eVisits in the digital era of Swedish primary care

Objective: To evaluate asynchronous digital visits (eVisits) with regard to digital communication, clinical decisionmaking,
and subsequent care utilization in the digital era of primary care in Sweden.

Methods: A mixed-methods approach was adopted across the various papers in the thesis, with all studies
evaluating the eVisit platform Flow in various clinical contexts.
- Paper I was a comparative study of digital triage decisions when presented with automated patient
history reports generated by the platform. Inter-rater reliability of triage decisions by majority vote in a
panel of five physicians was compared to triage decisions by a machine learning model trained using
data labelled by an expert primary care physician.
- Paper II was a qualitative focus group study of nurse and physician experiences of digital
communication at three primary health care centers using the platform. Themes were generated using
qualitative content analysis as described by Graneheim and Lundman.
- Papers III and IV were observational studies comparing office visits in the Skåne Region from Capio,
a large private health care provider, to eVisit patients from Capio Go, a national eVisit service. Adult
patients with a chief complaint of sore throat, dysuria, or cough/common cold/influenza were recruited.
eVisit patients were recruited prospectively digitally prior to their eVisit, while the office visit control
group was recruited retrospectively using letters. Paper III primarily compared antibiotic prescription
rates per sore throat visit, while paper IV primarily compared subsequent physical health care
utilization within two weeks for patients in the Skåne Region.

Results: Interrater reliability was low (Cohen κ 0.17) between the panel majority vote and the machine learning
model. Physicians and nurses experienced digitally filtered primary care, adjusting to a novel medium of
communication highlighting challenges in interpreting symptoms through text as well as alterations in practice
workflow using asynchronous communication. Antibiotics prescription rate within three days was not higher after
eVisits compared to office visits (169/798 (21.2%) vs. 124/312 (39.7%) for sore throat, respectively; P<.001). No
significant differences in subsequent physical visits within two weeks (excluding the first 48 h of expected “digi-physical”
care) were noted following eVisits compared to office visits (179 (18.0%) vs. 102 (17.6%); P = .854).

Conclusions: eVisits do not seem to be associated with over-prescription of antibiotics, or over-utilization of
physical health care when assessing common infectious symptoms. Given staff experiencing uncertainties in
interpretation of symptoms and triage decisions being inconsistent, eVisits may be best used as one of many
modalities to access primary care, with focus placed on facilitating patient-centered professional judgement by
staff, rather than automation of complex decisions.