📄 health systems and quality improvement

Coverage, Utilisation and Users of a Chat-Based Digital Primary Care Clinic in Publicly Funded Healthcare: A Registry-Based Observational Study in Finland

This registry-based observational study in Finland demonstrates that the introduction of a 24/7 chat-based digital clinic significantly increased primary care coverage and the proportion of digital encounters by 2025, with usage concentrated among younger, healthier individuals managing minor acute conditions, while approximately 60% of care pathways were resolved entirely within the digital channel.

Original authors: Dahlberg, A., Kaartinen, T., Jukarainen, S., Orre, P.

Published 2026-06-04

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CC BY 4.0

Original authors: Dahlberg, A., Kaartinen, T., Jukarainen, S., Orre, P.

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ⚕️ This is an AI-generated explanation of a preprint that has not been peer-reviewed. It is not medical advice. Do not make health decisions based on this content. Read full disclaimer

Imagine Finland's public healthcare system as a massive, busy train station. For years, everyone had to wait in the same long line at the ticket counter to get help, whether they had a tiny paper cut or a complex medical history.

This study looks at what happened when the station opened a new, high-tech "Chat Express" lane in 2021. This lane is open 24/7, where people can text a nurse instead of waiting in person. The researchers tracked the station's activity from 2019 to 2025 to see how this new lane changed the flow of passengers.

Here is the story of what they found, told in simple terms:

1. The "Pandemic Pause" and the New Lane

First, the researchers noticed a weird dip in 2020. It was like the whole station went quiet because of the pandemic; people were scared to come to the hospital. But once things opened back up, the station got busier than ever.

When the "Chat Express" lane opened, it didn't just add a few extra people; it became a major part of the station. By 2025, nearly 30% of all visits happened through this chat lane. It grew from handling about 1 in 5 visits to nearly 1 in 3.

2. Who is Using the Chat Lane?

If you walked into the Chat Express lane, you'd likely see a very different crowd than in the traditional waiting room.

The Chat Crowd: Mostly younger people (average age 33) and more women. They are like the "digital natives" who prefer texting over talking on the phone or waiting in a chair.
The Traditional Crowd: Mostly older adults (average age 52) and people with more complex, long-term health issues. They stick to the old ways—talking face-to-face or on the phone.

The study found that the people using the chat lane generally had fewer chronic health problems. It's as if the chat lane is a fast track for people with "quick, one-off" problems (like a sudden rash or a sore throat), while the traditional lane remains the hub for those managing complex, long-term journeys.

3. What Kinds of Problems Get Solved?

The chat lane is excellent at handling the "small stuff." The most common reasons people texted were:

Eye infections (like pink eye).
Bladder infections.
Asking to refill a prescription.
General colds or skin issues.

Think of the chat nurses as skilled gatekeepers. They are like a bouncer at a club who checks IDs. Most people get their problem solved right there in the chat. About 60% of the time, the chat nurse says, "Here's the advice you need, you're all set," and the person goes home without ever seeing a doctor.

4. When Does the Chat Lane Send You to the Doctor?

Sometimes, the chat nurse realizes, "This needs a doctor's eyes."

If the chat nurse thinks you need a prescription or a physical exam, they immediately escalate you to a doctor. About 18% of the time, this happens on the same day.
If you don't get a doctor right away, the study checked to see if you came back later. They found that about 17% of people came back within two weeks, and 23% came back within a month.
Crucially, when people did come back, it was usually for things that needed a physical touch, like checking a wound or listening to lungs. The chat lane didn't replace the doctor; it acted as a smart filter that sent the right people to the right place.

5. The "Digital Divide" Warning

The study ends with a gentle warning. While the chat lane is a huge success for younger, healthier people, it hasn't caught on with older adults or those with many health issues.

Imagine the station has a super-fast digital ticket machine, but the elderly passengers still struggle to use it. The researchers worry that if the station relies too much on the digital lane, it might leave the people who need help the most behind. They suggest that to make this fair, the station needs to offer "digital helpers" or keep the old ticket counters open for everyone.

The Bottom Line

The "Chat Express" lane is working well. It has made the station faster and more accessible for acute, minor problems, especially for younger people. It acts like a smart traffic cop, solving simple issues instantly and directing complex cases to the right place. However, to ensure everyone gets a fair ride, the system needs to make sure the older and sicker passengers aren't left stranded at the old ticket counter while the rest of the station speeds up.

Technical Summary: Coverage, Utilisation and Users of a Chat-Based Digital Primary Care Clinic in Publicly Funded Healthcare

Problem Statement
Digital primary care is increasingly integrated into publicly funded healthcare systems to address workforce shortages, rising demand, and access barriers. However, there is limited longitudinal evidence from Nordic settings regarding how integrated digital clinics affect overall system coverage, utilisation patterns, and patient pathways over time. Specifically, concerns persist regarding a potential "digital divide," where patients with higher health needs or barriers to care may be less likely to benefit from digital channels. This study addresses the gap in understanding the real-world integration of a 24/7 chat-based digital clinic within a publicly funded primary care provider in Finland, examining its impact on system-level metrics and the demographic/clinical profiles of its users.

Methodology
This is a retrospective, registry-based observational study conducted in the Päijät-Häme region of Finland, serving approximately 130,000 residents.

Data Source: The study utilized pseudonymised electronic health record (EHR) data comprising 2,796,976 primary care encounters recorded between January 1, 2019, and December 31, 2025.
Intervention Context: The study period covers pre-implementation (2019–2020), the establishment of a joint venture and introduction of digital services (2021–2022), and the operation of a centralised digital clinic under a standardised model (2023–2025).
Definitions:
- Digital User: A patient with at least one digital clinic encounter in a calendar year.
- Traditional User: A patient with no digital clinic encounters in that year.
- Coverage: Proportion of registered residents with at least one primary care encounter.
- Utilisation: Encounters per 1,000 registered residents.
Statistical Approach:
- Coverage Correction: Due to separate administrative systems for digital records in 2021–2023, an empirical overlap fraction ( $\phi$ ) was derived from fully linked 2024–2025 data to correct for double-counting patients using both modalities.
- Comparative Analysis: Demographic and clinical characteristics were compared between digital and traditional users using $\chi^2$ tests and Mann-Whitney U tests.
- Regression Modeling: Logistic regression models were fitted for each year (2023–2025) and pooled to assess the independent association between digital use and comorbidity burden (Charlson Comorbidity Index, CCI $\ge$ 1), adjusted for age and sex.
- Follow-up Analysis: Care pathways were analyzed for nurse-led digital encounters, tracking subsequent contacts within 48 hours, 14 days, and 30 days, distinguishing between planned (pre-booked) and unplanned encounters.

Key Contributions and Results

System-Level Trends (2019–2025):
- Primary care coverage declined from 36.5% in 2019 to 32.1% in 2020 (pandemic suppression) before stabilizing between 40% and 43% from 2022 onwards (40.7% in 2025).
- Total utilisation rose from 972 encounters per 1,000 residents in 2020 to 1,568 in 2025.
- The digital share of all primary care contacts increased from 19.6% in 2021 to 29.8% in 2025.
User Demographics and Comorbidity:
- Digital users were significantly younger (mean age 33.5 vs. 52.5 years) and more often female (60.7% vs. 52.1%) than traditional users.
- Unadjusted comorbidity prevalence (CCI $\ge$ 1) was lower in digital users (12.8%) compared to traditional users (25.6%).
- Simpson's Paradox: While pooled data across 2023–2025 suggested a slight increase in odds of comorbidity for digital users (Adjusted OR 1.04), year-stratified analysis revealed that within each individual year, digital users had consistently lower adjusted odds of comorbidity (OR range 0.87–0.90; all $P < .001$ ). This indicates that at any given time, digital users of equivalent age and sex carry a lower disease burden.
Clinical Scope:
- Digital encounters were predominantly for acute, low-complexity conditions. The most common ICPC-2 codes involved respiratory infections, general symptoms, and skin symptoms.
- Common physician-level diagnoses included conjunctivitis, acute cystitis, and prescription renewals.
- Approximately 60% of care pathways ended within the digital channel without a recorded follow-up.
Care Pathways and Follow-up:
- Following a nurse consultation, 18.0% of cases were escalated to a same-day physician consultation.
- Excluding pre-scheduled visits, 16.8% of patients had a subsequent unplanned contact within 14 days, and 23.4% within 30 days.
- In-person appointments were the most common follow-up modality for unplanned care, often for conditions requiring physical examination (e.g., skin lesions, suspected pneumonia).

Significance and Claims
The paper claims that the integration of a 24/7 chat-based digital clinic into publicly funded primary care has coincided with an increase in overall system coverage and a substantial shift in the modality of care delivery, with digital encounters accounting for nearly 30% of all contacts by 2025.

The study highlights that the digital channel primarily serves younger, healthier populations with acute, episodic needs, functioning effectively as a triage mechanism where nurses manage low-complexity cases and escalate only when clinically indicated. The authors note that the observed patterns raise equity concerns, as older adults and those with higher comorbidity burdens continue to rely on traditional care.

Crucially, the authors maintain a modest stance on causality. They explicitly state that because the digital clinic was introduced concurrently with broader organisational reforms (the joint venture) and during the post-pandemic recovery period, the independent contribution of the digital clinic to system-level changes cannot be definitively established. The findings are presented as observational evidence of integration patterns and user profiles rather than proof of causal efficacy. The paper concludes that while digital services offer efficiency, their expansion requires equity-conscious implementation strategies to prevent widening access gaps.