Students’ competence as eHealth and eWelfare service developers based on the International Medical Informatics Association IMIA’s curriculum structure and design thinking

Multidisciplinary cooperation is required to develop digital health and welfare services. The aim of this article is to determine the eHealth and eWelfare service design competences that multidisciplinary students need to be able to develop digital services in health and social care. A secondary aim is to develop a measurement tool based on the International Medical Informatics Association (IMIA) curriculm for future assessment of such competences. Based on basic descriptive statistics results show that most students felt they have good skills in e-communication, basic IT, literature retrieval and research methods; some students, however, reported that they lack these basic skills. It is crucial that instructors be aware of student variations so that they can support the learning of the basics and further the biomedical and health informatics (BMHI) and design thinking (DT) competences. Principal components analysis (PCA) was used to determine the principal components (PC) from measured responses to BMHI and DT sections. Data were collected from 64 students. The components were explored and compared to constructs used to design the original measurement tool. A twenty-component structure showed the simplest solution and explained (80%, 68%, 73%) of variances in BMHI and 83% DT competences, respectively, in the measurement tool, each part of which was analysed by PCA. The PC can be the core areas in different professions taking part in developing eHealth and eWelfare. The parts of measurement tools relied on item reliability and content validity testing. This study provided a base for further measurement tool revision and theoretical testing.


Introduction
Digital health and social care services play key roles in improving care and increasing patients' levels of engagement in their own care.To develop digital services, there needs to be worldwide changes to coordinate quality health services with universal access [1] as well as strong guidelines from national policy makers [2].Professional associations need to consider the need for multidisciplinary development work and support professionals to take part in it [3,4].To achieve effective development and implementation, the customercentric service culture in health care requires a humancentred design approach for co-creation of innovation [5].
In the near future, 90% of jobs will require digital skills.At the same time, nearly half (47%) of the population of the European Union (EU) does not have adequate digital skills.The EU Commission supports efforts to enhance citizens' digital skills and qualifications [6].Since 1995, the European Computer Driving License (ECDL) has provided a worldwide format for information communication technology (ICT) skills and general knowledge to all professionals at different educational levels [7].The biomedical and health informatics (BMHI) standardized curriculum for health and IT professionals developed by the International Medical Informatics Association (IMIA) is known worldwide [8][9][10].The curricula of Information Technology (IT) engineers include informatics [11] and nursing informatics has been part of nursing curricula for many years [12][13][14][15][16].Moreover, it is proposed that social science programmes include informatics in their curricula [17].However, research shows that there is still a need to develop nursing informatics education and competences [18].There are many ways to change education so that it becomes more multidisciplinary e.g.interprofessional workshops can be provided for healthcare students and teachers [19].Bachelor degree students are willing to work together in multidisciplinary groups, but educators need to coordinate such programmes [20].It is challenging to develop multidisciplinary teams and discussion is needed about roles and the need to accept plurality in order to meet the aim and respond to the needs of patients [21].
In the health informatics discipline, there have been multidisciplinary discussions about the suitability of the IT industry's Skills Framework for the Information Age (SFIA).During the process, IMIA's BMHI curriculum was mapped to SFIA.[22] For empowered and creative cooperation in the development of digital services, a common language is required [23].Developing digital services to a single digital market [6] needs large cooperation, when developing competences [23] and for lifelong learning [24].
The European Qualifications Framework (EQF) defined by the EU is the general framework for vocational qualifications.The bachelor level in college level 5 describes knowledge as 'comprehensive, specialized, factual and theoretical knowledge within a field of work or study and an awareness of the boundaries of that knowledge'.Universities of Applied Sciences (UAS) bachelor degrees are on level 6, requiring advanced knowledge within a field of work or study involving critical understanding of theories and principles.The perspective interface between different fields is added in level 7. EQF defines knowledge, skills and competences related to all degrees [25] and the directive describes minimum competences [26].In this study, a competence is understood as a combination of knowledge and skills.

Purpose and aims
The purpose of this article is to describe students' knowledge, skills and competence in eHealth and eWelfare service design before their participation in courses meant to develop digital health and social care services.The aim of the present study is to evaluate what types of eHealth and eWelfare service design competences multidisciplinary students need to be able to develop digital services in health and social care.An additional aim is to develop a measurement tool based on the International Medical Informatics Association (IMIA) curriculm to assess these competences in the future.A multidisciplinary study module was compiled in the international development project called Developer of Digital Health and Welfare (DeDiWe).The research questions are as follows: 1. How did the students assess their biomedical and health informatics knowledge, skills and competences before the courses? 2. How did the students assess their skills and competences in developing and designing digital services before the courses?

3.
What kind of biomedical and health informatics and design thinking knowledge, skills and competences do multidisciplinary students need to be able to develop digital services in health and social care?

Survey instrument
The purposeful questionnaire used in this study was based on the IMIA´s recommendations for curriculum content [8][9][10] for EQF levels 5 and 6 [25] and described the user's IT levels in relation to the IMIA curriculum [8][9][10].The questionnaire was cross-mapped with ECDL [7] and IMIA [8][9][10] contents.The questionnaire consisted of three parts: Background (14 scale variables), Biomedical and Health Informatics (BMHI; 72 scale variables) and Design Thinking Competences (DTC;10 scale variables).The questionnaire also contained open-ended questions: four on background and two on the DTC parts.
Background variables describe the participants' demographics, such as country, age, study programme and study path, study credits received before obtaining their bachelor's degree and study credits obtained after receiving their bachelor's degree.The IMIA's contentbased recommendations for knowledge levels and professional skills in BMHI is spread among four domains.In the present study, we used three domains-BMHI core knowledge and skills; medicine, health and biosciences and health-system organization; and informatics or computer science, mathematics and biometry [8][9][10] which were formulated to the fields of variables as general knowledge and skills, knowledge and understanding, skills and competence.We also added the social care perspective [17] to the BMHI variables [8][9][10].The questionnaire also contained questions about informatics not related to health and social care.The last part of the questionnaire included competences for design thinking (DT) [27] to describe the part of the questionnaire related to the service-design process.There were a total of 82 questions (Table 1) and a 5point Likert scale was used.The open-ended questions are not reported in this paper.

Data collection and analysis
Students (N=82) were recruited from European partner schools in Finland (n=42), Latvia (n=20) and Estonia (20).Data were collected using an e-questionnaire administered to students who had signed up for the course developed in the project called 'Developer of Digital Health and Welfare Service (DeDiWe)'.
Participation was voluntary and the responses were anonymized in the report.The e-questionnaire was distributed to all participating students through the eLearning platform used for the study unit in Autumn 2016.
Data were transferred from the e-questionnaire (Elomake) to an Excel spreadsheet.Prior to statistical analysis, the data were cleaned to check for outliers and missing values; there were no missing values.Data were analysed using IBM SPSS Statistic Data Editor Software 23.0 licensors 1989, 2015 (IBM Corporation, USA).Basic descriptive statistics were used for statistical analysis (parameters, percentages and arithmetic means).The distribution of variables was analysed by comparing Cronbach's alpha values between different parts of the questionnaire and significant values [28].These values are shown in Table 2.The BMHI variable results were organized into IMIA's three domains: BMHI core knowledge and skills; medicine, health and biosciences and health-system organization; and informatics or computer science, mathematics and biometry.According to content similarity, seven groups were formed within BMHI core knowledge and skill, three groups were formed within medicine, health and biosciences and health-system organization; and four groups were formed within informatics or computer science, mathematics and biometry.In the DT section, according to content similarity and theory structure [27], four groups were formed using the DT competences content.The results and descriptive statistics are presented in Tables 5, 7, 9 and 11.
The complexity of the mean scores for the self-assessed items were reduced by principal component analysis (PCA) and components eigenvalues greater than 1.The components obtained from PCA were rotated using the Varimax criterion [28].Subsequently, PCA was applied to all domains, which are described in Table 3. Bartlett's test of sphericity and the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy were used to justify the use of PCA based on a criterion of p <0,0001 and 0,6 or higher.In one domain, the KMO was 0,573, but all others were greater than 0,6.The absolute value used was less than 0,30 [28].

Results
Half of the students were nurses from Finland and were under 29 years of age.There were only a few nonhealth and social care students.Table 4 shows the students' background information, such as country, study programme, gender, age, study path, university, bachelor's degree field, credits required to obtain bachelor's degree, study credits before, highest degree before, graduation year from last studies distribution.The results were organized based on the BMHI's three categories; DT has its own categories.

Biomedical and health informatics core knowledge and skills
Students had the highest skills in software for personal communication (n=56 with total agree and agree), and skills in literature retrieval and research methods (n=35 with total agree and agree).Some students (n=4 with total disagree and disagree) did not have these skills.
The lowest skill level was in sensor technology (n=32 with total disagree and disagree).Skills in non-health related informatics themes were lower (mean 2.8) than understanding health and social informatics themes (mean 3,4).Many students (n=29 with total disagree and disagree) assessed that they did not have sufficient skills to work with legal and regulatory issues related to IT; however, students (n=41 with total agree and agree) assessed their skills as very high in privacy and security of patient data.Results of the BMHI core knowledge and skills questions are presented in Table 5.
To reduce the variability observed in self-reports regarding biomedical and health informatics core knowledge and skills (47 variables), we conducted a PCA, which identified 12 main components explaining 80% of the results.
Following are the main components and explain the percentages of the results of the analysis: 1) Understanding health and social informatics -31%; 2) Skills and understanding literature retrieval and research methods -9%; 3) Knowledge and skills of ethical and security issues -7%; 4) Understanding benefits of IT in health and social care -7%; 5) Understanding ethical and security issues in data management -5%; 6) Understanding and skills in health technology -4%; 7) Skills to work with terminologies -4%; 8) Skills to work with process modelling and reorganizationing -3%; 9) Understanding quality of documentation -3%; 10) Understanding information processes in health and social care -3%; 11) Skills in personal e-communication -2%; and 12) Skills using information processing to support practice -2%.The saturated variables are explained components and presented in Table 6.

Medicine, health and biosciences and health-system organization biometry knowledge, skills and competence
According to content similarity, four groups were formed from the medicine, health and biosciences and health-system organization content.Students had almost the same levels in all variables, however, the highest competences were found in the themes of human function and health (mean 3.6) and health and social care development (mean 3.6) and guiding clients in social and health care.Students' lowest competences were related to evidence-based clinical decision making.The results for students' medicine, health and biosciences, and health-system organization biometry knowledge, skills and competences are presented in Table 7.
To reduce the variability observed in self-reports regarding medicine, health and biosciences and healthsystem organization biometry knowledge and skills (with 12 variables), PCA was conducted, which allowed us to identify three components explaining 68% of the analysis results.
The following are the main components and explain the percentages of the results of the analysis: 1) Understanding patient safety initiatives -48%; 2) Understanding quality and resource management -11%; and 3) Understanding the basics of human functioning and health -9%.The saturated variables are explained components and presented in Table 8.

Informatics or computer science mathematics, biometry
The results describe how students assessed their informatics or computer science mathematics, biometry knowledge, skills and competence before they took the study unit (Table 9).According to content similarity, three groups were formed.Students had the highest competence in basic IT competence (mean 3.9) and the lowest competence in the category related to decision support systems (mean 2.9).Each variable was assessed on a scale ranging from total disagree to total agree.
To reduce the variability observed in self-reports regarding informatics or computer science mathematics, biometry (13 variables), PCA was conducted, which allowed us to identify three components explaining 73% of the analysis results.The following are the main components and explain the percentages of the results of the analysis: 1) Competence to take part in change management -47%; 2) Basic skills for IT and informatics projects -15%; and 3) Competence to work and develop decision support systems -20%.The saturated variables are explained components and presented in Table 10.Understanding and competence in project and change management G9 Understanding of project management 3,5   (N=64) Response rate Content (10) Mean Stadard Deviation Totally Disagree

Design thinking competence
These results describe how students assessed their skills and competences in developing and designing digital services before the study unit (Table 11).Students had the highest competence in skills in service design in general (mean 3.5) and the lowest in iterate diagrams (mean 3.0).
Working customer oriented' had no totally disagree responses.Every other statement had responses ranging from totally disagree to totally agree.The best competences that students seemed to have were working customer oriented (mean 4.0), identifying needs and setting goals to service design process (mean 3.4), analysing and coordinating resources in service design process (mean 3.2) and creating arguments based on evidence in service design process (mean 3.2).
To reduce the variability observed in self-reports regarding design thinking competence, we conducted PCA (10 variables), which allowed us to identify two components explaining 83% of the analysis results.The following are the main components and explain the percentages of the results of the analysis: 1) Have skills to take part in service design process -73%; and 2) Can identify needs and set goals to service design process in a customer oriented way -10%.The saturated variables are explained components and presented in Table 12.

Discussion
Educating professionals to develop digital health and welfare services in multidisciplinary groups is crucial for developing competence in biomedical health informatics and design thinking.Our research provides an overview of these competences as assessed by students before taking part in the DeDiWe course.
The descriptive results show that there are variations in students' knowledge, understanding, skills and competences to work in a digital world.Students' skills in software for personal communication were high.In medicine, health and biosciences and health-systems organization, the theme 'basic IT competence' had a high mean, however, some students assessed their skills as low.In BMHI core knowledge, in the theme 'understanding and skills in literature retrieval and research methods', students mainly evaluated their skills as quite good.In the EU [6], nearly half of the population lacks skills to work in a digitalized manner.It is important to recognize students who need extra support in basic IT competences, digital communication skills, literature retrieval and research methods so that they can improve their skills in BMHI and DT.
Students assessed their understanding and competence in project and change management as low.In change management, there were higher values for taking part in change management than for understanding change management.These results are connected to the EQF [25] general professional competences, where level 6 includes 'take responsibility for managing professional development of individuals and groups', which is connected to project and change management.Furthermore, decision making is already one of the core areas in the EQF, and decision support systems are now a part of routine work.In level 6, there is currently not a demand for 'interface between different fields'.On the other hand, many authors are willing to apply multidisciplinary cooperation [1,2,3,4,5,6,8,19,20,22,23,26], which is already on EQF level 6.These results are defining BMHI and DT competences in multidisciplinary perspectives and that´s why many of the subjects are described as understanding or having skills, which is lower than EQF 5 and 6 in general.Students assessed their informatics or computer science, mathematics and biometry knowledge, skills and competence as good.Human functioning and health themes and competence to guide the client in social and health care were assessed as high.Again, almost all of the survey participants were studying health and social services; however, the results indicate that high school curricula might provide a great deal of knowledge with regard to human functioning and a general understanding about health care.
The quality and safety theme had the highest values in understanding patient safety initiatives.Evidence-based clinical decision making is the core of professional understanding in interdisciplinary health care [3,4,26], but it is not as common in social care.These contents are important to members of multidisciplinary groups that are developing eHealth and eWelfare services.
In DT competences, there were variations between totally disagree to totally agree.Almost all students felt that their work was customer oriented.This is important, because to achieve effective development and implementation, the customer-centric service culture in health care requires a human-centred design approach [9].One-third of the students thought that they had at least some competences in the DT process.Students are in EQF level 5 and 6 5 [25], so all participants had general skills in development work.Students assessed skills for coordinating resources and setting goals as better to service design process.[27].The scores for understanding terminology may have been low because such insight requires specific understanding of the service design process, integrating diagrams and the context of the design.Weneger [23] stated that there needs to be a common language to have fruitful cooperation in a development process.Educators need to take this into considerations and incorporate these subjects as part of their courses, so that students have opportunities for collaboration in service design.Students can acquire these competences based on general service knowledge in the health and social care sector; evidence-based argumentation is especially common in health care [3,4,26].
PCA was used to determine the principal components (PC) from measured responses to each instrument.The results and components were explored and compared to constructs used to design the original measurement tool.A twenty (12, 3, 3, 2) component structure showed the simplest solution and explained (80%, 68%, 73%) of variances in the BMHI and (83%) in the DT competence measurement tool.PCA was applied to every part of the measurement tool.A twelvecomponent structure explained 80% of the variance in the biomedical core knowledge and skills.A three-PC structure explained 68% of the variance in the biomedical and health informatics core knowledge and skills.A three-component structure explained 73% of the PC in informatics or computer science, mathematics and biometry.A two-component structure explained 83% of the DT competences.Cronbach's alpha values were satisfactory.Components were mapped to each theory base structure.There were variation between PA components contents and theory based themes.
The questionnaire used in this study was purposeful.It made use of categories in Mantas et al. [8,9,10], ECDL [7] and Design Thinking [28] theory, as well as EQF [25] levels.Social sector and non-health and social related questions were added.The IMIA sections have different numbers of variables because the BMHI core knowledge and skills comprise the largest content in the IMIA curriculum.
Quantitative data from the questionnaire were reported in this study.Findings from the qualitative data were previously reported [20].Our results are not generalizable because of the small sample, which mainly reflects the opinions of the health care sector as represented by the student participants.However, these results imply that students have the knowledge, skills and competence to take part in multidisciplinary digital health and welfare service development.In this study, the competences were contextualized to bachelor studies.In the SFIA [22], all high level skills apply to the health informatics discipline; however, these results need to be contextualized and modified to suit the health industry.

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FinJeHeW 2018;10(1) 27 The questionnaire was evaluated with Cronbach's alpha values and significant values, and the reliability of the questionnaire was found to be good.Alpha values that are too high indicate an insufficient number of responses (Table 1) [28].In this study, there were only a few IT bachelor students and no IT engineer students.Aungst [19] found that there needs to be interprofessional teams of teachers to get interprofessional groups of students to participate in a study.Jones [21] found that there can be challenges to developing multidisciplinary teams.In the process of developing an SFIA in health informatics, large-scale cooperation and global understanding among the health industry needs to be part of the process [22].Greater multidisciplinary co-operation among teachers and student groups is required in these DeDiWe courses, to get more multidisciplinary students.
Students were informed that completing the questionnaire was voluntary, but were encouraged to respond because of the importance of the project.This, as well as the need for English skills, might have affected the response rate and the results.

Conclusion
The descriptive results show that most students have good skills in e-communication, basic IT, literature retrieval and research methods.However, some students reported that they do not have these basic skills.It is important for teachers to take this variability into consideration so that they can support their students in the basics and help them to acquire more BMHI and DT knowledge, skills and competences in multidisciplinary environments.Multidisiplinary cooperation needs common terminologies.The PCA components can be the core areas of Universities of Applied Science Curricula in different professions taking part in developing eHealth and eWelfare services.The parts of measurement tools relied on item reliability and content validity testing.This study provided a base for further measurement tool revision and theoretical testing.

Table 5 .
Descriptive Results for Biomedical and Health Informatics Core Knowledge and Skills (N=64).

Table 7 .
Descriptive Results for Medicine, Health and Biosciences and Health-System Organization (N=64).G=general knowledge, skills and competence, KU=BMHI knowledge and understanding, S= BMHI skills, C= BMHI competence

Table 8 .
Principal Components in Medicine, Health and Biosciences and Health-system Organization.

Table 9 .
Descriptive Results for Informatics or Computer Science Mathematics, Biometry.

Table 10 .
The Principal Components in Informatics or Computer Science Mathematics, Biometry.

Table 12 .
Principal Components in Design Thinking Competences.