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Owing to the shortage of medical professionals, as well as demographic and structural challenges, new care models have emerged to find innovative solutions to counter medical undersupply. Team-based primary care using medical delegation appears to be a promising approach to address these challenges; however, it demands efficient communication structures and mechanisms to reinsure patients and caregivers receive a delegated, treatment-related task. Digital health care technologies hold the potential to render these novel processes effective and demand driven.
The goal of this study is to recreate the daily work routines of general practitioners (GPs) and medical assistants (MAs) to explore promising approaches for the digital moderation of delegation processes and to deepen the understanding of subjective and perceptual factors that influence their technology assessment and use.
We conducted a combination of 19 individual and group interviews with 12 GPs and 14 MAs, seeking to identify relevant technologies for delegation purposes as well as stakeholders’ perceptions of their effectiveness. Furthermore, a web-based survey was conducted asking the interviewees to order identified technologies based on their assessed applicability in multi-actor patient care. Interview data were analyzed using a three-fold inductive coding procedure. Multidimensional scaling was applied to analyze and visualize the survey data, leading to a triangulation of the results.
Our results suggest that digital mediation of delegation underlies complex, reciprocal processes and biases that need to be identified and analyzed to improve the development and distribution of innovative technologies and to improve our understanding of technology use in team-based primary care. Nevertheless, medical delegation enhanced by digital technologies, such as video consultations, portable electrocardiograms, or telemedical stethoscopes, can counteract current challenges in primary care because of its unique ability to ensure both personal, patient-centered care for patients and create efficient and needs-based treatment processes.
Technology-mediated delegation appears to be a promising approach to implement innovative, case-sensitive, and cost-effective ways to treat patients within the paradigm of primary care. The relevance of such innovative approaches increases with the tremendous need for differentiated and effective care, such as during the ongoing COVID-19 pandemic. For the successful and sustainable adoption of innovative technologies, MAs represent essential team members. In their role as mediators between GPs and patients, MAs are potentially able to counteract patients’ resistance toward using innovative technology and compensate for patients’ limited access to technology and care facilities.
The current health care systems are facing major challenges. Several shortcomings are prevalent with regard to the availability of medical professionals and facilities, which impedes the provision of comprehensive care. In particular, rural areas are undergoing a rapid demographic change, leading to higher patient numbers and increased occurrences of age-related health issues, which results in a higher health care demand [
As a reaction and countermeasure to these challenges, new care models have emerged that alter the structures and delivery processes in health care and seek to free up resources and enable GPs to cope with increasing demands and contemporary restrictions [
In addition to approaches dealing with the prevalent issues in health care that involve innovative changes in personnel management and delegation, the application of digital technologies within care delivery and treatment processes has also been shown to be effective under specific conditions. Technologies such as telemedical video consultation systems for efficient patient-physician communication [
Drawing a synopsis of these two perspectives, the integration of digital technologies and new care delivery structures holds the potential to further improve health care quality and comprehensiveness, with the ultimate goal of maintaining or even improving the safety, satisfaction, and overall health of the patient. Research delivers initial insights in that regard, showing that the integration of technologies into multi-actor health care processes can yield higher allocative efficiency and organizational outcomes (eg, lower hospitalization rates) [
The shortage of medical professionals in Western countries has led to the development of multiple strategies to counter the difficulties related to the provision of medical services in primary care [
Considering these challenges of multi-actor approaches in primary care, the digitalization of health care technologies improves the ability to catalyze team-based, multidisciplinary, and resource-sensitive processes. Considering the uniqueness of multi-actor approaches in primary care, the technologies that are relevant are those that are capable of enhancing collaboration, communication, documentation, and patient intervention. Information and communication technologies (ICTs) in particular have the potential to optimize multi-actor care processes [
To date, the literature lacks studies that shed light on the potential and benefits of combining multi-actor care processes and supportive digital technologies in primary care. Hence, this study seeks to investigate the attitudes, perceptions, expectations, and needs of medical professionals located in a rural area, who play a role in multi-actor patient treatment processes. To accomplish this, our research draws upon qualitative results gathered from semistructured interviews as well as results from a web-based survey that was completed by both GPs and MAs. Both interviews and surveys were conducted in a region characterized by rural conditions and associated challenges. This mixed methods approach allows for a triangulation of findings and delivers richer insights into the target groups’ attitudes and perceptions regarding the use of digital technologies in health care, thus shedding further light on how these health care actors cope with increasing efforts provoked by the rural environment. Consequently, the objectives of this study are to investigate (1) the technologies that are suitable and effective for application in multi-actor care delivery and delegation processes in rural care and (2) the factors underlying the professionals’ use and perception of identified technologies that are already in use or exhibit future applicability.
We conducted a three-step, mixed methods approach to thoroughly investigate the phenomena of interest. As part of a regional project in Rhineland-Palatinate, Germany, with 11 different primary care physicians’ offices, this study empirically explored the potential of various digital technologies for enhancing delegation processes in rural primary care. Following our initial research objectives, we (1) collected and analyzed qualitative data from 19 interviews with GPs and MAs from 11 different primary care physicians’ offices participating in the project. Through our process of analysis, we discovered that the perceived differences between technologies that were already being used by medical professionals and new innovative technologies seemed to be important factors for the hypothetical adoption or rejection of innovative technologies. Therefore, to expand our understanding of the perception of innovative digital technologies by GPs and their MAs, we (2) conducted a web-based survey within the same population and used multidimensional scaling (MDS), which will be further explained later within this section, to reveal underlying patterns of technological preferences. GPs and MAs from our sample confirmed the results of our MDS in a subsequent workshop. Finally, we achieved a richer and deeper understanding of the investigated phenomena by (3) triangulating the results of both data sets [
As part of a regional project on the digitalization of delegation processes in German primary care, we conducted 19 qualitative interviews with GPs and MAs in 11 different rurally situated offices (we ensured to conduct at least one interview with participants from each office). All MAs that participated in this study underwent basic nonacademic clinical training for 3 years and had a supplementary qualification enabling them to undertake clinical tasks in ambulant care, comprising 190-270 hours of training. Originally, we had planned to conduct individual interviews only. Nevertheless, some offices asked us to conduct group interviews because of the high workload and time pressure. Therefore, we conducted 13 individual interviews and 6 group interviews with comparable characteristics.
Summary of interviewees’ characteristics.
Characteristic | Type of interview | ||||||
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Group | Individual | Total | ||||
Interviews, n (%) | 6 (32) | 13 (68) | 19 (100) | ||||
Duration (minutes), mean (SD) | 77 (23.4) | 59 (16.0) | 68 (20.0) | ||||
Participants, n (%) | 13 (50) | 13 (50) | 26 (100) | ||||
Age (years), mean (SD; range) | 43 (11.2; 26-59) | 49 (9.2; 31-61) | 46 (10.5; 26-61) | ||||
Job experience (years), mean (SD; range) | 20 (9.1; 7-35) | 26 (7.3; 9-37) | 23 (8.6; 7-37) | ||||
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Medical assistant | 8 (57) | 6 (43) | 14 (100) | |||
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General practitioner | 5 (42) | 7 (58) | 12 (100) | |||
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Male | 4 (57) | 3 (43) | 7 (100) | |||
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Female | 9 (47) | 10 (53) | 19 (100) |
In addition to demographic characteristics and general questions about their profession, we asked participants about (1) their current organizational processes of delegating medical services in ambulant care, the role of (digital) technologies for these processes, and possible solutions for emerging difficulties; (2) their relationship to patients and how (digital) technologies shape or affect them; and (3) the reciprocity of self-perception and the use of (digital) technologies, that is, how participants’ own understanding of their professional role affects their attitude toward (digital) technologies. The full interview guidelines can be found in
The regional project in Germany, which included this study, involved 11 GPs’ offices in rural areas. Following a purposeful sample [
To analyze the qualitative data, we followed a three-fold approach that was applied in a previous study in the health care domain [
Owing to inconsistencies in the findings from the qualitative study, which are discussed later in the
To visualize and analyze nonmetric sorting data to build clusters and interpret the latent dimensions of valuation, we used MDS. Through this approach, we were able to further examine the aforementioned contradictions from our qualitative findings.
Definition and summary of technologies used in the web-based survey to explore general practitioners’ and medical assistants’ latent dimensions of technology use.
Type of technology | Abbreviation used for analysis | Characteristics | Technologies already in use |
Telemedical electrocardiogram (12-lead) | TelECG | Records electronic signals of a patient’s heart to assess the cardiac health status of a patient with the same quality as a stationary 12-point ECGa, but allows remote operation at a patient’s home through MAsb and real-time data transmission to a physician | No |
Electronic medical record | EMR | Collects and stores patient data electronically; helps to organize and structure medical care in clinical settings | Yes |
Blood pressure monitor | BPM | Measures the blood pressure of a patient to assess information about a patient’s cardiac or general health status; can be either electronic or manual | Yes |
Blood coagulation monitor | BCM | Measures the coagulation level of a patient’s blood; often used on patients taking medication to thin their blood after cardiac or neurological incidents | Yes |
Telemedical stethoscope | TelSteth | Instrument to auscultate heart, lungs, or other body parts of a patient like a stethoscope, but allows remote operation at a patient’s home through MAs and real-time data transmission to a physician | No |
Mobile venoscope | MobVen | A mobile instrument to detect veins and venation through transillumination; facilitates the puncture of veins | No |
Smartphone | SP | Mobile phone with computer-like functions, including verbal and text-based communication, internet access, camera use, navigation, and its own operating system | Yes |
Blood glucose monitor | BGM | Measures the level of glucose in patient’s capillary blood; mainly used on patients with metabolic diseases, especially diabetes | Yes |
Digital appointment | DA | Audiovisual appointment (video consultation) between patient and general practitioner or patient and MA to digitally assess a patient’s health status | No |
Infrared thermometer | InfTherm | Measures the body temperature of a patient; indicates inflammatory processes in a patient’s body, for example, infections | Yes |
aECG: electrocardiogram.
bMA: medical assistant.
As this study aimed to determine the underlying dimensions of perception participants had to judge the value of a specific technology for their work, we contacted participants from our qualitative study and asked them to participate in our additional web-based survey. Therefore, we ensured a purposeful sampling approach within the same population of participants to draw conclusions from both data sets appropriately. Therefore, 2 members of the research group (MK and MM) contacted participants from the qualitative study who were then asked to participate in the survey study. The participants started the survey by providing their consent. From the initial 26 GPs and MAs participating in our qualitative interviews, 14 (54%) responded to our web-based survey, from which three data sets had to be removed because of incomplete data. The demographics of the remaining 11 participants are summarized in
MDS originates from psychological research, which has been used as an explorative approach for determining latent dimensions of nonmetric or metric data. It has been applied in different contexts regarding technology use, such as to differentiate between types of e-marketplaces [
Demographic information about participants from the web survey.
Characteristics | Values | |
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Male | 4 (36) |
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Female | 7 (64) |
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Medical assistant | 5 (45) |
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General practitioner | 6 (55) |
Age (years), mean (SD; range) | 45 (12.3; 27-62) | |
Job experience (years), mean (SD; range) | 21(9.1; 9-34) | |
Patient size of physician’s office (number of patients treated per year), mean (SD; range) | 4940 (1876.3; 1000-7600) |
In an MDS configuration, objects are represented as points in a multidimensional space (usually 2D or 3D). The distances between the points correspond to the empirical dissimilarity of the objects [
Eucledean distances allow an intuitive interpretation of geometrical configurations, as they represent our natural understanding of distances [
Compared with error functions from other statistical methods, such as regression analysis, a minimization of the
From our qualitative interviews with GPs and MAs, three main categories emerged for discussing the potentials of digital technologies in facilitating delegation processes: direct patient treatment, documentation and communication of treatment, and contrast of personal interaction and telemedicine. The main categories represent the highest level of content-related interpretation, following our approach for qualitative data analysis.
Our first category reflects participants’ perspectives on the important role of digital technologies for medical diagnosis and treatment through delegation. While recreating their daily work routines, GPs and MAs primarily described technologies that they already use to take direct measurements of medical parameters (mainly blood glucose levels, blood pressure, and blood coagulation levels) of patients in ambulant medical care. When considering the ongoing digitalization of the measurement of vital parameters (eg, continuous automated monitoring of blood glucose levels or the automated data transfer of blood pressure measures to a patient’s GP), participants evaluated present and future scenarios based on accuracy and instantaneousness of measurement, as well as the usability of technologies. For the measurement of blood pressure, GPs and MAs primarily use a combination of blood pressure cuff and stethoscope, both manual technologies. As digital versions of these measurement tools are easier to use but do not provide the same accuracy, GPs and MAs continue to use manual technology:
Sometimes, a patient has horrible blood pressure measurements [while using a digital blood pressure monitor], so you go to visit him. Then you measure it [blood pressure of the patient] yourself and tell the patient to put a new battery in it or something like that, so maybe it will take a better measurement next time.
Concerning the measurement of blood coagulation levels, both GPs and MAs mentioned the importance of technological innovation for the feasibility of delegation processes in ambulant care and time-efficient treatment processes. In the past, GPs or MAs had to take blood samples through venous punctuation and send them to a medical laboratory to determine a patient’s coagulation level. Digital versions of blood coagulation monitors can now instantly and accurately measure the parameters using capillary blood. Therefore, digital coagulation monitors are currently used almost exclusively for ambulant care:
In the past, . . . GPs had to visit the patients and had to take blood samples for coagulation, even before consultation hours. In the afternoon they had to see the patients again . . . it was very complicated, and now it’s easy, isn’t it?
Similar to blood coagulation levels, the blood glucose levels of patients are also usually measured with digital equipment, as only capillary blood is needed for an instant analysis and accuracy does not vary much in comparison to venous sampling. GPs mentioned that MAs were competent enough to assess whether a patient’s blood pressure, blood glucose level, or blood coagulation level necessitated notifying the GP about the patient’s health status. While discussing potential digital innovations for these kinds of technologies, such as automated data transfer or push notifications in case of an unusual deviation in a patient’s vital parameters, GPs preferred receiving the subjective interpretation from an MA through a direct phone call, as GPs were likely to ask additional questions about a patient in a potential emergency case:
They [MAs] give me a call when something’s wrong. . . . and they’re very quick—quicker than some typed message that I maybe wouldn’t hear. In this situation, automated data transfer isn’t of any use. When a patient has a blood glucose level of 60 [hypoglycemia], they know what to do; they know it’s too low and they have to do something.
Aside from already familiar technologies, participants discussed in detail the potential of two innovative digital technologies for ambulant medical care: mobile telemedical electrocardiograms (ECGs) and telemedical stethoscopes. In contrast to monitors for blood glucose levels, blood pressure, and blood coagulation levels, the interpretation of ECGs or auscultation sounds is highly complex and is usually not delegated to MAs. However, MAs are competent in recording patient data for the GP:
I can’t evaluate it [ECG], that’s the doctor’s business . . . I can put it on a patient . . . and then I bring it to the office. There it’s evaluated and the doctor decides what to do with it.
Therefore, a mobile version of an ECG that is able to transfer an ambulant patient’s data in real time to the GP’s office (hereafter called a telemedical ECG) was discussed in the interviews as an innovative technology that could be used in daily work. Mostly, GPs and MAs believed that this technology would be helpful in recording and analyzing a patient’s ECG data remotely. Especially when an ambulant patient’s medical issues occur spontaneously, MAs liked the idea because they could reassure themselves and the patient through a direct evaluation of the ECG data:
To transfer ECG data, that would be great. I’d like that a lot, I could imagine, to somewhat delegate medical problems . . .
Nevertheless, accuracy remained an important factor for GPs and MAs in deciding to actually use a telemedical ECG, as they emphasized the necessity of a telemedical ECG to generate a quality of medical data that are comparable with state-of-the-art stationary ECGs (12-lead). Although participants found the idea of a telemedical ECG highly interesting and relevant, the GPs were especially pessimistic about the cost-effectiveness. Owing to the high purchase prices and the lack of reimbursement by social health insurance, numerous GPs formulated resistance to actually purchasing a telemedical ECG:
If I had one [telemedical ECG], that would be really helpful, but you have to consider that I couldn’t even charge something for the use of it. . . . So alas, it’s a cost-benefit analysis once more.
Similarly, the opportunity to auscultate ambulant patients from a distance by instructing qualified MAs on how and where to put a digital stethoscope on the body of a patient seemed to be of high interest for GPs. By enabling the collection of medical data and real-time transfer to a GP’s office, telemedical stethoscopes were seen by GPs as a likely way to save time:
Well, it surely would make my work easier, if I don’t need to visit every older patient with a cold anymore, if I could just auscultate them remotely.
GPs and MAs mentioned that a telemedical stethoscope could be practical because of its variety of uses. Telemedical ECGs are used solely for medical issues involving functional cardiac abnormalities. Telemedical stethoscopes’ indications include cardiac, pulmonic, and unspecific medical problems.
Our second category contains the participants’ discussions of the potentials arising from digital documentation and communication. GPs and MAs emphasized the importance of mobility and ubiquity of information, but also mentioned hindrances for the sustainable use of digital technologies. While discussing the digitalization of communication about patients and their treatment processes, GPs and MAs pointed out the role of direct contact between GP and MAs in daily work routines. As MAs might unexpectedly encounter a patient with severe medical issues, all of the included GPs’ offices provided an emergency call system. Thus, MAs can talk to a GP at any time if they think it is necessary. In addition, participants talked about the use of private messaging systems for cases in which communication was not urgent. As one of the most recent widely discussed innovations in primary care, digital telemedicine systems that enable audiovisual communication (video consultation), combined with the remote transfer of medical data in real time (eg, telemedical stethoscopes) were perceived as helpful for delegation processes by GPs and MAs. Three different benefits were primarily associated with telemedicine systems: replacing a GP’s home visit through digitally mediated delegation, improving (ad hoc) diagnostics in ambulant medical care, and reassuring MAs in ambulant medical care. Although GPs were skeptical about fully replacing direct bilateral contact with a patient through telemedicine, telemedicine-mediated interactions involving MAs were considered helpful in some situations:
If I could actually have a look at the patient, like in a video conference, and our medical assistant asks some additional questions and I got some relevant parameters, I could really imagine saying, “Well, the patient’s all right; he’s stabile, so there’s no need for me to visit him.”
In addition, GPs mentioned that they would not rely on a patient’s ability to use a telemedicine system for diagnostic purposes on their own; for example, as the use of telemedical ECGs might be complex, and potential misuse might lead to misleading information. Therefore, the medical competence of MAs was discussed as an important factor for using digital technologies to potentially improve ambulant medical care and overcome a patient’s lack of competence in adequately using such technology. Telemedicine systems were considered by MAs to be useful as an innovative channel of communication that can help to better determine the potential diagnosis of a patient after they initially assess the patient’s health status:
If I could send some data directly to the doctor, that would make things easier. So that telemedicine, when I put on an ECG, the doctor might tell me from his desk, if it’s alright or not, if we have to call an ambulance or if he needs to visit the patient by himself.
Through telemedicine systems, MAs saw the possibility of contacting a GP regarding a medical situation that they were not fully able to assess. Closely related to the improvement of the quality of a diagnosis in delegation processes, telemedicine seemed to provide a feeling of security and reliability:
When facing a critical situation, I think it [video consultation] could help me to feel safe. Because I’m usually alone on-site . . . I think I would be more confident when I think the patient’s not looking good, I better turn it on and the doctor sees what I see.
Although telemedicine systems, therefore, appear to be helpful for direct communication in ambulant medical care, health records are used to collect and sort patient information and data over a longer period of time. Participants discussed the use of mobile electronic health records (EHRs), and MAs especially pointed out the importance of having access to relevant patient health records in ambulant medical care. As direct contact with a GP is usually reserved for critical situations, MAs discussed their need for a medium through which to collect relevant information about a patient’s health status. Although all participating offices installed some type of EHR in their systems, remote access to patient information seemed to be difficult, as mobile versions of EHR were not installed on suitable devices or their actual use was impractical. Nevertheless, participants emphasized the potential benefits of easy-to-use mobile documentation that could make manual documentation obsolete:
. . . and then I write it down, write it all down and sometimes I can’t figure out my handwriting afterwards and therefore it [mobile EHR] would be useful. So you can write it down directly and be connected to a patient’s entire medical history.
Although some participants mentioned that manual documentation was carried out very quickly while making home visits, most participants reported the necessity for double documentation later:
. . . here [doctor’s office], you’re sitting for hours to write down everything you did on home visits. It takes a lot of time. So, if you could just make your documentation while you’re still on home visits, that would save a lot of time.
Furthermore, GPs remarked on the lack of interoperability, not only between mobile software apps and applications in their office but also between their own documentation software and the software used by hospitals, nursing homes, or other GPs. Especially when patients move from clinical to ambulatory care, GPs pointed out that transferring the patient’s clinical data or updating medication takes a lot of time because the inability to transmit records electronically means that it must be done manually:
When a patient comes to me with his clinical reports, that’s a catastrophe. You get hand-written reports, . . . you have to transfer into the EHR. Also, it doesn’t work with ambulant nursing care, it doesn’t work with nursing homes.
Communication and documentation technologies seem to be essential factors for a dynamic and uninterrupted workflow, from the perspectives of GPs and MAs. Although telemedicine systems enabling audiovisual communication between the GP, MA, and patient or real-time remote transfer of medical data (ECG and auscultation sounds) are recognized as helpful digital innovations, the digital technologies that are already in use (EHR) do not seem to have reached their full potential because of a lack of interoperability and user-friendly mobile apps.
In our third category, we subsumed participants’ discussion of the risks and limitations of digital technologies concerning team-based primary care and the interaction between them and patients. Aside from considerations about the usefulness of digital technologies regarding direct patient interventions or superordinate processes of medical care, participants perceived the use of technology as contextual, that is, directly or indirectly embedded in a specific social interaction. Although the positive aspects of telemedicine system use were discussed, most participants were skeptical about replacing direct physical interaction with digitally mediated interaction:
It makes a difference . . . It’s not the same. I think the gold standard is a direct encounter, to be in the same room; that’s just different to [audio-visual telemedicine].
Participants further differentiated the limitations of telemedicine use into those resulting from a perceived restriction of relevant patient data (eg, skin conditions, walking behavior, or general appearance) and those resulting from the absence of bodily contact itself. In particular, GPs emphasized their need to use multiple sensory inputs to correctly diagnose a patient:
Well, I don’t know how he [the patient] smells, I can’t have a look at his skin. Is he sweating? Is his skin cold not supplied with enough blood? I want to examine him [physically]. And these are things that are most relevant for the diagnosis you find, in the end. For me, it plays an important role.
Some MAs argued that not only is the ability to evaluate the physical conditions of a patient reduced by digitalized home visits but also the ability to evaluate environmental factors, such as the general condition of a patient’s home or the presence of objects that could potentially increase the fall risk in older patients:
Also, it’s about fall risk; I have an eye on that. There might be a new carpet, causing a risk or cables lying in a patient’s way. I talk to the patient about these things, or his relatives.
Aside from more objective limitations, GPs and MAs discussed the meaning of bodily contact with a patient as a part of the social interaction itself. Participants mentioned the importance of direct contact with patients, not just to medically treat them correctly and comprehensively but also to form a relationship with them. Participants were not able to completely explain what underlying assumptions lead them to the impression that a direct, nondigitally mediated interaction is preferable to the use of telemedicine for the purpose of social interaction. Nevertheless, they emphasized the advantage of direct contact with the patient to build a relationship in which trust can be created and patients feel safe to talk about personal problems:
The bodily presence. The contact . . ., especially for older patients. My job is especially about old people. They need it. Or maybe some joking or something like that. You won’t do that when you’re on the computer. When you’re sitting directly with each other, then some things are discussed. And that’s missing while using telemedicine. If everything was to be digital, something would be missing.
In contrast, participants also considered the social effects that the use of technology itself has on patients, for example, the feeling of security and control when blood pressure or blood coagulation are being monitored. In particular, GPs compared the positive effect of technological use on patients with the placebo effect known from medication:
The patient has a good feeling, then. Technology is always great. Something beeps, some additional measurement for some specific symptoms. Technology has something like a placebo effect.
In addition, participants assumed that technology adoption by patients was highly affected by the attitude of the attending GP or MA. Participants reasoned that the technological adoption of patients might depend on the formulated medical necessity and the explanation given by the GP or MA:
But they don’t really ask many questions about it [long-term blood pressure monitor or ECG]. We tell them how it is done, how it works. And then it’s all right, so it’s very uncommon that someone asks questions about it. They rely on what we said about it.
In summary, GPs and MAs were aware of the factors that influence the relationship between them, the patient, and the use of technology. Participants reflected on the potential effects of innovative technologies on social interaction and discussed the limitations from their point of view. Interestingly, our three main categories, therefore, represent three different dimensions of technological use in ambulant medical delegation: (1) an interventional dimension involving direct patient contact, defining the action of care; (2) a superordinate dimension of communicating and documenting care; and (3) a reflective social dimension in which participants discussed contextual and relational factors of technology use.
In the process of analyzing and summarizing the qualitative findings from the focus group and individual interviews, contradictions were identified between the interviewees’ perceptions of innovative technologies and technologies that were already in use. Several times during the interviews, participants seemed to reject innovative technologies (eg, telemedicine systems used to contact patients from a distance) while using specific arguments (eg, risk of private data misuse) that they did not apply to technologies that were already in use (eg, smartphone use to communicate patient data). As the underlying mechanisms of subjective technology valuation must be considered an important factor for technology use [
By applying MDU, we explored the underlying dimensions of the GPs’ and MAs’ perceptions of the usefulness of relevant technologies in facilitating the process of delegation in medical ambulant care. Qualitative results suggest the various categories and factors that GPs and MAs use to evaluate different types of technologies; the subjective motivation and individual perception of technologies help to fully understand and explain the behavioral intention and the actual use of technology by medical professionals. By merging the results from both the qualitative and survey studies, we intended to contribute to a comprehensive understanding of the role of digital technologies in primary care delegation processes.
To determine the number of dimensions that are appropriate for interpretation, we analyzed the
As it showed the lowest
To provide a possible interpretation of our results, we changed the angles of our selected configuration and fixed one dimension after another (
Summary of different configuration characteristics.
Dimension | Number of iterations | |
1 | 12 | 0.41 |
2 | 62 | 0.24 |
3 | 113 | 0.18 |
4 | 10,000 | 0 |
3D configuration of technologies and participants to visualize the perceived technological relevance for daily work routines (numbers represent participants, words represent different technologies). BCM: blood coagulation monitor; BGM: blood glucose monitor; BPM: blood pressure monitor; DA: digital appointment; EHR: electronic health records; InfTherm: infrared thermometer; SP: smartphone; TelECG: telemedical electrocardiogram; TelSteth: telemedical stethoscope.
3D configuration with fixed first dimension (numbers represent participants, words represent different technologies). BCM: blood coagulation monitor; BGM: blood glucose monitor; BPM: blood pressure monitor; DA: digital appointment; EHR: electronic health records; InfTherm: infrared thermometer; SP: smartphone; TelECG: telemedical electrocardiogram; TelSteth: telemedical stethoscope.
3D configuration with fixed second dimension (numbers represent participants, words represent different technologies). BCM: blood coagulation monitor; BGM: blood glucose monitor; BPM: blood pressure monitor; DA: digital appointment; EHR: electronic health records; InfTherm: infrared thermometer; SP: smartphone; TelECG: telemedical electrocardiogram; TelSteth: telemedical stethoscope.
3D configuration with fixed third dimension (numbers represent participants, words represent different technologies). BCM: blood coagulation monitor; BGM: blood glucose monitor; BPM: blood pressure monitor; DA: digital appointment; EHR: electronic health records; InfTherm: infrared thermometer; SP: smartphone; TelECG: telemedical electrocardiogram; TelSteth: telemedical stethoscope.
In
Considering
Finally, we propose
In accordance with the initial objective of our survey study, our results suggest three latent dimensions of subjective technology valuation by GPs and MAs. First, participants appear to assess the (potential) value of a technology by its extent of practical implementation, that is, the
To ensure that the dimensions of participants’ perceptions are valid, we discussed and reflected our findings from MDU with 17 physicians and MAs from our sample, as recommended by the literature [
3D configuration with interpreted dimensions (numbers represent participants, words represent different technologies). BCM: blood coagulation monitor; BGM: blood glucose monitor; BPM: blood pressure monitor; DA: digital appointment; EHR: electronic health records; InfTherm: infrared thermometer; SP: smartphone; TelECG: telemedical electrocardiogram; TelSteth: telemedical stethoscope.
Reflecting the results from both the semistructured interviews and the survey study, we discussed the role of medical delegation for future primary care and the preconditions for a sustainable and effective implementation. Thereafter, we reasoned about specific aspects that are worth considering in the process of digitalizing primary care through mediated delegation and are needed to reflect possible (unintended) changes regarding the interaction between patients and medical professionals, that is, the subjectivity of medical data and the key role of MAs. Finally, we discussed possible challenges in the process of digitalizing primary care through mediated delegation and implications for theory and practice.
As it is an essential prerequisite for multi-actor care processes, our data show that GPs attribute high degrees of competence and expertise to MAs when it comes to assessing a patient’s health status and interpreting symptoms and parameters. Hence, MAs can pre-evaluate patient data and communicate it to the GP. In this process, both sides benefit from the integration of telemedical tools, such as digital measurement equipment and sensors, as the objective data they produce better inform the assessment of MAs. As a result, these tools expand the scope of what a GP can delegate and what an MA can actually do on site with the patient. As proposed by the diffusion of innovations model [
Another important factor that underlies the GPs’ and MAs’ perceptions of the use of technologies in direct patient care is the accuracy and instantaneousness of the applied sensors, the devices, and the resulting data. The participants stressed that the accuracy and quality of data is a major prerequisite for using digital technologies. For the evaluation of practicability and usefulness, GPs and MAs seem to consider the quality of medical data generated from a specific technology. Although usability might be relevant for technology use in general, participants rejected easier-to-use digital technologies because of their perceived lower precision. Furthermore, the objectiveness of technology is associated with participants’ subjective perceptions of technological relevance, implying that the development of digital technologies for measuring medical parameters should address not only innovative ways to measure but should also ensure at least a constant quality of data compared with already elaborated technologies and procedures. Moreover, the consideration of legal frameworks or boundaries at an early stage in the development process might increase the adoption of innovative digital technologies because of the GPs’ desire for cost-effectiveness, as the reimbursement of technology-mediated treatment by (social) health insurance companies seems to be an important factor for medical professionals when assessing a technology’s usefulness [
When it comes to the interpretation of medical data, our results suggest that GPs and MAs consider several subjective and environmental factors to be highly relevant, such as the state of a patient’s home, medical history, or complex sensory impressions. Although common telemedical solutions such as video consultation systems enable practitioners to derive an initial picture of the patient based on what the camera captures and what the patient verbalizes, such technologies are still perceived as limited [
The findings further indicate that the degree of responsibility and accountability with regard to actions performed by MAs when visiting a patient at home increases through the application of supportive telemedical tools. The data show that an MA, who is equipped with digital technologies such as telemedical stethoscopes or telemedical ECGs, is empowered to conduct a broad spectrum of diagnostic measures in a more autonomous and deliberate way. As a side effect, the presence of a supportive technology provides additional assurance to the MA as it augments the MA’s subjective assessments with objective data, for instance, in the form of vital parameter measurements and visualizations. Furthermore, digital ICTs are able to reassure MAs by providing an enhanced amount of information about a patient, for example, mobile apps of EHRs or an enhanced remote interaction between the GP, MA, and patient by bridging spatial and temporal limitations [
Considering the major challenges that arise from the individual use of telemedicine, such as the insecurity of patients (and their relatives) to assist in a remote examination by manipulating technology [
Furthermore, our results suggest that the adoption of digital technologies by GPs and MAs may be partially explained by the theoretical concept of bounded rationality. Considering the assumption that human decisions are not entirely based on a rational balancing of costs and benefits, but on heuristics and cognitive simplifications as well [
Through our empirical findings, we provide insights into digital technologies and their potential for multi-actor delegation processes in primary care in relation to research, medical practice, and the development and design of technology. For theoretical reasoning, our paper points out several factors that are relevant for expanding the understanding of technology use by medical professionals. Within the context of multi-actor approaches to delegation in primary care, the results suggest that MAs facilitate the use of and access to health care technology for patients. There, MAs might even be able to compensate for a possible lack of technological competence or skills and for the resistance of patients bypassing obstacles related to usability [
From a practical point of view, our findings indicate a strong potential and benefit of using digital technologies, especially those used for telemedical examinations and video consultation for delegation processes in ambulant primary care. This holds not only for GP-MA interaction but also between GPs and nurses or registered nurses and nursing assistants. Owing to a shift in the organization of health care that can be noticed in North and Middle European, or North American countries, the relevance of team-based primary care increases [
The results of our paper were bound to relatively small sample sizes. Although the explorative nature of our research objective matched our chosen methods of data collection and analysis, a potential bias might emerge from the fact that both studies were drawn from the same sample. In addition, data from our survey study represent only a part, but not the entire sample of our interview study, resulting in limited generalizability within the respective sample. Although GPs and MAs ensured the validity of our results from our survey study, our findings might partially reflect the tendency to confirm existing knowledge (from our interview study), rather than disprove them, known as confirmation bias [
Our study explores the potential of using digital technologies in primary care delegation processes. Interviews with GPs and MAs revealed the complex situational role of technology within these delegation processes. Although the results suggest that the importance of ICT is increasing because of its ability to remove spatial and temporal limitations, telemedical solutions appear to be promising, as they enable video consultation or automated transfer of medical data. In addition, telemedical solutions have the potential to facilitate direct patient treatment by merging medical and social competence to overcome demographic and structural changes, as well as to overcome deficits in patients’ technological competence. Therefore, digital technologies assist in finding innovative, case-sensitive, and cost-effective methods of treatment in primary care. Nonetheless, our study revealed the contextual nature of technology use in primary care. The adoption and implementation of technology underlie reciprocal processes involving different attitudes and perceptions within multi-actor settings. Furthermore, the results suggest that these attitudes and perceptions might be biased because of the underlying needs for action that are unique to medical treatments. Consequently, our study provides a foundation for further investigation of relational characteristics within multi-actor settings in primary care. Finally, practical suggestions are made to improve the development and distribution of innovative technologies for medical delegation processes.
Interview guidelines.
electrocardiogram
electronic health record
general practitioner
information and communication technology
medical assistant
multidimensional scaling
multidimensional unfolding
This study was conducted within the research project NaePas and supported by a grant from the district administration of Altenkirchen (Rhineland-Palatine, Germany).
None declared.