CC BY-NC-ND 4.0 · Yearb Med Inform 2022; 31(01): 047-059
DOI: 10.1055/s-0042-1742502
Special Section: Inclusive Digital Health
Working Group Contributions

Towards Equitable and Resilient Digital Primary Care Systems: An International Comparison and Insight for Moving Forward

IMIA Primary Care Informatics Working Group
Craig Kuziemsky
1   Office of Research Services and the School of Business, MacEwan University, Edmonton, Alberta, Canada
Siaw-Teng Liaw
2   WHO Collaborating Centre on eHealth, School of Population Health, UNSW Sydney, Kensington, NSW, Australia
Meredith Leston
3   Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Eagle House, Oxford, UK
Christopher Pearce
5   Outcome Health, Blackburn, Victoria, Australia
6   Monash University, Clayton, Victoria, Australia
Jitendra Jonnagaddala
2   WHO Collaborating Centre on eHealth, School of Population Health, UNSW Sydney, Kensington, NSW, Australia
Simon de Lusignan
3   Clinical Informatics and Health Outcomes Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Eagle House, Oxford, UK
4   Royal College of General Practitioners Research and Surveillance Centre, London, UK
› Author Affiliations


Objective: While the COVID-19 pandemic provided a global stimulus for digital health capacity, its development has often been inequitable, short-term in planning, and lacking in health system coherence. Inclusive digital health and the development of resilient health systems are broad outcomes that require a systematic approach to achieving them. This paper from the IMIA Primary Care Informatics Working Group (WG) provides necessary first steps for the design of a digital primary care system that can support system equity and resilience.

Methods: We report on digital capability and growth in maturity in four key areas: (1) Vaccination/Prevention, (2) Disease management, (3) Surveillance, and (4) Pandemic preparedness for Australia, Canada, and the United Kingdom (data from England). Our comparison looks at seasonal influenza management prior to COVID-19 (2019-20) compared to COVID-19 (winter 2020 onwards).

Results: All three countries showed growth in digital maturity from the 2019-20 management of influenza to the 2020-21 year and the management of the COVID-19 pandemic. However, the degree of progress was sporadic and uneven and has led to issues of system inequity across populations.

Conclusion: The opportunity to use the lessons learned from COVID-19 should not be wasted. A digital health infrastructure is not enough on its own to drive health system transformation and to achieve desired outcomes such as system equity and resilience. We must define specific measures to track the growth of digital maturity, including standardized and fit-for-context data that is shared accurately across the health and socioeconomic sectors.

Publication History

Article published online:
02 June 2022

© 2022. IMIA and Thieme. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Fagherazzi G, Goetzinger C, Rashid MA, Aguayo GA, Huiart L. Digital Health Strategies to Fight COVID-19 Worldwide: Challenges, Recommendations, and a Call for Papers. J Med Internet Res 2020 Jun 16;22(6):e19284.
  • 2 Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, et al. Telehealth transformation: COVID-19 and the rise of virtual care. J Am Med Inform Assoc 2020 Jun 1;27(6):957-62.
  • 3 Reeves JJ, Ayers JW, Longhurst CA. Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm. J Med Internet Res 2021 Feb 1;23(2):e24785.
  • 4 Dorn SD. Backslide or forward progress? Virtual care at U.S. healthcare systems beyond the COVID-19 pandemic. NPJ Digit Med 2021 Jan 8;4(1):6.
  • 5 Ensuring The Growth Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care, Health Affairs Blog, May 8, 2020. Available from:
  • 6 Liaw ST, Zhou R, Ansari S, Gao J. A digital health profile & maturity assessment toolkit: cocreation and testing in the Pacific Islands. J Am Med Inform Assoc 2021 Mar 1;28(3):494-503.
  • 7 Tilahun B, Gashu KD, Mekonnen ZA, Endehabtu BF, Angaw DA. Mapping the Role of Digital Health Technologies in Prevention and Control of COVID-19 Pandemic: Review of the Literature. Yearb Med Inform 2021 Aug;30(1):26-37.
  • 8 Baumgart DC. Digital advantage in the COVID-19 response: perspective from Canada's largest integrated digitalized healthcare system. NPJ Digit Med 2020 Aug 31;3:114.
  • 9 Basit MA, Lehmann CU, Medford RJ. Managing Pandemics with Health Informatics: Successes and Challenges. Yearb Med Inform 2021 Aug;30(1):17-25.
  • 10 Liaw ST, Kuziemsky C, Schreiber R, Jonnagaddala J, Liyanage H, Chittalia A, et al. Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development. Yearb Med Inform 2021 Aug;30(1):44-55.
  • 11 Shaw J, Brewer LC, Veinot T. Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review. JMIR Form Res 2021 Apr 5;5(4):e23233.
  • 12 Gilbert AW, Davies L, Doyle J, Patel S, Martin L, Jagpal D, et al. Leadership reflections a year on from the rapid roll-out of virtual clinics due to COVID-19: a commentary. BMJ Leader 2021;5:188-92.
  • 13 Coiera E, Ash J, Berg M. The Unintended Consequences of Health Information Technology Revisited. Yearb Med Inform 2016 Nov 10;(1):163-9.
  • 14 Zheng K, Abraham J, Novak LL, Reynolds TL, Gettinger A. A Survey of the Literature on Unintended Consequences Associated with Health Information Technology: 2014-2015. Yearb Med Inform 2016 Nov 10;(1):13-29.
  • 15 Champion C, Kuziemsky C, Affleck E, Alvarez GG. A systems approach for modeling health information complexity. International Journal of Information Management 2019;49:343-54.
  • 16 Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, et al. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res 2017 Nov 1;19(11):e367.
  • 17 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc 2007 Sep-Oct;14(5):542-9.
  • 18 Friedman C, Rubin J, Brown J, Buntin M, Corn M, Etheredge L, et al. Toward a science of learning systems: a research agenda for the high-functioning Learning Health System. J Am Med Inform Assoc 2015 Jan;22(1):43-50.
  • 19 Bhatti S, Commisso E, Rayner J. A Rapid Primary Healthcare Response to COVID-19: An Equity-Based and Systems-Thinking Approach to Care Ensuring that No One Is Left Behind. Healthc Q 2020 Oct;23(3):29-33.
  • 20 Berkowitz SA, Cené CW, Chatterjee A. Covid-19 and Health Equity - Time to Think Big. N Engl J Med 2020 Sep 17;383(12):e76.
  • 21 Hardie RA, Sezgin G, Imai C, Gault E, McGuire P, Sheikh MK, et al. Telehealth-based diagnostic testing in general practice during the COVID-19 pandemic: an observational study. BJGP Open 2022 Mar 22;6(1):BJGPO.2021.0123.
  • 22 Pagliari C. Digital health and primary care: Past, pandemic and prospects. J Glob Health 2021 Jul 2;11:01005.
  • 23 Veinot TC, Mitchell H, Ancker JS. Good intentions are not enough: how informatics interventions can worsen inequality. J Am Med Inform Assoc 2018 Aug 1;25(8):1080-8.
  • 24 Beaunoyer E, Dupéré S, Guitton MJ. COVID-19 and digital inequalities: Reciprocal impacts and mitigation strategies. Comput Human Behav 2020 Oct;111:106424.
  • 25 van Hattem NE, Silven AV, Bonten TN, Chavannes NH. COVID-19's impact on the future of digital health technology in primary care. Fam Pract 2021 Nov 24;38(6):845-7.
  • 26 Kariotis T, Prictor M, Chang S, Gray K. Evaluating the Contextual Integrity of Australia's My Health Record. Stud Health Technol Inform 2019 Aug 9;265:213-8.
  • 27 Pearce C, McLeod A, Supple J, Gardner K, Proposch A, Ferrigi J. Responding to COVID-19 with real-time general practice data in Australia. Int J Med Inform 2022 Jan;157:104624.
  • 28 Busingye D, Gianacas C, Pollack A, Chidwick K, Merrifield A, Norman S, et al. Data Resource Profile: MedicineInsight, an Australian national primary health care database. Int J Epidemiol 2019 Dec 1;48(6):1741-1741h.
  • 29 Jonnagaddala J, Godinho MA, Liaw ST. From telehealth to virtual primary care in Australia? A Rapid scoping review. Int J Med Inform 2021 Jul;151:104470.
  • 30 Wong ZS, Rigby M. Identifying and addressing digital health risks associated with emergency pandemic response: Problem identification, scoping review, and directions toward evidence-based evaluation. Int J Med Inform 2022 Jan;157:104639.
  • 31 Alami H, Lehoux P, Attieh R, Fortin J-P, Fleet R, Niang M, et al. A “Not So Quiet” Revolution: Systemic Benefits and Challenges of Telehealth in the Context of COVID-19 in Quebec (Canada). Frontiers in Digital Health 2021;3:133.
  • 32 Koch, K. The digital divide and the lack of broadband access during COVID-19. [cited 2022 March 24] Available from:
  • 33 NHS England (2019). The NHS long term plan. London. [cited 2022 March 24] Available from:
  • 34 Mahase E. Covid-19: NHS Test and Trace failed despite “eye watering” budget, MPs conclude. BMJ 2021 Oct 27;375:n2606.
  • 35 de Lusignan S, Jones N, Dorward J, Byford R, Liyanage H, Briggs J, et al. The Oxford Royal College of General Practitioners Clinical Informatics Digital Hub: Protocol to Develop Extended COVID-19 Surveillance and Trial Platforms. JMIR Public Health Surveill 2020 Jul 2;6(3):e19773
  • 36 Rheuban K, Shanahan C, Willson K. Telemedicine: Innovation Has Outpaced Policy. Virtual Mentor 2014 Dec 1;16(12):1002-9.
  • 37 Godinho MA, Martins H, Al-Shorbaji N, Quintana Y, Liaw ST. “Digital Health Diplomacy” in Global Digital Health? A call for critique and discourse. J Am Med Inform Assoc 2021;:ocab282.
  • 38 Godlee F. Covid 19: Why we need a global pandemic treaty. BMJ 2021;375:n2963.