Table 1.

Barriers and possible solutions.

	DESCRIPTION OF ROADBLOCK	SOLUTION
Leadership and governance
National guidelines and strategies	Lack of national guidelines and eHealth strategy.	Establish national or regional eHealth guidelines and strategy.
Stakeholder engagement	Poor involvement of critical national stakeholders.	Inclusive engagement with stakeholders by policymakers, including representatives of patients, practitioners, payers, industry and civil society.
Monitoring and evaluation standards.	Lack of clear monitoring and evaluation standards. No repeated monitoring of effectiveness, reach and impact of interventions.	Clear national standards for monitoring and evaluation of DHIs. Long-term monitoring of effectiveness and implications of digital health interventions. ‘unexpected effects’ registry.
Legislation, policy and compliance
National legislation on data security and access	Lack of national guidelines on data security and access. Local institutional guidelines are not harmonized.	Explicit national guidelines on data access and security. Promote harmonization of policies between institutions.
Lack of regulatory approval or guidance	Lack of regulatory standards; poor health technology assessment (HTA) standards.	Improve HTA and regulatory standards.
Strategy and investment
Reimbursement	Unclear reimbursement pathways for digital technologies.	Clear reimbursement strategy for DHI. Include economic evaluations in the design phase.
Long-term investment strategy	Lack of long-term investment strategy for sustainability of digital technologies.	Include long-term investment strategy as part of national guidelines.
Services and applications
Contextualisation	Intervention not adapted to the local context.	Perform a structured and holistic needs and context assessment before designing and implementing interventions. Health system assessment frameworks might be helpful tools.
Poor usability and design	Non-user focused design.	Employ user-centred and co-design principles. Include end-users (practitioners/patients) early in the design phase.
Infrastructure
National or regional digital infrastructure	No clear investment in national or regional digital infrastructure.	Investing in digital health infrastructure should be included as a national policy priority.
Healthcare provider systems	Local infrastructure does not allow the integration of new DHI.	Applications should be flexible and available in on- and offline modes.
Standards and interoperability
Data structure standards	National and international differences in data collection, storage and definitions standards.	Promote collective definitions and data storage formats. Emphasise implementation of open data platforms.
Health workforce
Poor needs assessment	Poor understanding of the health workforce needs.	Include clear health system and needs assessment in the design phase of DHIs.
Data literacy	Lack of understanding of DHI.	Provider education on the use of digital technology.
Low acceptability	Lack of perceived effectiveness and use of DHIs.	Inclusive technology design and education of use.
Patients
Poor digital literacy and skills	Lack of understanding of DHI (literacy), or not having physical capabilities to interact with DHI.	Patient education on the use of digital technology, context specific adaptations of technology to match patients’ physical abilities.
Low acceptability	Lack of perceived effectiveness and use of DHIs.	Inclusive technology design, education of use and user acceptance, usefulness and engagement evaluation alongside clinical trials and related research.