In the following, we summarise and contrast the results of the content analyses for both patients and physicians.
Expectations and impressions of patients
Initially, none of the patients had any experience with telemedical consultation and was, thus, informed in advance by the GP about the procedure. The expectations and feelings regarding the upcoming new type of consultation ranged from restlessness, tension, and indifference up to positive expectations of the "video telephony", which was perceived as modern. Overall, the hopes outweighed, for example, by the expected expert opinion regarding the medications taken or regarding suspected epilepsy. The following quotations show that the initial nervousness some patients felt, subsided during the consultation:
„ ... and I was, at that moment [preliminary talk with the GP] really restless, I have to say. Because I was excited about how this will go on. But this unrest has suddenly disappeared [during the consultation].” (35 years old male patient)
„... from the very beginning somehow it was strange, that you are sitting in front of the GP but the specialist was also present. This was really weird, but you were pretty fast used to it. That fitted very fast. […] Well, you didn't really notice that you were practically telephoning over the Internet.” (32 years old male patient)
This familiarisation effect to virtual communication was probably also due to the functioning technology and good sound and image quality. The technical solution seemed to recede into the background. Furthermore, the patients reported that a trustful relationship to the mainly unknown specialist could be set up immediately.
However, one women – the oldest interview participant – would have preferred direct contact.
„... well it is different, isn’t it? Face to face contact is always better, but I found it quite okay. The specialist was very kind and you were able to see him really well. All in all, it was good, it is possible to do it this way.” (64 years old female care giver)
Final evaluation of patients
The patients emphasised the amount of time they would normally have to spend visiting the special outpatient clinic. On the one hand, this included the long journey of up to one and a half hour each way, but also the waiting time on site. One patient told us that he also saved on fuel costs and another one was happy for not being forced to put in a day's leave. The mother of the disabled patient in particular was relieved about the significantly reduced organisational effort. Especially multimorbid patients and their caring relatives benefited from telecommunication, even more so if they lived in rural areas.
“…the driving, then I would have had to accompany him [to the specialist], then I would have had to deregister him from the workshop for the disabled and all that. And then I would have had to wait. So, I found it quite good.” (64 years old female care giver)
The patients were given a lot of space to tell stories based on the neurologist’s inquiries, e.g., about the history of the disease. The experiences with the current medication and possible side effects were perceived as a major topic, with even long-standing therapies were skeptically questioned by the neurologist. This led, for example, to a change in medication. One patient subsequently reported a significantly reduced seizure rate and intensity and therefore an increased quality of life. For some patients, the need for hospitalisation for more in-depth diagnosis which had already been suspected, was confirmed and appointments were made. A patient seemed relieved having found a proper specialist on hand, with the GP also wanting to take over the further coordination of e.g. transport and medication. In addition, a very unsettled patient felt that his concerns were very much taken into account in the consultation and told us in the later interview that the rapid clarification of the suspected diagnosis via video conferencing led to prompt reassurance in the event of further epileptic seizures:
„... the video-conference really helped me. I got calmer, became more balanced. With the next epileptic seizure, I was more relaxed shortly after. (22 years old female patient)
“… it was my first experience with internet telephony. But it is a good thing! It has to be said quite frankly, it is super!“ (32 years old male patient)
Preparations and expectations of physicians
The epileptologist was already experienced in telemedicine and emphasised that the telemedical setting in this pilot study allowed a consultation similar to the epilepsy consultation offered in his clinic.
His main initial concerns referred to the conduct of a proper anamnesis interview as well as to organisational and time efforts. However, especially with reference to the latter, these doubts were removed as he felt the telemedical consultation was well prepared by the GP. In total, he invested on average 15-20 minutes per consultation plus subsequent documentation. He said:
“The colleague [GP] talks to the patients, prepares them for the fact that now someone from another clinic, whom the patients except for one, I think, do not know personally, will ask very specific questions, that he is in the picture, that he already has medical findings.” (epileptologist)
The GP first had to select suitable patients. He identified a need of some of his epilepsy patients to have access to a specialist. It was important to him not to disturb a well-functioning patient-specialist relationship by participating in the teleconsultation with another specialist. However, especially for patients with inadequate medication as well as those with a poor relationship to their neurologist, he saw major advantages of this type of teleconsultation.
In his view, uncertainties in diagnoses and treatment could be clarified rapidly with major advantages for patients. This regarded, for instance, his wish for a second opinion on a patient’s unspecific symptoms that seemed to indicate epilepsy.
As to coordination of appointments, the GP experienced an increase in workload. Clearly, the coordination of three parties involved more effort than the coordination of an appointment only between two parties. In particular, the GP was concerned about the mother of the disabled patient, who he perceived to be dominant in discussions. However, during the teleconsultation these concerns turned out to be unnecessary. She got used to this new form of consultation quickly and seemed to be relieved and reassured afterwards. The GPs’ positive perception coincides with the statements of the patients. In sum, the GP found the pre- and post-processing work manageable, although he copied the preliminary findings and sent them to the neurologist for preparation. It was an advantage for him that he already knew the patients. Also, the follow-up was not different to conventional consultations, and the additional consultation report from the neurologist finally provided more comprehensive documentation on the patient case.
Nevertheless, for the specialist it was problematic that the patient case could not be saved as a case in the hospital information system and thus could not be billed. Future implementations would have to solve this problem. In addition, due to organisational issues, acute cases and very short-term appointments are a major challenge for this type of teleconsultation. The neurologist saw limited use for patients requiring a detailed neurological examination, e.g. those with Parkinson's disease, other movement disorders or multiple sclerosis. These cases would exceed the time frame and the expertise of the GP, and still require personal face-to-face counselling.
Final evaluation of physicians
The neurologist emphasised that telemedicine is very well suited for epilepsy patients, as much can be deduced from the medical history. Also, in this view, teleconsultation would also be suitable for patients with other diseases, e.g. those who have already been presented to his or another specialist department, have an up-to-date examination result or a clear treatment plan; patients, in other words, for whom the focus is more on follow-up care.
"Well, I'm thinking for example of stroke patients, who might at some point have to deal with the question of adjusting blood thinning, adjusting the risk factors, i.e. drugs that influence the risk factors, or patients, who may have been seen by a neurologist with a Parkinson's syndrome and where the point is that if you have an intolerance to the medication, you can perhaps decide to reduce the medication or switch to another one." (epileptologist)
Furthermore, the neurologist described the specialist care in the GP's region as insufficient. It is very difficult for patients to get an appointment at his epilepsy consultation. This is consistent with the experiences of the patients interviewed. The specialist was convinced that the offer of teleconsultation makes it easier to find an appointment quickly with a simple phone call from the GP. In addition, he suspected that some of the study participants would not have visited a specialist outpatient clinic of their own accord. From his point of view, the familiar GP could be a door opener with the offer of teleconsultation and lower the inhibition threshold of hesitant patients.
The GP saw great added value in teleconsultation, especially on a communicative level. In the form carried out here, it would also strengthen the relationship of trust with the patient. Above all, he felt like a partner of the neurologist; in each teleconsultation all three participants had communicated with each other at eye level. He saw himself first and foremost as a moderator who supports patients in describing their complaints and symptoms to the specialist and formulating their concerns. After the consultation, the GP summarised what had been discussed for the patients and discussed how to proceed. In some cases, previously unrecognised problems and gaps in knowledge became apparent. These could be discussed and clarified. In this respect, the teleconsultation offered the possibility to be on the same level of knowledge with the patient and the specialist. This is rarely the case in the German health system, where chronically ill and multimorbid patients consult a multitude of different specialists. The specialist's targeted questions provided the GP with further information about the patients. This was particularly beneficial for the patient-centred treatment of his patients.
GP uncertainties regarding further treatment could also be clarified quickly. Necessary therapy steps or adjustments such as hospital admissions or medication changes could be initiated. According to the neurologist, a brief specialist assessment via the telemedical consultation is a good way of making simple recommendations to the GP and clarifying whether action needs to be taken quickly or not. In case of a larger implementation of teleconsultation - for example, also for other diseases - the GP would like to see a network that takes over the coordination of appointments. In summary, despite the individual challenges both the GP and the neurologist experienced teleconsultation as enriching.
“And I see the added value in the fact that, if you have such a form of access to a specialist, you can choose the time together with the patient and here you can have a much more thorough and more profound form of consultation, if the three of us carry out the whole thing, which is where I see the great benefit and added value in the situation.” (GP)
From the neurologist’s point of view, the future expansion of this cooperative form of consultation is feasible and worthwhile for all sides involved. In addition, adjustments to the current concept of telemedicine should also be considered.
“That’s [teleconsultation] something we'll be able to absolutely master if it continues on this scale. It can also be expanded. It's not the mass of patients you see here now and it's not very frequent, regular appointments. Hm and if not, then you just have to think about other concepts, personnel concepts. But the way it works now, it works very well and the decisive thing is that the patients benefit from it. And the second point is that both sides, the general practitioner and us, profit from it. And I think that's also the way we go about it.” (epileptologist)