Difficulties to predict events like the SARS-CoV-2 (Covid-19) pandemic call for a rapid emergency response to reduce infection and mitigate the risk for overload of the health care system [1, 2]. Countries have used different antiviral strategies and non-pharmaceutical interventions to deal with the crisis [3, 4, 5]. Internationally, a common strategy has been to make more use of digital technologies for caring for patients [6, 7, 8]. Health care organisations report that a fast and dramatic take up of digital care occurred in the early months of the Covid-19 pandemic.
This rapid adoption of digital technology is reported to have helped reduce the spread of infection, and at the same time made health care more accessible for many [4, 9, 10]. It also enabled remote patient consultations and care to be provided in new ways that had not been usual, pre-pandemic [11]. For many people, health care was made safer and more accessible during a contagious situation with social distancing restrictions, and also reduced delay to gaining health care. Overall, the experience showed that digital visits could usefully enable contact between patients and health care providers, and substitute for physical visits in some situations [10]. Many of the digital solutions had been in use a long time before the pandemic, but with an unsatisfactory slow adoption [11, 12, 13].
Previous research
There are empirical studies into primary care video consultations before and during the early part the pandemic. These include studies of patient experiences in Sweden [14, 15, 16] and studies of physician’s experiences (Sweden [17, 18]; New Zealand: [19]), and a study of patient’s and physician’s experiences in Scotland before the pandemic [20], and in England in the early part of the pandemic [21]. One relevant review, one year before the pandemic, found limited evidence of healthcare professionals’ satisfaction when using video consultations, and that the evidence base was “equivocal” [22]. One Swedish interview study (n = 29) in Swedish primary health care, using the Job Demand-Control-Support model, found that physicians perceived working with digital consultation as flexible with high autonomy and reasonably low demands. However, most thought that if medical skills and abilities are to be maintained, full time work with digital care would not be possible [17].
Overall, our search for previous research found few peer-reviewed empirical studies only about video consultation in primary healthcare, and about generic patient-provider digital connection systems, apart from patient portals [23]. There is more research that considers on-line care services for people experiencing mental health challenges, and for other specific patient groups such as those diagnosed with cancer, diabetes, and heart disease, but most before 2020 [24]. We could not find any that report evidence of the experience of personnel in primary and community healthcare during the pandemic who used digital technologies for more than 12 months and covering different later phases of the pandemic such as those associated with the delta and omicron variants of the virus.
As regards digital connection systems (DCS) or “platforms” enabling provider and patients to make secure connections, there are a number of commentaries and blog publications. Our search and the two most recent reviews in 2021 did not find any empirical studies of provider’s experiences with DCS or patient portals in Sweden [25, 26]. There are some commentaries about ordinary telephone consultations during the pandemic which appear to have been the preferred method by many practitioners, especially for talking to vulnerable user/patients [27, 28].
Studies about the use of digital technology in response to the pandemic have mainly reported on the specific types of technology, patient needs, or the health care system targets addressed. The scientific contribution of the research is limited regarding implementation strategies. In a recent review by James et al [26], findings from 13 papers were synthesised. They concluded that there is an urgent need for more evidence to “support global efforts and match enthusiasm for extending use.” In their review Golinelli et al [10] concluded that national health systems, “have been proved to be particularly resistant to the digital transition in recent years” and proposed the need to keep track of models driven by the pandemic so as to better understand the implementation of digital solutions.
Overall, the search found a predominance of research into patient and provider experience which depended, in part, on the particular technology or DCS used to connect them. There was limited evidence about these subjects later in the pandemic when people had more experience and had returned to more face-to-face physical visits. In addition, there is little evidence of implementation strategies for rapidly scaling-up digital services such as video consultations in a large public primary and community service delivery organisation.
Stockholm healthcare background
Stockholm County Health Care Services (Swedish abbreviation, “SLSO”) is a tax-financed public health care delivery organisation that provides community-based health care services, such as primary care centers, psychiatric care, geriatric care, and habilitation for approximately 2.4 million inhabitants [29]. Private providers are also contracted by the Region Stockholm Government for publicly tax-funded primary and community health care in this mixed public and private service delivery healthcare system [30].
Clinical managers, also called service delivery unit-managers, in SLSO have a large degree of delegated managerial authority that matches their accountability for budgets, for managing employee performance and satisfaction, and for actions taken by the unit. Otherwise, the organisation is a typical line-management public bureaucracy structure with value- and trust-based governance [2, 31, 32].
Digital access and services had been introduced two years prior to the onset of the pandemic, but not taken up by many patients or providers. Over the study period, a smart phone application “Always Open” (abbreviated app) gave access to online services, including video consultations, for the public and for primary healthcare physicians and other public services in Region Stockholm, Sweden. This application gives the user/patient access to a digital operating system platform which connects to a booking function and other services, as well as to service delivery units, and connects personnel working for them to the user/patient [33, 34].
At an aggregate level, data about total weekly video visits to primary care in in Stockholm show that, at the peak of the first wave of Covid-19, video visits increased 16-fold compared to the same period one year before but did so from a low number of 2,000 for a population of 2.4 million. These observations are in line with reports about rapid scale-up and a substantial shift to digital health in several health care systems [35, 36, 37, 38]. In Stockholm, there was no systematic implementation, and the rapid take up of video and telephone visits during the pandemic was carried by local units independently exploring how the technology could be used for their different patients and uses. A central support function was available to these units to help with questions and issued they raised.
Region Stockholm has strategies to develop digital health, but no significant implementation strategies in the primary and community healthcare units [39]. With the rapid onset of the Covid-19 pandemic in Stockholm, the scale-up of digital care occurred by patients and providers using the “Always Open” mobile application, but without a management directive or a structured or planned implementation process. There were differences in the amount of use of video consultations between primary health care units, and also between other community health care units.
Study objectives
To address the knowledge gaps, the objectives were to, 1) describe and understand how a generic digital application for remote health care was taken up by providers in primary and community healthcare during the first 18 months of the Covid-19 pandemic, without an explicit and supported implementation strategy, 2) inform health care systems that are considering implementing or sustaining the use of similar digital health care technologies, and 3) assess for these purposes the usefulness of a generic framework that is increasingly used for research into the implementation of digital technological innovations in complex health care systems, the NASSS framework [40].
Theoretical framework
We chose the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework to analyse the data from the 12 focus group interviews performed in the study. The NASSS framework was developed to “help predict and evaluate the success of a technology-supported health or social care program” [40].
The framework consists of seven domains that are proposed to influence the degree of success or failure of technological innovations in health care: 1. The Condition: the nature of condition or illness, as well as comorbidities and socio-cultural influences; 2. The Technology: the material features, type of data generated, knowledge needed to use the technology, and the technology supply model; 3. The Value Proposition: the supply-side value to the developer and the demand-side value to the users; 4. The Adopters: the role and identity of personnel, the level of input from patients, and the availability and input from carers; 5. The Organisation: the organisation’s capacity to innovate, its readiness for this technology/change, the nature of adoption/funding decision, the extent of change needed to routines, and the work needed to implement change; 6. The Wider System: influence from political or policy pressure, regulatory or legal pressure, professional pressure, and socio-cultural pressure; and 7. Embedding and Adaptation over Time: the scope of adaptation over time and organisational resilience.
This framework has been used to inform the design of new technology, and to identify and help to address challenges in implementation [40]. Two studies applied the NASSS to assess digital technologies similar to the technology considered in our study. The first study applied the NASSS in a review of video consulting in healthcare [26]. The second study used the NASSS to develop a caregiver portal [41]. We used these as examples to check our interpretation of the seven domains against how these studies had classified their data in different domains. We aimed to produce a theory-informed analysis of our findings, and consider all seven domains of the NASSS framework, in order better to understand the constraints and facilitators affecting implementation described by the focus group participants.
Ethical considerations
The study was performed as a part of a larger project on “Implementation of management and organisation response to the Covid-19 outbreak: a study of the crisis organisation in Stockholm County’s healthcare area”, the research plan of which has been evaluated and approved by the Swedish Ethical Review Authority on 8 April 2020 (Dnr 2020–01521). We confirm that all methods were performed in accordance with relevant guidelines and regulations including the informed consent to participate in the study.