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eVisits in the digital era of Swedish primary care

Entezarjou, Artin LU orcid (2022) In Lund University, Faculty of Medicine Doctoral Dissertation Series
Abstract
Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,
and subsequent care utilization in the digital era of primary care in Sweden.

Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studies
evaluating the eVisit platform Flow in various clinical contexts.
- Paper I was a comparative study of digital triage decisions when presented with automated patient
history reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in a
panel of five physicians was compared to triage decisions by a machine learning model trained using
data labelled by an... (More)
Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,
and subsequent care utilization in the digital era of primary care in Sweden.

Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studies
evaluating the eVisit platform Flow in various clinical contexts.
- Paper I was a comparative study of digital triage decisions when presented with automated patient
history reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in a
panel of five physicians was compared to triage decisions by a machine learning model trained using
data labelled by an expert primary care physician.
- Paper II was a qualitative focus group study of nurse and physician experiences of digital
communication at three primary health care centers using the platform. Themes were generated using
qualitative content analysis as described by Graneheim and Lundman.
- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,
a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adult
patients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.
eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit control
group was recruited retrospectively using letters. Paper III primarily compared antibiotic prescription
rates per sore throat visit, while paper IV primarily compared subsequent physical health care
utilization within two weeks for patients in the Skåne Region.

Results: Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learning
model. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium of
communication highlighting challenges in interpreting symptoms through text as well as alterations in practice
workflow using asynchronous communication. Antibiotics prescription rate within three days was not higher after
eVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P<.001). No
significant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”
care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).

Conclusions: eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization of
physical health care when assessing common infectious symptoms. Given staff experiencing uncertainties in
interpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of many
modalities to access primary care, with focus placed on facilitating patient-centered professional judgement by
staff, rather than automation of complex decisions. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Ronny Gunnarsson, University of Gothenburg, Institute of Medicine
organization
publishing date
type
Thesis
publication status
published
subject
keywords
Telemedicine, Telehealth, Primary care, Antibiotic prescribing, Health care utilization, eHealth, eVisits, Family medicine, Machine learning, Artificial intelligence, Qualitative approaches, Implementation science, Change management, Staff attitudes, Triage, Digital health, Digital visits, Automation systems, Decision support in healthcare, Health care systems, Digi-physical care, Team work
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
issue
2022:43
pages
126 pages
publisher
Lund University, Faculty of Medicine
defense location
Agardh föreläsningssal, CRC, Jan Waldenströms gata 35, Skånes Universitetssjukhus i Malmö. Join by Zoom: https://lu-se.zoom.us/u/cekYwb0s
defense date
2022-04-08 09:00:00
ISSN
1652-8220
ISBN
978-91-8021-204-5
project
Thesis on digital primary care
language
English
LU publication?
yes
id
0e3b4571-f9c7-4943-8bb3-3caf86346713
date added to LUP
2022-03-16 17:22:29
date last changed
2022-03-22 11:45:06
@phdthesis{0e3b4571-f9c7-4943-8bb3-3caf86346713,
  abstract     = {{<b>Objective: </b>To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,<br/>and subsequent care utilization in the digital era of primary care in Sweden.<br/><br/><b>Methods: </b>A mixed-methods approach was adopted across the various papers in the thesis, with all studies<br/>evaluating the eVisit platform Flow in various clinical contexts.<br/>- Paper I was a comparative study of digital triage decisions when presented with automated patient<br/>history reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in a<br/>panel of five physicians was compared to triage decisions by a machine learning model trained using<br/>data labelled by an expert primary care physician.<br/>- Paper II was a qualitative focus group study of nurse and physician experiences of digital<br/>communication at three primary health care centers using the platform. Themes were generated using<br/>qualitative content analysis as described by Graneheim and Lundman.<br/>- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,<br/>a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adult<br/>patients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.<br/>eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit control<br/>group was recruited retrospectively using letters. Paper III primarily compared antibiotic prescription<br/>rates per sore throat visit, while paper IV primarily compared subsequent physical health care<br/>utilization within two weeks for patients in the Skåne Region.<br/><br/><b>Results:</b> Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learning<br/>model. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium of<br/>communication highlighting challenges in interpreting symptoms through text as well as alterations in practice<br/>workflow using asynchronous communication. Antibiotics prescription rate within three days was not higher after<br/>eVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P&lt;.001). No<br/>significant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”<br/>care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).<br/><br/><b>Conclusions: </b>eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization of<br/>physical health care when assessing common infectious symptoms. Given staff experiencing uncertainties in<br/>interpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of many<br/>modalities to access primary care, with focus placed on facilitating patient-centered professional judgement by<br/>staff, rather than automation of complex decisions.}},
  author       = {{Entezarjou, Artin}},
  isbn         = {{978-91-8021-204-5}},
  issn         = {{1652-8220}},
  keywords     = {{Telemedicine; Telehealth; Primary care; Antibiotic prescribing; Health care utilization; eHealth; eVisits; Family medicine; Machine learning; Artificial intelligence; Qualitative approaches; Implementation science; Change management; Staff attitudes; Triage; Digital health; Digital visits; Automation systems; Decision support in healthcare; Health care systems; Digi-physical care; Team work}},
  language     = {{eng}},
  number       = {{2022:43}},
  publisher    = {{Lund University, Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{eVisits in the digital era of Swedish primary care}},
  url          = {{https://lup.lub.lu.se/search/files/115373187/Avh_Artin_Entezarjou_HELA.pdf}},
  year         = {{2022}},
}