JMIR FORMATIVE RESEARCH

Yu et alOriginal Paper

Implementation of Shared Decision-Making Within Internet
Hospitals in China Based on Patients’ Needs: Feasibility Studyand Content Analysis
Tianzhi Yu1*, PhD; Chunjie Jin1*, MD; Xiaodan Wu2, PhD; Dianmin Yue2, PhD
1Internet Hospital, Tianjin Medical University General Hospital, Tianjin, China

2

School of Economics and Management, Hebei University of Technology, Tianjin, China*

these authors contributed equally

Corresponding Author:
Dianmin Yue, PhD
School of Economics and Management
Hebei University of Technology
No. 5340 Siping Road Beichen District
Tianjin, 300401
China
Phone: 86 13920955339
Email: dmingyue@hebut.edu.cn

Abstract
Background: Internet hospitals are developing rapidly in China, and their convenient and efficient medical services are being
increasingly recognized by patients. Many hospitals have set up their own internet hospitals to provide web-based medical services.
Tianjin Medical University General Hospital has established a multidisciplinary and comprehensive internet hospital to provide
diversified medical services according to the needs of patients. A way to further improve web-based medical services is byexamining how shared decision-making (SDM) can be carried out in internet hospital diagnosis and treatment services, thereby
improving patients’ medical experience.
Objective: The aim of this study was to analyze the feasibility of implementing doctor-patient SDM in internet hospital diagnosis
and treatment services based on patients’ needs in China.
Methods: In this study, the medical data of 10 representative departments in the internet hospital of Tianjin Medical University
General Hospital from January 1 to January 31, 2022, were extracted as a whole; 25,266 cases were selected. After excluding
2056 cases with incomplete information, 23,210 cases were finally included in this study. A chi-square test was performed toanalyze the characteristics and medical service needs of internet hospital patients in order to identify the strengths of SDM ininternet hospitals.
Results: The internet hospital patients from 10 clinical departments were significantly different in terms of gender (χ29=3425.6;
P<.001), age (χ236=27,375.8; P<.001), mode of payment (χ29=3501.1; P<.001), geographic distribution (χ29=347.2; P<.001),
and duration of illness (χ236=2863.3; P<.001). Patient medical needs included drug prescriptions, examination prescriptions,medical record explanations, drug use instructions, prehospitalization preparations, further consultations with doctors (unspecified
purpose), treatment plan consultations, initial diagnoses based on symptoms, and follow-up consultations after discharge. The
medical needs of the patients in different clinical departments were significantly different (χ272=8465.5; P<.001).
Conclusions: Our study provides a practical and theoretical basis for the feasibility of doctor-patient SDM in internet hospitals
and offers some implementation strategies. We focus on the application of SDM in web-based diagnosis and treatment in internet
hospitals rather than on a disease or a disease management software. The medical service needs of different patient groups canbe effectively obtained from an internet hospital, which provides the practical conditions for the promotion of doctor-patient
SDM. Our findings show that the internet hospital platform expands the scope of SDM and is a new way for the large-scale
application of doctor-patient SDM.
(JMIR Form Res 2023;7:e39965) doi: 10.2196/39965

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Yu et alKEYWORDS
internet hospital; shared decision-making between doctors and patients; patient needs; feasibility

Introduction
Background
Shared decision-making (SDM) between doctors and patients
is a decision-making process in which the doctor and patient
both participate and agree on the most suitable treatment plan
based on the complete information provided on the illness andrelevant treatments. The doctors use their professional
knowledge to elaborate on various possibilities, such astreatment options and benefits and harms, after taking into
consideration the patient’s values, inclinations, and situations[1,2]. SDM between doctors and patients depends on complete
information exchange and communication before thedetermination of the common goal of the doctors and thepatients. SDM is different from the traditional biomedical model,
in which the patient is only treated as a person with illness,without considering the patient’s psychological status or thesocial environment. SDM is also not equivalent to thebiopsychosocial medical model, in which the patient’s
preference is not fully considered or the medical activities are
only carried out under the domination of the doctor—thediagnosis and treatment are carried out in a paternalistic manner
or in an information-imparting manner. Doctor-patient SDM
has been widely used in the diagnosis and treatment of different
diseases, and it has proved to increase patients’ degree ofparticipation and satisfaction in a medical service.
Internet hospitals are a new form of medical service. Throughthe web-based exchange of information and communication,
doctors can diagnose diseases, prescribe drugs and examinations,and provide treatment guidance and health consultation forpatients’ rehabilitation. Web-based medical services facilitate
patients’ medical treatment, improve the efficiency of diagnosis
and treatment, and reduce the cost of patients’ disease treatment[3]. At the same time, the internet hospital diagnosis andtreatment information systems can record the whole process ofpatient diagnosis and treatment information and provide
electronic medical records, treatment plans, self-diagnosis
services, and other eHealth tools. Patients can receive further
clarification about their disease diagnosis, treatment plan, andprognosis by using the internet hospital software.
Doctor-patient SDM is mainly implemented in clinicaldepartments. The decision-making assistance tools
corresponding to each clinical department are developed for
different diseases under SDM guidance. The most suitable
treatment plan for the patients is selected according to the SDM
steps. For example, the implementation of a doctor-patient SDM
tool in patients with vitiligo has been reported to be very
successful and can be applied in other cases [4]. A doctor-patient
SDM tool has also been implemented in patients with functional
gastrointestinal diseases, and a variety of treatment options has
been introduced and improved [5]. A study showed that carryingout doctor-patient SDM among patients with epilepsy resulted
in higher-quality decision-making, more informed choices, andbetter treatment compliance [6]. Another study showed that thehttps://formative.jmir.org/2023/1/e39965

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application of doctor-patient SDM among surgical patientsbrought about higher patient satisfaction and value recognition,
which also reduced the anxiety and inner conflicts in patients[7]. The implementation of doctor-patient SDM in perinatal
patients effectively reduced the dilemma of maternal
decision-making [8]. The implementation of SDM for vaccine
injection can effectively increase the number of vaccine
injections [9].
With the development of information and communication
technology, SDM between doctors and patients has gradually
been implemented in the web-based medical electronic healthsystem to serve patients with specific diseases, anddecision-making aids in web versions and mobile phone versions
have been developed. The operation effect shows that sufficientdecision support can be obtained by using these tools. A study
on a web-based decision support tool for patients with metastaticcolon cancer showed that this tool was useful and enabled
patients in effective decision-making [10]. A study on aninteractive web tool for patients with dementia showed that thedecision guide’s chat and personal opinion features facilitatedcommunication between these patients and their health care
workers [11]. Carolinas Asthma Coach uses SDM for childasthma [12]. The AFib app uses SDM for atrial fibrillation
thromboembolism prevention [13]. e-Quit worRx is used in thetreatment plan decision-making for patients in a smoking
cessation program [14]. Power Up is used to record the mental
status of adolescents and supports SDM during adolescentmental treatment [15]. iBdecide is a web-based tool used foradolescents on ulcerative colitis treatment, and this toolpromotes patients’ active participation in doctor-patientcommunication [16]. A web-based SDM tool for fertility
preservation in women of childbearing age with breast cancer
was shown to effectively increase the ability of doctor-patientcommunication and patient’s independent decision-making [17].
A web-based tool that facilitated SDM between doctors andpatients with regard to neoadjuvant chemotherapy use inmuscle-invasive bladder cancer showed that it was beneficial
to predict the treatment outcomes of these patients [18]. As aninformation system tool for web-based patient consultation,internet hospitals have a high degree of informatization, havelarge storage capacity, and are a convenient mode ofcommunication. However, there is no research on theimplementation of doctor-patient SDM in internet hospitals.
This study analyzes the medical needs of internet hospitalpatients from the perspective of doctor-patient SDM todetermine the feasibility of implementing doctor-patient SDM
in internet hospitals.
Internet hospitals use network information technology to enable
patients to see a doctor online. However, the patients shouldhave visited a doctor offline first and have a basic understandingof their illness. Internet hospitals developed rapidly during the
COVID-19 outbreak, and the number of internet hospitals has
increased significantly since then. They have also played an
important role in epidemic prevention, epidemic control, anddaily web-based diagnosis and treatment [19]. This study was
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conducted on the internet hospital of Tianjin Medical University
General Hospital. This internet hospital was self-built, while
the information technology support is provided by Tianjin
Careate Medical Information Co, Ltd. This internet hospital
officially started operation in March 2020. This internet hospitalprovides services, including disease diagnosis and treatment,
express drug delivery, home nursing services, discharge
follow-up, and health consultation. Moreover, it speciallyprovides medical service guidance, doctor recommendations,self-diagnosis services, disease knowledge popularization
documents, complaint services, and other related services in theprocess of medical treatment.
Different from other internet hospitals without brick-and-mortar
hospitals, the medicines issued by the internet hospital of Tianjin
Medical University General Hospital can be obtained via
self-collection or express delivery. The issued examination
items can be obtained offline, and the continuity of online andoffline services can be realized perfectly. Figure 1 shows theregistration flowchart of the patients in the internet hospital. In
order to fully understand the patient’s condition and preferences,internet hospital patients are required to fill a form regarding

Yu et altheir illnesses, duration of illness, main purpose of seeking
medical service, the kind of help they expect, and allergy history
and upload past medical records at the registration stage. If thepatient has been visiting doctors at the hospital online or offline,
the doctor can ask for the complete medical records of thepatient’s outpatient, emergency, and inpatient treatments andcomprehensively understand the patient’s basic situation, diseaseprogression, and treatment plan tendencies. The use of internet
hospitals by patients to seek medical treatment is based on thepremise of basic early diagnosis of their own diseases, whichmakes SDM between doctors and patients more specific. Theinternet hospital also provides disease self-diagnosis services,disease popularization documents, and videos. Patients can learn
about the advantages and disadvantages of different disease
treatment plans through self-study. They can consult online
customer service staff about which doctor they should choose
for their diseases. Thus, they can choose a doctor in thatspecialty for the treatment of their diseases. Concurrently,
patients can learn about the disease treatment plan throughdisease popularization videos or articles published by the doctor
in advance.

Figure 1. The registration flowchart of the patients in the internet hospital.

The patients in internet hospitals are mainly those seeking
follow-up consultation for mild and chronic diseases. Patientswith acute and severe diseases are not suitable for internet
hospital diagnosis and treatment. It is also relatively difficult
to implement SDM between doctors and patients for patientswith acute and severe diseases [20]. In view of the current
popularization of medical knowledge, the improvement ofeducation levels, the internet as the powerful search tool, theinternet query function, and the medical guidance services
provided by the internet hospital, the problem of asymmetric
medical information between doctors and patients has gradually
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become balanced. Patients have a basic understanding of theirown disease treatments before consultation. There is a clear
direction in the selection of treatment options, which will be
more conducive to the implementation of SDM between doctors
and patients in the process of medical treatment in internet
hospitals. Doctors master the patient’s basic situation, diseaseprogression, and preferred treatment method before clinicalconsultation, thus laying the foundation for the next step tojointly decide the treatment plan with the patient.
The 3 main stages of doctor-patient SDM communication are
selection talk, during which the doctor introduces the available
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treatment options or lets the patient know that there are more
options; plan talk, during which the doctor elaborates on theadvantages and disadvantages of the options available; anddecision-making talk, during which the doctor discovers
patient’s preferences. Afterward, they jointly choose the final
treatment plan [21]. The doctors of the internet hospital basicallygrasp the patients’ preferences before consultation, and after
consultation, they mainly conduct a plan talk and adecision-making talk according to the patient’s condition. If theinternet hospital software can automatically provide
decision-making aids according to the patient’s disease diagnosis
during registeration, patients can know the advantages anddisadvantages of various plans. The plan talk can be resolved
before the consultation, and the efficiency of SDM between
doctors and patients can be greatly improved.

Objective
This paper intends to prove the feasibility of SDM between
doctors and patients in internet hospitals and discusses specificimplementation strategies based on the needs of the patients for
medical services in an internet hospital.

Methods
Data Sources
The essence of SDM between doctors and patients in an internet
hospital is the perfect match between doctors’ professional
knowledge and patients’ preferences for disease treatment needs.
The most appropriate method to solve the actual medical needs
is selected through the steps of understanding, communication,and decision-making. The Ottawa doctor-patient SDM
framework is divided into the following three parts:
decision-making needs, decision-making results, anddecision-making support. Of these, decision-making needs are
the primary issue to make clear [22]. In this paper, the medical
data of 10 representative departments in the internet hospital of
Tianjin Medical University General Hospital from January 1 toJanuary 31, 2022, were extracted as a whole. The selection of
10 departments took into account the characteristics of diseases
and differences in treatment methods, service objects, andservice mode between internal medicine departments andsurgery departments. Accordingly, 5 departments focusing on
internal medical treatment and 5 departments focusing on
surgical treatment were selected. The age and gender of thepatients were considered. The selected departments were
pediatrics, obstetrics and gynecology, cardiology, neurology,
nephrology, endocrinology, orthopedic surgery, neurosurgery,
general surgery, and lung tumor surgery, with a total of 25,266
cases. After excluding 2056 cases with incomplete information,
23,210 cases were finally included in this study. According to
the needs reported by the patients when they registered in theinternet hospital, the communication records of doctors andpatients, and the analysis of the final medical records, thepatients in the internet hospital were divided into 6 situations,as follows.
First, patients are very aware of their disease conditions andtreatments. They have clear purposes for medical treatment in
the internet hospital, such as patients with diabetes,
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Yu et alhypertension, hypercholesterolemia, hyperuricemia, cerebral
infarction, or Alzheimer disease, among others.
Second, patients know the illness but do not understand theprogress of the disease or the importance of regularre-examination. Patients need re-examination because of new
symptoms but do not know the specific re-examination items,
such as re-examination after cardiac stent surgery,re-examination after lung cancer surgery, regular re-examination
for patients with hyperthyroidism, and regular examination ofpregnant women.
Third, patients have doubts about the treatment effect after the
diagnosis and request to further confirm the direction ofdiagnosis and treatment, such as requiring adjustment for thetype or dosage of medication and seeking other treatment
options. Patients’ diseases include stunted growth, chronic
kidney disease, and hyperprolactinemia, among others. The
short-term disease treatment effect is not obvious. As such, thepatients require more effective treatment.
Fourth, the patient has undergone a preliminary diagnosis by adoctor. After that, the relevant test results have come out. They
need the doctor to further explain and formulate the next
diagnosis and treatment plan. For example, they need the doctor
to explain the computed tomography report, magnetic resonanceimage report, blood report, urine report, feces report, pathology
report, physical examination report, and other functional
examination reports.
Fifth, the patients do not understand the health condition, disease
symptoms, or other symptoms that are suspected to be causedby the existing disease. In addition, it is not strictly possible todetermine if the patients who seek medical treatment in theinternet hospital are return-visit patients. Many patients have
uncomfortable symptoms, and they choose web-based
consultation to know the reasons for their symptoms as well as
treatment plans. The symptoms include dizziness, insomnia,
tinnitus, cough, chest tightness, itching, and pain.
Sixth, the patient’s disease has been diagnosed, and the patientneeds to be hospitalized. The prehospitalization preparation
work should be done through the internet hospital, or theexaminations required for hospitalization should be subscribedin advance. The examination results will be reported to thedoctor directly before hospitalization in order to reduce theactual hospitalization length of stay.
According to patients’ understanding of their own diseases, theservice needs of internet hospital patients were divided into
drug prescription, examination prescription, medical record
explanation,
medication
guidance,
prehospitalization
preparation, disease follow-up consultation (unspecified
purpose), treatment plan consultation, initial diagnosis ofsymptoms, and follow-up consultation after discharge. A
chi-square test was performed to analyze the patientcharacteristics and the distribution of medical needs. This test
analyzes whether there were differences in the related data
indicators of the internet hospital patients among different
departments.

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Yu et al

Ethical Considerations
This study was reviewed by the ethics committee of the Tianjin
Medical University General Hospital (approval number
IRB2022-WZ-210). This research on patient services in aninternet hospital was an analysis of patients’ medical behavior
data, which did not involve human experiments orcompensation. The Tianjin Medical University General Hospital
approved the study data collection from the hospital information
system. In order to protect the privacy of patients, some data
were deleted during extraction, such as the patient’s name,address, and contact information, as well as other informationthat could be used to identify the patient. To the researchers,
the patients were anonymous or unidentified. The patient-related

data sets met the ethical requirements. The research teamcomplied with informed consent guidelines and have adhered
to local, national, regional, and international law and regulations
regarding the protection of personal information, privacy, andhuman rights. The ethics committee of the Tianjin Medical
University General Hospital approved this study after review.

Results
Table 1 and Table 2 show the characteristics of the patients andtheir service needs in the internet hospital, respectively. The
data show that the internet hospital can supply the diagnosis
and treatment services in different clinical departments to meetthe needs of different patient groups.

Table 1. Characteristics of the patients using the services of an internet hospital (N=23,210).
Characteristics

Pediatrics, n

Endocrinol- Nephrolo- Cardioogy, ngy, nvascular,n

Neurology, nLung tumor
surgery, nObstetrics
and gynecology, nOrthopedic
surgery, nGeneralsurgery, nNeurosurgery,
n

Male

1137

132

989

2097

1421

360

N/Aa

377

98

364

Female

1015

3586

1025

1987

1731

470

3969

597

193

473

≤15

2152

22

2

8

9

N/A

6

10

4

4

>15 to ≤30

N/A

1150

321

242

311

30

1332

189

71

123

>30 to ≤45

N/A

2118

725

1138

651

161

2126

347

122

238

>45 to ≤60

N/A

963

508

1161

732

294

381

237

46

238

>60

N/A

654

458

1535

1449

345

124

191

48

234

Medical insurance

90

3417

1342

3119

1937

446

2233

564

181

491

Self-paid

2062

1490

672

965

1215

384

1736

410

110

346

Local patient 1802

3991

1652

3480

2310

570

2939

719

234

632

Nonlocal pa- 350
tient

916

362

604

842

260

1030

255

57

205

GenderAge (years)

Payment

RegionDuration of illness (days)

a

≤7

1421

1340

694

1303

857

260

2314

357

149

332

>7 to ≤30

328

410

157

441

289

117

489

156

48

105

>30 to ≤183

162

764

323

573

558

178

516

230

43

154

>183 to
≤365

82

514

220

360

263

97

210

62

16

52

>365

159

1879

620

1407

1185

178

440

169

35

194

N/A: Not applicable.

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Yu et alTable 2. Patients’ medical service needs in the 10 clinical departments (N=27,445).
Service needs

Pediatrics, n

EnNephrolodocrinol- gy, nogy, nCardiovascular, n

Neurology, Lung tumornsurgery, nObstetrics
Orthopedic
and gynecol- surgery, nogy, nGeneralsurgery,n

Neurosurgery,n

Prescribing drugs 147

743

543

1421

1099

44

243

116

26

166

Prescribing exam- 113
inations

526

221

262

119

78

319

41

30

52

Explanation of
medical records

243

1643

746

696

387

373

1229

188

43

158

Symptoms at ini- 1131
tial diagnosis

293

97

457

843

45

795

386

123

177

Medication guid- 369
ance

1051

186

856

498

33

414

48

28

498

Prehospitalization preparation

11

21

90

68

35

40

94

30

8

25

Treatment plan
consultation

242

485

171

414

346

166

578

248

56

120

Follow-up consul- 76
tation after discharge

186

82

458

165

234

240

64

15

224

Disease follow177
up consultation(unspecified purpose)

716

158

220

126

40

616

26

4

27

Table 1 shows that there were significant differences in thegender (χ29=3425.6; P<.001), age (χ236=27,375.8; P<.001),
mode of payment (χ29=3501.1; P<.001), geographic distribution(χ29=347.2; P<.001), and duration of illness (χ236=2863.3;
P<.001) among the patients using the services of the internet
hospital. The majority of the patients in these internet hospitals
were female, accounting for 64.77% (15,035/23,210) of thesample population. The proportion of patients aged 30 to 45
years was the highest, accounting for 32.85% (7624/23,210) of
the sample population. Patients younger than 60 years accounted
for 78.29% (18,172/23,210), and older adults accounted for21.71% (5029/23,210) of the sample population. Patientscovered by medical insurance accounted for 59.54%(13,820/23,210), and patients who paid their own expenses
accounted for 40.46% (9390/23,210) of the sample population.
Patients in Tianjin accounted for 78.97% (18,329/23,210), andpatients from other places accounted for 21.03% (4881/23,210).
Patients with illness for less than 7 days accounted for 38.89%(9027/23,210), and patients with illness for more than 7 days
accounted for 61.11% (14,183/23,210) of the sample population.
Patients whose duration of illness was longer than 1 year
accounted for 26.99% (6266/23,210) of the sample population.
Internet hospitals provide a convenient way for web-based
medical treatment and medical insurance settlement. Female
and young patients were more likely to use web-based healthcare. The local patients were also willing to choose thisconvenient method of medical treatment. In particular, patientswith chronic diseases need multiple consultations; therefore,
internet hospitals are the best choice for consultation for suchpatients. With the development of internet hospitals, patient
reception and the service radius will become larger. Internet
hospitals have a large number of patients, and they can
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especially facilitate the long-term diagnosis and treatment ofpatients with chronic diseases, which is conducive to thelarge-scale implementation of SDM.
Table 2 shows that there is a significant difference in the internet
hospital service needs of patients in different departments(χ272=8465.5, P<.001). Among the service needs of patients,
report explanation, drug prescription, preliminary symptom
diagnosis, and medication guidance ranked as the top 4 needs,
which accounted for 67.51% (18,528/27,445) of the total
demand. Patients who choose internet hospitals for treatment
have a basic understanding of their disease. They directly choose
drug prescriptions and examination prescriptions, makeappointments for hospitalization, seek medication guidance,and seek follow-up consultation after discharge. They accountfor 45.39% (12,456/27,445) of the total demand. Patients who
do not understand their own discomfort symptoms are basicallypatients with mild symptoms. They also seek medical treatment
through the initial diagnosis of symptoms, and these patients
account for 15.84% (4347/27,445) of the total demand. In
addition, patients who do not know their own conditions andonly rely on doctors to issue treatment plans unilaterally accountfor 17.99% (4936/27,445) of the total demand. Due to thecontinuity of disease diagnosis and treatment, patients may notcomplete the whole diagnosis and treatment process during only
1 consultation. Internet hospitals provide subsequent diagnoses
and treatment platforms. Internet hospitals can easily prescribe
drugs, interpret reports, provide drug guidance, diagnose
symptoms, and follow up on consultation after treatment. The
analysis of patients’ service needs showed that internet hospitals
can provide diversified diagnoses and treatment services, laying
the practical foundation for the feasibility study of doctor-patient
SDM in internet hospitals.
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Yu et alDiscussion

hospitals are generally those with mild, long-term, or chronic
diseases; therefore, the time for communication is sufficient.

Principal FindingsInternet hospitals provide multidisciplinary medical services
and achieve full coverage of different medical service needs.
Even local patients are willing to use web-based diagnosis andtreatment services. Internet hospitals provide a convenient way
to seek medical service. Web-based medical treatment reducestransportation costs and waiting time costs. Online and offline
medical service information links make services more efficientand timely. Moreover, internet hospitals provide online medical
insurance reimbursement payment, which more effectively
solves the problem of patient payment. China’s internet hospitals
are a new medical mode that has developed rapidly in the past
5 years. Previous studies, such as those regarding Carolinas
Asthma Coach [12], the AFib app [13], e-Quit worRx [14],Power Up [15], and iBdecide [16], focused on the applicationof doctor-patient SDM through a disease or a disease
management software. To date, no doctor-patient SDM app has
been used in an internet hospital. Internet hospitals provide agood platform and a big patient group for promoting
doctor-patient SDM apps. The internet hospital is also a newway for the large-scale application of doctor-patient SDM. The
data on patients’ service needs provided by internet hospitals
show that it is favorable to implement doctor-patient SDM ininternet hospitals. However, it is necessary to consider thecharacteristics of the patients and service needs of the internet
hospital, make full use of the advantages of internet hospitals(eg, online communication, storage and query functions, andconvenient medical services for patients), and carry out thetargeted promotion and application of doctor-patient SDM.

The implementation of SDM should result in a grasp of thepatients’ needs. According to the analysis of patient service
needs in internet hospitals, the needs of patients in different
departments are significantly different. Thus, differentiatedstrategies should be adopted according to the needs of patientsin different departments in order to promote SDM between
doctors and patients. From the perspective of the needs ofpatients in an internet hospital, the patients who visit a doctor
are divided into 2 groups. The first group comprises patientswith chronic diseases and have made multiple consultations.
They have clear preferences for treatment plans and their
purpose. They already know what medicine and examination
items should be prescribed. In this case, it is easy for doctors
to judge patients’ preferences and choose a plan based on pastdiagnosis and treatment records, as the doctor’s and patient’s
treatment plans are basically the same. For example, doctors
can directly prescribe drugs or examinations according topatients’ requirements or conduct prehospitalization preparations
and follow-up consultations after discharge. The second group
comprises patients whose diagnosis, treatment, andre-examination are not clear. The patient cannot make a direct
demand for medical treatment. The doctor needs to make a
judgment based on the medical records provided by the patientand further confirm the disease diagnosis. The medical service
needs of these patients include report explanation, medication
guidance, treatment plan consultation, initial symptom diagnosis,
and disease follow-up consultation (unspecified purpose). The
focus of doctor-patient SDM in internet hospitals should be on
the second group of patients.

There are many advantages of doctor-patient SDM in internet
hospitals. Patients in internet hospitals are mainly patients withchronic diseases and mild diseases. Especially for patients whose
service needs are drug prescriptions, examination appointments,
prehospitalization preparations, medication guidance, andfollow-up consultations after discharge, decision-making isrelatively easy and simple, since the purposes are clear. For
medical needs, such as medical record explanation, disease
follow-up consultation (unspecified purpose), treatment plan
consultation, and initial symptom diagnosis, the decision-making
process is relatively complicated due to the existence of
unknown conditions and the unclear purpose of the patient’s
consultation. However, the support of the eHealth informationin the internet hospital information system has a great advantage
over offline doctor-patient SDM. First of all, most of the patientsin internet hospitals are younger than 60 years, and parents ofchildren patients should communicate with the doctors online
to lay a foundation for effective communication. Second, thepatient’s condition and patient’s preferences can be grasped inadvance. Compared with the on-site decision-making process
of offline outpatients or inpatients, patients in internet hospitals
can understand the plan and explain their preferences clearly.
Doctors can understand the basic conditions of their patients
before they receive the patients, which greatly improves theefficiency of doctor-patient communication. Lastly, the illnessesof patients who make decisions are relatively simple. Comparedto patients with acute and critical diseases, patients in internet

SDM tools should be developed for doctors and patients ofinternet hospitals. There is no clear definition for doctor-patient
SDM aid tools. They can be understood as tools that integrate
articles, pictures, and videos, among other media, that are related
to disease diagnosis, treatment, and rehabilitation. The maincontent expressed should be the adaptation of different treatment
plans to the intended population. According to the classificationof common diseases, clinical departments should formulatedifferential disease diagnosis plans, examination and testingplans, treatment plans, medication plans, regular re-examinationplans, and rehabilitation plans. Clinical departments can send
medical service information or supply self-service inquiry
functions to patients via internet hospital software. Clinicaldepartments can also focus on formulating relevant plans forpatients’ reference and decision-making according to thedifferentiation of patients’ needs. With the help of theinformation system, doctors in internet hospitals can not only
conveniently query the historical medical records of patients
but also easily provide corresponding auxiliary tools for SDM
to patients. Patients can also easily query the medical records
of previous visits, the voice or written records of SDM
communication between doctors and patients, the videos ofdoctors explaining the diseases they are specialized in, andpopular science articles. Thus, the awareness of disease
conditions and treatment options is enhanced. It is more helpful
if patients take the initiative to participate in SDM between
doctors and patients. Given that the service needs of internet

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hospital patients are mainly the explanation of reports, theprescription of drugs, the initial diagnosis of symptoms, andguidance on medications, the development of auxiliary tools
should focus on the differential diagnosis of diseases, treatment
plans, and medication guidance.
Many factors influence SDM between doctors and patients in
an internet hospital. Hospitals, doctors, and patients are the main
driving forces for the implementation of doctor-patient SDM
in internet hospitals. Hospitals should incorporate doctor-patient
SDM into internet hospital diagnosis and treatment and promote
the implementation of doctor-patient SDM at the policy level.
Doctors are the determining factor in the SDM between doctors
and patients. They should formulate a doctor-patient SDM tool
based on the type of disease and apply it to disease diagnosis
and treatment activities. Under the guidance of doctors, patientsshould make full use of doctor-patient SDM tools and combine
their own preferences with SDM to determine the most suitablediagnosis and treatment plan. Hospitals, doctors, and patientsshould form a good cooperation mechanism to effectively
promote the SDM between doctors and patients. Internet
hospitals provide a platform for patients and doctors tocommunicate. Carrying out SDM between doctors and patients
can improve the quality of medical services and the satisfactionof patients, which can indirectly improve patient loyalty. SDM
also results in the formation of a continuous, stable, andharmonious doctor-patient service relationship, as doctors caneasily monitor the disease progression of patients; in fact, SDM
is more conducive to disease treatment.

Yu et alLimitations
This study has some limitations. First, we only selected internet
hospital data from representative clinical departments andanalyzed the related needs. We did not cover all disciplines,
and there is a certain one-sidedness in the needs of patients ininternet hospitals. Second, the development of aid tools and theinformation platforms suitable for internet hospital SDM need
to be further studied, especially in terms of how to embed theauxiliary tools for doctor-patient SDM in the internet hospital
information platform. Both artificial intelligence and the robot
dialogue method can be used to solve the issues with the firststage (selection talk) and second stage (plan talk) of
doctor-patient SDM, which will be the contents of future
research.

Conclusions
This study proves the feasibility of implementing SDM ininternet hospitals and provides some implementation strategies.
Internet hospitals should promote SDM between doctors andpatients at the overall level. The clinical departments should
jointly formulate standardized auxiliary tools for SDM between
doctors and patients for common diseases, provide these tools
to patients for learning and consideration in advance, and guidepatients to carry out SDM to improve decision-making
efficiency. Different from previous studies, this study focuseson the application of SDM in web-based diagnosis and treatment
rather than on a disease or a disease management software.
Through the function of this web-based platform, the application
scope of SDM can be expanded, and a new field of SDM
application can be developed. Thus, internet hospitals provide
a new way for the large-scale application of doctor-patient SDM.

Acknowledgments
This study was supported by grants from Tianjin Municipality Education Department Major Research Project of Social Sciences(2022JWZD21).

Data Availability
The data analyzed during this study are included in this published paper. The raw data sets are not publicly available because ofpatient privacy protection.

Conflicts of Interest
None declared.

References
1.
2.
3.
4.

5.
6.

Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med 2012 Mar
01;366(9):780-781. [doi: 10.1056/NEJMp1109283] [Medline: 22375967]
Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making.
JAMA 2014 Oct 01;312(13):1295-1296. [doi: 10.1001/jama.2014.10186] [Medline: 25268434]
Han Y, Lie RK, Guo R. The internet hospital as a telehealth model in China: Systematic search and content analysis. J MedInternet Res 2020 Jul 29;22(7):e17995 [FREE Full text] [doi: 10.2196/17995] [Medline: 32723721]
Shourick J, Ahmed M, Seneschal J, Passeron T, Andreux N, Qureshi A, et al. Development of a shared decision-making
tool in vitiligo: an international study. Br J Dermatol 2021 Oct;185(4):787-796. [doi: 10.1111/bjd.20137] [Medline:
33830502]
Fox JC, Lipstein EA. Shared decision making in Gastroenterology: Challenges and opportunities. Mayo Clin Proc Innov
Qual Outcomes 2020 Mar 09;4(2):183-189 [FREE Full text] [doi: 10.1016/j.mayocpiqo.2019.11.003] [Medline: 32280929]
Pickrell WO, Elwyn G, Smith PEM. Shared decision-making in epilepsy management. Epilepsy Behav 2015 Jun;47:78-82.
[doi: 10.1016/j.yebeh.2015.01.033] [Medline: 25862468]

https://formative.jmir.org/2023/1/e39965

XSL• FO
RenderX

JMIR Form Res 2023 | vol. 7 | e39965 | p. 8
(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
7.
8.
9.
10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

Yu et alNiburski K, Guadagno E, Abbasgholizadeh-Rahimi S, Poenaru D. Shared decision making in surgery: A meta-analysis ofexisting literature. Patient 2020 Dec;13(6):667-681. [doi: 10.1007/s40271-020-00443-6] [Medline: 32880820]
Megregian M, Emeis C, Nieuwenhuijze M. The impact of shared decision-making in perinatal care: A scoping review. J
Midwifery Womens Health 2020 Nov;65(6):777-788. [doi: 10.1111/jmwh.13128] [Medline: 32767740]
Scalia P, Durand MA, Elwyn G. Shared decision-making interventions: An overview and a meta-analysis of their impact
on vaccine uptake. J Intern Med 2022 Apr;291(4):408-425. [doi: 10.1111/joim.13405] [Medline: 34700363]
Keikes L, de Vos-Geelen J, de Groot JWB, Punt CJ, Simkens LH, Trajkovic-Vidakovic M, et al. Implementation, participationand satisfaction rates of a web-based decision support tool for patients with metastatic colorectal cancer. Patient Educ Couns
2019 Jul;102(7):1331-1335. [doi: 10.1016/j.pec.2019.02.020] [Medline: 30852117]
Span M, Smits C, Jukema J, Groen-van de Ven L, Janssen R, Vernooij-Dassen M, et al. An interactive web tool for facilitating
shared decision-making in dementia-care networks: A field study. Front Aging Neurosci 2015;7:128 [FREE Full text] [doi:10.3389/fnagi.2015.00128] [Medline: 26217221]
McWilliams A, Reeves K, Shade L, Burton E, Tapp H, Courtlandt C, et al. Patient and family engagement in the designof a mobile health solution for pediatric asthma: Development and feasibility study. JMIR Mhealth Uhealth 2018 Mar
22;6(3):e68 [FREE Full text] [doi: 10.2196/mhealth.8849] [Medline: 29567637]
Kapoor A, Hayes A, Patel J, Patel H, Andrade A, Mazor K, et al. Usability and perceived usefulness of the AFib 2gether
mobile app in a clinical setting: Single-arm intervention study. JMIR Cardio 2021 Nov 19;5(2):e27016 [FREE Full text][doi: 10.2196/27016] [Medline: 34806997]
Tubb MR, Meulen MBV, Pallerla H, Regan S, Doarn CR. Clinical evaluation of e-Quit worRx: a mobile app to enhancesmoking cessation shared decision making in primary care. Mhealth 2019;5:22 [FREE Full text] [doi:10.21037/mhealth.2019.06.03] [Medline: 31463308]
Liverpool S, Edbrooke-Childs J. Feasibility and acceptability of a digital intervention to support shared decision-making
in children's and young people's mental health: Mixed methods pilot randomized controlled trial. JMIR Form Res 2021
Mar 02;5(3):e25235 [FREE Full text] [doi: 10.2196/25235] [Medline: 33650973]
Daraiseh NM, Black A, Minar P, Meisman A, Saxe M, Lipstein EA. iBDecide: A web-based tool to promote engagement
in shared decision-making among adolescents with ulcerative colitis. Patient Educ Couns 2022 Jun;105(6):1628-1633. [doi:10.1016/j.pec.2021.10.023] [Medline: 34756638]
Tseng LM, Lien PJ, Huang CY, Tsai YF, Chao TC, Huang SM. Developing a web-based shared decision-making tool for
fertility preservation among reproductive-age women with breast cancer: An action research approach. J Med Internet Res
2021 Mar 17;23(3):e24926 [FREE Full text] [doi: 10.2196/24926] [Medline: 33729164]
Galsky MD, Diefenbach M, Mohamed N, Baker C, Pokhriya S, Rogers J, et al. Web-based tool to facilitate shared decision
making with regard to neoadjuvant chemotherapy use in muscle-invasive bladder cancer. JCO Clin Cancer Inform 2017
Nov;1:1-12 [FREE Full text] [doi: 10.1200/CCI.17.00116] [Medline: 30657403]
Ding L, She Q, Chen F, Chen Z, Jiang M, Huang H, et al. The internet hospital plus drug delivery platform for healthmanagement during the COVID-19 pandemic: Observational study. J Med Internet Res 2020 Aug 06;22(8):e19678 [FREEFull text] [doi: 10.2196/19678] [Medline: 32716892]
Giuliani E, Melegari G, Carrieri F, Barbieri A. Overview of the main challenges in shared decision making in a multiculturaland diverse society in the intensive and critical care setting. J Eval Clin Pract 2020 Apr;26(2):520-523. [doi:10.1111/jep.13300] [Medline: 31661726]
Hernández-Leal MJ, Codern-Bové N, Pérez-Lacasta MJ, Cardona A, Vidal-Lancis C, Carles-Lavila M, ProShare Group.
Development of support material for health professionals who are implementing Shared Decision-making in breast cancer
screening: validation using the Delphi technique. BMJ Open 2022 Feb 01;12(2):e052566 [FREE Full text] [doi:10.1136/bmjopen-2021-052566] [Medline: 35105575]
Ottawa Hospital Research Institute. About us - Patient decision aids. Ottawa Hospital Research Institute. URL: https://decisionaid.ohri.ca/about.html [accessed 2020-06-23]

Abbreviations
SDM: shared decision-making

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Yu et alEdited by A Mavragani; submitted 30.05.22; peer-reviewed by L Ding, S Sarejloo; comments to author 21.07.22; revised version
received 19.09.22; accepted 28.11.22; published 06.01.23
Please cite as:
Yu T, Jin C, Wu X, Yue D
Implementation of Shared Decision-Making Within Internet Hospitals in China Based on Patients’ Needs: Feasibility Study andContent Analysis
JMIR Form Res 2023;7:e39965
URL: https://formative.jmir.org/2023/1/e39965
doi: 10.2196/39965
PMID:©Tianzhi Yu, Chunjie Jin, Xiaodan Wu, Dianmin Yue. Originally published in JMIR Formative Research(https://formative.jmir.org), 06.01.2023. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete
bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license
information must be included.

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