE Full text] [CrossRef] [Medline]
  15. Belle A, Thiagarajan R, Soroushmehr SMR, Navidi F, Beard DA, Najarian K. Big data analytics in healthcare. Biomed Res Int. 2015;2015:370194. [FREE Full text] [CrossRef] [Medline]
  16. Dwivedi R, Mehrotra D, Chandra S. Potential of Internet of Medical Things (IoMT) applications in building a smart healthcare system: a systematic review. J Oral Biol Craniofac Res. Mar 2022;12(2):302-318. [FREE Full text] [CrossRef] [Medline]
  17. Yoon H-J. Blockchain technology and healthcare. Healthc Inform Res. Apr 2019;25(2):59-60. [FREE Full text] [CrossRef] [Medline]
  18. Petrigna L, Musumeci G. The metaverse: a new challenge for the healthcare system: a scoping review. J Funct Morphol Kinesiol. Aug 30, 2022;7(3):63. [FREE Full text] [CrossRef] [Medline]
  19. Yu J, Zhang J, Sengoku S. Innovation process and industrial system of US Food and Drug Administration–approved software as a medical device: review and content analysis. J Med Internet Res. Nov 24, 2023;25:e47505. [FREE Full text] [CrossRef] [Medline]
  20. Eckert M, Volmerg JS, Friedrich CM. Augmented reality in medicine: systematic and bibliographic review. JMIR Mhealth Uhealth. Apr 26, 2019;7(4):e10967. [FREE Full text] [CrossRef] [Medline]
  21. Halbig  A, Babu  S, Gatter  S, Latoschik  M, Brukamp K, von Mammen  S. Opportunities and challenges of virtual reality in healthcare – a domain experts inquiry. Front Virtual Real. Mar 23, 2022;3:3. [CrossRef]
  22. Xu Y, Liu X, Cao X, Huang C, Liu E, Qian S, et al. Artificial intelligence: a powerful paradigm for scientific research. Innovation (Camb). Nov 28, 2021;2(4):100179. [FREE Full text] [CrossRef] [Medline]
  23. Sarker IH. Machine learning: algorithms, real-world applications and research directions. SN Comput Sci. Mar 2021;2(3):160. [FREE Full text] [CrossRef] [Medline]
  24. Mehta N, Pandit A, Shukla S. Transforming healthcare with big data analytics and artificial intelligence: a systematic mapping study. J Biomed Inform. Dec 2019;100:103311. [FREE Full text] [CrossRef] [Medline]
  25. Yin J, Ngiam KY, Teo HH. Role of artificial intelligence applications in real-life clinical practice: systematic review. J Med Internet Res. Apr 22, 2021;23(4):e25759. [FREE Full text] [CrossRef] [Medline]
  26. Iyamu I, Gómez-Ramírez O, Xu AX, Chang H-J, Watt S, Mckee G, et al. Challenges in the development of digital public health interventions and mapped solutions: findings from a scoping review. Digit Health. 2022;8:20552076221102255. [CrossRef] [Medline]
  27. Whitelaw S, Pellegrini D, Mamas M, Cowie M, Van Spall HGC. Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. Eur Heart J Digit Health. Mar 04, 2021;2(1):62-74. [FREE Full text] [CrossRef] [Medline]
  28. Jacob KS. Public health in low- and middle-income countries and the clash of cultures. J Epidemiol Community Health. Jul 2009;63(7):509. [CrossRef] [Medline]
  29. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. Feb 2005;8(1):19-32. [CrossRef]
  30. Yew SQ, Trivedi D, Adanan NIH, Chew BH. Facilitators and barriers of digital health technologies implementation in hospital settings in lower-income and middle-income countries since the COVID-19 pandemic: a scoping review protocol. BMJ Open. Jan 31, 2024;14(1):e078508. [FREE Full text] [CrossRef] [Medline]
  31. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. Oct 02, 2018;169(7):467-473. [FREE Full text] [CrossRef] [Medline]
  32. Jbi. JBI Manual for Evidence Synthesis. JBI Global Wiki. 2024. URL: https://jbi-global-wiki.refined.site/space/MANUAL [accessed 2024-08-04]
  33. Feldstein AC, Glasgow RE. A Practical, Robust Implementation and Sustainability Model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. Apr 2008;34(4):228-243. [CrossRef] [Medline]
  34. Naeem M, Ozuem W, Howell K, Ranfagni S. A step-by-step process of thematic analysis to develop a conceptual model in qualitative research. International Journal of Qualitative Methods. Nov 08, 2023;22:22. [CrossRef]
  35. PRISMA Flow Diagram. PRISMA Statement. 2020. URL: https://www.prisma-statement.org/prisma-2020-flow-diagram [accessed 2024-08-04]
  36. Abdulai M, Aldheleai H, Bokhari M. Health care professionals' use of health information systems (HIS) in Indian hospitals. IJCA. Apr 19, 2021;174(28):5-12. [CrossRef]
  37. Alboraie M, Abdalgaber M, Youssef N, Moaz I, Abdeen N, Abosheaishaa H, et al. Healthcare providers' perspective about the use of telemedicine in Egypt: a national survey. Int J Telemed Appl. Mar 12, 2022;2022:3811068-3811068. [FREE Full text] [CrossRef] [Medline]
  38. Jiang Y, Sun P, Chen Z, Guo J, Wang S, Liu F, et al. Patients' and healthcare providers' perceptions and experiences of telehealth use and online health information use in chronic disease management for older patients with chronic obstructive pulmonary disease: a qualitative study. BMC Geriatr. Jan 03, 2022;22(1):9. [FREE Full text] [CrossRef] [Medline]
  39. Ning Y, Dong Z, Jia Z, Zhao W, Ding Y, Wang Q, et al. Development of mobile health-based interventions to promote physical activity in patients with head and neck cancer: a qualitative study. Front Public Health. 2023;11:1260804. [CrossRef] [Medline]
  40. Shardha H, Kumar G, Sagar N, Kumar R, Qazi M, Munir S, et al. Perceptions of telemedicine among healthcare professionals in rural tertiary care hospitals of rural Sindh, Pakistan: a qualitative study. Ann Med Surg (Lond). Feb 2024;86(2):726-733. [CrossRef] [Medline]
  41. Yu-Tong T, Yan Z, Zhen L, Bing X, Qing-Yun C. Telehealth readiness and its influencing factors among Chinese clinical nurses: a cross-sectional study. Nurse Educ Pract. Jan 2022;58:103278. [FREE Full text] [CrossRef] [Medline]
  42. Mekuria S, Adem HA, Ayele BH, Musa I, Enyew DB. Routine health information system utilization and associated factors among health professionals in public health facilities in Dire Dawa, eastern Ethiopia: a cross-sectional study. Digit Health. 2023;9:20552076231203914. [FREE Full text] [CrossRef] [Medline]
  43. Ngugi PN, Were MC, Babic A. Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya. BMC Med Inform Decis Mak. Dec 26, 2021;21(1):362. [CrossRef] [Medline]
  44. Tesfa GA, Kalayou MH, Zemene W. Electronic health-information resource utilization and its associated factors among health professionals in Amhara regional state teaching hospitals, Ethiopia. Adv Med Educ Pract. 2021;12:195-202. [CrossRef] [Medline]
  45. Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Asressie M, Minyihun A, et al. Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia. Health Res Policy Syst. Dec 09, 2021;19(1):141. [FREE Full text] [CrossRef] [Medline]
  46. Baradwan S, Al-Hanawi M. Perceived Knowledge, Attitudes, and Barriers Toward the Adoption of Telemedicine Services in the Kingdom of Saudi Arabia: Cross-Sectional Study. JMIR formative research. 2023. :7. [CrossRef]
  47. Mussi CC, Luz R, Damázio DDR, Santos EMD, Sun V, Porto BSDS, et al. The large-scale implementation of a health information system in Brazilian university hospitals: process and outcomes. Int J Environ Res Public Health. Oct 25, 2023;20(21):6971. [CrossRef] [Medline]
  48. Borges do Nascimento IJ, Abdulazeem H, Vasanthan LT, Martinez EZ, Zucoloto ML, Østengaard L, et al. Barriers and facilitators to utilizing digital health technologies by healthcare professionals. NPJ Digit Med. Sep 18, 2023;6(1):161-128. [FREE Full text] [CrossRef] [Medline]
  49. Berardi C, Antonini M, Jordan Z, Wechtler H, Paolucci F, Hinwood M. Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework. BMC Health Serv Res. Feb 26, 2024;24(1):243. [FREE Full text] [CrossRef] [Medline]
  50. Mumtaz H, Riaz MH, Wajid H, Saqib M, Zeeshan MH, Khan SE, et al. Current challenges and potential solutions to the use of digital health technologies in evidence generation: a narrative review. Front Digit Health. Sep 28, 2023;5:1203945. [FREE Full text] [CrossRef] [Medline]
  51. Chidambaram S, Jain B, Jain U, Mwavu R, Baru R, Thomas B, et al. An introduction to digital determinants of health. PLOS Digit Health. Jan 2024;3(1):e0000346. [FREE Full text] [CrossRef] [Medline]
  52. Sambo L, Simões J, do Rosario O, Martins M. Firth JD, Conlon CP, Cox TM, Firth J, Conlon C, Cox T, editors. Financing Health Care In Low-Income Developing Countries: A Challenge For Equity In Health. Oxford, UK. Oxford University Press; Jan 2020:168-176.
  53. Sureshkumar K, Bindu M, John S, Kamarul IM. Editorialvidence on low-cost technologies for neurological rehabilitation in low and middle-income countries. Frontiers in Neurology. 2023. :14.
  54. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. Aug 01, 2020;20(1):1193. [CrossRef] [Medline]
  55. Huang C, Wang J, Wang S, Zhang Y. Internet of medical things: A systematic review. Neurocomputing. 2023. :557. [CrossRef]
  56. National Institute for Health and Care Excellence (NICE). Evidence standards framework for digital health technologies. NICE. Mar 2019. URL: https:/​/www.​nice.org.uk/​about/​what-we-do/​our-programmes/​evidence-standards-framework-for-digital-health-technologies [accessed 2025-02-11]
  57. Functional classification, according to their intended use, of digital solutions used in the context of medical and paramedical care. Haute Autorité de Santé. 2021. URL: https:/​/www.​has-sante.fr/​upload/​docs/​application/​pdf/​2021-03/​dm_eval_270_proposition_classification.​pdf [accessed 2024-08-04]
  58. World Health Organization (WHO). Classification of digital health interventions v1. WHO. 2018. URL: https://iris.who.int/bitstream/handle/10665/260480/WHO-RHR-18.06-eng.pdf?sequence=1 [accessed 2024-08-04]
  59. Food and Drug Administration (FDA). Digital Health Center of Excellence. FDA. 2024. URL: https://www.fda.gov/medical-devices/digital-health-center-excellence [accessed 2024-08-04]


DHT: digital health technology
GNI: gross national income
IT: information technology
LMIC: lower- and middle-income country
mHealth: mobile health
PCC: Population-Concept-Context
PRISM: Practical, Robust Implementation and Sustainability Model
PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews
WHO: World Health Organization


Edited by T de Azevedo Cardoso; submitted 21.06.24; peer-reviewed by D Linde, E Baker; comments to author 29.10.24; revised version received 01.11.24; accepted 09.12.24; published 06.03.25.

Copyright

©Sheng Qian Yew, Daksha Trivedi, Nurul Iman Hafizah Adanan, Boon How Chew. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.03.2025.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.