Report: Video appointments in the primary care physician’s practice
What are Norwegian primary care physicians’ experiences with and beliefs about video appointments in 2019? Here are the results of a representative survey with 100 Norwegian primary care physicians.
The use cases that primary care physicians are positive towards are follow-ups for patients on sick leave, various forms of medical guidance, reducing the risk of infection, and relieving certain patient groups from traveling to the doctor’s office
Respondents who have previous experience with video appointments have found ways to incorporate them into their practice in a way that ensures medical prudence.
Survey background
We conducted this survey from March 27, 2019 to June 3, 2019, with a representative sample of 100 Norwegian primary care physicians (PCPs). The results have been tested for statistical significance. We have used the ordinary least squares method (OLS) throughout, in which we have controlled for gender, age-group, and number of patients. For further details on our materials and methods , please go to the end of the article.
In which cases are video appointments suitable?
The following twelve use cases are based on a report issued by the Norwegian Directorate of eHealth in 2019 on the use of e-consultations in primary care and urgent care, and supplemented by other scenarios that were mentioned when we pilot-tested the survey with five PCPs.
Narrowing down the application of video appointments in the PCP’s practice to twelve use cases makes it easier to see where the potential lies, and if there is a difference in beliefs between PCPs with previous experiences of video appointments and PCPs without.
Percentage of primary care physicians who agree that this scenario is suitable for video appointments.
Primary care physicians who have previous experience with video appointments are statistically more likely to feel positively about the use of video appointments in the following three instances (see methods section for more details):
As an alternative to telephone calls
PCPs who have had more than 5 video appointments answer that they believe video can act as an alternative to telephone calls more often than those who have had fewer than 5, however, this result is too uncertain for us to state that it is a statistically significant difference (p-value 0.137).
As an alternative to textual e-consultations
PCPs who have had more than 5 video appointments are estimated to be 26% more likely to believe that video appointments are a suitable replacement of textual e-consultations (p-value 0.019).
Follow-ups for patients on sick leave
PCPs who have had more than 5 video appointments are estimated to be 17% more likely to believe that follow-up appointments for patients on sick leave can be done over video (p-value 0.094).
Doctor’s notes (e.g., for high school students)
PCPs who have had more than 5 video appointments are estimated to be 21% more likely to believe that doctor’s notes can be given via video appointment (p-value 0.065).
As an alternative to telephone calls
PCPs who have had more than 5 video appointments answer that they believe video can act as an alternative to telephone calls more often than those who have had fewer than 5, however, this result is too uncertain for us to state that it is a statistically significant difference (p-value 0.137).
As an alternative to textual e-consultations
PCPs who have had more than 5 video appointments are estimated to be 26% more likely to believe that video appointments are a suitable replacement of textual e-consultations (p-value 0.019).
Follow-ups for patients on sick leave
PCPs who have had more than 5 video appointments are estimated to be 17% more likely to believe that follow-up appointments for patients on sick leave can be done over video (p-value 0.094).
Doctor’s notes (e.g., for high school students)
PCPs who have had more than 5 video appointments are estimated to be 21% more likely to believe that doctor’s notes can be given via video appointment (p-value 0.065).
As an alternative to telephone calls
PCPs who have had more than 5 video appointments answer that they believe video can act as an alternative to telephone calls more often than those who have had fewer than 5, however, this result is too uncertain for us to state that it is a statistically significant difference (p-value 0.137).
What percentage of appointments can be done over video?
Our list of diagnosis groups is based on data collected by Statistic Norway (SSB) on the number of consultations per diagnosis group in 2018. The selected diagnosis groups make up two-thirds of primary care physicians’ consultations.
We asked the respondents to estimate the percentage of appointments that could be done over video per diagnosis group.
The lowest estimates are unsurprisingly for accidents and injuries, and for respiratory tract infections. The highest estimates are for mental illness or disorders.
On average, respondents estimate that a total of 8.6% of appointments can be done over video.
There are no significant statistical differences in the estimates made by PCPs who have had more than 5 video appointments and those who have had fewer than 5. Nor are there significant differences with regard to gender or age. (For more details, see the methods section ).
What are the advantages and disadvantages of video appointments for patients?
We asked the primary care physicians what they consider to be the advantages and disadvantages of video appointments from the patient’s perspective. Respondents have the same answers (n=78) regardless of whether or not they have previous experience with video appointments.
The respondents see two primary advantages for patients: that they save time, and that the physician can be more available to the patient. They name examples, such as that the patient doesn’t have to take off of work, and can have a doctor’s appointment even if they are a long distance from the doctor’s office or are not healthy enough to travel to the office.
Advantages: As a patient, you don’t have to take off from work. Your PCP, who knows you and is familiar with your medical history, is available to you no matter where in the world you are. If you have reduced mobility or are in palliative care, your PCP is available to you without you having to get into a taxi or non-emergency medical transportation. Disadvantages: Now and then, there’s a need for further examination that requires extra appointments at the doctor’s office for the same issue.
Man, age-group 30-39, semi-rural location (Buskerud) Has had over 5 video appointments, has 750-1250 patients
The disadvantages are over-medicating or malpractice, improper treatment, and time wasted when a large percentage of patients will have to come into the office regardless. (If one is having video appointments only with patients whose issues can’t be solved through the medical secretary or other existing electronic methods, then the issue probably requires an in-person visit. So, why add the extra step of a video appointment?) I don’t see how saving time on travel or increased availability for the patient is favorable if the medical issue is not one that a patient would contact their doctor about otherwise.
Man, age-group 40-49, urban location (Oslo) Has had 0 video appointments, has over 1500 patients
Advantages: Shorter absences from work, no commute, no waiting in the waiting room (for the often-delayed doctor). A daily video drop-in period will offer increased access to medical help. Disadvantages: The patient has to pay (as opposed to telephone calls). They risk logging in and waiting for a while. Not everything can be handled over video, so they risk having to come into the doctor’s office anyways.
Woman, age-group 30-39, isolated rural location (Finnmark) Has had over 5 video appointments, has 750-1250 patients
Advantages: As a patient, you don’t have to take off from work. Your PCP, who knows you and is familiar with your medical history, is available to you no matter where in the world you are. If you have reduced mobility or are in palliative care, your PCP is available to you without you having to get into a taxi or non-emergency medical transportation. Disadvantages: Now and then, there’s a need for further examination that requires extra appointments at the doctor’s office for the same issue.
Man, age-group 30-39, semi-rural location (Buskerud) Has had over 5 video appointments, has 750-1250 patients
The disadvantages are over-medicating or malpractice, improper treatment, and time wasted when a large percentage of patients will have to come into the office regardless. (If one is having video appointments only with patients whose issues can’t be solved through the medical secretary or other existing electronic methods, then the issue probably requires an in-person visit. So, why add the extra step of a video appointment?) I don’t see how saving time on travel or increased availability for the patient is favorable if the medical issue is not one that a patient would contact their doctor about otherwise.
Man, age-group 40-49, urban location (Oslo) Has had 0 video appointments, has over 1500 patients
Advantages: Shorter absences from work, no commute, no waiting in the waiting room (for the often-delayed doctor). A daily video drop-in period will offer increased access to medical help. Disadvantages: The patient has to pay (as opposed to telephone calls). They risk logging in and waiting for a while. Not everything can be handled over video, so they risk having to come into the doctor’s office anyways.
Woman, age-group 30-39, isolated rural location (Finnmark) Has had over 5 video appointments, has 750-1250 patients
Advantages: As a patient, you don’t have to take off from work. Your PCP, who knows you and is familiar with your medical history, is available to you no matter where in the world you are. If you have reduced mobility or are in palliative care, your PCP is available to you without you having to get into a taxi or non-emergency medical transportation. Disadvantages: Now and then, there’s a need for further examination that requires extra appointments at the doctor’s office for the same issue.
Man, age-group 30-39, semi-rural location (Buskerud) Has had over 5 video appointments, has 750-1250 patients
A disadvantage for patients that the respondent's state is that video appointments don’t allow for physical examination nor laboratory tests, which may result in a patient visit to the office after all, or that the physician might overlook important details about the patient’s condition. This is related to the respondents’ reported belief that communication between doctor and patient is worse over video than it is in person. We discuss medical prudence for video appointments in-depth further down in the article.
The respondents also say that video appointments require a certain level of technical competence from the patient.
What are the advantages and disadvantages for physicians?
Regarding advantages and disadvantages for physicians, there are some recurring themes in the PCPs’ responses: Economics, time commitment, communication, and prudent medical practice.
Economics
Regarding economics, there is a concern of increased expenditure (5 respondents). On the other hand, there are respondents who believe that PCPs who use video appointments are paid more (12 respondents) because video appointments have a higher price than telephone calls, and because video calls are typically shorter than in-person appointments.
Time commitment
When it comes to the time commitment of video appointments, responses are divided. Respondents see video appointments as both potentially time-wasting (16 respondents), but also time-saving (24 respondents). Those who have previous experience with video calls generally have a more positive view of the time usage of video appointments.
Video appointments can save time in a number of circumstances. For example, they can save time as a replacement for home visits (3 respondents) or by increasing the physician’s flexibility in that they can work from anywhere, not only the doctor’s office (2 respondents). Video appointments can also create more flexibility for the physician, not just the patient (11 respondents).
Video appointments can waste time by creating a situation where a physician is doing the same work twice (3 respondents), or putting them in a position to work on technical troubleshooting.
Demand and patient groups
That video appointments may result in an increase in demand (12 respondents) is predicted more often by those respondents who have no previous experience with video appointments than with those who have. This is linked to a concern that video appointments will come at a cost to vulnerable and marginalized patients (4 respondents), by, for example, more resourceful patients taking up more time and having better access and technical knowledge. We discuss ethics and medical prudence further down in the article.
Communication
Some respondents report that it’s more difficult to have good communication over video (10 respondents) than in person. On the other hand, they allow for better communication than telephone calls (5 respondents).
I don’t see any significant advantages. Higher quality and safer decisions when the patient is there in the room. For other things, there’s always the telephone. Video requires an appointed time-slot, and the extra time needed for logging in, etc., without the corresponding benefit to the doctor. Economic incentive must be considerable. With the patient there in person, you can quickly get them any necessary lab tests without needing to book another appointment. With all of these elements, video just creates twice as much work. Research should be done on the risk of increased malpractice when "guessing vitals" rather than taking vitals. For example: The patient says they have a fever, but you can’t verify it or measure their temperature. The patient says they have back pain, but you can’t observe their gait when they walk from the waiting room to the office.
Woman, age-group 40-49, rural location (Hordaland) Has had 0 video appointments, has 1250-1500 patients
Advantages: They’re effective - can have more appointments per day, save time on walking to and from the waiting room, little administrative work (patients who have had them before can show up during the video drop-in hours without needing to contact the receptionist first). Can help in keeping wait times in the waiting room down as many issues can be discussed over video without the need for an in-person appointment. Can attend to issues when they’re fresh - not after the patients has waited 4 weeks for their appointment. Raises the patient’s threshold for making phone calls (patients have to actually be logged in at the correct time, and also need to pay for the consultation). Better control over one’s own workday; I take those video appointments that I have time for during the drop-in period, and am relieved of endless telephone calls in the afternoon. Video appointments also pay more than telephone calls. Disadvantages: You can’t predict how many people will show up for the video drop-in hours (but I have not yet had any experience of sitting and idly waiting). It requires some time in the beginning stages to teach patients about which issues are suitable for video.
Woman, age-group 30-39, isolated rural location (Finnmark) Has had over 5 video appointments, has 750-1250 patients.
Disadvantages: Yet another mode of communication you have to be available for. Yet another expense. Difficult to get some patients (most, I’d think) to understand why video appointments cost the same amount as in-person appointments. The boundary between telephone appointments (free for the patient) and video appointments can be confusing. Advantages? I see the advantages for patients, especially those with psychiatric needs or those on long-term sick leave. I don’t see any direct advantages for physicians, especially as you have to pay for equipment, for the monthly expense, and it’s yet one more actor interfering with how the EHR systems operate. It’s hard enough already. For the PCP it means loss of income, paying expenses for the service, but no one else takes the economic responsibility when things aren’t in working order. The doctor is responsible for the patient’s security, data security, and economic insecurity.
Man, age-group 50-59, semi-rural location (Telemark) Has had 0 video appointments, has over 1500 patients
Advantages: It gives me a competitive advantage because I can offer a good deal to many of my patients, many of whom have to travel long distances to get to my office or who have a busy every-day life, and video appointments tend to be shorter than in-person appointments = more time for other things, and I don’t have to take the trip out to patients in my district (which has several islands). Disadvantages: Laws that are not up-to-date with technological developments.
Man, age-group 40-49, rural location (Rogaland) Has had over 5 video appointments, has 1250-1500 patients
I don’t see any significant advantages. Higher quality and safer decisions when the patient is there in the room. For other things, there’s always the telephone. Video requires an appointed time-slot, and the extra time needed for logging in, etc., without the corresponding benefit to the doctor. Economic incentive must be considerable. With the patient there in person, you can quickly get them any necessary lab tests without needing to book another appointment. With all of these elements, video just creates twice as much work. Research should be done on the risk of increased malpractice when "guessing vitals" rather than taking vitals. For example: The patient says they have a fever, but you can’t verify it or measure their temperature. The patient says they have back pain, but you can’t observe their gait when they walk from the waiting room to the office.
Woman, age-group 40-49, rural location (Hordaland) Has had 0 video appointments, has 1250-1500 patients
Advantages: They’re effective - can have more appointments per day, save time on walking to and from the waiting room, little administrative work (patients who have had them before can show up during the video drop-in hours without needing to contact the receptionist first). Can help in keeping wait times in the waiting room down as many issues can be discussed over video without the need for an in-person appointment. Can attend to issues when they’re fresh - not after the patients has waited 4 weeks for their appointment. Raises the patient’s threshold for making phone calls (patients have to actually be logged in at the correct time, and also need to pay for the consultation). Better control over one’s own workday; I take those video appointments that I have time for during the drop-in period, and am relieved of endless telephone calls in the afternoon. Video appointments also pay more than telephone calls. Disadvantages: You can’t predict how many people will show up for the video drop-in hours (but I have not yet had any experience of sitting and idly waiting). It requires some time in the beginning stages to teach patients about which issues are suitable for video.
Woman, age-group 30-39, isolated rural location (Finnmark) Has had over 5 video appointments, has 750-1250 patients.
Disadvantages: Yet another mode of communication you have to be available for. Yet another expense. Difficult to get some patients (most, I’d think) to understand why video appointments cost the same amount as in-person appointments. The boundary between telephone appointments (free for the patient) and video appointments can be confusing. Advantages? I see the advantages for patients, especially those with psychiatric needs or those on long-term sick leave. I don’t see any direct advantages for physicians, especially as you have to pay for equipment, for the monthly expense, and it’s yet one more actor interfering with how the EHR systems operate. It’s hard enough already. For the PCP it means loss of income, paying expenses for the service, but no one else takes the economic responsibility when things aren’t in working order. The doctor is responsible for the patient’s security, data security, and economic insecurity.
Man, age-group 50-59, semi-rural location (Telemark) Has had 0 video appointments, has over 1500 patients
Advantages: It gives me a competitive advantage because I can offer a good deal to many of my patients, many of whom have to travel long distances to get to my office or who have a busy every-day life, and video appointments tend to be shorter than in-person appointments = more time for other things, and I don’t have to take the trip out to patients in my district (which has several islands). Disadvantages: Laws that are not up-to-date with technological developments.
Man, age-group 40-49, rural location (Rogaland) Has had over 5 video appointments, has 1250-1500 patients
I don’t see any significant advantages. Higher quality and safer decisions when the patient is there in the room. For other things, there’s always the telephone. Video requires an appointed time-slot, and the extra time needed for logging in, etc., without the corresponding benefit to the doctor. Economic incentive must be considerable. With the patient there in person, you can quickly get them any necessary lab tests without needing to book another appointment. With all of these elements, video just creates twice as much work. Research should be done on the risk of increased malpractice when "guessing vitals" rather than taking vitals. For example: The patient says they have a fever, but you can’t verify it or measure their temperature. The patient says they have back pain, but you can’t observe their gait when they walk from the waiting room to the office.
Woman, age-group 40-49, rural location (Hordaland) Has had 0 video appointments, has 1250-1500 patients
How can one ensure that video appointments conform to prudent medical practice?
The real dividing line between physicians who have had video appointments and those who have not is how they view medical prudence when using video.
Time commitment
Many respondents believe the lack of physical examination to be a disadvantage for patients (28 respondents) and as well as for physicians as it may weaken medical prudence (n=20). One aspect of video appointments that can actually improve medical prudence is that it’s easier to have better follow-up appointments (n=16).
The physicians with less experience with video appointments are the most concerned. The reason that the physicians with experience don’t report the same concerns is presumably that they have found good solutions to them. We asked the respondents with experience of over 5 video appointments how they handle issues raised in video appointments that require physical examination, lab tests, or similar:
This hasn’t happened yet. Probably most patients would find paying for both a video and in-person appointment to be unfair.
Man, age-group 40-49, rural location (Nordland) Has had over 5 video appointments, has 750-1250 patients
I usually set up an office appointment with the patient for some time in the following days. It’s never happened, but if the video appointment was in the late afternoon and there was an emergency issue, I would have recommended the patient contact the emergency room.
Woman, age-group 30-39, isolated rural location (Finnmark) Has had over 5 video appointments, has 750-1250 patients
Order a lab test so that the patient can come in to take it in the following days without a doctor’s appointment.
Man, age-group 30-39, semi-rural location (Møre og Romsdal) Has had over 5 video appointments, has 500-750 patients
Under certain circumstances, the patient will see a nurse who performs the examination or takes tests according to my instruction, at other times the patient has to see me.
Man, age-group 40-49, rural location (Rogaland) Has had over 5 video appointments, has 1250-1500 patients
Schedule them for a quick appointment at the office. If there’s the need for a blood test, I can order the test electronically and the next day the patient can go to the lab. Then the tests are ready for an appointment at my office.
Woman, age-group 40-49, urban location (Oslo) Has had over 5 video appointments, has 750-1250 patients
This hasn’t happened yet. Probably most patients would find paying for both a video and in-person appointment to be unfair.
Man, age-group 40-49, rural location (Nordland) Has had over 5 video appointments, has 750-1250 patients
I usually set up an office appointment with the patient for some time in the following days. It’s never happened, but if the video appointment was in the late afternoon and there was an emergency issue, I would have recommended the patient contact the emergency room.
Woman, age-group 30-39, isolated rural location (Finnmark) Has had over 5 video appointments, has 750-1250 patients
Order a lab test so that the patient can come in to take it in the following days without a doctor’s appointment.
Man, age-group 30-39, semi-rural location (Møre og Romsdal) Has had over 5 video appointments, has 500-750 patients
Under certain circumstances, the patient will see a nurse who performs the examination or takes tests according to my instruction, at other times the patient has to see me.
Man, age-group 40-49, rural location (Rogaland) Has had over 5 video appointments, has 1250-1500 patients
Schedule them for a quick appointment at the office. If there’s the need for a blood test, I can order the test electronically and the next day the patient can go to the lab. Then the tests are ready for an appointment at my office.
Woman, age-group 40-49, urban location (Oslo) Has had over 5 video appointments, has 750-1250 patients
This hasn’t happened yet. Probably most patients would find paying for both a video and in-person appointment to be unfair.
Man, age-group 40-49, rural location (Nordland) Has had over 5 video appointments, has 750-1250 patients
The above responses are representative of the answers we received to this question. The most common answer is that the physician would order any necessary laboratory tests or have the patient come in for a physical appointment, or recommend the emergency room when appropriate.
Materials and methods
The data collection method we chose was a questionnaire survey directed towards primary care physicians in which we combined quantitative and qualitative methods. The survey had a total of 18 questions. Five primary care physicians with varying amounts of experience with video appointments gave us feedback on the survey’s design before it was released.
Recruitment
The data collection period began March 27, 2019 and ended June 3, 2019. The only requirement of the respondents was that they work as primary care physicians. All respondents who answered “no” to this question were disqualified. Respondents who only answered the first page of the survey, which included only demographic variables, were not included in the results. The data collection period concluded when 100 primary care physicians had completed the survey to make sure that the results would be published while the issues included were still relevant.
The only incentive given to respondents was that Confrere would donate 50 NOK ($5.55) per physician who completed the survey to Doctors Without Borders. The survey was anonymous, and the respondents’ IP addresses were blocked from registration.
Respondents were recruited through several means:
Facebook ads directed towards healthcare personnel in Norway
Status updates on Facebook by Confrere
Emails sent to Confrere’s customers
The last page of the survey which encouraged respondents to share the survey with other primary care physicians
According to TNS Gallup, 87% of the Norwegian population used Facebook weekly or frequently in the fourth quarter of 2018. A closed Facebook group for Norwegian PCPs, “Allmennlegeinitiativet”, has around 3000 members. There are approximately 4700 primary care physicians in Norway. Based on this, we inferred that we could reach a representative sample of Norwegian primary care physicians via Facebook ads.
In the recruitment, we tried to use neutral language to avoid selection bias that could result in a majority of respondents who were either very positive or very negative towards video appointments.
Representative sample
In our survey, the sample appeared to be sufficiently representative enough to allow us to generalize the main findings when comparing the demographic data collected to that of the entire population of Norwegian primary care physicians. Regarding all demographics--gender, age, county, and number of patients--the survey’s respondents are in very similar range to primary care physicians nationwide, as according to the official register. However, we cannot rule out that random variation and selection bias may have caused inaccurate and skewed results.
Source: legelisten.no (Norwegian directory of PCPs)
There is no official statistic on how many primary care physicians in Norway use video appointments. In their 2019 report on video appointments, the Norwegian directorates for health and e-health had “identified a dozen PCPs actively using video appointments.” In a questionnaire survey conducted by the Consumer Council of Norway (n=161), 8% of PCPs stated that they use video appointments. In our survey, we have consciously over-represented the group that has had experience with video appointments as we have encouraged customers of Confrere to take the survey. Thus we have gotten representative groups of physicians who both have and have not had experience with video appointments.
No video appointments
60% (60)
1-5
9% (9)
More than 5
31% (31)
Statistical tests
We used the ordinary least squares method (OLS) in which we included gender, age group, number of patients, and if PCPs had more than 5 video appointments as explanatory variables in order to measure whether the differences between the groups were statistically significant. We also tested whether the results were sensitive to which control variables were included, which they were not unless otherwise noted. We did not assume linear effects of age nor number of patients but rather allowed for non-linear effects by including dummy variables for age groups (30-39, 40-49, 50-59, 60-69) and three categories of number-of-patients (under 750, 750-1249, and 1250 or more).
We refer only to the results that have lower p-values than the 10% level as statistically significant.
For each diagnosis group, the respondents indicated whether they believed that “under 10%”, “10-20%”, or “over 20%” of consultations for the corresponding diagnosis group could be done over video. In order to test if there was a statistically significant difference between the responses by those who had had over 5 video appointments versus those who had had fewer than 5 video appointments, each of these categories had to be assigned a number. We chose to interpret “under 10%” as 3%, “10-20%” as 15%, and “over 20%” as 30%. We then calculated the average portion of consultations that the physicians estimated to be suitable for video across the 12 diagnosis groups.
To estimate whether the estimated proportion of consultations suitable for video is influenced by whether the physician has had more than 5 video appointments, we used the ordinary least squares method (OLS) with dummies (/ yr) for gender, age groups, and number of patients as control (as well as a constant), with the left hand side variable as the average portion of consultations suitable for video. We found that whether or not the physicians had experience with video appointments did not have a significant correlation with the proportion of diagnoses they predicted would be suitable for video (p-value 0.85). Regardless of the average value set for the categories "below 10%", "10-20%" and "above 20%”, for example, 3-15-30, 5-15-20, or 9-12-40, the p-value is above 0.6 (the beta also changes sign). The result, therefore, appears robust.
Defining “under 10%”, “10-20%” and “over 20%” as 3-15-30 brings us to the conclusion that an estimated 8.6% of appointments are suitable for video. If we instead use 5-15-20, the portion is 9.4%. In other words, this finding is to a very small extent influenced by how these proportions are quantified.
Data analysis was carried out with the help of STATA 13.
Please get in touch with us at support@confrere.com for regression tables and code files.
