Abstract
Background: Clinical decision support systems (CDSS) are increasingly embedded in national telemedicine services, however how different stakeholders who use them experience these tools, particularly in low- and middle-income countries, is less explored. In the assisted model of India's eSanjeevani service, spoke health workers enter structured symptoms and hub clinicians review a symptom summary and an artificial intelligence (AI)-generated differential diagnosis.
Objective: To describe role-specific experiences of eSanjeevani's CDSS functions and to estimate how acceptance coexists with specific reported difficulties within each role.
Methods: We analyzed a program feedback web survey completed between 11 July and 29 July, 2025 by hub clinicians and spoke providers. Prespecified item profiles covered review of summaries and suggested diagnoses, the perceived relation of suggestions to the clinician's own diagnosis, ease of use and intention to use (hub), and symptom-capture utility, question quantity, question relevance, summary presentation and satisfaction (spoke). Within-role contrasts were reported as absolute differences in acceptance with Newcombe 95% CIs. Short open comments underwent content analysis.
Results: The cohort comprised 190 hub and 662 spoke respondents from 13 and 15 states (21.4% and 19.3% of eligible providers). Among hub respondents, 76.8% regularly reviewed the symptom summary and 58.9% the suggested diagnoses; 72.6% judged suggestions matched (32.6%) or appropriate but different (40.0%), 7.9% mostly inappropriate, and 11.1% reported that suggestions were mostly not generated. Overall, 85.3% intended to keep using the tools. Affirmative intention was 98.4% when suggestions matched, 66.7% when they were mostly inappropriate (difference vs matched or appropriate -23.2 percentage points, 95% CI -48.5 to -4.0) and 61.9% when mostly absent (-25.7, 95% CI -47.1 to -7.3); technical issues, reported by 38.4%, made little difference (-2.8, 95% CI -14.1 to 7.3). Among spoke respondents, 63.4% rated question quantity appropriate, with miscalibration in both directions (15.6% too many; 16.6% too few); 89.9% found the questions relevant and 91.8% found the summary clear. Satisfaction was 75.3% and did not differ materially between those reporting too many questions and those reporting an appropriate number (-2.7, 95% CI -12.8 to 6.0). Comments located spoke difficulties in question burden and missing complaints, and hub difficulties in freezing and in the scope and availability of suggestions. Estimates were stable across cohort, ambiguity and state-exclusion sensitivity analyses.
Conclusions: Acceptance of eSanjeevani's CDSS was high in both roles. For hub clinicians it tracked the perceived quality and availability of AI suggestions rather than technical friction; spoke workers accepted the question burden, but its two-directional miscalibration points toward complaint-specific, adaptive questioning. These provider reports do not measure diagnostic accuracy. They identify log-based and audit-based indicators that the next evaluation cycle should measure directly.