Preferences for Alternative Care Modalities Among French Adults With Chronic Illness

Key Points Question What is an ideal balance between alternative care modalities implemented during the COVID-19 pandemic and traditional care in the postpandemic care model? Findings This survey study of 1529 chronically ill adults found that patients would choose alternative care (ie, teleconsultations, symptom-checkers, and remote monitoring) over the traditional care equivalent for 22% to 52% of their future needs. The study identified 67 care activities, patient characteristics, and characteristics of alternative care modalities for which patients considered it appropriate to replace traditional with alternative care. Meaning Alternative care modalities implemented during the pandemic could be used to deliver nearly half of patients’ postpandemic care.

eMethods 1: Survey (English translation) ---Home page ---During the COVID-19 pandemic, the ways in which patients access health care services changed and new, technology-based services emerged, aiming to limit the spread of the virus. These changes may affect the way we access health care even after the end of the COVID-19 pandemic.
For example, a hospital that replaced in-person consultations with teleconsultations in 2020 may decide to offer both types of consultations to their patients after the end of the pandemic.
This survey aims to understand how we can adapt regular care (that is, the way you used to receive care before the pandemic started), by adopting components from the care models applied during the pandemic. First, we will present you a list of things that changed in health care delivery during the pandemic in a short video. You will then be asked questions about how we could best combine these new care components with regular care in order to create the ideal care model for you.
Participation in this survey takes 15 to 20 minutes.

Your vision of the future of health care
In the video below, we present examples of changes in health care delivery that took place during the pandemic. To see a written list of these changes, click here: https://inspirecompare.fr/compare/Window_after_interviews.pdf [embedded video https://youtu.be/GbfOYypjmn0] Imagine that all these innovations put in place during the pandemic remain available to you, in the long-term, after the end of the pandemic. How could we integrate these innovations (if at all) in the care of patients with chronic illnesses in order to improve health care after the end of the pandemic?
The innovations presented here are only a few of the modifications in health care delivery experienced by patients during the pandemic. Do not hesitate to express your own ideas in your answers to the questions below. Do not hesitate to give detailed responses so that we can better understand your point of view.
Imagine the ideal care for yourself, in the long term. By ideal care we mean the care you wish to receive as a patient, according to your own criteria (e.g., more effective, less burdensome, etc.).
1. In which ways would it be different from the regular care you received before the pandemic? * 2. How would the innovations in health care delivery, implemented during the pandemic and presented above help you obtain this ideal care? * ---Page 2 ---Imagine that after the end of the pandemic, you could use symptom checkers to receive advice at instances of new or worsening symptoms of your illness, instead of having to contact your physician.
c. For what proportion of these instances would you choose to use a symptom checker?* In the remaining instances you would contact your physician.
[0 to 100% sliding scale, labelled: "None of these instances" to "All of these instances"] d. Please use the text box below to explain why you chose this response. [text box] ---Page 4 ---

Monitoring your health at home
The questions below concern only patients who use self-monitoring tools to monitor and manage their condition (e.g., a glucose meter, a blood pressure cuff, a symptom diary, etc). Do you use such monitoring tools? *  Yes

 No
[Note: the following 2 questions were presented only to participants who selected "Yes" in the above question.] During the pandemic, some patients shared the data collected using self-monitoring tools with their physician, remotely and outside of regular consultations (e.g., by giving their physician direct access to their dashboard, by sending the data via e-mail). This enabled their physician to adjust their treatment outside of consultations.
a. Had you shared monitoring data remotely with your physician at least once before the pandemic? * Imagine that after the end of the pandemic, you could share data collected by using a self-monitoring tool with your physician, remotely, when you need a medical opinion on your data. This would enable your physician to adjust your treatment outside of regular consultations.
c. For what proportion of these instances would you choose to share your data with your physician remotely, outside of consultations? * In the remaining instances you would share your data with your physician in consultation.
[0 to 100% sliding scale, labelled: "None of these instances" to "All of these instances"] d. Please use the text box below to explain why you chose this response. [text box] ---Page 5 ---Finally, of the options below, please select all that apply to you:*  I am a health care professional (e.g., physician, nurse, physiotherapist, etc.)  I am a caregiver to an ill family member or friend  I am neither a health care professional nor a caregiver * Starred questions require a response to continue to the next page of the survey. Then, one author (T.O.) selected eligible studies according to the following criteria: • Inclusion criteria: Systematic reviews, including at least 1 primary study on COVID-19, including at least 1 primary study describing technology-based or non-technology-based reorganization of care. • Exclusion criteria: Reviews of apps available on smartphone app stores (i.e., not including any studies), reviews including only primary studies on the diagnostic accuracy of technologybased interventions implemented during the COVID-19 pandemic.
After screening, we included the following 8 systematic reviews: The PRISMA flow chart is presented below: Qualitative data extraction was performed by one author (T.O.) by using content analysis. The author sought to identify components of technology or nontechnology based reorganization of care from primary studies included in the systematic review, by examining the results section and the summary tables of the 8 included reviews. The identified components of reorganization of care were synthesized in a single list by comparing the extracted data across systematic reviews and merging similar components into a single entry. A revised version of this list, written in non-technical language, was presented to the survey participants to illustrate the concept of blended care and to encourage idea generation. eMethods 3: Description of survey development and piloting

Question development
The first two questions were developed based on brief solution-focused therapy counseling techniques. One technique used in solution-focused therapy is visualization of the future at a time when the patient's therapy goal will have been achieved. The counselor can ask questions to bring this ideal future into focus. For example, a patient who comes into therapy with the request to grow their self-confidence may be asked to describe a day in the future, when they will have become self-confident, in great detail (e.g., "How would your self-confidence show in work meetings?", "How will family dinners be different then compared to now?" Based on this, the authors drafted the following questions: "Imagine the ideal care for yourself, in the long term. In which ways would it be different from the regular care you received before the pandemic?
Which components of your pre-pandemic care would be carried over to your ideal care?
Which components of your pre-pandemic care would be removed completely or replaced by pandemiccare innovations, to achieve your ideal care?
How would the innovations in health care delivery, implemented during the pandemic and presented above help you obtain this ideal care?" Question testing in cognitive interviews and piloting We then conducted cognitive interviews with 3 patients (a 26-year-old woman with major depressive disorder, a 20-year-old woman with type 1 diabetes and generalized anxiety disorder, and a 57-year-old woman with hypothyroidism).
The patients were presented with a draft of the survey on the ComPaRe platform and were asked to complete it while thinking out loud, in the presence of one of the authors (T.O.). At the end of each webpage, the patients were asked standard cognitive interviewing questions (e.g., "What do you think this question is trying to identify?", "Could you rephrase this question, in your own words?"), and were asked to provide any suggestions that could improve the study.
Based on the feedback, we retained the first and last question reported above. Questions two and three produced no original data (i.e., they elicited responses that were repetitive of previous responses). We also decided to merge the two questions: "Imagine the ideal care for yourself, in the long term. In which ways would it be different from the regular care you received before the pandemic? How would the innovations in health care delivery, implemented during the pandemic and presented above help you obtain this ideal care? " Finally, the survey was pilot-tested with four participants of the ComPaRe cohort. Pilot-testing replicated the dissemination process of the final survey: the four participants received an email inviting them to participate in the survey, containing a link to their account on the ComPaRe platform, where the survey could be completed. They were additionally asked to time survey completion. After completing the main survey, participants were asked 3 additional questions in a separate webpage: the duration of survey completion, to describe any problems or difficulties they encountered in the survey and to propose additional modifications that, in their view, could improve the survey (open-ended questions).
Survey completion lasted an average of 21 minutes (range: 5-30 minutes). Participants main difficulty was caused by the term « ideal care », which was not specified further. Participants were unsure whether the term referred to ideal care for themselves, physicians, the care system, patients in general, etc. The question was reworded to specify this. Participants also proposed that the question be broken into two smaller questions. This led to the final version of the question: "Imagine the ideal care for yourself, in the long term. By ideal care we mean the care you wish to receive as a patient, according to your own criteria (e.g., more effective, less burdensome, etc.).
1. In which ways would it be different from the regular care you received before the pandemic? 2. How would the innovations in health care delivery, implemented during the pandemic and presented above help you obtain this ideal care?"

Questions 3-5
Question development The following three compulsory questions refer to the use of alternative traditional care modalities. The authors aimed to develop questions that were not vague or general (e.g., "Would you use teleconsultations in the future?"). Inspired by the use of percentages and proportions, which is a common technique used to develop concrete goals in psychotherapy (e.g., "I will commute to work by bike instead of by car 3 days out of 5"), the authors developed the following question format: "For what proportion of your future consultations, would you choose to use teleconsultations?" Question testing in cognitive interviews and piloting Patients provided positive feedback for this question in the cognitive interviews. They found it easy to conceptualize their care as a whole that can be completed partially by using new care modalities. Both the participants and interviewer found that the thinking process that led participants to select a proportion was informative, and should be captured for further analysis. Therefore, the participants and the interviewer agreed to add an optional open-ended question to each of the close-ended questions: "Please use the text box below to explain why you chose this response." Pilot-testing did not lead to any changes in questions 3-5.

Cover letter
We drafted a brief cover letter that was sent to participants via e-mail, describing the purpose of the survey, the completion time (determined from piloting the survey with four participants, see below), and a link to the participant's account on the ComPaRe website where they could complete the survey. The cover letter was accompanied by the name and photograph of one of the authors (V.T.T.). The cover letter was presented to participants in cognitive interviewing and piloting. No modifications were proposed by participants.

Care activities
Adapt treatment -Remote care is inappropriate to confirm the efficacy of a newly prescribed treatment and quick treatment/dosage changes until the right fit for the patient is found.
Remote care is appropriate to confirm the efficacy of a newly prescribed treatment and quick treatment/dosage changes until the right fit for the patient is found.

Address minor complaints +
Remote care is appropriate for minor complaints as opposed to serious, severe symptoms.
Remote care is inappropriate for the patient's annual consultation, the consultation in which the patient and the physician do a more in-depth review the patient's overall health status.
As a learning tool about the disease + Remote care can be used to help patients understand their illness better. 0 (0.0) 0 (0.0) 1 (0.1) 6 (0.4) 1 (0.2) 1 (0.1) As consultation aid + The remote care tool can be used to collect information that can facilitate subsequent 0 (0.0) 0 (0.0) 24 (1.6) 12 (0.8) 7 (1.1) 6 (0.8) consultations with physicians (including to identify which physician they should contact, e.g., which of their specialists), or help patients better understand the diagnosis and instructions given to them by their physician after the consultation.
Communication on sensitive issues -Remote care is inappropriate for discussing sensitive topics, including receiving worrisome news (e.g., a new diagnosis).

For informal caregivers +
The remote care tool can be used by the patient's informal caregivers to further support the patient.

For information purposes +
The remote care tool should be used for information purposes only, similar to a website publishing generic health information.
Remote care is appropriate to help patients identify if a new/worsening symptom is linked to their chronic disease or to a different disease.
Identify treatment misuse -Remote care is inappropriate to identify the intentional or accidental misuse of potentially dangerous medication, such as opioids.
Remote care is appropriate to identify the intentional or accidental misuse of potentially dangerous medication, such as opioids.
Remote care is appropriate for patients who would like to have consultations with more than one physician simultaneously.
Replace online information-seeking + Remote care can be used to replace information-seeking in nonlegitimate/unvetted websites or forums, which may give the patient erroneous information.
Routine follow-up consultations -Teleconsultations are inappropriate for routine consultations (e.g., follow-up to control a stable condition, consultations described as "just a discussion to touch base" or "simple follow-ups" by participants). Do not use this code if the participants state a specific reason (corresponding to another code) why teleconsultations are inappropriate for routine follow-up, such as the need for physical examination.
Routine follow-up consultations + Teleconsultations are appropriate for routine consultations (e.g., follow-up to control a stable condition, consultations described as "just a discussion to touch base" or "simple follow-ups" by participants).
To prepare in-person consultation + Teleconsultations are appropriate to decide if an in-person consultation is needed.
To rapidly appraise urgency + Remote care is appropriate to appraise the urgency and severity one's symptoms and assess whether they should seek medical help. This helps patients feel reassured and avoid unnecessary consultations. Participants state that remote care can be used as a decision aid for the patient to estimate whether they should seek urgent care, schedule a consultation with their physician soon, or wait until the next scheduled consultation.
To supplement physician's abilities + Remote care is appropriate when the patient's physician requires support (e.g., younger, less experienced physicians; physicians who have followed the patient for a long time and may become less attentive over time). Remote care is appropriate to address urgent needs in which medical advice is rapidly required. This may refer to participants' view that teleconsultation appointments are easier to obtain with shorter delays than in-person consultations, so that they can rapidly address emerging needs for medical care.

Use with General Practitioners (GPs) -
The remote care tool should not be used with one's general practitioner (as opposed to one's specialist).
Remote care is appropriate for supporting patients' own expertise (e.g., after a patient examines their symptoms and decides on the best course of action, a symptomchecker can be used to confirm the patient's decision).
When other types of care are unavailable + Using a symptom-checker is appropriate when traditional care is unavailable (e.g., on the weekend or at night, when the patient's physician cannot be reached, when the patient's physician may be unwilling to provide a phone consultation, when the next available consultation is too far from the appearance of a symptom).

Care innovation characteristics
If data safety is guaranteed +  If the patient has control over sending the data + Remote care should be used if the patient has control over when their data will be sent to or accessed by their physician.
If the tool is explained by the physician + A necessary condition to use symptomcheckers is that the physician explains their use to the patient in advance.
If the tool is supervised by a physician + Use of remote care tools (symptomcheckers and remote monitoring) requires that they are supervised by a physician in one of the following ways: 1) in case of alert, the results of the symptom-checker are directly sent to a physician who takes over the process, or 2) when the symptomchecker has produced a result, a physician calls the user to review/go in-depth in the diagnostic (regardless of alert), 3) using remote monitoring requires the certainty that the monitored data will be reviewed and taken into account by the physician. If there is quality assurance + Quality assurance or vetting (such as an official recommendation of a symptomchecker website from the French national health system) is a requisite (as a characteristic of the remote care tool) for appropriate remote care use, to separate legitimate from lesser-quality versions of the remote care tool. Participants state they would need help to judge if a tool is trustworthy in order to use it.

Patient characteristics
Emerging illnesses -Remote care is appropriate for illnesses known in the medical community. It is inappropriate for new, emerging illnesses for which a solid knowledge base does not exist.
Employed patients + Remote care is appropriate for employed patients who may find it difficult or undesirable to take time off work for inperson care. Limited treatment variation -Remote care is inappropriate for patients whose treatment protocol is rarely modified/cannot be modified irrespective of their symptoms, as opposed to patients whose treatment depends on their symptoms or vitals.

Responsive
Care will be more dynamic and responsive to patients' needs. Patients will receive care (e.g., consultations with a specialist, treatment adaptation) exactly when care is needed, without having to wait several months for a consultation. Consultations will be responsive to patients' needs instead of following a non-personalized template that mandates follow-up appointments at pre-specified time intervals.
270 (17.7) 206 (13.5) Empathetic Care will be characterized by empathetic communication between patients and physicians. Physicians will have good communication skills and patients will feel heard, seen and understood. 77 (5.0) 63 (4.1)

Interconnected
The professionals involved in the patient's care network will communicate with each other to facilitate information exchange. The patient will not have to be the sole messenger transferring information on their illness(es) between professionals.

Collective
Care is described as a system in which resources are shared (e.g., less severely ill patients will receive remote care to free physicians' time for more severely ill patients

Lean
There will be fewer in-person consultations considered unnecessary by the patient, thereby reducing associated travel and wait, the term "less heavy" was also coded as "Lean". 470 (30.7) 432 (28.2) More personalised Care will be personalised to each individual patient. 27 (1.8) 16 (1.0)

Informative
Information about the patients' illness and care will be clearly provided during their care, from official sources, such as by their physician, including orientation towards the right specialist for their illness. Patients will not have to struggle to get information about their illness or resort to unverified online resources. This refers to information about the illness and treatments, not one's personal data (e.g., adding exam results to a patient's health records).

(2.9) 34 (2.2)
Not redundant Care will not require patients to do the same thing multiple times (e.g., to do the same blood test twice, because it was ordered by two different specialists a few weeks apart). 16 (1.0) 10 (0.7) Automated Some processes of care should be automated, instead of requiring vigilance and action from patients (e.g., taking follow-up appointments, having prescriptions automatically renewed without having to put in a request).
17 (1.1) 10 (0.7) Closer follow-up Patients will be followed more closely and regularly, by having more consultations, by having more frequent contact with their physician in-between consultations, or by using remote monitoring. 64 (4.2) 60 (3.9)

Better documented
The patient's care will be better documented. For example, all documents regarding the patient's illness, such as lab test results, will be available to patients and stored in their medical record, patients will regularly receive reports providing an overview of their illness and consultation 'minutes'. This is associated with reducing redundancy and improving information flows within the patient's care network (see codes "Not redundant" and "Interconnected"). This code does not refer to generic information about the patient's illness, but to their documentation of data produced by their personal care.

(2.3) 21 (1.4)
Maintain in-person patient-physician contact Care will be at least partially based on in-person patient-physician encounters. It will not be fully remote, either for practical reasons (e.g., need for physical examination) or for social reasons (e.g., to maintain human contact and facilitate the patient-physician relationship) or due to patient preferences and beliefs regarding the superiority of in-person care.
233 (15.2) 199 (13.0) As before Care should return to traditional, pre-pandemic care. No remote care modalities used during the pandemic should be adopted in the long term, either because the patient's pre-pandemic care is ideal, or because they do not believe that their care can change drastically (e.g., because they consider pre pandemic levels of in-person care to be necessary). Pre-schedule the follow-up consultation (when needed) during the current consultation. 9 (0.6) 8 (0.5) Schedule blood draw appointments Patients will be able to book blood draw appointments with labs to avoid wait. 1 (0.1) 0 (0.0) Make long-term appointments available Patients will be able to make appointments further into the future. 1 (0.1) 0 (0.0)

Use online scheduling tools
Consultations (including hospital consultations) will be scheduled online via a dedicated website. The consultation scheduling website will offer functions such as presenting all available time slots so that the patient can choose the most convenient time slot, alerts when earlier consultation slots become available due to cancellation, and the option to select the reason for consultation (e.g., renew prescription, adapt treatment due to side effects), offering different time slots depending on urgency. 77 (5.0) 54 (3.5) Expand consultation times Expand the time slots available for patients to consult their physicians. 2 (0.1) 0 (0.0) Pre-consultation screening Pre-consultation screening (phone/video call) Patients have a brief phone or video call with their physician to decide if they need a consultation. Patients receive a protocol guiding them to test different treatments (e.g., different doses of the prescribed medication) until they find the one they respond best to. 1 (0.1) 0 (0.0) Reduce examinations Reduce the number of medical examinations and tests requested of patients. 1 (0.1) 1 (0.0)

Transform in-person care modalities
Do lab tests at home Biological samples required for lab tests, such as blood draws, will be taken at home by a health care professional or by the patient and then sent to a lab for analysis. 10 (0.7) 4 (0.3) Receive interventions at home Deliver interventions that are usually done in hospital, such as IV drips, at home instead. 11 (0.7) 14(0.9) Silo hospitals Establish separate hospitals for different patient groups according to their illness. 1 (0.1) 1 (0.0) Organize at-home hospitalization directly The patient can benefit from at-home hospitalization without having to pass by the emergency room first.
1 (0.1) 0 (0.0) Move care into the community Patients will be able to do medical acts, such as lab tests and medical visits, in their local community, instead of having to go to the hospital. For example, specialist physicians could practice at community health centres on prespecified dates, instead of patients having to travel to medical centres specialized in their illness located in a different region. 9 (0.6) 11 (0.7) Bundle appointments Bundle different appointments (exams, consultations) at the same place, on the same day 17 (1.1) 16 (1.0) Bundle blood draws and pharmacy visits Offer the option to do blood draws at the pharmacy and directly pick up the adapted medication based on the results. 1 (0.1) 1 (0.1) Create multispecialty offices Create medical offices that group physicians of all specialties relevant to a specific illness, including medical laboratory services, as a "one stop shop" for patients with a given illness. 5 (0.3) 2 (0.1) Allocate separate spaces to patients with Provide adapted care spaces for patients with Multiple chemical sensitivity and Electromagnetic hypersensitivity.
1 (0.1) 0 (0.0) electromagnetic or multiple chemical sensitivity Allocate less crowded slots to chronically ill patients Allocate less crowded time slots to chronically ill patients for in-person consultations, so they come in contact with fewer people (e.g., to minimize the risk of contracting an infectious disease) 1 (0.1) 0 (0.0) Delegate consultationadjacent tasks to nonphysicians Some consultation-adjacent tasks could be done by trained nurses or pharmacists. These may include routine consultations (in which the main aim is to check that the patient's condition remains stable by means of physical examination or review of test results, and renew their prescription), consultations aiming at prevention, or consultations with specialized nurses who, either alone or by consulting with a specialized physician, can support the patient and their family physician in managing the illness. Physicians could also collaborate with nurses in delivering blended care (e.g., local nurses could perform a physical examination and take the patient's vitals and transmit the data to the patient's physician, who then can adapt the patient's medication if needed). 8 (0.5) 11 (0.7) Introduce remote care modalities

Use teleconsultations
Participants suggested that teleconsultations should be part of post-pandemic care. Participants differ regarding the way in which they suggest teleconsultations be used. Some participants emphasized that the choice of teleconsultations versus in-person consultations should be left up to the patient, and others highlighted the need to keep some in-person consultations. Some participants suggested that teleconsultations be used under specific conditions (e.g., when the illness is stable and no physical exam is required). Finally, some participants reported that teleconsultations would result in more regular or frequent care, and that teleconsultation appointments are easier to get with shorter delays, compared to in-person consultations. 658 (43.0) 594 (38.9)

Online physiotherapy
Replace physiotherapy consultations with pre-recorded or live online physiotherapy sessions. 2 (0.1) 0 (0.0) Consultation-preparatory questionnaires Before each consultation, patients can fill in questionnaires to provide physicians with information about their health. 1 (0.1) 0 (0.0) Remote prescription for lab tests before consultation Patients will be able to remotely receive prescriptions for lab tests (e.g., via email or through the patient portal associated with their personal health record). This will save patients a consultation whose sole purpose is the prescription of lab tests, and it can help patients do lab tests rapidly in response to the evolution of their illness (e.g., as soon as their symptoms worsen). Remote referral Obtain referral letter to a specialist physician remotely. 2 (0.1) 1 (0.1)

Brief communication between consultations
Being able to contact one's regular physician briefly, to address specific concerns or questions (e.g., about side effects of prescribed medication) in a synchronous or asynchronous manner. This may take the form of "mini teleconsultations" (i.e., brief 5-or 10-minute contact by phone or video call to address specific topics between proper consultations), e-mails, or chat via messaging platforms.
222 (14.5) 135 (8.8) Remote monitoring Transmission of monitoring data from a monitoring tool, such as a wearable sensor, a medical device, or a symptom log, to one's physician, for reactive treatment adaptation 92 (6.0) 66 (4.3)

Remote prescription renewal
Patients will be able to obtain a prescription remotely, such as by email, after teleconsultations. This includes prescriptions for medication and lab tests. 322 (21.1) 283 (18.5)

Automated prescription renewal
The patient will have their medication prescription renewed remotely, without having a consultation or teleconsultation. The renewal may be automated for the same prescription, if the patient does not notify the physician of change in their condition, or it may be coupled with remote monitoring (i.e., the physician can renew or send a modified prescription, depending on the patient's monitoring data). Establish an online platform where trained peers with the same illness as the patient provide support, supervised by a physician.
1 (0.1) 0 (0.0) Medical advice available 24/7 Patients will be able to receive medical advice around the clock. 7 (0.5) 11.4 (0.7) Online portal for physicians to crowdsource advice Create a secure online portal for physicians to obtain colleagues' advice and opinions on a specific patient, identified through their national health insurance number. 1 (0.1) 0.4 (0.0) Remote access to health care professionals for questions Give patients the possibility to remotely contact health care professionals other than their own physician, to ask questions and receive responses in real time. This may take the form of a website, direct chat, or videocall. 5 (0.3) 8.9 (0.6) Psychological support Provision of psychological support to patients. 14 (0.9) 10.3 (0.7) Helplines for medical information Create helplines that offer information to patients regarding their illness, including answers to specific, urgent questions.
16 (1.0) 13.1 (0.9) Helplines for psychological support Create helplines that offer psychological support to patients. The hotlines may be staffed by health care professionals or trained peers with the same illness as the patient calling. 20 (1.3) 23.9 (1.6) Coordinate patients' care network Close the edges between unconnected nodes in the patient's care network.

Remote physician-tophysician consultation
The patient's physician will consult with a specialist regarding the patient's case, either to spare the patient an additional consultation with a specialist, or because the specialist may be otherwise inaccessible to the patient (e.g., consulting with an international expert on the patient's condition). The physician may contact the specialist via an online platform and share patient data with consent (e.g., test results, the recording of the physical examination or the entire consultation between the patient and their own physician). 35 (2.3) 25 (1.6) Alert patients when their physicians communicate on their case When physicians communicate on their common patient, the patient will receive an alert. 1 (0.1) 0 (0.0) Have a single health care professional as "point of reference" Patients will have a specific, single health care professional (most often proposed to be the family physician, but also potentially a specialized physician or a nurse) who will manage and coordinate the care of their chronic illness(es), consult other physicians on behalf of the patient if necessary, and chaperone patients in solving any problems that may come up (e.g., in their interaction with medical laboratories). 20 (1.3) 13 (0.8) Record-sharing between physicians Physicians will share their records of their common patients. 2 (0.1) 5 (0.3) GP performs physical examination in place of specialist If the patient's specialist is difficult to access (e.g., because they are located in a different city), physical examinations can be performed by the patient's GP and communicated to their specialist, to facilitate teleconsultations with the specialist. Establish the use of a single personal health record per patient, accessible online by the patient and all their health care professionals upon authorization by the patient. Physicians will both read this record in consultations, and update it with new information (e.g., notes, lab and examination results, prescriptions) so that all information about the patient is stored in one place. This can enable continuity of care and synchronize care between different specialists. Some participants specifically refer to encouraging French physicians to use the Dossier medical partagé (the virtual, shared personal health record application available to patients in France through the national insurance system).

Enhance human intelligence
Enhance human intelligence (of the patient or the physician) by using artificial intelligence tools that perform tasks complementary to human cognition. Artificial intelligence tools for diagnosis Automated tools based on artificial intelligence can support physicians in diagnosis (e.g., in the case of rare diseases which often take a long time to diagnose, partly because of poor physician knowledge Provide self-monitoring tools that offer data summaries and visualisations, with the possibility to share the monitoring data with physicians. 11 (0.7) 9 (0.6)

Equate remote and inperson prescriptions
Medication prescriptions obtained remotely should have the same validity as those obtain in person (e.g., same duration of validity, ability to prescribe all medications remotely). 3 (0.2) 10 (0.7) Consultation cap Set a limit of patients per physician per day (except for emergency services) to allow for more indepth and longer consultations. 1 (0.1) 0 (0.0)

Targeted information dissemination
Push-content systems, such as newsletters, will offer information and advice targeted to the patient's illness. This may include news about research on their illness and information on emerging situations that can reassure patients, such as advice for coping with seasonal infectious illnesses for patients with a given chronic illness.
8 (0.5) 5 (0.3) Online self-management or coaching modules Coaching and synchronous or asynchronous online courses can provide non-pharmacologic selfmanagement skills to patients, tailored to their illness. Suggested topics include patient education, pain management, exercise and stress management. Suggested formats include videos, live streaming, and apps. The online modules can be stand-alone, or they can be offered to patients after a few in-person sessions.
14 (0.9) 3 (0.2) Interactive, illnessspecific webinars Refers to patients being able to attend online informational seminars on their illness led by specialists to whom they can also pose questions 5 (0. Provide patients with documents related to their care using remote technologies.

Store information on patient's insurance card
Store important information on patients' insurance card. The idea is that as people carry their card with them most of the time, the information would be readily available at emergencies or for patients with memory impairment, and that it provides a practical way of accessing a patient's virtual prescriptions. 7 (0.5) 3 (0.2) Regular patient briefing Patients will regularly receive a written summary of their care (e.g., exam results, treatments tested, health events experienced). 2 (0.1) 1 (0.0) Receive documents by email Patient receives documents, such as summary reports of consultations, by email (except for prescriptions, lab test results and referral letters, for which separate codes were used).
17 (1.1) 23 (1.5) Administrative acts Facilitate administrative tasks. Replace insurance card with face recognition systems Replace insurance card with face recognition systems.
1 (0.1) 0 (0.0) Apply for reimbursement online Facilitate application for reimbursement by giving patients the option to transmit documents online, instead of by post. 4 (0.3) 1 (0.1) Change insurance and employment regulations Change regulations regarding the insurance coverage and employment of chronically ill people.

Eliminate required referrals
Patients will be able to have a reimbursed consultation with a specialist without a referral letter from their family physician. A referral letter is currently required in France to obtain reimbursement.