A total of 25 clinicians and nurses from different clinical and administrative departments participated in our research in the first round, and the number of 15 medical personnel participated in the second round. Participant characteristics are summarized in
Summary of participants’ characteristics.
| The first round survey (Size: 25) | |
|---|---|
| Age (mean: 37.24) | |
| 20–30 | 4 |
| 31–40 | 14 |
| 41–50 | 5 |
| 51–60 | 2 |
| Years of practice (mean: 12.68) | |
| 0–10 | 11 |
| 11–20 | 11 |
| >20 | 3 |
| Category of department | |
| Clinical departments (18) | Obstetrics and Gynecology (5/18) |
| Pediatrics (5/18) | |
| Otolaryngology (1/18) | |
| Emergency (1/18) | |
| Reproductive Medicine (1/18) | |
| Nutrition (1/18) | |
| Acupuncture and Tuina (1/18) | |
| Traditional Chinese Medicine (2/18) | |
| Dermatology (1/18) | |
| Health care department (3) | Children's Psychology and Rehabilitation (2/3) |
| Women's Health (1/3) | |
| Medical technology department (3) | Clinical Laboratory (1/3) |
| Pathology (1/3) | |
| Ultrasound (1/3) | |
| Administrative department (1) | Administrative Department (1/1) |
| Professional title | |
| Professor of medicine | 3 |
| Associate doctor | 5 |
| Attending doctor | 10 |
| Resident doctor | 3 |
| Deputy nurse-in-charge | 1 |
| Nurse-in-charge | 3 |
| Whether to participate in the Internet online consultation platform | |
| Yes | 13 |
| No | 12 |
| The second round survey (size: 15) | |
| Age (mean: 35.20) | |
| 31–40 | 14 |
| 41–50 | 1 |
| Years of practice (mean: 7.6) | |
| 0–10 | 12 |
| 11–20 | 3 |
| Category of department | |
| Clinical departments (11) | Neurology (1/11) |
| Urology (1/11) | |
| Otolaryngology (1/11) | |
| Obstetrics and Gynecology (2/11) | |
| Cardiology (1/11) | |
| Reproductive Medicine (2/11) | |
| Endocrinology (2/11) | |
| Nephropathy (1/11) | |
| Health care department (1) | Children's Psychology and Rehabilitation (1/1) |
| Medical technology department (2) | Nuclear Medicine Department (1) |
| Information Department (1) | |
| Administrative department (1) | Administrative Department (1/1) |
| Professional title | |
| Associate doctor | 12 |
| Attending doctor | 3 |
| Whether to participate in the Internet online consultation platform | |
| Yes | 12 |
| No | 3 |
We finished the data analysis after the first round survey, the obtained data was encoded and mapped to the TDF domain and COM-B model, and a coding tree was formed: the first-level coding refers to the three elements in the COM-B model, the second-level coding includes the 14 domains of the TDF framework, and the third-level coding includes 26 themes summarized by the questionnaire survey. In addition to topics derived from structural problems, each theme is supported by representative quotes (
Table of findings by TDF domains and COM-B model (
| Domains | Themes (barriers/enablers) | References |
|---|---|---|
| Capability (34.00%) | ||
| 1. Knowledge: What doctors and patients know on Internet hospital diagnosis and treatment. | Doctors’ affirmative understanding of Internet hospital practice (E) | "The Internet hospital is a progressive product that can facilitate patients’ treatment……" |
| Patients’ limited exposure/knowledge of eHealth (B) | More than half of the participants said that patients’ view that in-person medical care is superior to telemedicine is an important reason that hinders medical staff from participating in Internet hospital diagnosis and treatment. | |
| 2. Skills: What doctors know about how they should perform on the Internet hospital. | Diagnostic capability: Put forward higher requirements for doctors’ diagnostic ability (B) | "I need to complete the diagnosis and treatment tasks independently without the guidance of a superior doctor.” |
| Interpersonal skills: Put forward higher requirements for doctors’ interpersonal and communication skills (B) | "Online diagnosis and treatment is mostly discontinuous, the delay time is long, the family expression is often lengthy, consuming the patience of medical staff." | |
| Technical proficiency and relevant training (B) | "Poor application of technology will affect work efficiency." | |
| 10. Memory, attention and decision processes: Decision process regarding Internet hospital diagnosis and treatment. | Difficulties in decision process (B) | "Due to resource constraints and inability to check the body, there is an evaluation bias." |
| 14. Behavioural regulation: Management of doctors’ diagnosis and treatment behavior in Internet hospitals. | Lack of clear treatment guidelines (B) | "At present, there is a lack of specific guidelines for Internet hospital diagnosis and treatment." |
| Opportunity (14.81%) | ||
| 11. Environmental context and resources: Influence of the environment on doctors’ behaviour. | Limited resources (B) | "Doctors have limited time and energy, and discontinuous communication can eat into rest time." |
| Technical limitation (B) | "Network speed affects the effectiveness of Internet diagnosis and treatment." | |
| Not ideal setup (B) | "If the Internet hospital system and mechanism is more sound and can effectively protect the safety of doctors, nurses and patients… I support the launch of the Internet hospital." | |
| 12. Social influences: How others influence doctors’ behaviour of Internet diagnosis and treatment. | Patients’ preferences and needs (E) | "It is easier for people to see a doctor and consult a doctor, and they can visit a specialist without limitation by geography." |
| Social pressure(B) | "Many parents are prone to anxiety and expect complete satisfaction without seeing the patient." | |
| Motivation (51.19%) | ||
| 3. Social/professional role and identity: Personal qualities such as professional attitude and responsibility of medical personnel. | Professional Identity/Professional sense of responsibility (E) | "I have a sense of responsibility and care for the patients in the Internet hospital." |
| 4. Beliefs about capabilities: Perceived capability of doctors to perform Internet diagnosis and treatment. | Lack of self-efficacy (B) | "The psychological experience of doctors in online diagnosis and treatment is different from that offline: Online consultation is relatively uncertain so I may feel unsure about my diagnosis." |
| 5. Optimism: The confidence of medical personnel in the outcomes that can be achieved by participating in Internet hospitals. | The doctor's past experience brings confidence (E) | "Personally, I made inquiries in some public accounts and pay different prices for different doctors, they all listened carefully and answered questions in detail, rather than copied and pasted the textbook for you, so that you feel the money is well spent." |
| Medical risk and low diagnostic accuracy in past practice (B) | "At present, the rate of misdiagnosis and missed diagnosis on the Internet consultation is high." | |
| 6. Beliefs about Consequences: The doctors’ opinion about what could happen from performing Internet diagnosis and treatment. | Positive outcome expectations in the full medical processes, patients’ experience impression, and hospital social benefits (E) | "Avoid some face to face embarrassment (for example, some diseases are difficult for patients to talk about), reduce traffic jams around the hospital, and avoid unnecessary second visit to the hospital for prescribing the same medicine." |
| Negative outcome expectation: Limited effectiveness and low accuracy in diagnosis (B) | "It is not conducive to physical examination and family guidance, because rehabilitation professional needs a lot of physical examination, and the family guidance (of rehabilitation movements) sometimes need to be taught face-to-face." | |
| 7. Reinforcement: Measures to stimulate the willingness of medical personnel to participate. | Lack of economic incentives (B) | "Not charging allows some people to waste resources excessively." |
| Low diagnostic accuracy in past practice (B) | "Online diagnosis will not be too accurate, and the rate of misdiagnosis and missed diagnosis is high." | |
| 8. Intentions: The inclination of doctors to practice Internet diagnosis and treatment. | Lack of motivation: Added workload and hope for monetary rewards (B) | "Internet diagnosis and treatment takes more time and should be paid economically." |
| The use of Internet hospitals can promote effective diagnosis and treatment (E) | "I can know the situation of patients in advance, which is conducive to the return visit and save time." | |
| 9. Goals: How important is Internet hospital practice for stakeholders. | Low priority of the Internet hospital (B) | "Internet hospitals have been basically suspended due to excessive use of personal time, inefficient communication and high medical risks." |
| Better achieving the goal of whole-process medical treatment (E) | "Using the Internet makes it easy to answer patient consultations and follow up regularly." | |
| 13. Emotion: How doctors feel during the Internet hospital process. | Hesitation (B) | "Due to the uncertainty of online consultation, the psychological feelings of doctors in online diagnosis and treatment are different from offline, and they will be mentally uncertain and hesitation." |
| Lack of trust between doctors and patients (B) | "The process of communication lacks emotional support, and it is difficult to establish a sense of trust between doctors and patients in a short time." | |
Visualization of survey results in COM-B and TDF frameworks.
Seven themes including four TDF domains (Knowledge; Skills; Memory, Attention and Decision Processes; Behavioral regulation) relate to capability component. The mentions of these seven themes accounted for 34.00% of the total.
Some participants expressed affirmation of Internet hospital, and their positive understanding promoted their participation in the Internet hospital.
However, we know from participants that the main reason why they do not participate in the Internet hospital is because, some patients' disagreement with the effect of online treatment in their subjective willingness and refuse to use it. It follows that patient's limited knowledge of eHealth's effectiveness is a barrier of Internet hospital implementation.
The characteristics of online consultation in Internet hospitals determine that doctors need to complete diagnosis independently without access to patients, which puts forward higher requirements for professional ability.
Mental abilities like interpersonal skills and emotional intelligence are critical for effective diagnosis and treatment (
As relatively new technology, technical proficiency and training will impact use experience and effect. Adequate training is required for competence, but over 50% of respondents felt insufficiently trained.
Lack of examination, incomplete acquisition of medical history and other information, and discontinuous and incomplete communication of diseases make it difficult to obtain complete and sufficient information, which brings challenges to the diagnosis process.
Clinical practice guidelines exist widely in all medical fields and help to form normative medical behavior. A participant indicated a need for a practice guidelines.
Five themes including two TDF domains (Environmental context and resources; Social influences) relate to opportunity component. The mentions of these six themes accounted for 14.81% of the total.
Participants noted resource constraints, mostly time, made effective implementation of Internet-based clinics difficult. Technical restrictions prevent effective Internet treatment, reducing diagnostic efficacy.
Imperfect system processes and lack of external support (e.g., legal protection and evaluation mechanisms) hinder Internet hospitals from achieving ideal operating environments, reducing participation.
The advantages of Internet hospitals can indeed meet the specific needs or preferences of patients in practice, and provide a good social environment for the development of Internet hospitals.
The high demands and expectations of some patients and their families have brought social pressure virtually to doctors and nurses.
Fourteen themes including eight TDF domains (Social/professional role and identity; Beliefs about capabilities; Optimism; Beliefs about consequences; Reinforcement; Goals; Emotion) relate to motivation component. The mentions of these fourteen themes accounted for 51.19% of the total.
As a medical personnel, their sense of responsibility to patients urges them to do a good job of Internet diagnosis and treatment. More than 60% of the participants indicated that the obstacles (such as distance and cost) in the offline diagnosis and treatment of patients were the reason why they were willing to participate in the Internet hospital. It can be seen that the professional attitude of medical personnel hoping to better serve patients would also prompt them to participate in the Internet hospital.
The limited time, the higher requirements for diagnostic ability, and the uncertainty caused by the lack of relevant examinations all may make doctors question whether they can effectively serve patients. This lack of self-efficacy can hinder their use of Internet hospitals (
Medical personnel who have had positive experiences with Internet consultations as patients tend to be optimistic about Internet medical treatment. However, medical risks due to the lack of adequate legal safeguards and low accuracy in Internet diagnosis reduce medical personnel confidence in achieving their goals.
Unlike the “Optimism” domain which emphasizes confidence in achieving the best possible outcome, this domain focuses on the participants' prediction of a variety of possible outcomes. Affected by different realistic factors, medical personnel will have different expectations of results, which will have different impacts on their participation.
Internet hospitals use digital technology for accessible and convenient medical services, promoting follow-up visits and patient compliance. Participants noted social benefits of Internet hospital applications for hospitals, such as image and popularity is also an enabler. However, diagnostic difficulties including the absence of physical examination, incomplete history, bias in patient narratives and discontinuity in communication may lead to inaccurate diagnoses. Inadequate legal and institutional protection may harm doctor-patient relationships, hindering medical personnel participation.
Some participants expressed their disagreements of lack of economic incentives because free use may bring a waste of resources, but also make oneself lack of motivation as it occupies non-working time. The low diagnostic accuracy in past practice may also reduce their probability to participate in the Internet hospital (
Participants expressed a intention to be rewarded financially for their extra workload. The lack of an appropriate reward may hinder their decision to participate in Internet care.
The use of Internet hospitals can promote effective diagnosis and treatment from the aspects of return visit, follow-up and patient tracking. The actual needs of medical personnel in these areas will increase their propensity to participate in Internet hospitals.
“Goals” domain indicated the importance of Internet hospital to participants. Some participants placed Internet hospital as a low priority due to factors such as time, diagnostic accuracy and risk, but others saw it as a better achieving the goal of whole-process medical treatment which would facilitate their participation.
Internet therapy will bring different emotional responses and feelings than offline therapy. As we mentioned in “2.3.2 Beliefs about capabilities”, the uncertainty of online counseling can leave doctors feeling uncertain. Hesitation is one of the emotional barrier factors of Internet hospital promotion.
Internet hospital consultation mostly stays in text communication, and the lack of face-to-face communication make it difficult to build trust between doctors and patients, which is another obstacle mentioned by participants.
The ten most frequently mentioned factors are summarised in
Summary of the ten most frequently mentioned factors.
| Barriers | |
| 2. Skills |
Diagnostic capability: Put forward higher requirements for doctors’ diagnostic ability |
| 10. Memory, attention and decision processes |
Difficulties in decision process |
| 11. Environmental context and resources |
Limited resources |
| Not ideal setup | |
| 4. Beliefs about capabilities |
Lack of self-efficacy |
| 5. Optimism |
Medical risk and low diagnostic accuracy in past practice |
| 6. Beliefs about consequences |
Negative outcome expectation: Limited effectiveness and low accuracy in diagnosis |
| Enablers | |
| 12. Social influences |
Patients’ preferences and needs |
| 6. Beliefs about consequences |
Positive outcome expectations in the full medical processes, patients’ experience impression, and hospital social benefits |
| 8. Intentions |
The use of Internet hospitals can promote effective diagnosis and treatment |