Table 4.

Learning environments that stimulate Population Health Management: expectations, intended PHM strategies and prior experiences as reported by stakeholders

Stakeholder groups’*expectation (short (5-), middle (10-), long (20 years) term)		Stakeholder groups’ intended strategies (short (5-), middle (10-), long (20 years) term)
Short	H, HCI, M, PCG, PM: Learning environment are being developed. H, HCI: Learning hospital networks will be established. B, HCI, M, PCG, PM: Municipalities and healthcare insurers will more and more exchange data and share purchase knowledge and expertise to gain insight into costs and benefits. PCG, PM, PRO: Start of regional IT structure.	H: Invest in technological developments, education, knowledge and employment of staff and in creating and strengthening an innovation culture. B, H, HCI, M, PCG, PM, PRO: Invest in technological means and training. Provide insight into needs, quality and costs for clear decision support. Investigate what indicators and data are needed for Value Based Health Care and Positive Health. HCI, PCG, PRO: Invest in business cases and the Plan-Do-Study-Act cycle at all levels. Invest in value for money, i.e. by linking Patient-Reported Outcome MeasureS to data, introducing nudging (e.g. care-miles).
Middle	H, HCI, PCG, PM, M: increase in E-health, personalized health and start of patient-ownership of health files. More care is delivered closer to home with use of technology. Patients have an active role in shared decision-making based on data. H, PCG, PM: Technology will lead to a higher demand for technical staff and a need for other competences and training. Staffing will be a challenge.	H: Appoint an intermediate between the user of technology and the supplier of technology. H, HCI, PCG, PM: Organize patient ownership of health files and technical devices.
Long	PRO, PM, H, PCG: Technology has changed professionals’ and patients’ roles. Regional health policy is based on population data and matching financial arrangements. National IT structure	–
Prior strategies and outcomes		contextual factors-mechanisms
H, HCI, M, PCG, PM: low investments in technology. Investments are just enough to meet the requirements of electronic patient files, quality records and the existing method of financing. H, HCI, M, PCG: Efforts to share data. This is difficult within initiatives, especially when 2/more healthcare insurers take part or between healthcare insurers and municipalities. H, PCG, PRO: Stimulation of more insight into health records and needs, costs and quality of care and support. This subject is high on the agenda of the public.		HCI, PCG, H, PM: Organizations work on timely and targeted feedback to providers and administrators. Organizations increasingly understand that this can contribute to insight into the demand and needs of the population, quality of care, and cost-effectiveness and to the willingness to choose the best treatment-support at the lowest price, to innovate consistently and to organize (long-term) financial arrangements. H: investments in technology are necessity to achieve a shaper hospital profile. B, H, HCI, M, PCG, PM: The data-technology lacks behind the desired information need, which induced tenseness. H, HCI, PCG: for hospitals investments in technology were key. Hospitals were reluctant to share data with primary care groups and healthcare insurers as this could influence their financial budget. HCI: Some organizations are reluctant to share cost data with the healthcare insurer because opening their books will set back their bargaining power. Continuous leadership support is important when sharing data to support a learning environment. M, HCI: lack of insight into data produced tensions between municipalities and healthcare insurers. H, HCI, PCG: lack of clarity on regulative restrictions on specific types of data-sharing between healthcare insurers, hospitals, primary care groups and between health care insurers. B, HCI, M, PCG, PM, PRO: Care and support is increasingly planned around patients. Organizations are more aware that, in principle, patients or their family have control. In addition, as citizens-patients are co-creators of their own health, insight into health records and needs, and the quality and costs of prevention, care and community services is necessary to enable this co-creatorship. The influence of citizens-patients will increasingly be supported by modern technology. B, H, HCI, M, PCG, PM, PRO: The real upheaval in healthcare will only take place if patients increasingly use this technology.

*B = Businesses; H = Hospital; HCI = Health care insurer; M = Municipality; PM = Program manager; PCG = Physician care group; PRO = Patient representative organization