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4. THEME 3: Inclusion approaches in digital health

4.1 Brief introduction to digital inclusion and patient’s rights

Eveliina Ignatius, University of Helsinki and Ministry of social affairs and health Finland
Digital inclusion should be seen as a broad foundation for patients’ rights. It is important to acknowledge that digital inclusion is linked to both the societal accept­ability of technology use and the boundaries of that acceptability.
Technology in healthcare is not a new topic, but it is one that continues to raise pressing questions. Health­care and medicine are progressive fields where techno­logi­cal inno­vations and advance­ments are often visible and concrete to all of us; Longer life expect­ancy, increased well-being, and more effective treat­ments are evident in our everyday life – not merely as statisti­cal indi­cators. At the same time, techno­logy in health­care holds a double role. It offers great opportunities but also brings risks. Patients have an equal right to benefit from techno­logi­cal progress, including new treat­ment methods or assistive techno­logies. Yet regulation must ensure that funda­mental rights – such as privacy and patient’s autonomy – are safeguarded.
Digital inclusion provides a strong foundation for patient’s rights. Here digital inclusion must be understood broadly, and It is useful to recall the widely used UN-backed definition: “Digital inclusion is defined as ‘equitable, meaningful, and safe access to use, lead, and design of digital technologies, services, and associated opportunities for everyone, everywhere’”. (UN Digital Inclusion) This broad definition is also supported by the European union’s objectives, which encompass several aspects such as digital skills, connectivity, accessibility, linguistic barriers and access. For patients, this means that inclusion is not just about having access to a computer or an app, but about being able to use healthcare technologies and healthcare services supported by technology in ways that are safe, understandable, and respectful of individual needs.

Universal Foundations, Individual Adaptations

Healthcare is inherently rights-sensitive field, closely tied to human dignity, right to life and equality. This underlines the importance of the perspective of the service user – that is, the patient – at every level of decision-making. The first step is to adopt the approach of universal design (or ‘design for all’) which today also has a solid legal base, emphasized by the UN Convention on the Rights of the Persons with Disabilities. (UN CRPD Art. 4.1(f) and Art. 9) This universal approach includes accessibility standards, the goal of user-awareness and everything that is vital for the foundation of inclusivity. In healthcare, this means designing patient portals, telemedicine services, and eHealth applications so that they are accessible to older persons, persons with disabilities, and people with different levels of digital literacy and digital skills. Even when the end-user is a healthcare professional rather than a patient, universal design provides a framework to ensure broad usability.
According to the UN CRPD Art. 2, Universal Design is defined as “the design of products, environments, programmes and services to be usable by all people, to the greatest extent possible, without the need for adaptation or specialized design. “Universal design” shall not exclude assistive devices for particular groups of persons with disabilities where this is needed.” (UN CRPD Art. 4.1(f) and Art. 9 on accessibility)
However, rights are most tangible at the individual level. Moving from universality to individuality, technology in healthcare often requires adaptation to specific circumstances. Depending on the patient, the condition, and the technology, different levels of support may be necessary. A child, a person with a cognitive disability, or someone who is skeptical of digital tools will all need to be approached differently. For example, in the context of the right to privacy, European data protection regulation provides concrete guidance. EU GDPR Article 12 requires that information be given in clear and plain language, and Recital 60 encourages the use of icons to make data practices visible and intelligible. The European Data Protection Board’s Guidelines on Transparency further emphasize that information must be tailored to the average member of the intended audience (European Data Protection Board 2018). In practice, this means healthcare organisations should use multiple formats to ensure that patients really understand how their data and technology are being used. All in all, in healthcare, one should not assume by default that every patient possesses average technological capabilities.

Trust, Autonomy, and Professional Expertise

At the same time, healthcare is a domain with a unique relationship of trust between the patient and the healthcare professional. This is not just any relation­ship between professional and service user. Especially in the public sector healthcare there is usually a need for balance between professional, clinical decision-making and patient autonomy. The healthcare professional brings professional expertise and responsibility for treatment, while the patients have the right to make informed choices about their own care and treatment. Hence, there exists a constant dialogue involving balance in medical decisions.
Although this is a very traditional topic of health care, modern technology seems to introduce new nuances to it as technology is no longer perceived solely as a tool for professionals in the traditional sense. Instead, today technology – such as Artificial Intelligence – can be a strong supporter of the professional decision-making process or treatment, which brings about questions how we should consider this change from the perspective of patient’s autonomy.  Respect for patient autonomy requires that the introduction of new technologies also considers differences not only between patient groups, but also within them. Patients in the same category – for example older persons or cancer patients – may have very different preferences and abilities.
For this reason, the competence of healthcare professionals is crucial. Future generations may be more naturally “technology-native,” but today we all need to be more and more prepared to use different technologies. Professionals are the ones who bring technology to the patient. Unlike everyday consumer technologies, healthcare tools are highly specialised. The professional must have the knowledge to integrate these tools responsibly, to explain their use clearly, and to adapt their use to the individual patient’s needs. Training and digital literacy for healthcare staff is therefore a key element of inclusion. This competence also means knowing when not to use digital tools—sometimes a face-to-face explanation or a paper form may better respect the patient’s situation. From the patient’s perspective, the safeguarding of rights mainly depends on healthcare professionals, with the patient–professional relationship remaining the fundamental basis of those rights, no matter how the organization providing for it is built.
Digital inclusion should be seen as a broad foundation for patients’ rights. It is important to acknowledge that digital inclusion is linked to both the societal acceptability of technology use and the boundaries of that acceptability. Also, emphasizing the relationship between the healthcare professional and the patient is also a key component in implementing technology in a human-centered manner – one that respects human dignity and promotes humanity and compassion. And this is actually the place to underline that inclusive development requires cross-border and interdisciplinary dialogue; it is vital as we need to reconsider some old questions and maybe some new ones as well.

References

European Data Protection Board, Guidelines on Transparency under Regulation 2016/679 (2018). https://www.edpb.europa.eu/our-work-tools/our-documents/article-29-working-party-guidelines-transparency-under-regulation_en
United Nations. Undated. Digital inclusion. Available from: Definition_Digital-Inclusion.pdf (un.org)
UN CRPD Art. 4.1(f) and Art. 9 on accessibility.

4.1.1 Users’ perspectives on digital services and the risk of reinforcing inequalities

Tarja Heponiemi, Finnish Institute for health and welfare, Finland
In recent years, digital health and social care services have rapidly expanded, partly replacing face-to-face interactions – particularly in Nordic countries. While this offers new opportunities, it also increases the risk for digital exclusion. Not everyone has equal possibility or ability to use digital services and take responsibility for their own wellbeing. Those with the greatest need for health and social care are often the ones facing the most challenges in adopting and adapting to digital services, potentially deepening existing social and health inequalities.

There are inequalities in access to and use of digital services

Individuals who are economically, socially, or health-wise disadvantaged tend to use digital services less frequently than their more advantaged peers. Poor health, functional limitations, cognitive difficulties, loneliness, and psychological distress are all associated with reduced access to healthcare services. Importantly, poor digital competence partly explains these associations. Specifically, we found that poor digital competence accounted for approximately 12% of the association of cognitive impairments with poor healthcare access, 9% of long-term functional limitations, and 8% of loneliness. (Heponiemi et al., 2023)
Impairments in vision (both near and distance), limited upper limb mobility, and poor cognitive and physical performance – as measured by tests such as memory assessments and the chair rise test – are significant predictors of internet non-use and low digital competence over time. Notably, we found that older individuals who perform poorly on the word list memory test had a 3.8-fold higher risk of not using the internet compared to those with better performance. (Heponiemi et al., 2023)

Not all users benefit equally from digital health and social care services

Digital services are often seen as less useful by those experiencing socioeconomic or health-related challenges. Financial hardship – such as needing to compromise on food, medications, or medical visits – is particularly linked to low perceived usefulness. Poor self-rated health and limited social contacts are also associated with reduced perceived value. Additionally, older adults, individuals with lower educational attainment, and rural residents report fewer benefits, partly due to disparities in access, digital skills, and service use. (Heponiemi et al., 2020)
Further analyses show that individuals with lower personal, economic, and social offline resources perceive digital services as less beneficial, largely due to poor access, limited digital skills, and negative attitudes toward digital services. These findings highlight the need to address both structural and attitudinal barriers to improve the perceived value and usability of digital services among disadvantaged groups. (Heponiemi et al., 2021)
Among older adults, the most commonly perceived benefit of digital services is their ease of use regardless of time and location. Perceived usefulness is greater among those with convenient access to local services, good functional ability, good vision, the ability to learn new things, and those living with someone. Internet access and the ability to use it independently are also strongly linked to higher perceived benefits. (Kainiemi et al., 2023)

Especially vulnerable groups face digital inclusion challenges

Vulnerable groups – including older adults, migrants, mental health service users, frequent users of health services, and the unemployed – often face barriers in accessing digital services. These barriers include limited digital and/​or local language skills, lack of support and training, poor health, absence of secure e-identification, and unsuitable devices. Digital services are frequently perceived as inadequate substitutes for face-to-face care, due to challenges in communication and limited applicability across diverse situations. Concerns about data security and mistrust toward digital platforms are also common. Contact with healthcare professionals in digital settings is often experienced as less personal and more prone to misunderstandings. In addition, digital alternatives are not always available when needed, and some individuals in vulnerable groups remain unaware of existing services or their potential benefits. (Kaihlanen et al., 2022)
Among mental health service users improved access to care, support for mental well-being, and the convenience of receiving services from home may support the use of remote mental health services. Whereas, the lack of non-verbal communication, difficulties in expressing and interpreting emotions, technical problems, issues related to service organization and usability, varying levels of professional readiness to deliver remote care, and concerns about safety and data security may hinder the use. (Coomans et al., 2024)
Individuals with mental health problems express heightened concern about the safety of web-based services. Poor mental health is independently associated with negative attitudes toward digital plat­forms, beyond the influence of socio­demographic factors. These negative perceptions are especially pronounced among older adults and men. (Rantanen et al., 2021)

Conclusions

Previous research shows that the risk of digital exclusion from services and deterioration in well-being is particularly high among already vulnerable groups. Thus, the high increase of digital services may exacerbate existing social and health-related inequalities. However, it is important to keep in mind that situation is more complex than it seems, as individuals in these groups vulnerable to digital exclusion are highly diverse. Our recent review shows four perspectives which reflect suitability to digital services in health and social care: (1) skill-based suitability, (2) suitability based on general ability to maintain health, (3) suitability based on attitude and experience, and (4) suitability based on practical matters. (Kaihlanen et al., 2023)
It is essential that governments and service providers take proactive steps to enhance digital inclusion. Based on findings from the DigiIN project (“Towards socially inclusive digital society – trans­forming service culture”), several recommen­dations have been proposed to support this goal. To ensure that digital health and social services are inclusive and effective, it is important to guarantee the clarity and accessibility of service content. Continuous and accessible support should be provided to help users navigate digital services. Efforts are needed to promote digital inclusion among older adults and other vulnerable groups. The impact of digitalization on the work of health and social care professionals should be recognized and managed. Education and professional development must be strengthened to meet the evolving needs of a digitalized health and social care. Furthermore, successful implementation of new digital technologies in health and social care requires efforts. (Kaihlanen et al., 2025)

References

Coomans, S. K., Virtanen, L., Kaihlanen, A. M., Rantanen, T., Clemens, T., & Heponiemi, T. (2024). Remote mental health services during the COVID-19 pandemic in Finland and the Netherlands: a qualitative study. Discov Ment Health, 4(1), 30. https://doi.org/10.1007/s44192-024-00088-z  
Heponiemi, T., Gluschkoff, K., Leemann, L., Manderbacka, K., Aalto, A.-M., & Hyppönen, H. (2021). Digital inequality in Finland: Access, skills and attitudes as social impact mediators. New Media & Society, 0(0), 14614448211023007. https://doi.org/10.1177/14614448211023007  
Heponiemi, T., Jormanainen, V., Leemann, L., Manderbacka, K., Aalto, A. M., & Hypponen, H. (2020). Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study. J Med Internet Res, 22(7), e17616. https://doi.org/10.2196/17616  
Heponiemi, T., Kaihlanen, A. M., Virtanen, L., Kainiemi, E., Saukkonen, P., Koponen, P., Koskinen, S., & Elovainio, M. (2023). The Mediating Role of Digital Competence in the Associations Between the Factors Affecting Healthcare Utilization and Access to Care. Int J Public Health, 68, 1606184. https://doi.org/10.3389/ijph.2023.1606184  
Heponiemi, T., Kainiemi, E., Virtanen, L., Saukkonen, P., Sainio, P., Koponen, P., & Koskinen, S. (2023). Predicting Internet Use and Digital Competence Among Older Adults Using Performance Tests of Visual, Physical, and Cognitive Functioning: Longitudinal Population-Based Study. J Med Internet Res, 25, e42287. https://doi.org/10.2196/42287  
Kaihlanen, A., Borodulin, K., Kouvonen, A., Kujala, S., Rantanen, T., Taipale, S., Buchert, U., Juujärvi, S., Järveläinen, E., Kainiemi, E., Silvennoinen, P., Simola, S., Virtanen, L., & Heponiemi, T. (2025). Ratkaisuja sosiaali- ja terveydenhuollon digitalisaatioon – näin tuet asiakkaiden yhdenvertaisuutta ja ammattilaisten työtä. Terveyden ja hyvinvoinnin laitos. https://www.julkari.fi/bitstream/handle/10024/151106/URN_ISBN_978-952-408-480-2.pdf  
Kaihlanen, A. M., Virtanen, L., Buchert, U., Safarov, N., Valkonen, P., Hietapakka, L., Horhammer, I., Kujala, S., Kouvonen, A., & Heponiemi, T. (2022). Towards digital health equity - a qualitative study of the challenges experienced by vulnerable groups in using digital health services in the COVID-19 era. BMC Health Serv Res, 22(1), 188. https://doi.org/10.1186/s12913-022-07584-4  
Kaihlanen, A. M., Virtanen, L., Kainiemi, E., & Heponiemi, T. (2023). Professionals Evaluating Clients' Suitability for Digital Health and Social Care: Scoping Review of Assessment Instruments. J Med Internet Res, 25, e51450. https://doi.org/10.2196/51450  
Kainiemi, E., Saukkonen, P., Virtanen, L., Vehko, T., Kyytsonen, M., Aaltonen, M., & Heponiemi, T. (2023). Perceived benefits of digital health and social services among older adults: A population-based cross-sectional survey. Digit Health, 9, 20552076231173559. https://doi.org/10.1177/20552076231173559  
Rantanen, T., Gluschkoff, K., Silvennoinen, P., & Heponiemi, T. (2021). The Associations Between Mental Health Problems and Attitudes Toward Web-Based Health and Social Care Services: Evidence From a Finnish Population-Based Study. J Med Internet Res, 23(9), e28066. https://doi.org/10.2196/28066

4.2 Nordic perspectives on digital inclusion

Sari Palojoki and Riikka Vuokko, Ministry of social affairs and health, Finland
Digital inclusion extends beyond technical access: it requires trust, clear communi­cation, and the ability to benefit from services in practice.
The European Health Data Space (EHDS), which entered into force in 2025, marks a milestone in Europe’s digital health development. By creating a common framework for secure use and exchange of health data, the EHDS aims to empower citizens with greater control over their personal health information, strengthen patient rights, and facilitate cross-border access to healthcare.
To deliver on this promise, inclusiveness is essential. Digital health should be usable and accessible for everyone irrespective of age, location, socioeconomic background, language, or digital skills. Digital inclusion extends beyond technical access: it requires trust, clear communication, and the ability to benefit from services in practice. Without these, digital trans­formation may risk reinforcing existing inequalities and excluding vulnerable groups.
The Nordic countries are well positioned to lead by example. Their universal welfare systems, advanced digital infrastructures, and high levels of public trust create strong foundations for inclusive digital health. Yet gaps exist. Older adults, rural residents, persons with disabilities, and those with limited language or technology skills continue to face barriers to participation.
Coordinated Nordic action under the Council of Ministers offers an opportunity to exchange best practices, test innovative solutions, and ensure that inclusiveness remains central in the implementation of the EHDS. This chapter highlights how each Nordic country is promoting equitable participation in the digital health transition.

4.2.1 Danish Joint Government Principles for Digital Inclusion

Kenneth Bøgelund Ahrensberg, Danish Health Data Authority, Denmark

The Danish welfare state is among the most digital in the world, and with that comes responsibility

Denmark is one of the most digitalized societies globally. Early on, central, regional and local government decided to take joint responsibility for an ambitious digital transformation in the public sector, and today, communication between citizens and authorities is primarily digital. However, for some citizens, the increasing digitalization poses a challenge. Approxi­mately one-fifth of Danish adults experience some degree of difficulty in interacting digitally with public authorities. It is a democratic problem if the digital transformation becomes a barrier to participating in the welfare society.
As a society, we have a responsibility to harness the potentials of the digital development, contributing to improved welfare, growth and the green transition. It is our ambition that Denmark remains a digital forerunner. With that comes an obligation to create good conditions for citizens challenged by digitalization. There will always be those who find it difficult to be digitally self-reliant or who have special needs as digital users. Therefore, digital inclusion is an imperative, which we must continuously focus on when digitalizing, and a key priority across the public sector. We aim to be a forerunner in user-friendly and inclusive digitalization, empowering individuals and adding value for all citizens.
With six principles for digital inclusion, the Agency for Digital Government, Local Government Denmark and Danish Regions collectively set the direction for public digitalization with thought and consideration for all citizens. Inclusive digitalization begins in each project and within each organization. This is how we digitalize responsibly and inclusively.

Six Principles for Digital Inclusion

The joint government principles for digital inclusion aim to promote responsible and inclusive digitalisation. However, the principles only add value when they are reflected in decisions, projects and in the interaction between citizens and public authorities. The principles are advisory and meant to assist authorities in their efforts towards inclusive digitalisation.

Making the Principles a Reality

The principles are relevant for anyone involved in public digitalisation or public service in areas where the interaction with citizens is digital.
As management or a decision-maker, you have a particular responsibility to ensure that citizen-oriented digitalisation considers all citizens. For this purpose, you can use the principles for digital inclusion as strategic landmarks and as a guide when balancing relevant considerations. The principles can also help you support your employees in their work. As an employee or specialist, you can use the principles in your work with citizen-oriented digitalisation, service design, citizen contact, or procurement of digital solutions. For example, the principles can form the basis for dialogue with suppliers of digital solutions.
Principperforinklusion.digst.dk, a Danish platform, provides specific tools, materials, cases and examples for each principle to support the work with inclusive digitalisation in a public organisation.
  • Be Aware of the Consequences of Digitalisation. Decisions about digitalisation should support the rights of all citizens and minimise risks of exclusion.
  • Design Solutions for All Citizens. Citizen-oriented digital solutions should be developed with diverse involvement of citizens, be based on citizens’ needs and be usable for as many as possible.
  • Communicate so Everyone Understands. Authorities should use easy-to-understand language and employ supporting tools and measures.
  • Assist Citizens with Their Digital Tasks. Citizens should have easy access to help and guidance in their digital interaction with the public sector.
  • Help the Helpers. It should be easy, secure, and safe for helpers to assist digitally.
  • Provide Usable Alternatives. When citizens cannot be digital, alternative options should be available.

Reference

Principles for Digital Inclusion 1st edition. The Danish Agency for Digital Government, Local Government Denmark and Danish Regions. June 2024. https://en.digst.dk/media/qnbdfahu/principles-for-digital-inclusion-eng.pdf

4.2.2 Ensuring Digital Inclusion in Finnish Health Services

Sari Palojoki, Riikka Vuokko, Ministry of social affairs and health Finland
Finland is internationally recognized as a pioneer in digital health services. The national digital health infrastructure, including MyKanta-portal and electronic prescription deployment, have set benchmarks for gradual integration into regional and local health information systems (Palojoki, Vuokko 2024). Building on this foundation, the forthcoming European Health Data Space (EHDS) implementation creates opportunities for more efficient health service delivery based on health data but also may raise challenges for accessibility and equity (European Commission 2025). Without explicit inclusiveness, digitalization may risk reinforcing, rather than reducing, health inequalities. Accessible digital services strengthen both population health and public trust in the healthcare system.
Despite Finland’s advanced digitalization, gaps in participation in digital society remain. Nearly 40% of Finns frequently need support with online services (DVV 2023), and around one in five report requiring guidance with digital health tools (THL 2023). Vulnerable groups include older adults, people with lower education, migrants, and those in poorer health (see e.g., Hörhammer et al. 2025, Leppiman et al. 2021). Barriers relate to language, complex interfaces, and the lack of secure electronic identification, essential for accessing public services. As digital channels increasingly replace face-to-face encounters, risk of a widening digital divide may arise. Managing personal health information through platforms such as MyKanta also presupposes skills and capacities not yet universal.
As an example of recent development, as a part of Finland’s Recovery and resilience plan actions (Valtionkonttori 2025), digital inclusion perspectives were included in projects that supported access to care in digital processes. One of the examples is digital mentoring that strengthens the digital skills of social and health care professionals. In the Central Ostrobothnia welfare region, the digitally advanced employees were allocated, at first, two hours per week to provide low-threshold support to their colleagues. In addition, it was possible to exchange experiences via a chat channel. In January 2024, there were 37 mentors, and by the end of May 2025, the number had increased to 42. The mentors' superiors were not always aware of their staff's digital skills. The increase in superior support for mentoring activities was a positive development. (RRP, PIL4 INV4 tp 2, 2024)
Currently, at the Ministry, based on the recent digitalization strategy (STM 2023) it was recognized to focus on digital inclusion. Looking ahead, following focus areas are central. First, user-centred design should involve groups most at risk of exclusion. Second, multi-channel provision should remain so digital tools do not fully replace telephone or in-person services. Third, accessibility and language support must be embedded by default, including e.g., multilingual options, and compliance with accessibility standards. Fourth, targeted investment in digital skills is needed, especially for older citizens and vulnerable groups, delivered through low-threshold training and partnerships with civil society. Finally, systematic monitoring and evaluation should ensure that inclusion targets are met and guide service improvement. (DVV 2023, Ghorbanian Zolbin et al. 2025) For example, the regional service providers and various third-party organizations provide support for digital skills and peer support (e.g., SeniorSurf 2025).  
Digital inclusion is both ethical and practical. Inclusive digital services have potential to support prevention, enable earlier interventions, and ease pressure on specialized care. Especially, universal access underpins social justice and trust in healthcare (Paccoud et al., 2023). Equity in digital access is therefore not only a fairness issue but also a question of sustainability. Thus, this area deserves attention.

References

DVV 2023. Finnish people are keeping up with digital development, but we must have digital support. Available from: https://dvv.fi/en/-/finnish-people-are-keeping-up-with-digital-development-but-we-must-have-digital-support
European Commission 2025. Regulation (EU) 2025/327 of the European Parliament and of the Council of 11 February 2025 on the European Health Data Space and amending Directive 2011/24/EU and Regulation (EU) 2024/2847 https://eur-lex.europa.eu/eli/reg/2025/327/oj/eng
Ghorbanian Zolbin, M., Kujala, S. ., Widén, G., Eriksson-Backa, K., & Huvila, I. (2025). Digital inclusion among older adults: Identifying potential solutions. Human Technology, 21(1), 51–72. https://doi.org/10.14254/1795-6889.2025.21-1.3
Hörhammer I, Suvanto J, Kinnunen M, Kujala S. Usefulness of self-guided digital services among mental health patients: The role of health confidence and sociodemographic characteristics. Int J Med Inform. 2025 Feb;194:105693. doi: 10.1016/j.ijmedinf.2024.105693. Epub 2024 Nov 12. PMID: 39556968.
Leppiman, A., Riivits-Arkonsuo, I., Pohjola, A. (2021). Old-Age Digital Exclusion as a Policy Challenge in Estonia and Finland. In: Walsh, K., Scharf, T., Van Regenmortel, S., Wanka, A. (eds) Social Exclusion in Later Life. International Perspectives on Aging, vol 28. Springer, Cham. https://doi.org/10.1007/978-3-030-51406-8_32  
Paccoud I, Leist AK, Schwaninger I, van Kessel R, Klucken J. Socio-ethical challenges and opportunities for advancing diversity, equity, and inclusion in digital medicine. DIGITAL HEALTH. 2024;10. doi:10.1177/20552076241277705
Palojoki S, Vuokko R 2024. Kanta information system services: Assessment of the development of digitalisation in healthcare 2010–2024. Reports and Memorandums of the Ministry of Social Affairs and Health 2025:8. http://urn.fi/URN:ISBN:978-952-00-4197-7
RRP, PIL4 INV4 tp 2.Digimentoritoiminta Keski-Pohjanmaan hyvinvointialueella. Operating model description. Armi Niemelä 15.4.2024. Available from: https://www.innokyla.fi/fi/toimintamalli/digimentoritoiminta-keski-pohjanmaan-hyvinvointialueella-rrp-pil4-inv4-tp-2
SeniorSurf. Vanhustyön keskusliitto ja Sosiaali- ja terveysministeriö 2025. Available from: https://seniorsurf.fi/seniorit/opastuspaikat/
THL 2023. Digitaaliset palvelut ja digitaalinen asiointi. Terve Suomi -ilmiöraportit. Terveyden ja hyvinvoinnin laitos 11.12.2023. Available from: https://www.thl.fi/tervesuomi_verkkoraportit/ilmioraportit_2023/digitaaliset_palvelut_ja_digitaalinen_asiointi.html
Valtionkonttori 2025. Suomen elpymis- ja palautumissuunnitelman (RRP) toimeenpano ja seuranta. Valtionkonttori 9.10.2025. Available from: https://www.valtiokonttori.fi/palvelut/rahoitus-ja-lainapalvelut/suomen-elpymis-ja-palautumissuunnitelman-toimeenpano-ja-seuranta/

4.2.3 Icelandic Perspectives on Ongoing Digital Transformation and Digital Inclusion

Guðrún Auður Harðardóttir, Directory of Health Iceland
Digital transformation in healthcare has accelerated globally, with the Nordic countries at the forefront. Leveraging a strong digital infrastructure and a commitment to innovation, Iceland has made significant progress in modernizing its healthcare system. At the same time, the European Union has introduced the European Health Data Space (EHDS) regulation, aiming to harmonize access to and use of health data across EU and EEA member states.
Key initiatives are the island.is portal and the national patient portal, heilsuvera.is. The island.is portal provides centralized access to hundreds of government services—and currently, there is work in process to move the national patient portal under the island.is environment.
Citizens access their personal- and health information using an electronic ID (eID), which is compliant with eIDAS regulations (Island.is 2025). Iceland has introduced numerous strategic plans to strengthen digital transformation and digital inclusion. In July 2021, a national digital strategy was published to promote inclusive digital public services for all citizens. Furthermore, Iceland has developed strategies for cloud computing, cybersecurity, artificial intelligence, and data governance, all of which support the digital transformation of public institutions (Government of Iceland 2025).
The Ministry of Health´s Health Strategy to 2030 and the Digital Healthcare Policy promote the use of interoperable digital solutions and collaboration among healthcare entities to improve health outcomes. The emphasize is on patient-centered care and secure data accessi­bility with interoperable EHR´s and empowered citizens who can access and manage their health digitally via the national patient portal. The strategies outlines three main objectives:
  • Empower individuals to actively participate in their own treatment
  • Improve interoperability and coordination between systems
  • Support innovation and research, including AI and personalized medicine (Ministry of health 2021)
Iceland’s digital health infrastructure features interconnected electronic health records (EHRs), including maternal- and birth records, and interactive question­naires, enabling healthcare professionals to securely share patient data across institutions and geographic regions, ensuring timely access to clinical information and supporting coordinated care. The centralized national patient portal is interoperable with the national EHR system and accessible to all citizens through a single access point: island.is. Parents have access to their childrens´ health data up to the age of 16. Moreover, an Act was recently passed that allows proxys to act on behalf of marginalized populations. Last year, 86% of citizens 16 yrs. and older used the patient portal at some point in time.
An electronic prescription system (ePrescription) was implemented in 2010, and all pharmacies in Iceland participate. Furthermore, data from hospitals and primary care centers is transmitted in real time from the EHRs to the national registries at the Directorate of Health.
However, despite notable progress, challenges and gaps remain. Existing systems require modernization, and international standards must replace locally developed standards to ensure interoperability and enable meaningful cross-border health data exchange that supports continuity of care.
Iceland is currently in the process of implementing EU4Health digital services, which will facilitate the sharing of patient data across borders. This transformation demands the adoption of international standards and a fundamental shift in how health data is managed in Iceland.
Digital transformation depends on the inclusion of all citizens. Digital inclusion is central to ensuring equitable access for all citizens, regardless of location, age, or ability. The approach of the Icelandic government is holistic, integrating digital transformation across public services, health systems, and infrastructures by aligning policies to ensure equal access to health services and patient data, to promote digital literacy and support remote care and telehealth.

Conclusion

Digital transformation in Iceland’s healthcare system is rapidly progressing, and the EHDS regulation presents an opportunity to harmonize and strengthen this development through the implemen­tation of common standards for meaning­ful sharing of health data across borders, better decision making, empowered citizens and improved health outcomes.
Digital transformation needs to benefit all. It is not merely a technological shift – it is a societal transformation. With a clear policy and aligned digital policies, robust infrastructure, and innovation in healthcare services, Iceland is building a system that is more efficient and serves both individuals and society as a whole, ensuring that no one is left behind.

References

Digital healthcare policy. Ministry of health, September 2021. Available from:  https://www.government.is/library/01-Ministries/Ministry-of-HealTh/PDF-skjol/Digital%20healthcare%20policy.pdf
Government of Iceland 2025. https://www.stjornarradid.is/
Island.is 2025. Öll opinber þjónusta á einum stað [All of Iceland's public services in one place], https://island.is/
We Are Social & Meltwater 2023. Digital 2023 Iceland. Simon Kemp, 13.2.2023. Available from: https://datareportal.com/reports/digital-2023-iceland

4.2.4 Norwegian Perspectives on ongoing digital transformation and digital Inclusion

Marianne Bårtvedt van Os, Directorate of health, Norway

Digital transformation

Along with the other Nordic countries, Norway is among the most digitalized countries in the world. Digitalization is not the goal in itself. Rather, it is the tool we need to realize the new data opportunities (like AI) and to solve many of the major societal challenges we are facing. 
Norway already had a long journey with digitalization of health services and building e-health infrastructure. The implementation of EHR-systems started early and was built up nation-wide. The focus is now on modernizing and improving the EHR-systems, increase digital sharing of information (data and documents) and improve the use and utilization of data (i.e., automatic data harvesting, aggregated analysis, monitoring, data mining). Norway also has developed national e-health solutions like our national health portal helsenorge.no, summary care record, e-prescription solutions and a secure digital network foundation. The goals of the EHDS are very much in line with the goals of our national e-health strategy (Helsedirektoratet 2025), and we are working in the same direction. The ambition is that the EHDS regulation can become an accelerator to implement much of what we are already doing and have planned in the e-health area (EHDS konsekvensvurdering – Gapanalyse).

Digital inclusion

Digital inclusion is a central political and societal concern in Norway. Our national digitalization strategy 2024 – 2030 (Digital Norway of the Future 2024) emphasizes that all people regardless of age, ability, income, language must be included and have equal access. It is about trust, and it is about fairness. It is about ensuring that digitalization benefits us all.
Norway has a digitally mature population. Most are online and have experience using digital services. However, some are unable to use digital services or do not want to use digital services, for various reasons. Based on existing figures, it is estimated that around 20 per cent of the adult population is vulnerable when using public digital services (Digdir 2023).
A lack of digital competence, administra­tive skills, trust, and confidence are among the individual challenges that create barriers to the use of digital solutions. In addition, factors related to the solutions themselves, such as a lack of universal design, poor user interface, complexity, or a lack of cohesion, can hinder citizens from using them.
Towards 2030, the Government will ensure that everyone can take part in digitalization. We will strengthen our efforts to increase the digital competence of those groups experiencing digital barriers and digital exclusion. We shall make sure that everyone is offered an electronic identity. We shall strengthen the population’s resilience to digital disinformation. Children and young people shall be ensured a safe digital upbringing. We shall ensure a good digital-analogue balance in kindergartens, schools and in the leisure time of children and young people.
Specific goals 2030 are following:
  • The number of persons over the age of 12 in Norway who have a high security eID shall be 5 million. Currently, this figure is 4.5 million.
  • 95 per cent of the population should have basic digital skills, and everyone should be offered the opportunity to develop such skills. Currently, 86 per cent of the population has digital skills.
In June 2023, the Government launched an Action plan for increased inclusion in a digital society (Handlingsplan for auka inkludering i eit digitalt samfunn 2023). The action plan aims to ensure that all citizens receive equal public services, regardless of background, language skills or age. The action plan primarily targets those groups that experience digital barriers and digital exclusion
Users must be included to a greater extent in the development of digital services. This also applies to services aimed at children and young people. A collaborative forum for digital inclusion has been established and is managed by the Norwegian Digitalization Agency. The forum consists of representatives from the public sector, voluntary organizations and the business sector and works to facilitate equal public services, irrespective of digital skills. The Norwegian Digitali­zation Agency also published a national Index on Digital Inclusion (Uutilsynet 2025). The Index shows where we have come the furthest and where we need to strengthen our efforts.
In order to secure full digital inclusion, it is also important to secure analogue alternatives for the non-digital citizens, i.e., extra services via telephone or mail, and to have good and effective consent mechanisms for next of kin to act on behalf of the non-digital citizens.  
AI may pose challenges for equality and non-discrimination, but can also be used to promote inclusion, for example through text reading, speech-to-text and audio description of images, and in programs that support persons with dyslexia with writing. AI will also be able to assist persons who do not speak Norwegian through written and oral translations from other languages

Conclusion

Digital inclusion in Norway is about creating a society where no one is left behind due to lack of digital competence or inaccessible solutions. Norway has made significant progress through legislation, national strategies, and collaborative initiatives, but continued efforts are needed to ensure equal participation for all.

References

Digdir 2023. Kor mange opplever digitalt utanforskap? Digitaliseringsdirektoratet 17.4.2023. Available from: https://www.digdir.no/rikets-digitale-tilstand/kor-mange-opplever-digitalt-utanforskap/4456
The Digital Norway of the Future. Government.no, 4.11.2024. Available from: https://www.regjeringen.no/en/dokumenter/the-digital-norway-of-the-future/id3054645/
EHDS konsekvensvurdering – Gapanalyse pr. 11. april 2025. Helsedirektoratet, May 2025. Available from: https://www.helsedirektoratet.no/rapporter/ehds-konsekvensvurdering--gapanalyse-pr.11.april-2025
Handlingsplan for auka inkludering i eit digitalt samfunn. Kommunal- og distriktsdepartementet, 6/2023. Available from: https://www.regjeringen.no/contentassets/32548e91c3024d338370372985fb371c/nn-no/pdfs/h-2544-n.pdf
Nasjonal e-helsestrategi for helse- og omsorgssektoren. Helsedirektoratet, January 2025. Available from: https://www.helsedirektoratet.no/digitalisering-og-e-helse/nasjonal-e-helsestrategi
Uutilsynet 2025. Nasjonal indeks for digital inkludering (DI-indeks), Digitaliseringsdirektoratet. Available from: https://www.uutilsynet.no/innsikt-og-analyse/nasjonal-indeks-digital-inkludering-di-indeks/2897

4.2.5 Swedish Digital Transformation in Health Care: The Perspective of Inclusion

Johanna Ulfvarson, Swedish eHealth Agency and Karolinska Institutet, Sweden 
Swedish society is founded on democratic values that emphasize equal worth, participation, and equality for all. The right to inclusion and the opportunity for independence are fundamental principles. As stated in the Swedish Constitution, “the public sector shall work to ensure that all people can achieve participation and equality in society”.
The overarching goal of Sweden’s digitalization policy is to become the world leader in harnessing the opportunities of digital transformation. The national strategy highlights that everyone should be familiar with digital tools and services and have the opportunity to engage in digital development based on their individual circumstances (Regerings­kansliet).
Digital accessibility and usability in Sweden are primarily governed by two key laws that set clear standards for how digital environments should be designed and operated. While these laws apply to different sectors and actors, they share a common goal: to create a more accessible society for all. The Law on Accessibility to Digital Public Services mandates that all public sector websites meet legislative accessibility requirements, aiming to improve digital access for all users, including those with disabilities. The Discrimination Act prohibits both direct and indirect discrimination and requires proactive measures to prevent exclusion and promote equality (Sveriges Riksdag). Additional legislation relevant to digital accessibility includes the Electronic Communications Act and the Public Procurement Act (Digital inkludering, PTS).
From an international perspective, Sweden is a frontrunner in the use of digital services. According to the EU’s statistical office, over 98% of Swedes used the internet daily in 2024 for various purposes. While the population generally demonstrates high digital competence, some groups still lack basic digital skills (European Commission).
The Swedish government envisions a sustainable, digital society where every individual can participate and benefit. To ensure digital inclusion, access, usability, and consideration of individual conditions are essential. Sweden’s national digitali­zation strategy prioritizes digital competence to simplify the use of digital services. Digital solutions hold great potential to create more inclusive services, but true inclusion requires actively addressing digital exclusion by ensuring access, promoting digital literacy, and designing user-friendly systems for all (Sweden's digitalization strategy 2025–2030).
Accessibility and inclusion depend on understanding the end-users – their identities, needs, and contexts. Although definitions and monitoring frameworks are still evolving, there is growing recognition of the need for inclusive, accessible, and equitable digital services (Nordregio Report).
Healthcare professionals have varying requirements depending on their roles, while patients present diverse conditions, preferences, and expectations. Many patients interact with multiple healthcare providers, and existing bottlenecks in the Swedish healthcare system further complicate accessibility.
The government has emphasized that digitalization and the development of a national digital infrastructure will enhance healthcare quality, improve patient safety, empower patients, and reduce admini­stra­tive burdens for healthcare professionals.
To achieve these goals, several initiatives are underway. One example, led by the Swedish eHealth Agency, is the develop­ment of a shared National Digital Infrastructure (NDI) for healthcare. This infrastructure enables secure and efficient information sharing across systems and stakeholders. A key component of the NDI is the National Interoperability Function, which focuses on standardization to ensure seamless data exchange. When information is shared securely, health data becomes accessible to authorized individuals.
The new EU framework for the European Health Data Space (EHDS) promotes equal access and safe secondary use of health data. However, successful implementation requires capacity-building, clear public communication, and measurable inclusion across care pathways. For the EHDS system to function effectively, digital health data must be shared – whether it involves patients accessing their own records, healthcare professionals collaborating across borders, or researchers utilizing anonymized data for scientific purposes.

Conclusion

Digital maturity does not automatically lead to digital inclusion. Sweden is actively working to bridge the digital divide through targeted initiatives, particularly for vulnerable populations. Despite facing challenges in establishing a unified national digital infrastructure and standardized systems across regions, municipalities, and care providers, Sweden’s commitment to innovation has yielded significant progress. Digital services such as e-prescriptions, online medical records, and virtual care appointments are now standard, giving all residents the opportunity to manage their health digitally.
The next critical step is the development of robust, interoperable systems for health data exchange – ensuring that digital transformation in healthcare is not only advanced, but truly inclusive.

References

Regeringskansliet https://www.regeringen.se/
Digital inkludering, Post och Telestyrelsen, 2025
European Commission, 2025. State of the Digital Decade 2025 report. Shaping Europe’s digital future
Nordregio Report 2024:3. National Digital Inclusion Initiatives in the Nordic and Baltic Countries

4.3 Digital capabilities of health personnel during work transformation

Tia-Maria Kirkonpelto and Taina Mäntyranta, Ministry of social affairs and health Finland
Workplaces need digital mentors with both technological expertise and expertise on key focus areas. Personnel are expected to take bold initiatives and maintain their own skills.
Digitalization has led to major work transformation and changes working conditions of all professional groups in health care. It is important to recognize digital capa­bili­ties of the personnel and support not only capacity building at individual level but also in overall development of workplace culture.
The Ministry of Social Affairs and Health in Finland has published a handbook on the best practices for competence development in digital health services that could be used to promote digital capa­bilities and continuous improvement approach at the level of individuals and work communities. The handbook is grounded on material collected in 2024 consisting of descriptions of previously identified best practices, a statistical survey, professionals’ interviews, and workshops.
The digital capabilities of healthcare personnel vary not only between individual care professionals and organizations but also between different regions due to, for example, organizational history and structure. Most of the care personnel felt that their digital competence was good, but particularly artificial intelligence literacy was considered weaker compared to what the perceived importance of the topic would deserve. Some of the care personnel regarded their basic digital skills insufficient. The handbook presents recommendations for each target group amongst the care personnel to support work practices: networking to develop competence with providers of education, and digital competence management as change to support capacity building, and work ability management. A need to actively involve care personnel in, for example, digitalization development and decision-making at different stages of digital transformation. A possibility with digitalization was recognized as transition from legacy processes to renew work processes with more modern approaches.  Health care organizations may encourage use of digital mentors, who have both technological expertise and sufficient health care knowledge. Care personnel are offered possibilities to maintain their own skills. It is suggested that remuneration schemes will be created for the best digital capacity building initiatives.

Reference

Käsikirja: Digitalisaatiota ja sitä koskevien toimintatapojen, osaamisen ja kulttuurin edistäminen [Handbook: Promoting Digitalisation and the Related Practices, Competence and Operating Culture]. Toim. Tepponen, Merja, Ahonen, Outi, Turja, Tuuli. Sosiaali- ja terveysministeriön julkaisuja 2024:37, http://urn.fi/URN:ISBN:978-952-00-8657-2

4.3.1 Strengthening digital competencies for AI-enabled health care

Outi Ahonen and Birgitta Tetri, Laurea University of Applied Sciences, Finland
In the European Digital Decade aim, is deepen European resilience to digital society. The four key pillars are defined: digitalisation of public services, digital transformation of businesses, secure and performant sustainable digital infra­structures and a digitally skilled population and highly skilled digital professionals (European Comission 2021). To make effective use of digital health and social care processes in public services, there needs to be strong infrastructure, capable and flexible enterprises, professionals need to be competent, and citizens must also have the skills to use eHealth and welfare services.
In Finland, a national report commissioned by the Ministry of Social Affairs and Health has examined the current situation, experiences, and needs of healthcare organizations in developing the digital skills of healthcare personnel and the digital capacity of work communities. The report also highlighted variations in digital competence across regions, individuals, and organisations, identified best practices, and supported the development of networks to strengthen professionals’ digital competencies. In addition, it defined the roles of different professionals in supporting competence development in Finnish health and social care (Tepponen, Ahonen & Turja 2024).
Internationally the health informatics competencies have been framed and largely accepted (Mantas et al. 2010) and then updated (Bichel-Findlay et al. 2023). Finland has developed a national digital competence framework for health and social care professionals at the bachelor’s level (Tiainen et al. 2021) and professional specialisa­tion education (Ahonen at al. 2024) as well as a competence framework for medical doctors (Tuovinen et al. 2021). However, the rapid development of Artificial Intelligence (AI) highlights the need to revisit and update these frameworks through literature reviews and national discussions (e.g., Ministry of Social Affairs and Health project, reference pending). In the national self-assessment, health and social care professionals’ digital competence was described through six themes: informatics competencies, knowledge management competencies, competence to monitor health and well-being in digital environments, person-centred guidance in digital environments, ethical competencies, and AI-related competencies.
Social and healthcare professionals reported that digitalisation supports the meaningfulness of their work and helps balance traditional and digital practices. They felt the current level of digitalisation was suitable, with a functional balance between remote and in-person services. Professionals also expressed a predomi­nantly positive view of their work community’s digital readiness, reflecting Finland’s success in advancing digitali­sation in the sector. At the same time, variation in competence levels was observed: interviewees estimated that about one-third of staff had deficiencies in digital skills. While gaps existed in basic skills, there was also expertise in more advanced areas. Overall, capabilities were seen to have improved compared to earlier assessments. (Tepponen et al. 2024.) To address these competence gaps, it is important to strengthen national and regional collaboration with educational institutions and to provide both formal and informal learning opportunities for health and social care professionals (Turja & Ahonen 2024).
Harnessing the opportunities of digi­talisation in the social and health care sector requires multidisciplinary and robust expertise. The DigiNet network (2025) was established to promote competence development and research in welfare technology and the digitalisation of the welfare sector. Expanding the network to include wellbeing services counties strengthens regional expertise and supports the adoption of digital solutions in service delivery. Experts from universities, universities of applied sciences, and vocational institutions work together in DigiNet to link academic expertise with the practical needs of working life, ensuring that competence development genuinely supports digital transformation.
Against this background, DigiNet now aims to update the definition of AI competence for social and health care professionals and to coordinate the development and delivery of related training. With dedicated funding, the network will revise the national digital competence definition, originally created several years ago, to account for changes brought by artificial intelligence. This will be achieved through expert engagement, national networks, research-based knowledge, and co-creation methods. The project will also produce curriculum content in the form of a micro-credential module to support competence develop­ment in wellbeing services counties and within health and social care degree programmes. There are results that also short learning courses are increasing students’ competencies in continues education (Sanerma et al. 2025).
In its next phase, DigiNet will coordinate curriculum development into training modules through collaboration between educational institutions. This work can be resourced either through core funding or with the support of additional external funding, depending on the interests of the institutions involved. Looking ahead, the work must support change management by defining professionals’ competencies and future educational needs. Planning for this requires project funding for continuing education at both national and regional levels, as well as negotiation between educational institutions and wellbeing services counties. Strong cooperation with working-life partners is essential to create effective education solutions that strengthen professionals’ ability to work in an increasingly digitalised health and social care sector.
As AI continues to reshape working life processes at an accelerating pace, only strong and trust-based networks can ensure the sector adapts effectively. DigiNet plays a central role in coordinating educational efforts across degree programmes and continuing education, and Nordic and wider international collaboration is needed to secure the best solutions for all partners.

References

Ahonen, O. M., Sanerma, P., Rauha, A., Naakka, H., Perälä, S., Paldanius, M., & Heinonen, J. (2024). Self-evaluated competences of multidisciplinary students before and after professional specialisation education in digital social and health care services. Finnish Journal of EHealth and EWelfare, 16(2), 158–174. https://doi.org/10.23996/fjhw.143128
Bichel-Findlay J, Koch S, Mantas J, Abdul SS, AlShorbaji N, Ammenwerth E, et al. Recommendations of the International Medical Informatics Association (IMIA) on education in biomedical and health informatics: Second revision. Int J Med Inform. 2023 Feb; 170:104908. https://doi.org/10.1016/j.ijmedinf.2022.104908
DigiNet-oppilaitosverkosto, University of Applied Sciences Laurea. Available from: https://diginet-verkosto.fi/etusivu/
European Comission 2021. COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT, THE COUNCIL, THE EUROPEAN ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS 2030 Digital Compass: the European way for the Digital Decade. COM/2021/118 final. Available from: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:52021DC0118
Mantas, J., Ammenwerth, E., Demiris, G., Hasman, A., Haux, R., Hersh, W., Hovenga, E., Lun, K.C., Marin, H., Martin-Sanchez, F., Wright G. 2010. IMIA Recommendations on Education Task Force. Recommendations of the International Medical Informatics Association (IMIA) on Education in Biomedical and Health Informatics. First Revision. Methods of information in medicine 49(2): 105–120.
Tepponen, M., Ahonen, O, Turja T. 2024. Handbook: Promoting Digitalisation and the Related Practices, Competence and Operating Culture. Publications of the Ministry of Social Affairs and Health 2024:37 Publisher Ministry of Social Affairs and Health. http://urn.fi/URN:ISBN:978-952-00-8657-2
Tiainen, M., Ahonen, O., Hinkkanen, L., Rajalahti, E., & Värri, A. (2021). The definitions of health care and social welfare informatics competencies . Finnish Journal of EHealth and EWelfare, 13(2), 147–159. https://doi.org/10.23996/fjhw.100690
Tuovinen, T., Reponen, J.,Isoviita, V-M., Koskela, T., Levy, A., Pääkkönen, J., Ravaja, N., Saari, T., Taina, M., Veikkolainen, P., Värri A. ja Kulmala, P. 202. Sähköisten terveyspalveluiden opetus lääketieteessä. Duodecim.2021; 137; 1807–13. https://www.duodecimlehti.fi/xmedia/duo/duo16387.pdf
Turja, T., & Ahonen, O. 2025. Perceptions of AI competence in social and healthcare services: Readiness, reliance and realism. Finnish Journal of EHealth and EWelfare, 17(1), 73–83. https://doi.org/10.23996/fjhw.155017
Sanerma, P., Rauha, A., Naakka, H., Perälä, S., Paldanius, M., Heinonen, J., & Ahonen, O. (2025). Students’ descriptions of capabilities acquired in multi-professional specialisation education. Finnish Journal of EHealth and EWelfare, 17(3), 380–393. https://doi.org/10.23996/fjhw.148573
Nordic Council of Ministers I www.norden.org/publications I pub@norden.org