General Practitioners' Experiences With Potentials and Pitfalls of Video Consultations in Norway During the COVID-19 Lockdown: Qualitative Analysis of Free-Text Survey Answers

Experiences of patients with complex needs at municipal emergency outpost satellites

BACKGROUND

In 2015, Norway introduced stricter requirements for organizing primary emergency care. These changes led to new solutions such as municipal emergency outpost satellites, providing inhabitants shorter access to care in resource-limited areas. This study explores patient experiences at emergency outpost satellites staffed by a nurse on site with a general practitioner (GP) available via video consultation.

METHODS

A qualitative study was conducted with seven patients, aged 62-82, with complex needs, from four small and medium-sized municipalities in Vestland County, Norway. Data were collected through individual semi-structured interviews, which took place within 6 months of an acute consultation at an emergency outpost satellite. The data were analysed using systematic text condensation (STC).

RESULTS

Patients had both positive and negative experiences with video consultations. They valued short travel distances and quick GP access via video link. Video consultations often replicated several aspects of in-person visits, with nurses playing a crucial role in organizing and ensuring that care was provided effectively. Nurses were key mediators, supporting patients before, during, and after the consultation. However, some patients were dissatisfied with the lack of a physical GP presence, technical issues, and communication challenges.

CONCLUSIONS

The participants' experience of communication with the GP and nurse was crucial for the video consultation to be perceived as satisfactory. Participants felt that video consultations reduced travel burdens and provided quick clarification. Nurses played an important mediating role, but poor communication and technical issues made some participants feel unsafe using the emergency outpost satellites.

The Impact and Wider Implications of Remote Consultations for General Practice in Norway: Qualitative Study Among Norwegian Contract General Practitioners

BACKGROUND

The digital shift toward remote consultations in general practice needs ongoing monitoring to understand its impact on general practice organizations and the wider health care system.

OBJECTIVE

This study aimed to explore how remote consultations impact on contracted general practitioner (GP) practices and how GPs perceive the implications of this uptake for the overall health care system.

METHODS

In total, 5 focus groups were conducted with a total of 18 GPs from all 4 health regions of Norway in 2022. The material was subjected to Braun and Clarke's thematic analysis.

RESULTS

The analysis yielded six themes: (1) the design of novel effective clinical pathways: remote consultations empower GPs to tailor new effective clinical trajectories, blending modalities to address diverse needs across clinical episodes-from initial triage, through investigations to case closure; (2) increased workday flexibility: remote consultations introduce variability into daily work, allowing GPs to adjust patient contact intensity, and leading to a less stressful work-home balance; (3) erosion of organizational boundaries: easy remote access to GPs appears to reduce patients' tolerance for minor illness and self-care, hindering effective gatekeeping and shifting GPs' focus from proactive to more reactive work, increasing work-related stress; (4) degradation of clinical shrewdness: confronted with an increasing amount of unsorted and trivial remote inquiries, GPs observe challenges in detecting and prioritizing serious cases; (5) dilemmas related to responsibility, ethics, and legislation: remote consultations highlight a tension for contract GPs between legal responsibilities and ethical obligations, with implications for patients with limited health literacy; this may entail suboptimal evaluation or delayed treatment-potentially contributing to increased health care inequity; and (6) retaining clinical core values in a changing world. Overall, GPs affirm that remote consultations have come to stay and describe efforts to effectively manage the advantages and disadvantages inherent in such interactions to safeguard clinical effectiveness and organizational sustainability of primary health care.

CONCLUSIONS

The widespread adoption of remote consultations in the Norwegian contract GP scheme fundamentally reshapes the dynamics of GP work and the overall health care system. Awareness and proactive management of these changes are essential for maintaining sustainable, high-quality primary health care.

Hammering nails with a screwdriver: how GPs perceive video consultations

BACKGROUND

Early in the COVID-19 pandemic, the use of video consultation (VC) expanded considerably, with GPs indicating high satisfaction with it. However, use of VC declined as lockdown measures were eased.

AIM

To explore reasons why VC use has declined in Norwegian general practice since the start of the pandemic by investigating GPs' experiences with VC and their attitudes towards it in a post-pandemic setting.

DESIGN & SETTING

Qualitative study using semi-structured interviews with 13 GPs in southern Norway between May 2022 and March 2023.

METHOD

Data analysis was conducted by applying the six steps of Braun and Clarke's reflexive thematic analysis.

RESULTS

Although the implementation of VCs was unplanned, most participants were able to use this modality without much problem. Several GPs initially envisioned long-term VC use. However, despite certain positives, VCs were largely sidelined in favour of face-to-face and telephone consultations, owing to their practicality and VC's limited usefulness when considering the extra effort required. Nonetheless, GPs recognised ways of using VC that might exploit its strengths, but they highlighted how its sustained use would require them to replace other consultation modalities. They also identified extrinsic factors that might lead to the increased use of VC, including improved VC technology and patient demand.

CONCLUSION

Although VC is now part of many GPs' consultation toolboxes, its perceived relative lack of usefulness and extra effort compared with other remote consultation modalities mean that most GPs have chosen to abandon it as a routine consultation modality.

Effects of COVID-19 on Irish general practice activity from 2019 to 2021: a retrospective analysis of 500,000 consultations using electronic medical record data

BACKGROUND

General practice (GP) is crucial to primary care delivery in the Republic of Ireland and is almost fully computerised. General practice teams were the first point of contact for much COVID-19-related care and there were concerns routine healthcare activities could be disrupted due to COVID-19 and related restrictions.

AIMS

The study aimed to assess effects of the pandemic on GP activity through analysis of electronic medical record data from general practice clinics in the Irish Midwest.

METHODS

A retrospective, descriptive study of electronic medical record data relating to patient record updates, appointments and medications prescribed across 10 GP clinics over the period 2019-2021 inclusive.

RESULTS

Data relating to 1.18 million record transactions for 32 k patients were analysed. Over 500 k appointments were examined, and demographic trends presented. Overall appointment and prescribing activity increased over the study period, while a dip was observed immediately after the pandemic's arrival in March 2020. Delivery of non-childhood immunisations increased sixfold as a result of COVID-19, childhood immunisation activity was maintained, while cervical smears decreased in 2020 as the screening programme was halted. A quarter of consultations in 2020 and 2021 were teleconsultations, and these were more commonplace for younger patients.

CONCLUSIONS

General practice responded robustly to the pandemic by taking on additional activities while maintaining routine services where possible. The shift to teleconsulting was a significant change in workflow. Analysing routinely collected electronic medical record data can provide valuable insights for service planning, and access to these insights would be beneficial for future pandemic responses.

The Added Value of Using Video in Out-of-Hours Primary Care Telephone Triage Among General Practitioners: Cross-Sectional Survey Study

Background

Many countries have introduced video consultations in primary care both inside and outside of office hours. Despite some relational and technical limitations, general practitioners (GPs) have reported the benefits of video use in the daytime as it provides faster and more flexible access to health care. Studies have indicated that video may be specifically valuable in out-of-hours primary care (OOH-PC), but additional information on the added value of video use is needed.

Objective

This study aimed to investigate triage GPs' perspectives on video use in GP-led telephone triage in OOH-PC by exploring their reasons for choosing video use and its effect on triage outcome, the decision-making process, communication, and invested time.

Methods

We conducted a cross-sectional questionnaire study among GPs performing telephone triage in the OOH-PC service in the Central Denmark Region from September 5, 2022, until December 21, 2022. The questionnaire was integrated into the electronic patient registration system as a pop-up window appearing after every third video contact. This setup automatically linked background data on the contact, patient, and GP to the questionnaire data. We used descriptive analyses to describe reasons for and effects of video use and GP evaluation, stratified by patient age.

Results

A total of 2456 questionnaires were completed. The most frequent reasons for video use were to assess the severity (n=1951, 79.4%), to increase the probability of self-care (n=1279, 52.1%), and to achieve greater certainty in decision-making (n=810, 33%) (multiple answers were possible for reasons of video use). In 61.9% (n=1516) of contacts, the triage GPs anticipated that the contact would have resulted in a different triage outcome if video had not been used. Use of video resulted in a downgrading of severity level in 88.3% (n=1338) of cases. Triage GPs evaluated the use of video as positive in terms of their decision-making process (n=2358, 96%), communication (n=2214, 90.1%), and invested time (n=2391, 97.3%).

Conclusions

Triage GPs assessed that the use of video in telephone triage did affect their triage outcome, mostly by downgrading the level of care needed. The participating triage GPs found video in OOH-PC to be of added value, particularly in communication and the decision-making process.

Behavioural intentions towards use of digital video consultations in primary care: a survey study on physicians', nurses' and psychologists' perceptions in Swedish primary care

OBJECTIVES

The study aimed to describe the experiences of physicians, nurses and psychologists employed in primary care in using digital video consultations. The second objective was to study the association between the predictors of behaviour and behavioural intentions to use digital consultations and to relate underlying behavioural beliefs to experiences of digital consultations in primary care. Overall, the research questions focused on the association between previous training, profession or theory-based behavioural predictors and behavioural intentions to use digital video consultations.

DESIGN

A web survey based on the theory of planned behaviour was sent to primary care professionals in western Sweden who had implemented digital video consultations. The questionnaire contained both closed and open-ended questions focusing on theory-based predictors of behavioural intentions, such as as attitudes, subjective norms and perceived behavioural control. Data were analysed with a mixed-methods approach using quantitative and qualitative analyses.

PARTICIPANTS

The questionnaire was distributed between June and October 2022 to 140 primary healthcare centres in western Sweden, of which 47 agreed to participate. Overall, the questionnaire was sent out to 969 clinicians, representing physicians, nurses and psychologists.

RESULTS

Physicians and nurses had lower experience and less positive attitudes towards digital video consultations compared with psychologists. No statistically significant differences were seen among the groups in behavioural intentions to use digital video consultations. The regression analysis showed that attitude was the strongest predictor of behavioural intentions among primary care physicians, while attitude and perceived behavioural control were associated with behavioural intentions among nurses. No associations between predictors and intentions were found among psychologists.

CONCLUSIONS

The medical professionals reported high behavioural intentions to use digital video consultation despite different levels of experience. Attitude and perceived behavioural control were predictors of behavioural intentions among physicians and nurses, indicating that future implementation should consider the professions' participation in the process.

How do parents experience video triage when seeking care for their acute ill children? A qualitative study in a Danish out-of-hours primary care setting

OBJECTIVE

The objective is to explore parents' experiences with telephone contacts to out-of-hours primary care (OOH-PC) that include use of one-way video (video triage).

DESIGN

A qualitative interview study using Braun and Clarke's thematic analysis approach.

SETTING

OOH-PC in the Central Denmark Region.

PARTICIPANTS

A convenience sampling strategy was used to include parents of young children (aged 1-5 years), who received video triage in OOH-PC: nine women and one man aged 31-42 years. Data were collected from 26 April to 23 May 2023.

RESULTS

Three main themes were developed, each containing two subthemes: Theme 1. Video triage accelerates diagnostic clarity and prompt action, enhancing feeling of safety: Parents experienced that video triage provided faster diagnostic clarification than telephone triage. The visual assessment in video triage reduced uncertainties of describing symptoms and increased the parents' feeling of safety. Theme 2. Video triage changed the communicative and relational behaviour: Parents found video triage impersonal as it focused on the physical examination. The conversation before activation of video was found important, as it established a feeling of trust and reassurance. Theme 3. Experiences of presence and involvement in video triage: Parents found their active involvement in video triage challenging, as it required divided attention and shared responsibility.

CONCLUSIONS

Our study indicates the importance of paying attention to the changes in communication and consultation processes afforded by the implementation of one-way video triage. One-way video triage is experienced as a valuable tool for examination, yet it is also perceived to impair the building of trust in the patient-physician relationship.

Reasons for encounter in video contacts at a Danish out-of-hours primary care service: a questionnaire study

OBJECTIVE

To investigate reasons for encounter in telephone triage contacts to an out-of-hours primary care service for which general practitioners (GPs) use video consultations (video contact), overall and stratified for patient age and time of day.

DESIGN

A cross-sectional questionnaire study among GPs doing telephone triage in an out-of-hours primary care service. The questionnaire was integrated into the electronic patient registration system, popping up after every third video contact. This setup automatically linked patient register data, including age and sex, with the questionnaire data.

SETTING

The study was conducted from 5 September 2022 to 21 December 2022 at the out-of-hours primary care service in the Central Denmark Region.

PARTICIPANTS

649 volunteer GPs who answered 2452 questionnaires.

MAIN OUTCOME MEASURES

Reasons for encounter in video contacts registered with codes from International Classification of Primary Care (ICPC) coding system, V.2 (ICPC-2).

RESULTS

GPs doing telephone triage in out-of-hours primary care used video contacts for a broad range of ICPC-2 codes within few ICPC-2 chapters. 83% of all reasons for encounter were due to symptoms in chapters S 'Skin' (34.5%), R 'Respiratory' (21.8%), A 'General and unspecified' (14.7%) and L 'Musculoskeletal' (12.0%) in the ICPC-2 classification system. Video contacts concerning skin and musculoskeletal symptoms were more frequent among older children and adults compared with young children. Respiratory symptoms and general and unspecified symptoms dominated by fever were more frequent among video contacts for young children compared with older children and adults.

CONCLUSION

Our study suggests a focused use of video contacts in an out-of-hours primary care setting; the majority of registered ICPC-2 codes were within few ICPC-2 chapters.

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs

BACKGROUND

In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs.

AIM

To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway.

DESIGN & SETTING

A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020.

METHOD

Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities.

RESULTS

A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations.

CONCLUSION

During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.

Suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. A mixed method study of GPs' experiences

OBJECTIVE

To explore Norwegian GPs' experiences with and perceived suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic.

DESIGN

We used a mixed methods research design. An online survey with 301 respondents was combined with qualitative interviews with ten GPs.

SETTING

Norwegian general practice.

RESULTS

Most GPs agreed it was difficult to assess a patient's ability to work without physical attendance for a first-time certification in remote consultations. However, extending a certification was considered less problematic. If physical examinations were required, the GPs would ask the patient to come to the office. The most suitable diagnoses for remote certification were respiratory infections and COVID-19-related diagnoses, as well as known chronic and long-term diseases. The GPs emphasized the importance of knowing both the patient and the medical problem. The GP-patient relationship could be affected by remote consultations, and there were mixed views on the impact. Many GPs found it easier to deny a request for a sickness certification in remote consultations. The GPs expressed concern about the societal costs and an increased number of certifications if remote consultations were too easily accessible. The study was conducted during the COVID-19 pandemic, and the findings should be interpreted in that context.

CONCLUSIONS

Our study shows that issuing sickness certifications in remote consultations were viewed to be suitable for COVID-19 related problems, for patients the GP has met before, for the follow-up of known medical problems, and the extension of sickness certifications. Not meeting the patient face-to-face may affect the GP-patient relationship as well as make the GPs' dual role more challenging.

Patients' experiences with receiving sick leave certificates via remote consultations in Norway during the COVID-19 pandemic: a nationwide online survey

OBJECTIVES

To explore patients' experiences with receiving sick leave certificates via remote consultations during the COVID-19 pandemic and investigate whether there were differences among the types of remote consultation (telephone, video or text).

DESIGN

A nationwide online patient survey consisting of quantitative data supplemented by qualitative opinions conducted in Norway.

SETTING

Primary care.

PARTICIPANTS

Patients who received a sick leave certificate via remote consultation in the period from 16 November to 15 December 2020.

RESULTS

Of the 5429 respondents, 3233 (59.6%) received a sick leave certificate via telephone consultation, 657 (12.1%) via video consultation and 1539 (28.3%) via text-based e-consultation. Most respondents (76.8%) were satisfied. Only 10% of the respondents thought that the doctor would have obtained more information through an office appointment. The majority of the respondents (59.6%) found that they had as much time to explain the problem as at an office appointment. Some patients also thought that it was easier to formulate the problem via a remote consultation (18.2%) and agree with the doctor on the sick leave (10.3%).The users of text-based e-consultations were the most satisfied (79.3%, p<0.001) compared with those using telephone or video consultations. Among users of text-based e-consultations, there was a higher proportion of patients who thought that they had more time to explain the problem compared with an office appointment (p<0.001), it was easier to explain the problem (p<0.001) and agree with the doctor (p<0.001). Most respondents would use the same type of remote consultation if they were to contact the general practitioner (GP) for the same problem, with the highest proportion among the users of video consultations (62.1%, p<0.001).

CONCLUSIONS

Patients were satisfied with communicating and receiving sick leave certificates via remote consultations. Future studies should investigate patients' and GPs' use and experiences in a postpandemic setting.