The present study sought to integrate both top-down (policy- and evidence-based) and bottom-up methods (needs assessment data tailored to HCPs in the participating countries) to develop recommendations for promoting digital health transformation in clinical practice across Europe. To our knowledge, there are no previous studies that aim to make recommendations on digital transformation using a similar methodology at an international level or to achieve definitive validation of the recommendations in a multinational healthcare context. Although there are other recommendations (e.g. [1, 28]), this study is characterized by several methodological and contextual specificities:

  1. (a)

    from a methodological perspective, the inclusion of a needs assessment conducted directly among HCPs from participating countries as a bottom-up component, allowing for the capture of local and context-specific needs that may not be adequately addressed in global policy documents, and the testing of the resulting recommendations in a CDC setting, which allowed for direct, transparent interactions with real-time discussions to validate the recommendations,

  2. (b)

    from a contextual perspective, the study provides recommendations directed at the European countries involved, although these may also be considered by other countries and systems. The integrated and constructive approach concluded with a consensus conference that generated ten detailed recommendations categorized in three primary domains of investment and aligned closely with the needs of HCPs. Moreover, the study has acknowledged the contribution of HCPs (i.e. those who are in contact with patients): their involvement is especially significant given that digitalization is likely to transform their daily routines, their education [29], and their interaction with patients and relatives [30]. Their effective engagement in the process of developing recommendations may also promote the involvement of patients in accepting digital tools, thus embedding a dissemination process regarding the value of digitalization [18].

When analysing the individual recommendations that have emerged, some thought should be given to their implementation. First, it is suggested that the generational gap across HCPs should be considered, such as the differences in ideas, behaviours, cultural norms, and ways of approaching life, including regarding digitalization. In this context, the digital divide has been considered an important factor [31], since young HCPs (millennials/generation Z) are digital natives while those born in previous decades (e.g. baby boomers) may struggle to recognize the potential of digital solutions [32]. Therefore, as emerged from the recommendations, encouraging HCPs to welcome the digitalization of the workplace, and ensuring basic/advanced and general/specific competence, is crucial for harmonizing the digital literacy possessed by HCPs that may facilitate the transformation. In addition, the shortage of HCPs (e.g., nurses in the four countries included) could be a potential barrier that further hinders the digital transformation in healthcare.

Second, specific recommendations relate to ethical and legal aspects while using digital health technologies in practice. Strong ethical and legal foundations have been considered mandatory for their successful and respectful use [33]. The developed recommendations underline the importance of creating conditions that enable HCPs to reflect on these issues bound into their daily working practices; while it could be argued that this constitutes the basis for the digital transformation of healthcare, it is also important to note that due to the profound differences across healthcare systems, societies, and legal frameworks, specific training should be performed on a local and case-to-case basis [33].

Third, given the high speed at which digital technology evolves, it should be noted that recommendations approved refer to the current Healthcare 4.0, where smart healthcare is healthcare that implements all the technologies of Industry 4.0, which includes big data, the Internet of Things (i.e. Internet of Health Things, Internet of Medical Things, and Internet of Nano Things), augmented reality, virtual reality, artificial intelligence, and robotics, together with high-performance mobile connectivity (e.g., 5G) and a pervasive use of cloud computing [34, 35]. Furthermore, digital transformation concerns not only systems and tools but also a new way of managing infrastructures, applications, and services, and the creation of innovative solutions for the management and maintenance of machines and programs, including security and privacy management [34, 35]. In other words, the approved recommendations may be considered at the micro level for healthcare service delivery purposes and may be expanded in other directions embracing all aspects of digitalization.

The implementation of the proposed recommendations should be designed at micro and macro, local, regional, and national levels. Above all, since the ten recommendations are focused on HCPs, they should also be involved in evaluating their effectiveness. An initial self-evaluation aimed at detecting the stage of digital maturity [36] may address how to shape the approved recommendation regarding their implementation and effectiveness.

Strengths and limitations

This study has some strengths and several limitations that should be acknowledged.

The combination of top-down and bottom-up approaches to ensure comprehensive stakeholder engagement has been addressed with strong methodology. This multifaceted strategy ensures that recommendations are informed by a wide range of perspectives and can be implemented practically in daily care. The broad engagement of a diverse group of stakeholders, including HCPs, HCMs, and multi-professional participants, in the DELIVER project and Transnational Congress was crucial for the development of well-rounded and widely acceptable recommendations. The various phases of the study, which spanned more than three years, have been summarized here to ensure transparency regarding the timetable, objectives, content and actors involved, with the authors’ data available on specific elements.

However, only four European countries were involved in the study, which may limit the generalizability of the recommendations to other regions, particularly those with different healthcare systems, digital maturity levels, and cultural contexts. Therefore, more countries should be included in future studies. Moreover, although several HCPs were involved, researchers should engage HCPs from more diverse backgrounds and age groups, and with different experiences of digitalization. Furthermore, a comprehensive approach without differentiating between the various kinds of technologies that might be applied in healthcare has been adopted (e.g. [37]), resulting in general recommendations that should be shaped according, also, to the technologies implemented.

Furthermore, in formulating the recommendations, we did not explicitly follow a specific theoretical framework for digital transformation, such as the Technology, People, Organizations, and Management (TPOM) Framework [38]. Nonetheless, the fundamental principles regarding the interplay between technology, people, their organization and management have been incorporated into the content of the recommendations. Future studies based on an established theoretical foundation could provide a clear framework for evaluating the effectiveness of the implementation of the recommendations. This could include measures such as adoption rates, user satisfaction and improvements in healthcare and patient outcomes.

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