Iiris Hörhammer

Background: Health information technology (HIT) interventions are complex, yet theory-based approaches such as logic models or Theory of Change (ToC) remain rarely applied in medical informatics, although they could clarify assumptions, link activities to outcomes, and support design and evaluation. Objectives: This scoping review examined how logic models and ToC have been used in HIT research across disciplines. Methods: Following the PRISMA-ScR guidelines, databases were searched up to August 2025. Eligible studies explicitly applied logic models or ToC to HIT. Data were extracted on HIT type, purpose of using logic models, and reported benefits and challenges. Results: Sixty-nine studies met inclusion criteria, most published after 2020. A majority of studies developed logic models for patient-facing HIT such as mHealth or telehealth. Logic models were mainly used to support HIT design or evaluation and were mostly newly developed. Reported benefits of using logic models included conceptual clarity and better stakeholder communication; challenges involved resource demands and limited generalisability. Conclusions: Logic models and ToC are increasingly used for HIT but remain inconsistently applied and seldom reused. Standardised reporting and repositories could strengthen theory-informed evaluation in medical informatics.

Background: Health information technology (HIT) interventions are complex, context-dependent, and often insufficiently theorized, which can hinder their design, implementation, and evaluation. Program theory approaches such as logic models and theory of change (ToC) are well-established in public health and implementation science for articulating causal assumptions. Their use in medical informatics, however, appears inconsistent. A systematic overview of how logic models and ToC have been applied to HIT interventions is therefore needed to support theory-informed development and cumulative learning in the field. Objective: We aimed to map how logic models, ToC, and related program theory approaches have been conceptualized, constructed, and applied in HIT-related interventions across disciplines. A secondary objective was to identify implications for medical informatics research and practice. Methods: Following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), searches were conducted in PubMed, Web of Science, Academic Search Elite, APA PsycArticles, and CINAHL. Eligible publications used a logic model, ToC, or related construct within an HIT intervention in any health care or social-care setting. Next, 2 reviewers independently screened records and extracted data on study characteristics, type and purpose of HIT, model structure, theoretical foundations, and reported benefits and challenges. Results: A total of 69 publications (2012‐2025) met the criteria. Use of program theory increased markedly after 2020 and spanned medical informatics, public health, health services research, and implementation science. Logic models were most frequently applied to patient-facing and self-management technologies, particularly mobile health, telehealth, and home-based remote monitoring. Most models were used to support HIT development or evaluation. Of the total, 60 (87%) studies provided a logic model visualization, although structures varied considerably. Out of 69, 50 (72%) studies cited guidelines for model development, most commonly UK Medical Research Council guidance, realist evaluation, or the Kellogg Logic Model. Out of 69 studies, 28 (41%) used behavioral or implementation frameworks, such as Capability, Opportunity, Motivation–Behavior model (COM-B), Consolidated Framework for Implementation Research (CFIR), Expert Recommendations for Implementing Change (ERIC), Fit between Individuals, Task, and Technology (FITT), or Non-adoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability (NASSS) to populate model content. Only 3 (4%) studies reused an existing model. Reported benefits concerned improved theorization, structured evaluation, and stakeholder engagement; challenges included limited empirical evidence, high resource demands, and tensions between specificity and generalizability. Conclusions: Program theory approaches are increasingly used to conceptualize and evaluate HIT interventions; yet, their application in medical informatics remains fragmented. More systematic and theory-informed use of logic models could enhance conceptual clarity, methodological rigor, and cumulative learning. Future work should promote model reuse, establish repositories, strengthen reporting standards, and integrate program theory in HIT education and research to support coherent development, evaluation, and scaling of digital health interventions.

BACKGROUND Health information technology (HIT) interventions are complex, context-dependent, and often insufficiently theorized, which can hinder their design, implementation, and evaluation. Programme theory approaches such as logic models and Theory of Change (ToC) are well established in public health and implementation science for articulating causal assumptions and guiding evaluation. Their use in medical informatics, however, appears inconsistent and insufficiently understood. A systematic overview of how logic models and ToC have been applied to HIT interventions is therefore needed to support theory-informed development and cumulative learning in the field. OBJECTIVE This scoping review aimed to map how logic models, ToC, and related programme theory approaches have been conceptualized, constructed, and applied in HIT-related interventions across disciplines. A secondary objective was to identify implications for medical informatics research and practice. METHODS Following PRISMA-ScR, a protocol was preregistered. Searches were conducted in PubMed, Web of Science, Academic Search Elite, APA PsycArticles and CINAHL. Eligible publications explicitly used a logic model, ToC, or related construct within an HIT intervention in any healthcare or social-care setting. Two reviewers independently screened records and extracted data on study characteristics, type and purpose of HIT, model structure, theoretical foundations, and reported benefits and challenges. Findings were synthesized descriptively and thematically. RESULTS Sixty-nine publications (2012–2025) met the criteria. Use of programme theory increased markedly after 2020 and spanned medical informatics, public health, health services research, and implementation science. Logic models were most frequently applied to patient-facing and self-management technologies, particularly mobile health, telehealth, and home-based remote monitoring. Most models were used to support HIT development or evaluation. Eighty-seven percent of studies provided a visualization, although structures varied considerably. Seventy-two percent cited guidelines for model development, most commonly MRC guidance, realist evaluation, or the Kellogg Logic Model. Forty-one percent used behavioural or implementation frameworks such as COM-B, CFIR, ERIC, FITT, or NASSS to populate model content. Only three studies reused an existing model. Reported benefits concerned improved theorization, structured evaluation, and stakeholder engagement; challenges included limited empirical evidence, high resource demands, and tensions between context specificity and generalizability. CONCLUSIONS Programme theory approaches are increasingly used to conceptualize and evaluate HIT interventions, yet their application in medical informatics remains fragmented and inconsistently reported. More systematic and theory-informed use of logic models could enhance conceptual clarity, methodological rigour, and cumulative learning. Future work should promote model reuse, establish repositories, strengthen reporting standards, and integrate programme theory in HIT education and research to support coherent development, evaluation, and scaling of digital health interventions. CLINICALTRIAL Ammenwerth E, Bindel M, Hörhammer I. Logic Models on Interventions Including Health Information Technology: A Scoping Review Across Disciplines (Protocol) [Internet]. Open Science Framework (OSF). 2025. Available from: https://osf.io/zru3n/overview

Background: The NORDeHEALTH project studies patient-accessible electronic health records (PAEHRs) in Estonia, Finland, Norway, and Sweden. Such country comparisons require an analysis of the sociotechnical context of these services. Although sociotechnical analyses of PAEHR services have been carried out in the past, a framework specifically tailored to in-depth cross-country analysis has not been developed. Objective: This study aims to develop and evaluate a method for a sociotechnical analysis of PAEHRs that advances a framework for sociotechnical analysis of eHealth solutions first presented by Sittig and Singh. This first article in a series presents the development of the method and a cross-country comparison of the contextual factors that enable PAEHR access and use. Methods: The dimensions of the framework for sociotechnical analysis were thoroughly discussed and extended in a series of workshops with international stakeholders, all being eHealth researchers focusing on PAEHRs. All countries were represented in the working group to make sure that important national perspectives were covered. A spreadsheet with relevant questions related to the studied services and the various dimensions of the sociotechnical framework was constructed and distributed to the 4 participating countries, and the project participants researched various national sources to provide the relevant data for the comparisons in the 10 sociotechnical dimensions. Results: In total, 3 dimensions were added to the methodology of Sittig and Singh to separate clinical content from features and functions of PAEHRs and demonstrate basic characteristics of the different countries regarding national and regional steering of health care and information and communications technology developments. The final framework contained the following dimensions: metadata; hardware and software computing infrastructure; features and functions; clinical content shared with patients; human-computer interface; people; workflow and communication; the health care organization’s internal policies, procedures, and culture; national rules, regulations, and incentives; system measurement and monitoring; and health care system context. The dimensions added during the study mostly concerned background information needed for cross-country comparisons in particular. Several similarities were identified among the compared countries, especially regarding hardware and software computing infrastructure. All countries had, for example, one national access point, and patients are provided a PAEHR automatically. Most of the differences could be identified in the health care system context dimension. One important difference concerned the governing of information and communications technology development, where different levels (state, region, and municipality) were responsible in different countries. Conclusions: This is the first large-scale international sociotechnical analysis of services for patients to access their electronic health records; this study compared services in Estonia, Finland, Norway, and Sweden. A methodology for such an analysis was developed and is presented to enable comparison studies in other national contexts to enable future implementations and evaluations of PAEHRs.

The Nordic countries are, together with the United States, forerunners in online record access (ORA), which has now become widespread. The importance of accessible and structured health data has also been highlighted by policy makers internationally. To ensure the full realization of ORA’s potential in the short and long term, there is a pressing need to study ORA from a cross-disciplinary, clinical, humanistic, and social sciences perspective that looks beyond strictly technical aspects. In this viewpoint paper, we explore the policy changes in the European Health Data Space (EHDS) proposal to advance ORA across the European Union, informed by our research in a Nordic-led project that carries out the first of its kind, large-scale international investigation of patients’ ORA—NORDeHEALTH (Nordic eHealth for Patients: Benchmarking and Developing for the Future). We argue that the EHDS proposal will pave the way for patients to access and control third-party access to their electronic health records. In our analysis of the proposal, we have identified five key principles for ORA: (1) the right to access, (2) proxy access, (3) patient input of their own data, (4) error and omission rectification, and (5) access control. ORA implementation today is fragmented throughout Europe, and the EHDS proposal aims to ensure all European citizens have equal online access to their health data. However, we argue that in order to implement the EHDS, we need more research evidence on the key ORA principles we have identified in our analysis. Results from the NORDeHEALTH project provide some of that evidence, but we have also identified important knowledge gaps that still need further exploration.

BACKGROUND The NORDeHEALTH project studies patient-accessible electronic health records (PAEHRs) in Estonia, Finland, Norway, and Sweden. Such country comparisons require an analysis of the sociotechnical context of these services. Although sociotechnical analyses of PAEHR services have been carried out in the past, a framework specifically tailored to in-depth cross-country analysis has not been developed. OBJECTIVE This study aims to develop and evaluate a method for a sociotechnical analysis of PAEHRs that advances a framework for sociotechnical analysis of eHealth solutions first presented by Sittig and Singh. This first article in a series presents the development of the method and a cross-country comparison of the contextual factors that enable PAEHR access and use. METHODS The dimensions of the framework for sociotechnical analysis were thoroughly discussed and extended in a series of workshops with international stakeholders, all being eHealth researchers focusing on PAEHRs. All countries were represented in the working group to make sure that important national perspectives were covered. A spreadsheet with relevant questions related to the studied services and the various dimensions of the sociotechnical framework was constructed and distributed to the 4 participating countries, and the project participants researched various national sources to provide the relevant data for the comparisons in the 10 sociotechnical dimensions. RESULTS In total, 3 dimensions were added to the methodology of Sittig and Singh to separate clinical content from features and functions of PAEHRs and demonstrate basic characteristics of the different countries regarding national and regional steering of health care and information and communications technology developments. The final framework contained the following dimensions: metadata; hardware and software computing infrastructure; features and functions; clinical content shared with patients; human-computer interface; people; workflow and communication; the health care organization’s internal policies, procedures, and culture; national rules, regulations, and incentives; system measurement and monitoring; and health care system context. The dimensions added during the study mostly concerned background information needed for cross-country comparisons in particular. Several similarities were identified among the compared countries, especially regarding hardware and software computing infrastructure. All countries had, for example, one national access point, and patients are provided a PAEHR automatically. Most of the differences could be identified in the health care system context dimension. One important difference concerned the governing of information and communications technology development, where different levels (state, region, and municipality) were responsible in different countries. CONCLUSIONS This is the first large-scale international sociotechnical analysis of services for patients to access their electronic health records; this study compared services in Estonia, Finland, Norway, and Sweden. A methodology for such an analysis was developed and is presented to enable comparison studies in other national contexts to enable future implementations and evaluations of PAEHRs.

Background: Although many surveys have been conducted on patients accessing their own health records in recent years, there is a limited amount of nationwide cross-country data available on patients’ views and preferences. To address this gap, an international survey of patient users was conducted in the Nordic eHealth project, NORDeHEALTH. Objective: We aimed to investigate the sociodemographic characteristics and experiences of patients who accessed their electronic health records (EHRs) through national patient portals in Norway, Sweden, Finland, and Estonia. Methods: A cross-sectional web-based survey was distributed using the national online health portals. The target participants were patients who accessed the national patient portals at the start of 2022 and who were aged ≥15 years. The survey included a mixture of close-ended and free-text questions about participant sociodemographics, usability experience, experiences with health care and the EHR, reasons for reading health records online, experience with errors, omissions and offense, opinions about security and privacy, and the usefulness of portal functions. In this paper, we summarized the data on participant demographics, past experience with health care, and the patient portal through descriptive statistics. Results: In total, 29,334 users completed the survey, of which 9503 (32.40%) were from Norway, 13,008 (44.35%) from Sweden, 4713 (16.07%) from Finland, and 2104 (7.17%) from Estonia. National samples were comparable according to reported gender, with about two-thirds identifying as women (19,904/29,302, 67.93%). Age distributions were similar across the countries, but Finland had older users while Estonia had younger users. The highest attained education and presence of health care education varied among the national samples. In all 4 countries, patients most commonly rated their health as “fair” (11,279/29,302, 38.48%). In Estonia, participants were more often inclined to rate their health positively, whereas Norway and Sweden had the highest proportion of negative health ratings. Across the whole sample, most patients received some care in the last 2 years (25,318/29,254, 86.55%). Mental health care was more common (6214/29,254, 21.24%) than oncological care (3664/29,254, 12.52%). Overall, most patients had accessed their health record “2 to 9 times” (11,546/29,306, 39.4%), with the most frequent users residing in Sweden, where about one-third of patients accessed it “more than 20 times” (4571/13,008, 35.14%). Conclusions: This is the first large-scale international survey to compare patient users’ sociodemographics and experiences with accessing their EHRs. Although the countries are in close geographic proximity and demonstrate similar advancements in giving their residents online records access, patient users in this survey differed. We will continue to investigate patients’ experiences and opinions about national patient-accessible EHRs through focused analyses of the national and combined data sets from the NORDeHEALTH 2022 Patient Survey.