Twelve patients participated in the study, a majority were women (75%), and most were married or living with others (67%) (Table 1). There were two females and two males among the four physiotherapists. They were aged 31, 60, 66, and 67 years old. Two were general physiotherapists, one was a specialist in manual therapy, and one was a specialist in psychomotor physiotherapy (40). Three were considered very experienced, working as physiotherapists for more than 20 years, and one was less experienced, working less than five years. The physiotherapists had some experience using questionnaires in previous research projects. The SUS scores for the four physiotherapists were 75.0, 82.5, 85.0 and 87.5 points, interpreted as good to excellent usability (38) (Fig. 4).
Higher scores towards the outer edge of the plot mean better usability. For items 2, 4, 6, 8 and 10, the scale is reversed so that a high value is a positive result (good usability), e.g., item 8 shows a mean score of 100, meaning none found the system cumbersome to use.
Results from the interview analysis
From the analysis of the interviews, we first (1) identified the participants´ overall impression of usability and acceptability. We then identified four main themes that were prominent in the interviews: (2) A tool for exploring and preparing, (3) Building a therapeutic relationship, (4) Patient involvement, and (5) Recovery expectations.
1) Overall impression of usability and acceptability (facilitators and barriers)
Both patients and physiotherapists reported that the language used in the CDSS was understandable and informative. Overall, physiotherapists described the CDSS as well-structured, simple to use, and possible to integrate into a first consultation with a patient. Some reported that the structuring of the CDSS reflected their current workflow in consultations. The physiotherapists used the CDSS between one to three consultations for a patient, in most cases two. In the first consultation, the focus was on the patient profile and the examination as a part of the patient's anamnesis. The second focused on finding the most similar patients and deciding the treatment. Physiotherapists reported that the time used on the CDSS was acceptable, with 10–30 minutes on the patient profile, resembling the time usually spent on anamnesis, and 10–15 minutes on the treatment decision screen. However, patients were divided on whether they had spent enough time on the different parts of the CDSS.
Both physiotherapists and patients were particularly positive about the usability of the patient profile. The combination of figures, text, symbols, and colours was perceived as nicely presented, easy to understand, self-explanatory and relevant for knowledge about the prognosis. The patient profile gave a quick and clear picture of the patient's state of health. In addition, the amount of information presented in the profile was acceptable for the physiotherapists and most patients.
The user acceptance of finding similar patients for treatment suggestions was, on the other hand, more divided. When viewing the three best matches, some physiotherapists underlined the value of having multiple factors to aid in selecting the most similar patient and discussing with the patient which to pursue. However, some user interface elements were described as messy, containing excessive, irrelevant, or confusing information that patients found challenging to understand, thus requiring thorough explanation. The functionality of finding appropriate treatment based on treatment descriptions from previous patients also received variable feedback. Treatment descriptions were described as sometimes too extensive or too sparse to learn from, unsuitable for the patient’s problem, or requiring explanation from the physiotherapist to enable the patient to participate in finding treatment. If not considered relevant for the patient at hand, the physiotherapists refrained from showing the descriptions to the patients.
2) A tool for exploring and preparing
The patients reported that gathering information before the first consultation through the baseline questionnaires was beneficial. They appreciated that the physiotherapist had background knowledge of their situation before arriving at the clinic since they then did not have to explain everything in the consultation, thereby saving time. Some felt a sense of relief having filled in the questionnaires, either due to a fear of forgetting something potentially important or by having to address difficult topics when meeting someone new: "Sometimes you can be afraid to open up about difficult things in consultations like this, and then it can be a support that the physiotherapist knows the background and can ask targeted questions” [Patient 11].
After filling in the questionnaire, patients described that they had become more aware of topics to focus on with the physiotherapist and thought differently about their health. Overall, the patients were empowered and felt positive about increasing their reflectivity on how the situation affected their sleep, work, and social activity. Some described a sense of relief by not suffering from anything serious: “I felt pretty healthy when I saw what people could be bothered with, so then I felt pretty good” [Patient 07]. On the other hand, recognising that the situation was more severe than suspected, one patient became afraid of the scope and progression of her pain, questioning her coping skills: “I am so used to living with pain that I think I'm coping quite well. That's why I got confused when I saw that I wasn't coping as well as I thought I did” [Patient 1].
When describing the physiotherapists, the patients used words such as well prepared, enthusiastic, and going to the heart of the matter faster due to the information they had. All physiotherapists said they appreciated having information available before the first consultation to get to know the patient and prepare for the consultation. They believed the CDSS would help to guide them to think more comprehensively about their patients by mapping all relevant aspects of their health situation, facilitating the anamnesis. However, one physiotherapist was sceptical of how it could shape physiotherapists´ questions and further investigation and warned against relying too much on the information.
3) Building a therapeutic relationship
Using the patient profile together was described by both patients and physiotherapists as a good starting point for conversations and getting to know each other. Physiotherapists found this particularly useful for building therapeutic relations. During the conversation, physiotherapists described validating the patient's responses and checking whether the information was correct. Although physiotherapists addressed approximately the same themes in an ordinary anamnesis as when using the patient profile, they usually did so in a less systematic and comprehensive order. As such, the CDSS helped to structure the dialogue and to focus on what is important during the consultation. Most physiotherapists thought the patients reflected well on their situation and said the patient profile made it easier to agree on where to focus. However, two physiotherapists underlined the need to be cautious, warning against becoming deterministic, especially if the patient presented with high and multifaceted symptoms.
Patients described that they got a good first impression of the physiotherapists after using the tool, a sense of being seen, heard, and not treated as just another patient in line: “You feel that someone has prepared and that you are seen in a different way when people are prepared when you arrive” [Patient 06]. One patient found the physiotherapist’s excitement for the CDSS motivating since he explained the CDSS in a language she understood and involved her by letting her watch the screen and participate in assessments. Others also appreciated how the CDSS helped align the patient-therapist mutual understanding of the current problem and how to proceed with the treatment: “I liked best that we have a common picture of me and the plan ahead” [Patient 10].
Visualising the patient profile on the screen was pointed out by patients as a facilitator if they struggled to explain the problems or express themselves. Patients with high symptom severity in the patient profile stated that they did not become scared or depressed since they were already aware of their situation. Instead, it led to constructive conversations with the physiotherapist, who was interested, responsive and empowered them with explanations and a better understanding of the situation.
4) Patient involvement
Although the interviews showed that patient involvement in the different parts of the CDSS varied greatly, all patients felt they participated and could elaborate in discussions around their patient profiles. The patients also appreciated to participate in deciding on the activity for the patient-specific functional scale (PSFS) (41) and the main goal for the treatment together with the physiotherapist. The physiotherapists highlighted the dialogue on defining the activity and determining goals as useful. By involving patients in defining a treatment goal and an important patient-specific function, the physiotherapists believed the patients increased their awareness of the visit and the purpose of the treatment.
The patient involvement varied for the patient matching. Some patients described actively participating in the patient selection process, discussing treatment suggestions, and deciding if something should be omitted or added to the suggested treatment. One patient allowed to take an active part in the process stated that she felt more included and more on the level of the physiotherapist when deciding on treatment. Some pointed out the opportunity to question the treatment suggested by the physiotherapist. However, one patient found it difficult to participate and relate to a system she had not seen before, and several others stated that they relied on the physiotherapist´s expertise.
Even though patients felt included in decisions, some wished they had spent more time on the part of the CDSS suggesting treatment. In contrast, one patient had no or little expectation of participating in the process of choosing treatment and was surprised when she had to be an active part herself. A few patients had not seen the treatment decision screen at all. Thus, some were unaware of this part of the CDSS, whereas others said the physiotherapist prepared the matching beforehand. As such, some patients were merely presented with the result without seeing similar patients, with no discussions or joint decisions on the patient’s preferences. “The patient was involved and was the main architect in defining the main goal of treatment. And I think they do it with a little support from me, while I am more responsible for how we will get to that goal. So there, I'm probably not good enough to involve the patient” [Physiotherapist 3]. Some physiotherapists admitted they had potential for improvement regarding patient involvement, while others said that patients generally agreed on the selected treatment. The physiotherapists stated that the CDSS gave support for their own choice of treatment rather than functioning as a tool for making shared decisions with the patient: "You need to use it like any other tool you have in the clinic, as part of the treatment tools you have, either to support you or to require some reflection on the treatment methods" [Physiotherapist 4].
While some physiotherapists used the CDSS to support treatment already decided, others described it as a tool for focusing more on treatment within a biopsychosocial framework. Most physiotherapists described the treatment recommendations as supporting or substantiating their current practice while helping to reassess their thinking of best practice. However, one physiotherapist believed it could spread uncertainty if the treatment description differed from their own view. While most physiotherapists expressed openness about learning and applying new treatments as suggested by the CDSS, some also communicated uncertainties in addressing certain issues (e.g., mental health and sleep). On the other hand, one physiotherapist was more sceptical and, to some degree, unwilling to adapt to other suggestions.
5) Recovery expectations
Several patients found the CDSS promising in identifying suitable treatment based on other similar patients. One patient described how the CDSS provided her with reassurance: " (…) the reassurance that someone else had been through it and that the treatment has worked" [Patient 9]. Having one’s problems contrasted against someone else, maybe experiencing worse problems, also felt reassuring for some. However, this was not the case if the CDSS could not find similar optimal patients: “It was a 20–30 years difference between me and the best match. So, then I wondered if I had the health of a 60-year-old” [Patient 9].
Several patients found the three months patients’ trajectory graphs very motivating. Knowing their situation would improve over time was reassuring: “I looked at some graphs that one person hadn't improved in the first few weeks, but then he had a great improvement after a while. I remember I noticed that” [Patient 12]. Also, the trajectories were seen as helpful in visualising how one variable, such as pain, could be constant, whereas others such as coping or functioning could improve over the same time. One physiotherapist pointed out that the trajectories might give patients unrealistic expectations, questioning their usefulness: “Can it create unrealistic expectations when they look at the good progress, and after three months, we are sitting there, and they are much worse off?” [Physiotherapist 2]. However, the other physiotherapists believed the patient trajectories could be used to create positive beliefs and recovery expectations.