As this is a new and still emerging research field, we opted for an embedded mixed methods design [32] to formatively evaluate the use of the pediatric app in the context of SOPC for adults. We, therefore, decided to conduct face-to-face discussions with SOPC teams for adults in the form of focus groups to effectively assess the individual needs and concerns of each SOPC team. To further assess which features should be prioritized in the further development of the app for adult SOPC, we carried out a quantitative needs assessment, which was incorporated as part of the focus groups (Figure 1). This approach allowed us to openly explore the assessment of digital transformation needs and concerns while simultaneously quantitatively mapping the needs considered to be particularly relevant by the participating SOPC team members.

This study is part of the research project “TAPE” (Telehealth in Outpatient Palliative Care for Adults) and builds upon the previous project “TelPa_kids,” which developed the apps for patients and SOPC team members. These applications seamlessly synchronize with the PalliDoc patient documentation system for use in SOPC [14,16]. App development was based on a needs assessment conducted with patients, caregivers, and pediatric SOPC team members [15]. The patient app allows patients to access educational and informational materials, the electronic palliative patient file (ie, medication plan), upload data (documents, photos, and videos), document questionnaires, and electronic patient-reported outcomes (ePRO), as well as engage in live video contact [14-16]. The app for SOPC team members enables all processes required for the electronic data processing of patient care, such as documenting contacts, updating medication, creating prescriptions, and recording other entries in the electronic palliative patient file. In addition, it allows users to easily access contact information on their smartphones to make calls, compose emails, and navigate to the patient’s location. The app does not support administrative functions relevant to billing or care data analysis. When the patient app is made available, the range of features for SOPC team members’ apps will be expanded to include telehealth functions such as questionnaire assessment, ePRO, and video contact. Figure 2 provides an example of a screenshot showing some available functions for the SOPC teams.

The company distributing the app was once again available for this project and handled the technical implementation and deployment of the software. However, the prior and current research presented here were conducted independently of the provider’s subsequent technical implementation.

The TAPE project team is located in the federal state of Hesse, Germany, and is part of the Palliative Care Team for Children in Kassel, Germany. Since 5 members of the research team (MD, MN, TV, SW, and SF) serve in dual roles as researchers and practitioners in pediatric SOPC, they had unique insights into and access to the field of study, which led to a strong motivation to improve palliative home care through digitalization, but may also have influenced their perception and analysis of the data. The project team proceeded on the assumption that the pediatric App would also be suitable for adult care settings, but that there might be differences in terms of the scope of functions and areas of application.

The sampling strategy used a combination of purposive sampling and convenience sampling. The aim of the purposive sampling for the focus group study was to select 2 typical cases of German SOPC teams for adults, representing 1 team with an urban service area and 1 team with a rural service area [33]. In addition, representatives of all professional groups involved in SOPC were to be recruited within the 2 teams in order to represent a broad spectrum of needs and concerns, including conflicting ones. The representatives had to already have experience with the primary app and be working in direct contact with patients, either physical or remote (eg, office clerks with contact via email, phone, or the app). The specific inclusion criteria were as follows: staff working in specialized outpatient palliative care for adults (eg, physicians, nurses, office clerks, social workers, and pastoral care workers), fluency in written and spoken German, staff with direct patient contact, and use of the PalliDoc Mobile app.

Team members who did not meet all of these criteria were excluded from the study. The total study duration was from March 2022 to March 2025 and primarily focused on the acquisition of participants, as well as the conduction and analysis of the focus groups. The recruitment of the 2 teams took place via the professional network of the authors. Initial contact with the rural team occurred between MD and the team leader in March 2022, as this team was interested in using the original children’s app for adult care and adapting it as part of a study. Due to their availability and willingness to participate, this team was the first to be included. Later, in October 2023, a member of the research team (MD) contacted the urban team by phone with the specific aim of recruiting a more diverse sample for the study. This researcher knew from previous personal contacts that the urban team also shared an interest in implementing the app and therefore acted as a gatekeeper for recruitment. It was communicated that, if possible, all team members from all professional groups should be present. However, participation in the focus groups was voluntary, so the final composition of the sample was random and not determined until the day of the session. The participants were informed that the discussion would focus on digital transformation needs and concerns (using the general German term “Digitalisierung,” English “digitalization”) regarding the use of the pediatric app. Due to the participants’ high level of intrinsic motivation and interest in further digitalizing their work, there was a very high level of participation and no objections to participating in the study. Once the urban team had been included in the sample, the recruitment was completed.

The study was approved by the Ethics Committee of the University of Kassel (05/13/24, EKFB01 No. 202416) and was conducted in accordance with the Declaration of Helsinki. All participants were comprehensively informed of their rights, and a written declaration of consent was obtained prior to the questionnaire survey and focus groups. All data were collected in pseudonymized form—each participant had been allocated a unique code, known only to the research team. For analysis, only the pseudonymized transcripts were used. The participants did not receive any form of compensation for their participation in the study.

A total of 25 members from the 2 included SOPC teams for adults participated in the 2 focus groups (Table 1). This enabled the perspectives of 13 nurses, 8 physicians, 2 psychosocial workers, and 2 office clerks to be incorporated into the study. All participants, except for 1 office clerk in the rural team, had completed additional training in PC. There were no refusals or dropouts during the study.

The analysis of the focus groups of the investigated SOPC teams for adults showed that the needs and concerns regarding the further digitalization of their work and use of the app essentially address 3 functional groups. On the one hand, additional features were requested that have so far played no or only a subordinate role in child care. These features focused on voice control as well as digitization and organization. On the other hand, features with a focus on telehealth were hardly or not at all used by the teams for adults, although they are frequently used in child care [26].

The integration of telehealth was discussed more controversially in both SOPC teams for adults. Across regions and professions, digitalization is seen merely as a supplement to personal care and is restricted to interprofessional communication, for example, between physicians and nurses. In contrast to pediatric care, where patients and families receive the patient app to allow video contacts and ePRO assessment, the communication options in SOPC for adults are limited and restricted to the use of other means of communication, such as telephone, and where applicable, common messenger services. The latter are mainly used in urban practice in the psychosocial field and are critically assessed there, especially with regard to the lack of demarcation:

Even though telecommunication applications are considered to have the potential to reduce workload, there are major reservations regarding the technical requirements, the potential loss of personal contact with patients, and the possible overburdening of patients, their caregivers, and nursing staff:

The preference for digital functions that do not include telehealth components was also reflected in the analysis of the positive and negative rankings of the needs mentioned during the focus group discussion (Figure 3). A total of 60 votes were awarded, of which 41 were positive and 19 were negative. The integration of voice control in the app system was seen as most promising (n=8 positive and no negative votes for voice input; n=6 positive and no negative votes for voice output), whereas AI-powered content processing within the app was seen as the most critical aspect (n=2 positive and n=7 negative votes). As was already evident from the interviews, the integration of telehealth also received predominantly negative ratings (no positive and n=4 negative votes for telemetry; n=2 positive and n=4 negative votes for video contacts; no positive or negative votes for messenger services). Functions addressing digitization or organizational tasks were viewed as mostly positive (n=5 positive and no negative votes for digital patient signature; n=6 positive and n=1 negative votes for electronic prescription; n=4 positive and no negative votes for import of medication plan; n=2 positive and no negative votes for notification function and completeness check of entries; n=2 positive and n=1 negative votes for economic route planning).

To derive concrete use cases for practical application in the field of SOPC, we further supplemented the qualitative data with the quantitative results from the needs prioritization in a joint display. To this end, 3 members of the research team (SF, SW, and MD) reviewed the material for clues and points of reference drawn from specific everyday situations and used them to develop possible scenarios for clinical practice. We therefore merged the identified categories of needs along with their frequency of positive and negative ratings and a key quote, which represents (1) one central field of application in clinical practice and (2) a major concern referring to this category. For better readability, the practical use cases were divided following the respective main categories: digitalization, “features with focus on voice control” (Figure 4), and telehealth, “features with focus on telehealth” (Figure 5).

In this study, we examined the key needs and concerns of SOPC staff for adults when transferring a digital application from the pediatric palliative care sector to the adult sector. We found that SOPC teams for adults seem to be satisfied with the existing app. However, both qualitative and quantitative findings show that telehealth, which was prioritized by pediatric SOPC teams [15], is neither currently used nor desired by teams providing care for adults. Instead, they requested a wide range of digitization and digitalization features that go beyond the current functional range of the existing app. This includes above all features like voice-controlled input and output for the patient documentation system, enabling a single HCP to efficiently prepare for and document home visits while driving. Despite acknowledging this potential, SOPC staff for adults remain reluctant to trust AI-generated summaries and AI-edited voice input in documentation, illustrating a form of algorithm aversion [30,36-38]. Additionally, they expressed a strong need for features that support organizational and administrative tasks, such as enabling digital signatures and streamlining the introduction of e-prescriptions.

Digitalization in SOPC appears to be a complex and sensitive process. The needs and concerns regarding digitalization measures, such as the integration of apps, can vary significantly even within a single care setting—such as the SOPC—depending on the patient group or geographic area. Nevertheless, HCPs are satisfied with the support provided by mHealth. However, to realize the full potential of digitalization measures, specific, tailored solutions are needed, particularly in light of the growing need for palliative care against the backdrop of staff shortages. The mixed method approach presented here, along with the materials provided in the supplementary material including the category system for the identified needs (Multimedia Appendix 1) and concerns (Multimedia Appendix 2); all freely available under a Creative Commons License 4.0), can serve as a template for implementing, evaluating, and adapting technical solutions from related care sectors to enable rapid, effective, and cost-efficient digitalization [1].

To evaluate the user experience in digitalization, the fundamental concept of the Unified Theory of Acceptance and Use of Technology model [38] can be used here. This allows for the classification of user acceptance based on two underlying factors that depend directly on the technology used: (1) perceived usefulness, which is the main factor mediating perceived performance; and (2) usability, which serves as the main factor mediating effort expectancy. To measure these 2 factors, the 6-item Telehealth Usability and Perceived Usefulness Short Questionnaire is available, which is based on a longer questionnaire and available in many languages [39-42]. This allows the user experience to be evaluated and classified after an app has been implemented.

In this specific pilot project, for example, the low acceptance of telehealth and expressed reservations toward video contacts and AI in SOPC for adults can be attributed to the following factors: (1) perceived usefulness is lower in health care due to significantly shorter distances and a higher proportion of end-of-life care for individuals who are dying, where telehealth is clearly not an option, and (2) effort expectancy is higher, with an assumed lower affinity for technology among significantly older patients and their relatives. This assessment is consistent with surveys on technology acceptance and age [22,39,43]. When introducing AI, algorithm-based documentation has the potential to change the perception of individual patient care among HCPs and must be made comprehensible to users to avoid distortion and prevent misinformation.

Furthermore, our results show that HCPs with no experience in telehealth and the regular use of video contacts critically assess its potential use in SOPC for adults and do not use this function. Lundereng et al [30] reported 18 pilot studies that used video contact in SOPC and summarized mixed assessments from HCPs regarding its feasibility and usefulness. It remains unclear to what extent the piloting of video contacts was desired by HCPs or policymakers and whether its use could be continued after the pilot studies were completed. In addition, no HCPs in our study advocated the use of telehealth for monitoring in SOPC, as described in 16 pilot studies by Lundereng et al [30], and individual studies show challenges in maintaining its use [44,45]. Our ongoing evaluation of the TelPa_kids project also shows low and unsustained use of video contacts in pediatric SOPC [16]. This suggests that the continued use of telehealth in the daily practice of SOPC seems to be challenging beyond its use in pilot projects, as described for nursing homes, for example [45]. Nevertheless, differences in HCPs' attitudes and urban vs rural care settings offer valuable insights for international contexts, as supraregional findings from all over the globe indicate that telehealth may improve access to palliative care, especially in structurally weak and geographically dispersed care areas and thus save time and resources [46-50].

This study is the first to explicitly investigate concrete digitalization needs and concerns in SOPC for adults, particularly with regard to the use of telehealth as implemented via a digital application adapted from the pediatric care context. However, differences in care models and geographical distances restrict the extent to which the German context can be applied to international SOPC. The study assessed further needs and concerns based on the use of a specific app (the PalliDoc Mobile app) [14], which also limits the transferability of the results. Moreover, the small number of only 2 SOPC teams with a total of 25 participants in the focus groups limits the generalizability of the findings. However, this comparative analysis with 2 specific teams enables a detailed examination of team-specific differences in digital transformation and may provide a roadmap for individual teams seeking to advance their digital transformation efforts by addressing their specific needs and concerns. Therefore, our mixed methods approach allows for the rapid assessment of digitalization measures. Methodologically, the prioritization technique using open votes could have led to biased results. Also, the reliability of focus groups is influenced by social dynamics, and preexisting team consensus may have overshadowed individual opinions on additional issues [51].

The provision of SOPC for patients who are severely ill and dying in their homes is a delicate and individualized process that depends on patient characteristics and the geographic area covered. It is associated with distinct team-specific challenges and corresponding needs and concerns related to digitalization. Based on our findings, customized solutions seem to be needed in order to achieve a sustainable improvement in the use of new technologies in SOPC, as cross-setting solutions may lead to a certain degree of satisfaction but ultimately fall short of the mark. The results of our study underline the need to assess setting-specific needs and concerns when implementing digital technologies. Accordingly, each digitization or digitalization measure, telehealth application, or AI application should be adapted to the respective care setting. Telehealth may have the potential to substantially transform decentralized SOPC; however, despite its availability, it does not appear to be embraced by adult palliative care professionals. The use of a combination of qualitative and quantitative methods has proven to be particularly helpful in this context and may serve as a model. The results provide a foundational basis and can contribute to further research. For this purpose, ethical, legal, and social aspects are of paramount importance, and the perspective of the patient should be incorporated into digital transformation processes in the context of SOPC.