eConsultation – A Digital Service Centre

eConsultation is a digital service centre that offers solutions not only for remote care but also for health care enterprise resource planning and reporting. The eConsultation service also enables remote assessment of the need for care, remote treatment and appointment operations, as well as consultation between professionals, also between different organisations. [1]

eConsultation provides clients with a website and a mobile app. The service allows the client to contact a professional through the chat service without the need for identification. The client can see the average queuing time and the number of other clients ahead of them in the queue. The client may be invited to attend a remote appointment or a video call either according to a previously set up schedule or by email or by text message. [1] 

The professional’s interface provides a chat functionality to invite other professionals to chat and share attachments with the client. The alternative is a video call between the professional and the client. [1] 

Research evidence related to the assessed product 

As far as consultation between professionals is concerned, there is no researched data on the effectiveness of the service.  

The following effects are based on information provided by the company:  

A decrease in the number of referrals has been reported in the HUS psychiatric sector, coinciding with the introduction of eConsultation. Similarly, the instructions given in connection with the service for routing and formulating a referral, as well as eConsultation’s role as referral recipient, appear to promote a more streamlined process. According to the company, benefits have been realised in consultations between different specialised health care organizations as the need for patients to travel has diminished. [1] 

eConsultation collects information from the patient in advance, which allows a professional to focus on the specifics of the client’s situation. This may speed up and improve the treatment process. [1] There is no scientific evidence of the impact of the collection of advance data. 

Client feedback collected by the service provider on the chat service and its usefulness has been mainly positive. In addition, feedback is solicited from the occupational health video appointments, the mental health and substance abuse services appointments, and from the centralised primary health care service, and the experiences in these too are mainly positive. [1] 

The eConsultation chatbot, based on artificial intelligence, acts as a first response to an unidentified customer arriving to the service website. The chatbot has been in use at Päijät-Sote and Ylä-Savon Sote since October 2021, and its use has since been extended to the North Savo Wellbeing Services County as well as the private sector. The chatbot does not make decisions on the client’s need for care, but guides clients through the service pathway through search terms defined by professionals. Comprehensive statistical data on the performance and use of the chatbot have been collected during the operational period. The reduced use of the live chat concurrent with the introduction of the chatbot may indicate that chatbot has been accepted as an alternative to a traditional live chat. [1]

Literature reviews 

Several studies on telehealth have been published in recent years and, especially during the COVID-19 pandemic, teleconsultation has become a key issue [2]. A review carried out in 2021 demonstrates that remote care can reduce the need for hospital services, in particular with regard to the number of days spent in the hospital [3]. Telemedicine is usually implemented through videoconferencing and telephone connections. Videoconferencing offers several advantages over telephony, including fewer medication errors, greater diagnostic accuracy, and improved decision-making accuracy [4]. 

Remote assessment of the need for care 

A systematic literature review conducted in 2019 assessed the effects of the remote assessment of the need for care on health care. According to the review, remote assessment of the need for care can improve access to health care, reduce emergency and urgent care visits, and provide primary health care advice. However, there remain unresolved issues, such as the long-term impact of such assessments of the need for care and the necessary training for personnel. Although the results are promising, further research is necessary to gain a better understanding of the long-term effects of the remote assessment of the need for care as well as patient satisfaction. [5] 

Efficiency and suitability of remote contacts 

Although telemedicine can offer an effective alternative to traditional face-to-face consultations for many patient groups, it is important to note that its effectiveness may vary with different circumstances, patient groups, and medical fields [2,6]. In diabetic patients, remote treatment appears to improve blood sugar management and reduce LDL cholesterol. However, no significant differences have been observed between video conferencing and face-to-face treatment with regard to mental health and substance abuse problems. In patients with heart failure, remote treatment improves quality of life, but does not impact mortality compared to traditional treatment. [6] 

A study conducted in Finland demonstrates that the remote treatment model for neurological care can improve access to treatment and reduce waiting times, and both patients and doctors are satisfied with the service [7]. The Current Care Guidelines editors have issued a Good Practice consensus recommendation stating that remote consultations and contacts can be made use of in matters related to the patient’s health that do not require a clinical examination at an in-person appointment. Remote contact may also be suitable for monitoring long-term illnesses, providing lifestyle guidance, assessment of the need for acute care, as well as mental health services. [8] 

Mobile technologies in communication between health care professionals and care management 

Available data on the impact of mobile technologies on the communication between health care professionals as well as care management has been extensively discussed. A 2020 Cochrane review examined the role of mobile technologies in the health care field. The review found that mobile technologies can significantly speed up the initiation of a patient’s treatment, especially when primary care providers and paramedics consult with specialists. At the same time, they provide increased opportunities for clinical trials and reduce referrals to specialised medical care, e.g. in fields such as skin diseases and chronic kidney diseases. Some health care providers expressed uncertainty about the remote treatment of dermatological illnesses as compared to face-to-face treatment. This uncertainty focused in particular on diagnostics and the drafting of treatment plans. However, it is likely that accumulated experience will reduce uncertainty. [9] 

Artificial intelligence-based chat programs 

The growing need for health care services and the possibilities of artificial intelligence have motivated the development of artificial intelligence-based chat programs, such as chatbots, to support health care provision. Studies have demonstrated the general effectiveness of chatbots in health care, but robust evidence is not yet available in adequate amounts and further studies are needed. [10] 

Risk management is based on the ISO 14971:2019 risk management standard and also meets the requirements of ISO 27001 as well as Traficom’s Criteria to Assess the Information Security of Cloud Services (PiTuKri) (v 1.1), as applicable and adequate. Each SaaS (Software as a Service) solution has been subject to separate risk analyses, which are reviewed for recentness at least annually and in general at any time changes to the system are made. [1] 

The company’s guidelines define communication practices for emergencies, such as notifying Valvira or Fimea of an incident. The company also has guidelines related to hazardous situations, near miss events, as well as dealing with negative customer feedback or complaints. [1] 

The company is not aware of any safety incidents or other anomalies in the safety of patients or clients caused by the service [1].  

If there are connection problems with the Internet connection required by the product, the service will be able to recover from momentary interruptions without any data loss over the break. For example, if a live chat is ongoing, the messages will be delivered after the internet connection has been restored. [1]

The service will incur deployment and maintenance costs. The cost of deployment includes technical delivery, possible integrations, and training. The costs vary according to the size of the organisation and the integrations sought. Maintenance costs consist of access rights, support, and maintenance and their amount depends on the organisation and extent of use [1]. 

On the basis of the information provided by the service provider, it appears that the cost of using the service is reasonable when compared to providing a corresponding service by other means. 

The assessment was carried out using the list of data security and data protection requirements for social welfare and health care procurement and the response material provided by SAG Flowmedik Ltd [1,11]

Crisis preparedness and prevention  

The service is audited annually by an external body as well as through the company’s internal auditing. eConsultation is automatically scanned on a weekly basis for generalised security threats. The company personnel have been allocated responsibilities to act as part of a “quick response” team in case of disruptions. 

User management 

When processing confidential information, strong identification is required. The service supports role-based user management, and the recentness of access rights is monitored at least biannually. 

Equipment

The product is a SaaS service. 

The service is provided through the Cloud 9 data centre environments provided by Telia. The processing and data centres are provided with round-the-clock security and access control. No devices remotely connected to the cloud are stored in the Flowmedik premises outside working hours. The storage on all devices is protected by encryption. 

Data protection 

Encryption keys are generated using SHA-256 hashes. The encryption algorithm used is AES-256 and the encrypted data is stored in the database in a BASE64 format. The database is backed up twice a day. The data is stored and processed in accordance with the GDPR and only within the EU/EEA. 

General guidance on procurement

During the purchase phase it is always important to contact the IT management, data security specialist and data protection specialist of the organisation. Please discuss with them whether the product in question fulfils your requirements. In addition, we recommend that wellbeing services counties utilise the European Union Agency for Cybersecurity’s (ENISA) data security procurement guidelines [12]. 

eConsultation is a comprehensive remote care, enterprise resource planning and reporting solution, i.e. a digital service centre. The service is available in principle for any operating system with a web browser. The service also includes native iOS and Android mobile applications for end users as well as professionals. The mobile applications support the accessibility functionality of VoiceOver (iOS) and TalkBack (Android). The service is optimised to work on all smart devices. [1] 

A white label solution will always be drawn up for the purchaser organisation, meaning the content of the service (for example, the colour contrasts and text content of the service) and the accessibility statement will always be specific to the purchaser. Availability and accessibility testing will be carried out on a per-purchaser basis. [1] 

The company seeks to design the user interfaces and other content of the service in accessible plain language and to take into account persons with poor Finnish skills. Other special user groups have also been taken into account in the service: 

• Screen readers can be used by people with poor eyesight, visual impairments, or deficient colour vision, and attention has been paid to colour contrasts.  

• Persons with hearing impairment and sign language speakers have been taken into consideration in, for example, ensuring the live chat and chatbot are entirely text-based.  
• The service is easy to use and guides the user through the process, helping persons with cognitive limitations. [1] 

The accessibility issues that have arisen have mainly concerned content provided by the purchasing organisations themselves. Efforts have been made to reduce these by instructing the purchaser organisation in the production of materials. 

Instructions for use are available directly in the system after logging in for both professional and client users. In addition, the company will provide the instructions during the deployment project to the organisation, which may choose to make them available e.g. through their internal network. There is also a demo version of the product that can be used during the deployment process. [1] 

According to the service accessibility statement, the service conforms to technical accessibility requirements equivalent to level A, AA, and AAA of the WCAG 2.1 guideline [1]. The accessibility may be impacted, among other things, by the modules to be deployed and the content and visual appearance input by the purchaser organisation. The purchaser organisation’s writers are instructed as to the required formatting of the content. The content of the service is fairly rigidly defined, so it is easy for the organisation to produce accessible content. [1] 

According to the company, the assessment of usability and accessibility is part of the continuous development process. The accessibility assessment of the service will be updated as necessary if its content or functionalities change significantly. [1] 

General guidance on procurement

The purchasing organisation shall take into account the accessibility requirements set out in the legislation in force at the time. [13-15] 

Interoperability 

The service can be integrated into various electronic patient records as well as other systems, including, but not limited to, LifeCare, Acute, and Esko, using e.g. the REST/JSON and HL7 standards. The service can make use of data from other systems (e.g. Suomi.fi identification) through interfaces. [1] 

Technical stability 

The company uses the lifecycle standard IEC 62304 for medical devices software, made up of three elements: 

quality management ISO 13485, risk management ISO 14971 and application risk classification IEC 82304. Application development is differentiated into three environments: development (DEV), testing (TEST), and production (PROD). Before the source code is deployed to production, the application goes through a number of testing steps and checks already at the development stage. [1] 

Updates of the service takes place in the background without affecting the users or the functioning of the service. The service is updated several times a month as needed. Updates are usually scheduled outside official hours as well as service hours for the most used services. [1] 

If necessary, it is possible to revert to an earlier version of the application [1]. 

In the last 6 months, the service has never been out of use [1]. 

Observations about artificial intelligence (AI) 

– The eConsultation artificial intelligence service acts as a first response to an unidentified end customer who arrives to the service website to search for information or electronic services. The chatbot makes use of the machine learning and natural language processing model based on the chatbot.com service.[1] 

According to information provided by the company, the accuracy, precision, and recall performance parameters of the chatbot have reached a 90% level. [1] 

About 700 service pathway models with thousands of search terms have been integrated into the system. The artificial intelligence reasoning is based on confidence scores; in uncertain situations the chatbot guides the user to a fallback function where they are recommended to seek more specific information on the sought subject. The chatbot will communicate directly with the user if it did not fully understand the input. It provides clear instructions to simplify the written message or alternatively offers specific service pathways that can help the user find the information or service they need. [1] 

Training and product support 

The company will provide training during the deployment projects as necessary. Such training sessions will be recorded if they are organised remotely. As a rule, the sessions are held in Finnish, but training in Swedish and English is also possible. The service provides clear and comprehensive instructions for professionals. Experience to date shows that professionals have most needed support from the business in conducting video appointments. [1] 

Error messages can be received by email, by telephone, or through the Jira ServiceDesk service. If a user tries to misuse the application or encounters an otherwise exceptional error situation, the application will provide the user with a clear error message. [1] 

The purchaser organisation provides guidance to clients using the service. The service offers an electronic feedback channel and the user has the possibility to also be in contact via email. The company will respond to all contacts within 14 days. [1] 

Distribution of the product 

The service is available in various wellbeing services counties, including HUS, Varha, OmaHäme, Satakunta, Päijät-Sote and Pohde. Some of the wellbeing services counties have been using the service since 2018. [1] 

1. The Digi-HTA questionnaire filled out by the company, not public information. 
2. Carrillo de Albornoz S, Sia KL, Harris A. The effectiveness of teleconsultations in primary care: systematic review. Fam Pract. 2022 Jan 19;39(1):168-182. doi: 10.1093/fampra/cmab077. PMID: 34278421; PMCID: PMC8344904. 
3. Peters GM, Kooij L, Lenferink A, van Harten WH, Doggen CJM. The Effect of Telehealth on Hospital Services Use: Systematic Review and Meta-analysis. J Med Internet Res. 2021 Sep 1;23(9):e25195. doi: 10.2196/25195. PMID: 34468324; PMCID: PMC8444037.  
4. Rush KL, Howlett L, Munro A, Burton L. Videoconference compared to telephone in healthcare delivery: A systematic review. Int J Med Inform. 2018 Oct;118:44-53. doi: 10.1016/j.ijmedinf.2018.07.007. Epub 2018 Jul 25. PMID: 30153920. 
5. Rushton S, Boggan JC, Lewinski AA, Gordon AM, Shoup JP, Van Voorhees E, Whited JD, Tabriz AA, Adam S, Fulton J, Kosinski AS, Van Noord MG, Williams JW Jr, Goldstein KM, Gierisch JM. Effectiveness of Remote Triage: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2019 Jul. PMID: 31971698.  
6. Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015 Sep 7;2015(9):CD002098. doi: 10.1002/14651858.CD002098.pub2. PMID: 26343551; PMCID: PMC6473731. 
7. Kuusisto, H. (2016). Tieto liikkuu, potilas ei: neurologisen lähetepotilaan etähoito: mallin käyttöönotto ja arviointi (Mobile data, stationary patient – Introduction and evaluation of telemedicine model in neurological referral patient care). (Dissertation, University of Eastern Finland). 
8. Mikkola I, Riekki M, Sipilä R, Suomalaisen lääkäriseuran Duodecimin nimittämän Perusterveydenhuollon avovastaanottotoiminnan mallit sote-järjestelmässä Hyvä käytäntö  konsensussuosituspaneelin puolesta. Perusterveydenhuollon avovastaanottotoiminnan mallit sote-järjestelmässä, Hyvä käytäntö -konsensussuositus (Available only in Finnish). Available at: https://www.terveysportti.fi/apps/dtk/ltk/article/hsu00024 Accessed on 26.1.2024.
9. Gonçalves-Bradley DC, J Maria AR, Ricci-Cabello I, Villanueva G, Fønhus MS, Glenton C, Lewin S, Henschke N, Buckley BS, Mehl GL, Tamrat T, Shepperd S. Mobile technologies to support healthcare provider to healthcare provider communication and management of care. Cochrane Database Syst Rev. 2020 Aug 18;8(8):CD012927. doi: 10.1002/14651858.CD012927.pub2. PMID: 32813281; PMCID: PMC7437392. 
10. Milne-Ives M, de Cock C, Lim E, Shehadeh MH, de Pennington N, Mole G, Normando E, Meinert E. The Effectiveness of Artificial Intelligence Conversational Agents in Health Care: Systematic Review. J Med Internet Res. 2020 Oct 22;22(10):e20346. doi: 10.2196/20346. PMID: 33090118; PMCID: PMC7644372. 
11. National Cyber Security Centre: Information security and data protection requirements for social welfare and healthcare procurements. Available at: https://www.kyberturvallisuuskeskus.fi/en/ncsc-news/instructions-and-guides/information-security-and-data-protection-requirements-social Accessed on 26.1.2024.
12. The European Union Agency for Cybersecurity Procurement Guidelines for Cybersecurity in Hospitals. Available at: https://www.enisa.europa.eu/publications/good-practices-for-the-security-of-healthcare-services Accessed on 26.1.2024.
13. Act on the Provision of Digital Services 306/2019 (Available only in Finnish). Available at: https://www.finlex.fi/fi/laki/alkup/2019/20190306  Accessed on 26.1.2024.
14. Regional State Administrative Agency of Southern Finland, Accessibility supervision unit. The requirements of the Act on Provision of Digital Services. Available at: https://www.webaccessibility.fi/requirements-of-the-act-on-the-provision-of-digital-services/ Accessed on 26.1.2024.
15. Act on public Procurement and concession contracts 1397/2016 (Available only in Finnish). Available at: https://www.finlex.fi/fi/laki/alkup/2016/20161397 Accessed on 26.1.2024.

Petra Falkenbach, Head of Assessment, FinCCHTA 

Jari Haverinen, Special Planning Officer, FinCCHTA 

Raija Järvinen, Special Planning Officer, FinCCHTA 

Teemu Mustola, Special Planning Officer, FinCCHTA 

Tommi Hanhela, Information Security Expert, University of Oulu 

Jere Kinnunen, Information Security Expert, University of Oulu 

Antti Koskela, Information Security Expert, University of Oulu