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In summary, 19 KFs and the corresponding 57 projections formed the basis of the final BS, WS and TS (scenario cores) when considering the selected crisis event, that is, war, and in the context of perceived safety and DTR in healthcare. This process was based on a 5-year perspective. The TS represented a realistic future direction, whereas the BS represented additional future needs and objectives. Finally, the WS focused more on the future consequences of a restricted consideration of perceived safety in the context of DTR. In total, 92 participants participated in multiple phases, and 130 participants participated in all phases (see table 1).
The scenario field
The scenario field was characterised by 16 overarching interrelated domains (see figure 2) based on 105 multifactorial dimensions of the influencing factors (see online supplemental appendix 1a) and 216 main categories that focused on several context levels, that is, the individual and the DT itself, the community/organisation and the system. Apart from the domain ‘equity’, which was only related to emotional safety, all domains included dimensions of both emotional and psychological safety. We observed that the scenario field was enriched by data collected via our various methods. Compared with our scoping review,6 almost two-thirds of the new main categories came from the workshops and use cases. The data indicated that perceived safety was related to positive and negative outcomes, among other outcomes, regarding DT implementation. A lower level of perceived safety could lead to avoidance of DT use, for example, when DTs do not meet the participant’s needs, when competences are limited, when negative feelings result in the continued use of analogue alternatives or when DTs are used differently, partially or only under certain conditions. In contrast, a higher level of perceived safety was associated with, for example, DT acceptance, adoption, adherence and positive feelings of well-being, trust and self-confidence. However, increased DT use can also promote refusal behaviours related to the unknown (see online supplemental appendix 1b).
Domains of emotional and psychological safety resulted from our data sources on system level; community/organisational level; individual level and digital technology level. Black sphere=covered by most frequently by 12 dimensions (3 data sources); grey sphere=covered by 3–11 dimensions (3 data sources); light grey sphere=covered by 6 and 3 dimensions (2 data sources); *Only emotional safety.
The domains contained several dimensions (range: n=3–12). Considering these results, the domain ‘knowledge and competence’ may be considered essential as it was emphasised most often (n=12) and contained most of the main categories. Here, perceived safety was related to, for example, digital (health) literacy and its promotion, empowerment, technical understanding and capabilities pertaining to DT use, and readiness. The domain ‘control’ may be also considered essential as it was emphasised very often (n=11) and from several perspectives, that is, being controlled by DT, having control due to DT and gaining control over DT. ‘Experiences and attitudes’ (n=10) were related to, for example, previous experiences, openness and the individual’s own habits/rituals. The other domains, for example, ‘perceived benefits in healthcare’ (n=8) and ‘perceived disadvantages in healthcare’ (n=7), were associated with positive and negative feelings of safety, respectively. In contrast, positively addressing ‘enhanced treatment options by DT’ could also result in negative impacts in cases featuring implementation concerns due to a lack of concepts regarding digital care. Although other domains were also associated with 7 or a lower number of dimensions, they were not of minor importance because they appeared in all data sources or in two data sources as in the case of ‘communication’ (n=6) and ‘professionality’ (n=3).
Identified KFs and projections
21 KFs were identified by the participants as very likely (probability, range=52.94%–91.42%) and particularly relevant (relevance, range=68.75%–96.97%) in the contexts of perceived safety and DT. The lowest probability was associated with the factor ‘research gaps regarding DT (…)’, whereas the highest probability was associated with two factors, that is, ‘understandable language/communication between humans and DT’ and ‘reliability of the DT (…)’. This factor was also rated as the highest in terms of relevance. The lowest value was associated with ‘professionality due to DT (…)’. The number of KFs could not be reduced by impact analysis (see online supplemental appendix 2a,b).
Final scenarios and scenario cores
On the basis of participant feedback, a qualitative synthesis of four factors resulted in a final set of 19 KFs, each of which was associated with the three (positive, negative and trend) projections. Specifically, (n=57) represents the (raw) BS, WS and TS (see table 2).
19 final key factors and their projections according to the development of best, worst and trend scenarios
Although we observed a mix of BS, WS and TS projections, considering the consistency of the raw scenarios, the following exhibited a good fit: BS (C=1.80), WS (C=1.60) and TS (1.00). During the scenario process, the TS projections that appeared in the WS or BS could result in corresponding developments. The WS, which included trend projections, showed slightly better consistency than did the alternatives (1.63 vs 1.60). Thus, the more consistent scenario was chosen. The TS projections included were as follows: ‘Human resources to support the implementation of DT remain scarce (with a negative effect on perceived safety)’ and ‘easy, efficient handling of DT is limited by poor underlying analogue processes and structures that are copied into DT without reflection (…)’. The qualitative data also indicated that the latter projection was equal to the WS/TS projection. The included trend projections in the BS were not chosen due to their lower consistency. Finally, the contribution values provided an overview of the core elements of each scenario (see online supplemental appendix 2b).
These scenarios and the final scenarios were approved by the participants in light of the qualitatively developed scenario cores. For all scenarios, especially those pertaining to the BS, the projection of ‘demand-oriented, flexible availability and usability of DT’ (value of 1.0) was critical. With respect to the WS, three further projections (each 0.9) offered the greatest contributions: ‘knowledge concerning the opportunities and limitations of DT (…)’; ‘consideration of (HCRs’) health status and resources when using DT (…)’; and ‘professionalism due to DT (…)’. With respect to the TS, ‘self-confidence in addressing DT (…)’ was associated with the highest contribution value (0.9). Although the quantitative data focused on slightly different aspects than did the qualitative data, the participants completed the following three scenario cores, captured the KFs and, to some degree, the consequences: (BS) ‘the user in focus (…) reliability, user-friendliness, equity of access, suitability of DT for everyday use’; (WS) ‘lasting damage to the individual, the organisation and society’ and (TS) ‘act of establishing a balance among various demands and realities pertaining to digitalisation in healthcare – self-confidence/trust (as key) – so that the gap between people who are digitally ‘left behind’ and those who are digitally competent’ can be considered. At the core, the TS emphasises ‘tensions between requirements for change and reality’ (see figure 3 and online supplemental appendix 3a, b).
Trend scenario.
Consequences of the scenarios
Ethical, psychosocial, health-related, legal, political and economic consequences were determined, and controversies related to digital (health) literacy or affinity were identified. For example, in the case of the BS, many KFs could be improved over 5 years from an ethical perspective, with the exception that not every target group could be reached. This situation might be characterised by ambivalence towards self-determination options in the context of digitalised healthcare (technology open vs technology denying) by questioning the self-determination options of technology-denying people. Hence, in the case of the WS and TS, social divisions may occur due to the inadequate and unequal distribution of digital healthcare services. Political radicalisation and a lack of solidarity resulting from a low-needs orientation are expected, but an increasing aversion to (digital) healthcare is also expected due to inhibitory attitudes among the population. In the case of the TS, negative consequences were observed regarding perceptions of inequalities in healthcare depending on digital competence given that being digitally competent could be related to loss perceptions resulting from inequalities due to equalisation with respect to digital offers, whereas being less digitally competent may result in a feeling of need and being left alone.
Considering the relevant legal aspects for both the BS and TS, new requirements for legislation regarding DTR are necessary to consider the context of perceived safety. In the case of the TS, the delegitimisation of the system (increasing the (legal) probability of legal action), for example, due to unequal opportunities, could be expected. With respect to politics in the case of the TS, perceptions of responsibility are emphasised, whereas with respect to education in the case of the WS, a loss of competencies of care is expected. With respect to the research, additional private research findings are expected to be forthcoming. From an economic perspective, in the case of the BS/TS, increased efficiency regarding the provision of healthcare via DTs is expected, but in the case of the TS, this expectation holds only among HCPs and digitally competent people. In contrast, digital and analogue healthcare inefficiencies are expected in the case of the TS, especially among people with a lower level of digital competence. Regarding the WS, setbacks in DT development and usage as well as negative effects regarding patient safety are expected.
In general, disadvantages in healthcare are assumed to exacerbate or preserve the inequality of opportunities and the inequities regarding healthcare access. In contrast, a newly informed culture of digitalisation that is enlightened by politics may be implemented in society. Alternatively, however, a balanced relationship between humans and DT in healthcare that considers the importance of people’s concerns, replacement and dehumanisation may emerge or increased healthcare quality may result.
Scenarios, scenario cores, corresponding consequences: considering crisis events
The crisis war was chosen after two election rounds (pro a12/b10), followed by climate change (pro a11/b5) and cyber-attacks (pro a11/b1). All scenarios were characterised by a point in time at which the crisis would occur and be associated with controversies. If a war were to occur instantly, the insufficient perceived safety associated with DTR would have consequences concerning the resilience of the healthcare system. In other words, the scenarios lose relevance (see online supplemental appendix 3c). Such a crisis could be characterised by a general shift in priorities and the threat of digital warfare with respect to health data. However, it was also expected that a war could lead to innovations in healthcare through transfer actions.
In cases in which the different scenarios were reached over 5 years, the TS was determined to be the most vulnerable because of the high degree of uncertainty resulting from persistent and exacerbated disadvantages in healthcare, for example, a reduction in equal opportunities and access due to the absence of backup systems (analogue/digital) or the absence of advantages resulting from the other scenarios. Knowledge, however, can be drawn from other parties. For example, the BS and WS were simultaneously viewed positively allowing the digital communication could be performed (BS) and analogue’s resilient backup of healthcare structures remains available (WS). Although perceived safety decreases in the case of war, acceptance of DTs could increase.
Participants’ overarching recommendations for action
The overarching recommendations for action provided by participants were related to education, politics and research and did not differ even when a crisis was considered. In summary, promoting digital (health) literacy throughout society (global), establishing a low threshold for access to care, reducing inequalities and offering consults and teaching in digitalisation were emphasised. Furthermore, guaranteeing technical standards, enhancing the credibility and legitimacy of healthcare policy, and facilitating the efficient implementation of DTs were viewed as necessary. Finally, open and transparent scientific communication, which can also ensure high-quality and multidimensional research, was recommended.
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