Public health digitalization in Europe

Abstract Background As digitalization is progressively permeating all aspects of society, how can be it fruitfully employed to sustain the public health goals of quality, accessibility, efficiency and equity in health care and prevention? In this paper, we reflect on the potential of applying digital tools to public health and discuss some key challenges. Methods We first define ‘digitalization’ in its broader sense, as well as applied to public health. We then build a conceptual framework where key public health domains are associated to available digital technologies in a matrix that help to identify digital features that bolster public health action. We also provide illustrative data and evidence on the application of digital solutions on selected public health areas. In the second part, we identify the strategic pillars for a successful European strategy for public health digitalization and we outline how the approach being pursued by the European Public Health Association (EUPHA) applies to digital health. Results From a public health perspective, digitalization is being touted as providing several potential benefits and advantages, including support for the transition from cure to prevention, helping to put people and patients at the center of care delivery, supporting patient empowerment and making healthcare system more efficient, safer and cheaper. These benefits are enabled through the following features of digital technologies: (i) Personalization and precision; (ii) Automation; (iii) Prediction; (iv) Data analytics and (v) Interaction. Conclusion A successful European strategy for public health digitalization should integrate the following pillars: political commitment, normative frameworks, technical infrastructure, targeted economic investments, education, research, monitoring and evaluation. EUPHA acknowledges digitalization is an asset for public health and is working both to promote the culture of “public health digitalization”, as well as to enable its planning, implementation and evaluation at the research, practice and policy level.


E
arly this year, the Topol Review, an independent study commissioned by the UK Department of Health and Social Care, provided a number of recommendations to 'prepare the healthcare workforce to deliver the digital future'. 1 The document outlines how technological innovation is likely to change medical practice, clinical staff functions and role, and how health services delivery and clinical staff training should be re-structured to best embrace digital innovation. Depending on our background, sensitivity and knowledge, for some of us 'digital health' is about technology; for others, it refers to new ways of communication or to automation in care. Although all these definitions are not necessarily wrong, it is important to pursue alignment and common vision about the added value of applying digitalization to health. 'Digital' refers to data or signals recorded, stored, expressed and transmitted as series of the digits 1 and 0 (signal present or absent). The shift from mechanical and analog technology to digital technology initiated the Digital Revolution which started during the so called 3rd Industrial Revolution and has continued during the ongoing 4th Industrial Revolution where digital technologies, such as artificial intelligence, genome editing, augmented reality, robotics and 3-D printing are rapidly shaping all aspects of society and, most importantly, 'the way humans create, exchange, and distribute value'. 2 This has impacts on health. There are two different dimensions to consider: the way digital tools can support and improve healthcare delivery; and the impact of societal digitalization on physical and mental health. 3 With regard to the first dimension, there is no doubt that digital tools application to the different fields of medicine will dramatically improve diagnostics, treatments and ultimately health outcomes. When it comes to public health the process is less straight forward. In this paper, we aim at reflecting on the potential and challenges of applying digital tools to public health 4 , starting with one major premise: while clinical care is limited to diagnosis, cure and rehabilitation, public health encompasses all aspects of society, the environment, human and animal life. Public health stands largely outside hospitals and healthcare facilities; public health deals with health policy and management, with health education, health promotion and heath communication, with the physical and social environment, with animal health and food safety; public health adds prevention to the care paths. Similarly, as commented in a Nature editorial on the digital revolution 'An explosion in information technology is remaking the world, leaving few aspects of society untouched'. 5 Considering the broad spectrum covered by both public health and digitalization gives an idea of the additional layer of complexity when envisaging a framework for 'public health digitalization'.

Objectives and methods
The current paper first aims at defining 'digitalization' in its general sense, as well as when applied to health and public health. We highlight the added value of digitalization for public health, reinforcing that digitalization is not an aim in itself but a means to implement better public health programmes and policies. We then build a conceptual framework where key public health domains are associated to available digital technologies in a matrix that help to identify digital features that bolster public health action. Based on literature review data and consultations with experts, we provide illustrative data and evidence on the application of digital solutions on selected public health domains. In the second part of the paper we identify the strategic pillars for a successful European strategy for public health digitalization, narrowing down aspects related to: European and national-level political commitment, normative frameworks, technical infrastructure, targeted economic investments, training and education, research, monitoring and evaluation. We illustrate how the European Public Health Association (EUPHA) and its new Digital Health section can be a front runner in leading the change towards the digitalization of public health in Europe, also through the framework of EUPHA's strategy.
The added value of digitalization for public health Digitalization as a means, not an end in itself Digitalization should not modify public health principles; rather it should support and enable their implementation. We see digitalization as a means, a set of tools, not an aim for public health. Digital public health is therefore not a discipline per se but an asset our community has to fulfill its aims and mission. The health system goals of quality, accessibility, efficiency and equity of healthcare, embraced by public health professionals are unaltered by the process of digitalization. 6 Acknowledging that digitalization is a technological revolution permeating all aspects of society, how can it be fruitfully employed to sustain the 'science and art of preventing disease, prolonging life and promoting health and well-being through the organized efforts and informed choices of society, organizations, public and private, communities and individuals'? 7 As public health in Europe faces substantial challenges 8 -including the aging population, the burgeoning burden of non-communicable diseases, the influence of vested interests on their behavioral risk factors, the sustainability of national health services, and the health divide between and within countries, we should seek to better understand the potential of digital technologies in supporting the public health effort.

Digital features which bolster public health action
The Topol review categorizes digital healthcare technologies as: (i) genomics, (ii) digital medicine, (iii) artificial intelligence and (iv) robotics (their detailed list and definitions are available as Supplementary appendix S1). 1 Classification of digital technologies for public health is hampered by the rapid pace at which they develop, and by the paucity of comprehensive data on their application, adoption and impact. We propose a conceptual framework (table 1) that aims at summarizing the features and characteristics of digital technologies that can fruitfully be applied to the wide spectrum of European public health action; at all levels and in its different domains. In table 1, we summarize public health domains and, separately, we list the categories of available digital technologies that can be applied to them. This matrix exercise helps to identify and depict the digital solutions' features that bolster and potentially add value to public health practice. These are: (i) Personalization and precision; (ii) Automation; (iii) Prediction; (iv) Data analytics (including big data and interoperability) and (v) Interaction. For these features, we provide selected examples and supporting evidence.
Personalization and precision: Although the concept of 'Precision Public Health' has been criticized, 9,10 it is a fact that advances in data analytics and genomics allow us to target more effectively and efficiently public health interventions. 10 It is increasingly recognized that several genome-based applications have the potential for tailored primary and secondary prevention. [11][12][13] Also, training of healthcare professionals can be personalized using virtual reality and artificial intelligence tools; similarly, for example, personalized health coaching can be conducted through virtual consultations with chatbots or digital health promotion interventions can target selected audience identified through the analysis of electronic patient records. 14 Automation: Automation is intended as the use of control systems and information technologies to make a process operate automatically. Automation in healthcare management is being implemented for example with decision support systems, automated flagging of adverse clinical events, 15 drugs dispensing systems and health services scheduling. 16 Simpler than that, electronic health records data can largely support automatic reporting to public health agencies on notifiable diseases and chronic conditions. Prediction: Large amounts of electronic data from different sources (health data but also meteorological forecasts, social media and geographic information systems data) are used to inform both AI Note: a Refer to Supplementary appendix S1 for definitions. and non-AI prediction models that can early detect or predict, for example, adverse events, healthcare associated infections, infectious diseases' outbreaks or health emergencies, [17][18] allowing effective prevention and early intervention. In clinical practice, supervised and unsupervised AI-based models are increasingly used for automated image interpretation; in public health this can be applied to screening programmes.
Data analytics: Digital tools brought a revolution in data gathering and sharing and in their analytics, with major applications to public health. First, the amount of available data has exponentially grown. Large volumes of structured, semi-structured and unstructured data (big data) are mined for information and used in machine learning projects and other advanced analytics applications, both in public health research and practice. 19 Second, data are rapidly (timeliness) shared and transmitted (i.e. telemedicine or real time surveillance applications) and linked with other data sources (interoperability) with major potential applications to health management, public health monitoring, reporting and public health analytic research, among others.
Interaction: Digital solutions allow patients, as well as the general population to generate their own health data 20 and, most importantly from a public health point of view, to monitor and interpret them, with large impact on patients' empowerment. Similarly, smartphone applications support behavioral risk factors (i.e. physical activity) self-management with impact on primary prevention. Internet and social media introduced interaction in communication about health (as compared with unidirectional communication of traditional media where it was not possible to share or comment on published content), this bolstering the general population's active role in health decisions.
The features nailed down above can support advances and progress in public health practice, in public health education and training, in public health policy (both inside and outside the health sector), and in public health research. The theoretical conceptual framework we developed allows to distill the potential public health benefits and advantages brought by digitalization (Box 1), the disadvantages, risks and potential pitfalls being highlighted in other papers of the supplement. 21,22 Digitalization supports the transition from cure to prevention One of the biggest gains of digital health is that it supports a shift from cure to prevention; this holding true both for primary and secondary prevention.
With regard to the former, as acknowledged by WHO, digital health technologies offer ways to self-manage health which positively impact on behavioral risk factors' distribution. For example, a systematic review assessed the potential benefits of digital health interventions on cardiovascular disease (CVD) outcomes and risk factors and reported telemedicine, Web-based strategies, e-mail, mobile phones, mobile applications, text messaging and monitoring sensors-based interventions to reduce CVD events, hospitalizations and mortality and to lower BMI and weight, as compared with normal care. 23 Evidence on the impact of digital preventive interventions are accumulating for communicable and non-communicable diseases including, among others, diabetes and mental health. [24][25][26][27] With regard secondary prevention, as advances in genomics and its application to clinical routine are increasingly allowing to identify people at risk of developing diseases with genetic basis, as well as to predict response to treatment, the role of secondary prevention will become more and more central in the future. Indeed, recent EU-funded projects concluded that the potential of personalized medicine will and should step out of diagnosis and treatment and be exploited for disease prevention. 28 As digitalization supports the system migrating from treatment toward (early) diagnosis and prevention, public health strengthens its action and role within the wider health sector.
Evidence detailing and quantifying the actual fulfillment of the theoretical potential public health benefits and advantages brought by digitalization reported in Box 1 is accumulating, but still currently lacking in many aspects. Also, besides evidence gathering, implementation of effective digital solutions in different public health domains is running at different speeds in different contexts and scale-up timing varies across settings.
To take full advantage of the potential offered by digitalization to broader public health action, minimizing its potential risks 21,22 a whole system thinking should be put in place, encompassing all pillars described in the next section.

Pillars for a successful European strategy for public health digitalization
The digitalization of public health should not be treated as a discrete element to focus on in silo, rather it should be considered in a broader value chain 29 to best achieve populations' health and wellbeing. Indeed, if-as underlined by the OECD-digital technologies are reshaping societal boundaries, 29 a successful European strategy for public health digitalization should integrate all pillars reported in Box 2.

Political commitment
The European Commission has recently published key policy documents which give clear direction to EU activities to support the digital Transformation of Health and Care for the coming years. 30,31 The EU Communication on Digital Transformation of Health and Care in the Digital Single Market identifies three priorities: (i) Citizens' secure access to their health data, across the EU; (ii) Personalized medicine through shared European data infrastructure and (iii) Citizen empowerment with digital tools for user feedback and person-centered care. In 2018, the WHO Regional Office for Europe launched the WHO/Europe initiative for Digitalization of Health Systems as an immediate European regional action for delivery the WHA Resolution on mHealth/ digital health urging Member States to prioritize the development, evaluation, implementation, scale-up and greater utilization of digital technologies, as a means of promoting equitable, affordable and universal access to health for all. 32

Training and education
How can the future public health workforce be prepared to act in a digitalized working environment? We expect, in general, digitalization to modify the roles and functions of staff (Supplementary appendix S2 for an imaginative representation of future public health professionals), to move the boundaries of the competencies they will be required to have. In addition, it is likely that the definition itself of public health workforce 38 will expand to include professionals with technical background (i.e. informaticians and engineers) employed to support the implementation of digital programmes for different public health purposes. Education and training in public health should accompany these trajectories. More importantly, education and training should not give instructions on how to deal with future technologies; yet, it should aim at increasing professionals' digital literacy, 39,40 to make sure they will be able to embrace innovation. Although no systematic assessment has been performed, empirical data from Europe suggests elements of digital health are still rarely included in public health graduate and post-graduate programmes, the most advanced examples being in the UK. However, curricula are rapidly evolving, medical schools are including digital health credits both in clinical and non-clinical modules and selected universities offer double degrees in Medicine and Engineering. 41 Research Digitalization in public health should not be an empty slogan, rather its planning, introduction and implementation should be informed by evidence. Despite strengthened political commitment and increasing economic investments in digital health technology, research outputs on its application in public health are 'still in their infancy'. The theoretical benefits and advantages of digital public health solutions outlined in the sections above are far from being quantitatively assessed in different settings. Still, there is interest in building and accumulating evidence on the topic as demonstrated by the Horizon 2020 Work Programme 2018-2020 call on 'Digital transformation in Health and Care' 42 which includes 21 topics, all of which with a projected public health impact, and the recent launch of new dedicated peer reviewed journals. 43 Research on public digital health is hampered by a number of design issues including the choice of appropriate control groups, the definition of relevant clinical, organizational and process outcomes, the transferability of its findings to different settings, without forgetting the need for being transparent and independent. Operational research should be carried out drawing from health services and biomedical informatics scholarly for studies on digital health interventions' efficacy, effectiveness and cost-effectiveness. 44

Monitoring and evaluation
The impact of digital solutions on health and healthcare, once applied, must be measured and assessed. This is essential to inform decision making and resources allocation. In 2019, the European Commission Expert Panel on effective ways of investing Box 2 Pillars for a successful European strategy for public health digitalization Political commitment: strong political commitment and government leadership are needed to implement digital public health strategies at the national level, and across Europe. Normative and regulatory frameworks: a clear set of regulation should support interoperability to allow safe and effective data exchange between different information and communication technology systems at the national and European level. Technical infrastructure: National and regional health authorities, as well as hospitals and healthcare agencies should be equipped with technical infrastructure to support the implementation of digital solutions. Economic investments: the successful implementation of digital public health solutions needs targeted public and private economic investments. Training and education: the public health workforce need to be trained to embrace digital solutions and university curricula should increasingly include multidisciplinary digital health modules.
Research: R&D as well as operational research should be carried out drawing from health services and biomedical informatics scholarly for studies on digital health interventions' impact, efficacy and cost-effectiveness. Monitoring and evaluation: the introduction and monitoring of public health digital solutions in different settings should be supported by technology evaluations based on targeted, solid and shared Health Technology Assessment (HTA) models. in Health (EXPH) issued a report providing guidance on how to technically assess the impact of digital transformation of health services. 6 In more detail, the Expert Panel reinforced that at the central and local level the decisions to adopt, use or reimburse digital health services should be based on data regarding their performance in the light of health system goals. EXPH outlined available frameworks and systematic methods for measuring the impact of the digital transformation of healthcare regarding different dimensions, including access to care, clinical and organizational outcomes, patient participation, use of resources and sustainability. In this context and with the aim of possibly establishing a European repository for evaluation methods and reports, it is important to consider how to best adapt Heath Technology Assessment (HTA) models to assess digital projects. In addition to HTA of digital solutions prior to their introduction, implementation monitoring should be carried out, reporting on how health and health systems evolve, also as a consequence of digitalization. 6 The role of EUPHA in leading the change towards the digitalization of public health EUPHA, founded in 1992, is a strong, independent and broad science-based public health network, currently counting 86 members from 47 countries of the WHO European Region. As umbrella organization for public health associations, with a unique leading position in Europe, its mission is to facilitate and activate a strong voice of the public health community by enhancing visibility of the evidence and strengthening the capacity of public health professionals. 38 Within this mission, supporting the process of effective public health digitalization has been identified within the priority areas of interest. In particular, EUPHA is committed to work to ensure that the digital potential is 'used' to pursue and fulfill European public health goals of improved health and well-being and narrowed health inequalities. EUPHA acknowledges the potential of digitalization as an asset for public health, a means to better deliver care and prevention and will work both to promote within its broader community the culture of 'public health digitalization', as well as to enable its planning, implementation and evaluation at the research, practice and policy level. On this premise in February 2019 in the context of the first ever WHO Symposium on the Future of Digital Health Systems in the European Region, EUPHA co-hosted a session on digitalization and public health, defined as the 'Beautiful Marriage'. In the session, the extent to which digital health and public health communities are working together to co-create a healthy and fair future was discussed, concluding that the huge potential offered by joining forces is still far from being exploited. Strengthening efforts towards its fruitful exploitation, EUPHA action across Europe adds value to the ongoing efforts to achieve effective, sustainable, accessible, safe and fair public health digitalization carried out by stakeholders in regions and states, in national and international organizations, as well as by single health professionals. Part of EUPHA action on digital public health is carried out in the context of the European Public Health (EPH) Conference (Box 3) and within EUPHA's thematic sections.
Acknowledging the importance of the current and future role of digitalization in public health and building on the enriching discussion stimulated by the EPH scientific sessions reported in Box 3, the establishment of a EUPHA thematic Section on Digital Health has been proposed with the aim of bringing together researchers, policymakers and practitioners across Europe working on digital public health for knowledge sharing and capacity building. The Section will work across competences, disciplines and settings to apply EUPHA's strategic objectives 48 to the field of digital health. The Section will aim at building advocacy, and at gathering, producing and disseminating evidence on the need for and on the impact of digital solutions for public health. It will bring together a core group of experts in selected digital health aspects, facilitate the exchange of national-level best practices and stimulate the Europe-level debate to place digital public health high in the EU policy, research and education agenda The details of the application of EUPHA Strategy 48 to the work of the Section on Digital Health, by single domain, is reported in table 2.

Supplementary data
Supplementary data are available at EURPUB online.