The large-scale implementation of e-consultations with the GP: a mixed-methods evaluation of the impact on health system, GPs and patients

AIM The aim of this project is to study the impact of e-consultations with the GP on the health system, General Practitioners (GPs) and patients. METHODS The project uses quantitative and qualitative methods to evaluate the large-scale implementation of e-consultations in Norway. Research is structured around three main activities. 1. Retrospective cohort study. Data from national health registries (Kommunalt pasient- og brukerregister KPR) will be collected and analyzed to study the use of e-consultations with the GP in Norway, and especially explore how heavy users of GP services use or do not use e-consultations. 2. Prospective cross-sectional study. Focus group interviews will explore how GPs experience clinical appropriateness, safety, communication, doctor-patient relationship in e-consultations. A prospective cross-sectional study will be conducted to investigate the perspectives of GPs and patients towards e-consultations. At least 100 GPs and their patients will be asked to evaluate the perceived quality of 1,500 conducted e-consultations. GPs will also evaluate organizational models and workload. 3. Patient interviews and survey. In-depth interviews with elderly patients recruited through the Pensioners Association will be conducted as elderly patients are considered the main group of non-users. A national citizen survey will be conducted on the national health portal helsenorge.no to explore the patients’ knowledge, use and attitudes towards e-consultations. RESULTS 1. Retrospective cohort study. Applications to the regional ethics committee and data protection officer were sent and approved 2022. An application was sent to helsedata at the end of 2022 and approved in May 2023. Data from KPR were delivered by the Norwegian Directorate of Health in spring 2024. The data include all physical consultations and e-consultations with the GP conducted in Norway in the period 2022-2023. The data analysis is ongoing. The results will be published in a scientific article. 2. Prospective cross-sectional study. Five focus group interviews with GPs were conducted. Data were analyzed using thematic analysis. Two scientific articles ("The Dynamics of Doctor-Patient Communication in Remote Consultations. A qualitative Study among Norwegian Contract GPs" and "The Impact and Wider Implications of Remote Consultations for General Practice in Norway: A Qualitative Study Among Norwegian Contract GPs") were submitted to the Journal of Medical Internet Research. Both articles have already been through a review round. A course for GPs named "Better quality in e-consultations" was developed by the project team in collaboration with SKIL in 2022 and 2023. Two surveys were included as part of this course. The first focused on how GPs and patients perceive clinical suitability, safety, communication and doctor-patient relationships in e-consultations. The other focused on organizational models and workload. The course was launched in February 2023 and ended in September 2024. Data analysis for both surveys is ongoing. The results will be included in at least two scientific articles. 3. Patient interviews and survey. Semi-structured interviews were conducted in november-december 2022 with 16 patients over 65 years with experience of using text-based e-consultations. Data were analysed through thematic analysis. A scientific paper has been published in 2023 in the Scandinavian Journal of Primary Health Care. A national citizen survey was conducted to explore: 1) when and for what purposes patients use e-consultations with the GP, 2) whether e-consultations replace a traditional GP appointment or create new demand, 3) which characteristics of the patients and e-consultations are associated with the different use of e-consultations. The survey was developed in collaboration with helsenorge and published in January-February 2023. Data have been analysed and two scientific articles ("Use of e-consultations with the general practitioner in Norway: An online survey of user experience" and "Patients' feedback on improvements two text-based e-consultations. A survey study of users of the official health portal in Norway") have been submitted to the Journal of Medical Internet Research and Frontiers in Digital Health. CONCLUSION All data collection in the project has been completed. Data analysis and publication of some scientific articles as well as completion of two PhD courses remain. This project will provide key stakeholders, policymakers and practitioners with research-generated knowledge on the impact of e-consultations, thus supporting optimal use of the service in routine practice and maximize its benefits.

BACKGROUND In Norway, e-consultations with the GP experienced a tremendous implementation pace following the COVID-19 pandemic. As a complex intervention, it is crucial to study the process of implementation, wider adoption and scale up. It is also important to understand whether the use of e-consultations ensures equity in access to care and assess the impact on the health system, GPs and patients. METHODS The project adopts a mixed-methods approach, combining quantitative and qualitative methods to evaluate the large-scale implementation of e-consultations in Norway. Research is structured around three working packages (WPs). WP1. A retrospective cohort study will be conducted to study changes in adoption and use of e-consultations over time and explore the impact on equitable access to care. Data will be obtained from national health registries. Temporal trends will be examined through time-series analysis. Multilevel regression models will be used to explore relationships between utilization and patient characteristics. WP2. A prospective cross-sectional study will be conducted to study the perspectives of GPs and patients towards the perceived quality of video consultations. Focus groups will explore the topics of clinical appropriateness, safety, communication, doctor-patient relationship, organizational models and workload. 50-100 GPs will be recruited and asked to evaluate 1,500 video consultations through an online survey. Patients will evaluate the same video consultations. Interviews with GPs will be conducted to study how different organizational models affect workload and availability. WP3. The perspectives of digitally active users and non-users will be explored through questions integrated into a national citizen survey conducted to explore citizens’ knowledge, use and attitudes towards digital health solutions. Additional interviews will be conducted on elderly as the main group of non-users who are not digitally active.