Regarding participation in projects related to DH, 82% of respondents said that they were not involved in any, and 67% were unaware of any DH-related project or initiative taking place in their place of work. Most respondents (90%) thought that the COVID-19 pandemic significantly influenced the adoption of DH.

Responses concerning DH-related tools used day-to-day are shown in Figure 1. Almost 84% of responders used electronic medical information systems, and more than two-thirds used implantable technologies (sensors and devices), social media networks, mobile apps, and telemedicine in their professional activity.

Figure 1.

Day-to-day use of digital health tools.

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Responses concerning the importance of each of the tools evaluated are shown in Table 2, and a radar chart with the weighted mean for each is presented in Figure 2. Around 85% of participants considered electronic medical information systems (electronic health records, medical decision support platforms, clinical and institutional monitoring) either very important or extremely important; this was considered the most important tool, with a weighted mean of 4.35. Implantable technologies with sensors or devices for decision-making and adaptation of medical therapy (e.g. blood glucose monitors or implantable heart rate monitors) were also considered very or extremely important by 85% of respondents and had a weighted mean of 4.28. On the other hand, smartwatches were the least important, with a weighted mean of 3.42.

Figure 2.

Weighted mean for the importance of each of the following digital health-related tools/applications in improving cardiovascular healthcare.

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The section on expectations concerning the impact of DH on the daily routine of cardiovascular healthcare was subdivided into six statements, the responses to which are provided in Table 3. A total of 78% of respondents agreed (partially or completely) that DH contributes to improving health outcomes. The majority agreed (partially or completely) that DH helps to improve the health literacy of the population (64%) and that it decreases healthcare costs (63%), while approximately half of responders (53%) agreed that DH increases patient satisfaction. Responses concerning threats to doctors’ and patients’ privacy and the impact on HCPs’ workload varied widely.

An overview of all nine barriers is given in Table 4 and a radar chart with a weighted mean for each of the barriers is shown in Figure 3. At least half of the participants categorized the following barriers as ‘very important’ or ‘extremely important’: limited access to electronic devices (65%), inability of patients to use smartphones (62%), lack of legal regulation of DH (60%), lack of motivation among patients (60%), lack of reimbursement/funding of the medical act (56%), and lack of recognition of and trust in DH (55%).

Figure 3.

Weighted mean of each of the nine factors’ contribution to difficulty in the implementation of digital health applications/tools in clinical practice.

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The weighted means calculated highlight patients’ inability to use smartphones as the most significant barrier (3.81), followed by limited access to electronic devices (3.80) and lack of legal regulation of DH (3.79).

Cardiovascular HCPs were familiar with this subject, and the majority recognized the most appropriate definition of DH. However, only a minority took part in DH-related projects, which is probably related to the lack of investment in this field.13

Most respondents agreed that the COVID-19 pandemic significantly influenced the adoption of DH, which is consistent with the existing evidence. Indeed, during the COVID-19 pandemic, the adoption of telemedicine consultations increased sharply in less than a year.14,15

Cardiovascular HCPs considered DH tools that were already implemented and that they were already familiar with to be more important. Specifically, electronic medical information systems and implantable technologies were believed to be the most important in improving cardiovascular healthcare. Undeniably, the Portuguese electronic medical information system and implantable technologies are widespread tools, making the performance of cardiovascular HCPs more effective and efficient.16–18 Social media were also a much-used and highly-rated tool, which is in line with the existing evidence: a recent (2021) study carried out in Portugal also showed that the attitude of cardiovascular HCPs toward the use of social media and its potential to improve clinical outcomes is very positive.19 In addition, remote monitoring has emerged as a transformative breakthrough, representing a powerful ally in preventing and treating cardiovascular disease, with a growing body of evidence emphasizing its added clinical value.20 For example, implantable loop recorders offer enhanced clinical value and are well-recognized tools among medical practitioners.21

On the other hand, smartwatches and robotics were the least used and considered the least important for healthcare. This may suggest a certain fear of the unknown and doubts regarding the potential of new tools. It may be that these tools are less trusted by cardiovascular HCPs simply because they are not as established in clinical routines as others, and not because they are less effective.22–24 As an example, although validation of cuffless blood pressure devices is complex and needs to be tailored according to their functions and calibration, the European Society of Hypertension has provided guidance on validation procedures to ensure that only accurate devices will be used in the assessment and management of hypertension.25

Concerning expectations toward DH, approximately 78% of respondents agreed that it helps to improve healthcare outcomes. Most believe it is useful in reducing healthcare costs and increasing patient satisfaction. Although little evidence on cardiovascular HCPs’ expectations of DH is available, other studies have shown a similar positive outlook, including in the Portuguese medical community.26 In addition, one recent study published in 2019 in the Netherlands concluded that cardiologists are optimistic about DH. Most of them also considered that it was clinically beneficial and improves patient satisfaction and information.8 Another study, published in Spain in 2017, revealed that physicians believed in the usefulness of telemedicine in improving healthcare systems and that the attitude of cardiovascular HCPs toward this concept is a facilitating factor for its implementation.11

Responses concerning threats to doctors’ and patients’ privacy and the impact on HCPs’ workload were not consensual. The available evidence suggests that the possibility of privacy violation will always be present. Nevertheless, various privacy-preserving mechanisms have recently been developed in DH models to address this issue.27 Evidence of the impact of DH on health professionals’ workload is scarce. However, there are some striking examples of its added clinical value, such as decreases in office visits and rehospitalizations with remote monitoring of ICDs, and optimization of time to diagnosis in unexplained syncope with implantable loop recorder monitoring.21,28

Despite the enormous expectations for DH, our respondents identified some critical barriers, notably patients’ inability to use smartphones, limited access to electronic devices, and the lack of legal regulation of DH. A systematic review published in 2021 that aimed (among other things) to discuss barriers to the uptake of DH technology in cardiovascular care reported that “difficult-to-use technology” was one of the most common patient-level barriers, which is in line with our results.29 Lack of legal clarity, lack of patient motivation and DH literacy skills, and limited access to DH care were also concerns identified in a similar study by the European Society of Cardiology (ESC), published in 2021.9 Our survey also supports these findings. However, different results were found concerning the lack of evidence regarding its effectiveness and cost-effectiveness. While this was reported as a significant concern in the ESC study, it was the lowest-rated barrier in our questionnaire. This could be explained by the large number of studies published in the past few years demonstrating the cost-effectiveness of DH,4,30,31 the results of which were probably not so clear when the ESC survey was published.

DH has undergone substantial evolution over the past two decades. The COVID-19 pandemic expedited the digital transformation of the healthcare sector, thereby exerting a direct influence on the entire healthcare ecosystem.14 The rapid advancement of DH can be attributed to technological innovations and increasing demand for enhanced and personalized healthcare services. Anticipated developments in the future include the deeper integration of digital tools within healthcare practices, alongside a greater emphasis on leveraging data to improve healthcare outcomes and elevate patient experiences.32,33

The present study indicates a positive outlook among cardiovascular HCPs concerning the forthcoming landscape of DH. Nonetheless, numerous challenges remain on the horizon. It is imperative to establish preparedness at leadership, systemic, and individual levels to effectively navigate these emerging technologies. This preparation is pivotal for harnessing the benefits and optimizing investments associated with DH. Prioritizing comprehensive training and support is essential, particularly for those requiring greater familiarity with DH and its associated tools.

The path forward should be focused on the promotion of a patient-centered and clinically pertinent DH tool development pipeline. This trajectory must be accomplished with meticulous attention to privacy and security standards, all within a framework of heightened regulatory clarity. Concurrently, investments aimed at ensuring the accessibility of electronic devices, alongside the dissemination of scientific updates and medical education of the public, merit consideration as an integral part of this ongoing technological revolution.9,34

One of the limitations of our study is the low response rate (10% of those contacted by e-mail). A low response rate can introduce the risk of non-response bias, whereby the characteristics and perspectives of non-respondents differ from those of respondents, leading to an incomplete or skewed representation of the target population. This, in turn, may limit the extent to which the study's results can be confidently applied to broader contexts or populations.

The fact that the survey was conducted online also represents a limitation. Since DH is closely connected to technology and internet access, respondents were likely to be more interested and knowledgeable about DH than non-responders. Therefore, the results of expectations on DH could be slightly overestimated, and concerns about the barriers to the implementation of DH could be underestimated.

Employing strategies to enhance questionnaire content, use multiple communication channels, emphasize the study's significance, and employ personalized reminders could help to improve the response rates in future studies. Although it may seem challenging to develop effective strategies to improve participation rates,35 implementing these measures can enhance the quality and applicability of research outcomes in the dynamic field of digital health.

Not every item of the questionnaire had to be answered. Therefore, some questions had a higher response rate than others. Respondents likely chose not to answer certain questions because they were unsure of their response, which could have led to the results being skewed toward the extremes.

Finally, this was a survey conducted in Portugal. Thus, our results cannot be generalized to other countries.