Supporting the digital transformation journey through monitoring systems in healthcare. A comparative analysis of European empirical approaches through an adaptation of the IPOO framework

This study explores how digital transformation (DT) is operationalized and measured within Health System Performance Assessments (HSPAs) across European Union (EU) countries. By conducting a documentary analysis of national HSPAs through the READ approach, we identified 11 EU countries that include digital health metrics and extracted a total of 93 Key Performance Indicators (KPIs). These indicators were systematically categorized using the Input-Process-Output-Outcome (IPOO) framework and clustered into four deductively derived domains and corresponding sub-domains. Building on this empirical foundation, we propose a novel conceptual framework that integrates theoretical and practical dimensions of DT monitoring. The framework assigns representative KPIs to each IPOO phase and highlights critical but currently under-monitored areas. Despite notable progress in areas such as electronic health records, telemedicine, and digital service usage, the findings reveal persistent challenges. Furthermore, significant variability exists across countries in the adoption and computability of DT indicators. By providing a structured model and a comprehensive pool of indicators, this study contributes to both academic literature and practical policymaking. It supports efforts to guide DT measurement across healthcare systems while maintaining the flexibility needed to adapt to diverse national contexts. Future research should explore the evolving integration of DT metrics and continue to address gaps that hinder effective performance monitoring and policy development in healthcare digitalization.