Background

Over the last three decades, there has been considerable interest in the use of digital health to enhance the quality, efficiency, and safety of health care [1,2]. Digital health and eHealth are often used interchangeably and broadly defined as “the use of information and communications technology in support of health and health-related fields” [3]. An analysis of various digital health definitions revealed three distinct yet overlapping uses such as monitoring, tracking, and informing health (eg, mobile devices, mobile sensors and wearables, apps, social media); enabling health communication among various stakeholders (eg, telehealth, virtual consultations); and storing, managing, and utilizing health data (eg, electronic medical records, electronic medication systems) [4]. Digital health tools have the potential to provide health care workers with a holistic view of patients’ medical conditions through access to their health-related data and improved communication, regardless of distance and access [5]. Furthermore, the use of digital technology in health care could potentially reduce turnaround times, resource use, medication errors, and adverse drug events; increase the use of preventive care; and enable greater adherence to clinical guidelines [6-8].

Training and educating health care workers to be digitally competent is important for several reasons.

First, with the growing use of digital technology in health care, the roles and responsibilities of the health workforce are transforming in an unprecedented manner, intensifying the need for capacity building and continuous professional development. For example, a recent review commissioned by the United Kingdom Secretary of State for Health and Social Care (ie, the Topol Review) reported that within the next two decades, the majority of jobs in the National Health Service (NHS) will have a digital component [9]. Second, the importance and potential of remote care has been brought to light recently with the COVID-19 pandemic. Virtual consultation devices and electronic systems are indispensable tools used to diagnose and treat patients with potential COVID-19 infections as well as all other infections [10,11]. Third, even though the current and next generation of practitioners may be seen as “digital natives” [12], surveys of health care workers show that they would appreciate more training on digital technology [13,14]. Finally, improving digital literacy capabilities could lead to better adoption and implementation of digital services and technologies in health care settings [15]. Similarly, poor digital health literacy was found to be the most common barrier to the digital transformation of health care [16], and thus, the adoption of health technologies has been gradual in countries such as the United States [17], Europe [16], and Australia [18]. For the above-mentioned reasons, there is an increasing number of medical schools introducing digital health training into their curricula [12,19,20].

Such training programs should be guided by a clear framework of digital health competencies suited for different health care worker groups, settings, contexts, seniority, and role. Although there is an increasing number of individual digital health competency frameworks and reviews focusing on a specific health care worker role or setting [21-24], there is a need for consolidation, analysis, and a comprehensive overview of existing frameworks for all health care worker groups. This includes frameworks that are specific for and those that are relevant across different health professions, roles, or settings. Such an overview is important to inform increasingly interdisciplinary teams working in medicine and health care and corresponding future training initiatives, policy development, and research.

Study Design

We followed the guidelines by the Joanna Briggs Institute [25] in performing a literature review and guidelines by Tricco et al [26] in creating a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. The protocol for this review was registered with the Open Science Framework [27]. In this review, we used the World Health Organization’s definition of digital health as “the combination of e-health and m-health as well as emerging areas, such as the use of advanced computing sciences in big data, genomics and artificial intelligence” [3].

Study Characteristics

The search generated 14,229 articles, of which 14,091 were from database searches and 138 from gray literature. After duplicates were removed and screening was completed, 33 articles were deemed eligible for inclusion. Of these, 27 articles presented individual frameworks. The remaining 6 articles presented preliminary findings followed by finalized versions of their frameworks (Staggers et al [31,32]; Egbert et al [33,34]; Hubner et al [35,36]), adding 3 more individual frameworks. As a result, a total of 30 frameworks are presented in this review (Figure 1), of which 16 were found through a gray literature search.

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Figure 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart.

In terms of methodology, 14 frameworks employed literature review as an initial step, subsequently finalizing the frameworks through the use of expert consultations (n=5) [37-41], focus group discussions (n=3) [33,34,42,43], Delphi methodology (n=5) [31,32,44-47], or expert surveys [48]. In total, 11 other frameworks used one or a combination of methodologies (ie, Delphi, expert discussions, workshops, surveys) to reach consensus, largely by engaging various experts such as informaticists, health professionals, educators, and academics [21,22,36,49-56]. Of the remaining frameworks, 2 used only literature review to select relevant competencies [57,58], and 3 frameworks were built on the foundation of other published frameworks [59-61]. In addition, the frameworks were developed by a team of authors from a single university or institute (eg, University of Minnesota, School of Nursing) [44], by an international- or national-level organization (eg, IMIA, Australian Health Informatics Council [AHIEC]) [49,57], or by means of a collaborative effort to produce frameworks such as Technology Informatics Guiding Education Reform (TIGER) [35,36,52] and Health Information Technology Competencies (HITCOMP) [41].

In terms of geographical relevance, 15 frameworks were country-specific [21,33,37,38,40,42,45,47,48,50,55-59], 1 was specific to the European Union region [61], 5 were applicable globally [35,36,41,49,52,54], and the remaining did not specify (n=9). In terms of health care settings, 4 were developed for remote care delivery [39,51,53,60], 1 framework each for hospitals [48], acute care [41], and homecare [50], while the remaining frameworks either were applicable to all health care settings (n=5) [42,45,56,57,59] or did not specify (n=18). In terms of health professions, 14 frameworks targeted nurses, 4 targeted doctors, of which one also included dentists, and 1 framework each targeted psychiatrists, dietitians, and public health professionals; 9 frameworks targeted health care workers in general, of which 5 specified the inclusion of administrative, information technology (IT) support, and health informatics specialist roles [41,52,54,57,61], and 1 specified the inclusion of allied health professionals [39]. Among the nursing frameworks, 7 were meant for in-service nurses [21,31,32,42-44,46,48], 5 for preservice nursing students [33-37,53,58], and 2 for both [22,50]. Of the 4 medicine-focused frameworks, one focused on in-service doctors [40], another on preservice medical students [55], and 2 on both [59,60]. The framework characteristics and summary of the findings of the included studies are presented in Table 1 and Table 2, respectively. Additional details of the included studies are presented in Multimedia Appendix 6 [21,22,31-63].

Principal Findings

Of the 30 digital health competency frameworks, 14 solely targeted nursing staff. The frameworks predominantly originated from high-income countries and were developed based on literature reviews, followed by expert discussions or a Delphi approach. More than half of the included frameworks, especially those providing national-level recommendations, were from gray literature sources. Most frameworks were published between 2016 and 2019, highlighting the growing interest in digital health competencies in recent years.

The purpose of the retrieved digital health competency frameworks and the intended audience was clearly stated in most frameworks. The earliest frameworks and almost half of all the included frameworks were meant for nurses. This could be due to the significantly larger proportion of nurses in the health workforce [65]. Nurses play a crucial role in supporting health care environments by being a constant point of contact between patients and doctors; thus, there are various aspects of digital capabilities that are required of them (eg, using staff scheduling systems, extracting data from clinical systems, navigating decision support systems) [22]. These nursing-focused frameworks have inspired subsequent works for other health care workers. For example, several competency areas subsumed under broad areas for nurses in the TIGER framework [36] were marked as standalone competency areas (ie, communication, legal issues, interoperability and integration, and life cycle management) for a wider spectrum of health care workers in version 2.0 of the TIGER framework [52]. Notably, only one framework was found for allied health professionals (ie, dietitians) [45], which highlights the perceived lack of interest in educating and training this group of workers in digital health. However, the Health Informatics Society of Australia, now known as the Australasian Institute of Digital Health, highlighted the need to focus on allied health care workers as their involvement is becoming increasingly important in decision making to improve patient care and health outcomes [66]. Furthermore, although there were frameworks for doctors and medical students collectively, only one framework was intended solely for undergraduate medical education. The framework was a national guideline for medical students in Canada briefly describing 25 eHealth competencies [55]. Medical practice relies heavily on communication, which is now achieved through various digital means; thus, the skills to utilize a range of digital technologies should be comprehensive and included in medical education [67]. Moreover, with the COVID-19 pandemic, doctors are required to handle patient consultations digitally [11]. A 2018 survey conducted by European Medical Students’ Association revealed that a majority of medical students rated their eHealth skills to be “poor” or “very poor” and desired for adequate digital health literacy [14].

Most of the included frameworks are useful for application in education or practice, mainly owing to the specificity of competencies, the organization of competencies according to proficiency levels or health care worker roles, and the illustration of case studies and examples to be applicable to various settings. On the other hand, frameworks by Trangenstein et al [43] and Jidkov et al [40] presented only broad competency themes, as it was believed that exhaustive lists of competencies could lead to poor adoption [40]. As the included digital health competency frameworks were heterogeneous in purpose, audience, and setting, it is challenging to determine a single framework as exemplary. Nevertheless, HITCOMP, which was developed via an iterative methodology, was found to be the most comprehensive framework, covering 21 out of the 28 identified competency domains, listing 1025 competencies, and targeting a wide audience of health care workers and medical specialties [41].

The key thrust of work in this area involves competencies related to informatics, followed by eHealth, telehealth or telebehavioral or telepsychiatry, digital capability, and health IT competencies. This distinction may be superficial, given that the definitions and terminologies seem to overlap across frameworks and the nomenclatural differences do not necessarily convey differences in competencies. For example, the interprofessional eHealth framework developed by Thye et al [54] utilized a range of informatics frameworks [33,41,49].

Although frameworks often drew upon each other, there were considerable variations among the identified competencies. The Egbert et al [33,34] framework identified the 5 most relevant competency areas (out of 24) for 5 nursing roles in Austria, Germany, and Switzerland. The TIGER framework [35,36] used the same competency areas and methodology as Egbert et al [33,34] and additionally reached out to experts worldwide for their inputs. The resulting relevant competency areas for a nurse in an IT management role, for example, varied considerably between both frameworks. For this role, competency areas, risk management and project management, ranked the top 5 internationally in the TIGER framework [35,36]; however, it was only relevant in 1 out of 3 countries in the Egbert et al [34] framework. In addition, eHealth, telematics, and telehealth, which were ranked as top 5 by Egbert et al [34] for 2 out of 3 countries (ie, Germany and Austria), did not make it to the top 10 list in the TIGER framework [35,36]. This suggests that the IT management role for nurses could be defined differently depending on each setting. Hence, a clear definition of the role is important to match the appropriate competency skills to a health care worker role.

In our thematic analysis of the competencies included in the retrieved frameworks, we identified 28 competency domains. The most prevalent domain relates to competencies aimed at providing knowledge on informatics concepts and processes. Examples of these include basic computer knowledge, information systems concepts, and principles of informatics, which are fundamental skills to health care workers intending to maximize the use of digital technologies. The other common domains included the ability of health care workers to manage data from health information systems and records and to be well-versed in digital communications. Most of the health-related data today exist in digital form; therefore, it is imperative for health care workers to be able to understand the purpose, basic structures, use, and storage of electronic health records (EHRs). In addition, as digital health entails new forms of communication (eg, virtual consultations, email, chatbots), it is imperative for health care workers to be able to relate information accurately yet efficiently, timely, and delicately to patients, colleagues, and other collaborating stakeholders [68]. Furthermore, the rise in the adoption and utilization of digital technologies has spurred new issues relating to the use of IT [69], which corresponds to the next two common domains of competencies (ie, ethics, legal, or regulations, and privacy and security). These domains stress the importance of health care workers’ adherence to legal and regulatory requirements and to keep up to date with privacy and security policies pertaining to the appropriate use of digital technologies.

Some categories that were found in more recent frameworks, such as attitudes toward the use of IT, medication and prescription, IT advocacy, and public health, reflect the emerging trends in digital capabilities required by health care workers. For example, with the widespread adoption of EHRs and e-prescribing being a key functionality, it is imperative for physicians to be able to perform prescribing tasks efficiently and adapt to new features as systems continually evolve [70]. In addition, as digital technologies have an increasing role in the management of health of communities and populations, frameworks have also started to incorporate competencies related to public health [71]. Similarly, the acceptance of IT and its incorporation into everyday practice hinges on health care workers advocating for their use and being mindful of contextual factors and beliefs that would enable their use in different settings, such as high-income and low- and middle-income countries (LMICs). Other distinct domains such as leadership, administrative, managerial, and financial bring to attention that a digitally competent workforce should also be able to utilize technologies to oversee organizational-level aspects. It was also noted that competencies related to artificial intelligence, robotics, and social media, which are very relevant in current times, were not explicitly mentioned in the included frameworks [5,9,72]. One possible explanation could be that some of these are subsumed under broader categories, for example, competencies regarding the use of social media could be part of the communication category, or that these digital areas have yet to be covered in digital health competency frameworks.

From this synthesis of digital health competency frameworks, we would like to propose recommendations for the development of future frameworks (Textbox 2). First, an iterative methodology that includes literature review and consultations with local and international experts is ideal for a comprehensive framework. Second, it is encouraged for upcoming frameworks to explore competency areas that appeared in more recent frameworks, to cover upcoming digital health areas (ie, health apps, artificial intelligence, autonomous decision-support systems), and to be open to future revisions to be up to date with technological developments. For example, HITCOMP is projected to continue mapping and aligning competencies with the curriculum and other major initiatives [64]. Finally, the lack of a comprehensive and international framework applicable to allied health professionals and LMICs warrants the development of frameworks that include these populations and settings. For example, only the TIGER framework includes case studies of LMICs, such as China, India, and Nigeria [73].

The findings from this review can also inform and guide future training initiatives on digital health. When designing an educational or training program, it may not be possible to cover numerous competencies presented in a framework; rather, the program should focus on a specific set of competencies suitable for a particular group of health care workers, role, level of seniority, geographical, and health care setting. However, the identified competency domains prevalent in more than half of the included frameworks (ie, informatics concepts and processes, health information management, communication, ethics, legal, or regulations, and privacy and security) should be considered essential interprofessional competencies and thus should be incorporated into training and education efforts for any health care worker group. In addition, several digital competencies presented in the included frameworks may already be covered within the existing curriculum. For example, competencies within the Analysis and Research category may have been integrated within epidemiology training and evidence-based medicine education, respectively. Therefore, educators should consider integrating digital health training within existing parts of the curriculum and teaching it in an applied manner as much as possible. For example, the use of EHRs could be incorporated into the internal medicine curriculum.