Digital primary and community healthcare: practitioner’s experience in Stockholm during the Covid-19 pandemic and future development

DOI: https://doi.org/10.21203/rs.3.rs-1865105/v1

Abstract

Background: Health care organizations report that that the Covid-19 pandemic accelerated their use of digital technologies. We wanted to better understand how rapid and large scale-up took place without any systematic implementation in public primary and community health care in the Stockholm region, Sweden, as well as future development plans.

Methods: Qualitative data from twelve focus group interviews with clinical managers (n=99) were analysed using a directed content analysis. The seven domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework was used to understand the implementation process, as described by the clinical managers in the focus groups.

Results: The participants reported that they made their own local decisions to make more use of the existing technology provided by the health system for appointments, video and telephone calls. Most participants took the view that the technology was ready to use, despite some limitations. Most challenges for making more use of the technology that were reported were individual clinician’s and patient preferences, how ready their unit was for making changes to practice and organisation. Some raised concerns about how standardizing some aspects possibly conflicted with the decentralised management model of the organisation. The overall experience was reported to be positive, with an intention to sustain the achievements.

Conclusions: Focus group interviews found that that unit managers were positive about the digital technology system for remote care. For the future, they wanted changes to be made at different levels of the health system to help them to better combine digital and physical care in their unit. Possibilities to use digital technology to integrate primary and hospital health care were identified.

Background

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.

Methods

Study design and methods

The design is a qualitative study using directed content analysis [42]. To collect the perceptions of providers about digital healthcare and the system that connected them to patients, we chose a focus group interview method as the most appropriate for the research objectives [43]. This method allowed flexibility to explore issues raised in the group as well as minimising the time burdens for the participants. It also contributed to their shared learning from their colleagues’ experiences.

Study participants

To further minimise the burden on personnel at a time of high workload and staff sickness and to get a wide perspective, we chose the clinical managers of the service delivery units. They were invited to the meetings by their divisional managers, with whom we collaborated during the study. They also worked as clinicians in their unit and had a detailed understanding of the issues involved for all clinical and administrative personnel in their unit.

Twelve focus group interviews were performed between September and November 2021. In total, 99 clinical managers (13 men, 86 women, Appendix 1). Each group represented a specific service within the organisation: primary health care, psychiatry, geriatrics, rehabilitation, out-patient somatic specialist health care or advanced care in the home. All the different services of the SLSO organisation were represented. The clinical managers had a background as doctors, nurses, physiotherapists, or psychologists, and various levels of managerial skills and experience.

Data collection and analysis

One researcher (KSC) experienced in qualitative methods without any established relationship with the participants conducted all twelve focused group interviews using a semi-structured interview guide with broad, open-ended questions (Appendix 2). Two to sixteen persons participated in each group. The study took place at different facilities in Stockholm, for eight groups physically, and for four groups digitally, due to a later increase in infection levels. Each focus group lasted one hour. Informed consent was obtained from all clinical managers to participate. The researcher took detailed notes of what was said by the participants, and in some cases, discussions were recorded to review certain details afterwards. The text from the interviews were analysed using directed content analysis following Hsieh and Shannon [42]. The codebook used was based on the NASSS framework (Appendix 3). The researcher (first author, KSC) performed the coding. To establish trustworthiness co-authors (MO, JO) separately verified the analysis, and all authors agreed upon the final qualitative analysis. Information from the interviews was checked with corresponding information found in documents about “Always Open” (data triangulation). Validation was achieved by presentation to divisional managers and the management team [43]. In order to illustrate results for the reader, specific examples of common findings are presented in the results section using the researcher’s notes from the interviews.

Results

The analysis of the focus group data into the seven domains of the framework resulted in 290 codes (Table 1). The analysed data is presented under its appropriate NASSS-domain in the following results. Additionally, the dataset generated during this study with sub-categories and sub-sub-categories is available in Appendix 4.

 

Table 1. Summary of codes used for the deductive analysis of findings

 

Domain 1: The condition or illness

The focus group participants described “Always Open” as an innovation, with the possibility to help patients with many different types of illnesses or conditions, and during several different phases of their illness. Related to this, the participants stressed the importance of letting every patient’s need, regardless of illness or condition, guide how his or her care is delivered, including preventative visits and letting the patient choose between a digital or physical visit.

Domain 2: The technology

All focus groups discussed different functions for users that “Always Open” performed, including those that they wanted that were not available when the groups were conducted.

In general, the groups said that “Always Open” works better than most other communication tools they had used within their organization, and several expressed a wish to move all the organization’s digital services or platforms into the app, thus collecting them in one place. This included the patients’ electronic health record (EHR). However, some groups said that the app’s interface design was “clumsy”, old-fashioned, and difficult to use. Some mentioned the risk that staff and patients may give up using the app if it is too difficult to work with. To practice how certain functions worked, a suggestion made in one group was to create for providers a virtual patient that they could use for a test before the consultation.

”We want to be able to try out functions in a test environment rather than testing in actual patient-facing situations, in order to check how it works. We need a safe test environment with a pretend patient”.

This, and some other groups, also stressed the importance of using the chat function to improve triage and auto-generate referrals for blood sampling and follow-up. One group suggested using the app. to recruit patients for research, especially for clinic-based research by staff.

”We want to be able to recruit patients. “Are you interested in contributing to research?…” ought to be one of our offers”.

Competition from numerous private digital care providers was identified as a possible threat to wider implementation and sustainment of “Always Open”, unless the app. was continually developed, simplified and made easier to use by those who did not use it. However, a number of groups observed that the main reason driving SLSO to develop its own app. was that private online providers had successfully entered the digital health care market in earlier years.

”Had [competitors] and others not existed, we wouldn’t be sitting here discussing digitalisation today”.

Domain 3: The value proposition

Many groups observed how “Always Open” could add to SLSO’s value proposition through enhancing ”accessibility and continuity”, and described factors that could add value to both patients and staff.

Several group participants mentioned that their patients can conduct certain tasks online on their own or take part in real-time learning sessions via the app, in addition to certain physical examinations and treatments. Others mentioned examples of ways in which video visits increased the quality of the visit. One mentioned that when there is a need to observe a patient in their natural surroundings, such as a child with a neuropsychiatric disorder having breakfast, the clinician can now receive higher quality observations via the app rather than observing the patient at the clinic. Some reported that younger patients often feel more relaxed talking via video rather than face to face because they are more used to this type of communication. Others mentioned that patients with immunosuppressed conditions, fatigue, or severe bowel problems, get more out of every hour with their clinician when they are not stressed with the discomfort of travel.

However, although the quality of visits for some patients may be higher, the participants of some groups observed that more resources are sometimes required for digital visits than for physical ones. Digital group visits were also said to require an extra person to deal with technical issues that may arise during a learning session.

”You have to have two staff members during the digital group meetings. The first one has to be able to focus on the patient work while the second one functions as a “digital receptionist” in order to be able to help the patients with technical issues in case they accidentally drop out of the meeting”.

The functionality that allowed patients to book digital visits was said by some participants to have the potential of reducing the number of phone calls for appointment booking, as well as making it possible for patients to book outside of opening hours. Some participants reported that digital visits also had resulted in fewer late cancellations, and increased accessibility to language translators. Also, that it made it easier for personnel to work at home and increased flexibility of working, all of which increased staff work satisfaction. Several groups said that “Always Open” could possibly become the region’s main patient gateway for those seeking care and a coordinated single-entrance, now that so many inhabitants had downloaded the app.

Domain 4: The adopter system

The groups discussed factors related to both personnel and patients that may influence the implementation and success of “Always Open.” Many participants said that their staff had not received structured learning to work with “Always Open.” As the pandemic developed, rapid changes were made to the app. which meant that staff were “left on their own” to learn about ways to deliver care via digital tools. All groups expressed a wish to learn from these experiences, and to standardise certain procedures in digital care pathways for facilities across the region to utilize the new technology in an optimal way. Some specifically wished to learn how to improve their patient-education skills for digital visits.

As regards adoption by patients, most group participants took the view that patients had, in general, adapted well to the digital way of seeking and receiving care. Several mentioned that patients often conduct care-related tasks from home, such as blood pressure monitoring, filling out forms and assessment scales, booking appointments, and seemed to take greater responsibility for their own care. Participants also mentioned the importance of staff trusting their patients to perform these tasks correctly, and to report back to their clinician if they had any problems.

”Almost all patients are positive towards digitalisation of care visits. They mention that some improvements are needed but basically nobody wants to return to the old ways of doing things”.

Domain 5: The organisation

The groups discussed several factors within the SLSO organisation that may influence how “Always Open” is implemented and utilised. Many group participants described actions that indicate that SLSO is capable of rapid change and improvement. The most commonly mentioned example was the fast transition from traditional physical visits to digital visits by the service delivery units when the pandemic started. Also, that different staff meetings were moved to digital meetings, almost as quickly. Others were that SLSO central support developed video education quickly, and the units used digital patient education for individuals and groups.

However, many participants also said that the knowledge of some managers and personnel about their own organisation, SLSO, was too low, and that they could make changes without knowing how it affects other services. Some observed that many did not know about the SLSO out of hours online-only care service for all patients, “HLM Online” (accessible only via “Always Open”).

“I hardly knew HLM Online existed and I have always referred my patients to the local emergency room or to one of our competing online practitioners. From now on we’ll try to refer more patients to HLM Online”.

Lack of knowledge about one’s own organisation, as well as non-standardised pathways for seeking digital care was said to hinder the SLSO’s value proposition of being able provide accessibility and continuity of care in an integrated health system. Some participants also commented that the organisation had yet to decide how to triage patients via the app. Several groups discussed, without reaching consensus, options such as triaging all patients via HLM Online, triage via the patient’s care facility of choice, or a mix of both.

”How can the (physical) care facilities increase their collaboration with HLM Online? What should the patient’s way in look like?”

SLSO’s technological readiness for “Always Open” was generally described in the groups as high, with adequate internet connectivity and hardware. Participants also described a high willingness of unit personnel to work with the technology. They stressed the importance of organised practical training, as well as practical manuals, to minimise the problem.

”There ought to be good central information on how to carry out digitalised care. All knowledge regarding patient accessibility exists, for example for patients with impaired vision, but it ought to be gathered in one place and in an easily accessible way”.

Participants described several changes to work routines that were, or may be, required to increases the number of digital visits. Some managers expressed concerns that the digitalized way of delivering and coordinating care might increase costs for their unit. Some were concerned about a possible growing case mix of the region’s more complex or “more difficult patients” when offering increased continuity via “Always Open” (and that private digital-only providers could refuse to serve at the time the groups were held).

Two groups described new management challenges with more digital working for personnel. They are responsible for working environment, but when staff work from home there may be ergonomic issues and there is some indication that personnel work longer hours than scheduled. Some also mentioned that creative teamwork is more difficult to conduct remotely. Several managers described digitalisation as a continuing process and stressed the importance of allowing themselves time every week to keep developing the systems and practices at their unit.

Domain 6: The wider system

All groups described factors outside of the organization (on regional or national level) that helped or hindered their implementation of digital services in their unit and the functionality of “Always Open.”

Several groups took the view that “Always Open” could and should become Region Stockholm’s main patient portal for coordinating care and referrals. However, that further development was hindered by the legal requirement that specifies that, for “Always Open” to become the main contact point in the region, it needed to be accessible via computer, which it currently is not. Another hindering regulation mentioned was related to the European General Data Protection Regulations (GDPR) which restricts use and exchange of sensitive personal information. This affects how digital group sessions are conducted, either with multiple patients or with multiple clinicians, and affects the choice of communication platform used for certain types of conversations.

”We are not allowed to use Teams for any work regarding patients but sometimes we have done so anyway, if we have decided beforehand not to mention patients’ names, in order to be able to show film clips or program software”.

”Patient safety issues (regarding digitalised care) have been driven too hard and it often hinders digitalised care to be delivered. It makes it difficult to conduct network group meetings regarding children, sign language lessons for parents, sharing teaching material, and film clips”.

Several groups mentioned that accessible and equitable care may be hindered because “Always Open” requires the person to use digital identification (commonly a bank identification (ID) app. that verifies their identity), to connect to make appointments or to take part in digital care visits. Some group participants described having to use “work-arounds” for people without digital ID.

”In order to be able to conduct distance contacts with patients who don’t have digital IDs, we in the unit contact the patient digitally via his or her (physical) visit with the physician (using the physician’s professional “Always Open” account), who has logged on to “Always Open”.

Several groups described that their reimbursement for visits favour physical over digital visits. They described that the regional purchaser organisation has made detailed decisions regarding reimbursed services.

”The purchaser organisation has micro-managed which activities should be reimbursed and how, which has resulted in, for example, new visits to speech therapists need to be delivered physically and follow-up visits can be delivered digitally, even though it is better to do it the other way around”.

Some suggested that increasing the capitation part of the reimbursement scheme could be a method to achieve a more channel-neutral reimbursement for services delivered, be they physical or digital visits, or via telephone. They said it would be important that the reimbursement be closely related to resource utilisation.

Some groups described both patients and society at large as “stuck” on the traditional idea of physically visiting one’s family physician at the local health care unit regarding minor conditions, rather than booking a digital visit and or using the region’s online-only doctor service (HLM online).

”Some ask: ”But aren’t I going behind my care facility’s back?” [to use HLM online]. Patients are not aware that their physician can read HLM Online’s patient records. This is something that the clinicians need to inform their patients about”.

Domain 7: Embedding and adaptation over time

As regards adaptation of the DCS and “Always Open” systems, most groups commented that the SLSO informatics team and others have make changes during the first 18 months of the pandemic that had increased its functions and usability for patients and providers, such as the possibility to conduct group visits. Many also described changes to patients’ traditional care processes by combining digital and physical visits as part of the treatment plan (”digiphysical care” [39]:

”You can do a mix – digiphysically”.

”You can work both ways and you should work both ways. Not one or the other. We cannot box ourselves into certain systems. We need to remember that we work with fellow human beings who have lives outside being a patient, and that we ought to help each other”.

Discussion

The primary and community provider experiences reported above were of one DCS during the first 18 months of the pandemic. This system was developed and run internally by a publicly-owned and funded large primary and community healthcare provider. The interpretation of the NASSS framework and the European General Data Protection Regulation (GDPR) could be considered challenges [44, 45, 46]. Study limitations include participant’s memory bias, disadvantages of data collected from focus group meetings [47], and no data about patient experiences using the “Always Open” app. No further data than that reported was collected about the participants of the focus group meetings to assess how representative they were of other managers and clinicians in the organisation. Whether findings, using the same methods, would be the same in other organisations, or settings and with other connection systems and applications is unlikely, and to some degree depends on how similar the technology and type of setting is to the one in this study.

Our search before the study found limited research or evidence-based guidelines that could help primary and community healthcare clinicians and patients to decide for which patient conditions a video or other digital consult was appropriate, and when a physical visit was necessary. In our study all groups found the application to be useful, regardless of condition. Some studies found that video consulting was abandoned because of usability issues or complexity of implementation, or because of the centrality of multidisciplinary teams in diagnosis and care [48, 49].

Neither could we find research that could help to change daily routines or organisation of the work of personnel at primary and community care units by using video consults and other digital technologies, or to re-organise systems to be able to include future likely technologies that would save time and provide better services to patients. We did find some descriptions of the organisation of access and care process steps through a Swedish DCS, compared to traditional primary care telephone access steps [15]. In our study the need for changes to work routines was highlighted in all groups.

Although there are limitations to our study, it does provide empirical evidence of the extended experience of providers over a longer term when physical visit became more common. It gives some understanding of the issues to be addressed to build on the digital momentum started in the first year of the pandemic. The study was not of an app. for one patient population, disease or single-purpose, and could provide some evidence comparable to use of patient portals in other health systems. The app was reported by participants in most groups to be useful for all conditions or illness and could help to provide a more person-centered care.

Similar to other early pandemic studies, the participants in the groups reported the value of the digital technology to prevent infection of health care workers while also providing access to care for patients during restrictions [50]. Other studies have reported the usefulness of coronavirus symptom checklists for triage and remote surveillance of patients treated in their homes for Covid-19 infections, which was also reported in our study [10, 51]. One Danish study reported reverting to physical visits when it became possible for patients to visit a primary or community care unit, which was familiar and seemed to be preferred by many patients [52]. This was not reported in our study where the group participants generally reported wanting to continue to use the technology and remote patient visits when it was appropriate.

The rapid adoption of the app and DCS during the pandemic was carried out without a systematic implementation strategy. This finding is different from observations from other studies which stress the importance of a well-resourced and intentional strategy. However, many group participants stressed the need for systematic staff training during “normal conditions,” which is consistent with reports from other authors about what is necessary to achieve widespread implementation [48, 49, 54, 55].

Despite the initial absence of training, due to the level of urgency to implement the technology at hand, the implementation was generally carried out successfully and resulted in an initial 16-fold scale-up over the course of a few weeks. All groups reported that, although there were shortcomings to the technology, “Always Open” increased communication possibilities. Benefits were reported for both patients and clinicians, but limitations such as the need of a smart phone to use the system was pointed out. Most groups took the view that the technology was ready to use, despite the limitations they raised, but for future development there were issues related to people- and organisation-readiness for change.

Overall, the analysis of the focus group data showed a high level of decision making in the local units and actions to increase their use of an existing technology. One part-explanation of the service delivery unit’s rapid and independent take up of the DCS may be the 15-year programme of management decentralisation within the large primary and community healthcare organisation [2, 31, 32]. Service delivery mangers had become familiar with a relatively large degree of authority delegated to them and with using the flexibility to organise and manage their service “business units” to meet the objectives and principles of the larger organisation.

Future research: The NASSS framework

Overall, we found NASSS to be very helpful for analysing our data but we see an opportunity to offer our observations for its further development. The NASSS framework proved useful for capturing important aspects for introducing a new technology into a large health care provider organisation and its units [40]. Even though the developers of the NASSS give quite detailed guidance for classifying data into the seven domains [44], we found it necessary to use two strategies to make an adequate classification. The first was to consider how others had interpreted the seven domains of the NASSS [26, 41, 56, 57, 58]. The second was when focus group members’ statements could be classified in more than one domain, for example, “the app. is not very user friendly for some patients”. Should this be classified as an issue of the technology (D2), or the value proposition (D3), or the adopter system (D4), or possibly the wider context (D6) or classified in all or some of these? The strategy of the research team of three (the authors) was to discuss and agree how to classify the statements made by focus groups members and the codes.

We also noted challenges with classification in relation to some domains and suggest there is scope to develop NASSS further to address these issues. One way forward could be to develop versions of NASSS for different types of digital health technologies, such as, in our case, a development of an existing technology and not an original innovation. Based on our experiences using NASSS for this particular study and setting, our current vision regarding development of the model is depicted in Fig. 1.

In domain three (value proposition), we suggest that the definition could be more specified on the supply-side. We found in our study that personnel value the technology because it makes their work more flexible and enables them to work from home. It is not only a “role changer” as defined in domain four (adopter system), but also a strong driver as a value proposition. Also, how easy it is for competitors to enter the market with their version is placed under domain two (technology) but, in our case, belongs between domain five (organisation) and six (wider system) as it is a development of an existing technological innovation.

Conclusions

This limited study of an app. and a digital system that connects providers and patients reported the first empirical evidence of unit managers’ perceptions about this system over 18 months during the COVID-19 pandemic in a public primary and community health care organisation. During the 18 months of the pandemic the system was further improved, and also infection rates declined and vaccinations increased, which made physical visits easier. This made it possible to begin to understand the possible longer-term use of the digital technology from the provider’s perspective. As with other health systems, participants of the focus groups reported a rapid adoption of the digital system and video consults, and also the strengths and weaknesses of the system, and indicated that they intended to sustain their use of the system.

Many factors could explain the rapid adoption. We speculate that a part-explanation was the 15-year management decentralisation programme in the primary and community health care organisation. Other studies show that this developed the capability of unit managers to provide flexible services suited to local needs. Questions for the future include, will the high use of digital services be sustained, and if so, why and how? How will variations in use of digital services between the units and standardisation be addressed when there is a digital first policy, as in a number of health systems? How can equity of access and care be ensured for persons who are unable to use computers or mobile phones?

Declarations

Acknowledgements

The contributions of all the interviewees and the following persons are acknowledged with gratitude: Vibeke Sparring, researcher and senior administrator of research and development in SLSO, managed the ethics application and associated professor Ulf Lockowandt, Chief Operating Officer in Stockholm County Health Services provided data on Always Open. 

Authors’ contributions

MO, JO and KSC designed the study. The interviews and coding were performed by KSC. The analysis was made by all authors. MO drafted the first manuscript and made further revisions to subsequent manuscripts. MO, JO and KSC contributed substantially to the final version. All authors read and approved the final manuscript.

Funding

Open access funding provided by Karolinska Institute. This study has been conducted as a part of the ordinary operations.

Availability of data and materials

The datasets used and/or analysed during the current study and data associated, are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study has been 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). All methods were performed in accordance with the relevant guidelines and regulations including the informed consent to participate in the study. The Swedish Ethical Review Authority (Dnr 2020–01521) did approve that oral consent was to be obtained from interviewees.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

1 Department of Learning, Informatics, Management and Ethics, Medical

Management Centre, Karolinska Institutet, Stockholm, Sweden. 2 Stockholm County 

Healthcare Services, Region Stockholm

References

  1. Haldane V, De Foo C, Abdalla SM, Jung A-S, Tan M, Wu S, Chua A, Verma M, Shrestha P, Singh S, Perez T, Tan SM, Bartos M, Mabuchi S, Bonk M, McNab C, Werner GK, Panjabi R, Nordstrom A, Legido-Quigley H. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nature Medicine. 2021;27(6), 964–980. https://doi.org/10.1038/s41591-021-01381-y
  2. Ohrling M, Solberg Carlsson K, Brommels M. No man is an island: management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in a large public decentralised service delivery organisation. BMC Health Serv Res. 2022; 22, 371. https://doi.org/10.1186/s12913-022-07716-w
  3. Imai N, Gaythorpe K, Abbott S, Bhatia S, van Elsland S, Prem K, Liu Y, Ferguson NM. Adoption and impact of non-pharmaceutical interventions for COVID-19. Wellcome open research. 2020; 5, 59. https://doi.org/10.12688/wellcomeopenres.15808.1
  4. Ohrling M, Øvretveit J, Lockowandt U, Brommels M, Sparring V. Management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in Stockholm, Sweden, and winter preparations. J Prim Health Care. 2020;12(3):207–14. https:// doi. org/ 10. 1071/ HC200 82.
  5. Bo Y, Guo C, Lin C, Zeng Y, Li HB, Zhang Y, … Lao XQ. Effectiveness of non-pharmaceutical interventions on COVID-19 transmission in 190 countries from 23 January to 13 April 2020. International Journal of Infectious Diseases. 2021;102,247–253. https://doi.org/10.1016/j.ijid.2020.10.066
  6. Keesara S, Jonas A, Schulman K. Covid-19 and Health Care's Digital Revolution. N Engl J Med. 2020 Jun 04;382(23):e82. [doi: 10.1056/NEJMp2005835] [Medline: 32240581] 5.
  7. Fagherazzi G, Goetzinger C, Rashid MA, Aguayo GA, Huiart L. Digital Health Strategies to Fight COVID-19 Worldwide: Challenges, Recommendations, and a Call for Papers. J Med Internet Res 2020 Jun 16;22(6):e19284 [FREE Full text] [doi: 10.2196/19284] [Medline: 32501804]
  8. Mahmood S, Hasan K, Colder Carras M, Labrique A. Global Preparedness Against COVID-19: We Must Leverage the Power of Digital Health. JMIR Public Health Surveill 2020 Apr 16;6(2):e18980 [FREE Full text] [doi: 10.2196/18980] [Medline: 32297868]
  9. Atique S, Bautista JR, Block LJ, Lee JJ, Lozada‐Perezmitre,E, Nibber R, O’Connor S, Peltonen L, Ronquillo C, Tayaben J, Thilo FJS, Topaz M. A nursing informatics response to COVID‐19: Perspectives from five regions of the world. J Advanced Nurs. 2020; 76(10), 2462–2468. https://doi.org/10.1111/jan.14417
  10. Golinelli D, Boetto E, Carullo G, Nuzzolese AG, Landini MP, Fantini MP. Adoption of Digital Technologies in Health Care During the COVID-19 Pandemic: Systematic Review of Early Scientific Literature. Journal of Medical Internet Research. 2020;22(11), e22280–e22280. https://doi.org/10.2196/22280
  11. Petracca F, Ciani O, Cucciniello M, Tarricone R. Harnessing Digital Health Technologies During and After the COVID-19 Pandemic: Context Matters. Journal of medical Internet research. 2020;22(12):e21815–
  12. Herrmann M, Boehme P, Mondritzki T, Ehlers JP, Kavadias S, Truebel H. Digital Transformation and Disruption of the Health Care Sector: Internet-Based Observational Study. J Med Internet Res. 2018 Mar 27;20(3):e104 [FREE Full text] [doi: 10.2196/jmir.9498] [Medline: 29588274]
  13. Perakslis ED. Strategies for delivering value from digital technology transformation. Nat Rev Drug Discov 2017 Feb;16(2):71-72. [doi: 10.1038/nrd.2016.265] [Medline: 28082744]
  14. Milos Nymberg V, Borgström Bolmsjö B, Wolff M, Calling S, Gerward S, Sandberg M. Having to learn this so late in our lives...’ Swedish elderly patients’ beliefs, experiences, attitudes and expectations of e-health in primary health care. Scandinavian Journal of Primary Health Care. 2019;37:1, 41-52, DOI: 10.1080/02813432.2019.1570612.
  15. Gabrielsson-Järhult F, Kjellström S, Areskoug Josefsson K. Telemedicine consultations with physicians in Swedish primary care: a mixed methods study of users’ experiences and care patterns, Scandinavian Journal of Primary Health Care. 2021; 39:2, 204-213, DOI: 10.1080/02813432.2021.1913904
  16. Imlach F, McKinlay E, Middleton L, et al. Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences. BMC Fam Pract. 2020; 21269. https://doi.org/10.1186/s12875-020-01336-1
  17. Björndell C, Premberg A. Physicians’ experiences of video consultation with patients at a public virtual primary care clinic: a qualitative interview study, Scandinavian Journal of Primary Health Care. 2021; 39:1, 67-76, DOI: 10.1080/02813432.2021.1882082.
  18. Glock H, Milos Nymberg V, Borgström Bolmsjö B, Holm J, Calling S, Wolff M, Pikkemaat M. Attitudes, Barriers, and Concerns Regarding Telemedicine Among Swedish Primary Care Physicians: A Qualitative Study. International Journal of General Medicine. 2021; Volume 14, pages 9237-9246.
  19. Wilson G, Currie O, Bidwell S, Saeed B, Dowell A, Halim AA, Toop L, Richardson A, Savage R, Hudson B. Empty waiting rooms: the New Zealand general practice experience with telehealth during the COVID-19 pandemic. N Z Med J. 2021 Jul 9;134(1538):89-101. PMID: 34239148.
  20. Donaghy E, Atherton H, Hammersley V, McNeilly H, Bikker A, Robbins L, et al. Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care. Br J Gen Pract 2019 Sep;69(686):e586-e594, doi: 10.3399/bjgp19X704141.
  21. Murphy M, Scott LJ, Salisbury C, et al. Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study. Br J Gen Pract. 2021;71(704):e166-e177. Published 2021 Feb 25. doi:10.3399/BJGP.2020.0948
  22. Ignatowicz A, Atherton H, Bernstein CJ, Bryce C, Court R, Sturt J, et al. Internet videoconferencing for patient–clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations. DIGITAL HEALTH. 2019;5:2055207619845831–2055207619845831
  23. Otte-Trojel T, Rundall TG, de Bont A, et al. The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente. BMC Health Serv Res. 2015; 15, 559. https://doi.org/10.1186/s12913-015-1208-2
  24. Shaw SE, Seuren LM, Wherton J, et al. Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction. J Med Internet Res. 2020;22(5):e18378. Published 2020 May 11. doi:10.2196/18378
  25. Garfan S, Alamoodi AH, Zaidan BB, et al. Telehealth utilization during the Covid-19 pandemic: A systematic review. Comput Biol Med. 2021;138:104878. doi:10.1016/j.compbiomed.2021.104878
  26. James H, Papoutsi C, Wherton J, Greenhalgh T, Shaw S. Spread, Scale-up, and Sustainability of Video Consulting in Health Care: Systematic Review and Synthesis Guided by the NASSS Framework J Med Internet Res 2021;23(1):e23775 DOI: 10.2196/23775
  27. Jaklevic MC. Telephone visits surge during the pandemic, but will they last? JAMA. 2020;324(16):1593–1595. doi:10.1001/ jama.2020.17201.
  28. Li K, Chen J, Woodward M. How the old-fashioned telephone could become a new way for some to see their doctor. The Conversation. 2020; August 12.
  29. SLSO. Stockholms läns sjukvårdsområde (Stockholm County Healthcare Services). Stockholm: SLSO; [Cited 2022 June 11]. Available from: https:// www. slso.sll.se
  30. Anell A, Glenngård AH, Merkur S. Sweden health system review. Health systems in transition. 2012;14(5):1–159 (http:// www. ncbi. nlm. nih. gov/pubmed/ 22894 859).
  31. Ohrling M, Tolf S, Solberg-Carlsson K, Brommels M. That's how it should work: the perceptions of a senior management on the value of decentralisation in a service delivery organisation. Journal of Health Organization and Management. 2021a, Vol. 35 No. 5, pp. 596-613. https://doi.org/10.1108/JHOM-12-2020-0474
  32. Ohrling M, Tolf, S, Solberg-Carlsson K, Brommels, M. Managers do it their way: How managers act in a decentralised healthcare services provider organisation – a mixed methods study. Health Services Management Research : an Official Journal of the Association of University Programs in Health Administration. 2021b. 95148482110654–. https://doi.org/10.1177/09514848211065467
  33. Vårdgivarguiden 2022 Alltid Oppet (Always Open Provider guide), December 6, 2021, https://vardgivarguiden.se/it-stod/e-tjanster-och-system/alltid-oppet , accessed 18 april 2022.
  34. SLSO, 2022 ”Appen Alltid öppet,” (Application Always Open)[Online]. Available: https://www.slso.sll.se/vard-hos-oss/vardcentralerhuslakarmottagningar/appen-alltid-oppet/ . [Used 17april 2022].
  35. Ohannessian R, Duong TA, Odone A. Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: a call to action. JMIR Public Health Surveill 2020 Apr 02;6(2):e18810 [FREE Full text] [doi: 10.2196/18810] [Medline: 32238336]
  36. Lonergan PE, Washington Iii SL, Branagan L, Gleason N, Pruthi RS, Carroll PR, et al. Rapid utilization of telehealth in a comprehensive cancer center as a response to COVID-19: cross-sectional analysis. J Med Internet Res 2020 Jul 06;22(7):e19322 [FREE Full text] [doi: 10.2196/19322] [Medline: 32568721]
  37. Pérez Sust P, Solans O, Fajardo JC, Medina Peralta M, Rodenas P, Gabaldà J, et al. Turning the crisis into an opportunity: digital health strategies deployed during the COVID-19 outbreak. JMIR Public Health Surveill 2020 May 04;6(2):e19106 [FREE Full text] [doi: 10.2196/19106] [Medline: 32339998]
  38. Hong Z, Li N, Li D, Li J, Li B, Xiong W, et al. Telemedicine during the COVID-19 pandemic: experiences from western China. J Med Internet Res 2020 May 08;22(5):e19577 [FREE Full text] [doi: 10.2196/19577] [Medline: 32349962]
  39. Statens Offentliga Utredningar 2019:42. Digifysiskt vårdval Tillgänglig primärvård baserad på behov och kontinuitet, slutbetänkandet , Slutbetänkande av utredningen Styrning för en mer jämlik vård SOU 2019:42, (Swedish Public Inquiry 2019 Digi-physical care choice: accessible primary care based on need and continuity, the final report, Final report of the inquiry “Guidance for more equal care” Stockholm, www.nj.se/offentligapublikationer
  40. Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, Hinder S, Fahy N, Procter R, Shaw S. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies, J Med Internet Res 2017;19(11):e367 URL: https://www.jmir.org/2017/11/e367
  41. Longacre ML, Keleher C, Chwistek M, Odelberg M, Siemon M, Collins M, Fang CY. Developing an Integrated Caregiver Patient-Portal System. Healthcare. 2021; 9(2):193. https://doi.org/10.3390/healthcare9020193
  42. Hsieh HF, Shannon SE. Three Approaches to Qualitative Content Analysis. Qualitative Health Research. 2005; Vol 15, issue 1277.
  43. Green J, Thorogood N. Qualitative Methods for Health Research (Introducing Qualitative Methods series) (9781446253090): 2014. Judith Green, Nicki Thorogood: Books. pp 95-96
  44. Greenhalgh T, Maylor H, Shaw S, Wherton J, Papoutsi C, Betton V, Nelissen N, Gremyr A, Rushforth A, Koshkouei M, Taylor J. The NASSS-CAT Tools for Understanding, Guiding, Monitoring, and Researching Technology Implementation Projects in Health and Social Care: Protocol for an Evaluation Study in Real-World Settings. JMIR Res Protoc 2020;9(5):e16861 DOI: 10.2196/16861
  45. GDPR (2016) Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation), OJ 2016 L 119/1 http://ec.europa.eu/justice/data-protection/reform/files/regulation_oj_en.pdf
  46. Hoofnagle CJ, van der Sloot B, Zuiderveen Borgesius F. The European Union general data protection regulation: what it is and what it means. Information & Communications Technology Law. 2019; 28:1, 65-98, DOI: 10.1080/13600834.2019.1573501.
  47. Stewart D, Shamdasani P. Focus Groups: Theory and Practice. 2015. Sage, London
  48. Greenhalgh T, Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, et al. Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study. J Med Internet Res 2018 Apr 17;20(4):e150 [FREE Full text] [doi: 10.2196/jmir.9897] [Medline: 29625956]
  49. Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, et al. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. Southampton (UK): NIHR Journals Library; 2018.
  50. Turer RW, Jones I, Rosenbloom ST, Slovis C, Ward MJ. Electronic personal protective equipment: A strategy to protect emergency department providers in the age of COVID-19. J Am Med Inform Assoc 2020 Jun 01;27(6):967-971 [FREE Full text ] [doi: 10.1093/jamia/ocaa048 ] [Medline: 32240303 ]
  51. Judson TJ, Odisho AY, Neinstein AB, Chao J, Williams A, Miller C, et al. Rapid design and implementation of an integrated patient self-triage and self-scheduling tool for COVID-19. J Am Med Inform Assoc 2020 Jun 01;27(6):860-866 [FREE Full text ] [doi: 10.1093/jamia/ocaa051 ] [Medline: 32267928 ]
  52. Due TD, Thorsen T, Andersen JH. Use of alternative consultation forms in Danish general practice in the initial phase of the COVID-19 pandemic – a qualitative study. BMC Fam Pract. 2021; 22, 108. https://doi.org/10.1186/s12875-021-01468-y
  53. Bhatta R, Aryal K, Ellingsen G. Opportunities and Challenges of a Rural-telemedicine Program in Nepal. J Nepal Health Res Counc 2015;13(30):149-153. [Medline: 26744201]
  54. Wade VA, Taylor AD, Kidd MR, Carati C. Transitioning a home telehealth project into a sustainable, large-scale service: a qualitative study. BMC Health Serv Res 2016 May 16;16(1):183 [FREE Full text] [doi: 10.1186/s12913-016-1436-0] [Medline: 27185041]
  55. Gremyr A, Gare BA, Greenhalgh T, Malm U, Thor J, Andersson A-C. Using Complexity Assessment to Inform the Development and Deployment of a Digital Dashboard for Schizophrenia Care: Case Study. Journal of medical Internet research. 2020;22(4):e15521–e15521.
  56. Yakovchenko V, McInnes D, Petrakis B, Gillespie C, Lipschitz J, McCullough, M., Richardson L, Vetter B, Hogan T Implementing Automated Text Messaging for Patient Self-management in the Veterans Health Administration: Qualitative Study Applying the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability Framework JMIR Mhealth Uhealth 2021;9(11):e31037 DOI: 10.2196/31037
  57. Rudin RS, Perez S, Rodriguez JA, Sousa J, Plombon S, Arcia A, Foer D, Bates, DW, Dalal, AK. User-centered design of a scalable, electronic health record-Integrated remote symptom monitoring intervention for patients with asthma and providers in primary care. J Am Med Inform Assoc. 2021 Oct 12;28(11):2433-2444. doi:10.1093/jamia/ocab157. PMID: 34406413; PMCID: PMC8510383