The number of health-related software in consumer and research-oriented applications is increasing rapidly. Symptom Checker Apps (SCA) are one example for health-related software that could have a major impact on health systems on all levels. SCA process medical symptoms that users enter by applying algorithms and databases with medical information (1). Based on these symptoms, they generate a list of probable causes and suggest medical follow-up actions (e.g., wait at home, see a doctor, go to the emergency room). SCA advertise that they use artificial intelligence (AI) and big data as basis of their algorithms (1–3); however, it is rarely specified by developers how and to which extent AI is implemented in these applications. Even though there are already strong claims from ethical research that emphasize the importance of criteria like transparency, trustworthiness, agency and responsibility for artificial intelligence-driven decision support systems like SCA (4–6).
The “google play store” already lists 249 applications (retrieved 24.03.21) for the key words ‘symptom checker’ (7). At the moment SCA are not hardly regulated, even though they can be classified as high risk applications according to the National Institute for Health and Care Excellence (NICE(8)). According to NICE, the use of high risk applications requires the highest evidence level 3b (8).
SCA can be used on any device with internet access and are often free mobile-based applications, thus easily downloadable in app stores or accessible with an internet browser if a suitable technical device and internet access is available to users. Nevertheless, users must be able to handle technical devices and to interpret the SCA’s output. This could lead to a disadvantage of specific population groups e.g. seniors, people with disabilities (9) or people with limited economic resources (10). Some SCA exclude specific user groups for symptom analysis e.g. pregnant women, children, seniors and patients with specific comorbidities (11). Although, some users found that SCA are useful tools for self-diagnosis and even reported positive health effects (12). Other users had problems providing and interpreting concrete information on symptom time patterns or severity (13). The output of SCA recommends actions and probable causes for the entered symptoms, which can lead to confusion and negotiations due to mismatch with users’ experience or expectation (14). Such negotiations may initiate unnecessary health-care seeking behavior (15).
In terms of their medical value and validity, commercially available SCA struggle with accurate triage (determining user’s medical condition based on their input and recommending the optimal course of action). A review of 23 studies showed that SCA often suggested risk-averse actions (16, 17). SCA’s diagnostic and triage accuracy is still limited and was even less reliable in non-urgent scenarios, which are common in primary care (16). A recently published study compared the performance of n = 8 SCA with the performance of telephone consultation of n = 7 GP by using 100 case vignettes. GP outperformed SCA on all assessed outcomes (accuracy, condition suggestion, appropriateness and safety of urgency advice). The comparison was limited to telephone consultations and did not comprise direct patient-physician contact. Some SCA performed over-conservative, simultaneously other applications tended to take advices with risks for users (11). In high performing health care systems, this can cause preventable costs and increase the risk of unnecessary procedures that could lead to avoidable risks for patient’s safety (2, 18).On the other hand, in structurally weak regions with restricted access to medical care, SCA can provide a first-line assessment that otherwise would not be available (19).
In summary, potential risks of the use of SCA (exclusion of users, stress, induction of health-seeking behavior) contrast advertised opportunities of SCA like patient empowerment and better health care for underserved regions. There is a substantial gap in the literature concerning the effect of SCA on different health care systems, different levels of health care (micro-, meso- and macro-level (20)) within these systems and on the system’s different participants (users, non-users, health care providers). If SCA become more widely used, their ethical, legal and social impact on those levels and participants must be better understood despite complex interactions and methodological challenges.
In this study we aim to clarify ethical, legal and social impacts of SCA on users, non-users, GP, the primary health care systems and their work by means of an independent, empirical, integrated multi-perspective, multi-disciplinary discussion. Due to the lack of systematic research of SCA in primary health care, the recent study uses an explorative hypothesis generating approach in which the above-mentioned discussion is informed by four foci of interest and the study aims as stated in Table 1.
Foci of the present study
Focus 1) Ethical, legal and social issues of SCA use
− identification of ethical, social and legal issues in the recent scientific literature on SCA (e.g. usage linked to inequities in health care, patient autonomy, modification of role concepts and agency)
Focus 2) SCA epidemiology: Users, non-users and predictors of use
− describe the user group (individuals using SCA) and non-user group (individuals not using SCA)
− determine the degree of use
o identify variables that are reliable predictors for SCA use
− identify vulnerable groups that might be disadvantaged through the implementation of SCA
Focus 3) Patterns and impact of SCA use: User level
− comprehensive description of SCA use from a user perspective
− identify needs that are fulfilled with SCA use
− identify wants unfulfilled by SCA use
− identify possible risks associated with SCA use
− assess how users handle SCA information and action recommendations
− identify SCA effects on user agency, (e-)health literacy, wellbeing and self-care
Focus 4) Impact of SCA use on health care systems and health care workers
− changes that will specially focused on: changes in the patient-physician-relationship, strategies of handling pre-informed patients, changes in the role concept of physicians and requirements of GP, as well as potential psychosocial risks and demands and perceived work stress resulting from these changes.