Forty participants contributed data to the study, comprising 17 medical students, 12 medical educators and 11 digital sector experts. Most of the medical educator participants were both experienced educators and medical practitioners. Similarly, most digital sector expert participants were experienced medical practitioners involved with the practical application of clinical informatics (Table 1). Data analysis identified eleven sub-themes that were refined and grouped into four superordinate themes: “Understand the Local Digital Health Ecosystem and Landscape”, “Safe, Secure and Ethical Information Literacy and Management”, “Proficiency in Digital Health Tools and Associated Technologies”, and “Scholarly Research and Evidence-based Practice”. Each of the four themes has been summarised into an overarching digital health competence domain (Table 2). These four domains are interrelated and partially overlap in scope. Before expanding on each domain, we introduce an overarching contextual observation uncovered during the interviews. The following sections present results from the four core competence domains, with illustrative quotes.
Student heterogeneity
There was notable heterogeneity in the self-perceived digital proficiency among the medical student participants. The student focus groups provided varying perspectives, demonstrating mixed confidence, interest, and perceived readiness for the digital healthcare environment. Some self-assured digital native students expressed little interest in digital health, questioning the primary benefits of such content and how it would enhance their medical education.
The people who are writing those parts of the curriculum, not to generalise, but a lot of them maybe feel like that is a really difficult area. And maybe those are the technology things that they’re struggling with. But they’re not necessarily the technology things that we’re struggling with. And so, it’s kind of like you’re writing a curriculum for yourself, not for us. (ALM5, S3, FG1)
I think if someone put teaching into our curriculum. It was like, you have a digital health session. I would probably roll my eyes and rather not go. (ALM5, S1, FG1)
I think part of that is, I feel like medical students might not be the target audience. You know that sort of digital… having grown up with that sort of stuff, the basic issues we’re running into, probably isn’t how do I? You know, work this thing? It’s more like I don’t have access, so I can’t do things like. (ALM5 S2, FG1)
A digital sector expert held the perception that emerging medical professionals, being digital natives, possess both inherent technological aptitude and natural confidence in their digital capabilities.
You see the new graduates, you know, the young doctors, associates, registrars coming through to the practice very quick to pick up the IT stuff very quick to adopt, very comfortable with doing that, whereas it can be much harder to get the more established colleagues to adapt those new things. (DSE3)
However, not all the medical students shared the same high level of self-assurance in their perceived technology competence. Many student participants with lower confidence in their abilities showed greater interest in the subject and expressed a need for formal digital health education.
I think it’s probably super important going forward that there is more training because, at the moment, going into clinical years, I do feel a little bit out of depth (ALM4, S11, FG3).
Several interview participants recognised the disparity in confidence and capability with technology, expressing disappointment in some students’ proficiency with basic technology skills.
I think we sometimes overestimate how capable they really are with digital things. (E11)
Even touch typing, I mean, I am still stunned that people come out of university and cannot touch type. (DSE7)
Domain 1: understand the local digital health ecosystem and landscape
The first identified competence domain centres on the need for students to understand the local digital health ecosystem and the landscape. Data from student focus groups revealed that many students did not fully appreciate the broad scope of the local digital health ecosystem and wanted to learn more about it.
A general lecture would be a good start, really, because when you talk about digital health. I really do have to sit down and think on what that includes. So, I think that’s already an indication of how lacking of knowledge you have in this area. (ALM5, S6, FG2)
Despite some recognition of its interconnectedness, many students perceived digital health primarily through specific applications, such as telemedicine for remote patient care. However, they appreciated the relevance of digital health for their future, especially when they had experienced its use first-hand.
As soon as we got into the hospital, you kind of see the relevance of it, and I felt a lot more interested in wanting to learn how it’ll work and how to use it to my advantage. (ALM5, S5, FG2)
Digital sector experts reasoned that when students more fully comprehend the local digital health landscape and their role within it, they are better equipped to identify and assess the strengths, weaknesses, opportunities, and threats of both current and emerging digital health interventions. They noted that a holistic understanding enables students to critically evaluate digital health solutions and their implications for effective healthcare delivery within the local context.
Understanding what comes in and where it comes from, what’s done with that information, you know, and all the things to consider when you’re doing it. That would certainly be a place to start for me. (DSE08)
Even just an overview of how it’s used in clinical practice and the different issues facing it, you know, facing clinicians when they’re trying to, you know, trying to get through their day. (DSE11)
Domain 2: safe, secure and ethical information literacy and management
This domain builds on the foundational macro-level knowledge of the previous domain. While it overlaps with acquiring a high-level understanding of the local clinical workflows, it is more concerned about the workflow content and data management. It underscores the importance of safe, secure, and ethical patient data management. Several digital sector experts and medical educator participants emphasised the need for students to understand patient data collection, storage, transmission and how it is used within the digital health ecosystem. They highlighted critical curriculum competencies to promote safe, secure, and ethical information literacy and data management.
We need safe, competent practitioners, and at the top of my list is actually privacy and security, which I think just a basic understanding of the importance of protecting health information. (DSE2)
In terms of the ethics of it, it’s a matter of being aware of what the unintended consequences of making some digital move. (E6)
Some participants recognised the need for students to gain a thorough understanding of local regulations, policies, and data governance principles, particularly in relation to the local cultural context. They emphasised the importance of special considerations for Indigenous and diverse populations concerning the use and management of patient data with digital technologies. For instance, a digital sector expert highlighted the necessity for students to understand data sovereignty and the complexities of data sharing between organisations.
What are the issues about sharing data between organisations? What is Māori data sovereignty? You know what is taonga? [data or information that is considered precious and significant to the Māori people] You know all these different things that affects the New Zealand digital health ecosystem. (DSE11)
Domain 3: proficiency in digital health tools and associated technologies
The third competence domain involves developing hands-on skills and building confidence in using digital technology and digital health tools. Participants agreed that by the time students graduate, they need to be proficient in effectively using the technology they are most likely to encounter in the local clinical environment. This proficiency is essential for making informed clinical decisions that ensure safe, secure, and ethical patient care. As one digital sector expert commented:
Students ‘should understand what tools are available, how do you use them effectively? And yeah, and they need to have quite a good understanding of how those tools work in order to use them properly (DSE7).
This proficiency extends beyond the clinical environment to encompass using technology effectively for confidential and secure electronic communication for all digital activities, ensuring that demonstrable digital professionalism is maintained in all online interactions with patients and colleagues. As another digital sector expert pointed out:
A lot of what we do is non-clinical type work. How do you do that? How do you set yourself up on a VPN to work remotely from home? So, if people aren’t expecting that, it can come as a bit of a shock to the system… there’s a lot of non-clinical facing administrative type work that still needs to be done efficiently using good tools. (DSE1)
This sentiment was succinctly summarised by a digital sector expert who suggested that by the time medical students graduate, they should confidently be able to answer the following questions: “How do I use organisation tools? How do I communicate? (DSE2).
The primary concern among some of the less confident student focus group participants was learning to use specific applications necessary for their roles. Some also disagreed with the assumption that, as digital natives, they require little to no training, recognising a need for adequate training.
I think just mostly some more like formal teaching on how to use like different apps and stuff, rather than just like assuming that students or others will know how to use them and kind of leaving it up to them. Because not all the time, not everyone does. (ALM5, S13, FG3)
However, a medical educator noted that the extensive variety of site-specific applications make in-depth exploration of applications impractical in an academic setting:
We don’t teach, really, how to use the system because, as we said, it’s different. It’s a bit like operating systems for our hardware or software. It’s a different system at every hospital. (E3)
Participants suggested that focusing on the fundamental principles and the broader, holistic perspective of digital health is a more effective use of medical school resources for developing digital health competence, rather than delving into the specifics of individual applications. A medical educator added that clinicians and professional staff within the workplace are better equipped to train students in the necessary system commands and demonstrate the use of specific applications within the clinical context:
I think things like training them on how to use a particular electronic health record system probably should be done by the hospital that they’re going to work in. (E2)
Several interview participants reiterated that training in consultation skills is an integral component of achieving proficiency with digital health tools. This is exemplified by demonstrable behaviour in digital professionalism, as future doctors must also consider patients’ technology capabilities. A General Practitioner (GP) who is also a digital sector expert illustrated this by highlighting the triadic relationship between the doctor, patient, and computer when developing a shared management plan: ‘How you maintain the consultation while using these tools without the tools taking over the consultation, I think that’s kind of a really important’ (DSE3).
Building on the theme of digital professionalism, medical educator participants also emphasised the importance of incorporating the responsible use of social media into digital health proficiency education:
Social media and using social media and as a doctor. So helping students work through the, the tensions between sharing everything and maintaining their professional identity and behaving professionally, given social media. I mean, I would take that as being also an important part of being a digitally competent doctor. (E9)
Most participants recognised digital professionalism as a crucial facet of technological proficiency, particularly in emerging areas like artificial intelligence (AI). They acknowledged that sufficient understanding and proficiency in using AI, alongside maintaining professional conduct, is essential for preparing students to meet the challenges of the modern digital healthcare environment. Some students noted the potential benefits and limitations of generative AI in this context, with one student commenting:
I feel like teaching on it would be quite valuable, because I know, like, even though it is this really cool piece of technology. I know there are like downfalls like when you’re like asking it clinical type questions.… how to work around those kinds of like pitfalls and the technology to get like the best outcome from it. (ALM5, S7, FG4).
A senior medical educator fully endorsed the use of generative AI as a pedagogy tool, noting that:
Students should use it and learn how to use it. It’s the same as they need to learn how to use a calculator or software package.… So I think we should embrace this. I think we should teach on it. (E3)
Domain 4: scholarly research and Evidence-based practice
The final domain, building on the others, focusses on enabling students to apply evidence-based research and critical appraisal skills into digital health settings. This integration enables students to effectively evaluate the opportunities and risks associated with digital health tools. Participants noted that, akin to the skills required for practicing evidence-based medicine, students must develop and apply reflection, critical thinking, and scholarly rigour. These skills are essential for competently assessing the efficacy, effectiveness, suitability, and risks of digital health interventions and include:
How do I access and trust information that I’m resourcing digitally? So, how do I pick through what’s accurate and what’s not? And what do I use to help make those decisions? (DSE2)
How to find information resources, how to translate those information resources, and to inform your practice. (DSE11)
The ability to look up evidence-based information using online techniques. I don’t mean Dr. Google. (E7)
Educators also suggested that, along with technology proficiency, digital professionalism, and ethical responsibility, students also need to exhibit the foresight to anticipate future trends, challenges, and opportunities in the field of digital health and develop the scholarly skills to communicate complex ideas clearly and concisely in writing, for example:
The ability to use an array of programs to run to assist the skills in terms of research in terms of writing reports in terms of analysis and the ability to look up guideline-based techniques for prescribing and so on. (E7)
Synthesising information and then presenting it in an electronic format with appropriate referencing. I think that’s a useful skill because that incorporates both the critical appraisal component and also being able to work with different formats. (E9)
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