A SYSTEMATIC LITERATURE REVIEW ON E-HEALTH IMPLEMENTATION AND POLICIES *

. Despite the existing attention to e-Health implementation, there are several gaps and bottlenecks related to its implementation and policies. Starting from previous research, this paper presents a systematic literature review that we conducted to determine the current state of the art in e-Health implementation and policies, with particular attention to the European area. After the research and filtering of the papers, 49 papers were selected to be carefully examined and compared according to a set of criteria including objective, targeted and implementation compliance. Based on the obtained results, we identified several gaps and suggested recommendations to fill them. Based on the results, the topic has yet to be discussed and deepened, bringing to synthesis the different experiences gained in the field by both operators and researchers


Introduction
Implementation of electronic health (e-Health) at a national level creates a fundamental innovation in health care.Alongside technical challenges, E-Health implementations outside numerous technological, social and organizational issues are often ignored.Accepting those e-Health achievement necessities to involve all stakeholders, achieve organizational changes and lighten resistance, e-Health implementation ambitions at observing social and organizational factors influencing large-scale health systems and at recognizing best practices.The e-Health implementation would fundamental welfares such as an important cost saving -due to information that identical exams would be eluded -an upgrading of the strength of care assistance by the opportunity of sharing user health history records between providers and health institutions (Weng et al., 2017;

Literature Review
The nature of the European e-Health, applied at the National level showed dated and unsolved bottlenecks within a large number of European States.The implementation provides both, opportunities and challenges for the redesigning of economic and service structures (Benjamin, et al. 2019).It is strategic to implement e-Health because it could allow maintaining and adding to the creation of information systems, both, patients and medical, in a specific way, but also as organizational value (Squitieri, et al, 2017;Zhao, et al, 2019;Bloom, et al, 2019).Furthermore, to create value means implementing e-Health, working in alignment, coordination, and co-creation.
Value in e-Health means changing the information system at all levels of organizational structure (Kelly, et al. 2019;Casado-Vara et al, 2019).Past studies (Hwang et al 2008;van Gemert-Pijnen, et al. 2011) has exposed that the innovative vision, as it is increasingly along the adoption and the application process, results in an ultimate implementation that is frequently far from the initial vision.The implementation is comparable to the introduction of the main management innovation.The key phases of the projected growth would be the macro and microactions.These two levels must be in continuous interaction to realize the implementation (Baltussen et al 2019;Wong et al., 2019).A recent study argues that these implementation processes are functional for generating positive value in health (Fenwick et al., 2020;Rothery, et al 2020;Iqbal, et al. 2019;Porter et al, 2019;Urena, et al. 2019;Finkelstein, et al. 2019).According to the literature (Chohan, 2019), e-Health can improve collective and individual service delivery (Romzek, et al., 2014;Bryson, et al., 2014;Mintromet al, 2017;Cluley et al 2020).
Furthermore, success and sustainability are strongly related also to deep cultural change within the health departments which, as underlined in literature (Martins, et al., 2019;Ferlie et al., 2019;Cronemberger et al, 2019), is one of the main obstacles is the health professionals' resistance.There are interesting contributions that consider e-Health implementation as enabling factor to create an information system in health (Martins, et al., 2019;Ferlie, et al.,2019;Cronemberger et al, 2019;Palanisamy et al 2019).Given today's changes in the health market, due to the pandemic Covid 19 (Capone et al, 2021), that involves the world, most health departments' is implementing e-Health, which ensures a continuous improvement of health services and their adaptation to change.Nevertheless, avoiding these errors, in starting stage, is strategic, in fact: e-Health serves as a basis for knowledge sharing, quality of service (Yang, 2016), regulatory compliance, and stakeholder collaboration (Lepore et al., 2018, Tuikka, et al., 2016;Bonomi, 2016).Furthermore, in the average and a long time, the difficulties in correcting errors increase exponentially over the life cycle (Krebs, et al, 2015;Cooper, et al., 2019;Porter 2010;Campanella et al. 2016;Adler-et al., 2015;Desautels, et al., 2016;Tavares, et al 2016;).The inappropriate use of digital tools, both, by customers and health personnel is a typical mistake to be avoided, discussed and explored in the literature (Nguyen, et al., 2014;Strong, et al., 2014;).To overcome this shortcoming and expand the use of E-Health, the Governments, have introduced an extensive investment to overcome these bottlenecks supporting new educational behavior, for both, the customers and healthcare (Aldosari, 2017;Fukami, et al, 2019;Joukes, et al., 2019).These support actions are also concentrated within the department or where e-Health is used, to improve its organizational dimension: flexibility, complexity, and variability (Martel, et al., 2018;Saleem, et al 2018;Bonomi, et al., 2015).In this paper, we rely on guidelines depicted in (Keele, 2007) to conduct a systematic literature review (SLR) that aims to determine the current state of the art in E-Health and identify the gaps that should be filled in this research area.An SLR is distinguished from other types of literature review primarily by a comprehensive literature search and specification of research questions that should be addressed (Keele, 2007).
To the best of our knowledge, (Ross, et al 2016) is the existing literature review that focuses on the implementation of E-Health.The authors from 2009 to 2014, have classified 37 papers related to the topic.Our SLR complements that of (Ross, et al, 2016) in terms of both literature and criteria.Indeed, after the search and filtering of papers, 49 have been chosen.To compare published research (Ross, et al 2016) we have established a set of criteria, such as the objective, target domain, representation format, conformance, implementation, and evaluation.Our study also aims to see how the characteristics of E-Health have evolved over the past few years by comparing our results with those of Ross et al 2016.The paper, using the SLR tool, concerning the implementation of e-Health, aims to better understand the phenomenon and inform operators in the sector what can be the possible reflections and actions to be evaluated to implement e-Health.The remainder of this paper is organized as follows: after the introduction, and conceptual background section 2 highlights the main literature contributes linked to the topic and aim of the paper, section 3 methodology, highlight the SRL criteria, section 4 display results, and finally in section 5 there are conclusive.

Methodology
A Systematic Literature Review (SLR) is a specific type of literature reviews that is characterized by (Keele, 2007):  A specification of research questions that should be addressed;  A comprehensive and unbiased search for the relevant literature;  An explicit definition of inclusion and exclusion criteria; One of the main reasons for undertaking an SLR is to summarize and evaluate existing work in a given research area, identify their gaps, and suggest work to address them.Based on the guidelines depicted in (Keele, 2007), we conducted our SLR in several stages:  Formulating the research questions  Extracting and filtering papers  Defining evaluation and comparison criteria  Presenting and discussing the obtained results The remainder of this section describes the details of each stage.

Formulating the research questions
The specification of research questions (RQs) is the most important part of any SLR as they guide authors throughout the review process (Keele, 2007).The RQs that should be addressed in our SLR are formulated as follows: RQ1: What are the areas and goals targeted by E Health implementations these last years?RQ2: What are the formats used for the representation of E-Health implementations?RQ3: Do the proposed implementations comply with the implementation mechanism specified by the WHO? RQ4: How is E-Health implementation demonstrated and evaluated.

Extracting and filtering papers
To retrieve papers proposing E-Health implementation, we constructed our search string firstly by combining the main terms E-Health and Implementation.To make the search as comprehensive as possible and not forget any main terms, we replaced the term E-Health with Application and the term Implementation was replaced by several derived words (e.g., Implementing) or belonging to the same semantic field (e.g., Delivery solution, Standard, Customers, System).The final search string is structured as follows: Search string = ("E-Health" OR "Implementation" AND "Applic*" OR "Delsol*" OR "Standa*" OR "Custom*" OR "System").We resorted to several databases and search engines like Web of Science, Scopus, Science Direct, Google Scholar, and IEEE Xplore Digital Library.Besides, each found article was used for a backward search through its related work section.Our SLR targets all E-Health implementation published over the time of 2016 to 2021 in journals, conference/workshop proceedings, and book chapters.For this, we filtered the obtained papers according to the following exclusion criteria:  Papers published before November 6 2016 whether or not they are treated in Ross et al 2016;  Papers that are not published in journals, conference/workshop proceedings, and book chapters such as master and doctoral theses;  Papers that do not propose a new e-Health implementation;  Papers are written in a language other than English;  Papers that describe the same E-Health implementation in the same way.Filtering has greatly reduced the number of papers.In fact, after the paper collection, we obtained a total of 93 papers.Next, we discarded papers that were published before November 6, 2016, duplicate/similar papers and those in which we did not find an E-Health implementation.However, we have kept the papers that propose an E-Health implementation whether it is a primary or secondary contribution.Accordingly, a set of 49 papers was retained for an in-depth examination in our SLR.Figure 1 displays the main steps of the paper extraction and filtering process.

Defining evaluation and comparison criteria
To evaluate and compare the E-Health implementation, we have defined the following criteria:  Publication type: indicates if the extension has been published in a journal, a conference/workshop proceeding, or a book chapter. Aim: indicates the reason for which the implementation was proposed or the problem that it solves. Category: we have defined two categories to classify the E-Health Implementation according to their purpose.The first category is intended to represent or handle the processes of a particular domain of healthcare: e.g., cardiology, orthopedics, and vascular diseases.The second category aims to improve healthcare performance: e.g., cost, security, compliance, and quality.The extensions of the second category are independent of a specific domain but, they can be used in any domain. E-Health implementation related to software: specifies the version of the software. Implementation name: indicates whether a name has been assigned to the proposed solution. Main domain: Designates the main domain targeted by an implementation knowing that some extensions deal with multiple domains (e.g., quality in healthcare processes) but only the main domain is considered. Demonstration: indicates whether an implementation has been demonstrated through an operational example before to be inserted within e.g., the department, or the hospital.
 Implementation Modality: mentions whether technologies have been implemented either by integrating them into an existing tool or by developing a new tool. Evaluation: specifies for each tool (existing and modify or new) whether it has been evaluated and which method is used for the evaluation.Conformity: determines whether an E-health implementation complies with the ISO both standards and recommendations also, in terms of whether it is reused, customized, or extended

Results
In table 1, we define for each e-Health implementation the publication type ('J' for the journal, 'C' for conference or workshop and 'Ch' for chapter), the main purpose of the implementation as well as the category ('Imp' 'for improvement and 'SD' for specificdomain).It is possible to note, from table 1, that the majority of publications type are in Journals.We can explain this by the fact that e-Health implementation is consistent enough in terms of operative and theory contribution to be submitted to journals.In line with this, the distribution by category is balanced between improvement and specific domain.In table 2, e-Health implementation is compared according to their name, main domain, demonstration, implementation, and evaluation.In table 2, a few documents indicate the name of e-health implemented, in terms of brand and tools.This is possible, considering the indirect advertising that can result.Furthermore, more than 50% of papers, have indicated domain.The domain is related to specific applications, e.g., EHR, but also the development of big data and communication.The papers that have indicated the domain also contain the demonstration, more than 50%.The implementation is related to the hospital, while in a few papers there is not an evaluation approach.In addition, also in terms of theory and model, interesting information emerging related to both key factors, and bottlenecks.The Demonstration, implementation and evaluation, within hospitals are, also strictly linked to, our previous study.These reasons highlight that all variables have been considered in functional properties in our previous study.In table 3, we compare the E-Health implementation taking into account the conformity criterion: ISO standard, recommendations, reused, customized or extended.In Table 3, most authors represent their E-Health implementation in the form of both, theory and model.However, 23/40, papers, make a comparison of E-Health implementation to their conformity and related it with ISO standards, recommendations, reused, customized, and extend.This comparison is little used despite its specific and standard recommendation.In Tables 2 and 3, big data are widely used.Furthermore, these two implementations, take into account, on the one hand, the relationship with the external environment by defining everything that can occur during the implementation and execution, and, on the other, the impact on the process flow in terms of information about what activities require to be performed and what they generate.In Table 3, recommendations and customization are present in all 23 documents.We believe that this result is logical, as this category includes the main elements to define the behavior of the electronic health implementation process.Furthermore, in Table 3, recommendation and customization are present, in each paper, together.As a result, recommendation and customization are strongly related to the implementation of e-Health.The statistics reveal that: less than half of the papers comply with e-Health implementation which hampers the comparability.This reflection emerges from the statistics of Table 3, in which the phase of recommendations is always linked to personalization, therefore, if on the one hand, ISO standards are followed, on the other hand, they are customized to the specific needs of those who adopt those technologies.The latter result, to be understood in depth, needs to study and research the different cases of implementation, for example in hospitals.The not simple understanding of this implementation highlights literature more inclined toward theoretical study and models.All implementations use the recommended tools, although, case studies in different contexts are little explored and as a result, absentee comparisons.Therefore, we can expect publications that study the differences between specific cases.The objective of our literature review is to complement that of (Ross et al., 2016) in terms of both literature and criteria.In particular: a) the publications related to the implementation of e-Health have increased slightly.This finding is in line with the study by Ross et al., (2016).Although, these results are useful, is possible argue that:  the influence of the recent and still ongoing pandemic, Covid 19, which requires social distancing of distance care, has brought attention also not only to medical research to the topic of e-Health;  this shows that the topic of research has gained maturity and implementations are more consistent, at the current stage with the new dynamics of treatment, the pandemic phase, and we believe that it will increase further in the coming years;  the topic examined in Ross et al., (2016) is slight, more oriented towards theoretical and model implementations, in our study, which follows the Author's study, the focus on implementation sees growth for studies that verify compliance, standards, recommendations and customized solutions.Our SRL shows greater attention to the customization of the solutions within the implementation carried out.

Discussion
In this paper, SLR was conducted to determine the current state of the art in e-Health implementation and identify our research gaps.The extraction and filtering of papers resulted in a set of 49 e-Health implementations.The e-Health implementation is evaluated and compared according to a set of criteria (Marino et al, 2022(Marino et al, , 2021(Marino et al, , 2021a(Marino et al, , 2021b)).The SLR can contribute to helping both, research and operative researchers choose the e-Health implementation.After this SRL, is possible to deduce the following points:  The targeted areas and objectives are not very diversified;  Despite a slight improvement in recent years, less than half of the extensions conform to the theory and model approaches;  The specific domain of e-Health implementation is yet little developed;  e-Health implementations are rarely evaluated in terms of comparison of case studies, despite the existence of several theoretical studies.Based on these points, we suggest the following path that may bridge the identified gaps and advance the field of E-Health implementation:  Authors should develop e-Health implementation to provide considerations to enable a better understanding of the phenomenon;  In addition, a clear methodology should be provided throughout the development of comparison between case studies with attention to the target domain related to implementation;  It is desirable to define global standards and not only standards valid in each Country; Finally, the studies should make more effort in the operational implementation of e-Health, by integrating it into a theory and model to prove its feasibility.Based on these indications, the topic has yet to be discussed and deepened, bringing to synthesis the different experiences gained in the field by both operators and researchers.

Conclusions
This last step is devoted to the presentation, interpretation, and analysis of the results obtained after a deeper examination of each paper.For this, we begin by classifying, comparing, and assessing all e-Health implementations in tables according to the criteria defined in the previous stage.Finally, we interpret the obtained results and provide explanations.What emerges from our research is the presence of several gaps and bottlenecks associated to e-Health implementation and policies.Accepting those e-Health achievement necessities to involve all stakeholders, achieve organizational changes and lighten resistance, e-Health implementation ambitions at observing social and organizational factors influencing large-scale health systems and at recognizing best practices.A multi-level transition process that sees a non-unanimous action within the individual systems of government and that represents a further future analysis of what are the current and future paths on which to evolve this digital transition.

Figure 1 .
Figure 1.Process of paper extraction and filtering Source: our elaboration

Table 1 .
Comparison of e-Health implementation according to their publication type, aim, and category

Table 2 .
Comparison of e-Health implementation to their Authors, e Health name, domain, demonstration, implementation, and evaluation

Table 3 .
Comparison of e-Health implementation to their conformity: ISO standard, recommendations, reused, customized, extended