Table 1.

Overview of codes

Code	Question	Example text passage	Example answer
1. Condition	1A. Why was the technology introduced?	[…] health information technology (HIT) systems for shared electronic medication plans. These systems enable patients and health care professionals to use and manage a common list of current medications across sectors and settings. Shared electronic medication plans have great potential to improve medication management and patient safety, […]a	ChatGPT3.5: - The technology (HIT systems for shared electronic medication plans) was introduced to improve medication management and patient safety
	1B. Is there a specific disease area mentioned?		ChatGPT3.5: - The paragraph does not mention a specific disease area. The focus is on medication management and patient safety in a broader context
2. Technology	2A. What are the key features of the technology?	12A multidisciplinary digital communication tool, Congredi (Fast Guide, Oud Gastel, the Netherlands), was implemented to improve communication about care among providers. It includes an interactive multidisciplinary care plan and a secure e-mailing channel. It was selected on the basis of jointly developed functional specifications; The Tool Congredi is a communication tool for providers, and it was originally developed for primary care by a general practitioner. It consists of an option to share data in a care plan and asynchronous communication options using secure email. The included multidisciplinary care plan was based on the social, functional, mental, physical, and communication problem inventory domain model.15 Providers received a practical instruction training session lasting 4 h and demonstrating use of the Congredi tool. The patient had to give permission to begin a record and to invite providers to link. After patient permission was obtained, a provider opened a Congredi record for the patient and filled in a care plan. Other providers who were involved with the patient and had access to Congredi could be invited by link so that they could view the care plan and use it interactively. Provider actions were recorded in the system. The following are three main categories of actions: care actions (problem assessment, defining care goals, observing patients' health status, and adapting care goals), e-mailing, and inviting other providers to link. All providers had the ability to update the care plan and initiate actions; they received alerts when there were e-mails in their inboxes.b	ChatGPT4.0: -An online platform for creating, using, and managing a list of all the medications a patient was taking and had taken in the past - Pilot project: addition of a shared electronic medication plan system onto the existing eHealth platform; new collaborative model based on the patient-GP-pharmacy triad to make primary care medication management safer in cases involving polypharmacy - information exchange between the patient and an intervening health care professional
	2B. What knowledge and/or support is required to use the technology?		ChatGPT4.0: No information is provided in the given paragraph
	2C. What is the technology supply model?		ChatGPT4.0: - The tool is a communication tool for providers, particularly developed for primary care - Originally developed by a general practitioner - Providers receive training on its use, and patient permission is obtained to initiate a record
	2D. What is said current technology use and uptake?		ChatGPT4.0: - No information is provided in the given paragraph
3. Value proposition	3B.1. What is the technology's positive value proposition in terms of e.g., desirability, efficacy, safety, and cost effectiveness amongst others, excluding beneficial effects on staff?	Among those who did have concerns, concerns for both personal and patient privacy were top of the list (Fig. 3).; In this study, we found that after 1 year of use, the implementation of a private Facebook group for a large, multi-site FHT was ultimately not successful, despite cross-site communication having previously been identified to be in need of improvement by FHT members.12; Use of the group depended heavily on the study team and was not sustained. Survey respondents expressed high levels of concern about both patient and provider privacy and viewed the Facebook group as unnecessary, adding extra time and work to their already busy days; Our survey results suggest that FHT members were inherently suspicious of Facebook, even with guides on privacy settings in place and the recommendation to create a separate profile.c	Researcher B: - No information is provided in the given paragraph
	3B.2. What is the technology's negative value proposition in terms of e.g., desirability, efficacy, safety, and cost effectiveness amongst others, excluding beneficial effects on staff?		Researcher B: - High levels of concern about both patient and provider privacy (using a Facebook group) . Facebook group was viewed as unnecessary, adding extra time and work to the already busy day of the participants - FHT members were inherently suspicious of Facebook, even with guides on privacy settings in place and the recommendation to create a separate profile
4. Adopters	4A. What changes in staff roles, practices and routines, and identities are implied?	4.2. Professional tasks and responsibilities reconfigured The informants reported changes in how much information they sent and received due to the simpler means of communication. We might say that more exchange of information is the structural effect of the introduction of e-messaging that, in turn, leads to unforeseen changes in tasks and responsibilities. Two nurses report how they use e-messages below: Nurse A: We answer questions from the GP. We write general information if they [patients] have an appointment with the GP, and if we think they won’t remember to bring up everything that they should; then we send some kind of update in advance, so that all issues are addressed Interviewer: Before the implementation of the e-messages system, did you provide this information via telephone? Nurse B: Yes, but not always, because it was so cumbersome via the telephone, so you would just skip it. I think e-messaging has made it easier. You can inform via a few keystrokes instead of waiting on the telephone Nurse B points to the fact that she informs the GP more often after the introduction of e-messaging, for example, before a patient arrives for his/her appointment with the GP. It means that the GP may receive information that is more comprehensive and up-to-date, ensuring a better quality of service. Similarly, some of the nurses reported that they use e-messages to inform the GP that patients have been admit-ted to hospital, signalling that the GP should be prepared for changes in the patients’ medications GPs are also of the opinion that they send more messages. However, one highlighted a problematic aspect of communication becoming too easy: We send more messages. Earlier, we used to let them accumulate until Tuesdays [when they had meetings with homecare], and then some problems were solved at that time. Now we send them at once, right. The volume of the messages they [homecare] receive has increased as a result. And that might be a problem. Cause we often ‘shoot from the hip’. We see a problem, and then we send it [a message], so we won’t forget. Earlier, we would have thought, “can we try to solve it?”, “can we try to find out?”, “can we ask the patient to bring the pill dispenser?,” can we ask for a “dis-charge note from the hospital?” It [the increased volume of messages] becomes a burden for homecare services. (GP municipality B) The homecare nurses did not cite message overload or messages not carefully thought out as frequent problems. Thus, there may be a discrepancy between what is comprehended as ‘too much’ from a GP’s perspective and from a homecare nurse’s perspective. It is also necessary to keep in mind that we are examining individual experiences. However, some nurses did talk about receiving too much/irrelevant information via e-message, but this was explained as a consequence of (poor) functionality in the e-message system, where some message types automatically imported extensive amounts of information from the EPR and attached it to the message The interviews show agreement across the informants that more information is sent and received, indicating that e-message users have more knowledge of patients than do nonusers. Two unintended consequences are worth noting from the example quotes presented above: (1) e-messaging may become a structural means of change, allowing nurses to become more active organisers and facilitators of GP’s work, which in turn can mean better follow-up of patients. (2) It may also be argued that e-messaging becomes a tool for getting things done and eliminating cognitive overload but in doing so unnecessarily transfers one’s own work to another actor.; 4.3. Empowering nurses Another issue associated with HIT that was not addressed prior to the introduction of e-messaging is the power balance between homecare nurses and GPs. Shifts in the balance of power may occur as a result of the new form of communication. Through the automatic documentation of communication provided by e-messaging, the nurses felt their requests had more weight. Two quotes illustrate this: First, it is documented every time we have made an inquiry. And they [GPs] can’t ignore an e-message. When there is a message, they have to answer. So, that is very much an advantage. (nurse municipality A) We haven’t been spoilt when it comes to having contact with the GP. It’s like...we try to get hold of them, and they are supposed to call back, but it doesn’t always happen. Sometimes it feels like we are not taken seriously. But when you have sent an e-message, then it is there [in their EPR system]. And they have to open it, and they have to send an answer. (nurse municipality A) When the nurses talked about what e-messages meant to them, they often described the positive effect of the automatic documentation on their dialogues with the GPs. Previously, messages for GPs were often mediated through their medical secretaries and could get ‘lost’, according to the nurses – meaning that the GP never called back. According to the nurses, requests documented in the EPR have more weight than a post-it note from a secretary, and they found that it resulted in a more conscientious follow-up from the GP Furthermore, nurses used phrases such as “having their back covered” and “having documented that you have done your job”. Such expressions illustrate how nurses use e-messages for attaining accountability and to fulfil the demands of the public, their colleagues, patients and next of kin. E-messaging might be viewed as a tool that empowers nurses if used consciously.d	ZenoChat: - Changes in staff roles, practices, and routines are implied by the introduction of e-messaging - More exchange of information is the structural effect of the introduction of e-messaging, which leads to unforeseen changes in tasks and responsibilities - Nurses use e-messages to inform the GP more often and with more comprehensive and up-to-date information - E-messaging becomes a structural means of change, allowing nurses to become more active organizers and facilitators of GP's work, which in turn can mean better follow-up of patients - E-messaging becomes a tool for getting things done and eliminating cognitive overload but in doing so unnecessarily transfers one's own work to another actor - The power balance between homecare nurses and GPs may shift as a result of the new form of communication - Through the automatic documentation of communication provided by e-messaging, nurses feel their requests have more weight - Requests documented in the EPR (Electronic Patient Record) have more weight than a post-it note from a secretary, resulting in a more conscientious follow-up from the GP - E-messaging might be viewed as a tool that empowers nurses if used consciously
	4B. What is the technology's desirability for staff? (Including beneficial effects on staff?)		ZenoChat: - The technology's desirability for staff is not explicitly mentioned in the given paragraph - However, e-messaging may become a tool that empowers nurses and allows them to become more active organizers and facilitators of GP's work, which could lead to improved job satisfaction
5. Organization	5A. What is the organization’s readiness and/or capacity for technology-supported change?	In Australia, video consultations have been funded by Medicare (the universal health insurance system) since 2011; however, general practitioners are not rebated to deliver telehealth services, only to attend patients in person to support video consultations from medical specialists […] Overall, it was very challenging to make video consultations a routine method of delivering general medical ser-vices to long term care facilities. Existing communications infrastructure was usually not suitable, with bandwidth being the greatest barrier.e	Researcher B: - Video consultations were very challenging as a routine method of delivering general medical services to long term care facilities, as existing communications infrastructure was usually not suitable, amongst others due to bandwidth
	5B. What is said about adoption and funding?		Researcher B: - Video consultations have been funded by Medicare (the universal health insurance system) since 2011 - A problem with funding is that general practitioners are not rebated to deliver telehealth services, only to attend patients in person to support video consultations from medical specialists;
	5C. What work is involved in implementation and who will do it?		Researcher B: - The paragraph does not provide specific information about the work involved in implementation or who will do it
6. Wider system	6A. What is the context for program rollout (e.g., political, economic, regulatory, professional (e.g., medicolegal), and sociocultural)?	The Norwegian primary health care is managed by the municipalities and includes home health care, with approximately 31,000 nurses and 4,000 GPs being contracted. These two services are organized separately, governed and financed differently, and also have incompatible EHR systems; (b)Legislation does not permit them to share EHR systems, but they are obliged to exchange patient information when required.28 The nurses in home health care and GPs have many common patients, thus indicating that ensuring a good clinical communication is essential.f	Researcher A: - Home health nurses and GPs work in different systems and are financed and governed differently - Home health nurses and GPs have incompatible EHR systems - Legislation does not allow sharing of EHR systems
7. Embedding and adaptation over time	7A. How much scope is there for adapting and coevolving the technology and the service over time?	5.1. Incorporating other diseases and social determinants A comprehensive integrated care delivery system needs to respond to a broad range of diseases and risks relevant to population health. We have laid some groundwork for taking our present system beyond pregnancy and early childhood. In parallel, the team has initiated a non-communicable disease CHW follow-up program that supports patients detected at the hospital level, and we plan to initiate a surgical follow-up program in the coming year. As an entry point into the social determinants of health, we have also developed an approach to measure household expenditures on health, medical debt, and medical impoverishment, and are currently analyzing these data. Over time, we aim to incorporate these various streams of household-level health, socio-economics, and disease risk data into the comprehensive integrated care digital platform.g	ChatFlash: - The team has initiated a non-communicable disease CHW follow-up program - The team plans to initiate a surgical follow-up program in the coming year - They have developed an approach to measure household expenditures on health, medical debt, and medical impoverishment - The team aims to incorporate household-level health, socio-economics, and disease risk data into the comprehensive integrated care digital platform over time
The codes are displayed as proposed by Greenhalgh et al. in their NASSS framework (Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies) [18]. The questions under each code were taken from the NASSS framework and partially adapted. A coded text passage under each code is given as an example together with an answer provided by one of the four chatbots or a human References for the example text passage: a Bugnon B, Geissbuhler A, Bischoff T, et al. Improving Primary Care Medication Processes by Using Shared Electronic Medication Plans in Switzerland: Lessons Learned From a Participatory Action Research Study. JMIR Form Res 2021; 5: e22319 b Jong CC de, Ros WJG, van Leeuwen M, et al. Professionals' Use of a Multidisciplinary Communication Tool for Patients With Dementia in Primary Care. Comput Inform Nurs 2018; 36: 193–198 c Lofters AK, Slater MB, Nicholas Angl E, et al. Facebook as a tool for communication, collaboration, and informal knowledge exchange among members of a multisite family health team. J Multidiscip Healthc 2016; 9: 29–34 d Melby L and Hellesø R. Introducing electronic messaging in Norwegian healthcare: unintended consequences for interprofessional collaboration. Int J Med Inform 2014; 83: 343–353 e Wade V, Whittaker F and Hamlyn J. An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities. J Telemed Telecare 2015; 21: 490–493 f Lyngstad M, Melby L, Grimsmo A, et al. Toward Increased Patient Safety? Electronic Communication of Medication Information Between Nurses in Home Health Care and General Practitioners. Home Health Care Management & Practice 2013; 25: 203–211 g Citrin D, Thapa P, Nirola I, et al. Developing and deploying a community healthcare worker-driven, digitally- enabled integrated care system for municipalities in rural Nepal. Healthc (Amst) 2018; 6: 197–204