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During the spread of the novel coronavirus disease (COVID-19), internet hospitals in China were engaged with epidemic prevention and control, offering epidemic-related online services and medical support to the public.
The aim of this study is to explore the role of internet hospitals during the prevention and control of the COVID-19 outbreak in China.
Online epidemic-related consultations from multicenter internet hospitals in China during the COVID-19 epidemic were collected. The counselees were described and classified into seven type groups. Symptoms were recorded and compared with reported patients with COVID-19. Hypochondriacal suspicion and offline visit motivation were detected within each counselees’ group to evaluate the social panic of the epidemic along with the consequent medical-seeking behaviors. The counselees’ motivation and the doctors’ recommendation for an offline visit were compared. Risk factors affecting the counselees’ tendency of hypochondriacal suspicion and offline visit motivation were explored by logistic regression models. The epidemic prevention and control measures based on internet hospitals were listed, and the corresponding effects were discussed.
A total of 4913 consultations were enrolled for analysis with the median age of the counselees at 28 years (IQR 22-33 years). There were 104 (2.12%) healthy counselees, 147 (2.99%) hypochondriacal counselees, 34 (0.69%) exposed counselees, 853 (17.36%) mildly suspicious counselees, 42 (0.85%) moderately suspicious counselees, 3550 (72.26%) highly suspicious counselees, and 183 (3.72%) severely suspicious counselees. A total of 94.20% (n=4628) of counselees had epidemic-related symptoms with a distribution similar to those of COVID-19. The hypochondriacal suspicion (n=2167, 44.11%) was common. The counselees’ motivation and the doctors’ recommendation for offline visits were inconsistent (
Internet hospitals can serve different types of epidemic counselees, offer essential medical supports to the public during the COVID-19 outbreak, reduce the social panic, promote social distancing, enhance the public’s ability of self-protection, correct improper medical-seeking behaviors, reduce the chance of nosocomial cross-infection, and facilitate epidemiological screening, thus, playing an important role on preventing and controlling COVID-19.
From late 2019 to early 2020, an outbreak of novel coronavirus disease (COVID-19) spread throughout China and soon became a global concern [
We collected 8913 consecutive deidentified free online consultations generated between January 25, 2020, and February 25, 2020, from 30 general public internet hospitals in 11 provinces of China outside of the Hubei area. The consultants were certified doctors from the general public hospitals, and the counselees were local residents who were not admitted to the offline hospitals and supposed to have epidemic-related questions. All of the data were extracted from the platform of Zoenet Health Company Limited [
Variables including age, sex, symptoms, reattendance, epidemiological exposure history, hypochondriacal suspicion, offline visit recommendation, and offline visit motivation were recorded. The epidemic-related symptoms were classified into common and uncommon epidemic symptoms. Fever (axillary temperature of 37.5°C or higher), cough, expectoration, myalgia, and fatigue were classified into common symptoms from which most of the patients with COVID-19 outside of Wuhan in China suffered from as described by Xiao-Wei Xu et al [
We classified the counselees into seven type groups, including healthy counselees, hypochondriacal counselees, exposed counselees, mildly suspicious counselees, moderately suspicious counselees, highly suspicious counselees, and severely suspicious counselees (
Classification of different counselees.
The amount and the percentage of counselees with positive hypochondriacal suspicion, offline visit motivation, and an offline visit recommendation were counted and calculated within different counselee groups. All symptoms were extracted and compared with patients with reported COVID-19 [
Univariate and multivariate logistical regression analyses were conducted to predict the risk factors for hypochondriacal suspicion and offline visit motivation. Predictors that were statistically significant in the univariate analyses (
Statistical analysis was done by Python (version 3.6; Python Software Foundation). The forest figure showing the results of logistic regressions was drawn by R (version 3.6.2; R Foundation for Statistical Computing).
Ethic approval was obtained from the medical research ethics committee of the first affiliated hospital of Xiamen University, Xiamen, China (protocol number 3502Z2020YJ05) before the start of the study.
A total of 4913 consultations were finally enrolled for analysis including 2031 (41.34%) males and 2882 (58.66%) females. The median age was 28 years (IQR 22-33 years). All children younger than 12 years had online consultations completed by their guardians. Epidemiological exposure history was reported for 259 (5.27%) counselees. Epidemic-related symptoms were reported for 4628 (94.20%) counselees, and 3733 (75.98%) had common-epidemic symptoms. Hypochondriacal suspicion was reported for 2165 (44.07%) counselees, and 869 (17.69%) were motivated to do an offline visit. A total of 190 (3.87%) were in severe condition with an affirmative offline visit recommendation. Only 2 severe cases had no epidemic-related symptoms, but both of them had hypochondriacal suspicion: a 39-year-old male who felt precordial discomfort and a 2-year-old girl who was found in a drowsy state by her parents. Most severe counselees were children less than 10 years old (102/190, 53.7%).
After classification of all the counselees, 104 (2.12%) were healthy counselees, 147 (2.99%) were hypochondriacal counselees, 34 (0.69%) were exposed counselees, 853 (17.36%) were mildly suspicious counselees, 42 (0.85%) were moderately suspicious counselees, 3550 (72.26%) were highly suspicious counselees, and 183 (3.72%) were severely suspicious counselees. Hypochondriacal suspicion and offline-visit motivation were common within different types of counselees. However, fewer counselees had received affirmative offline-visit recommendations (
Hypochondriacal suspicion, offline visit motivation, and offline visit recommendation in different counselees’ type groups.
Counselee type | Hypochondriacal suspicion, n (%) | Offline visit motivation, n (%) | Offline visit recommendation, n (%) |
Healthy counselees, n=104 | 0 (0.0) | 3 (2.9) | 0 (0.0) |
Hypochondriacal counselees, n=147 | 147 (100.0) | 18 (12.2) | 2 (1.4) |
Exposed counselees, n=34 | 32 (94.1) | 12 (35.3) | 0 (0.0) |
Mildly suspicious counselees, n=853 | 419 (49.1) | 132 (15.5) | 1 (0.1) |
Moderately suspicious counselees, n=42 | 38 (90.5) | 18 (42.9) | 0 (0.0) |
Highly suspicious counselees, n=3550 | 1378 (38.8) | 635 (17.9) | 185 (5.2) |
Severely suspicious counselees, n=183 | 151 (82.5) | 51 (27.9) | 2 (1.1) |
Total number, N=4913 | 2165 (44.07) | 869 (17.69) | 190 (3.87) |
For the 4628 counselees with epidemic-related symptoms, cough (n=2118, 45.76%) was the most common symptom, followed by fever (n=2021, 43.67%), nasal congestion (n=981, 21.20%), expectoration (n=752, 16.25%), sore throat (n=735, 15.88%), headache (n=443, 9.57%), fatigue (n=415, 8.97%), shortness of breath (n=365, 7.89%), diarrhea (n=350, 7.56%), myalgia (n=301, 6.50%), nausea and vomiting (n=282, 6.09%), and chills (n=16, 0.35%) (see
The symptom distribution of online counselees and COVID-19 patients. COVID-19: coronavirus disease.
The counselees’ motivation and the doctors’ recommendation for offline visits were significantly different (χ21=13.4230,
The multivariate logistic regression models showed that epidemiological exposure, adulthood, shortness of breath, diarrhea, and unrelated symptoms can independently increase the probability of hypochondriacal suspicion; fever and cough can reduce the probability of hypochondriacal suspicion. Severe illness, fever, epidemiological exposure, and hypochondriacal suspicion can increase the probability of offline visit motivation; however, reattending counselees were less likely to have offline visit motivation (
The independent risk factors for hypochondriacal suspicion and offline visit motivation.
Our results showed that the epidemic of COVID-19 brought panic and hypochondria to the public, further inducing improper health-seeking behaviors and increased demand of medical care services. Along with the arrival of information times, the traditional management style could not adapt to the public’s needs during the period of the COVID-19 outbreak. Internet hospitals may serve different types of epidemic counselees, helping prevent and control the epidemic of COVID-19 in China.
As the epidemic of COVID-19 in China overlapped with the high incidence for common cold and seasonal influenza [
Under the stress of the epidemic, an increasing number of people need professional medical guidance, but the offline hospital visits should be strictly restricted to cut off nosocomial transmission routes. The demanding medical services and the inaccessibility of medical care became one of outstanding contradictions during the COVID-19 outbreak. The internet hospitals may solve this dilemma by offering equitable and inclusive online services to assist the epidemic control [
After recent years of development, the internet hospitals in China can now break through the limitations of time and space with excellent accessibility, providing a variety of medical services to all citizens [
Through the above measures, internet hospitals may help prevent and control the COVID-19 epidemic with both primary and auxiliary functions. In terms of primary functions, first, internet hospitals may reduce the crowd gatherings in offline hospitals through multiple approaches. Through online education and propaganda [
In the aspect of auxiliary functions, internet hospitals provide basic medical support to the public during the epidemic. Affected by the outbreak, numerous nonemergency outpatient departments were closed in Chinese hospitals, causing most offline clinics to be unavailable for the public. Through internet hospitals, the patients could keep in touch with their attending doctors. For those who had new mild symptoms, the doctors could give professional advice on self-management of care and treatment. For those in severe conditions, online doctors may guide them to visit offline hospitals as soon as possible in case of deterioration. Moreover, during the period of individual self-isolation, internet hospitals may join the social capital, improving quality of life by reducing anxiety and stress [
Fully understanding the positive role played by internet hospitals during the epidemic, we should also realize their limitations. First, online consultation is an indirect way of communication. Due to the lack of information such as physical and auxiliary examinations, online doctors may only give rough medical advice for primary care patients. Second, most of the internet hospitals in China currently offer only passive order-based services to the public. In terms of epidemic screening, it is necessary to cooperate with offline approaches to make better use of the internet hospitals’ online advantages. Third, the audience of internet hospitals has not yet covered the whole population due to the difference in public acceptance, which can be reflected by the unbalanced distribution of the counselees’ ages. Furthermore, the accessibility of the internet is another limitation of internet hospitals.
To make better use of internet hospitals during the epidemic, more efforts are needed, such as recruiting more doctors, especially psychologists [
This study has some limitations. First, our data was collected outside of the Hubei province. In relatively low-prevalence areas, the hypochondria and panic rate might be underestimated. Meanwhile, the characteristics of the counselees were collected according to their description rather than standardized questionnaires. Some symptoms might be neglected by the counselees and, thus, also underestimated. Second, there are other forms of online consultation services, including paid services held by general public hospitals or private companies [
The complete results of logistic regression models.
Centers for Disease Control and Prevention
coronavirus disease
odds ratio
This study was funded by the special project for COVID-19 prevention and control of Xiamen city (3502Z2020YJ05).
ZW contributed to the study concept and design. ZC and YC contributed to the acquisition of data. KG and ZX contributed to the semantic and statistical analysis. KG drafted the manuscript. All authors contributed to the interpretation of the results and gave final approval of the manuscript.
ZC and YC are employees of Zoenet Health Company Limited, which cooperated with public hospitals to offer the free online consultation services.