Patients' experiences with digital GP communication

Six out of ten GP patients find it easier to write electronic messages of a non-medical nature than to make calls. Just over four out of ten find it easier to explain clinical issues in writing than orally, while 24 per cent prefer traditional consultation.

These are among the findings of a Norwegian study that has looked at users' experiences with digital services such as electronic appointment booking and prescription renewal, digital non-medical requests and text-based e-consultation.

First author Paolo Zanaboni and co-author, researcher Asbjørn Fagerlund at the Norwegian Centre for E-health Research are behind the study, which was published in the BMJ Open in June 2020. The study is among the first in the world where national implementation of digital services in general practice has been investigated.

Hard to know

E-consultation should be used for non-urgent issues, and normally GPs should respond within five days. 37 percent of the users who participated in the study had done a text-based e-consultation with their GP. Nearly three out of four patients thought that e-consultation led to better follow-up, and 58 per cent thought that the quality of treatment improved with the possibility of e-consultation.

"Better quality" is a self-reported experience, and does not say anything about the treatment or the underlying condition. These are numbers that are difficult to find. We are not entirely sure what people understand by quality - it can be the way they are met," says Asbjørn Fagerlund.

Not so unexpectedly, eight out of ten patients thought that it was easier and more efficient to book an appointment electronically than over the phone, and more than nine out of ten thought it was easier to renew the prescription digitally. Almost half of those who had renewed the prescription electronically thought it contributed to greater adherence to the medication.

Ask for response

Fagerlund, who is a trained psychologist, has personally performed the text analyzes in the study.

"In the free text section, we see that many patients request a form of receipt that the inquiry has been received, and what happens to it. People do not like when sensitive request "disappears" in a black hole, and you are left waiting."

"What can doctors do to better accommodate patients?"

"In practical terms, give the patient a confirmation that the inquiry has been received, that it has been opened by the GPs and when the patient can expect to receive an answer. These are simple service functions that it should be possible to achieve."

Saving time is not necessarily the only thing that makes patients happy, the researcher believes.

"Digital services are often about time use where the discussions are partly motivated by a desire for efficiency. Another way of looking at this is what patients actually save in time from the time they send their questions until they get answers. It may take several days for the doctor to respond, and in the meantime the patient may think that he should do something. People like to get things done. Many might have chosen to have the problem solved the same day by a regular consultation, even if they had spent an hour each way traveling and had to sit and wait at the doctor's office."

Secondary gain

65 per cent of those who answered the questionnaires were women. Nearly six out of ten participants had at least three years of university education. About 25 per cent had a health background, and the majority of those who used digital services thought that their computer skills were well above average. More than half of all respondents were employed. Elderly people over the age of 65 accounted for 15 per cent of the answers.

Electronic appointment booking was the most used service, followed by prescription renewal. The patients stated that while they previously spent an average of 13.5 minutes to make an appointment over the phone, it took on average only 4.4 minutes via helsenorge.no. Renewal of prescriptions meant a time saving of almost 10 minutes.

"The answers were as expected. It was interesting to see who uses the services; those who use the services the most also seem to be the most competent users. A secondary benefit of this is that more time is freed up for, for example, the elderly, who use digital services to a very small extent - and may not need to use it either," Fagerlund comments.

Unknown response rate

The participants were recruited from people who had used at least one of the services via the national health portal helsenorge.no. The survey was conducted over two weeks in November 2017. A total of 2,043 users chose to respond to the survey that appeared on the health portal.

The researchers do not have figures on how large a share these 2,043 made up of all users - something the authors also point out as one of the weaknesses of the study.

"We believe the results are representative of those who use the services, although there will always be a risk that it is the most or least satisfied who take the time to respond."

"What do you know about those who do not use digital services?"

"It is this group that is most interesting," Fagerlund states. "Most people have not been on helsenorge.no. Non-use is a topic that always hangs over such research. What characterizes these, therefore, becomes only speculation. We can assume that it is a lack of digital competence or that they are satisfied with the availability of their GP, are close to help and have a pattern of use that they think works."

GP study

In May 2019, Asbjørn Fagerlund, Inger Marie Holm and Paolo Zanaboni published in the BMJ Open the results of a qualitative study among nine GPs.

Most GPs experienced that digital services free up time for both patients, office staff and doctors. One doctor had calculated that telephone inquiries were reduced by about 25 percent. GPs also pointed to better accessibility through e-consultation and especially a better opportunity to follow up the chronically ill.

"The doctors said that some patients are more open and express themselves more easily in writing in e-consultation than face to face, and one doctor had a patient who had written things he had not told anyone."

Few issues ended up on the downside. The doctors pointed out that digital appointment booking gives doctors less information about the reason why the patient wants an appointment. Several doctors also called for more defined and standardized routines for the use of digital services.

The doctors agreed that children, the elderly and patients with little computer skills need alternatives to digital contact with the GP.

"Several GPs believed that digital services are not suitable for the mentally ill. At the same time, some doctors said that they had received a number of inquiries from the mentally ill - inquiries that otherwise might not have come if the patients had to call the GP or during a physical consultation."

Different routines

The routines for e-health communication varied both between the doctors' offices and among doctors at the same doctor's office.

"The GP offices are well established and well run. My personal opinion is that the GP's ability to adapt operations to local variations is a strength, and could stand in contrast to standardized routines. What GPs demand in our study is another form of "starter pack" with recommendations for proposed routines about what to do, when and how. When we conducted the study, the number of e-consultations was so low that these consultations did not conflict with the usual routines. As the use increases, the need for structure increases," says Fagerlund and adds:

"The GPs in the study were early-users who wanted to try out the services, and some of them have also had input into the development of the services. When there is a mass rollout, there will be greater variation in enthusiasm. And if they and the patients are happy, it could be a disruptive element for doctors to be forced to do something new when the current system works well."

Over- and underestimates

Figures from the Norwegian Directorate of Health show that e-consultations (video consultation or digital communication via text) accounted for 2.4 per cent of all consultations in the period January to November last year. Preliminary figures from the Norwegian Directorate of Health show that e-consultations in June and July this year accounted for 21-22 per cent of all consultations. The pandemic contributed to the share in March and April being up to 35-41 percent.

According to the authors of the article, it is estimated that approximately 30 per cent of all GP consultations in the future will be e-consultations - and up to 40 per cent with the use of m-health. By m-health is meant the use of mobile devices that make it possible to self-measure / register personal health data.

"When are we at 40 percent share of e-consultations?"

"We tend to overestimate the short-term effects of innovation, while we underestimate the long-term effects. Maybe these are generational issues. Once digital services have been established and incorporated, physicians have a system that can be activated in situations where it is desirable to limit physical accumulations of patients in the waiting room, for example in a pandemic situation. Going forward, it is a lot about using the digital services that are available, also among GPs," says Asbjørn Fagerlund.

Text: Lisbeth Nilsen