Video consultations in pediatric emergency services: Case study on technology use and satisfaction

The COVID-19 pandemic has led to significant disruptions at the health, social, and economic levels (Alscher et al. 2023). Numerous innovations have been used to contain the diverse consequences of the pandemic. New vaccines have been deployed, organizational and management models have been improved, and digital innovations have been introduced (Saw et al. 2021, Smith et al. 2021, Kis et al. 2021). However, the digitalization initiatives initiated in the healthcare sector have lost momentum. For example, video consultations declined by 40% between 2021 and 2023 (Techniker 2024). One reason for this is a lack of large-scale cross-country or cross-sector projects. This is surprising given that policymakers and researchers are clearly calling for comprehensive digitalization of healthcare for the population (Sachverständigenrat, 2021). Digital technologies help to better coordinate care needs and services, reduce diagnostic and treatment errors, shorten hospital stays, facilitate access to care, optimize health research, and improve important patient self-management (D'Onofrio, 2022).
Patient self-management is an important factor in successful healthcare systems in that it significantly promotes patient autonomy and thus self-efficacy. The experience of self-efficacy, in turn, is a key prerequisite for successful healthcare, promotion, and prevention (Schmutte et al. 2009, Eller et al. 2018). Telemedicine technologies that promote self-management and efficacy are therefore particularly promising. Video consultations are one such technology. They not only promote patient self-management but also increase the frequency of contact with therapists, facilitate the opportunity to interact with patients in their own homes, and provide more precise medical monitoring and improved emergency care (Frielitz et al. 2021).

> Against this background, the research question is examined using a single-case study design based on Yin (2014). It examines how video consultations are used as a comprehensive form of care in the healthcare industry and what levels of satisfaction they generate among patients. The project of the North Rhine Association of Statutory Health Insurance Physicians on the introduction of video consultations serves as the empirical basis, with the aim of deriving policy and management recommendations for action on large-scale digital projects in the healthcare industry.
Video consultations to support self-management
The discussion of optimal relationships between therapists and their patients has a long tradition in health research. In the case of children as patients, the particular challenge is that the concern for the child's well-being is shared between therapists and parents or guardians (Inthorn and Paul 2017). The concept of shared concern for the child's well-being leads to various consequences on psychological, social, economic, and legal levels.
From a sociological perspective, shared care leads to communicative negotiation processes between therapist and guardians on the one hand, and between the guardians themselves on the other (Inthorn and Paul 2017). A significant aspect of these negotiations is the self-management of patients and their guardians. This is often equated with empowerment and aims to develop the knowledge, skills, and motivation of patients and their guardians so that they are able to make active contributions to improving their own health or the health of their children (Lorig and Holman 2003). Maintaining and improving health is therefore also in the hands of the patients and guardians. This is a challenge in that equality between mothers and fathers has not yet been achieved. Care work is largely performed by mothers, although an increasing number of fathers are signaling a willingness to do so (BMFSFJ 2021).
Against this background, successful self-management manifests itself "equally on a cognitive and emotional level and encompasses the personal attitude toward [...] one's health status, the social environment, communication and decision-making processes regarding one's own health, as well as the relationship with the therapist" (Kemper 2019). With regard to the communication and decision-making processes mentioned, self-management promotes the important autonomy of patients and thus provides resources for individual and collective processes of salutogenesis (Herriger 2002, Entwistle et al. 2010). A resource that has received much attention in recent times is video consultation technology. These are telemedical interventions that use audiovisual communication technologies to offer mobile diagnostics, consultation, and monitoring, i.e., independent of location and across multiple spaces (BMG 2024).

Case study on video consultations in pediatric emergency services
Background to data collection
The North Rhine Association of Statutory Health Insurance Physicians (KV Nordrhein) introduced video consultations in pediatric emergency services as part of a pilot project to relieve pressure on emergency practices and specifically manage patient flows (KVNO 2023). The goal of the project was to use modern telemedicine solutions to relieve pressure on emergency practices by directing less urgent cases to medically appropriate care structures, thus making care more efficient. This is of great importance given the healthcare density of 9.5 million people in North Rhine, including 3.31 million children. The project was implemented at the end of 2023 in collaboration with partners samedi GmbH (platform for online appointment scheduling and video consultations), adesso SE (project management), and Duria eG (documentation system of the KV emergency service). The contract was awarded on September 6, 2023, and the first video consultation in the pediatric emergency service was conducted on December 1, 2023. The pilot project ended on January 31, 2024. The project was scientifically monitored and evaluated by the Health Policy and Strategic Security Department of the North Rhine Health Insurance Association. The evaluation of the pilot project was conducted comprehensively in two parts:
(A) the process evaluation within the framework of service provision and
(B) the satisfaction and self-efficacy evaluation of a patient survey.

(A) As part of the process evaluation, the feasibility, practical implementation, and utilization of the video consultation were systematically examined. Various data sources were used for this purpose. These included the appointment booking software "samedi," billing data from the practice management system Duria, and reports from the telephone on-call service 116117. The data obtained were used for the descriptive analysis of the patient population, the booked appointments, and the video consultations actually conducted.
consultations. The aim of this evaluation was to obtain a comprehensive picture of how well the implementation of video consultations is working and to what extent they are being used by patients.
(B) The satisfaction and self-efficacy evaluation was conducted as part of a patient survey. This survey assessed the patient's perception and outcome of the care process. The focus was on measuring patient satisfaction and evaluating the video consultation with regard to the perceived quality of care. Data was collected using a standardized online questionnaire that was sent to patients after the video consultations. The results of the survey are intended to provide information on the extent to which the video consultation meets patients' needs and how patients evaluate the newly introduced telemedicine care.

Use of video consultations
There was no significant difference in the gender of the patients (boys and girls) who used the video consultation. The mean age distribution of the children treated was 3.9 years with a standard deviation of 3.7 years (see Figure 1).
A total of 2,261 video consultations were booked during the project phase. Of these, 665 appointments were scheduled online (29.4% of the total). Of the booked appointments, 2,015 were completed, corresponding to a completion rate of 89%. The completed appointments constitute the population of this study (n = 2,015). In addition, there were 236 bookings that were canceled before the appointment (see Figure 2).
Video consultations were used nationwide in North Rhine (see Figure 3). It was found that the consultations were primarily used in smaller towns and districts. The top three districts were Remscheid, Oberbergischer Kreis, and Kleve District. The service was used less in larger cities such as Essen, Mönchengladbach, and Oberhausen.
The number of confirmed diagnoses was 1,635, with the top five confirmed diagnoses being fever (18%), respiratory infection (14%), conjunctivitis (10%), viral disease (6%), and vomiting/diarrhea (5%). For 12%) of the diagnoses, an e-prescription was also issued, which the patients received electronically via the video consultation, of which almost 50%) were for eye drops/ointments (with and without antibiotics).

Evaluation results and recommendations
The (A) process evaluation of service provision shows that video consultations are almost equivalent to physical consultations, especially for low-threshold interventions. The average duration of 7.1 minutes of video consultations (standard deviation: 3.4 minutes) is within the range of the duration of an average doctor's appointment, which in Germany is 7.6 minutes (Hanke 2022). These digital technologies also represent a means of relieving the burden on maternal care within the healthcare system and thus promoting shared care and equality. The service is easier and more accessible for fathers to use, thus motivating fathers to translate their concern for child welfare into concrete actions. Previous studies show that mothers take over 80–90% of pediatrician visits, while fathers only take their children to the doctor in 10–20% of cases (BMFSFJ 2021). This is in line with our recommendation to expand the availability of video technologies in order to achieve more balanced equality in health care.
In the (B) patient satisfaction survey, 595 of the 653 participants completed the survey in full, corresponding to 30% of the total population and a completion rate of 91%. To participate in the consultations, 65% of the parents used their smartphones, 10% used their tablets, and 25% used their laptops or PCs (with webcams). This demonstrates how important mobile, and thus flexible, location-independent technologies have become in healthcare. We would like to emphasize that the future of digital healthcare is mobile, coupled with the recommendation to plan future digital healthcare projects with the patient-centered premise of "ehealth first."
The video consultations conducted showed a completion rate of 45%. A total of 28% of the parents subsequently visited a general practitioner for the next available consultation based on a recommendation from the video consultation, 19% immediately visited an emergency practice based on a recommendation, and 8% did not provide any information on their further course of treatment. Only 5% of the children also visited an emergency practice without a recommendation from the video consultation, which underscores the steering effect of the intervention. Overall, 73% of the video consultations did not lead to further use of emergency practices/resources (i.e., 45% completion plus 28% regular doctor's visit). This represents a significant relief of scarce resources in the emergency services sector, even if the offer of a low-threshold video consultation may also generate supply-induced demand. If this relief
If this could also be achieved in the area of outpatient emergency care in clinics and hospitals, significant cost savings and a significant improvement in quality would be achievable by concentrating on genuine emergencies – especially on cost-intensive Sundays and public holidays. We therefore recommend expanding video consultations to other emergency areas within clinics and hospitals. We see interesting potential in geriatrics and elderly care in particular, particularly due to demographic trends in society. Further studies could examine forms of self-management in these areas, and to what extent video consultations, as a telemedical service, can also support adults in providing health care to their parents in geriatric medicine.
Parents' satisfaction with video consultations is high: 86% for consultation quality (vs. 5% neutral and 9% dissatisfied), 88% for platform usability (vs. 6% neutral and 6% dissatisfied), and 85% for connection quality (vs. 7% neutral and 8% dissatisfied). This result is consistent with the satisfaction with physical doctor's appointments in Germany, which, according to surveys by the National Association of Statutory Health Insurance Physicians, is 91%. However, it should be noted that with physical consultations, there is still a trust advantage due to repeat visits, which also influences perceptions of treatment quality. The Net Promoter Score (NPS) was used to measure overall satisfaction. It is a clear and proven measurement tool and has a high correlation with business success (Reichheld, 2003). A very positive NPS score of +61.7 was determined among participants in the video consultations (see Figure 4).
Typical NPS scores in public administration range from 0 to +20, in industry from +30 to +50, and for leading technology companies such as Amazon, Apple, or Microsoft, the score is +50 (e.g., Bain 2018), so that a score of over 60 can be classified as very good or excellent.
Digital Health – let’s start with the parents
This study on nationwide emergency care via video consultation in pediatrics shows high levels of satisfaction among parents and guardians (approximately 90% and NPS approximately 60%, respectively) and demonstrates the potential for significant improvement and enhancement of outpatient care. A case completion rate of almost half, reducing the burden on limited emergency room hours, and rapid completion during regular doctor's office hours support this. Furthermore, the technology can help ease the burden on maternal care within the healthcare system and promote equality through low-threshold access. The "eHealth First" premise must be followed here – our study results clearly demonstrate the high importance of mobile technology use for patients and caregivers.
Although the study is limited to pediatrics, the results demonstrate that, especially in pediatrics, high quality of care and very high levels of satisfaction are achieved, following the guiding principle "Let's start with the parents." This is an important finding for policymakers, healthcare managers, and medical services research.
This was confirmed by the then Federal Minister of Health, Prof. Dr. Karl Lauterbach (2023), in his recommendation for the KV North Rhine project on the short message service X: 'The video consultation for children, now offered by the KV North Rhine [...], is very useful. This significantly relieves the burden on practices. Other KVs should also use this.'
In addition, the study shows significant potential for expansion to other emergency areas in hospitals, medical practices, and similar care facilities. Particularly in the field of geriatrics and elderly care, there are interesting application possibilities because the aging of our society is expected to continue and we see similarities in the care concepts of parents for children and adult children for their parents. This could expand video consultations and specifically improve healthcare through digital health.